Barriers and facilitators associated with establishment of emergency department-initiated buprenorphine for opioid use disorder in rural Maine

PURPOSE

The opioid epidemic in the United States continues to grow, particularly impacting rural communities served by critical access hospitals (CAHs) in Maine. Buprenorphine is an effective medication for the treatment of opioid use disorder (OUD) that can be successfully initiated in the emergency department (ED). However, many EDs have not implemented programs to initiate buprenorphine. This study sought to identify barriers and facilitators to successful implementation of buprenorphine programs inCAH EDs.

METHODS

Semistructured interviews were conducted with ED directors of Maine CAHs regarding barriers and facilitators to developing programs for ED-initiated buprenorphine. Seventeen Maine CAH EDs exist and 11 of their directors agreed to participate and completed interviews, which were audio-recorded, transcribed, and analyzed using a thematic approach.

RESULTS

Four themes and 11 subthemes were identified, including (1) compelled to act-directors' personal experiences with patients facilitated the development of buprenorphine programs in their EDs; (2) leadership and mentorship-peer mentorship from other CAH ED directors facilitated, and senior hospital administrators facilitated, or created a barrier in some cases; (3) stigma-fear that EDs would be overcrowded by drug-seeking patients was a common barrier; and (4) follow-up-finding appropriate outpatient follow-up for OUD patients created the greatest logistical barrier.

DISCUSSION

ED directors' clinical experience with OUD patients, supportive hospital leadership, and peer mentorship facilitated ED-initiated buprenorphine programs in rural Maine CAH EDs. Overcoming stigma, developing community outreach, and appropriate follow-up were the greatest barriers. Future research should focus on enhancing peer mentorship, administrative support, community outreach, and staff education.

A randomized study of massed three-week cognitive behavioural therapy schedule for panic disorder

OBJECTIVE

To compare the efficacy of massed vs. spaced group cognitive behavioural therapy (CBT) for patients with panic disorder with or without agoraphobia (PD).

METHOD

Thirty-nine PD patients were randomly assigned to massed group CBT (daily 4-h sessions in week 1, two 2-h sessions in week 2 and one 2-h session in week 3) or traditional spaced weekly group CBT (13 consecutive, weekly 2-h sessions). The content and number of hours in the two treatment schedules were identical. Outcome was assessed after treatment, and at 3, 6 and 18 months of follow-up.

RESULTS

Both treatment groups achieved significant improvement on all measures with large pre- to post-treatment and pre-treatment to follow-up effect sizes. No between-group differences were registered. Adherence and patient satisfaction did not differ between groups.

CONCLUSION

The massed, 3-week group CBT schedule proved to be effective and feasible for PD patients with outcomes comparable with that of standard, spaced group CBT.

High contents of hypotaurine and thiotaurine in hydrothermal-vent gastropods without thiotrophic endosymbionts

Invertebrates at hydrothermal vents and cold seeps must cope with high levels of toxic H2S. In addition, these and all marine invertebrates must balance internal osmotic pressure with that of the ocean. Cells usually do so with organic osmolytes, primarily free amino acids (e.g., taurine, glycine) and methylamines (e.g., betaine). At vents and seeps, clams, mussels, and vestimentiferans with thiotrophic endosymbionts have high levels of hypotaurine and thiotaurine (a product of hypotaurine and HS-). These serve as osmolytes but their primary function may be to transport and/or detoxify sulfide; indeed, thiotaurine has been proposed to be a marker of thiotrophic symbiosis. To test this, we analyzed Depressigyra globulus snails and Lepetodrilus fucensis limpets from Juan de Fuca Ridge vents (1,530 m). Neither has endosymbionts, though the latter has thiotrophic ectosymbionts. Some specimens were rapidly frozen, while other live ones were kept in laboratory chambers, some with and others without sulfide. Non-vent gastropods from a variety of depths (2-3,000 m) were also collected. Tissues were analyzed for major osmolytes and taurine derivatives. The dominant osmolytes of non-vent snails were betaine in all species, and either taurine in shallow-living species or scyllo-inositol, glycerophosphorylcholine, and other amino acids in deep-sea species. In contrast, the dominant osmolytes were hypotaurine and betaine in D. globulus, and hypotaurine in L. fucensis. Both species had thiotaurine (as well as hypotaurine) at levels much greater than previously reported for vent and seep animals without endosymbionts. The ratio of thio- to thio- plus hypotaurine, a possible indicator of sulfide exposure, decreased in both species when kept in laboratory chambers with low or no sulfide, but stayed at high levels in snails kept with 3-5 mM sulfide. Thus, in some vent animals without endosymbionts, sulfide may be detoxified via conversion of hypotaurine to thiotaurine. The latter may be a marker of high sulfide exposure but not of thiotrophic endosymbionts.

Negative content of thinking in panic disorder and major depression--a self-report study

The purpose of the present study was to investigate the character and extent of negative thought content in panic disorder (PD) and the relation between thinking and bodily sensations. Content of thinking was explored in several areas, some of which are not exclusively related to anxiety. A structured diagnostic interview (SCID), a self-rating scale (SCL-90R), a sentence construction test (The Incomplete Sentences Blank (ISB)), and an inventory of childhood memories of parental rearing (the EMBU) were administered to 47 PD patients, 15 patients with major depression (MD), and 30 normal subjects. Thus, measures of implicit as well as explicit thinking, measures of thinking on present as well as past issues, and methods allowing negative as well as positive thought content to be expressed, were used. We found that PD was characterized by more negative thinking of anxiogenic, depressive, and dependent nature and less neutral or positive thinking than the normal subjects, primarily in issues related to the present. These negative thoughts were correlated with bodily symptoms. Very few significant differences were found between PD and MD, but a subgroup of PD with comorbidity of MD exceeded the other groups on measures of negative thoughts as well as bodily symptoms.

Neuropsychological characteristics of Huntington's disease carriers: a double blind study

A cohort of 33 people at risk for Huntington's disease (HD), applying for genetic testing, were tested with a battery of neuropsychological tests covering attentional, visuospatial, learning, memory, and planning functions. A psychiatric rating scale, SCL-90R, was also applied, mainly as a control, since cognitive dysfunction could be ascribed to functional disorders as well as neurodegenerative processes. Self-rating did not indicate any psychiatric symptoms in carriers or non-carriers. However, significantly inferior cognitive functioning in the gene carriers was disclosed by the neuropsychological tests. Primarily, attentional, learning, and planning functions were affected. It is concluded that premorbid cognitive decline occurs in HD.

Three years follow-up of panic disorder patients: a naturalistic study

Forty Danish panic disorder patients participating in a placebo controlled study of alprazolam and imipramine (The Cross National Collaborative Panic Study, Phase II) were followed up by a telephone interview three years later, with essentially the same battery of evaluation procedures applied at baseline, end of study, and follow-up. The main finding was that panic disorder is a chronic disorder, but fluctuating in form and severity in the course of time. Twenty-five percent of the patients no longer fulfilled the DSM-III criteria for panic disorder, but had substantial disability due to a variety of symptoms, including panic attacks at infrequent rate, generalized anxiety symptoms, affective symptoms, and phobic avoidance behavior. Nearly three fourths of the patients were under treatment at follow-up. Benzodiazepines were the drugs most often prescribed, usually in combination with supportive psychotherapy. It was concluded that the different types of treatment offered were insufficient. Variables predicting panic disorder or substantial disability at 3-years follow-up were few.

Psychotherapy of the suicidal patient

Three different psychological theories of depression, the psychoanalytic, the behavioural and the cognitive-behavioural, and their psychotherapeutic principles are presented. A common, central aim of these therapies is to prevent suicide. But whenever suicidal ideation becomes dominant, the therapeutic method should be changed to a directive, counselling and reassuring form.

[Panic disorder. The pattern of somatic contacts in patients]

The epidemiology, phenomenology and treatment of panic disorder have been thoroughly studied in recent years. The symptomatology of panic attacks may mimic cardiopulmonary, neurological and gastrointestinal disease. Forty Danish panic patients with panic disorder of ten years' duration had had contact with several medical specialists, hospital emergency and outpatient services. Thus, 28% had visited neurologists, 8% cardiologists and 20% an emergency service. One third had been admitted to hospital departments. Almost all patients had consulted psychiatrists or psychologists. Ninety had been treated with a benzodiazepine, 35% with tricyclic antidepressants and 57% with neuroleptics. To prevent costly medical testings and delay in accurate diagnosis in psychiatric and somatic settings, the phenomenology of panic disorders should be recognized by all medical specialists and general practitioners.

Characteristics of panic disorder patients responding to placebo

Forty-one panic disorder patients receiving placebo were investigated in a double-blind comparison of alprazolam, imipramine and placebo in panic disorder. A significantly higher drop-out rate was found in the placebo group than in the active treatment groups, but placebo response was found in 34% of the patients, defined as reduction of panic attacks to zero, and in 23%, defined as a score of greater than or equal to 8 on the Physician Global Improvement Scale (0-10 points). Several predictors of response to placebo were found. The responders had fewer panic attacks than the nonresponders at baseline. They also reported less psychopathology and were less help-seeking than the nonresponders. The implications for psychopathology and possible response to psychotherapy among responders and nonresponders are discussed. It is hypothesized that the responders show more signs of realistic processing of internal and external stimuli and fewer signs of subjective distress than the nonresponders. Responders will therefore probably be more responsive to psychotherapy than nonresponders.

Efficacy and safety of alprazolam, imipramine and placebo in treating panic disorder. A Scandinavian multicenter study

As part of the cross-national collaborative panic study, a double-blind comparison of alprazolam, imipramine and placebo was performed in Scandinavian outpatients with panic disorder according to DSM-III; 41 patients were randomly allocated to each drug. Doses were increased for 3 weeks to an average of about 6 mg alprazolam, 150 mg imipramine and a corresponding number of placebo capsules, which were then given for 5 weeks. No more than supportive psychotherapy was given. Key symptoms were rated weekly. The drugs were tapered for 4 or 8 weeks and the patients were followed up for 6 months. Compliance at 3 weeks was 95% for alprazolam, 83% for imipramine and 88% for placebo; at 8 weeks 95% for alprazolam, 73% for imipramine and 46% for placebo. At 3 weeks plasma determination showed that the proportion taking diazepam outside the protocol was 0% for alprazolam, 19% for imipramine and 31% for placebo; at 8 weeks the corresponding proportions were 3%, 11% and 16%. Intention-to-treat analysis showed that freedom from panic attacks was obtained for 68% with alprazolam, 61% with imipramine and 34% with placebo. Alprazolam was more effective than imipramine and placebo on anticipatory anxiety and phobic symptoms. Globally rated by physicians and patients, about 60% had complete remission with alprazolam and imipramine and 30% on placebo. At least partial remission was obtained in about 85% with alprazolam, 70% with imipramine and 40% with placebo. Alprazolam had a more rapid onset of action than imipramine on all symptoms. Side effects were generally mild, with a preponderance of drowsiness for alprazolam and anticholinergic effects for imipramine. Tapering was uneventful without significant discontinuation phenomena. During taper and follow-up, several patients in remission relapsed, leaving approximately 30% patients in complete remission in all groups. To obtain more stable improvement, either long-term drug treatment or combinations of drug treatment and psychotherapy should be evaluated.

Validation criteria for panic disorder as a nosological entity

Panic disorder (DSM-III, DSM-III-R) has been thoroughly studied in recent years. The main evidence for panic disorder as a nosological entity is reviewed, to delineate some important questions for future research. Validation criteria include epidemiological, phenomenological, genetic, neurobiological, pharmacological and behavioral findings. Biological, behavioral and psychodynamic considerations on etiology, pathogenesis and treatment are presented.

Rorschach-profile in panic disorder

The Rorschach test was applied to four groups: 41 Panic Disorder (PD), 14 Major Depression (MD), 11 Generalized Anxiety Disorder (GAD) and 18 normal subjects. The aims were to describe the test profile of PD patients and to discuss implications for cognitive processing ability and personality structure. A hypothesis of a borderline personality structure in PD patients, based on psychodynamic literature, was tested, but was not unambiguously supported. A "loose", borderline-like personality structure and disturbances in processing abilities, however, characterized PD-patients. The normal subjects surprisingly provided many Fabulized Combinations, a response type, considered suspect of borderline pathology, but also showed more signs of integrative and synthesizing abilities than the other groups.

Patterns of response during placebo treatment of panic disorder

Data from the cross-national study of panic disorder are used for an analysis of response patterns. The main purpose of the study is a search for specific placebo patterns and a discussion of possible differences in patterns from patients treated with alprazolam, imipramine, and placebo. Four outcome measures were registered at baseline and weekly during the treatment period: the number of panic attacks, Physician's Global Evaluation of treatment effect, the Overall Phobia Score and the level on the Hamilton Rating Scale for Anxiety. Response patterns from the 3 treatment groups are described and compared, and subsequently categorized with regard to completeness and persistency. No specific placebo pattern is recognized. Some differences are found, however, as many placebo patients demonstrate an early and temporary remission. The variations in response patterns do not compromise the blindness of the study, and their predictive validity is low.