Effects of a trauma-informed mindful recovery program on comorbid pain, anxiety, and substance use during primary care buprenorphine treatment: A proof-of-concept study.

BACKGROUND: A mindfulness-based intervention that reduces comorbid pain, anxiety, and substance use during office-based opioid treatment (OBOT) could enhance retention and prevent overdose. We conducted a pilot study of the Mindful Recovery OUD Care Continuum (M-ROCC), a 24-week trauma-informed program with a motivationally-sensitive curriculum. METHODS: Patients prescribed buprenorphine (N = 18) enrolled in M-ROCC. We collected urine toxicology biweekly. At 0, 4, and 24 weeks, participants completed PROMIS-Pain, PROMIS-Anxiety, Mindfulness (FFMQ), Experiential Avoidance (BEAQ), Interoceptive Awareness (MAIA), and Self-Compassion (SCS-SF) scales. We estimated changes over time using mixed models. Participants completed qualitative interviews at 4 and 24 weeks. RESULTS: Positive urine toxicology decreased over time for cocaine (ß = -.266, p = .008) and benzodiazepines (ß = -.208, p = .028). M-ROCC reduced PROMIS-Pain (Z = -2.29; p = .022), BEAQ (Z = -2.83; p = .0005), and increased FFMQ (Z = 3.51; p < .001), MAIA (Z = 3.40; p = .001), and SCS-SF (Z = 2.29; p = .022). Participants with co-morbid anxiety had decreased PROMIS-Anxiety (Z = -2.53; p = .012). Interviewed participants commonly used mindfulness practices for stress and anxiety (12/12, 100%), and to reduce pain catastrophizing and rumination (7/12, 58%). CONCLUSION AND SCIENTIFIC SIGNIFICANCE: This is the first study to report the effects of a 24-week mindfulness program during buprenorphine treatment on common comorbidities, including pain interference, anxiety, cocaine, and benzodiazepine use. The findings that M-ROCC is associated with reduced experiential avoidance, as well as increased interoceptive awareness and self-compassion, align with proposed mechanisms that are now extended to OUD treatment. Future larger randomized controlled trials are needed before effectiveness can be established and the role of these mechanisms can be confirmed.

Feasibility and acceptability of mindful recovery opioid use care continuum (M-ROCC): A concurrent mixed methods study.

As opioid overdose deaths increase, buprenorphine/naloxone (B/N) treatment is expanding, yet almost half of patients are not retained in B/N treatment. Mindfulness-based interventions (MBIs) designed to promote non-judgmental awareness of present moment experience may be complementary to B/N treatment and offer the potential to enhance retention by reducing substance use and addressing comorbid symptoms. In this pilot study, we examined the feasibility and acceptability of the Mindful Recovery OUD Care Continuum (M-ROCC), a trauma-informed, motivationally sensitive, 24-week MBI. Participants (N = 18) were adults with Opioid Use Disorder prescribed B/N. The study team conducted assessments of satisfaction, mindfulness levels, and home practice, as well as qualitative interviews at 4 and 24-weeks. M-ROCC was feasible in a sample with high rates of childhood trauma and comorbid psychiatric diagnoses with 89% of participants retained at 4-weeks and 72% at 24-weeks. Positive qualitative interview responses and a high rate of participants willing to refer a friend (100%) demonstrates program acceptability. Participant mindfulness increased from baseline to 24-weeks (ß = 0.24, p = 0.001, d = 0.51), and increases were correlated with informal mindfulness practice frequency (r = 0.7, p < 0.01). Although limited by small sample size, this pilot study highlights the feasibility and acceptability of integrating MBIs into standard primary care Office-Based Opioid Treatment (OBOT) among a population with substantial trauma history.

Implementing group visits for opioid use disorder: A case series.

Background: Group-based models of Office-Based Opioid Treatment with buprenorphine-naloxone (B/N) are increasingly being implemented in clinical practice to increase access to care and provide additional therapeutic benefits. While previous studies reported these Group-Based Opioid Treatment (GBOT) models are feasible for providers and acceptable to patients, there has been no literature to help providers with the more practical aspects of how to create and maintain GBOT in different outpatient settings. Case series: We present 4 cases of GBOT implementation across a large academic health care system, highlighting various potential approaches for providers who seek to implement GBOT and demonstrate "success" based on feasibility and sustainability of these models. For each case, we describe the pros and cons and detail the personnel and resources involved, patient mix and group format, workflow logistics, monitoring and management, and sustainability components. Discussion: The implementation details illustrate that there is no one-size-fits-all approach, although feasibility is commonly supported by a team-based, patient-centered medical home. This approach includes the capacity for referral to higher levels of mental health and addiction support services and is bolstered by ongoing provider communication and shared resources across the health system. Future research identifying the core and malleable components to implementation, their evidence base, and how they might be influenced by site-specific resources, culture, and other contextual factors can help providers better understand how to implement a GBOT model in their unique clinical environment.

Building a Group-Based Opioid Treatment (GBOT) blueprint: a qualitative study delineating GBOT implementation.

BACKGROUND: Group-Based Opioid Treatment (GBOT) has recently emerged as a mechanism for treating patients with opioid use disorder (OUD) in the outpatient setting. However, the more practical "how to" components of successfully delivering GBOT has received little attention in the medical literature, potentially limiting its widespread implementation and utilization. Building on a previous case series, this paper delineates the key components to implementing GBOT by asking: (a) What are the core components to GBOT implementation, and how are they defined? (b) What are the malleable components to GBOT implementation, and what conceptual framework should providers use in determining how to apply these components for effective delivery in their unique clinical environment? METHODS: To create a blueprint delineating GBOT implementation, we integrated findings from a previously conducted and separately published systematic review of existing GBOT studies, conducted additional literature review, reviewed best practice recommendations and policies related to GBOT and organizational frameworks for implementing health systems change. We triangulated this data with a qualitative thematic analysis from 5 individual interviews and 2 focus groups representing leaders from 5 different GBOT programs across our institution to identify the key components to GBOT implementation, distinguish "core" and "malleable" components, and provide a conceptual framework for considering various options for implementing the malleable components. RESULTS: We identified 6 core components to GBOT implementation that optimize clinical outcomes, comply with mandatory policies and regulations, ensure patient and staff safety, and promote sustainability in delivery. These included consistent group expectations, team-based approach to care, safe and confidential space, billing compliance, regular monitoring, and regular patient participation. We identified 14 malleable components and developed a novel conceptual framework that providers can apply when deciding how to employ each malleable component that considers empirical, theoretical and practical dimensions. CONCLUSION: While further research on the effectiveness of GBOT and its individual implementation components is needed, the blueprint outlined here provides an initial framework to help office-based opioid treatment sites implement a successful GBOT approach and hence potentially serve as future study sites to establish efficacy of the model. This blueprint can also be used to continuously monitor how components of GBOT influence treatment outcomes, providing an empirical framework for the ongoing process of refining implementation strategies.

Impact of Medical Scribes in Primary Care on Productivity, Face-to-Face Time, and Patient Comfort.

BACKGROUND: Medical scribes are a clinical innovation increasingly being used in primary care. The impact of scribes in primary care remain unclear. We aimed to examine the impact of medical scribes on productivity, time spent facing the patient during the visit, and patient comfort with scribes in primary care. METHODS: We conducted a prospective observational pre-post study of 5 family and internal medicine-pediatrics physicians and their patients at an urban safety net health clinic. Medical scribes accompanied providers in the examination room and documented the clinical encounter. After an initial phase-in period, we added an additional 20-minute patient slot per 200-minute session. We examined productivity by using electronic medical record data on the number of patients seen and work relative value units (work RVUs) per hour. We directly observed clinical encounters to measure the amount of time providers spent facing patients and other visit components. We queried patient comfort with scribes by using surveys administered after the visit. RESULTS: Work RVUs per hour increased by 10.5% from 2.59 prescribe to 2.86 post-scribe (P < .001). Patients seen per hour increased by 8.8% from 1.82 to 1.98 (P < .001). Work RVUs per patient did not change. After scribe implementation, time spent facing the patient increased by 57% (P < .001) and time spent facing the computer decreased by 27% (P = .003). The proportion of the visit time that was spent face-to-face increased by 39% (P < .001). Most (69%) patients reported feeling very comfortable with the scribe in the room, while the proportion feeling very comfortable with the number of people in the room decreased from 93% to 66% (P < .001). CONCLUSIONS: Although the full implications of medical scribe implementation remain to be seen, this initial study highlights the promising opportunity of medical scribe implementation in primary care.

A Comparison of the Effects of Two Prompt-Fading Strategies on Skill Acquisition in Children with Autism Spectrum Disorders.

Research has demonstrated that most-to-least (MTL) and least-to-most (LTM) prompting are effective in helping children with Autism Spectrum Disorders acquire a variety of new skills. However, when directly compared to one another, the efficiency and efficacy of the prompting procedures have been variable. The inconsistencies in the literature could be due to selecting prompt topographies that do not promote correct responding. To address this, the present study began by assessing different prompt topographies and then compared most-to-least (MTL) and least-to-most (LTM) prompt-fading with only prompt topographies that were potent enough to promote correct responding. The subsequent comparison of prompt-fading procedures revealed that MTL prompting was more effective and efficient than LTM prompting for all three participants. Further implications for practice and future research are discussed.

Using Shared Medical Appointments to Increase Access to Buprenorphine Treatment.

INTRODUCTION: This study examines patient experiences with shared medical appointments for buprenorphine treatment at a safety net primary care clinic. METHODS: This is a cross-sectional observational study of 28 participants in a primary care buprenorphine shared medical appointments program. RESULTS: Participants reported appreciating the group visit format, gaining increased coping skills, and having more stable housing and less legal difficulty after starting the program. CONCLUSION: The implementation of shared medical appointments for buprenorphine treatment benefits clinicians and patients. The nurse care manager and buprenorphine prescriber can efficiently attend to the clinical needs of multiple patients.

The development of USP botanical dietary supplement monographs, 1995-2005.

The development of USP botanical dietary supplement monographs by the Subcommittee on Natural Products (1995-2000) and the Dietary Supplements-Botanicals Committee of Experts (2000-2005) of the USP is described in this review. Featured details include the USP as an organization, focusing upon its history, mission, and publication of the United States Pharmacopeia-National Formulary (USP-NF); the formulation and composition of botanical dietary supplement monographs and related general chapters, as well as appropriate admission criteria; and a summary of the accomplishments of the Committees (1995-2005).

Roughened silver electrodes for use in metal-enhanced fluorescence.

Roughened silver electrodes are widely used for surface-enhanced Raman scattering (SERS). We tested roughened silver electrodes for metal-enhanced fluorescence. Constant current between two silver electrodes in pure water resulted in the growth of fractal-like structures on the cathode. This electrode was coated with a monolayer of human serum albumin (HSA) protein that had been labeled with a fluorescent dye, indocyanine green (ICG). The fluorescence intensity of ICG-HSA on the roughened electrode increased by approximately 50-fold relative to the unroughened electrode, which was essentially non-fluorescent and increased typically two-fold as compared to the silver anode. No fractal-like structures were observed on the anode. Lifetime measurements showed that at least part of the increased intensity was due to an increased radiative decay rate of ICG. In our opinion, the use of in situ generated roughened silver electrodes will find multifarious applications in analytical chemistry, such as in fluorescence based assays, in an analogous manner to the now widespread use of SERS. To the best of our knowledge this is the first report of roughened silver electrodes for metal-enhanced fluorescence.

Independent evaluator knowledge of treatment in a multicenter comparative treatment study of panic disorder.

The purpose of this study was to examine independent evaluators' (IEs) blindness to treatment condition during a Multicenter Comparative Treatment Study of Panic Disorder. IEs were 15 doctoral- and masters-level clinicians in psychology, social work, and medicine. They conducted three post-treatment assessments with each patient. Immediately after each assessment interview, IEs completed a form indicating which of the five possible treatments they believed the patient had received and any specific information that provided IEs with information about a patient's treatment condition. These forms were completed for 170 patients. Analyses were conducted to determine the accuracy of guesses about treatment condition by IEs during post-treatment assessments, the relationship between accuracy of IE guessing and actual treatment assignment, the relationship between accurate guessing and outcome ratings, and contributors to the breaking of the blind. A significant relationship was found between IE guesses and actual treatment at all three assessment points, across individual IEs, treatment sites, and IE professional affiliations. IEs were no more accurate in their guessing about patients taking medication than those receiving behavior therapy. Patients and project staff inadvertently provided information to IEs that enhanced the rates of accurate guessing. Implications of these findings on interpretation of the treatment study are discussed, and recommendations are made for improving blindness procedures.

Aggregation of Silver Nanoparticle-Dextran Adducts with Concanavalin A and Competitive Complexation with Glucose.

Tiopronin-protected silver nanoparticles (average diameter = 5 nm) were partially displaced by (2-mercapto-propionylamino) acetic acid 2,5-dioxo-pyrrolidin-1-ylesters via ligand exchange, and the succinimide-terminated silver particles were bound to amine-labeled Dextran 3000 (1 amine/per chain) or Dextran 10 000 (2.5 amine/per chain), respectively. The particle-Dextran 10 000 adducts were self-aggregated by interactions of multiple amines on Dextran and multi-functionalized ligands on the particle. The transverse plasmon band was blue shifted while the longitudinal plasmon at 575 nm increased, corresponding to the compact aggregation of particles. The particle-Dextran 3000 adducts, which were not aggregated, were coupled to Concanavalin A (Con A) to facilitate the aggregation of particles. The aggregated particles displayed an absorbance spectral change depending on the mole ratio of Con A/particle-Dextran 3000. The particle-Dextran 3000 adduct was released by a competitive complexation of glucose. This process was monitored by both the change in plasmon absorbance and wavelength, with the glucose concentration. The aggregation and dissociation of Con A/particle-Dextran complexes were also verified by TEM images.

Metallic colloid wavelength-ratiometric scattering sensors.

Gold and silver colloids display strong colors as a result of electron oscillations induced by incident light, which are referred to as the plasmon absorption. This absorption is dependent on colloid-colloid proximity, which has been the basis of absorption assays using colloids. We now describe a new approach to optical sensing using the light scattering properties of colloids. Colloid aggregation was induced by avidin-biotin interactions, which shifted the plasmon absorption to longer wavelengths. We found the spectral shift results in changes in the scattering at different incident wavelengths. By measuring the ratio of scattered intensities at two incident wavelengths, this measurement was made independent of the total colloid concentration. The high scattering efficiency of the colloids resulted in intensities equivalent to fluorescence when normalized by the optical density of the fluorophore and colloid. This approach can be used in a wide variety of assay formats, including those commonly used with fluorescence detection.

Electrochemical and Laser Deposition of Silver for Use in Metal-Enhanced Fluorescence.

We describe two reagentless methods of silver deposition for metal-enhanced fluorescence. Silver was deposited on glass positioned between two silver electrodes with a constant current in pure water. Illumination of the glass between the electrodes resulted in localized silver deposition. Alternatively, silver was deposited on an Indium Tin Oxide cathode, with a silver electrode as the anode. Both types of deposited silver produced a 5-18-fold increase in the fluorescence intensity of a nearby fluorophore, indocyanine green (ICG). Additionally, the photostability of ICG was dramatically increased by proximity to the deposited silver. These results suggest the use of silver deposited from pure water for surface-enhanced fluorescence, with potential applications in surface assays and lab-on-a-chip-based technologies, which ideally require highly fluorescent photostable systems.

Fluorescence Spectral Properties of Indocyanine Green on a Roughened Platinum Electrode: Metal-Enhanced Fluorescence.

The interactions of fluorophores with noble metal particles can modify their emission spectral properties, a relatively new phenomenon in fluorescence. We subsequently examined indocyanine green (ICG), which is widely used in medical testing and imaging, in close proximity to an electrically roughened platinum electrode. The emission intensity and lifetimes were decreased about 2-fold on the roughened surface as compared to a smooth Pt surface, and the photostability about the same. Platinum does not appear promising for metal enhanced fluorescence, at least for long wavelength fluorophores.

Increased Sensitivity of Fluorescence Detection Using Metallic Nanoparticles.

A new technique called radiative decay engineering can be used to modify fluorescence emissions by changing the free space conditions around the fluorophores.

Silver Fractal-like Structures for Metal-Enhanced Fluorescence: Enhanced Fluorescence Intensities and Increased Probe Photostabilities.

Substantial increases in fluorescence emission from fluorophore-protein-coated fractal-like silver structures have been observed. We review two methods for silver fractal structure preparation, which have been employed and studied. The first, a roughened silver electrode, typically yielded a 100-fold increase in fluorophore emission, and the second, silver fractal-like structures grown on glass between two silver electrodes, produced a ≈500-fold increase. In addition, significant increases in probe photostability were observed for probes coated on the silver fractal like structures. These results further serve to compliment our recent work on the effects of nobel metal particles with fluorophores, a relatively new phenomenon in fluorescence we have termed both "metal-enhanced fluorescence" [1] and "radiative decay engineering" [2,3]. These results are explained by the metallic surfaces modifying the radiative decay rate (Γ) of the fluorescent labels. We believe that this new silver-surface preparation, which results in ultrabright and photostable fluorophores, offers a new generic technology platform for increased fluorescence signal levels, with widespread potential applications to the analytical sciences, imaging, and medical diagnostics.