Physicians practicing in methadone treatment programs: who are they and what do they do?

OBJECTIVE: This study examines the characteristics and roles of physicians practicing in methadone maintenance treatment programs (MTPs). METHODS: Physicians and clinic directors at 172 MTPs in the United States completed surveys. MTPs were selected for study participation based on their locations (large urban, urban, or nonurban area) ownership status (for profit and non-profit), and size (patient capacity of 1-100, 101-300, and 300+). Weighted data were analyzed with descriptive and multivariate methods. RESULTS. Physicians were primarily white males aged 45 or older; 44% had 10 or more years of experience working in methadone treatment. Physicians reported spending 26% of their time completing administrative tasks. Most reported that they determine dosing levels on an individual patient basis. Average maintenance dose was 69 mg/day. CONCLUSIONS: Physicians' treatment practices play a major role in overall treatment, treatment retention, and outcomes. Physicians at for-profit and large urban MTPs reported spending the most time in direct patient contact.

Implications of managed care for methadone treatment. Findings from five case studies in New York State.

Several policy changes are being debated in New York State that may affect the financing and delivery of methadone maintenance treatment. The goals of this article are to provide greater understanding of the potential impact of managed care on methadone treatment in New York State, and greater understanding of the consequences of arbitrary limits on methadone treatment. Toward these goals, in October 1996, we conducted 1-day site visits at five methadone treatment programs in New York State to learn their views and concerns, and to examine their strategic responses to potential changes in treatment financing and delivery. The treatment programs we visited expressed concern about subjecting methadone patients to any of the potential policy changes because they felt that, if implemented without regard for the special needs of methadone patients, these reforms could hurt treatment access, retention, and quality of care. All the programs stated that limits on treatment would increase drug use and, consequently, increase crime and risk of infectious disease, and cause overall deterioration of the community.

Electrodeposited iridium oxide pH electrode for measurement of extracellular myocardial acidosis during acute ischemia.

In the present paper, fabrication, characterization, and physiological applications of a solid-state pH electrode are described. The pH sensing layer was based on an anodic electrodeposited iridium oxide film (AEIROF). Sputtered platinum electrodes (1 mm diameter) fabricated on flexible Kapton films or platinum wires were used as planar or cylindrical supports. Each electrode site was coated with Nafion to attenuate the interference of anionic redox species and to protect the electrode surface during in vivo measurements. Performance of the AEIROF was evaluated, for the first time, as a pH electrode and proved to have a slightly super-Nernstian response with slope of -63.5 +/- 2.2 mV/pH unit for both wire and planar sputtered platinum electrodes. Linear pH responses were obtained in the pH range 2-10. The electrodes have a working lifetime of at least 1 month with accuracy of about 0.02 pH unit and fast response time. The electrodes showed very low sensitivities for different species, such as Na+, K+, Li+, NH4+, Ca2+, Mg2+, dissolved oxygen, lactate, ascorbate, and urate, which are important for physiological applications. The electrodes were applied in extracellular pH measurements during brief regional ischemia in a swine heart and no-flow ischemia in an isolated rabbit papillary muscle. A first report on extracellular pH, K+, and lactate simultaneous measurements during no-flow ischemia using the AEIROF pH electrode and the previously described K+ and lactate electrodes is presented as well.

Risedronate gastrointestinal absorption is independent of site and rate of administration.

PURPOSE: Two studies were conducted to compare the absorption of risedronate administered as a solution to three different gastrointestinal sites (study A) and to determine the extent of absorption of risedronate solution administered by rapid and slow infusion to the second part of the duodenum (study B). METHODS: Each study was designed as a single-dose, crossover (three periods, study A; two periods, study B) trial in healthy male subjects, with a 14-day washout period between dosing. Subjects fasted overnight before drug administration and for 4 hours after drug administration. In study A, a risedronate solution of 40 mg in 30 mL of water was administered directly into the stomach, the second part of the duodenum, or the terminal ileum over 1 minute via a nasoenteral tube in a three-period crossover design. In study B, a risedronate solution of 40 mg in 30 mL of water was administered directly into the second part of the duodenum over 1 minute and over 1 hour in a randomized, two-period crossover design. Serum and urine samples were obtained for 48 hours after dosing for risedronate analysis. RESULTS: Eight subjects completed each study. No statistically significant site-specific differences in any pharmacokinetic parameter were observed (study A). Based on the area under the serum concentration-time profile and the amount of drug excreted in the urine unchanged, the extent of risedronate absorption did not differ significantly following a rapid or a slow infusion (study B). Only minor symptomatic complaints were reported by subjects, such as headaches and body aches. CONCLUSIONS: These studies indicate that the rate and extent of risedronate absorption are independent of the site of administration along the gastrointestinal tract, and that the extent of absorption is not affected by the rate of administration.

Factors that influence the use and perceptions of employee assistance programs at six worksites.

Employee assistance programs (EAPs) have gained significant importance in contemporary worksites. This article uses data from 6 case studies to examine several research questions regarding the relationship between worker demographic (e.g., gender, job tenure, and marital status), substance use, and workplace policies and the actual and potential use of the company EAP. Unlike in most of the existing literature, the authors did not find that gender, marital status, or job dissatisfaction are statistically related to actual or potential EAP use at most worksites. However, job tenure and some substance use behaviors were related to actual EAP use in a positive and statistically significant way. Another important finding, underlying the credible integration of EAPs into worksite culture, is the positive and robust relationship between employee trust and confidence in the EAP and actual use. The results of our study both reinforce some long-established principles in the EAP field and encourage further consideration of other beliefs.

A structured instrument for estimating the economic cost of drug abuse treatment. The Drug Abuse Treatment Cost Analysis Program (DATCAP).

Drug abuse treatment programs need to know the cost of the services they provide. Indeed, continued public and private funding is now being linked to cost and performance measures, and programs can use financial data to improve organizational efficiency. However, one of the dangers of promoting cost studies at treatment programs is that most program staff are not technically prepared to perform a cost analysis and little user-friendly information is available to offer assistance. Furthermore, not all cost methods are consistent, which can lead to noncomparable estimates that are difficult to use for policy or planning purposes. Our paper tries to fill this gap in the research literature and provide treatment programs with a much-needed technical assistance tool. Specifically, we present a structured and scientifically-based instrument for estimating the economic cost of treatment services. The Drug Abuse Treatment Cost Analysis Program (DATCAP) is described in detail along with a companion instrument to analyze treatment financing; the Drug Abuse Treatment Financing Analysis Program (DATFin). The components of both instruments are outlined and findings from a variety of actual case studies are presented. Lastly, we discuss the DATCAP User's Manual, which will enable individual programs to begin collecting the necessary data and estimating economic costs at their own clinics.

Health care reforms and managed care for substance abuse services: findings from eleven case studies.

In 1992, the United States spent $820 billion on health care. For the same year, an estimated 15 percent of the U.S. population, approximately 43 million people, were uninsured. As health care costs continue to rise, the number of people able to afford coverage continues to decline. Given these statistics, it is not surprising that concern over health care reform is at the forefront of government policy. Over the past few years, policymakers have faced the challenge of creating a more cost-efficient, universal health care system. Many of the proposed reforms rely heavily on managed care practices and treatment limits to help control costs. The impact of managed care is already apparent in primary health care where private insurers have been using it for years (e.g., HMOs, PPOs). However, its full impact on substance abuse treatment services remains unknown. In this paper, we present the perceptions, opinions, and experiences of eleven drug treatment programs regarding the actual or anticipated effects of managed care and health care reforms on the delivery, financing, and costs of substance abuse treatment. We also present an analysis of these programs' current costs and financing. We believe that the information presented in this paper provides timely insights into the substance abuse treatment system; these insights should assist policymakers in developing optimal health care reform policies.

Fibromyalgia. Part I. Review of the literature.

Fibromyalgia presents with generalized body pain, multiple tender points, and associated ancillary symptoms, including fatigue and nonrestorative sleep. The abnormal sleep pattern is the most common accepted etiology for this condition. The diagnosis may be made on the basis of a classic presentation of symptoms and clinical findings. The treatment of fibromyalgia includes aerobic exercise and the use of tricyclic antidepressants to modulate the sleep disorder with less than excellent results. In spite of the frustrations in treating this condition successfully, many patients are relieved to be provided with a diagnosis and to obtain sympathetic and supportive care from their physicians.

Effects of a videotape feedback package on the peer interactions of children with serious behavioral and emotional challenges.

Peer interactions are among the greatest challenges experienced by children who have severe emotional and behavioral problems. This study evaluated an intervention package designed to increase the ratio of these children's desirable to undesirable interactions. The package included three principal components: (a) observation of videotapes following regularly scheduled peer activity sessions; (b) self-evaluation of the children's peer interactions observed on the videotapes; and (c) delayed feedback and reinforcement for desirable peer interactions. Five students from two elementary schools participated. Multiple baseline designs and one reversal were used to evaluate the effects of the intervention package. The results showed that the intervention produced lower levels of undesirable peer interactions and higher ratios of desirable to undesirable interactions for all participants. The results are discussed in regard to their conceptual and applied implications and in terms of specific directions for future research.

Functional assessment, curricular revision, and severe behavior problems.

An adolescent female with multiple handicaps and a long history of severely disruptive behavior participated in a functional assessment linked directly to specific revisions in her school curriculum. During Phase 1, reversal designs were used to test hypotheses pertaining to antecedent and curricular influences on problem behavior. During Phase 2, a multiple baseline across afternoon and morning time periods demonstrated that the curricular revisions were effective in eliminating severely disruptive behavior and increasing on-task responding. Data also showed that inappropriate "psychotic" speech was reduced and appropriate social interactions were increased. Follow-up results showed that the changes were maintained throughout the school year. Questionnaire data provided social validation of the procedures and outcomes. The findings are discussed in relation to their implications for functional assessment, individualized curricula, and positive programming for students with disabilities and serious behavior problems.

Limit for qualitative detection of benzoylecgonine in urine using EMIT reagents and the Hitachi 705 automatic analyzer.

The limit of detection for the cocaine metabolite (hydrolysis product), benzoylecgonine, using Syva EMIT reagents and the Hitachi 705 automatic analyzer has been found to be 10 ng/mL at the 99% confidence level. For this determination 30 controls were prepared from a single urine pool known to be negative for cocaine metabolite. Urine samples of 90 patients were found to be drug-free when analyzed by selected ion monitoring gas chromatography/mass spectrometry for ecgonine methyl ester and benzoylecgonine at sensitivities of less than 0.4 ng/mL and 1.3 ng/mL, respectively. To test matrix effects on the limit of detection, these samples were screened with the Hitachi 705. Results for eight of the known negative samples fell above the 10-ng/mL limit of detection while only one presumptive positive resulted at an arbitrary 20-ng/mL cutoff. Detection limits were also determined using 20 different negative patients' urine samples fortified with benzoylecgonine. At the 99% confidence level using EMIT d.a.u. and 705 reagents the detection limits were found to be 44 ng/mL and 35 ng/mL, respectively. It was found that 62% of patients' samples positive for benzoylecgonine fell below the 300-ng/mL cutoff and above a cutoff at 50 ng/mL.

Extending the detection limit of the TDx fluorescence polarization immunoassay for benzoylecgonine in urine.

This modified calibration method decreases from 300 to 27 micrograms/L the limit of detection for the cocaine metabolite (hydrolysis product), benzoylecgonine, by the Abbott Laboratories TDx fluorescence polarization immunoassay. For this determination we used 30 controls prepared from a single urine pool known to be negative for cocaine metabolite. Assay of 80 controls prepared from 20 different patients' urine samples yielded a limit of detection of 44 micrograms/L. To test these limits of detection, we analyzed 90 patients' urine samples known to be negative for cocaine metabolite and 74 patients' samples known to be positive for cocaine metabolite, using the TDx with our revised calibration. Results for two of the known negative samples and 96% of the samples containing cocaine in the 50 to 100 micrograms/L range fell above the 44 micrograms/L limit. The TDx showed excellent calibration stability. For 28 days during the test, the instrument was not recalibrated. During this period the day-to-day analysis of 50 micrograms/L controls produced a mean TDx response of 0.485 (SD 0.007) with a coefficient of variation of 1.5%.

A self-monitoring package for teaching subtraction with regrouping to students with learning disabilities.

In this investigation, we evaluated the effectiveness of a self-monitoring package with 3 learning disabled students whose responding to subtraction problems had been highly inconsistent and unsuccessful. Following a two-phase baseline of didactic instruction and special incentives, an error analysis was used to develop individualized self-monitoring checklists that the students then responded to as they completed their subtraction assignments. In the context of a multiple baseline design, the self-monitoring procedures produced immediate gains in correct responding, with more stable levels of successful performance occurring across sessions. In a subsequent maintenance phase, the checklists were removed and the previous incentives condition was reinstated, resulting in continued levels of successful responding. The results are compared to the literature on self-monitoring and learning disabilities and discussed in terms of the continuing need for effective and efficient instructional strategies.

Removal of an esophageal foreign body using a Foley catheter.

A two-year-old child presented with dysphagia due to a coin lodged in his mid-esophagus. It was removed by passing a Foley catheter beyond the foreign object, inflating the balloon and slowly withdrawing the catheter. A similar technique using a pediatric Foley catheter can remove smooth-surfaced foreign bodies from the nose. A review of the methods and indications for the procedures suggests their usefulness in emergency department practice.

A modified, simple device for the emergency administration of percutaneous transtracheal ventilation.

Studies of percutaneous transtracheal ventilation with intermittent jets of oxygen under high pressure have demonstrated a tendency toward carbon dioxide retention and poor alveolar washout. A modification of the percutaneous transtracheal ventilation fevice to include an expiratory phase improves pulmonary gas exchange and minimizes the possibility of CO2 retention. The most common complication is subcutaneous emphysema caused by incorrect catheter placement. Although endotracheal intubation is unquestionably the treatment of choice, percutaneous transtracheal ventilation does offer a viable alternative when intubation cannot be rapidly accomplished.

Centrifugal cytology. III. The utilization of centrifugal cytology for the preparation of fixed stained dispersions of cells separated by bovine serum albumin bouyant density centrifugation.

This paper describes the modification of Centrifugal Cytology for the preparation of permanent, fixed, stained dispensions for both light and scanning electron microscopy of cells which have been isolated on bovine serum albumin (BSA) boyant density gradients. The principal problem with BSA gradient fractions is that the albumin which is present even after dilution is precipitated by the glutaraldehyde fixative. This problem has been solved by the layering of an intermediate D2O solution under the BSA and subsequent removal of the BSA solution and the underlaying with D2O containing glutaraldehyde. A special layering machine facilitates and expedites these operations. This technique has also been applied to BSA-seperated guinea pig and chicken bone marrow cells, as well as Ehrlich ascites tumor cells, hen and human blood cells. The number of celll present in each area of the slide is maintained at a constant value by utlizing a table of dilution factors. This table was generated by a computer program which calculates the concentration of cells present in the rractions and divides it by the number of celll desired.

Buoyant density separation of cells. I. The buoyant distribution of guinea pig bone marrow cells.

Guinea pig bone marrow cells were separated by buoyant density utilizing linear gradients of bovine serum albumin (BSA). It has finally become possible to characterize the cells present in the density fractions in terms of classical morphology. The development of the Cell Type computer program which calculates the percentages of the individual types of cells present in the fractions and their buoyant density distributions and plots the data has greatly facilitated and improved the accuracy of these studies. Approximately 40 cell types were observed in guinea pig bone marrow. Cells with definitive morphologies such as erythrocytes, the neutrophilic series, the binucleate blast megakaryocyte precursor and cells in mitosis band as virtually single peaks. Cells which are parts of continua or can easily be wrongly classified are found in multiple peaks. The small lymphocytes which are known to be polydisperse are found as five peaks. Because of the very strong benzidine staining by the glutaraldehyde-fixed hemoglobin, some of the erythroblasts were wrongly staged, resulting in a multimodal distribution. The presence of macrocytes further complicated these distributions. The rule that the younger cells are always less dense than the mature cells was adhered to in those cases where the cells could be definitively characterized, such as the neutrophilic series and the blasts. These results indicate that morphology is a good first approximation of reality.

Centrifugal Cytology, IV. The Prearation of fixed stained dispersions of gynecological cells.

The Centrifugal Cytology technique has been utilized to produce glutaraldehyde fixed stained dispersions of both conventional Ayre scrapes and Davis pipet (PAPette) samples. Light microscope studies of dispersions of both types of cells on conventional microscope slides indicated that both the tinctorial and morphological appearance of the cells after Papanicolaou staining was very similar to that observed with conventional smears and that the same criteria could be utilized with the Centrifugal Cytology dispersions to screen the cells for cancer as had previously been used with the smears. A preliminary study indicated that six out of six positives with no false negatives or false positives were found. The Centrifugal Cytology technique appears to have promise as a method for preparing suspension samples such as pipets of gynecologic cells. Scanning electron microscope studies reveal that the squamous epithelial cells are very thin and at least some of them are covered by a network structure.