Addressing Alcohol-Impaired Driving Title

This document is available to the public from the National Technical Information Service, 
Springfield, Virginia 22161


Technical Report Documentation Page

1. Report No.
 DOT HS 809 076
2. Government Accession No.
 
3. Recipient's Catalog No.
 
4. Title and Subtitle

Addressing Alcohol-Impaired Driving: Training Physicians to Detect and Counsel Their Patients Who Drink Heavily

5. Report Date
July 2000
6. Performing Organization Code
 NTS31
7. Author(s)

Frederick P. Rivara, M.D., M.P.H.
Chris Dunn, Ph.D.
Evan Simpson, M.P.H.

8. Performing Organization Report No.

 

9. Performing Organization Name and Address

University of Washington
Harborview Injury Prevention and Research Center
325 9th Avenue, Box 359960
Seattle, Washington 98104-2499

10. Work Unit No. (TRAIS)
 
11. Contract or Grant No.

DTNH22-97-H-35072

12. Sponsoring Agency Name and Address

National Highway Traffic Safety Administration
Office of Research and Traffic Records
Research and Evaluation Division
400 7th Street, S.W., Washington, D.C. 20590

13. Type of Report and Period Covered
14. Sponsoring Agency Code
 
15. Supplementary Notes

Jon Walker and Amy Berning served as Contracting Officer's Technical Representatives on this project.

16. Abstract

Alcohol is the most common chronic disease in trauma patients, and one of the most common in patients treated in primary care. Studies have shown that brief counseling intervention in trauma centers and primary care clinics are efficient in reducing drinking and its related illness and injury. Unfortunately, although trauma centers and primary care clinics are ideal settings for such brief alcohol interventions, routine screening and brief counseling for alcohol problems is not commonly practiced by physicians in these settings. The goal of this project was to address alcohol abuse at the individual patient level and at the community level. At the individual patient level, the project encouraged physicians to perform a protocol for brief alcohol interventions to address alcohol abuse. This protocol consists of screening for alcohol problems, brief counseling, and referral. This was primarily done by offering training in this protocol to physicians, residents and medical students. The project focused on the pacific northwestern United States (Washington, Alaska, Montana, and Idaho).

17. Key Words

Alcohol Screening
Brief Alcohol Interventions
Training
Trauma
Primary Care

18. Distribution Statement

This report is available from the National Technical Information Service, Springfield, Virginia 22161 (703) 605-6000. It is also available, free of charge, from the NHTSA web site at: www.nhtsa.dot.gov

19. Security Classif. (of this report)

Unclassified

20. Security Classif. (of this page)

Unclassified

21. No. of Pages

48

22. Price
 
Form DOT F 1700.7 (8-72) Reproduction of completed page authorized

Table of Contents 

EXECUTIVE SUMMARY

BACKGROUND

METHODS and OUTCOMES

CONCLUSIONS

REFERENCES

APPENDIX

Executive Summary

Addressing Alcohol-Impaired Driving:
Training Physicians to Detect and Counsel their Patients Who Drink Heavily

Alcoholism is the most common chronic disease in trauma patients, affecting 25% to 40% of those treated in major trauma centers. Alcoholism results in repeated episodes of trauma, drunk driving and alcohol related crashes. A prior study by our group found that trauma patients with alcohol problems were more than twice as likely to be readmitted with injuries during the next two years than patients without problem drinking.

Interventions for problem drinking are effective. A summary of 32 randomized trials of brief interventions enrolling 5,718 patients indicate that such interventions are effective in decreasing problem drinking and lowering subsequent health care utilization. A randomized controlled trial of trauma patients indicated that interventions reduce drinking at 12 months after intervention by two-thirds and cut recidivism for new injuries by 50%.

Despite these findings, few trauma centers or primary care physicians routinely screen for alcohol problems. The goal of this project was to decrease the risk of driving while intoxicated and the risk of alcohol related crashes by encouraging health care providers to address alcohol abuse at the individual patient level and at the community level. Specifically, we did the following:

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Background

The problem: Alcoholism is the most common chronic disease in trauma patients, and one of the most common in primary care practices. It affects 25% to 40% of trauma patients, compared to 2% to 5% for other co-morbidities (Morris et al, 1990). Screening questionnaires such as the Michigan Alcoholism Screening Test (MAST) are positive in as many as 75% of medical trauma patients with a positive blood alcohol test and are even positive in 26% of trauma patients with no detectable blood alcohol on admission (Rivara et al, 1993). In addition, the relationship between alcohol and trauma is not limited to adults. In a study of 319 injured patients aged 18 to 20 years, 22% were legally intoxicated (legal limit at that time was .1 grams/dL) and 49% had a positive MAST score (Rivara et al, 1992). In primary care patients, there is a strong link between alcohol abuse and morbidity/mortality.

Alcoholism results in repeated episodes of trauma, including Driving while Intoxicated (DWI) related crashes. Five-year follow-up of alcoholic trauma patients admitted to a level I trauma center in Detroit revealed an injury recurrence rate of 44% (Sims et al, 1989). A study by our group in Seattle found that patients who were intoxicated or who had a positive MAST score were 2.5 and 2.2 times as likely to be readmitted within the next 1-2 years as were patients without these markers (Rivara et al, 1993).

Unfortunately, routine screening and intervention for alcoholism is not common at trauma centers or in primary care settings. One survey of trauma centers found that 71% did not screen patients for alcohol abuse (Soderstrom, 1987). The most common reason for not including alcohol screening as a routine part of care was that such screening "had little clinical importance." A key reason for failure to refer patients for alcohol treatment is negative attitudes of medical staff regarding chemical dependency treatment effectiveness due to their frequent exposure in medical settings to patients who may have received such treatment but continue to drink. This attitude even carries over into textbooks. The most recent edition of Cecil Textbook of Medicine (Diamond, 1996) states that alcohol problems are rarely identified by primary care physicians before medical or socioeconomic problems arise, and the book does not recommend screening.

Despite pessimism on the part of medical staff about the effectiveness of specialized chemical dependency programs, intervention has been shown in studies to make a substantial difference. In a long term study of 3,729 persons with alcoholism, health care costs after treatment were reduced by 55% from pre-treatment levels, whereas health care costs for a matched control group of untreated drinkers increased by 202% (Holder et al, 1992).

Brief interventions are appropriate both for primary care and for specialty, including trauma center, settings. They may be used in the time frame of an office visit or hospitalization for trauma or other cause, and can be based on information obtained from a systematic screening procedure. To date, reports of 32 randomized trials of brief interventions enrolling 5,718 patients indicate that such interventions are more effective than no counseling and often as effective as more extensive treatment (Bien et al, 1993). According to the U.S. Preventive Services Task Force, "All persons who use alcohol should be informed of the health and risks associated with consumption, and many patients may benefit from referrals to appropriate consultants and community programs specializing in the treatment of alcohol." (USPSTF, 1996).

One recent study of brief intervention by physicians was a randomized trial conducted in 17 community-based primary care centers in Wisconsin involving over 700 patients (Fleming et al, 1997). At 12 month follow-up, there was a significant reduction in 7-day alcohol use, episodes of binge drinking and of excessive drinking. Another randomized controlled study of 762 trauma patients admitted to a level I regional trauma center found that brief interventions resulted in a reduction of alcohol use at 12 months (reduction of 21.8 vs 6.7 standard drinks per week compared to baseline), a 47% reduction in re-injuries requiring trauma center or emergency department (ED) care, and a 23% reduction in DWI citations (Gentilello, 1999).

Since 70% of people in the United States visit their physician at least once every 2 years, brief advice from physicians can have enormous implications for the health care system and a major impact on alcohol use, impaired driving and DWI-related crashes and injuries. A recent editorial concluded: "Dissemination of [alcohol] screening and counseling skills will require efforts from medical schools, residency training programs, and continuing medical education centers (Parish, 1997). "

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Methods and Outcomes

The project was a multi-faceted program aimed at decreasing problem drinking and reducing alcohol related motor vehicle crashes. The components of the program and results of each are described below. First, however, it is important to define terms used in the report:

"Alcohol problems": includes the entire range of severity of problems from mild to severe. This continuum includes terms such as "hazardous drinking" (drinking so as to risk negative consequences such as injury or illness, alcohol abuse (drinking despite negative consequences), and alcohol dependence (being "addicted" or "hooked’ on alcohol and showing symptoms such as tolerance, withdrawal, not quitting despite wanting to quit, and impaired social or professional functioning).

"Alcohol screening": asking patients special questions about their drinking or using lab values (breath, urine, or blood) to detect alcohol in the body.

"Brief intervention": same as "brief counseling", a short counseling session, sometimes as brief as 5-10 minutes, in which a physician or other health care provider discusses with the patient his/her alcohol consumption, consequences, and negotiates a behavior change with that patient. The patient often does not expect to get a brief intervention because he/she is visiting a physician or is in the hospital for some other medical reason. Brief interventions are appropriate and helpful for all patients with alcohol problems. For those with milder alcohol problems, a brief intervention may be all they need to motivate them to change their drinking by quitting or cutting down to within low-risk guidelines. For patients who are dependent on alcohol, a brief intervention can sometimes trigger their seeking specialized treatment for chemical dependency because the brief intervention included a referral for such treatment.

"Specialized treatment for alcohol problems": Specialized chemical dependency treatment provided by certified chemical dependency counselors. Always longer and more intensive than a brief intervention. Many patients needing specialized treatment fail to get it. Not all patients with alcohol problems recover using this specialized care. Many recover on their own.

Medical Student Training:

One method for training medical students is to use "standardized patients." A standardized patient is usually a paid actor who is told in advance what symptoms and medical problems to present in the training session. This cluster of symptoms is "standardized" in that the actor presents the same clinical picture to every student being trained and evaluated, so that their supervisors can assess the degree to which the students accurately detect the symptoms they are supposed to be learning to recognize. In this way, the supervisor can evaluate how well the student asks questions to first identify the symptom in question, and then how well the student follows through with proper medical treatment. In 1991, the first standardized patients having to do with alcohol abuse were used to train senior medical students as a part of the University of Washington School of Medicine's Standardized Patient Assessment Program. Since that time, similar cases have periodically been included in assessments of second through fourth year students.

Following these training encounters between student and standardized patients, standardized patients complete clinical performance checklists. These checklists assess whether students asked them specific alcohol screening questions which the students had been instructed to ask when alcohol abuse is suspected. These questions typically include ones about frequency and quantity of alcohol use as well as the four CAGE screening questions (Have you ever Cut down on your drinking? Have you ever been Annoyed by others complaining about your drinking? Have you ever felt Guilty about your drinking? Have you ever had an Eye-opener?). Other key questions students are trained to ask are whether the patient views alcohol use as a problem and, if so, whether the patient has any interest in working on the problem. Options for working on the problem that students are taught to discuss with patients include specialized treatment, attending Alcoholics Anonymous, and cutting down or abstaining on one’s own.

Data obtained by the UW School of Medicine indicates that although medical student performance as indicated by these checklist items has remained consistent over the years, attitudes change. In the time from early medical school to final years of residency, hopeful and respectful attitudes toward patients with alcohol problems diminish, and clinical efforts toward directly addressing these problems with patients decline.

To improve students’ attitudes toward problem drinkers, to increase their awareness of alcohol abuse among their patients, and to encourage them to actively screen and intervene with alcohol-abusing patients, we did the following as part of this project:

Delivered a 2-hour lecture for every Surgery Clerkship rotation on: the prevalence of alcohol problems among surgery patients with traumatic injuries, the outcomes of brief interventions for alcohol problems in trauma centers, how to screen for alcohol problems, and how to perform brief interventions. Dr. Chris Dunn, addiction psychologist, and Dr. Larry Gentilello, trauma surgeon, delivered these lectures. Students were encouraged to share and discuss their current attitudes and perceptions toward patients with drinking problems, as well as their past experiences in dealing with these patients. Brief interventions were demonstrated in role plays in which the trainer played the doctor and students played the patient. Then, students were given chances to practice these skills in role plays with supportive feedback by the trainer. All of these training activities were done within a single 2-hour time slot. This was done for each clerkship involving approximately 20 students per clerkship rotation.

We delivered a 2-hr. lecture for every Psychiatry Clerkship rotation. Dr. Richard Ries, psychiatrist, and Dr. Chris Dunn delivered these lectures. The focus of this lecture was to introduce students to a workbook on how to do a brief intervention with a psychiatry patients abusing alcohol/drugs. This workbook (see Appendices) guides students through the screening, assessment, and counseling process, emphasizing the need for students to collaborate with their multi-disciplinary treatment teams. Since psychiatry is a required rotation, all 160 third-year medical students were trained each year. Informal follow-up with Psychiatry Clerkship students who performed a brief intervention using the workbook yielded a range of feedback. Some students felt that their patient was not fully engaged in the intervention. Other students perceived the brief intervention to be useful for the patient and valuable for their own training.

The overall reception of the medical student training—both for surgery and psychiatry students-- was very positive. This is a sample of positive comments received on the lecture evaluations: "A very interesting and useful lecture." "I didn’t know I could make a difference in patients with drinking problems." "Excellent demonstration and role plays." "I can use technique with any kind of patient I see."

Dr. Dunn participated on an expert panel as part of a lecture given to all students in one of their first year courses, Introduction to Clinical Medicine. This panel included community providers who taught students about the kinds of treatment services they provide and answered questions from students about recovery from alcohol and drug abuse. The emphasis was on how brief interventions can help motivate patients to participate in such treatment services. Since Introduction to Clinical Medicine is required of all first year students, all 160 students were trained each year during the course of the grant.

Resident Training:

The University of Washington has a large residency program in all specialties. In addition, there are numerous other residency programs in family medicine in Seattle and throughout the region. Residency training extends from three to 8 years, depending on the medical specialty. It is a time of intense learning experiences. Unfortunately, with rare exceptions, training in the screening for, and identification, of alcohol abusers has not been routine.

The behavior change methods we taught to residents for this project were distilled from motivational interviewing, a brief counseling style that avoids argument and applies behavior change strategies (Miller & Rollnick, 1991). These strategies are matched to patients’ stages of change readiness in Prochaska’s and DiClemente’s model (Prochaska, 1986). Skilled clinicians intervene according to the patient’s stage of change readiness rather than trying to get every patient they see to take immediate action. This principle also applies to trainers who must consider residents’ varying stages of readiness to screen their patients and intervene. These motivational interviewing techniques have been shown to be successful in decreasing problem drinking (e.g., Gentilello, 1999; Fleming, 1997).

Our training goals were to instill optimism in residents by using this readiness to change model, to teach them to ask standardized screening questions, and to apply behavior change techniques when necessary. During this training we showed residents outcome data from brief intervention studies and taught them screening and intervention skills using demonstration and role-play.

The curriculum of each residency program has regularly scheduled conferences. We asked residency coordinators for substance abuse training time with residents, and depending upon the amount of training time made available to us, we offered one of two training options:

A brief (20-min.) introduction to the concepts of screening and brief intervention. Handouts summarizing the brief intervention approach were distributed (see Appendices). A laminated card was given to residents to carry in their pockets. This card contained alcohol screening questions, guidelines for low-risk alcohol consumption, and condensed brief counseling protocols for patients abusing and dependent on alcohol. These cards included local phone numbers for appropriate local resources for patients needing specialized chemical dependence treatment.

Intensive (60-120 min.) skills training during which residents were presented with various case vignettes (or they were encouraged to present their own) which included alcohol abuse as a confounding factor of some medical condition. Residents discussed these cases, and these discussions were used as jumping-off points for demonstrating and practicing brief intervention skills. These residents were given the same handouts.

Immediately prior to receiving their training (Time 1), residents willing to comply with our request for data collection completed a questionnaire asking them to estimate the following:

Results:

One month after the training (Time 2), residents were contacted by email or pager and asked the same questions. We had experimented with the use of written surveys but found that the response rate among these busy physicians was low. We therefore used the pager/email system to obtain higher response rates. Of 139 residents trained by the time data were analyzed, Time 1 and 2 data were available for 57 (41%) residents. Forty-four had Time 1 data only, 22 had Time 2 data only, and 16 had neither.

As seen in Table 1, before the Training (Time 1), residents reported screening for alcohol problems in an average of only 27.2% of all their patients. One month after the training (Time 2), this rose to an average of 38.1%. At Time 1, residents reported that they had provided brief alcohol interventions to 6.3% of all the patients they had seen in the previous week. At Time 2, this had increased to 9.9%.

Residents’ confidence in their abilities to screen their patients for alcohol problems increased from an average of 5.8 to an average of 6.8. These scores refer to a scale from 1 to 10, where 1 is not at all confident and 10 is extremely confident. Their average confidence scores in their ability to provide brief counseling for alcohol problems increased from 4.9 to 6.0 on a 1-10 scale.

Table 1 also shows that there were no changes from time 1 to Time 2 in residents’ estimates of the prevalence of patients in their practices with "no problems," "mild problems," and "severe problems."

Table 1: 
Comparison of resident’s mean behavior and attitude scores before and after training

Variable

Time T1

Time T2

% of all patients residents saw in the past week whom they estimated to have no alcohol problems

55.5%

58.8%

% of all patients residents saw in the past week whom they estimated to have mild alcohol problems

28.1%

27.7%

% of all patients residents saw in the past week whom they estimated to have severe alcohol problems

14.0%

13.4%

% of all patients residents saw in the past week whom they screened for alcohol problems

27.2%

38.1%

% of all patients whom you saw last week to whom they gave brief counseling for alcohol problems

6.3%

9.9%

Confidence in screening ability (from 1-10, where 1 is not at all confident and 10 is extremely confident)

5.8

6.8

Confidence in brief counseling ability (from 1-10, where 1 is not at all confident and 10 is extremely confident)

4.9

6.0

We believe that the residents are reasonably knowledgeable about the prevalence of alcohol problems in their patient populations but do not have the sense of self-efficacy to screen for problem drinking and to manage alcohol problems. Resident training in screening for alcohol problems and in conducting brief interventions should be improved, as our intervention did for the residents exposed to the intervention. However, we believe that the intervention would be more successful if presented as a more generalizable tool with which to intervene on problem behavior, whether it be alcohol use, smoking, exercise or diet. Resident acceptance of the investment in adequately learning the means of motivational interviewing would thereby be enhanced.

University of Washington School of Medicine Curriculum Development:

The first two years of medical school at the University of Washington consist of formal course work. We believed that it is important for students to become exposed to information concerning alcohol abuse and counseling during this period as well as during clinical clerkships. To increase the amount of substance abuse training in this curriculum, we surveyed all UW School of Medicine Human Biology Course Coordinators who teach our Human Biology curriculum courses, asking for descriptions of any substance abuse content offered by them or anybody lecturing as part of their courses. The results of this survey are shown below in Table 2.

Table 2: 
Current Substance Abuse (SA) Content in Human Biology Curriculum: Results of Survey of all Classroom Medical School Instructors

Title

Qtr

Substance Abuse (SA) Content

Micro Anatomy (Histology)

A1

no SA content

Anatomy & Embryology

A1

SA mentioned in context of living anatomy of the liver & portal circulation

Mechanisms in Cell Physiology

A1

discusses synaptic mechanism of cocaine

ICM I

A1

lecture on interviewing patients about use of alcohol and drugs

Biochemistry I-A

A1

no SA content

Human Behavior I-A

A1

lecture on fetal alcohol syndrome

Cell & Tissue/Injury

W1

Mechanism of alcohol-induced cell death & pathogenesis of liver disease

Nat History Infectious Diz I-A

W1

covers problems associated with AIDS, bacteremia, endocarditis, and hepatitis with alcohol/drugs

ICM I

W1

lecture on SA, patients in recovery describe experiences

Introduction to Immunology

W1

No SA content

Biochemistry I-B

W1

No SA content

Human Behavior I-B

W1

No SA content

Epidemiology

S1

Not specifically addressed, but research methods taught apply to SA research

Head, Neck, EN & T

S1

No SA content

Nervous System

S1

No SA content

Natural History Infec Diz I-B

S1

Discusses wound botulism associated w/ cocaine inhalation

S1

Lecture/discussion on topic similar to A1 and W1 quarters

Cardiovascular System

A2

No SA content

Respiratory System

A2

20 minutes on smoking, no other substances covered

ICM II

A2

Making and giving SA diagnosis: interview and write HPI on a patient w/SA problem

Principles of Pharmacology I A2 Pharmacology of alcohol, toxicity, dependence, tolerance, abuse potential
Endocrine System A2 No SA content
Systemic Pathology A2 Discusses liver disease: dose & cirrhosis
Genetics A2 No SA content
Skin System A2 No SA content
ICM II W2 Visit AA mtg, interview an AA member, hand in write-up of HPI on their SA
Gastrointestinal System W2 Seminar on liver disease w/case discussion on liver transplant
Hematology W2 Discussed as part of sickle cell disease lecture:
Musculoskeletal System W2 No SA content
Medicine, Health & Society W2 No SA content
ICM II S2 Interviewing styles demonstrated, panel discussion, attend AA meeting
Urinary System S2 No SA content
Human Behavior II S2 1 hr. alcohol abuse and 1 hr. substance abuse
Principles of Pharmacology II S2 Stimulants: mech. of action, clinical use, side effects, psychotomimetics
Reproduction S2 Nothing in syllabus, passing remarks on steroid abuse effects on males
Nutrition for Physicians S2 Consequences of alcohol abuse covered in one of the lectures

Note: A= autumn, W= winter, S= spring. 
"1" and "2" refer to first and second years of medical school, when all course work is taken.

This survey demonstrated that teaching on alcohol abuse can be done in many courses throughout the curriculum. It is more effective to include discussions in many different courses rather than confining it to one short period during medical school.

We surveyed all Clinical Clerkship Coordinators who are responsible for developing curriculum for the clinical rotations constituting the second two years of medical school. These results are shown below in Table 3.

Table 3: 
UW Substance Abuse Training Content in 6 Required Clerkships: Survey of Clinical Clerkship Coordinators.

Clerkship

Substance Abuse Training Experiences Provided

Psychiatry
(Ries, Dunn)

 

Advanced assessment of substance use/abuse/dependence
2-hr. lecture and demonstration of a brief intervention
Treatment models and recovery taught
Structured intervention work-up with Psychiatry patient with SA problem
Perform brief intervention with that patient
Visit different Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous meetings other than those visited in ICM II course

Surgery
(Dunn)

90-minute lecture on alcohol abuse, trauma, and brief interventions has been cancelled

Pediatrics
(Robertson)

Students given syllabus of 36 case scenarios (at least one case addresses substance abuse).
Most students have contacts with Fetal Alcohol Syndrome, cocaine babies, and teens abusing substances, but not guaranteed
Occasional lecture on adolescent substance abuse
Adolescent substance abuse lecture seldom given anymore

Family
(Stern)

19 common problems in Family Practice are focused on; Substance abuse is subsumed under only one of these topics, "depression"
Alcoholism not focused on as common problem ("too many others to do")
One chapter to read on alcoholism and drug abuse
May include SA among required web site references for students

Medicine
(Paauw)

There is an alcohol abuse section in the student syllabus that is required reading
Most students take care of alcohol and drug-abusing patients in clinic, but not specifically mandated

All the rotations above are required of all medical students. The results indicate that students are exposed to information about substance abuse at a number of times during their clinical training. This repeat exposure is very useful in changing behavior and instilling skills and a sense of self-efficacy.

Table 4: 
Recommended Substance Abuse (SA) Training Topics 

(from International Medical Education Model, Fleming & Murray):

Topic

Topic Description

1

Epidemiology & Phenomenology

Continuum of SA problems (low-risk, hazardous, abuse/dependence)
Natural history of SA disorders
Prevalence of SA disorders vs. other medical disorders
Special populations w/special SA problems
Stages of change readiness

2

Etiology & Prevention

Risk & buffer factors
Clinically-based prevention opportunities

3

Special Populations

Adolescents, women, elderly
Age & gender physiological differences
Screening & assessment issues
Patients with psychiatric disorders

4

All drugs of abuse

Trends in use, availability, preparations of, routes of administration of all drugs of abuse
Behavioral effects of all drugs of abuse
Biopsychosocial consequences of acute & chronic abuse of all drugs
Clinical signs & symptoms of each

5

Clinical Research

Research methods used for epidemiological & clinical studies
Outcomes of various SA treatment modalities
SA treatment outcomes vs. outcomes for other chronic disorders

6

Screening & Assessment

Standardized screening & assessment techniques
Interviewing skills

7

Brief intervention

Learn how non-specialists can treat SA
Listening to patients and giving them feedback and advice
How to do brief interventions across numerous medical specialties

8

Alcohol-related Medical Problems

Medical conditions caused or exacerbated by SA: perinatal & FAS, HTN, cardiac, stroke, GI, pancreatitis, malabsorption, liver, cancers, sexual dysfunction, HA, sleep problems, peripheral neuropathy, organic brain disorders, hematological problems

9

Specialized Treatment

Continuum of treatment modalities: what they are and what they do
The art of referring patients for treatment

10

AA & Self-help Groups

Know basics of AA and other self-help groups
Referring to and visiting meetings
Meet successfully recovering people

11

Pharmaco-therapy

Neurobiology of drug actions and craving

12

Medical Detoxification

Neurobiology and clinical treatment of withdrawal for all drugs of abuse
Withdrawal & co-morbid conditions

13

Management of Anxiety & Pain

Abuse potential of commonly prescribed drugs
Breathalyzer/drug testing
Assessment of pain & psychiatric symptoms
Pharmacological & non-pharmacological treatment of pain
Pain contracts, informed consent procedures

14

Tobacco Cessation

Screening & brief intervention procedures
Pharmacotherapy
Office-based systems

15

Harm Reduction Methods

Pregnancy
IV drug users
Sexually transmitted disease prevention

16

Psychiatric Comorbidity

Psychiatric problems caused, complicated, exacerbated by substance abuse

17

Legal & Ethical Issues

Patient autonomy
Confidentiality and charting issues around SA
Protection of records, liability, child abuse

Continuing Medical Education for Practitioners:

The University of Washington Continuing Medical Education (CME) office is the primary source of continuing medical education programs for clinicians in the Pacific Northwest. The UW School of Medicine also operates an on-line newsletter for physicians in the region. CME programs were advertised through this route, and specific information about this project’s activities was included on a regular basis. We accomplished the following:

Contacted the heads of CME programs for the WAMI states to offer them our training package which included physician workshops of various lengths of training time. We found that the heads of CMEs in the Washington, Alaska, Montana and Idaho region are very familiar with those topics that attract physicians to CME lectures and those topics that do not yield good turnouts. Unfortunately, they told us that our topic of brief alcohol interventions was a difficult one to promote. However, we were able to schedule and deliver numerous free physician CME training workshops. These workshops followed the same format as that described above for training resident physicians. These training sessions are summarized in Table 6 below.

Length (hrs.)

Group

Participants

1.5

General internal medicine (GIM) residents

10

2.0

Rehabilitation unit nurses

55

1.5

GIM residents

6

2.0

Valley family medicine residents

8

1.5

Family medicine residents

8

0.75

1 x 1 detailing with MD *

1

0.25

1 x 1 detailing with MD *

1

2.0

Family medicine residents

5

0.5

GIM residents

4

0.5

GIM residents

5

1.5

Family Medicine residents

6

0.5

GIM residents

5

0.75

Family medicine residents, Tacoma, WA

20

0.5

GIM residents

5

1.0

Neurology residents

15

0.5

GIM residents

5

0.5

1 x 1 detailing with MD *

1

0.5

1 x 1 detailing with MD *

0

0.5

1 x 1 detailing with MD *

1

2.0

UW Medical students

9

2.0

Family medicine residents, Tacoma

6

1.25

Family medicine residents, Tacoma

1

1.25

Family medicine residents, Tacoma

6

0.5

1 x 1 detailing with MD*

1

1.5

GIM residents

9

1.0

Trauma residents and surgeons

9

1.5

Surgery Clerkship student lecture

20

.75

Family medicine residents, Tacoma

20

1.5

Surgery Clerkship student lecture

20

.5

1 x 1 detailing with MD*

1

1.0

Valley Hospital physicians *

30

2.0

Psychiatry clerkship students

20

2.5

Family medicine residents, Tacoma

20

1.5

Surgery Clerkship medical students

20

1.5

GIM residents

12

1.0

Obstetrics and Gynecology physicians & residents *

25

1.0

Obstetrics and Gynecology residents

8

3.0

GIM residents, Spokane, WA

30

3.0

Nursing students

20