Shifting blame: Buprenorphine prescribers, addiction treatment, and prescription monitoring in middle-class America

Growing nonmedical prescription opioid analgesic use among suburban and rural Whites has changed the public's perception of the nature of opioid addiction, and of appropriate interventions. Opioid addiction has been recast as a biological disorder in which patients are victims of their neurotransmitters and opioid prescribers are irresponsible purveyors of dangerous substances requiring controls. This framing has led to a different set of policy responses than the "War on Drugs" that has focused on heroin trade in poor urban communities; in response to prescription opioid addiction, prescription drug monitoring programs and tamper-resistant opioid formulations have arisen as primary interventions in place of law enforcement. Through the analysis of preliminary findings from interviews with physicians who are certified to manage opioid addiction with the opioid pharmaceutical buprenorphine, we argue that an increase in prescriber monitoring has shifted the focus from addicted people to prescribers as a threat, paradoxically driving users to illicit markets and constricting their access to pharmaceutical treatment for opioid addiction. Prescriber monitoring is also altering clinical cultures of care, as general physicians respond to heightened surveillance and the psychosocial complexities of treating addiction with either rejection of opioid dependent patients, or with resourceful attempts to create support systems for their treatment where none exists.

Buprenorphine Maintenance for Opioid Dependence in Public Sector Healthcare: Benefits and Barriers

BACKGROUND

Since its U.S. FDA approval in 2002, buprenorphine has been available for maintenance treatment of opiate dependence in primary care physicians' offices. Though buprenorphine was intended to facilitate access to treatment, disparities in utilization have emerged; while buprenorphine treatment is widely used in private care setting, public healthcare integration of buprenorphine lags behind.

RESULTS

Through a review of the literature, we found that U.S. disparities are partly due to a shortage of certified prescribers, concern of patient diversion, as well as economic and institutional barriers. Disparity of buprenorphine treatment dissemination is concerning since buprenorphine treatment has specific characteristics that are especially suited for low-income patient population in public sector healthcare such as flexible dosing schedules, ease of concurrently treating co-morbidities such as HIV and hepatitis C, positive patient attitudes towards treatment, and the potential of reducing addiction treatment stigma.

CONCLUSION

As the gap between buprenorphine treatment in public sector settings and private sector settings persists in the U.S., current research suggests ways to facilitate its dissemination.

Effects of regulation on methadone and buprenorphine provision in the wake of Hurricane Sandy

Hurricane Sandy led to the closing of many major New York City public hospitals including their substance abuse clinics and methadone programs, and the displacement or relocation of thousands of opioid-dependent patients from treatment. The disaster provided a natural experiment that revealed the relative strengths and weaknesses of methadone treatment in comparison to physician office-based buprenorphine treatment for opioid dependence, two modalities of opioid maintenance with markedly different regulatory requirements and institutional procedures. To assess these two modalities of treatment under emergency conditions, semi-structured interviews about barriers to and facilitators of continuity of care for methadone and buprenorphine patients were conducted with 50 providers of opioid maintenance treatment. Major findings included that methadone programs presented more regulatory barriers for providers, difficulty with dose verification due to impaired communication, and an over reliance on emergency room dosing leading to unsafe or suboptimal dosing. Buprenorphine treatment presented fewer regulatory barriers, but buprenorphine providers had little to no cross-coverage options compared to methadone providers, who could refer to alternate methadone programs. The findings point to the need for well-defined emergency procedures with flexibility around regulations, the need for a central registry with patient dose information, as well as stronger professional networks and cross-coverage procedures. These interventions would improve day-to-day services for opioid-maintained patients as well as services under emergency conditions.

Turn off the TV and dance! Participation in culturally tailored health interventions: implications for obesity prevention among Mexican American girls

Our evaluation study identifies facilitators and barriers to participation among families participating in the treatment arm of Stanford ECHALE. This culturally tailored obesity prevention trial consisted of a combined intervention with two main treatment components: 1) a folkloric dance program; and 2) a screen time reduction curriculum designed for 7-11 year old Latinas and their families. We conducted 83 interviews (40 parents and 43 girls) in participant homes after 6 months of enrollment in the ECHALE trial. The Spradley ethnographic method and NVivo 8.0 were used to code and analyze narrative data. Three domains emerged for understanding participation: 1) family cohesiveness; 2) perceived gains; and 3) culturally relevant program structure. Two domains emerged for non-participation: program requirements and perceived discomforts. Non-parametric, Spearman's rank correlation coefficients were calculated to assess the relationships with participant attendance data. Sustained participation was most strongly influenced by the domain perceived gains when parents reported better self-esteem, confidence, improved attitude, improved grades, etc. (Spearman r = .45, P = .003). Alternatively, under the domain, perceived discomforts, with subthemes such as child bullying, participation in the combined intervention was inversely associated with attendance (Spearman r = -.38, P = .02). Family-centered, school-based, community obesity prevention programs that focus on tangible short-term gains for girls may generate greater participation rates, enhance social capital, and promote community empowerment. These factors can be emphasized in future obesity prevention program design and implementation.

Declining sexually transmitted infections among female sex workers: the results of an HIV and sexually transmitted infection prevention strategy in Honduras, 2006-08

In 2006, we implemented an HIV and sexually transmitted infection (STI) prevention programme for female sex workers (FSWs) in three Honduran cities. All FSW attending STI clinics underwent regular examinations and STI testing. Information on condom use with different partners was collected at each visit. After three years, we detected a significant decline in the prevalence of syphilis from 2.3% at the first screening to 0.0% at the third screening (P = 0.05), and of chlamydia, from 6.1% to 3.3% (P = 0.01). No changes were observed in the prevalence of gonorrhoea or trichomoniasis. The cumulative HIV prevalence remained constant (P = 0.44). Reports of condom use with clients increased from 93.8% to 98.9% (P < 0.001). The implementation of an HIV/STI prevention programme in FSW has contributed to increases in condom use with clients and the reduction in syphilis and chlamydia prevalence. The intervention should be strengthened and considered as part of a national health policy strategy.

Cytotoxic and antioxidant activities of selected Lamiales species from Mexico

CONTEXT

Methanol extracts obtained from eight species belonging to four families of the Lamiales order native to Mexico were investigated for biological action.

OBJECTIVE

Cytotoxicity and antioxidant activity of methanol extracts have been investigated.

MATERIALS AND METHODS

Cytotoxic activity was evaluated by the sulphorhodamine B protein staining assay against KB (nasopharyngeal), HEp-2 (larynx), HF-6 (colon), MCF7 (breast), PC-3 (prostate), and Ca Ski (cervix) carcinoma cell lines. To analyze the antioxidant activity, common stable radicals chromogens, 2,2-azino-bis(3-ethylbenzthiazoline-6-sulfonic acid (ABTS+) and DPPH (1,1-diphenyl-2-picrylhydrazyl) were used. The ferric reducing antioxidant power (FRAP) and the total phenolic content of the samples were also determined.

RESULTS

Some of the extracts, such as Limosella aquatica L. (Scrophulariaceae), Mimulus glabratus Kunth. (Phrymaceae), Pedicularis mexicana Zucc. ex Benth. (Orobanchaceae), and Penstemon campanulatus (Cav.) Willd. (Plantaginaceae) displayed remarkably selective cytotoxic activity. However, the extract from Veronica americana (Raf.) Schwein (Plantaginaceae) showed the highest activity with IC₅₀ values of 1.46 and 0.169 g/ μL on PC-3 and HF-6 cells, respectively. With the exception of M. glabratus, all the extracts showed different degrees of antioxidant activity with IC₅₀ values from 0.89 up to 1.8 in the ABTS assay; from 0.49 up to 1.25 mg/mL in the DPPH assay and with the FRAP evaluation, 36 to 68 equivalents in mM of FeSO₄. V. americana also showed the highest antoxidant activity with IC₅₀ values from 0.491 and 0.892 mg/mL, on DPPH and ABTS assays, respectively.

DISCUSSION AND CONCLUSION

These findings demonstrated that the species studied have great potential cytotoxic and antioxidant activity.

Florfenicol feed supplemented decrease the clinical effects of Mycoplasma hyopneumoniae experimental infection in swine in México

The therapeutic value of Florfenicol feed supplemented was evaluated in conventional pigs to eliminate consequences of chronic infection of Mycoplasma hyopneumoniae. The experimental animals were pigs with an average of 16 kg, after intratracheally inoculation with M. hyopneumoniae they were divided in two experimental groups: (a) the non-medicated; and (b) the feed supplemented group (20 g Florfenicol/ton of feed) during the ensuing 35 days. The average daily weight gain of the Florfenicol-treated pigs (0.33±0.14 kg/day) was significantly higher than that of the non-treated ones (0.21±0.10 kg/day). In medicated animals was still impaired relative to that of the uninfected ones control group (0.39±0.02 kg/day). The average percentage of pneumonic gross lesions extensions' of the pigs groups was: 13.99% for M. hyopneumoniae infected non-medicated group; 1.79% M. hyopneumoniae infected, Florfenicol-treated group and, 0.56% of the uninfected control group. M. hyopneumoniae; colonization was detected at these levels in 7 and 9 members of the respective infected groups. The extent of the pneumonic lesions and M. hyopneumoniae generally was greater in the non-medicated pigs. Therefore, oral administration of Florfenicol via feed ingestion seemed to be somewhat effective in ameliorating the clinical effects of M. hyopneumoniae infection of swine.

State of the art and recommendations. Kangaroo mother care: application in a high-tech environment

Since Kangaroo Mother Care (KMC) was developed in Colombia in the 1970s, two trends in clinical application emerged. In low-income settings, the original KMC modelis implemented. This consists of continuous (24 h/day; 7 days/week) and prolonged mother/parent-infant skin-to-skin contact; early discharge with the infant in the kangaroo position; (ideally) exclusive breastfeeding and, adequate follow up. In affluent settings, intermittent KMC with sessions of one or a few hours skin-to-skin contact for a limited period is common. As a result of the increasing evidence of the benefits of KMC for both infants and families in all intensive care settings, KMC in a high-tech environment was chosen as the topic for the first European Conference on KMC, and the clinical implementation of the KMC modelin all types of settings was discussed at the 7th International Workshop on KMC Kangaroo Mother Care protocols in high-tech Neonatal Intensive Care Units (NICU) should specify criteria for initiation, kangaroo position, transfer to/from KMC, transport in kangaroo position, kangaroo nutrition, parents'role, modification of the NICU environment, performance of care in KMC, and KMCin case of infant instability.

CONCLUSION

Implementation of the original KMC method, with continuous skin-to-skin contact whenever possible, is recommended for application in high-tech environments, although scientific evaluation should continue.

Vasoactive and antioxidant activities of plants used in Mexican traditional medicine for the treatment of cardiovascular diseases

This study demonstrated that the aqueous extracts of plants employed in Mexican traditional medicine for the treatment of cardiovascular diseases are able to modify the tone of arterial smooth muscle. Agastache mexicana (Kunth) Lint & Epling (Labiatae), Chenopodium murale L. (Chenopodiaceae), Chirantodendron pentadactylon Larreat (Sterculiaceae), Dracocephalum moldavica L. (Labiatae), Psittacanthus calyculatus G. Don (Loranthaceae), Prunus serotina ssp. capuli (Cav. ex Spreng) McVaugh (Rosaceae), and Sechium edule Sw. (Cucurbitaceae) contain secondary metabolites that promote vascular relaxation and display antioxidant activities. As expected, their antioxidant effects showed a significant correlation with the polyphenolics content. However, a lower correlation was found between the antioxidant activity and the maximum vasodilatory effect, suggesting that the vasodilatation elicited by the plant extracts could be only partly attributed to their antioxidant properties. The extract of P. calyculatus, which displayed a maximum vasorelaxant effect that was higher than that of acetylcholine, induced endothelium-dependent vasodilatation. Futhermore, the vasorelaxant response to the P. calyculatus extract was reduced after adding an inhibitor of soluble guanylate cyclase activity, providing evidence that the NO/cGMP pathway is involved. On the other hand, the extracts of Bocconia frutescens L. (Papaveraceae), Magnolia grandiflora L. (Magnoliaceae), and Solanum rostratum Dunal (Solanaceae) induced concentration-dependent contraction of rat aortic rings, suggesting that these plants have potential health benefits for the treatment of ailments such as venous insufficiency. The pharmacological activities of the extracts studied provide scientific support for their ethnomedical use.

Towards universal Kangaroo Mother Care: recommendations and report from the First European conference and Seventh International Workshop on Kangaroo Mother Care

The hallmark of Kangaroo Mother Care (KMC) is the kangaroo position: the infant is cared for skin-to-skin vertically between the mother's breasts and below her clothes, 24 h/day, with father/substitute(s) participating as KMC providers. Intermittent KMC (for short periods once or a few times per day, for a variable number of days) is commonly employed in high-tech neonatal intensive care units. These two modalities should be regarded as a progressive adaptation of the mother-infant dyad, ideally towards continuous KMC, starting gradually and progressively with intermittent KMC. The other components in KMC are exclusive breastfeeding (ideally) and early discharge in kangaroo position with strict follow-up. Current evidence allows the following general statements about KMC in affluent and low-income settings: KMC enhances bonding and attachment; reduces maternal postpartum depression symptoms; enhances infant physiologic stability and reduces pain, increases parental sensitivity to infant cues; contributes to the establishment and longer duration of breastfeeding and has positive effects on infant development and infant/parent interaction. Therefore, intrapartum and postnatal care in all types of settings should adhere to a paradigm of nonseparation of infants and their mothers/families. Preterm/low-birth-weight infants should be regarded as extero-gestational foetuses needing skin-to-skin contact to promote maturation.

CONCLUSION

Kangaroo Mother Care should begin as soon as possible after birth, be applied as continuous skin-to-skin contact to the extent that this is possible and appropriate and continue for as long as appropriate.

State of the art and recommendations. Kangaroo mother care: application in a high-tech environment

Since Kangaroo Mother Care (KMC) was developed in Colombia in the 1970s, two trends in clinical application emerged. In low income settings, the original KMC model is implemented. This consists of continuous (24 h/day, 7 days/week) and prolonged mother/parent-infant skin-to-skin contact; early discharge with the infant in the kangaroo position; (ideally) exclusive breastfeeding; and, adequate follow-up. In affluent settings, intermittent KMC with sessions of one or a few hours skin-to-skin contact for a limited period is common. As a result of the increasing evidence of the benefits of KMC for both infants and families in all intensive care settings, KMC in a high-tech environment was chosen as the topic for the first European Conference on KMC, and the clinical implementation of the KMC model in all types of settings was discussed at the 7th International Workshop on KMC. Kangaroo Mother Care protocols in high-tech Neonatal Intensive Care Units (NICU) should specify criteria for initiation, kangaroo position, transfer to/from KMC, transport in kangaroo position, kangaroo nutrition, parents' role, modification of the NICU environment, performance of care in KMC, and KMC in case of infant instability.

CONCLUSION

Implementation of the original KMC method, with continuous skin-to-skin contact whenever possible, is recommended for application in high-tech environments, although scientific evaluation should continue.

Survival of advanced melanoma patients with normal LDH treated with oblimersen, temozolomide, and nab-paclitaxel

9080

Background: Oblimersen (OBL), temozolomide (TMZ), and abraxane (ABX) act synergistically in preclinical studies with melanoma cell lines. Bcl-2 antisense therapy in combination with dacarbazine was encouraging in advanced melanoma patients(pts) with normal LDH. Methods: Chemotherapy-naïve advanced melanoma pts (ECOG PS ≤ 2, baseline LDH ≤1.1 × ULN, measurable disease per RECIST) were enrolled on a phase I/II protocol. The treatment regimen consisted of 56-day cycles of OBL (7 mg/kg/d continuous IV infusion, d 1–7 and 22–28), TMZ (75 mg/m2/d, d 1–42), and ABX (175 mg/m2 in Cohort 1, 260 mg/m2 in Cohort 2, d 7 and 28). Immunohistochemical (IHC) staining for Bcl-2, Bcl-XL, BAK and caspase 3 was performed in pre- and post-therapy tumor samples. Serum shed collagen cryptic epitope levels were monitored. Results: 18 pts were treated (Cohort 1 = 14 pts [1–6 cycles];Cohort 2 = 4 pts [2–3 cycles]). Median age was 58 years (range: 34–78). Disease sites included liver (6), other visceral sites (10), skin, subcutaneous tissue, and lymph nodes (2). The overall survival (OS) was 14.7 months and showed a trend towards superiority when compared to both arms of the prior oblimersen trial (DTIC, OS 9.7 months, p = 0.078 and DTIC-OBL, OS 11.4 months, p = 0.31) in pts with the same LDH cut-off (Bedikian et al. JCO. 2006). 50% of pts survived > 1 year. One CR lasted 25+ mo, five PR (>50% tumor reduction) lasted > 2 cycles, and 7 SD lasted > 3 cycles. Five PD after 1 cycle were seen. One ocular melanoma pt survived 15 mo despite PD. Shed cryptic epitopes correlated with clinical response versus disease progression. Alteration of the tumor biology based on phenotypic changes in Bcl-2, Bcl-xL, BAK and caspase 3 correlated with response to treatment. Conclusions: Our data suggest that the combination of OBL, TMZ, and ABX is synergistic in advanced melanoma pts with normal LDH, possibly translating into improved OS compared to prior regimens with dacarbazine ± OBL. Biomarker studies support the rationale that Bcl-2 antisense therapy specifically impacts apoptotic signaling pathways in melanoma cells from metastatic tumor. The survival data in the limited number of pts enrolled in cohort 1 and 2 of this trial are encouraging; further exploration with this combination is underway using 1-hour infusions of OBL.

No significant financial relationships to disclose.

Exciton autoionization in ion-induced electron emission

We report on measurements of electron emission spectra from surfaces of highly oriented pyrolytic graphite (HOPG) excited by 1-5 keV He+ and Li+ which, for He+, exhibit a previously unreported high-energy structure. Through a full quantum dynamic description that allows for the calculation of neutralization and electron-hole pair excitation, we show that these high-energy electrons can arise from autoionization of excitons formed by electron promotion to conduction band states close to the vacuum level. The same calculation explains the observed absence of high-energy excitons for Li+ on HOPG.

Long-term effects of D-003, a mixture of high molecular weight acids from sugarcane wax, on bones of ovariectomized rats: a one year study

This study was done to determine the long-term effect of D-003 on bones of ovariectomized (ovx) rats distrib-uted in 4 groups: a false-operated and three groups of ovx rats: one treated with the vehicle and two with D-003 (5 and 250 mg/kg). D-003 significantly prevented, in a dose-dependent fashion, the trabecular bone volume (TBV), trabecular number (TbN) and trabecular thickness (TbTh) reduction induced in ovx rats and the increase of trabecular separation (TbSp) osteoclast number (OcN) and osteoclast surface (OcS/BS) increased in the positive controls versus the sham group. It is concluded that D-003 administered for 12 months prevented bone loss and decreased bone resorption in ovx rats, without evidences of impaired bone quality.

Effects of early experience and genotype on serotonin transporter regulation in infant rhesus macaques

The moderating effect of early experience on gene-behavior associations has been well characterized. The molecular events that allow for such moderation are not well understood, however. We assessed the impact of early experience and serotonin transporter linked promoter polymorphism (rh5-HTTLPR) genotype on peripheral serotonin transporter (5-HTT) regulation in response to a maternal/social separation and relocation stressor in infant rhesus macaques. We further tested the hypothesis that modulation of 5-HTT regulation by rearing and/or genotype is mediated by glucocorticoid (GC) availability. Fifty-three infant (3-4 months of age) rhesus macaques that were either nursery reared (NR) or mother reared (MR) were genotyped for rh5-HTTLPR. Infants were blood sampled within 2.5 h of maternal or social separation/relocation and again 5 h later. Infants were then administered dexamethasone, a synthetic GC and blood sampled 16.5 h later. 5-HTT RNA was quantified from peripheral blood mononuclear cells. Plasma cortisol was measured at all time points. The MR individuals upregulated 5-HTT significantly during maternal/social separation, while NR individuals did not. Concomitant increases in cortisol were not observed, but dexamethasone treatment stimulated 5-HTT expression regardless of genotype/rearing group, and 5-HTT expression in the post-stressor sample was correlated with plasma cortisol levels at all time points. Our data indicate that early experience exerted a strong influence on 5-HTT regulation during a stressor in infant rhesus macaques independent of rh5-HTTLPR genotype. We also showed that GCs may stimulate 5-HTT expression but that there likely exist faster-acting transcriptional regulators of 5-HTT that are in place as a function of experience.

Molecular characterization of the hemagglutinin-neuraminidase gene of porcine rubulavirus isolates associated with neurological disorders in fattening and adult pigs

"Blue eye disease" is a viral infection of swine endemic in Mexico, which produces fatal encephalitis accompanied by respiratory signs and corneal opacity in suckling piglets. An atypical blue eye disease outbreak presented high rates of neurological signs in fattening and adult pigs from 2000 to 2003. In order to identify the basis of increased neurovirulence, the hemagglutinin-neuraminidase (HN) gene of several porcine rubulavirus isolates were sequenced and compared with that of La Piedad Michoacan virus and other isolates that did not produce neurological disorders in weaned pigs. Nine amino acid mutations distinguished the high neurovirulent PAC6-PAC9 viruses, whereas five mutations characterized the low neurovirulent PAC2 and PAC3 viruses. HN protein three-dimensional models showed that the main conformation and functional domains were preserved, although substitutions A223T and A291D occurred in PAC2 and PAC3 viruses, as well as A511K and E514K presented in PAC6-PAC9 viruses considerably modified the properties of the HN protein surface. The increased positive charge of the HN protein of PAC6-PAC9 viruses seems to be associated with their increased neurovirulence.