Faculty Bibliography

The feasibility of long-term extended-release naltrexone (XR-NTX) alcohol treatment is unknown. Following an initial 12-week, single-arm, observational trial of XR-NTX plus medical management (MM) in primary care, we offered 48 additional weeks of XR-NTX treatment (12 additional monthly injections) in two public primary care clinics as a naturalistic extension study. Of 65 alcohol dependent adults initiating XR-NTX treatment, 40 (62%) completed the initial 12-week XR-NTX observational trial, and 19 (29%) continued treatment for a median of 38weeks total (range, 16-72weeks; median 8 total XR-NTX injections). Among active extension phase participants, self-reported rates of drinking days (vs. last 30 days pre-treatment baseline) were low: median 0.2 vs. 6.0drinks per day; 82 vs. 38% days abstinent; 11 vs. 61% heavy drinking days. Long-term XR-NTX treatment in a primary care MM model was feasible and may promote lasting drinking reductions or alcohol abstinence (clinical trial: NCT00620750).

OBJECTIVE: : There is a need to build the ranks of health care professionals engaged in substance abuse (SA)-focused clinical research. The authors simultaneously developed and evaluated SARET, the Substance Abuse Research Education and Training program. The fundamental goal of this interprofessional program is to stimulate medical, dental, and nursing student interest and experience in SA research. Evaluation aims to understand program feasibility and acceptability and to assess short-term impact. METHODS: : SARET comprises 2 main components: stipend-supported research mentorships and a Web-based module series, consisting of 6, interactive, multimedia modules addressing core SA research topics, delivered via course curricula and in the research mentorships. Authors assessed program feasibility and impact on student interest in conducting SA research by tracking participation and conducting participant focus groups and online surveys. RESULTS: : Thirty early health care professional students completed mentorships (25 summer, 5 yearlong) and 1324 completed at least 1 Web-module. SARET was considered attractive for the opportunity to conduct clinically oriented research and to work with health care professionals across disciplines. Mentorship students reported positive impact on their vision of SA-related clinical care, more positive attitudes about research, and, in some cases, change in career plans. Web-based modules were associated with enhanced interest in SA (35% increase, P = 0.005, in those somewhat/very interested for neurobiology module) and SA research (+38%, P < 0.001 for activation, +45%, P < 0.001 for personal impact, +7%, P = 0.089 for neurobiology). CONCLUSIONS: : The SARET program stimulates SA clinical and research interest among students of nursing, medicine, and dentistry and may lend itself to dissemination.

Objectives. We have described and evaluated the impact of a unique fellowship program designed to train postdoctoral, physician fellows in research at the interface of medicine and public health. Methods. We developed a rigorous curriculum in public health content and research methods and fostered linkages with research mentors and local public health agencies. Didactic training provided the foundation for fellows' mentored research initiatives, which addressed real-world challenges in advancing the health status of vulnerable urban populations. Results. Two multidisciplinary cohorts (6 per cohort) completed this 2-year degree-granting program and engaged in diverse public health research initiatives on topics such as improving pediatric care outcomes through health literacy interventions, reducing hospital readmission rates among urban poor with multiple comorbidities, increasing cancer screening uptake, and broadening the reach of addiction screening and intervention. The majority of fellows (10/12) published their fellowship work and currently have a career focused in public health-related research or practice (9/12). Conclusions. A fellowship training program can prepare physician investigators for research careers that bridge the divide between medicine and public health. (Am J Public Health. Published online ahead of print May 17, 2012: e1-e7. doi:10.2105/AJPH.2011.300486).

ABSTRACT: BACKGROUND: Despite concerns about its health and social consequences, little is known about the prevalence of illicit opioid use in New York City. Individuals who misuse heroin and prescription opioids are known to bear a disproportionate burden of morbidity and mortality. Service providers and public health authorities are challenged to provide appropriate interventions in the absence of basic knowledge about the size and characteristics of this population. While illicit drug users are underrepresented in population-based surveys, they may be identified in multiple administrative data sources. METHODS: We analyzed large datasets tracking hospital inpatient and emergency room admissions as well as drug treatment and detoxification services utilization. These were applied in combination with findings from a large general population survey and administrative records tracking prescriptions, drug overdose deaths, and correctional health services, to estimate the prevalence of heroin and non-medical prescription opioid use among New York City residents in 2006. These data were further applied to a descriptive analysis of opioid users entering drug treatment and hospital-based medical care. RESULTS: These data sources identified 126,681 cases of opioid use among New York City residents in 2006. After applying adjustment scenarios to account for potential overlap between data sources, we estimated over 92,000 individual opioid users. By contrast, just 21,600 opioid users initiated drug treatment in 2006. Opioid users represented 4% of all individuals hospitalized, and over 44,000 hospitalizations during the calendar year. CONCLUSIONS: Our findings suggest that innovative approaches are needed to provide adequate services to this sizeable population of opioid users. Given the observed high rates of hospital services utilization, greater integration of drug services into medical settings could be one component of an effective approach to expanding both the scope and reach of health interventions for this population.

One of the 3 goals for accountable care organizations is to improve population health. This will require that accountable care organizations bridge the schism between clinical care and public health. But do health care delivery organizations and public health agencies share a concept of "population"? We think not: whereas delivery systems define populations in terms of persons receiving care, public health agencies typically measure health on the basis of geography. This creates an attribution problem, particularly in large urban centers, where multiple health care providers often serve any given neighborhood. We suggest potential innovations that could allow urban accountable care organizations to accept accountability, and rewards, for measurably improving population health.

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

CONTEXT: No randomized trials have examined treatments for prescription opioid dependence, despite its increasing prevalence. OBJECTIVE: To evaluate the efficacy of brief and extended buprenorphine hydrochloride-naloxone hydrochloride treatment, with different counseling intensities, for patients dependent on prescription opioids. DESIGN: Multisite, randomized clinical trial using a 2-phase adaptive treatment research design. Brief treatment (phase 1) included 2-week buprenorphine-naloxone stabilization, 2-week taper, and 8-week postmedication follow-up. Patients with successful opioid use outcomes exited the study; unsuccessful patients entered phase 2: extended (12-week) buprenorphine-naloxone treatment, 4-week taper, and 8-week postmedication follow-up. SETTING: Ten US sites. Patients A total of 653 treatment-seeking outpatients dependent on prescription opioids. INTERVENTIONS: In both phases, patients were randomized to standard medical management (SMM) or SMM plus opioid dependence counseling; all received buprenorphine-naloxone. MAIN OUTCOME MEASURES: Predefined 'successful outcome' in each phase: composite measures indicating minimal or no opioid use based on urine test-confirmed self-reports. RESULTS: During phase 1, only 6.6% (43 of 653) of patients had successful outcomes, with no difference between SMM and SMM plus opioid dependence counseling. In contrast, 49.2% (177 of 360) attained successful outcomes in phase 2 during extended buprenorphine-naloxone treatment (week 12), with no difference between counseling conditions. Success rates 8 weeks after completing the buprenorphine-naloxone taper (phase 2, week 24) dropped to 8.6% (31 of 360), again with no counseling difference. In secondary analyses, successful phase 2 outcomes were more common while taking buprenorphine-naloxone than 8 weeks after taper (49.2% [177 of 360] vs 8.6% [31 of 360], P < .001). Chronic pain did not affect opioid use outcomes; a history of ever using heroin was associated with lower phase 2 success rates while taking buprenorphine-naloxone. CONCLUSIONS: Prescription opioid-dependent patients are most likely to reduce opioid use during buprenorphine-naloxone treatment; if tapered off buprenorphine-naloxone, even after 12 weeks of treatment, the likelihood of an unsuccessful outcome is high, even in patients receiving counseling in addition to SMM. Trial Registration clinicaltrials.gov Identifier: NCT00316277