Exploring the Impact of External Facilitation Using Evidence-Based Implementation Strategies for Increasing Motivational Interviewing Capacity Among Outpatient Substance Use Disorder (SUD) Treatment Providers

The large majority of individuals who access substance use disorders (SUD) treatment do not receive evidence-based care. Little attention has been paid to the notion that the scale-up of evidence-based practices (EBPs) has been limited in large part due to a weakness in the "distribution system" for bringing new innovations to the attention of practitioners and into practice settings. This study explores the impact of the Training and Practice Implementation Institute (TPII; funded by the New York City Department of Health and Mental Hygiene), an intensive technical assistance initiative that offers external facilitation to outpatient SUD treatment providers via the incorporation of multiple evidence-based implementation strategies to enhance the practice of motivational interviewing (MI). Findings from this study show that staff completed a large majority (86%) of required training/technical assistance (TTA) activities across the 9-month implementation period, demonstrating a high level of engagement among staff and the feasibility of externally facilitated intensive TTA delivered to community-based organizations for the purpose of enhancing implementation of MI for SUDs. Results also show statistically significant improvements in the delivery of MI's technical components among staff, though did not reveal corresponding improvements in the delivery of MI's relational components. An understanding of the potential return on investment associated with externally facilitated TA, offers organizations an opportunity to inform the allocation of limited resources to areas where they will have the greatest impact and ultimately improve the quality and efficacy of services.

Public Health Detailing to Increase Naloxone Access in NYC Pharmacies

BACKGROUND

Drug overdose is a public health crisis in the United States. Opioid overdose deaths are preventable using naloxone, an opioid antagonist that reverses the effect of an opioid and prevents fatal overdose.

OBJECTIVES

This study aimed to evaluate changes in naloxone standing order status, attitudes, and practice behavior after an 8-week public health detailing campaign on increasing naloxone access conducted among pharmacists in independent pharmacies in New York City (NYC).

METHODS

Campaign recommendations were to (1) enroll in the NYC pharmacy naloxone standing order program, (2) offer naloxone to at-risk patients, and (3) educate patients on how to use naloxone. Evaluation was performed using initial and follow-up surveys administered to pharmacists during detailing visits and Department of Health and Mental Hygiene data on pharmacies in the standing order program.

RESULTS

Detailing visits were completed with 1153 pharmacists; follow-up visits were completed with 457 (40%). Self-reported attitudes and practice behavior related to the 3 campaign recommendations improved (P < 0.01). After the campaign, 519 new pharmacies enrolled in the standing order program.

CONCLUSIONS

The detailing campaign substantially increased the number of pharmacies enrolled in the standing order program and was associated with improved attitudes and practice behavior related to naloxone provision to varying degrees. Other jurisdictions could consider detailing pharmacists as a strategy to increase naloxone access.

Costs of opioid overdose education and naloxone distribution in New York City

Background: Naloxone is an opioid antagonist medication that can be administered by lay people or medical professionals to reverse opioid overdoses and reduce overdose mortality. Cost was identified as a potential barrier to providing expanded overdose education and naloxone distribution (OEND) in New York City (NYC) in 2017. We estimated the cost of delivering OEND for different types of opioid overdose prevention programs (OOPPs) in NYC. Methods: We interviewed naloxone coordinators at 11 syringe service programs (SSPs) and 10 purposively sampled non-SSPs in NYC from December 2017 to September 2019. The samples included diverse non-SSP program types, program sizes, and OEND funding sources. We calculated one-time start up costs and ongoing operating costs using micro-costing methods to estimate the cost of personnel time and materials for OEND activities from the program perspective, but excluding naloxone kit costs. Results: Implementing an OEND program required a one-time median startup cost of $874 for SSPs and $2,548 for other programs excluding overhead, with 80% of those costs attributed to time and travel for training staff. SSPs spent a median of $90 per staff member trained and non-SSPs spent $150 per staff member. The median monthly cost of OEND program activities excluding overhead was $1,579 for SSPs and $2,529 for non-SSPs. The costs for non-SSPs varied by size, with larger, multi-site programs having higher median costs compared to single-site programs. The estimated median cost per kit dispensed excluding and including overhead was $19 versus $25 per kit for SSPs, and $36 versus $43 per kit for non-SSPs, respectively. Conclusions: OEND operating costs vary by program type and number of sites. Funders should consider that providing free naloxone to OEND programs does not cover full operating costs. Further exploration of cost-effectiveness and program efficiency should be considered across different types of OEND settings.

Increasing Access to Buprenorphine in Safety-Net Primary Care Clinics: The New York City Buprenorphine Nurse Care Manager Initiative

The Buprenorphine Nurse Care Manager Initiative (BNCMI) sought to increase access to opioid use disorder treatment in underserved New York City populations by expanding buprenorphine treatment capacity in safety-net primary care clinics.During 2016 to 2020, BNCMI added 116 new buprenorphine providers across 27 BNCMI clinics, and 1212 patients were enrolled; most patients identified as Latinx or Hispanic and were Medicaid beneficiaries.BNCMI increased access to buprenorphine, reached underserved populations, and is part of the New York City Health Department's multipronged approach to reducing opioid overdose deaths.

Examining opioid-involved overdose mortality trends prior to fentanyl: New York City, 2000-2015

BACKGROUND

Rates of overdose death in New York City (NYC) increased 26% from 2000 to 2015, with a notable decrease in rate from 2006 to 2010. Beginning in 2016, the synthetic opioid fentanyl entered the NYC illicit drug market and has been associated with large increases in overdose death. This study assessed NYC trends in opioid-involved overdose death prior to fentanyl to understand the contribution of specific opioids and inform overdose prevention strategies.

METHODS

Data were derived from death certificates linked to postmortem toxicology testing. We stratified cases into three mutually exclusive groups: (1) heroin without opioid analgesics (OAs); (2) OAs without heroin; and (3) the combination of heroin and OAs. We calculated mortality rates by year, and compared rates by the demographic characteristics age, sex, and race/ethnicity. Joinpoint regression identified junctures in trends between 2000 and 2015.

RESULTS

Rates of overdose death involving heroin without OAs decreased from 2006 to 2010, then increased from 2010 to 2015 among males, persons age 15 to 54, and Blacks and Whites. Rates of overdose death involving OAs with and without heroin increased from 2000 to 2015 across all demographic subgroups.

CONCLUSIONS

The identified trends in overdose death are suggestive of demographic shifts in drug use. In particular, the tamper-resistant reformulation of oxycodone 80 mg may have increased the use of heroin among primary OA users. Notably, older adults may have had established heroin use practices prior to the proliferation of OAs and thus may have been less likely to modify drug use practices.

Relay: A Peer-Delivered Emergency Department-Based Response to Nonfatal Opioid Overdose

Relay, a peer-delivered response to nonfatal opioid overdoses, provides overdose prevention education, naloxone, support, and linkage to care to opioid overdose survivors for 90 days after an overdose event. From June 2017 to December 2018, Relay operated in seven New York City emergency departments and enrolled 649 of the 876 eligible individuals seen (74%). Preliminary data show high engagement, primarily among individuals not touched by harm reduction or naloxone distribution networks. Relay is a novel and replicable response to the opioid epidemic.

Racial Differences in Opioid Overdose Deaths in New York City, 2017

This study evaluates racial differences in opioid overdose deaths in New York City for 2017.

Impact of a prescription drug monitoring program use mandate on potentially problematic patterns of opioid analgesic prescriptions in New York City

PURPOSE

To evaluate New York State's mandate that prescribers query the prescription drug monitoring program (PDMP) prior to prescribing Schedule II-IV medications.

METHODS

We conducted an interrupted time series analysis of opioid analgesic prescriptions dispensed to adult New York City (NYC) residents using data from New York State's PDMP. Our main outcomes were the rate of (a) greater than or equal to five prescriber episodes, (b) greater than or equal to five prescriber and greater than or equal to five pharmacy episodes, and (c) paying for prescriptions with both cash and insurance, per quarter, per 100 000 NYC residents. We defined three periods: (a) the baseline period (January 2011 to July 2012), (b) the anticipatory period (September 2012 to July 2013) after mandate law enactment but before mandate implementation, and (c) the postmandate period (September 2013 to December 2015). For each outcome, we used autoregressive linear regression models to account for correlation in outcomes over time.

RESULTS

At the end of the postmandate period, the rate of greater than or equal to five prescriber episodes was 58% lower than expected (absolute difference: -17.2 per 100 000 NYC residents; 95% CI, -31.2 to -3.1), the rate of greater than or equal to five prescriber and greater than or equal to five pharmacy episodes was 88% lower than expected (absolute difference: -8.6; 95% CI, -11.0 to -6.3), and the rate of cash and insurance payment episodes was 50% lower than expected (absolute difference: -145.4; 95% CI, -279.4 to -11.6).

CONCLUSIONS

While outcomes were relatively rare, New York State's PDMP mandate was associated with significant decreases in rates of potentially problematic patterns of opioid analgesic prescriptions.

Study protocol for a pragmatic trial of the Consult for Addiction Treatment and Care in Hospitals (CATCH) model for engaging patients in opioid use disorder treatment

BACKGROUND

Treatment for opioid use disorder (OUD) is highly effective, yet it remains dramatically underutilized. Individuals with OUD have disproportionately high rates of hospitalization and low rates of addiction treatment. Hospital-based addiction consult services offer a potential solution by using multidisciplinary teams to evaluate patients, initiate medication for addiction treatment (MAT) in the hospital, and connect patients to post-discharge care. We are studying the effectiveness of an addiction consult model [Consult for Addiction Treatment and Care in Hospitals (CATCH)] as a strategy for engaging patients with OUD in treatment as the program rolls out in the largest municipal hospital system in the US. The primary aim is to evaluate the effectiveness of CATCH in increasing post-discharge initiation and engagement in MAT. Secondary aims are to assess treatment retention, frequency of acute care utilization and overdose deaths and their associated costs, and implementation outcomes.

METHODS

A pragmatic trial at six hospitals, conducted in collaboration with the municipal hospital system and department of health, will be implemented to study the CATCH intervention. Guided by the RE-AIM evaluation framework, this hybrid effectiveness-implementation study (Type 1) focuses primarily on effectiveness and also measures implementation outcomes to inform the intervention's adoption and sustainability. A stepped-wedge cluster randomized trial design will determine the impact of CATCH on treatment outcomes in comparison to usual care for a control period, followed by a 12-month intervention period and a 6- to 18-month maintenance period at each hospital. A mixed methods approach will primarily utilize administrative data to measure outcomes, while interviews and focus groups with staff and patients will provide additional information on implementation fidelity and barriers to delivering MAT to patients with OUD.

DISCUSSION

Because of their great potential to reduce the negative health and economic consequences of untreated OUD, addiction consult models are proliferating in response to the opioid epidemic, despite the absence of a strong evidence base. This study will provide the first known rigorous evaluation of an addiction consult model in a large multi-site trial and promises to generate knowledge that can rapidly transform practice and inform the potential for widespread dissemination of these services.

TRIAL REGISTRATION

NCT03611335.

Increased Presence of Fentanyl in Cocaine-Involved Fatal Overdoses: Implications for Prevention

After remaining stable from 2010 to 2014, the  rate of cocaine-involved overdose death increased sharply from 2015 to 2016. This study aims to determine the contribution of opioids, and fentanyl in particular, to the increase in cocaine-involved overdose death from 2015 to 2016. Using New York City death certificate data linked to medical examiner toxicology data, we identified all overdose deaths where post-mortem toxicology results were positive for cocaine from 2010 to 2016. We analyzed cocaine-involved overdose deaths by co-occurring substances. Age-adjusted rates per 100,000 residents were calculated for 6-month intervals from 2010 to 2016. Data suggest that increased deaths involving opioids, specifically fentanyl, accounted for most of the increase in cocaine-involved deaths from 2015 to 2016.

Witnessed overdoses and naloxone use among visitors to Rikers Island jails trained in overdose rescue

With the opioid overdose mortality rates rising nationally, The New York City Department of Health and Mental Hygiene (NYC DOHMH) has worked to expand overdose rescue training (ORT) and naloxone distribution. This study sought to determine rates of overdose witnessing and naloxone use among overdose rescue-trained visitors to the NYC jails on Rikers Island. We conducted a six-month prospective study of visitors to NYC jails on Rikers Island who received ORT. We collected baseline characteristics of study participants, characteristics of overdose events, and responses to witnessed overdose events, including whether the victim was the incarcerated individual the participant was visiting on the day of training. Bivariate analyses compared baseline characteristics of participants who witnessed overdoses to those who did not, and of participants who used naloxone to those who did not. Overall, we enrolled 283 participants visiting NYC's Rikers Island jails into the study. Six months after enrollment, we reached 226 participants for follow-up by phone. 40 participants witnessed 70 overdose events, and 28 participants reported using naloxone. Of the 70 overdose events, three victims were the incarcerated individuals visited on the day of training; nine additional victims were recently released from jail and/or prison. Visitors to persons incarcerated at Rikers Island witness overdose events and are able to perform overdose rescues with naloxone. This intervention reaches a population that includes not only those recently released, but also other people who experienced overdose.

Naloxone use among overdose prevention trainees in New York City: A longitudinal cohort study

BACKGROUND

Providing naloxone to laypersons who are likely to witness an opioid overdose is now a widespread public health response to the national opioid overdose epidemic. Estimating the proportion of individuals who use naloxone can define its potential impact to reduce overdose deaths at a population level. We determined the proportion of study participants who used naloxone within 12 months following training and factors associated with witnessing overdose and naloxone use.

METHODS

We conducted a prospective, observational study of individuals completing overdose prevention training (OPT) between June and September 2013. Participants were recruited from New York City's six largest overdose prevention programs, all operated by syringe exchange programs. Questionnaires were administered at four time points over 12 months. Main outcomes were witnessing or experiencing overdose, and naloxone administration.

RESULTS

Of 675 individuals completing OPT, 429 (64%) were approached and 351 (52%) were enrolled. Overall, 299 (85%) study participants completed at least one follow-up survey; 128 (36%) witnessed at least one overdose. Of 312 witnessed opioid overdoses, naloxone was administered in 241 events (77%); 188 (60%) by the OPT study participant. Eighty-six (25%) study participants administered naloxone at least once. Over one third of study participants (30, 35%) used naloxone 6 or more months after training.

CONCLUSIONS

Witnessing an overdose and naloxone use was common among this study cohort of OPT trainees. Training individuals at high risk for witnessing overdoses may reduce opioid overdose mortality at a population level if sufficient numbers of potential responders are equipped with naloxone.

Developing Syndromic Surveillance to Monitor and Respond to Adverse Health Events Related to Psychoactive Substance Use: Methods and Applications

INTRODUCTION

Recent increases in drug overdose deaths, both in New York City and nationally, highlight the need for timely data on psychoactive drug-related morbidity. We developed drug syndrome definitions for syndromic surveillance to monitor drug-related emergency department (ED) visits in real time.

MATERIALS AND METHODS

We used 2012 archived syndromic surveillance data from New York City hospitals to develop definitions for psychoactive drug-related syndromes. The dataset contained ED visit-level information that included patients' chief complaints, dates of visits, ZIP codes of residence, discharge diagnoses, and dispositions. After manually reviewing chief complaints, we developed a classification scheme comprising 3 categories (overdose, drug mention, and drug abuse/misuse), which we used to define 25 psychoactive drug syndromes. From July 2013 through December 2015, the New York City Department of Health and Mental Hygiene performed daily syndromic surveillance of psychoactive drug-related ED visits using the 25 syndrome definitions.

RESULTS

Syndromic surveillance triggered 4 public health investigations, supported 8 other public health investigations that had been triggered by other mechanisms, and resulted in the identification of 5 psychoactive drug-related outbreaks. Syndromic surveillance also identified a substantial increase in synthetic cannabinoid-related visits (from an average of 3 per week in January 2014 to >300 per week in July 2015) and an increase in heroin overdose visits (from 80 to 171 in the first 3 quarters of 2012 and 2014, respectively) in a single neighborhood.

PRACTICE IMPLICATIONS

Syndromic surveillance using these novel definitions enabled monitoring of trends in psychoactive drug-related morbidity, initiation and support of public health investigations, and targeting of interventions. Health departments can refine these definitions for their jurisdictions using the described methods and integrate them into existing syndromic surveillance systems.

Public Health Detailing-A Successful Strategy to Promote Judicious Opioid Analgesic Prescribing

OBJECTIVES

To evaluate knowledge and prescribing changes following a 2-month public health detailing campaign (one-to-one educational visits) about judicious opioid analgesic prescribing conducted among health care providers in Staten Island, New York City, in 2013.

METHODS

Three detailing campaign recommendations were (1) a 3-day supply of opioids is usually sufficient for acute pain, (2) avoid prescribing opioids for chronic noncancer pain, and (3) avoid high-dose opioid prescriptions. Evaluation consisted of a knowledge survey, and assessing prescribing rates and median day supply per prescription. Prescribing data from the 3-month period before the campaign were compared with 2 sequential 3-month periods after the campaign.

RESULTS

Among 866 health care providers visited, knowledge increased for all 3 recommendations (P < .01). After the campaign, the overall prescribing rate decreased similarly in Staten Island and other New York City counties (boroughs), but the high-dose prescribing rate decreased more in Staten Island than in other boroughs (P < .01). Median day supply remained stable in Staten Island and increased in other boroughs.

CONCLUSIONS

The public health detailing campaign improved knowledge and likely prescribing practices and could be considered by other jurisdictions to promote judicious opioid prescribing.

Evaluation of overdose prevention trainings in New York City: Knowledge and self-efficacy among participants 12 months after training

BACKGROUND

Prevention of unintentional opioid overdose deaths is effective through overdose prevention trainings (OPTs), in which laypersons are taught overdose response through six actions. This longitudinal study examines trainee knowledge 12 months after OPT completion.

METHODS

Participants were enrolled following OPT at six sites. At the 12-month follow-up, participants were asked to name the drug overdoses that naloxone reverses and name overdose response actions. A 6-point scale was created and was comprised of the number of correct overdose response actions mentioned (check breathing; administer sternum rub; call 911; give rescue breathing; administer naloxone; put victim in recovery position). Mean knowledge was compared by participant sociodemographic characteristics, confidence, and site of OPT training (indoors versus outdoors).

RESULTS

Of 344 OPT participants, 273 were reached at 12 months. Nearly all (99%) participants identified that naloxone reverses heroin overdoes; 77% identified that naloxone reverses opioid analgesics overdoses; and 68% identified that naloxone reverses methadone overdoses. Overdose response actions most frequently mentioned were giving naloxone (86%) and calling 911 (76%). The remaining four actions were mentioned by less than 40% of participants. Overall mean knowledge score was 2.7 out of 6. Mean knowledge scores were higher for college graduates than those with less than college education (3.2 vs 2.6, P < 0.001), for those who felt very confident (mean score [ms] = 2.9), compared to somewhat confident (ms = 2.4) and a little or not at all confident (ms = 1.5) in their ability to reverse an overdose (P < .001), and for indoor-training recipients (3.0 vs 2.5, P = 0.02). There were no differences in mean knowledge scores for trainees by age, race, or gender.

CONCLUSIONS

These findings suggest the need for several improvements in OPT curriculum, including emphasis on naloxone reversal of opioid analgesic and methadone overdoses, and all 6 rescue actions. Lower knowledge scores among outdoor-trained participants likely reflect session brevity, suggesting that outdoor trainings need to be enhanced.

Decrease in rate of opioid analgesic overdose deaths - Staten Island, New York City, 2011-2013

From 2000 to 2011, the rate of unintentional drug poisoning (overdose) deaths involving opioid analgesics increased 435% in Staten Island, from 2.0 to 10.7 per 100,000 residents. During 2005-2011, disparities widened between Staten Island and the other four New York City (NYC) boroughs (Bronx, Brooklyn, Manhattan, and Queens); in 2011, the rate in Staten Island was 3.0-4.5 times higher than in the other boroughs. In response, the NYC Department of Health and Mental Hygiene (DOHMH) implemented a comprehensive five-part public health strategy, with both citywide and Staten Island-targeted efforts: 1) citywide opioid prescribing guidelines, 2) a data brief for local media highlighting Staten Island mortality and prescribing data, 3) Staten Island town hall meetings convened by the NYC commissioner of health and meetings with Staten Island stakeholders, 4) a Staten Island campaign to promote prescribing guidelines, and 5) citywide airing of public service announcements with additional airing in Staten Island. Concurrently, the New York state legislature enacted the Internet System for Tracking Over-Prescribing (I-STOP), a law requiring prescribers to review the state prescription monitoring system before prescribing controlled substances. This report describes a 29% decline in the opioid analgesic-involved overdose death rate in Staten Island from 2011 to 2013, while the rate did not change in the other four NYC boroughs, and compares opioid analgesic prescribing data for Staten Island with data for the other boroughs. Targeted public health interventions might be effective in lowering opioid analgesic-involved overdose mortality rates.

Illnesses and deaths among persons attending an electronic dance-music festival - New York City, 2013

Outdoor electronic dance-music festivals (EDMFs) are typically summer events where attendees can dance for hours in hot temperatures. EDMFs have received increased media attention because of their growing popularity and reports of illness among attendees associated with recreational drug use. MDMA (3,4-methylenedioxymethamphetamine) is one of the drugs often used at EDMFs. MDMA causes euphoria and mental stimulation but also can cause serious adverse effects, including hyperthermia, seizures, hyponatremia, rhabdomyolysis, and multiorgan failure. In this report, MDMA and other synthetic drugs commonly used at dance festivals are referred to as "synthetic club drugs." On September 1, 2013, the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) received reports of two deaths of attendees at an EDMF (festival A) held August 31-September 1 in NYC. DOHMH conducted an investigation to identify and characterize adverse events resulting in emergency department (ED) visits among festival A attendees and to determine what drugs were associated with these adverse events. The investigation identified 22 cases of adverse events; nine cases were severe, including two deaths. Twenty-one (95%) of the 22 patients had used drugs or alcohol. Of 17 patients with toxicology testing, MDMA and other compounds were identified, most frequently methylone, in 11 patients. Public health messages and strategies regarding adverse health events might reduce illnesses and deaths at EDMFs.

A buprenorphine education and training program for primary care residents: implementation and evaluation

BACKGROUND

Although substance use disorders are highly prevalent, resident preparation to care for patients with these disorders is frequently insufficient. With increasing rates of opioid abuse and dependence, and the availability of medication-assisted treatment, one strategy to improve resident skills is to incorporate buprenorphine treatment into training settings.

METHODS

In this study, esidency faculty delivered the BupEd education and training program to 71 primary care residents. BupEd included (1) a didactic session on buprenorphine, (2) an interactive motivational interviewing session, (3) monthly case conferences, and (4) supervised clinical experience providing buprenorphine treatment. To evaluate BupEd, the authors assessed (1) residents' provision of buprenorphine treatment during residency, (2) residents' provision of buprenorphine treatment after residency, and (3) treatment retention among patients treated by resident versus attending physicians.

RESULTS

Of 71 residents, most served as a covering or primary provider to at least 1 buprenorphine-treated patient (84.5 and 66.2%, respectively). Of 40 graduates, 27.5% obtained a buprenorphine waiver and 17.5% prescribed buprenorphine. Treatment retention was similar between patients cared for by resident PCPs versus attending PCPs (90-day retention: 63.6% [n = 35] vs. 67.9% [n = 152]; P = .55).

CONCLUSION

These results show that BupEd is feasible, provides residents with supervised clinical experience in treating opioid-dependent patients, and can serve as a model to prepare primary care physicians to care for patients with opioid dependence.

Buprenorphine treatment outcomes among opioid-dependent cocaine users and non-users

BACKGROUND AND OBJECTIVES

National treatment guidelines state that polysubstance users, including cocaine users, may not be appropriate candidates for office-based buprenorphine treatment. However, data to support this recommendation are sparse and conflicting, and the implications of this recommendation may include limiting the usefulness of buprenorphine treatment, as cocaine use is common among opioid-dependent individuals seeking buprenorphine treatment. We compared buprenorphine treatment outcomes (6-month treatment retention and self-reported opioid use over 6 months) in opioid-dependent cocaine users versus non-users who initiated buprenorphine treatment at an urban community health center.

METHODS

We followed 87 participants over 6 months, collecting interview and medical record data. We used logistic regression models to test whether baseline cocaine use was associated with treatment retention and mixed effects nonlinear models to test whether baseline cocaine use was associated with self-reported opioid use.

RESULTS

At baseline, 39.1% reported cocaine use. In all participants, self-reported opioid use decreased from 89.7% to 27.4% over 6 months, and 6-month treatment retention was 54.5%. We found no significant difference in 6-month treatment retention (AOR = 1.56, 95% CI: .58-4.17, p = .38) or self-reported opioid use (AOR = .89, 95% CI: .26-3.07, p = .85) between cocaine users and non-users.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

This study demonstrates that buprenorphine treatment retention is not worse in cocaine users than non-users, with clinically meaningful improvements in self-reported opioid use. These findings suggest that opioid-dependent cocaine users attain considerable benefits from office-based buprenorphine treatment and argue for the inclusion of these patients in office-based buprenorphine treatment programs.

Which skills are associated with residents' sense of preparedness to manage chronic pain?

OBJECTIVE

To identify gaps in residents' confidence and knowledge in managing chronic nonmalignant pain (CNMP) and to explore whether specific skills or pain knowledge was associated with global preparedness to manage CNMP.

DESIGN

Cross-sectional web-based survey.

SETTING AND PARTICIPANTS

Internal medicine residents in Bronx, NY.

MAIN OUTCOME MEASURES

The authors assessed the following: 1) confidence in skills within the following four content areas: physical examination, diagnosis, treatment, and safer opioid prescribing; 2) pain-related knowledge on a 16-item scale; and 3) global preparedness to manage CNMP (agreement with, "I feel prepared to manage CNMP"). Gaps in confidence were skills in which fewer than 50 percent reported confidence. Gaps in knowledge were items in which fewer than 50 percent answered correctly. Using logistic regression, the authors examined whether skills or knowledge was associated with global preparedness.

RESULTS

Of 145 residents, 92 (63 percent) responded. Gaps in confidence included diagnosing fibromyalgia, performing corticosteroid injections, and using pain medication agreements. Gaps in knowledge included pharmacotherapy for neuropathic pain and interpreting urine drug test results. Twenty-four residents (26 percent) felt globally prepared to manage CNMP. Confidence using pain medication agreements (adjusted odds ratio [AOR], 5.99; 95% confidence interval [CI], 2.02-17.75), prescribing long-acting opioids (AOR, 5.85; 95% CI, 2.00-17.18), and performing corticosteroid injection of the knee (AOR, 5.76; 95% CI, 1.16-28.60]) were strongly associated with global preparedness.

CONCLUSIONS

Few internal medicine residents felt prepared to manage CNMP. Our findings suggest that educational interventions to improve residents' preparedness to manage CNMP should target complex pain syndromes (eg, fibromyalgia and neuropathic pain), safer opioid prescribing practices, and alternatives to opioid analgesics.

2012 Update in addiction medicine for the generalist

This article presents an update on addiction-related medical literature for the calendar years 2010 and 2011, focusing on studies that have implications for generalist practice. We present articles pertaining to medical comorbidities and complications, prescription drug misuse among patients with chronic pain, screening and brief interventions (SBIs), and pharmacotherapy for addiction.

They don't know what they don't know: internal medicine residents' knowledge and confidence in urine drug test interpretation for patients with chronic pain

BACKGROUND

Urine drug testing (UDT) can help identify misuse or diversion of opioid medications among patients with chronic pain. However, misinterpreting results can lead to false reassurance or erroneous conclusions about drug use.

OBJECTIVE

To examine the relationship between resident physicians' knowledge about UDT interpretation and confidence in their ability to interpret UDT results.

DESIGN

Cross-sectional survey.

PARTICIPANTS

Internal medicine residents in a university health system in the Bronx, from 2010 to 2011.

MAIN MEASURES

We assessed knowledge using a 7-item scale (UDT knowledge score), and confidence in UDT interpretation using a single statement ("I feel confident in my ability to interpret the results of urine drug tests"). We conducted chi-square tests, t-tests, and logistic regression to determine the association between knowledge and confidence, and in exploratory analyses to examine whether resident characteristics (gender, training level, and UDT use) moderated the relationship between knowledge and confidence.

KEY RESULTS

Among 99 residents, the mean UDT knowledge score was 3.0 out of 7 (SD 1.2). Although 55 (56 %) of residents felt confident in their ability to interpret UDT results, 40 (73 %) of confident residents had a knowledge score of 3 or lower. Knowledge score was not associated with confidence among the full sample or when stratified by training level or UDT use. The association between knowledge and confidence differed significantly by gender (interaction term p<0.01). Adjusting for training level and UDT use, knowledge was positively associated with confidence among females (AOR 1.79, 95 % CI: 1.06, 3.30), and negatively associated with confidence among males (AOR 0.47, 95 % CI: 0.23, 0.98).

CONCLUSIONS

Despite poor knowledge about UDT interpretation, most resident physicians felt confident in their ability to interpret UDT results. Gender differences warrant further exploration, but even confident physicians who use UDT should evaluate their proficiency in interpreting UDT results. Educational initiatives should emphasize the complexities of UDT interpretation.

Evaluation of a substance use disorder curriculum for internal medicine residents

Teaching about diagnosis, treatment, and sequelae of substance use disorders (SUDs) is insufficient in most Internal Medicine residency programs. To address this, the authors developed, implemented, and evaluated a novel and comprehensive SUD curriculum for first year residents (interns) in Internal Medicine, which anchors the ensuing 3-year longitudinal SUD curriculum. This intern curriculum includes didactic and experiential elements and allows skills practice. Topics include local epidemiology of substance abuse, neurobiology of SUDs, and screening, treatment, and referral. The entire curriculum is delivered over 7 hours during a month-long ambulatory rotation. Among 58 interns who have completed a pre-post evaluation of the curriculum, the majority reported an increased sense of responsibility for and confidence in treating patients with SUDs.

A comparison of buprenorphine induction strategies: patient-centered home-based inductions versus standard-of-care office-based inductions

Although novel buprenorphine induction strategies are emerging, they have been inadequately studied. To examine our newly developed patient-centered home-based inductions, we conducted a subgroup analysis of 79 opioid-dependent individuals who had buprenorphine inductions at an urban community health center. Participants chose their induction strategy. Standard-of-care office-based inductions were physician driven, with multiple assessments, and observed, and the patient-centered home-based inductions emphasized patient self-management and included a "kit" for induction at home. We conducted interviews and extracted medical records. Using mixed nonlinear models, we examined associations between induction strategy and opioid use and any drug use. Compared with those with standard-of-care office-based inductions, participants with patient-centered home-based inductions had no significant differences in opioid use (adjusted odds ratio [AOR] = 0.63, 95% confidence interval [CI] = 0.13-2.97) but greater reductions in any drug use (AOR = 0.05, 95% CI = 0.01-0.37). Taking into account the limitations of our observational cohort study design, we conclude that participants with patient-centered home-based inductions had similar reductions in opioid use and greater reductions in any drug use than those with standard-of-care office-based inductions. It is essential that new induction strategies be based on existing models or theories and be well studied.

Factors associated with complicated buprenorphine inductions

Despite data supporting its efficacy, barriers to implementation of buprenorphine for office-based treatment are present. Complications can occur during buprenorphine inductions, yet few published studies have examined this phase of treatment. To examine factors associated with complications during buprenorphine induction, we conducted a retrospective chart review of the first 107 patients receiving buprenorphine treatment in an urban community health center. The primary outcome, defined as complicated induction (precipitated or protracted withdrawal), was observed in 18 (16.8%) patients. Complicated inductions were associated with poorer treatment retention (than routine inductions) and decreased over time. Factors independently associated with complicated inductions included recent use of prescribed methadone, recent benzodiazepine use, no prior experience with buprenorphine, and a low initial dose of buprenorphine/naloxone. Findings from this study and further investigation of patient characteristics and treatment characteristics associated with complicated inductions can help guide buprenorphine treatment strategies.

HIV provider endorsement of primary care buprenorphine treatment: a vignette study

BACKGROUND AND OBJECTIVES

Opioid dependence is common among HIV-infected persons in the United States. Factors associated with HIV care providers recommending buprenorphine for opioid dependence are poorly defined. Using vignettes, we sought to identify HIV provider characteristics associated with endorsing buprenorphine treatment in primary care.

METHODS

We used a cross-sectional survey of HIV providers, including 497 physicians, nurse practitioners, and physician assistants attending HIV educational conferences in 2006. Anonymous questionnaires distributed to conference attendees contained one of two vignettes depicting opioid-dependent patients. Respondents recommended type of substance abuse treatment for the vignette patient. Using logistic regression, we tested patient and provider factors associated with HIV provider endorsement of buprenorphine in primary care.

RESULTS

Sixteen percent of providers endorsed buprenorphine treatment in primary care for vignette patients. Family physicians and general internists (AOR=2.8, CI=1.1-7.1), African American providers (AOR=3.0, CI=1.3-6.8), and those with previous buprenorphine prescribing experience (AOR=4.6, CI=1.2-17.9) were more likely to endorse buprenorphine treatment in primary care.

CONCLUSIONS

HIV providers infrequently endorsed buprenorphine treatment in primary care for vignette patients. Generalist and African American providers and those with previous buprenorphine prescribing experience are more likely to endorse buprenorphine treatment in primary care. Targeting generalist and minority providers may be one strategy to promote effective integration of HIV care and opioid addiction treatment.

Association between alcohol consumption and both osteoporotic fracture and bone density

OBJECTIVE

Alcoholism is a risk factor for osteoporotic fractures and low bone density, but the effects of moderate alcohol consumption on bone are unknown. We performed a systematic review and meta-analysis to assess the associations between alcohol consumption and osteoporotic fractures, bone density and bone density loss over time, bone response to estrogen replacement, and bone remodeling.

METHODS

MEDLINE, Current Contents, PsychINFO, and Cochrane Libraries were searched for studies published before May 14, 2007. We assessed quality using the internal validity criteria of the US Preventive Services Task Force.

RESULTS

We pooled effect sizes for 2 specific outcomes (hip fracture and bone density) and synthesized data qualitatively for 4 outcomes (non-hip fracture, bone density loss over time, bone response to estrogen replacement, and bone remodeling). Compared with abstainers, persons consuming from more than 0.5 to 1.0 drinks per day had lower hip fracture risk (relative risk=0.80 [95% confidence interval, 0.71-0.91]), and persons consuming more than 2 drinks per day had higher risk (relative risk=1.39 [95% confidence interval, 1.08-1.79]). A linear relationship existed between femoral neck bone density and alcohol consumption. Because studies often combined moderate and heavier drinkers in a single category, we could not assess relative associations between alcohol consumption and bone density in moderate compared with heavy drinkers.

CONCLUSION

Compared with abstainers and heavier drinkers, persons who consume 0.5 to 1.0 drink per day have a lower risk of hip fracture. Although available evidence suggests a favorable effect of alcohol consumption on bone density, a precise range of beneficial alcohol consumption cannot be determined.

Barriers to obtaining waivers to prescribe buprenorphine for opioid addiction treatment among HIV physicians

BACKGROUND

Illicit drug use is common among HIV-infected individuals. Buprenorphine enables physicians to simultaneously treat HIV and opioid dependence, offering opportunities to improve health outcomes. Despite this, few physicians prescribe buprenorphine.

OBJECTIVE

To examine barriers to obtaining waivers to prescribe buprenorphine.

DESIGN

Cross-sectional survey study.

PARTICIPANTS

375 physicians attending HIV educational conferences in six cities in 2006.

APPROACH

Anonymous questionnaires were distributed and analyzed to test whether confidence addressing drug problems and perceived barriers to prescribing buprenorphine were associated with having a buprenorphine waiver, using chi-square, t tests, and logistic regression.

RESULTS

25.1% of HIV physicians had waivers to prescribe buprenorphine. In bivariate analyses, physicians with waivers versus those without waivers were less likely to be male (51.1 vs 63.7%, p < .05), more likely to be in New York (51.1 vs 29.5%, p < .01), less likely to be infectious disease specialists (25.5 vs 41.6%, p < .05), and more likely to be general internists (43.6 vs 33.5%, p < .05). Adjusting for physician characteristics, confidence addressing drug problems (adjusted odds ratio [AOR] = 2.05, 95% confidence interval [95% CI] = 1.08-3.88) and concern about lack of access to addiction experts (AOR = 0.56, 95% CI = 0.32-0.97) were significantly associated with having a buprenorphine waiver.

CONCLUSIONS

Among HIV physicians attending educational conferences, confidence addressing drug problems was positively associated with having a buprenorphine waiver, and concern about lack of access to addiction experts was negatively associated with it. HIV physicians are uniquely positioned to provide opioid addiction treatment in the HIV primary care setting. Understanding and remediating barriers HIV physicians face may lead to new opportunities to improve outcomes for opioid-dependent HIV-infected patients.

Nurse practitioner and physician assistant interest in prescribing buprenorphine

Office-based buprenorphine places health care providers in a unique position to combine HIV and drug treatment in the primary care setting. However, federal legislation restricts nurse practitioners (NPs) and physician assistants (PAs) from prescribing buprenorphine, which may limit its potential for uptake and inhibit the role of these nonphysician providers in delivering drug addiction treatment to patients with HIV. This study aimed to examine the level of interest in prescribing buprenorphine among nonphysician providers. We anonymously surveyed providers attending HIV educational conferences in six large U.S. cities about their interest in prescribing buprenorphine. Overall, 48.6% (n = 92) of nonphysician providers were interested in prescribing buprenorphine. Compared to infectious disease specialists, nonphysician providers (adjusted odds ratio [AOR] = 2.89, 95% confidence interval [CI] = 1.22-6.83) and generalist physicians (AOR = 2.04, 95% CI = 1.09-3.84) were significantly more likely to be interested in prescribing buprenorphine. NPs and PAs are interested in prescribing buprenorphine. To improve uptake of buprenorphine in HIV settings, the implications of permitting nonphysician providers to prescribe buprenorphine should be further explored.

Hepatitis C management by addiction medicine physicians: results from a national survey

Drug users are disproportionately affected by hepatitis C virus (HCV), yet they face barriers to health care that place them at risk for levels of HCV-related care that are lower than those of nondrug users. Substance abuse treatment physicians may treat more HCV-infected persons than other generalist physicians, yet little is known about how such physicians facilitate HCV-related care. We conducted a nationwide survey of American Society of Addiction Medicine physicians (n = 320) to determine substance abuse physicians' HCV-related management practices and to describe factors associated with these practices. We found that substance abuse treatment physicians promote several elements of HCV-related care, including screening for HCV antibodies, recommending vaccinations against hepatitis A and B, and referring patients to subspecialists for HCV treatment. Substance abuse physicians who also provide primary medical or HIV-related care were most likely to facilitate HCV-related care. A significant minority of physicians were either providing HCV antiviral treatment or willing to provide HCV antiviral treatment.

Colocating buprenorphine with methadone maintenance and outpatient chemical dependency services

Buprenorphine may be used to treat opioid dependence in office-based settings, but treatment models are needed to ensure access to psychosocial services needed by many patients. We describe a novel buprenorphine treatment program colocated with methadone maintenance and outpatient chemical dependency services. We conducted a retrospective chart review of the first 40 consecutive patients initiating buprenorphine treatment in this program to determine characteristics associated with treatment retention. Exclusion criteria were current alcohol or benzodiazepine dependence. Secondary drug users and patients who were psychiatrically or medically ill were included. At 6 months, 60% (n = 24) were retained, 13% (n = 5) tested positive for opiates, and 25% (n = 10) tested positive for secondary substances. Patients who were older (odds ratio [OR] per year of age = 1.1, confidence interval [CI] = 1.0-1.2) and those who were employed (OR = 9.8, CI = 1.8-53.1) were more likely to remain in treatment, but other variables were not associated with retention. Our experience demonstrates that buprenorphine can be successfully integrated into outpatient substance abuse treatment.

Attending physicians' and residents' attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital

BACKGROUND AND OBJECTIVES

Opioid abuse and dependence are increasing. Pharmacotherapy with an opioid agonist reduces adverse consequences of opioid dependency. Physicians can now prescribe buprenorphine for opioid dependency in the primary care setting. This study assessed primary care providers' attitudes and beliefs about opioid addiction treatment with buprenorphine.

METHODS

Ninety-nine resident and attending physicians from six ambulatory clinics associated with a university hospital were interviewed with an adapted questionnaire eliciting attitudes and beliefs about opioid addiction treatment options, including buprenorphine.

RESULTS

While only 37.8% of respondents believed primary care providers should prescribe buprenorphine, and 35.7% reported interest in prescribing buprenorphine, 72.1% were willing to prescribe it with training and support. Common training/support needs were buprenorphine education/training (83.8%), available consultation (19.2%), and on-site counselors (18.2%). The most frequent reasons for not prescribing buprenorphine were lack of knowledge or training (47.5%) and lack of time (25.3%). Physicians involved in primary care-oriented programs (versus non-primary care programs) were more likely to have positive attitudes regarding buprenorphine.

CONCLUSIONS

Most physicians would be willing to prescribe buprenorphine with proper training and support. Barriers and training/support needs must be addressed to develop effective opioid addiction treatment programs in the primary care setting.

Validity of a self-reported history of a positive tuberculin skin test. A prospective study of drug users

OBJECTIVE

To define the prevalence of and factors associated with having a negative purified protein derivative (PPD) among persons who self-report a prior positive PPD and to define the safety of repeat testing in such persons.

DESIGN

Observational cohort study.

SETTING

Methadone maintenance program with onsite primary care.

PATIENTS/PARTICIPANTS

Current or former drug users enrolled in methadone maintenance treatment.

INTERVENTIONS

Structured interview, tuberculin skin testing regardless of self-reported PPD status, and anergy testing.

MEASUREMENTS AND MAIN RESULTS

Nearly one third (31%) of participants who self-reported a prior positive PPD had a negative measured PPD, despite receipt of a "booster" PPD. A single participant (0.5%) blistered in response to the PPD without lasting ill effect. Participants with PPD results discordant from their history were more likely to be HIV-seropositive and nonreactive to the anergy panel. The discordance rate among HIV-infected participants was 43%, and was largely attributable to immune dysfunction. Among HIV-seronegative participants, the discordance rate was 27%. Recent crack-cocaine use was independently associated with discordance in the absence of HIV infection.

CONCLUSIONS

We confirmed that planting a PPD in patients who self-report a positive PPD history confers minimal risk. Substantial rates of discordance exist between self-reported history of a positive PPD and measured PPD status. Further research is needed to define the optimal management of PPD-negative patients who self-report a prior positive PPD and who have not received prior treatment for latent tuberculosis.