Rotation in a Smoking Cessation Clinic Improves Nicotine Dependence Treatment Provided by First-Year Internal Medicine Trainees.

BACKGROUND AND OBJECTIVES: Over 70% of smokers visit a physician annually, and physicians are well-positioned to assist patients in smoking cessation. Residency offers the ideal setting to train physicians in best practices for treatment of nicotine dependence. We hypothesized that experiential learning during a smoking cessation medical clinic (SCMC) rotation would be associated with an improvement in smoking cessation practice of internal medicine (IM) interns in outpatient primary care and inpatient settings. METHODS: This was a prospective study performed at a large university-affiliated hospital. Forty IM interns rotated through SCMC. After a lecture on nicotine addiction and treatment, interns treated SCMC patients under direct supervision of an attending pulmonologist. Interns' smoking cessation practices before and after SCMC rotation were evaluated through chart review over 1 year. Upon study completion, a survey to assess confidence was administered. Paired t tests measured changes in rates of identifying smokers, offering pharmacological treatment and counseling. RESULTS: A total of 5,622 outpatient and 683 inpatient charts of interns' encounters with patients were reviewed. Following SCMC rotation, there was an increase in identifying active smokers (7.1% versus 18.7%), prescribing therapy for smoking cessation (6.5% versus 18.0%), and providing counseling (30.9% versus 42.3%) to outpatients. For inpatients, there was an increase in nicotine replacement during admission (12.9% versus 37.4%) and prescription of therapy upon discharge (5.7% versus 16.1%). Interns reported confidence in providing appropriate counseling and treatment. CONCLUSIONS: SCMC experience positively impacted smoking cessation treatment by IM interns, causing a measurable change in their practice.

Mindfulness and Modification Therapy for Behavioral Dysregulation: A Comparison Trial Focused on Substance Use and Aggression.

OBJECTIVES: Disorders of behavioral dysregulation often involve more than one dsyregulated behavior (e.g., drug abuse and aggression, alcohol abuse and gambling). The high co-occurrence suggests the need of a transdiagnostic treatment that can be customized to target multiple specific behaviors. METHOD: The current pilot study compared a 20-week, individual transdiagnostic therapy (mindfulness and modification therapy [MMT]) versus treatment as usual (TAU) in targeting alcohol problems, drug use, physical aggression, and verbal aggression in self-referred women. Assessments were administered at baseline, post-intervention, and 2-month follow-up. RESULTS: Wilcoxon signed-ranked tests and multilevel modeling showed that MMT (n = 13) displayed (a) significant and large decreases in alcohol/drug use, physical aggression, and verbal aggression; (b) significantly greater decreases in alcohol/drug use and physical aggression than did TAU (n = 8); and (c) minimal-to-no deterioration of effects at follow-up. Both conditions showed significant decreases in verbal aggression, with no statistically significant difference between conditions. MMT also displayed greater improvements in mindfulness. CONCLUSIONS: Preliminary findings support the feasibility and efficacy of MMT in decreasing multiple dysregulated behaviors.

Misuse of atypical antipsychotics in conjunction with alcohol and other drugs of abuse.

Non-medical use of atypical antipsychotics by substance abusers has been reported in the literature, although no detailed studies exist. Among 429 addiction treatment inpatients screened, 73 (17.0%) reported misuse of antipsychotics with alcohol, opioids, cocaine, methamphetamine and/or cannabis; 39 (9.1%) within the past year. Of past year misusers, 25 (64.1%) were interviewed. Most were male (76.0%), non-Caucasian (56.0%), and polysubstance abusers (84.0%). Quetiapine, the most abused drug (96.0%), was obtained primarily from doctors (52.0%) and family/friends (48.0%). Reasons for use included to "recover" from other substances (66.7%), "enhance" the effects of other substances (25.0%), and "experiment" (20.8%). The most frequently reported positive effect was "feeling mellow" (75.0%); negative effects were consistent with antipsychotic use (e.g., feeling thirsty, trouble concentrating). Compared to a normative sample of inpatient substance abusers, ASI composite scores were higher. Findings suggest that physicians should assess for use/misuse of atypical antipsychotics among patients with addiction.

Readiness for behaviour change in non-alcoholic fatty liver disease: implications for multidisciplinary care models.

BACKGROUND & AIMS: Weight management is a cornerstone of treatment for overweight/obese persons with non-alcoholic fatty liver disease (NAFLD). This exploratory study sought to: (i) evaluate readiness to change weight-related behaviours; (ii) assess psychosocial characteristics that may interfere with weight loss; and (iii) evaluate how baseline psychosocial features associate with 6-month change in weight in persons with NAFLD receiving standard medical care. The purpose of this investigation was to develop hypotheses regarding relationships between psychosocial factors and weight for use in future fully powered studies and clinical interventions METHODS: Fifty-eight overweight/obese participants with NAFLD completed baseline measures of personality, psychiatric symptoms and readiness for behaviour change and were followed up for 6 months in standard care. RESULTS: One-third of participants (31.0%) were not interested in making weight-related behaviour changes; 58.6% were considering making a change, and 10.4% of individuals were actively working on or preparing to change. Six-month change in weight was non-significant and was not associated with baseline readiness for change. Depression, low conscientiousness and high neuroticism were associated with higher weight at 6-month follow-up with small to large effect sizes. CONCLUSIONS: Although participants received nutritional education and guidance, very few individuals presented in the active stage of change. Although readiness for change did not predict subsequent change in weight, personality factors and psychiatric symptoms were associated with weight outcomes. Integrated multidisciplinary approaches that address psychiatric needs and provide behavioural support for weight loss may help patients with NAFLD implement sustained lifestyle changes.

Reasons for opioid use among patients with dependence on prescription opioids: the role of chronic pain.

The number of individuals seeking treatment for prescription opioid dependence has increased dramatically, fostering a need for research on this population. The aim of this study was to examine reasons for prescription opioid use among 653 participants with and without chronic pain, enrolled in the Prescription Opioid Addiction Treatment Study, a randomized controlled trial of treatment for prescription opioid dependence. Participants identified initial and current reasons for opioid use. Participants with chronic pain were more likely to report pain as their primary initial reason for use; avoiding withdrawal was rated as the most important reason for current use in both groups. Participants with chronic pain rated using opioids to cope with physical pain as more important, and using opioids in response to social interactions and craving as less important, than those without chronic pain. Results highlight the importance of physical pain as a reason for opioid use among patients with chronic pain.

Sublingual buprenorphine for chronic pain: a survey of clinician prescribing practices.

OBJECTIVES: Sublingual buprenorphine, with and without naloxone, is indicated for the treatment of opioid use disorders. Although not approved for pain, some evidence suggests it may be a safe and effective alternative to conventional opioid analgesics, particularly for those with addiction problems. This study surveyed pain specialists to examine the extent to which sublingual buprenorphine was prescribed for chronic pain and explore associated clinician attitudes and characteristics. METHOD: A 36-item survey examining clinician attitudes and characteristics related to sublingual buprenorphine and other opioids was distributed to 1307 members of the American Pain Society, a multidisciplinary professional group. Members were provided a paper copy of the survey and URL to an online version. A follow-up letter was mailed after 2 weeks. RESULTS: Overall, 230 completed surveys were returned (18.5%). Of clinicians who prescribed opioids for chronic pain (92.5%), 19.7% reported prescribing sublingual buprenorphine for chronic pain at least once; of these prescribers, 39.6% did not have a DEA X-waiver to prescribe sublingual buprenorphine for opioid dependence. Prescribers were more likely than nonprescribers to find sublingual buprenorphine effective for chronic pain. Prescribers were also significantly more likely to view sublingual buprenorphine as safer than full agonists in terms of addiction, overdose, and drug interaction. No differences emerged between prescribers and nonprescribers regarding perceptions of potential for drug diversion or in terms of overall opioid prescribing behaviors. DISCUSSION: Results suggest that sublingual buprenorphine is indeed being used to treat chronic pain; however, the circumstances when this occurs are not entirely clear.

Developing PeerLink to engage out-of-care HIV+ substance users: training peers to deliver a peer-led motivational intervention with fidelity.

Substance use among HIV+ individuals can be a barrier to HIV care, resulting in poor health outcomes. Motivational interviewing (MI) is an effective intervention to reduce substance abuse and increase HIV-related health. Healthcare workers from various backgrounds can be effectively trained in delivering MI interventions; however, there has been limited evidence that peers can effectively deliver MI interventions with fidelity. Peers have traditionally worked in HIV care settings and represent a valid context for a peer-delivered intervention focused on motivational issues. We trained four peers in MI. In this paper, we describe the intervention, explain the MI training methods, and investigate whether peers can be trained in MI with fidelity. The MI training included didactic instruction, group workshops, and individual feedback sessions. Two of four peers achieved MI treatment fidelity as measured by the Motivational Interviewing Treatment Integrity Code Version 3.0. Overall, peers had difficulty using open-ended questions and querying pros and cons, skills thought necessary to elicit change talk. They also tended to give too much direct advice where reflections would have been appropriate. A challenge was training peers to change familiar ways of communicating. Nonetheless, they did well at assessing and highlighting motivation to change. The total training hours (40 h) was long compared with other published MI studies. However, the intervention included several components with two targeted change behaviors. It is likely that peers can be trained in MI with fidelity in less time given a more streamlined intervention. When working with peers who have life stressors similar to the target group, it is important to be flexible in the training.

Is there a better way to monitor abstinence among substance abusers awaiting transplantation?

PURPOSE OF REVIEW: Conventional biomarkers are poor measures of ongoing abstinence. Due to short and variable windows of detection, the chances that an active substance user will be detected during the 6-month waiting period depend on the testing method and the drug. Herein we discuss hair testing as an alternative matrix for monitoring abstinence. Issues and obstacles related to adoption of a more uniform testing protocol are identified. RECENT FINDINGS: Hair testing is a powerful matrix with the capacity to detect drugs for up to 90 days. Seemingly a logical choice for use in situations in which continuous abstinence is required, it mostly has been employed in Europe with forensic populations such as alcoholics seeking drivers license reinstatement. Only two studies have been conducted in transplant patients. In both, hair testing detected more active users than other modalities. SUMMARY: Use of conventional biomarkers results in variable rates of drug detection, raising questions about fairness of the selection process. Hair analysis significantly increases detection rates. Programs adopting hair analysis should be prepared for more patients to be disqualified during the 6-month waiting period, but those testing negative at baseline could, theoretically, proceed with transplantation sooner. Selection of more optimal candidates also could improve outcomes.

Relationship of axis II pathology to sex- and drug-related risk behaviors among patients in HIV primary care.

Some HIV+ patients continue to engage in high-risk behaviors post-diagnosis. To tailor risk reduction interventions for "positives," it is necessary to understand contributing factors. We recently showed that HIV+ patients with co-morbid Axis I psychiatric and substance use disorders had the highest rates of ongoing risk behavior and those without diagnoses the lowest; substance dependence was more impactful than psychiatric disorders. In this companion paper, we provide complementary information about Axis II pathology based on data obtained from the same sample of 179 patients receiving HIV primary care. Patients were categorized as sub-threshold or as having personality traits/disorders (BR ≥ 75) on any of the 14 personality scales of the Millon Multiaxial Personality Inventory (MCMI-III). HIV risk behaviors assessed included (1) the number of sexual partners; (2) any sex without a condom; (3) lifetime and recent injection drug use (IDU); and (4) sharing of injection equipment. After controlling for a diagnosis of alcohol or drug dependence, borderline patients were more likely to have multiple sexual partners and to use condoms irregularly. Trends for multiple sex partners also were observed among patients with antisocial and depressive personality traits/disorders. Antisocial patients also were more likely to be current IDUs. Positives with personalities characterized by risk-taking tendencies and/or decreased capacity to engage in good self-care may benefit from risk reduction interventions that take their feelings of power/invincibility or (conversely) powerlessness/helplessness into account. For patients with antisocial and/or borderline traits/disorders, a "one size fits all" intervention focusing primarily on skills training is likely to fail because the underlying factors driving behavior are not being adequately addressed.

Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: a 2-phase randomized controlled trial.

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.

Adapting an evidence-based HIV prevention intervention for pregnant African-American women in substance abuse treatment.

An adaptation of an evidence-based, woman-focused intervention designed to reduce HIV risk behaviors was conducted for pregnant, African-American women in substance abuse treatment in North Carolina. The intervention adaptation process included focus groups, expert panels, and the filming of women who spoke about their experiences with pregnancy, drug use, sex risk behaviors, HIV testing and treatment, need for substance abuse treatment, violence, and victimization. The assessment instrument was adapted for pregnant women and the intervention was organized into a 4-session PowerPoint presentation, with an additional session if a woman tested positive for HIV. All sessions and assessment instrument were installed on laptop computers for portability in treatment programs. We pilot tested our adaptation with 59 pregnant African-American women who had used an illicit drug within the past year and were enrolled in substance abuse treatment. At baseline, 41% were currently homeless, 76% were unemployed, 90% had not planned their current pregnancy, and approximately 70% reported drug use since finding out about the pregnancy. This sample of participants rated the intervention sessions and were highly satisfied with their experience, resulting in a mean satisfaction score of 6.5 out of 7. Pregnant African-American women who use drugs need substance abuse treatment that they do not currently access. Woman-focused HIV interventions help to address intersecting risk behaviors and need for treatment prevalent among this vulnerable group.

Psychopathology and transmission risk behaviors in patients with HIV/AIDS.

The role of psychiatric and substance use disorders in HIV transmission has not been fully elucidated, particularly among those living with the virus. We compared sex and drug risk behaviors for 228 HIV+ patients in four diagnostic groups: (1) no diagnosis; (2) psychiatric only; (3) substance dependence only; and (4) co-morbid psychiatric and substance dependence. Significant group differences were observed for having multiple sex partners, condom use, and injection drug use (IDU), but not for sharing of injection equipment. Patients with co-morbid psychiatric and substance disorders reported multiple sex partners most frequently, while substance dependence contributed to irregular condom use and IDU. Analysis by substance use subgroup (no dependence, alcohol dependence only, drug dependence only, co-morbid alcohol, and drug dependence) showed that alcohol dependence contributed to having multiple sex partners, while alcohol and drug dependence both contributed to irregular condom use. Meanwhile, only drug dependence contributed to drug risk. HIV+ patients should be screened for psychopathology, with risk reduction interventions tailored to diagnostic group to achieve maximum effect.

Characteristics of pain patients with opioid-use disorder.

BACKGROUND: "Nonmedical" (i.e., illicit) use of opioid analgesics has skyrocketed among the general population during the past decade, with similar increases observed among pain patients who take opioids by prescription. OBJECTIVE: Because 1 in 3 opioid-maintained pain patients may be affected, it is essential that healthcare providers learn more about this subpopulation as a first step toward improved detection, brief intervention, referral, and general management. METHOD: The authors examined baseline data for 40 chronic-pain patients in a treatment trial targeting opioid analgesic abuse. RESULTS: Abuse-disorder patients were dysfunctional and had high rates of psychiatric disorders and troublesome personality traits. Providers characterized patients as manipulative, drug-seeking, and noncompliant; patients complained that they were pharmacologically undertreated and were considered "addicts." Despite having severe pain and addiction, their average daily opioid dose was only 69% of that used to treat addiction in the same geographic region. CONCLUSION: Abuse-disorder patients had a similar physical but worse psychiatric/personality presentation than other chronic-pain patients, which suggests the need for increased psychiatric involvement.

Methadone maintenance treatment for youth: experiences of clients, staff, and parents.

In order to better understand the components of effective treatment for the understudied population of opioid-dependent youth, separate focus groups were conducted in 2006 with clients, clinical staff, and clients' parents (total n = 22) at a novel methadone maintenance program for adolescents and young adults in suburban New York. Focus group sessions were audiotaped, transcribed, and analyzed for common themes. Clients, staff, and parents all reported that effective treatment for opioid addiction among young people is a long-term program, combines pharmacological and behavioral approaches, emphasizes a high degree of individual attention from staff, and incorporates clients' family members. The study's limitations were noted.

Patient versus therapist alliance: whose perception matters?

Development of working alliance was examined for 25 opioid-abusing pain patients and their therapists. Patients participated in an eight-session intervention based on adherence strategies and employment of a supportive, psychoeducational approach; methadone was prescribed for pain. Treatment goals included opioid analgesic adherence and decreasing pain, functional interference, and substance abuse. Patients and therapists completed the Helping Alliance Questionnaire-II following each treatment session. At baseline, scores of patients and therapists indicated good alliance. Patient alliance grew significantly over time regardless of addiction severity and independent of treatment outcomes. In contrast, therapist alliance grew only for patients without substance abuse comorbidity and/or who had good outcomes. Patients' and therapists' alliance scores were consistent during sessions focused on emotional bonds but diverged during sessions that demanded behavior change, suggesting that therapists may have reacted negatively to patients' lack of progress. Whether therapists' reactions to poor performers impacted subsequent patient outcomes is unknown but should be investigated.

Smoking stage of change is associated with retention in a smoke-free residential drug treatment program for women.

Prochaska and DiClemente's Transtheoretical Model predicts dropout from substance-abuse treatment. However, it is not known whether readiness to quit smoking is associated with attrition from drug treatment programs with smoking restrictions. This study examined the relationship between smoking characteristics, smoking stage of change, and both length of stay (LOS) and discharge type among 75 perinatal substance abusers attending a smoke-free residential treatment program. URICA scores predicted LOS (P=.0004) and discharge type (P=.01). Women in action and maintenance remained in treatment longer and were more likely to complete treatment compared to those in precontemplation. Findings were not accounted for by addiction severity. Women with little interest in quitting smoking may have difficulty adhering to smoking restrictions during treatment for other drug problems, resulting in increased attrition. Alternatively, smoking stage of change may be a "proxy" for overall readiness to change in this population.

Personality disturbances in drug-dependent women: relationship to childhood abuse.

This study examined associations between childhood abuse and personality disturbances in 228 drug-dependent women. Thirty-six percent denied abuse, 50% reported emotional, 42% physical, and 42% sexual abuse. Million Clinical Multiarial Inventory (MCMI-III) scores > 74 provided evidence of personality disturbance and scores on Minnesota Multiphasic Personality Inventory-2 (MMPI-2) scales measuring somatic complaints, depression, anxiety and postraumatic stress disorder (PTSD) served as covariates. Emotional and physical abuse survivors were at increased risk for borderline, masochistic, and avoidant disturbances and decreased risk for narcissistic disturbances. Emotional abuse survivors were also less likely to be sadistic whereas physical abuse survivors were more likely to be paranoid. Sexual abuse survivors were twice as likely be antisocial; however, no association was found with borderline personality. Finally, an increased prevalence of severe personality disturbances was observed among those experiencing multiple types of abuse. Childhood trauma predisposes drug-dependent women to develop troublesome personality characteristics that are independent of drug addiction and other psychological problems associated with childhood trauma.

Psychopathology is associated with completion of residential treatment in drug dependent women.

This study characterized drug dependent women based on current psychopathology (MCMI-III) and then examined the relationship between psychopathology and treatment retention. Participants included 97 pregnant (88%), African-American (78%), single (90%) 30-year old women enrolled in a 6-month residential drug treatment program for women and children. Clustering on personality test scores using Ward's technique identified three subgroups with mild (24%), moderate (59%) and severe (18%) psychopathology. Treatment completion rates varied by group (66%, 45% and 29%), with half of the high severity group leaving against medical advice (AMA) within 60 days. Although the majority of low severity women completed the program as scheduled, they may also have done well in a less intensive treatment modality. Conversely, it appears that women with severe psychopathology may require a more flexible, psychiatrically-oriented approach than is found in most residential settings including greater emphasis on psychiatric issues, individual psychotherapy, and pharmacotherapy.

Victimization and perpetration among perinatal substance abusers.

This study examined associations between demographic, psychiatric, substance abuse, and childhood abuse variables and past 30-day victimization and perpetration among 77 perinatal substance abusers. Victimization rates were 70% emotional, 34% physical, 29% sexual, and 42% personal freedom violations. For perpetration, incidence was 71% emotional, 25% physical, 5% sexual, and 9% personal freedom violations. Through univariate regression, Addiction Severity Index (ASI) psychiatric and drug composite scores, childhood physical abuse, borderline personality disorder (BPD) and post-traumatic stress disorder (PTSD) were found to significantly predict victimization. In contrast, ASI psychiatric and drug composite scores, BPD, PTSD, and aggressive-sadistic and antisocial personality disorders were found to significantly predict perpetration. In multiple regression models, ASI drug and psychiatric composite scores accounted for the majority of the variance for both victimization and perpetration, suggesting that women with high ASI scores should be queried about their involvement in abusive acts at time of admission to drug treatment.