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Methadone treatment reduces human immunodeficiency virus (HIV) risk, but the effects of primary-care-based buprenorphine/naloxone on HIV risk are unknown. The purpose of this study was to determine whether primary-care-based buprenorphine/naloxone was associated with decreased HIV risk behavior. We conducted a longitudinal analysis of 166 opioid-dependent persons (129 men and 37 women) receiving buprenorphine/naloxone treatment in a primary care clinic. We compared baseline and 12- and 24-week overall, drug-related, and sex-related HIV risk behaviors using the AIDS/HIV Risk Inventory (ARI). Buprenorphine/naloxone treatment was associated with significant reductions in overall and drug-related ARI scores from baseline to 12 and 24 weeks. Intravenous drug use in the past 3 months was endorsed by 37%, 12%, and 7% of patients at baseline and at 12 and 24 weeks, respectively (p< .001). Sex while you or your partner were "high" was endorsed by 64%, 13%, and 15% of patients at baseline and at 12 and 24 weeks, respectively (p< .001). Inconsistent condom use during sex with a steady partner was high at baseline and did not change over time. We conclude that primary-care-based buprenorphine/naloxone treatment is associated with decreased drug-related HIV risk, but additional efforts may be needed to address sex-related HIV risk when present. PMID:17933486
Sullivan, Lynn E; Moore, Brent A; Chawarski, Marek C; Pantalon, Michael V; Barry, Declan; O'Connor, Patrick G; Schottenfeld, Richard S; Fiellin, David A
Buprenorphine Treatment of Opioid Dependence: A Review
Buprenorphine, a partial mu-agonist opioid, is a promising pharmacotherapy for the treatment of opioid dependence. One hundred and eight papers are organized according to 3 components essential to buprenorphine's use as a pharmacotherapy for opioid dependence: inducting patients onto buprenorphine, maintaining patients on buprenorphine, and discontinuing patients from buprenorphine treatment. The research suggests that inducting patients onto buprenorphine should lead
Warren K. Bickel; Leslie Amass
Opioid abuse and addiction have increased in frequency in the United States over the past 20 years. In 2009, an estimated 5.3 million persons used opioid medications nonmedically within the past month, 200 000 used heroin, and approximately 9.6% of African Americans used an illicit drug. Racial and ethnic minorities experience disparities in availability and access to mental health care, including substance use disorders. Primary care practitioners are often called upon to differentiate between appropriate, medically indicated opioid use in pain management vs inappropriate abuse or addiction. Racial and ethnic minority populations tend to favor primary care treatment settings over specialty mental health settings. Recent therapeutic advances allow patients requiring specialized treatment for opioid abuse and addiction to be managed in primary care settings. The Drug Addiction Treatment Act of 2000 enables qualified physicians with readily available short-term training to treat opioid-dependent patients with buprenorphine in an office-based setting, potentially making primary care physicians active partners in the diagnosis and treatment of opioid use disorders. Methadone and buprenorphine are effective opioid replacement agents for maintenance and/or detoxification of opioid-addicted individuals. However, restrictive federal regulations and stigmatization of opioid addiction and treatment have limited the availability of methadone. The opioid partial agonist-antagonist buprenorphine/naloxone combination has proven an effective alternative. This article reviews the literature on differences between buprenorphine and methadone regarding availability, efficacy, safety, side-effects, and dosing, identifying resources for enhancing the effectiveness of medication-assisted recovery through coordination with behavioral/psychological counseling, embedded in the context of recovery-oriented systems of care. PMID:23092049
Bonhomme, Jean; Shim, Ruth S.; Gooden, Richard; Tyus, Dawn; Rust, George
Despite well-documented efficacy, US physicians have been relatively slow to embrace the use of buprenorphine for the treatment of opioid dependence. In order to introduce and support the use of buprenorphine across the San Francisco Department of Public Health system of care, the Buprenorphine Pilot Program was initiated in 2003. Program treatment sites included a centralized buprenorphine induction clinic and
David Hersh; Sherri L. Little; Alice Gleghorn
Prior buprenorphine experience is associated with office-based buprenorphine treatment outcomes
Objectives As buprenorphine treatment and illicit buprenorphine use increase, many patients seeking buprenorphine treatment will have had prior experience with buprenorphine. Little evidence is available to guide optimal treatment strategies for patients with prior buprenorphine experience. We examined whether prior buprenorphine experience was associated with treatment retention and opioid use. We also explored whether type of prior buprenorphine use (prescribed or illicit use) was associated with these treatment outcomes. Methods We analyzed interview and medical record data from a longitudinal cohort study of 87 individuals who initiated office-based buprenorphine treatment. We examined associations between prior buprenorphine experience and 6-month treatment retention using logistic regression models, and prior buprenorphine experience and any self-reported opioid use at 1, 3, and 6 months using non-linear mixed models. Results Most (57.4%) participants reported prior buprenorphine experience; of these, 40% used prescribed buprenorphine and 60% illicit buprenorphine only. Compared to buprenorphine-naďve participants, those with prior buprenorphine experience had better treatment retention (AOR=2.65, 95% CI=1.05–6.70). Similar associations that did not reach significance were found when exploring prescribed and illicit buprenorphine use. There was no difference in opioid use when comparing participants with prior buprenorphine experience to those who were buprenorphine-naive (AOR=1.33, 95% CI=0.38–4.65). Although not significant, qualitatively different results were found when exploring opioid use by type of prior buprenorphine use (prescribed buprenorphine vs. buprenorphine-naďve, AOR=2.20, 95% CI=0.58–8.26; illicit buprenorphine vs. buprenorphine-naďve, AOR=0.47, 95% CI=0.07–3.46). Conclusions Prior buprenorphine experience was common and associated with better retention. Understanding how prior buprenorphine experience affects treatment outcomes has important clinical and public health implications. PMID:23722632
Cunningham, Chinazo O.; Roose, Robert J.; Starrels, Joanna L.; Giovanniello, Angela; Sohler, Nancy L.
Comparison of Buprenorphine Treatment for Opioid Dependence in Three Settings
Although use of buprenorphine in the treatment of opioid dependence is expected to continue to increase, little is known about the optimal setting for providing the medical and psychosocial care required with buprenorphine pharmacotherapy. OBJECTIVE This study compared buprenorphine therapy delivered in three distinct treatment settings: an opioid-treatment program (OTP) offering individual counseling; a group counseling program utilizing the manualized Matrix Model (MMM) of cognitive-behavioral treatment; and a private clinic setting mirroring standard medical management for buprenorphine treatment provided specifically at a psychiatrist's private practice (PCS). METHOD Participants were inducted on buprenorphine and provided with treatment over a 52-week study duration. All participants were scheduled for weekly treatment visits for the first 6 study weeks, and two sites reduced treatment to monthly visits for dispensing of medication and psychosocial counseling. Outcomes include opioid use, participant retention in treatment, and treatment participation. RESULTS Participants presenting for treatment at the sites differed only by race/ethnicity, and opioid use did not differ by site. Retention differed by treatment site, with the number of participants who stayed in the study until the end of 20 weeks significantly associated with treatment site. The mean number of minutes spent in each individual counseling session also differed by site. Although no difference in opioid use by treatment site was found, results document a significant association between opioid use and buprenorphine dose. DISCUSSION These results show some differences by treatment site, although the similarity and relative ease in which the sites were able to recruit participants for treatment with buprenorphine, and minor implementation problems reported suggests the feasibility of treatment with buprenorphine across various treatment settings. CONCLUSION Similar rates of continued opioid use across study sites and few qualitative reports of problems indicates that treatment with buprenorphine and associated psychosocial counseling are safe and relatively easy to implement in a variety of treatment settings. PMID:22105061
Hillhouse, Maureen; Donovick, Roger; Cunningham-Rathner, Jerry; Charuvastra, Charlie; Torrington, Matthew; Esagoff, Asher E.; Ling, Walter
Barriers to Primary Care Physicians Prescribing Buprenorphine
PURPOSE Despite the efficacy of buprenorphine-naloxone for the treatment of opioid use disorders, few physicians in Washington State use this clinical tool. To address the acute need for this service, a Rural Opioid Addiction Management Project trained 120 Washington physicians in 2010–2011 to use buprenorphine. We conducted this study to determine what proportion of those trained physicians began prescribing this treatment and identify barriers to incorporating this approach into outpatient practice. METHODS We interviewed 92 of 120 physicians (77%), obtaining demographic information, current prescribing status, clinic characteristics, and barriers to prescribing buprenorphine. Residents and 7 physicians who were prescribing buprenorphine at the time of the course were excluded from the study. We analyzed the responses of the 78 remaining respondents. RESULTS Almost all respondents reported positive attitudes toward buprenorphine, but only 22 (28%) reported prescribing buprenorphine. Most (95%, n = 21) new prescribers were family physicians. Physicians who prescribed buprenorphine were more likely to have partners who had received a waiver to prescribe buprenorphine. A lack of institutional support was associated with not prescribing the medication (P = .04). A lack of mental health and psychosocial support was the most frequently cited barrier by both those who prescribe and who do not prescribe buprenorphine. CONCLUSION Interventions before and after training are needed to increase the number of physicians who offer buprenorphine for treatment of addiction. Targeting physicians in clinics that agree in advance to institute services, coupled with technical assistance after they have completed their training, their clinical teams, and their administrations is likely to help more physicians become active providers of this highly effective outpatient treatment. PMID:24615308
Hutchinson, Eliza; Catlin, Mary; Andrilla, C. Holly A.; Baldwin, Laura-Mae; Rosenblatt, Roger A.
Poor access to buprenorphine maintenance treatment (BMT) may contribute to illicit buprenorphine use. This study investigated illicit buprenorphine use and barriers to BMT among syringe exchange participants. Computer-based interviews conducted at a New York City harm reduction agency determined: prior buprenorphine use; barriers to BMT; and interest in BMT. Of 102 opioid users, 57 had used illicit buprenorphine and 32 had used prescribed buprenorphine. When illicit buprenorphine users were compared to non-users: barriers to BMT ("did not know where to get treatment") were more common (64 vs. 36%, p<0.01); mean levels of interest in BMT were greater (3.37±1.29 vs. 2.80±1.34, p=0.03); and more participants reported themselves likely to initiate treatment (82 vs. 50%, p<0.01). Illicit buprenorphine users were interested in BMT but did not know where to go for treatment. Addressing barriers to BMT could reduce illicit buprenorphine use. PMID:25205666
Fox, Aaron D; Chamberlain, Adam; Sohler, Nancy L; Frost, Taeko; Cunningham, Chinazo O
Previous studies have not examined patterns of pain treatment use among patients seeking office-based buprenorphine-naloxone treatment (BNT) for opioid dependence. Objectives To examine, among individuals with pain seeking BNT for opioid dependence, the use of pain treatment modalities, perceived efficacy of prior pain treatment, and interest in pursuing pain treatment while in BNT. Methods 244 patients seeking office-based BNT for opioid dependence completed measures of demographics, pain status (i.e. "chronic pain (CP)" [pain lasting at least 3 months] vs. "some pain (SP)" [pain in the past week not meeting the duration criteria for chronic pain]), pain treatment use, perceived efficacy of prior pain treatment, and interest in receiving pain treatment while in BNT. Results In comparison to the SP group (N = 87), the CP group (N = 88) was more likely to report past-week medical use of opioid medication (AOR 3.2, 95% CI 1.2–8.4), lifetime medical use of non-opioid prescribed medication (AOR 2.2, 95% CI 1.1–4.7), and lifetime use of prayer (AOR 2.8, 95% CI 1.2–6.5), and was less likely to report lifetime use of yoga (AOR 0.2, 95% CI 0.1–0.7) to treat pain. While the two pain groups did not differ on levels of perceived efficacy of prior lifetime pain treatments, in comparison to the SP group, the CP group was more likely to report interest in receiving pain treatment while in BNT (P < 0.001). Conclusions Individuals with pain seeking BNT for opioid dependence report a wide range of conventional, complementary, and alternative pain-related treatments and are interested (especially those with CP) in receiving pain management services along with BNT. PMID:23041680
Barry, Declan T.; Savant, Jonathan D.; Beitel, Mark; Cutter, Christopher J.; Moore, Brent A.; Schottenfeld, Richard S.; Fiellin, David A.
Effect of Incarceration History on Outcomes of Primary Care Office-based Buprenorphine/Naloxone
Background Behaviors associated with opioid dependence often involve criminal activity, which can lead to incarceration. The impact of a history of incarceration on outcomes in primary care office-based buprenorphine/naloxone is not known. Objective The purpose of this study is to determine whether having a history of incarceration affects response to primary care office-based buprenorphine/naloxone treatment. Design In this post hoc secondary analysis of a randomized clinical trial, we compared demographic, clinical characteristics, and treatment outcomes among 166 participants receiving primary care office-based buprenorphine/naloxone treatment stratifying on history of incarceration. Main Results Participants with a history of incarceration have similar treatment outcomes with primary care office-based buprenorphine/naloxone than those without a history of incarceration (consecutive weeks of opioid-negative urine samples, 6.2 vs. 5.9, p?=?0.43; treatment retention, 38% vs. 46%, p?=?0.28). Conclusions Prior history of incarceration does not appear to impact primary care office-based treatment of opioid dependence with buprenorphine/naloxone. Community health care providers can be reassured that initiating buprenorphine/naloxone in opioid dependent individuals with a history of incarceration will have similar outcomes as those without this history. PMID:20213205
Moore, Brent A.; Sullivan, Lynn E.; Fiellin, David A.
PURPOSE: Buprenorphine is an alternative to methadone for the maintenance treatment of heroine dependence and may be effective on a thrice weekly basis. Our objective was to evaluate the effect of thrice weekly buprenorphine maintenance for the treatment of heroin dependence in a primary care clinic on retention in treatment and illicit opioid use.SUBJECTS AND METHODS: Opioid-dependent patients were randomly
PatrickG O'Connor; AlisonH Oliveto; JuliaM Shi; ElisaG Triffleman; KathleenM Carroll; ThomasR Kosten; BruceJ Rounsaville; JulianaA Pakes; RichardS Schottenfeld
A qualitative study of the adoption of buprenorphine for opioid addiction treatment.
Qualified physicians may prescribe buprenorphine to treat opioid dependence, but medication use remains controversial. We examined adoption of buprenorphine in two not-for-profit integrated health plans, over time, completing 101 semi-structured interviews with clinicians and clinician-administrators from primary and specialty care. Transcripts were reviewed, coded, and analyzed. A strong leader championing the new treatment was critical for adoption in both health plans. Once clinicians began using buprenorphine, patients' and other clinicians' experiences affected decisions more than did the champion. With experience, protocols developed to manage unsuccessful patients and changed to support maintenance rather than detoxification. Diffusion outside addiction and mental health settings was nonexistent; primary care clinicians cited scope-of-practice issues and referred patients to specialty care. With greater diffusion came questions about long-term use and safety. Recognizing how implementation processes develop may suggest where, when, and how to best expend resources to increase adoption of such treatments. PMID:24268947
Green, Carla A; McCarty, Dennis; Mertens, Jennifer; Lynch, Frances L; Hilde, Anadam; Firemark, Alison; Weisner, Constance M; Pating, David; Anderson, Bradley M
Background Having opioid dependence and HIV infection are associated with poor HIV-related treatment outcomes. Methods HIV-infected, opioid-dependent subjects (N = 295) recruited from 10 clinical sites initiated buprenorphine/naloxone (BUP/NX) and were assessed at baseline and quarterly for 12 months. Primary outcomes included receiving antiretroviral therapy (ART), HIV-1 RNA suppression, and mean changes in CD4 lymphocyte count. Analyses were stratified for the 119 subjects not on ART at baseline. Generalized estimating equations were deployed to examine time-dependent correlates for each outcome. Results At baseline, subjects on ART (N = 176) were more likely than those not on ART (N = 119) to be older, heterosexual, have lower alcohol addiction severity scores, and lower HIV-1 RNA levels; they were less likely to be homeless and report sexual risk behaviors. Subjects initiating BUP/NX (N = 295) were significantly more likely to initiate or remain on ART and improve CD4 counts over time compared with baseline; however, these improvements were not significantly improved by longer retention on BUP/NX. Retention on BUP/NX for three or more quarters was, however, significantly associated with increased likelihood of initiating ART (? = 1.34 [1.18, 1.53]) and achieve viral suppression (? = 1.25 [1.10, 1.42]) for the 64 of 119 (54%) subjects not on ART at baseline compared with the 55 subjects not retained on BUP/NX. In longitudinal analyses, being on ART was positively associated with increasing time of observation from baseline and higher mental health quality of life scores (? = 1.25 [1.06, 1.46]) and negatively associated with being homo- or bisexual (? = 0.55 [0.35, 0.97]), homeless (? = 0.58 [0.34, 0.98]), and increasing levels of alcohol addiction severity (? = 0.17 [0.03, 0.88]). The strongest correlate of achieving viral suppression was being on ART (? = 10.27 [5.79, 18.23]). Female gender (? = 1.91 [1.07, 3.41]), Hispanic ethnicity (? = 2.82 [1.44, 5.49]), and increased general health quality of life (? = 1.02 [1.00,1.04]) were also independently correlated with viral suppression. Improvements in CD4 lymphocyte count were significantly associated with being on ART and increased over time. Conclusions Initiating BUP/NX in HIV clinical care settings is feasible and correlated with initiation of ART and improved CD4 lymphocyte counts. Longer retention on BPN/NX was not associated with improved prescription of ART, viral suppression, or CD4 lymphocyte counts for the overall sample in which the majority was already prescribed ART at baseline. Among those retained on BUP/NX, HIV treatment outcomes did not worsen and were sustained. Increasing time on BUP/NX, however, was especially important for improving HIV treatment outcomes for those not on ART at baseline, the group at highest risk for clinical deterioration. Retaining subjects on BUP/NX is an important goal for sustaining HIV treatment outcomes for those on ART and improving them for those who are not. Comorbid substance use disorders (especially alcohol), mental health problems, and quality–of-life indicators independently contributed to HIV treatment outcomes among HIV-infected persons with opioid dependence, suggesting the need for multidisciplinary treatment strategies for this population. PMID:21317590
Altice, Frederick L.; Bruce, R. Douglas; Lucas, Gregory M.; Lum, Paula J.; Korthuis, P. Todd; Flanigan, Timothy P.; Cunningham, Chinazo O.; Sullivan, Lynn E.; Vergara-Rodriguez, Pamela; Fiellin, David A.; Cajina, Adan; Botsko, Michael; Nandi, Vijay; Gourevitch, Marc N.; Finkelstein, Ruth
Buprenorphine diffusion: the attitudes of substance abuse treatment counselors
In October 2002, the Food and Drug Administration approved buprenorphine for use in the treatment of opioid dependence. Successful diffusion, adoption, and implementation of this medication within the treatment field depend in part on substance abuse counselors. Using questionnaire data obtained from 2,298 counselors in community-based treatment programs in the private and public sectors between June 2002 and July 2004,
Hannah K. Knudsen; Lori J. Ducharme; Paul M. Roman; Tanja Link
Given that buprenorphine + naloxone is prescribed for opioid-dependent pregnant women, it is important to examine the extent to which it differs from buprenorphine alone, methadone, or methadone-assisted withdrawal on neonatal and maternal outcomes. Summary statistics on maternal and neonatal outcomes were collected from 7 previously published studies examining treatment for opioid-dependent pregnant women that represented a range of research methodologies. Outcomes from these studies were compared to the same outcomes for 10 women treated with the combined buprenorphine + naloxone product. There were no significant differences in maternal outcomes for buprenorphine + naloxone compared to buprenorphine, methadone, or methadone-assisted withdrawal. Preliminary findings suggest no significant adverse maternal or neonatal outcomes related to the use of buprenorphine + naloxone for the treatment of opioid dependence during pregnancy. However, further research should examine possible differences between buprenorphine + naloxone and buprenorphine alone or methadone in fetal physical development. PMID:23531704
Lund, Ingunn O.; Fischer, Gabriele; Welle-Strand, Gabrielle K.; O'Grady, Kevin E.; Debelak, Kimber; Morrone, William R.; Jones, Hendrée E.
Comparison of Behavioral Treatment Conditions in Buprenorphine Maintenance
Background and aims The Controlled Substances Act requires physicians in the United States to provide or refer to behavioral treatment when treating opioid-dependent individuals with buprenorphine; however no research has examined the combination of buprenorphine with different types of behavioral treatments. This randomized controlled trial compared the effectiveness of 4 behavioral treatment conditions provided with buprenorphine and medical management (MM) for the treatment of opioid dependence. Design After a 2-week buprenorphine induction/stabilization phase, participants were randomized to 1 of 4 behavioral treatment conditions provided for 16 weeks: Cognitive Behavioral Therapy (CBT=53); Contingency Management (CM=49); both CBT and CM (CBT+CM=49); and no additional behavioral treatment (NT=51). Setting Study activities occurred at an outpatient clinical research center in Los Angeles, California, USA. Participants Included were 202 male and female opioid-dependent participants. Measurements Primary outcome was opioid use, measured as a proportion of opioid-negative urine results over the number of tests possible. Secondary outcomes include retention, withdrawal symptoms, craving, other drug use, and adverse events. Findings No group differences in opioid use were found for the behavioral treatment phase (Chi-square=1.25, p=0.75), for a second medication-only treatment phase, or at weeks 40 and 52 follow-ups. Analyses revealed no differences across groups for any secondary outcome. Conclusion There remains no clear evidence that cognitive behavioural therapy and contingency management reduce opiate use when added to buprenorphine and medical management in opiates users seeking treatment. PMID:23734858
Ling, Walter; Hillhouse, Maureen; Ang, Alfonso; Jenkins, Jessica; Fahey, Jacqueline
Intrathecal Buprenorphine in the Treatment of Phantom Limb Pain
hantom limb pain is a chronic pain perceived in an absent part of the body. It can totally con- sume a patient's life. Suggested treatments for this complaint are many, but none have proved to have lasting efficacy. We have treated two patients suffering from phan- tom limb pain. Intrathecal buprenorphine provided not only immediate and long-lasting pain relief, but
Keiichi Omote; Hideya Ohmori; Mikito Kawamata; Maki Matsumoto; Akiyoshi Namiki
Combined abuse of clonidine and amitriptyline in a patient on buprenorphine maintenance treatment.
Buprenorphine/naloxone maintenance therapy is often prescribed in primary care to treat opioid dependence. Previous reports have described concomitant abuse of opioids and clonidine. In this case, a primary care patient on buprenorphine/naloxone maintenance therapy demonstrating altered mental status, hallucinations, falls, and rebound hypertension was found to be concomitantly abusing clonidine and amitryptyline, which share metabolic pathways with buprenorphine. Clinicians should be aware of patients' combining amitryptyline, clonidine, and gabapentin with buprenorphine to achieve a mood altering state, avoid co-prescribing them if possible, and maintain communication with pharmacies and other providers when they are prescribed. PMID:25314340
Seale, J Paul; Dittmer, Trent; Sigman, Erika J; Clemons, Holly; Johnson, J Aaron
Combined Abuse of Clonidine and Amitriptyline in a Patient on Buprenorphine Maintenance Treatment
Buprenorphine/naloxone maintenance therapy is often prescribed in primary care to treat opioid dependence. Previous reports have described concomitant abuse of opioids and clonidine. In this case, a primary care patient on buprenorphine/naloxone maintenance therapy demonstrating altered mental status, hallucinations, falls, and rebound hypertension was found to be concomitantly abusing clonidine and amitryptyline, which share metabolic pathways with buprenorphine. Clinicians should be aware of patients' combining amitryptyline, clonidine, and gabapentin with buprenorphine to achieve a mood altering state, avoid co-prescribing them if possible, and maintain communication with pharmacies and other providers when they are prescribed. PMID:25314340
Dittmer, Trent; Sigman, Erika J.; Clemons, Holly; Johnson, J. Aaron
Background The recommended standard of care calls for treating opioid-dependent pregnant women with methadone and observing neonates exposed in utero for five to seven postnatal days to see if treatment for neonatal abstinence syndrome (NAS) is needed. Data from a large multisite randomized clinical trial comparing buprenorphine vs. methadone for the treatment of opioid dependence during pregnancy suggest buprenorphine-exposed neonates had less severe NAS, but may require pharmacologic treatment for NAS later than methadone-exposed neonates. The present study examined whether time to pharmacologic treatment initiation differed in a relatively large non-blinded clinical sample of buprenorphine- vs. methadone-exposed neonates treated for NAS. Methods Medical records for 75 neonates exposed to buprenorphine (n = 47) or methadone (n = 28) in utero who required treatment for NAS were examined. Time elapsed between birth and initiation of pharmacologic treatment was calculated for each neonate and time to treatment initiation compared between groups. Results Median time to treatment initiation (hours:minutes, IQR) was significantly later in buprenorphine- vs. methadone-exposed neonates (71:02, 44:21-96:27 vs. 34:12, 21:00-55:41, respectively, p<.001). Estimates of mean time to treatment initiation from parametric analyses that adjusted for maternal and neonatal characteristics were very similar (73:10 (95% CI: 61:00 to 87:18) vs. 42:36 (95% CI: 33:06 to 53:30), respectively, p = .0005). This difference was not dependent on maternal age or neonatal sex, gestational age, or birth weight. Conclusions These findings confirm results from randomized clinical trials, adding generality to the observation that buprenorphine-exposed neonates require treatment significantly later than methadone-exposed neonates. PMID:23845658
Gaalema, Diann E.; Heil, Sarah H.; Badger, Gary J.; Metayer, Jerilyn S.; Johnston, Anne M.
Buprenorphine versus methadone in the treatment of opioid-dependent cocaine users
This study compared the efficacy of buprenorphine to methadone for decreasing cocaine use in patients with combined opioid and cocaine use. Participants (n=51) were enrolled in a 26-week treatment program and randomly assigned to either buprenorphine or methadone. Dosing was double-blind and double-dummy. Patients were stabilized on either 8 mg sublingual buprenorphine or 50 mg oral methadone, with dose increases
Eric C. Strain; Maxine L. Stitzer; Ira A. Liebson; George E. Bigelow
In October 2002, the U.S. Food and Drug Administration approved buprenorphine-naloxone (Suboxone®) sublingual tablets as an opioid dependence treatment available for use outside traditionally licensed opioid treatment programs. The NIDA Center for Clinical Trials Network (CTN) sponsored two clinical trials assessing buprenorphine-naloxone for short-term opioid detoxification. These trials provided an unprecedented field test of its use in twelve diverse community-based treatment programs. Opioid-dependent men and women were randomized to a thirteen-day buprenorphine-naloxone taper regimen for short-term opioid detoxification. The 234 buprenorphine-naloxone patients averaged 37 years old and used mostly intravenous heroin. Direct and rapid induction onto buprenorphine-naloxone was safe and well tolerated. Most patients (83%) received 8 mg buprenorphine-2 mg naloxone on the first day and 90% successfully completed induction and reached a target dose of 16mg buprenorphine-4 mg naloxone in three days. Medication compliance and treatment engagement was high. An average of 81% of available doses was ingested, and 68% of patients completed the detoxification. Most (80.3%) patients received some ancillary medications with an average of 2.3 withdrawal symptoms treated. The safety profile of buprenorphine-naloxone was excellent. Of eighteen serious adverse events reported, only one was possibly related to buprenorphine-naloxone. All providers successfully integrated buprenorphine-naloxone into their existing treatment milieus. Overall, data from the CTN field experience suggest that buprenorphine-naloxone is practical and safe for use in diverse community treatment settings, including those with minimal experience providing opioid-based pharmacotherapy and/or medical detoxification for opioid dependence. PMID:15204675
Amass, Leslie; Ling, Walter; Freese, Thomas E.; Reiber, Chris; Annon, Jeffrey J.; Cohen, Allan J.; M.F.T.; McCarty, Dennis; Reid, Malcolm S.; Brown, Lawrence S.; Clark, Cynthia; Ziedonis, Douglas M.; Krejci, Jonathan; Stine, Susan; Winhusen, Theresa; Brigham, Greg; Babcock, Dean; L.C.S.W.; Muir, Joan A.; Buchan, Betty J.; Horton, Terry
Inquiries about and initiation of buprenorphine treatment in an inner-city clinic.
Despite increases in opioid dependence, availability of buprenorphine treatment remains limited. Reasons may include health center concerns about becoming overwhelmed or attracting patients who differ from the local community. This study documents inquiries about and initiation of buprenorphine treatment in an inner-city health center. From 2006-2008, we collected demographic information and subsequent treatment data for everyone who inquired about treatment. Of the 324 people who inquired, 55.6% initiated treatment. The number of inquiries increased gradually over time, and most came from local community residents (80.4%). These results may allay health center concerns, and can help planning for buprenorphine treatment. PMID:19591064
Cunningham, Chinazo O; Giovanniello, Angela; Sacajiu, Galit; Li, Xuan; Brisbane, Mia; Sohler, Nancy L
Buprenorphine-Naloxone Maintenance Following Release from Jail
Primary care is understudied as a reentry drug and alcohol treatment setting. This study compared treatment retention and opioid misuse among opioid-dependent adults seeking buprenorphine\\/naloxone maintenance in an urban primary care clinic following release from jail versus community referrals. Postrelease patients were either (a) induced to buprenorphine in-jail as part of a clinical trial, or (b) seeking buprenorphine induction post
Joshua D. Lee; Ellie Grossman; Andrea Truncali; John Rotrosen; Andrew Rosenblum; Stephen Magura; Marc N. Gourevitch
Buprenorphine for Human Immunodeficiency Virus/Hepatitis C Virus-coinfected Patients
Objectives Buprenorphine is associated with enhanced human immunodeficiency virus (HIV) treatment outcomes including increased antiretroviral therapy initiation rates, adherence, and CD4+ cell counts among HIV-infected opioid-dependent individuals. Buprenorphine facilitates hepatitis C virus (HCV) treatment in opioid-dependent patients with HCV monoinfection. Less is known about buprenorphine's role in HIV/HCV coinfection. Methods We conducted a retrospective chart review to evaluate HCV care for HIV-infected buprenorphine patients in the first 4 years of buprenorphine's integration into a Rhode Island HIV clinic. Results Sixty-one patients initiated buprenorphine. All had HCV antibody testing; 57 (93%) were antibody-positive. All antibody-positive patients underwent HCV RNA testing; 48 (84%) were RNA-positive. Of these, 15 (31%) were not referred to HCV care. Among chronically infected patients, 3 received HCV treatment after buprenorphine; all had cirrhosis and none achieved viral eradication. At buprenorphine induction, most patients had inadequately controlled HIV infection, with detectable HIV RNA (59%) or CD4+ cell count less than or equal to 350/µL (38%). Conclusions Buprenorphine has shown limited success to date as a bridge to HCV treatment within an HIV clinic. Buprenorphine's stabilization of opioid dependence and HIV disease may permit the use of HCV therapy over time. PMID:22614935
Taylor, Lynn E.; Maynard, Michaela A.; Friedmann, Peter D.; MacLeod, Cynthia J.; Rich, Josiah D.; Flanigan, Timothy P.; Sylvestre, Diana L.
Methadone versus buprenorphine maintenance for the treatment of heroin-dependent outpatients.
The aim of this study was to assess the efficacy of methadone compared with buprenorphine maintenance therapy in heroin-dependent patients over a treatment period of 18 weeks. Subjects were randomized to receive either methadone or buprenorphine in a comparative double-blind study and consisted of 164 heroin-dependent male patients who met the DSM-IV criteria for heroin dependence and were seeking treatment. The 164 subjects included 41 patients in 1-mg, 41 patients in 3-mg, and 41 patients in 8-mg dosage group of buprenorphine, and also 41 patients in the 30-mg dosage group of methadone. The mean age was 31.4 years for total buprenorphine group and 33.7 years for methadone group (the mean age differences in 4 groups were not statistically significant). Subjects received buprenorphine at a dose of 1, 3, or 8 mg per day or methadone at a dose of 30 mg per day and were treated in an urban outpatient clinic, offering a 1-hour weekly individual counseling session. Days retained in treatment were measured. Completion rates by buprenorphine dosage group were 29.3% for the 1-mg dose group, 46.3% for the 3-mg dose group, 68.3% for the 8-mg dose group, and 61% for the 30-mg methadone dose group. Retention in the 8-mg dose group was significantly better than in the 1-mg dose group (p=.00041) and in the 3-mg dose group (p=.045); other comparison (1 mg dose with 3 mg dose) was not significant. Methadone group was significantly better than 1mg buprenorphine dose group (p=.004), but was not significantly different from 3 mg buprenorphine dose group (p=.18) or 8 mg buprenorphine dose group (p=.49). The results support the efficacy of buprenorphine for outpatient treatment of heroin dependence and seem to indicate that the highest dose (8 mg) of buprenorphine was the best of the three doses of buprenorphine, and also support the superiority of 30 mg of methadone compared to 1 mg dose of buprenorphine for Iranian heroin-dependent patients to increase their retention in treatment. PMID:12810142
Ahmadi, Jamshid
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
Robert J. Roose; Hillary V. Kunins; Nancy L. Sohler; Rashiah T. Elam; Chinazo O. Cunningham
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 non-linear 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=0.58–4.17, p=0.38) or self-reported opioid use (AOR=0.89, 95%CI=0.26–3.07, p=0.85) 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. PMID:23795874
Cunningham, Chinazo O.; Giovanniello, Angela; Kunins, Hillary V.; Roose, Robert J.; Fox, Aaron D.; Sohler, Nancy L.
This study was designed to compare the neonatal abstinence syndrome (NAS) in neonates of methadone and buprenorphine maintained pregnant opioid-dependent women and to provide preliminary safety and efficacy data for a larger multi-center trial. This randomized, double-blind, double-dummy, flexible dosing, parallel-group controlled trial was conducted in a comprehensive drug-treatment facility that included residential and ambulatory care. Participants were opioid-dependent pregnant
E. Jonesa; Rolley E. Johnsona; Donald R. Jasinskib; Kevin E. O'Gradyc; Christian A. Chisholmd; Robin E. Choof; Michael Crocettie; Robert Dudase; Cheryl Harrowe; Marilyn A. Huestisf; Lauren M. Janssone; Michael Lantzd; Barry M. Lesterg; Lorraine Miliod
Buprenorphine-naloxone maintenance following release from jail.
Primary care is understudied as a reentry drug and alcohol treatment setting. This study compared treatment retention and opioid misuse among opioid-dependent adults seeking buprenorphine/naloxone maintenance in an urban primary care clinic following release from jail versus community referrals. Postrelease patients were either (a) induced to buprenorphine in-jail as part of a clinical trial, or (b) seeking buprenorphine induction post release. From 2007 to 2008, N = 142 patients were new to primary care buprenorphine: n = 32 postrelease; n = 110 induced after community referral and without recent incarceration. Jail-released patients were more likely African American or Hispanic and uninsured. Treatment retention rates for postrelease (37%) versus community (30%) referrals were similar at 48 weeks. Rates of opioid positive urines and self-reported opioid misuse were also similar between groups. Postrelease patients in primary care buprenorphine treatment had equal treatment retention and rates of opioid abstinence versus community-referred patients. PMID:22263712
Lee, Joshua D; Grossman, Ellie; Truncali, Andrea; Rotrosen, John; Rosenblum, Andrew; Magura, Stephen; Gourevitch, Marc N
Top Manager Effects on Buprenorphine Adoption in Outpatient Substance Abuse Treatment Programs
To examine the influence of top managers' characteristics on the adoption of buprenorphine for opioid dependence among U.S. outpatient substance abuse treatment units, this investigation analyzed a cross-sectional national study of 547 such units in the 2004–2005 wave of the Drug Abuse Treatment System Survey. Administrators reported their demographics, training, and treatment orientation, as well as features of the unit and its pattern of use of buprenorphine. Nationally, 15.8% of programs offered any buprenorphine services. Greater adoption of buprenorphine correlated with directors' younger age, longer tenure, male gender, and weaker endorsement of abstinence as the most important treatment goal. Availability of naltrexone and medical services also correlated positively with buprenorphine adoption. The authors conclude that leaders' characteristics are related to the adoption of innovative practices in addiction treatment programs. Future work should examine whether leadership development for community addiction programs might speed up the diffusion of buprenorphine and other innovative, evidence-based practices. PMID:19296223
Friedmann, Peter D.; Jiang, Lan; Alexander, Jeffrey A.
This article examines changes from 2005 to 2011 in the use of an evidence-based clinical innovation, buprenorphine use, among a nationally representative sample of opioid treatment programs and identifies characteristics associated with its adoption. We apply a model of the adoption of clinical innovations that focuses on the work needs and characteristics of staff; organizations' technical and social support for the innovation; local market dynamics and competition; and state policies governing the innovation. Results indicate that buprenorphine use increased 24% for detoxification and 47% for maintenance therapy between 2005 and 2011. Buprenorphine use was positively related to reliance on private insurance and availability of state subsidies to cover its cost and inversely related to the percentage of clients who injected opiates, county size, and local availability of methadone. The results indicate that financial incentives and market factors play important roles in opioid treatment programs' decisions to adopt evidence-based clinical innovations such as buprenorphine use. PMID:24051897
Andrews, Christina M; D'Aunno, Thomas A; Pollack, Harold A; Friedmann, Peter D
Facts about Buprenorphine for Treatment of Opioid Addiction
... stop taking them, you will feel sick. This sickness is called withdrawal . Dependence is not the same ... people. Side effects are feelings of discomfort or sickness that come with taking medicine. Buprenorphine has a ...
Predictors of Outcome in LAAM, Buprenorphine, and Methadone Treatment for Opioid Dependence
This study examined (1) predictors of treatment outcome for opioid-dependent participants in a single-site controlled trial comparing methadone, buprenorphine, and LAAM treatments and (2) the extent to which various subpopulations of patients may have more successful outcomes with each medication. The relationships between patient demographics, drug use history, and psychological status and outcome measures of treatment retention, opiate use, and
Lisa A. Marsch; Mary Ann Chutuape Stephens; Timothy Mudric; Eric C. Strain; George E. Bigelow; Rolley E. Johnson
In a recent article, Lund et al sought to compare maternal and neonatal outcomes of various treatment regimens for opioid dependence during pregnancy.1 In their background, discussion the authors state that "In the United States buprenorphine plus naloxone [Suboxone(®)] … has been the preferred form of prescribed buprenorphine due to its reduced abuse liability relative to buprenorphine alone [Subutex(®)]." This claim is certainly consistent with the view of the firm that has manufactured and sold both products, Reckitt Benckiser. In September of 2011, the company announced that it was "… discontinuing distribution and sale of Subutex(®) tablets as we believe that mono product (product containing buprenorphine alone with no naloxone) creates a greater risk of misuse, abuse and diversion …".2 Supporting evidence for the alleged "reduced abuse liability" appears to be lacking, however, and evidence cannot be located in the two references cited by Dr. Lund and his co-authors, which in fact are silent on the subject of abuse potential.3,4 In contrast, it has been reported that the transition to buprenorphine/naloxone from the mono formulation has been associated with "… no reduction in injection risk behaviors among IDUs."5. PMID:23772177
Newman, Robert G; Gevertz, Susan G
This study compared clinical and demographic profiles of three opioid dependent user groups, while also measuring their response to one year of buprenorphine-medication assisted treatment (B-MAT). Opioid prescription, street, and combination (street + prescription) users completed the Addiction Severity Index (ASI) multiple times over the course of one treatment year. Although groups differed on all measured demographics (p's < .05),
Joseph Tkacz; Jamie Severt; Cheryl Kassed; Charles Ruetsch
Background Opioid-dependent HIV-infected patients are less likely to receive HIV quality of care indicators (QIs) compared with nondependent patients. Buprenorphine/naloxone maintenance therapy (bup/nx) could affect the quality of HIV care for opioid-dependent patients. Methods We abstracted 16 QIs from medical records at nine HIV clinics 12 months before and after initiation of bup/nx versus other treatment for opioid dependence. Summary quality scores (number of QIs received/number eligible × 100) were calculated. We compared change in QIs and summary quality scores in patients receiving bup/nx versus other participants. Results One hundred ninety-four of 268 participants (72%) received bup/nx and 74 (28%) received other treatment. Mean summary quality scores increased over 12 months for participants receiving bup/nx (45.6% to 51.6%, P < 0.001) but not other treatment (48.6% to 47.8%, P = 0.788). Bup/nx participants experienced improvements in six of 16 HIV QIs versus three of 16 QIs in other participants. Improvements were mostly in preventive and monitoring care domains. In multivariable analysis, bup/nx was associated with improved summary quality score (? 8.55; 95% confidence interval, 2.06–15.0). Conclusions In this observational cohort study, HIV-infected patients with opioid dependence received approximately half of HIV QIs at baseline. Buprenorphine treatment was associated with improvement in HIV QIs at 12 months. Integration of bup/nx into HIV clinics may increase receipt of high-quality HIV care. Further research is required to assess the effect of improved quality of HIV care on clinical outcomes. PMID:21317600
Korthuis, P. Todd; Fiellin, David A.; Fu, Rongwei; Lum, Paula J.; Altice, Frederick L.; Sohler, Nancy; Tozzi, Mary J.; Asch, Steven M.; Botsko, Michael; Fishl, Margaret; Flanigan, Timothy P.; Boverman, Joshua; McCarty, Dennis
A Comparison of Attitudes Toward Opioid Agonist Treatment among Short-Term Buprenorphine Patients
Background Obtaining data on attitudes toward buprenorphine and methadone of opioid-dependent individuals in the United States may help fashion approaches to increase treatment entry and improve patient outcomes. Objectives This secondary analysis study compared attitudes toward methadone and buprenorphine of opioid-dependent adults entering short-term buprenorphine treatment (BT) with opioid-dependent adults who are either entering methadone maintenance treatment or not entering treatment. Methods The 417 participants included 132 individuals entering short-term BT, 191 individuals entering methadone maintenance, and 94 individuals not seeking treatment. Participants were administered an Attitudes toward Methadone scale and its companion Attitudes toward Buprenorphine scale. Demographic characteristics for the three groups were compared using ?2 tests of independence and one-way analysis of variance. A repeated-measures multivariate analysis of variance with planned contrasts was used to compare mean attitude scores among the groups. Results Participants entering BT had significantly more positive attitudes toward buprenorphine than toward methadone (p < .001) and more positive attitudes toward BT than methadone-treatment (MT) participants and out-of-treatment (OT) participants (p < .001). In addition, BT participants had less positive attitudes toward methadone than participants entering MT (p < .001). Conclusions Participants had a clear preference for a particular medication. Offering a choice of medications to OT individuals might enhance their likelihood of entering treatment. Treatment programs should offer a choice of medications when possible to new patients, and future comparative effectiveness research should incorporate patient preferences into clinical trials. Scientific Significance These data contribute to our understanding of why people seek or do not seek effective pharmacotherapy for opioid addiction. PMID:22242643
Kelly, Sharon M.; Brown, Barry S.; Katz, Elizabeth C.; O'Grady, Kevin E.; Mitchell, Shannon Gwin; King, Stuart; Schwartz, Robert P.
Developing and Implementing a New Prison-Based Buprenorphine Treatment Program
ERIC Educational Resources Information Center
Research suggests that buprenorphine treatment may be a promising intervention for incarcerated individuals with heroin addiction histories. However, its implementation varies from corrections-based methadone because of unique challenges regarding dosing, administration, and regulation. Describing the first randomized clinical trial of…
Kinlock, Timothy W.; Gordon, Michael S.; Schwartz, Robert P.; Fitzgerald, Terrence T.
Sublingual Buprenorphine for Treatment of Neonatal Abstinence Syndrome: A Randomized Trial
ABSTRACT OBJECTIVE.In utero exposure,to drugs of abuse can lead to neonatal,abstinence syn- drome, a condition that is associated with prolonged hospitalization. Buprenorphine is a partial,-opioid agonist used for treatment,of adult detoxification and mainte-
Walter K. Kraft; Eric Gibson; Kevin Dysart; Vidula S. Damle; Jennifer L. Larusso; Jay S. Greenspan; David E. Moody; Karol Kaltenbach; Michelle E. Ehrlich
ERIC Educational Resources Information Center
This Treatment Improvement Protocol (TIP) addresses the clinical use of buprenorphine in the treatment of opioid addiction. TIPs are best-practice guidelines for the treatment of substance use disorders that make the latest research in substance abuse treatment available to counselors and educators. The content was generated by a panel of experts…
Boone, Margaret; Brown, Nancy J.; Moon, Mary A.; Schuman, Deborah J.; Thomas, Josephine; Wright, Denise L.
Cost-Effectiveness of Buprenorphine and Naltrexone Treatments for Heroin Dependence in Malaysia
Aims To aid public health policymaking, we studied the cost-effectiveness of buprenorphine, naltrexone, and placebo interventions for heroin dependence in Malaysia. Design We estimated the cost-effectiveness ratios of three treatments for heroin dependence. We used a microcosting methodology to determine fixed, variable, and societal costs of each intervention. Cost data were collected from investigators, staff, and project records on the number and type of resources used and unit costs; societal costs for participants' time were estimated using Malaysia's minimum wage. Costs were estimated from a provider and societal perspective and reported in 2004 US dollars. Setting Muar, Malaysia. Participants 126 patients enrolled in a randomized, double-blind, placebo-controlled clinical trial in Malaysia (2003–2005) receiving counseling and buprenorphine, naltrexone, or placebo for treatment of heroin dependence. Measurements Primary outcome measures included days in treatment, maximum consecutive days of heroin abstinence, days to first heroin use, and days to heroin relapse. Secondary outcome measures included treatment retention, injection drug use, illicit opiate use, AIDS Risk Inventory total score, and drug risk and sex risk subscores. Findings Buprenorphine was more effective and more costly than naltrexone for all primary and most secondary outcomes. Incremental cost-effectiveness ratios were below $50 for primary outcomes, mostly below $350 for secondary outcomes. Naltrexone was dominated by placebo for all secondary outcomes at almost all endpoints. Incremental treatment costs were driven mainly by medication costs, especially the price of buprenorphine. Conclusions Buprenorphine appears to be a cost-effective alternative to naltrexone that might enhance economic productivity and reduce drug use over a longer term. PMID:23226534
Ruger, Jennifer Prah; Chawarski, Marek; Mazlan, Mahmud; Ng, Nora; Schottenfeld, Richard
Drug users are marginalized from typical primary care, often resulting in emergency department (ED) usage and hospitalization due to late-stage disease. Though data suggest methadone decreases such fragmented healthcare utilization (HCU), the impact of buprenorphine maintenance treatment (BMT) on HCU is unknown. Chart review was conducted on opioid dependent patients seeking BMT, comparing individuals (N=59) who left BMT ? 3 days with those retained on BMT (N=150), for ED use and hospitalization. Using negative binomial regressions, including comparison of time before BMT induction, ED utilization and hospitalization was assessed. Overall, ED utilization was 0.93 events per person year and was significantly reduced by BMT, with increasing time (retention) on BMT. BMT had no significant effect on hospitalizations or average length of stay. PMID:22534003
Schwarz, Ryan; Zelenev, Alexei; Bruce, R. Douglas; Altice, Frederick L.
In the current study, buprenorphine (BUP) and its major metabolite, nor-buprenorphine (NBUP), were determined in hair samples from former heroin users following Suboxone® treatment. Hair samples from 36 subjects were analyzed. The drugs of interest were isolated from hair by solid-liquid extraction with methanol and were determined by liquid chromatography-mass spectrometry, using an electrospray ionization interface. The analytical parameters of the method (such as linearity, limits of quantification, recovery, accuracy, and precision) were determined. The inter-quartile range of BUP levels was from 11.4 to 37.4?pg/mg (mean value 56.6?pg/mg) for the proximal hair segment, from 5.8 to 43.3?pg/mg for the middle hair segment (mean value 25.3?pg/mg), while a range from 4.3 to 33.9?pg/mg (mean value 105.2?pg/mg) for the distant to the root hair segment was determined. For NBUP the corresponding inter-quartile range was from 27.0 to 147.6 for the proximal segment (mean value 95.4?pg/mg), from 21.5 to 164.7?pg/mg for the middle segment (mean value 102.0?pg/mg) and from 20.4 to 103.6?pg/mg for the distant segment (mean value 156.8?pg/mg). The mean BUP/NBUP concentration ratio was 0.5. The daily dose of Suboxone® correlated significantly with BUP and NBUP levels in hair (p?=?0.001 and p?=?0.023) as well as with the BUP/NBUP ratio (p?=?0.010). No significant correlation was found between the levels of BUP and NBUP and the duration of Suboxone® administration. The developed and validated method was successfully used for the determination of BUP and NBUP in hair samples collected from former heroin users under Suboxone® treatment. PMID:24817054
Belivanis, Stamatis; Tzatzarakis, Manolis N; Vakonaki, Elena; Kovatsi, Leda; Mantsi, Mary; Alegakis, Athanasios; Kavvalakis, Matthaios P; Vynias, Dionisios; Tsatsakis, Aristidis M
Constant refinement of opioid dependence (OD) therapies is a condition to promote treatment access and delivery. Among other applications, the partial opioid agonist buprenorphine has been studied to improve evidence-based interventions for the transfer of patients from opioid agonist to antagonist medications. This paper summarizes PubMed-searched clinical investigations and conference papers on the transition from methadone maintenance to buprenorphine and from buprenorphine to naltrexone, discussing challenges and advances. The majority of the 26 studies we examined were uncontrolled investigations. Many small clinical trials have demonstrated the feasibility of in- or outpatient transfer to buprenorphine from low to moderate methadone doses (up to 60–70 mg). Results on the conversion from higher methadone doses, on the other hand, indicate significant withdrawal discomfort, and need for ancillary medications and inpatient treatment. Tapering high methadone doses before the transfer to buprenorphine is not without discomfort and the risk of relapse. The transition buprenorphine-naltrexone has been explored in several pilot studies, and a number of treatment methods to reduce withdrawal intensity warrant further investigation, including the co-administration of buprenorphine and naltrexone. Outpatient transfer protocols using buprenorphine, and direct comparisons with other modalities of transitioning from opioid agonist to antagonist medications are limited. Given its potential salience, the information gathered should be used in larger clinical trials on short and long-term outcomes of opioid agonist-antagonist transition treatments. Future studies should also test new pharmacological mechanisms to help reduce physical dependence, and identify individualized approaches, including the use of pharmacogenetics and long-acting opioid agonist and antagonist formulations. PMID:22280332
Mannelli, Paolo; Peindl, Kathleen S.; Lee, Tong; Bhatia, Kamal S.; Wu, Li-Tzy
Randomized trial of buprenorphine for treatment of concurrent opiate and cocaine dependence
Background Buprenorphine is a partial ?-opiate agonist and ?-opiate antagonist with established efficacy in the treatment of opiate dependence. Its efficacy for cocaine dependence is uncertain. This study evaluated buprenorphine for the treatment of concomitant cocaine and opiate dependence. Methods Two hundred outpatients currently dependent on both cocaine and opiates were randomly assigned to double-blind groups receiving a sublingual solution of buprenorphine (2, 8, or 16 mg daily, or 16 mg on alternate days, or placebo), plus weekly individual drug abuse counseling, for 13 weeks. The chief outcome measures were urine concentrations of opiate and cocaine metabolites (quantitative) and proportion of urine samples positive for opiates or cocaine (qualitative). Group differences were assessed by use of mixed regression modeling. Results The target dose of buprenorphine was achieved in 179 subjects. Subjects receiving 8 or 16 mg buprenorphine daily showed statistically significant decreases in urine morphine levels (P = .0135 for 8 mg and P < .001 for 16 mg) or benzoylecgonine concentrations (P = .0277 for 8 mg and P = .006 for 16 mg) during the maintenance phase of the study. For the 16-mg group, mean benzoylecgonine concentrations fell from 3715 ng/mL during baseline to 186 ng/mL during the withdrawal phase; mean morphine concentrations fell from 3311 ng/mL during baseline to 263 ng/mL during withdrawal. For the 8-mg group, mean benzoylecgonine concentrations fell from 6761 ng/mL during baseline to 676 ng/mL during withdrawal; mean morphine concentrations fell from 3890 ng/mL during baseline to 661 ng/mL during withdrawal. Qualitative urinalysis showed a similar pattern of results. Subjects receiving the highest dose showed concomitant decreases in both urine morphine and benzoylecgonine concentrations. There were no significant group differences in treatment retention or adverse events. Conclusions A sublingual buprenorphine solution at 16 mg daily is well tolerated and effective in reducing concomitant opiate and cocaine use. The therapeutic effect on cocaine use appears independent of that on opiate use. PMID:14749690
Montoya, Ivan D.; Gorelick, David A.; Preston, Kenzie L.; Schroeder, Jennifer R.; Umbricht, Annie; Cheskin, Lawrence J.; Lange, W. Robert; Contoreggi, Carlo; Johnson, Rolley E.; Fudala, Paul J.
Objective: To evaluate the economic impact of buprenorphine\\/naloxone (B\\/N) as an agonist opioid treatment for opiate dependence. Methods: A budgetary impact analysis model was designed to calculate the annual costs (drugs and associated costs) to the Spanish National Healthcare System of methadone versus B\\/N. Data for the model were obtained from official databases and expert panel opinion. Results: It was
José Martínez-Raga; Francisco González Saiz; César Pascual; Miguel A. Casado; Francisco J. Sabater Torres
Background The non-compliant use of opioid substitution treatment (OST) medicines is widespread and well-documented. However, less is known about characteristics of non-compliant OST medicine use and the factors that predict it. The two main goals of this study are to compare characteristics of non-compliant levomethadone, methadone, and buprenorphine use and to explore factors that may differentially predict it among opioid dependent persons in treatment. Methods Data from 595 opioid dependent patients with non-compliant OST medicine use were analyzed. Characteristics of use between substances were compared using chi-squared tests and predictive factors were explored through multinomial logistic regressions. Results Non-compliant levomethadone and methadone use was characterized by more frequent parallel consumption of other psychoactive substances and intravenous use, whereas buprenorphine was more often procured without a prescription. Regarding predictive factors, methadone was perceived to relieve withdrawal symptoms better than buprenorphine and levomethadone was perceived as being better at modulating the effects of other substances and worst at enhancing mood. Conclusions Patterns of non-compliant use differ according to OST medicine. These patterns are considered with the reduction of non-compliant use and the improvement of treatment in mind. PMID:24885218
Buprenorphine and methadone maintenance in jail and post-release: a randomized clinical trial.
Buprenorphine has rarely been administered as an opioid agonist maintenance therapy in a correctional setting. This study introduced buprenorphine maintenance in a large urban jail, Rikers Island in New York City. Heroin-dependent men not enrolled in community methadone treatment and sentenced to 10-90 days in jail (N=116) were voluntarily randomly assigned either to buprenorphine or methadone maintenance, the latter being the standard of care for eligible inmates at Rikers. Buprenorphine and methadone maintenance completion rates in jail were equally high, but the buprenorphine group reported for their designated post-release treatment in the community significantly more often than did the methadone group (48% vs. 14%, p<.001). Consistent with this result, prior to release from Rikers, buprenorphine patients stated an intention to continue treatment after release more often than did methadone patients (93% vs. 44%, p<.001). Buprenorphine patients were also less likely than methadone patients to withdraw voluntarily from medication while in jail (3% vs. 16%, p<.05). There were no post-release differences between the buprenorphine and methadone groups in self-reported relapse to illicit opioid use, self-reported re-arrests, self-reported severity of crime or re-incarceration in jail. After initiating opioid agonist treatment in jail, continuing buprenorphine maintenance in the community appears to be more acceptable to offenders than continuing methadone maintenance. PMID:18930603
Magura, Stephen; Lee, Joshua D; Hershberger, Jason; Joseph, Herman; Marsch, Lisa; Shropshire, Carol; Rosenblum, Andrew
Effects of buprenorphine versus buprenorphine\\/naloxone tablets in non-dependent opioid abusers
Rationale: Buprenorphine is an opioid agonist-antagonist under development in the United States as a sublingual medication for treatment\\u000a of opioid dependence. Buprenorphine may be abused; therefore, tablets combining buprenorphine with naloxone have been developed\\u000a with the intent of reducing the abuse risk in people physically dependent upon opioids. The characteristics and abuse potential\\u000a of buprenorphine and buprenorphine\\/naloxone tablets in non-dependent
Eric C. Strain; Kenneth Stoller; Sharon L. Walsh; George E. Bigelow
Background Opioid dependence and HIV infection are associated with poor health-related quality of life (HRQOL). Buprenorphine/naloxone (bup/nx) provided in HIV care settings may improve HRQOL. Methods We surveyed 289 HIV-infected opioid-dependent persons treated with clinic-based bup/nx about HRQOL using the Short Form Health Survey (SF-12) administered at baseline, 3, 6, 9, and 12 months. We used normalized SF-12 scores which correspond to a mean HRQOL of 50 for the general U.S. population (SD 10, possible range 0–100). We compared mean normalized mental and physical composite and component scores in quarters 1, 2, 3, and 4 with baseline scores using GEE models. We assessed the effect of clinic-based bup/nx prescription on HRQOL composite scores using mixed effects regression with site as random effect and time as repeated effect. Results Baseline normalized SF-12 scores were lower than the general U.S. population for all HRQOL domains. Average composite mental HRQOL improved from 38.3 (SE 12.5) to 43.4 (SE 13.2) (? 1.13 [95% CI 0.72, 1.54]) and composite physical HRQOL remained unchanged (? 0.21 [95% CI ?0.16, 0.57]) over 12 months follow-up. Continued bup/nx treatment across all four quarters was associated with improvements in both physical (? 2.38 [95% CI 0.63, 4.12]) and mental (? 2.51 [95% CI 0.42, 4.60]) HRQOL after adjusting for other contributors to HRQOL. Conclusions Clinic-based bup/nx maintenance therapy is potentially effective in ameliorating some of the adverse effects of opioid dependence on HRQOL for HIV-infected populations. PMID:21317593
Korthuis, P. Todd; Tozzi, Mary Jo; Nandi, Vijay; Fiellin, David A.; Weiss, Linda; Egan, James E.; Botsko, Michael; Acosta, Angela; Gourevitch, Marc N.; Hersh, David; Hsu, Jeffrey; Boverman, Joshua; Altice, Frederick L.
Background In Finland, buprenorphine (Subutex) is the most abused opioid. In order to curb this problem, many treatment centres transferred ("forced transfer") their buprenorphine patients to the buprenorphine plus naloxone (Suboxone) combination product in late 2003. Methods Data from a retrospective study involving five different treatment centers, examining the effects of switching patients to Suboxone, were gathered from 64 opioid-dependent patients who had undergone the medication transfer. Results Most patients (90.6%) switched to Suboxone at the same dose of buprenorphine that they had been receiving as Subutex (average 22 mg). The majority of these patients (71.9%) were maintained at the same dose of Suboxone throughout the 4-week study period. During the first 4 weeks, 50% of the patients reported adverse events and at the four month time point, 26.6% reported adverse events. However, due to adverse events one patient only discontinued treatment with Suboxone during the 4-week study period, and five during the four month follow-up period. Of the 26 patients in the follow-up period, Suboxone was misused intravenously once each by 4 patients and twice by 1 patient. These 5 patients all reported that injecting Suboxone was like injecting "nothing" with any euphoria, or that it was a bad experience. Conclusion We conclude that when patients are transferred from high doses (> 22 mg) of buprenorphine to the combination product, dose adjustments may be necessary especially in the later phase of the treatment. We recommend that a transfer from Subutex to Suboxone should be carefully discussed and planned in advance with the patients and after the transfer adverse events should be regularly monitored. With regard of buprenorphine IV abuse, the combination product seems to have a less abuse potential than buprenorphine alone. PMID:18559110
Simojoki, Kaarlo; Vorma, Helena; Alho, Hannu
Initiation of buprenorphine during incarceration and retention in treatment upon release.
We report here on a feasibility study of initiating buprenorphine/naloxone prior to release from incarceration and linking participants to community treatment providers upon release. The study consisted of a small number of Rhode Island (RI) prisoners (N = 44) diagnosed with opioid dependence. The study design is a single arm, open-label pilot study with a 6-month follow up interview conducted in the community. However, a natural experiment arose during the study comparing pre-release initiation of buprenorphone/naloxone to initiation post-release. Time to post-release prescriber appointment (mean days) for initiation of treatment outside Rhode Island Department of Corrections (RIDOC) versus inside RIDOC was 8.8 and 3.9, respectively (p = .1). Median post release treatment duration (weeks) for outside RIDOC versus inside RIDOC was 9 and 24, respectively (p = .007). We conclude that initiating buprenorphine/naloxone prior to release from incarceration may increase engagement and retention in community-based treatment. PMID:23541303
Zaller, Nickolas; McKenzie, Michelle; Friedmann, Peter D; Green, Traci C; McGowan, Samuel; Rich, Josiah D
The effects of buprenorphine in buprenorphine-maintained volunteers
Buprenorphine is a mu opioid partial agonist currently used as an analgesic, and being developed for the treatment of opioid\\u000a dependence. The purpose of this study was to determine the abuse liability of parenteral buprenorphine in volunteers maintained\\u000a on daily sublingual (SL) buprenorphine (8?mg). In a residential laboratory, eight volunteers underwent pharmacologic challenges\\u000a two times per week. Medication challenges were
Eric C. Strain; Sharon L. Walsh; Kenzie L. Preston; Ira A. Liebson; George E. Bigelow
Diversion of methadone and buprenorphine from opioid substitution treatment: a staff perspective.
Abstract Opioid substitution treatment (OST) is still controversial, despite positive results. The issue of diversion to the illicit drug market is a cornerstone in the criticism typically voiced against the treatment. Little research is available concerning how professionals who work in OST view the issue of diversion. In this article, we discuss existing ideas and attitudes toward diversion of methadone and buprenorphine among OST staff in Sweden. The article is based on semi-structured interviews with 25 professionals working in eight OST-programs in southern Sweden. Diversion was seen as a deleterious phenomenon by the interviewees. Three problematic aspects were highlighted: medical risks in the form of overdose fatalities and the recruitment of new opiate/opioid users; negative consequences for the legitimacy of OST; and moral objections, since diversion means that the patients remain in a criminal environment. However, positive aspects were also highlighted. Illicit methadone or buprenorphine is perceived as safer than heroin. In this way, diversion can fulfill a positive function; for instance, if there is a shortage of access to regular treatment. Patients who share their medication with opioid-dependent friends are seen as less culpable than those who sell to anyone for money. PMID:25364995
Johnson, Björn; Richert, Torkel
National data indicate that patients treated with buprenorphine for opiate use disorders are more likely to be White, highly educated, and to have greater incomes than those receiving methadone, but patterns of buprenorphine dissemination across demographic areas have not been documented in major metropolitan areas where poverty, minority populations and injection heroin use are concentrated. Rates of buprenorphine and methadone treatment are compared among areas of New York City defined by their income and ethnic/racial composition. Residential social areas (hereinafter called social areas) were defined as aggregations of ZIP codes with similar race/ethnicity and income characteristics, and were formed based on clustering techniques. Treatment rates were obtained for each New York City ZIP code: buprenorphine treatment rates were based on the annual number of buprenorphine prescriptions written, and the methadone treatment rate on the number of methadone clinic visits for persons in each ZIP code. Treatment rates were correlated univariately with ethnicity and income characteristics of ZIP codes. Social area treatment rates were compared using individual ANOVA models for each rate. Buprenorphine and methadone treatment rates were significantly correlated with the ethnicity and income characteristics of ZIP codes, and treatment rates differed significantly across the social areas. Buprenorphine treatment rates were highest in the social area with the highest income and lowest percentage of Black and Hispanic residents. Conversely, the methadone treatment rate was highest in the social area with the highest percentage of low income and Hispanic residents. The uneven dissemination of 0pioid maintenance treatment in New York City may be reflective of the limited public health impact of buprenorphine in ethnic minority and low income areas. Specific policy and educational interventions to providers are needed to promote the use of buprenorphine for opiate use disorders in diverse populations. PMID:23702611
Hansen, Helena B.; Siegel, Carole E.; Case, Brady G.; Bertollo, David N.; DiRocco, Danae; Galanter, Marc
ERIC Educational Resources Information Center
Objective: To examine predictors of opioid abstinence in buprenorphine/naloxone (Bup/Nal)-assisted psychosocial treatment for opioid-dependent youth. Method: Secondary analyses were performed of data from 152 youth (15-21 years old) randomly assigned to 12 weeks of extended Bup/Nal therapy or up to 2 weeks of Bup/Nal detoxification with weekly…
Subramaniam, Geetha A.; Warden, Diane; Minhajuddin, Abu; Fishman, Marc J.; Stitzer, Maxine L.; Adinoff, Bryon; Trivedi, Madhukar; Weiss, Roger; Potter, Jennifer; Poole, Sabrina A.; Woody, George E.
Supply of buprenorphine waivered physicians: The influence of state policies.
Buprenorphine, an effective opioid use disorder treatment, can be prescribed only by buprenorphine-waivered physicians. We calculated the number of buprenorphine-waivered physicians/100,000 county residents using 2008-11 Buprenorphine Waiver Notification System data, and used multivariate regression models to predict number of buprenorphine-waivered physicians/100,000 residents in a county as a function of county characteristics, state policies and efforts to promote buprenorphine use. In 2011, 43% of US counties had no buprenorphine-waivered physicians and 7% had 20 or more waivered physicians. Medicaid funding, opioid overdose deaths, and specific state guidance for office-based buprenorphine use were associated with more buprenorphine-waivered physicians, while encouraging methadone programs to promote buprenorphine use had no impact. Our findings provide important empirical information to individuals seeking to identify effective approaches to increase the number of physicians able to prescribe buprenorphine. PMID:25218919
Stein, Bradley D; Gordon, Adam J; Dick, Andrew W; Burns, Rachel M; Pacula, Rosalie Liccardo; Farmer, Carrie M; Leslie, Douglas L; Sorbero, Mark
Buprenorphine withdrawal syndrome in a newborn
A pregnant woman who was addicted to heroin rapidly withdrew from illicit drugs after the onset of a 4 mg\\/day buprenorphine treatment. In the newborn's blood, urine, and meconium 20 hours after birth, high concentrations of buprenorphine and its metabolite norbuprenorphine were detected, with a higher buprenorphine\\/norbuprenorphine ratio than in adults, possibly as a consequence of immature hepatic function; no
Pierre Marquet; Jean Chevrel; Pierre Lavignasse; Louis Merle; Gérard Lachâtre
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. PMID:20682186
Whitley, Susan D; Sohler, Nancy L; Kunins, Hillary V; Giovanniello, Angela; Li, Xuan; Sacajiu, Galit; Cunningham, Chinazo O
This study examined the adoption of buprenorphine for the treatment of opiate dependence among U.S. substance abuse treatment facilities and their characteristics at the time of the initial availability of the medication. Data come from a 2003 national survey of all substance abuse treatment facilities in the U.S. Out of our sample of 13,060 facilities, 5.5% of facilities reported they
Alison L. Koch; Cynthia L. Arfken; Charles R. Schuster
Aims. To determine the cost-effectiveness of buprenorphine maintenance therapy for opiate addiction in the United States, particularly its effect on the HIV epidemic. Design. We developed a dynamic model to capture the effects of adding buprenorphine maintenance to the current opiate dependence treatment system. We evaluated incremental costs, including all health-care costs, and incremental effectiveness, measured as quality-adjusted life years
Paul G. Barnett; Gregory S. Zaric; Margaret L. Brandeau
Effects of buprenorphine and methadone in methadone-maintained subjects
Buprenorphine, a partial mu opioid agonist, is an experimental medication under development for the treatment of opioid dependence as an alternative to methadone maintenance. The present study examined the relationship between level of opioid physical dependence and response to buprenorphine administration as part of a program to develop procedures for transferring patients from methadone to buprenorphine treatment. This laboratory study
S. L. Walsh; H. L. June; K. J. Schuh; K. L. Preston; G. E. Bigelow; M. L. Stitzer
Buprenorphine prescribing practices and exposures reported to a poison center--Utah, 2002-2011.
Buprenorphine is an effective medication for the treatment of opioid dependence. Its use has increased in the United States as a result of the Drug Addiction Treatment Act of 2000, which allowed physicians to prescribe certain medications as part of office-based treatment for opioid addiction. In France, widespread use of medication-assisted therapy, primarily buprenorphine treatment, was associated with an 80% decrease in overdose deaths from heroin or cocaine from 465 in 1996 to 89 in 2003. With the expanded use of buprenorphine, an increase in exposures among children and adults has been reported in the United States. These exposures (including unintentional and intentional, therapeutic and nontherapeutic) have resulted in adverse effects and, in a small number of cases, death. To assess statewide increases in buprenorphine use and the number of reported exposures, the Utah Department of Health analyzed data from the Utah Controlled Substance Database (CSD) and the Utah Poison Control Center (PCC). The results of that analysis indicated a statewide increase in the annual number of patients prescribed buprenorphine from 22 in 2002 to 9,793 in 2011, and a concurrent increase in the annual number of prescribers writing buprenorphine prescriptions from 16 to 1,088. Over the same period, the number of exposures to buprenorphine reported annually to the PCC increased from six to 81. However, comparison of the ratios of buprenorphine exposures to patients and prescribers in 2002 with data for 2011 indicated substantial decreases from 6/22 for patients and 6/16 for prescribers in 2002 to 81/9,793 for patients and 81/1,088 for prescribers in 2011. Three of the total 462 buprenorphine exposures reported during 2002-2011 in Utah, in a teen and two adults, were associated with fatal outcomes. Increased buprenorphine prescribing in Utah during 2002-2011 likely represents expanded access to critically needed opioid addiction treatment; however, safeguards should be in place to prevent adverse effects. Prescribers and pharmacists are encouraged to counsel patients carefully regarding the safe use, storage, and disposal of buprenorphine. PMID:23235296
The transdermal 7-day buprenorphine matrix patch provides a constant and user-friendly pain management when chronic musculoskeletal pain requires opioids. This analysis of clinical routine data evaluated the benefit of this treatment for patients previously receiving oral long-term treatment with weak opioids alone. Data of 310 patients previously treated with tramadol or tildate/naloxone and part of a multicentre observational study with 3295 patients were analyzed. In 89.7% of the 310 patients oral treatment with weak opioids was replaced by the 7-day buprenorphine patch due to insufficient analgesia. During treatment with the 7-day buprenorphine patch there was a clinically significant decrease of the mean pain intensity at rest during the day from 5.7 to 2.9, on physical effort during the day from 7.3 to 3.8 and at night from 5.2 to 2.3 (11-point NRS scale, p < or = 0.001). In addition, quality of life aspects such as mobility, self-reliance and quality of sleep improved, which are relevant for individual patient satisfaction with pain management. For patients with previous long-term tramadol or tilidate/naloxone treatment the switch to the 7-day buprenorphine matrix patch proved to be effective and safe for the management of chronic pain. The user-friendly 7-day application interval contributes to improving compliance and a reducing exposure to tablets. PMID:21591321
Schutter, U; Ritzdorf, I; Heckes, B
Opioids continue to be first-line pharmacotherapy for patients suffering from cancer pain. Unfortunately, subtherapeutic dosage prescribing of pain medications remains common, and many cancer patients continue to suffer and experience diminished quality of life. A large variety of therapeutic options are available for cancer pain patients. Analgesic pharmacotherapy is based on the patient's self-report of pain intensity and should be tailored to meet the requirements of each individual. Most, if not all, cancer pain patients will ultimately require modifications in their opioid pharmacotherapy. When changes in a patient's medication regimen are needed, adequate pain control is best maintained through appropriate dosage conversion, scheduling immediate release medication for withdrawal prevention, and providing as needed dosing for breakthrough pain. Transdermal opioids are noninvasive, cause less constipation and sedation when compared to oral opioids, and may improve patient compliance. A relative potency of 100:1 is recommended when converting the patient from oral morphine to transdermal fentanyl. Based on the limited data available, there is significant interpatient variability with transdermal buprenorphine and equipotency recommendations from oral morphine of 75:1–110:1 have been suggested. Cancer patients may require larger transdermal buprenorphine doses to control their pain and may respond better to a more aggressive 75–100:1 potency ratio. This review outlines the prescribing of transdermal fentanyl and transdermal buprenorphine including how to safely and effectively convert to and use them for those with cancer pain. PMID:25170278
Skaer, Tracy L
Participant Characteristics and Buprenorphine Dose
Background Clinical parameters for determining buprenorphine dose have not been adequately examined in treatment outcome research. Objectives The current study is a secondary analysis of data collected in a recently completed comparison of buprenorphine taper schedules conducted as part of the National Institute on Drug Abuse's (NIDA) Clinical Trials Network (CTN) to assess whether participant baseline characteristics are associated with buprenorphine dose. Methods After 3 weeks of flexible dosing, 516 participants were categorized by dose provided in the final dosing week (9.3% received a final week dose of 8mg buprenorphine, 27.3% received 16mg, and 63.4% received 24mg). Results Findings show that final week dose groups differed in baseline demographic and drug use characteristics including education, heroin use, route of drug administration, withdrawal symptoms, and craving. These groups also differed in opioid use during the four dosing weeks, with the lowest use in the 8mg group and highest use in the 24mg group (p < 0.0001). Additional analyses address withdrawal symptoms, and craving. Conclusions and Scientific Significance Final week dose groups differed in demographic and drug use characteristics, and the group receiving the largest final week dose had the highest rate of continued opioid use. These findings may contribute to the development of clinical guidelines regarding buprenorphine dose in the treatment of opioid dependence, however further investigations that include random assignment to dose by baseline characteristics are needed. PMID:21854290
Hillhouse, Maureen; Canamar, Catherine; Doraimani, Geetha; Thomas, Christie; Hasson, Al; Ling, Walter
Buprenorphine's physiological effects are produced when it attaches to specific opiate receptors that are designated mu, kappa, or delta. Buprenorphine, a partial agonist at the mu receptor and an antagonist at the kappa receptor, produces typical morphine-like effects at low doses. At higher doses, it produces opiate effects that are less than those of full opiate agonists. Knowledge of the
Donald R. Wesson
In France, high-dosage buprenorphine (HDB) is the main substitution treatment for narcotic addiction. Few data have been published concerning clinical factors predicting a good response to this treatment in a daily practice. A hospital-based multicenter clinical research program (PHRC) was undertaken in heroin-addicted patients, diagnosed according to DSM-III-R, to detect clinical criteria susceptible of predicting a good response to HDB
Marie-France Poirier; Xavier Laqueille; Valérie Jalfre; Dominique Willard; Marie Chantal Bourdel; Jacques Fermanian; Jean Pierre Olié
Outpatient opioid addiction treatment with sublingual buprenorphine pharmacotherapy has rapidly expanded in the United States and abroad, and, with this increase in medication availability, there have been increasing concerns about its diversion, misuse, and related harms. This narrative review defines the behaviors of diversion and misuse, examines how the pharmacology of buprenorphine alone and in combination with naloxone influence its abuse liability, and describes the epidemiological data on buprenorphine diversion and intravenous misuse, risk factors for its intravenous misuse, and the unintended consequences of misuse and diversion. Physician practices to prevent, screen for, and therapeutically respond to these behaviors, which are a form of medication nonadherence, are discussed, and gaps in knowledge are identified. Outpatient opioid addiction treatment with sublingual buprenorphine pharmacotherapy experiences from other countries that have varied health care systems, public policies, and access to addiction treatment are shared to make clear that diversion and misuse occur across the world in various contexts, for many different reasons, and are not limited to buprenorphine. Comparisons are made with other opioids with known abuse liability and medications with no known abuse. The objective was to facilitate understanding of diversion and misuse so that all factors influencing their expression (patient and provider characteristics and public policy) can be appreciated within a framework that also recognizes the benefits of addiction treatment. With this comprehensive perspective, further careful work can help determine how to minimize these behaviors without eroding the current benefits realized through improved addiction treatment access and expansion. PMID:25221984
Lofwall, Michelle R; Walsh, Sharon L
Buprenorphine use in pregnant opioid users: a critical review.
Pregnancy in opioid users poses a number of problems to treating physicians. Most guidelines recommend maintenance treatment to manage opioid addiction in pregnancy, with methadone being the gold standard. More recently, buprenorphine has been discussed as an alternate medication. The use and efficacy of buprenorphine in pregnancy is still controversial. This article reviews the current database on the basis of a detailed and critical literature search performed in MEDLINE (206 counts). Most of the relevant studies (randomised clinical trials and one national cohort sample) were published in the last 2 years and mainly compared buprenorphine with methadone. Some studies are related to maternal outcomes, others to foetal, neonatal or older child outcomes. With respect to maternal outcomes, most studies suggest that buprenorphine has similar effects to methadone. Very few data from small studies discuss an effect of buprenorphine on neurodevelopment of the foetus. Neonatal abstinence syndrome is common in infants of both buprenorphine- and methadone-maintained mothers. As regards neonatal outcomes, buprenorphine has the same clinical outcome as methadone, although some newer studies suggest that it causes fewer withdrawal symptoms. Since hardly any studies have investigated the combination of buprenorphine with naloxone (which has been suggested to possibly have teratogenic effects) in pregnant women, a switch to buprenorphine monotherapy is recommended in women who become pregnant while receiving the combination product. These novel findings indicate that buprenorphine is emerging as a first-line treatment for pregnant opioid users. PMID:23775478
Soyka, Michael
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 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 non-linear models, we examined associations between induction strategy and opioid use and any drug use. Compared to those with standard-of-care office-based inductions, participants with patient-centered home-based inductions had no significant differences in opioid use (AOR=0.63, 95%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 well-studied. PMID:21310583
Cunningham, Chinazo O.; Giovanniello, Angela; Li, Xuan; Kunins, Hillary V.; Roose, Robert J.; Sohler, Nancy L.
Establishing effective cage-side pain assessment methods is essential if post-surgical pain is to be controlled effectively in laboratory animals. Changes to overall activity levels are the most common methods of assessment, but may not be the most appropriate for establishing the analgesic properties of drugs, especially in mice, due their high activity levels. Use of drugs that can affect activity (e.g. opioids) is also a problem. The relative merits of both manual and automated behaviour data collection methods was determined in two inbred mouse strains undergoing vasectomy following treatment with one of 2 buprenorphine dose rates. Body weights and the effects of surgery and buprenorphine on faecal corticosterone were also measured. Surgery caused abnormal behaviour and reduced activity levels, but high dose buprenorphine caused such large-scale increases in activity in controls that we could not establish analgesic effects in surgery groups. Only pain-specific behaviour scoring using the manual approach was effective in showing 0.05 mg/kg buprenorphine alleviated post-vasectomy pain. The C57 mice also responded better to buprenorphine than C3H mice, indicating they were either less painful, or more responsive to its analgesic effects. C3H mice were more susceptible to the confounding effects of buprenorphine irrespective of whether data were collected manually or via the automated approach. Faecal corticosterone levels, although variable, were higher in untreated surgery mice than in control groups, also indicating the presence of pain or distress. Pain-specific scoring was superior to activity monitoring for assessing the analgesic properties of buprenorphine in vasectomised mice. Buprenorphine (0.01 mg/kg), in these strains of male mice, for this procedure, provided inadequate analgesia and although 0.05 mg/kg was more effective, not completely so. The findings support the recommendation that analgesic dose rates should be adjusted in relation to the potential severity of the surgical procedure, the mouse strain, and the individual animals' response. PMID:24098748
Wright-Williams, Sian; Flecknell, Paul A.; Roughan, Johnny V.
Establishing effective cage-side pain assessment methods is essential if post-surgical pain is to be controlled effectively in laboratory animals. Changes to overall activity levels are the most common methods of assessment, but may not be the most appropriate for establishing the analgesic properties of drugs, especially in mice, due their high activity levels. Use of drugs that can affect activity (e.g. opioids) is also a problem. The relative merits of both manual and automated behaviour data collection methods was determined in two inbred mouse strains undergoing vasectomy following treatment with one of 2 buprenorphine dose rates. Body weights and the effects of surgery and buprenorphine on faecal corticosterone were also measured. Surgery caused abnormal behaviour and reduced activity levels, but high dose buprenorphine caused such large-scale increases in activity in controls that we could not establish analgesic effects in surgery groups. Only pain-specific behaviour scoring using the manual approach was effective in showing 0.05 mg/kg buprenorphine alleviated post-vasectomy pain. The C57 mice also responded better to buprenorphine than C3H mice, indicating they were either less painful, or more responsive to its analgesic effects. C3H mice were more susceptible to the confounding effects of buprenorphine irrespective of whether data were collected manually or via the automated approach. Faecal corticosterone levels, although variable, were higher in untreated surgery mice than in control groups, also indicating the presence of pain or distress. Pain-specific scoring was superior to activity monitoring for assessing the analgesic properties of buprenorphine in vasectomised mice. Buprenorphine (0.01 mg/kg), in these strains of male mice, for this procedure, provided inadequate analgesia and although 0.05 mg/kg was more effective, not completely so. The findings support the recommendation that analgesic dose rates should be adjusted in relation to the potential severity of the surgical procedure, the mouse strain, and the individual animals' response. PMID:24098748
Wright-Williams, Sian; Flecknell, Paul A; Roughan, Johnny V
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. PMID:25163931
McClure, Bridget; Mendoza, Sonia; Duncan, Laura; Rotrosen, John; Hansen, Helena
Costs of care for persons with opioid dependence in commercial integrated health systems
Background When used in general medical practices, buprenorphine is an effective treatment for opioid dependence, yet little is known about how use of buprenorphine affects the utilization and cost of health care in commercial health systems. Methods The objective of this retrospective cohort study was to examine how buprenorphine affects patterns of medical care, addiction medicine services, and costs from the health system perspective. Individuals with two or more opioid-dependence diagnoses per year, in two large health systems (System A: n = 1836; System B: n = 4204) over the time span 2007–2008 were included. Propensity scores were used to help adjust for group differences. Results Patients receiving buprenorphine plus addiction counseling had significantly lower total health care costs than patients with little or no addiction treatment (mean health care costs with buprenorphine treatment?=?$13,578; vs. mean health care costs with no addiction treatment?=?$31,055; p?.0001), while those receiving buprenorphine plus addiction counseling and those with addiction counseling only did not differ significantly in total health care costs (mean costs with counseling only: $17,017; p?=?.5897). In comparison to patients receiving buprenorphine plus counseling, those with little or no addiction treatment had significantly greater use of primary care (p?.001), other medical visits (p?=?.001), and emergency services (p?=?.020). Patients with counseling only (compared to patients with buprenorphine plus counseling) used less inpatient detoxification (p?.001), and had significantly more PC visits (p?=?.001), other medical visits (p?=?.005), and mental health visits (p?=?.002). Conclusions Buprenorphine is a viable alternative to other treatment approaches for opioid dependence in commercial integrated health systems, with total costs of health care similar to abstinence-based counseling. Patients with buprenorphine plus counseling had reduced use of general medical services compared to the alternatives. PMID:25123823
In France, high-dosage buprenorphine (HDB) is the main substitution treatment for narcotic addiction. Few data have been published concerning clinical factors predicting a good response to this treatment in a daily practice. A hospital-based multicenter clinical research program (PHRC) was undertaken in heroin-addicted patients, diagnosed according to DSM-III-R, to detect clinical criteria susceptible of predicting a good response to HDB administered during a 3-month treatment period. At the inclusion time in the study, a diagnostic structured interview (DIGS) was performed, and the Addiction Severity Index (ASI), Zuckerman scale, depression scale from Jouvent, and CGI were scored. MMPI was also administered. Good response was defined as an ongoing participation in the study, with absence of opiate detected in 75% of urine collected during the last month of treatment. Only subjects treated for at least 1 month were eligible for analyses. One hundred fifteen patients were recruited and 73 were analyzed. Patients received 8.5+/-2.6 mg (m+/-S.D.) of buprenorphine for 1 to 3 months. A forward stepwise logistic regression showed that six clinical parameters may predict a good response to treatment: probability to respond to buprenorphine was higher in subjects having a high psychopathology (ASI) subscore, low disinhibition and boredom susceptibility factor scores (Zuckerman scale), no alcohol dependence, no family history of addiction or mood disorder, and duration of opiate dependence less than 10 years. Only the MMPI D subscale was a psychological pattern correlated to a good response to substitution treatment. These findings are important to consider when making the decision to prescribe HDB substitution treatment in opiate addiction. PMID:14751421
Poirier, Marie-France; Laqueille, Xavier; Jalfre, Valérie; Willard, Dominique; Bourdel, Marie Chantal; Fermanian, Jacques; Olié, Jean Pierre
Socio-demographic Profile and Help-seeking Behaviour of Buprenorphine Abusers in Singapore
Introduction: The US Food and Drug Administration (FDA) approved buprenorphine or Subutex for the treatment of opiate dependence in October 2002. Buprenorphine is a partial agonist of the mu-opioid receptor; although initial animal research suggested a low abuse potential for buprenorphine, it was subsequently shown to have an abuse potential similar to that of morphine or hydromorphone. The objectives of
Munidasa Winslow; Wei-Ling Ng; Subramaniam Mythily
Objective: The objective of this secondary analysis was to explore differences in baseline clinical characteristics and opioid replacement therapy treatment outcomes by type (heroin, opioid analgesic [OA], or combined [heroin and OA]) and route (injector or non-injector) of opioid use. Method: A total of 1,269 participants (32.2% female) were randomized to receive one of two study medications (methadone or buprenorphine/naloxone [BUP]). Of these, 731 participants completed the 24-week active medication phase. Treatment outcomes were opioid use during the final 30 days of treatment (among treatment completers) and treatment attrition. Results: Non-opioid substance dependence diagnoses and injecting differentiated heroin and combined users from OA users. Non-opioid substance dependence diagnoses and greater heroin use differentiated injectors from non-injectors. Further, injectors were more likely to be using at end of treatment compared with non-injectors. OA users were more likely to complete treatment compared with heroin users and combined users. Non-injectors were more likely than injectors to complete treatment. There were no interactions between type of opioid used or injection status and treatment assignment (methadone or BUP) on either opioid use or treatment attrition. Conclusions: Findings indicate that substance use severity differentiates heroin users from OA users and injectors from non-injectors. Irrespective of medication, heroin use and injecting are associated with treatment attrition and opioid misuse during treatment. These results have particular clinical interest, as there is no evidence of superiority of BUP over methadone for treating OA users versus heroin users. PMID:23739025
Potter, Jennifer S.; Marino, Elise N.; Hillhouse, Maureen P.; Nielsen, Suzanne; Wiest, Katharina; Canamar, Catherine P.; Martin, Judith A.; Ang, Alfonso; Baker, Rachael; Saxon, Andrew J.; Ling, Walter
Background and Objectives A paucity of studies has examined the pain experiences of opioid dependent individuals seeking office-based buprenorphine-naloxone treatment (BNT). We set out to examine, among those seeking BNT: (a) the prevalence of pain types (i.e., recent pain, chronic pain), (b) the characteristics of pain (intensity, frequency, duration, interference, location, and genesis), and (c) substance use to alleviate pain. Methods We surveyed 244 consecutive individuals seeking office-based buprenorphine-naloxone treatment (BNT) for opioid dependence about physical pain and associated substance use. Results Thirty-six percent of respondents reported chronic pain (CP) (i.e., pain lasting at least 3 months) and 36% reported "some pain" (SP) (i.e., past week pain not meeting the threshold for CP). In comparison to SP respondents, those with CP were, on average, older; reported greater current pain intensity, pain frequency, typical pain duration, typical pain intensity, and typical pain interference; were more likely to report shoulder or pelvis and less likely to report stomach or arms as their most bothersome pain location; and were more likely to report accident or nerve damage and less likely to report opioid withdrawal as the genesis of their pain. Both pain subgroups reported similarly high rates of past-week substance use to alleviate pain. Conclusions and Scientific Significance The high rates of pain and self-reported substance use to manage pain suggest the importance of assessing and addressing pain in BNT patients. PMID:23617861
Barry, Declan T.; Savant, Jonathan D.; Beitel, Mark; Cutter, Christopher J.; Moore, Brent A.; Schottenfeld, Richard S.; Fiellin, David A.
Buprenorphine substitution treatment in France: drug users' views of the doctor-user relationship
The French system for drug substitution, or maintenance treatment, established in 1996, differs from the often strict conditions attached to methadone clinics in other countries. Because of the predominant role of general practitioners and the flexible prescription rules for Subutex® in France, the relationship between the physician and the drug user becomes a central element in the treatment. This article deals with the expectations that these users have of the physician, and their perception of his or her attitude towards them. In order to identify possible reasons for the absence of treatment compliance and of Subutex® misuse, it focuses on the users' assessment of the physician's response to the problems they report. This study, based on a diversified sample of 28 persons in treatment, showed 4 patterns of relationships between physicians and users, which differed in their focus: a) dosage, b) compliance, c) the person and d) obtaining a prescription. In all four case types, users had difficulty reporting other drug use or intravenous Subutex® injection within this relationship in which the stigma attached to drug dependence seems to reappear. Moreover, the lack of clarity about the treatment objectives and time frame limits the users' ability to integrate the treatment into their lives and to commit themselves to it. The heterogeneity and fragility of the users' situations are elements related to dependence that, during contact with the physician, require regular assessment of the individual's situation and of the treatment objectives. This constant reappraisal of the situation with the physician should help to optimize the treatment and avoid the hiatus that can generate or continue "misuse." PMID:17442473
Guichard, Anne; Lert, France; Brodeur, Jean-Marc; Richard, Lucie
Buprenorphine is used as a sublingual medication in the treatment of opioid dependence. However, its misuse by i.v. injection may limit its acceptability and dissemination. A buprenorphine/naloxone (ratio 4:1) combination has been developed to reduce diversion and abuse. So far, the relevance of this combination has not been investigated in the animal models traditionally used to study the reinforcing effects of drugs of abuse. The aim of this study was to compare the rewarding effects, assessed by conditioned place preference (CPP), of buprenorphine and buprenorphine/naloxone combination following i.v. administration in mice. Animals were treated with different doses of buprenorphine or buprenorphine/naloxone combination (ratio 4:1), and CPP conditioning trial duration was 5 or 30 min. At the longest trial duration, a bell-shaped dose-response curve was obtained with buprenorphine, which was shifted significantly to the right with naloxone combination. At the shortest trial duration, an aversive effect was observed with the buprenorphine/naloxone combination in animals, involving opioid receptor-like 1 (ORL1). These findings may explain the discrepancies reported in the literature as some authors have shown a reduced buprenorphine/naloxone misuse compared to buprenorphine in opioid abusers, while others have not. PMID:24606726
Canestrelli, Corinne; Marie, Nicolas; Noble, Florence
For the first time, relationships among maternal buprenorphine dose, meconium buprenorphine and metabolite concentrations, and neonatal outcomes are reported. Free and total buprenorphine and norbuprenorphine, nicotine, opiates, cocaine, benzodiazepines, and metabolites were quantified in meconium from 10 infants born to women who had received buprenorphine during pregnancy. Neither cumulative nor total third-trimester maternal buprenorphine dose predicted meconium concentrations or neonatal
SL Kacinko; HE Jones; RE Johnson; RE Choo; MA Huestis
We determined the specialty, geographic location, practice type and treatment capacity of waivered clinicians in Washington State. We utilized the April 2011 Drug Enforcement Agency roster of all waivered buprenorphine prescribers and cross-referenced the data with information from the American Medical Association and online resources. Waivered physicians, as compared to Washington State physicians overall, are more likely to be primary care providers, be older, less likely to be younger than 35years, and more likely to be female. Isolated rural areas have the lowest provider to population ratios. Ten counties lack either a buprenorphine provider or a methadone clinic. In rural areas, waivered physicians work predominately in federally-subsidized safety-net settings, which underscores the need for continued governmental support of primary care and mental health in these settings. PMID:22939650
Kvamme, Erik; Catlin, Mary; Banta-Green, Caleb; Roll, John; Rosenblatt, Roger
We determined the specialty, geographic location, practice type and treatment capacity of waivered clinicians in Washington State. We utilized the April 2011 Drug Enforcement Agency roster of all waivered buprenorphine prescribers and cross-referenced the data with information from the American Medical Association and online resources. Waivered physicians, as compared to Washington State physicians overall, are more likely to be primary care providers, be older, less likely to be younger than 35 years, and more likely to be female. Isolated rural areas have the lowest provider to population ratios. Ten counties lack either a buprenorphine provider or a methadone clinic. In rural areas, waivered physicians work predominately in federally-subsidized safety-net settings, which underscores the need for continued governmental support of primary care and mental health in these settings. PMID:22939650
Kvamme, Erik; Catlin, Mary; Banta-Green, Caleb; Roll, John; Rosenblatt, Roger
Physician adoption of buprenorphine treatment of opioid dependence may be limited in part by concerns regarding the induction process. Although national guidelines recommend observed induction, some physicians utilize unobserved induction outside the office. The aim of this pilot randomized clinical trial was to assess preliminary safety and effectiveness of unobserved versus observed office buprenorphine\\/naloxone induction among patients entering a 12-week
Erik W. Gunderson; Xin-Qun Wang; David A. Fiellin; Benjamin Bryan; Frances R. Levin
Transfer of Buprenorphine Into Breast Milk and Calculation of Infant Drug Dose
Little is known about the safety of buprenorphine (BUP) in breastfeeding. The aim of this work was to investigate the transfer of buprenorphine and its main active metabolite, norbuprenorphine (n-BUP), into human milk and to determine the drug dose and effects in exposed infants. Seven lactating women, who were maintained on BUP treatment because of previous opiate addiction, were studied
Synnove Lindemalm; Per Nydert; Jan-Olov Svensson; Lars Stahle; Ihsan Sarman
Treatment Approaches (Palliative Care)
... about such topics as religion, death, and afterlife. Palliative Care Websites American Academy of Hospice and Palliative Medicine ... Life Physician Education Resource Center European Association for Palliative Care Growth House, Inc. Hospice Cares International Hospice Institute & ...
Buprenorphine: dose-related blockade of opioid challenge effects in opioid dependent humans.
This study assessed the blockade of hydromorphone challenge effects (cumulative s.c. doses of 0, 6 and 18 mg) during chronic buprenorphine treatment of opioid dependent subjects. Buprenorphine was administered daily via the sublingual route in ascending doses of 2, 4, 8 and 16 mg. Hydromorphone challenges were conducted after 10 to 14 days of chronic administration of each buprenorphine dose and 24 h after the last buprenorphrine dose. Buprenorphrine itself only produced dose-related effects in respiration rate. While subjects were maintained on 2 mg of buprenorphine, the hydromorphone challenge produced dose-related changes in physiological and self-report measures. As the dose of buprenorphine was increased, hydromorphone effects on self-report measures were attenuated to a greater extent than was noted for pupil diameter. The results of this study confirm previous reports of buprenorphine blockade of opioid agonist effects in humans and extent those findings by demonstrating both a buprenorphine dose-effect function and a dissociation between the potency of buprenorphine's opioid blockade for self-report vs. physiological measures. PMID:2459370
Bickel, W K; Stitzer, M L; Bigelow, G E; Liebson, I A; Jasinski, D R; Johnson, R E
The efficacy of buprenorphine and methadone was compared in the outpatient detoxification of heroin addicts. Forty-five patients were randomized to receive either sublingual buprenorphine or oral methadone under double-dummy and double-blind conditions to study the pharmacology of buprenorphine in a 90-day detoxification protocol. The patients were administered either 2 mg buprenorphine or 30 mg methadone for 3 weeks followed by 4 weeks of dose reductions and 6 weeks of placebo medication. No significant between-group differences were seen on measures of treatment retention, drug use, or symptom report. During the hydromorphone challenge, methadone attenuated opioid effects to a greater extent than did buprenorphine on both physiologic (pupil constriction) and self-report measures. However, this did not result in greater abuse of illicit opioid drugs by subjects taking buprenorphine. The results of this clinical trial indicated that buprenorphine was acceptable to patients and as effective as methadone in the detoxification treatment of heroin addicts. PMID:3275523
Bickel, W K; Stitzer, M L; Bigelow, G E; Liebson, I A; Jasinski, D R; Johnson, R E
Opioid Abstinence Reinforcement Delays Heroin Lapse during Buprenorphine Dose Tapering
ERIC Educational Resources Information Center
A positive reinforcement contingency increased opioid abstinence during outpatient dose tapering (4, 2, then 0 mg/day during Weeks 1 through 3) in non-treatment-seeking heroin-dependent volunteers who had been maintained on buprenorphine (8 mg/day) during an inpatient research protocol. The control group (n = 12) received $4.00 for completing…
Greenwald, Mark K.
Open-label trial of an injection depot formulation of buprenorphine in opioid detoxification
Buprenorphine, a partial mu-opioid agonist, has been shown effective for treatment of opioid dependence but also has some abuse potential. A novel formulation of buprenorphine, using a polymer microcapsule depot sustained-release technology, has been developed which may offer effective treatment of opioid dependence while also minimizing risks of patient noncompliance and illicit diversion. This open-label, first-in-human study evaluated the safety
Bai-Fang X. Sobel; Stacey C. Sigmon; Sharon L. Walsh; Rolley E. Johnson; Ira A. Liebson; Elie S. Nuwayser; James H. Kerrigan; George E. Bigelow
Patients being treated with buprenorphine usually have a history of opioid dependence and may be predisposed to misuse of drugs. Concurrent drug misuse increases the risk of life-threatening drug interactions. This retrospective data analysis observed which nonprescribed and illicit drugs were most commonly detected in the urine of patients from pain management clinics taking buprenorphine with or without a prescription. GC, LC/MS and LC-MS-MS were used to quantify 20,929 urine specimens. The most prevalent illicit drug used in both the groups (prescribed and nonprescribed buprenorphine) was marijuana, followed by cocaine. The most prevalent nonprescribed medications abused by both the groups were benzodiazepines, followed by oxycodone and hydrocodone. The overall prevalence of illicit and nonprescribed drug use was significantly higher in subjects who used buprenorphine without a prescription versus prescribed use. Of the concurrent use of marijuana and cocaine with buprenorphine, cocaine is most concerning since it decreases exposure to buprenorphine (lower area under the concentration-time curve and maximum concentration). The concurrent use of nonprescribed benzodiazepines with buprenorphine can cause excess sedation leading to respiratory depression and even death. These findings highlight the importance of educating patients about these potential toxicities. Furthermore, pain providers should consider expanding the spectrum of drugs that they monitor in patients under treatment. PMID:24080973
Guo, Alexander Y; Ma, Joseph D; Best, Brookie M; Atayee, Rabia S
Opiate addiction is associated with many adverse health and social harms, fatal overdose, infectious disease transmission, elevated health care costs, public disorder, and crime. Although community-based addiction treatment programs continue to reduce the harms of opiate addiction with narcotic substitution therapy such as methadone maintenance, there remains a need to find a substance that not only blocks opiate-type receptors (mu, delta, etc.) but also provides agonistic activity; hence the impetus arose for the development of a combination of narcotic antagonism and mu receptor agonist therapy. After three decades of extensive research the federal Drug Abuse Treatment Act 2000 (DATA) opened a window of opportunity for patients with addiction disorders by providing increased access to options for treatment. DATA allows physicians who complete a brief specialty-training course to become certified to prescribe buprenorphine and buprenorphine/naloxone (Subutex, Suboxone) for treatment of patients with opioid dependence. Clinical studies indicate buprenorphine maintenance is as effective as methadone maintenance in retaining patients in substance abuse treatment and in reducing illicit opioid use. With that stated, we must consider the long-term benefits or potential toxicity attributed to Subutex or Suboxone. We describe a mechanism whereby chronic blockade of opiate receptors, in spite of only partial opiate agonist action, may ultimately block dopaminergic activity causing anti-reward and relapse potential. While the direct comparison is not as yet available, toxicity to buprenorphine can be found in the scientific literature. In considering our cautionary note in this commentary, we are cognizant that to date this is what we have available, and until such a time when the real magic bullet is discovered, we will have to endure. However, more than anything else this commentary should at least encourage the development of thoughtful new strategies to target the specific brain regions responsible for relapse prevention. PMID:21948099
Blum, Kenneth; Chen, Thomas JH; Bailey, John; Bowirrat, Abdulla; Femino, John; Chen, Amanda LC; Simpatico, Thomas; Morse, Siobhan; Giordano, John; Damle, Uma; Kerner, Mallory; Braverman, Eric R.; Fornari, Frank; Downs, B.William; Rector, Cynthia; Barh, Debmayla; Oscar-Berman, Marlene
The history of the development of buprenorphine as an addiction therapeutic.
This paper traces the early 21st century success of the agonist-antagonist buprenorphine and the combination drug buprenorphine with naloxone within the broader quest to develop addiction therapeutics that began in the 1920s as the search for a nonaddictive analgesic. Drawing on archival research, document analysis, and interviews with contemporary actors, this paper situates the social organization of laboratory-based and clinical research within the domestic and international confluence of several issues, including research ethics, drug regulation, public attitudes, tensions around definitions of drug addiction, and the evolving roles of the pharmaceutical industry. The fervor that drove the champions of buprenorphine must be understood in relation to (1) the material work of research and pharmaceutical manufacturing; (2) the symbolic role of buprenorphine as a solution to numerous problems with addiction treatment evident by the mid-1970s; the destigmatization and individualization of addicts as patients; and (3) the complex configurations of public and private partnerships. PMID:22256949
Campbell, Nancy D; Lovell, Anne M
Assessing Need for Medication-Assisted Treatment for Opiate-Dependent Prison Inmates
Individuals with a history of heroin dependence are overrepresented in American correctional facilities and 75% of inmates with a drug use disorder do not receive treatment during incarceration or after release. Medication-assisted treatment (MAT) with opiate agonists, such as methadone or buprenorphine, constitutes standard of care; to guide planning for an expansion of drug treatment services in correctional facilities, a
Carmen E. Albizu-García; José Noel Caraballo; Glorimar Caraballo-Correa; Adriana Hernández-Viver; Luis Román-Badenas
Assessing Need for Medication-Assisted Treatment for Opiate-Dependent Prison Inmates
Individuals with a history of heroin dependence are overrepresented in American correctional facilities and 75% of inmates with a drug use disorder do not receive treatment during incarceration or after release. Medication-assisted treatment (MAT) with opiate agonists, such as methadone or buprenorphine, constitute standard of care; to guide planning for an expansion of drug treatment services in correctional facilities, a
Carmen E. Albizu-García; José Noel Caraballo; Glorimar Caraballo-Correa; Adriana Hernández-Viver; Luis Román-Badenas
Although the classical function of myelin is the facilitation of saltatory conduction, this membrane and the oligodendrocytes, the cells that make myelin in the central nervous system (CNS), are now recognized as important regulators of plasticity and remodeling in the developing brain. As such, oligodendrocyte maturation and myelination are among the most vulnerable processes along CNS development. We have shown previously that rat brain myelination is significantly altered by buprenorphine, an opioid analogue currently used in clinical trials for managing pregnant opioid addicts. Perinatal exposure to low levels of this drug induced accelerated and increased expression of myelin basic proteins (MBPs), cellular and myelin components that are markers of mature oligodendrocytes. In contrast, supra-therapeutic drug doses delayed MBP brain expression and resulted in a decreased number of myelinated axons. We have now found that this biphasic-dose response to buprenorphine can be attributed to the participation of both the ?-opioid receptor (MOR) and the nociceptin/orphanin FQ receptor (NOP receptor) in the oligodendrocytes. This is particularly intriguing because the NOP receptor/nociceptin system has been primarily linked to behavior and pain regulation, but a role in CNS development or myelination has not been described before. Our findings suggest that balance between signaling mediated by (a) MOR activation and (b) a novel, yet unidentified pathway that includes the NOP receptor, plays a crucial role in the timing of oligodendrocyte maturation and myelin synthesis. Moreover, exposure to opioids could disrupt the normal interplay between these two systems altering the developmental pattern of brain myelination. PMID:22002899
Eschenroeder, Andrew C; Vestal-Laborde, Allison A; Sanchez, Emilse S; Robinson, Susan E; Sato-Bigbee, Carmen
Oral buprenorphine and aspirin analgesia in rats undergoing liver transplantation
Summary The objective of this study was to establish effective postoperative analgesia for Dark Agouti rats undergoing liver transplantation with minimal additional stress due to handling and no adverse effect on transplant outcome. Oral administration of buprenorphine (0.5 mg =kg=dose) or aspirin (100 mg =kg=dose) in raspberry-Ż avoured gelatine were compared to controls receivingno treatment or plain gelatine. The drugs
P. Jablonski; B. O. Howden
Transdermal delivery of buprenorphine through cadaver skin.
The skin permeation of buprenorphine base and HCl salt through cadaver skin was investigated. The octanol-water partition coefficient and solubilities of both buprenorphine free base and HCl salt were determined at 32 degrees C. As expected, buprenorphine free base was more lipophilic than its HCl salt and was practically insoluble in aqueous buffer at pH 8.7. The drug solubility decreased exponentially as the pH of the solution increased, whereas the permeability coefficient increased as the donor solution pH decreased. The skin flux of buprenorphine.HCl was significantly higher than that of the free base from propylene glycol/lauric acid vehicle mixtures. Buprenorphine base permeation through tape-stripped epidermis suggested that in addition to stratum corneum, viable epidermis presented a significant diffusion barrier because of the very low aqueous solubility of the free base observed. The mean steady-state skin fluxes of buprenorphine.HCl were 20.3 and 29.7 micrograms/cm2/h from propylene glycol:lauryl alcohol: ethanol (80:15:5) and propylene glycol: propylene glycol monolaurate: water (80:15:5) vehicle mixtures, respectively. The skin flux of buprenorphine.HCl from various monolithic matrix patches was also evaluated. When capric acid, lauric acid, and lauryl alcohol were separately incorporated into an adhesive matrix, the skin flux of buprenorphine.HCl was enhanced by a factor of 2 to 3.5. Finally, based on the total body clearance and minimum effective concentration of buprenorphine, a transdermal delivery rate of 2.5 micrograms/cm2/h from a 20-cm2 patch was estimated. The in vitro skin permeation data clearly suggest that transdermal delivery of buprenorphine is feasible to achieve a desired systemic analgesic effect. PMID:8169777
Roy, S D; Roos, E; Sharma, K
Adverse effects on growth rates in rats caused by buprenorphine administration.
As a routine postoperative treatment, a single dose of buprenorphine was given to rats at a dose of 0.05 mg/kg subcutaneously. However, some rats developed abnormal secretions around the nose and mouth and some animals died 3-5 days after surgery and analgesic treatment. At autopsy a yellow fibrous mass was found in the stomach and intestines. Observations of animals given buprenorphine revealed an abnormal ingestion of bedding material. This caused a disturbance to normal digestion, with gastric distension, weight loss or decreased growth rate, constipation and occasionally death. In this study rats were monitored for 6 days following surgery and analgesic treatment. A comparison of growth rates was made between rats given saline and buprenorphine or nalbuphine and between animals kept on bedding or grid floors for the first 24h after treatment. Of the animals held on bedding, the buprenorphine-treated animals did not lose weight as the other animals did, but had on the other hand a decreased growth rate during the measuring period of 6 days after surgery. When denied access to bedding for the first 24 h after surgery, rats given saline or nalbuphine had a reduced weight gain over the first 24 h, similar to the groups held on bedding. Rats held on grid floors and given buprenorphine continued to gain weight for the first 24 h. From day 3, there was no significant difference between the groups, which all gained weight. PMID:10817460
Jacobson, C
Adequate drug treatment for substance users continues to be a challenge for most U.S. cities. To address heroin addiction in Baltimore, the Baltimore Buprenorphine Initiative was implemented as a joint project to promote individualized, patient-centered buprenorphine therapy in conjunction with behavioral treatment to accelerate recovery from opioid addiction. The purpose of this analysis was to explore differences in recovery trajectories predicting length of stay and use this information to predict characteristics that influence an individual's ability to remain in the Baltimore Buprenorphine Initiative program. The sample consisted of 1,039 subjects enrolled in the program between January 2008 and June 2009. The regression modeling determined that age, income, employment, and higher level of treatment were significant predictors of length of stay in the recovery program. The findings of this study have practical implications for the design and implementation of heroin addiction programs. The research indicates that focusing on these specific predictive variables early in the program design phase could increase recovery success rates as measured by length of stay. PMID:24613946
Murphy, Lyn Stankiewicz; Oros, Marla T; Dorsey, Susan G
Preliminary evidence suggests that there is minimal withdrawal after the cessation of chronically administered buprenorphine and that opioid withdrawal symptoms are delayed compared with those of other opioids. The present study compared the time course and magnitude of buprenorphine withdrawal with a prototypical ?-opioid agonist, morphine. Healthy, out-of-treatment opioid-dependent residential volunteers (N = 7) were stabilized on either buprenorphine (32 mg/day i.m.) or morphine (120 mg/day i.m.) administered in four divided doses for 9 days. They then underwent an 18-day period of spontaneous withdrawal, during which four double-blind i.m. placebo injections were administered daily. Stabilization and spontaneous withdrawal were assessed for the second opioid using the same time course. Opioid withdrawal measures were collected eight times daily. Morphine withdrawal symptoms were significantly (P < 0.05) greater than those of buprenorphine withdrawal as measured by mean peak ratings of Clinical Opiate Withdrawal Scale (COWS), Subjective Opiate Withdrawal Scale (SOWS), all subscales of the Profile of Mood States (POMS), sick and pain (0-100) Visual Analog Scales, systolic and diastolic blood pressure, heart rate, respiratory rate, and pupil dilation. Peak ratings on COWS and SOWS occurred on day 2 of morphine withdrawal and were significantly greater than on day 2 of buprenorphine withdrawal. Subjective reports of morphine withdrawal resolved on average by day 7. There was minimal evidence of buprenorphine withdrawal on any measure. In conclusion, spontaneous withdrawal from high-dose buprenorphine appears subjectively and objectively milder compared with that of morphine for at least 18 days after drug cessation. PMID:24227768
Tompkins, D Andrew; Smith, Michael T; Mintzer, Miriam Z; Campbell, Claudia M; Strain, Eric C
Buprenorphine misuse by injecting drug users was assessed in a survey of 350 needle exchangers, either amphetamine (57%) or heroin users (42%). 89% of heroin users and 24% of amphetamine users reported using buprenorphine at some time during the previous year. Most users reported illicit acquisition. Among illicit users, 87% of heroin users reported intake for withdrawal treatment or self-detoxification,
A. Hakansson; A. Medvedeo; M. Andersson; M. Berglund
Previous studies comparing buprenorphine and clonidine provided little information about subjective factors associated with the effective management of opioid withdrawal. This study sought to compare detoxification programs using these medications with regard to side-effects and related distress, general well-being, perceived self-efficacy and social support. A total of 200 treatment-seeking heroin-dependent patients, aged 18–50, were randomly assigned to buprenorphine or clonidine
Alexander M. Ponizovsky; Alexander Grinshpoon; Anatoly Margolis; Rami Cohen; Paula Rosca
Buprenorphine versus methadone in pregnant opioid-dependent women: a prospective multicenter study
Patients and methods In order to investigate the effects of exposure to buprenorphine compared with methadone during pregnancy, a prospective multicenter\\u000a study was conducted in collaboration with maternity hospitals, maintenance therapy centers, and general practitioners involved\\u000a in addiction care. Ninety pregnant women exposed to buprenorphine and 45 to metadone were selected for the study.\\u000a \\u000a \\u000a \\u000a \\u000a Results During pregnancy, some women were exposed to
Isabelle Lacroix; Alain Berrebi; Daniel Garipuy; Laurent Schmitt; Yamina Hammou; Catherine Chaumerliac; Maryse Lapeyre-Mestre; Jean-Louis Montastruc; Christine Damase-Michel
Rationale Although buprenorphine is effective in treating opioid dependence, optimal maintenance doses of buprenorphine or the buprenorphine/naloxone combination have not yet been established. Objective The present study was designed to evaluate the effects of buprenorphine/naloxone maintenance (2/0.5, 8/2, 32/8 mg sublingual) on the reinforcing and subjective effects of heroin (0, 12.5, 25, 50, and 100 mg intranasal) in heroin-dependent individuals. Methods During test weeks, participants (N=7) first sampled a dose of heroin and $20. During subsequent choice sessions, participants could choose to self administer heroin and/or money. Participants responded under a modified progressive-ratio schedule (PR 50, …, 2800) during a 10-trial self-administration task. Results Heroin break point values and subjective responses were significantly lower under 8/2 and 32/8 mg buprenorphine/naloxone compared to 2/0.5 mg. The self-administration and subjective effects data for heroin in the presence of buprenorphine/naloxone were compared to a separate control group of recently detoxified participants (N=8) in order to obtain estimates for the apparent in vivo dissociation constant (KA), the efficacy estimate (tau), and the estimated fraction of receptors remaining after buprenorphine/naloxone treatment (q). The apparent in vivo dissociation constant for heroin ranged from 50–126 mg (KA) and the efficacy estimate ranged from 13–20 (tau). In addition, 2/0.5, 8/2 and 32/8 mg buprenorphine/naloxone dose-dependently reduced the receptor population by 74%, 83%, and 91%, respectively. Conclusions These data demonstrate that both 8/2 and 32/8 mg buprenorphine/naloxone were well tolerated and effective in reducing the reinforcing and subjective effects of heroin, relative to the 2/0.5 mg dose. The data also show for the first time in humans that it is possible to quantify the efficacy and affinity of heroin for mu opioid receptors and that 80–90% of mu receptors need to be inactivated in order to obtain significant reductions in heroin-induced effects. These results have important implications for future studies in which it will be possible to obtain estimates of relative affinity and efficacy of different agonists at mu opioid receptors. PMID:16025322
Comer, Sandra D.; Walker, Ellen A.; Collins, Eric D.
This pilot study examined the efficacy of the N-type calcium channel blocker gabapentin to improve outcomes during a brief detoxification protocol with buprenorphine. Treatment-seeking opioid-dependent individuals were enrolled in a 5-wk, double blind, placebo-controlled trial examining the effects of gabapentin during a 10-day outpatient detoxification from buprenorphine. Participants were inducted onto buprenorphine sublingual tablets during week 1, were randomized and inducted onto gabapentin or placebo during week 2, underwent a 10-day buprenorphine taper during weeks 3–4 and then were tapered off gabapentin/placebo during week 5. Assessments included thrice-weekly opioid withdrawal scales, vitals, and urine drug screens. Twenty-four individuals (13 male, 17 Caucasian, 3 African American, 4 Latino, mean age 29.7 yrs) participated in the detoxification portion of the study (gabapentin, N=11; placebo, N=13). Baseline characteristics did not differ significantly between groups. Self-reported and observer-rated opioid withdrawal ratings were relatively low and did not differ between groups during the buprenorphine taper. Urine results showed a drug x time interaction, such that the probability of opioid-positive urines significantly decreased over time in the gabapentin versus placebo groups during weeks 3–4 (OR=0.73, p=0.004). These results suggest that gabapentin reduces opioid use during a 10-day buprenorphine detoxification procedure. PMID:23855333
Sanders, Nichole C.; Mancino, Michael J.; Gentry, W. Brooks; Guise, J. Benjamin; Bickel, Warren K.; Thostenson, Jeff; Oliveto, Alison H.
Illicit use of methadone and buprenorphine among adolescents and young adults in Sweden
Background Illicit use of methadone and buprenorphine has been described as a growing problem in Sweden in recent years, and has been associated with an increased drug-related mortality. Critics claim that the substances have become popular among adolescents and that they function as a gateway to heroin use. The aim of this study is to investigate, firstly, the extent to which illicit use of methadone and buprenorphine occurs among adolescents and young adults in Sweden, and secondly, at what stage in a user's drug career these substances tend to appear. Methods The study is based on surveys and structured interviews on drug use among various populations of young people, in addition to qualitative interviews with 86 informants who, in their professional capacity, encounter adolescents or young adults who are using illicit drugs. Results Illicit use of methadone and buprenorphine is rare among young people in Sweden. According to high school surveys, less than 0.1% have tried these substances. Among young drug users in general, few have tried the substances, and there is nothing to indicate that they act as gateway drugs. Among adolescents and young adults with severe drug problems, however, the illicit use of methadone and buprenorphine is more common (54% in a compulsory care sample). These substances normally enter the drug career late, and few use them as their main drug of choice. Other prescription drugs, like benzodiazepines and tramadol, are used by adolescents to a far greater extent. Diversion and illicit use of methadone and buprenorphine is not seen as a serious problem by the professionals interviewed. A general view is that the substances are mainly used by people with a heroin or polydrug addiction, often for "self-medication" purposes. However, several informants express concern that methadone and buprenorphine may cause fatalities among young drug users without an opioid tolerance. Conclusions Illicit use of methadone and buprenorphine among young drug users is not a widespread problem in Sweden. Harm-reduction measures should target drug users with more severe problems, among whom illicit use of methadone and buprenorphine is more common and pose a medical risk. Illicit use of other prescription drugs, which are less controlled and more widely used by young people, is an important issue for further research. PMID:24139199
The reinforcing and subjective effects of intravenous and intranasal buprenorphine in heroin users.
Abuse of buprenorphine (BUP) by the intravenous (IV) route has been documented in several studies, and reports of intranasal (IN) abuse are increasing. However, no studies have directly compared the effects of BUP when it is administered intranasally and intravenously. The present secondary analysis used data from two separate studies to compare the reinforcing and subjective effects of IV and IN buprenorphine. One study evaluated IV buprenorphine (N=13) and the other evaluated IN buprenorphine (N=12). Participants were maintained on 2 mg sublingual (SL) BUP and tested with each intranasal or intravenous buprenorphine test dose (0 mg, 2 mg, 4 mg, 8 mg, and 16 mg). During morning laboratory sessions, participants received money (US $20) and sample doses of IN or IV BUP, and then completed subjective effects questionnaires. Later that day, they completed a self-administration task to receive 10% portions of the drug and/or money they previously sampled. In general, positive subjective ratings for both IV and IN BUP were significantly greater than placebo, with IV BUP having a greater effect than IN BUP. All active BUP doses (IV and IN) maintained significantly higher progressive ratio breakpoint values than placebo, but breakpoint values for IV BUP were greater than for IN BUP. Buprenorphine is an effective maintenance treatment for opioid dependence, valued for its ability to reduce the positive subjective effects of other opioids. Nevertheless, the present data demonstrate that in participants maintained on a low dose of SL BUP, the medication itself has abuse liability when used intravenously or intranasally. PMID:24793093
Jones, Jermaine D; Madera, Gabriela; Comer, Sandra D
Interaction of buprenorphine and its metabolite norbuprenorphine with cytochromes p450 in vitro.
Buprenorphine is a thebaine derivative used in the treatment of heroin and other opiate addictions. In this study, the selective probe reactions for each of the major hepatic cytochromes P450 (P450s) were used to evaluate the effect of buprenorphine and its main metabolite norbuprenorphine on the activity of these P450s. The index reactions used were CYP1A2 (phenacetin O-deethylation), CYP2A6 (coumarin 7-hydroxylation), CYP2C9 (diclofenac 4'-hydroxylation), CYP2C19 (omeprazole 5-hydrxoylation), CYP2D6 (dextromethorphan O-demethylation), CYP2B6 (7-ethoxy-4-trifluoromethyl-coumarin 7-deethylation), CYP2E1 (chlorzoxazone 6-hydroxylation), and CYP3A4 (omeprazole sulfoxidation). Buprenorphine exhibited potent, competitive inhibition of CYP2D6 (Ki 10 +/- 2 microM and 1.8 +/- 0.2 microM) and CYP3A4 (Ki 40 +/- 1.6 microM and 19 +/- 1.2 microM) in microsomes from human liver and cDNA-expressing lymphoblasts, respectively. Compared with buprenorphine, norbuprenorphine demonstrated a lower inhibitory potency with CYP2D6 (22.4% inhibition at 20 microM norbuprenorphine) and CYP3A4 (13.6% inhibition at 20 microM) in microsomes from human cDNA-expressing lymphoblast cells. Furthermore, buprenorphine was shown to be a substrate of CYP2D6 (Km = 600 microM; Vmax = 0.40 nmol/min/mg protein) and CYP3A4 (Km = 36 microM; Vmax = 0.19 nmol/min/mg protein). The present in vitro study suggests that buprenorphine and its major metabolite norbuprenorphine are inhibitors of CYP2D6 and CYP3A4; however, at therapeutic concentrations they are not predicted to cause potentially clinically important drug interactions with other drugs metabolized by major hepatic P450s. PMID:12756210
Zhang, Wenjiang; Ramamoorthy, Yamini; Tyndale, Rachel F; Sellers, Edward M
Standardizing treatment: a crisis in cancer care.
The Institute of Medicine has emphasized the roles of multidisciplinary treatment planning, evidence-based clinical practice guidelines, and regionalization of healthcare in optimizing the quality of cancer care. We discuss these critical elements as they pertain to head and neck cancer care. PMID:23910477
Lewis, Carol M; Weber, Randal S
Care and Treatment for Congenital Heart Defects
... can also learn about: Surgical procedures Cardiac catheterizations Heart transplants Preparing children for surgery Feeding Tips Children's special ... Symptoms & Diagnosis • Care & Treatment Introduction Surgery Cardiac ... Transplants Preparing Children for Surgery - Feeding Tips - Children's Special ...
Postcastration analgesia in ponies using buprenorphine hydrochloride.
Buprenorphine has recently obtained UK Marketing Authorisation for horses. The analgesic effects are long lasting, and have considerable potential for postoperative pain relief. This observer blinded, randomised study aimed to evaluate postsurgical analgesia in ponies premedicated with buprenorphine prior to castration under intravenous anaesthesia. Ponies received either 0.01 mg/kg bodyweight (BW) buprenorphine (group B) or an equivalent volume of 5 per cent glucose (group C) given intravenously before induction of anaesthesia. Pain was assessed and recorded using dynamic interactive visual analogue scores (DIVAS 0-100) and a Simple Descriptive Scale (SDS 0-3) (high scores=most pain) before and 1, 3, 6, 9, 12 and 24 hours after anaesthesia. Rescue analgesia was given if DIVAS>40 mm. Data were analysed using the Mann-Whitney U test at P<0.05. Median (range) areas under the curve for DIVAS were 63 (0-383) mm hour in group B and 209 (0-391) mm hour in group C (P=0.0348). The SDS was lower in group B than in group C (P=0.038). Three group B and five group C animals required rescue analgesia. Buprenorphine did not produce any serious adverse effects. Buprenorphine at 0.01 mg/kg BW intravenously administered before anaesthesia provided near-comprehensive postoperative analgesia after surgical castration in ponies. PMID:23736517
Love, E J; Taylor, P M; Whay, H R; Murrell, J
Medication-assisted treatment for opioid dependence is safe and effective, yet negative perceptions about methadone and buprenorphine may discourage patients from entering treatment. One source of information that may influence viewers' perceptions is television. We performed a content analysis of a popular reality television program on addiction treatment. Although many patients had histories of opioid use, there were no positive messages about methadone or buprenorphine. The two main messages were that they (1) are primarily drugs of abuse, and (2) not acceptable treatment options. These messages reinforce negative stereotypes and may perpetuate stigma. There were multiple missed opportunities to provide evidence-based information. PMID:22587811
Roose, Robert; Fuentes, Liza; Cheema, Mandeep
A comparison of buprenorphine taper outcomes between prescription opioid and heroin users
Objectives Dependence on prescription opioids (PO) is a growing problem. Although most research with buprenorphine has focused on heroin dependent populations, we hypothesize that individuals dependent on prescription opioids (PO) display characteristics that may predict different outcomes in treatment, particularly in short-term taper procedures in which comorbidities such as pain conditions may complicate taper. Methods This secondary data analysis examined differences in outcomes between PO users (n = 90) and heroin users (n = 426) following a buprenorphine taper. Data were collected in a multisite randomized clinical trial conducted by the National Drug Abuse Treatment Clinical Trials Network at 11 study sites across the United States. After a 4-week buprenorphine induction/stabilization phase, 516 opioid-dependent individuals were randomized into one of two taper lengths (7 vs. 28 days) to assess the association between taper length and outcome. The primary outcome was measured by urine drug test for opioids at the end of the taper period. Craving, withdrawal, and buprenorphine dose were also examined. Results After controlling for baseline demographic and drug use differences between the opioid use groups, results indicate that a higher percentage of the PO group (49%) provided an opioid free urine drug specimen at the end of taper compared to the heroin group (36%; ?2 (1) = 6.592, p < .010). Conclusion Short term taper is not recommended as a stand-alone treatment, however patients may taper from buprenorphine as part of a treatment plan. Despite greater co-morbidity, PO users appear to have favorable taper outcomes compared to heroin users. Further studies are required to examine longer term treatment outcomes. PMID:23222095
Nielsen, S; Hillhouse, M; Thomas, C; Hasson, A; Ling, W
Comparison of the Efficacy of Buprenorphine and Clonidine in Detoxification of Opioid-Dependents
Background Since the number of drug users is increasing, applying a method of detoxification with fewer side effects during withdrawal from opioids and greater reliability seems to be necessary. In addition, without maintenance treatment, there will be limited success of treatment. This study aimed to compare success rates of detoxification with sublingual buprenorphine and clonidine and to evaluate addiction relapse in patients using naltrexone in a six-month follow-up. Methods This double-blind trial was carried out on opioid dependent patients in a psychiatric hospital in Kerman (Iran) during 2007-09. The subjects were randomly selected from individuals who had referred for detoxification. They were allocated to two groups to receive either clonidine (n = 21) or buprenorphine (n = 14). The success rates of the two methods were assessed at the end of the course and patients were discharged while prescribed with 25 mg daily use of naltrexone. They were followed up for six months and the continuous use of naltrexone and relapse of substance abuse were evaluated. Findings A total number of 35 patients entered the study. Success of detoxification with naltrexone was confirmed in all cases. One person (8.4%) in the clonidine group and no patient in the buprenorphine group had a clinical opiate withdrawal scale (COWS) score of more than 12 (P > 0.05). The mean levels of objective signs and subjective symptoms of withdrawal and the desire for drug abuse had significant reductions during detoxification period in both groups (P < 0.001). However, the difference in these variables between the two groups was not statistically significant (P > 0.05). Naltrexone was used for an average of one month in 43% and 64% of subjects in the clonidine and buprenorphine groups, respectively. In addition, 62% of patients in the clonidine group and 92.8% of subjects in the buprenorphine group received maintenance treatment. Nevertheless, the mean number of days staying in treatment was not significantly difference between the two groups (P > 0.05). Conclusion Buprenorphine is as effective as clonidine in controlling withdrawal symptoms. A greater percentage of patients detoxified by buprenorphine received maintenance treatment, but there was not a significant difference in relapse rates between the two methods. PMID:24494140
Ziaaddini, Hassan; Nasirian, Mansooreh; Nakhaee, Nouzar
Coordinating care and treatment for cancer patients.
Survival following a diagnosis of cancer is contingent upon an interplay of factors, some non-modifiable (e.g., age, sex, genetics) and some modifiable (e.g., volitional choices) but the majority determined by circumstance (personal, social, health system context and capacity, and health policy). Accordingly, mortality and survival rates vary considerably as a function of geography, opportunity, wealth and development. Quality of life is impacted similarly, such that aspects of care related to coordination and integration of care across primary, community and specialist environments; symptom control, palliative and end-of-life care for those who will die of cancer; and survivorship challenges for those who will survive cancer, differs greatly across low, middle and high-income resource settings. Session 3 of the 4th International Cancer Control Congress (ICCC-4) focused on cancer care and treatment through three plenary presentations and five interactive workshop discussions: 1) establishing, implementing, operating and sustaining the capacity for quality cancer care; 2) the role of primary, community, and specialist care in cancer care and treatment; 3) the economics of affordable and sustainable cancer care; 4) issues around symptom control, support, and palliative/end-of-life care; and 5) issues around survivorship. A number of recommendations were proposed relating to capacity-building (standards and guidelines, protocols, new technologies and training and deployment) for safe, appropriate evidence-informed care; mapping and analysis of variations in primary, community and specialist care across countries with identification of models for effective, integrated clinical practice; the importance of considering the introduction, or expansion, of evidence-supported clinical practices from the perspectives of health economic impact, the value for health resources expended, and sustainability; capacity-building for palliative, end-of-life care and symptom control and integration of these services into national cancer control plans; the need for public education to reduce the fear and stigma associated with cancer so that patients are better able to make informed decisions regarding follow-up care and treatment; and the need to recognize the challenges and needs of survivors, their increasing number, the necessity to integrate survivorship into cancer control plans and the economic and societal value of functional survival after cancer. Discussions highlighted that coordinated care and treatment for cancer patients is both a ' systems'challenge and solution, requiring the consideration of patient and family circumstances, societal values and priorities, the functioning of the health system (access, capacity, resources, etc.) and the importance assigned to health and illness management within public policy. PMID:22631594
Yip, Cheng Har; Samiei, Massoud; Cazap, Eduardo; Rosenblatt, Eduardo; Datta, Niloy Ranjan; Camacho, Rolando; Weller, David; Pannarunothai, Supasit; Goh, Cynthia; Black, Fraser; Kaur, Ranjit; Fitch, Margaret; Sutcliffe, Catherine; Sutcliffe, Simon
Management of opioid addiction with buprenorphine: French history and current management.
The way in which opioid addiction is managed in France is unique, as it is based on the prescription of buprenorphine by general practitioners and is dispensed by retail pharmacies. This policy has had a direct, positive impact on the number of deaths caused by heroin overdose, which was reduced by four-fifths between 1994 and 2002. In addition, certain associated comorbidities, such as infection with the human immunodeficiency virus, have also been reduced; the incidence of acquired immune deficiency syndrome in intravenous drug users fell from 25% in the mid-1990s to 6% in 2010. Since the implementation of this French model of opioid management, major scientific progress has been made, leading to a better understanding of the pathophysiologic mechanisms of addiction and of the management modalities required for its treatment. However, despite notable advances in scientific knowledge and in the implementation of devices, opioid addiction remains a major public health care issue in France, with 275,000-360,000 "problem drug users" being reported in 2011. The situation is still particularly worrying due to psychoactive substance use and misuse of opioid substitution treatments. Since 2003, there has been a persistent increase in the number of deaths and comorbidities related to opioid addiction, principally hepatitis C virus infection, which affects up to 40% of intravenous drug users. In France, the direct involvement of general practitioners in the management of opioid addiction is indisputable. Nevertheless, management could be optimized through better understanding of the pathophysiologic mechanisms of the disease, better knowledge of the pharmacology of opioid substitution treatments, and clear definition of short-, medium- and long-term treatment objectives. Data related to the management of opioid addiction by general practitioners in France have been published in 2005. Since then, the context has changed, other drugs were launched on the market such as generics of buprenorphine, methadone capsule, and Suboxone. Thus, an update seems necessary. This paper provides a description of opioid addiction management objectives and treatment modalities for general practitioners, based on currently available knowledge. PMID:24623988
Poloméni, Pierre; Schwan, Raymund
Tobacco use disorder treatment in primary care
Abstract Objective To test a team-based, site-specific, multicomponent clinical system pathway designed for enhancing tobacco use disorder treatment by primary care physicians. Design A prospective cohort study. Setting Sixty primary care sites in Alberta. Participants A convenience sample of 198 primary care physicians from the population of 2857. Main outcome measures Data collection occurred between September 2010 and February 2012 on 3 distinct measures. Twenty-four weeks after the intervention, audits of the primary care practices assessed the adoption and sustainability of 10 tobacco clinical system pathway components, a survey measured changes in physicians' treatment intentions, and patient chart reviews examined changes in physicians' consistency with the treatment algorithm. Results The completion rate by physicians was 89.4%. An intention-to-treat approach was undertaken for statistical analysis. Intervention uptake was demonstrated by positive changes at 4 weeks in how many of the 10 clinical system measures were performed (mean [SD] = 4.22 [1.60] vs 8.57 [1.46]; P < .001). Physicians demonstrated significant favourable changes in 9 of the 12 measures of treatment intention (P < .05). The 18 282 chart reviews documented significant increases in 6 of the 8 algorithm components. Conclusion Our findings suggest that the provision of a tobacco clinical system pathway that incorporates other members of the health care team and builds on existing office infrastructures will support positive and sustainable changes in tobacco use disorder treatment by physicians in primary care. This study reaffirms the substantive and important role of supporting how treatment is delivered in physicians' practices. PMID:25022640
Kunyk, Diane; Els, Charl; Papadakis, Sophia; Selby, Peter
Late Effects of Treatment and Palliative Care
\\u000a Identifying late effects of treatment and integrating palliative care when appropriate, are increasingly recognized as important\\u000a elements of childhood tumor management. Patients with CNS tumors are at high risk for mortality, and survivors have high morbidity\\u000a rates related to the late effects of treatment. While intensified therapy has improved survival in patients with pediatric\\u000a brain tumors (Packer et al. 1999,
Denah Taggart; Robert Goldsby; Anuradha Banerjee
Treatment preferences among depressed primary care patients
OBJECTIVE: To understand patient factors that may affect the probability of receiving appropriate depression treatment, we examined\\u000a treatment preferences and their predictors among depressed primary care patients.\\u000a \\u000a \\u000a DESIGN: Patient questionnaires and interviews.\\u000a \\u000a \\u000a \\u000a \\u000a SETTING: Forty-six primary care clinics in 7 geographic regions of the United States.\\u000a \\u000a \\u000a \\u000a \\u000a PARTICIPANTS: One thousand one hundred eighty-seven English-and Spanish-speaking primary care patients with current depressive symptoms.
Megan Dwight-Johnson; Cathy D. Sherbourne; Diana Liao; Kenneth B. Wells
In recent years, interest in shortening of opioid detoxification has increased with the rising demands to find more cost-effective approaches for treatment of opioid dependence. This study was designed to evaluate the efficacy of administration of high doses of buprenorphine during 24 h in the management of acute opioid withdrawal. A total of 40 treatment-seeking opioid dependents were admitted and
Seyed Mohammad Assadi; Mohsen Hafezi; Azarakhsh Mokri; Emran Mohammad Razzaghi; Padideh Ghaeli
Children of Cocaine: Treatment and Child Care.
ERIC Educational Resources Information Center
Information concerning the treatment and care of children addicted to cocaine is provided. Contents: (1) describe the drug; (2) put cocaine use in its historical and demographic perspectives; (3) report findings of a study documenting the incidence of maternal substance abuse in Pinellas County, Florida; (4) point out false perceptions,…
Howze, Kate; Howze, Wendell M.
Despite the increasing use of rabbits as companion animals and models for biomedical research, rabbits have not been extensively studied to identify an efficacious postsurgical analgesic that does not cause systemic complications. The synergy of NSAID and systemic opioids is well-documented, and their combined use reduces the amount of either drug required for adequate analgesia. We measured fecal corticosterone metabolites (FCM) in rabbits after a minimally invasive vascular cut-down procedure. Rabbits received buprenorphine (0.03 mg/kg SC every 12 h for 3 d), meloxicam (0.2 mg/kg SC every 24 h for 3 d), buprenorphine–meloxicam (0.01 mg/kg–0.1 mg/kg SC every 24 h for 3 d), or a single dose of 0.5% bupivacaine (0.5 mL) infused locally at the incision site. By day 3 after surgery, buprenorphine, meloxicam, and bupivacaine groups showed elevated FCM levels, which continued to rise until day 7 and then gradually returned to baseline by day 28. In the buprenorphine–meloxicam group, FCM was relatively unchanged until day 3, when treatment was discontinued, and then began to rise. Rabbits in the buprenorphine–meloxicam group gained more weight over the 28-d study than did those in the other 3 treatment groups. This study shows that in rabbits low-dose buprenorphine administered with meloxicam effectively mitigates the FCM response that develops after surgery without the adverse effects associated with higher doses. PMID:24041213
Goldschlager, Gregg B; Gillespie, Virginia L; Palme, Rupert; Baxter, Mark G
Despite the increasing use of rabbits as companion animals and models for biomedical research, rabbits have not been extensively studied to identify an efficacious postsurgical analgesic that does not cause systemic complications. The synergy of NSAID and systemic opioids is well-documented, and their combined use reduces the amount of either drug required for adequate analgesia. We measured fecal corticosterone metabolites (FCM) in rabbits after a minimally invasive vascular cut-down procedure. Rabbits received buprenorphine (0.03 mg/kg SC every 12 h for 3 d), meloxicam (0.2 mg/kg SC every 24 h for 3 d), buprenorphine-meloxicam (0.01 mg/kg-0.1 mg/kg SC every 24 h for 3 d), or a single dose of 0.5% bupivacaine (0.5 mL) infused locally at the incision site. By day 3 after surgery, buprenorphine, meloxicam, and bupivacaine groups showed elevated FCM levels, which continued to rise until day 7 and then gradually returned to baseline by day 28. In the buprenorphine-meloxicam group, FCM was relatively unchanged until day 3, when treatment was discontinued, and then began to rise. Rabbits in the buprenorphine-meloxicam group gained more weight over the 28-d study than did those in the other 3 treatment groups. This study shows that in rabbits low-dose buprenorphine administered with meloxicam effectively mitigates the FCM response that develops after surgery without the adverse effects associated with higher doses. PMID:24041213
Goldschlager, Gregg B; Gillespie, Virginia L; Palme, Rupert; Baxter, Mark G
Gender and care: access to HIV testing, care, and treatment.
HIV transmission and occurrence of AIDS in the Middle East and North Africa region (MENA) is increasing, while access to ART in the region lags behind most low to middle-income countries. Like in other parts of the world, there is a growing feminization of the epidemic, and men and women each confront unique barriers to adequate HIV prevention and treatment services, while sharing some common obstacles as well. This paper focuses on important gender dimensions of access to HIV testing, care and treatment in the MENA region, including issues related to stigma, religion and morality, gender power imbalances, work status, and migration. Culturally specific policy and programmatic recommendations for improving HIV prevention and treatment in the MENA region are offered. PMID:19553777
Remien, Robert H; Chowdhury, Jenifar; Mokhbat, Jacques E; Soliman, Cherif; Adawy, Maha El; El-Sadr, Wafaa
This small series of case reports illustrates a significantly faster and well tolerated method for a relatively rapid detoxification from high-dose methadone as compared to traditional methadone detoxification regimens. After inducing a withdrawal state using oral naltrexone, the patients were quickly "rescued" with buprenorphine (a combination of buprenorphine/naloxone). By administering a medication that attenuates withdrawal symptoms, patients immediately began to feel better and were better able to invest themselves in the overall treatment. The patients were then able to taper off opioids in a matter of days with minimal discomfort. The average length of stay was seven days, and no patients left before completing the program. PMID:19727311
Urban, Vanessa; Sullivan, Rolly
Concurrent use of cocaine and heroin is a major public health issue with no effective relapse prevention treatment currently available. To this purpose, a combination of buprenorphine and naltrexone, a mixed very-low efficacy mu-opioid receptor agonist/kappa-opioid receptor antagonist/nociceptin receptor agonist, was investigated. The tail-withdrawal and the conditioned place preference (CPP) assays in adult Sprague Dawley rats were used to show that naltrexone dose-dependently blocked the mu-opioid receptor agonism of buprenorphine. Furthermore, in the CPP assay, a combination of 0.3?mg/kg buprenorphine and 3.0?mg/kg naltrexone was aversive. A combination of 0.3?mg/kg buprenorphine and 1.0?mg/kg naltrexone was neither rewarding nor aversive, but still possessed mu-opioid receptor antagonist properties. In the CPP extinction and reinstatement method, a combination of 0.3?mg/kg buprenorphine and 1.0?mg/kg naltrexone completely blocked drug-primed reinstatement in cocaine-conditioned rats (conditioned with 3?mg/kg cocaine, drug prime was 3?mg/kg cocaine) and attenuated drug-primed reinstatement in morphine-conditioned rats (conditioned with 5?mg/kg morphine, drug prime was 1.25?mg/kg morphine). These data add to the growing evidence that a buprenorphine/naltrexone combination may be protective against relapse in a polydrug abuse situation. PMID:23240906
Cordery, Sarah F; Taverner, Alistair; Ridzwan, Irna E; Guy, Richard H; Delgado-Charro, M Begońa; Husbands, Stephen M; Bailey, Christopher P
[Severe distal ischemic syndrome after buprenorphine volunteer intra-arterial injection].
High dosage buprenorphine (HDB) is a sublingual maintenance treatment of opioid dependence which have proved its substantial Public Health results, but it is also known to be frequently abused and diverted, in particular for intravenous injection, with deleterious consequences. Intra-arterial use is more rarely reported with this substance, just like its complications, mainly ischemic, potentially necrotic, phenomena. We report here such a case, with a 30 years-old man suffering from severe ischemia of the thumb, the forefinger and the middle finger few hours after direct injection of a suspension of buprenorphine crushed tablets in right radial arteria. A treatment combining surgery (video-thoracoscopic thoracic sympathectomy) and medicines (heparin, iloprost and piribedil mesilate), permitted a semi-complete digital rehabilitation (only forefinger pulp necrosis persisted and required a distal amputation), and the patient was discharged after 2 weeks. PMID:22186079
Glaizal, Mathieu; Lucciardi, Joseph; Tichadou, Lucia; Spadari, Michel; Hayek-Lanthois, Maryvonne; Micallef, Joëlle; de Haro, Luc
The experimental use of amphibian models in biomedical research increases yearly, but there is a paucity of reports concerning analgesic use in many of these species. In this study, buprenorphine given by intracoelomic injection and butorphanol added to the tank water were compared for analgesic effect in the eastern red-spotted newt after bilateral forelimb amputations. Newts undergoing anesthesia but not surgery and newts having surgery but not given analgesia postoperatively were used as control groups. Animals were tested for food consumption, spontaneous movement, response to tapping on the tank, response to being touched, and body posture. Both buprenorphine by intracoelomic injection and butorphanol in tank water significantly promoted resumption of normal behavior after bilateral surgical amputation of the forelimbs. The difference between analgesic treatment and no analgesic treatment was maintained until 72 h after surgery. PMID:19383214
Here is reported an unusual case of substance dependence with buprenorphine, mephentermine, & promethazine. This combination taken through intramuscular route produced a relatively mild & delayed abstinence syndrome with features viz. increased sleep and appetite in the patients. The neurophysiological basis for use of this rare form of additive (mephentermine) with buprenorphine is speculated. PMID:21455380
Mendhekar, D.N.; Sharma, Himanshu; Dali, J.S.
Changing roles and responses of health care workers in HIV treatment and care.
A key limiting factor in the scale up and sustainability of HIV care and treatment programmes is the global shortage of trained health care workers. This paper discusses why it is important to move beyond conceptualising health care workers simply as 'inputs' in the delivery of HIV treatment and care, and to also consider their roles as partners and agents in the process of health care. It suggests a framework for thinking about their roles and responses in HIV care, considers the current evidence base, and concludes by identifying key areas for future research on health care workers' responses in HIV treatment and care in low and middle income settings. PMID:19055620
Rajaraman, Divya; Palmer, Natasha
Depression Treatment Preferences in Older Primary Care Patients
Purpose: For depressed older primary care patients, this study aimed to examine (a) characteristics associated with depression treatment preferences; (b) predictors of receiving preferred treatment; and (c) whether receiving preferred treatment predicted satisfaction and depression outcomes. Design and Methods: Data are from 1,602 depressed older primary care patients who participated in a multisite, randomized clinical trial comparing usual care to
Amber M. Gum; Patricia A. Arean; Enid Hunkeler; Lingqi Tang; Wayne Katon; Polly Hitchcock
Background The idea that the impact of opioid agonist treatment is influenced by the psychopathological profile of heroin addicts has not yet been investigated, and is based on the concept of a specific therapeutic action displayed by opioid agents on psychopathological symptoms. In the present report we compared the effects of buprenorphine and methadone on the psychopathological symptoms of 213 patients (106 on buprenorphine and 107 on methadone) in a follow-up study lasting 12 months. Methods Drug addiction history was collected by means of the Drug Addiction History Rating Scale (DAH-RS) and psychopathological features were collected by means of the Symptom Checklist-90 (SCL-90), using a special five-factor solution. Toxicological urinalyses were carried out for each patient during the treatment period. Results No statistically significant differences were detected in psychopathological symptoms, including 'worthlessness-being trapped', 'somatization', and 'panic-anxiety'. Methadone proved to be more effective on patients characterized by 'sensitivity-psychoticism', whereas buprenorphine was more effective on patients displaying a 'violence-suicide' symptomatology. Conclusions Heroin-dependent patients with psychiatric comorbidities may benefit from opioid agonist treatment not only because it targets their addictive problem, but also, precisely due to this, because it is effective against their mental disorder too. PMID:21569624
Cocaine Use Reduction with Buprenorphine (CURB): Rationale, design, and methodology?
Background Effective medications to treat cocaine dependence have not been identified. Recent pharmacotherapy trials demonstrate the potential efficacy of buprenorphine (BUP) (alone or with naltrexone) for reducing cocaine use. The National Institute on Drug Abuse Clinical Trials Network (CTN) launched the Cocaine Use Reduction with Buprenorphine (CURB) investigation to examine the safety and efficacy of sublingual BUP (as Suboxone®) in the presence of extended-release injectable naltrexone (XR-NTX, as Vivitrol®) for the treatment of cocaine dependence. This paper describes the design and rationale for this study. Methods This multi-site, double-blind, placebo-controlled study will randomize 300 participants across 11 sites. Participants must meet the DSM-IV criteria for cocaine dependence and past or current opioid dependence or abuse. Participants are inducted onto XR-NTX after self-reporting at least 7 days of abstinence from opioids and tolerating a naloxone challenge followed by oral naltrexone and are then randomly assigned to one of three medication conditions (4 mg BUP, 16 mg BUP, or placebo) for 8 weeks. Participants receive a second injection of XR-NTX 4 weeks after the initial injection, and follow-up visits are scheduled at 1 and 3 months post-treatment. Participants receive weekly cognitive behavioral therapy (CBT). Recruitment commenced in September, 2011. Enrollment, active medication, and follow-up phases are ongoing, and recruitment is exceeding targeted enrollment rates. Conclusions This research using 2 medications will demonstrate whether BUP, administered in the presence of XR-NTX, reduces cocaine use in adults with cocaine dependence and opioid use disorders and will demonstrate if XR-NTX prevents development of physiologic dependence on BUP. PMID:23159524
Mooney, Larissa J.; Nielsen, Suzanne; Saxon, Andrew; Hillhouse, Maureen; Thomas, Christie; Hasson, Albert; Stablein, Don; McCormack, Jennifer; Lindblad, Robert; Ling, Walter
The treatment gap in mental health care.
Mental disorders are highly prevalent and cause considerable suffering and disease burden. To compound this public health problem, many individuals with psychiatric disorders remain untreated although effective treatments exist. We examine the extent of this treatment gap. We reviewed community-based psychiatric epidemiology studies that used standardized diagnostic instruments and included data on the percentage of individuals receiving care for schizophrenia and other non-affective psychotic disorders, major depression, dysthymia, bipolar disorder, generalized anxiety disorder (GAD), panic disorder, obsessive-compulsive disorder (OCD), and alcohol abuse or dependence. The median rates of untreated cases of these disorders were calculated across the studies. Examples of the estimation of the treatment gap for WHO regions are also presented. Thirty-seven studies had information on service utilization. The median treatment gap for schizophrenia, including other non-affective psychosis, was 32.2%. For other disorders the gap was: depression, 56.3%; dysthymia, 56.0%; bipolar disorder, 50.2%; panic disorder, 55.9%; GAD, 57.5%; and OCD, 57.3%. Alcohol abuse and dependence had the widest treatment gap at 78.1%. The treatment gap for mental disorders is universally large, though it varies across regions. It is likely that the gap reported here is an underestimate due to the unavailability of community-based data from developing countries where services are scarcer. To address this major public health challenge, WHO has adopted in 2002 a global action programme that has been endorsed by the Member States. PMID:15640922
Kohn, Robert; Saxena, Shekhar; Levav, Itzhak; Saraceno, Benedetto
Change in symptoms of erectile dysfunction in depressed men initiating buprenorphine therapy?
Aims The aim of this study is to describe the change in erectile dysfunction (ED) symptoms in the first 12 weeks of outpatient buprenorphine therapy. Background Erectile dysfunction is highly prevalent in men who use illicit opioids when compared with the general population. To date, no study has examined ED symptoms over time in men initiating buprenorphine therapy for opioid dependence. Methods A randomized, double blind, placebo-controlled trial was conducted to determine whether escitalopram treatment of depressive symptoms begun 1 week prior to buprenorphine induction would improve treatment retention. Male patients completed the International Index of Erectile Function scale at baseline prior to induction and monthly thereafter. A score of 25 or less on the erectile function domain (range 1–30) is considered indicative of erectile dysfunction. Findings A total of 111 male subjects enrolled: mean age 38.5 (± 9.7) years, 80.1% non-Hispanic Caucasian; 67.3% reported heroin as their opioid of choice. Mean IIEF at baseline was 20.4 (± 10.5). At baseline, 44.1% of the entire cohort had erectile dysfunction; among those who identified as sexually active at baseline, 26.1% had ED. Baseline erectile function was inversely and significantly correlated with age (r = ?.27, p = .006), but was not associated significantly with race, heroin use, years of opioid use, smoking, or hazardous use of alcohol. Compared to baseline, mean erectile function was significantly improved (p = .001) at 3 months, and sexual desire (p = .002) improved significantly at both 2- and 3-month assessments. Conclusion Erectile dysfunction is highly prevalent in depressed males using illicit opioids. Men who remain in buprenorphine treatment for 3 months show improvement in erectile function and sexual desire. PMID:23891461
Cioe, Patricia A.; Anderson, Bradley J.; Stein, Michael D.
IMPORTANCE Although abuse of prescription opioids (POs) is a significant public health problem, few experimental studies have investigated the treatment needs of this growing population. OBJECTIVE To evaluate, following brief stabilization with a combination of buprenorphine hydrochloride and naloxone hydrochloride dihydrate, the relative efficacy of 1-, 2-, and 4-week buprenorphine tapering regimens and subsequent naltrexone hydrochloride therapy in PO-dependent outpatients. DESIGN, SETTING, AND PARTICIPANTS A double-blind, 12-week randomized clinical trial was conducted in an outpatient research clinic. Following a brief period of buprenorphine stabilization, 70 PO-dependent adults were randomized to receive 1-, 2-, or 4-week tapers followed by naltrexone therapy. INTERVENTION During phase 1 (weeks 1–5 after randomization), participants visited the clinic daily; during phase 2 (weeks 6–12), visits were reduced to thrice weekly. Participants received behavioral therapy and urine toxicology testing throughout the trial. MAIN OUTCOMES AND MEASURES The percentage of participants negative for illicit opioid use, retention, naltrexone ingestion, and favorable treatment response (ie, retained in treatment, opioid abstinent, and receiving naltrexone at the end of the study). RESULTS Opioid abstinence at the end of phase 1 was greater in the 4-week compared with the 2- and 1-week taper conditions (P = .02), with 63% (n = 14), 29% (n = 7), and 29% (n = 7) of participants abstinent in the 4-, 2-, and 1-week conditions, respectively. Abstinence at the end of phase 2 was also greater in the 4-week compared with the 2- and 1-week conditions (P = .03), with 50% (n = 11), 16% (n = 4), and 20% (n = 5) of participants abstinent in the 4-, 2-, and 1-week conditions, respectively. There were more treatment responders in the 4-week condition (P = .03), with 50% (n = 11), 17% (n = 4), and 21% (n = 5) of participants in the 4-, 2-, and 1-week groups considered responders at the end of treatment, respectively. Retention and naltrexone ingestion also were superior in the 4-week vs briefer tapers (both P = .04). Experimental condition (ie, taper duration) was the strongest predictor of treatment response, followed by buprenorphine stabilization dose. CONCLUSIONS AND RELEVANCE This study represents a rigorous experimental evaluation of outpatient buprenorphine stabilization, brief taper, and naltrexone maintenance for treatment of PO dependence. Results suggest that a meaningful subset of PO-dependent outpatients may respond positively to a 4-week taper plus naltrexone maintenance intervention. PMID:24153411
Sigmon, Stacey C.; Dunn, Kelly E.; Saulsgiver, Kathryn; Patrick, Mollie E.; Badger, Gary J.; Heil, Sarah H.; Brooklyn, John R.; Higgins, Stephen T.
Treatment and care of TB across Europe
There continues to be profound differences in TB incidences as well as in TB treatment and care across Europe in recent years. High TB incidences are observed in Eastern Europe and especially among injecting drug users (IDUs), and there are large overlaps with a HIV epidemic, which is also far from being under control in this region. Further, mortality rates among HIV-positive patients with TB in Eastern Europe were in the 2000s 3–5 fold higher compared with other parts of Europe. As of 2014, there remain many challenges in the organizational set-up of TB care in Eastern Europe and often only limited possibilities of support for the vulnerable IDU populations, including in particular opioid substitution therapy. Further, high prevalences of multi-drug-resistant TB (MR-TB) are an increasing problem in Eastern Europe which in several settings reached beyond 50% among patients previously treated for TB. Obviously, this causes problems for immediate therapy of the individual patients and for development of secondary resistance during therapy. The panel of TB drugs available in TB clinics in Eastern Europe is often limited, and a quick TB diagnosis and acknowledgement of the resistance pattern to guide initial therapy seems to be a priority. For HIV-positive patients in particular, better access to cART may also be an important tool to reduce the TB incidence among these patients. Thus, treatment and care of TB patients in especially Eastern Europe are facing a variety of diagnostic and therapeutic challenges in the coming years. PMID:25394012
Kirk, Ole
Effects of Buprenorphine, Meloxicam, and Flunixin Meglumine as Postoperative Analgesia in Mice
C57BL/6NCrl male mice (n = 60; age, 6 to 7 wk) underwent partial hepatectomy or no surgery and were given 1 of 3 analgesics pre- and postoperatively. Food and water consumption, body weight, running wheel activity, locomotor activity, and serum corticosterone concentrations were measured before and after surgery. Mice that were surgically manipulated weighed significantly less on days 1 through 3 after surgery than did mice not manipulated surgically. On the day of surgery, the surgery groups consumed significantly less feed (–1.5 ± 0.35 g) than did nonsurgery groups. There were no differences in water consumption on any day between surgery and nonsurgery groups or among the 3 analgesic groups. For running wheel activity, significant decreases in the surgery groups were seen at day 1 after surgery compared with baseline. Surgery groups that received buprenorphine and meloxicam returned to baseline activity levels on day 2 after surgery. Open-field testing revealed no significant differences in locomotor activity in any groups; however, posttreatment locomotor activity in the buprenorphine nonsurgery group was increased compared with baseline, and posttreatment locomotor activity in the flunixin meglumine surgery group was decreased compared with baseline. Serum corticosterone concentrations were within normal limits regardless of treatment in all groups. Comparison of the overall results indicated that meloxicam and buprenorphine, at the dose given, appear to be suitable postoperative analgesics for partial hepatectomy in mice. Flunixin meglumine at the given dosage (2.5 mg/kg) may not provide adequate analgesia for partial hepatectomy. PMID:21439211
Tubbs, Jacquelyn T; Kissling, Grace E; Travlos, Greg S; Goulding, David R; Clark, James A; King-Herbert, Angela P; Blankenship-Paris, Terry L
Summary Buprenorphine to.l, 0.2, 0.3 or 0.4 mg\\/kg) in a flavoured gelatin base was administered preoperatively to rats undergoing a flank laparotomy. A control group of animals underwent surgery and received only flavoured gelatin. Body weight loss was significantly greater in the group which received no analgesia than in any of the analgesic-treated groups (P < 0.01). Food consumption was
P. A. Flecknell; J. V. Roughan; R. Stewart
The pharmacological treatment of opioid addiction—a clinical perspective
This article reviews the main pharmacotherapies that are currently being used to treat opioid addiction. Treatments include\\u000a detoxification using tapered methadone, buprenorphine, adrenergic agonists such as clonidine and lofexidine, and forms of\\u000a rapid detoxification. In opioid maintenance treatment (OMT), methadone is most widely used. OMT with buprenorphine, buprenorphine-naloxone\\u000a combination, or other opioid agonists is also discussed. The use of the
Philipp Lobmaier; Michael Gossop; Helge Waal; Jorgen Bramness
A clinical trial of buprenorphine: Comparison with methadone in the detoxification of heroin addicts
The efficacy of buprenorphine and methadone was compared in the outpatient detoxification of heroin addicts. Forty-five patients were randomized to receive either sublingual buprenorphine or oral methadone under double-dummy and double-blind conditions to study the pharmacology of buprenorphine in a 90-day detoxification protocol. The patients were administered either 2 mg buprenorphine or 30 mg methadone for 3 weeks followed by
Warren K Bickel; Maxine L Stitzer; George E Bigelow; Ira A Liebson; Donald R Jasinski; Rolley E Johnson
Consumer Attitudes about Opioid Addiction Treatment: A focus group study in New York City
Objective To develop effective programs for people who are opioid-dependent and to impact the opioid epidemic in New York City, it is crucial that we monitor attitudes about opioid addiction treatments among opioid users who have experienced barriers to engagement and retention in addiction treatment. Design We conducted a qualitative study using focus groups. Methods We conducted six focus groups in three needle exchanges in New York City, which were audio recorded, transcribed, and systematically coded. We report on the main themes related to the study objectives. Participants Participants of each needle exchange who were opioid-dependent and had some knowledge of both methadone and buprenorphine were eligible. Results There were four main findings. Participants felt: (1) buprenorphine is an appropriate option only for those heroin users who are motivated to stop using; (2) they have less control over their addiction treatment with methadone than they would have with buprenorphine; (3) buprenorphine treatment is not accessible to many New York City residents who would benefit from this treatment; and (4) lack of access to buprenorphine treatment is the cause of treatment-related diversion. Conclusions Both methadone maintenance and buprenorphine treatment opportunities are necessary to address the diverse treatment needs of opioid-dependent people in New York City. However, the current medical model of buprenorphine treatment may be too restrictive for some opioid-dependent people, and may be contributing to the use of illicit buprenorphine. New models to deliver buprenorphine treatment may address these problems. PMID:23709320
Weiss, Linda; Egan, James E.; Lopez, Carolina; Favaro, Jamie; Cordero, Robert; Cunningham, Chinazo
ROAD TRAFFIC CRASHES AND PRESCRIBED METHADONE AND BUPRENORPHINE: A FRENCH REGISTRY-BASED CASE among patients under buprenorphine or methadone has not been subject to epidemiological investigation so traffic crash and the use of buprenorphine and methadone. Methods: Data from three French national
Boyer, Edmond
Buprenorphine is a frequently used opioid in the treatment of neuropathic pain component that is often present in patients with cancer. A case of a 41-year-old patient was depicted whose pain syndrome was associated with the chondrosarcoma growth originating from the sacral bone and numerous surgical interventions and radiotherapy. Improvement in analgesia and good toleration of therapy were observed after switching from transdermal fentanyl to transdermal buprenorphine while maintaining treatment with antidepressants and anticonvulsants. This case report indicates a possibility of a safe switch of transdermal opioids at home, which may provide benefits in terms of analgesia and adverse effects and in consequence have positive impact on the patients' quality of life. This is also accompanied by constant psychological, social, and spiritual support provided to the patient and family. PMID:23349342
Leppert, Wojciech
The abuse of smoked cocaine base, also known as 'crack', continues to be a major public health problem and to date the success of pharmacological or behavioral interventions has been limited. The purpose of this study was to evaluate the efficacy of a behavioral (alternative reinforcer-saccharin) and pharmacological (0.01 mg\\/kg buprenorphine) treatment alone and in combination. Five adult male rhesus
Joshua S. Rodefer; Adande J. Mattox; Sherry S. Thompson; Marilyn E. Carroll
The simultaneous i.v. administration of heroin and cocaine, called a 'speedball,' is often reported clinically, and identification of effective pharmacotherapies is a continuing challenge. We hypothesized that treatment with combinations of a monoamine releaser d-amphetamine, and a mu partial agonist, buprenorphine, might reduce speedball self-administration by rhesus monkeys. Speedballs (0.01 mg\\/kg\\/inj cocaine+0.0032 mg\\/kg\\/inj heroin) and food (1 g banana-flavored pellets)
Nancy K Mello; S Stevens Negus
Race, Managed Care, And The Quality Of Substance Abuse Treatment
The adoption of managed behavioral health care by state Medicaid agencies has the potential to increase the quality of treatment for racial minorities by promoting access to substance abuse treatment and creating more appropriate utilization patterns. This paper examines three indicators of quality for white, Black, and Hispanic Medicaid clients who received substance abuse treatment in Massachusetts between 1992 and
Marilyn C. Daley; Grant A. Ritter; Dominic Hodgkin; Richard H. Beinecke
Offers of hepatitis C care do not lead to treatment.
Since 2002, clinicians have been encouraged to offer chronic hepatitis C virus (HCV) treatment to patients with injection drug use histories. We conducted 69 baseline and 35 follow-up interviews between September 2002 and November 2004 with HCV patients who were treatment-naďve and receiving regular medical care at an HIV or methadone clinic in New York City at baseline. Of the 31 patients reinterviewed, 20 (65%) were offered treatment but only 2 (7%) were treated. Reasons for failure to be reinterviewed were loss to follow-up at the original site of care (30), death (6), and refusal to be reinterviewed (2). Whereas offers of HCV treatment may be increasing, there is a need to improve continuity of care, patient-provider communication, and patient education regarding HCV treatment options for treatment rates to improve. PMID:17394085
Schackman, Bruce R; Teixeira, Paul A; Beeder, Ann B
Rhinosinusitis treatment protocol: Changing provider habits in primary care
Objective: Sinus infections are common and represent a high cost to the health care industry. Clinical protocols can be used to develop cost-effective treatment strategies. Our objective was to show that a protocol for rhinosinusitis can change provider practice patterns in primary care. Study Design and Setting: We used a literature search, survey of primary caregivers, and chart review from
William C. Kinney
38 CFR 21.242 - Resources for provision of treatment, care and services.
Code of Federal Regulations, 2012 CFR
...for provision of treatment, care and services. 21.242...for provision of treatment, care and services. (a) General...VA medical centers are the primary resources for the provision of medical treatment, care and services for...
38 CFR 21.6242 - Resources for provision of medical treatment, care and services.
Code of Federal Regulations, 2012 CFR
...provision of medical treatment, care and services. 21.6242...provision of medical treatment, care and services. (a) General...VA medical centers are the primary resources for the provision of medical treatment, care and services for...
38 CFR 21.242 - Resources for provision of treatment, care and services.
Code of Federal Regulations, 2013 CFR
...for provision of treatment, care and services. 21.242...for provision of treatment, care and services. (a) General...VA medical centers are the primary resources for the provision of medical treatment, care and services for...
38 CFR 21.242 - Resources for provision of treatment, care and services.
Code of Federal Regulations, 2010 CFR
...for provision of treatment, care and services. 21.242...for provision of treatment, care and services. (a) General...VA medical centers are the primary resources for the provision of medical treatment, care and services for...
38 CFR 21.242 - Resources for provision of treatment, care and services.
Code of Federal Regulations, 2011 CFR
...for provision of treatment, care and services. 21.242...for provision of treatment, care and services. (a) General...VA medical centers are the primary resources for the provision of medical treatment, care and services for...
38 CFR 21.6242 - Resources for provision of medical treatment, care and services.
Code of Federal Regulations, 2013 CFR
...provision of medical treatment, care and services. 21.6242...provision of medical treatment, care and services. (a) General...VA medical centers are the primary resources for the provision of medical treatment, care and services for...
Treatment of Neurocritical Care Emergencies in Pregnancy.
OPINION STATEMENT: Neurologic emergencies are a major cause of morbidity and mortality in pregnant women. In part because the patient population is young, the nihilistic approach that often accompanies neurologically devastating disorders in other contexts is largely absent. A number of studies have demonstrated improved patient outcomes in the setting of aggressive care delivered by neurointensivists in a specialty-specific environment. It stands to reason that young, pregnant women who suffer from neurologically devastating disorders and who have a wide range of prognosis may also benefit from such specialized care. Close collaboration between obstetricians and neurointensivists is critical in this context. A number of unique considerations in diagnosis and management present dilemmas in the context of pregnancy, such as radiation dose from diagnostic neuroimaging, choice of pharmacotherapy for seizures, anticoagulation, and the method of delivery in the context of cerebral mass lesions and elevated intracranial pressure. Patients and their physicians are often faced with the additional challenge of balancing the relative risks and benefits of the impact of a management approach on both mother and fetus. In general, this balance tends to favor the interests of the mother, but the impact on the fetus becomes more relevant over the course of the pregnancy, especially in the third trimester. A low threshold for admission to an intensive care unit (ideally one that specializes in neurointensive care) should be used for pregnant patients. Because of the limited information regarding long-term outcomes in this population, rigid prognosis formation and early care limitations should be deferred in the immediate period. After the patient is stabilized and a plan has been charted for the remainder of the pregnancy, every effort should be made to engage patients in aggressive, urgent neurologic rehabilitation. PMID:22298283
Sheth, Sangini S; Sheth, Kevin N
The identification, referral and specific treatment of midlife patients in primary care who are distressed by mood, anxiety, sleep and stress-related symptoms, with or without clinically confirmed menopausal symptoms, are confounded by many structural issues in the delivery of women's healthcare. Diagnosis, care delivery, affordability of treatment, time commitment for treatment, treatment specificity for a particular patient's symptoms and patient receptiveness to diagnosis and treatment all play roles in the successful amelioration of symptoms in this patient population. The value of screening for depression in primary care, the limitations of commonly used screening instruments relative to culture and ethnicity, and which clinical care systems make best use of diagnostic screening programs will be discussed in the context of the midlife woman. The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) program illustrates the relatively high rate of unremitted patients, regardless of clinical setting, who are receiving antidepressants. Nonmedication treatment approaches, referred to in the literature as 'nonsomatic treatments', for depression, anxiety and stress, include different forms of cognitive-behavioral therapy, interpersonal therapy, structured daily activities, mindfulness therapies, relaxation treatment protocols and exercise. The specificity of these treatments, their mechanisms of action, the motivation and time commitment required of patients, and the availability of trained practitioners to deliver them are reviewed. Midlife women with menopausal symptoms and depression/anxiety comorbidity represent a challenging patient population for whom an individualized treatment plan is often necessary. Treatment for depression comorbid with distressing menopausal symptoms would be facilitated by the implementation of a collaborative care program for depression in the primary care setting. PMID:18039069
Alexander, Jeanne Leventhal; Richardson, Gregg; Grypma, Lydia; Hunkeler, Enid M
Background Opioid dependence treatment traditionally involves methadone clinics, for which dispensing schedules can be cumbersome. Buprenorphine, a partial agonist of the mu receptor and antagonist of the kappa receptor, is a potential outpatient alternative to methadone. Funded by a grant from the State of Maryland's Community Health Resources Commission (CHRC), the Buprenorphine Outpatient Outcomes Project (BOOP) evaluates the outcome of Suboxone (buprenorphine/naloxone) treatment on abstinence from heroin use, rates of emergency room visits and hospitalizations, legal issues, and quality of life. Methods Active heroin users were recruited between June 2007 and June 2010 and induction therapy with Suboxone was instituted during hospitalization. Once discharged, patients were followed as outpatients for maintenance treatment and counseling. Data were collected from electronic medical records, Maryland state legal records, and SF-36® Health Surveys regarding several parameters and patients were categorized according to duration of treatment with Suboxone into one of three groups: <1 month, 1–3 months, and >3 months. Results A total of 220 participants were included in the study. The age range of participants was 18–67 years with most being African American males. Eighty-three (38%) remained in the study for at least 1 month, with 37 of the 83 (45%) remaining in treatment for >3 months. Ten of the 37 (27%) never relapsed after their longest period of abstinence from heroin. During the first year after initiating treatment with Suboxone, hospitalization and emergency room visit rates for all 220 participants decreased by 45 and 23%, respectively, as compared to the year prior to starting treatment. The number of legal charges for drug possession decreased from 70 to 62. Anecdotally, the quality of life seemed to improve in those who were treated with Suboxone for longer periods of time and received regular counseling. Conclusion Overall, Suboxone is an effective treatment method for heroin addiction and is a viable outpatient therapy option. Individualized treatment plans and counseling must be implemented for maximum benefits to be seen. Retention of patients for a long duration of therapy was difficult, but for those who did remain, benefits were seen in overall health, abstinence from heroin use, cognition, and quality of life. PMID:24765257
Sittambalam, Charmian D.; Vij, Radhika; Ferguson, Robert P.
The Cost of HIV Treatment and Care: A Global Review
This review of published studies on the costs of HIV treatment and care describes some of the recent developments that have influenced these costs in industrialised and industrialising countries, especially within the context of changing drug treatments. Some of the different approaches to estimating the economic impact of HIV infection are briefly presented. The methods used to review the literature
Eduard J. Beck; Alec H. Miners; Keith Tolley
Adolescent Substance Abuse Treatment: Organizational Change and Quality of Care
ERIC Educational Resources Information Center
Substance abuse treatment agencies serving youth face unique barriers to providing quality care. Interviews with 17 adolescent programs found that family engagement, community involvement, and gender and diversity issues affected treatment delivery. Programs report organizational change efforts with implications for future process improvement…
Rieckmann, Traci; Fussell, Holly; Doyle, Kevin; Ford, Jay; Riley, Katherine J.; Henderson, Stuart
HIV treatment and care systems: the way forward.
This article summarizes the conclusions and recommendations from the articles in this supplement. It presents a call for greater clarity of thinking related to projections of future need for HIV treatment and care. The demands placed on HIV treatment and care services will increase for the foreseeable future while the resources available for this are likely to remain constant or to decline. This highlights the need for realistic budgeting by national governments. The key strategies that should be employed to sustain HIV treatment and care programmes in high HIV-prevalence low and middle-income countries over the coming decade include further decentralization, task shifting, and integration of HIV services with other chronic disease treatment services. At the same time, greater attention will need to be given to the provision of mental healthcare for those living with HIV; to the specific treatment needs of children, adolescents, pregnant women and older people; and to the standard collection of validated indicators of treatment outcomes within national programmes. For the considerable gains that have been achieved to be sustained, funders--both internal and external to the country concerned--need to prioritize investment in operations research to maximise the efficiency of their other investments in HIV treatment and care services. PMID:23303436
Ross, David A; South, Annabelle; Weller, Ian; Hakim, James
Clinical pharmacology of buprenorphine in healthy, lactating goats.
The pharmacokinetics and the effects of the opioid buprenorphine on behavior, cardiovascular parameters, plasma concentrations of cortisol and vasopressin were studied in the goat. After intravenous injection at a dosage of 0.02 mg/kg bw, the terminal half-life was 73.8+/-19.9 min (mean+/-SD), the apparent volume of distribution 5.22+/-1.01 L/kg, and total body clearance 79.1+/-18.5 mL/min/kg. After intramuscular administration of buprenorphine at the same dosage, bioavailability was complete and clearance was 54.7+/-16.6 mL/min/kg. Heart rate, blood pressure and concentrations of cortisol and vasopressin in plasma increased after drug administration. The goats became agitated and stopped ruminating. The effects were more pronounced the first time the animals received the drug, especially the influence on the hormone levels. The concentrations of cortisol and vasopressin in plasma remained unaffected after the second dose despite a wash-out period of 3-6 weeks. Buprenorphine may be an unsuitable drug in goats because of the profound inhibition of rumination and the agitation it causes. The short half-life of buprenorphine may limit its use if long-term analgesia is required but be advantageous if a short acting drug is desirable. PMID:17472657
Ingvast-Larsson, C; Svartberg, K; Hydbring-Sandberg, E; Bondesson, U; Olsson, K
Disaccharides in urine samples as markers of intravenous abuse of methadone and buprenorphine.
Methadone and buprenorphine are commonly used as oral substitutes in opiate maintenance programs to treat persons who are dependent on heroin. During these programs, patients are not allowed to continue using illicit drugs. Abstinence can easily be monitored by urine tests with immunochemical methods. It is well known that the intravenous abuse of heroin substitutes like methadone or buprenorphine has become common as well. The methadone-prescribing physician has no opportunity to check whether the opiate maintenance treatment patient takes his substitution medicines orally as intended or continues with his intravenous misuse now substituting the methadone instead of injecting heroin. In Germany, substitutes are available as liquids and tablets that contain carbohydrates as adjuvants. Sucrose is used to increase viscosity in liquids, while lactose is needed for pressing tablets (e.g., Methaddict® and Subutex®). In case of oral ingestion, disaccharides are broken down into monosaccharides by disaccharidases in the small intestine. These monosaccharides are absorbed into the blood stream by special monosaccharide transporters. Disaccharidases do not exist in blood, thus sucrose and lactose are not split if substitute medicines are injected intravenously. Our assumption, therefore, was that they are excreted unchanged in urine. We investigated a method for the detection of disaccharides in urine as markers of intravenous abuse of substitutes. Urine samples of 26 intravenous substitute abusers showed all positive results for lactose (76.9%) and/or sucrose (73.1%). The method is assumed to be useful to detect intravenous abuse of substitutes. PMID:24099717
Jungen, Hilke; Andresen-Streichert, Hilke; Müller, Alexander; Iwersen-Bergmann, Stefanie
Patient-centred care: making cancer treatment centres accountable.
Patient-centred care is argued to be an essential component in the delivery of quality health and cancer care. This manuscript discusses the need to generate credible data which indicates the quality of patient-centred care provided by cancer treatment centres. Patient-centred care covers six domains including physical comfort; emotional support; respect for patients' preferences and values; integration and coordination; involvement of family and friends; and the provision of information, communication and education to enable patients to understand and make informed decisions about their care. First, we identify priority areas within each domain. Next, we propose three questions that should be asked of every patient across the six domains of patient-centred care. The first question explores whether patients were specifically asked by a healthcare provider at the cancer treatment centre about their concerns, values and preferences. Research indicates that it cannot be assumed that clinicians are aware of patient's needs or preferences in these six areas. Second, if the answer from the patient suggests that they would like assistance, then it would be expected that this would be offered. Thirdly, if the patient indicates that they would like such assistance and it is provided, then it might be expected that the patient would report that the provided assistance did relieve their suffering, or the assistance provided was consistent with their preferences, needs and values. Regular measurement and reporting of these aspects of patient-centred cancer care has the potential to identify deficits and inequities in care delivery, allow for comparisons across treatment centres and stimulate an improvement in the patient-centred care provided to cancer patients. PMID:24696084
Zucca, Alison; Sanson-Fisher, Rob; Waller, Amy; Carey, Mariko
42 CFR 136a.34 - Care and treatment of people losing eligibility.
Code of Federal Regulations, 2012 CFR
...2012-10-01 2012-10-01 false Care and treatment of people losing...HUMAN SERVICES INDIAN HEALTH Transition Provisions § 136a.34 Care and treatment of people losing...and those receiving inpatient care under contract, including...
42 CFR 136a.34 - Care and treatment of people losing eligibility.
Code of Federal Regulations, 2013 CFR
...2013-10-01 2013-10-01 false Care and treatment of people losing...HUMAN SERVICES INDIAN HEALTH Transition Provisions § 136a.34 Care and treatment of people losing...and those receiving inpatient care under contract, including...
Potentiation of buprenorphine antinociception with ultra-low dose naltrexone in healthy subjects
Previous reports have demonstrated greater antinociception following administration of a buprenorphine\\/naloxone combination compared to buprenorphine alone among healthy volunteers. The aim of the current investigation was to determine whether buprenorphine antinociception could be enhanced with the addition of ultra-low dose naltrexone, using a range of dose ratios. A repeated-measures, double-blind, cross-over trial was undertaken with 10 healthy participants. The effects
J. L. Hay; S. F. La Vincente; A. A. Somogyi; C. B. Chapleo; J. M. White
AIMS: The clinical effectiveness of buprenorphine-naloxone (bup-nx) and clonidine for opioid detoxification in in-patient and out-patient community treatment programs was investigated in the first studies of the National Institute of Drug Abuse Clinical Trials Network.\\u000aDESIGN: Diagnostic and Statistical Manual version IV (DSM IV)-diagnosed opioid-dependent individuals seeking short-term treatment were randomly assigned, in a 2 : 1 ratio favoring bup-nx,
Walter Ling; Leslie Amass; Steve Shoptaw; Jeffrey J. Annon; Maureen Hillhouse; Dean Babcock; Greg Brigham; Judy Harrer; Malcolm S. Reid; Joan A. Muir; Betty J. Buchan; Debbie Orr; George Woody; Jonathan Krejci; Douglas M. Ziedonis
Information needed to decide about cardiovascular treatment in primary care.
There is growing consensus that treatment of cardiovascular risks should be based on multiple rather than single factors and on absolute rather than relative risks. Thresholds for treatment should reflect the level of absolute risk at which the benefits and hazards of treating outweigh the benefits and hazards of not treating. Once a decision has been made to initiate a treatment programme, clinicians need to know the patient's absolute risk. At this level of risk do the benefits of treatment outweigh the hazards? Given this information, which treatment option does the patient prefer? Using cardiovascular disease as an example, I review some measures that assist decision making in primary care. Practice guidelines should routinely include accessible presentation of treatment outcomes on benefit, hazard, and costs for a range of absolute risks. These measures enable patients and their doctors to weigh the pros and cons of treatment in their particular circumstances. PMID:9022493
Robson, J.
Study Objective: This study examined documented treatment recommendations provided for sleep disorders and sleep problems in pediatric primary care, the persistence of sleep problems and sleep disorders in children and adolescents, and the relationship between sleep issues and health care utilization. Methods: In-depth chart review of pediatric primary care patient visits (n = 750 patients) from 2007 through 2010. Results: Only 26 children (5.2% of those with a sleep disorder/ problem) received a treatment recommendation, with half of these recommendations behavioral in nature. Sleep disorders and sleep problems were highly persistent across time for up to a third of children. Children with sleep disorders had significantly more sick visits/calls (mean = 8.84, 95% CI 7.77-9.90) than children without a sleep disorder (mean = 6.34, 95% CI 5.56-7.12). Conclusions: Very few children or adolescents were found to have documented treatment recommendations or referrals for diagnosed sleep disorders or sleep problems. In addition, given that sleep disorders and sleep problems are highly persistent, as well as result in more sick visits/calls, it is important that pediatric primary care providers screen for and identify these issues across development. Furthermore, it is essential to provide health care providers with more education and support on sleep disorders and sleep problems in pediatric primary care. Citation: Meltzer LJ; Plaufcan MR; Thomas JH; Mindell JA. Sleep problems and sleep disorders in pediatric primary care: treatment recommendations, persistence, and health care utilization. J Clin Sleep Med 2014;10(4):421-426. PMID:24733988
Meltzer, Lisa J.; Plaufcan, Melissa R.; Thomas, Jocelyn H.; Mindell, Jodi A.
Few studies in community settings have evaluated predictors, mediators, and moderators of treatment success for medically supervised opioid withdrawal treatment. This report presents new findings about these factors from a study of 344 opioid dependent men and women prospectively randomized to either buprenorphine-naloxone or clonidine in an open-label 13-day medically-supervised withdrawal study. Subjects were either inpatient or outpatient in community treatment settings; however not randomized by treatment setting. Medication type (buprenorphine-naloxone versus clonidine) was the single best predictor of treatment retention and treatment success, regardless of treatment setting. Compared to the outpatient setting, the inpatient setting was associated with higher abstinence rates but similar retention rates when adjusting for medication type. Early opioid withdrawal severity mediated the relationship between medication type and treatment outcome with buprenorphine-naloxone being superior to clonidine at relieving early withdrawal symptoms. Inpatient subjects on clonidine with lower withdrawal scores at baseline did better than those with higher withdrawal scores; inpatient subjects receiving buprenorphine-naloxone did better with higher withdrawal scores at baseline than those with lower withdrawal scores. No relationship was found between treatment outcome and age, gender, race, education, employment, marital status, legal problems, baseline depression, or length/severity of drug use. Tobacco use was associated with worse opioid treatment outcomes. Severe baseline anxiety symptoms doubled treatment success. Medication type (buprenorphine-naloxone) was the most important predictor of positive outcome; however the paper also considers other clinical and policy implications of other results, including that inpatient setting predicted better outcomes and moderated medication outcomes. PMID:18805656
Ziedonis, Douglas M.; Amass, Leslie; Steinberg, Marc; Woody, George; Krejci, Jonathan; Annon, Jeffrey J.; Cohen, Allan J.; Waite-O'Brien, Nancy; Stine, Susan M.; McCarty, Dennis; Reid, Malcolm S.; Brown, Lawrence S.; Maslansky, Robert; Winhusen, Theresa; Babcock, Dean; Brigham, Greg; Muir, Joan; Orr, Deborah; Buchan, Betty J.; Horton, Terry; Ling, Walter
Consumerism and health care: the example of fertility treatment.
This paper discusses the concepts of consumerism and the consumer of health care, and applies them to the example of fertility treatment, drawing on the health policy literature and data from a study of couples undergoing fertility treatment. It is argued that the concept of the consumer is a slippery one, that it provides only a partial view of being a patient, and that in particular it neglects emotional issues. PMID:9578201
Meerabeau, L
To improve outcomes among injection drug users with HIV and/or chronic hepatitis B, it is important to identify drug interactions between antiretroviral and opiate therapies. We report the results of a study designed to examine the interaction between buprenorphine and the nucleos(t)ide reverse transcriptase inhibitors (NRTI) didanosine (ddI), lamivudine (3TC), and tenofovir (TDF). Opioid-dependent, buprenorphine/naloxone-maintained, HIV-negative volunteers (n = 27) participated in two 24-hour sessions to determine (1) pharmacokinetics of buprenorphine alone and (2) pharmacokinetics of both buprenorphine and either ddI, 3TC, or TDF. Among buprenorphine/naloxone-maintained study participants, no significant changes in buprenorphine pharmacokinetics were observed following ddI, 3TC, or TDF administration. Buprenorphine had no significant effect on NRTI concentrations. Concomitant use of buprenorphine with ddI, 3TC, or TDF results in neither a significant pharmacokinetic nor pharmacodynamic interaction. PMID:20132118
Baker, Jennifer; Rainey, Petrie M.; Moody, David E.; Morse, Gene D.; Ma, Qing; McCance-Katz, Elinore F.
Developing Self-Care Practices in a Trauma Treatment Course
ERIC Educational Resources Information Center
This article describes the development of self-care practices of social work students who were part of a larger study of students' experiences in a graduate course on the treatment of trauma. Consensual qualitative research methods were used to analyze 17 participant journals submitted at 4 times during the course. Findings indicated that…
Shannon, Patricia J.; Simmelink-McCleary, Jennifer; Im, Hyojin; Becher, Emily; Crook-Lyon, Rachel E.
Assessing Conformity to Standards for Treatment Foster Care.
ERIC Educational Resources Information Center
This study examined conformity to the Program Standards for Treatment Foster Care among 42 statewide programs. Findings suggest fair to good overall conformity, with considerable variation among programs. A discussion of methodological and substantive considerations for future research and evaluation using this approach is included. (Contains…
Farmer, Elizabeth M. Z.; Burns, Barbara J.; Dubs, Melanie S.; Thompson, Shealy
Characteristics and Trajectories of Treatment Foster Care Youth
ERIC Educational Resources Information Center
Using cross-sectional analyses in conjunction with dynamic modeling (hierarchical linear modeling), the authors profiled 119 treatment foster care youth and constructed behavioral change trajectories for a subset of 97 children. Children generally showed improvements in internalizing and critical pathology problem domains but remained the same on…
Hussey, David L.; Guo, Shenyang
Coordination of Heart Attack Care Trims Time to Treatment
Prior Trauma Exposure for Youth in Treatment Foster Care
ERIC Educational Resources Information Center
Very little research has focused on rates of trauma exposure for youth in treatment foster care (TFC). Available research has utilized record review for assessing exposure, which presents limitations for the range of trauma types examined, as records are predominantly focused on abuse and neglect. The current study examines exposure rates and…
Dorsey, Shannon; Burns, Barbara J.; Southerland, Dannia G.; Cox, Julia Revillion; Wagner, H. Ryan; Farmer, Elizabeth M. Z.
Optimising pharmacological maintenance treatment for COPD in primary care.
Chronic obstructive pulmonary disease (COPD) is a multi-faceted disease that is a major cause of morbidity and mortality worldwide, and is a significant burden in terms of healthcare resource utilisation and cost. Despite the availability of national and international guidelines, and effective, well-tolerated pharmacological treatments, COPD remains substantially under-diagnosed and under-treated within primary care. As COPD is both preventable and treatable there is an urgent need to raise the awareness and profile of the disease among primary care physicians and patients. Increasing evidence suggests that initiation of long-acting bronchodilator treatment at an early stage can significantly improve the patient's long-term health and quality of life (QoL). Recent large-scale trials in COPD have confirmed the longterm benefits of maintenance treatment with long-acting bronchodilators. A wide range of benefits have been shown in selected patient groups including improved lung function and QoL, reduced exacerbations and, in some studies, delayed disease progression and improved survival. In this review, we consider recent developments in our understanding of COPD, including current and emerging pharmacological treatment options, and identify steps for optimising early diagnosis and pharmacological treatment of COPD within the primary care environment. PMID:21103801
Jones, Rupert; Řstrem, Anders
Treatment Foster Care in a System of Care: Sequences and Correlates of Residential Placements
ERIC Educational Resources Information Center
We examined Treatment Foster Care (TFC) in residential trajectories for youth with psychiatric disorders and aggressive behavior. We analyzed residential placements of a statewide sample of youth during the 12 months preceding and following admission to TFC. Prior to TFC, the majority of youth were residing in more restrictive settings (group…
Farmer, Elizabeth M. Z.; Wagner, H. Ryan; Burns, Barbara J.; Richards, Jesse T.
Depression-Like Effect of Prenatal Buprenorphine Exposure in Rats
Studies indicate that perinatal opioid exposure produces a variety of short- and long-term neurobehavioral consequences. However, the precise modes of action are incompletely understood. Buprenorphine, a mixed agonist/antagonist at the opioid receptors, is currently being used in clinical trials for managing pregnant opioid addicts. This study provides evidence of depression-like consequence following prenatal exposure to supra-therapeutic dose of buprenorphine and sheds light on potential mechanisms of action in a rat model involving administration of intraperitoneal injection to pregnant Sprague-Dawley rats starting from gestation day 7 and lasting for 14 days. Results showed that pups at postnatal day 21 but not the dams had worse parameters of depression-like neurobehaviors using a forced swimming test and tail suspension test, independent of gender. Neurobehavioral changes were accompanied by elevation of oxidative stress, reduction of plasma levels of brain-derived neurotrophic factor (BDNF) and serotonin, and attenuation of tropomyosin-related kinase receptor type B (TrkB) phosphorylation, extracellular signal-regulated kinase (ERK) phosphorylation, protein kinase A activity, cAMP response element-binding protein (CREB) phosphorylation, and CREB DNA-binding activity. Since BDNF/serotonin and CREB signaling could orchestrate a positive feedback loop, our findings suggest that the induction of oxidative stress, reduction of BDNF and serotonin expression, and attenuation of CREB signaling induced by prenatal exposure to supra-therapeutic dose of buprenorphine provide evidence of potential mechanism for the development of depression-like neurobehavior. PMID:24367510
Hung, Chih-Jen; Wu, Chih-Cheng; Chen, Wen-Ying; Chang, Cheng-Yi; Kuan, Yu-Hsiang; Pan, Hung-Chuan; Liao, Su-Lan; Chen, Chun-Jung
In this study, the author examined the impact of youth and family preplacement risk factors on multidimensional treatment foster care (MTFC) parent—youth interactions,youth treatment completion, and outcomes for boy and girl adolescents who have problems with chronic delinquency. In particular, she looked at (a) how levels of preplacement youth and family risk factors for chronically delinquent boys and girls who
Dana K. Smith
Use of buprenorphine in pregnancy: patient management and effects on the neonate
It is estimated that 55–94% of infants born to opioid-dependent mothers in US will show signs of opioid withdrawal. Buprenorphine has been reported to produce little or no autonomic signs or symptoms of opioid withdrawal following abrupt termination in adults. To date, there have been 21 published reports representing approximately 15 evaluable cohorts of infants exposed to buprenorphine in utero.
Rolley E. Johnson; Hendrée E. Jones; Gabriele Fischer
Background Women have higher rates of depression and often experience depression symptoms during critical reproductive periods, including adolescence, pregnancy, postpartum, and menopause. Collaborative care intervention models for mood disorders in patients receiving care in an OB-GYN clinic setting have not been evaluated. Study design and methodology for a randomized, controlled trial of collaborative care depression management versus usual care in OB-GYN clinics and the details of the adapted collaborative care intervention and model implementation are described in this paper. Methods Women over age 18 years with clinically significant symptoms of depression, as measured by a Patient Health Questionnaire-9 (PHQ-9) score ?10 and a clinical diagnosis of major depression or dysthymia, were randomized to the study intervention or to usual care and were followed for 18 months. The primary outcome assessed was change over time in the SCL-20 depression scale between baseline and 12 months. Baseline Results 205 women were randomized: 57% white, 20% African American, 9% Asian or Pacific Islander, 7% Hispanic, and 6% Native American. Mean age was 39 years. 4.6% were pregnant and 7.5% were within 12 months postpartum. The majority were single, (52%), and 95% had at least the equivalent of a high school diploma. Almost all patients met DSM IV criteria for major depression (99%) and approximately 33% met criteria for dysthymia. Conclusions An OB-GYN collaborative care team including a social worker, psychiatrist and OB-GYN physician who met weekly and used an electronic tracking system for patients were essential elements of the proposed depression care treatment model described here. Further study of models that improve quality of depression care that are adapted to the unique OB-GYN setting are needed. PMID:23939510
LaRocco-Cockburn, Anna; Reed, Susan D.; Melville, Jennifer; Croicu, Carmen; Russo, Joan; Inspektor, Michal; Edmondson, Eddie; Katon, Wayne
Psychiatric intensive care units (PICUs) were first developed in the UK in the early 1970s and have become an integral part of inpatient services. This paper reviews all aspects of PICU provision from its origins to the most recent studies of intensive care treatment and philosophy. A search of CINAHL, MEDLINE and British Nursing Index databases revealed ample research and discussion papers from the past 30 years to permit a thorough review of the available literature. This divides roughly into discussion and descriptive research on topics related to: (a) the infrastructure of PICUs, including bed numbers, staffing levels, admission criteria and aspects of the physical environment; and (b) the treatment provided to patients on the PICU, both pharmacological and psychosocial, plus a limited amount of evaluative research on the efficacy of PICU care. This paper provides a summary and overview of these issues based upon currently available literature. It concludes that there is strong evidence for wide variation in the provision and nature of PICU care, reflecting idiosyncratic and localized development of services. Moreover, there is an almost complete lack of evidence on the efficacy of PICU care for particular types of patients and problems, leaving a paucity of research upon which PICU infrastructure, policy and therapeutic approach can be based. PMID:12472822
Crowhurst, N; Bowers, L
Treatment of Acute Ischemic Stroke: Beyond Thrombolysis and Supportive Care
The initial therapeutic approach to acute ischemic stroke consists of thrombolytic therapy and early initiation of supportive\\u000a care, usually commenced prior to the determination of the underlying stroke etiology. Varying stroke mechanisms may call for\\u000a specific, etiology-based treatment. The majority of strokes result from cardioembolism, large-vessel atherothromboembolism,\\u000a and small-vessel occlusive disease. There are scant data to support the use of
Neelofer Shafi; Scott E. Kasner
Novelty seeking as a predictor of treatment retention for heroin dependent cocaine users
This study examined the relationship between novelty seeking between treatment retention and among heroin dependent cocaine users. Participants were treated with buprenorphine maintenance and contingency management. The Tridimensional Personality Questionnaire's (TPQ) Novelty Seeking scale was administered to 68 participants prior to buprenorphine induction. Demographics, mood and anxiety disorders, antisocial personality disorder, and substance use were also assessed. Variables with significant
Todd C Helmus; Karen K Downey; Cynthia L Arfken; Melinda J Henderson; Charles R Schuster
45 CFR 211.6 - Reception; temporary care, treatment, and assistance.
Code of Federal Regulations, 2012 CFR
...Reception; temporary care, treatment, and...Section 211.6 Public Welfare Regulations Relating to Public Welfare OFFICE OF FAMILY...ADMINISTRATION FOR CHILDREN AND FAMILIES, DEPARTMENT...AND HUMAN SERVICES CARE AND TREATMENT...
45 CFR 211.6 - Reception; temporary care, treatment, and assistance.
Code of Federal Regulations, 2011 CFR
...Reception; temporary care, treatment, and...Section 211.6 Public Welfare Regulations Relating to Public Welfare OFFICE OF FAMILY...ADMINISTRATION FOR CHILDREN AND FAMILIES, DEPARTMENT...AND HUMAN SERVICES CARE AND TREATMENT...
45 CFR 211.6 - Reception; temporary care, treatment, and assistance.
Code of Federal Regulations, 2013 CFR
...Reception; temporary care, treatment, and...Section 211.6 Public Welfare Regulations Relating to Public Welfare OFFICE OF FAMILY...ADMINISTRATION FOR CHILDREN AND FAMILIES, DEPARTMENT...AND HUMAN SERVICES CARE AND TREATMENT...
38 CFR 21.6242 - Resources for provision of medical treatment, care and services.
Code of Federal Regulations, 2011 CFR
... false Resources for provision of medical treatment, care and services. 21...Training for Certain New Pension Recipients Medical and Related Services § 21.6242 Resources for provision of medical treatment, care and services....
38 CFR 21.6242 - Resources for provision of medical treatment, care and services.
Code of Federal Regulations, 2010 CFR
... false Resources for provision of medical treatment, care and services. 21...Training for Certain New Pension Recipients Medical and Related Services § 21.6242 Resources for provision of medical treatment, care and services....
Treatment Matching in the Posthospital Care of Depressed Patients
Objective This study assessed the efficacy of 1) matching patients to treatments and 2) adding additional family therapy or cognitive therapy in a group of recently discharged patients with major depression. Method Patients with major depression were recruited during a psychiatric hospitalization. After discharge, they were randomly assigned to one of four treatment conditions that were either "matched" or "mismatched" to their pattern of cognitive distortion and family impairment. The four treatment conditions were 1) pharmacotherapy alone; 2) combined pharmacotherapy and cognitive therapy; 3) combined pharmacotherapy and family therapy; and 4) combined pharmacotherapy, cognitive therapy, and family therapy. Randomly assigned treatment continued for 24 weeks on an outpatient basis. Results Among patients with at least moderate depressive symptoms at hospital discharge, low rates of remission (16%) and improvement (29%) were obtained. Matched treatment led to a significantly greater proportion of patients who improved and greater reductions over time in interviewer-rated depressive symptoms than mismatched treatment. However, matched treatment did not produce greater change in self-reported depression or interviewer-rated suicidal ideation. Treatment that included a family therapy component also led to a greater proportion of patients who improved and to significant reductions in interviewer-rated depression and suicidal ideation than treatment without family therapy. Conclusions These results suggest that 1) current treatments are not very efficacious in the aftercare of hospitalized depressed patients, 2) treatment matching moderately improves outcome for patients who are symptomatic at hospital discharge, and 3) inclusion of family therapy improves the outcome of posthospital care for depressed patients. PMID:16263854
Miller, Ivan W.; Keitner, Gabor I.; Ryan, Christine E.; Solomon, David A.; Cardemil, Esteban V.; Beevers, Christopher G.
Objective To investigate whether PALSA PLUS, an on-site educational outreach programme of non-didactic, case based, iterative clinical education of staff, led by a trainer, can increase access to and comprehensiveness of care for patients with HIV\\/AIDS.Design Cluster randomised trial.Setting Public primary care clinics offering HIV\\/AIDS care, antiretroviral treatment (ART), tuberculosis care, and ambulatory primary care in Free State province, South
Merrick Zwarenstein; Lara R Fairall; Carl Lombard; Pat Mayers; Angeni Bheekie; René G English; Simon Lewin; Max O Bachmann; Eric Bateman
Background Opioid maintenance treatment (OMT) has a positive impact on substance use and health outcomes among HIV-infected opioid dependent patients. The present study investigates non-medical use of opioids by HIV-infected opioid-dependent individuals treated with buprenorphine or methadone. Methods The MANIF 2000 study is a longitudinal study that enrolled a cohort of 476 HIV-infected opioid-dependent individuals. Data were collected in outpatient hospital services delivering HIV care in France. The sample comprised all patients receiving OMT (either methadone or buprenorphine) who attended at least one follow-up visit with data on adherence to OMT (N = 235 patients, 1056 visits). Non-medical use of opioids during OMT was defined as having reported use of opioids in a non-medical context, and/or the misuse of the prescribed oral OMT by an inappropriate route of administration (injection or sniffing). After adjusting for the non-random assignment of OMT type, a model based on GEE was then used to identify predictors of non-medical use of opioids. Results Among the 235 patients, 144 (61.3%) and 91 (38.9%) patients were receiving buprenorphine and methadone, respectively, at baseline. Non-medical use of opioids was found in 41.6% of visits for 83% of individual patients. In the multivariate analysis, predictors of non-medical use of opioids were: cocaine, daily cannabis, and benzodiazepine use, experience of opioid withdrawal symptoms, and less time since OMT initiation. Conclusions Non-medical use of opioids was found to be comparable in OMT patients receiving methadone or buprenorphine. The presence of opioid withdrawal symptoms was a determinant of non-medical use of opioids and may serve as a clinical indicator of inadequate dosage, medication, or type of follow-up. Sustainability and continuity of care with adequate monitoring of withdrawal symptoms and polydrug use may contribute to reduced harms from ongoing non-medical use of opioids. PMID:22123176
Effective management of postoperative pain is an essential component of the care and welfare of laboratory animals. A sustained-release formulation of buprenorphine (Bup-SR) has recently been introduced to the veterinary market and has been reported to provide analgesia for as long as 72 h. Using evoked mechanical and thermal hypersensitivity tests, we here evaluated the antinociceptive effects of Bup-SR in a model of incisional pain in rats. Paw withdrawal responses were obtained before and 1 through 4 d after surgery. Rats are assigned to receive Bup-SR (0.3, 1.2, or 4.5 mg/kg SC once) or buprenorphine HCl (Bup HCl, 0.05 mg/kg SC twice daily for 3 d). Responses to mechanical and thermal stimuli in the 1.2 and 4.5 Bup-SR groups did not differ from those of rats in the Bup HCl group. Thermal latency on day 3 in rats that received 0.3 mg/kg Bup-SR was significantly different from baseline, indicating that this dose effectively decreased thermal hypersensitivity for at least 48 h. Marked sedation occurred in rats in the 4.5 Bup-SR group. Our findings indicate that Bup-SR at 0.3 or 1.2 mg/kg SC is effective in minimizing hypersensitivity with minimal sedation for at least 48 h (thermal hypersensitivity) and 72 h, respectively, in the incisional pain model in rats. PMID:24602547
Chum, Helen H; Jampachairsri, Katechan; McKeon, Gabriel P; Yeomans, David C; Pacharinsak, Cholawat; Felt, Stephen A
Effective management of postoperative pain is an essential component of the care and welfare of laboratory animals. A sustained-release formulation of buprenorphine (Bup-SR) has recently been introduced to the veterinary market and has been reported to provide analgesia for as long as 72 h. Using evoked mechanical and thermal hypersensitivity tests, we here evaluated the antinociceptive effects of Bup-SR in a model of incisional pain in rats. Paw withdrawal responses were obtained before and 1 through 4 d after surgery. Rats are assigned to receive Bup-SR (0.3, 1.2, or 4.5 mg/kg SC once) or buprenorphine HCl (Bup HCl, 0.05 mg/kg SC twice daily for 3 d). Responses to mechanical and thermal stimuli in the 1.2 and 4.5 Bup-SR groups did not differ from those of rats in the Bup HCl group. Thermal latency on day 3 in rats that received 0.3 mg/kg Bup-SR was significantly different from baseline, indicating that this dose effectively decreased thermal hypersensitivity for at least 48 h. Marked sedation occurred in rats in the 4.5 Bup-SR group. Our findings indicate that Bup-SR at 0.3 or 1.2 mg/kg SC is effective in minimizing hypersensitivity with minimal sedation for at least 48 h (thermal hypersensitivity) and 72 h, respectively, in the incisional pain model in rats. PMID:24602547
Chum, Helen H; Jampachairsri, Katechan; McKeon, Gabriel P; Yeomans, David C; Pacharinsak, Cholawat; Felt, Stephen A
Integrated care for pregnant women on methadone maintenance treatment
Abstract Objective To describe the characteristics of a national cohort of pregnant women on methadone maintenance treatment (MMT) and to provide treatment outcome data for integrated care programs. Design Retrospective chart review. Setting Three different integrated care programs in geographically distinct cities: the Toronto Centre for Substance Use in Pregnancy in Toronto, Ont; the Herzl Family Practice Centre in Montreal, Que; and the Sheway clinic in Vancouver, BC. Participants Pregnant women meeting criteria for opioid dependence and attending an integrated care program between 1997 and 2009. Women were excluded if they were on MMT only for chronic pain. Main outcome measures Patient demographic characteristics, concurrent medical and psychiatric disorders, and substance use outcome data. Results A total of 102 opioid-dependent pregnancies were included. The mean age was 29.7 years and 64% of women were white. Women in Montreal were more likely to have partners and had fewer children. Differences in living and housing situations among the sites tended to resolve by the time of delivery. Almost half of this cohort tested positive for hepatitis C. Women had a high prevalence of depression and anxiety across all sites. Half of this cohort was on MMT before conception and for the other half, MMT was initiated at a mean gestational age of 20.7 weeks, resulting in a mean dose of 82.4 mg at delivery. At the first visit, polysubstance use was common. Prescription opioid use was more frequent in Toronto and heroin use was more prevalent in Vancouver and Montreal. For the entire population, significant reductions were found by the time of delivery for illicit (P < .001) and prescription opioids (P = .001), cocaine (P < .001), marijuana (P = .009), and alcohol use (P < .001). Conclusion Despite geographic differences, all 3 integrated care programs have been associated with significant decreases in substance use in pregnant opioid-dependent women. PMID:24130301
Ordean, Alice; Kahan, Meldon; Graves, Lisa; Abrahams, Ronald; Boyajian, Talar
Potentiation of buprenorphine antinociception with ultra-low dose naltrexone in healthy subjects.
Previous reports have demonstrated greater antinociception following administration of a buprenorphine/naloxone combination compared to buprenorphine alone among healthy volunteers. The aim of the current investigation was to determine whether buprenorphine antinociception could be enhanced with the addition of ultra-low dose naltrexone, using a range of dose ratios. A repeated-measures, double-blind, cross-over trial was undertaken with 10 healthy participants. The effects of each buprenorphine:naltrexone ratio (100:1, 133:1, 166:1, and 200:1) on cold pressor tolerance time and respiration were compared to the effects of buprenorphine only. The 166:1 ratio was associated with significantly greater tolerance time to cold pressor pain than buprenorphine alone. Minimal respiratory depression and few adverse events were observed in all conditions. These findings suggest that, as previously described with naloxone, the addition of ultra-low dose naltrexone can enhance the antinociceptive effect of buprenorphine in humans. This potentiation is dose-ratio dependent and occurs without a concomitant increase in adverse effects. PMID:20728384
Hay, J L; La Vincente, S F; Somogyi, A A; Chapleo, C B; White, J M
Background Empirical evidence is needed to guide adequate post-partum pain relief of methadone and buprenorphine stabilized patients. Objectives To first determine the adequacy of pain control using non-opioid and opioid medication in participants stabilized on buprenorphine or methadone before a vaginal delivery. Second, to compare the amount of non-opioid and opioid medication needed for adequate pain control for buprenorphine-and methadone-maintained patients during the immediate post-partum period. Methods Pain control adequacy and amount of non-opioid and opioid medication needed in buprenorphine- (n=8) and methadone-maintained (n=10) patients over the first five days post-partum were examined. Results Pain ratings and number of opioid medication doses decreased over time in both medication groups. While the buprenorphine and methadone groups began with similar mean daily ibuprofen (IB) doses, the buprenorphine group decreased its IB use, while the methadone group increased its IB use. Conclusions and Scientific Significance Patients treated daily with either buprenorphine or methadone can have adequate pain control post-partum with opioid medication and IB. Pain control is dependent on the opioid-agonist medication in use at delivery, and must be individualized. PMID:19462298
Jones, Hendree E.; O'Grady, Kevin; Dahne, Jennifer; Johnson, Rolley; Lemoine, Laetitia; Milio, Lorriane; Ordean, Alice; Selby, Peter
A controlled comparison of buprenorphine and clonidine for acute detoxification from opioids.
We compared the short-term efficacy of a high-dose, 3 day regimen of buprenorphine to a standard 5-day course of clonidine in attenuating the signs and symptoms of the acute opioid abstinence syndrome during rapid detoxification from heroin in 25 men and women admitted to a closed inpatient research ward for this randomized, double-blind, parallel-group trial. Among the 18 completers, there were no significant differences between the buprenorphine and clonidine groups on five subjective and six physiological measures. However, clonidine lowered blood pressure and buprenorphine provided more effective early relief of withdrawal symptoms. PMID:7851278
Cheskin, L J; Fudala, P J; Johnson, R E
Prevention and treatment of periodontal diseases in primary care.
Scope and purposeThe aim of this guidance is to support the dental team to; manage patients with periodontal diseases in primary care appropriately; improve the quality of decision making for referral to secondary care; improve the overall oral health of the population. It focuses on the prevention and non-surgical treatment of periodontal diseases and implant diseases in primary care. The surgical treatment of periodontal and implant diseases and the management of patients by periodontal specialists or in a secondary care setting are outwith the scope of this guidance and are not discussed in detail. The guidance is based on existing guidelines, including those from the British Society of Periodontology, relevant systematic reviews, research evidence and the opinion of experts and experienced practitioners.MethodologyThe methodological approach is based on the international standards set out by the Appraisal of Guidelines Research and Evaluation (AGREE) Collaboration (www.agreetrust.org). The guiding principle for developing guidance within SDCEP is to first source existing guidelines, policy documents, legislation or other recommendations. Similarly, relevant systematic reviews are also initially identified. These documents are appraised for their quality of development, evidence base and applicability to the remit of the guidance under development. In the absence of these documents or when supplementary information is required, other published literature and unpublished work may be sought.Review and updatingThe guidance will be reviewed in three years and updated accordingly.RecommendationsRecommendations are provided for assessment and diagnosis; changing patient behaviour; treatment of gingival conditions; periodontal conditions; long term maintenance; management of patients with dental implants; referral and record keeping. The key recommendations highlighted are: Assess and explain risk factors for periodontal diseases to patientsScreen all patients for periodontal diseases at every routine examinationCarry out a full periodontal examination for patients with BPE scores 3, 4 and (*)Use the Oral Hygiene TIPPS (talk, instruct, practise, plan, support) behaviour change strategy to address inadequate plaque removalRaise the issue of smoking cessation where appropriateEncourage patients to modify other lifestyle factors that may impact on their oral healthEnsure the patient is able to perform optimal plaque removalRemove supra-gingival plaque, calculus and stain and sub-gingival depositsEnsure that local plaque retentive factors are correctedRemove supra-gingival plaque, calculus and stain and correct any local plaque retentive factors. Carry out root surface instrumentation at sites ?4 mm probing depth where sub-gingival deposits are present or which bleed on probingDo not use antimicrobial medication to treat chronic periodontitisRemove supra-gingival plaque, calculus and stain and sub-gingival deposits and ensure that local plaque retentive factors are correctedAssign an individual's risk level based on the patient's medical history and oral health status and schedule recall appointments accordinglyEnsure the patient is able to perform optimal plaque removal around the dental implant(s)Examine the peri-implant tissues for signs of inflammation and bleeding on probing and/or suppuration and remove supra- and sub- mucosal plaque and calculus deposits and excess residual cementPerform radiographic examination only where clinically indicatedConsult any locally produced referral guidelines and the BSP 'Referral Policy and Parameters of Care' to determine if the patient is a suitable candidate for referralCarry out initial therapy to address inadequate plaque removal, smoking status (if applicable) and to remove supra- and sub-gingival depositsProvide supportive periodontal therapy and monitoring for patients who have been discharged from secondary careRecord the results of the periodontal examinations (basic and/or full) carried out and the current standard of oral hygieneRecord the diagnosis, suggested treatment plan
Matthews, Debora C
This paper summarizes the views of Australian health care chaplains concerning their role and involvement in patient\\/family health care treatment decisions. In general terms the findings indicated that the majority of chaplains surveyed believed that it was part of their pastoral role to help patients and their families make decisions about their health care treatment. Differences in involvement of volunteer
Lindsay B. Carey; Jeffrey Cohen
Inappropriate treatment of people with dementia in residential and day care
Dependence on the help provided by other people increases the risk of a person being inappropriately treated. Our objective was to investigate inappropriate treatment and its context in the care of people with dementia. Some 85 clients across eight care units providing dementia care were observed by means of a structured Dementia Care Mapping method (DCM). Of the 17 DCM
Saila Sormunen; Päivi Topo; Ulla Eloniemi-Sulkava; Outi Räikkönen; Anneli Sarvimäki
Child-related dimensions of placement stability in treatment foster care
Research shows increasing numbers of emotionally disturbed children entering foster care nationwide. As a result, there is growing interest in a special form of foster care known as therapeutic or treatment foster care. However, little information is currently available on the kinds of children who can benefit from this form of mental health care or on interactions between child characteristics
Martha Morrison Dore; Eleanor Eisner
Buprenorphine diversion and misuse in outpatient practice.
: This case is an amalgamation of several real patients in office-based treatment for prescription opioid dependence synthesized into a single theoretical case. The case illustrates the various ways in which medication diversion and misuse may be encountered in clinical practice and therapeutic responses designed to maximize positive treatment outcomes. It is followed by discussions from several expert addiction medicine providers from 3 different countries, giving their perspectives on the salient aspects of this case. This case conference should be of particular interest to clinicians working with opioid-dependent patients in an outpatient setting. PMID:25221985
Lofwall, Michelle R; Martin, Judith; Tierney, Matt; Fatséas, Mélina; Auriacombe, Marc; Lintzeris, Nicholas
Objective This study was undertaken to evaluate the adequacy of a hospital formulated oral morphine preparation for management of neonatal\\u000a abstinence syndrome (NAS) and to compare clinical features in infants exposed to methadone or buprenorphine in utero. Method Between October 1998 and October 2004 all infants born to mothers treated with buprenorphine or methadone during pregnancy\\u000a were enrolled into this prospective
Nathalie Colombini; Riad Elias; Muriel Busuttil; Myriam Dubuc; Marie-Ange Einaudi; Martine Bues-Charbit
Nanocarriers and nanoparticles for skin care and dermatological treatments
Nanotechnology (nano: One billionth) is a novel arena with promising applications in the field of medicine, especially pharmaceuticals for safe and targeted drug delivery. The skin is a phenomenal tool for investigation of nanocarriers for drug delivery for topical and dermatological application. The physicochemical characteristics of the nanoparticles, such as rigidity, hydrophobicity, size and charge are crucial to the skin permeation mechanism. Many nanocarriers such as polymeric, inorganic and lipid nanoparticles and nanoemulsions have been developed and some like carbon nanotubes and fullerenes still need further exploration for future use in skin care and dermatological treatments. Risks of nanopollution and cytotoxicity also need to be kept in mind while exploring various nanoparticles for medical use. PMID:24350003
Gupta, Sanjeev; Bansal, Radhika; Gupta, Sunita; Jindal, Nidhi; Jindal, Abhinav
Increasing interest has been shown in shared decision making (SDM) to improve mental health care communication between underserved immigrant minorities and their providers. Nonetheless, very little is known about this process. The following is a qualitative study of fifteen primary care providers at two Federally Qualified Health Centers in New York and their experience during depression treatment decision making. Respondents described a process characterized in between shared and paternalistic models of treatment decision making. Barriers to SDM included discordant models of illness, stigma, varying role expectations and decision readiness. Respondents reported strategies used to overcome barriers including understanding illness perceptions and the role of the community in the treatment process, dispelling stigma using cultural terms, orienting patients to treatment and remaining available regarding the treatment decision. Findings from this study have implications for planning SDM interventions to guide primary care providers through treatment engagement for depression. PMID:24104206
Patel, Sapana R; Schnall, Rebecca; Little, Virna; Lewis-Fernández, Roberto; Pincus, Harold Alan
The challenge: streamlining HIV treatment and care while improving outcomes
ART coverage among HIV-positive population varies, depending on the countries, between 10% (e.g. Indonesia) and 65% (Botswana). Death rates and new HIV infections have been linked to ART coverage. Therefore, streamlining tasks and roles to expand treatment and care and to provide quality and equitable health is an ongoing concern globally. One concept that has been applied to improve the delivery of HIV services is that of task shifting. Defined as the systematic delegation of tasks from doctors to cadre with less training such as nurses or lay workers, task shifting has been used as an effective strategy to address the current healthcare worker shortage in many African countries. A body of literature supports the use of task shifting as a successful approach in delivering healthcare services including HIV testing, counselling and ART treatment. In addition, in a time of economic burden and scare resources, task shifting may also help to relieve the situation. This concern is highlighted in recommendation of WHO to strengthen and expand human capacity among healthcare workers. The major issues that are raised are: How can task shifting be implemented in a way that is sustainable? How can clinical care services be organized to maximize the potential of the task-shifting approach while ensuring safety, efficiency and effectiveness? What preconditions must be met, what are the country-specific factors that will guide decision-making in the implementation of task shifting? In addition, task shifting should be implemented alongside other efforts to increase the numbers of skilled health workers. Quality assurances mechanisms should provide the necessary checks balances to protect both service users and health workers. PMID:25394002
Clumeck, Nathan
Increasing numbers of patients are treated in integrated primary care mental health programs. The current study examined predictors of satisfaction with treatment in patients from a randomized clinical trial of late-life generalized anxiety disorder (GAD) in primary care. Higher treatment satisfaction was associated with receiving CBT rather than enhanced usual care. Treatment credibility, treatment expectancies, social support, and improvements in depression and anxiety symptoms predicted higher treatment satisfaction in the total sample. In the CBT group, only credibility and adherence with treatment predicted satisfaction. This suggests that older patients receiving CBT who believe more strongly in the treatment rationale and follow the therapist's recommendations more closely are likely to report satisfaction at the end of treatment. In addition, this study found that adherence mediated the relationship between treatment credibility and treatment satisfaction. In other words, patients' perceptions that the treatment made sense for them led to greater treatment adherence which then increased their satisfaction with treatment. PMID:23434724
Hundt, Natalie E.; Armento, Maria E. A.; Porter, Bennett; Cully, Jeffrey A.; Kunik, Mark E.; Stanley, Melinda
Comparative pharmacokinetics of intravenous fentanyl and buprenorphine in healthy greyhound dogs.
The purpose of this study was to compare the pharmacokinetics of two highly protein-bound, lipophilic opioid drugs. Fentanyl (10 ?g/kg) and buprenorphine (20 ?g/kg) were administered intravenously (IV) to six healthy greyhound dogs (three males and three females). The doses were based on clinically administered doses for dogs. Plasma drug concentrations were determined using liquid chromatography with mass spectrometry, and noncompartmental pharmacokinetics were estimated with computer software. The volume of distribution (area) was larger for fentanyl (7.42 L/kg) compared to buprenorphine (3.54 L/kg). The plasma clearance of fentanyl (38.6 mL·min/kg) was faster than buprenorphine (10.3 mL·min/kg). The terminal half-life of fentanyl (2.22 h) was shorter than buprenorphine (3.96 h). Despite similar physicochemical properties including octanol-water partition coefficient and pKa, the pharmacokinetics of fentanyl and buprenorphine were not similar. Both fentanyl (84%) and buprenorphine (95-98%) are considered highly protein bound, but the differences in protein binding may contribute to the lack of similarity of pharmacokinetics in healthy dogs. PMID:24684621
KuKanich, B; Allen, P
Managing Mental Health Problems in Everyday Life: Drug Treatment Client's Self-Care Strategies
ERIC Educational Resources Information Center
Little is understood about the self-care activities undertaken by drug treatment clients. Using data from a qualitative study of drug treatment and mental health we identify the self-care practices of drug treatment clients diagnosed with anxiety and depression. Seventy-seven participants were interviewed in four sites across Australia.…
Holt, Martin; Treloar, Carla
Managing Mental Health Problems in Everyday Life: Drug Treatment Clients' Self-Care Strategies
Little is understood about the self-care activities undertaken by drug treatment clients. Using data from a qualitative study\\u000a of drug treatment and mental health we identify the self-care practices of drug treatment clients diagnosed with anxiety and\\u000a depression. Seventy-seven participants were interviewed in four sites across Australia. Participants described a range of\\u000a self-care practices for mental health including: self-medication, seeking
Martin Holt; Carla Treloar
Using Motivational Interviewing as a Supplement to Obesity Treatment: A Stepped-Care Approach
Objective: This investigation was designed to improve behavioral weight loss program (BWLP) treatment outcomes by providing stepped care (SC) to individuals experiencing difficulties with weight loss during treatment. SC entails transition to more intensive treatments when less intensive treatments fail to meet treatment goals. In a BWLP, motivational interviewing (MI) may increase participants' motivation toward behavioral change and thus complement
Robert A. Carels; Lynn Darby; Holly M. Cacciapaglia; Krista Konrad; Carissa Coit; Jessica Harper; Mary E. Kaplar; Kathleen Young; Chelsea A. Baylen; Amelia Versland
Individuals with alcohol and/or drug use disorders often fail to receive care, or evidence-based care, yet the literature shows health economic benefits. Comparative effectiveness research is emerging that examines approved approaches in terms of real, total healthcare cost/utilization. Comprehensive retrospective insurance claims analyses are few but tend to be nationally distributed and large. The emerging pattern is that, while treatment in general is cost effective, specific therapeutics can yield different health economic outcomes. Cost/utilization data consistently show greater savings with pharmacotherapies (despite their costs) versus psychosocial treatment alone. All FDA-approved addiction pharmacotherapies (oral naltrexone, extended-release naltrexone, acamprosate, disulfiram, buprenorphine, buprenorphine/naloxone, and methadone) are intended for use in conjunction with psychosocial management, not as stand-alone therapeutics; hence, pharmacotherapy costs must offer benefits in addition to abstinence alone or psychological therapy. Patient persistence is problematic, and (despite its cost) extended-release pharmacotherapy may be associated with lower or no greater total healthcare cost, mostly due to reduced hospitalization. The reviewed studies use rigorous case-mix adjustment to balance treatment cohorts but lack the randomization that clinical trials use to protect against confounding. Unlike trials, however, these studies can offer generalizability to diverse populations, providers, and payment models-and are of particular salience to payers. PMID:25236185
Gastfriend, David R
BACKGROUND There is growing evidence about illicit use of buprenorphine in the U.S. The study aims to: 1) identify prevalence and predictors of illicit buprenorphine use in a community sample of 396 young adult (18-23 years old) non-medical users of pharmaceutical opioids; 2) describe knowledge, attitudes and behaviors linked to illicit buprenorphine use as reported by a qualitative sub-sample (n=51). METHODS Participants were recruited using respondent-driven sampling. Qualitative interview participants were selected from the larger sample. The sample (n=396) was 54% male and 50% white; 7.8% reported lifetime illicit use of buprenorphine. RESULTS Logistic regression analysis results indicate that white ethnicity, intranasal inhalation of pharmaceutical opioids, symptoms of opioid dependence, and a greater number of pharmaceutical opioids used in lifetime were statistically significant predictors of illicit buprenorphine use. Qualitative interviews revealed that buprenorphine was more commonly used by more experienced users who were introduced to it by their "junkie friends." Those who used buprenorphine to self-medicate withdrawal referred to it as a "miracle pill." When used to get high, reported experiences ranged from "the best high ever" to "puking for days." Participants reported using buprenorphine/naloxone orally or by intranasal inhalation. Injection of buprenorphine without naloxone was also reported. CONCLUSION Our findings suggest that illicit buprenorphine use is gaining ground primarily among whites and those who are more advanced in their drug use careers. Continued monitoring is needed to better understand evolving patterns and trends of illicit buprenorphine use. PMID:22036303
Daniulaityte, Raminta; Falck, Russel; Carlson, Robert G.
Abstract Objectives The effectiveness of treatments for youth depression in primary care, under usual practice conditions, is largely unstudied. This study aims at estimating the effect of "appropriate treatment," defined as treatment that approximates guideline standards, on clinical outcomes for depressed primary care youth patients by using observational analyses from a randomized trial. Methods Participants were 344 youths aged 13–21 enrolled in the Youth Partners in Care trial. Youths screening positive for depression from six primary care practices in five different health care organizations were randomly assigned to either (1) usual care enhanced by provider education on depression evaluation and management, or (2) a quality improvement (QI) intervention designed to improve access to antidepressant medications and/or cognitive behavior therapy for depression; usual practice conditions otherwise applied. Observational analysis was conducted on the effects of appropriate treatment (antidepressant medication use by algorithms or 6 or more psychotherapy visits) on severe depression (Center for Epidemiologic Studies-Depression score ?24) at 6 months. Selection into treatment is accounted for by using instrumental variables analysis, with randomized QI intervention status as the instrument. Results At 6 months, youths receiving "appropriate treatment," compared with others, were significantly less likely to have severe depression (10.9% vs. 45.2%, p<0.0001). Similar findings were observed among youths with depressive disorders and sub-syndromal depressive symptoms, and among Latino and other youths. Conclusions Among depressed primary care youths, care that approximates guideline standards but retains leniency substantially reduces the likelihood of severe depression at 6 months. Such findings apply to youths with or without depressive disorder, and among Latino youth. PMID:22251025
Wells, Kenneth B.; Tang, Lingqi; Carlson, Gabrielle A.
Confidentiality protections versus collaborative care in the treatment of substance use disorders
Practitioners in federally-assisted substance use disorder (SUD) treatment programs are faced with increasingly complex decisions when addressing patient confidentiality issues. Recent policy changes, intended to make treatment more available and accessible, are having an impact on delivery of SUD treatment in the United States. The addition of electronic health records provides opportunity for more rapid and comprehensive communication between patients' primary and SUD care providers while promoting a collaborative care environment. This shift toward collaborative care is complicated by the special protections that SUD documentation receives in SUD treatment programs, which vary depending on what care is provided and the setting where the patient is treated. This article explores the special protections for substance abuse documentation, discrepancies in treatment documentation, ways to deal with these issues in clinical practice, and the need for more knowledge about how to harmonize treatment in the SUD and primary care systems. PMID:23972141
Pilot Study of Behavioral Treatment in Dementia Care Units.(practice Concepts)(author Abstract)
ERIC Educational Resources Information Center
Purpose: This article reports on the development and use of behavioral treatment as a well-being intervention for individuals with dementia residing at special care units in a nursing home. Design and Methods: The project took place upon the construction and opening of two new homelike units for dementia care in a rural community-care center.…
Lichtenberg, Peter A.; Kemp-Havican, Julie; MacNeill, Susan E.; Johnson, Amanda Schafer
This study evaluated primary care providers' (PCPs, pediatricians, and nurse practitioners) knowledge, current practices, and perceived barriers to childhood obesity prevention and treatment, with an emphasis on first-year well-child care visits. A questionnaire was distributed to 192 PCPs in the primary care network at The Children's Hospital of Philadelphia (CHOP) addressing (i) knowledge of obesity and American Academy of Pediatrics
Jordan G. Spivack; Maggie Swietlik; Evaline Alessandrini; Myles S. Faith
ERIC Educational Resources Information Center
The chronic and relapsing nature of substance abuse points to the need for continuing care after a primary phase of treatment. This article reviews the economic studies of continuing care, discusses research gaps, highlights some of the challenges of conducting rigorous economic evaluations of continuing care, and offers research guidelines and…
Popovici, Ioana; French, Michael T.; McKay, James R.
ERIC Educational Resources Information Center
Preventing adolescent pregnancy is a national research priority that has had limited success. In the present study, the authors examined whether Multidimensional Treatment Foster Care (MTFC) relative to intervention services as usual (group care [GC]) decreased pregnancy rates among juvenile justice girls mandated to out-of-home care. Girls (13-17…
Kerr, David C. R.; Leve, Leslie D.; Chamberlain, Patricia
The primary care setting is considered the entry point of adolescents with mental illness in the health care system. This article informs primary care providers about the diagnostic features and differential of mood disorders in adolescents, screening and assessment, as well as evidence-based psychosocial and psychopharmacologic therapies. The article also provides a framework for decision making regarding initiating treatment in the primary care setting and referral to mental health services. Furthermore, the article highlights the importance of the collaboration between primary care and mental health providers to facilitate engagement of adolescents with mood disorders and adherence to treatment. PMID:25124208
Neves, Marilia G; Leanza, Francesco
Stepped-care in obesity treatment: Matching treatment intensity to participant performance
This investigation examined the effectiveness of a self-help (SH), stepped-care (SC) weight loss program. Based on a failure to achieve pre-assigned weight loss goals, participants were eligible to be stepped-up from a SH program to two levels of treatment intensity (weight loss group [WLG]; individual counseling [IC]) beyond SH. The primary outcome was change in body weight. Fifty-three overweight/obese adults (BMI?27 kg/m2; mean BMI of 37.3, SD=6.6, 89% Caucasian, and 77% female) participated in an 18-week weight loss intervention. During several phases of the investigation, those stepped-up to more intensive treatment lost comparable weight to those who were not stepped-up. Nevertheless, by the end of treatment, individuals who remained in SH (M = 8.6%) lost a significantly greater percentage of weight than individuals who received SH+IC (M = 4.7%; p<.05) and individuals in SH+IC lost a significantly greater percentage of weight than individuals who received SH+WLG+IC (M = 1.6%; p<.05). While some individuals benefited from being stepped-up to greater intensity treatment, other individuals experienced little benefit. The application of SC principles to the treatment of obesity needs further study. PMID:22365792
Carels, Robert A.; Young, Kathleen M.; Hinman, Nova; Gumble, Amanda; Koball, Afton; Oehlhof, Marissa Wagner; Darby, Lynn
Stepped-care in obesity treatment: matching treatment intensity to participant performance.
This investigation examined the effectiveness of a self-help (SH), stepped-care (SC) weight loss program. Based on a failure to achieve pre-assigned weight loss goals, participants were eligible to be stepped-up from a SH program to two levels of treatment intensity (weight loss group [WLG]; individual counseling [IC]) beyond SH. The primary outcome was change in body weight. Fifty-three overweight/obese adults (BMI?27 kg/m(2); mean BMI of 37.3, SD=6.6, 89% Caucasian, and 77% female) participated in an 18-week weight loss intervention. During several phases of the investigation, those stepped-up to more intensive treatment lost comparable weight to those who were not stepped-up. Nevertheless, by the end of treatment, individuals who remained in SH (M=8.6%) lost a significantly greater percentage of weight than individuals who received SH+IC (M=4.7%; p<.05) and individuals in SH+IC lost a significantly greater percentage of weight than individuals who received SH+WLG+IC (M=1.6%; p<.05). While some individuals benefited from being stepped-up to greater intensity treatment, other individuals experienced little benefit. The application of SC principles to the treatment of obesity needs further study. PMID:22365792
Carels, Robert A; Young, Kathleen M; Hinman, Nova; Gumble, Amanda; Koball, Afton; Oehlhof, Marissa Wagner; Darby, Lynn
Effect of Rifampin and Nelfinavir on the Metabolism of Methadone and Buprenorphine in Primary that primary cultures of human hepato- cytes could predict potential drug interactions with methadone, or nelfinavir before incubation with methadone or buprenorphine. Culture me- dia (0Â60 min) was analyzed
Omiecinski, Curtis
Objective To estimate the impact of chronic medical conditions on depression diagnosis, treatment, and follow-up care in primary care settings. Design This was a cross-sectional study that used interviewer-administered surveys and medical record reviews. Three hundred fifteen participants were recruited from 3 public primary care clinics. Depression diagnosis, guideline-concordant treatment, and follow-up care were the primary outcomes examined in individuals with depression alone compared with individuals with depression and chronic medical conditions measured using the Charlson Comorbidity Index (CCI). Results Physician diagnosis of depression (32.6%), guideline-concordant depression treatment (32.7%), and guideline-concordant follow-up care (16.3%) were all low. Logistic regression analysis showed no significant difference in the likelihood of depression diagnosis, guideline-concordant treatment, or follow-up care in individuals with depression alone compared with those with both depression and chronic medical conditions. Participants with severe depression were, however, twice as likely to receive a diagnosis of depression as participants with moderate depression. In addition, participants with moderately severe and severe depression received much less appropriate follow-up care than participants with moderate depression. Among participants receiving a depression diagnosis, 74% received guideline-concordant treatment. Conclusion Physician depression care in primary care settings is not influenced by competing demands for care for other comorbid medical conditions. PMID:19264935
Ani, Chizobam; Bazargan, Mohsen; Hindman, David; Bell, Douglas; Rodriguez, Michael; Baker, Richard S.
Buprenorphine (BPN) is widely used as a substitution treatment for opioid addiction. Some cases of abuse and misuse, especially associated with various benzodiazepines (BZDs), have been described, and a previous study has shown that BZDs increase the sedative effect of BPN and decrease its anxiogenic properties. To investigate the reward effect that may lead to the abusive combination of BPN and BZD, we studied the influence of different doses of three BZDs extensively used with BPN by drug addicts on conditioned place preference behavior in mice. BPN (0.3, 1, 3 mg/kg) was injected subcutaneously into male mice alone or in combination with a BZD administered intraperitoneally: dipotassium clorazepate (CRZ; 1, 4, 16 mg/kg), diazepam (DAZ; 0.5, 1, 5 mg/kg), or bromazepam (BMZ; 0.5, 1, 3 mg/kg). Amphetamine (8 mg/kg) was used as a reference drug. Reward effects of BPN alone or in combination were measured in a conditioned place preference paradigm using an unbiased procedure. Our results showed that groups treated with BPN associated with different doses of diazepam and clorazepate, but not bromazepam, spent significantly more time in the drug-paired compartment compared to the group treated with BPN alone. Our study shows that joint consumption of diazepam and clorazepate, but not bromazepam, can increase the reward properties of BPN alone in mice. These results could help to explain the use of this type of drug combination in the drug addict population. PMID:24617653
Ma, Lin-Lin; Freret, Thomas; Lange, Mathilde; Bourgine, Joanna; Coquerel, Antoine; Lelong-Boulouard, Véronique
Increasing rates of maternal opioid use during pregnancy and neonatal withdrawal, termed neonatal abstinence syndrome (NAS), are public health concerns. Prenatal buprenorphine maintenance treatment (BMT) versus methadone maintenance treatment (MMT) may improve neonatal outcomes, but associations vary. To summarize evidence, we used a random-effects meta-analysis model and estimated summary measures of BMT versus MMT on several outcomes. Sensitivity analyses evaluated confounding, publication bias, and heterogeneity. Subjects were 515 neonates whose mothers received BMT and 855 neonates whose mothers received MMT and who were born from 1996 to 2012 and who were included in 12 studies. The unadjusted NAS treatment risk was lower (risk ratio=0.90, 95% confidence interval (CI): 0.81, 0.98) and mean length of hospital stay shorter (-7.23 days, 95% CI: -10.64, -3.83) in BMT-exposed versus MMT-exposed neonates. In treated neonates, NAS treatment duration was shorter (-8.46 days, 95% CI: -14.48, -2.44) and morphine dose lower (-3.60 mg, 95% CI: -7.26, 0.07) in those exposed to BMT. BMT-exposed neonates had higher mean gestational age and greater weight, length, and head circumference at birth. Fewer women treated with BMT used illicit opioids near delivery (risk ratio=0.44, 95% CI: 0.28, 0.70). Simulations suggested that confounding by indication could account for some of the observed differences. Prenatal BMT versus MMT may improve neonatal outcomes, but bias may contribute to this protective association. Further evidence is needed to guide treatment choices. PMID:25150272
Brogly, Susan B; Saia, Kelley A; Walley, Alexander Y; Du, Haomo M; Sebastiani, Paola
Treatment Research in Mental Illness: Improving the Nation's Public Mental Health Care
Treatment Research in Mental Illness: Improving the Nation's Public Mental Health Care through NIMH of treatments for mental illnesses in the U.S. The NIMH, through the Division of Services and Intervention, pharmacological, and psychosocial treatment modalities for the treatment of mental disorders and behavioral
Baker, Chris I.
The goal of the current study was to compare the efficacy, adverse effects, and plasma buprenorphine concentrations of sustained-release buprenorphine (SRB) and buprenorphine after subcutaneous administration in dogs undergoing ovariohysterectomy. In a prospective, randomized, blinded design, 20 healthy adult female Beagle dogs underwent routine ovariohysterectomy and received multimodal analgesia consisting of meloxicam and one of two buprenorphine formulations. Dogs were randomly assigned to receive either SRB (0.2 mg/kg SC, once) or buprenorphine (0.02 mg/kg SC every 12 h for 3 d). Blinded observers assessed all dogs by using sedation scores, pain scores, temperature, HR, RR, and general wellbeing. Dogs were provided rescue analgesia with 0.02 mg/kg buprenorphine SC if the postoperative pain score exceeded a prede- termined threshold. Blood samples were collected, and mass spectrometry was used to determine plasma buprenorphine concentrations. Data were analyzed with a linear mixed model and Tukey-Kramer multiple comparison. Age, body weight, anesthetic duration, surgical duration, sevoflurane concentration, and cardiorespiratory variables did not differ significantly between groups. Dogs in both formulation groups had comparable postoperative sedation and pain scores. One dog from each formulation group had breakthrough pain requiring rescue analgesia. Plasma buprenorphine concentrations remained above a hypothesized therapeutic concentration of 0.6 ng/mL for 136.0 ± 11.3 and 10.67 ± 0.84 h for SRB and buprenorphine, respectively. Based on the results of this study, multimodal analgesic regimens consisting of meloxicam and either buprenorphine or SRB are equally efficacious in managing pain associated with an ovariohysterectomy and show comparable side effects. PMID:25255072
Nunamaker, Elizabeth A; Stolarik, Deanne F; Ma, Junli; Wilsey, Amanda S; Jenkins, Gary J; Medina, Chris L
This paper presents findings from a structured review of treatment models that are relevant to group care and residential treatment settings for children involved with the child welfare system. Initiated and guided by The California Evidence-Based Clearinghouse for Child Welfare, five treatment models – Positive Peer Culture, Teaching Family Model, Sanctuary Model, Stop-Gap Model, and Re-ED – were reviewed for effectiveness. In this paper, each model s treatment features are described and relevant outcome studies reviewed in terms of their effectiveness as well as relevance for child welfare practice. Findings indicate that four of the models are either supported or promising in terms of evidence for effectiveness. Implications for group care practice and research are discussed. PMID:22468014
James, Sigrid
Background The aim of this study was to compare the efficacy and safety of sublingual buprenorphine with intravenous morphine sulfate for acute renal colic in the emergency department. Methods In this double-dummy, randomized controlled trial, we enrolled patients aged 18 to 55 years who had a clinical diagnosis of acute renal colic. Patients received either 2 mg sublingual buprenorphine with an IV placebo, or 0.1 mg/kg IV morphine sulfate with a sublingual placebo. Subjects graded their pain with a standard 11-point numeric rating scale (NRS) before medication administration and 20 and 40 minutes after that. The need for rescue analgesia and occurrence of side effects were also recorded in the two groups. Results Of 69 patients analyzed, 37 had received buprenorphine, and 32 had taken morphine. Baseline characteristics were similar in both groups. NRS pain scores were reduced across time by administration of both buprenorphine (from 9.8 to 5.22 and then 2.30) and morphine (from 9.78 to 4.25 and then 1.8), significantly (P <0.0001). The two regimens did not differ significantly for pain reduction (P?=?0.260). Dizziness was more frequently reported by the buprenorphine group (62.1% versus 37.5%, P <0.05) but other adverse effects observed within 40 minutes were similar in the two groups. Conclusions Sublingual buprenorphine (2 mg) is as effective as morphine sulfate (0.1 mg/kg) in acute renal colic pain management. PMID:24386894
Purpose The pharmacokinetics, analgesic efficacy, and irritancy potential of Buprederm™, a new transdermal delivery system of buprenorphine,\\u000a was evaluated.\\u000a \\u000a \\u000a \\u000a Methods Single and multiple dose pharmacokinetic studies were conducted in mice and rabbits. The analgesic efficacy and skin irritation\\u000a potential were determined by tail flick and writhing tests in mice and by the Draize dermal scoring system in rabbits.\\u000a \\u000a \\u000a \\u000a Results Fast absorption of buprenorphine
Dongwon Kim; Jindeog Song; Chang Hoon In; Seung-Wei Jeong; Sang Hun Lee; Bumchan Min; Dongho Lee; Sun-Ok Kim
The use of buprenorphine as an analgesic after rodent embryo transfer.
Many researchers are reluctant to administer analgesia after rodent embryo transfer, primarily out of concern that analgesia will affect embryo implantation. According to the Animal Welfare Act and the Guide, however, embryo transfer constitutes major survival surgery and is likely to cause pain and distress despite its minimally invasive nature. The authors examined the effects of a single dose of the analgesic buprenorphine on mice that underwent embryo transfer. In mice treated with buprenorphine, the number of viable implanted embryos was typically equal to or greater than that in untreated mice. All mice seemed quiet, alert and active after surgery. PMID:18216800
Krueger, Karen L; Fujiwara, Yuko
Mental Illness Stereotypes and Clinical Care: Do People Avoid Treatment Because of Stigma?
Despite evidence that pharmacological and psychosocial treatments yield significant benefits for many psychiatric disorders, many people who might otherwise profit from treatment fail to access care or do not fully adhere to services once they are begun. One interpretation of a health belief model suggests that the stigma of mental illness and corresponding treatments is a significant, perceived cost that
Patrick W. Corrigan; Nicolas Rüsch
Antiretroviral HIV treatment and care for injecting drug users: an evidence-based overview
1 COMMENTARY Antiretroviral HIV treatment and care for injecting drug users: an evidence the advent of highly-active antiretroviral treatment (HAART). The overall benefit from antiretroviral HIV treatment has, however, been lesser in HIV-infected IDUs than in other patient groups (e.g. men who have sex
Paris-Sud XI, Université de
Afrocentric treatment in residential substance abuse care. The Iwo San.
Alcohol and other drug treatment programs continue to report relatively low success rates among African-American participants. We propose that there is a need to consider treatment approaches that are more culturally competent. An Afrocentric paradigm is suggested and instituted as the central theme of a residential drug treatment program. Elements of an Afrocentric orientation and how these principles are used to guide the development of a treatment philosophy are discussed. PMID:9218242
Jackson, M S; Stephens, R C; Smith, R L
Service Delivery in Substance Abuse Treatment: Reexamining "Comprehensive" Care
Substance abuse treatment clients present with an array of service needs in various life domains. Ideal models of addiction\\u000a treatment incorporate provision or linkages to services to meet clients' multiple needs; in turn, these wraparound and supportive\\u000a services are associated with improvements in client retention and treatment outcomes. Using data from large samples of specialty\\u000a addiction treatment providers in the
Lori J. Ducharme; Heather L. Mello; Paul M. Roman; Hannah K. Knudsen; J. Aaron Johnson
Recent discussion in the adolescent treatment community has centered on the therapeutic merits of continuum of care treatment for adolescent and young adult substance abusing populations. However, despite this discussion, few studies to date have actually looked at how adolescents and young adults view continuum of care treatment in practice. In this paper a continuum of care offered within a
Tanya Hedges Duroy; Sarah L. Schmidt; Patricia D. Perry
Background. As prevention of mother-to-child transmission of HIV (PMTCT) programs and HIV treatment programs rapidly expand in parallel, it is important to determine factors that influence the transition of HIV-infected women from maternal to continuing care. Design. This study aimed to determine rates and co-factors of accessing HIV care by HIV-infected women exiting maternal care. A cross-sectional survey of women
Phelgona A. Otieno; Pamela K. Kohler; Rose K. Bosire; Elizabeth R. Brown; Steven W. Macharia; Grace C. John-Stewart
Stepped care treatment for depression and anxiety in primary care. a randomized controlled trial
Background Depressive and anxiety disorders are common in general practice but not always treated adequately. Introducing stepped care\\u000a might improve this. In this randomized trial we examined the effectiveness of such a stepped care model.\\u000a \\u000a \\u000a \\u000a \\u000a Methods The study population consisted of primary care attendees aged 18-65 years with minor or major DSM-IV depressive and\\/or anxiety\\u000a disorders, recruited through screening. We randomized 120
Wike Seekles; Annemieke van Straten; Aartjan Beekman; Harm van Marwijk; Pim Cuijpers
Treatment Foster Care for Improving Outcomes in Children and Young People: A Systematic Review
ERIC Educational Resources Information Center
Objective: To assess the impact of treatment foster care (TFC) on psychosocial and behavioral outcomes, delinquency, placement stability, and discharge status for children and adolescents who, for reasons of severe medical, social, psychological and behavioural problems, were placed in out-of-home care in restrictive settings or at risk of…
Turner, William; Macdonald, Geraldine
Hip fracture treatments--what happens to patients from residential care?
Hip fractures are a growing problem and new models of care have been called for. However, patients from residential care are rarely considered in these discussions. Hip fracture is a common serious problem for older people in residential care with profound effects on subsequent mobility and quality-of-life. There are no Australian data documenting differences in hospital treatments offered to patients from the community and residential care to inform discussions. In a prospective audit we describe the treatment and 4 month outcomes of patients with fractured hips who were admitted to Flinders Medical Centre in South Australia from the community and residential care between August 1998 and June 1999. Information was collected on prefracture health, types of surgical and rehabilitation treatments and dependency. Of the 215 older adults who were admitted during this time, 183 agreed to participate (119 from community and 64 from residential care). Surgical management of the fracture was not affected by admission accommodation. Those from residential care had short hospital stays, less rehabilitation and access to physiotherapy. Although 61% of those from residential care were classified as independently mobile prefracture, by 4 months this had declined to 32% of survivors. Strategies to improve outcomes in those from residential care include: early identification of those walking independently prefracture with assessment by rehabilitation teams. Inclusion of liaison with community therapists in the clinical pathway and in selected cases use of 'rehabilitation at home' services to provide physiotherapy services should be considered. PMID:11207957
Crotty, M; Miller, M; Whitehead, C; Krishnan, J; Hearn, T
The Impact of Publicly Funded Managed Care on Adolescent Substance Abuse Treatment Outcomes
This study compares the 12-month changes in substance use following admission to substance abuse treatment in Massachusetts between adolescents enrolled in Medicaid managed care and other publicly funded adolescents. Two hun- dred and fifty-five adolescents were interviewed as they entered substance abuse treatment and at 6 and 12 month follow-ups. Medicaid enrollment data were used to determine the managed care
Brooke S. Harrow; Christopher P. Tompkins; Paul D. Mitchell; Kevin W. Smith; Stephen Soldz; Linda Kasten; Kathleen Fleming
Objectives To determine oral health status, dental treatment needs, and to identify barriers that prevent easy access to dental care by elderly care home residents in Lodz. Background Studies in many countries show that oral health status of elderly care home residents is poor and there is an urgent need to improve it. Methods The study included 259 care home residents, aged 65 years and older. The oral examination was performed. In face-to-face interviews, subjects were asked about frequency of cleaning teeth and/or dentures, whether they needed assistance, and whether the assistance was available; they were also asked about the perceived dental needs, and about the time since their last visit to a dentist and the purpose of the visit. If they had not visited the dentist in the past 12 months, they were asked about reasons for failing to visit the dentist. Results Forty-six percent of the subjects were edentulous. Only 5.8% of all participants had a sufficient number of functional natural teeth. Dental treatment was found to be necessary in 59.8% of the respondents. One in four subjects reported reduced ability of correctly cleaning teeth and dentures themselves, of whom only one-third were helped by others. An insufficient level of hygiene was found in every other subject. About 42% of residents had not visited a dentist for over 5 years, mainly due to organizational reasons. Conclusion Expanding the current scope of medical care for the elderly care home residents to include dental care would improve their currently poor oral health status. PMID:25284997
Gaszynska, Ewelina; Szatko, Franciszek; Godala, Malgorzata; Gaszynski, Tomasz
Treatment of hypophosphatemia in the intensive care unit: a review
INTRODUCTION: Currently no evidence-based guideline exists for the approach to hypophosphatemia in critically ill patients. METHODS: We performed a narrative review of the medical literature to identify the incidence, symptoms, and treatment of hypophosphatemia in critically ill patients. Specifically, we searched for answers to the questions whether correction of hypophosphatemia is associated with improved outcome, and whether a certain treatment
Daniël A Geerse; Alexander J Bindels; Michael A Kuiper; Arnout N Roos; Peter E Spronk; Marcus J Schultz
Perioperative Pain Management for Patients on Chronic Buprenorphine: A Case Report
Here we present a patient with a Type I Chiari malformation who was receiving buprenorphine for chronic pain who underwent two separate urogynecologic procedures for removal of vaginal mesh with two different pain management regimens. For the first procedure at an outside hospital, the patient's usual dose of buprenorphine (8 mg sublingual every 8 hours) was continued up through her surgery and then a full opioid receptor agonist was used for postoperative pain management. The patient complained that this resulted in very poor pain control for her in the postoperative period. Prior to her second procedure, which was performed at our institution, buprenorphine was switched to a full opioid agonist (oral hydromorphone 4 mg every 4 to 6 hours, maximum 20 mg per day) for 5 days prior to surgery; postoperative pain was managed with full opioid receptor agonists. The patient again reported suboptimal pain control in spite of substantially increased doses of opioids. This case report highlights the difficulty of perioperative pain management for patients on chronic buprenorphine and emphasizes the need for additional investigation. PMID:24307971
Chern, Sy-Yeu S; Isserman, Rebecca; Chen, Linda; Ashburn, Michael; Liu, Renyu
The amount of opioid users receiving opioid maintenance therapy has increased significantly over the last few years. As a result, an increasing number of children are prenatally exposed to long-lasting opioids such as methadone and buprenorphine. This article reviews the literature on the cognitive development of children born to mothers in opioid maintenance therapy. Topics discussed are the effects of
Carolien Konijnenberg; Annika Melinder
Treatment of Osteoporosis in Long-Term Care
The major determinants of admission at longterm care institutions (LTCI) include severe disability, poor social\\/familial support,\\u000a advanced cognitive impairment, and either sequelae or end stages of chronic diseases such as Alzheimer's disease, diabetes,\\u000a and heart and renal failure. All these conditions have made elderly patients unable to cope with their life in the community\\u000a (1), requiring a higher amount of
Gustavo Duque; Louise Mallet
Television and beliefs about health care and medical treatment
A representative sample of London television viewers answered questions on their attitudes to the quality of medical care\\u000a they might receive if hospitalized, on their beliefs about the scope for control over one's health, on the Just World Scale,\\u000a and on their experience of viewing each of three TV series dealing with health matters. One series is an anodyne soap
Mallory Wober; Barrie Gunter
A costly separation between withdrawing and withholding treatment in intensive care
Ethical analyses, professional guidelines and legal decisions support the Equivalence Thesis for life-sustaining treatment: if it is ethical to withhold treatment, it would be ethical to withdraw the same treatment. In this article we explore reasons why the majority of medical professionals disagree with the conclusions of ethical analysis. Resource allocation is considered by clinicians to be a legitimate reason to withhold but not to withdraw intensive care treatment. We analyse 5 arguments in favour of non-equivalence, and find only relatively weak reasons to restrict rationing to treatment withholding. On the contrary, resource allocation provides a strong argument in favour of equivalence: non-equivalence causes preventable death in critically ill patients. We outline two proposals for increasing equivalence in practice: (1) reduction of the mortality threshold for treatment withdrawal, (2) time-limited trials of intensive care. These strategies would help to move practice towards more rational treatment limitation decisions. PMID:22762352
Wilkinson, DJC; Savulescu, J
A costly separation between withdrawing and withholding treatment in intensive care.
Ethical analyses, professional guidelines and legal decisions support the equivalence thesis for life-sustaining treatment: if it is ethical to withhold treatment, it would be ethical to withdraw the same treatment. In this paper we explore reasons why the majority of medical professionals disagree with the conclusions of ethical analysis. Resource allocation is considered by clinicians to be a legitimate reason to withhold but not to withdraw intensive care treatment. We analyse five arguments in favour of non-equivalence, and find only relatively weak reasons to restrict rationing to withholding treatment. On the contrary, resource allocation provides a strong argument in favour of equivalence: non-equivalence causes preventable death in critically ill patients. We outline two proposals for increasing equivalence in practice: (1) reduction of the mortality threshold for treatment withdrawal, (2) time-limited trials of intensive care. These strategies would help to move practice towards more rational treatment limitation decisions. PMID:22762352
Wilkinson, Dominic; Savulescu, Julian
A role for health communication in the continuum of HIV care, treatment, and prevention.
: Health communication has played a pivotal role in HIV prevention efforts since the beginning of the epidemic. The recent paradigm of combination prevention, which integrates behavioral, biomedical, and structural interventions, offers new opportunities for employing health communication approaches across the entire continuum of care. We describe key areas where health communication can significantly enhance HIV treatment, care, and prevention, presenting evidence from interventions that include health communication components. These interventions rely primarily on interpersonal communication, especially individual and group counseling, both within and beyond clinical settings to enhance the uptake of and continued engagement in care. Many successful interventions mobilize a network of trained community supporters or accompagnateurs, who provide education, counseling, psychosocial support, treatment supervision, and other pragmatic assistance across the care continuum. Community treatment supporters reduce the burden on overworked medical providers, engage a wider segment of the community, and offer a more sustainable model for supporting people living with HIV. Additionally, mobile technologies are increasingly seen as promising avenues for ongoing cost-effective communication throughout the treatment cascade. A broader range of communication approaches, traditionally employed in HIV prevention efforts, that address community and sociopolitical levels through mass media, school- or workplace-based education, and entertainment modalities may be useful to interventions seeking to address the full care continuum. Future interventions would benefit from development of a framework that maps appropriate communication theories and approaches onto each step of the care continuum to evaluate the efficacy of communication components on treatment outcomes. PMID:25007201
Tomori, Cecilia; Risher, Kathryn; Limaye, Rupali J; Van Lith, Lynn M; Gibbs, Susannah; Smelyanskaya, Marina; Celentano, David D
Adherence to HIV and TB Care and Treatment, the Role of Food Security and Nutrition.
Food security and nutrition play an important role in HIV and TB care and treatment, including for improving treatment outcomes, adherence and uptake of HIV and TB care. This AIDS and behaviour supplement on "Adherence to HIV and TB care and treatment, the role of food security and nutrition" provides an overview of the current evidence and knowledge about the barriers to uptake and retention in HIV and TB treatment and care and on whether and how food and nutrition assistance can help overcome these barriers. It contains nine papers on three topic areas discussing: (a) adherence and food and nutrition security in context of HIV and TB, their definitions, measurement tools and the current situation; (b) food and nutrition insecurity as barriers to uptake and retention; and (c) food and nutrition assistance to increase uptake and retention in care and treatment. Future interventions in the areas of food security, nutrition and social protection for increasing access and adherence should be from an HIV sensitive lens, linking the continuum of care with health systems, food systems and the community, complementing existing platforms through partnerships and integrated services. PMID:25092515
Claros, Joan M; de Pee, Saskia; Bloem, Martin W
Background: The aim of this study was to compare the levels of job satisfaction and its predictors among primary health care and treatment sectors' staff in East Azerbaijan Province, Iran. Methods: This comparative study was conducted in East Azerbaijan Province,Iran in 2011. A questionnaire survey was performed on 420 staff from health care and treatment sectors using multi-stage proportional cluster sampling method. Job satisfaction was measured in five aspects namely: structural and managerial; individual; social; work-itself; environmental and welfare job satisfaction factors.The job satisfaction measurement score was normalized to fall into a range of zero to 100. Statistical analyses were performed using Friedman and independent sample t-tests. Results: Overall satisfaction in health and treatment sectors was moderate with a mean score above 50. Hospital General Practitioners reported significantly higher job satisfaction score (mean ± SD=57.34 ± 17.02) compared to health care center General Practitioners (mean ± SD= 31.74±14.99). The highest satisfaction scores belonged to individual factors both in health care sector staff (64.83±18.50) and treatment sector staff (63.55±17.44). The lowest job satisfaction was observed with environmental and welfare factors (38.47±19.86 and 36.83±19.86, respectively). Conclusion: The job satisfaction significantly differs between primary health care and treatment sectors. Based on the results, environmental and welfare factors may be targeted to improve the job satisfaction in public health care system. PMID:24688957
Bagheri, Shokoufe; Janati, Ali; Kousha, Ahmad; Sadeghi-Bazargani, Homayoun; Asghari-Jafarabadi, Mohammad; Farahbakhsh, Mostafa
Health care reforms may offer several opportunities to build the mental health treatment capacity of primary care. Capitalizing on these opportunities requires identifying the types of clinical skills that the primary care team requires to deliver mental health care. This paper proposes a framework that describes mental health skills for primary care receptionists, medical assistants, nurses, nurse practitioners, and physicians. These skills are organized on three levels: cross-cutting skills to build therapeutic alliance; broad-based, brief interventions for major clusters of mental health symptoms; and evidence-based interventions for diagnosis specific disorders. This framework is intended to help inform future mental health training in primary care and catalyze research that examines the impact of such training. PMID:21915748
Brown, Jonathan D; Wissow, Lawrence S
The effects of prenatal exposure to buprenorphine or methadone on infant visual evoked potentials.
This study compared the neurological development of 4 month old infants exposed to buprenorphine or methadone during pregnancy to that of a control group of non-exposed infants. Participants were 30 buprenorphine-maintained women, 22 methadone-maintained women and 33 non opioid-dependent controls, and their infants. Women were enrolled during pregnancy as part of an open-label non-randomised flexible-dosing longitudinal study. Groups were matched for maternal age, parity, gravida, and tobacco and alcohol use. Infant neurological development was assessed by measuring latency of pattern reversal visual evoked potentials (VEP). One-way between groups analyses of variance (ANOVA) were conducted to test the statistical significance of differences between the mean latencies of the peak response to two different sized checkerboard patterns (48' and 69' of retinal arc). Infants prenatally exposed to methadone had significantly prolonged latencies, compared with infants in the control group and infants prenatally exposed to buprenorphine, in response to checks of 48' and 69'. VEP latencies of infants prenatally exposed to buprenorphine did not differ significantly from controls for either check size. After adjustment for covariates, prenatal exposure to methadone remained a significant predictor of VEP response to checks of 48', but not 69'. Maternal self-reported used of marijuana during pregnancy made a significant unique contribution to the variance in P1 latencies for both check sizes. Data from this controlled, non-randomised study suggest that buprenorphine may confer an advantage over methadone as a maintenance drug during pregnancy in terms of infant neural development at 4 months of age. PMID:19751825
Whitham, Justine N; Spurrier, Nicola J; Sawyer, Michael G; Baghurst, Peter A; Taplin, John E; White, Jason M; Gordon, Andrea L
This study compared pressure and thermal thresholds after administration of three opioids in eight cats. Pressure stimulation was performed via a bracelet taped around the forearm. Three ball-bearings were advanced against the forearm by inflation of a modified blood pressure bladder. Pressure in the cuff was recorded at the end point (leg shake and head turn). Thermal threshold was tested as previously reported using a heated probe held against the thorax [Dixon et al. (2002) Research in Veterinary Science, 72, 205]. After baseline recordings, each cat received subcutaneous methadone 0.2 mg/kg, morphine 0.2 mg/kg, buprenorphine 0.02 mg/kg or saline 0.3 mL in a four period cross-over study. Measurements were made at 15, 30, 45 min and 1, 2, 3, 4, 8, 12 and 24 h after the injection. Data were analysed by anova (P<0.05). There were no significant changes in thresholds after saline. Thermal threshold increased at 45 min after buprenorphine (maximum 2.8+/-3 degrees C), 1-3 h after methadone (maximum 3.4+/-1.9 degrees C) and 45 min to 1 h (maximum 3.4+/-2 degrees C) after morphine. Pressure threshold increased 30-45 min (maximum 238+/-206 mmHg) after buprenorphine, 45-60 min after methadone (maximum 255+/-232 mmHg) and 45-60 min and 3-6 h (maximum 255+/-232 mmHg) after morphine. Morphine provided the best analgesia, and methadone appears a promising alternative. Buprenorphines limited effect was probably related to the subcutaneous route of administration. Previously, buprenorphine has produced much greater effects when given by other routes. PMID:17083457
Steagall, P V M; Carnicelli, P; Taylor, P M; Luna, S P L; Dixon, M; Ferreira, T H
Service use and 2-year treatment outcomes were compared between chronically homelessness clients receiving comprehensive housing\\u000a and healthcare services through the federal Collaborative Initiative on Chronic Homelessness (CICH) program (n = 281) a sample of similarly chronically homeless individuals receiving usual care (n = 104) in the same 5 communities. CICH clients were housed an average of 23 of 90 days (52%) more than comparison group
Alvin S. MaresRobert; Robert A. Rosenheck
The Continuing Care Model of Substance Use Treatment: What Works, and When Is "Enough," "Enough?"
There is little disagreement in the substance use treatment literature regarding the conceptualization of substance dependence as a cyclic, chronic condition consisting of alternating episodes of treatment and subsequent relapse. Likewise, substance use treatment efforts are increasingly being contextualized within a similar disease management framework, much like that of other chronic medical conditions (diabetes, hypertension, etc.). As such, substance use treatment has generally been viewed as a process comprised of two phases. Theoretically, the incorporation of some form of lower intensity continuing care services delivered in the context of outpatient treatment after the primary treatment phase (e.g., residential) appears to be a likely requisite if all stakeholders aspire to successful long-term clinical outcomes. Thus, the overarching objective of any continuing care model should be to sustain treatment gains attained in the primary phase in an effort to ultimately prevent relapse. Given the extant treatment literature clearly supports the contention that treatment is superior to no treatment, and longer lengths of stay is associated with a variety of positive outcomes, the more prudent question appears to be not whether treatment works, but rather what are the specific programmatic elements (e.g., duration, intensity) that comprise an adequate continuing care model. Generally speaking, it appears that the duration of continuing care should extend for a minimum of 3 to 6 months. However, continuing care over a protracted period of up to 12 months appears to be essential if a reasonable expectation of robust recovery is desired. Limitations of prior work and implications for routine clinical practice are also discussed. PMID:24839597
Proctor, Steven L.; Herschman, Philip L.
Objective: Australian Indigenous peoples in remote and rural settings continue to have limited access to treatment for mental illness. Comorbid disorders complicate presentations in primary care where Indigenous youths and perinatal women are at particular risk. Despite this high comorbidity there are few examples of successful models of integrated treatment. This paper outlines these challenges and provides recommendations for practice
Tricia Nagel; David Kavanagh; Lesley Barclay; Thomas Trauer; Richard Chenhall; Jennifer Frendin; Carolyn Griffin
ERIC Educational Resources Information Center
Although effective outpatient treatments have been identified for the well-documented negative outcomes associated with delinquency and substance use, effective treatments for youths in out-of-home care are rare. In this study, 12- and 18-month substance use outcomes were examined for a sample of 79 boys who were randomly assigned to…
Smith, Dana K.; Chamberlain, Patricia; Eddy, J. Mark
Anxiety and depressive disorders and symptoms are quite prevalent in older adults as are alcohol problems. Older adults tend to minimize psychological problems and consider psychological symptoms to be related to physical illness. Engagement of the older adult in mental health\\/substance abuse treatment has been found to be more successful if it occurs in collaboration with primary care treatment. Collaboration
Elaine S. Rinfrette
Applying a stepped-care approach to the treatment of obesity
ObjectiveIn a stepped-care (SC) approach to treatment, more intensive interventions are implemented when less intensive interventions prove to be insufficient. It was hypothesized that a behavioral weight loss program with SC (BWLP+SC) would evidence superior treatment outcomes when compared with a BWLP without SC (BWLP).
Robert A. Carels; Lynn Darby; Holly M. Cacciapaglia; Olivia M. Douglass; Jessica Harper; Mary E. Kaplar; Krista Konrad; Sofia Rydin; Karin Tonkin
Proposed Standards of Care for the Treatment of Adult Sex Offenders.
ERIC Educational Resources Information Center
Proposes standards of care for the treatment of adult sex offenders, primarily in outpatient settings. Notes these standards will be presented at the Second International Conference on the Treatment of Sex Offenders in September 1991. Recommends professionals use the standards as minimal criteria for evaluation of the work and document exceptions…
Coleman, Eli; Dwyer, Margretta
[Treatment of fungus infection with diabetic foot--importance of the foot care].
Fungus infection is high frequently complicated of the diabetic foot. Especially onychomycosis make a injury neighbor toe skin or paronychia. This tiny lesion make a bacterial infection, and progress to foot gangrene unfortunately if patient delayed treatment. So it is important to do daily check of the foot and regularly foot care included nail care. Toenail onychomycosis need medicational treatment just after microscopically diagnosis. It is important to check the interaction between the antifungal medicine and other medicine, and side effect after started treatment. PMID:19069095
Shinjo, Takamichi
Older youth preparing to emancipate from the foster care system are often served in residential treatment settings where they have limited opportunities to practice skills for independent living in a community setting. Stepping these youth down to less restrictive environments such as treatment foster care is a growing trend, especially for youth with mental health issues. Yet, few studies have explored the youth's perspective on making this transition. This study utilized qualitative interviews with youths who were participating in a treatment foster care intervention study (n=8) to gain their perspectives on the process of transitioning from residential care. Youths were interviewed right before they exited residential care and two months after placement in the new foster home. Youths reported hopes for gaining family in the new home as well as fears of placement disruption. Findings point to the need to enlist youths in discussion and problem solving about difficulties they anticipate in the new home and expectations for their relationship with the new foster parents. In addition, the struggles described after two months in the home point to the need for youths to build specific skills to better manage ongoing relationships with foster parents and for foster parent training on how to help build these skills. PMID:22247580
Narendorf, Sarah Carter; Fedoravicius, Nicole; McMillen, J. Curtis; McNelly, David; Robinson, Debra R.
. From the Anthropology Department, National Museum of Natural History, Smithsonian Institution ABSTRACT; · characterizes the properties of modern handmade Chinese "Hsuan (Xuan)" and "Pi" papers (used in Asian Painting an opportunity to investigate the history and technology of Chinese paper in order to aid treatment development
Mathis, Wayne N.
Background and Purpose—The aim of the study was to compare the effect of conventional treatment with the effect of acute stroke unit care integrated with geriatric stroke unit care continuum. Methods—A 1-year study was undertaken with 2:1 randomization to stroke unit care or conventional care, with assessment by an independent team. The study was composed of 249 elderly patients (aged
Bjorn Fagerberg; Lisbeth Claesson; Gunilla Gosman-Hedstrom; Christian Blomstrand
Insomnia treatment experience and preferences among veterans affairs primary care patients.
Insomnia is common, but undertreated, among primary care patients. Within the Veterans Health Administration (VA), increasing attention has been given to the treatment of insomnia within primary care settings, but little research has examined Veterans' treatment preferences. We examined preferences for sleep treatment among VA primary care patients. Participants (N = 126: 98% male, 89% white; M age = 60 years) completed a brief survey. On the basis of Insomnia Severity Index scores, 22% reported subthreshold and 13% moderate insomnia. Fifty percent reported having issues with sleep (falling asleep, staying asleep, or sleeping too much) in the past 12 months; among these, only 44% reported any discussion of medication (34%) or other strategies (32%) to improve sleep with medical providers. The most preferred treatment approach was to work it out on one's own, followed by consulting the primary care provider (PCP). The most preferred modality was a one-on-one meeting with the PCP, followed by a one-on-one meeting with the behavioral health provider. In conclusion, VA primary care patients preferred handling sleep problems on their own, but if seeking help, they preferred working with PCPs over behavioral health providers. The majority of Veterans preferred individual treatment and strategies other than medication. PMID:25269123
Shepardson, Robyn L; Funderburk, Jennifer S; Pigeon, Wilfred R; Maisto, Stephen A
Treatment advances in neonatal neuroprotection and neurointensive care
Knowledge of the nature, prognosis, and ways to treat brain lesions in neonatal infants has increased remarkably. Neonatal hypoxic-ischaemic encephalopathy (HIE) in term infants, mirrors a progressive cascade of excito-oxidative events that unfold in the brain after an asphyxial insult. In the laboratory, this cascade can be blocked to protect brain tissue through the process of neuroprotection. However, proof of a clinical effect was lacking until the publication of three positive randomised controlled trials of moderate hypothermia for term infants with HIE. These results have greatly improved treatment prospects for babies with asphyxia and altered understanding of the theory of neuroprotection. The studies show that moderate hypothermia within 6 h of asphyxia improves survival without cerebral palsy or other disability by about 40% and reduces death or neurological disability by nearly 30%. The search is on to discover adjuvant treatments that can further enhance the effects of hypothermia. PMID:21435600
Johnston, Michael V; Fatemi, Ali; Wilson, Mary Ann; Northington, Frances
A primary care approach to substance misuse.
Substance misuse is common among patients in primary care settings. Although it has a substantial health impact, physicians report low levels of preparedness to identify and assist patients with substance use disorders. An effective approach to office-based treatment includes a coherent framework for identifying and managing substance use disorders and specific strategies to promote behavior change. Brief validated screening tools allow rapid and efficient identification of problematic drug use, including prescription medication misuse. After a positive screening, a brief assessment should be performed to stratify patients into three categories: hazardous use, substance abuse, or substance dependence. Patients with hazardous use benefit from brief counseling by a physician. For patients with substance abuse, brief counseling is also indicated, with the addition of more intensive ongoing follow-up and reevaluation. In patients with substance dependence, best practices include a combination of counseling, referral to specialty treatment, and pharmacotherapy (e.g., drug tapering, naltrexone, buprenorphine, methadone). Comorbid mental illness and intimate partner violence are common in patients with substance use disorders. The use of a motivational rather than a confrontational communication style during screening, counseling, and treatment is important to improve patient outcomes. PMID:23939642
Shapiro, Brad; Coffa, Diana; McCance-Katz, Elinore F
Beliefs, Death Anxiety, Denial, and Treatment Preferences in End-of-Life Care
This study examined cultural and religious beliefs, death anxiety, denial, and medical treatment preferences in end-of-life care in a sample of social work students, community residents, and medical students in a mid-western city of 49,000. Results indicated that most social work students, community residents, and medical students preferred palliative as opposed to life-prolonging care during terminal illness. The three groups
Cecelia L. W. Chan; David C. Perry; Diane Wiersgalla; Jennifer M. Schlinger; Dona J. Reese
Collaborative care map construction is proposed as an alternative reference to the clinical practice of treatment planning.\\u000a This reframe is intended to highlight the importance of client–therapist collaboration in "mapping out" care. Six therapist\\u000a postures or practices are presented and discussed that promote client involvement: (a) speaking tentatively, (b) revisiting\\u000a role induction, (c) inviting client preferences, (d) determining direction, (e)
Cynthia J. Osborn; John D. West; Aaron Kindsvatter; Susan B. Paez
Recently released with HIV/AIDS: primary care treatment needs and experiences.
The research objectives of this study are to describe the re-entry experiences of people recently released from jail who were living with HIV/AIDS, and to identify factors that influence their access to primary care and adherence to a treatment regimen. The research used a mixed-method, qualitative and quantitative research design. The findings indicate that the overall instability in the lives of many of the former inmates studied hampered their ability to attend to their HIV/AIDS-related health care needs. Most former inmates returned to the community with co-occurring problems related to housing and substance abuse. Complicating their access to health care were fragmented health care and correctional systems. The study highlights the need for coordination and collaboration between correctional facilities and community-based health care and human service providers that leads to a deliberative and planned transition from jail to service systems in the community. PMID:17675724
Fontana, Leonard; Beckerman, Adela
This exploratory study describes the child sexual abuse experiences of 53 youth (ages 14-17) in child protective services residential treatment care using three informants: youth (via the Childhood Trauma Questionnaire), residential treatment workers (via the Child Welfare Trauma Referral Tool), and the child protective services record. Child sexual abuse was self-reported by 38% of youth, with reporting by females almost four times higher. Child sexual abuse co-occurred with physical abuse, emotional abuse, and neglect in 75% of cases. Agreement between youth and residential treatment worker reports was high, while agreement between youth reports and their child protective services record was low. The study suggests systematic child sexual abuse screening among residential treatment care youth through self-reports and residential treatment worker reports. Case studies are provided, and implications for practice, policy, and future research are discussed. PMID:24640965
Milne, Lise; Collin-Vézina, Delphine
Optimal oncologic care of older men with prostate cancer, including effective prevention and management of the disease and treatment side effects (so-called best supportive care measures) can prolong survival, improve quality of life, and reduce depressive symptoms. In addition, the proportion of treatment discontinuations can be reduced through early reporting and management of side effects. Pharmacologic care may be offered to manage the side effects of androgen-deprivation therapy and chemotherapy, which may include hot flashes, febrile neutropenia, fatigue, and diarrhea. Nonpharmacologic care (e.g., physical exercise, acupuncture, relaxation) has also been shown to benefit patients. At the Georges Pompidou European Hospital, the Program of Optimization of Chemotherapy Administration has demonstrated that improved outpatient follow-up by supportive care measures can reduce the occurrence of chemotherapy-related side effects, reduce cancellations and modifications of treatment, reduce chemotherapy wastage, and reduce the length of stay in the outpatient unit. The importance of supportive care measures to optimize management and outcomes of older men with advanced prostate cancer should not be overlooked. PMID:23015682
Optimal oncologic care of older men with prostate cancer, including effective prevention and management of the disease and treatment side effects (so-called best supportive care measures) can prolong survival, improve quality of life, and reduce depressive symptoms. In addition, the proportion of treatment discontinuations can be reduced through early reporting and management of side effects. Pharmacologic care may be offered to manage the side effects of androgen-deprivation therapy and chemotherapy, which may include hot flashes, febrile neutropenia, fatigue, and diarrhea. Nonpharmacologic care (e.g., physical exercise, acupuncture, relaxation) has also been shown to benefit patients. At the Georges Pompidou European Hospital, the Program of Optimization of Chemotherapy Administration has demonstrated that improved outpatient follow-up by supportive care measures can reduce the occurrence of chemotherapy-related side effects, reduce cancellations and modifications of treatment, reduce chemotherapy wastage, and reduce the length of stay in the outpatient unit. The importance of supportive care measures to optimize management and outcomes of older men with advanced prostate cancer should not be overlooked. PMID:23015682
Scotté, Florian
Cancer care in Nepal: variables that affect diagnosis, treatment, and prognosis: a case study.
This manuscript presents a case study of a Nepalese woman experiencing breast cancer. Six themes were identified to have an impact on the diagnosis, treatment, and prognosis. They include: cultural impact on women's roles, socioeconomic status and education, surgical oncologist-patient relationship, surgical oncologist-nurse relationship, nurses' lack of oncology knowledge, and lack of a cancer screening and prevention program in Nepal. Cancer care is on the rise in Nepal. However, many of the variables identified above are not considered in the cancer care provided. Nepal has just opened its first national cancer center with the intent to improve cancer care throughout the country. PMID:11318261
Braun, C M; Itano, J K
Successful paediatric HIV treatment in rural primary care in Africa
ObjectiveClinical outcomes of HIV-infected children on antiretroviral treatment (ART) in a decentralised, nurse\\/counsellor-led programme.DesignClinical cohort.SettingKwaZulu-Natal, South Africa.PatientsHIV-infected children aged ?15 years on ART, June 2004–2008.Main outcome measuresSurvival according to baseline characteristics including age, WHO clinical stage, haemoglobin and CD4%, was assessed in Kaplan–Meier analyses. Hazard ratios for mortality were estimated using Cox proportional hazards regression and changes in laboratory parameters
N. Janssen; J. Ndirangu; M. L. Newell; RM Bland
ERIC Educational Resources Information Center
Background: In 2005 a new compulsory residential treatment program was developed for adolescents in need for protection against themselves or their environment. Objective: The aim of the present study was to examine the association of structural treatment characteristics of this new residential treatment program (i.e., duration of treatment,…
Nijhof, Karin S.; Vermulst, Ad A.; Veerman, Jan W.; van Dam, Coleta; Engels, Rutger C. M. E.; Scholte, Ron H. J.
Objective A review of substance use clinical trials indicates that sub-optimal methods are the most commonly used procedures to deal with longitudinal missing information. Methods Listwise deletion (i.e., using complete cases only), positive urine analysis (UA) imputation, and multiple imputation (MI) were used to evaluate the effect of baseline substance use and buprenorphine/naloxone tapering schedule (7 or 28 days) on the probability of a positive UA (UA+) across the 4-week treatment period. Results The listwise deletion generalized estimating equations (GEE) model demonstrated that those in the 28-day taper group were less likely to submit a UA+ for opioids during the treatment period (odds ratios (OR) = 0.57, 95% confidence interval (CI): 0.39–0.83), as did the positive UA imputation model (OR = 0.43, CI: 0.34–0.55). The MI model also demonstrated a similar effect of taper group (OR = 0.57, CI: 0.42–0.77), but the effect size was more similar to that of the listwise deletion model. Conclusions Future researchers may find utilization of the MI procedure in conjunction with the common method of GEE analysis as a helpful analytic approach when the missing at random assumption is justifiable. PMID:24014144
McPherson, Sterling; Barbosa-Leiker, Celestina; McDonell, Michael; Howell, Donelle; Roll, John
Recent military operations in Afghanistan and Iraq have involved multiple deployments and significant combat exposure, resulting in high rates of mental health problems. However, rates of treatment-seeking among military personnel are relatively low, and the military environment poses several obstacles to engaging in effective clinical interventions. The current paper first reviews barriers and facilitators of treatment-seeking and engagement among military personnel, including stigma, practical barriers, perceptions of mental health problems, and attitudes towards treatment. Next, this paper reviews treatment adaptations and other interventions that are intended to reduce barriers to care among active duty and returning military personnel. These include early interventions, brief formats, integrating clinicians into the medical and military context, technology-based interventions, addressing negative treatment perceptions, screening/early identification, and enlisting unit support. PMID:23063627
Zinzow, Heidi M; Britt, Thomas W; McFadden, Anna C; Burnette, Crystal M; Gillispie, Skye
Migraine and other headaches affect 54 million people in Germany. They rank among the ten most severely disabling complaints and the three most expensive neurological disorders. Nevertheless, they are not adequately recognized in the healthcare system with sketchy diagnoses and inadequate treatment. This inadequate care is not primarily due to a lack of medical and scientific knowledge on the development and treatment of headaches but is predominantly due to organizational deficits in the healthcare system and in the implementation of current knowledge. To overcome the organizational barriers the national headache treatment network was initiated in Germany. For the first time it allows national cross-sectoral and multidisciplinary links between inpatient and outpatient care. A hand in hand treatment programme, better education, better information exchange between all partners and combined efforts using clearly defined treatment pathways and goals are the basis for state of the art and efficient treatment results. The treatment network is geared towards the specialized treatment of severely affected patients with chronic headache disorders. A national network of outpatient and inpatient pain therapists in both practices and hospitals works hand in hand to optimally alleviate pain in a comprehensive cross-sectoral and multidisciplinary manner. For therapy refractive disorders, a high-intensive supraregional fully inpatient treatment can be arranged. This concept offers for the first time a nationwide coordinated treatment without limitation by specialization and bureaucratic remuneration sectors. PMID:23549863
Göbel, H; Heinze-Kuhn, K; Petersen, I; Göbel, A; Heinze, A
Psychiatric disorders and treatment among newly homeless young adults with histories of foster care
Objective While foster care placement is often preceded by stressful events such as childhood abuse, foster care itself often exposes children to additional severe stressors. A history of foster care, as well as the childhood abuse that often precedes it, is common among homeless young adults. However, whether a history of foster care elevates the likelihood of psychiatric disorders and treatment among homeless young adults, after adjustment for childhood abuse, is unknown. This study examined whether a history of foster care was associated with psychiatric disorders, prior psychiatric counseling, prescription of psychiatric medications, and prior psychiatric hospitalization among newly homeless young adults, controlling for childhood abuse and other covariates. Methods Among a consecutive sample of 424 newly homeless young adults (18 to 21 years) in a crisis shelter, logistic regression analyses determined the associations between foster care and any psychiatric disorder (affective, anxiety, personality, psychotic) and psychiatric treatment, adjusted for demographics, childhood abuse, substance abuse, prior arrest, unemployment, lack of high school diploma, and histories of psychiatric disorders and drug abuse among biological relatives. Results Homeless young adults with histories of foster care were 70% more likely to report any psychiatric disorder (AOR=1.70) and twice as likely to have received mental health counseling for a psychiatric disorder (AOR=2.17), been prescribed psychiatric medication (AOR=2.26), and been hospitalized for psychiatric problems (AOR=2.15) than those without such histories. Conclusions Histories of foster care should trigger screening for psychiatric disorders among homeless young adults to aid in the provision of treatment (counseling, medication, hospitalization) tailored to their psychiatric needs. PMID:22706986
Thompson, Ronald G.; Hasin, Deborah S.
Symptom monitoring, alleviation, and self-care among mexican americans during cancer treatment.
Monitoring the occurrence and severity of symptoms among Mexican American adults undergoing cancer treatments, along with their self-care to alleviate symptoms, are understudied; the current study aimed to fill this gap in the literature. A total of 67 Mexican Americans receiving outpatient oncology treatments in the southwestern United States participated. Instruments included a patient-report checklist, the Therapy-Related Symptom Checklist (TRSC), the Symptom Alleviation: Self-Care Methods tool, and a demographic and health information form. At least 40% of participants reported the occurrence of 12 symptoms: hair loss, feeling sluggish, nausea, taste change, loss of appetite, depression, difficulty sleeping, weight loss, difficulty concentrating, constipation, skin changes, and numb fingers and toes. More than a third also reported pain, vomiting, decreased interest in sexual activity, cough, and sore throat. The helpful self-care strategies reported included diet and nutrition changes; lifestyle changes; and mind, body control, and spiritual activities. Patient report of symptoms during cancer treatments was facilitated by the use of the TRSC. Patients use symptom alleviation strategies to help relieve symptoms during their cancer treatment. The ability to perform appropriate, effective self-care methods to alleviate the symptoms may influence adherence to the treatment regimen. PMID:25253108
Williams, Phoebe D; Lantican, Leticia S; Bader, Julia O; Lerma, Daniela
Increasing Hepatitis C treatment uptake among HIV-infected patients using an HIV primary care model
Background Access to Hepatitis C (HCV) care is low among HIV-infected individuals, highlighting the need for new models to deliver care for this population. Methods Retrospective cohort analysis that compared the number of HIV patients who initiated HCV therapy: hepatology (2005–2008) vs. HIV primary care model (2008–2011). Logistic-regression modeling was used to ascertain factors associated with HCV therapy initiation and achievement of sustained viral response (SVR). Results Of 196 and 163 patients that were enrolled in the HIV primary care and hepatology models, 48 and 26 were treated for HCV, respectively (p?=?0.043). The HIV/HCV-patient referral rate did not differ during the two study periods (0.10 vs. 0.12/patient-yr, p?=?0.18). In unadjusted analysis, predictors (p?0.05) of HCV treatment initiation included referral to the HIV primary care model (OR: 1.7), a CD4+ count ?400/mm3 (OR: 1.8) and alanine aminotranferase level ?63U/L (OR: 1.9). Prior psychiatric medication use correlated negatively with HCV treatment initiation (OR: 0.6, p?=?0.045). In adjusted analysis the strongest predictor of HCV treatment initiation was CD4+ count (?400/mm3, OR: 2.1, p?=?0.01). There was no significant difference in either clinic model (primary care vs. hepatology) in the rates of treatment discontinuation due to adverse events (29% vs. 16%), loss to follow-up (8 vs. 8%), or HCV SVR (44 vs. 35%). Conclusions Using a HIV primary care model increased the number of HIV patients who initiate HCV therapy with comparable outcomes to a hepatology model. PMID:23537147
This study examined whether delivery of psychotherapeutic strategies consistent with common elements of evidence-based (EB) treatments for child disruptive behavior problems was associated with parents' report of treatment effectiveness. The intensity of delivery of practice elements consistent with EB treatments was coded from a random sample of 538 videotaped psychotherapy sessions with 157 children/families and 75 therapists from six community-based clinics. Multilevel regression analyses tested whether intensity of EB practice elements was associated with parents' report of treatment effectiveness after 4 months, controlling for intensity of other practice elements. Results indicate parents reported greater perceived treatment effectiveness when community-based treatment included more intensive delivery of practice elements consistent with EB treatments to children. These findings may reassure providers about the acceptability of EB practice elements and may motivate efforts to integrate EB practice elements more intensively into community-based care. PMID:23296551
Haine-Schlagel, Rachel; Fettes, Danielle L; Garcia, Antonio R; Brookman-Frazee, Lauren; Garland, Ann F
Evaluation of drug-drug interaction between daclatasvir and methadone or buprenorphine/naloxone
Introduction Daclatasvir (DCV) is a potent hepatitis C virus (HCV) NS5A replication complex inhibitor with pangenotypic (1–6) activity in vitro. Methadone (MET) and buprenorphine (BUP) are opioid medications used to treat opioid addiction; patients on HCV therapy may require MET or BUP treatment. The effect of DCV on the pharmacokinetics (PK) of MET or BUP/naloxone (NLX) was assessed in subjects on stable MET or BUP. Materials and Methods An open-label, two-part study assessed the effect of steady-state oral administration of DCV on the PK of MET (Part 1, P1) or BUP/NAL (Part 2, P2). Safety/tolerability and pharmacodynamics (PD, opioid withdrawal scales/overdose assessment) were also assessed. Subjects (P1, N=14; P2, N=11) received daily single-dose oral MET (40–120mg) or BUP/NLX (8/2–24/6mg) based on their prescribed stable dose throughout, in addition to DCV (60mg QD) on Days 2–9. Serial PK sampling occurred predose and postdose till 24 hours on Day 1 (MET/BUP) and Day 10 (MET/BUP/DCV). Noncompartmental PK were derived. Geometric mean ratios (GMR) and 90% confidence intervals (90% CI) for MET/BUP/norBUP Cmax and AUCTAU were derived from linear mixed effects models. Results Subjects were aged 19–39 years, mostly white (P1, 93%; P2, 100%) and male (P1, 71%; P2, 91%). All subjects completed the study. No clinically meaningful effect was demonstrated as the GMR and 90% CIs fell within the prespecified interval (P1, 0.7–1.4; P2, 0.5–2.0: see Table 1). DCV coadministration was well-tolerated: overall, six (43%) subjects had adverse events (AEs) (all mild and resolved without treatment). DCV had no clinically significant effect on the PD of MET or BUP/NLX. Conclusions Steady-state administration of DCV 60mg QD had no clinically meaningful effect on the PK of MET or BUP/NLX and was generally well-tolerated, suggesting that no dose adjustments will be required. PMID:25394132
Garimella, Tushar; Wang, Reena; Luo, Wen-Lin; Wastall, Philip; Kandoussi, Hamza; Demicco, Michael; Bruce, Douglas; Hwang, Carey; Bertz, Richard; Bifano, Marc
A Primary Care Focus on the Treatment of Patients With Major Depressive Disorder
Major depressive disorder (MDD) is a common psychiatric illness affecting nearly 20% of adults in the United States at least once during their lifetime. MDD is frequently diagnosed and treated in the primary care setting. Management of the disease may be complicated by patients and family members feeling stigmatized by the diagnosis and not understanding that depression is a treatable medical illness, which, in turn, fosters low rates of adherence to medication schedules. Incomplete or delayed response to treatment, adverse events associated with antidepressants, and medical or psychiatric comorbidities also interfere with optimal depression management. This paper presents an overview of diagnostic and treatment guidelines for MDD and focuses on challenges encountered by primary care physicians. The role of antidepressant medications, psychotherapy, and nonpharmacologic interventions for the treatment of patients with MDD is described, and factors influencing treatment selection, such as adverse event profiles and patient characteristics are examined. PMID:21642822
Weihs, Karen; Wert, Jonathan M
Goals of care: a clinical framework for limitation of medical treatment.
A novel clinical framework called "goals of care" (GOC) has been designed as a replacement for not-for-resuscitation orders. The aim is to improve decision making and documentation relating to limitations of medical treatment. Clinicians assign a patient's situation to one of three phases of care - curative or restorative, palliative, or terminal -according to an assessment of likely treatment outcomes. This applies to all admitted patients, and the default position is the curative or restorative phase. GOC helps identify patients who wish to decline treatments that might otherwise be given, such as treatment with blood products. This includes patients for whom specific limitations apply because of their beliefs. GOC has been introduced at Royal Hobart Hospital, Tasmania, and at Northern Health, Melbourne. So far, audit data and staff feedback have been favourable. There have been no reported major incidents or complaints in which GOC has been causally implicated in an adverse outcome. PMID:25332031
Thomas, Robyn L; Zubair, Mohamed Y; Hayes, Barbara; Ashby, Michael A
Background Chronic musculoskeletal pain is the single most cited reason for use of complementary and alternative medicine (CAM). Primary care is the most frequent conventional medical service used by patients with pain in the UK. We are unaware, however, of a direct evidence of the extent of CAM use by primary care patients, and how successful they perceive it to be. Methods Aims and objectives To determine CAM use among patients with chronic musculoskeletal pain who have consulted about their pain in primary care. Study design Face-to-face interview-based survey. Setting Three general practices in North Staffordshire. Participants Respondents to a population pain survey who had reported having musculoskeletal pain in the survey and who had consulted about their pain in primary care in the previous 12 months as well as consenting to further research and agreeing to an interview. Information was gathered about their pain and the use of all treatments for pain, including CAM, in the previous year. Results 138 interviews were completed. 116 participants (84%) had used at least one CAM treatment for pain in the previous year. 65% were current users of CAM. The ratio of over-the-counter CAM use to care from a CAM provider was 3:2. 111 participants (80%) had used conventional treatment. 95 (69%) were using a combination of CAM and conventional treatment. Glucosamine and fish oil were the most commonly used CAM treatments (38%, 35% respectively). Most CAM treatments were scored on average as being helpful, and users indicated that they intended to use again 87% of the CAM treatments they had already used. Conclusion We provide direct evidence that most primary care consulters with chronic musculoskeletal pain have used CAM in the previous year, usually in combination with conventional treatments. The high prevalence and wide range of users experiences of benefit and harm from CAM strengthen the argument for more research into this type of medicine to quantify benefit and assess safety. The observation that most users of conventional medicine also used CAM suggests a continuing need for more investigation of effective pain management in primary care. PMID:17480212
Artus, Majid; Croft, Peter; Lewis, Martyn
A meta-analysis of the efficacy of fibromyalgia treatment according to level of care
Introduction The aim of this paper was to compare the efficacy of the treatments for fibromyalgia currently available in both primary care and specialised settings. Methods Published reports of randomised controlled trials (RCTs) researching pharmacological and non-pharmacological treatments in patients with fibromyalgia were found in the MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and PsychInfo databases. The most recent electronic search was undertaken in June 2006. Results We identified a total of 594 articles. Based on titles and abstracts, 102 full articles were retrieved, 33 of which met the inclusion criteria. These RCTs assessed 120 treatment interventions in 7789 patients diagnosed with primary fibromyalgia. Of them, 4505 (57.8%) were included in the primary care group of our study and 3284 (42.2%) in the specialised intervention group. The sample was mostly made up of middle-aged women, who have had fibromyalgia for a mean period of 6 to 10 years. The mean effect size of the efficacy of the 120 treatment interventions in patients with fibromyalgia compared with controls was 0.49 (95% confidence interval [CI] = 0.39 to 0.58; p < 0.001). In the primary care group it was 0.46 (95% CI = 0.33 to 0.58) while in specialised care it was 0.53 (95% CI = 0.38 to 0.69), with no statistical significance in the differences. We analysed the efficacy of treatments by comparing primary and specialised care in the different fibromyalgia groups and there were no significant differences. The variables of the studies that affected the improvements in the efficacy of fibromyalgia treatment were low quality of the studies and a shorter duration of treatment. However, both factors were biased by the heterogeneity of the studies. Other variables that also improved outcome and were not biased by the heterogeneity of the studies, were younger age of the patients and shorter duration of the disorder. On the contrary, gender and type of treatment (pharmacological vs. psychological) did not affect outcome. Conclusion Based on this meta-analysis and despite the heterogeneity of specialised care studies and of the other limitations described in this article, treating fibromyalgia in specialised care offers no clear advantages. PMID:18627602
Garcia-Campayo, Javier; Magdalena, Jesus; Magallon, Rosa; Fernandez-Garcia, Esther; Salas, Montserrat; Andres, Eva
Background: Up to 48% of patients with bipolar disorder are either nonadherent or partially adherent to antipsychotic drug treatment. Medication adherence may differ by bipolar disorder subtype.Objective: This study evaluated the association between antipsychotic treatment adherence and mental health care use among individuals with bipolar disorder with predominantly manic\\/mixed symptoms or predominantly depressive symptoms.Methods: Individuals with bipolar or manic disorder
Frank D. Gianfrancesco; Martha Sajatovic; Krithika Rajagopalan; Ruey-Hua Wang
The aim of this study was to compare the postoperative analgesic effects of robenacoxib and buprenorphine alone or in combination, in cats after ovariohysterectomy. Thirty healthy cats were randomly assigned to receive buprenorphine (0.02 mg/kg, n=10; GB), robenacoxib (2mg/kg, n=10; GR) or their combination at the same dosages (n=10; GBR) SC. After 30 min cats were sedated with an IM administration of medetomidine (0.02 mg/kg) and ketamine (5mg/kg). General anaesthesia was induced with propofol and after intubation was maintained with isoflurane. Before premedication and at 1, 2, 3, 4, 6, 8, 12 and 24h after extubation, pain and sedation were assessed using a simple descriptive pain scale, ranging from 0 (no pain/no sedation) to 4 (intense pain/ deep sedation). If the pain score was ? 3, rescue analgesia was provided using buprenorphine (0.02 mg/kg) administered IM. Pain score was higher in GB at 2, 3, 4, 6 and 8h compared to baseline and compared to GBR at the same study times. Moreover, the pain score was also higher in GB compared to GR at 2, 3, 4 and 6h. Pain score was similar at all study times between GR and GBR. Sedation at 1 and 2h was higher than baseline values in all groups. Cats in GB received rescue analgesia more often than cats assigned to GR or GBR. Robenacoxib was an effective analgesic drug in cats up to 24h after ovariohysterectomy. The addition of buprenorphine did not provide any additional analgesic effects compared to robenacoxib alone. PMID:23434263
Staffieri, F; Centonze, P; Gigante, G; De Pietro, L; Crovace, A
The role of coping in depression treatment utilization for VA primary care patients
Objective To examine the impact of Veterans' coping strategies on mental health treatment engagement following a positive screen for depression. Methods A mixed methods observational study using a mailed survey and semi structured interviews. Sample included 271 Veterans who screened positive for depression during a primary care visit at one of three VA medical centers and had not received a diagnosis of depression or prescribed antidepressants 12 months prior to screening. A subsample of 23 Veterans was interviewed. Results Logistic regression models showed that Veterans who reported more instrumental support and active coping were more likely to receive depression or other mental health treatment within three months of their positive depression screen. Those who reported emotional support or self distraction as coping strategies were less likely to receive any treatment in the same time frame. Qualitative analyses revealed that how Veterans use these and other coping strategies can impact treatment engagement in a variety of ways. Conclusions The relationship between Veterans' use of coping strategies and treatment engagement for depression may not be readily apparent without in depth exploration. Practice implications In VA primary care clinics, nurse care managers and behavioral health providers should explore how Veterans' methods of coping may impact treatment engagement. PMID:24315160
Osei-Bonsu, Princess E.; Bokhour, Barbara G.; Glickman, Mark E.; Rodrigues, Stephanie; Mueller, Nora M.; Dell, Natalie S.; Zhao, Shibei; Eisen, Susan V.; Elwy, A. Rani
Mr K is an 89-year-old married man with a number of comorbid conditions and multiple recent falls. He was referred to the IMPACT clinic (Interprofessional Model of Practice for Aging and Complex Treatments) as his primary care physician was concerned about his declining health and the growing care giver burden on his wife. Mr K's condition was deteriorating while the complexity of his case was increasing; therefore, an in-depth team assessment was sought to determine the best management plan and to assess his capacity to remain at home (his expressed preference). The IMPACT team met with Mr K and his wife for a 2 h interprofessional assessment. A comprehensive care plan was developed including specific recommendations for implementing change. After the visit to the IMPACT clinic, Mr K's care was returned to his regular family physician. PMID:22698900
Bell, Stephanie H; Tracy, C Shawn; Upshur, Ross E G
Factors that predict outcome of intensive care treatment in very elderly patients: a review
INTRODUCTION: Advanced age is thought to be associated with increased mortality in critically ill patients. This report reviews available data on factors that determine outcome, on the value of prognostic models, and on preferences regarding life-sustaining treatments in (very) elderly intensive care unit (ICU) patients. METHODS: We searched the Medline database (January 1966 to January 2005) for English language articles.
Sophia E de Rooij; Ameen Abu-Hanna; Marcel Levi; Evert de Jonge
Healing Childhood Ear Infections: Prevention, Home Care, and Alternative Treatment. 2nd Edition.
ERIC Educational Resources Information Center
This book describes current controversy in medical journals over existing treatments for chronic childhood earaches. It suggests that the causes of otitis media are a series of events which flourish when poor nutrition occurs, noting that careful attention to diet and nutrition to prevent food allergies, and the use of acupressure, homeopathic…
Schmidt, Michael A.
3 Objective: Epidemiologic research has demonstrated that the majority of mental illness in the community is not treated. Primary care physicians and the specialty mental health sector each have an important role in the provision of mental health services. Our goal is to clarify the extent of undertreatment of selected mental illnesses in Ontario and to examine how treatment is
Sagar V Parikh; Elizabeth Lin
This research study intended to determine which patient diagnostic group benefited most from an extended care psychiatric rehabilitation program (Program). Archival data were used to assess the completion rates among those subjected to one or more of the Program's treatment modalities. A correlational design was used to determine whether demographic or diagnostic variables were related to program completion. The results
Michael G. Rank; Iris Chaffin; Charles R. Figley; Tiffany Lawrence
Aggressive Adolescents in Residential Care: A Selective Review of Treatment Requirements and Models
ERIC Educational Resources Information Center
This article presents a selective inventory of treatment methods of aggressive behavior. Special attention is paid to types of intervention that, according to research, are frequently used in Dutch residential youth care. These methods are based on (1) principles of (cognitive) behavior management and control, (2) the social competence model, and…
Knorth, Erik J.; Klomp, Martin; Van den Bergh, Peter M.; Noom, Marc J.
ERIC Educational Resources Information Center
Background: Few studies have examined deliberate self-harm (DSH) among children in residential treatment in Canada. Most of the existing studies examined adolescent students or children from pediatric emergency departments. Objectives: The objectives of this study were to examine the prevalence of DSH among children in tertiary care residential…
Stewart, Shannon L.; Baiden, Philip; Theall-Honey, Laura; den Dunnen, Wendy
Objective: To assess the frequency of and the reasons for changing empiric antibiotics during the treatment of pneumonia ac- quired in the intensive care unit (ICU). A prospective multicenter study of 1 year's duration. Setting: Medical and surgical ICUs in 30 hospitals all over Spain. Patients: Of a total of 16 872 patients initially enrolled into the study, 530 patients
F. Alvarez-Lerma; R. Jorda; F. Barcenilla; Arnau de Vilanova; B. Galvan; M. Palomar; J. Serra; B. Bermejo; M. Sanchez Palacios; R. Girat; F. Alvarez Lerma; Maria del Rosell; J. Martinez; J. Insausti; P. Olaechea; A. Gilabert; C. Junque; F. Palacios; R. Calvo; E. Mesalles; J. Nava; A. Santos
Music therapy—a complementary treatment for mechanically ventilated intensive care patients
The aim of this study was to ascertain whether music therapy had a measurable relaxing effect on patients who were temporarily on a respirator in an intensive care unit (ICU) and after completion of respirator treatment investigate those patients' experiences of the music therapy. In the study both quantitative and qualitative measurements were applied. Twenty patients were included using consecutive
Sofia Almerud; Kerstin Petersson
Emerging Standards of Care for the Diagnosis and Treatment of Panic Disorder.
ERIC Educational Resources Information Center
Proposes eight emerging standards of care, based on a literature review, for the diagnosis and treatment of panic disorder without agoraphobia in adults. The diagnostic criteria were particularly analyzed in terms of comorbid psychological disorders, medical disorders, and substances that mimic panic symptoms. Defines minimal professional conduct.…
Beamish, Patrica M.; Granello, Darcy Haag; Granello, Paul F.; McSteen, Patricia B.; Stone, David A.
Compassion Fatigue Risk and Self-Care Practices among Residential Treatment Center Childcare Workers
ERIC Educational Resources Information Center
Exploration of the presence of risk for compassion fatigue among residential childcare workers (RCW) at residential treatment facilities and the relationship between self-care practices and compassion fatigue were explored. Using the Professional Quality of Life Survey (ProQOL-R III) to assess compassion fatigue, burnout, and compassion…
Eastwood, Callum D.; Ecklund, Kathryn
This Mid-Atlantic area Blues plan views genetic biomarkers as an important advancement in predicting recurrence rates and response to chemotherapy in estrogen-receptor-positive, node-negative, HER2-negative women with early-stage breast cancer. Care-First's Pay for Quality oncology program strives to combine clinically sound treatment with stable outcomes and predictable costs. PMID:19093337
Wong, Winston
Assessing Relationship Quality in Mandated Community Treatment: Blending Care with Control
ERIC Educational Resources Information Center
Traditional measures of the therapeutic alliance do not capture the dual roles inherent in relationships with involuntary clients. Providers not only care for, but also have control over, involuntary clients. In 2 studies of probationers mandated to psychiatric treatment (n = 90; n = 322), the authors developed and validated the revised Dual-Role…
Skeem, Jennifer L.; Louden, Jennifer Eno; Polaschek, Devon; Camp, Jacqueline
Living in Residential Care: Experiences in a Treatment Home for Adolescents in Sweden
This article reports on a qualitative study of adolescents living in residential care in Sweden. Six adolescents, three girls and three boys, who were the first to live in a newly opened treatment home, were interviewed about their experiences 2–3 years after they had left the home. Their experiences were in retrospect very different from each other. The results are discussed
Jan Johansson; Bengt Andersson
The well-being and treatment satisfaction of diabetic patients in primary care
BACKGROUND: The quality of life in patients with diabetes is reduced and emotional coping with the disease has great impact on patient well-being. OBJECTIVES: The aim of this study was to assess the psychological well-being and treatment satisfaction in patients with type 2 diabetes mellitus in primary care. STUDY DESIGN AND SETTING: Patients (n = 112) with type 2 diabetes
Esra Saatci; Gulruh Tahmiscioglu; Nafiz Bozdemir; Ersin Akpinar; Sevgi Ozcan; Hatice Kurdak
The objective of this study was to compare the postoperative analgesic effects of dexketoprofen, tramadol, and buprenorphine in dogs undergoing ovariohysterectomy. Seventy-five adult female dogs were randomly assigned to receive an intravenous injection (IV) of 1mg/kg of dexketoprofen (D), 0.02 mg/kg of buprenorphine (B) or 2mg/kg of tramadol (T). Pain assessment was performed during 48 h after ovariohysterectomy using a dynamic interactive visual analogue scale (DIVAS) and Glasgow composite measure pain scale (CMPS-SF). Rescue analgesia was required in 43%, 21%, and 5% of dogs in the B, T, and D groups, respectively, with significant differences between B and D (p=0.010) groups. The DIVAS and CMPS-SF values of the B group were significantly higher than those of the T and D groups. The most common undesirable effect was dysphoria in dexketoprofen group. Tramadol and dexketoprofen provide superior postoperative analgesia compared with buprenorphine in dogs undergoing ovariohysterectomy. PMID:23562407
Morgaz, J; Navarrete, R; Muńoz-Rascón, P; Domínguez, J M; Fernández-Sarmiento, J A; Gómez-Villamandos, R J; Granados, M M
Migration and geographic mobility increase risk for HIV infection and may influence engagement in HIV care and adherence to antiretroviral therapy. Our goal is to use the migration-linked communities of Santo Domingo, Dominican Republic, and New York City, New York, to determine the impact of geographic mobility on HIV care engagement and adherence to treatment. In-depth interviews were conducted with HIV+Dominicans receiving antiretroviral therapy, reporting travel or migration in the past 6 months and key informants (n=45). Mobility maps, visual representations of individual migration histories, including lifetime residence(s) and all trips over the past 2 years, were generated for all HIV+ Dominicans. Data from interviews and field observation were iteratively reviewed for themes. Mobility mapping revealed five distinct mobility patterns: travel for care, work-related travel, transnational travel (nuclear family at both sites), frequent long-stay travel, and vacation. Mobility patterns, including distance, duration, and complexity, varied by motivation for travel. There were two dominant barriers to care. First, a fear of HIV-related stigma at the destination led to delays seeking care and poor adherence. Second, longer trips led to treatment interruptions due to limited medication supply (30-day maximum dictated by programs or insurers). There was a notable discordance between what patients and providers perceived as mobility-induced barriers to care and the most common barriers found in the analysis. Interventions to improve HIV care for mobile populations should consider motivation for travel and address structural barriers to engagement in care and adherence. PMID:24839872
Taylor, Barbara S; Reyes, Emily; Levine, Elizabeth A; Khan, Shah Z; Garduńo, L Sergio; Donastorg, Yeycy; Hammer, Scott M; Brudney, Karen; Hirsch, Jennifer S
The study presented here compared the efficacy and safety of ertapenem and cefepime as initial treatment for adults with pneumonia acquired in skilled-care facilities or in hospital environments outside the intensive care unit (ICU). Non-ventilated patients developing pneumonia in hospital environments outside the ICU, in nursing homes, or in other skilled-care facilities were enrolled in this double-blind non-inferiority study, stratified
S. V. Yakovlev; L. S. Stratchounski; G. L. Woods; B. Adeyi; K. A. McCarroll; J. A. Ginanni; I. R. Friedland; C. A. Wood; M. J. DiNubile
Aims This study compared assertive continuing care (ACC) to usual continuing care (UCC) on linkage, retention and a measure of continuing care adherence. Outcome analyses tested the direct and indirect effects of both conditions and level of adherence on early (months 1-3) and longer-term (months 4-9) abstinence. Design Two-group randomized design. Setting Eleven counties surrounding a community-based residential treatment program
Mark D. Godley; Susan H. Godley; Michael L. Dennis; Rodney R. Funk; Lora L. Passetti
Background: In clinical trials of asthma, the outcomes are often good, but when the same treatment regimens are implemented in primary care, equally good results are not obtained. Objective: To investigate if addition of structured patient information and monitoring by an asthma diary in primary care improves asthma control. Methods: 141 patients from 19 primary care centres were studied. The
Mika Nokela; Marianne Heibert Arnlind; Per-Olof Ehrs; Ingvar Krakau; Lennart Forslund; Eva Wikström Jonsson
Introduction Tuberculosis (TB) requires at least six months of multidrug treatment and necessitates monitoring for response to treatment. Historically, public health departments (HDs) have cared for most TB patients in the United States. The Affordable Care Act (ACA) provides coverage for uninsured persons and may increase the proportion of TB patients cared for by private medical providers and other providers outside HDs (PMPs). We sought to determine whether there were differences in care provided by HDs and PMPs to inform public health planning under the ACA. Methods We conducted a retrospective, cross-sectional analysis of California TB registry data. We included adult TB patients with culture-positive, pulmonary TB reported in California during 2007–2011. We examined trends, described case characteristics, and created multivariate models measuring two standards of TB care in PMP- and HD-managed patients: documented culture conversion within 60 days, and use of directly observed therapy (DOT). Results The proportion of PMP-managed TB patients increased during 2007–2011 (p?=?0.002). On univariable analysis (N?=?4,606), older age, white, black or Asian/Pacific Islander race, and birth in the United States were significantly associated with PMP care (p<0.05). Younger age, Hispanic ethnicity, homelessness, drug or alcohol use, and cavitary and/or smear-positive TB disease, were associated with HD care. Multivariable analysis showed PMP care was associated with lack of documented culture conversion (adjusted relative risk [aRR]?=?1.37, confidence interval [CI] 1.25–1.51) and lack of DOT (aRR?=?8.56, CI 6.59–11.1). Conclusion While HDs cared for TB cases with more social and clinical complexities, patients under PMP care were less likely to receive DOT and have documented culture conversion. This indicates a need for close collaboration between PMPs and HDs to ensure that optimal care is provided to all TB patients and TB transmission is halted. Strategies to enhance collaboration between HDs and PMPs should be included in ACA implementation. PMID:25340876
Ehman, Melissa; Flood, Jennifer; Barry, Pennan M.
Despite an increasing number of military service members in need of mental health treatment following deployment to Iraq and Afghanistan, numerous psychological and practical barriers limit access to care. Perceived stigma about admitting psychological difficulties as well as frequent long distances to treatment facilities reduce many veterans' willingness and ability to receive care. Telemedicine and virtual human technologies offer a unique potential to expand services to those in greatest need. Telemedicine-based treatment has been used to address multiple psychiatric disorders, including posttraumatic stress disorder, depression, and substance use, as well as to provide suicide risk assessment and intervention. Clinician education and training has also been enhanced and expanded through the use of distance technologies, with trainees practicing clinical skills with virtual patients and supervisors connecting with clinicians via videoconferencing. The use of these innovative and creative vehicles offer a significant and as yet unfulfilled promise to expand delivery of high quality psychological therapies, regardless of clinician and patient location. PMID:20955335
Olden, Megan; Cukor, Judith; Rizzo, Albert "Skip"; Rothbaum, Barbara; Difede, JoAnn
Background The aim of this retrospective study was to analyse the treatment time and differences between the pre- and post-treatment peer assessment rating (PAR) index and aesthetic component (AC) of the index of orthodontic treatment need (IOTN) scores in children/adolescents with special health care needs (SHCNs), compared to non-special health care needs (NSHCNs) controls. Methods Based on certain inclusion and exclusion criteria, medical records of SHCNs and randomly selected NSHCNs controls at the Department of Orthodontics, University Hospital Muenster were analysed retrospectively for the treatment time, number of appointments, chair time ("moderate" or "considerable"), PAR scores, and AC scores. Sample size calculation, descriptive statistics, and explorative analyses were performed using the Mann–Whitney U Test. Results Twenty-nine children with SHCNs (21 boys, 9 girls; median age: 11 years, pre-treatment) and 29 children with NSHCNs (12 boys, 17 girls; median age: 12 years, pre-treatment) were enrolled in this study. The overall treatment time did not differ between the patient groups. However, more "considerable chair time" was needed for the SHCNs group compared to the control group (p?0.05), whereas "moderate chair time" was more often needed in patients with NSHCNs (p?=?0.001). The age of the patients at the first and last appointments showed significant statistical differences: children in the SHCNs group commenced orthodontic treatment earlier, by a median of 1 year, compared to children in the NSHCNs group. The SHCNs group had significantly higher pre- and post-treatment PAR scores (median 21/median 6) and AC scores (median 9/median 3) compared to NSHCNs patients (PAR: median 17/median 0; AC: median 5/median 1). However, the overall treatment time and the overall PAR and AC score reduction did not differ significantly between the SHCNs and NSHCNs groups. Conclusions While the overall treatment time and number of appointments did not differ, the overall chair time was higher in the SHCNs group. The pre- and post-treatment PAR and AC scores were significantly higher in the SHCNs group. PMID:24915851
Objectives: This study examines the prevalence of violence experienced by patients enrolled in the Step by Step program, a combined prenatal care\\/substance abuse treatment program at the Wake County Health Department in North Carolina. In addition, potential associations between violence and sociodemographic characteristics, substance use, and mental health are investigated. Method: All prenatal care\\/substance abuse treatment patients who met study
Sandra L. Martin; Brian Kilgallen; Deborah L. Dee; Spring Dawson; Jacquelyn Campbell
Background Opiate substitution treatment for heroin users reduces mortality, illicit drug use, crime, and risk-taking behaviour, and improves physical, mental and social functioning. Few extended studies have been carried out in UK primary care to study factors predicting recovery. Aim To establish whether primary care opiate substitution treatment is associated with improvements in outcomes over 11 years, in delivering recovery, and to identify predictive factors. Design and setting A prospective longitudinal cohort study, with repeated measures in the Primary Care Addiction Service, Sheffield, 1999–2011. Method A total of 123 eligible patients were assessed using the Opiate Treatment Index at entry to treatment and at 1, 5, and 11 years. Clinical records were used to assess factors including employment and discharge status. Results At 11 years, there was a high rate of drug-free discharge (22.0%) and medically-assisted recovery (30.9%), and low mortality (6.5%). Continuous treatment was associated with being discharged drug free (P = 0.005). For those still in treatment, there were highly significant reductions in heroin use and injecting, and significantly improved psychosocial functioning. There were strong positive correlations between mental health, physical health, and social functioning. Patients in employment had significantly better psychological and social functioning (P = 0.017, P = 0.007, respectively). Conclusion Opiate substitution treatment is associated over 11 years with full recovery, drug-free discharge and medically-assisted recovery. There is a strong association between the psychosocial variables, suggesting that intervention in any one of these areas may have extended benefits, by impacting on related variables and employment. The best predictor of a drug-free discharge was continuous uninterrupted treatment. PMID:23834887
Parmenter, Jamie; Mitchell, Caroline; Keen, Jenny; Oliver, Phillip; Rowse, Georgina; Neligan, Isabel; Keil, Christopher; Mathers, Nigel
Background Antiretroviral treatment (ART) was provided to more than nine million people by the end of 2012. Although ART programs in resource-limited settings have expanded treatment, inadequate retention in care has been a challenge. Ethiopia has been scaling up ART and improving retention (defined as continuous engagement of patients in care) in care. We aimed to analyze the ART program in Ethiopia. Methods A mix of quantitative and qualitative methods was used. Routine ART program data was used to study ART scale up and patient retention in care. In-depth interviews and focus group discussions were conducted with program managers. Results The number of people receiving ART in Ethiopia increased from less than 9,000 in 2005 to more than 439, 000 in 2013. Initially, the public health approach, health system strengthening, community mobilization and provision of care and support services allowed scaling up of ART services. While ART was being scaled up, retention was recognized to be insufficient. To improve retention, a second wave of interventions, related to programmatic, structural, socio-cultural, and patient information systems, have been implemented. Retention rate increased from 77% in 2004/5 to 92% in 2012/13. Conclusion Ethiopia has been able to scale up ART and improve retention in care in spite of its limited resources. This has been possible due to interventions by the ART program, supported by health systems strengthening, community-based organizations and the communities themselves. ART programs in resource-limited settings need to put in place similar measures to scale up ART and retain patients in care. PMID:24886686
Attrition through Multiple Stages of Pre-Treatment and ART HIV Care in South Africa
Introduction While momentum for increasing treatment thresholds is growing, if patients cannot be retained in HIV care from the time of testing positive through long-term adherence to antiretroviral therapy (ART), such strategies may fall short of expected gains. While estimates of retention on ART exist, few cohorts have data on retention from testing positive through long-term ART care. Methods We explored attrition (loss or death) at the Themba Lethu HIV clinic, Johannesburg, South Africa in 3 distinct cohorts enrolled at HIV testing, pre-ART initiation, and ART initiation. Results Between March 2010 and August 2012 we enrolled 380 patients testing HIV+, 206 initiating pre-ART care, and 185 initiating ART. Of the 380 patients enrolled at testing HIV-positive, 38.7% (95%CI: 33.9–43.7%) returned for eligibility staging within ?3 months of testing. Of the 206 enrolled at pre-ART care, 84.5% (95%CI: 79.0–88.9%) were ART eligible at their first CD4 count. Of those, 87.9% (95%CI: 82.4–92.2%) initiated ART within 6 months. Among patients not ART eligible at their first CD4 count, 50.0% (95%CI: 33.1–66.9%) repeated their CD4 count within one year of the first ineligible CD4. Among the 185 patients in the ART cohort, 22 transferred out and were excluded from further analysis. Of the remaining 163, 81.0% (95%CI: 74.4–86.5%) were retained in care through two years on treatment. Conclusions Our findings from a well-resourced clinic demonstrate continual loss from all stages of HIV care and strategies to reduce attrition from all stages of care are urgently needed. PMID:25330087
Fox, Matthew P.; Shearer, Kate; Maskew, Mhairi; Meyer-Rath, Gesine; Clouse, Kate; Sanne, Ian
Improving quality of care in substance abuse treatment using five key process improvement principles
Process and quality improvement techniques have been successfully applied in health care arenas, but efforts to institute these strategies in alcohol and drug treatment are underdeveloped. The Network for the Improvement of Addiction Treatment (NIATx) teaches participating substance abuse treatment agencies to use process improvement strategies to increase client access to, and retention in, treatment. NIATx recommends five principles to promote organizational change: 1) Understand and involve the customer; 2) Fix key problems; 3) Pick a powerful change leader; 4) Get ideas from outside the organization; and 5) Use rapid-cycle testing. Using case studies, supplemented with cross-agency analyses of interview data, this paper profiles participating NIATx treatment agencies that illustrate application of each principle. Results suggest that the most successful organizations integrate and apply most, if not all, of the five principles as they develop and test change strategies. PMID:22282129
Hoffman, Kim A.; Green, Carla A.; Ford, James H.; Wisdom, Jennifer P.; Gustafson, David H.; McCarty, Dennis
Too little time? The recognition and treatment of mental health problems in primary care.
OBJECTIVES: To assess the effect of practice characteristics on the diagnosis and treatment of mental health problems in primary care. DATA SOURCE: National Ambulatory Medical Care Survey (NAMCS) 1991-1994. STUDY DESIGN: We examine the effect of visit characteristics and practice characteristics on rates of diagnosis of mental health problems, rates of referral, and rates of use of psychotropic medications. We characterize each primary care physician's practice using information about the ways in which that physician treated patients who did not have mental health problems. PRINCIPAL FINDINGS: We find that median visit duration has a small, statistically insignificant effect on the rate of diagnosis and treatment of mental health problems. Physicians with large HMO caseloads are slightly more likely to diagnose mental health problems, but less likely to prescribe psychotropic medications, than are physicians who see few HMO patients. Practice style and specialty are important determinants of diagnosis and, to a lesser extent, of treatment. CONCLUSIONS: Physicians specialty and practice style are more strongly related to mental health diagnosis and treatment than are system characteristics such as visit duration and insurance composition. PMID:9776941
Glied, S
Background ADHD guidelines in the UK suggest that children and adults who respond to pharmacological treatment should continue for as long as remains clinically effective, subject to regular review. To what extent patients persist with treatment from childhood and adolescence into adulthood is not clear. This study aims to describe, in UK primary care, the persistence of pharmacological treatment for patients with ADHD who started treatment aged 6–17 years and to estimate the percentage of patients who continued treatment from childhood and adolescence into adulthood. Methods The Health Improvement Network (THIN) database was used to identify patients with ADHD who received their first prescription for methylphenidate/ dexamfetamine/atomoxetine, aged 6–17 years. Patients were monitored until their 'censored date' (the earliest of the following dates: date the last prescription coded in the database ended, end of the study period (31st December 2008), date at which they transferred out of their practice, date of death, the last date the practice contributed data to the database). Persistence of treatment into adulthood was estimated using Kaplan Meier analysis. Results 610 patients had follow-up data into adulthood. 213 patients (93.4% male) started treatment between 6–12 years; median treatment duration 5.9 years. 131 (61.5%) stopped before 18 years, 82 (38.5%) were still on treatment age ?18 years. 397 patients (86.4% male) started treatment between 13–17 years; median treatment duration was 1.6 years. 227 (57.2%) stopped before 18 years, 170 (42.8%) were still on treatment age ?18 years. The number of females in both age categories was too small to formally test for differences between genders in persistence of treatment. Conclusion Persistence of treatment into adulthood is lower (~40%) compared with published rates of persistence of the condition (~65% when symptomatic definition of remission used). Due to the limited number of patients with data past 18 years, it is important that ongoing monitoring of prescribing into later adulthood is undertaken, particularly to observe the effects of recommendations in new guidelines. PMID:23216881
AIMS To compare the O- (CYP2D6 mediated) and N- (CYP3A4 mediated) demethylation metabolism of tramadol between methadone and buprenorphine maintained CYP2D6 extensive metabolizer subjects. METHODS Nine methadone and seven buprenorphine maintained subjects received a single 100 mg dose of tramadol hydrochloride. Blood was collected at 4 h and assayed for tramadol, methadone, buprenorphine and norbuprenorphine (where appropriate) and all urine over 4 h was assayed for tramadol and its M1 and M2 metabolites. RESULTS The urinary metabolic ratio [median (range)] for O-demethylation (M1) was significantly lower (P= 0.0002, probability score 1.0) in the subjects taking methadone [0.071 (0.012–0.103)] compared with those taking buprenorphine [0.192 (0.108–0.392)], but there was no significant difference (P= 0.21, probability score 0.69) in N-demethylation (M2). The percentage of dose [median (range)] recovered as M1 was significantly lower in subjects taking methadone compared with buprenorphine (0.069 (0.044–0.093) and 0.126 (0.069–0.187), respectively, P= 0.04, probability score 0.19), M2 was significantly higher in subjects taking methadone compared with buprenorphine (0.048 (0.033–0.085) and 0.033 (0.014–0.049), respectively, P= 0.04, probability score 0.81). Tramadol was similar (0.901 (0.635–1.30) and 0.685 (0.347–1.04), respectively, P= 0.35, probability score 0.65). CONCLUSIONS Methadone inhibited the CYP2D6-mediated metabolism of tramadol to M1. Hence, as the degree of opioid analgesia is largely dependent on M1 formation, methadone maintenance patients may not receive adequate analgesia from oral tramadol. PMID:22369095
Coller, Janet K; Michalakas, Jennifer R; James, Heather M; Farquharson, Aaron L; Colvill, Joel; White, Jason M; Somogyi, Andrew A
Unheard voices: outcomes of tertiary care for treatment-refractory psychosis
Aims and method In up to a quarter of patients, schizophrenia is resistant to standard treatments. We undertook a naturalistic study of 153 patients treated in the tertiary referral in-patient unit of the National Psychosis Service based at the Maudsley Hospital in London. A retrospective analysis of symptoms on admission and discharge was undertaken using the OPCRIT tool, along with preliminary economic modelling of potential costs related to changes in accommodation. Results In-patient treatment demonstrated statistically significant improvements in all symptom categories in patients already identified as having schizophrenia refractory to standard secondary care. The preliminary cost analysis showed net savings to referring authorities due to changes from pre- to post-discharge accommodation. Clinical implications Despite the enormous clinical, personal and societal burden of refractory psychotic illnesses, there is insufficient information on the outcomes of specialised tertiary-level care. Our pilot data support its utility in all domains measured. PMID:25237502
Sarkar, S. Neil; Tracy, Derek K.; Fernandez, Maria-Jesus Mateos; Nalesnik, Natasza; Dhillon, Gurbinder; Onwumere, Juliana; Prins, Anne-Marye; Schepman, Karen; Collier, Tracy; White, Thomas P.; Patel, Anita; Gaughran, Fiona; Shergill, Sukhwinder S.
Background The value of integrated care through comprehensive, coordinated, and family-centered services has been increasingly recognized for improving health outcomes of children with special health care needs (CSHCN). In a randomized controlled trial (RCT), the integrated care provided through the Children's Treatment Network (CTN) was compared with usual care in improving the psychosocial health of target CSHCN. In this paper, we aimed to estimate the effect of CTN care by conducting multiple analyses to handle noncompliance in the trial. Methods The trial recruited target children in Simcoe County and York Region, ON, Canada. Children were randomized to receive CTN or usual care and were followed for 2 years. The CTN group received integrated services through multiple providers to address their specific needs while the usual care group continued to receive care directed by their parents. The outcome was change in psychosocial quality of life at 2 years. We conducted intention-to-treat, as-treated, per-protocol, and instrumental variable analyses to analyze the outcome. Results The trial randomized 445 children, with 229 in the intervention group and 216 in the control group. During follow-up, 52% of children in the intervention group did not receive complete CTN care for various reasons. At 2 years, we did not find a significant improvement in psychosocial quality of life among the children receiving CTN care compared with usual care (intention-to-treat mean difference 1.50, 95% confidence interval ?1.49 to 4.50; P = 0.32). Other methods of analysis yielded similar results. Conclusion Although the effect of CTN care was not significant, there was evidence showing benefits of integrated care for CSHCN. More RCTs are needed to demonstrate the magnitude of such an effect. The CTN study highlights the key challenges in RCTs when assessing interventions involving integrated care, and informs further RCTs including similar evaluations. PMID:24098089
Ye, Chenglin; Browne, Gina; Beyene, Joseph; Thabane, Lehana
Patient satisfaction with eletriptan in the acute treatment of migraine in primary care
Summary Objective: The efficxacy of triptans for acute migraine has been well established in clinical trials but not in primary care, where they are most commonly prescribed. The aim of this open-label study was to evaluate the effectiveness of eletriptan 40 mg in primary care, using a patient-weighted satisfaction scale. Methods: Eligible patients met International Headache Society criteria for migraine, with 1–6 attacks per month. Patients completed questionnaires at screening and following a single eletriptan-treated attack. Treatment satisfaction was evaluated using a six-item Medication Satisfaction Questionnaire (MSQ). MSQ item scores were weighted, based on the important score ratings, to yield individualised satisfaction scores. The primary end-point was the difference in weighted satisfaction scores between the patient's previous treatment and eletriptan 40 mg. Secondary end-points assessed quality of life (QOL), functioning and efficacy of treatment. Results: Of 590 patients screened, 437 completed the study. Degree (95.2%), time (88.8%) and duration (83.8%) of headache pain relief were rated as most important by patients. The mean (±SD) total satisfaction score on the MSQ was higher for eletriptan than previous therapy (2.2 ± 3.0 vs. 0.6 ± 2.4; p < 0.001). The high level of satisfaction with eletriptan vs. previous treatment reflects the improvements in QOL and functioning observed, and the high headache and pain-free response rates. Conclusions: Patient-weighted satisfaction with eletriptan 40 mg was higher than with previous treatment for all items. The use of patient-weighted importance ratings of satisfaction is a promising approach for establishing effectiveness of treatment in primary care. PMID:17877653
Nett, R B; Tiseo, P J; Almas, M; Sikes, C R
Recently Released with HIV\\/AIDS: Primary Care Treatment Needs and Experiences
The research objectives of this study are to describe the re-entry experiences of people recently released from jail who were living with HIV\\/AIDS, and to identify factors that influence their access to primary care and adherence to a treatment regimen. The research used a mixed-method, qualitative and quantitative research design. The findings indicate that the overall instability in the lives
Leonard. Fontana; Adela. Beckerman
Orlistat in the Long-term Treatment of Obesity in Primary Care Settings
Objective: To evaluate the long-term efficacy and toler- ability within primary care settings of orlistat, a gastro- intestinal lipase inhibitor, for the treatment of obesity. Design: Randomized, double-blind, placebo-con- trolled, multicenter study. Participants: A group of 796 obese patients (body mass index, 30-44 kg\\/m 2 ), treated with placebo 3 times a day (TID), 60 mg of orlistat TID, or
Jonathan Hauptman; Charles Lucas; Mark N. Boldrin; Harry Collins; Karen R. Segal
Depression Diagnosis and Antidepressant Treatment among Depressed VA Primary Care Patients
This study examined the extent to which 3559 VA primary care patients with depression symptomatology received depression diagnoses\\u000a and\\/or antidepressant prescriptions. Symptomatology was classified as mild (13%), moderate (42%) or severe (45%) based on\\u000a SCL-20 scores. Diagnosis and treatment was related to depression severity and other patient characteristics. Overall, 44%\\u000a were neither diagnosed nor treated. Only 22% of those neither
Chuan-Fen Liu; Duncan G. Campbell; Edmund F. Chaney; Yu-Fang Li; Mary McDonell; Stephan D. Fihn
Age differences in treatment response to a collaborative care intervention for anxiety disorders*†
Background Some data suggest that older adults with anxiety disorders do not respond as well to treatment as do younger adults. Aims We examined age differences in outcomes from the Coordinated Anxiety Learning and Management (CALM) study, an effectiveness trial comparing usual care to a computer-assisted collaborative care intervention for primary care patients with panic disorder, generalised anxiety disorder, post-traumatic stress disorder (PTSD), and/or social anxiety disorder. This is the first study to examine the efficacy of a collaborative care intervention in a sample that included both younger and older adults with anxiety disorders. We hypothesised that older adults would show a poorer response to the intervention than younger adults. Method We examined findings for the overall sample, as well as within each diagnostic category (clinicaltrials.gov identifier: NCT00347269). Results The CALM intervention was more effective than usual care among younger adults overall and for those with generalised anxiety disorder, panic disorder and social anxiety disorder. Among older adults, the intervention was effective overall and for those with social anxiety disorder and PTSD but not for those with panic disorder or generalised anxiety disorder. The effects of the intervention also appeared to erode by the 18-month follow-up, and there were no significant effects on remission among the older adults. Conclusions These results are consistent with the findings of other investigators suggesting that medications and psychotherapy for anxiety disorders may not be as effective for older individuals as they are for younger people. PMID:23580378
Wetherell, Julie Loebach; Petkus, Andrew J.; Thorp, Steven R.; Stein, Murray B.; Chavira, Denise A.; Campbell-Sills, Laura; Craske, Michelle G.; Sherbourne, Cathy; Bystritsky, Alexander; Sullivan, Greer; Roy-Byrne, Peter
Aggressive periodontitis is characterized by non-contributory medical history, rapid attachment loss and bone destruction and familial aggregation of cases. Aggressive periodontitis (both localized and generalized) is usually diagnosed in a young population. This is frequently the age that an orthodontic care is provided to this population. The aim of the present paper is to draw guidelines for periodontal evaluation and monitoring prior to and during active orthodontic treatment. Strict adherence to these guidelines as a routine protocol for periodontal examination prior, during and following orthodontic treatment may dramatically decrease the severity and improve the prognosis of patients with aggressive periodontitis in orthodontic clinics. PMID:23032199
LEVIN, Liran; EINY, Shmuel; ZIGDON, Hadar; AIZENBUD, Dror; MACHTEI, Eli E.
Anxiety in adolescents: Update on its diagnosis and treatment for primary care providers
Anxiety disorders are the most prevalent mental health concern facing adolescents today, yet they are largely undertreated. This is especially concerning given that there are fairly good data to support an evidence-based approach to the diagnosis and treatment of anxiety, and also that untreated, these problems can continue into adulthood, growing in severity. Thus, knowing how to recognize and respond to anxiety in adolescents is of the utmost importance in primary care settings. To that end, this article provides an up-to-date review of the diagnosis and treatment of anxiety disorders geared towards professionals in primary care settings. Topics covered include subtypes, clinical presentation, the etiology and biology, effective screening instruments, evidence-based treatments (both medication and therapy), and the long-term prognosis for adolescents with anxiety. Importantly, we focus on the most common types of anxiety disorders, often known as phobias, which include generalized anxiety disorder, social anxiety/social phobia, separation anxiety disorder, panic disorder, and specific phobias. In summary, anxiety is a common psychiatric problem for adolescents, but armed with the right tools, primary care providers can make a major impact. PMID:24600282
Siegel, Rebecca S; Dickstein, Daniel P
The aim of the study was to describe Swedish psychiatrists' experiences of involving the family in the treatment of women with postpartum psychosis. A qualitative design was used, and semistructured qualitative research interviews were conducted with nine psychiatrists from the south of Sweden. Data were analysed using qualitative content analysis. Four categories were found: the family as a resource, the family as coworkers, preparing the family for the future, and the family as a burden. The result showed that the psychiatrists considered the family to be a resource to which they devoted a great deal of care and effort. It was particularly important to involve the partner, informing about the course of the illness and the steps that need to be taken in the event of a relapse and reducing any guilt feelings. The psychiatrists instilled confidence and hope for a future of health and further child bearing. The family members' limited understanding of the treatment may impede the involvement of the family. Conclusion of the study was that the goal for family involvement was to facilitate the women's care and treatment. Further studies are needed to provide suggestions on how to develop family involvement in the care of women suffering from postpartum psychosis. PMID:24236289
Engqvist, I; Nilsson, K
The Diagnosis and Treatment of Bipolar Disorder: Decision-Making in Primary Care
Bipolar disorder is a chronic episodic illness, characterized by recurrent episodes of manic or depressive symptoms. Patients with bipolar disorder frequently present first to primary care, but the diversity of the potential symptoms and a low index of suspicion among physicians can lead to misdiagnosis in many patients. Frequently, co-occurring psychiatric and medical conditions further complicate the differential diagnosis. A thorough diagnostic evaluation at clinical interview, combined with supportive case-finding tools, is essential to reach an accurate diagnosis. When treating bipolar patients, the primary care physician has an integral role in coordinating the multidisciplinary network. Pharmacologic treatment underpins both short- and long-term management of bipolar disorder. Maintenance treatment to prevent relapse is frequently founded on the same pharmacologic approaches that were effective in treating the acute symptoms. Regardless of the treatment approach that is selected, monitoring over the long term is essential to ensure continued symptom relief, functioning, safety, adherence, and general medical health. This article describes key decision-making steps in the management of bipolar disorder from the primary care perspective: from initial clinical suspicion to confirmation of the diagnosis to decision-making in acute and longer-term management and the importance of patient monitoring.
Integrated trauma treatment in correctional health care and community-based treatment upon reentry.
Given the crisis of mass incarceration in the United States and the high prevalence of trauma histories among those incarcerated, it is imperative to improve service delivery to inmates in correctional facilities and to those undergoing reentry in community-based treatment settings. This article provides trauma definitions and categories, describes the sequelae of trauma, reviews research on the high prevalence of incarceration in this nation, and reviews research on the high prevalence of trauma among the incarcerated. This article also provides a menu of evidence-based and promising treatment approaches to address the overlap among trauma, mental illness, substance abuse, and behavioral problems. A synthesis of research via seven points is meant to guide practitioner and policy responses to the national challenge of meeting the needs of those undergoing reentry. PMID:21948808
Wallace, Barbara C; Conner, Latoya C; Dass-Brailsford, Priscilla
Rational Treatment Choices for Non-major Depressions in Primary Care
OBJECTIVE This review synthesizes available evidence for managing clinically significant dysphoric symptoms encountered in primary care, when formal criteria for major depression or dysthymia are not met. Discussion is focused on premenstrual dysphoric disorder (PMDD) and minor depression because of their significant prevalence in the primary care setting and the lack of clear practice guidelines for addressing each illness. DESIGN English language literature from prior systematic reviews was supplemented by searching medline, embase, the Cochrane Controlled Trials Registry, the Agency for Healthcare Research and Quality National Guideline Clearinghouse, and bibliographies of selected papers. Studies addressing the natural history or treatment of minor depression or PMDD were selected for review. Data were abstracted by 1 of 2 independent reviewers and studies were synthesized qualitatively. RESULTS Five individual studies that compared antidepressant or psychological treatments to placebo in patients with minor depression suggest short-term improvements in depressive symptoms with paroxetine, problem-solving therapy, and cognitive behavioral therapy, but not with amitryptiline. Modest benefits on mental health function were reported with paroxetine and with problem-solving therapy, but only in patients with severe functional impairment at baseline. Twenty-four controlled trials were identified that compared antidepressant or psychological treatments to placebo in patients with premenstrual dysphoric disorder. Pooled results from a recent systematic review of 15 randomized controlled trials and one additional trial abstract provide strong evidence for a significantly greater improvement in physical and psychological symptoms with serotonin-selective reuptake inhibitor medications when compared with placebo. Individual trials also suggest significantly greater improvements in symptom scores with venlafaxine, but not with tricyclic antidepressants. CONCLUSIONS The limited evidence base for minor depression provides only mixed support for a small to moderate benefit for few antidepressant medications and psychological treatments tested. For the treatment of severe psychological or physical symptoms causing functional impairment in patients with PMDD, sertraline and fluoxetine are clearly beneficial in carefully selected patients. PMID:11972726
Ackermann, Ronald T; Williams, John W
Costing Analysis of National HIV Treatment and Care Program in Vietnam
Background: Vietnam achieved rapid scale-up of antiretroviral therapy (ART), although external funds are declining sharply. To achieve and sustain universal access to HIV services, evidence-based planning is essential. To date, there had been limited HIV treatment and care cost data available in Vietnam. Methods: Cost data of outpatient and inpatient HIV care were extracted at 21 sentinel facilities (17 adult and 4 pediatric) that epitomize the national program. Step-down costing for administration costs and bottom-up resource costing for drugs, diagnostics, and labor were used. Records of 1401 adults and 527 pediatric patients were reviewed. Results: Median outpatient care costs per patient-year for pre-ART, first year ART, later year ART, and second-line ART were US $100, US $316, US $303, and US $1557 for adults; and US $171, US $387, US $320, and US $1069 for children, respectively. Median inpatient care cost per episode was US $162 for adults and US $142 for children. Non-antiretroviral (ARV) costs in adults at stand-alone facilities were 44% (first year ART) and 24% (later year ART) higher than those at integrated facilities. Adults who started ART with CD4 count ?100 cells per cubic millimeter had 47% higher non-ARV costs in the first year ART than those with CD4 count >100 cells per cubic millimeter. Adult ARV drug costs at government sites were from 66% to 85% higher than those at donor-supported sites in the first year ART. Conclusions: The study found that HIV treatment and care costs in Vietnam are economical, yet there is potential to further promote efficiency through strengthening competitive procurement, integrating HIV services, and promoting earlier ART initiation. PMID:23846564
Duong, Anh Thuy; Bales, Sarah; Do, Nhan Thi; Minh Nguyen, Thu Thi; Thanh Cao, Thuy Thi; Nguyen, Long Thanh
Understanding Attitudes Toward Use of Medication in Substance Abuse Treatment: A Multilevel Approach
Individual and organizational variables influence attitudes toward use of naltrexone, methadone, and buprenorphine for the treatment of alcohol and drug disorders. Previous research has not considered both sets of influences simultaneously. Hierarchical linear modeling tested the contribution of individual and organizational variables with data from the National Drug Abuse Treatment Clinical Trials Network treatment unit and workforce surveys (n =
John Fitzgerald; Dennis McCarty
Transdermal buprenorphine (TDB) is a widely used analgesic for moderate pain. TDB is generally well tolerated, but both irritant and allergic contact dermatitis occur at patch application sites. Oral opioid tolerance in patients with allergic contact dermatitis to TDB remains controversial. Here, we describe 3 patients with allergic contact dermatitis to TDB who subsequently used oral opioid derivatives without adverse reactions. Thus, oral intolerance to opioid derivatives is not a rule in patients with allergic contact dermatitis to TDB, but the possibility should be taken into consideration. PMID:24280659
Huilaja, Laura; Riekki, Riitta; Immonen, Aila; Tasanen, Kaisa
Transdermal buprenorphine for treating nociceptive and neuropathic pain: four case studies.
The use of opioids for treating neuropathic pain is controversial, and some studies have indicated that neuropathic pain may be relatively insensitive to typical mu-opioid analgesics such as morphine. However, it is becoming clear that different opioids produce analgesia by affecting different pain pathways. We present two cases of neuropathic pain and two cases of nociceptive pain with a significant neuropathic component that were treated with transdermal buprenorphine. In each case, sufficient pain relief was obtained and no problems were encountered in switching from prior analgesic therapy with larger doses of other opioids. PMID:15728068
Likar, Rudolf; Sittl, Reinhard
A 1-day meeting, attended by invited respiratory and primary-care specialists all of whom had an international profile and a specific interest in Chronic Obstructive Pulmonary Disease (COPD), considered specific research recommendations from the Global Initiative in Obstructive Lung Disease (GOLD) workshop report. Attendees discussed developing a tool to complement spirometry and help primary-care physicians assess treatment success in patients with
Jim Reid; David Price; Thys van der Molen; Bruno Housset; José Jardim; Paul Jones; Peter Kardos; Jean-François Muir; Pierluigi Paggiaro; Stephen Rennard; Emiel Wouters
Effective health care models to scale up combination antiretroviral therapy (ART) are needed in rural southwestern China. We aimed to evaluate the ART treatment outcomes and their associations with patients' demographic characteristics and pre-treatment clinical features in a scaled-up provincial ART program serving eight heavily HIV-affected prefectures in Yunnan Province. We abstracted information from a computerized database for adults initiating ART between July 2007 and September 2008. Survival functions of mortality and treatment failure were calculated by age group, gender, transmission mode, and baseline CD4 count. Multivariable Cox regression analyses were conducted to find independent associations of various demographic and baseline clinical features with outcome variables. Of the 1967 patients in the mortality analysis, there were 110 deaths, of which 16 were coded as accidents or suicides. Adjusted hazard ratios (AHR) associated with mortality were greater for patients with baseline CD4 counts <100 cells/µl vs. patients with CD4 counts ?200 cells/µl, for male vs. female, for single vs. married, and for those acquired HIV through injection drug use (IDU) vs. other modes of transmission. Successful treatment was 81.3% at six months after treatment started. Immunologic treatment failure was associated with baseline CD4 counts but not with demographic characteristics. Overall loss to follow-up rate was 2.1%. Collaboration between clinics and community networks are distinctive features of Yunnan's model for scaling up ART across a diverse, poor, and rural population. This study finds that the strategy can succeed even if 40% of the patients have a history of IDU. PMID:24116389
Chen, Juemin; Yu, Bo; Wang, Yungshen; Tang, Michele; Hu, Yanhong; Cai, Thomas; Zhang, Fujie; von Zinkernagel, Deborah; Harwell, Joseph I; Huang, Zhihuan Jennifer
Context Collaborative depression care management (DCM), by addressing barriers disproportionately affecting patients of racial/ethnic minority and low education, may reduce disparities in depression treatment and outcomes. Objective To examine the effect of DCM on treatment disparities by education and ethnicity among older depressed primary care patients. Design, Setting and Participants Analysis of data from a randomized controlled trial known as PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial). This analysis included patients from 20 primary care practices, 60 or older, and with major depression (n=396). We conducted model-based analysis to estimate potentially differential intervention effects by education, independent of those by ethnicity (and vice versa). Intervention Algorithm-based recommendations to physicians and care management by depression care managers. Main Outcome Measures Antidepressant use, depressive symptoms and intensity of DCM over 2 years Results The PROSPECT intervention had a larger and more lasting effect among less-educated patients. At month 12, the intervention increased the rate of adequate antidepressant use by 14.2 percentage points (pps) [95% confidence interval (CI): 1.7, 26.4] among the no-college group, compared with a null effect among the college-educated (?9.2 pps [95% CI: ?25.0, 2.7]); at month 24, the intervention reduced depressive symptoms by 2.6 points on the Hamilton Depression Rating Scale [95% CI: ?4.6, ?0.4] among no-college patients, 3.8 points [95% CI: ?6.8, ?0.4] more than among the college group. The intervention benefitted non-Hispanic whites more than minority patients. Intensity of DCM received by minorities was 60-70% of that by whites after the initial phase, but did not differ by education. Conclusions The PROSPECT intervention substantially reduced disparities by patient education, but failed to mitigate racial/ethnic disparities, in depression treatment and outcomes. Incorporation of culturally-tailored strategies in DCM models may be needed in order to extend their benefits to minorities. PMID:21646579
Bao, Yuhua; Alexopoulos, George S.; Casalino, Lawrence P.; Ten Have, Thomas R.; Donohue, Julie M.; Post, Edward P.; Schackman, Bruce R.; Bruce, Martha L.
A meta-analytic review on treatment dropout in child and adolescent outpatient mental health care.
A large proportion (28% up to 75%) of the treatments in youth mental health care results in premature termination (dropout). It is important to gain knowledge of the determinants of dropout because it can have very severe consequences. The aim of our meta-analytic review was to provide an overview of findings from empirical studies on this subject. We structured the often contradicting results from two perspectives. First, we compared studies with efficacy and effectiveness designs. Second, we compared studies which used a dropout definition based on the opinion of therapists, with those that took the number of predetermined completed sessions as a criterion. Third, we studied three groups of predictors, i.e., pre-treatment child variables, pre-treatment family or parent variables, and treatment and therapist variables or treatment participation barriers. The meta-analytic review showed that dropout percentages were strongly influenced by study design: Percentages were lower in efficacy than in effectiveness studies. Within effectiveness studies, the dropout percentages were lower when the therapist's opinion was used rather than when the number of sessions was used as a criterion. In efficacy studies on the contrary, the dropout percentages were similar for studies using the first or the second criterion. With respect to dropout predictors, results were less clear. Some of the dropout predictors were influenced by study design or dropout definition, but for most predictors this influence could not be analyzed because they were not studied in all groups of studies or because the effect sizes were small or non-significant. Treatment and therapist variables or experienced treatment participation barriers were overall stronger dropout predictors than the pre-treatment child variables and pre-treatment family or parent variables, although some strong predictive pre-treatment variables emerged as well. PMID:23742782
de Haan, Anna M; Boon, Albert E; de Jong, Joop T V M; Hoeve, Machteld; Vermeiren, Robert R J M
This study evaluated primary care providers' (PCPs, pediatricians, and nurse practitioners) knowledge, current practices, and perceived barriers to childhood obesity prevention and treatment, with an emphasis on first-year well-child care visits. A questionnaire was distributed to 192 PCPs in the primary care network at The Children's Hospital of Philadelphia (CHOP) addressing (i) knowledge of obesity and American Academy of Pediatrics (AAP) guidelines, (ii) anticipatory guidance practices at well visits regarding nutrition and exercise, and (iii) perceived barriers to childhood obesity treatment and prevention. Eighty pediatricians and seven nurse practitioners responded, and a minority correctly identified the definition (26%) and prevalence (9%) of childhood overweight and AAP guidelines for exercise (39%) and juice consumption (44%). Most PCPs (81%) spent 11-20 min per well visit during the first 2 years, and 79% discussed diet, nutrition, and exercise for > or =3 min. Although >95% of PCPs discussed juice, fruits and vegetables, sippy cups, and finger foods during the first year, over 35% never discussed fast food, TV, or candy, and 55% never discussed exercise. Few rated current resources as adequate to treat or prevent childhood obesity. Over 90% rated the following barriers for obesity prevention and treatment as important or very important: parent is not motivated, child is not motivated, parents are overweight, families often have fast food, watch too much TV, and do not get enough exercise. In conclusion, there is much room to improve PCPs' knowledge of obesity and AAP guidelines. Although PCPs rate fast-food consumption, TV viewing, and lack of exercise as important treatment barriers, many never discussed these topics during the first year. PMID:19910934
Spivack, Jordan G; Swietlik, Maggie; Alessandrini, Evaline; Faith, Myles S
Health-Care Delay in Malignant Melanoma: Various Pathways to Diagnosis and Treatment
We aimed to describe and compare patients diagnosed with malignant melanoma (MM), depending on their initial contact with care and with regard to age, sex, and MM type and thickness, and to explore pathways and time intervals (lead times) between clinics from the initial contact to diagnosis and treatment. The sample from northern Sweden was identified via the Swedish melanoma register. Data regarding pathways in health care were retrieved from patient records. In our unselected population of 71 people diagnosed with skin melanoma of SSM and NM types, 75% of patients were primarily treated by primary health-care centres (PHCs). The time interval (delay) from primary excision until registration of the histopathological assessment in the medical records was significantly longer in PHCs than in hospital-based and dermatological clinics (Derm). Thicker tumors were more common in the PHC group. Older patients waited longer times for wide excision. Most MM are excised rapidly at PHCs, but some patients may not be diagnosed and treated in time. Delay of registration of results from histopathological assessments within PHCs seems to be an important issue for future improvement. Exploring shortcomings in MM patients' clinical pathways is important to improve the quality of care and patient safety. PMID:24516469
Sundbom, Elisabet; Schmitt-Egenolf, Marcus
Background Vaginitis is a common complaint in primary care. In uncomplicated candidal vaginitis, there are no differences in effectiveness between oral or vaginal treatment. Some studies describe that the preferred treatment is the oral one, but a Cochrane's review points out inconsistencies associated with the report of the preferred way that limit the use of such data. Risk factors associated with recurrent vulvovaginal candidiasis still remain controversial. Methods/Design This work describes a protocol of a multicentric prospective observational study with one year follow up, to describe the women's reasons and preferences to choose the way of administration (oral vs topical) in the treatment of not complicated candidal vaginitis. The number of women required is 765, they are chosen by consecutive sampling. All of whom are aged 16 and over with vaginal discharge and/or vaginal pruritus, diagnosed with not complicated vulvovaginitis in Primary Care in Madrid. The main outcome variable is the preferences of the patients in treatment choice; secondary outcome variables are time to symptoms relief and adverse reactions and the frequency of recurrent vulvovaginitis and the risk factors. In the statistical analysis, for the main objective will be descriptive for each of the variables, bivariant analysis and multivariate analysis (logistic regression).. The dependent variable being the type of treatment chosen (oral or topical) and the independent, the variables that after bivariant analysis, have been associated to the treatment preference. Discussion Clinical decisions, recommendations, and practice guidelines must not only attend to the best available evidence, but also to the values and preferences of the informed patient. PMID:21281464
Although different health risks and behaviors displayed by contemporary U.S. immigrants create challenges for health care providers, knowledge on the health of and variations among African immigrant groups in the United States lags behind. This study compared health status, use of health care resources, and treatment strategies of 362 Ethiopian and Nigerian immigrants. The results indicated that mental health and
Josphine Chaumba
Objective: This study examined the influence of clinical and nonclinical fea- tures of case presentation on the diagno- sis and treatment of eating disorders in primary care. Method: Family physicians from a defined region of the UK were provided with two vignettes, characterizing eating disorder presentations in primary care. Case gender, ethnicity, weight status, and diabetes history were experimentally manipulated.
Laura Currin; Ulrike Schmidt; Glenn Waller
45 CFR 164.506 - Uses and disclosures to carry out treatment, payment, or health care operations.
Code of Federal Regulations, 2013 CFR
...disclosures to carry out treatment, payment, or health care operations. 164.506 Section 164.506 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES ADMINISTRATIVE DATA... Privacy of Individually Identifiable Health Information § 164.506 Uses...
45 CFR 164.506 - Uses and disclosures to carry out treatment, payment, or health care operations.
Code of Federal Regulations, 2011 CFR
...disclosures to carry out treatment, payment, or health care operations. 164.506 Section 164.506 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES ADMINISTRATIVE DATA... Privacy of Individually Identifiable Health Information § 164.506 Uses...
45 CFR 164.506 - Uses and disclosures to carry out treatment, payment, or health care operations.
Code of Federal Regulations, 2012 CFR
...disclosures to carry out treatment, payment, or health care operations. 164.506 Section 164.506 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES ADMINISTRATIVE DATA... Privacy of Individually Identifiable Health Information § 164.506 Uses...
Objective We suggest that clinicians consider models of shared decision-making for their potential ability to improve the treatment of major depression in the primary care setting and overcome limitations of collaborative care and other interventions. Methods We explore the characteristics and techniques of patient-clinician shared decision-making, with particular emphasis on this model's relevance to the unique treatment concerns of depressed older adults. Results We describe a shared decision-making intervention to engage older adults in depression treatment in the primary care sector. Conclusions It is timely to examine shared decision-making models for elderly depressed primary care patients given their potential ability to improve treatment adherence and clinical outcomes. PMID:19946872
Raue, Patrick J.; Schulberg, Herbert C.; Lewis-Fernandez, Roberto; Boutin-Foster, Carla; Hoffman, Amy S.; Bruce, Martha L.
Alcohol-dependent patients in inpatient detoxification were randomized to treatment-as-usual (TAU) intervention or brief family treatment (BFT) intervention to promote continuing care postdetoxification. BFT consisted of meeting with the patient and an adult family member (in person or over the phone) with whom the patient lived to review and recommend potential continuing care plans for the patient. Results showed that BFT patients (n = 24) were significantly more likely than TAU patients (n = 21) to enter a continuing care program after detoxification. This was a medium to large effect size. In the 3 months after detoxification, days using alcohol or drugs (a) trended lower for treatment-exposed BFT patients who had an in-person family meeting than for TAU counterparts (medium effect), and (b) were significantly lower for patients who entered continuing care regardless of treatment condition (large effect). PMID:17614242
O'Farrell, Timothy J; Murphy, Marie; Alter, Jane; Fals-Stewart, William
45 CFR 164.506 - Uses and disclosures to carry out treatment, payment, or health care operations.
Code of Federal Regulations, 2010 CFR
...disclosures to carry out treatment, payment, or health care operations. 164.506 Section 164.506 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES ADMINISTRATIVE DATA... Privacy of Individually Identifiable Health Information § 164.506 Uses...
Background & objectives: Depression remains largely undiagnosed in women residing in rural India and consequently many do not seek help. Moreover, among those who are diagnosed, many do not complete treatment due to high rates of attrition. This study was aimed to compare the effectiveness of enhanced care with usual care in improving treatment seeking and adherence to antidepressant medication in women with depression living in rural India. Methods: Six villages from rural Bangalore were randomized to either community health worker supported enhanced care or usual care. A total of 260 adult depressed women formed the final participants for the analysis. The outcome measures were number of women who sought and completed treatment, number of clinic visits, duration of treatment with antidepressant, changes in severity of depression (HDRS) and changes in quality of life [WHO-QOL (Brev) scale]. Results: A significantly greater number of women from the treatment intervention (TI) group completed the treatment and were on treatment for a longer duration compared to the treatment as usual (TAU) group. However, there were no significant differences in the severity of depression or quality of life between the TI and the TAU groups or between treatment completers and treatment dropouts at six months. Interpretation & conclusions: Enhanced care provided by the trained community health workers to rural women with major depression living in the community resulted in greater number of women seeking help and adhering to treatment with antidepressants. However, despite enhanced care a significant number of rural women diagnosed with depression either did not seek help or discontinued treatment prematurely. These findings have significant public health implications, as untreated depression is associated with considerable disability. PMID:24718398
Pradeep, Johnson; Isaacs, Anton; Shanbag, Deepthi; Selvan, Sumithra; Srinivasan, Krishnamachari
The clinical effectiveness of opioid maintenance for heroin dependence is believed to result from a medication's ability to decrease ?-opioid receptor (?OR) availability thereby replacing agonist effects, alleviating withdrawal symptoms and attenuating heroin effects. We empirically tested this hypothesis in five heroin-dependent volunteers who were successively maintained on 32, 16, 2, and 0 mg daily buprenorphine (BUP) tablet doses. We
Mark K Greenwald; Chris-Ellyn Johanson; David E Moody; James H Woods; Michael R Kilbourn; Robert A Koeppe; Charles R Schuster; Jon-Kar Zubieta
OBJECTIVES:Psychiatric and substance use disorders are common in hepatitis C patients and represent barriers to antiviral treatment. We evaluated the effect of integrating psychiatric and medical care on evaluation for and initiation of antiviral treatment in a cohort of 184 patients with chronic hepatitis C.METHODS:Integrated care consisted of screening for psychiatric problems with Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), Beck
Astrid Knott; Eric Dieperink; Mark L. Willenbring; Sara Heit; Janet M. Durfee; Mary Wingert; James R. Johnson; Paul Thuras; Samuel B. Ho
The treatment of depressed chinese americans using qigong in a health care setting: a pilot study.
Background. This pilot study examined the feasibility and efficacy of providing Qigong treatment in a health center to Chinese Americans with major depressive disorder (MDD). Methods. Fourteen Chinese Americans with MDD were enrolled, and they received a 12-week Qigong intervention. The key outcome measurement was the 17-item Hamilton Rating Scale for Depression (HAM-D17); the Clinical Global Impressions-Severity (CGI-S) and -Improvement (CGI-I), the Quality of Life Enjoyment and Satisfaction Questionnaire, Short Form (Q-LES-Q-SF), and the Multidimensional Scale of Perceived Social Support (MSPSS) were also administered. Positive response was defined as a decrease of 50% or more on the HAM-D17, and remission was defined as HAM-D17 ? 7. Patients' outcome measurements were compared before and after the Qigong intervention. Results. Participants (N = 14) were 64% female, with a mean age of 53 (±14). A 71% of participants completed the intervention. The Qigong intervention resulted in a positive treatment-response rate of 60% and a remission rate of 40% and statistically significant improvement, as measured by the HAM-D17, CGI-S, CGI-I, Q-LES-Q-SF, and the family support subscale of the MSPSS. Conclusions. The Qigong intervention provided at a health care setting for the treatment of primary care patients with MDD is feasible. Further studies with larger sample sizes are warranted. PMID:23690836
Yeung, Albert; Slipp, Lauren E; Jacquart, Jolene; Fava, Maurizio; Denninger, John W; Benson, Herbert; Fricchione, Gregory L
Background. The purpose was to test the effectiveness of two transdiagnostic group interventions compared to care as usual (CAU) for patients with anxiety, depressive or stress-related disorders within a primary health care context. Objectives. To compare the effects of cognitive-based-behavioural therapy (CBT) and multimodal intervention (MMI) on the quality of life and relief of psychological symptoms of patients with common mental disorders or problems attending primary health care centre. Methods. Patients (n = 278), aged 18–65 years, were referred to the study by the GPs and 245 were randomized to CAU or one of two group interventions in addition to CAU: (i) group CBT administered by psychologists and (ii) group MMI administered by assistant nurses. The primary outcome measure was the Mental Component Summary score of short form 36. Secondary outcome measures were Perceived Stress Scale and Self-Rating Scale for Affective Syndromes. The data were analysed using intention-to-treat with a linear mixed model. Results. On the primary outcome measure, the mean improvement based on mixed model analyses across post- and follow-up assessment was significantly larger for the MMI group than for the CBT (4.0; P = 0.020) and CAU (7.5; P = .001) groups. Participants receiving CBT were significantly more improved than those in the CAU group. On four of the secondary outcome measures, the MMI group was significantly more improved than the CBT and CAU groups. The course of improvement did not differ between the CBT group and the CAU group on these measures. Conclusions. Transdiagnostic group treatment can be effective for patients with common mental disorders when delivered in a primary care setting. The group format and transdiagnostic approach fit well with the requirements of primary care. PMID:24642702
Ejeby, Kersti
Respiratory depression has been attributed to buprenorphine (BUP) misuse or combination with benzodiazepines. BUP/naloxone (NLX) has been marketed as maintenance treatment, aiming at preventing opiate addicts from self-injecting crushed pills. However, to date, BUP/NLX benefits in comparison to BUP alone remain debated. We investigated the plethysmography effects of BUP/NLX in comparison to BUP/solvent administered by intravenous route in naive and BUP-tolerant Sprague-Dawley rats, and in combination with diazepam (DZP) or its solvent. In naive rats, BUP/NLX in comparison to BUP significantly increased respiratory frequency (f, P<0.05) without altering minute volume (VE). In combination to DZP, BUP/NLX significantly increased expiratory time (P<0.01) and decreased f (P<0.01), tidal volume (VT, P<0.001), and VE (P<0.001) while BUP only decreased VT (P<0.5). In BUP-tolerant rats, no significant differences in respiratory effects were observed between BUP/NLX and BUP. In contrast, in combination to DZP, BUP/NLX did not significantly alter the plethysmography parameters, while BUP increased inspiratory time (P<0.001) and decreased f (P<0.01) and VE (P<0.001). In conclusion, differences in respiratory effects between BUP/NLX and BUP are only significant in combination with DZP, with increased depression in naive rats but reduced depression in BUP-tolerant rats. However, BUP/NLX benefits in humans remain to be determined. PMID:24769261
Cohier, Camille; Chevillard, Lucie; Risčde, Patricia; Roussel, Olivier; Mégarbane, Bruno
The psychopharmacological treatment of depression in primary care in the Royal Navy.
Depression is a common mental health condition in the UK Armed Forces. Although psychopharmacology is usually a second line intervention, there is a place for antidepressants in the management of depression in primary care. This article will examine the diagnosis of depression, the indications for starting antidepressants, the choice of anti-depressants and the occupational considerations in the Royal Navy. The aim is to equip General Practitioners (GPs) and General Duties Medical Officers (GDMOs) with the clinical information needed to initiate psychopharmacological treatment for depression where indicated. PMID:25335316
Coetzee, R H
Covert treatment in psychiatry: do no harm, true, but also dare to care.
Covert treatment raises a number of ethical and practical issues in psychiatry. Viewpoints differ from the standpoint of psychiatrists, caregivers, ethicists, lawyers, neighbours, human rights activists and patients. There is little systematic research data on its use but it is quite certain that there is relatively widespread use. The veil of secrecy around the procedure is due to fear of professional censure. Whenever there is a veil of secrecy around anything, which is aided and abetted by vociferous opposition from some sections of society, the result is one of two: 1) either the activity goes underground or 2) it is reluctantly discarded, although most of those who used it earlier knew it was needed. Covert treatment has the dubious distinction of suffering both such secrecy and disapproval.Covert treatment has a number of advantages and disadvantages in psychotic disorders. The advantages are that it helps solve practical clinical problems; prevents delays in starting treatment, which is associated with clinical risks and substantial costs; prevents risk of self-destructive behaviour and/or physical assault by patient; prevents relapse; and prevents demoralization of staff. The disadvantages are that it maybe used with malafide intent by caregivers with or without the complicity of psychiatrists; it may be used to force conformity in dissenters; and the clinician may land himself in legal tangles even with its legitimate use. In addition, it may prevent insight, encourage denial, promote unhealthy practices in the treating staff and prevent understanding of why noncompliance occurs in the first place.Some support its use in dementia and learning disorders but oppose it in schizophrenia. The main reason is that uncooperative patients of schizophrenia (and related psychoses) are considered to be those who refuse treatment but retain capacity; while in dementia and severe learning disorder, uncooperative patients are those who lack capacity. This paper disputes this contention by arguing that although uncooperative patients of schizophrenia (and related psychoses) apparently retain capacity, it is limited, in fact distorted, since they lack insight. It presents the concept of insight-unconsciousness in a patient of psychosis. Just as an unconscious patient has to be given covert medical/surgical treatment, similarly an insight-unconscious patient with one of the different psychoses (in the acute phase or otherwise) may also have to be given covert treatment till he regains at least partial insight. It helps control psychotic symptoms and assists the patient in regaining enough insight to realize he needs treatment. Another argument against covert treatment is that people with schizophrenia have the capacity to learn and therefore can learn that they are required to take medications, but if medications are given covertly it may well fuel their paranoia. However, it should be noted that the patient who has lack of insight cannot learn unless he regains that insight, and he may need covert treatment to facilitate this process. Covert treatment can fuel the paranoia, true, but it can also control the psychotic symptoms sufficiently so that regular treatment can be initiated. In a patient who refuses to accept that he is sick and when involuntary commitment is not an option to be considered, covert treatment is the only option, apart from physical restraint. Ultimately, a choice has to be made between a larger beneficence (control of symptoms and start of therapy) and a smaller malevolence (necessary therapy, but without the patient's knowledge and consent).A number of practical clinical scenarios are outlined wherein the psychiatrist should adopt covert treatment in the best interests of the patient. Ethical issues of autonomy, power, secrecy and malafide intent arise; each of these can be countered only by non-malfeasance (above all, do no harm) under the overarch of beneficence (even above that, dare to care). An advance directive with health care proxy that sanctions covert treatment is presented. Questions raised by t
Singh, Ajai R
Social expectations surrounding sickness have undergone a transformation in Western welfare states. Emerging discourses about patients' roles and responsibilities do not however always map neatly onto patients' actions, experiences or desires. This paper emerges from a study in Ontario, Canada. Drawing on in-depth interviews with 5 women diagnosed with breast cancer we explore the activity and effort prompted for patients by the routine professional practice of outlining treatment options and encouraging patients to choose between them. We highlight research participants' complex responses to their responsibility for treatment decisions: their accepting, deflecting and reframing and their active negotiation of responsibility with professionals. The literature on treatment decision making typically characterizes people who resist taking an active role as overwhelmed, misinformed about the nature of treatment decisions, or more generally lacking capacity to participate. In this paper we suggest that patients' expressions of ambivalence about making treatment choices can be understood otherwise: as efforts to recast the identities and positions they and their physicians are assigned in the organization of cancer care. We also begin to map key features of this organization, particularly discourses of patient empowerment, and evidence-based medicine. PMID:20633970
Sinding, Christina; Hudak, Pamela; Wiernikowski, Jennifer; Aronson, Jane; Miller, Pat; Gould, Judy; Fitzpatrick-Lewis, Donna
The process of radiotherapy (RT) is complex and involves understanding of the principles of medical physics, radiobiology, radiation safety, dosimetry, radiation treatment planning, simulation and interaction of radiation with other treatment modalities. Each step in the integrated process of RT needs quality control and quality assurance (QA) to prevent errors and to give high confidence that patients will receive the prescribed treatment correctly. Recent advances in RT, including intensity-modulated and image-guided RT, focus on the need for a systematic RTQA program that balances patient safety and quality with available resources. It is necessary to develop more formal error mitigation and process analysis methods, such as failure mode and effect analysis, to focus available QA resources optimally on process components. External audit programs are also effective. The International Atomic Energy Agency has operated both an on-site and off-site postal dosimetry audit to improve practice and to assure the dose from RT equipment. Several countries have adopted a similar approach for national clinical auditing. In addition, clinical trial QA has a significant role in enhancing the quality of care. The Advanced Technology Consortium has pioneered the development of an infrastructure and QA method for advanced technology clinical trials, including credentialing and individual case review. These activities have an impact not only on the treatment received by patients enrolled in clinical trials, but also on the quality of treatment administered to all patients treated in each institution, and have been adopted globally; by the USA, Europe and Japan also. PMID:18952706
Ishikura, Satoshi
Abstract Multidimensional Treatment Foster Care (MTFC) has been shown to be an evidence based alternative to residential rearing and an effective method to improve behavior and attachment of foster children in the US. This preliminary study investigated an application of MTFC for preschoolers (MTFC-P) in the Netherlands focusing on behavioral outcomes in course of the intervention. To examine the following hypothesis: "the time in the MTFC-P intervention predicts a decline in problem behavior", as this is the desired outcome for children assigned to MTFC-P, we assessed the daily occurrence of 38 problem behaviors via telephone interviews. Repeated measures revealed significant reduced problem behavior in course of the program. MTFC-P promises to be a treatment model suitable for high-risk foster children, that is transferable across centres and countries. Trial registration Netherlands Trial Register: 1747. PMID:23216971
The purpose of this qualitative study was to discover the care meanings, expressions, and lived experiences of the chronically mentally ill living in an urban community as a subculture. This study was conceptualized within Leiningers Theory of Culture Care Diversity and Universality with the use of the Sunrise Model to explicate worldview, social structure factors, and historical and environmental context
Tamara Bloom George
This study explored survivors' perspectives on care delivery and supportive care needs during reentry. Fifty-one individual interviews were conducted with adult leukemia and lymphoma survivors, 3 to 48 months from treatment cessation. Survivors reported poor continuity of care across the patient-survivor transition, difficulty finding appropriate information/services, lack of preparation, lack of support for survivorship issues, and inadequate or poorly timed follow-up as factors contributing to adjustment difficulties at end of treatment and beyond. Improved care coordination is needed after active treatment, including use of an exit interview and delivery of services that are more congruent and better timed to meet ongoing and emergent survivorship needs. PMID:21391070
Parry, Carla; Morningstar, Elizabeth; Kendall, Jeffery; Coleman, Eric A
Although previous studies have shown that pharmacological agents, such as buprenorphine, and alternative nondrug reinforcers, such as money or sweetened solutions, reduce cocaine self-administration, few studies have examined the combined effects of these two approaches. The purpose of the present study was to evaluate the effects of the opioid partial agonist buprenorphine (0.1 mg\\/kg) and concurrent access to either water
Sandra D. Comer; Sylvie T. Lac; Cindy L. Wyvell; Marilyn E. Carroll
Background Healthcare reform in the United States is encouraging Federally Qualified Health Centers and other primary-care practices to integrate treatment for addiction and other behavioral health conditions into their practices. The potential of mobile health technologies to manage addiction and comorbidities such as HIV in these settings is substantial but largely untested. This paper describes a protocol to evaluate the implementation of an E-Health integrated communication technology delivered via mobile phones, called Seva, into primary-care settings. Seva is an evidence-based system of addiction treatment and recovery support for patients and real-time caseload monitoring for clinicians. Methods/Design Our implementation strategy uses three models of organizational change: the Program Planning Model to promote acceptance and sustainability, the NIATx quality improvement model to create a welcoming environment for change, and Rogers's diffusion of innovations research, which facilitates adaptations of innovations to maximize their adoption potential. We will implement Seva and conduct an intensive, mixed-methods assessment at three diverse Federally Qualified Healthcare Centers in the United States. Our non-concurrent multiple-baseline design includes three periods — pretest (ending in four months of implementation preparation), active Seva implementation, and maintenance — with implementation staggered at six-month intervals across sites. The first site will serve as a pilot clinic. We will track the timing of intervention elements and assess study outcomes within each dimension of the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework, including effects on clinicians, patients, and practices. Our mixed-methods approach will include quantitative (e.g., interrupted time-series analysis of treatment attendance, with clinics as the unit of analysis) and qualitative (e.g., staff interviews regarding adaptations to implementation protocol) methods, and assessment of implementation costs. Discussion If implementation is successful, the field will have a proven technology that helps Federally Qualified Health Centers and affiliated organizations provide addiction treatment and recovery support, as well as a proven strategy for implementing the technology. Seva also has the potential to improve core elements of addiction treatment, such as referral and treatment processes. A mobile technology for addiction treatment and accompanying implementation model could provide a cost-effective means to improve the lives of patients with drug and alcohol problems. Trial registration ClinicalTrials.gov (NCT01963234). PMID:24884976
Introduction We examined the prevalence of substance use disorders among homeless and vulnerably housed persons in three Canadian cities and its association with unmet health care needs and access to addiction treatment using baseline data from the Health and Housing in Transition Study. Methods In 2009, 1191 homeless and vulnerably housed persons were recruited in Vancouver, Toronto, and Ottawa, Canada. Interviewer administered questionnaires collected data on socio-demographics, housing history, chronic health conditions, mental health diagnoses, problematic drug use (DAST-10?6), problematic alcohol use (AUDIT?20), unmet physical and mental health care needs, addiction treatment in the past 12 months. Three multiple logistic regression models were fit to examine the independent association of substance use with unmet physical health care need, unmet mental health care need, and addiction treatment. Results Substance use was highly prevalent, with over half (53%) screening positive for the DAST-10 and 38% screening positive for the AUDIT. Problematic drug use was 29%, problematic alcohol use was lower at 16% and 7% had both problematic drug and alcohol use. In multiple regression models for unmet need, we found that problematic drug use was independently associated with unmet physical (adjusted odds ratio [AOR] 1.95; 95% confidence interval [CI] 1.43–2.64) and unmet mental (AOR 3.06; 95% CI 2.17–4.30) health care needs. Problematic alcohol use was not associated with unmet health care needs. Among those with problematic substance use, problematic drug use was associated with a greater likelihood of accessing addiction treatment compared to those with problematic alcohol use alone (AOR 2.32; 95% CI 1.18–4.54). Conclusions Problematic drug use among homeless and vulnerably housed individuals was associated with having unmet health care needs and accessing addiction treatment. Strategies to provide comprehensive health services including addiction treatment should be developed and integrated within community supported models of care. PMID:24124470
Palepu, Anita; Gadermann, Anne; Hubley, Anita M.; Farrell, Susan; Gogosis, Evie; Aubry, Tim; Hwang, Stephen W.
Chronic gastrointestinal disorders are a source of substantial morbidity, mortality, and cost. They are common in general practice, and the primary care physician (PCP) has a central role in the early detection and management of these problems. The need to make cost-effective diagnostic and treatment decisions, avoid unnecessary investigation and referral, provide long-term effective control of symptoms, and minimize the risk of complications constitute the main challenges that PCPs face. The literature review shows that, although best practice standards are available, a considerable number of PCPs do not routinely follow them. Low rates of colorectal cancer screening, suboptimal testing and treatment of Helicobacter pylori infection, inappropriate use of proton pump inhibitors, and the fact that most PCPs are still approaching the irritable bowel disease as a diagnosis of exclusion represent the main gaps between evidence-based guidelines and clinical practice. This manuscript points out that updating of knowledge and skills of PCPs via continuing medical education is the only way for better adherence with standards and improving quality of care for patients with gastrointestinal diseases. PMID:24648750
Gikas, Aristofanis; Triantafillidis, John K
Treatment needs and diagnosis awareness in primary care patients with chronic kidney disease
Background GPs in England are required to keep a register of patients with chronic kidney disease (CKD). National Institute for Health and Clinical Excellence (NICE) guidelines recommend regular follow-up, but patients are perceived to be low risk and not requiring active management. Aim To assess treatment needs of CKD stage 3 patients in primary care, as well as their awareness of CKD. Design and setting A cross-sectional analysis from a longitudinal prospective study in 32 general practices. Method A total of 1741 participants underwent clinical assessment including urine and blood tests. Participants were asked about awareness of their CKD. Results were reviewed and a letter recommending treatment in line with NICE guidelines was sent to their GP. Results The mean age of participants was 73 ± 9 years; 60% (n = 1052) were female and diabetes was present in 17%; 67% of participants required further intervention. Most required improved control of hypertension (n = 1576; 33.1% of cohort). Other recommendations included advice to investigate anaemia (n = 1142; 8.2%) or stop nephrotoxic drugs (n = 1120; 7.5%). Less than 6% of participants met NICE criteria for referral to nephrology services and 41% were unaware of their CKD diagnosis. Multivariable analysis identified subjects with formal educational qualifications, age <75 years, estimated glomerular filtration rate (eGFR) 30–44 ml/min/1.73 m2, and significant albuminuria as more likely to be aware of their diagnosis. Conclusion The study data show that the majority of patients required at least one intervention to improve the management of their CKD. Most interventions could be delivered in primary care and only a minority required nephrology referral. Many patients were unaware of their CKD diagnosis, and efforts should be made to improve this to facilitate involvement in their care. PMID:22520909
McIntyre, Natasha J; Fluck, Richard; McIntyre, Chris; Taal, Maarten
Background. In Japan, the elderly population is growing rapidly, and therefore, so is the number of cancer patients who are not good candidates for aggressive surgery or chemotherapy. Radiation therapy offers excellent potential for the treatment of such patients, with minimal invasion and functional preservation. A Patterns of Care Study (PCS) examined the parameters of treatments used for patients with
T. Teshima; H. Ikeda; M. Abe; G. E. Hanks; J. B. Owen; H. Yoshioka; I. Tsukaguchi; M. Mori; T. Kiso; K. Ito
In recent years, concerns about climate change and the inefficient use and ongoing pollution of water resources have increased the political motivation to encourage water recycling. This has led to the widespread introduction of water saving measures and to advances in the decentralised treatment and reuse of wastewater. In particular, the treatment and reuse of greywater has received attention, although important information such as greywater substance loadings is still only rarely available. With the implementation of the European Water Framework Directive the focus on controlling and phasing-out Priority/Priority Hazardous Substances (PS/PHS) is growing, and it is vital to know their sources and flows in order to generate sustainable emission control strategies. The main objective of this study was to quantify the concentrations and loads of PS/PHS and personal care substances in bathroom greywater, and to thereby assess the contribution of household activities to municipal wastewater loads for these substances. Nickel and mercury may be sourced substantially from household activities as it shown in the paper that bathroom greywater contributed a significant proportion of the overall load of these substances at the municipal wastewater treatment plant. Organic matter in the influent greywater was found to be principally associated with large particles (>8 µm), however it was the dissolved and small sized particles that were predominantly removed in the treatment. PMID:21123919
Eriksson, E; Donner, E; Ledin, A
Background To achieve good clinical outcomes with HAART, patient adherence to treatment and care is a key factor. Since the literature on how to care for pediatric HIV patients is limited, we describe here adherence interventions implemented in our comprehensive care program in a resource-limited setting in Kenya. Methods We based our program on factors reported to influence adherence to HIV care and treatment. We describe, in detail, our program with respect to how we adapted our clinical settings, implemented psycho-social support activities for children and their caregivers and developed treatment literacy for children and teenagers living with HIV/AIDS. Results This paper focused on the details of the program, with the treatment outcomes as secondary. However, our program appeared to have been effective; for 648 children under 15 years of age who were started on HAART, the Kaplan-Meier mortality survival estimate was 95.27% (95%CI 93.16–96.74) at 12 months after the time of initiation of HAART. Conclusion Our model of pediatric HIV/AIDS care, focused on a child-centered approach with inclusion of caregivers and extended family, addressed the main factors influencing treatment adherence. It appeared to produce good results and is replicable in resource-limited settings. PMID:19025581
Van Winghem, Joelle; Telfer, Barbara; Reid, Tony; Ouko, Judith; Mutunga, Angela; Jama, Zaina; Vakil, Shobha
A sensitive liquid chromatographic-high-resolution mass spectrometric (LC-HR-MS) assay for buprenorphine and its urinary metabolites has been developed that requires minimal sample preparation. The results obtained have been compared with those given by (i) cloned enzyme donor immunoassay (CEDIA) and (ii) homogeneous enzyme immunoassay (HEIA) in the analysis of patient urines submitted for buprenorphine analysis. Centrifuged urine (100 µL) was diluted with internal standard solution (25 µL) + LC eluent (875 µL), and 50 µL of the prepared sample were analyzed (Accucore Phenyl-Hexyl column). MS detection was in alternating positive and negative mode using heated electrospray ionization (ThermoFisher Q Exactive). Intra- and inter-assay accuracy and precision were 104-128 and <11%, respectively, at 5 µg/L. Limits of detection were 1.3 µg/L (buprenorphine, norbuprenorphine and buprenorphine glucuronide) and 2.5 µg/L (norbuprenorphine glucuronide). Immunoassay sensitivity and selectivity were 97 and 100% (HEIA) and 99 and 84% (CEDIA), respectively, compared with LC-HR-MS. In 120 patient urines, norbuprenorphine glucuronide was easily the most abundant analyte except when adulteration with buprenorphine had occurred. The median immunoreactive buprenorphine species present (unhydrolysed urine) were 7.5 and 13% for HEIA and CEDIA, respectively. However, codeine, dihydrocodeine, morphine and morphine-3-glucuronide did not interfere in the HEIA assay. PMID:24925983
Belsey, Sarah L; Couchman, Lewis; Flanagan, Robert J
Background Opioids are psychoactive analgesic drugs prescribed for pain relief and palliative care. Due to their addictive potential, effort and vigilance in controlling prescriptions is needed to avoid misuse and dependence. Despite the effort, the prevalence of opioid use disorder continues to rise. Opioid substitution therapies are commonly used to treat opioid dependence; however, there is minimal consensus as to which therapy is most effective. Available treatments include methadone, heroin, buprenorphine, as well as naltrexone. This systematic review aims to assess and compare the effect of all available opioid substitution therapies on the treatment of opioid dependence. Methods/Design The authors will search Medline, EMBASE, PubMed, PsycINFO, Web of Science, Cochrane Library, Cochrane Clinical Trials Registry, World Health Organization International Clinical Trials Registry Platform Search Portal, and the National Institutes for Health Clinical Trials Registry. The title, abstract, and full-text screening will be completed in duplicate. When appropriate, multiple treatment comparison Bayesian meta-analytic methods will be performed to deduce summary statistics estimating the effectiveness of all opioid substitution therapies in terms of retention and response to treatment (as measured through continued opioid abuse). Discussion Using evidence gained from this systematic review, we anticipate disseminating an objective review of the current available literature on the effectiveness of all opioid substitution therapies for the treatment of opioid use disorder. The results of this systematic review are imperative to the further enhancement of clinical practice in addiction medicine. Systematic review registration PROSPERO CRD42013006507. PMID:25239213
Patterns of care and treatment outcomes for primary thyroid lymphoma: a single institution study
Purpose The aim of this study was to analyze the patterns of care and treatment outcomes in patients with primary thyroid lymphoma (PTL) in a single institution. Materials and Methods Medical records of 29 patients with PTL treated between April 1994 and February 2012 were retrospectively reviewed. Diagnosis was confirmed by biopsy (n = 17) or thyroidectomy (n = 12). Treatment modality and outcome were analyzed according to lymphoma grade. Results The median follow-up was 43.2 months (range, 3.8 to 220.8 months). The median age at diagnosis was 57 years (range, 21 to 83 years) and 24 (82.8%) patients were female. Twenty-five (86.2%) patients had PTL with stage IEA and IIEA. There were 8 (27.6%) patients with mucosa-associated lymphoid tissue (MALT) lymphoma and the remaining patients had high-grade lymphoma. Patients were treated with surgery (n = 2), chemotherapy (n = 7), radiotherapy (n = 3) alone, or a combination of these methods (n = 17). Treatment modalities evolved over time and a combination of modalities was preferred, especially for the treatment of high-grade lymphoma in recent years. There was no death or relapse among MALT lymphoma patients. Among high-grade lymphoma patients, 5-year overall survival (OS) and 5-year progression-free survival (PFS) were 75.6% and 73.9%, respectively. Complete remission after initial treatment was the only significant prognostic factor for OS (p = 0.037) and PFS (p = 0.003). Conclusion Patients with PTL showed a favorable outcome, especially with MALT lymphoma. Radiotherapy alone for MALT lymphoma and chemotherapy followed by radiotherapy for high-grade lymphoma can be effective treatment options for PTL. PMID:24501704
Cha, Hyejung; Kim, Jun Won; Suh, Chang-Ok; Kim, Jin Seok; Cheong, June-Won; Lee, Jeongshim; Keum, Ki Chang; Lee, Chang Geol
Aims To test the feasibility and effectiveness of Brief Counseling Intervention (BCI) and Naltrexone integrated into tuberculosis (TB) care in Tomsk, Russia. Design Using factorial randomized controlled trial design, patients were randomized into: Naltrexone, Brief Behavioral Compliance Enhancement Therapy (BBCET), treatment as usual (TAU); BCI, TAU; Naltrexone, BBCET, BCI, TAU; TAU. Setting and Participants In the Tomsk Oblast, hospitalized TB patients diagnosed with Alcohol Use Disorders (AUDs) by the DSM-IV were referred upon the start of TB treatment. Of the 196 cohort, the mean age was 41 years and 82% were male. Severe TB (84.7% had cavitary disease), and smoking (92.9%) were common. The majority had a diagnosis of an AUD (63.0%). 27.6% reported nearly daily drinking and consumed a median of 16 standard drinks per day. Measurements Primary outcomes were "favorable" TB outcome (cured, completed treatment) and change in mean number of abstinent days in the last month of study compared with baseline. Change in mean number of heavy drinking days, defined as 4 drinks per day and 5 drinks per day for women and men respectively, and TB adherence, measured as percent of doses taken as prescribed under direct observation, were secondary outcomes. Analysis based on "intention to treat" was performed for multivariable analysis. Findings Primary TB and alcohol endpoints between naltrexone and no-naltrexone or BCI and no-BCI groups did not differ significantly. TB treatment adherence and change in number of heavy drinking days also did not differ significantly among treatment arms. Among individuals with a prior quitting attempt (n=111), naltrexone use was associated with an increased likelihood of favorable TB outcomes (92.3% versus 75.9%, P=0.02). Conclusions In Tomsk Oblast, Russia, tuberculosis patients with severe Alcohol Use Disorders who were not seeking alcohol treatment did not respond to naltrexone or behavioral counselling integrated into tuberculosis care; however, those patients with past attempts to quit drinking had improved tuberculosis outcomes. PMID:23490304
Shin, Sonya; Livchits, Viktoria; Connery, Hilary Smith; Shields, Alan; Yanov, Sergei; Yanova, Galina; Fitzmaurice, Garrett M.; Nelson, Adrianne K.; Greenfield, Shelly F.
National guidelines for the pharmacologic treatment of chronic obstructive pulmonary disease (COPD) can be clarified for busy primary care practitioners who must deal with dozens of such treatment algorithms. MEDLINE searches and reviews of national evidence-based guidelines identified clinical trials and meta-analyses with relevant information on the stage-by-stage pharmacologic treatment of COPD. After formal presentations to a panel of pulmonary
Nicholas Gross; David Levin
Background To evaluate and compare effects of an integrative treatment (IT), therapeutic acupuncture (TA), and conventional treatment (CT) in alleviating symptoms of anxiety and depression in psychologically distressed primary care patients. Methods An open, pragmatic randomized controlled trial comparing the three treatment regimens at four and eight weeks after treatment. The study sample consisted of 120 adults (40 per treatment arm) aged 20 to 55 years referred from four different primary health care centres in western Sweden for psychological distress. Psychological distress was evaluated at baseline, and after 4 and 8 weeks of treatment using the Hospital Anxiety and Depression scale (HAD). Treatment sessions lasted about 60 minutes in IT and 45 minutes in TA. Results No baseline differences were found between groups on HAD depression or anxiety. HAD anxiety and depression decreased significantly more in the IT and TA groups than in the CT group both after 4 and 8 weeks of treatment, but not between IT and TA. Improvements in the TA and IT groups were large and clinically significant, whereas CT effects were small and clinically non-significant. Conclusions Both IT and TA appear to be beneficial in reducing anxiety and depression in primary care patients referred for psychological distress, whereas CT does not. These results need to be confirmed in larger, longer-term studies addressing potentially confounding design issues in the present study. Trial registration ISRCTN trial number NCT01631500. PMID:24200100
Health care for patients with HIV infection in developing countries has increased substantially in response to major international funding. Scaling up treatment programs requires timely data on the type, quantity, and quality of care being provided. Increasingly, such programs are turning to electronic health records (EHRs) to provide these data. We describe how a medical school in the United States and another in Kenya collaborated to develop and implement an EHR in a large HIV/AIDS care program in western Kenya. These data were used to manage patients, providers, and the program itself as it grew to encompass 18 sites serving more than 90,000 patients. Lessons learned have been applicable beyond HIV/AIDS to include primary care, chronic disease management, and community-based health screening and disease prevention programs. EHRs will be key to providing the highest possible quality of care for the funds developing countries can commit to health care. Public, private, and academic partnerships can facilitate the development and implementation of EHRs in resource-constrained settings. PMID:19858941
Braitstein, Paula; Einterz, Robert M; Sidle, John E; Kimaiyo, Sylvester; Tierney, William
Economic efficiency of primary care for CVD prevention and treatment in Eastern European countries
Background Cardiovascular disease (CVD) is the main cause of morbidity and mortality worldwide, but it also is highly preventable. The prevention rate mainly depends on the patients' readiness to follow recommendations and the state's capacity to support patients. Our study aims to show that proper primary care can decrease the CVD-related morbidity rate and increase the economic efficiency of the healthcare system. Since their admission to the European Union (EU), the Eastern European countries have been in a quest to achieve the Western European standards of living. As a representative Eastern European country, Romania implemented the same strategies as the rest of Eastern Europe, reflected in the health status and lifestyle of its inhabitants. Thus, a valid health policy implemented in Romania should be valid for the rest of the Eastern European countries. Methods Based on the data collected during the EUROASPIRE III Romania Follow Up study, the potential costs of healthcare were estimated for various cases over a 10-year time period. The total costs were split into patient-supported costs and state-supported costs. The state-supported costs were used to deduce the rate of patients with severe CVD that can be treated yearly. A statistical model for the evolution of this rate was computed based on the readiness of the patients to comply with proper primary care treatment. Results We demonstrate that for patients ignoring the risks, a severe CVD has disadvantageous economic consequences, leading to increased healthcare expenses and even poverty. In contrast, performing appropriate prevention activities result in a decrease of the expenses allocated to a (eventual) CVD. In the long-term, the number of patients with severe CVD that can be treated increases as the number of patients receiving proper primary care increases. Conclusions Proper primary care can not only decrease the risk of major CVD but also decrease the healthcare costs and increase the number of patients that can be treated. Most importantly, the health standards of the EU can be achieved more rapidly when primary care is delivered appropriately. JEL I18, H51 PMID:23433501
Background Beliefs concerning the causes of mental illness may help explain why there are significant disparities in the rates of formal mental health service use among racial/ethnic minority elderly as compared with their Caucasian counterparts. This study applies the Cultural Influences on Mental Health framework to identify the relationship between race/ethnicity and differences in: (1) beliefs on the cause of mental illness; (2) preferences for type of treatment; and (3) provider characteristics. Method Analyses were conducted using baseline data collected from participants who completed the Cultural Attitudes toward Healthcare and Mental Illness Questionnaire, developed for the PRISM-E (Primary Care Research in Substance Abuse and Mental Health for the Elderly) study, a multi-site randomized trial for older adults (65+) with depression, anxiety, or at-risk alcohol consumption. The final sample consisted of 1257 non-Latino Whites, 536 African-Americans, 112 Asian-Americans, and 303 Latinos. Results African-Americans, Asian-Americans, and Latinos had differing beliefs regarding the causes of mental illness when compared to Non-Latino Whites. Race/ethnicity was also associated with determining who makes healthcare decisions, treatment preferences, and preferred characteristics of healthcare providers. Conclusions This study highlights the association between race/ethnicity and health beliefs, treatment preferences, healthcare decisions, and consumers' preferred characteristics of healthcare providers. Accommodating the values and preferences of individuals can be helpful in engaging racial/ethnic minority patients in mental health services. PMID:21992942
Jimenez, Daniel E.; Bartels, Stephen J.; Cardenas, Veronica; Daliwal, Sanam S.; Alegria, Margarita
Role of the primary care physician in diagnosis and treatment of early renal damage.
In spite of all the technical advances and resources dedicated to the treatment of endstage renal disease (ESRD), it is still a growing problem all over the world. To address this issue adequately, it is crucial to detect chronic kidney disease patients early and optimize their care. However, a lack of awareness and appropriate management of potential underlying kidney disease, even in high-risk patients, seems to be common in many parts of the world, even though many of the measures recognized to decrease the risk and slow the progression of kidney disease are most effective when initiated early. Type 2 diabetes mellitus patients (a high-risk population) with early nephropathy treated by nephrologists have better preservation of their renal function than do patients treated only by family physicians. However, referral of patients to the nephrologist at earlier stages of disease than is recommended is not always feasible. A more plausible alternative may be that general practitioners learn to diagnose and treat these patients. We have demonstrated that an educational intervention increased family practitioners' clinical competence, which resulted in preserved renal function in diabetic patients with early renal disease. Variables not well controlled either by the nephrologist or the primary care physicians are those related to lifestyle and diet. These unhealthy habits are common in Westernized societies, and primary care physicians may be the most suitably positioned to promote health. Even so, counseling by physicians is not always effective in reducing risky habits, particularly when the health team is overworked; strategies such as community resources (including support groups) may also play a role. Preliminary results of an ongoing study based on a self-help and support group strategy that is coordinated by a multidisciplinary team (family practitioner, social worker, dietician, and physical trainer) show improvements in the lifestyle and dietary habits of patients with overweight or obesity, diabetes, or hypertension. All these findings support the need to implement health promotion programs with the participation of multidisciplinary teams. PMID:19484880
Cueto-Manzano, Alfonso M; Cortés-Sanabria, Laura; Martínez-Ramírez, Héctor R
Objective: This thesis examines the opinions of emergency nurses towards the possible primary care patient. It aims to explore what emergency nurses consider the reasons possible primary care patients present to an Emergency Department for treatment. This thesis also compares these nursing perceptions to those of patients.\\u000aBackground: Literature speaks of health professionals' opinions towards patients who present to an
Rebekkah Middleton
Dyspnea Review for the Palliative Care Professional: Treatment Goals and Therapeutic Options
Abstract Although dyspnea is frequently encountered in the palliative care setting, its optimal management remains uncertain. Clinical approaches begin with accurate assessment, as delineated in part one of this two-part series. Comprehensive dyspnea assessment, which encompasses the physical, emotional, social, and spiritual aspects of this complex symptom, guide the clinician in choosing therapeutic approaches herein presented as part two. Global management of dyspnea is appropriate both as complementary to disease-targeted treatments that target the underlying etiology, and as the sole focus when the symptom has become intractable, disease is maximally treated, and goals of care shift to comfort and quality of life. In this setting, current evidence supports the use of oral or parenteral opioids as the mainstay of dyspnea management, and of inhaled furosemide and anxiolytics as adjuncts. Nonpharmacologic interventions such as acupuncture and pulmonary rehabilitation have potential effectiveness, although further research is needed, and use of a simple fan warrants consideration given its potential benefit and minimal burden and cost. PMID:22268406
Kamal, Arif H.; Maguire, Jennifer M.; Wheeler, Jane L.; Currow, David C.
A Randomized Trial of a Hepatitis Care Coordination Model in Methadone Maintenance Treatment
Objectives. We evaluated the efficacy of a hepatitis care coordination intervention to improve linkage to hepatitis A virus (HAV) and hepatitis B virus (HBV) vaccination and clinical evaluation of hepatitis C virus (HCV) infection among methadone maintenance patients. Methods. We conducted a randomized controlled trial of 489 participants from methadone maintenance treatment programs in San Francisco, California, and New York City from February 2008 through June 2011. We randomized participants to a control arm (n?=?245) and an intervention arm (n?=?244), which included on-site screening, motivational-enhanced education and counseling, on-site vaccination, and case management services. Results. Compared with the control group, intervention group participants were significantly more likely (odds ratio [OR]?=?41.8; 95% confidence interval [CI]?=?19.4, 90.0) to receive their first vaccine dose within 30 days and to receive an HCV evaluation within 6 months (OR?=?4.10; 95% CI?=?2.35, 7.17). A combined intervention adherence outcome that measured adherence to HAV–HBV vaccination, HCV evaluation, or both strongly favored the intervention group (OR?=?8.70; 95% CI?=?5.56, 13.61). Conclusions. Hepatitis care coordination was efficacious in increasing adherence to HAV–HBV vaccination and HCV clinical evaluation among methadone patients. PMID:23947319
Delucchi, Kevin L.; McKnight, Courtney; Hettema, Jennifer; Khalili, Mandana; Min, Albert; Jordan, Ashly E.; Pepper, Nicole; Hall, Jessica; Hengl, Nicholas S.; Young, Christopher; Shopshire, Michael S.; Manuel, Jennifer K.; Coffin, Lara; Hammer, Hali; Shapiro, Bradley; Seewald, Randy M.; Bodenheimer, Henry C.; Sorensen, James L.; Des Jarlais, Don C.; Perlman, David C.
[Pharmaceuticals and personal care products (PPCPs) in the effluent of sewage treatment plants].
In recent years, there is an increasing concern about pharmaceuticals and personal care products (PPCPs), newly identified as micro-pollutants, due to their potential ecological risks. Sewage treatment plant (STP) is well demonstrated as the most significant way for PPCPs to enter into the environment. Therefore, PPCPs' discharge control from STPs' effluents is the key to reduce their ecological risks. Based on the therapeutic classes of PPCPs, this paper individually reviews the pharmacology, function, application and ecotoxicology of antibiotics, anti-inflammatory drugs, psychiatric drugs, beta-blockers, environmental estrogen, lipid regulators, musk fragrances and other PPCPs. A great attention is paid to typical PPCPs frequently detected in STPs' effluents worldwide and their maximum concentrations were reported during 1998-2012, which provides important information for PPCPs' discharge control in STPs. Finally, the potential research fields on this topic are proposed. PMID:24191585
Zheng, Shao-Kui; Li, Xiao-Feng
Human influenza A H5N1 in Indonesia: health care service-associated delays in treatment initiation
Background Indonesia has had more recorded human cases of influenza A H5N1 than any other country, with one of the world's highest case fatality rates. Understanding barriers to treatment may help ensure life-saving influenza-specific treatment is provided early enough to meaningfully improve clinical outcomes. Methods Data for this observational study of humans infected with influenza A H5N1 were obtained primarily from Ministry of Health, Provincial and District Health Office clinical records. Data included time from symptom onset to presentation for medical care, source of medical care provided, influenza virology, time to initiation of influenza-specific treatment with antiviral drugs, and survival. Results Data on 124 human cases of virologically confirmed avian influenza were collected between September 2005 and December 2010, representing 73% of all reported Indonesia cases. The median time from health service presentation to antiviral drug initiation was 7.0 days. Time to viral testing was highly correlated with starting antiviral treatment (p?0.0001). We found substantial variability in the time to viral testing (p?=?0.04) by type of medical care provider. Antivirals were started promptly after diagnosis (median 0 days). Conclusions Delays in the delivery of appropriate care to human cases of avian influenza H5N1 in Indonesia appear related to delays in diagnosis rather than presentation to health care settings. Either cases are not suspected of being H5N1 cases until nearly one week after presenting for medical care, or viral testing and/or antiviral treatment is not available where patients are presenting for care. Health system delays have increased since 2007. PMID:23786882