Urinary Tract Infection in Children

Faculty Development in Faculty Development in Addiction MedicineAddiction Medicine::

A Family Practice Residency – A Family Practice Residency – Private Foundation PartnershipPrivate Foundation Partnership

Ken Saffier, MDKen Saffier, MDContra Costa Regional Medical Center FMR, Martinez, CAContra Costa Regional Medical Center FMR, Martinez, CA

Steve Eickelberg, MD, and Gail Jara, BASteve Eickelberg, MD, and Gail Jara, BAMedical Education and Research Foundation for the Medical Education and Research Foundation for the

Treatment of Alcoholism and Other Drug DependenciesTreatment of Alcoholism and Other Drug Dependencies

Learning ObjectivesLearning Objectives

By the end of this seminar, learners will be able to: By the end of this seminar, learners will be able to:

1. Identify the obstacles that often interfere with 1. Identify the obstacles that often interfere with teaching about substance use disorders. teaching about substance use disorders.

2. Learn how private foundation support can facilitate 2. Learn how private foundation support can facilitate faculty development. faculty development.

3. Describe curricular elements that can improve 3. Describe curricular elements that can improve faculty and residents’ recognition, treatment, and faculty and residents’ recognition, treatment, and referral of patients with substance use disorders. referral of patients with substance use disorders.

Missed OpportunitiesMissed Opportunities

CASA STUDYCASA STUDY

650 PCP’s + 500 patients in CD treatment650 PCP’s + 500 patients in CD treatment

54% said “PCP DID NOTHING”54% said “PCP DID NOTHING”

11% said “PCP KNEW & DID NOTHING”11% said “PCP KNEW & DID NOTHING”

32% of PCP’s Screen for Substance Use32% of PCP’s Screen for Substance Use

Missed Opportunity: National Survey of Primary Care Physicians and Patients, 2000, Missed Opportunity: National Survey of Primary Care Physicians and Patients, 2000,

National Center on Addiction and Substance Abuse (CASA) National Center on Addiction and Substance Abuse (CASA) www.casacolumbia.orgwww.casacolumbia.org

Missed Opportunities: Dx

9 in 10 US physicians fail to spot substance abuse in 9 in 10 US physicians fail to spot substance abuse in adult patients.adult patients.4 out of 10 miss the diagnosis in teens4 out of 10 miss the diagnosis in teens

CASA, 2000, Missed OpportunityCASA, 2000, Missed Opportunity

MD’s Most Likely To Diagnose MD’s Most Likely To Diagnose Adult’s Substance AbuseAdult’s Substance Abuse

Family practitionerFamily practitioner

Felt most prepared to diagnose SAFelt most prepared to diagnose SA

Strong believer in tx effectivenessStrong believer in tx effectiveness

Received CME training in past 5 yrs. Received CME training in past 5 yrs.

Received SA training in medical schoolReceived SA training in medical school

Missed Opportunity: National Survey of Primary Care Physicians and Patients, 2000, Missed Opportunity: National Survey of Primary Care Physicians and Patients, 2000, National Center on Addiction and Substance Abuse (CASA) National Center on Addiction and Substance Abuse (CASA) www.casacolumbia.orgwww.casacolumbia.org

Patients’ Experience:Patients’ Experience:

55% of PCP’s prescribed drugs that 55% of PCP’s prescribed drugs that

could be dangerous could be dangerous

30% of patients: ”PHYSICIAN KNEW ABOUT 30% of patients: ”PHYSICIAN KNEW ABOUT PATIENT’S ADDICTION AND STILL PATIENT’S ADDICTION AND STILL PRESCRIBED PSYCHOACTIVE PRESCRIBED PSYCHOACTIVE SUBSTANCES.”SUBSTANCES.”

75% of PCP’s not involved in TX decision75% of PCP’s not involved in TX decision

Missed Opportunity: National Survey of Primary Care Physicians and Patients, 2000, Missed Opportunity: National Survey of Primary Care Physicians and Patients, 2000,

National Center on Addiction and Substance Abuse (CASA) National Center on Addiction and Substance Abuse (CASA) www.casacolumbia.orgwww.casacolumbia.org

Barriers to Implementing Substance Barriers to Implementing Substance Abuse Curriculum in Resident EducationAbuse Curriculum in Resident Education

Negative attitudesNegative attitudes

Lack of faculty development and expertiseLack of faculty development and expertise

Competition for curricular timeCompetition for curricular time

Lack of funding, financial pressuresLack of funding, financial pressures

Lack of treatment resourcesLack of treatment resources

Lack of adequate training settingsLack of adequate training settings

Negative AttitudesNegative Attitudes

AngerAnger

AvoidanceAvoidance

DiscouragementDiscouragement

FatalismFatalism

FrustrationFrustration

FutilityFutility

HelplessnessHelplessness

JudgmentalJudgmental

Barriers to Implementing Substance Abuse Barriers to Implementing Substance Abuse Curriculum in Resident EducationCurriculum in Resident Education


– Personal/familyPersonal/family

– ProfessionalProfessional

– InstitutionalInstitutional

– Societal/culturalSocietal/cultural

Key Personal ExperiencesKey Personal Experiences

Family of Origin

Other relationships

Work

ProfessionalProfessional

Barriers to Implementing Substance Abuse Barriers to Implementing Substance Abuse Curriculum in Resident EducationCurriculum in Resident Education


– PersonalPersonal



– SocietalSocietal

Factors Contributing to Negative AttitudesFactors Contributing to Negative Attitudes

Limited positive work/professional experiencesLimited positive work/professional experiences

Past experiences with difficult patients w/o positive Past experiences with difficult patients w/o positive mentoring or role modelsmentoring or role models

Overexposure to chronic, relapsing patientsOverexposure to chronic, relapsing patients

Lack of treatment resourcesLack of treatment resources

Lack of positive training, educational settingsLack of positive training, educational settings

Narrow view of professional responsibility Narrow view of professional responsibility

Only managing w/d, OD, med complicationsOnly managing w/d, OD, med complications

Barriers to Implementing Substance Barriers to Implementing Substance Abuse Curriculum in Resident Abuse Curriculum in Resident

EducationEducation


– PersonalPersonal



– SocietalSocietal

Factors Contributing to Negative AttitudesFactors Contributing to Negative Attitudes

Negative societal attitudes and stereotypesNegative societal attitudes and stereotypes

Alcoholics and addicts are the dregs of society.Alcoholics and addicts are the dregs of society.

They cause incredible harm to their families and They cause incredible harm to their families and society. Why should we help them?society. Why should we help them?

They deserve the self destructiveness they get.They deserve the self destructiveness they get.

Why bother? Treatment doesn’t work. They don’t Why bother? Treatment doesn’t work. They don’t want to get better.want to get better.

Criminalizing addictive diseaseCriminalizing addictive disease

Consequences of Negative Attitudes Consequences of Negative Attitudes and Behaviorsand Behaviors

At-risk persons not recognized & screenedAt-risk persons not recognized & screened

Affected persons not diagnosed & treatedAffected persons not diagnosed & treated

Denial of existence of SA problemsDenial of existence of SA problems

Consequences of Negative Attitudes Consequences of Negative Attitudes and Behaviorsand Behaviors

Enabling hi-risk behavior (prescriptions, social Enabling hi-risk behavior (prescriptions, social support rather than treatment, etc.)support rather than treatment, etc.)

Punitive managementPunitive management

Patronizing Patronizing

Nagging behaviorNagging behavior

Barriers to Implementing Substance Barriers to Implementing Substance Abuse Curriculum in Resident Education: Abuse Curriculum in Resident Education:

A National Survey A National Survey

Most common perceived barriers: Most common perceived barriers: (1997 national survey) (1997 national survey)

Lack of time 63%Lack of time 63%

Lack of faculty expertise 33%Lack of faculty expertise 33%

Lack of institutional support 21%Lack of institutional support 21%

Lack of training sitesLack of training sites 21% 21% (n= 309/448 programs)(n= 309/448 programs)Isaacson, J.H., et. al., A National Survey of Training in Substance Use Isaacson, J.H., et. al., A National Survey of Training in Substance Use

Disorders in Residency Programs, J Stud. Alcohol, 61: 912-915, Disorders in Residency Programs, J Stud. Alcohol, 61: 912-915, 20002000

Overcoming the BarriersOvercoming the Barriers

Maintaining and developing positive Maintaining and developing positive attitudes:attitudes:

– Clinical experiences (with positive outcomes)Clinical experiences (with positive outcomes)

– Supervision by expert role modelSupervision by expert role model

– Ongoing access to addiction medicine Ongoing access to addiction medicine consultant throughout trainingconsultant throughout training

MMedical edical EEducation & ducation & RResearch esearch FFoundation oundation

For The For The Treatment of Alcoholism and Other Drug Treatment of Alcoholism and Other Drug

DependenciesDependencies

M E R FM E R F 575 Market Street, Suite 2125575 Market Street, Suite 2125

San Francisco, CA 94105San Francisco, CA 94105

M E R FM E R F

1988 Created 1988 Created

MISSION STATEMENTMISSION STATEMENT

PREVENT THE HARM BEING DONE PREVENT THE HARM BEING DONE

TO PATIENTS BY PHYSICIANS WHO TO PATIENTS BY PHYSICIANS WHO

LACK THE LACK THE KNOWLEDGEKNOWLEDGE, , SKILLSKILL AND AND

TRAININGTRAINING TO RECOGNIZE AND TO RECOGNIZE AND

TREAT ADDICTIONTREAT ADDICTION

M E R FM E R F

Private Donations Private Donations

Focus on improving identification and care of Focus on improving identification and care of patients with substance use problemspatients with substance use problems

Educate Educate – Medical EducatorsMedical Educators– ResidentsResidents– Medical StudentsMedical Students

M E R FM E R F

W H Y ?W H Y ?

M E R FM E R F Deficient Medical Education about Deficient Medical Education about

Substance UseSubstance Use

Unacceptably low rates of identifying Unacceptably low rates of identifying persons with substance use problemspersons with substance use problems

Difficulties creating space in Medical Difficulties creating space in Medical School and Residency CurriculumSchool and Residency Curriculum

Committed to overcome Deficiencies, Committed to overcome Deficiencies, Improve identification and Improve Improve identification and Improve patient care patient care

M E R FM E R F

Missed Opportunities – Northern CAMissed Opportunities – Northern CA

627 Alcohol Dependent & Problem Drinkers627 Alcohol Dependent & Problem Drinkers

926 Consec. Admissions to CD Treatment926 Consec. Admissions to CD Treatment

Interviewed one year laterInterviewed one year later

2/3 ≥ 1 MEDICAL VISITS w/in last year2/3 ≥ 1 MEDICAL VISITS w/in last year

Weisner, C. & Matzer, H., Alcoholism: Clin. Exp. Res., July Weisner, C. & Matzer, H., Alcoholism: Clin. Exp. Res., July 20032003

M E R FM E R F

PROBLEM DRINKERS -- VISITS TO MDPROBLEM DRINKERS -- VISITS TO MD

65 % had a 65 % had a medical visitmedical visit in the past year. in the past year.

< 25% had drinking problem addressed.< 25% had drinking problem addressed.

Weisner & Matzger;Weisner & Matzger; Alc: Clin. Exp. Res., Alc: Clin. Exp. Res., 20032003

M E R FM E R F

DSM-IV ALCOHOL DEPENDENTDSM-IV ALCOHOL DEPENDENT

62% -- Alcohol use NOT addressed 62% -- Alcohol use NOT addressed during medical visitduring medical visit

PROBLEM DRINKERS W/O DEPENDENCEPROBLEM DRINKERS W/O DEPENDENCE

84% -- Alcohol use NOT addressed 84% -- Alcohol use NOT addressed during medical visitduring medical visit

Weisner, C. & Matzger, H., Alcoholism: Clin. Exp. Res., July 2003Weisner, C. & Matzger, H., Alcoholism: Clin. Exp. Res., July 2003

M E R FM E R F

20 years Organized Medicine Recognizes 20 years Organized Medicine Recognizes Need to Increase Medical Education toNeed to Increase Medical Education to Improve DETECTION & TREATMENTImprove DETECTION & TREATMENT

NIAAANIAAA Institute of MedicineInstitute of Medicine AMAAMA APAAPA AAFP AAFP

M E R FM E R F

20 YEARS WITHOUT CHANGE20 YEARS WITHOUT CHANGE

No Changes:No Changes: – Screening RateScreening Rate or # of Pt’s screened or # of Pt’s screened

– Recognition/Recognition/DiagnosisDiagnosis RateRate

– Number of Patients Number of Patients DischargedDischarged with a with a Diagnosis of AlcoholismDiagnosis of Alcoholism

– Number of Patients Receiving Psych. or Number of Patients Receiving Psych. or Addiction Addiction ConsultationConsultation

Mayo Clinic Proceedings Mayo Clinic Proceedings

20012001

M E R FM E R F

QUALITY OF HEALTH CARE DELIVERED QUALITY OF HEALTH CARE DELIVERED TO ADULTS IN THE UNITED STATESTO ADULTS IN THE UNITED STATES McGlynn, et. al., NEJM, June 2003McGlynn, et. al., NEJM, June 2003

54% of Recommended/Standard care is54% of Recommended/Standard care is delivered for 25 common conditionsdelivered for 25 common conditions

HighHigh - 79% - Senile Cataracts - 79% - Senile CataractsMediumMedium - 53% - Asthma - 53% - AsthmaLowestLowest - 10% - Alcohol Dependence - 10% - Alcohol Dependence

M E R FM E R F

OPPORTUNITIESOPPORTUNITIES

M E R FM E R F

PRIMARY CARE PRIMARY CARE

OUTPATIENT CLINIC VISITSOUTPATIENT CLINIC VISITS> 20% of Patients Seen Exceed NIAAA Alcohol > 20% of Patients Seen Exceed NIAAA Alcohol

Consumption GuidelinesConsumption Guidelines

2 – 9% Prevalence of Alcohol Dependence2 – 9% Prevalence of Alcohol Dependence

NIAAA, July 2005NIAAA, July 2005

9 – 35% Prevalence of Harmful Drinking9 – 35% Prevalence of Harmful Drinking

Fiellien, et. Al., Ann. Int. Med., 2000Fiellien, et. Al., Ann. Int. Med., 2000

M E R FM E R F

70 % of population sees PCP at 70 % of population sees PCP at least once every 2 yearsleast once every 2 years200 million patient visits to PCP 200 million patient visits to PCP annuallyannually

Source: CASA(2000) Source: CASA(2000) Missed OpportunityMissed Opportunity

M E R FM E R F

ADDRESSING NEED ADDRESSING NEED

WITH EDUCATIONWITH EDUCATION

M E R FM E R F FULFILLMENT OF MERF’S MISSIONFULFILLMENT OF MERF’S MISSION

Scholarships to multi-day addiction medicine Scholarships to multi-day addiction medicine educational conferences/workshops educational conferences/workshops – Residents Residents – Residency Educators/FacultyResidency Educators/Faculty

Mentored learning experienceMentored learning experience

Collegial/group learning environmentCollegial/group learning environment

Basic medical science informationBasic medical science information

M E R FM E R F

Clinical Problem solving -- DiscussionClinical Problem solving -- Discussion

Familiarization discussing substance use, Familiarization discussing substance use, abuse, addictionabuse, addiction

Improve comfort discussing substance use Improve comfort discussing substance use [demystifying] [demystifying]

M E R FM E R F Collegial Interaction Facilitated Collegial Interaction Facilitated and Encouragedand Encouraged

– Conference facultyConference faculty

– MentorsMentors

– Fellow attendees and scholarship recipientsFellow attendees and scholarship recipients

– MealsMeals

– Special Conference EventsSpecial Conference Events

M E R FM E R F

TESTIMONIALS TESTIMONIALS

M E R FM E R F

““I found all elements helpful. The lectures I found all elements helpful. The lectures were fantastic. I feel my comfort level with were fantastic. I feel my comfort level with ETOH patients has definitely improved.” ETOH patients has definitely improved.”

““I feel like part of the larger body of people I feel like part of the larger body of people in the field of addiction treatment now.” in the field of addiction treatment now.”

““The conference provided me with much The conference provided me with much needed information.”needed information.”

M E R FM E R F

““Interacting with the experts in the field Interacting with the experts in the field and other residents and the people at and other residents and the people at MERF was excellent.” MERF was excellent.”

““I wish all of the residents in my program I wish all of the residents in my program could get this education.” could get this education.”

““Very informative…contrary to some Very informative…contrary to some teaching at my program, the attitude and teaching at my program, the attitude and approach to dealing with SA was approach to dealing with SA was refreshing.” refreshing.”

M E R FM E R F

FROM EDUCATORSFROM EDUCATORS

““The things I learned.…have already The things I learned.…have already changed my practice and the residents’ changed my practice and the residents’ education.”education.”

““My next step is to incorporate this My next step is to incorporate this knowledge into curricular and clinical knowledge into curricular and clinical teaching.” teaching.”

““I felt like I walked away with a new I felt like I walked away with a new toolbox.…..to use in my teaching.” toolbox.…..to use in my teaching.”

UC Davis FMR NetworkUC Davis FMR Network

8 residencies, over 200 residents8 residencies, over 200 residents

Redding to Merced, Sacramento to Martinez Redding to Merced, Sacramento to Martinez

Yearly annual retreat for all residents and Yearly annual retreat for all residents and some facultysome faculty

Very supportive residency network directorVery supportive residency network director

Addiction Medicine at UCD FMR Addiction Medicine at UCD FMR Network ProgramsNetwork Programs

Two faculty specializing in addiction Two faculty specializing in addiction medicine with a passion for teachingmedicine with a passion for teaching– Active members of the California Society of Active members of the California Society of

Addiction MedicineAddiction Medicine– Goals: To increase and integrate addiction Goals: To increase and integrate addiction

medicine in residency curriculamedicine in residency curricula

A variety of didactic presentations and A variety of didactic presentations and clinical rotationsclinical rotationsSharing of resources, presentationsSharing of resources, presentations

Addiction Medicine at UCD FMR Addiction Medicine at UCD FMR Network ProgramsNetwork Programs

3 programs send residents to office-based 3 programs send residents to office-based addiction/family medicine practice (Stockton).addiction/family medicine practice (Stockton).

Yearly report to residency program directorsYearly report to residency program directors

3 teleconference meetings/yr. of interested 3 teleconference meetings/yr. of interested faculty to share ideas, resourcesfaculty to share ideas, resources

ADM Learning Objectives

To promote positive provider attitudes to To promote positive provider attitudes to increase screening for substance abuse, increase screening for substance abuse, referrals to treatment, and improved referrals to treatment, and improved treatment outcomes. treatment outcomes. To recognize the many manifestations of To recognize the many manifestations of addictive disease.addictive disease.To illustrate how substance use disorders To illustrate how substance use disorders are treatable with medical and non-are treatable with medical and non-medical interventions.medical interventions.

Integrating ADM into One FMR –Integrating ADM into One FMR –MartinezMartinez

““Growing” a faculty with ADM expertiseGrowing” a faculty with ADM expertise– 8 MERF scholarship participants8 MERF scholarship participants– FP, IM, OB/GYN, BM, Peds FP, IM, OB/GYN, BM, Peds

Faculty Leadership GroupFaculty Leadership Group– One member - UCSF Faculty Development One member - UCSF Faculty Development

Fellowship (also a MERF Scholar) – Addiction Fellowship (also a MERF Scholar) – Addiction Medicine Curriculum ProjectMedicine Curriculum Project

Quarterly Addiction Medicine Noon Conferences Quarterly Addiction Medicine Noon Conferences – 3 year cycle– 3 year cycle

Problem Based Learning Seminars Problem Based Learning Seminars

Integrating ADM into One FMRIntegrating ADM into One FMR

(More) clinical experiences into R1 (More) clinical experiences into R1 Behavior Medicine rotationBehavior Medicine rotationPain and Addiction consult clinicPain and Addiction consult clinic

Future: Buprenorphine training for all Future: Buprenorphine training for all (including more faculty)(including more faculty)Future: Develop, reinforce and document Future: Develop, reinforce and document ADM skills on all rotations with our growing ADM skills on all rotations with our growing ADM faculty. ADM faculty.

What Do Faculty Want and Need?What Do Faculty Want and Need?Survey of ParticipantsSurvey of Participants

Ways to teach Ways to teach – a compassionate approach to SAa compassionate approach to SA– Stages of change and motivational interviewingStages of change and motivational interviewing

How to teach interviewing skills for How to teach interviewing skills for addiction issues in time limited primary care addiction issues in time limited primary care settings.settings.Dedicated session for residency faculty Dedicated session for residency faculty addressing effective teaching strategies addressing effective teaching strategies including role modeling, didactic teaching. including role modeling, didactic teaching.

FacultyFaculty (cont’d):(cont’d):

Motivating residents to get interested in Motivating residents to get interested in addiction medicine as an integral part of addiction medicine as an integral part of caring for poor populations.caring for poor populations.

How to approach teaching residents who How to approach teaching residents who have little experience with SA – have little experience with SA – overcoming stereotypes of SA’s.overcoming stereotypes of SA’s.

Learn more about the biological aspects of Learn more about the biological aspects of addictionaddiction


PPT presentations that go beyond just PPT presentations that go beyond just informationinformation

Innovative teaching methodsInnovative teaching methods

Teaching approaches other than lectures Teaching approaches other than lectures to maintain interest.to maintain interest.

Good teaching aids: videos, cd’s, dvd’sGood teaching aids: videos, cd’s, dvd’s


How to prevent cynicism amongst How to prevent cynicism amongst residents.residents.Outside speakers, including recovering Outside speakers, including recovering alcoholic’s testimonyalcoholic’s testimonyCollegial support and other faculty willing Collegial support and other faculty willing to helpto helpScarcity of SA resources in community, Scarcity of SA resources in community, leading to frustration of residents (and leading to frustration of residents (and staff)staff)

Residency Directors Want & Need:Residency Directors Want & Need:Survey of ParticipantsSurvey of Participants

Innovative curricula that help residents Innovative curricula that help residents better understand these problems.better understand these problems.

Assistance in SA trainingAssistance in SA training

Physicians who care for people with Physicians who care for people with addictions regularlyaddictions regularly

How to incorporate this important material How to incorporate this important material in a curriculum that has little time for more.in a curriculum that has little time for more.

Residency directorsResidency directors (cont’d):(cont’d):

Videos for didactics or outside lectures on Videos for didactics or outside lectures on a variety of subjects such as detox a variety of subjects such as detox protocols, teen addiction, treatment.protocols, teen addiction, treatment.

Speakers and support from MERF or Speakers and support from MERF or CSAM in training residents.CSAM in training residents.

Recommendations from CSAM on what is Recommendations from CSAM on what is essential info. and skills.essential info. and skills.

Clinical or research fellowships in ADMClinical or research fellowships in ADM

Summary & ConclusionsSummary & Conclusions

Acknowledge and understand obstacles that Acknowledge and understand obstacles that interfere with substance abuse teaching.interfere with substance abuse teaching.Obtain support from inside and outside of Obtain support from inside and outside of program.program.Foundation support provides a unique Foundation support provides a unique incentive for faculty and program directors.incentive for faculty and program directors.Goal: Integrate instead of compete for Goal: Integrate instead of compete for curricular time.curricular time.

Summary & Conclusions Summary & Conclusions (cont’d):(cont’d):

Designated faculty member(s) as local Designated faculty member(s) as local “champions” promote ongoing development “champions” promote ongoing development and expertise for faculty and residents.and expertise for faculty and residents.Promote 3 ingredients for successful Promote 3 ingredients for successful education:education:– Clinical experiences (with positive outcomes)Clinical experiences (with positive outcomes)– Supervision by expert role models– Ongoing access to addiction medicine Ongoing access to addiction medicine

consultant throughout trainingconsultant throughout training

Substance Use Disorders Substance Use Disorders Curriculum GuidelinesCurriculum Guidelines

Endorsed by AAFP, STFM, ADFM, AFPRD.Endorsed by AAFP, STFM, ADFM, AFPRD.

http://www.aafp.org/x16533.xmlhttp://www.aafp.org/x16533.xml

Selected Websites

www.projectmainstream.netwww.projectmainstream.net An interdisciplinary An interdisciplinary national effort to improve health professional national effort to improve health professional education on substance abuse.education on substance abuse.www.amersa.orgwww.amersa.org Association for Medical Association for Medical Education and Research in Substance AbuseEducation and Research in Substance AbuseAlcohol Screening and Brief Intervention Alcohol Screening and Brief Intervention Curriculum Curriculum http://www.bu.edu/act/mdalcoholtraining/slides/inhttp://www.bu.edu/act/mdalcoholtraining/slides/index.htmldex.html An excellent multimedia curriculum from An excellent multimedia curriculum from Boston University.Boston University.

Selected ReferencesSelected References

Helping Patients Who Drink Too MuchHelping Patients Who Drink Too Much, , A Clinician’s Guide, 2005 Edition, A Clinician’s Guide, 2005 Edition, US Department of Health and Human US Department of Health and Human Services, NIH Publication No. 05-3769, Services, NIH Publication No. 05-3769, www.niaaa.nih.govwww.niaaa.nih.gov

Chappel, JN, Schnoll, SH. Physician Chappel, JN, Schnoll, SH. Physician attitudes: effect on the treatment of attitudes: effect on the treatment of chemically dependent patients. JAMA chemically dependent patients. JAMA 1977;237:2318-23191977;237:2318-2319

Selected ReferencesSelected References

Weisner, C, Matzger, Helen (2003). Missed Weisner, C, Matzger, Helen (2003). Missed opportunities in addressing drinking behavior in opportunities in addressing drinking behavior in medical and mental health services, Alcohol medical and mental health services, Alcohol Clin Exp Res, 27:1132-1141Clin Exp Res, 27:1132-1141

Missed Opportunity: National Survey of Primary Missed Opportunity: National Survey of Primary Care Physicians and Patients, 2000, National Care Physicians and Patients, 2000, National Center on Addiction and Substance Abuse Center on Addiction and Substance Abuse (CASA) (CASA) www.casacolumbia.orgwww.casacolumbia.org

Selected ReferencesSelected ReferencesSubstance Abuse and Mental Health Administration Substance Abuse and Mental Health Administration

Center for Substance Abuse TreatmentCenter for Substance Abuse Treatment

Treatment Improvement Protocol Treatment Improvement Protocol (TIP)(TIP) Series Series

A Guide to Substance Abuse Services for A Guide to Substance Abuse Services for Primary Care Clinicians #24Primary Care Clinicians #24Brief Interventions and Brief Therapies for Brief Interventions and Brief Therapies for Substance Abuse #34Substance Abuse #34Enhancing Motivation for Change in Substance Enhancing Motivation for Change in Substance Abuse Treatment #35Abuse Treatment #35

National Clearinghouse for Alcohol and Drug InformationNational Clearinghouse for Alcohol and Drug Information

(800) 729 – 6686 or (301) 468 – 2600(800) 729 – 6686 or (301) 468 – 2600www.health.orgwww.health.org

Urinary Tract Infection in Children

Health & Medicine

Transcript of Urinary Tract Infection in Children