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Copyright Notice This document is the property of Alberta Health Services (AHS). On April 1, 2009, AHS brought together 12 formerly separate health entities in the province: nine geographically based health authorities (Chinook Health, Palliser Health Region, Calgary Health Region, David Thompson Health Region, East Central Health, Capital Health, Aspen Regional Health, Peace Country Health and Northern Lights Health Region) and three provincial entities working specifically in the areas of mental health (Alberta Mental Health Board), addiction (Alberta Alcohol and Drug Abuse Commission) and cancer (Alberta Cancer Board). Physician referrals to addiction treatment services for women at risk of using substances while pregnant A literature review of barriers and recommendations Physician referrals to addiction treatment services for women at risk of using substances while pregnant A literature review of barriers and recommendations August 2006 Alberta Alcohol and Drug Abuse Commission (AADAC) Prepared by Jesse Jahrig and Komali Naidoo, AADAC Research Services Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES Suggested citation Alberta Alcohol and Drug Abuse Commission. (2006). Physician referrals to addiction treatment services for women at risk of using substances while pregnant: A literature review of barriers and recommendations. Edmonton, Alberta, Canada: Author. Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES Table of contents Executive Summary ..................................................................5 Introduction ................................................................................7 Background..............................................................................................7 Rates of substance use during pregnancy ........................................................7 Physician referrals ..............................................................................................8 Methods ..................................................................................................9 Literature search ................................................................................................9 Literature search process ..................................................................................9 Barriers ....................................................................................10 Before clinic visit ....................................................................................10 At-risk women ..................................................................................................11 System..............................................................................................................14 Practice ..................................................................................................15 Identification ....................................................................................................15 Intervention ......................................................................................................19 During clinic visit ....................................................................................19 Identification and intervention ..........................................................................19 Follow-up ..............................................................................................24 Recommendations ..................................................................25 1. Address risk perception and awareness of problems among at-risk women ..............................................................................................25 2. Improve at-risk women’s perception of treatment services and the prenatal clinic ........................................................................................27 3. Co-ordinate the referral system ..................................................................28 4. Increase at-risk women’s awareness of addiction treatment services and the referral process ..............................................................................28 5. Standardize physician screening and referral practice................................29 6. Use suggested screening tools for tobacco and other drug use ................30 7. Provide education and training for physicians ............................................31 8. Provide financial compensation to physicians ............................................32 9. Encourage physicians to follow up with patients ........................................32 10. Provide physicians with feedback about referred patients ........................33 Conclusion ..............................................................................33 References ..............................................................................34 Table of tables Table 1: Literature search methods: Concepts and keywords ................9 Table 2: Barriers faced by patient and physician during the referral process ..................................................................10 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES Executive Summary Use of alcohol, tobacco and other drugs is an important concern for women of child-bearing age, especially when it occurs during pregnancy. Substance use during pregnancy can be harmful to the mother and can affect the child’s physical and cognitive development. Therefore, it is imperative that pregnant women and women of child-bearing age who are at risk of substance use have access to help for substance use issues. Physicians play a pivotal role in linking at-risk women1 with treatment services for substance use. When at-risk women visit their physician, it is vital that physicians be actively involved in the screening and referral process for substance use during pregnancy. This literature review was conducted to explore physician referrals of women at risk of using substances while pregnant to addiction treatment services. Specifically, it was intended to answer two main questions: What are some of the main barriers to referrals? What can be done to improve the process for all involved? Several findings were identified in the literature. A brief summary of these follows. Address risk perception and awareness of problem among at-risk women Most women are aware that alcohol use during pregnancy is harmful, but research indicates that some women may not acknowledge the risks of their own substance use during pregnancy. It is therefore recommended that measures be taken to help women recognize that their substance use during pregnancy is problematic and to raise awareness of the health risks involved. Improve at-risk women’s perception of treatment services and the prenatal clinic At-risk women have criticized addiction treatment services for numerous reasons, and it is reasonable to assume that at-risk women who hold negative views of treatment services may be disinclined to seek help in using those services. Therefore, it is recommended that action be taken to improve at-risk women’s perception of treatment services and the prenatal clinic. Co-ordinate the referral system Ineffective and poorly co-ordinated referral networks have been reported in the literature as a barrier to referring at-risk women to treatment services. Consequently, it is recommended that the relevant health organizations work toward a clearly defined referral system. 1 The term “at-risk women” in the context of this literature review refers to women of child-bearing age (15 to 54 years old) and pregnant women who use substances or are at risk of using substances during pregnancy. 5 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES Increase awareness among at-risk women of addiction treatment services and the referral process The literature indicates that at-risk women are uncertain of what help is available, where to get help and how to get help. To rectify this, appropriate health organizations need to target at-risk women to increase awareness about addiction treatment services and the referral process. Standardize physician screening and referral practice Research reveals that physicians would value clinical practice guidelines to manage substance use issues. Thus, efforts should be made to develop standard practice guidelines for managing substance use among at-risk women. Use suggested screening tools for tobacco and other drug use Use of inappropriate screening methods to identify substance use among women and pregnant women has been documented in the literature. It is integral that physicians use appropriate screening tools for substance use such as the T-ACE or TWEAK, but not use the CAGE, Alcohol Use Disorders Identification Test (AUDIT) or Michigan Alcoholism Screening Test (MAST), which have been criticized for being inappropriate when dealing with this population of women. Provide education and training for physicians The literature indicates that physicians believe training materials on substance issues would be useful. Proper education and training may help physicians develop better relationships with their patients, and may help overcome other barriers. Provide financial compensation to physicians Physicians may be more inclined to manage substance use issues if subsidy or reimbursement programs are in place. Encourage physicians to follow up with patients Even after physicians have made referrals, it is still important that they follow up with their patients to provide support, motivation and regular screening. Provide physicians with feedback about referred patients Feedback can reinforce effective actions and allow adjustments to be made to less effective actions. Providing feedback may also improve physicians’ view about the effectiveness of addiction treatment; this is important because physicians will be more likely to refer to treatment services they feel are effective. 6 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES Introduction This literature review is intended to provide evidence-based information on engaging and increasing physician referrals to addiction services. It examines referral practices and models of service delivery provided by physicians to at-risk women. Discussed specifically is the referral process, including current practices as well as barriers confronted by patients and physicians during this process. Whenever possible, references are made to articles with national and provincial relevance. Background Rates of substance use during pregnancy Three major categories of substance use will be discussed throughout this literature review: tobacco use, alcohol use and illicit drug use. To help contextualize this review, rates of substance use during pregnancy are reported below. It should be noted that research indicates there may be systematic under-reporting of substance use, especially for alcohol and illicit drugs (Cavanagh, 1999; Gladstone, Nulman, & Koren, as cited in Health Canada, 2000b; U.S. Department of Health and Human Services [USDHHS], 1990). Therefore, it is plausible that actual rates of substance use are higher than those reported in the literature. Tobacco Rates of tobacco use during pregnancy in Canada range from 19% to 30% based on several national studies from 1994 to 2003 (Alberta Alcohol and Drug Abuse Commission [AADAC], 2004; Health Canada, 2003b; Statistics Canada, 2003). In Alberta, rates range from 23% to 33% (AADAC, 2004; Alberta Health and Wellness, Reproductive Health Working Group, 2004; Statistics Canada, 2003). Alcohol According to Canadian surveys, 14% to 25% of women across Canada reported drinking at some point during pregnancy (AADAC, 2004; Dzakpasu, Mery, & Trouton, 1998; Health Canada, 2003b; Public Health Agency of Canada, 2004; Statistics Canada, 2003), and 7% to 9% reported drinking throughout their pregnancy (Dzakpasu et al., 1998). In contrast with these national findings, the results of a provincial report on alcohol consumption during pregnancy (Alberta Health and Wellness, Reproductive Health Working Group, 2004) were lower: just 4% of Alberta women reported drinking while pregnant. Illicit drugs Reported prevalence of drug use during pregnancy in Canada is scarce and varied. In studies in Vancouver, Montreal and Toronto, reported rates of drug 7 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES use during pregnancy ranged from 4% (Ling, Albersheim, & Halstead, 1997) to 13% (Albersheim & MacKinnon, 1993). In the Downtown Eastside of Vancouver the rate climbed to 30% (Loock et al., as cited in Whynot, 1998). As for Alberta, the Reproductive Health Working Group (2004) found that just 2% of women provincewide reported drug use during pregnancy. Again, these numbers may be subject to under-reporting. Physician referrals At-risk women entering motherhood have been identified as having an enhanced motivation to make positive changes for themselves and their unborn child, including decreasing or ceasing substance use (Albersheim, 1992; Beckett, 1995; British Columbia Ministry of Health Services, as cited in AADAC, 2004; Bruce and Williams, 1994; Dow-Clarke, MacCalder, & Hessel, 1994; Finkelstein, 1994; Gomez, 1997; Little & Streissguth, 1978). In Canada, 70% of women reported that they would stop using alcohol if they became pregnant, and 42% who were currently pregnant said they would stop using alcohol (Environics Research Group, 2002). This opportunity might be optimized by increasing physician identification of clients through a screening process, as well as by increasing physician referrals to treatment services. However, the frequency with which physicians screen and refer at-risk women to substance use treatment services is reported as low in the literature (Best Start, 2005; Donovan, 1991; Health Canada, 2003a; Miner, Holtan, Braddock, Cooper, & Kloehn, 1996; Howell, Heiser, & Harrington, 1999; Nanson, Bolaria, Snyder, Morse, & Weiner, 1995; Nevin, Parshuram, Nulman, Koren, & Einarson, 2002). The large majority of research on maternal substance use suggests much room for improvement in terms of screening and referral practices. To improve the frequency with which physicians refer at-risk women to appropriate treatment, it is necessary to examine the referral process, identify those involved in the referral process, and assess the barriers to referral. As such, it is useful to address the referral process in three different stages: what happens before, during and after a visit to the physician. When possible, it is also beneficial to examine these three stages from the perspective of at-risk women, physicians, and other health organizations that provide service to similar clients. Accordingly, the organization of the literature reviewed reflects these stages and perspectives. Refer to Table 1 for a brief summary of the barriers faced by patients and physicians during the different stages of the referral process; this summary highlights the main themes that emerged from the literature review. 8 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES Table 1: Barriers faced by patient and physician during the referral process Before clinic visit · patient denial of problem · patient denial of risks involved with substance use during pregnancy · patient denial of the need for professional help · patient’s lack of awareness of where and how to get help · patient places low priority on getting help · poorly co-ordinated referral system · inadequate physician practice in screening and referring patients During clinic visit · patient does not answer physician’s screening questions honestly or openly · physician discomfort dealing with substance issues · lack of proper education and training for physicians · lack of financial compensation for physicians · physician perception of addiction treatment efficacy Follow-up · lack of patient follow-through after receiving a referral · lack of physician follow-up with referred clients Methods Literature search The literature search was intended to find evidence-based information about barriers to referrals made by physicians to at-risk women. As such, evidence-based material connecting these categories was pursued. When necessary, the scope of the literature search expanded to substance use among the general population to fill in gaps where there was a lack of research specific to women and pregnancy. In addition to focusing on referrals, physicians and women, the literature search was used to locate information about health policy, practice and recommendations. As mentioned, this literature review was intended to provide evidence-based information that is provincially and nationally relevant; therefore, provincial and national information was searched initially and international studies were searched subsequently. Literature search process Concepts and keywords The following concepts and keywords were searched in the literature in combination with other concepts and keywords. The list of keywords is not inclusive. 9 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES Table 2: Literature search methods: Concepts and keywords Concept Keywords (not inclusive) client or patient perspective and awareness, motivation, barriers, prevalence, attitude, role in substance use issues characteristics, service needs, women, female, maternal, pregnancy, prenatal, at risk, perinatal, primary care physician perspective and role in substance use issues training, education, preparation, instruments, methods, tools, screen, diagnose, detect, identify, intervene, barriers, prevalence, best practice & actual practice, attitude, type of referral, practices, on-site counsellor, facilitators, follow-up, referral effectiveness, attitude, relationship with clients, counsellors, treatment services, physician, doctor, practitioner, clinic referrals counsel, advise, refer, management, recommend, support, guidance, intervention, treatment services substance use substance, drugs, cocaine, crystal meth, heroin, street drugs, marijuana, cannabis, pot, opiates, alcohol, drink, alcoholism, tobacco, smoke, cigarettes, addiction Databases The literature was searched using the following databases: PsycINFO, Medline, ERIC, MasterFILE Premier, Psychology and Behavioral Sciences Collection. Other Internet databases, institute websites, relevant organizational sources, government sources, and Google were also searched. These sources were searched for articles, papers, dissertations, book chapters, and manuals. The literature search was restricted to publications occurring between 1995 and 2006. Useful references cited in the literature originally reviewed were also acquired and subsequently reviewed. As a result, some of these research articles date back to before 1995. The literature search yielded hundreds of articles, about 175 of which are cited in this literature review. The final allocation of literature spanned from 1972 to 2006. The majority of the literature cited was published after 1995. Barriers Before clinic visit Perhaps the most obvious barrier to a physician referral is that it cannot take place unless the prospective patient sees a physician. Many pregnant substance users do not seek prenatal care at all (Hankin, McCaul, & Heussner, 2000; Kelly et al., 1999; Melnikow, Alemagno, Rottman, & Zyzanski, 1991; Pagnini & Rechman, 2000) or if they do, it may be late in their pregnancy, when negative health effects to the mother and fetus may already have occurred (Armstrong, as cited in Masotti, Szala-Meneok, Selby, Ranford, & Koughnett, 2003; Astley, Bailey, Talbot, & Clarren, 2000; 10 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES Brady, Bisscher, Feder, & Burns, 2003; Hankin et al., 2000; Kelly et al., 1999; Klein & Zahnd, 1997; Roberts & Nanson, 2000; Tait, 2000). Brady et al. (2003) found that 17% of women did not receive prenatal care until their third trimester, or did not receive any prenatal care at all. Additionally, the more substances are used, the less likely prenatal services are to be used (Brady et al., 2003; Hankin et al., 2000). There are a variety of barriers that can prevent any interaction between physicians and at-risk women, and it is often the potential patient who must overcome the majority of these barriers. These barriers include denial that there is a problem, denial of the risks involved (Poole & Isaac, 2001; Tait, 2000; Testa & Reifman, 1996), denial of the need for professional help (Hughes, Epstein, Andrasik, Neff, & Thompson, 1982; Klein & Zahnd, 1997; Poole & Isaac, 2001), lack of awareness of where and how to get help (Allen, 1994; Currie, 2001; Grant, 1997; McElaney, as cited in Morse, 2000; Tait, 2000), and negative attitudes and perspectives about treatment services and the prenatal clinic (Beckman & Amaro, 1986; Currie, 2001; Deville and Kopelman, 1998; Finkelstein, Kennedy, Thomas, & Kearns, 1997; Poole & Isaac, 2001; Tait, 2000). In addition, getting help for substance use issues may be a low priority because of competing life priorities at-risk women face (Brady et al., 2003; Milligan et al., 2002). A poorly co-ordinated referral system can also hamper referrals (Donovan, 1991; Miner et al., 1996). Understanding the barriers that prevent at-risk women from visiting a physician is important because these barriers result in a decreased opportunity for referrals to be made. At-risk women Risk perception and awareness of problem Although most women are aware that alcohol use during pregnancy can cause lifelong disabilities in a child (University of Alberta, Population Research Laboratory, 2004), research still shows that some women may not acknowledge that their own substance use during pregnancy is problematic (Poole & Isaac, 2001; Tait, 2000; Testa & Reifman, 1996). In 2001, Poole and Isaac conducted a study in British Columbia that sampled substance-using mothers in treatment from across the province in an attempt to identify barriers to seeking treatment. Seventeen per cent of the mothers interviewed were pregnant at the time of the study. The results revealed that 43% of mothers and pregnant women who were using substances felt their substance use was not a problem. In another study, Testa and Reifman (1996) found that at-risk women who drank during pregnancy, but still had a healthy child, held a decreased perception of the risks involved. Similarly, in a Manitoba study in which pregnant substance users were interviewed, one respondent reported, ...my mother drank with all of us and all of us are healthy. I thought, ah, it’s just BS what they say about alcohol... And so I never thought it could really harm a baby. (Tait, 2000) 11 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES In another Canadian survey, the researchers found that women who consumed more alcohol were more likely to think it was safe to drink while pregnant (Environics Research Group, 2002). These misperceptions about substance use during pregnancy are partially caused by a combination of misinformation provided by unreliable sources and a lack of information provided by credible sources such as health professionals (Tough, Clarke, Hicks, & Clarren, 2005; Baric & MacArthur, 1977). A 2005 Canadian study showed that 69% of family physicians felt that misinformation about the safety of drug use during pregnancy prevented women from seeking treatment (Tough et al., 2005). Self-perceived need for professional help Many women do realize that their own maternal substance use has adverse effects on the baby; however, this does not necessarily mean they will seek professional help. Studies show that some mothers feel they can handle the problem on their own and do not require professional help (Hughes et al., 1982; Klein & Zahnd, 1997; Poole & Isaac, 2001). For example, Poole and Isaac (2001) found that 62% of at-risk women in B.C. believed they could cut down drinking on their own. The literature suggests that women who do not think they need help may be less likely to contact a physician for help with their substance use. Attitudes and perspectives about treatment services Presumably, the likelihood that at-risk women will consult a physician for a referral to substance treatment may be influenced by their attitudes towards treatment. At-risk women who hold negative attitudes about treatment may avoid seeking services for the purpose of receiving a referral, including physician services. In the literature, at-risk women have criticized treatment services because of a lack of appropriate programs for women only, a lack of programs for parental services and parental training, a lack of child-care services, long waiting lists, distant services accompanied by a lack of transportation, and a limited number of referral services in rural regions (Tait, 2000; Currie, 2001; Dore & Doris, 1997). More personal barriers to treatment include fear of having their child apprehended by social services; feelings of denial, guilt and shame; a sense of stigma and lack of confidentiality; social costs; and opposition from family and friends (Beckman, 1994; Beckman & Amaro, 1986; Poole & Isaac, 2001; Tait, 2000). These barriers are found in any geographic location, but are exacerbated in smaller urban and rural communities (Currie, 2001; Finkelstein et al., 1997; Poole & Isaac, 2001). Additionally, at-risk mothers may be reluctant to enter treatment because of a lack of culturally sensitive programming (Currie, 2001; Lundquist & Jackson, as cited in Stockburger, 2003). The literature suggests that at-risk women who hold negative views of treatment services may be less likely to seek help in gaining access to these services, including help obtained through their physician. 12 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES Attitudes and perspectives about the prenatal clinic There is limited research on barriers related to attitudes and perspectives about the prenatal clinic, yet it is plausible that the majority of the barriers regarding attitudes and perspectives about treatment will apply when visiting a health professional. The available research corroborates this notion. Studies show that the threat of legal intervention, primarily child apprehension, is a barrier for at-risk women to seek prenatal care (Jessup, Humphreys, Brindis, & Lee, 2003; Moss, 1991; Sullivan, 1990; Tait, 2000). Additionally, women of child-bearing age who were using substances have reported avoiding prenatal visits because they feared their care provider would discover their drug use (Milligan et al., 2002). Moreover, substance-using mothers have reported that prenatal clinics have treated them poorly, and that as a result they have refrained from prenatal visits (Milligan et al., 2002). In a U.S. focus group study conducted by Milligan et al. (2002), one participant said, When providers find out you use drugs, they treat you bad, i.e., like an addict. [They] put you on the table like you’re a piece of meat.... Addicts, being addicts, underprivileged, and you done been through the ringer and you’re trying to get your life back on perspective and they treat you like a bunch of crap. Similarly, Canadian Aboriginal women have reported experiencing poor treatment when using health services. Specifically, Aboriginal women have reported being subjected to cultural insensitivity and racism (Stout, Kipling, & Stout, 2001). Disrespectful treatment could cause women to become disinclined to revisit for care (Benoit, Carrol, & Chaudhry, 2003). Awareness of services and how to access them I just didn’t realize how the system worked. There’s no real paper stating that this is the way you go about getting treatment. —an at-risk woman (Poole & Isaac, 2001) Once at-risk women resolve to get help, it is critical that they be aware of available help and how to reach it; however, this is not always the case (Allen, 1994; Currie, 2001; Grant, 1997; McElaney, as cited in Morse, 2000; Roberts & Nanson, 2001; Tait, 2000). Women have reported wanting help but not knowing where or how to get it (McElaney, as cited in Morse, 2000). In Poole and Isaac’s 2001 study, over half of the at-risk B.C. women sampled reported not knowing what help was available. It may also be the case that at-risk women may not understand how to obtain a referral (Tait, 2000). The gravity of being unaware of where and how to receive help is illustrated by a quote from an interviewee in Tait’s Manitoba study of substance-using mothers: Realizing I’m an alcoholic, I have a drinking problem, and trying to understand that I’m an alcoholic... I really didn’t know who to talk to about it. That was when I was still pregnant with my last daughter. 13 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES It can be inferred from the findings above that women who are unaware of how or where to get help may be less likely to seek a physician’s help. Prenatal care within the context of other determinants of health Women who use substances may often face many other problems, such as a drug lifestyle, abusive relationship, employment issues, depression, lack of child care, poverty and homelessness (Brady et al., 2003; Milligan et al., 2002). Many of these problems fall under the Public Health Agency of Canada’s (2003) key determinants of health, such as income and social status, social support networks, employment and working conditions, and social environments. Considering this, it might be assumed that these problems may interfere with or take precedence over the pursuit of prenatal care. Milligan et al. (2002) found that in focus groups with women of childbearing age who had substance use problems, many women identified their lifestyle as a barrier to seeking prenatal care. One participant’s response reflects the low priority of prenatal care in the context of other problems: Do you think that I’m going to look at my watch and say, “It’s nine o’clock everybody, so put down the [crack] pipe so I can go to my prenatal care appointment”? (Milligan et al., 2002) System Lack of a standardized referral system Although any referral to treatment services is positive no matter the source, a poorly co-ordinated referral system will not foster referrals. The literature indicates that a structured and integrated referral system is not common in actual practice. One reason for this is that there are numerous providers of referral for substance use treatment (e.g., mental health services, social services, health organizations, community support groups, emergency rooms, child protective services, family and parenting programs, religious institutions, pharmacists, women’s shelters and crisis centres, as well as physicians), which makes establishing and co-ordinating a referral process difficult. In fact, certain at-risk women are more likely to receive a referral from sources other than their physician. For instance, research has shown that women who use substances also tend to suffer depression, anxiety and post-traumatic stress disorders. Women suffering from these disorders are more likely to seek help at a general mental health centre, and may follow a different path to treatment (Schober & Annis, 1996; Weisner, Greenfield, & Room, 1995). One study also indicated that women are more likely than men to rely on referrals from family or friends as opposed to family physicians (Grant, 1997). Ultimately, this research implies that a standard and co-ordinated referral process does not exist in most communities. Ineffective and poorly co-ordinated referral networks have been reported as a barrier to referring at-risk women to treatment services (Donovan, 1991; Miner et al., 1996). 14 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES Practice Studies indicate that the general population who abuse alcohol seldom go to treatment services directly, and often seek guidance from their physician (Jones & Helrich, as cited in Boyd, 1985; Murphey, as cited in Boyd, 1985). This accentuates the important role of physicians to detect whether their at-risk patients use substances and, if so, to appropriately refer them. During a typical visit to a clinic, substance use must first be identified, and then a referral can be made. Because positive identification commonly leads to some type of intervention (which, among other things, includes a referral), identification is integral to the referral process. The following is an overview of some identification and referral practices. Identification Three common ways to screen for substance use are biochemical testing, clinical interviews, and use of screening tools (i.e., standardized questionnaires). Biochemical tests Biochemical tests can be effective to determine substance use. There are many biological markers for substance use, which can be identified by testing urine toxicology, carbohydrate-deficient transferrin, gamma-glutamyl transpeptidase, blood alcohol levels, alcohol metabolites, enzyme levels, mean corpuscular volume, altered proteins, etc. (Allen, Litten, Fertig, & illanaukee, 2000; Bearer et al., 1999; Glantz & Woods, 1991; Stratton, Howe, & Battaglia, 1996). However, there is debate in the medical community regarding the ability of biochemical tests and biological markers to distinguish one-time or occasional use versus long-term addiction (Goldsmith, as cited in Wheeler, 1993; Moss, 1989; U.S. Preventive Services Task Force, 1989). Furthermore, some laboratory tests have been criticized for limited sensitivity and susceptibility to contamination (Taylor, Zaichkin, & Bailey, 2002; Conigrave, Saunders, & Whitfield, 1995; Schellenberg, Benard, Le Goff, Bourdin, & Weill, 1989). For instance, a 1994 technical bulletin by the American College of Obstetricians and Gynecologists (as cited in Taylor et al., 2002) reported that urine toxicology testing has a limited ability to detect substance use; consequently, ACOG does not recommend the use of universal toxicology screening as standard practice to detect substance use in pregnant women. Clinician interview/self-report The clinician interview is an informal screening method in which the issue of substance use is broached by either physician or patient and discussed without using formal screening or testing (Hicks, Sauve, Lyon, Clarke, & Tough, 2003). Physicians quite often discuss alcohol use with pregnant women, and this may or may not be followed up with the use of a screening tool (Tough et al., 2005). Notably, the clinician interview relies heavily upon 15 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES the accuracy of patients’ self-report to informal questioning (Hicks et al., 2003). Unfortunately, in an informal setting, self-reported alcohol and other drug use during pregnancy is highly variable, and often results in underreporting (Chang et al., 1998; Chasnoff, 1989; Finkelstein, 1993). Despite this unreliability, this self-report method is still a practice for detection of substance use during pregnancy. A study of metropolitan Toronto physicians (Nevin et al., 2002) showed that 66% relied on their patients’ self-report in order to detect alcohol use during pregnancy. Furthermore, research suggests that less than a quarter of substance-using women voluntarily report their use (Corse, McHugh, & Gordon, 1995). In review, the literature suggests that a reliance on informal self-report may in some cases be an unreliable method for substance use detection, considering how seldom substance-using women voluntarily raise the issue or honestly answer informal questions. Screening tools Since the clinical interview may be inadequate, physicians may adopt a more formal approach for detecting substance use, an approach that incorporates formal screening tools. These tools can be administered by the physician or self-administered by the patient. Although screening tools still rely on self-report, a formalized self-report encourages more honest responses; research has shown that use of formal screening tools and protocol results in many times the number of occurrences of substance use detection than does the use of no screening tools or protocol (Chasnoff, 1989; Cyr & Wartman, as cited in Saitz et al., 2002). Moreover, screening tools have been proposed as superior to both the clinician interview and biochemical testing in detecting excessive alcohol use (Bernadt et al., as cited in Chang, 1997; Chasnoff, 1989). Therefore, screening tools are often recommended as an effective practice to detect substance use, particularly for alcohol and other drug use. There are a number of screening tools for alcohol, tobacco and other drugs. (For a comprehensive review of various screening tools, refer to Center for Substance Abuse Prevention [CSAP], 1993.) Specific tools for detecting tobacco or illicit drug use were seldom used in the studies cited in this literature review. However, screening tools for alcohol were used in many studies. Commonly used alcohol questionnaires to gauge alcohol use among at-risk women include the Michigan Alcoholism Screening Test (MAST) (Selzer, Vinokur, & van Rooijen, 1975), the Alcohol Use Disorders Identification Test (AUDIT) (Babor, De La Fuente, Saunders, & Grant, 1989), and the CAGE (Ewing, 1984). However, these tools were designed to detect alcoholism in men and are not considered effective to detect alcoholism in women, let alone alcohol use during pregnancy (CSAP, 1993; Chang, 2001; Goldberg, Mullen, Ries, Psaty, & Ruch, 1991). Thus, identification of at-risk women can be compromised by use of ineffective screening tools. More sensitive tools exist, such as the TWEAK and T-ACE (Chang, 2001; Russell, 1994). The TWEAK is viewed as one of the most accurate and 16 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES sensitive tools to detect risk drinking during pregnancy (CSAP, 1993). The TWEAK is reported as brief, easy to administer, and simple to score (CSAP, 1993). On the other hand, it has been criticized for not being sensitive enough to target moderate problem drinkers or at-risk patients (CSAP, 1993; Sokol, Delaney-Black, & Nordstrom, 2003). Another tool that is used is the T-ACE (Sokol, Martier, & Ager, 1989), which was designed to detect at-risk drinking among pregnant patients. Like the TWEAK, T-ACE is reported as quick, easy to administer, and easy to score (CSAP, 1993). It has been praised for bypassing the denial syndrome frequently experienced by alcohol users, but has been criticized for not identifying moderate drinkers (CSAP, 1993). Despite the claimed sensitivity of these tools, they are not always used. For instance, Nevin et al. (2002) found that 34% of physicians used the inappropriate CAGE tool to screen for alcohol use during pregnancy, and that no physicians reported using the TWEAK. Tough et al. (2005) found that 74% of family physicians used a screening tool for alcohol with their prenatal patients. However, 87% of those physicians who used a screening tool reported using the CAGE and only 23% reported using the T-ACE. (Some physicians used more than one tool.) A survey conducted by the American College of Obstetricians and Gynecologists (Hollander, 2002) found that only 23% of physicians used a standardized screening tool; the exact tool was not specified. Physician reasons for screening A U.S. study (Zellman et al., 1999) examined the reasons physicians responded to suspected prenatal substance use. According to the study, physicians most often acted on suspicions in order to help the patient, to protect the fetus and prevent fetal problems, and to cease their patients’ substance use. About half of the physicians felt that legal requirements and workplace policy were also important reasons for a response. Less than a quarter reported fear of a lawsuit as an important reason for responding to suspected substance use. Screening protocol Research among the general population (not just at-risk women) shows that physicians may fail to recognize substance abuse (Buchsbaum, Buchanan, Poses, Schnoll, & Lawton, 1992; Cleary et al., 1988; Coulehan, ZettlerSegal, Block, McClelland, & Schulberg, 1987; Institute for Health Policy, as cited in Saitz et al., 2002; Isaacson, Butler, Zacharek, & Tzelepis, 1994; Kamerow, as cited in Saitz et al., 2002; Saitz, Mulvey, Plough, & Samet, 1997). In one study, 42% of patients reported that their physicians were unaware of their substance use (Saitz et al., 1997). Furthermore, physicians are less likely to diagnose or take an alcohol history from women than from men (Awad & Wattis, as cited in Chang, 1997; Beckman & Amaro, 1986; Shapiro et al., 1984). As for at-risk women, there is a paucity of research 17 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES describing physician detection rates of substance use. However, there are numerous protocol- and practice-related barriers that may hinder identification of substance use among at-risk women; as Zellman et al. (1999, p. 29) state, “substance use in pregnancy is a frequently missed diagnosis.” It has been suggested that physicians do not appropriately or routinely screen all at-risk women (including pregnant women), and often only screen patients who they suspect or are fairly certain are using substances (Best Start, 2005; Donovan, 1991; Health Canada, 2003a; Hollander, 2002; Howell et al., 1999; Miner et al., 1996; Nanson et al., 1995; Nevin et al., 2002). A survey conducted by Health Canada (2003a) showed that less than 50% of health care providers discussed risks of alcohol use during pregnancy with their at-risk female patients. Similar rates have been found in the United States (Fleming, as cited in Enoch & Goldman, 2002; Hollander, 2002). Hollander (2002) reported on a 1998 U.S. study, which indicated that just 50% of physicians offered advice about alcohol use to all pregnant women, 36% of physicians did so only when they knew or suspected alcohol use was an issue, and 13% of physicians offered prenatal advice to women who had a history of substance use. It should also be noted that in this study, 97% physicians stated they obtained information about alcohol use from their obstetric patients. Although the methods for doing so included physicians asking women if they drink (48%), and having a non-physician staff member ask the patient about alcohol use (41%), 19% of physicians obtained information by having the patient answer an alcohol-related question on a form that patients complete. Only 23% of physicians reported using a standardized screening tool. Further barriers related to protocol include the following: · Physicians may not take an active role in detecting substance use because there is a lack of policy and procedures defining the role physicians play in systematically identifying substance-using women (Li, Olsen, Kvigne, & Welty, 1999; U. S. Government Accounting Office, as cited in Zellman, Jacobson, DuPlessis, & DiMatteo, 1992). · Physicians may be less likely to screen if they do not perceive a screening instrument as validated and if there is a lack of clear, science-based guidelines (Miner et al., 1996). · Some physicians believe substance use is not prevalent among their patients; for instance, Donovan (1991) found that some New Jersey physicians denied that fetal alcohol syndrome occurred in their practices. · Physicians who inquire about alcohol use seldom probe with follow-up questions (Miner et al., 1996). Given these barriers, it is plausible that insufficient practice and protocol may lead to significant rates of undetected substance use among women who are pregnant or of child-bearing age. 18 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES Intervention Physicians’ responsibilities are not typically limited to identifying substance use; they often intervene to provide counsel or offer referrals to their patients. Physicians may provide counsel to women by encouraging them to stop on their own, advising them to delay pregnancy or supplying written information about substance use during pregnancy (Handmaker & Wilbourne, 2001; May, 1995; Roberts & Nanson, 2000). Physicians may also provide a referral to substance treatment services, or to other services such as community support organizations, social services and mental health programs (Handmaker & Wilbourne, 2001; May, 1995; Roberts & Nanson, 2000). Whether or not a physician chooses to intervene with a referral or another type of intervention will affect overall referral rates. One study indicates that referrals may not be physicians’ first choice for intervention (Hollander, 2002). The American College of Obstetricians and Gynecologists conducted a survey in 1998 and found that upon a positive screen for alcohol use, most physicians chose to discuss the adverse effects of prenatal alcohol use with women who were moderate drinkers (three to 13 drinks per week) and heavy drinkers (14 or more drinks per week). Notably, 86% of physicians discussed the effects with moderate drinkers, and 97% with heavy drinkers. In the same study, 83% of physicians dealing with moderate drinkers and 92% of physicians dealing with heavy drinkers said they would discourage patients from drinking during pregnancy. Seventy-nine per cent of physicians would tell moderate drinkers and 88% of physicians would tell heavy drinkers to discontinue alcohol use while pregnant. However, just 21% of physicians referred at-risk women who were moderate drinkers to treatment services, and 61% of physicians referred heavy drinkers (Hollander, 2002). During clinic visit In review, identification and intervention practices are key factors in the referral process. Apart from physician practice, further factors affecting the referral outcome come into play during the patient’s visit to their physician. The following is an exploration of some of the common influences and barriers facing the patient, physician and overall system that affect the identification of at-risk women and the referral process. Identification and intervention Substance use identification and referral barriers are often intertwined. These barriers include patients’ honesty and willingness to facilitate a referral (Sloan, Gay, Snyder, & Bales, 1992; Tait, 2000); physicians’ comfort levels (Beich, Gannik, & Malterud, 2002; Donovan, 1991; Spandorfer, Israel, & Turner, 1999; Zellman et al., 1999); fear of patients’ reaction (Donovan, 1991; Miner et al., 1996; Svikis et al., 1997); capability, 19 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES education, and training (Aira, Kuahanen, Larivaara, & Rautio, 2003; Donovan, 1991; Fucito, Gomes, Murnion, & Haber, 2003; Herbert & Bass, 1997; Li et al., 1999; Miner et al., 1996); time constraints (Aira et al., 2003; Cornuz, Ghali, Carlantonio, Pecoud, & Paccaud, 2000; Donovan, 1991; Kaner, Heather, McAvoy, Lock, & Gilvarry, 1999; Li et al., 1999; Miner et al., 1996; Richmond & Anderson, 1994; Rush, Ellis, Crowe, & Powell, 1994; Spandorfer et al., 1999; Zellman et al., 1992); financial compensation (Hollander, 2002; Roche & Richard, 1991; Zellman et al., 1992); physician satisfaction (Miner, Giner, Lacalle, Franco, & Belasco, 1990; Saitz et al., 2002; Sansone, 2000); and perceived effectiveness of treatment services (Aira et al., 2003; Kaner et al., 1999; Laudet & White, 2005; Miner et al., 1996). Patient self-report Q: Did the doctor ask you about your [substance] use? A: Well they did ask me but I lied to them. I’m not going to tell them because Child and Family Services would have got called. (quoted from Tait, 2000) As mentioned earlier, one barrier to identification during a clinical interview or completion of a screening tool is that self-report depends largely on the at-risk woman to honestly answer questions about substance use. However, women who use substances (especially those who use during pregnancy) may be unwilling to divulge information regarding their substance use, particularly alcohol and other drug use, because they may be in denial; feel guilt; fear shame, stigma and judgment; or fear consequences such as child apprehension or legal intervention (Finkelstein, 1994; Howell et al., 1998; Jacobson, Chiodo, Sokol, & Jacobson, 2002; Moss, 1991; Roberts & Nanson, 2000; Sloan et al., 1992; Sullivan, 1990; Tait, 2000). Interestingly, physicians who consistently find their patients responding dishonestly may decrease their screening practices for substance use (Donovan, 1991; Li et al., 1999). Moreover, some physicians place the responsibility for recovery primarily on the patient, and emphasize that it is the patient who must take the initiative. Roche, Guray and Saunders (1991) conducted interviews with physicians about their views on alcohol and other drug problems among the general public. Roche et al. reported that physicians did not feel it was their responsibility to initiate the recovery process; as one physician stated, The only role for the doctor in substance abuse is where people want to do something about it anyway. Another physician interviewed in the same study felt that help would go for naught because the physician cannot change the patient’s lifestyle: I assume alcohol is in the background of all problems in my area but you can’t change their [patients’] lifestyle, so you forget about it. 20 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES Poorly phrased questions exacerbate these barriers and can cause patients to become more reticent (Corse et al., 1995; Morse, 2000). That is, if health providers phrase their interview questions or comments negatively (such as, “Now that you’re pregnant, just don’t drink,” “You don’t drink or use drugs, do you?” or “You know you shouldn’t do that when you’re pregnant”), it may inadvertently hinder open discussion and inhibit voluntary self-report (Corse et al., 1995; Morse, 2000). Physician discomfort and perceived patient reaction Like patients, physicians may feel discomfort when the issue of substance use emerges (Beich et al., 2002; Donovan, 1991; Spandorfer et al., 1999). This is more apparent for issues of alcohol or illicit drug use than for tobacco use (Jones-Webb, McKiver, Pirie, & Miner, 1999; Miner et al., 1996). Physicians may experience discomfort because screening interferes with establishing and maintaining a relationship, it imposes an unwelcome judgment role, and it entails intrusive questioning (Beich et al., 2002; Spandorfer et al., 1999). In addition, physicians may be uncomfortable raising the issue because they do not want to offend their patients (Donovan, 1991). Zellman et al. (1999) suggest that this discomfort causes physicians to avoid such issues. A physician interviewed by Roche et al. (1991) stated, Confronting or scaring them [patients] makes them feel worse about themselves. In terms of patient reaction, physicians perceive at-risk women to be reluctant to consent to the administration of a screening tool, and have reported that patient unwillingness is a barrier to screening for substance use (Li et al., 1999). Several studies have shown that physicians who are uncertain about how to approach or deal with at-risk women fear that inquiring about substance abuse during pregnancy may deter and drive women away from prenatal care (Donovan, 1991; Miner et al., 1996; Svikis et al., 1997). Physician education and training ...to get through the undergraduate course, and pass the exams. You’re not thinking about the wider social issues and you don’t appreciate the problems of alcoholism and managing patients, until you’ve got your own practice. –an interviewed physician (Roche et al., 1991) A lack of relevant education and training is often cited in the literature as reasons that physicians do not identify substance use, particularly alcohol and illicit drug use, in the general population as well as in at-risk women (Aira et al., 2003; Beckman, 1994; Donovan, 1991; Fucito et al., 2003; Herbert & Bass, 1997; Li et al., 1999; Miner et al., 1996). Some physicians may simply be unaware of safe drinking levels (Fucito et al., 2003; Howell et al., 1996; Roche & Richard, 1991). For instance, a Minnesota study showed that physicians were uncertain of the risks associated with different 21 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES degrees of alcohol use, were unaware of the scope of the problem, were uncertain of the best time to screen during pregnancy, and did not know the optimal medical recommendation (Miner et al., 1996). Further, in a Cincinnati study, some obstetricians believed that drinking was acceptable in the third trimester (Kenner, 1998). Physicians may also lack confidence in obtaining accurate information, and are consequently reluctant to screen for substance use (Miner et al., 1996). Other research suggests that physicians may be capable of diagnosing substance use, but lack proper training to handle the issue with their patients; that is, capable physicians may fear their inquiries will open a “Pandora’s box” of issues they are unprepared to manage (Durand, 1994; Li et al., 1999; Rosett & Weiner, 1981). There are a considerable number of physicians who feel unprepared to deal with alcohol and other drug use. In a Canadian study, just 55% of physicians and 41% of pediatricians reported feeling prepared to manage pregnant women who use alcohol (Tough et al., 2005). Interestingly, physicians who are younger and who have graduated more recently may be better equipped to handle such problems (Hollander, 2002; Roche & Richard, 1991; Roche et al., 1991; Fucito et al., 2003). A U.S. survey showed that 27% of physicians felt medical school did not adequately prepare them to assess alcohol use among pregnant women, 35% thought their training was adequate, and the remainder (38%) felt their training was very good or outstanding. The study also showed that physicians who felt better about their training were those who graduated after 1989; the level of satisfaction dropped drastically for earlier graduates. Compared with those who graduated after 1989, those who graduated before 1973 were 40% less likely to feel very prepared to determine alcohol use, 80% less likely to use a screening tool, and generally offered less advice to women who used alcohol during pregnancy. Physicians who graduated before 1973 were 10 times more likely to feel they received inadequate medical school training (Hollander, 2002). Financial compensation Lack of financial compensation as a barrier to treating substance-using patients has been documented in the literature on both the general public and at-risk women (Roche et al., 1991). In a study conducted by Roche et al., one physician stated, [It is] not financially rewarding to counsel because patients who are waiting will go elsewhere. Likewise, for at-risk women, research indicates that one disincentive for physicians to engage in the identification and intervention process is that they may not be reimbursed for their time spent (Zellman et al., 1992). Hollander (2002) found that a lack of insurance reimbursement was a barrier to providing screening services, more so among physicians who graduated from medical school before 1973 than among those who graduated after 1989. 22 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES Physician time constraints It is well reported in the literature that lack of time is a barrier physicians face when dealing with substance use, whether it be in the general population or in at-risk women (Aira et al., 2003; Cornuz et al., 2000; Donovan, 1991; Kaner et al., 1999; Li et al., 1999; Miner et al., 1996; Richmond & Anderson, 1994; Rush et al., 1994; Spandorfer et al., 1999; Zellman et al., 1992). In a study involving Canadian physicians (Tough et al., 2005), 59% reported not having enough time to talk to women about alcohol before they are pregnant. Physicians’ response that time is a limitation to identifying substance use certainly has merit (U.S. Preventive Services Task Force, 1996), but a researcher in this field suggests that this response may only be taken at face value because physicians take the time to deal with other similar preventive health issues, such as diabetes or follow-up of high blood pressure (Aira et al., 2003). Physician satisfaction and perception of addiction treatment efficacy Satisfaction is important to consider because it influences physician motivation to identify and treat addictions (Sansone, 2000). Specifically, physicians who gain less satisfaction from caring for patients may have a reduced intrinsic motivation to identify and provide intervention to their patients with addictions (Sansone, 2000). Thus, it is not surprising that physicians who are more satisfied with their efforts are more likely to diagnose patients with alcohol problems (Miner et al., 1990). However, Saitz et al. (2002) found that physicians were significantly less likely to experience satisfaction from caring for patients with alcohol or other drug problems than from caring for those with hypertension. Considering this research, it is plausible that dealing with patients who use alcohol or other drugs yields less satisfaction for physicians, and that physicians may therefore be less motivated to identify and treat addictions. In studies involving the general population, physicians have reported being more likely to refer patients to treatment services if those services have proven effective in the past (Kaner et al., 1999). Correspondingly, physicians who doubt the availability and effectiveness of a program will refrain from referring at-risk women to it (Miner et al., 1996). Unfortunately, some physicians believe their intervention efforts have little impact on their patients and view treatment services as ineffective (Aira et al., 2003; Laudet & White, 2005; Richmond & Anderson, 1994; Roche et al., 1991). Studies indicate that physicians have low expectations for the effectiveness of treatment services, especially those that emphasize “powerlessness” (giving up control) and spirituality (Aira et al., 2003; Laudet & White, 2005; Roche et al., 1991). Despite some physicians’ belief that their screening and intervention efforts have little or no impact, there is an abundance of research suggesting that physician intervention does in fact protect against substance use during pregnancy (Boyd, 1985; Cunningham, Sobell, Sobell, Agrawal, & Toneatto, 23 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES 1993; Ershoff, Mullen, & Quinn, 1989; Jones-Webb et al., 1999; Manwell, Fleming, Mundt, Stauggacher, & Barry, 2000; Minor & Van Dort, 1982; Rosenblatt, 1989; Secker-Walker, Solomon, Flynn, & Skelly, 1995; Windsor et al., 1985). Moreover, treatment services have proven effective in reducing and eliminating substance use among at-risk women (Beschner, Reed, & Mondanaro, 1981; Bien, Miller, & Tonigan ,1993; Finnegan, 1979; Mondanaro, 1987). In studies involving the general population, it has been suggested that physicians hold the misperception that treatment services are ineffective because physicians commonly receive feedback from clients who relapse or end up in acute emergency situations (Aira et al., 2003). Presumably, this type of feedback may lead physicians to believe that their counselling efforts or the treatment services were not effective. It is not surprising, then, that physicians report that caring for patients with alcohol and other drug problems yields less satisfaction than caring for patients with other problems such as hypertension or depression (Saitz et al., 2002). In review, the literature suggests that lower physician satisfaction may result in less substance use intervention and treatment referrals for at-risk women. Notably, experiencing repeated failure and little success may result in physicians reducing not only their intervention practices, but also their identification practices (Li et al., 1999). Follow-up Patient follow-through Even after a physician has made a referral, this does not necessarily translate into a patient entering treatment. One study showed that among the general population of patients who screened positively for substance use and who received a referral from their physician, only 2% to 11% accepted a referral, and of these, approximately 67% actually kept their appointments (Goldberg et al., 1991). The researchers concluded that less than 5% of positively screened patients ever followed through on the referral. There are many reasons for this, some of which have been discussed earlier in this literature review as barriers with regard to at-risk women’s attitudes about treatment services. Women who are more likely to accept treatment when it is offered usually suffer more severe substance use problems, have undergone treatment in the past, have partners who use alcohol, and have experienced physical and/or sexual abuse during pregnancy (Messer, Clark, & Martin, 1996). Physician follow-up There is little literature on physician follow-up with pregnant substance users. One study indicated that after identifying tobacco use in an initial prenatal visit, physicians only provided counsel for 21% of the return visits made by pregnant patients, despite the fact that the guidelines for these 24 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES physicians recommended questioning and counsel on all return visits (Moran, Thorndike, Armstrong, & Rigotti, 2003). Recommendations The following recommendations address the information and barriers presented in this literature review. Though the specific purpose of these recommendations is to improve physician referral rates to addiction treatment services, they may be beneficial in areas beyond referrals. Therefore, when appropriate, the reader is referred to sources of more detailed information that is relevant, but beyond the scope of this recommendations section. Implementing these recommendations will vary extensively in terms of the source of delivery, the method of delivery, the demographics of the target population (e.g., culture), relevant policy and regulations, and so forth. It is also recognized that for every challenge, there typically exist several solutions. Therefore, it is not practical to list all imaginable service delivery scenarios in this document. Rather, the purpose of these recommendations is to provide a launching point for stakeholders by addressing the barriers raised in the literature review. It is essential that stakeholders take the initiative in developing innovative and successful strategies to address issues concerning referrals of at-risk women. When considering how these recommendations will be delivered to at-risk women, it is important to emphasize an approach that promotes a safe and welcoming environment, that is respectful and non-judgmental, that is tailored to at-risk women, that is culturally relevant, and that delivers a consistent message. These characteristics are all key underpinnings necessary to arrive at a successful outcome (Leslie & Roberts, 1991; Working Group for FAS, 1999a; 1999b; 1999c). 1. Address risk perception and awareness of problem among at-risk women Despite high awareness of the harmful consequences of alcohol use during pregnancy (University of Alberta, 2004), women may not recognize that their own substance use during pregnancy is problematic (Poole & Isaac, 2001; Tait, 2000; Testa & Reifman, 1996). This may result in fewer women seeking help or receiving a referral. Therefore, measures should be taken to increase the number of women who acknowledge their own substance use during pregnancy as hazardous. For example, at-risk women could be provided with resources that help them to identify and discuss their own risks of substance use during pregnancy. It has also been found that certain groups of women (e.g., those who consume higher amounts of alcohol) may be less aware of the harm of substance use during pregnancy (Environics Research Group, 2002). Therefore, it may also be useful to focus relevant awareness and educational campaigns on at-risk women. 25 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES An effort that combines the aforementioned goals may improve the likelihood that at-risk women will seek help. In turn, this may potentially increase the number of physician referrals to treatment services. The content of such an effort to promote acknowledgement and awareness should · illustrate the health consequences to the mother · facilitate self-acknowledgement among at-risk women about the risks of their own use. This could be done by disseminating relevant resources (i.e., materials that incorporate the T-ACE or TWEAK). · debunk myths about substance use during pregnancy (e.g., emphasize that even if a woman has had a healthy baby despite using substances during pregnancy, drinking during a future pregnancy still poses significant health risks) · be delivered by a credible source, such as a physician Delivery of the above messages need not be the sole responsibility of the physician; it could occur through various community agencies, venues and initiatives. A popular method to raise public awareness is a media campaign. A Health Canada study (Environics Research Group, 2002) involved a nationwide survey of 907 women and 300 men. One part of the survey gauged recall of advertisements addressing alcohol use during pregnancy. Fifty-two per cent of women recalled ads about alcohol use during pregnancy. Women most often recalled seeing information or ads about alcohol use during pregnancy on television (56%), at a doctor’s office/hospital/clinic (27%), in magazines (26%), on the radio (11%) and on posters (10%). In addition, women were asked for their opinion on the effectiveness of different ways to inform them about the risks of drinking during pregnancy. Women felt that television advertising (74%), sending information to doctors and health-care professionals (70%), and posters in waiting rooms and clinics (62%) were all very effective methods to inform them about the health risks of alcohol use during pregnancy; these were followed by ads in buses, subways or bus shelters (44%), and posters or brochures in pharmacies (42%). Women were more likely than men to favour these methods. Other methods to publicize information include utilizing a community task force or committee; offering courses, seminars and luncheons; having guest speakers at community events, and conducting lectures. (For more on dissemination strategies, see Canadian Health Services Research Foundation, 2004; Harmsworth & Turpin, 2000; Lomas, 1997). Whatever the method of dissemination, there are a few key points that should be followed: · It should have a message that is laid out in plain language. · It should be widely accessible. · It should target areas where at-risk women can be reached. 26 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES 2. Improve at-risk women’s perception of treatment services and the prenatal clinic Women who hold negative views of treatment services or of the prenatal clinic may be hesitant to seek referrals for such service. It is therefore recommended that providers of addiction treatment services take the initiative to enhance their reputation among at-risk women. There are several key steps in doing so: · Treatment service providers and prenatal clinics garner input about how they are perceived by relevant communities and how these communities envision their role. · Treatment service providers and prenatal clinics assess and resolve common criticisms of their service delivery (e.g., legal intervention, child apprehension) and programs (e.g., culturally inappropriate). · Treatment service providers and prenatal clinics revamp their image as appropriate. For instance, treatment service providers may consider rephrasing or renaming programs so they have less social stigma tied to them. This notion has met with success before; a program involving Native American populations in the United States was able to increase the rate of accepted referrals for alcohol use to 56%. This high rate of acceptance was attributed to the phrasing of the referred program as a prevention program rather than a social work or alcohol program (LeMaster & Connell, 1994; Masis & May, 1991). · Treatment service providers and prenatal clinics bolster their revamped image in the target community. One example of how addiction treatment services in particular could improve their reputation requires proving the effectiveness of treatment to at-risk women as well as to physicians. At-risk women may be more likely to seek addiction treatment services if they are convinced of its effectiveness. It has been reported that over 60% of at-risk women believe they can cut back drinking on their own (Poole & Isaac, 2001). However, this is highly unsuccessful. At-risk women must be made aware that self-administered treatment or no treatment at all results in considerably less success than treatment provided by an addiction treatment service provider (Brown, 2001; Miller, Walters, & Bennett, 2001; Prendergast, Podus, Chang, & Urada, 2002; Winters, Stinchfield, Opland, Weller, & Latimer, 2000). Also, physicians have reported reluctance in referring their at-risk patients to addiction treatment services because of uncertainty that the treatment is effective (Miner et al., 1996). On the other hand, Kaner et al. (1999) found that physicians were more likely to make a referral if the referred service had been proven effective. Therefore, convincing physicians of treatment effectiveness is also important in order to improve referrals. In order to convince at-risk women and physicians that professional treatment is effective, treatment services need to be evaluated and, 27 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES if necessary, improved. When a program is deemed effective, this message needs to be circulated throughout communities, with emphasis in the communities where at-risk women and physicians can be reached. 3. Co-ordinate the referral system Physicians report a poorly co-ordinated referral system as a barrier to providing referrals (Donovan, 1991; Miner et al., 1996). A 2005 study of Canadian physicians and pediatricians showed that 73% of physicians and 48% of pediatricians felt referral resources for women of child-bearing age with alcohol problems were very helpful (Tough et al., 2005). The study also showed that 67% of physicians and 54% of pediatricians felt that a registry of FAS/FAE specialists available for consultation would be very helpful. This indicates that physicians do find referral systems useful. If well-defined referral systems were readily available, physicians would likely be more inclined to use them. Some at-risk women may be more likely to seek help at places other than a medical clinic, such as a general mental health centre (Schober & Annis, 1996; Weisner et al., 1995). It is therefore important that a continuum of care be in place to ensure that women who seek help receive effective and efficient care. To this end, health organizations, agencies and governments should take it upon themselves to bridge gaps and promote relationships with one another. Once relationships and partnerships have been established, these groups can define effective referral processes, transfer knowledge and educate each other about the best ways to manage and help at-risk women. In turn, this could facilitate a seamless flow among services provided by different health organizations. 4. Increase at-risk women’s awareness of addiction treatment services and the referral process The literature indicates that at-risk women are unsure of what help is available, and where and how to get help (Allen, 1994; Currie, 2001; Grant, 1997; Howell et al., 1996; McElaney, 1991; Poole & Isaac, 2001; Roche & Richard, 1991; Tait, 2000). To remedy this, health organizations (particularly addictions treatment providers and medical clinics) should develop a presence in areas that are frequented by at-risk women. Determining these areas may require some research into the different demographics and characteristics of at-risk women. Some areas may include social organizations, health communities, schools, income assistance offices, neighbourhood and friendship centres, and relevant government ministries. Once areas have been identified, treatment service providers need to broadcast information about their services and the processes required to receive those services, specifically outlining the referral process (which should be well defined and straightforward). Research suggests using a community task force to advocate such messages (Working Group for FAS, 1999a; 1999b; 1999c). Outreach efforts to at-risk women have also been recommended 28 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES in the literature (Howell et al., 1999; Namyniuk, Brems, & Carson, 1997; other dissemination strategies can be reviewed in Canadian Health Services Research Foundation, 2004; Harmsworth & Turpin, 2000; Lomas, 1997). 5. Standardize physician screening and referral practice Tough et al. (2005) report that 60% of Canadian physicians and 67% of Canadian pediatricians would value clinical practice guidelines related to fetal alcohol syndrome (FAS). The Alberta Medical Association and Health Canada have published best practice guidelines for preventing FAS, which includes formal screening guidelines for at-risk women. These guidelines may be used as a source to develop standard practice guidelines for managing substance use among at-risk women as well as among the general public. (For complete guidelines, see Working Group for FAS, 1999a; 1999b; 1999c; Roberts & Nanson, 2001.) Moreover, guideline development could be proposed to appropriate health agencies, specifically the Alberta Medical Association, the College of Physicians and Surgeons of Alberta, and the Royal College of Physicians and Surgeons of Canada. Because of the large numbers of at-risk women and the potential consequences of substance use during pregnancy, it is often recommended and warranted that routine screening for all women of child-bearing age be conducted using effective screening tools (Health Canada, 2000b; Legge, Roberts, & Butler, 2000; Morse, 2000; Working Group for FAS, 1999b; 1999c). Combining multiple methods of screening (biological, clinician interview/self-report, and proven screening tools) would likely prove the most successful method to detect substance use. Contrary to the notion that physician identification and intervention is of little consequence, it should be viewed as an optimal opportunity to make a positive impact on the life of an at-risk woman and her child. There are numerous reasons it is important for physicians to routinely screen and, if necessary, refer at-risk patients: · Patients may be reluctant to self-report or voluntarily discuss substance use, and a screening tool should yield more honest answers. · Routine screening may help the physician develop rapport with the patient, which may encourage an open atmosphere; in turn, this may increase referral rates. In fact, physicians have indicated that their patients have responded positively to their intervention because the patients felt the inquiry stemmed from genuine concern for their health and well-being (Beich et al., 2002). · Early identification and treatment can have a major impact on the health of the fetus. For pregnant women who are using substances but are unaware of their pregnancy, or for women who are using substances and likely to become pregnant, early identification of a substance problem can prevent health problems in the fetus. 29 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES · Physicians are one of the best sources of information for at-risk women, especially because at-risk women value their physician’s counsel (Boyd, 1985; Cunningham et al., 1993; Ershoff et al., 1989; Jones-Webb et al., 1999; Manwell et al., 2000; Minor & Van Dort, 1982; Rosenblatt, 1989; Secker-Walker et al., 1995; Windsor et al., 1985). If physicians convey that substance use during pregnancy is an issue worthy of attention, it may be more likely that at-risk women will take positive action. Even pregnant women who do not disclose alcohol use to their physician still heed the advice given (Rosett et al., as cited in Working Group for FAS, 1999c). · At-risk women may be reluctant to be identified as substance users and reluctant to receive referrals for treatment; thus, consistent screening and referral efforts may eventually reach intractable women who were not initially identified, as well as motivate others who were previously referred but have not yet utilized the service. 6. Use suggested screening tools for tobacco and other drug use The TWEAK and the T-ACE were described earlier in this literature review as effective and recommended screening tools for alcohol use among at-risk women (Chang, 1997; Chang et al., 1998). However, in the articles reviewed, there were few incidences where physicians chose to use a formal screening tool to identify tobacco or other drug use. Nevertheless, tools have been developed to screen for alcohol, tobacco and other drug use during the prenatal and pregnant periods. Two of these tools are the Hospital Screening Questionnaire (HSQ) (CSAP, 1993) and the Pregnancy Information Program (PIP) (Lapham, Kring, & Skipper, 1991). The HSQ is an extensively used questionnaire that is advantageous because it assesses patients’ alcohol, tobacco and other drug usage over time (pre-pregnancy, during pregnancy, and in the perinatal period). One drawback of the HSQ is the high quantity of questions; however, it has been suggested that the questionnaire could be modified to fit a more timesensitive environment (CSAP, 1993). The second screening tool, the PIP, is a patient-interactive computer program that follows a self-administered questionnaire format. The PIP provides risk assessment data for dietary habits; alcohol, tobacco and other drug use; psychosocial stressors; and social support. The program was designed specifically for pregnant and postpartum women. The program has been used successfully in clinical settings to screen women of different cultures for substance use (CSAP, 1993; Lapham et al., 1991). A screening tool’s cultural sensitivity is important, especially in light of the findings of Horn, Wanberg and Foster (1990), which demonstrated marked cultural differences in responses to their screening instrument (CSAP, 1993). The Maternal Substance Use Assessment Methods Reference Manual (CSAP, 1993) reports that patients preferred the PIP to a written questionnaire; that there were high concurrence rates with urine testing; and that compared with the written questionnaire, 30 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES the program detected similar rates of tobacco use, but significantly higher rates of alcohol and other drug use (Allen & Skinner, 1987; CSAP, 1993; Lapham et al., 1991; Lapham, Henley, & Kleyboecker, 1993). In support of this latter finding, some research indicates that computer-delivered self-assessments yield more valid responses than face-to-face administrations (CSAP, 1993; Russell et al., 1996). One reported drawback to the use of the PIP is the purchasing cost of the program (CSAP, 1993). The HSQ and the PIP are two of many tools that may be used to screen for use of substances other than just alcohol. (For a complete review of screening tools, please see CSAP, 1993 and Wild, Hodgins, Thygesen, Cooper, & Curtis, 2004). Whatever the tool chosen, it is important to determine the tool’s effectiveness and sensitivity within the population of at-risk women. It is also critical that physicians receive training to use the tool and recognize the value and benefit of using it. Proven success with evidence-based tools and subsequent dissemination of the results are both key to the uptake of such practices in the clinical and the health community. 7. Provide education and training for physicians Physicians have expressed a need and desire for relevant educational information on substance use during pregnancy (Miner et al., 1996). Tough et al. (2005) found that 49% of Canadian family physicians and 45% of Canadian pediatricians felt that literature on the impact of alcohol use during pregnancy was very helpful. In the same study, 50% of physicians and 54% of pediatricians reported feeling that materials or training on FAS/FAE were very helpful, and 34% of physicians and 17% of pediatricians reported feeling that training on addictions counselling was very helpful. Proper education and training may help physicians develop better relationships with their patients and help overcome barriers such as discomfort, fear of patient reaction, and lack of confidence to manage such cases. Among many things, educational efforts should inform physicians about the prevalence of substance use during pregnancy; emphasize the importance of screening, referral and early engagement (for more details see Pepler, Motz, Moore, & Leslie, n.d.); and promote collaboration within the general community and the health community. Perhaps the most important focus of any education or training effort is on effective physician communication with the patient. As mentioned, a non-judgmental, respectful, consistent and culturally sensitive message is fundamental to any approach; this seems especially central in the case of the physician-patient relationship. Research has shown that effective physician communication with the patient can ameliorate tension and confrontation (Boyd, 1985). Patients are also more motivated to follow their physician’s advice if there exists a supportive relationship (Boyd, 1985). Several educational and training resources directed at physicians that incorporate the above elements are available, and could be drawn from 31 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES to develop educational efforts aimed at preventing substance use during pregnancy. Current resources include courses offered by Continued Medical Education (CME), which is recognized as an authority in ongoing physician education. For example, the Doctors and Tobacco Reduction in Pregnant Women project (Barrett, 2005) has recommended that an online or face-toface CME course be offered to physicians in the Red Deer region to help reduce tobacco use. Another resource stems from the Tobacco Reduction and Assessment project, which has developed a training manual targeted at physicians managing tobacco dependence with their patients. Educational efforts may also involve providing physicians with training in motivational interviewing techniques (Miller & Rollnick, 2002; Miller, Zweben, DiClemente, & Rychtarik, 1994) as well as educating physicians about the transtheoretical model of behaviour change, also known as the stages of change model (Prochaska, DiClemente, Velicer, Ginpil, & Norcross, 1985; Prochaska & Goldstein, 1991; Prochaska & Velicer, 1997). 8. Provide financial compensation to physicians It has been suggested that adequate reimbursement protocol would improve identification and intervention rates (Green, Eriksen, & Schor, 1988). Physicians need to be made aware of government subsidy programs that allocate reimbursement funding for specific tasks such as managing at-risk women. As well, subsidy and reimbursement programs should be established if they do not exist. In doing so, government bodies concerned with the issue of pregnancy and substance use need to be made aware of the lower costs and greater benefits of funding preventative medicine as opposed to spending on lifelong treatment. Gortmaker (1981) reported that funds spent on prenatal care reduce by two to three times the future costs of supporting babies who were exposed to substances during gestation, as well as their families. However, this study was based on the U.S. health system, so caution must be taken in generalizing this to Canada. Nevertheless, subsidy or reimbursement programs for physician management of at-risk women may be a viable option for funding in the area of preventative medicine. 9. Encourage physicians to follow up with patients It is recommended that physicians follow up with their patients frequently, even during periods between pregnancies, for several reasons: · Even though a woman may not screen positive one time, it does not mean she will not screen positive the next. · One screening may not be enough to elicit honest self-report, and consistent screening may be necessary before an at-risk women feels comfortable enough to respond openly. Similarly, one referral may not be enough to motivate an at-risk woman to enter treatment; several referrals may be necessary. 32 Physician referrals to addiction treatment services: A literature review AADAC | RESEARCH SERVICES · Because high-risk mothers may be least likely to get care early in pregnancy, it is of particular importance to screen them whenever possible, even during periods before or after pregnancy (Masotti et al., 2003). · Follow-up is vital in developing rapport and establishing continuity of care, both of which may increase the likelihood that an at-risk woman will seek physician direction for substance use. 10. Provide physicians with feedback about referred patients Whether at-risk women receive a referral and do not seek treatment services, or whether they seek treatment services and successfully cease substance use, it is critical that physicians receive feedback about the outcomes of their efforts. This will reinforce actions that result in positive outcomes while allowing physicians to adjust actions that have not met with success. At the same time, however, if physicians do not receive feedback, they must trust that their efforts have a positive impact. For instance, pregnant women who do not divulge their substance use to their physician will still heed advice their physician provides (Rosett et al., as cited in Working Group for FAS, 1999c). Providing physicians with feedback may also improve their view about the effectiveness of addiction treatment, which is important because physicians are more likely to refer to treatment services they feel are effective (Kaner et al., 1999). Conclusion This literature review has explored the referral practices and models of service delivery provided by physicians to at-risk women. 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