Editorials

Screening and Intervening for Patients with Substance Use Disorders

DANIEL C. VINSON, M.D., M.S.P.H.
University of Missouri School of Medicine Columbia, Missouri

See related article on page 1529.

As Mersy¹ points out in his article in this issue of American Family Physician, substance use problems are common and serious. They are also hidden.

Most patients' problems with hazardous drinking or substance use go unrecognized in most practices.² Some disorders can be identified by the symptoms and signs described in the article, especially if they occur in combination. Why should physicians be concerned? Because even when there are several indications that substance use may be playing a role in the patient's problems, we tend to miss the diagnosis.

Brief interventions for problem drinking work.³ Fleming and colleagues in Wisconsin⁴ replicated a study done in the United Kingdom.⁵ In both studies, patients in primary care practices were screened. If they were drinking more than safe limits (more than two drinks per day, on average), appointments were made for two 10- to 15-minute intervention visits with a family physician, plus two telephone contacts by an office nurse. One year later, approximately 40 percent of the patients in the intervention groups had moderated their drinking to safe levels, compared with 20 percent in the control groups. In the Wisconsin trial, the differences between intervention and control groups were still present four years later. Outcomes such as length of hospital stays were significantly reduced in the intervention group. For every $1 spent on brief interventions, $4.30 was saved.⁶

How should patients with more serious alcohol problems be managed? Here, too, the evidence shows that treatments work.⁷ In Miller and Wilbourne's article,⁷ brief interventions by primary care clinicians top the list of effective treatments. Many other treatments--social skills training, community reinforcement, behavior contracting, behavior marital therapy, case management--also have solidly documented effectiveness.

How should we screen? Mersy¹ is correct: Pick a screening test that works in your practice and use it. Written or oral tests are more sensitive than laboratory tests; carbohydrate-deficient transferrin does not become abnormal until the patient is drinking more than four drinks per day every day--considerably above the threshold of hazardous drinking. Furthermore, this test is available only through certain reference laboratories. The CAGE questions and the Alcohol Use Disorders Identification Test are well tested and effective.⁸ A single question also is effective: "When was the last time you had more than X drinks in one day?" where X = 4 for women and 5 for men.⁹ A positive screen would be within the preceding three months. Pick a screening approach, use it routinely, and develop a charting system so you do not have to screen patients more than once unless their situation changes.

What about drug abuse? Unfortunately, there are few validated screening instruments and few studies of brief interventions for substance use disorders other than alcohol. The CAGE questionnaire expanded to include drugs is one effective screening approach.¹⁰ Until we know more about which brief interventions are effective in patients with drug use problems, extrapolating findings from studies of brief interventions with problem drinkers is reasonable.

What should the content of a "brief intervention" be? Several approaches are effective, including a straightforward physicians' guide (available online at www.niaaa.nih.gov/
publications/physicn.htm), patient handout (www.niaaa.nih.gov/publications/handout. htm), and more involved, yet still readily learned motivational-enhancement techniques.¹¹ Problem drinking meets all the criteria for conditions that family physicians should screen for and address, and the U.S. Preventive Services Task Force agrees.¹² Despite this, we have not incorporated alcohol screening to the extent that is recommended.² Family physicians can be effective coaches in helping patients change their behaviors. Taking up that call will require that we change our own.

Daniel C. Vinson, M.D., M.S.P.H., is a professor in the Department of Family and Community Medicine at the University of Missouri School of Medicine, Columbia. He received his medical degree from the University of North Carolina at Chapel Hill School of Medicine, where he also completed his residency.

Address correspondence to Daniel C. Vinson, M.D., M.S.P.H., Department of Family and Community Medicine, M231 Health Sciences, University of Missouri-Columbia, Columbia, MO 65212 (e-mail: vinsond@health.missouri.edu). Reprints are not available from the author.

REFERENCES

1. Mersy DJ. Recognition of alcohol and substance abuse. Am Fam Physician 2002;67:1529-36.
2. Spandorfer JM, Israel Y, Turner BJ. Primary care physicians' views on screening and management of alcohol abuse: inconsistencies with national guidelines. J Fam Pract 1999;48:899-902.
3. Moyer A, Finney JW, Swearingen CE, Vergun P. Brief interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment-seeking and non­treatment-seeking populations. Addiction 2002;97:279-92.
4. Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers. JAMA 1997;277:1039-45.
5. Wallace P, Cutler S, Haines A. Randomised controlled trial of general practitioner intervention in patients with excessive alcohol consumption. BMJ 1988;297:663-8.
6. Fleming MF, Mundt MP, French MT, Manwell LB, Stauffacher EA, Barry KL. Brief physician advice for problem drinkers: long-term efficacy and benefit-cost analysis. Alcohol Clin Exp Res 2002;26:36-43.
7. Miller WR, Wilbourne PL. Mesa grande: a methodological analysis of clinical trials of treatments for alcohol use disorders. Addiction 2002;97:265-77.
8. Bradley KA, Bush KR, McDonell MB, Malone T, Fihn SD. Screening for problem drinking: comparison of CAGE and AUDIT. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. J Gen Intern Med 1998;13:379-88.
9. Williams R, Vinson DC. Validation of a single screening question for problem drinking. J Fam Pract 2001;50:307-12.
10. Brown RL, Leonard T, Saunders LA, Papasouliotis O. The prevalence and detection of substance use disorders among inpatients ages 18 to 49: an opportunity for prevention. Prev Med 1998;27:101-10.
11. Rollnick S, Mason P, Butler C. Health behavior change: a guide for practitioners. Edinburgh, N.Y.: Churchill Livingstone, 1999.
12. Screening for problem drinking. In: Guide to clinical preventive services: report of the U.S. Preventive Services Task Force. 2d ed. Baltimore: Williams & Wilkins, 1996:567-82.

Hormone Therapy: Continuing Discussion and Debate

BARBARA S. APGAR, M.D., M.S.
University of Michigan Medical School
Ann Arbor, Michigan

DAVID G. WEISMILLER, M.D., Sc.M.
Brody School of Medicine
East Carolina University
Greenville, North Carolina

On July 9, 2002, the Data and Safety Monitoring Board of the Women's Health Initiative (WHI) announced the abrupt termination of the continuous hormone replacement therapy (now referred to as hormone therapy, or HT) portion of the WHI trials sponsored by the National Institutes of Health. Confusion and disbelief were common reactions to the announcement--patients seemed to focus on terms such as "harm" and "alternatives," while clinicians focused on "relative" versus "absolute" risk. No clear directions for counseling strategies were proposed after the announcement was made.

The continuous combined conjugated equine estrogen (CEE) and medroxyprogesterone acetate (MPA) regimen that was used in the WHI trial is one of the most commonly studied HT regimens and has been strategically marketed as beneficial for multiple conditions in postmenopausal women.

The WHI trial, a large-scale study of preventive and treatment therapies for postmenopausal women, was designed to assess the long-term risk/benefit ratio of continuous estrogen replacement therapy (ERT) and combination HT. The combination clinical trial and observational study, which was scheduled to conclude in 2005, enrolled 161,809 women between 1993 and 1998. A total of 16,608 women were randomized to combination HT versus placebo.¹ Before the publication of the WHI data,² there was a paucity of definitive studies addressing the issue of benefit or harm from HT. Observational studies showed that women who used HT lived longer and with fewer health problems than those who did not use HT. Perhaps HT was the real reason for the longevity and good health of those women, or perhaps the women using HT were simply healthier than their counterparts.

For more than a decade, it was generally thought that HT reduced cardiovascular risk in healthy postmenopausal women.³ However, the Heart and Estrogen/Progestin Replacement Study (HERS I) in 1998⁴ and HERS II in 2002⁵ demonstrated that HT did not prevent or reduce the risk of fatal myocardial infarction in postmenopausal women with preexisting coronary heart disease (CHD). Therefore, the American Heart Association stated that initiation or continuance of HT for secondary prevention of CHD is not recommended.⁶

What did the WHI trial demonstrate?² It showed that estrogen is effective in reducing menopausal symptoms such as vasomotor events, vaginal dryness and, perhaps, mood swings at the time of the menopausal transition. There was an increased absolute risk for nonfatal stroke only (8 per 10,000 women per year), a twofold increase in absolute risk of venous thromboembolism (18 per 10,000 women per year), and an increased absolute risk of CHD events, including nonfatal myocardial infarction, among HT users
(7 per 10,000 women per year). Overall, there was no apparent cardiovascular protection in HT users.

An increased absolute risk of breast cancer (8 per 10,000 women per year) was demonstrated in women who used HT for more than 5.2 years. Although the risk of endometrial cancer significantly increased in estrogen-only users, the addition of a progestogen significantly decreased that risk. On the benefit side, the WHI demonstrated an absolute benefit for reduced incidence of osteoporotic hip fractures (5 per 10,000 women per year) and colon cancer (6 per 10,000 women per year).

In a systematic review developed for the U.S. Preventive Services Task Force (USPSTF) and funded by the Agency for Healthcare Research and Quality (AHRQ), benefits and harms of HT were assessed, outcome rates were calculated, and meta-analyses were performed when appropriate.⁷ Despite conflicting results, the overall message is that the long-term harm of HT outweighs the benefits. It appears that the increased relative risk of HT versus placebo or the potential harms of increased risk of venous thromboembolism, breast cancer, stroke, and myocardial infarction associated with continuous HT outweigh the benefits of reduced incidence of colon cancer and osteoporotic hip fractures. For some outcomes, such as breast cancer and cholecystitis, the risk increases over time. For outcomes such as venous thromboembolism and myocardial infarction, the risk is greatest in the first years of use.

The North American Menopause Society (www.menopause.org) Advisory Panel suggests using the following points of discussion when counseling women about HT, with the understanding that the lowest effective dosage for the shortest duration should be used:

1. Each woman considering the use of HT should undergo a risk-profile analysis and be educated to understand the risks and benefits of HT use. The terms "long-" and "short-term" therapy should be abandoned, because the risk profile of the individual patient should guide the duration of benefit.
2. Relief of menopausal symptoms (e.g., vasomotor events, vaginal dryness) is the primary indication for use of HT.
3. Although various HT regimens are approved by the U.S. Food and Drug Administration for the prevention of postmenopausal osteoporosis, alternative therapies such as bisphosphonates should be considered.
4. Use of HT for primary and secondary prevention of CHD should be abandoned. Although it is unclear whether estrogen alone is beneficial in this regard, it should not be used for this indication.
5. There have been no definitive studies on alternative routes of administering HT, and it should not be assumed that regimens other than CEE and MPA are less harmful.
6. Data are lacking on the optimal method of discontinuing HT.
7. Although the Advisory Panel could not agree on the extended use of HT, it was suggested that it may be acceptable under the following circumstances, provided informed consent is obtained and there is strict follow-up: in women for whom symptom relief outweighs the risks, women with symptoms who are at risk for osteoporosis, and women with significant osteoporosis risk who are unable to tolerate alternative therapies for that condition.

So what should we tell our patients? HT has a limited place and is recommended based on risk assessment. The unopposed CEE arm of the WHI trial is continuing to study postmenopausal women who have had hysterectomies. A new chapter on menopause has been written--and the discussion and debate on HT will undoubtedly continue for quite some time.

REFERENCES

1. Design of the Women's Health Initiative clinical trial and observational study. The Women's Health Initiative Study Group. Control Clin Trials 1998; 19:61-109.
2. Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial. JAMA 2002;288:321-33.
3. Grodstein F, Manson JE, Colditz GA, Willett WC, Speizer FE, Stampfer MJ. A prospective, observational study of postmenopausal hormone therapy and primary prevention of cardiovascular disease. Ann Intern Med 2000;133:933-41.
4. Hulley S, Grady D, Bush T, Furberg C, Herrington D, Riggs B, et al. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/progestin Replacement Study (HERS) Research Group. JAMA 1998;280:605-13.
5. Hulley S, Furberg C, Barrett-Connor E, Cauley J, Grady D, Haskell W, et al. Noncardiovascular disease outcomes during 6.8 years of hormone therapy: Heart and Estrogen/progestin Replacement Study follow-up (HERS II). JAMA 2002;288:58-66.
6. Mosca L, Collins P, Herrington DM, Mendelsohn ME, Pasternak RC, Robertson RM, et al. Hormone replacement therapy and cardiovascular disease: a statement for healthcare professionals from the American Heart Association. Circulation 2001; 104:499-503.
7. Nelson HD, Humphrey LL, Nygren P, Teutsch SM, Allan JD. Postmenopausal hormone replacement therapy: scientific review. JAMA 2002;288:872-87.

Barbara S. Apgar, M.D., M.S., is a clinical professor of family medicine at the University of Michigan Medical School in Ann Arbor and associate editor of American Family Physician.

David G. Weismiller, M.D., Sc.M., is assistant professor of family medicine and director of the Women's Health Fellowship at the Brody School of Medicine at East Carolina University, Greenville, N.C.

Address correspondence to Barbara S. Apgar, M.D., M.S., 883 Sciomeadow Dr., Ann Arbor, MI 48104. Reprints are not available from the authors.