The IMPOWR Network Divided or Single Exposure Study (DOSE) Protocol: A Randomized Controlled Comparison of Once Versus Split Dosing of Methadone for the Treatment of Comorbid Chronic Pain and Opioid Use Disorder

BACKGROUND

The Divided or Single Exposure (DOSE) trial is a double-blind, placebo-controlled examination of once versus split dosing of methadone for comorbid pain and opioid use disorder (OUD) among persons receiving methadone for OUD treatment.

METHODS

This multisite trial consists of a 12-week active intervention phase and 6-month follow-up period. Persons receiving methadone who endorse clinically-significant chronic pain are randomized into once-daily dosing or split dosing that is managed remotely via an electronic pillbox. Clinical pain is assessed weekly and using ecological momentary assessments. Experimentally-evoked pain is assessed using a quantitative sensory testing battery. Additional outcomes related to OUD, including withdrawal and craving, are also collected.

RESULTS

The study hypothesizes that persons assigned to the split dosing condition will report lower pain and opioid withdrawal relative to persons assigned to the traditional once-daily dosing strategy.

CONCLUSIONS

Split dosing is a relatively common technique in OUD treatments; therefore, if data support this hypothesis, there is high potential for implementation.

Transitioning off methadone: A qualitative study exploring why patients discontinue methadone treatment for opioid use disorder

INTRODUCTION

Patients who discontinue methadone for opioid use disorder are at increased risk of overdose and death. We know little about how patients make the decision to stop treatment. This study explored reasons why patients discontinue methadone treatment.

METHODS

We conducted 20 individual semi-structured patient interviews and two staff focus groups, each with five participants, at two opioid treatment programs in Baltimore, MD, in the United States from June 2021 to May 2022. Patient interviews and staff focus groups covered three domains: 1) reasons why patients may want to discontinue methadone; 2) perspectives about the ideal length of methadone treatment; and 3) changes that could improve retention. We used a modified grounded theory approach to code interviews, identify emergent themes, and develop a conceptual model.

RESULTS

We identified three themes related to patients' internal relationships to methadone: patients (1) viewed methadone as a bridge to opioid-free recovery, (2) believed that long-term methadone damages the body, and (3) felt that methadone increases craving for cocaine; and three themes related to their external relationships with opioid treatment programs and society at large: patients (4) viewed daily dosing as burdensome, (5) feared methadone inaccessibility could trigger relapse, and (6) experienced stigma from friends, family, and peers. Patients with internal reasons planned to stop as soon as possible and asked for education about perceived side effects and treatment for cocaine craving to promote retention. Patients with external reasons were willing to continue for longer and asked for adaptive take-home policies and reduced societal stigma around methadone.

CONCLUSIONS

Patients want to discontinue methadone either because of their internal relationship to methadone and its real or perceived side effects, or because of their external experiences with opioid treatment programs and societal stigma of methadone. To improve retention, clinical and policy changes should consider responses to both of these categories of reasons.

The influence of pH upon the antifungal activity of phenol and benzoic acid

The toxicity of phenol and benzoic acid to spores of Aspergillus niger is due to the unionised molecules.

Studies on Bacterial Populations in Solutions of Phenols

The shape of time-survivor curves for E. coli suspended in aqueous solutions of benzylchlorophenol depends on the concentration of the bactericide. In some concentrations the last survivors exhibit unexpected multiplication. The death of the organisms is accompanied by the release of cell-constituents having an ultra-violet absorption maximum at 260 mμ. Growth occurred when E. coli exudate was added to aqueous suspensions of E. coli whereas in its absence the organisms died. The numbers of viable organisms depended upon the concentration of the added cell exudate. The fate of the last survivors of a suspension of E. coli in benzylchlorophenol solution was controlled by re-suspending them in components of the reaction mixture. Removal of cell-exudate produced rapid death and the removal of bactericide led to multiplication of the organisms. It is concluded that cell exudate constituted the nutrient substrate for multiplication of last survivors in an initially bactericidal system. The theories of disinfection and the influence of cell exudate upon the shape of time-survivor curves are discussed.

Exposure to violence among substance-dependent pregnant women and their children

This study examined the prevalence of exposure to violence among drug-dependent pregnant women attending a multidisciplinary perinatal substance abuse treatment program. Participants (N = 715) completed the Violence Exposure Questionnaire within 7 days after their admission to the program. Their rates of lifetime abuse ranged from 72.7% for physical abuse to 71.3% for emotional abuse to 44.5% for sexual abuse. Their rates of abuse remained high during their current pregnancy, ranging from 40.9% for emotional abuse to 20.0% for physical abuse to 7.1% for sexual abuse. Nearly one third of the women reported having physical fights with their current partner (lifetime), and 25% of these women reported that children were present during those physical fights. A total of 30% of the women perceived a need for counseling regarding exposure to violence for themselves and 15% perceived a need for counseling for their children. Study findings confirm previous reports of high rates of abuse and violence exposure among substance-abusing pregnant women and their strong need for counseling for psychosocial sequelae. This study affirmed the value of routine screening for violence exposure in this at-risk population as well as the need to train therapists in specific strategies for helping such women address this complex array of problems.

An empirical evaluation of an expanded Nursing Stress Scale

In the study of work-related stress among nurses, the Nursing Stress Scale (NSS) is the best known and most widely used scale. This article presents an overview of the NSS and its use, and describes the development of an expanded instrument (ENSS) to measure sources and frequency of stress perceived by nurses. Findings are based on a random sample of 2,280 nurses in Ontario working in a wide range of work settings. Pretests for the study indicated that an expanded version of the NSS was necessary in order to adequately measure sources of stress among nurses. The sources of stress comprised nine subscales--death and dying, conflict with physicians, inadequate preparation, problems with peers, problems with supervisors, workload, uncertainty concerning treatment, patients and their families, and discrimination. Confirmatory factor analyses, run on two randomly selected halves of the sample, came close to meeting standard criteria levels. The alpha coefficients of eight of the subscales were .70 or higher, and concurrent and construct validity assessments provided strong support for the expanded NSS.

Gender and health: reassessing patterns and explanations

Recent research on gender and health challenges the prevailing notion of women's generalized health disadvantage by revealing a more variable pattern of gender differences in health. As such differences come to be comprehended as more complex than previously thought, there is a need to reassess the pathways linking gender and health. Using data from a Canadian national probability sample, we examine: (1) gender differences in distress, self-rated health, chronic conditions, restricted activity and heavy drinking; and (2) the role of gender-based differential exposure and vulnerability to chronic stress and life events in explaining observed differences. We find that women report more distress and chronic conditions than men, but gender differences are reversed for heavy drinking, and negligible for self-rated health and restricted activity. Although women reported more chronic stress and life events, their greater exposure accounted for only some of the gender disparity in health, and only for distress. Differential vulnerability to stressors played no role in explaining gender differences in health. These findings raise questions about a gendered, generalized health response to the vicissitudes of life and suggest the need for further theoretical and empirical exploration of "gendered" experiences and their pathways to health.

Gender differences in structural and behavioral determinants of health: an analysis of the social production of health

This paper explores aspects of the social production of health by focussing on the ways in which levels of health are shaped by structures of social inequality and behaviors or 'lifestyles'. We address two questions: What is the relative importance of the social, structural and behavioral determinants of health? And, are there gender differences in the determinants of health? These questions are explored using multiple regression analyses of data from the 1994 Canadian National Population Health Survey. Two measures of health are used: subjective health status and the Health Utilities Index (a measure of functional health status). By structural determinants we refer to age, family structure, main activity, education, occupation, income and social support. Behavioral determinants include lifestyle factors related to smoking, drinking, weight and physical activity. Findings indicate that the structures of social inequality are the most important determinants of health acting both independently and through their influence on the behavioral determinants of health. There are very real differences in the factors that predict women's and men's health. For women, social structural factors appear to play a more important role in determining health. Being in the highest income category, working full-time and caring for a family and having social support are more important predictors of good health for women than men. Smoking and alcohol consumption are more important determinants of health status for men than women, while body weight and being physically inactive are more important for women than men. Our findings suggest the value of models which include a wide range of structural and behavioral variables and affirm the importance of looking more closely at gender differences in the determinants of health.

"You just look at our work and see if you have any freedom on earth": Ghanaian women's accounts of their work and their health

Research on women's health in the developing world has focussed on reproductive issues and has defined women primarily as wives and mothers. Moreover, women's health problems have typically been defined by experts such as health care professionals and policymakers. The research reported here aimed to capture women's own views of their main health problems and how they explain them. The study was conducted in the Volta region of Ghana, West Africa and it involved interviews with 75 women of varying background and social circumstances. Reproductive health problems did not figure prominently among the problems women described almost three quarters of them spoke at length of psycho-social health problems such as 'thinking too much' and 'worrying too much'. These, in turn, were often linked with problems such as tiredness and not being able to sleep. Headaches and bodily aches and pains were also mentioned by many of the women. In explaining the source of these problems, one of the strongest themes in women's accounts was the importance of their work roles. Women spoke of the gender division of labor, their heavy workloads, the 'compulsory' nature of their work, their financial insecurity and the considerable financial responsibility they assumed for their children. These contributed to the worry they experienced and led them into many different work activities. They also talked about specific links between the nature of their work and the health problems they experienced, in particular, the physical toll of their work. We suggest that it is important to document the content of women's work, both paid and unpaid, showing the ways in which it influences their physical and mental health. Women in developing countries have too long been defined as childbearers and their important roles as workers have too often been neglected.

Complaints against nurses: a reflection of 'the new managerialism' and consumerism in health care?

This paper discusses the effects of restructuring on nursing as a profession through an examination of the issue of complaints in Ontario. It argues that new managerialist techniques and associated changes in the nature of work are reducing the autonomy of nurses and making it difficult for them to meet the standards of their profession. Simultaneously, the Ontario government has increased the power of the public in the disciplinary process and the College of Nurses of Ontario is encouraging patients to register their complaints. The growth of consumerism in health care, coupled with the disciplinary process, individualizes complaints and deemphasizes their relationship to restructuring. Moreover, in response to the increasing number of complaints - complaints which more often come from the public - nursing organizations have encouraged the legalization of the disciplinary process, thus fostering the individualization of the issues.

Gender differences in work and family life

Work. What comes to mind? Most of us think in terms of the work for which we are paid or the jobs that we would like to have. Seldom do we also think of the things we do at home, the care that we provide for our families. Yet, this unpaid work can influence our job, just as the demands of the workplace can affect our home life. Together, the expectations of both types of work can sometimes be over-whelming.

"I just cope from day to day": unpredictability and anxiety in the lives of women

Data are presented from in-depth interviews with 35 women in an industrial town in South Wales, U.K., many of whom were from low income households. The research aimed to explore women's own concerns about their health and the ways in which health problems affected their lives. This paper focuses on one prominent theme in these interviews: unpredictability. In particular, women described how their lives had become less predictable and amenable to control as a result of health problems--epilepsy, asthma, ME, anxiety, nerves and panic attacks, for example. Women's accounts are used to show how they experienced these problems, how they influenced women's self-identity and the ways in which women struggled to cope with the dreadful uncertainty that characterized their days. They often hid these problems, and the privacy of this aspect of their lives is striking. The data are set within the context of class and gender relations which diminish women's control over their lives and erode their self-esteem and sense of autonomy. Class and gender combine with ill health to create the conditions for women's sense of unpredictability and powerlessness. They can aggravate and provoke the health problems women described: women spoke of the challenges they faced in their roles as wives and mothers, the problems associated with widowhood, the loss of their jobs, the impact of unemployment and their efforts to cope with severe financial problems. In part, these provided them with a framework for understanding the uncertainty, anxiety, nerves and panic they experienced.

Paid work, unpaid work and social support: a study of the health of male and female nurses

Paid work, unpaid work in the home and social support are important elements of the social production of health and illness, though their combined effects on both women and men have only recently become a focus of research. This paper examines their association with the health problems of nurses, presenting data from a survey of a proportional random sample of 2285 male and female nurses registered in the Province of Ontario. The data are first analysed for the full sample and then multiple regression analyses are run separately for male and female Registered Nurses. The demands of paid work (overload, exposure to hazards), unpaid work (time pressures, caring for a dependent adult) and overall stress in life are associated with greater health problems. There is also evidence of significant links between social support and health. A poor relationship with a supervisor is associated with health problems. On the other hand, enjoying a confiding relationship with a friend and having up to 4 children reduces the likelihood of experiencing health problems. The features of nursing associated with fewer health problems are challenge, statisfaction with work and working under 20 hours a week. Several common themes emerge in the analyses of women and men: overload, hazard exposure, satisfaction with work, having 3-4 children and level of overall stress in life. Yet the models are also very different and point to the need for further analyses of the social production of health problems in relation to gender. They also suggest that female nurses, in particular, may suffer the effects of restructuring in the health care sector. Workload issues are especially important for women. Younger women, those reporting time pressures and caring for a dependent adult are more likely to report health problems. Having a confiding relationship with a friend is associated with fewer health problems for women. Among men, those who dislike housework are more likely to experience health problems. Satisfaction with work and overall stress in life were associated with health problems for both men and women, though there may be gender differences in what generates satisfaction and stress.

Workplace organizational correlates of lost-time accident rates in manufacturing

We report the results of a questionnaire survey of manufacturing workplaces related to the lost-time frequency rates (LTFR) for Workers' Compensation claims. Six types of industry were chosen.' metal articles, plastic articles, grain products, textile manufacturing, printing, and automobile manufacturing. LTFR were standardized by type of industry. Stratifying simultaneously by number of employees and LTFR category, we sampled 718 workplaces. A mail questionnaire to labor and management representatives provided at least some information on 58%. Response rates were similar across LTFR categories, and telephone interviews of non-responders showed little difference in their replies from those obtained in completed questionnaires. A large number of variables were examined. Apart from statistical significance, we looked for consistency in trends across LTFR categories and in patterns for similar questions. Significant associations grouped into several areas. Lower LTFR were associated with: concrete demonstration by management of its concern for the workforce; greater involvement of workers in general decision-making; greater willingness of the Joint Health and Safety Committee to solve problems internally; and greater experience of the workforce. Variables that were not significant included profitability and financial performance. A final stepwise multiple regression explained 19% of the variance in LTFR, although this analysis suffered from several limitations.

Stress, anxiety and depression: women's accounts of their health problems

In a study of a stratified random sample of 356 Canadian women, stress, anxiety and depression were among the most frequently reported health problems. The first part of this paper outlines the different social characteristics of those who reported stress, anxiety and depression. Women experienced mental health problems differently depending on their socio-economic status, ethnicity, family structure, the quality of family relationships and the nature of their participation in the labour market. It is argued that we need a more detailed analysis of these aspects of women's estate if we are to understand the social production of mental health and variations between women. Subsequent sections of the paper discuss women's own understanding of the sources of their mental health problems. While they spoke of the particularities of their own lives, these were often located in the context of broader social influences. They emphasized the social aetiology of mental health, noting the importance of gender roles and images of women. They described the heavy workload of women, issues of identity and their social legacies. In conclusion, it is noted that women appear to normalize the mental health problems they report. This may, in part, reflect the lack of social reinforcement and validation of their experiences.

Women's views of their main health problems

Though there has been increased emphasis on women's health and on community participation in the development of health policy, 'ordinary women' have seldom been asked about their major health concerns. This paper reports on a survey of a stratified random sample of 356 women in Hamilton. Among their main worries regarding health were various cancers and heart disease. The health problems they had experienced in the previous six months which had bothered them most were stress, arthritis, being overweight, migraines/chronic headaches and tiredness. On the basis of these and similar data presented here, it is argued that such community surveys provide an important source of data. They identify somewhat different priorities than approaches which rely on the opinions of experts and other key informants.

State mediation of conflicts over work refusals: the role of the Ontario Labour Relations Board

A key feature of occupational health and safety legislation is that it has sought to compartmentalize health and safety issues by creating structures and processes that depart from "typical" social relations of production. The Ontario Labour Relations Board, in adjudicating disputes concerning work refusals, faces the difficult, if not impossible, task of defining and maintaining a sphere in which workers have an uncommon latitude and power. Analysis of cases before the Board during the 1980s shows how it errs on the side of caution and uses criteria related to "typical" social relations of production to define convincing testimony and assess workers' entitlement to redress. Similarly, employers' interests and the requirements of the labor process are a reference point in the Board's definition of the scope of workers' rights and what constitute legitimate penalties for the "abuse" of these. Yet decisions are not wholly biased toward employers; dissenting opinions reveal important differences and progressive rulings establish precedents that could be a basis for future decisions.

Workers' perceptions, knowledge and responses regarding occupational health and safety: a report on a Canadian study

This paper presents data from interviews with 492 rank and file workers. It examines aspects of workers' perceptions, knowledge and actions regarding workplace hazards and views these as indicators of the potential strength of labour in improving occupational health and safety. Respondents had a strong consciousness of ways in which their work might damage their health and they or their fellow workers had experienced half of the symptoms they mentioned. However, they lacked information on the results of environmental and medical monitoring, their core legal rights and the more effective strategies for reducing hazards. Few respondents sought information and few were persistent in dealing with their worries about hazards. Knowledge of their rights under the current occupational health and safety legislation was linked with taking such actions. It is suggested that workers' pursuit of their health and safety concerns might be facilitated if they had better access to information about their legal rights and mechanisms for dealing with hazards in the workplace.

Company doctors: standards of care and legitimacy: a case study from Canada

Company doctors have been criticized for poor standards of care and bias towards their employers interests. This paper reports on interviews with 24 company doctors in the province of Ontario, Canada. It uses company doctors' accounts of their work and careers to highlight aspects of corporate medicine which may help to produce questionable standards of care and present obstacles to doctors' attempts to increase their legitimacy. Apparent variations in the quality of care in contract practice and full-time employment in a company are discussed and it is suggested that greater attention may need to be devoted to improving the standards of care in smaller companies. Patterns of recruitment, doctors' beliefs about the changing nature of occupational medicine, as well as contradictory definitions of the proper sphere of occupational medicine may also have an effect on standards of care and the degree of legitimacy accorded to company doctors. The responses of doctors to charges of bias are discussed and it is suggested that they may neglect the major reason for such charges--that they are employed by companies and are thereby constrained to favour their employers' interests. The paper proposes the need for further research on standards of occupational medical care, whether these vary with respect to context of practice and whether there are appreciable differences in standards of practice among doctors employed by companies, unions, universities and government. Modest proposals for future health policy are also indicated.

The prolongation of the in vitro dissolution of a soluble drug (phenethicillin potassium) by microencapsulation with ethyl cellulose

Microcapsules of phenethicillin potassium as a model water-soluble drug, coated with ethyl cellulose, have been prepared (core: wall ratios 1:1, 1:2 and 1:3) in which the taste has been masked, the odour almost eliminated and the release retarded. Sieve analysis showed that with decreasing core: wall ratios there was a trend towards increasing amounts of larger sized microcapsules. At constant core:wall ratios in vitro release of drug was generally greatest from the larger microcapsules. This result correlated with the surface areas of the microcapsules which became less as the asymmetry of the microcapsules diminished with decrease in microcapsule size. There was a linear relation between the amount of ethyl cellulose and the time for 60% release of drug, and the release pattern was analogous to that from insoluble porous matrices. Scanning electron micrographs showed the microcapsules to be irregularly shaped with circular surface pores, and they did not alter in shape or size during dissolution. Tableting of 1:1 core: wall ratio microcapsules significantly further retarded the dissolution.

The mechanical properties of some binders used in tableting

Films of acacia, gelatin, methylhydroxyethyl cellulose, polyvinylpyrrolidone (PVP) and starch have been prepared with moisture levels of 2·0 to 20·0% w/w obtained by equilibration at relative humidities from 0 to 90%. Tensile strengths of 60 mm × 2 mm strips of these films have been determined by stressing to failure at a constant rate of 6·6 times 10−5 ms−1 in a tensile strength apparatus. From the stress-strain curves the modulus of elasticity, yield strength and the work done in breaking unit cross-sectional area of the films have been calculated. This has given an indication of the binders’ mechanical behaviour over the range of moisture contents likely to be encountered in tableting.

The relation beween he bactericidal activities and certain physico-chemical properties of some fluorophenols

The antibacterial activities, as demonstrated by the Rideal-Walker coefficients and viable counts, of mono-, 2,4,5– tri-, 2,3,5,6- tetra- and pentafluorophenol increase with the number of substituent fluorine atoms. The thermodynamic activities (Ferguson values) range from 0·083 to 0·022, and indicate a non-specific physical mode of action. Linear correlations occur between the equitoxic concentrations of the compounds to Escherichia coli (99·9% mortality after 50 min contact) and their molecular weights, number of fluorine substituents and water solubilities. A similar relation exists between the molar concentrations at the Rideal-Walker end points and the oleyl alcohol-water partition coefficients; no correlation occurs between toxicity and the cyclohexane-water partition coefficients. The surface tensions of equitoxic solutions vary between 57·5 and 63·2 mNm−1 (dynes/cm).

The dissolution of paracetamol tablets and the in vitro transfer of paracetamol with and without sorbitol

MANY adjuvants such as sorbitol, glucosamine hydrochloride and sodium hexametaphosphate, have been added to oral dosage forms to improve the absorption of drugs, but Wagner (1961) emphasizes that the attribution of beneficial results to them is not always unequivocal. With sorbitol in paracetamol tablets, it has been suggested that the improved absorption is due to the sorbitol acting on the metabolism of paracetamol and as a dispersing agent (Gwilt, Robertson & others, 1963). The combination of paracetamol and sorbitol provides a readily assayable system with which to examine the role of the adjuvant.

I have examined the effect of sorbitol on the aqueous solubility and partitioning of paracetamol and have studied the dissolution rate of paracetamol from commercial tablets containing paracetamol with or without sorbitol with the aim of evaluating the effect of the adjuvant on the availability of the drug.

The effect of concentration, time and temperature on the viability of Penicillium notatum spores exposed to phenols

Spores of Penicillium notatum exposed to resorcinol, p-chlorophenol, m-cresol, chlorocresol and hexylresorcinol, give values for the concentration exponent, n, from 7.3 to 3.7 when calculated from first order reaction velocities; higher values are obtained from the times for fixed mortality levels. Values of the temperature coefficient, θ, vary from 1.045–1.331. The log survivor-time curves are convex to the axes for resorcinol and increasingly concave in the order of decreasing water solubility for the other phenols. Equitoxic (99% mortality in 20 min) molar concentrations of the phenols have about a 680-fold range, but Ferguson values, except for resorcinol, vary only from 0.10 to 0.26.