Faculty Bibliography

ABSTRACT 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

The Rikers Island Key Extended Entry Program (KEEP) has offered methadone treatment for opioid dependent inmates incarcerated in New York City's jails since 1986. In response to a trend toward low-dose methadone maintenance prescribing, a quality improvement (QI) protocol trained KEEP counselors, physicians, and pharmacists in the evidence base supporting moderate-to-high methadone maintenance doses in order to maximize therapeutic effects and rates of successful reporting to community methadone treatment programs (MTPs) post release. Discharge dose level and length of incarceration data were analyzed for 2 groups of KEEP patients discharged pre/post-QI. Among patients incarcerated for 21 or more days, the proportion of those on moderate-to-high doses of methadone increased significantly. Patients who reached a moderate-to-high methadone dose demonstrated higher rates of reporting to community MTP versus lower doses, both pre- and post-QI. Overall, a higher proportion of all patients reported to community MTP post-QI.

A feasibility study was conducted to pilot test the ability of 5 sites to recruit, treat, and retain opioid-dependent offenders in a trial of extended-release injectable naltrexone (XR-NTX). The participants, 61 previously opioid-dependent individuals under legal supervision in the community, received up to 6 monthly injections of Depotrex brand naltrexone and completed a 6-month follow-up interview. Six-month outcomes showed that those who completed treatment had significantly fewer opioid-positive urines and were less likely to have been incarcerated than those who had not completed treatment. The findings indicate that XR-NTX holds promise as a feasible, effective treatment option for opioid-dependent offenders.

Substance use screening in a primary care setting compared the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST version 3.0), Two-Item Conjoint Screen (TICS), National Institute on Alcohol Abuse and Alcoholism (NIAAA) daily limit single item, and electronic medical record (EMR). Among 236 consecutive adults, ASSIST moderate- to high-risk substance use prevalence was tobacco, 15.3%; alcohol, 8.5%; cannabis, 5.1%; cocaine, 2.5%; and opioids, 2.5%. Compared to ASSIST, a positive TICS was 45% (95% confidence interval [CI], 27-64%) sensitive, 99% (95-100%) specific; the NIAAA single-item screen was 80% (56-94%) sensitive, 87% (82-91%) specific. The NIAAA single item correlated closely with alcohol ASSIST. TICS and EMR were less sensitive for any nontobacco substance use

BACKGROUND: The authors developed and evaluated an interactive, Web-based module to train medical students in screening and brief intervention (SBI) for unhealthy alcohol use. METHODS: First-year students were randomized to module versus lecture. Change in knowledge, attitudes, and confidence were compared. Performance was assessed by objective structured clinical examination (OSCE) and analyzed by intention to treat and treatment received. RESULTS: Of 141 consenting students, 64% (n = 90) completed an intervention (54% lecture vs. 70% Web assigned). Knowledge, confidence, and attitudes improved in both groups, with more improvement in Advise-Assist knowledge for Web students (14% vs. -3%, p = .003). Web students outperformed their lecture peers in both general communication (65% vs. 51% items well done, p = .004) and alcohol-specific tasks (54% vs. 41%, p = .021) on OSCE. Analysis by treatment received enhanced between-group differences. CONCLUSION: Use of a Web-based module to teach SBI is associated with greater knowledge gain and skills performance compared with a lecture covering similar content. The module provides an efficient means for training in this area

PURPOSE: To prepare to develop a medical school curriculum on substance abuse disorders (SADs), the authors conducted a review of the quality of the sparse published literature. METHOD: The authors searched MEDLINE (1950 through December 2008) using OVID, PsycINFO, and PubMed to identify all studies of SAD interventions targeted toward undergraduate medical students. Of the 1,084 studies identified initially, 31 reported sufficient data to allow the authors to evaluate quality using Medical Education Research Study Quality Instrument (MERSQI) scores. The authors also determined the impact of the studies by considering three-year citation rate and journal impact factor. A detailed review of the literature provided data on contact hours and intervention content. RESULTS: The three-rater intraclass correlation coefficient for total MERSQI score was 0.82 (95% confidence interval: 0.70-0.90). The mean MERSQI score was 10.42 of a possible 18 (SD 2.59; range: 6.33-14.83). MERSQI scores were higher for more recently published studies and correlated with three-year citation rate but not impact factor. The mean contact time for 26 studies was 29.25 hours (range: 0.83-200 hours). CONCLUSIONS: The literature provides a variety of educational methods to train medical students in SAD detection and intervention skills. This literature is of variable quality and provides limited guidance for development of curricula and medical education policy. Better methods of curriculum evaluation and publication guidelines would help ensure that this literature has a positive impact on educational practice and public health

The feasibility of using extended-release injectable naltrexone (XR-NTX) to treat alcohol dependence in routine primary care settings is unknown. An open-label, observational cohort study evaluated 3-month treatment retention, patient satisfaction, and alcohol use among alcohol-dependent patients in two urban public hospital medical clinics. Adults seeking treatment were offered monthly medical management (MM) and three XR-NTX injections (380 mg, intramuscular). Physician-delivered MM emphasized alcohol abstinence, medication effects, and accessing mutual help and counseling resources. Seventy-two alcohol-dependent patients were enrolled; 90% (65 of 72) of eligible subjects received the first XR-NTX injection; 75% (49 of 65) initiating treatment received the second XR-NTX injection; 62% (40 of 65), the third. Among the 56% (n = 40) receiving three injections, median drinks per day decreased from 4.1 (95% confidence interval = 2.9-6) at baseline to 0.5 (0-1.7) during Month 3. Extended-release naltrexone delivered in a primary care MM model appears a feasible and acceptable treatment for alcohol dependence