A safe and effective method for converting cancer patients from intravenous to transdermal fentanyl.

BACKGROUND: Therapeutic fentanyl blood levels are reached approximately 12-16 hours after the initial application of transdermal fentanyl patches. For this reason, fentanyl patches should not be used to treat acute exacerbations of cancer pain. Acute cancer-related pain can be treated with fentanyl administered by continuous intravenous infusion (CII) in combination with patient-controlled analgesia (PCA). Patients then can be switched from intravenous (IV) to transdermal fentanyl once stable pain relief has been achieved. The objective of the current case series was to evaluate and describe the safety and effectiveness of a method for converting hospitalized patients with cancer-related pain from IV to transdermal fentanyl. METHODS: The authors prospectively evaluated 15 consecutive cancer patients during the conversion from IV to transdermal fentanyl. In all patients, a transdermal patch delivering fentanyl at a rate equivalent to that of the final continuous IV infusion was applied. The CII rate was decreased by 50% 6 hours after application of the fentanyl patch and then discontinued after another 6 hours. Demand boluses of IV fentanyl equivalent in dosage to 50-100% of the final CII rate remained available via PCA during the 24 hours after patch application. Pain intensity (on a scale of 0-10), sedation (on a scale of 0-3), and hourly PCA administration (microg/hr) were assessed and recorded immediately prior to application of the fentanyl patch and 6, 12, 18, and 24 hours thereafter. RESULTS: Pain intensity, sedation, and hourly PCA administration appeared to remain stable throughout the transition from IV to transdermal fentanyl. CONCLUSIONS: The results of the current study demonstrate that the conversion from IV to transdermal fentanyl can be accomplished safely and effectively using a 1:1 (IV:transdermal) conversion ratio and a two-step taper of the CII over 12 hours.

Intravenous methadone in the management of chronic cancer pain: safe and effective starting doses when substituting methadone for fentanyl.

BACKGROUND: Patients often are rotated from other opioids to methadone when side effects occur before satisfactory analgesia is achieved. Various strategies have been proposed to estimate safe and effective starting doses of methadone when rotating from morphine and hydromorphone; however, there are no guidelines for estimating safe and effective starting doses of methadone when rotating from fentanyl. METHODS: The authors prospectively observed 18 consecutive patients experiencing chronic pain from cancer who underwent opioid rotation from intravenous patient-controlled analgesia (PCA) with fentanyl to intravenous PCA with methadone. Patients were switched from fentanyl to methadone because of uncontrolled pain associated with sedation or confusion. A conversion ratio of 25 microg/hour of fentanyl to 0.1 mg/hour of methadone was used to calculate the initial dose of methadone in all patients. RESULTS: Mean pain scores decreased from 8.1 to 4.8 on Day 1 after the switch and to 3.22 on Day 4 after the switch. Mean sedation scores were 1.5 before the switch and 0.44 and 0.16 on Days 1 and 4, respectively. Among the 6 patients who experienced confusion while on fentanyl before the switch, 5 improved within 2 days of the switch. None of the patients experienced toxicity from methadone. CONCLUSIONS: On the basis of this preliminary study, the authors suggest that when switching from intravenous fentanyl to methadone a conversion ratio of 25 microg/hour of fentanyl to 0.1 mg/hour of methadone may be safe and effective.

Consumer-run service participation, recovery of social functioning, and the mediating role of psychological factors.

OBJECTIVE: This study examined the relationship between participation in consumer-run services and recovery of social functioning among persons diagnosed as having serious mental illness. It also assessed the role of psychological factors in mediating this relationship. METHODS: Research questions investigated were whether involvement in consumer-run services is positively associated with recovery when premorbid and demographic factors are controlled for, whether psychological factors are positively associated with recovery irrespective of involvement in consumer-run services, and whether the relationship between involvement in consumer-run services and recovery is mediated by the psychological factors. The factors examined were self-efficacy, hopefulness, and active coping strategies. Sixty participants with a past or present diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder and at least one past psychiatric hospitalization were recruited from a community mental health center and two consumer-run programs. Data were collected on hopefulness, self-efficacy, coping strategies, social functioning, and premorbid and demographic characteristics. RESULTS: Findings indicated that participants involved in consumer-run services had better social functioning than those involved only in traditional mental health services, that psychological variables were significantly associated with social functioning, and that the relationship between involvement in consumer-run services and social functioning was partly mediated by the use of more problem-centered coping strategies. Premorbid and demographic factors did not account for the relationship between psychosocial variables and social functioning, although education was a significant predictor of social functioning. CONCLUSIONS: The findings support the view that psychosocial factors may play a role in facilitating good community adjustment for individuals diagnosed as having serious mental illness.

A comparison of dose-response curves in cognitive-behavioral and psychodynamic psychotherapies.

Changes in patient- and therapist-rated process items, and patient-rated symptom severity assessed over a maximum of 30 sessions of psychodynamic or cognitive-behavioral psychotherapy were compared in an outpatient mental-health clinic. Patients' ratings in psychodynamic psychotherapy on two of the process items were superior to ratings by patients in cognitive-behavioral therapy, and interactions with time were discovered for an interpersonal item. Comparisons between patients who reported their initial symptom severities as most severe and those with less severe symptoms also were made, with results indicating differential effects of treatment according to perceptions of symptom severity. Interactions between length of stay in treatment and number of sessions also were investigated. Findings indicated that patients benefit from psychotherapy over time and support the usefulness of a contextual model for psychotherapy funding.

Motivating smoking cessation among dental patients: smokers' interest in biomarker testing for susceptibility to tobacco-related cancers.

This study examined interest in receiving biomarker testing for tobacco-related cancer susceptibility among 148 smokers seeking routine oral health care in a public dental clinic. Patients completed a brief, self-report survey assessing their smoking history, tobacco-related illness history, readiness to quit smoking, perceived risk and worry about cancer, and their interest in being tested for genetic susceptibility for tobacco-related cancers. Participants were socioeconomically and ethnically diverse, and were primarily long-standing, nicotine-dependent smokers. Most reported (83%) interest in biomarker feedback, and most (86%) understood that a certain genetic make-up could place them at increased risk for tobacco-related cancers. Those participants who felt that quitting smoking would reduce future cancer risk, were at least in the contemplation stage of quitting readiness, felt more worried and more at risk for developing cancer, women and younger smokers were more interested in genetic testing (all ps < 0.20). Multivariate logistic regression analyses indicated that gender and risk perceptions were associated with interest in testing. The public dental clinic setting holds potential for innovative smoking cessation interventions using personalized risk feedback.

Methodological problems encountered in research with psychiatric inpatients: a case example.

In this article, problems associated with several methods commonly employed in research with psychiatric inpatients are discussed and the implications that these problems have for the validity of research with this population are explored, using an investigation of the relationship between moral reasoning and aggression among psychiatric inpatients as a case example. Specific issues examined include the adequacy of hospital records for diagnosing patients, the difficulty of determining when it is appropriate to approach recently admitted patients for research, and problems in the measurement of behavioral and psychological variables such as aggression and moral reasoning. Suggestions and recommendations for addressing these issues in future research are offered.

Interpersonal perceptions of depressed and borderline inpatients.

Distortions in interpersonal perceptions among patients with borderline personality disorder (BPD) were explored to investigate the validity of object relations theories. Depressed patients with BPD were compared to patients with major depressive disorder (MD) without BPD. Subjects were 77 male and female inpatients (BPD = 55, MD = 22). The mean ages were 30.5 for BPD subjects and 36.3 for MD subjects. Perceptions of patients, relatives, and interviewers were compared on the following measures: Structural Analysis of Social Behavior, Perceived Criticism Scale, and Camberwell Family Interview. Findings are consistent with object relations theory. BPD patients saw themselves as hostile, labile, and unstable. MD patients avoid acknowledging and responding to relatives criticallity.

Ethnic diversification in clinical psychology graduate training.

Thirty-eight directors and 334 advanced graduate students from clinical psychology programs completed a survey on ethnic minority training offered in clinical doctoral programs. Comparisons were made between directors' and students' ratings on the following variables: students' level of interest in ethnic minority training, the importance of this training, and the effectiveness of the clinical programs' minority-related education. Minority and nonminority students' responses were also compared on these variables. Supplementary data were collected on ethnic minority education in coursework, research, and clinical practica. Findings indicate that students, relative to clinical directors, assign more importance to ethnic minority training and lower efficacy ratings to their programs' ethnic minority education. The results also suggest that minority students feel more strongly about the value of ethnic minority training than do their nonminority peers and the directors. The implications of these results are discussed, and recommendations are made to address identified problems.

Marijuana usage in relation to harmfulness ratings, perceived likelihood of negative consequences, and defense mechanisms in high school students.

This study investigated high school students' marijuana usage patterns in relation to their harmfulness ratings of 15 licit and illicit drugs, perceived negative consequences from using marijuana, and types of defense mechanisms employed. Subjects were classified into one of five pattern-of-use groups based on marijuana usage: principled nonusers, nonusers, light users, moderate users, and heavy users. Principled nonusers (individuals who have never used marijuana and would not do so if it was legalized) rated marijuana, hashish, cocaine, and alcohol as significantly more harmful than heavy users. A cluster analysis of the drugs' harmfulness ratings best fit a three cluster solution and were named medicinal drugs, recreational drugs, and hard drugs. In general, principled nonusers rated negative consequences from using marijuana as significantly more likely to occur than other groups. Principled nonusers and heavy users utilized reversal from the Defense Mechanism Inventory, which includes repression and denial, significantly more than nonusers, indicating some trait common to the two extreme pattern-of-use groups.

Psychiatry residency selection criteria for american and foreign medical graduates : a comparative study.

A survey of training directors in psychiatry was conducted to explore criterion areas in foreign medical graduate selection by comparing the perceived importance of 11 selection criteria between American medical graduates (AMGs) and foreign medical graduates (FMGs). Our study found that training directors use much the same criteria for evaluating FMGs as AMGs. For both groups, great emphasis was placed on personality factors, psychological mindedness, ability to communicate, and performance in the interview. Referrals by faculty received equal importance for both groups. The examination scores were seen as more important for FMGs and the transcripts and the reference letters marginally more important for AMGs. This is interpreted as a reflection of a lack of reliable sources of information about medical education received from abroad and a greater familiarity with, and confidence in, the evaluative methods used in American medical schools. Familiarity with American subcultures was seen as a more important criterion for evaluating FMGs than AMGs. The implications of these findings are discussed, and some suggestions are made regarding selection of FMGs.

Principal components analysis of therapeutic orientations of doctoral programs in clinical psychology.

A principal components analysis was conducted on a data set that consisted of ratings of therapeutic orientations reported by directors of clinical psychology training programs in 96 clinical psychology programs in the U.S. Two principal components emerged, which contrasted (1) behavioral vs. psychoanalytic approaches and (2) humanistic vs. conditioning approaches. A plotting of factor scores revealed relatively clear separation among programs primarily identified with either behavioral or psychoanalytic/humanistic approaches. The majority of training programs, however, clustered around the midpoint on both underlying factor dimensions, an indication of the adoption of multiple approaches in training.

A comparison of male users and nonusers of marijuana on the perceived harmfulness of drugs.

Subjects (n = 108) who volunteered to participate in a study in which they expected to smoke marijuana were asked, as part of a screening procedure, to rate the harmfulness of a number of illicit drugs including marijuana. Subjects were separated into three groups according to their reported history of use of marijuana. The three groups were: naive users (at least 1 but no more than 25 incidences of use in a lifetime), light users (1 to 3 incidences of use per week), and heavy users (at least 5 incidences of use per week). Groups did not differ in terms of their perceived harmfulness of any of the drugs. Cluster analyses of the results for each group and for the total group indicated three distinct clusters: the drugs perceived to be the most harmful were heroin, morphine, and LSD; drugs perceived to be less harmful were cocaine, amphetamines, barbiturates, and nicotine; and the drugs perceived to be the least harmful were caffeine and marijuana, with marijuana being judged the least harmful of all the drugs.

Imitating the autistic child: facilitating communicative gaze behavior.

The nonverbal autistic child exhibits a persistent and characteristic feature known as gaze aversion. Since gaze interaction between the autistic child and the clinician [or adult] is a requisite experience in therapeutic learning, procedures that modify gaze behavior in autistic children serve an important clinical function. The present research was designed to investigate three kinds of adult-child interaction that differentially affected changes in gaze behavior. The interaction procedure in which the experimenter imitated the autistic child's object and action performances resulted in the greatest change in the frequency and the duration of gaze behavior. An analysis of these methodologies reveals information concerning contextual and therapeutic variables that affected the gaze behavior in six autistic children.

The effect of an anticipated reverse smoking rule on the perceived distraction of persons attending organizational meetings.

Smokers (n = 41) and nonsmokers (n = 54) were asked to complete parallel questionnaires. Each questionnaire contained 27 questions which described a task-oriented meeting varying in duration and importance or interest value. Three durations (15, 30, and 60 minutes) were crossed with three levels of interest value to produce nine item types. The questionnaires for smokers indicated that for all the meetings smoking was strictly prohibited, while those for the nonsmoker indicated that smoking was allowed and was going on. For each question, subjects were asked to rate the degree of distraction they perceived themselves as experiencing. Nonsmokers perceived themselves as being more distracted by an anticipated reverse smoking rule than did smokers; as length of meeting increased, perceived distraction increased, and as importance of the meeting increased, perceived distraction decreased.

The personality of the cigarette smoker: some empirical data.

Smokers and nonsmokers are compared in terms of (1) psychological needs, (2) self-descriptions, (3) self-esteem, (4) academic achievement in high school and college, and (5) marijuana use. On the EPPS smokers scored significantly higher on the needs for Autonomy (p less than .01), Change (p less than .02) and Heterosexuality (p less than .05), while nonsmokers scored higher on the needs for Achievement (p less than .05), Deference (p less than .001), and Order (p less than .001). Smokers rated themselves as being more sociable (p less than .05), while nonsmokers rated themselves as being more careful (p less than .05) and reliable (p less than .05). While the two groups did not differ on a measure of self-esteem, smokers were found to have lower grades in high school (p less than .05) and college (p less than .01) and to be more likely (p less than .0001) to use marijuana. These findings are compared to the results of previous studies and the need for future research is discussed.