Forgotten Fundamentals: A Review of State Legislation on Nutrition for Incarcerated Pregnant and Postpartum People

Adequate nutritional intake during pregnancy is critical to infant health and development. People with the capacity for pregnancy who are incarcerated have limited control over their diets and rely on prisons and jails to meet their nutritional needs. This study examined state and federal statutes pertaining to nutrition care for pregnant people while incarcerated. Following a systematic search and review, we identified four qualitative codes relating to access to vitamins, supplemental food, additional hydration, and prenatal nutrition education. Summaries of state and federal statutes pertaining to nutrition were developed and compared with current prenatal nutrition recommendations. Less than a third of states had nutrition-related mandates and no states had statutes that included all key nutrition recommendations. No federal statutes addressed nutrition during pregnancy. Additionally, our review found no provisions for enforcement of the limited nutritional statutes that do exist. To mitigate adverse health consequences for pregnant people and their fetuses, policymakers should enact or amend legislation to align nutrition standards in all prisons and jails with national policy recommendations and provide mechanisms to oversee compliance.

Maternal and neonatal outcomes among incarcerated women who gave birth in custody

BACKGROUND

In the United States, the population of incarcerated women has increased by more than 600% since the 1980s. With this rise, correctional facilities have faced new challenges meeting the health care needs of women, especially those who are pregnant. This retrospective cohort study sought to describe five indicators of maternal and neonatal health among women who gave birth in custody, and to compare outcomes among incarcerated women who did and did not receive enhanced pregnancy support.

METHODS

We used deidentified electronic health records (EHRs) to examine maternal and neonatal birth outcomes (ie, mode of birth, low birthweight, preterm birth, APGAR score, NICU admission) among women who gave birth in custody. Regression models examined differences in outcomes between women who received enhanced pregnancy support-group prenatal education and one-on-one doula visits-and a historical control group of women who received standard prenatal care.

RESULTS

Adverse maternal and neonatal birth outcomes in this sample were rare. No differences in outcomes were found between incarcerated women who received enhanced pregnancy support and the historical control group.

CONCLUSIONS

Despite evidence for the benefits of enhanced pregnancy support in the general population, this study did not find differences in outcomes between incarcerated women who did and did not receive support. Integrated data from prison and hospital records are innovative, but effect measurement is limited by sample size. Future research should include primary data collection on maternal, neonatal, and dyadic outcomes longitudinally and across prisons.

Trajectories of Alcohol Use and Related Harms for Managed Alcohol Program Participants over 12 Months Compared with Local Controls: A Quasi-Experimental Study

AIM

Investigate changes in alcohol use and related harm using the first multisite, controlled, longitudinal study of Managed Alcohol Programs (MAPs). MAPs provide regular doses of alcohol, accommodation, social supports and healthcare to unstably housed people with alcohol dependence.

METHODS

A multisite, quasi-experimental, longitudinal study was conducted in day centres, shelters and residential programs for unstably housed people. There were 59 MAP participants from six Canadian cities and 116 local controls. Self-reported alcohol consumption and harms were assessed at 0-2, 6 and 12 months. Liver function test results were accessed for MAP participants.

RESULTS

Both groups had similar reductions in mean drinks per day (MAP: -8.11; controls: -8.54 controls, P < 0.001) and days drinking per month (MAP: -2.51 days, P < 0.05; control: -4.81 days, P = 0.0001) over 6--12 months. Both reduced non-beverage alcohol consumption. MAP participants reported significantly fewer harms at both 0-2 and 6 months than controls. MAP participants had similar total consumption to controls, but spread out over more days (25.41 versus 19.64 days per month, P = 0.001). After leaving a MAP, participants' liver status deteriorated, with increases in both aspartate transaminase and bilirubin levels. MAP sites with effective policies on outside drinking drank less and had fewer harms.

CONCLUSION

MAP participants drank less hazardously than controls, especially with effective management of non-MAP drinking. Reductions in alcohol use and harms occurred for both groups, although MAP participants reported fewer harms at 0-6 months. Departing an MAP was associated with deterioration in liver status. Although providing stable housing, MAPs did not worsen health or increase alcohol use.

The Cochrane 2018 Review on Brief Interventions in Primary Care for Hazardous and Harmful Alcohol Consumption: A Distillation for Clinicians and Policy Makers

AIMS

An updated Cochrane systematic review assessed effectiveness of screening and brief intervention to reduce hazardous or harmful alcohol consumption in general practice or emergency care settings. This paper summarises the implications of the review for clinicians.

METHODS

Cochrane methods were followed. Reporting accords with PRISMA guidance. We searched multiple resources to September 2017, seeking randomised controlled trials of brief interventions to reduce hazardous or harmful alcohol consumption in people attending general practice, emergency care or other primary care settings for reasons other than alcohol treatment. Brief intervention was defined as a conversation comprising five or fewer sessions of brief advice or brief lifestyle counselling and a total duration of less than 60 min. Our primary outcome was alcohol consumption, measured as or convertible to grams per week. We conducted meta-analyses to assess change in consumption, and subgroup analyses to explore the impact of participant and intervention characteristics.

RESULTS

We included 69 studies, of which 42 were added for this update. Most studies (88%) compared brief intervention to control. The primary meta-analysis included 34 studies and provided moderate-quality evidence that brief intervention reduced consumption compared to control after one year (mean difference -20 g/wk, 95% confidence interval -28 to -12). Subgroup analysis showed a similar effect for men and women.

CONCLUSIONS

Brief interventions can reduce harmful and hazardous alcohol consumption in men and women. Short, advice-based interventions may be as effective as extended, counselling-based interventions for patients with harmful levels of alcohol use who are presenting for the first time in a primary care setting.

Corrections officers' knowledge and perspectives of maternal and child health policies and programs for pregnant women in prison

BACKGROUND

In response to the dramatic increase in the number of women incarcerated in the United States-and a growing awareness that a small proportion of women enter prison pregnant and have unique health needs-some prisons have implemented policies and programs to support pregnant women (defined here as maternal and child health [MCH] policies and programs). Corrections officers (COs) are key stakeholders in the successful implementation of prison policies and programs. Yet, little empirical research has examined prison COs' knowledge and perspectives of MCH policies and programs, particularly the impact such policies and programs have on COs' primary job responsibility of maintaining safety and security. The objective of this mixed-methods study was to understand COs' knowledge and perspectives of MCH policies and programs in one state prison, with a specific emphasis on the prison's pregnancy and birth support (doula) program.

RESULTS

Thirty-eight COs at a single large, Midwestern women's prison completed an online survey, and eight of these COs participated in an individual, in-person qualitative interview. Results indicated that COs' perspectives on MCH policies and programs were generally positive. Most COs strongly approved of the prison's doula program and the practice of not restraining pregnant women. COs reported that MCH policies and programs did not interfere, and in some cases helped, with their primary job task of maintaining safety and security.

CONCLUSIONS

Findings support expansion of MCH programs and policies in prisons, while underscoring the need to offer more CO training and to gather more CO input during program development and implementation. MCH services that provide support to pregnant women that are outside the scope of COs' roles may help reduce CO job demands, improve facility safety, and promote maternal and child health.

Most nursing home social service directors lack training in working with lesbian, gay, and bisexual residents

The purpose of this descriptive study is to report findings from a nationally representative mail-in survey of nursing home social service directors (n = 1,071) who were asked if they had received at least one hour of training in six different areas of cultural competency in the past five years. Of the six areas, the lowest percentage of directors reported having training in homophobia. Three-fourths of the sample had not received even one hour of homophobia training over the past five years. Directors who were more recently educated were more likely to report having received homophobia training, as were directors with a college degree, and those who worked in nursing homes located in the West and South regions of the United States. Directors with the most experience were less likely to report having received training. Findings call for immediate development and dissemination of heterosexism and homophobia training of social service staff, policy changes within the nursing home, and policy advocacy priorities for social workers.

A comparison of residential heroin detoxification patients and methadone maintenance patients

Interviews were conducted with 101 heroin dependent persons entering a residential drug-free detoxification unit in 1989. These self-report data were compared with those previously collected in 1985-6 from 457 methadone maintenance patients. The detoxification patients injected less frequently, used less heroin, had been physically dependent for a shorter period and were more likely to be single, unemployed and to have been charged with a criminal offence in the last 12 months. It is suggested that these findings may indicate that addicts who use more heroin are less likely to seek drug-free detoxification. The wider implication of the finding is that future surveys of injecting drug users should assume that there are significant differences between heroin users entering different modalities of treatment.

Medical education in substance use disorders

This paper outlines recent developments in drug and alcohol medical education, and highlights improved prospects for prevention and appropriate management of substance use disorders. The paper also presents a model of effective drug and alcohol medical education designed to induce both clinical competence and effective practice behaviour. Of particular note is the trend towards greater emphasis on skills development, especially clinical interaction skills. This emphasis is underpinned by an increasingly behavioural orientation, whereby concern is focused on fostering clinical competence in specific skills, e.g. identification, history taking and interventions. Practical examples of the application of such approaches are noted. In addition, relevance of concepts, such as self-efficacy and role legitimacy, to the area of drug and alcohol medical education is highlighted. Together with recent data on early intervention, and the widespread recognition and support for medical practitioners' involvement in drug and alcohol problems, future prospects are viewed as very encouraging.

A cost-effectiveness analysis of heroin detoxification methods in the Australian National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD)

This economic evaluation was part of the Australian National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD) project. Data from four trials of heroin detoxification methods, involving 365 participants, were pooled to enable a comprehensive comparison of the cost-effectiveness of five inpatient and outpatient detoxification methods. This study took the perspective of the treatment provider in assessing resource use and costs. Two short-term outcome measures were used-achievement of an initial 7-day period of abstinence, and entry into ongoing post-detoxification treatment. The mean costs of the various detoxification methods ranged widely, from AUD 491 dollars(buprenorphine-based outpatient); to AUD 605 dollars for conventional outpatient; AUD 1404 dollars for conventional inpatient; AUD 1990 dollars for rapid detoxification under sedation; and to AUD 2689 dollars for anaesthesia per episode. An incremental cost-effectiveness analysis was carried out using conventional outpatient detoxification as the base comparator. The buprenorphine-based outpatient detoxification method was found to be the most cost-effective method overall, and rapid opioid detoxification under sedation was the most cost-effective inpatient method.

The role of alcohol expectancy and drinking refusal self-efficacy beliefs in university student drinking

AIMS

University student alcohol misuse is a considerable problem. Alcohol expectancy research has contributed significantly to our understanding of problem drinking in young adults. Most of this research has investigated positive expectancy alone. The current study utilized two measures of alcohol expectancy, the alcohol expectancy questionnaire (AEQ) and the drinking expectancy profile [consisting of the drinking expectancy questionnaire (DEQ) and the drinking refusal self-efficacy questionnaire] to predict severity of alcohol dependence, frequency of drinking, and the quantity of alcohol consumed per occasion.

METHODS

Measures of drinking behaviour and alcohol expectancy were completed by 174 undergraduate university students.

RESULTS

Positive alcohol expectancy factors accounted for significant variance in all three drinking indices, with the DEQ adding additional variance to AEQ scores on frequency and severity of alcohol dependence indices. Negative expectancy did not add incremental variance to the prediction of drinking behaviour in this sample. Drinking refusal self-efficacy and dependence beliefs added additional variance over positive and negative expectancies in the prediction of all three drinking parameters.

CONCLUSIONS

Positive expectancy and drinking refusal self-efficacy were strongly related to university student drinking. The incorporation of expectancy as a means of informing prevention approaches in tertiary education shows promise.

Impact of alcohol education and training on general practitioners' diagnostic and management skills: findings from a World Health Organization collaborative study

OBJECTIVE

The potential of general practitioners (GPs) to reduce the prevalence of alcohol-related problems via alcohol intervention contrasts sharply with actual practice. One explanation for GPs' limited involvement in alcohol intervention is that they have had inadequate training or continuing medical education (CME) on alcohol-related issues. This study examined GPs' experience of alcohol-related CME and its possible relationship with attitudes and practice behavior regarding alcohol-related problems.

METHOD

A questionnaire-based survey was returned by 2,139 GPs from 13 countries across Western and Eastern Europe. North America and Australasia. Diagnostic and management skills were assessed by responses to standardized case vignettes.

RESULTS

The survey response rate was 54%. Approximately one third of GPs (32%) reported receiving no alcohol-related CME, while 8% could not remember whether or not they had received any such training or education. Of the remaining GPs (n = 1,217), 23% reported less than 4 hours (low levels) and 37% reported 4 or more hours (high levels) of alcohol-related CME. GPs who reported higher levels of alcohol-related CME were more likely to obtain information about alcohol, were more prepared to counsel problem drinkers and managed more patients for alcohol issues than did colleagues reporting lower levels of CME. Those with greater CME experience were also more confident about their ability to alleviate alcohol-related problems and reported more appropriate management strategies than did GPs with less CME experience.

CONCLUSIONS

Greater exposure to alcohol-related CME appears to result in better diagnosis and more appropriate management of alcohol-related problems by GPs. Whether this is directly due to the CME itself or because GPs with greater interest in alcohol issues seek out such experience cannot be ascertained from the current study and requires further investigation.

Interactional skills of students from traditional and non-traditional medical schools before and after alcohol education

OBJECTIVE

To compare alcohol-related intervention and general interactional skills performance of medical students from a traditional (Sydney) and a non-traditional (Newcastle) medical school, before and after participation in an alcohol education programme about brief intervention.

DESIGN

In two controlled trials, students received either a didactic alcohol education programme or didactic input plus skills-based training. Prior to and after training, all students completed videotaped interviews with simulated patients.

SETTING

The Faculties of Medicine at the University of Newcastle and the University of Sydney, Australia.

SUBJECTS

Fifth-year medical students (n=154).

RESULTS

Both alcohol-related intervention and general interactional skills scores of the Newcastle students were significantly higher than those of the Sydney students at pre-test but not after training. Although alcohol-related interactional skills scores improved after training at both universities, they did not reach a satisfactory level. The educational approach used had no effect on post-test scores at either university.

CONCLUSIONS

Significant baseline differences in interactional skills scores favouring non-traditional over traditional students were no longer evident after both groups had been involved in an alcohol education programme. Further research is required to develop more effective alcohol intervention training methods.

The Australian National Workplace Health Project: design and baseline findings

BACKGROUND

This paper describes the study design, recruitment, measurement, and initial recruitment outcomes of Australia's largest workplace intervention trial, the National Workplace Health Project.

METHODS

This was a cluster-randomized trial of socio-behavioral and environmental interventions focusing on key behaviors of physical activity, healthy food choices, cigarette smoking, and alcohol consumption, as well as motivational readiness for change. Twenty worksites were randomized separately for each intervention using a two-by-two factorial design. All participants underwent a health risk appraisal and measurements were made at baseline and at 1 and 2 years.

RESULTS

The overall response rate for the baseline survey was 73% with 61% attending the health risk appraisal. The sample was predominantly male, English-speaking, married, blue-collar workers. Overall, 12% reported unsafe alcohol consumption, 26% were current smokers, 44% were physically inactive, 74% ate at most one piece of fruit per day, and 26% ate at most one serving of vegetables per day. Intervention and control conditions were similar at baseline for the primary outcomes, except that a higher proportion of the sociobehavioral intervention condition was more physically active (59%) than the corresponding control condition (53%).

CONCLUSIONS

This study will permit the rigorous evaluation of the efficacy of sociobehavioral and environ mental intervention approaches to workplace health promotion. Although participants were randomized by worksite, intervention and control conditions were similar at baseline; any differences in the primary out come variables will be controlled for in the analysis.

Platelet adenylyl cyclase activity as a trait marker of alcohol dependence. WHO/ISBRA Collaborative Study Investigators. International Society for Biomedical Research on Alcoholism

BACKGROUND

There is compelling evidence that genetic factors play a major role in the development of alcohol dependence. Platelet adenylyl cyclase (AC) activity has been proposed as a biochemical marker for differentiating alcohol-dependent and nondependent subjects, but the sensitivity and specificity of this marker have not been ascertained. The objective of this study was to determine the sensitivity and specificity of platelet AC activity in identifying alcohol-dependent subjects and to ascertain the effect of medical/ psychiatric variables, drinking and smoking history, and age and body weight on AC activity.

METHODS

The cross-sectional study was conducted from 1995 to 1998. Participants were 210 Australian White men who were community volunteers and alcohol treatment inpatients in Sydney, Australia. There were 41 nondrinkers, 140 drinkers, and 29 men who were entering alcohol treatment. The main outcome measure was platelet AC activity. Classification variables were plasma ethanol, gamma-glutamyltransferase, aspartate aminotransferase, serum carbohydrate-deficient transferrin (CDT), and urinary 5-hydroxytryptophol/5-hydroxyindoleacetic acid (5-HTOL/5-HIAA) levels, and World Health Organization/International Society for Biomedical Research on Alcoholism Interview Schedule variables, which included alcohol use and dependence criteria.

RESULTS

Among subjects who reported abstinence for at least 4 days, both cesium fluoride (CsF)- and forskolin-stimulated platelet AC activities were significantly lower in those with a lifetime history of alcohol dependence compared with those with no such history (p < 0.005 and p < 0.05, respectively). The sensitivity and specificity of CsF-stimulated AC activity to discriminate individuals with a lifetime history of alcohol dependence were 75% and 79%, respectively. Similar values for sensitivity and specificity for CsF-stimulated AC activity were calculated when discriminating current alcohol dependence in the subjects in our sample. Irrespective of the history of alcohol dependence, persons who had consumed alcohol recently (within the last 3-4 days) showed significantly higher mean basal, CsF-stimulated, and forskolin-stimulated AC activity (p < 0.001), as did those who had elevated 5-HTOL/5-HIAA ratios or CDT levels, indicative of recent (heavy) drinking. The "normalization" of platelet AC activity to baseline levels after an individual stops drinking may be related to the generation of new platelets during the abstinence period. Conduct disorder and antisocial personality disorder were not associated with low AC activity, but low forskolin-stimulated AC activity was associated with major depression.

CONCLUSIONS

We found that CsF- and forskolin-stimulated platelet AC activity discriminates between subjects with and without alcohol dependence in a population of subjects who had not consumed significant quantities of ethanol recently. Recent alcohol consumption is a confounding variable that can alter the measured levels of AC activity. Forskolin-stimulated platelet AC activity also may be influenced by a history of major depression.

Patterns of drinking in Thai men

Alcohol problems have increased considerably in Thailand in recent years, in common with many other countries in South East Asia. Little is known about the patterns or contexts of alcohol consumption in these countries, and so efforts to develop preventative strategies have been hampered. To identify current patterns related to alcohol consumption, we recruited 91 alcohol-dependent subjects, 77 hazardous or harmful drinkers, and 144 abstainers or light drinkers. A structured interview incorporating the World Health Organization 'tri-level' method to determine the amount and frequency of drinking, and the Alcohol Use Disorders and Associated Disabilities to diagnose alcohol dependence and harmful drinking was used. Median alcohol intake was 75 and 49 g/drinking day in the alcohol-dependent and harmful or hazardous groups respectively. The former group drank on average 25 days/month, whereas the harmful or hazardous drinkers drank 10 days/month. Drinking alone was more common in the alcohol-dependent group (67%), whereas harmful or hazardous drinkers typically drank with friends (58%), and infrequent drinkers drank only at social functions (61%). Only 28% of alcohol-dependent subjects perceived themselves as dependent on alcohol. The alcohol-dependent subjects and hazardous or harmful drinkers were more likely to currently smoke cigarettes and have a history of marijuana use than were non-drinkers, infrequent or light drinkers. Antisocial personality disorder was more commonly associated with alcohol dependence. In conclusion, alcohol dependence was characterized by continual drinking, whereas hazardous or harmful consumption was associated with an intermittent pattern. Other forms of substance use and personality disorder were associated with alcohol dependence. Clearer understanding of these factors would be of great benefit in planning an intervention programme for excessive drinking in Thailand.

Contrasting views and experiences of health professionals on the management of comorbid substance misuse and mental disorders

OBJECTIVES

To determine opinions and experiences of health professionals concerning the management of people with comorbid substance misuse and mental health disorders.

METHOD

We conducted a survey of staff from mental health services and alcohol and drug services across Queensland. Survey items on problems and potential solutions had been generated by focus groups.

RESULTS

We analysed responses from 112 staff of alcohol and drug services and 380 mental health staff, representing a return of 79% and 42% respectively of the distributed surveys. One or more issues presented a substantial clinical management problem for 98% of respondents. Needs for increased facilities or services for dual disorder clients figured prominently. These included accommodation or respite care, work and rehabilitation programs, and support groups and resource materials for families. Needs for adolescent dual diagnosis services and after-hours alcohol and drug consultations were also reported. Each of these issues raised substantial problems for over 70% of staff. Another set of problems involved coordination of client care across mental health and alcohol and drug services, including disputes over duty of care. Difficulties with intersectoral liaison were more pronounced for alcohol and drug staff than for mental health. A majority of survey respondents identified 13 solutions as practical. These included routine screening for dual diagnosis at intake, and a range of proposals for closer intersectoral communication such as exchanging client information, developing shared treatment plans, conducting joint case conferences and offering consultation facilities.

CONCLUSIONS

A wide range of problems for the management of comorbid disorders were identified. While solution of some problems will require resource allocation, many may be addressed by closer liaison between existing services.

Hazardous alcohol use: its delineation as a subthreshold disorder, and approaches to its diagnosis and management

The last 20 years have seen a significant paradigm shift in how we view alcohol misuse. The dichotomous model of "alcoholism" and "normal drinking" has now been replaced by the concept of a spectrum of disorders. In this new framework, "hazardous alcohol use" is defined as a repeated pattern of drinking that confers the risk of harmful consequences. It is a typical example of a subthreshold disorder. Where actual physical or psychological harm or social problems have occurred, the terms "harmful alcohol use" and "alcohol abuse," respectively, are applied. These conditions would typically be considered to be above the clinical threshold. The most severe disorder, alcohol dependence, is a psychobiological syndrome with often severe physical, psychological, and social sequelae. This article describes how the concept of hazardous alcohol use originated, and reviews the intervention techniques that have been developed to induce and assist hazardous drinkers to reduce their consumption to nonhazardous levels. The findings from a series of World Health Organization (WHO) collaborative studies on brief interventions for hazardous alcohol use are described. This work has resulted in the development of the Alcohol Use Disorders Identification Test (AUDIT) screening instrument, which can detect over 90% of hazardous drinkers in a range of settings, and the demonstration that 5 minutes' structured advice can reduce hazardous consumption by 30%. The later phases of this program of work have examined strategies to promote the dissemination of brief interventions for hazardous alcohol use throughout primary health care, and the nationwide, systematic, and sustained utilization of these interventions.

Hepatitis C in injecting drug-using women during and after pregnancy

BACKGROUND

A high proportion of female injecting drug users (IDU) have evidence of hepatitis C virus (HCV) infection. We undertook a prospective study of patients attending a clinic for pregnant IDU to determine the impact of pregnancy on the course of HCV infection and whether pregnancy is affected by HCV infection.

METHODS

One hundred and thirty-one IDU were recruited and followed up with liver function tests, HCV serology and HCV-RNA tests.

RESULTS

Of 131 patients, 125 had HCV antibodies (anti-HCV positive) at delivery, and of these 62% were HCV-RNA positive. The anti-HCV-negative women were younger and had a shorter duration of drug use than the anti-HCV-positive women. There were no differences between viraemic and non-viraemic women with respect to age, ethnicity, duration of injecting drug use, methadone maintenance dose, hepatitis B exposure or reported high-risk behaviour. Alanine aminotransferase (ALT) levels were higher and the proportion with ALT > 55 IU/L higher in viraemic women. Viraemia persisted in all 55 women who were viraemic at term. Eleven had an ALT flare post-partum that was unrelated to viral load and was clinically unsuspected. Four had concurrent elevated gamma-glutamyltranspeptidase and were considered to be drinking alcohol at hazardous levels. Four of 23 women who were HCV-RNA negative at term became positive during follow up.

CONCLUSIONS

Pregnancy does not adversely affect the course of hepatitis C. A modest rebound in ALT levels, but not HCV-RNA, occurs after delivery in some viraemic women. This supports the theory that immune mechanisms rather than direct viral cytopathology are involved in hepatocyte injury during HCV infection. Hepatitis C infection did not influence pregnancy complications and outcomes.

Changing attitudes and beliefs of staff working in methadone maintenance programs

Starting in 1989, an attempt was made to change the aim of methadone treatment in NSW from abstinence to harm-minimisation. A study was undertaken to measure change in attitudes among staff working in public methadone programs in Sydney. Using scales developed in a 1989 survey, we found a statistically significant and meaningful reduction in support for abstinence-oriented policies had occurred by 1992. There was no change in staff's support for the punishment of illicit drug use or their knowledge of the risks and benefits of methadone maintenance. This suggests problems with staff attitudes and, indirectly, the effectiveness of public health interventions, can be addressed using educational campaigns.

Transmission of hepatitis C virus to infants of human immunodeficiency virus-negative intravenous drug-using mothers: rate of infection and assessment of risk factors for transmission

The risk of perinatal transmission of hepatitis C virus (HCV) from a cohort of 95 human immunodeficiency virus (HIV)-negative intravenous drug users (IVDU) is described, 89 of whom were positive for antibodies to HCV (anti-HCV). Infection, defined as the presence of HCV RNA in a serum sample collected from an infant at any time during follow-up, was detected in six of 63 (9.5%) infants born to HCV antibody-positive viraemic mothers. No mother who was HCV RNA negative at delivery transmitted HCV to her infant. Hepatitis C virus antibodies became undetectable in uninfected infants by 15 months, but persisted in all HCV-infected infants throughout follow-up. An abnormal alanine aminotransferase (ALT) level was observed on at least one occasion in all HCV-infected infants and in six occasions in uninfected infants. Two of the six HCV-infected infants became HCV RNA negative during follow-up by 27 and 29 months. Both of these infants had a large ALT elevation (mean peak ALT 398U l-1) at around 12 months of age. Analysis of a range of potential risk factors revealed that maternal HCV RNA load was important in predicting transmission, but suggested that other factors play a role in perinatal transmission from mother to child. No difference was found between mothers who transmitted HCV to their infants and those who did not for HCV genotype, duration of drug use, duration of methadone use, methadone dose, history of alcohol abuse, past hepatitis B virus (HBV) infection, mode of delivery, maternal and gestational age, birth weight and incidence of breast-feeding. Mothers who transmitted HCV to their infants had a longer duration between membrane rupture and delivery than the mothers who did not transmit (P = 0.03). HCV RNA was not detected in breast milk and colostrum samples from 38 viraemic mothers, including two who transmitted HCV to their infant.

Concordance between ICD-10 alcohol and drug use disorder criteria and diagnoses as measured by the AUDADIS-ADR, CIDI and SCAN: results of a cross-national study

Agreement between the AUDADIS-ADR, CIDI and SCAN in case identification for ICD-10 alcohol and drug use disorders and diagnostic criteria was investigated in three countries, Luxembourg, Greece and the US. Overall, agreement for ICD-10 dependence diagnoses between the three instruments was fair to good for alcohol, opioids and cocaine, but generally lower for dependence diagnoses for other substance. In contrast, concordance between instruments for harmful use diagnoses was extremely poor for all substances. Implications of these major findings are discussed in terms of the relationship between prevalence, reliability and concordance and indications and cautions regarding cross-instrument comparisons.

Reliability of the alcohol and drug modules of the Alcohol Use Disorder and Associated Disabilities Interview Schedule--Alcohol/Drug-Revised (AUDADIS-ADR): an international comparison

The purpose of the present study was to examine the test-retest reliability of the alcohol and drug modules of the AUDADIS-ADR in three sites: Bangalore, India, Jebel, Romania and Sydney, Australia. The overall reliability of ICD-10, DSM-IV and DSM-III-R dependence diagnoses was found to be good to excellent for each substance, including alcohol, for each time frame, regardless of whether the total sample or user subsample figured into the calculations. Reliability associated with corresponding harmful use and abuse diagnoses were mixed, but generally lower. Reliability statistics for Bangalore were generally lower than those of the Jebel and Sydney sites, particularly for alcohol diagnostic criteria. Implications of these results are discussed, in conjunction with results from the discrepancy interview protocol analyses within sites, in terms of future revisions to the AUDADIS-ADR and its training procedures tailored to developing countries.

A controlled trial of educational strategies to teach medical students brief intervention skills for alcohol problems

OBJECTIVES

Comparatively little is known about the most effective educational strategies to train medical students to successfully intervene in their patients' alcohol problems. The relative effectiveness of two educational programs to teach medical students brief intervention skills for managing alcohol problems was examined.

METHODS

Teaching took place over 3 hr and was either the traditional didactic teaching program on the principles and practice of brief and early intervention or an interactive program involving a shortened lecture, clinical practice, and small group feedback on clinical performance. Students were assessed on a 10-min videotaped encounter with a simulated patient before and after teaching according to how they addressed alcohol-related issues and on their general interactional skills.

RESULTS

Performance on alcohol-related issues and interactional skills were significantly improved after teaching, although still poor in terms of clinical performance. A between-groups comparison on pre/ postteaching difference scores indicated interactive training was no more effective than traditional didactic lectures in developing the knowledge and skills needed for a brief alcohol intervention.

CONCLUSION

The need for more detailed teaching sessions on sensitive areas such as alcohol use in indicated.

General practice receptionists' attitudes and beliefs towards preventive medicine before and after training and support interventions

OBJECTIVES

Receptionists are an integral part of the primary care service. We aimed to discover their views on preventive medicine issues.

METHOD

One hundred and fifty receptionists from general practices in Sydney, Australia, completed a questionnaire on their attitudes and beliefs towards preventive medicine and brief intervention for alcohol. They were matched according to practice variables into a control, no, minimal, or maximal training and support condition. In all conditions except the control condition, receptionists received 5 minutes of initial training in implementing a brief intervention programme; the amount of ongoing support varied across conditions. Attitudes and beliefs were re-assessed 3 months later.

RESULTS AND CONCLUSIONS

The results indicated that when no training and support were given, receptionists developed negative views towards being involved in preventive medicine activities. When training and support were provided, these negative effects were abolished.

Managing alcohol and drug problems in general practice: a survey of trainees' knowledge, attitudes and educational requirements

To establish baseline data on Family Medicine Programme trainees' knowledge of and attitudes to drug and alcohol problems, we posted questionnaires to all trainees in New South Wales, Queensland, Victoria and South Australia. A total of 1647 trainees was surveyed, with a response rate of 55 per cent (n = 908). The mean age of respondents was 29 years and 54 per cent were female. The majority of respondents (58 per cent) were in their final year of training. Overall knowledge levels were reasonably good (the mean score was 76 per cent), but there were significant areas of deficit. Senior trainees generally performed better than their junior counterparts. Knowledge was best for alcohol and weakest for opiates. Attitudes towards involvement with drug and alcohol problems were very positive; however, confidence in the efficacy of various interventions was mixed.

Establishment and evaluation of a statewide drug and alcohol specialist advisory service

The New South Wales Drug and Alcohol Specialist Advisory Service aims to provide prompt, relevant and reliable advice on the clinical management of drug- and alcohol-related problems to health professionals throughout New South Wales. We gauged the performance of the Service against present indicators by interviewing 120 callers who had contacted the Service during its first two years. Accessibility and the quality of information provided were rated highly. Of the 120 respondents, 105 (90 per cent) rated the speed of response to their calls as very good or excellent, and 109 (91 per cent) considered the advice given to be very relevant to their needs. Nearly all (97 per cent) indicated their intention to reuse the Service, and 78 (65 per cent) nominated it as their preferred source of clinical advice on drug and alcohol problems. The Service has established itself as an accessible and reliable source of advice on the management of drug and alcohol problems, especially for rural health professionals. This model of a telephone-based consultancy could have application in other medical specialities.

Physicians' attitudes and retention of patients in their methadone maintenance programs

A study was undertaken to investigate the influence of methadone prescribers' commitment to abstinence-oriented policies on retention in their maintenance programs. Two hundred and eighty patients recently enrolled in single-person, private methadone programs were interviewed and followed for 8 years. The prescribing physicians' scores on an Abstinence Orientation Scale, derived from an independent sample of methadone program staff, were significantly associated with their patients' risk of premature discharge. The influence of program orientation on retention was greater the higher the maximum dose of methadone. More attention should be paid to the effect of staff attitudes and beliefs on the effectiveness of maintenance treatment.

Attitudes and beliefs of staff working in methadone maintenance clinics

Two attitudinal scales measuring commitment to abstinence-oriented treatment policies and disapproval of illicit drug use were derived from a survey of 90 staff working in 10 public methadone maintenance clinics in Sydney, Australia. The two scales were shown to be valid constructs by confirmatory factor analysis and to be internally reliable and to have high test-retest reliability. The factors underlying the two scales were highly correlated (r = .77), indicating support for policies that enforce abstinence and limit the duration of maintenance is highly associated with personal disapproval of drug use. There was no significant correlation between staff's knowledge of the benefits of methadone maintenance and their support for abstinence-oriented policies.

Substance abuse disorders: psychiatric trainees' knowledge, diagnostic skills and attitudes

OBJECTIVE

The drug and alcohol related knowledge and attitudes of trainee psychiatrists were examined to obtain a baseline measure of these factors in order to determine whether current training is appropriate and adequate.

METHOD

A questionnaire was distributed to trainees enrolled in the training program of the Royal Australian and New Zealand College of Psychiatrists in New South Wales, Victoria, Queensland and South Australia (N = 425). Questions were asked relating to theoretical knowledge, diagnostic and problem solving skills for a number of drug groups; further questions concerned the respondents' attitudes and opinions on aspects of management.

RESULTS

Sixty per cent of recipients returned the questionnaire. Theoretical and applied knowledge levels were of an adequate standard overall, but highly variable. Notable areas of weakness included knowledge of opiates, barbiturates and stimulants. Trainees' views regarding treatment options were also variable. Alcoholics Anonymous was considered the best supported form of treatment from evidence from controlled trials. Low levels of self efficacy and little support were recognised for early intervention strategies.

CONCLUSIONS

While positive views were generally expressed towards involvement with patients with alcohol and drug problems, specific strategies to enhance training and performance are needed. Findings are discussed in terms of continuing education. It is recommended that if sufficient training in this area is not provided then psychiatrists will have little confidence in appropriate therapeutic approaches in treating substance misusers.

Predictive capacity of the AUDIT questionnaire for alcohol-related harm

The Alcohol Use Disorders Identification Test (AUDIT) is a 10-item questionnaire designed to screen for hazardous and harmful alcohol consumption. We examined its ability to predict alcohol-related illness and social problems, hospital admission and mortality over a 2-3-year period. At initial interview, 330 ambulatory care patients were assessed using a detailed interview including the AUDIT questions and laboratory tests. After 2-3 years, 250 (76%) subjects were reassessed and their experience of alcohol-related harm determined. Of those who scored eight or more on AUDIT at initial interview, 61% experienced alcohol-related social problems compared with 10% of those with lower scores (p < 0.0001); they also had a significantly greater experience of alcohol-related medical disorders and hospitalization. AUDIT score was a better predictor of social problems and of hypertension than laboratory markers. Its ability to predict other alcohol-related illnesses was similar to the laboratory tests. However, gamma glutamyltransferase was the only significant predictor of mortality. We conclude that AUDIT should prove a valuable tool in screening for hazardous and harmful alcohol consumption so that intervention can be provided to those at particular risk of adverse consequences.

The AUDIT questionnaire: choosing a cut-off score. Alcohol Use Disorder Identification Test

The Alcohol Use Disorders Identification Test (AUDIT) is a 10-item questionnaire designed by the World Health Organization to screen for hazardous alcohol intake in primary health care settings. In this longitudinal study we examined its performance in predicting alcohol-related harm over the full range of its scores using receiver operating characteristic analyses. Three hundred and thirty ambulatory care patients were interviewed using a detailed assessment schedule which included the AUDIT questions. After 2-3 years, subjects were reviewed and their experience of alcohol-related medical and social harm assessed by interview and perusal of medical records. AUDIT was a good predictor of both alcohol-related social and medical problems. Cut-off points of 7-8 maximized discrimination in the prediction of trauma and hypertension. Higher cut-offs (12 and 22) provided better discrimination in the prediction of alcohol-related social problems and of liver disease or gastrointestinal bleeding, but high specificity was offset by reduced sensitivity. We conclude that the recommended cut-off score of eight is a reasonable approximation to the optimal for a variety of endpoints.