Ethics competencies in the business of dentistry.

Ethics is the systematic study of human conduct examined in the light of moral values and principles. It is the most important competency in dentistry, in business, and in life. Competency in ethics requires an understanding of its accepted principles, and such competency is the obligation of every dental professional.

Leaving methadone treatment: lessons learned, lessons forgotten, lessons ignored.

Despite the demonstrated benefits of methadone maintenance, there have been concerns about the ethics, necessity and expense of maintaining addicts on methadone indefinitely. The inability of many patients to achieve normative levels of psychosocial functioning with methadone, combined with widely held attitudes favoring drug abstinence over replacement medication, has led to attempts to promote time-limited methadone treatment. This paper reviews the published research literature on post-discharge outcomes of patients exiting from extended methadone detoxification, "abstinence-oriented" methadone programs, and regular methadone maintenance programs. Virtually all of these studies document high rates of relapse to opioid use after methadone treatment is discontinued. Most of the patients studied left treatment without meeting clinical criteria for detoxification, although high relapse rates were also reported for patients who completed this program. The detrimental consequences of leaving methadone treatment are dramatically indicated by greatly increased death rates following discharge. Until more is learned about how to improve post-detoxification outcomes for methadone patients, treatment providers and regulatory/funding agencies should be very cautious about imposing disincentives and structural barriers that discourage or impede long-term opiate replacement therapy.

Hepatitis C and substance use in a sample of homeless people in New York City.

This study examined the prevalence of hepatitis C virus (HCV) antibodies and its association with substance use and sexual behavior among a sample of 139 persons visiting a mobile medical clinic in Manhattan. Ninety percent were unstably housed or were living on the street. The prevalence of HCV antibodies was 32%. Prevalence was also high for hepatitis B core antibodies (47%), HIV antibodies (15%), and syphilis exposure (14%); 76% tested positive for cocaine. Among subjects who reported ever injecting (20%), 86% were HCV positive; 19% of non-injectors were HCV positive. In separate multivariate logistic regression models (with injection controlled), HCV was predicted by quantitative hair assays for cocaine and self-reported duration of crack-cocaine use. Alcohol dependence and sexual behavior did not predict HCV. Hepatitis C is a significant public health problem among the urban homeless population, with injection drug use and, to a lesser extent, cocaine use implicated as risk factors.

The association between cocaine use and HIV/STDs among soup kitchen attendees in New York City.

We examined the associations of cocaine use with HIV/sexually transmitted diseases (STDs) in a sample of 184 soup kitchen attendees using a mobile medical van in Manhattan (male = 66%; black or Hispanic = 81%; cocaine use, primarily crack = 75%; ever injected drugs = 22%). In addition to confirming the association between years of cocaine use and HIV antibodies in this sample (odds ratio [OR] = 2.11; p <.05) we examined the pattern of associations of cocaine use and non-HIV STDs under the hypothesis that the strength of an association depends on the efficiency of sexually transmitting a particular STD (high, moderate, and low for syphilis, hepatitis B and hepatitis C, respectively). As predicted, years of cocaine use was strongly associated with syphilis (OR = 2.07; p <.05), moderately associated with hepatitis B core antibodies (OR = 1.50; p <.05), and not significantly associated with hepatitis C antibodies (OR = 1.48; p >.05). A reverse pattern of associations between opiate use (injection drug use) and the three STDs points to the singular significance of cocaine use in the sexual transmission of STDs, and by inference, HIV. This conclusion is further bolstered by correlations of biologic (hair assays) and self-reported measurements of cocaine use (but not opiates) with self-reports of high risk sexual behavior among the women (number of partners and selling sex) and men (number of partners and buying sex). These data underscore the need for effective cocaine treatment and HIV interventions tailored to the large numbers of cocaine users in inner cities.

Mission possible: vascular access-decreasing the use of catheters in the Texas hemodialysis community.

In 1999, the End-Stage Renal Disease Network of Texas, Inc, #14 (NW14) initiated a quality improvement project in support of the Health Care Finance Administration's End-Stage Renal Disease Health Care Quality Improvement Program. The project, titled "Mission Possible: Vascular Access: Decreasing the Utilization of Catheters in the Texas Hemodialysis Community," aims to assist the Texas dialysis community decrease the use of hemodialysis catheters. This report reviews the goal of the project, baseline vascular access survey results, and quality improvement activities initiated to help dialysis professionals implement quality management processes that will improve the quality of care for Texas dialysis patients.

A latent variable analysis of coexisting emotional deficits in substance abusers: alexithymia, hostility, and PTSD.

The emotional disturbance of substance abusers is often described as an inability to identify and express feelings coupled with an excess vulnerability to experience negative affect. However, there is only limited empirical support for this perspective. To validate this description, we first defined components of alexithymia, hostility, and posttraumatic stress disorder (PTSD) derived from established measures of each by conducting confirmatory factor analyses based on a self-report data set from a clinical sample of 253 alcoholics and drug addicts. We then fashioned and tested overarching latent variables representing the three aspects of emotional dysfunction (i.e., alexithymia, hostility, and PTSD) and finally tested the correlations among these overarching variables. We found a strong association between a factor labeled Bottled-Up Emotions and another labeled Neurotic Hostility (r = .62) as well as an association between PTSD and Bottled-Up Emotions (r = .66). The structure, magnitude, and intercorrelation of the latent variables did not depend on the type of psychoactive substance abused. These results support the view that features of alexithymia and hostility coexist in substance abusers and that this joint deficit is part of a broad disturbance across multiple psychological domains including pathological response to traumatic stress.

Modulating effect of alcohol use on cocaine use.

Clinical observations have indicated that alcohol may be employed by cocaine/crack users to attenuate negative effects of cocaine, especially when "coming down" from a cocaine binge. This issue was examined by interviewing 66 dual cocaine/alcohol users, with opiate dependence histories, enrolled in methadone treatment. A path analysis model was specified to test several hypotheses concerning the possible modulating effects of alcohol use on cocaine use. About 60% of the subjects reported often employing alcohol to ameliorate discomfort associated with tapering or ceasing cocaine/crack use. The main findings were: (a) more intense cocaine/crack craving and feeling that cocaine/crack use was out of control both led to increased use of alcohol to come down; (b) the more frequently alcohol was used to come down, the less use of cocaine/crack; and (c) more cocaine/crack use and more use of alcohol to come down both led to increased heavy alcohol use. Thus, treating alcohol abuse in this population must take into account the important function it serves in modulating cocaine/crack use.

Substance misuse and related infectious diseases in a soup kitchen population.

Representative samples of female (N = 119) and male (N = 100) guests were selected at two inner city soup kitchens. In the preceding month, 75% used cocaine/crack and 25% used heroin/opiates as determined by hair analysis. Relatively few guests (25%) were in substance dependency treatment. Infectious disease rates were: HIV (16%), hepatitis B exposure (21%), hepatitis B carrier (6%), syphilis exposure (15%). Years of injecting drug use and homelessness/marginal housing were associated with HIV infection and hepatitis B exposure. Soup kitchens should be prime locations for outreach to cocaine/crack and heroin users in need of treatment, medical care, and interventions to prevent infectious disease transmission.

A group motivational treatment for chemical dependency.

Patient "motivation" has been implicated as a critical component in addiction treatment outcomes. To date, treatments utilizing motivational elements have been conducted as individual interventions. We describe the development of a Group Motivational Intervention (GMI), a four-session, manual-driven group approach that employs key hypothesized motivational elements. These include the six motivational elements derived by Miller and Sanchez (1994) from successful alcoholism treatments, described with the acronym, FRAMES (feedback, responsibility, advice, menu of options, empathy, and self-efficacy). GMI is additionally informed by concepts derived from "self-determination theory" (Deci & Ryan, 1985), concerned with understanding motivation as either internal/autonomous or external/controlled. Evidence indicates that people will value and persist longer in behaviors that they perceive as autonomously motivated. GMI techniques utilize the interpersonal factors found to be autonomy-supportive in self-determination theory. Preliminary results from a randomized clinical trial suggest that key motivational processes are affected by GMI: patients perceive the GMI environment and group leader as significantly more "autonomy supportive" than treatment "as usual."

Partnering to improve rehabilitation opportunities for persons with end-stage renal disease in Texas.

In 1986, congress added language to the End-Stage Renal Disease (ESRD) Network mandates to encourage the participation of patients, providers, and facilities in vocational rehabilitation programs. The goal of this mandate was to attain the original program estimates of patients rehabilitated that were formulated a decade earlier. Each of the 18 ESRD Networks has developed unique strategies to meet the congressional mandates. In 1997, the ESRD Network of Texas, Inc. (The Network) initiated a project to increase the number of persons with ESRD working or in school. The initiative has resulted in a partnership with the Texas Rehabilitation Commission (TRC) to provide ESRD education to rehabilitation counselors. As a direct result of this partnership the TRC has directed that counselors be assigned to Texas dialysis facilities to help identify candidates for vocational rehabilitation. It is hoped that the efforts of the TRC, dialysis community, and the ESRD Network will result in more persons with ESRD attaining an active and productive life.

Enhanced treatment outcomes for cocaine-using methadone patients.

Cocaine dependent methadone patients were randomly assigned to 6 months of high intensity cognitive-behavioral therapy or low intensity therapy. A repeated measures ANOVA was conducted with patients stratified on severity of cocaine use at baseline. Both treatment groups showed significant and equivalent reductions in cocaine use during the post-treatment period. Completing either therapy and lower cocaine severity at baseline were associated with lower proportion of cocaine-positive urines across a 48-week post-treatment period. Examination of the treatment x cocaine severity interaction provided some evidence that high-severity patients improved more if exposed to high intensity treatment than to low intensity treatment. Positive outcomes for therapy completers relative to non-completers increased over time. The results are consistent with several clinical trials showing that: (1) participation in treatment is associated with reductions in cocaine use; and (2) the relationship between treatment intensity and outcome is not linear and may better be explained by an interaction between patient and treatment factors.

The autonomy of mood disorders among cocaine-using methadone patients.

This study uses an algorithm to determine whether patients dually diagnosed with a mood disorder and cocaine dependence have either (a) an autonomous mood disorder (onset of mood disorder prior to substance use disorder (SUD) or mood disorder symptoms persist during periods of abstinence or (b) a nonautonomous mood disorder (onset of SUD preceded mood disorder and mood disorder symptoms remit during periods of abstinence). The relationship among autonomy, patient characteristics, and treatment completion is examined. The sample included 67 methadone patients with a mood disorder (87% major depression, 13% bipolar) who were enrolling in a 6-month psychosocial treatment for cocaine use. Of these subjects, 27% were rated as having an autonomous mood disorder and 73% a nonautonomous mood disorder. Mean age was 37 years; 55% were female and 82% were Hispanic or African-American. All subjects had been stabilized on methadone (mean = 70 mg). During the 30 days prior to study intake, subjects with an autonomous mood disorder, compared to subjects with a nonautonomous mood disorder, reported fewer days using cocaine (12.5 versus 21.1) and fewer days drinking four or more drinks of alcohol (1.1 versus 6. 1). Treatment completion was associated with less cocaine use, autonomy, and African-American ethnicity. However, when these variables were controlled using logistic regression, only autonomous mood disorder and ethnicity predicted treatment completion. These results suggest that autonomy may be a useful construct to measure, and that subjects with nonautonomous mood disorders may need special efforts to ensure treatment retention.

Changes in HIV risk behaviors among cocaine-using methadone patients.

Cocaine use among methadone patients has been related to higher prevalence of HIV risk behaviors. HIV risk behaviors for cocaine-using patients in methadone treatment (N = 207) were examined for two time periods, the current month in-treatment and the month previous to treatment admission. All needle-related and sexually-related risk behaviors (except for needle hygiene) significantly and substantially declined over the average two year time interval. Several variables were associated with needle and sexual risks in multivariate regression analyses. Dropping apparent opiate use underreporters from the analyses did not alter the results. From a harm reduction perspective, high priority should be given to retaining cocaine-using patients in methadone maintenance, intensifying in-program services for those with anti-social personality, bipolar disorder or alcoholism, as well as increasing access to needle exchanges and free condoms.

Gender differences in psychiatric comorbidity among cocaine-using opiate addicts.

Psychiatric comorbidity was examined for a sample of 212 methadone patients dually addicted to opiates and cocaine, focusing on gender differences. Diagnoses were determined by the SCID for DSM-III-R. Men displayed more lifetime (but not current) substance use disorders, while women displayed more lifetime and current non-substance use disorders. There were several significant interactions among psychiatric disorders and gender. Women were more likely than men to present with concurrent mood and anxiety disorders. Women with ASPD were unlikely to have alcohol use disorder, but likely to have opioid use disorder. Men with anxiety were likely to be diagnosed with ASPD. Treatment implications of the findings are discussed.

Problem-based learning at the University of Southern California School of Dentistry.

Responding to the recent Institute of Medicine report on dental education, the Center for Craniofacial Molecular Biology (CCMB) of the University of Southern California School of Dentistry has developed a parallel track program in dental education leading to the D.D.S. degree. This program was proposed in May of 1995, and the first class of twelve students was admitted in September of that year. Currently two classes are enrolled and plans to admit a further twelve students (Class of 2001) are in place. The educational strategy for this program is totally problem-based. Students work in groups of six with a faculty facilitator, not necessarily a content expert. Facilitators are largely drawn from the multidisciplinary pool of research faculty at the center. All learning is mediated through biomedical and biodental problem cases. No formal lectures or classes are scheduled. The learning of clinical dental skills is promoted through focussed dental patient simulations in which students review clinical charts, radiographs, medical reports and then explore identified, hands-on learning needs using patient simulators in a clinical context. Early patient exposure is obtained through dental office visits and other special patient clinics. Initial experience with this program suggests that the problem-based learning (PBL) students learn as well (if not better) than their traditional program peers and develop excellent group and cognitive analytical skills. The absence of a pool of dentally related biomedical cases suitable for a PBL program has necessitated the use of innovative approaches to their development and presentation. It is believed that this educational approach will produce dental clinicians equipped with the self-motivated, life-long learning skills required in the ever-changing world of bio-dental sciences in the twenty-first century.

Bromocriptine for cocaine dependence. A controlled clinical trial.

On the basis of the dopamine depletion theory, bromocriptine has been tested to treat cocaine withdrawal and dependence. The authors conducted a 6-week study with 1 week of pretreatment observation and 5 weeks of a randomized, double-blind, placebo-controlled clinical trial of bromocriptine for DSM-III-R-defined cocaine dependence in methadone-maintained male patients. The bromocriptine group (n = 24) did not differ from the placebo group (n = 26) in self-reported cocaine use, proportion of positive urine toxicology samples, craving for cocaine, resistance to cocaine use, or mood symptoms between the pretreatment baseline and the last week of the clinical trial. Both groups showed significant reduction in self-reported frequency of cocaine use, resistance to craving, and mood symptoms during participation in the protocol. The results of this study are consistent with recent clinical and laboratory findings in primary cocaine users. Despite initially promising pilot studies, recent evidence does not support the efficacy of bromocriptine to reduce cocaine use or craving.

Stress levels and related variables among dental students in Jerusalem, Israel.

The aim of the study was to assess levels of stress and associated socio-demographic variables among dental students in their clinical years in the School of Dental Medicine at the Hebrew University and Hadassah in Jerusalem, and compare the findings with those of a similar study undertaken 10 years previously. The study was carried out among the 4th, 5th and 6th year students because these years involve maximum clinical activity. 112 students out of a population of 120 participated. Students were asked to complete a 17-item anonymous questionnaire composed of items describing potential stressors in the learning environment. The quantitative requirement system per completion of dental procedures received the highest stress scores among all students (3.15 +/- 0.82), followed by 'fear from staying behind peers without being able to catch up'. The lowest scores were given to 'learning new vocabulary as well as new concepts'. These findings were similar to those obtained 10 years ago, despite curriculum and social changes in the interim. Based on the median split of the population, it was found that among the high-stress group, significantly more students evaluated their achievements in school as below average, than did the low-stress group (gamma 2, P = 0.017). The % of students who were parents was significantly higher among the high-stress group, than the others (P = 0.021). Female students reported higher stress in the items comprising 'Clinical work'. The results were similar to those of the previous study, despite curricular changes introduced in the interim.

Follow-up of inpatient cocaine withdrawal for cocaine-using methadone patients.

Significant proportions of opiate-dependent persons entering methadone treatment are also addicted to cocaine and continue to use cocaine during treatment. One standard response to cocaine use has been inpatient detoxification. This study examined the effectiveness of this procedure by comparing pre- and posttreatment urine toxicologies for methadone patients who had been hospitalized for cocaine withdrawal. The results showed a negligible effect on cocaine abstinence (less than 1 out of 10 patients abstinent 12 weeks after detox) and a modest reduction in the frequency of cocaine use (one-quarter decline in urine tests positive after 12 weeks). These findings raise serious doubts about the cost-effectiveness of inpatient cocaine detoxification. Better strategies need to be implemented to enhance the chances of remaining abstinent once detoxified.