Faculty Bibliography

Introduction: Online drug markets and social media are facilitating the spread of information and sale of illicit substances. Online sites, such as Craigslist and Bluelight, underscore an emerging shift in contemporary drug consumerism. Case Descriptions: We report on two cases. Case 1 is a 42-year-old male with a history of heroin-use disorder, presented for an initial visit to an office-based buprenorphine program, and reported having acquired heroin from Craigslist. Despite several harrowing experiences, Craigslist remained Patient 1's primary method of purchasing heroin during a 14-month period. Craigslist ads also redirected the patient to the web site Bluelight, which facilitated access to updated information on open-air drug markets in New York City. Case 2 is a 23-year-old male, who was admitted to inpatient detoxification and utilized the site for the sale of heroin in order to fund his own use of heroin. He sold heroin via Craigslist for 1 year until his arrest, noting undeterred advertising and largely uncomplicated transactions. He secured largely professionals buyers that purchased a steady quantity of heroin over extended periods of time. Discussion: Online drug marketplaces offer platforms to extend public health surveillance, harm reduction, and treatment entry strategies for internet users with substance-use disorders.

Few studies have evaluated text message (TM) content preferences to support evidence-based treatment approaches for opioid use disorders, and none in primary care office-based buprenorphine treatment (OBOT) settings. This study assessed the acceptability and preferences for a tailored TM intervention in support of core OBOT medical management components (e.g., treatment adherence, encouraging abstinence, 12-step group participation, motivational interviewing, and patient-provider communication as needed). 97 patients enrolled in a safety net OBOT program completed a 24 item survey instrument and consisted of multiple choice responses, 7-point Likert-type scales, binomial "Yes/No" questions, and open-ended responses. The sample was predominately male (81%), had an average age of 46 years, and was diverse (64% ethnic/racial minorities); 56% lacked stable employment. Respondents were interested in receiving TM appointment reminders (90%), information pertaining to their buprenorphine treatment (76%), supportive content (70%), and messages to reduce the risk of relapse (88%). Participants preferred to receive relapse prevention TM during all phases of treatment: immediately after induction into buprenorphine treatment (81%), a 'few months' into treatment (57%), and after discontinuing buprenorphine treatment (72%). Respondents also expressed interest in TM content enhancing self-efficacy, social support, and frequent provider communication to facilitate unobserved "home" induction with buprenorphine. Older participants were significantly less receptive to receiving TM appointment reminders, however were as interested in receiving supportive, informational, and relapse prevention components compared to younger respondents. Implications for integrating a TM support system in OBOT are discussed.

BACKGROUND: Integrating mobile phone technologies in addiction treatment is of increasing importance and may optimize patient engagement with their care and enhance the delivery of existing treatment strategies. Few studies have evaluated mobile phone and text message (TM) use patterns in persons enrolled in addiction treatment, and none have assessed the use in safety net, office-based buprenorphine practices. METHODS: A 28-item, quantitative and qualitative semistructured survey was administered to opiate-dependent adults in an urban, publicly funded, office-based buprenorphine program. Survey domains included demographic characteristics, mobile phone and TM use patterns, and preferences pertaining to their recovery. RESULTS: Surveyors approached 73 of the 155 eligible subjects (47%); 71 respondents completed the survey. Nearly all participants reported mobile phone ownership (93%) and TM use (93%), and most reported "very much" or "somewhat" comfort sending TM (79%). Text message contact with 12-step group sponsors, friends, family members, and counselors was also described (32%). Nearly all preferred having their providers' mobile phone number (94%), and alerting the clinic via TM in the event of a potential relapse to receive both supportive TM and a phone call from their buprenorphine provider was also well received (62%). CONCLUSIONS: Mobile phone and TM use patterns and preferences among this sample of office-based buprenorphine participants highlight the potential of adopting patient-centered mobile phone-based interventions in this treatment setting.

Aims: We conducted a descriptive, cross-sectional survey exploring mobile phone and TM use patterns and preferences pertaining to their substance treatment in a public sector, office-based buprenorphine program. Methods: A 28-item, quantitative and qualitative semistructured survey was administered to 71 patients enrolled in a public sector, office-based buprenorphine program between June and September 2013. Survey domains included: demographic characteristics, mobile phone and TM use patterns, and mobile phone and TM use patterns and preferences pertaining to their substance treatment. Results: Mobile phone ownership was common (93%) with no significant differences in ownership among self-reported homeless, recently incarcerated, and unemployed respondents. Most reported sending or receiving TM (93%) and reporting 'very much' or 'somewhat' comfort sending TM (79%). Contacting buprenorphine providers by phone (30%) or TM (17%) was uncommon, however most preferred to use either form of communication to reach their provider (67%). Older patients received less TM (25) compared to younger age groups (128) yet were as interested as the rest of the clinic population to have their provider's mobile phone number (96%) and send TM if at risk of relapse (78%). Conclusions: Our findings highlight the acceptability of enhancing patient-provider mobile phone and TM communications in a public sector, office-based buprenorphine clinic, even among respondents that were not comfortable in using TM. Although mobile phone ownership was very common, frequent turnover in phone ownership and changing phone numbers highlights challenges in feasibility for any future m health interventions in this clinical setting

BACKGROUND: On October 2012, Hurricane Sandy struck New York City, resulting in unprecedented damages, including the temporary closure of Bellevue Hospital Center and its primary care office-based buprenorphine program. OBJECTIVES: At 6 months, we assessed factors associated with higher rates of substance use in buprenorphine program participants that completed a baseline survey one month post-Sandy (i.e. shorter length of time in treatment, exposure to storm losses, a pre-storm history of positive opiate urine drug screens, and post-disaster psychiatric symptoms). METHODOLOGY: Risk factors of interest extracted from the electronic medical records included pre-disaster diagnosis of Axis I and/or II disorders and length of treatment up to the disaster. Factors collected from the baseline survey conducted approximately one month post-Sandy included self-reported buprenorphine supply disruption, health insurance status, disaster exposure, and post-Sandy screenings for PTSD and depression. Outcome variables reviewed 6 months post-Sandy included missed appointments, urine drug results for opioids, cocaine, and benzodiazepines. RESULTS: 129 (98%) patients remained in treatment at 6 months, and had no sustained increases in opioid-, cocaine-, and benzodiazepine-positive urine drug tests in any sub-groups with elevated substance use in the baseline survey. Contrary to our initial hypothesis, diagnosis of Axis I and/or II disorders pre-Sandy were associated with significantly less opioid-positive urine drug findings in the 6 months following Sandy compared to the rest of the clinic population. CONCLUSION: These findings demonstrate the adaptability of a safety net buprenorphine program to ensure positive treatment outcomes despite disaster-related factors.

Aims: (1) Assess feasibility of a text message appointment reminder (TMR) intervention (2) Determine the clinical impact of the TMR on appointment adherence Methods: A 52-item survey was administered to 100 patients in an urban, public sector, office-based buprenorphine program between June 2013 and March 2014. Survey domains included: demographic characteristics, communication patterns, and content preferences for supportive, informational, and relapse prevention TM interventions. A TMR was then sent 7, 4, 1 day prior to the patients' upcoming appointment followed by a 16 item survey that assessed satisfaction and feedback for the TM reminders (n = 72). Results: Respondents were predominately African-American (42%), unemployed or reliant on public assistance (68%), and lacked permanent housing (52%). MP ownership was common (93%) with the caveat of a high turnover of phones (2) and phone numbers (2) in the past year. Most reported TM use (93%) and comfort with sending TM (79%). The feasibility survey demonstrated satisfaction with the TMR (100%) and most preferred receiving text reminders (88%) in place of telephone reminders at 6 months. There was no significant difference between participants receiving the TMR compared to patients that did not receive the reminders. Conclusions: TM based interventions are an acceptable and feasible strategy for enhancing the delivery of care in a safety net, office-based buprenorphine program

Object Civilian gunshot wounds to the head (GSWH) are often deadly, but some patients with open cranial wounds need medical and surgical management and are potentially good candidates for acceptable functional recovery. The authors analyzed predictors of favorable clinical outcome (Glasgow Outcome Scale scores of 4 and 5) after GSWH over a 24-month period. Methods The authors posited 2 questions: First, what percentage of civilians with GSWH died in the state of Maryland in a given period of time? Second, what were the predictors of favorable outcome after GSWH? The authors examined demographic, clinical, imaging, and acute care data for 786 civilians who sustained GSWH. Univariate and logistic regression analyses were used to analyze the data. Results Of the 786 patients in this series, 712 (91%) died and 74 (9%) completed acute care in 9 trauma centers. Of the 69 patients admitted to one Maryland center, 46 (67%) eventually died. In 48 patients who were resuscitated, the Injury Severity Score was 26.2, Glasgow Coma Scale (GCS) score was 7.8, and an abnormal pupillary response (APR) to light was present in 41% of patients. Computed tomography indicated midline shift in 17%, obliteration of basal cisterns in 41.3%, intracranial hematomas in 34.8%, and intraventricular hemorrhage in 49% of cases. When analyzed for trajectory, 57.5% of bullet slugs crossed midcoronal, midsagittal, or both planes. Two subsets of admissions were studied: 27 patients (65%) who had poor outcome (25 patients who died and 2 who had severe disability) and 15 patients (35%) who had a favorable outcome when followed for a mean period of 40.6 months. Six patients were lost to follow-up. Univariate analysis indicated that admission GCS score (p < 0.001), missile trajectory (p < 0.001), surgery (p < 0.001), APR to light (p = 0.002), patency of basal cisterns (p = 0.01), age (p = 0.01), and intraventricular bleed (p = 0.03) had a significant relationship to outcome. Multivariable logistic regression analysis indicated that GCS score and patency of the basal cistern were significant determinants of outcome. Exclusion of GCS score from the regression models indicated missile trajectory and APR to light were significant in determining outcome. Conclusions Admission GCS score, trajectory of the missile track, APR to light, and patency of basal cisterns were significant determinants of outcome in civilian GSWH.

In October 2012, Bellevue Hospital Center (Bellevue) in New York City was temporarily closed as a result of Hurricane Sandy, the largest hurricane in US history. Bellevue's primary care office-based buprenorphine program was temporarily closed and later relocated to an affiliate public hospital. Previous research indicates that the relationships between disaster exposure, substance use patterns, psychiatric symptoms, and mental health services utilization is complex, with often conflicting findings regarding post-event outcomes (on the individual and community level) and antecedent risk factors. In general, increased use of tobacco, alcohol, and illicit drugs is associated with both greater disaster exposure and the development or exacerbation of other psychiatric symptoms and need for treatment. To date, there is limited published information regarding post-disaster outcomes among patients enrolled in office-based buprenorphine treatment, as the treatment modality has only been relatively approved recently. Patients enrolled in the buprenorphine program at the time of the storm were surveyed for self-reported buprenorphine adherence and illicit substance and alcohol use, as well as disaster-related personal consequences and psychiatric sequelae post-storm. Baseline demographic characteristics and insurance status were available from the medical record. Analysis was descriptive (counts and proportions) and qualitative, coding open-ended responses for emergent themes. There were 132 patients enrolled in the program at the time of the storm; of those, 91 were contacted and 89 completed the survey. Almost half of respondents reported disruption of their buprenorphine supply. Unexpectedly, patients with psychiatric comorbidity were no more likely to report increased use/relapse as a result. Rather, major risk factors associated with increased use or relapse post-storm were: (1) shorter length of time in treatment, (2) exposure to storm losses such as buprenorphine supply disruption, (3) a pre-storm history of red flag behaviors (in particular, repeat opioid-positive urines), and (4) new-onset post-storm psychiatric symptoms. Our findings highlight the relative resilience of buprenorphine as an office-based treatment modality for patients encountering a disaster with associated unanticipated service disruption. In responding to future disasters, triaging patient contact and priority based on a history of red-flag behaviors, rather than a history of psychiatric comorbidity, will likely optimize resource allocation, especially among recently enrolled patients. Additionally, patients endorsing new-onset psychiatric manifestations following disasters may be an especially high-risk group for poor outcomes, warranting further study.

Doppler ultrasonography is a standard in diagnosis of deep vein thrombosis (DVT) but is often delayed. Clinician-performed focused vascular sonography (FVS) has proven to accurately diagnose DVT in the ambulatory and emergency room settings. Whether trained medical residents can perform quality FVS in the critically ill is unknown. Medical residents were trained in a 2-hour module in FVS assessing for complete compressibility of common femoral and popliteal veins. Residents imaged consecutive medical ICU and intermediate care patients awaiting comprehensive, sonographer-performed and radiologist-interpreted examinations. Sensitivity, specificity, positive and negative predictive values of the focused examination were calculated against the comprehensive study. Fleiss Kappa (kappa), the degree of agreement between resident and radiologist, was calculated. Time savings was measured. Nineteen residents performed 143 studies on 75 patients. Twelve patients had above-the-knee DVTs, a prevalence of 16 %. All 6 common femoral and 7 of 9 popliteal vein DVTs were identified. None of 6 isolated superficial femoral DVTs were identified. Sensitivity for above-the-knee DVT was 63 %, specificity 97 %. Sensitivity for common femoral and popliteal DVT was 86 %, specificity 97 %. Residents showed substantial agreement with radiologists for diagnosis of DVT (kappa = 0.70, SE 0.114, p < 0.001).Time from order of a formal ultrasound to a radiologist's read averaged 14.7 h. The two-point compression ultrasound method demonstrated insufficient sensitivity in a cohort of critically ill medical patients due to a high-incidence of superficial femoral DVT. However, residents demonstrated substantial agreement with radiologists for the diagnosis of clinically relevant DVT after a 2-hour course. FVS should include the superficial femoral vein and is associated with a significant time savings.

BACKGROUND: The extent of damage in New York City following Hurricane Sandy in October 2012 was unprecedented. Bellevue Hospital Center (BHC), a tertiary public hospital, was evacuated and temporarily closed as a result of hurricane-related damages. BHC's large primary care office-based buprenorphine clinic was relocated to an affiliate public hospital for three weeks. The extent of environmental damage and ensuing service disruption effects on rates of illicit drug, tobacco, and alcohol misuse, buprenorphine medication supply disruptions, or direct resource losses among office-based buprenorphine patients is to date unknown. METHODS: A quantitative and qualitative semi-structured survey was administered to patients in BHC's primary care buprenorphine program starting one month after the hurricane. Survey domains included: housing and employment disruptions; social and economic support; treatment outcomes (buprenorphine adherence and ability to get care), and tobacco, alcohol, and drug use. Open-ended questions probed general patient experiences related to the storm, coping strategies, and associated disruptions. RESULTS: There were 132 patients enrolled in the clinic at the time of the storm; of those, 91 patients were recruited to the survey, and 89 completed (98% of those invited). Illicit opioid misuse was rare, with 7 respondents reporting increased heroin or illicit prescription opioid use following Sandy. Roughly half of respondents reported disruption of their buprenorphine-naloxone medication supply post-event, and self-lowering of daily doses to prolong supply was common. Additional buprenorphine was obtained through unscheduled telephone or written refills from relocated Bellevue providers, informally from friends and family, and, more rarely, from drug dealers. CONCLUSIONS: The findings highlight the relative adaptability of public sector office-based buprenorphine treatment during and after a significant natural disaster. Only minimal increases in self-reported substance use were reported despite many disruptions to regular buprenorphine supplies and previous daily doses. Informal supplies of substitute buprenorphine from family and friends was common. Remote telephone refill support and a temporary back-up location that provided written prescription refills and medication dispensing for uninsured patients enabled some patients to maintain an adequate medication supply. Such adaptive strategies to ensure medication maintenance continuity pre/post natural disasters likely minimize poor treatment outcomes.