Faculty Bibliography

OBJECTIVES/SPECIFIC AIMS: Substance use has substantial effects on oral health, and dental visits provide an opportunity to address substance use disorders. We surveyed dentists to learn whether they might play a role in substance use screening and interventions. METHODS/STUDY POPULATION: All dentists active in the PEARL dental practice-based research network were invited to complete a web-based survey in summer 2010. The 41-item survey assessed clinic policies and dentists' practices, attitudes, and perception of barriers regarding screening, counseling, and referrals for substance use. RESULTS/ANTICIPATED RESULTS: One hundred forty-three dentists completed the survey (68% response rate). Almost all respondents felt it was important to screen patients for tobacco (99%), alcohol (92%) and illicit drug (93%) use, though actual screening rates were much lower. Counseling or referrals were infrequently provided for users of alcohol (29%) and illicit drugs (25%), but were more common for tobacco (63%). The most frequently identified barrier to addressing substance use was insufficient knowledge/training. Other barriers were lack of referral sites, staff resistance, and time constraints. If reimbursement were available, many dentists said they would offer counseling and assistance for tobacco (67%), alcohol (52%), and illicit drugs (48%); an affirmative response was significantly more likely among the 43 dentists who saw Medicaid patients (p < 0.01). DISCUSSION/SIGNIFICANCE OF IMPACT: Dentists recognize the importance of screening for substance use, but lack the clinical training and systems that might allow them to intervene. If these barriers were reduced, dentists could be willing partners in addressing substance use disorders

[Correction Notice: An erratum for this article was reported in Vol 38(1) of The American Journal of Drug and Alcohol Abuse (see record 2012-04990-018). In the obituary of Dr. Malcolm S. Reid, his death date was published as 20 April 2010, but should read 23 April 2010.] Presents an obituary for Malcolm S. Reid, (1962-2010). He passed away after a year-long struggle with leukemia. Malcolm completed his undergraduate work at Brown University in 1984. He began his graduate work in pharmacology at the Karolinska Institute in Stockholm, leading to a PhD in 1990. Malcolm went on to a post-doctoral fellowship at the Sleep Disorders Research Center at Stanford from 1990 to 1993, and a second fellowship in the NIDA-funded Substance Abuse Treatment Research Program at the University of California at San Francisco (UCSF). Malcolm was a dedicated father, who, despite the demands of a research career, always made time for his wife, children, and extended family. Malcolm was also a dedicated teacher and mentor helping shape the careers of members of his research team, many of whom have gone on to get advanced degrees, and undergraduate and medical students. Through to the end, Malcolm remained an indomitable, fun-loving spirit with an infectious exuberance for life. His love of family was matched only by his dogged commitment to his lifelong goal of improving the treatment and care of substance-dependent patients.

OBJECTIVE: The purpose of this study was to explore changes in transaminase values associated with buprenorphine treatment and hepatitis C status among opioid dependent subjects aged 15-21. METHODS: 152 subjects seeking treatment for opioid dependence were randomized to 2-week detoxification with buprenorphine/naloxone (DETOX) or 12 weeks buprenorphine/naloxone (BUP). Liver chemistries including transaminases were obtained baseline and at 4, 8, and 12 weeks. 111 patients had at least one set of transaminases during treatment and were included in analyses of treatment effects. RESULTS: Overall, 8/60 BUP participants vs. 12/51 DETOX participants had at least one elevated ALT value during follow-up (Chi-square n.s.). 5/60 BUP participants vs. 11/51 DETOX participants had at least one elevated AST value (Chi-square = 3.194, p = .048). Twenty-eight out of 152 participants were hepatitis C (HCV) positive at baseline, and 4 seroconverted within 12 weeks, 2 in each group. HCV status was significantly associated with transaminase abnormalities (p = .009 and p = .006 for ALT an AST, respectively). HCV status had a strong effect on transaminase abnormalities among participants assigned to DETOX, but not among those assigned to BUP. CONCLUSIONS: No evidence was found for hepatotoxicity of buprenorphine in this exploratory analysis. HCV was present in a significant minority of participants and was a significant predictor of transaminase elevation. Results suggest that stabilization on buprenorphine may decrease the frequency of transaminase abnormalities associated with HCV in opioid dependent young people. The high rate of seroconversion underscores the importance of effective treatment and prevention.

Research has largely ignored the systematic examination of physicians' attitudes towards providing care for patients with chronic noncancer pain. The objective of this study was to identify barriers and facilitators to opioid treatment of chronic noncancer pain patients by office-based medical providers. We used a qualitative study design using individual and group interviews. Participants were 23 office-based physicians in New England. Interviews were audiotaped, transcribed, and systematically coded by a multidisciplinary team using the constant comparative method. Physician barriers included absence of objective or physiological measures of pain; lack of expertise in the treatment of chronic pain and coexisting disorders, including addiction; lack of interest in pain management; patients' aberrant behaviors; and physicians' attitudes toward prescribing opioid analgesics. Physician facilitators included promoting continuity of patient care and the use of opioid agreements. Physicians' perceptions of patient-related barriers included lack of physician responsiveness to patients' pain reports, negative attitudes toward opioid analgesics, concerns about cost, and patients' low motivation for pain treatment. Perceived logistical barriers included lack of appropriate pain management and addiction referral options, limited information regarding diagnostic workup, limited insurance coverage for pain management services, limited ancillary support for physicians, and insufficient time. Addressing these barriers to pain treatment will be crucial to improving pain management service delivery. PERSPECTIVE: This article demonstrates that perceived barriers to treating patients with chronic noncancer pain are common among office-based physicians. Addressing these barriers in physician training and in existing office-based programs might benefit both noncancer chronic pain patients and their medical providers

This report examines associations between the availability of human immunodeficiency virus (HIV)-related health services in substance abuse treatment programs and characteristics of the programs and the patients they serve. In a cross-sectional, descriptive design and via a validated survey, program administrators within the National Drug Abuse Treatment Clinical Trials Network provided information on program characteristics, patient characteristics (rates of risky sexual and drug behaviors and HIV infection), and the availability of 31 different HIV-related health services. Of 319 programs, 84% submitted surveys. Service availability rates ranged from: 10% (pneumococcal vaccination) to 86% (drug testing) for the 6 HIV-related services offered to all patients, 13% (Pap smear for women) to 54% (tuberculin skin testing) for the 6 services offered to new patients, 2% (sterile injection equipment) to 64% (male condoms) for the 4 risk-reduction services, 37% (Pap smear for women) to 61% (tuberculin skin testing) for the 11 biological assessments offered to HIV-positive patients, and 33% (medical treatments) to 52% (counseling) for the 4 other services offered to HIV-positive patients. The availability of these HIV-related services was associated with clinical settings, the types of addiction treatment services, the rates of risky drug and sexual behaviors, and HIV infection rates among patients. Availability of such services was below published guidelines. While the results provide another basis for the infection-related prevention benefits of substance abuse treatment, the variability in the availability of HIV-related health care deserves further study and has health policy implications in determining how to utilize substance abuse treatment in reducing drug-related HIV transmission

Employment difficulties are common among American Indian individuals in substance abuse treatment. To address this problem, the Southwest Node of NIDA's Clinical Trials Network conducted a single-site adaptation of its national Job Seekers Workshop study in an American Indian treatment program, Na'Nizhoozhi Center (NCI). 102 (80% men, 100% American Indian) participants who were in residential treatment and currently unemployed were randomized to (1) a three session, manualized program (Job seekers workshop: JSW) or (2) a 40-minute Job Interviewing Video: JIV). Outcomes were assessed at 3-month follow up: 1) number of days to a new taxed job or enrollment in a job-training program, and 2) total hours working or enrolled in a job-training program. No significant differences were found between the two groups for time to a new taxed job or enrollment in a job-training program. There were no significant differences between groups in substance use frequency at 3-month follow-up. These results do not support the use of the costly and time-consuming JSW intervention in this population and setting. Despite of the lack of a demonstrable treatment effect, this study established the feasibility of including a rural American Indian site in a rigorous CTN trial through a community-based participatory research approach.

OBJECTIVE: To determine the individual- and neighborhood-level predictors of frequent nonprescription in-pharmacy counseling. DESIGN: Descriptive, nonexperimental, cross-sectional study. SETTING: New York City (NYC) during January 2008 to March 2009. INTERVENTION: 130 pharmacies registered in the Expanded Syringe Access Program (ESAP) completed a survey. PARTICIPANTS: 477 pharmacists, nonpharmacist owners/managers, and technicians/clerks. MAIN OUTCOME MEASURES: Frequent counseling on medical conditions, health insurance, and other products. RESULTS: Technicians were less likely than pharmacists to provide frequent counseling on medical conditions or health insurance. Regarding neighborhood-level characteristics, pharmacies in areas of high employment disability were less likely to provide frequent health insurance counseling and pharmacies in areas with higher deprivation were more likely to provide counseling on other products. CONCLUSION: ESAP pharmacy staff members are a frequent source of nonprescription counseling for their patients in disadvantaged neighborhoods of NYC. These findings suggest that ESAP pharmacy staff may be amenable to providing relevant counseling services to injection drug users and warrant further investigation.

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

Studies suggest that community-based approaches could help pharmacies expand their public health role, particularly pertaining to HIV prevention. Thirteen pharmacies participating in New York's Expanded Syringe Access Program, which permits nonprescription syringe sales to reduce syringe-sharing among injection drug users (IDUs), were enrolled in an intervention to link IDU syringe customers to medical/social services. Sociodemographics, injection practices, beliefs about and experiences with pharmacy use, and medical/social service utilization were compared among 29 IDUs purchasing syringes from intervention pharmacies and 66 IDUs purchasing syringes from control pharmacies using chi-square tests. Intervention IDUs reported more positive experiences in pharmacies than controls; both groups were receptive to a greater public health pharmacist role. These data provide evidence that community-based participatory research aided in the implementation of a pilot structural intervention to promote understanding of drug use and HIV prevention among pharmacy staff, and facilitated expansion of pharmacy services beyond syringe sales in marginalized drug-using communities.

Multisite effectiveness trials such as those carried out in the National Drug Abuse Treatment Clinical Trials Network (CTN) are a critical step in the development and dissemination of evidence-based treatments because they address how such treatments perform in real-world clinical settings. As Brigham et al. summarized in a recent article (G. S. Brigham, D. J. Feaster, P. G. Wakim, & C. L. Dempsey C. L., 2009), several possible experimental designs may be chosen for such effectiveness trials. These include (a) a new treatment intervention (Tx) is compared to an existing mode of community based treatment as usual (TAU): Tx versus TAU; (b) a new intervention is added to TAU and compared to TAU alone: Tx + TAU versus TAU; or (c) a new intervention is added to TAU and compared to a control condition added to TAU: Tx + TAU versus control + TAU. Each of these designs addresses a different question and has different potential strengths and weaknesses. As of December 2009, the primary outcome paper had been published for 16 of the multisite randomized clinical trials conducted in the CTN, testing various treatments for drug abuse, HIV risk behavior, or related problems. This paper systematically examines, for each of the completed trials, the experimental design type chosen and its original rationale, the main findings of the trial, and the strengths and weaknesses of the design in hindsight. Based on this review, recommendations are generated to inform the design of future effectiveness trials on treatments for substance abuse, HIV risk, and other behavioral health problems