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Haque LY, Zuluaga P, Muga R, Fuster D. Treatment of alcohol use disorder in patients with alcohol-associated liver disease: Innovative approaches and a call to action. Addict Sci Clin Pract 2024; 19:19. [PMID: 38504384 PMCID: PMC10949674 DOI: 10.1186/s13722-024-00448-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 02/20/2024] [Indexed: 03/21/2024] Open
Abstract
Alcohol-associated liver disease is currently the leading cause of liver transplantation and liver deaths both in Europe and the United States. Efficacious treatments exist for alcohol use disorder, but they are seldomly prescribed for patients who need them. Besides, the presence of liver cirrhosis can complicate pharmacological treatment choices. In this review, we discuss established and innovative treatment strategies to treat unhealthy alcohol use in patients with alcohol-associated liver disease. We also describe the experience of our own institutions, Hospital Universitari Germans Trias i Pujol in Badalona (Spain) and Yale-New Haven Health and Yale Medicine (Connecticut. United States of America).
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Affiliation(s)
- Lamia Y Haque
- Department of Medicine, Digestive Diseases, & Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Paola Zuluaga
- Department of Internal Medicine, Addiction Unit, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, 08916, Badalona (Barcelona), Spain
| | - Robert Muga
- Department of Internal Medicine, Addiction Unit, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, 08916, Badalona (Barcelona), Spain
| | - Daniel Fuster
- Department of Internal Medicine, Addiction Unit, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, 08916, Badalona (Barcelona), Spain.
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2
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Canver B, Liptak A, Clark K, Tetrault JM, Holt SR. Preparing Physicians to Treat Addiction: Inclusion of Dedicated Addiction Training During Internal Medicine Residency. SUBSTANCE USE & ADDICTION JOURNAL 2024:29767342231224978. [PMID: 38254274 DOI: 10.1177/29767342231224978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
BACKGROUND Physicians in internal medicine lack comfort and skills required to diagnose and treat substance use disorder (SUD). Formal training in substance use treatment within primary care training has traditionally been inconsistent and sparse. The purpose of this study is to assess the impact of a longitudinal experiential addiction curriculum on the attitudes and experiences of graduates from a primary care/internal medicine residency program that included formal addiction didactics, rotations in an outpatient addiction clinic embedded within the resident primary care clinic, and exposure to addiction medicine faculty across treatment settings. METHODS A survey was emailed to all graduates from a single academic primary care residency program who graduated between 2016 and 2018 (n = 53). The survey assessed pharmacotherapy for SUD prescribing patterns, comfort with SUD pharmacotherapy, overall comfort treating SUD, experience correcting stigmatizing language, and providing guidance to colleagues on the care of patients with SUD. A subset of respondents (n = 14) were interviewed regarding their experience with the residency program's addiction medicine curriculum and its impact on their current clinical practice. RESULTS Sixty percent (n = 28) of graduates responded to the survey. All respondents felt comfortable using medications to treat SUD. Eighty-four percent perceived themselves as more comfortable using pharmacotherapy to treat SUD than their colleagues. Qualitative interviews revealed that this addiction medicine training shaped participants' attitudes toward patients with SUD and imparted them with the skills to address stigmatizing language. Participants described how they have become ambassadors of addiction medicine in their workplace and a resource to colleagues with less comfort in the management of SUD. CONCLUSION Graduates of a primary care/internal medicine residency with a dedicated addiction medicine curriculum are comfortable prescribing pharmacotherapy for SUD, taking an active role in reducing SUD-related stigma, and serving as a resource for colleagues.
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Affiliation(s)
- Bethany Canver
- Department of Internal Medicine and Addiction Medicine, Cooper Medical School of Rowan University and Cooper University Health Care, Camden, NJ, USA
| | - Alayna Liptak
- LifeLong West Berkeley Health Center, Berkley, CA, USA
| | - Katie Clark
- Program in Addiction Medicine and Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jeanette M Tetrault
- Program in Addiction Medicine and Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Stephen R Holt
- Program in Addiction Medicine and Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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3
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Nakaishi L, Sugden SG, Merlo G. Primary Care at the Intersection of Lifestyle Interventions and Unhealthy Substance Use. Am J Lifestyle Med 2023; 17:494-501. [PMID: 37426739 PMCID: PMC10328212 DOI: 10.1177/15598276221111047] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023] Open
Abstract
Primary care physicians are well-positioned to integrate lifestyle interventions into the management of patients with unhealthy substance use, who may also have mental and physical chronic health comorbidities. However, the COVID-19 pandemic exacerbated the U.S.'s poor state of health, revealing that its current approach to chronic disease management is neither effective nor sustainable. Today's full spectrum comprehensive care model requires an expanded toolkit. Lifestyle interventions broaden current treatment approaches and may enhance Addiction Medicine care. Primary care providers have the potential to have the greatest impact on unhealthy substance use care because they are experts in chronic disease management and their frontline accessibility minimizes healthcare barriers. Individuals with unhealthy substance use are at an increased risk of chronic physical conditions. Incorporating lifestyle interventions with unhealthy substance use care at every level of medicine, from medical school through practice, normalizes both as part of the standard care of medicine and will drive evidence-based best practices to support patients through prevention, treatment, and reversal of chronic diseases.
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Affiliation(s)
- Lindsay Nakaishi
- Family Medicine, University of Pittsburgh Medical Center St. Margaret, Pittsburgh, PA, USA (LN); Huntsman Mental Health Institute, Spencer Fox Eccles University of Utah School of Medicine, Salt Lake City, UT, USA (SS); and Psychiatry, NYU Grossman School of Medicine, Rory Meyers College of Nursing, New York University, New York, NY, USA (GM)
| | - Steven G Sugden
- Family Medicine, University of Pittsburgh Medical Center St. Margaret, Pittsburgh, PA, USA (LN); Huntsman Mental Health Institute, Spencer Fox Eccles University of Utah School of Medicine, Salt Lake City, UT, USA (SS); and Psychiatry, NYU Grossman School of Medicine, Rory Meyers College of Nursing, New York University, New York, NY, USA (GM)
| | - Gia Merlo
- Family Medicine, University of Pittsburgh Medical Center St. Margaret, Pittsburgh, PA, USA (LN); Huntsman Mental Health Institute, Spencer Fox Eccles University of Utah School of Medicine, Salt Lake City, UT, USA (SS); and Psychiatry, NYU Grossman School of Medicine, Rory Meyers College of Nursing, New York University, New York, NY, USA (GM)
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4
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Haque LY, Fiellin DA. Bridging the Gap: Dual Fellowship Training in Addiction Medicine and Digestive Diseases. Dig Dis Sci 2022; 67:2721-2726. [PMID: 35430700 PMCID: PMC9013212 DOI: 10.1007/s10620-022-07478-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2022] [Indexed: 02/06/2023]
Affiliation(s)
- Lamia Y Haque
- Program in Addiction Medicine, Yale School of Medicine, New Haven, US.
- Department of Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, US.
| | - David A Fiellin
- Program in Addiction Medicine, Yale School of Medicine, New Haven, US
- Department of Medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, US
- Department of Emergency Medicine, Yale School of Medicine, New Haven, US
- Department of Health Policy and Management, Yale School of Public Health, New Haven, US
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5
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McNeely J, Schatz D, Olfson M, Appleton N, Williams AR. How Physician Workforce Shortages Are Hampering the Response to the Opioid Crisis. Psychiatr Serv 2022; 73:547-554. [PMID: 34521210 PMCID: PMC8920951 DOI: 10.1176/appi.ps.202000565] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The United States is experiencing an unprecedented opioid crisis, with a record of about 93,000 opioid-involved overdose deaths in 2020, which requires rapid and substantial scaling up of access to effective treatment for opioid use disorder. Only 18% of individuals with opioid use disorder receive evidence-based treatment, and strategies to increase access are hindered by a lack of treatment providers. Using a case study from the largest municipal hospital system in the United States, the authors describe the effects of a workforce shortage on health system responses to the opioid crisis. This national problem demands a multipronged approach, including federal programs to grow and diversify the pipeline of addiction providers, medical education initiatives, and enhanced training and mentorship to increase the capacity of allied clinicians to treat patients who have an opioid use disorder. Workforce development should be combined with structural reforms for integrating addiction treatment into mainstream medical care and with new treatment models, including telehealth, which can lower patient barriers to accessing treatment.
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Affiliation(s)
- Jennifer McNeely
- Department of Population Health, Section on Tobacco, Alcohol, and Drug Use, New York University Grossman School of Medicine, New York City (McNeely, Schatz, Appleton); Office of Behavioral Health, New York City Health + Hospitals, New York City (Schatz); Columbia University Medical Center (Olfson) and Department of Psychiatry (Williams), Columbia University, New York City; New York State Psychiatric Institute, New York City (Williams)
| | - Daniel Schatz
- Department of Population Health, Section on Tobacco, Alcohol, and Drug Use, New York University Grossman School of Medicine, New York City (McNeely, Schatz, Appleton); Office of Behavioral Health, New York City Health + Hospitals, New York City (Schatz); Columbia University Medical Center (Olfson) and Department of Psychiatry (Williams), Columbia University, New York City; New York State Psychiatric Institute, New York City (Williams)
| | - Mark Olfson
- Department of Population Health, Section on Tobacco, Alcohol, and Drug Use, New York University Grossman School of Medicine, New York City (McNeely, Schatz, Appleton); Office of Behavioral Health, New York City Health + Hospitals, New York City (Schatz); Columbia University Medical Center (Olfson) and Department of Psychiatry (Williams), Columbia University, New York City; New York State Psychiatric Institute, New York City (Williams)
| | - Noa Appleton
- Department of Population Health, Section on Tobacco, Alcohol, and Drug Use, New York University Grossman School of Medicine, New York City (McNeely, Schatz, Appleton); Office of Behavioral Health, New York City Health + Hospitals, New York City (Schatz); Columbia University Medical Center (Olfson) and Department of Psychiatry (Williams), Columbia University, New York City; New York State Psychiatric Institute, New York City (Williams)
| | - Arthur Robin Williams
- Department of Population Health, Section on Tobacco, Alcohol, and Drug Use, New York University Grossman School of Medicine, New York City (McNeely, Schatz, Appleton); Office of Behavioral Health, New York City Health + Hospitals, New York City (Schatz); Columbia University Medical Center (Olfson) and Department of Psychiatry (Williams), Columbia University, New York City; New York State Psychiatric Institute, New York City (Williams)
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6
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Gugala E, Briggs O, Moczygemba LR, Brown CM, Hill LG. Opioid harm reduction: A scoping review of physician and system-level gaps in knowledge, education, and practice. Subst Abus 2022; 43:972-987. [PMID: 35426772 DOI: 10.1080/08897077.2022.2060423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Background: Harm reduction includes treatment and prevention approaches rather than abstinence, as a public health strategy for mitigating the opioid epidemic. Harm reduction is a new strategy for many healthcare professionals, and gaps in knowledge and practices may lead to barriers to optimal treatment. Our objective was to identify and describe gaps in physicians' knowledge, education, and practice in harm reduction strategies related to opioid overdose. Methods: We searched the PubMed, CINAHL, and Web of Science databases for articles published between 2015 and 2021, published in English, containing empirical evidence, addressing opioid harm reduction, and identifying gaps in physicians' knowledge, education, or practice. Results: Thirty-seven studies were included. Studies examined how physicians' perceptions or stigma influenced harm reduction efforts and addressed clinical knowledge gaps in overdose treatment and prevention and OUD treatment. Less than half of the studies addressed access issues at the system level, above the individual healthcare professional. Conclusion: Individual-level interventions should be addressed with professional continuing education and curricular-based changes through experiential and interprofessional education. System-level gaps can be remedied by increasing patient access to care, creating policies favorable to harm reduction, and extending resources to provide harm reduction strategies.
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Affiliation(s)
- Emma Gugala
- TxCORE and PhARM Program, The University of Texas at Austin College of Pharmacy, Austin, TX, USA
| | - Owanate Briggs
- TxCORE and PhARM Program, The University of Texas at Austin College of Pharmacy, Austin, TX, USA
| | - Leticia R Moczygemba
- TxCORE and PhARM Program, The University of Texas at Austin College of Pharmacy, Austin, TX, USA
| | - Carolyn M Brown
- TxCORE and PhARM Program, The University of Texas at Austin College of Pharmacy, Austin, TX, USA
| | - Lucas G Hill
- TxCORE and PhARM Program, The University of Texas at Austin College of Pharmacy, Austin, TX, USA
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7
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Winters AC, Aby ES, Fix OK, German M, Haque LY, Im GY. Joining the Fight: Enhancing Alcohol Treatment Education in Hepatology. Clin Liver Dis (Hoboken) 2021; 18:225-229. [PMID: 34840723 PMCID: PMC8605691 DOI: 10.1002/cld.1127] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/06/2021] [Accepted: 04/17/2021] [Indexed: 02/04/2023] Open
Affiliation(s)
- Adam C. Winters
- Los Angeles David Geffen School of MedicineDepartment of Medicine, Vatche and Tamar Manoukian Division of Digestive DiseasesUniversity of CaliforniaLos AngelesCA
| | - Elizabeth S. Aby
- Division of Gastroenterology and HepatologyUniversity of MinnesotaMinneapolisMN
| | - Oren K. Fix
- Department of Medical Education and Clinical SciencesWashington State University Elson S. Floyd College of MedicineSpokaneWA
| | - Margarita German
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWI
| | - Lamia Y.K. Haque
- Section of Digestive DiseasesYale University School of MedicineNew HavenCT
| | - Gene Y. Im
- Division of Liver DiseasesRecanati/Miller Transplantation InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
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8
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Holt SR, Tobin DG, Whitman L, Ellman M, Moriarty JP, Doolittle B. Creating a Satisfying Continuity Clinic Experience for Primary Care Trainees. Am J Med 2021; 134:547-553. [PMID: 33385340 DOI: 10.1016/j.amjmed.2020.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/17/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Stephen R Holt
- Yale Primary Care Internal Medicine Program, Yale-New Haven Hospital, Conn.
| | - Daniel G Tobin
- St. Raphael's Adult Primary Care Center of Yale-New Haven Hospital, Conn
| | - Laura Whitman
- York Street Campus Primary Care Center of Yale-New Haven Hospital, Conn
| | - Matthew Ellman
- Yale Internal Medicine Associates, Yale School of Medicine, New Haven, Conn
| | - John P Moriarty
- Yale Primary Care Internal Medicine Program, Yale-New Haven Hospital, Conn
| | - Benjamin Doolittle
- Yale Internal Medicine-Pediatrics Residency Program, Yale School of Medicine, New Haven, Conn
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9
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Walter LA, Hess J, Brown M, DeLaney M, Paddock C, Hess EP. Design and Implementation of a Curriculum for Emergency Medicine Residents to Address Medications and Treatment Referral for Opioid Use Disorder. Subst Use Misuse 2021; 56:458-463. [PMID: 33587018 DOI: 10.1080/10826084.2021.1879144] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Background: Medications for Opioid Use Disorder (MOUD) are recognized as successful treatments for Opioid Use Disorder (OUD). The Emergency Department is well situated to initiate MOUD and begin the referral process. Unfortunately, uptake of this practice among Emergency Medicine (EM) physicians has been slow. EM physicians may feel inadequately prepared to provide MOUD and addiction referral services due to lack of previous training and experience. The goal of this pilot study was to create, implement, and evaluate an OUD management curriculum for EM residents and measure impact on knowledge, practice, and empathy. Methods: A 4.5-hour curriculum was developed, incorporating the Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment mission statement as well as the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine resident physician milestones. The curriculum was inserted into an existing EM residency didactic block at an urban, tertiary care, residency program. Surveys were obtained pre- and post-intervention. Results: Post curriculum surveys demonstrated improved knowledge of buprenorphine/naloxone including indications, clinical effects and side-effects (p < 0.05). Surveys also noted increased comfort prescribing buprenorphine/naloxone for opioid withdrawal and misuse and instructing patients on home induction (p < 0.05). Additionally, residents responded positively regarding the impact of the curriculum on their understanding of the topic and their subsequent confidence in managing patients with OUD in the ED setting. Conclusion: A dedicated brief MOUD and referral curriculum can be effectively integrated into EM resident education to provide valuable clinical knowledge that may affect clinical practice.
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Affiliation(s)
- Lauren A Walter
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jennifer Hess
- Department of Emergency Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Michelle Brown
- Department of Health Services Administration, School of Health Professions, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Office of Interprofessional Simulation for Innovative Clinical Practice, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Matthew DeLaney
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Cayce Paddock
- Department of Medical Education, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Erik P Hess
- Department of Emergency Medicine, Vanderbilt University, Nashville, Tennessee, USA
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10
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Hadland SE. The Broken Care Continuum for Young Adults With Opioid Addiction. J Adolesc Health 2020; 67:735-736. [PMID: 33220792 PMCID: PMC7874886 DOI: 10.1016/j.jadohealth.2020.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 09/16/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Scott E. Hadland
- Grayken Center for Addiction / Department of Pediatrics, Boston Medical Center, One Boston Medical Center Place, Boston, MA, USA, 02118
- Boston University School of Medicine, Division of General Pediatrics, Department of Pediatrics, 88 East Newton Street, Vose Hall Room 322, Boston, MA, USA, 02118
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11
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Kirk JK, Yount T, Boyd CT, Cassidy-Vu L, Koehler AN, Spangler JG. Launching a Medication-Assisted Treatment in an Outpatient Office-Based Practice. J Prim Care Community Health 2020; 11:2150132720940723. [PMID: 32644863 PMCID: PMC7350034 DOI: 10.1177/2150132720940723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Opioid use and overdose are escalating in the United States. Primary care providers are in a strategic position to assess patients for medication-assisted treatment (MAT). Objectives: To describe the implementation of MAT in an integrated primary care residency clinic and assess provider comfort levels with evaluating patients for high-risk opioid use, conduct crucial conversations about MAT treatment options and referral to MAT for evaluation and treatment. Methods: As part of a Primary Care Training and Enhancement grant through Health Resources and Services Administration, we used an implementation process to allow for optimal clinic flow. The process included assessment of patient populations, identifying a provider champion, organizing multidisciplinary team, engaging a practice facilitator, designing clinic model and infrastructure, creating the electronic health record order sets along with provider and staff training. Providers responded to brief questions to evaluate comfort levels in 3 domains: identifying high-risk opioid use, conducting crucial conversations about treatment options and referral to MAT for evaluation and treatment. Discussion: Incorporating MAT within an integrated primary care clinic and residency program with waiver training for residents was a successful and innovative program. The availability of MAT provided a solution for patients that could benefit from this type of treatment. MAT presence gave providers the opportunity to refer these patients for treatment that had not previously been as accessible. Conclusion: An integrated primary care practice with an embedded MAT can be successful with an organized structure to optimize clinic flow.
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Affiliation(s)
- Julienne K Kirk
- Wake Forest School of Medicine, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Tamela Yount
- Northwest Area Health Education Center, Wake Forest School of Medicine, Winstons Salem, NC, USA
| | - Charlotte T Boyd
- Wake Forest School of Medicine, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Lisa Cassidy-Vu
- Wake Forest School of Medicine, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Aubry N Koehler
- Wake Forest School of Medicine, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - John G Spangler
- Wake Forest School of Medicine, Wake Forest Baptist Health, Winston-Salem, NC, USA
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12
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Computerized Cognitive Behavioral Therapy for Substance Use Disorders in a Specialized Primary Care Practice: A Randomized Feasibility Trial to Address the RT Component of SBIRT. J Addict Med 2020; 14:e303-e309. [PMID: 32371660 DOI: 10.1097/adm.0000000000000663] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Screening, Brief Intervention, and Referral to Treatment (SBIRT) has demonstrated efficacy for addressing unhealthy alcohol use in primary care, yet recent research indicates weaker efficacy for drug use as well as very limited success in referral to specialty care for patients with substance use disorder (SUD). Technology-based interventions for SUD delivered in primary care settings are a potential strategy of efficiently delivering treatment to those who need it. METHODS We conducted a randomized clinical trial evaluating feasibility, satisfaction, and substance use outcomes for 58 individuals with SUD. Participants being treated in a primary care practice which provides integrated addiction treatment were randomized to standard care or standard care plus access to a web-based SUD intervention (computer-based training in cognitive behavioral therapy, or CBT4CBT). Self-reported substance use and urine toxicology screens were assessed at 8 weeks after randomization. RESULTS Uptake of CBT4CBT in this setting was high; 77% of those assigned to this condition accessed the program at least once; of those, 77% completed all 7 modules. Satisfaction with the program was very high. Participants reported >90% days abstinent for all classes of drugs; with no significant differences between conditions. CONCLUSIONS This study demonstrates feasibility of implementing technology-based treatments in primary care settings to address weak follow-through with the referral component of SBIRT. The overall positive outcomes in this specialized, integrated treatment setting may have undercut the ability to demonstrate differential effects on substance use; results suggest evaluation in less specialized primary care settings is warranted. TRIAL REGISTRATION clinicaltrials.gov NCT03013478.
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13
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Donroe JH, Bhatraju EP, Tsui JI, Edelman EJ. Identification and Management of Opioid Use Disorder in Primary Care: an Update. Curr Psychiatry Rep 2020; 22:23. [PMID: 32285215 DOI: 10.1007/s11920-020-01149-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW The rising prevalence of opioid use disorder (OUD) and related complications in North America coupled with limited numbers of specialists in addiction medicine has led to large gaps in treatment. Primary care providers (PCPs) are ideally suited to diagnose and care for people with OUD and are increasingly being called upon to improve access to care. This review will highlight the recent literature pertaining to the care of patients with OUD by PCPs. RECENT FINDINGS The prevalence of patients with OUD in primary care practice is increasing, and models of office-based opioid treatment (OBOT) are evolving to meet local needs of both ambulatory practices and patients. OBOT has been shown to increase access to care and demonstrates comparable outcomes when compared to more specialty-driven care. OBOT is an effective means of increasing access to care for patients with OUD. The ideal structure of OBOT depends on local factors. Future research must explore ways to increase the identification and diagnosis of patients with OUD, improve treatment retention rates, reduce stigma, and promote interdisciplinary approaches to care.
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Affiliation(s)
- Joseph H Donroe
- Yale School of Medicine, 1450 Chapel Street, Office MOB211, New Haven, CT, 06511, USA.
| | | | - Judith I Tsui
- University of Washington School of Medicine, Seattle, WA, USA
| | - E Jennifer Edelman
- Yale School of Medicine, 1450 Chapel Street, Office MOB211, New Haven, CT, 06511, USA.,Yale Schools of Medicine and Public Health, E.S. Harkness Memorial Hall, Building A, 367 Cedar Street, Ste Suite 401, New Haven, CT, 06510, USA
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14
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Pinilla S, Lenouvel E, Strik W, Klöppel S, Nissen C, Huwendiek S. Entrustable Professional Activities in Psychiatry: A Systematic Review. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2020; 44:37-45. [PMID: 31732885 DOI: 10.1007/s40596-019-01142-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 10/31/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Entrustable professional activities (EPAs) represent discrete clinical tasks that can be entrusted to trainees in psychiatry. They are increasingly being used as educational framework in several countries. However, the empirical evidence available has not been synthesized in the field of psychiatry. Therefore, the authors conducted a systematic review in order to summarize and evaluate the available evidence in the field of EPAs in undergraduate and graduate medical education in psychiatry. METHODS The authors searched PubMed, Cochrane Library, ERIC, Embase, PsycINFO, all Ovid journals, Scopus, Web of Science, MedEdPORTAL, and the archives of Academic Psychiatry for articles reporting quantitative and qualitative research as well as educational case reports on EPAs in undergraduate and graduate psychiatry education published since 2005. All included articles were assessed for content (development, implementation, and assessment of EPAs) and quality using the Quality Assessment Tool for Studies with Diverse Designs. RESULTS The authors screened 2807 records and included a total of 20 articles in the final data extraction. Most studies were expert consensus reports (n = 6, 30%) and predominantly conducted in English-speaking countries (n = 17, 85%). Papers reported mainly EPA development and/or EPA implementation studies (n = 14, 70%), whereas EPA assessment studies were less frequent (n = 6, 30%). Publications per year showed an increasing trend both in quantity (from 1 in 2011 to 7 in 2018) and quality (from a QATSDD score of 27 in 2011 to an average score of 39 in 2018). The main focus of the articles was the development of individual EPAs for different levels of training for psychiatry or on curricular frameworks based on EPAs in psychiatry (n = 10, 50%). The lack of empirical controlled studies does currently not allow for meta-analyses of educational outcomes. CONCLUSIONS The concept of EPA-based curricula seems to become increasingly present, a focus in the specialty of psychiatry both in UME and GME. The lack of empirical research in this context is an important limitation for educational practice recommendations. Currently there is only preliminary but promising data available for using EPAs with regard to educational outcomes. EPAs seem to be effectively used from a curriculum design perspective for UME and GME in psychiatry.
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Affiliation(s)
- Severin Pinilla
- University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland.
| | - Eric Lenouvel
- University Hospital of Old Age Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Werner Strik
- University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Stefan Klöppel
- University Hospital of Old Age Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Christoph Nissen
- University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Sören Huwendiek
- Institute for Medical Education, University of Bern, Bern, Switzerland
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Muvvala SB, Schwartz ML, Petrakis I, O'Connor PG, Tetrault JM. Stitching a solution to the addiction epidemic: A longitudinal addiction curricular thread across four years of medical training. Subst Abus 2020; 41:475-479. [PMID: 31951809 DOI: 10.1080/08897077.2019.1709606] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Despite the enormous burden and public health impact, addiction continues to be one of the most under-treated chronic diseases primarily because of the lack of adequately trained work force of medical providers. To address this issue, medical schools should greatly expand education on addiction. Methods: The six-step Kern model of curriculum development was used as a framework to create an addiction curriculum which includes didactic activities, workshop exercises, practice-based learning activities, clinical simulations, and clinical experiences. Results: The authors and other members of the addiction thread committee conducted a comprehensive needs assessment, developed curriculum goals and objectives, and worked with course and clerkship directors to develop and enhance educational strategies and implement a longitudinal curricular thread woven across all four years of medical school curriculum. Conclusion: Development and implementation of a comprehensive addiction curriculum is feasible, and this model could lay the ground work for implementation at other institutions.
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Affiliation(s)
| | - Michael L Schwartz
- Neuroscience, Yale School of Medicine (YSM), New Haven, Connecticut, USA
| | - Ismene Petrakis
- Psychiatry, Yale School of Medicine (YSM), New Haven, Connecticut, USA
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Pytell JD, Buresh ME, Graddy R. Outcomes of a novel office-based opioid treatment program in an internal medicine resident continuity practice. Addict Sci Clin Pract 2019; 14:46. [PMID: 31856915 PMCID: PMC6921403 DOI: 10.1186/s13722-019-0175-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 12/11/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The integration of opioid use disorder (OUD) care and competencies in graduate medical education training is needed. Previous research shows improvements in knowledge, attitudes, and practices after exposure to OUD care. Few studies report outcomes for patients with OUD in resident physician continuity practices. METHODS A novel internal office-based opioid treatment (OBOT) program was initiated in a resident continuity clinic. Surveys of resident and staff knowledge and attitudes of OBOT were administered at baseline and 4 months. A retrospective chart review of the 15-month OBOT clinic obtained patient characteristics and outcomes. RESULTS Twelve patients with OUD were seen in the OBOT clinic. Seven patients (58%) were retained in care at the end of the study period for a range of 9-15 months. Eight patients demonstrated a good clinical response. Surveys of residents and staff at 4 months were unchanged from baseline showing persistent lack of comfort in caring for patients with OUD. CONCLUSIONS OBOT can be successfully integrated into resident continuity practices with positive patient outcomes. Improvement in resident and staff attitudes toward OBOT were not observed and likely require direct and frequent exposure to OUD care to increase acceptance.
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Affiliation(s)
- Jarratt D Pytell
- Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Mason Lord Building, East Tower, 2nd Floor, Baltimore, MD, 21224, USA.
| | - Megan E Buresh
- Division of Addiction Medicine, Johns Hopkins Bayview Medical Center, 5200 Eastern Avenue, Mason Lord Building, East Tower, 2nd Floor, Baltimore, MD, 21224, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ryan Graddy
- Division of Addiction Medicine, Johns Hopkins Bayview Medical Center, 5200 Eastern Avenue, Mason Lord Building, East Tower, 2nd Floor, Baltimore, MD, 21224, USA
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Coyle A. A Decade of Teaching and Learning in Internal Medicine Ambulatory Education: A Scoping Review. J Grad Med Educ 2019; 11:132-142. [PMID: 31024643 PMCID: PMC6476084 DOI: 10.4300/jgme-d-18-00596.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 11/20/2018] [Accepted: 01/16/2019] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Ambulatory training in internal medicine residency programs has historically been considered less robust than inpatient-focused training, which prompted a 2009 revision of the Accreditation Council for Graduate Medical Education (ACGME) Program Requirements in Internal Medicine. This revision was intended to create a balance between inpatient and outpatient training standards and to spur innovation in the ambulatory setting. OBJECTIVE We explored innovations in ambulatory education in internal medicine residency programs since the 2009 revision of the ACGME Program Requirements in Internal Medicine. METHODS The authors conducted a scoping review of the literature from 2008 to 2017, searching PubMed, ERIC, and Scopus databases. Articles related to improving educational quality of ambulatory components of US-based internal medicine residency programs were eligible for inclusion. Articles were screened for relevance and theme categorization and then divided into 6 themes: clinic redesign, curriculum development, evaluating resident practice/performance, teaching methods, program evaluation, and faculty development. Once a theme was assigned, data extraction and quality assessment using the Medical Education Research Study Quality Instrument (MERSQI) score were completed. RESULTS A total of 967 potentially relevant articles were discovered; of those, 182 were deemed relevant and underwent full review. Most articles fell into curriculum development and clinic redesign themes. The majority of included studies were from a single institution, used nonstandardized tools, and assessed outcomes at the satisfaction or knowledge/attitude/skills levels. Few studies showed behavioral changes or patient-level outcomes. CONCLUSIONS While a rich diversity of educational innovations have occurred since the 2009 revision of the ACGME Program Requirements in Internal Medicine, there is a significant need for multi-institution studies and higher-level assessment.
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The Deepening Opioid Crisis in North America: Historical Context and Current Solutions. CURRENT ADDICTION REPORTS 2018. [DOI: 10.1007/s40429-018-0228-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Tesema L, Marshall J, Hathaway R, Pham C, Clarke C, Bergeron G, Yeh J, Soliman M, McCormick D. Training in office-based opioid treatment with buprenorphine in US residency programs: A national survey of residency program directors. Subst Abus 2018. [PMID: 29513136 DOI: 10.1080/08897077.2018.1449047] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND The prevalence of opioid use disorder (OUD) has increased sharply. Office-based opioid treatment with buprenorphine (OBOT) is effective but often underutilized because of physicians' lack of experience prescribing this therapy. Little is known about US residency training programs' provision of OBOT and addiction medicine training. METHODS The authors conducted a survey of residency program directors (RPDs) at all US residency programs in internal medicine, family medicine, and psychiatry to assess the frequency with which their residents provide care for OUD, presence and features of curricula in OBOT and addiction medicine, RPDs' beliefs about OBOT, and potential barriers to providing OBOT training. RESULTS The response rate was 49.5% (476 of 962). Although 76.9% of RPDs reported that residents frequently manage patients with OUD, only 23.5% reported that their program dedicates 12 or more hours of curricular time to addiction medicine, 35.9% reported that their program encourages/requires training in OBOT, and 22.6% reported that their program encourages/requires obtaining a Drug Enforcement Administration (DEA) waiver to prescribe buprenorphine. Most RPDs believe that OBOT is an important treatment option for OUD (88.1%) and that increased residency training in OBOT would improve access to OBOT (73.7%). The authors also found that programs whose RPD had favorable views of OBOT were more likely to provide OBOT and addiction medicine training. Psychiatry programs were most likely to provide OBOT training and their RPDs most likely to have beliefs about OBOT that were positive. Commonly cited barriers to implementing OBOT training include a lack of waivered preceptors (76.9%), competing curricular priorities (64.1%), and a lack of support (social work and counseling) services (54.0%). CONCLUSIONS Internal medicine, family medicine, and psychiatry residents often care for patients with OUD, and most RPDs believe that increased residency training in OBOT would increase access to this treatment. Yet, only a minority of programs offer training in OBOT.
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Affiliation(s)
- Lello Tesema
- a Los Angeles County Department of Health Services , Los Angeles , California , USA
| | - Jeffrey Marshall
- b Department of Pulmonary and Critical Care Medicine , Yale University , New Haven , Connecticut , USA
| | - Rachel Hathaway
- c Department of Medicine , Cambridge Health Alliance , Cambridge , Massachusetts , USA
| | - Christina Pham
- d Department of Medicine , University of California , San Francisco , California , USA
| | - Camille Clarke
- e Department of Medicine, School of Medicine , Loma Linda University , Loma Linda , California , USA
| | - Genevieve Bergeron
- c Department of Medicine , Cambridge Health Alliance , Cambridge , Massachusetts , USA
| | - James Yeh
- f Department of Medicine , Brigham and Women's Hospital , Boston , Massachusetts , USA
| | - Michael Soliman
- g Department of Medicine , Beth Israel Deaconess Medical Center , Boston , Massachusetts , USA
| | - Danny McCormick
- c Department of Medicine , Cambridge Health Alliance , Cambridge , Massachusetts , USA
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Tetrault JM, Petrakis IL. Partnering with Psychiatry to Close the Education Gap: An Approach to the Addiction Epidemic. J Gen Intern Med 2017; 32:1387-1389. [PMID: 28766126 PMCID: PMC5698217 DOI: 10.1007/s11606-017-4140-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 04/19/2017] [Accepted: 07/12/2017] [Indexed: 12/20/2022]
Abstract
Addiction has reached epidemic proportions in the U.S., yet the workforce prepared to care for this population is woefully inadequate. Of the 23 million Americans suffering from addiction, only 11% receive treatment, creating a substantial treatment gap. There have been calls to improve addiction education at all levels of training in order to prepare medical providers with the skills to identify patients with substance use, briefly treat if indicated, and/or refer more complex cases to specialty care. These calls have been put forth to address the education gap, wherein physicians in training are exposed to numerous patients who are suffering from addiction but have few curricular hours dedicated to the identification and management of this population. We propose that strategic partnerships between psychiatry and internal medicine can address the education gap that exists with regard to addiction, ultimately addressing the treatment gap which is plaguing this country.
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Affiliation(s)
- Jeanette M Tetrault
- Department of Internal Medicine, Yale University School of Medicine, 367 Cedar Street, Suite 305, New Haven, CT, 06510, USA.
| | - Ismene L Petrakis
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA.,VA Connecticut Healthcare System, West Haven, CT, USA
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Donroe JH, Holt SR, O'Connor PG, Sukumar N, Tetrault JM. Interpreting quantitative urine buprenorphine and norbuprenorphine levels in office-based clinical practice. Drug Alcohol Depend 2017; 180:46-51. [PMID: 28866369 DOI: 10.1016/j.drugalcdep.2017.07.040] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 07/25/2017] [Accepted: 07/29/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Quantitative urine buprenorphine testing is used to monitor patients receiving buprenorphine for the treatment of opioid use disorder (OUD), however the interpretation of urine buprenorphine testing is complex. Currently, interpretation of quantitative buprenorphine testing is guided by data from drug assay development studies and forensic labs rather than clinical treatment cohorts. METHODS In this retrospective study, we describe the patterns of urine buprenorphine and norbuprenorphine levels in patients prescribed sublingual buprenorphine for OUD in an office-based addiction treatment clinic. Urine buprenorphine and norbuprenorphine levels were analyzed in patients who reported having adulterated their urine, patients clinically suspected of adulterating their urine, and patients without concern for urine adulteration. Finally, we tested the accuracy of urine buprenorphine, norbuprenorphine, and norbuprenorphine: buprenorphine ratio (Norbup:Bup) to identify adulterated urine samples. RESULTS Patients without suspicion for urine adulteration rarely provided specimens with buprenorphine >=1000ng/ml (4.4%), while the proportion provided by those who endorsed or were suspected of urine adulteration was higher (42.9%, 40.6%, respectively). Compared to patients without reported urine adulteration, specimens from patients who reported or were suspected of urine adulteration had significantly higher buprenorphine (p=0.0001) and lower norbuprenorphine (<0.0001) levels, and significantly lower Norbup:Bup ratios (p=0.04). Buprenorphine >=700ng/ml offered the best accuracy for discriminating between adulterated and non-adulterated specimens. CONCLUSION This study describes the patterns of urine buprenorphine and norbuprenorphine levels from patients with OUD receiving buprenorphine treatment in an office-based addiction treatment clinic. Parameters for identifying urine adulterated by submerging buprenorphine medication in the urine specimen are discussed.
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Affiliation(s)
- Joseph H Donroe
- Yale University School of Medicine, Department of Internal Medicine,1450 Chapel Street, Office M330, New Haven, CT 06511, USA.
| | - Stephen R Holt
- Yale University School of Medicine, Department of Internal Medicine, 1450 Chapel Street, Office P312, New Haven, CT 06511, USA.
| | - Patrick G O'Connor
- Yale University School of Medicine, Department of General Internal Medicine, 367 Cedar Street, Suite 402, New Haven, CT 06510, USA.
| | - Nitin Sukumar
- Yale University School of Public Health, Yale Center for Analytical Sciences, 300 George Street, Suite 511, New Haven, CT 06510, USA.
| | - Jeanette M Tetrault
- Yale University School of Medicine, Department of Internal Medicine, 367 Cedar Street, Suite 305, New Haven, CT 06510, USA.
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