Generalist physicians should incorporate alcohol and drug abuse detection and brief intervention in the care of their patients. A suggestion of alcohol or drug abuse or a positive response to the CAGE questions deserves further assessment such as clarification about adverse consequences, inquiry about loss of control, determination of the patient's perception of the substance use, and an assessment of the patient's readiness to change behavior. Brief intervention with the patient in the clinical setting about alcohol or drug use can be effective. Motivational interviewing, a directive, patient-centered counseling style for enhancing motivation for change, can make brief interventions more effective by incorporating the patient's readiness to address alcohol or drug use. A useful clinical approach is presented that is tailored to the patient's stage of readiness to change alcohol or drug abuse behavior.
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"Medical educators have started addressing the need for physician training in unhealthy SU screening, assessment, and management [29-34]. Formal curricula on these subjects have been developed [35,36] and evaluated [37,38] and recommendations for the medical care of addicted patients have been published [13,39,40] Nonetheless, dissemination of up-to-date addiction research and clinical recommendations into physician practice and residency curricula remains a significant challenge [41,42]. "
[Show abstract][Hide abstract] ABSTRACT: Unhealthy substance use is the spectrum from use that risks harm, to use associated with problems, to the diagnosable conditions of substance abuse and dependence, often referred to as substance abuse disorders. Despite the prevalence and impact of unhealthy substance use, medical education in this area remains lacking, not providing physicians with the necessary expertise to effectively address one of the most common and costly health conditions. Medical educators have begun to address the need for physician training in unhealthy substance use, and formal curricula have been developed and evaluated, though broad integration into busy residency curricula remains a challenge.
We review the development of unhealthy substance use related competencies, and describe a curriculum in unhealthy substance use that integrates these competencies into internal medicine resident physician training. We outline strategies to facilitate adoption of such curricula by the residency programs. This paper provides an outline for the actual implementation of the curriculum within the structure of a training program, with examples using common teaching venues. We describe and link the content to the core competencies mandated by the Accreditation Council for Graduate Medical Education, the formal accrediting body for residency training programs in the United States. Specific topics are recommended, with suggestions on how to integrate such teaching into existing internal medicine residency training program curricula.
Given the burden of disease and effective interventions available that can be delivered by internal medicine physicians, teaching about unhealthy substance use must be incorporated into internal medicine residency training, and can be done within existing teaching venues.
Full-text · Article · Mar 2010 · BMC Medical Education
"In 2004, the US Services Preventive Task Force recommended the use of brief counseling intervention in primary care, where its efficacy has been confirmed; this practice is among the most effective and cost-effective of preventive care services (Bertholet, Daeppen, Wietlisbach, Fleming, & Burnand, 2005; Solberg, Maciosek, & Edwards, 2008). Assessing readiness to change is recommended as part of brief interventions to tailor advice and counseling, and physicians have been encouraged to see changes in readiness as short term goals on the path to behavior change (Samet, Rollnick, & Barnes, 1996). "
[Show abstract][Hide abstract] ABSTRACT: We studied whether readiness to change predicts alcohol consumption (drinks per day) 3 months later in 267 medical inpatients with unhealthy alcohol use. We used 3 readiness to change measures: a 1 to 10 visual analog scale (VAS) and two factors of the Stages of Change Readiness and Treatment Eagerness Scale: Perception of Problems (PP) and Taking Action (TA). Subjects with the highest level of VAS-measured readiness consumed significantly fewer drinks 3 months later [Incidence rate ratio (IRR) and 95% confidence interval (CI): 0.57 (0.36, 0.91) highest vs. lowest tertile]. Greater PP was associated with more drinking [IRR (95%CI): 1.94 (1.02, 3.68) third vs. lowest quartile]. Greater TA scores were associated with less drinking [IRR (95%CI): 0.42 (0.23, 0.78) highest vs. lowest quartile]. Perception of Problems' association with more drinking may reflect severity rather than an aspect of readiness associated with ability to change; high levels of Taking Action appear to predict less drinking. Although assessing readiness to change may have clinical utility, assessing the patient's planned actions may have more predictive value for future improvement in alcohol consumption.
Full-text · Article · May 2009 · Addictive behaviors
"In primary care, BI is recommended by national practice guidelines (US Preventive Services Task Force, 2004), and, as part of BI, clinicians are encouraged to assess motivation and readiness to change, and to help patients increase readiness . These changes in readiness are seen as short term goals on the way to decreased consumption [7,8]. "
[Show abstract][Hide abstract] ABSTRACT: The course of alcohol consumption and cognitive dimensions of behavior change (readiness to change, importance of changing and confidence in ability to change) in primary care patients are not well described. The objective of the study was to determine changes in readiness, importance and confidence after a primary care visit, and 6-month improvements in both drinking and cognitive dimensions of behavior change, in patients with unhealthy alcohol use.
Prospective cohort study of patients with unhealthy alcohol use visiting primary care physicians, with repeated assessments of readiness, importance, and confidence (visual analogue scale (VAS), score range 1-10 points). Improvements 6 months later were defined as no unhealthy alcohol use or any increase in readiness, importance, or confidence. Regression models accounted for clustering by physician and adjusted for demographics, alcohol consumption and related problems, and discussion with the physician about alcohol.
From before to immediately after the primary care physician visit, patients (n = 173) had increases in readiness (mean +1.0 point), importance (+0.2), and confidence (+0.5) (all p < 0.002). In adjusted models, discussion with the physician about alcohol was associated with increased readiness (+0.8, p = 0.04). At 6 months, many participants had improvements in drinking or readiness (62%), drinking or importance (58%), or drinking or confidence (56%).
Readiness, importance and confidence improve in many patients with unhealthy alcohol use immediately after a primary care visit. Six months after a visit, most patients have improvements in either drinking or these cognitive dimensions of behavior change.
Full-text · Article · May 2009 · BMC Public Health