10 - Heart
Tierney, Lawrence M., McPhee, Stephen J., Papadakis, Maxine A.
Current Medical Diagnosis & Treatment, 45th Edition
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Approach to the Patient & Health Maintenance
Michael Pignone MD, MPHS
Stephen J. McPhee MD
See http://www.cmdtlinks.com
GENERAL APPROACH TO THE PATIENT
The approach to diagnosis begins with the history and pertinent physical examination—both susceptible to errors of omission and commission. The medical interview serves several functions. It is used to collect information of help in diagnosis (the “history” of the present illness), to assess and communicate prognosis, to provide emotional support, and to reach agreement with the patient about further diagnostic procedures and therapeutic options. It also serves as an opportunity to influence patient behavior, such as in motivational discussions about smoking cessation or medication adherence. Interviewing techniques that avoid domination by the clinician increase patient involvement in care and patient satisfaction. Effective clinician-patient communication and increased patient involvement can improve health outcomes.
Patient Compliance
For many illnesses, treatment depends on difficult fundamental behavioral changes, including alterations in diet, taking up exercise, giving up smoking, cutting down drinking, and adhering to complex medication regimens. Compliance is a problem in every practice; up to 50% of patients fail to achieve full compliance, and one-third never take their medicines. Many patients with medical problems, even those with access to care, do not seek appropriate care or may drop out of care prematurely. Compliance rates for short-term, self-administered therapies are higher than for longterm therapies and are inversely correlated with the number of interventions, their complexity and cost, and the patient's perception of overmedication.
As an example, in HIV-infected patients, adherence to antiretroviral therapy is a crucial determinant of treatment success. Studies have unequivocally demonstrated a close relationship between patient compliance and plasma HIV RNA levels, CD4 cell counts, and mortality. Adherence levels of > 95% are needed to maintain virologic suppression. However, studies show that over 60% of patients are < 90% adherent and that adherence tends to decrease over time. Patient reasons for nonadherence include simple forgetfulness, being away from home, being busy, and changes in daily routine. Other reasons include psychiatric disorders (depression or substance abuse), uncertainty about the effectiveness of treatment, lack of knowledge about the consequences of poor adherence, regimen complexity, and treatment side effects.
Patients seem better able to take prescribed medications than to comply with recommendations to change their diet, exercise habits, or alcohol intake or to perform various self-care activities (such as monitoring blood glucose levels at home). For short-term regimens, adherence to medications can be improved by giving clear instructions. Writing out advice to patients, including changes in medication, may be helpful. Because low functional health literacy is common (almost half of English-speaking patients are unable to read and understand standard health education materials), other forms of communication—such as illustrated simple text, videotapes, or oral instructions— may be more effective. For non–English-speaking patients, clinicians and health care delivery systems can work to provide culturally and linguistically appropriate health services.
To help improve adherence to long-term regimens, clinicians can work with patients to reach agreement on the goals for therapy, provide information about the regimen, ensure understanding by using the “teachback” method, counsel about the importance of adherence and how to organize medication-taking, reinforce self-monitoring, provide more convenient care, prescribe a simple dosage regimen for all medications (preferably one or two doses daily), suggest ways to help in remembering to take doses (time of day, mealtime, alarms) and to keep appointments, and provide ways to simplify dosing (medication boxes). Single-unit doses supplied in foil-backed wrappers should be avoided for patients who have difficulty opening them. Medication boxes with compartments (eg, Medisets) that are filled weekly are useful. Microelectronic devices can provide
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feedback to show patients whether they have taken doses as scheduled or to notify patients within a day if doses are skipped. The clinician can also enlist social support from family and friends, recruit an adherence monitor, and provide rewards and recognition for the patient's efforts to follow the regimen.
Compliance is also improved when a trusting doctor-patient relationship has been established and when patients actively participate in their care. Clinicians can improve patient compliance by inquiring specifically about the behaviors in question. When asked, many patients admit to incomplete compliance with medication regimens, with advice about giving up cigarettes, or with engaging only in “safe sex” practices. Although difficult, sufficient time must be made available for communication of health messages. Other ways of assessing medication compliance include pill counts and refill records; monitoring serum, urine, or saliva levels of drugs or metabolites; watching for appointment nonattendance and treatment nonresponse; and assessing predictable drug effects such as weight changes with diuretics or bradycardia from bblockers. Even partial compliance, as with drug treatment of hypertension and diabetes mellitus, improves outcomes compared with noncompliance.
Guiding Principles of Care
Ethical decisions are often called for in medical practice, at both the “micro” level of the individual patientclinician relationship and at the “macro” level of the allocation of resources. Ethical principles that guide the successful approach to diagnosis and treatment are honesty, beneficence, justice, avoidance of conflict of interest, and the pledge to do no harm. Increasingly, Western medicine involves patients in important decisions about medical care, including how far to proceed with treatment of patients who have terminal illnesses (see Chapter 5).
The clinician's role does not end with diagnosis and treatment. The importance of the empathic clinician in helping patients and their families bear the burden of serious illness and death cannot be overemphasized. “To cure sometimes, to relieve often, and to comfort always” is a French saying as apt today as it was five centuries ago—as is Francis Peabody's admonition: “The secret of the care of the patient is in caring for the patient.”
DeWalt DA et al: Literacy and health outcomes: a systematic review of the literature. J Gen Intern Med 2004;19:1228.
Golin C et al: Impoverished diabetic patients whose doctors facilitate their participation in medical decision making are more satisfied with their care. J Gen Intern Med 2002;17:857.
Haynes RB et al: Helping patients follow prescribed treatment: clinical applications. JAMA 2002;288:2880.
McDonald HP et al: Interventions to enhance patient adherence to medication prescriptions: scientific review. JAMA 2002;288:2868.
McPhee SJ: Caring for a 70-year-old Vietnamese woman. JAMA 2002;287:495.
Rajput V et al: Ethical issues in hospital medicine. Med Clin North Am 2002;86:869.
HEALTH MAINTENANCE & DISEASE PREVENTION
Preventive medicine is categorized as primary, secondary, or tertiary. Primary prevention aims to remove or reduce disease risk factors (eg, immunization, giving up or not starting smoking). Secondary prevention techniques promote early detection of disease or precursor states (eg, routine cervical Papanicolaou screening to detect carcinoma or dysplasia of the cervix). Tertiary prevention measures are aimed at limiting the impact of established disease (eg, partial mastectomy and radiation therapy to remove and control localized breast cancer). Table 1-1 gives recent data for deaths from preventable causes in the United States. Table 1-2 compares recommendations for periodic health examinations as developed by the United States Preventive Services Task Force, the American College of Physi
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cians, and the Canadian Task Force on the Periodic Health Examination. Despite emerging consensus on many of the services, controversy persists for others. Many effective preventive services are underutilized. One analysis concluded that the following services had the most potential for improvement, based on their effectiveness and underuse: counseling about smoking cessation; screening older adults for vision impairment; screening and counseling adults and adolescents about alcohol abuse; screening older adults for colorectal cancer; screening young women for chlamydia infection; and vaccinating older adults against pneumococcal disease.
Table 1-1. Estimated annual deaths from preventable causes in the United States in the 1990s. | ||||||||||||||||
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Table 1-2. Expert recommendations for preventive care for asymptomatic, low-risk adults. | ||||||||||||||||||||||||||||||||||||||||||||||||||||
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Coffield AB: Priorities among recommended clinical preventive services. Am J Prev Med 2001;21:1.
Walsh JM et al: Prevention in the year 2002: some news, some issues. Prim Care Clin North Am 2002;29:727.
PREVENTION OF INFECTIOUS DISEASES
Much of the decline in the incidence and fatality rates of infectious diseases is attributable to public health measures—especially immunization, improved sanitation, and better nutrition.
Immunization remains the best means of preventing many infectious diseases. In the United States, childhood immunization has resulted in near elimination of measles, mumps, rubella, poliomyelitis, diphtheria, pertussis, and tetanus. Haemophilus influenzae type b invasive disease has been reduced by more than 95% since introduction of the first conjugate vaccines. However, substantial vaccine-preventable morbidity and mortality continue to occur among adults from vaccine-preventable diseases such as hepatitis A, hepatitis B, influenza, and pneumococcal infections. For example, in adults in the United States, there are an
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estimated 50,000–70,000 deaths annually from influenza, hepatitis B, and invasive pneumococcal disease. Yet in 2002, only 66% and 62% of elderly persons reported receiving influenza and pneumococcal vaccines (respectively). The American College of Physicians recommends that clinicians should review each adult's immunization status at age 50; assess risk factors that would indicate a need for pneumococcal vaccination and annual influenza immunizations; reimmunize at age 65 those who received an immunization against pneumococcus more than 6 years before; ensure that all adults have completed a primary diphtheria-tetanus immunization series, and administer a single booster at age 50; and assess the postvaccination serologic response to hepatitis B vaccination in all recipients who have ongoing risks of exposure to blood or body fluids (eg, sharp injuries, blood splashes).
Recently, needle-free jet injectors have been used successfully in administering trivalent inactivated influenza vaccine. In randomized, controlled trials, a novel triple-antigen (S, pre-S1, and pre-S2) recombinant hepatitis B vaccine (Hepacare) appears to be more effective than currently available single-antigen (S only) vaccine (Engerix B, Recombivax-HB). The new triple-antigen vaccine is also effective in more than three-quarters of inadequate responders to current single-antigen vaccines.
In 2002, the Advisory Committee on Immunization Practices approved a schedule for the routine vaccination of persons aged 19 years and older. Recommended immunization schedules for children and adolescents are set forth in Table 30-4. Persons traveling to countries where infections are endemic should take precautions described in Chapter 30. Immunization registries—confidential, population-based, computerized information systems that collect vaccination data about all residents of a geographic area—can be used to increase and sustain high vaccination coverage. Currently, approximately half of children in the United States younger than 6 years are participating in a registry, and national health objectives aim to increase this figure to 95% by 2010.
Skin testing for tuberculosis and treating selected patients reduce the risk of reactivation tuberculosis (see Table 9-12). Attention to technique helps separate negative from positive results. Drawing a line on the skin with a medium ballpoint pen, starting 1–2 cm away from the skin reaction and then stopping when resistance is felt, gives a more precise measurement of induration. Patients with HIV infection are at an especially high risk for tuberculosis. This is discussed in Chapter 31, as is multidrug-resistant tuberculosis.
HIV infection is now the major infectious disease problem in the world. Since sexual contact is a common mode of transmission, prevention relies on eliminating unsafe sexual behavior by promoting abstinence, later onset of first sexual activity, decreased number of partners, and use of latex condoms. Appropriately used, condoms can reduce the rate of HIV transmission by nearly 70%. Couples with one infected partner who used condoms inconsistently had a considerable risk of infection: the rate of seroconversion was 4.8 per 100 persons per year, leading to an estimated cumulative incidence of 12.7% after 24 months. No seroconversions were noted with consistent condom use. Unfortunately, as many as one-third of HIV-positive individuals continue unprotected sexual practices after learning that they are HIV-infected. Tailored group educational intervention focused on practicing “safer sex” can reduce their transmissionrisk behaviors with partners who are not HIV-positive. Other approaches to prevent HIV infection include treatment of sexually transmitted diseases, development of vaginal microbicides, and vaccine development. Increasingly, cases of HIV infection are transmitted by injection drug use. HIV prevention activities should include provision of sterile injection equipment for these individuals.
In immunocompromised patients, live vaccines are contraindicated but many killed or component vaccines are safe and recommended. Asymptomatic HIVinfected patients have not shown adverse consequences when given live MMR and influenza vaccinations as well as tetanus, hepatitis B, H influenzae type b, and pneumococcal vaccinations—all should be given. However, if poliomyelitis immunization is required, the inactivated poliomyelitis vaccine is indicated. In symptomatic HIV-infected patients, live virus vaccines such as MMR should generally be avoided, but annual influenza vaccination is safe.
Whenever possible, immunizations should be completed before procedures that require or induce immunosuppression (organ transplantation or chemotherapy), or that reduce immunogenic responses (splenectomy). However, if this is not possible, the patient may mount only a partial immune response, yet even this partial response can be of benefit. Patients who undergo allogeneic bone marrow transplantation lose preexisting immunities and should be revaccinated. In many situations, family members should also be vaccinated to protect the immunocompromised patient, although oral live polio vaccine should be avoided because of the risk of infecting the patient.
New cases of poliomyelitis have been reported in Haiti and the Dominican Republic recently, slowing its eradication in the Western Hemisphere.
The 2001 anthrax attacks in the United States have raised concern about the nation's vulnerability to a smallpox attack. Resumption of smallpox vaccination was undertaken for some health care workers, police and firemen, etc. However, smallpox vaccine has a higher complication rate than any other vaccine currently being used. Expected adverse events in a mass smallpox vaccination campaign include fever (less than one case per five vaccine recipients), rash (less than one case per one hundred recipients), encephalitis (less than three cases per million), and death (less than two cases per million). Observed complications included a higher incidence of myocardial infarction than anticipated.
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Careful prevaccination exclusion of high-risk individuals (those with eczema or immunosuppression or coronary artery disease) is essential to minimize such complications. More than 25% of potential vaccine recipients would require such exclusion, and these individuals would remain susceptible to smallpox infection.
Avery RK: Immunizations in adult immunocompromised patients: which to use and which to avoid. Cleve Clin J Med 2001;68:337.
Horwood F et al: Pneumococcal and influenza vaccination: current situation and future prospects. Thorax 2002;57(Suppl 2):II24.
Iseman M: A 52-year-old man with a positive PPD. JAMA 2001;286:2015.
Kalichman SC et al: Effectiveness of an intervention to reduce HIV transmission risks in HIV-positive people. Am J Prev Med 2001;21:84.
Lane JM et al: Evaluation of 21st-century risks of smallpox vaccination and policy options. Ann Intern Med 2003;138: 488.
Young MD et al: Adult hepatitis B vaccination using a novel triple antigen recombinant vaccine. Hepatology 2001;34:372.
PREVENTION OF CARDIOVASCULAR DISEASE
Cardiovascular diseases, including coronary heart disease and stroke, represent two of the most important causes of morbidity and mortality in developed countries. Several risk factors increase the risk for coronary disease and stroke. They can be divided into those that are modifiable (eg, lipid disorders, hypertension, cigarette smoking) and those that are not (eg, gender, age, family history of early coronary disease). This section considers the role of screening for and treating modifiable risk factors.
Impressive declines in age-specific mortality rates from heart disease and stroke have been achieved in all age groups in North America during the past 2 decades. The chief reasons for this favorable trend appear to be modification of risk factors, especially cigarette smoking and hypercholesterolemia, plus more aggressive detection and treatment of hypertension and better care for patients with heart disease.
Cigarette Smoking
Cigarette smoking remains the most important cause of preventable morbidity and early mortality. In 2000, there were an estimated 4.84 million premature deaths in the world attributable to smoking, 2.41 million in developing countries and 2.43 million in industrialized countries. More than three-quarters (3.84 million) of these deaths were in men. The leading causes of death from smoking were cardiovascular diseases (1.69 million deaths), chronic obstructive pulmonary disease (COPD) (0.97 million deaths), and lung cancer (0.85 million deaths). Nicotine is highly addictive, raises brain levels of dopamine, and produces withdrawal symptoms on discontinuation. Cigarettes are responsible for one in every five deaths in the United States, yet smoking prevalence rates have been increasing among high school and college students. Cigar smoking has also increased; there is also continued use of smokeless tobacco (chewing tobacco and snuff), particularly among young people. Tobacco dependence may have a genetic component.
Smokers have twice the risk of fatal heart disease, 10 times the risk of lung cancer, and several times the risk of cancers of the mouth, throat, esophagus, pancreas, kidney, bladder, and cervix; a twofold to threefold higher incidence of stroke and peptic ulcers (which heal less well than in nonsmokers); a twofold to fourfold greater risk of fractures of the hip, wrist, and vertebrae; four times the risk of invasive pneumococcal disease; and a twofold increase in cataracts. In the United States, over 90% of cases of COPD occur among current or former smokers. Both active smoking and passive smoking are associated with deterioration of the elastic properties of the aorta and with progression of carotid artery atherosclerosis. Smoking has also been associated with increased risks of leukemia, of colon and prostate cancers, of breast cancer among postmenopausal women who are slow acetylators of N-acetyltransferase-2 enzymes, osteoporosis, and Alzheimer's disease. In cancers of the head and neck, lung, esophagus, and bladder, smoking is linked to mutations of the P53 gene, the most common genetic change in human cancer. Patients with head and neck cancer who continue to smoke during radiation therapy have lower rates of response than those who do not smoke. Olfaction and taste are impaired in smokers, and facial wrinkles are increased. Heavy smokers have a 2.5 greater risk of agerelated macular degeneration. Smokers die 5–8 years earlier than never-smokers.
The children of smokers have lower birth weights, are more likely to be mentally retarded, have more frequent respiratory infections and less efficient pulmonary function, have a higher incidence of chronic ear infections than children of nonsmokers, and are more likely to become smokers themselves.
In addition, exposure to environmental tobacco smoke has been shown to increase the risk of cervical cancer, lung cancer, invasive pneumococcal disease, and heart disease; to promote endothelial damage and platelet aggregation; and to increase urinary excretion of tobacco-specific lung carcinogens. The incidence of breast cancer may be increased as well. Of approximately 450,000 smoking-related deaths in the United States annually, as many as 53,000 are attributable to passive smoking.
Smoking cessation lessens the risks of death and of myocardial infarction in people with coronary artery disease; reduces the rate of death and acute myocardial infarction in patients who have undergone percutaneous coronary revascularization; lessens the risk of stroke; slows the rate of progression of carotid atherosclerosis; and is associated with reversal of chronic bronchitis and improved pulmonary function. On average,
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women smokers who quit smoking by age 35 add about 3 years to their life expectancy, and men add more than 2 years to theirs. Smoking cessation can increase life expectancy even for those who stop after the age of 65.
Fortunately, adult rates in the United States are now at an all-time low—23%—but rates are climbing for young people.
Although tobacco use constitutes the most serious common medical problem, it is undertreated. Over 70% of smokers see a physician each year, but only 20% of them receive any medical quitting advice or assistance. (Persons whose physicians advise them to quit are 1.6 times as likely to attempt quitting.) About 4% of smokers are able to quit each year.
Table 1-3. Actions and strategies for the primary care clinician to help patients quit smoking. | ||||||||||||||||||||||||||||||
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The five steps for helping smokers quit are summarized in Table 1-3. Common elements of supportive smoking cessation treatments are reviewed in Table 1-4. A system should be implemented to identify smokers, and advice to quit should be tailored
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to the patient's level of readiness to change. Pharmacotherapy to reduce cigarette consumption is ineffective in smokers who are unwilling or not ready to quit. Conversely, all patients trying to quit should be offered pharmacotherapy except those with medical contraindications, women who are pregnant or breast-feeding, and adolescents. Nicotine replacement therapy doubles the chance of successful quitting. Guidelines for its use are presented in Table 1-5. Suggestions for the nicotine patch are listed in Table 1-6 and for nicotine gum in Table 1-7. The nicotine patch, gum, and lozenges are available over-the-counter, and nicotine nasal spray and inhalers by prescription. When the spray is combined with the patch, cessation rates are substantially higher. The sustained-release antidepressant drug bupropion (150–300 mg/d) is an effective smoking cessation agent and is associated with minimal weight gain, although seizures are a contraindication. It acts by boosting brain levels of dopamine and norepinephrine, mimicking the effect of nicotine. Bupropion, either alone or in combination with a nicotine patch, has been shown to produce significantly higher abstinence rates (30–35% at 1 year) than either a patch alone or placebo. Weight gain was less in the combined program (Table 1-8).
Weight gain occurs in most patients (80%) following smoking cessation. For many it averages 2 kg, but for others (10–15%) major weight gain—over 13 kg—may occur.
Clinicians should not show disapproval of patients who have not stopped smoking or who are not ready to make a quit attempt. Thoughtful advice that emphasizes the benefits of cessation and recognizes common barriers to success can increase motivation to quit and quit rates. An intercurrent illness such as acute bronchitis or acute myocardial infarction may motivate even the most addicted smoker to quit. Individualized or group counseling is very cost-effective, even more so than treating hypertension. Smoking cessation counseling by telephone (“quitlines”) has proved effective. An additional strategy is to recommend that any smoking take place out of doors to limit the effects of passive smoke on housemates and coworkers. This can lead to smoking reduction and quitting. The
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clinician's role in smoking cessation is summarized in Table 1-4.
Table 1-4. Common elements of supportive smoking treatments. | ||||||||||||
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Table 1-5. Clinical guidelines for prescribing nicotine replacement products. | ||
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Ahluwalia JS et al: Sustained-release bupropion for smoking cessation in African Americans: a randomized controlled trial. JAMA 2002;288:468.
Burns DM: Epidemiology of smoking-induced cardiovascular disease. Prog Cardiovasc Dis 2003;46:11.
Critchley JA et al: Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review. JAMA 2003;290:86.
Parmet S et al: JAMA patient page. Smoking and the heart. JAMA 2003;290:146.
Shiffman S et al: Efficacy of a nicotine lozenge for smoking cessation. Arch Intern Med 2002;162:1267.
Stead LF et al: Telephone counselling for smoking cessation. Cochrane Database Syst Rev 2003;(1):CD002850.
Stevens LW: JAMA patient page. Kicking the habit. JAMA 2002;288:532.
Lipid Disorders
Lower low-density lipoprotein (LDL) cholesterol concentrations and higher high-density lipoprotein (HDL) levels are associated with a reduced risk of coronary heart disease. Elevated triglyceride levels and elevated plasma lipoprotein(a) are independent risk factors for coronary heart disease. The absolute benefits of screening for—and treating—abnormal lipid levels depend on the presence of other cardiovascular risk factors. If other risk factors are present, cardiovascular risk is higher and the benefits of therapy are greater. Patients with diabetes mellitus or known cardiovascular disease are at still higher risk and benefit from treatment even when lipid levels are normal.
Compliance with statin-type drugs is better than for the other classes of lipid-lowering agents. Multiple large randomized, placebo-controlled trials have convincingly demonstrated significant reductions in total mortality and major coronary events with lowering levels of LDL cholesterol by statin therapy including both middle-aged and elderly individuals. These results were achieved in a broad range of patients including those with or without a history of
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coronary artery disease, those with elevated or average LDL-C levels, and those undergoing successful percutaneous transluminal coronary angioplasty. Statins also appear to reduce the risk of stroke and, in the case of high-potency statins, marked LDL-C reductions (< 100 mg/dL) produce regression of carotid artery atherosclerosis.
Table 1-6. Suggestions for the clinical use of the nicotine patch. | ||||||||||||||||||||||||||||||||||||
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Guidelines for therapy are discussed in Chapter 28.
Collins R et al: MRC/BHF Heart Protection Study of cholesterollowering with simvastatin in 5963 people with diabetes: a randomized placebo-controlled trial. Lancet 2003;361:2005.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults: Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults P.10
(Adult Treatment Panel III). JAMA 2001;285:2486.
Law MR et al: Quantifying effect of statins on low density lipoprotein cholesterol, ischaemic heart disease, and stroke: systematic review and meta-analysis. BMJ 2003;326:1423.
Serruys PW et al: Fluvastatin for prevention of cardiac events following successful first percutaneous coronary intervention: a randomized controlled trial. JAMA 2002;287:3215.
Shepherd J et al: Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. Lancet 2002;360:1623.
Hyperhomocysteinemia
Elevated plasma homocysteine may be an independent risk factor for coronary artery disease and may impart a risk similar to that associated with cigarette smoking or hyperlipidemia. At this time, there is insufficient evidence to justify screening for elevated serum homocysteine, but patients should be encouraged to maintain an adequate intake of folate, pyridoxine (vitamin B6), and vitamin B12. Elevated levels can be reduced with folate and pyridoxine treatment and with smoking cessation (although not smoking reduction), but their clinical significance is unknown. One randomized trial found that such pharmacologic therapy significantly reduced homocysteine levels and decreased the rate of coronary restenosis and the need for revascularization after percutaneous transluminal coronary angioplasty.
Table 1-7. Suggestions for the clinical use of nicotine gum. | ||||||||||||
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Booth GL et al: Preventive health care, 2000 update: screening and management of hyperhomocysteinemia for the prevention of coronary artery disease events. Canadian Task Force on Preventive Health Care. CMAJ 2000;163:21.
Bushara M et al: Smoking cessation, but not smoking reduction, reduces plasma homocysteine levels. Clin Cardiol 2002;25:23.
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Homocysteine Studies Collaboration: Homocysteine and risk of ischemic heart disease and stroke: a meta-analysis. JAMA 2002;288:2015.
Schnyder G et al: Decreased rate of coronary restenosis after lowering of plasma homocysteine levels. N Engl J Med 2001;345:1593.
Tice JA et al: Cost-effectiveness of vitamin therapy to lower plasma homocysteine levels for the prevention of coronary heart disease: effect of grain fortification and beyond. JAMA 2001;286:936.
Trimarchi H et al: Randomized trial of methylcobalamin and folate effects on homocysteine in hemodialysis patients. Nephron 2002;91:58.
Hypertension
Over 43 million adults in the United States have hypertension, but 31% are unaware of their elevated blood pressure; 17% are aware but untreated; 29% are being treated but have not controlled their blood pressure (still greater than 140/90 mm Hg); and only 23% are well controlled. In every adult age group, higher values of systolic and diastolic blood pressure carry greater risks of stroke and congestive heart failure. Systolic blood pressure is a better predictor of morbid events than is diastolic blood pressure. Clinicians can apply specific blood pressure criteria, such as those of the Joint National Committee, to decide at what levels treatment should be considered in individual cases. Table 11-1 presents a classification of hypertension based on blood pressures. Primary prevention of hypertension can be accomplished by strategies aimed at both the general population and special high-risk populations. The latter include persons with high-normal blood pressure or a family history of hypertension, blacks, and individuals with various behavioral risk factors such as physical inactivity; excessive consumption of salt, alcohol, or calories; and deficient intake of potassium. Effective interventions for primary prevention of hypertension include reduced sodium and alcohol consumption, weight loss, and regular exercise. Potassium supplementation lowers blood pressure modestly, and a diet high in fresh fruits and vegetables and low in fat, red meats, and sugar-containing beverages also reduces blood pressure. Interventions of unproved efficacy include pill supplementation of potassium, calcium, magnesium, fish oil, or fiber; macronutrient alteration; and stress management. A major cause of the recent impressive decline in stroke deaths has been improved diagnosis and treatment of hypertension. Diets rich in fruits and vegetables may also protect against stroke. Pharmacologic management of hypertension is discussed in Chapter 11.
Table 1-8. Suggestions for the clinical use of bupropion SR. | ||||||||||||
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Chobanian AV et al: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289:2560.
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Dahlof B et al: Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet 2002;359:995.
Hyman DJ et al: Characteristics of patients with uncontrolled hypertension in the United States. N Engl J Med 2001;345: 479.
Law MR et al: Value of low dose combination treatment with blood pressure lowering drugs: analysis of 354 randomised trials. BMJ 2003;326:1427.
Sheridan S et al: Screening for high blood pressure: a review of the evidence for the U.S. Preventive Services Task Force. Am J Prev Med 2003;25:151.
Chemoprevention
As discussed in Chapters 10 and 24, regular use of low-dose aspirin (81–325 mg) can reduce the incidence of myocardial infarction in patients at increased risk for heart disease. However, a randomized, controlled trial found that antioxidant vitamin (vitamin E, vitamin C, and beta-carotene) supplementation produced no significant reductions in the 5-year incidence of—or mortality from—vascular disease, cancer, or other major outcomes in high-risk individuals with coronary artery disease, other occlusive arterial disease, or diabetes mellitus.
Hayden M et al: Aspirin for the primary prevention of cardiovascular events: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002;136:161.
Heart Protection Study Collaborative Group: MRC/BHF Heart Protection Study of antioxidant vitamin supplementation in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002;360:23.
Vivekananthan DP et al: Use of antioxidant vitamins for the prevention of cardiovascular disease: meta-analysis of randomised trials. Lancet 2003;361:2017.
PREVENTION OF PHYSICAL INACTIVITY
Lack of sufficient physical activity is the second most important contributor to preventable deaths, trailing only tobacco use. A sedentary lifestyle has been linked to 28% of deaths from leading chronic diseases. The Centers for Disease Control and Prevention (CDC) has recommended that every adult in the United States should engage in 30 minutes or more of moderateintensity physical activity on most days of the week. This guideline complements previous advice urging at least 20–30 minutes of more vigorous aerobic exercise three to five times a week.
Patients who engage in regular moderate to vigorous exercise have a lower risk of myocardial infarction, stroke, hypertension, hyperlipidemia, type 2 diabetes mellitus, diverticular disease, and osteoporosis. The benefits of exercise appear to be dose-dependent, with a major difference in benefit between no and mild to moderate exercise and a smaller difference in benefit between moderate and vigorous exercise. Persons who engage in regular exercise have a lower long-term risk of coronary events, including fatal myocardial infarctions (in both men and women), and in middle-aged and older individuals, exercise improves coronary and endothelial and smooth muscle function and reduces the risk of hypertension. In older nonsmoking men, walking 2 miles or more per day is associated with an almost 50% lower mortality. The relative risk of stroke was found to be less than one-sixth in men who exercised vigorously compared with those who were inactive; the risk of type 2 diabetes mellitus was about half among men who exercised five or more times weekly compared with those who exercised once a week. Glucose control is improved in diabetics who exercise regularly, even at a modest level. In sedentary individuals with dyslipidemia, high amounts of highintensity exercise produce significant beneficial effects on serum lipoprotein profiles. Physical activity is associated with a lower risk of colon cancer (although not rectal cancer) in men and women and of breast and reproductive organ cancer in women. Finally, weightbearing exercise (especially resistance and high-impact activities) increases bone mineral content and retards development of osteoporosis in women and contributes to a reduced risk of falls in older persons.
Exercise may also confer benefits on those with chronic illness. Men and women with chronic symptomatic osteoarthritis of one or both knees benefited from a supervised walking program, with improved self-reported functional status and decreased pain and use of pain medication. Exercise produces sustained lowering of both systolic and diastolic blood pressure in patients with mild hypertension. In addition, physical activity can help patients maintain ideal body weight. Individuals who maintain ideal body weight have a 35–55% lower risk for myocardial infarction than with those who are obese. Physical activity reduces depression and anxiety, improves adaptation to stress, improves sleep quality, and enhances mood, self-esteem, and overall performance.
However, physical exertion can rarely trigger the onset of acute myocardial infarction, particularly in persons who are habitually sedentary. Increased activity increases the risk of musculoskeletal injuries, which can be minimized by proper warm-up and stretching, and by gradual rather than sudden increase in activity. Other potential complications of exercise include angina pectoris, arrhythmias, sudden death, and asthma. In insulin-requiring diabetics who undertake vigorous exercise, the need for insulin is reduced; hypoglycemia may be a consequence.
Only about 20% of adults in the United States are active at the moderate level—and only 8% currently exercise at the more vigorous level—recommended for health benefits. Instead, 60% report irregular or no leisure time physical activity.
Clinicians should advise patients about the benefits and risks of exercise, prescribe an exercise program appropriate for each patient, and provide advice that will help prevent injuries or cardiovascular complications. The value of routine electrocardiography stress testing prior to initiation of an exercise program in middleaged
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or older adults remains controversial. Patients with ischemic heart disease or other cardiovascular disease require medically supervised, graded exercise programs. Medically supervised exercise reduces the risk of death for patients with congestive heart failure. Exercise should not be prescribed for patients with decompensated congestive heart failure, complex ventricular arrhythmias, unstable angina pectoris, hemodynamically significant aortic stenosis, or significant aortic aneurysm. Fiveto 10-minute warm-up and cool-down periods, stretching exercises, and gradual increases in exercise intensity help prevent musculoskeletal and cardiovascular complications.
Physical activity can be incorporated into any person's daily routine. For example, the clinician can advise a patient to take the stairs instead of the elevator, to walk or bike instead of driving, to do housework or yard work, to get off the bus one or two stops earlier and walk the rest of the way, to park at the far end of the parking lot, or to walk during the lunch hour. The basic message should be the more the better and anything is better than nothing. The best counseling techniques for increasing physical activity remain unclear, but a written prescription for activity appears to be more effective than advice alone.
Carter ND et al: Community-based exercise program reduces risk factors for falls in 65to 75-year-old women with osteoporosis: randomized controlled trial. CMAJ 2002;167:997.
Eden KB et al: Does counseling by clinicians improve physical activity? A summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002;137:208.
Kraus WE et al: Effects of the amount and intensity of exercise on plasma lipoproteins. N Engl J Med 2002;347:1483.
Piepoli MF et al: Exercise training meta-analysis of trials in patients with chronic heart failure (ExTraMATCH). BMJ 2004;328:189.
Thomas KS et al: Home based exercise programme for knee pain and knee osteoarthritis: randomised controlled trial. BMJ 2002;325:752.
PREVENTION OF OVERWEIGHT & OBESITY
Obesity is now a true epidemic and public health crisis that both clinicians and patients must face. Normal body weight is defined as a body mass index (BMI), calculated as the weight in kilograms divided by the height in meters squared, of < 25 kg/m2; overweight is defined as a BMI = 25.0–29.9 kg/m2, and obesity as a BMI > 30 kg/m2. The prevalence of obesity in US children, adolescents, and adults has grown dramatically since 1990. Currently, 59 million Americans (16%) are overweight or obese. Prevalence varies by race and age, with older African American and Latina women having the greatest prevalence of obesity. This trend has been linked both to declines in physical activity and to increased caloric intake in diets rich in fats and carbohydrates. As noted above, only about 20% of Americans are physically active at a moderate level, and only 8% at a more vigorous level, and 60% report irregular or no leisure time physical activity. In addition, only 3% of Americans meet four of the five recommendations for the intake of grains, fruits, vegetables, dairy products, and meat of the Food Guide Pyramid. Only one of four Americans eats the recommended five or more fruits and vegetables per day. Levels of the endogenous gut hormone fragment peptide YY3-36 (PYY) are low in the obese persons, suggesting that PYY deficiency may contribute to the pathogenesis of obesity.
Obesity is clearly associated with type 2 diabetes mellitus, hypertension, cancer, osteoarthritis, cardiovascular disease, obstructive sleep apnea, and asthma. One of the most important sequelae of the rapid surge in prevalence of overweight and obesity between 1990 and 2000 has been a dramatic 30–40% increase in the prevalence of type 2 diabetes mellitus. In addition, almost one-quarter of the US population currently has metabolic syndrome, putting them at high risk for the development of coronary heart disease. The relationship between overweight and obesity and diabetes, hypertension, and coronary artery disease is thought to be due to insulin resistance and compensatory hyperinsulinemia. Persons with a BMI 340 have death rates from cancers that are 52% higher for men and 62% higher for women than the rates in men and women of normal weight. Significant trends of increasing risk of death with higher BMIs are observed for cancers of the stomach and prostate in men and for cancers of the breast, uterus, cervix, and ovary in women, and for cancers of the esophagus, colon and rectum, liver, gallbladder, pancreas, and kidney, non-Hodgkin's lymphoma, and multiple myeloma in both men and women.
In the Framingham Heart Study, overweight and obesity were associated with large decreases in life expectancy. For example, 40-year-old female nonsmokers lost 3.3 years and 40-year-old male nonsmokers lost 3.1 years of life expectancy because of overweight, and 7.1 years and 5.8 years of life expectancy, respectively, because of obesity. Obese female smokers lost 7.2 years and obese male smokers lost 6.7 years of life expectancy compared with normal-weight smokers, and 13.3 years and 13.7 years, respectively, compared with normal-weight nonsmokers. Clinicians must work to identify and provide the best prevention and treatment strategies for patients who are overweight and obese.
Prevention of overweight and obesity involves both increasing physical activity and dietary modification to reduce caloric intake. Clinicians can help guide patients to develop personalized eating plans to reduce energy intake, particularly by recognizing the contributions of fat, concentrated carbohydrates, and large portion sizes (see Chapter 29). To prevent the longterm chronic disease sequelae of overweight or obesity, clinicians must work with patients to modify other
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risk factors, eg, by smoking cessation (see above) and strict glycemic and blood pressure control (see Chapters 27 and 11).
Treatment of obesity involves dietary counseling and therapy, pharmacotherapy (see Chapter 29), and surgery. Counseling interventions or pharmacotherapy can produce modest (3 to 5 kg) sustained weight loss over 6–12 months. Pharmacotherapy appears safe in the short term; long-term safety is still not established. Counseling appears to be most effective when intensive and combined with behavioral therapy. Maintenance strategies can help preserve weight loss.
In dietary therapy, one randomized trial comparing a low-carbohydrate, high-protein, high-fat (Atkins) diet to a low-calorie, high-carbohydrate, low-fat (conventional) diet, the low-carbohydrate diet produced a greater weight loss (absolute difference, approximately 4%) than did the conventional diet for the first 6 months, but the differences were not significant at 1 year. In a second randomized trial, severely obese subjects with a high prevalence of diabetes or the metabolic syndrome lost more weight during 6 months on a carbohydrate-restricted diet than on a calorieand fat-restricted diet. Adherence was poor and attrition was high in both studies. Longer and larger studies are required to determine the long-term safety and efficacy of low-carbohydrate, high-protein, high-fat diets.
Bariatric surgical procedures, eg, vertical banded gastroplasty and Roux-en-Y gastric bypass, are reserved for patients with morbid obesity whose BMI exceeds 40, or for less severely obese patients (with BMIs between 35 and 40) with high-risk comorbid conditions such as life-threatening cardiopulmonary problems (eg, severe sleep apnea, pickwickian syndrome, and obesity-related cardiomyopathy) or severe diabetes mellitus. In selected patients, surgery can produce substantial weight loss (10 to 159 kg) over 1 to 5 years, with rare but sometimes severe complications.
Avenell A et al: What are the long-term benefits of weight reducing diets in adults? A systematic review of randomized controlled trials. J Hum Nutr Diet 2004;17:317.
Buchwald H et al: Bariatric surgery: a systematic review and metaanalysis. JAMA 2004;292:1724.
Calle EE et al: Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults. N Engl J Med 2003;348:1625.
Kazaks A et al: Obesity: food intake. Prim Care 2003;30:301.
McTigue KM et al: Screening and interventions for obesity in adults: summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2003;139:933.
Reaven GM: Importance of identifying the overweight patient who will benefit the most by losing weight. Ann Intern Med 2003;138:420.
Samaha FF et al: A low-carbohydrate as compared with a low-fat diet in severe obesity. N Engl J Med 2003;348:2074.
Torpy JM et al: JAMA patient page. Bariatric surgery. JAMA 2002;288:2918.
Torpy JM et al: JAMA patient page. Obesity. JAMA 2003;289:1880.
CANCER PREVENTION
Primary Prevention
Cigarette smoking is the most important preventable cause of cancer. Primary prevention of skin cancer consists of restricting exposure to ultraviolet light by wearing appropriate clothing and use of sunscreens. In the past 2 decades, there has been a threefold increase in the incidence of squamous cell carcinoma and a fourfold increase in melanoma in the United States. Individuals who engage in regular physical exercise and avoid obesity have lower rates of breast and colon cancer. Prevention of occupationally induced cancers involves minimizing exposure to carcinogenic substances such as asbestos, ionizing radiation, and benzene compounds. Chemoprevention may be an important part of primary cancer prevention (see Chapter 40). Tamoxifen for breast cancer prevention is discussed in Chapters 16 and 40.
Screening & Early Detection
Screening has been shown to prevent death from cancers of the breast, colon, and cervix through cancer screening procedures. Current cancer screening recommendations from the American Cancer Society, the Canadian Task Force on Preventive Health Care, and the United States Preventive Services Task Force are shown in Table 1-9.
The appropriate form and frequency of screening for breast cancer is controversial. A large randomized trial of breast self-examination conducted among factory workers in Shanghai found no benefit. A systematic review performed for the United States Preventive Services Task Force found that mammography was moderately effective in reducing breast cancer mortality for women 40–74 years of age. The absolute benefit was greater for older women, and the risk of falsepositive results was high for all women.
All current recommendations call for cervical and colorectal cancer screening. Prostate cancer screening, however, is controversial, as no completed studies have answered the question whether early detection and treatment after screen detection produce sufficient benefits to outweigh harms of treatment. Providers and patients are advised to discuss how to proceed in light of this uncertainty. Single serum prostate-specific antigen (PSA) measurements appear to offer relatively high sensitivity and specificity to detect prostate cancer. The sensitivity is about 65%, the specificity about 80%, and the positive predictive value for prostate cancer is about 45%. When both the digital rectal examination and serum PSA are abnormal, PSA specificity increases, but sensitivity falls (to 30%) and predictive value rises only slightly. Whether early detection and treatment alter the natural course of the disease remains to be seen. There are still no data on the morbidity
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and mortality benefits of such screening. Unlike the American College of Physicians, the American Cancer Society recommends that providers offer annual PSA testing for men over age 50. Screening is not recommended by any group for men who have estimated life expectancies of less than 10 years. Decision aids have been developed to help men weigh the arguments for and against PSA screening.
Table 1-9. Cancer screening recommendations for average-risk adults, 2003. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Annual or biennial fecal occult blood testing reduces mortality from colorectal cancer by 16–33%. The risk of death from colon cancer among patients undergoing at least one sigmoidoscopic examination is reduced by 60–80% compared with that among those not having sigmoidoscopy. Colonoscopy has also been advocated as a screening examination. While it is more accurate than flexible sigmoidoscopy for detecting cancer and polyps, its value in reducing colon cancer mortality has not been studied. Recent studies have shown that CT colography (virtual colonoscopy) is also able to detect cancers and polyps with reasonable accuracy.
Screening for cervical cancer with a Papanicolaou smear is indicated in sexually active adolescents and in adult women every 1–3 years. Screening for vaginal cancer with a Papanicolaou smear is not indicated in women who have undergone hysterectomies for benign disease with removal of the cervix—except in diethylstilbestrol (DES)-exposed women (see Chapter 17). Women over age 70 who have had normal results on three or more previous Papanicolaou smears may elect to stop screening.
Barry MJ: Health decision aids to facilitate shared decision making in office practice. Ann Intern Med 2002;136:127.
Harris R et al: Screening for prostate cancer: an update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002;137:917.
Humphrey LL et al: Breast cancer screening: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002;137:347.
Pickhardt PJ et al: Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. N Engl J Med 2003;349:2191.
Pignone M et al: Screening for colorectal cancer in adults at average risk: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002;137:132.
Saraiya M et al: Interventions to prevent skin cancer by reducing exposure to ultraviolet radiation: a systematic review. Am J Prev Med. 2004;27:422.
Sawaya GF et al: Risk of cervical cancer associated with extending the interval between cervical-cancer screenings. N Engl J Med 2003;349:1501.
Torpy JM et al: JAMA patient page. Colon cancer screening. JAMA 2003;289:1334.
PREVENTION OF INJURIES & VIOLENCE
Injuries remain the most important cause of loss of potential years of life before age 65. Road traffic injuries, self-inflicted injuries, falls, and interpersonal violence are the major sources of injuries. Injuries affect mostly older women and young men, often causing long-term disability. For example, each year in the United States, more than 500,000 people are nonfatally injured while riding bicycles. In 1999, 750 bicyclists died in crashes and more than 95% of them were not wearing helmets.
Although there has been a steady decline in motor vehicle accident deaths per miles driven, road traffic injuries remain the tenth leading cause of death and the ninth leading cause of the burden of disease. Although seat belt use protects against serious injury and death in motor vehicle accidents, at least onefourth of adults and one-third of teenagers do not use seat belts routinely. Air bags are protective for adults but not for small children. The rate of helmet use by bicyclists and motorcyclists is significantly increased in states with helmet laws. By the end of 2000, bicycle helmet use in 15 communities monitored by the CDC's National Center for Injury Prevention and Control had risen from 40% to 55%, exceeding the Healthy People 2000 goal. Young men appear most likely to resist wearing helmets. Clinicians should try to educate their patients about seat belts, safety helmets, the risks of using cellular telephones while driving, drinking and driving—or using other intoxicants or long-acting benzodiazepines and then driving—and the risks of having guns in the home. Chronic alcohol abuse adversely affects outcome from trauma and increases the risk of readmission for new trauma. Males aged 16–35 are at especially high risk for serious injury and death from accidents and violence, with blacks and Latinos at greatest risk. For 16and 17-year-old drivers, the risk of fatal crashes increases with the number of passengers. Deaths from firearms have reached epidemic levels in the United States and will soon surpass the number of deaths from motor vehicle accidents. Having a gun in the home increases the likelihood of homicide nearly threefold and of suicide fivefold. Alcohol and illicit drug use are associated with an increased risk of violent death. Clinicians should be alert to signs of depression and suicidal ideation and should initiate interventions to prevent suicide.
In elderly patients, the risk of hip fracture when falling can be reduced by as much as 80% by wearing hip protectors, but only about half of patients use them regularly.
Finally, clinicians have a critical role in detection, prevention, and management of physical or sexual abuse—in particular, routine assessment of women for risk of domestic violence. Inclusion of a single question about domestic violence in the medical history— “At any time, has a partner ever hit you, kicked you, or otherwise physically hurt you?”—increased identification of this common problem from nil to 11.6%. Another screening device consists of three questions: (1) “Have you ever been hit, kicked, punched, or otherwise hurt by someone within the past year? If so, by whom?” (2) “Do you feel safe in your current relationship?”
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(3) “Is there a partner from a previous relationship who is making you feel unsafe now?” Asking these questions increased identification of domestic violence to 29.5% of women in an emergency department. The effect of screening and identifying intimate partner violence on health outcomes has not been well studied to date.
Physical and psychological abuse, exploitation, and neglect of older adults are serious underrecognized problems. Clues to elder mistreatment include the patient's appearance, recurrent urgent-care visits, missed appointments, suspicious physical findings, and implausible explanations for injuries.
Ahmad M et al: Elder abuse and neglect: what physicians can and should do. Cleve Clin J Med 2002;69:801.
Cameron ID et al: A randomised trial of hip protector use by frail older women living in their own homes. Inj Prev 2003;9: 138.
Chen LH et al: Carrying passengers as a risk factor for crashes fatal to 16and 17-year-old drivers. JAMA 2000;283:1578.
Gerbert B et al: Physicians' response to victims of domestic violence: toward a model of care. Women Health 2002;35:1.
JAMA patient page. Partner violence. JAMA 2002;288:662.
Krasnoff M et al: Domestic violence screening and referral can be effective. Ann Emerg Med 2002;40:485.
Nelson HD et al: Screening women and elderly adults for family and intimate partner violence: a review of the evidence for the U. S. Preventive Services Task Force. Ann Intern Med 2004;140:387.
Rivara FP et al: Injury prevention. (Two parts.) N Engl J Med 1997;337:NN543, 613. ,
Shinoda-Tagawa T et al: Trends in hospitalization after injury: older women are displacing young men. Inj Prev 2003;9: 214.
SUBSTANCE ABUSE: ALCOHOL & ILLICIT DRUGS
Substance abuse is a major public health problem in the United States and is estimated to be a factor in 41% of highway fatality accidents. The lifetime prevalence of alcoholism is estimated to be between 12% and 16%. Approximately two-thirds of high school seniors are regular users of alcohol. Underdiagnosis of alcohol abuse is substantial, both because of patient denial and lack of detection of clinical clues. A substantial decline in alcohol-related fatalities testifies to the success of educational and law-enforcement efforts to stop drinking and driving. Even so, alcoholimpaired driving remains prevalent, especially among men aged 18–34 years. Binge drinking among college students has recently increased.
As with cigarette use, clinician identification and counseling about alcoholism may improve the chances of recovery. About 10% of all adults seen in medical practices are problem drinkers. An estimated 15–30% of hospitalized patients have problems with alcohol abuse or dependence, but the connection between patients' presenting complaints and their alcohol abuse is often missed. The CAGE test (see Table 1-10) is both sensitive and specific for chronic alcoholism. However, it is less sensitive in detecting heavy or binge drinking in elderly patients and has been criticized for being less applicable to minority groups or to women. Others recommend asking three questions: (1) How many days per week do you drink (frequency)? (2) On a day when you drink alcohol, how many drinks do you have in one day (quantity)? (3) On how many occasions in the last month did you drink more than five drinks (binge drinking)? The Alcohol Use Disorder Identification Test (AUDIT) consists of questions on the quantity and frequency of alcohol consumption, on alcohol dependence symptoms, and on alcohol-related problems (Table 1-10). It has been found to accurately detect hazardous drinking, harmful drinking, and alcohol dependence and does not seem to be affected by ethnic or gender bias. Choice of therapy remains controversial. However, use of screening procedures and brief intervention methods (see Table 1-11 and Chapter 25) can produce a 10–30% reduction in long-term alcohol use and alcohol-related problems. However, brief advice and counseling without regular follow-up and reinforcement cannot sustain significant longterm reductions in unhealthy drinking behaviors. Several pharmacologic agents are effective in reducing alcohol consumption. For example, naltrexone and topiramate may be effective in preventing relapse to drinking when combined with psychosocial treatment.
Use of illegal drugs—including cocaine, methamphetamine, and so-called “designer drugs”—either sporadically or episodically remains an important problem. Disturbing trends include an increase in use of marijuana and inhalants among eighth graders and high school students and an increase in abuse of prescription pain medications. Many drug users are employed, and many use drugs during pregnancy. Cocaine or tobacco use during early pregnancy substantially increases the risk of miscarriage. Abuse of anabolic-androgenic steroids has been associated with use of other illicit drugs, alcohol, and cigarettes and with violence and criminal behavior. As with alcohol abuse, the recognition of drug abuse presents special problems and requires that the clinician actively consider the diagnosis. Clinical aspects of substance abuse are discussed in Chapter 25.
Currently, evidence does not support the use of carbamazepine, disulfiram, mazindol, phenytoin, nimodipine, lithium, antidepressants, or dopamine agonists in the treatment of cocaine dependence. Buprenorphine has potential as a medication to ameliorate the signs and symptoms of withdrawal from opioids and has been shown to be effective in reducing concomitant cocaine and opiate abuse. Slow tapering with temporary substitution of methadone
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and buprenorphine—accompanied by medical supervision and ancillary medications—can reduce withdrawal severity, but most patients relapse to heroin use. Cessation of methadone maintenance is possible using buprenorphine by transfer from methadone to buprenorphine and subsequent buprenorphine reductions. Evidence does not support the use of naltrexone in maintenance treatment of opioid addiction.
Table 1-10. Screening for alcohol abuse. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Table 1-11. Basic counseling steps for patients who abuse alcohol. | ||
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Breen CL et al: Cessation of methadone maintenance treatment using buprenorphine: transfer from methadone to buprenorphine and subsequent buprenorphine reductions. Drug Alcohol Depend 2003;71:49.
de Lima MS et al: Pharmacological treatment of cocaine dependence: a systematic review. Addiction 2002;97:931.
Fudala PJ et al: Office-based treatment of opiate addiction with a sublingual-tablet formulation of buprenorphine and naloxone. N Engl J Med 2003;349:949.
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Gerbert B et al: Using innovative video doctor technology in primary care to deliver brief smoking and alcohol intervention. Health Promot Pract 2003;4:249.
Gilson AM et al: A reassessment of trends in the medical use and abuse of opioid analgesics and implications for diversion control: 1997–2002. J Pain Symptom Manage 2004;28:176.
JAMA patient page. Cocaine addiction. JAMA 2002;287:146.
Montoya ID et al: Randomized trial of buprenorphine for treatment of concurrent opiate and cocaine dependence. Clin Pharmacol Ther 2004;75:34.
Saitz R et al: Addressing alcohol problems in primary care: a cluster randomized, controlled trial of a systems intervention. The screening and intervention in primary care (SIP) study. Ann Intern Med 2003;138:372.
Whitlock EP et al: Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2004;140:557.
Wutzke SE et al: The long-term effectiveness of brief interventions for unsafe alcohol consumption: a 10-year follow-up. Addiction 2002;97:665.
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