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Overall mortality related to HIV infection has declined with the advent of highly active anti-retroviral therapy (HAART). The purpose of this study was to examine the five-year outcomes of a cohort of 175 consecutive patients with HIV infection and injection drug use followed at a primary care practice. Patients were seen for their first visit between June 1994 and May 1998. At five years from their initial visit, 53 patients (30.3%) had died, while 47 (26.9%) were still active patients in our primary care practice. Of those who died, HIV was the cause of death in a little over half of patients (55%) followed by liver disease (15%) and drug overdose (11%). Only 80 patients ever received highly active anti-retroviral therapy (HAART) and 52 (65%) of these achieved an undetectable viral load. Patients who never received HAART had a five-year mortality of 34.8%, compared to 25.0% in patients who ever received HAART, p < .001. Our data underscore the high burden of morbidity and mortality associated with HIV infection among IDUs despite the availability of effective treatment. [ABSTRACT FROM AUTHOR]

Abstract Background Online medical education curricula offer new tools to teach and evaluate learners. The effect on educational outcomes of using learner feedback to guide curricular revision for online learning is unknown. Methods In this study, qualitative analysis of learner feedback gathered from an online curriculum was used to identify themes of learner feedback, and changes to the online curriculum in response to this feedback were tracked. Learner satisfaction and knowledge gains were then compared from before and after implementation of learner feedback. Results 37,755 learners from 122 internal medicine residency training programs were studied, including 9437 postgraduate year (PGY)1 residents (24.4 % of learners), 9864 PGY2 residents (25.5 %), 9653 PGY3 residents (25.0 %), and 6605 attending physicians (17.0 %). Qualitative analysis of learner feedback on how to improve the curriculum showed that learners commented most on the overall quality of the educational content, followed by specific comments on the content. When learner feedback was incorporated into curricular revision, learner satisfaction with the instructive value of the curriculum (1 = not instructive; 5 = highly instructive) increased from 3.8 to 4.1 (p Conclusions Learners give more feedback on the factual content of a curriculum than on other areas such as interactivity or website design. Incorporating learner feedback into curricular revision was associated with improved educational outcomes. Online curricula should be designed to include a mechanism for learner feedback and that feedback should be used for future curricular revision.

Abstract Background There is little data on the impact of office-based buprenorphine therapy on criminal activity. The goal of this study was to determine the impact of primary care clinic-based buprenorphine maintenance therapy on rates of criminal charges and the factors associated with criminal charges in the 2 years after initiation of treatment. Methods We collected demographic and outcome data on 252 patients who were given at least one prescription for buprenorphine. We searched a public database of criminal charges and recorded criminal charges prior to and after enrollment. We compared the total number of criminal cases and drug cases 2 years before versus 2 years after initiation of treatment. Results There was at least one criminal charge made against 38% of the subjects in the 2 years after initiation of treatment; these subjects were more likely to have used heroin, to have injected drugs, to have had any prior criminal charges, and recent criminal charges. There was no significant difference in the number of subjects with any criminal charge or a drug charge before and after initiation of treatment. Likewise, the mean number of all cases and drug cases was not significantly different between the two periods. However, among those who were opioid-negative for 6 or more months in the first year of treatment, there was a significant decline in criminal cases. On multivariable analysis, having recent criminal charges was significantly associated with criminal charges after initiation of treatment (adjusted odds ratio 3.92); subjects who were on opioid maintenance treatment prior to enrollment were significantly less likely to have subsequent criminal charges (adjusted odds ratio 0.52). Conclusions Among subjects with prior criminal charges, initiation of office-based buprenorphine treatment did not appear to have a significant impact on subsequent criminal charges.

Abstract: The American Society of Addiction Medicine (ASAM) has published clinical practice guidelines (CPGs) since 2015. As ASAM's CPG work continues to develop, it maintains an organizational priority to establish rigorous standards for the trustworthy production of these important documents. In keeping with ASAM's mission to define and promote evidence-based best practices in addiction prevention, treatment, and recovery, ASAM has rigorously updated its CPG methodology to be in line with evolving international standards. The CPG Methodology and Oversight Subcommittee was formed to establish and publish a methodology for the development of ASAM CPGs and to develop an ASAM CPG strategic plan. This article provides a focused overview of the ASAM CPG methodology., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Addiction Medicine.)

Alcohol-associated liver disease is a common and severe sequela of excessive alcohol use; effective treatment requires attention to both liver disease and underlying alcohol use disorder (AUD). Alcohol withdrawal syndrome (AWS) can be dangerous, is a common barrier to AUD recovery, and may complicate inpatient admissions for liver-related complications. Hepatologists can address these comorbid conditions by learning to accurately stage alcohol-associated liver disease, identify AUD using standardized screening tools (eg, Alcohol Use Disorder Identification Test), and assess risk for and symptoms of AWS. Depending on the severity, alcohol withdrawal often merits admission to a monitored setting, where symptom-triggered administration of benzodiazepines based on standardized scoring protocols is often the most effective approach to management. For patients with severe liver disease, selection of benzodiazepines with less dependence on hepatic metabolism (eg, lorazepam) is advisable. Severe alcohol withdrawal often requires a "front-loaded" approach with higher dosing, as well as intensive monitoring. Distinguishing between alcohol withdrawal delirium and HE is important, though it can be difficult, and can be guided by differentiating clinical characteristics, including time to onset and activity level. There is little data on the use of adjuvant medications, including anticonvulsants, dexmedetomidine, or propofol, in this patient population. Beyond the treatment of AWS, inpatient admission and outpatient hepatology visits offer opportunities to engage in planning for ongoing management of AUD, including initiation of medications for AUD and referral to additional recovery supports. Hepatologists trained to identify AUD, alcohol-associated liver disease, and risk for AWS can proactively address these issues, ensuring that patients' AWS is managed safely and effectively and supporting planning for long-term recovery., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Study of Liver Diseases.)

Background: While opioid use disorder (OUD) is prevalent, little is known about what patients with OUD in sustained remission think about the chronic disease model of OUD and their perspectives of the cause, course, and ongoing treatment needs of their OUD., Objective: To (1) examine patient perceptions of the chronic disease model of addiction and disease identity and (2) use an explanatory model framework to explore how these perceptions inform ongoing treatment needs and help maintain abstinence., Design: Qualitative study of a cross-sectional cohort of patients with OUD in long-term sustained remission currently receiving methadone or buprenorphine. Participants completed a single in-depth, semi-structured individual interview., Participants: Twenty adults were recruited from two opioid treatment programs and two office-based opioid treatment programs in Baltimore, MD. Half of the participants were Black, had a median (IQR) age of 46.5 (43-52) years and the median (IQR) time since the last non-prescribed opioid was 12 (8-15) years., Approach: Hybrid deductive-inductive thematic analysis of the transcribed interviews., Key Results: Some participants described a chronic OUD disease identity where they continue to live with OUD. Participants who maintain an OUD identity describe inherent traits or predetermination of developing OUD. Maintaining a disease identity helps them remain vigilant against returning to drug use. Others described a post-OUD/survivor identity where they no longer felt they had OUD, but the experience remains. Each perspective informed attitudes about continued treatment with methadone or buprenorphine and strategies to remain in remission., Conclusions: The identity that people with OUD in sustained remission maintain was the lens through which they viewed other aspects of their OUD including cause and ongoing treatment needs. An alternative, post-OUD/survivorship model emerged or was accepted by participants who did not identify as currently having OUD. Understanding patient perspectives of OUD identity might improve patient-centered care and improve outcomes., (© 2021. Society of General Internal Medicine.)

For patients with opioid use disorder transitioning from methadone or requiring opioid analgesia, initiating buprenorphine for opioid use disorder can be difficult because of the risk of precipitated withdrawal. Low-dose initiation, also known as micro-dosing, is an alternative to standard initiation. Prior studies relied on nonstandard dosing of tablets or films, patches, or buccal formulations, all of which are unavailable in many hospitals. We report a novel approach to micro-dosing using intravenous buprenorphine. Two patients, one on methadone maintenance and another requiring postoperative opioid analgesia, were transitioned to buprenorphine with concurrent full-agonist opioids and without precipitated withdrawal., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 American Society of Addiction Medicine.)

Background: There is variation in the treatment of patients with severe alcohol withdrawal and a need for effective protocols. The purpose of this study was to evaluate the implementation of a symptom-triggered benzodiazepine protocol using the 5-item Brief Alcohol Withdrawal Scale (BAWS) for treatment of alcohol withdrawal in intensive care units (ICUs)., Methods: This retrospective study included admissions to ICUs of 2 hospitals over 6 months who had an alcohol withdrawal protocol ordered and experienced severe withdrawal. Records were reviewed to collect demographic data, benzodiazepine exposure, duration of treatment, and withdrawal severity., Results: The protocol was ordered and implemented in 279 admissions; 48 (17.9%) had severe withdrawal defined as a BAWS of 6 or more. The majority of the 48 patients were from the emergency department (79.2%); mean hospital length of stay was 11.2 days and mean ICU stay 6.6 days; 31.3% required mechanical ventilation. A little more than half were treated only with the protocol (53.2%); 25.0% received additional benzodiazepines, 20.8% dexmedetomidine, 10.4% propofol, 25.0% antipsychotics and 2.0% phenobarbital., Conclusion: Among ICU patients treated for alcohol withdrawal with a symptom-triggered benzodiazepine protocol using a novel 5-item scale, most did not develop severe withdrawal, and of those who did, approximately half were treated with the protocol alone.

Background: Severe alcohol withdrawal syndrome (SAWS) is highly morbid, costly, and common among hospitalized patients, yet minimal evidence exists to guide inpatient management. Research needs in this field are broad, spanning the translational science spectrum. Goals: This research statement aims to describe what is known about SAWS, identify knowledge gaps, and offer recommendations for research in each domain of the Institute of Medicine T 0 -T 4 continuum to advance the care of hospitalized patients who experience SAWS. Methods: Clinicians and researchers with unique and complementary expertise in basic, clinical, and implementation research related to unhealthy alcohol consumption and alcohol withdrawal were invited to participate in a workshop at the American Thoracic Society 2019 International Conference. The committee was subdivided into four groups on the basis of interest and expertise: T 0 -T 1 (basic science research with translation to humans), T 2 (research translating to patients), T 3 (research translating to clinical practice), and T 4 (research translating to communities). A medical librarian conducted a pragmatic literature search to facilitate this work, and committee members reviewed and supplemented the resulting evidence, identifying key knowledge gaps. Results: The committee identified several investigative opportunities to advance the care of patients with SAWS in each domain of the translational science spectrum. Major themes included 1 ) the need to investigate non-γ-aminobutyric acid pathways for alcohol withdrawal syndrome treatment; 2 ) harnessing retrospective and electronic health record data to identify risk factors and create objective severity scoring systems, particularly for acutely ill patients with SAWS; 3 ) the need for more robust comparative-effectiveness data to identify optimal SAWS treatment strategies; and 4 ) recommendations to accelerate implementation of effective treatments into practice. Conclusions: The dearth of evidence supporting management decisions for hospitalized patients with SAWS, many of whom require critical care, represents both a call to action and an opportunity for the American Thoracic Society and larger scientific communities to improve care for a vulnerable patient population. This report highlights basic, clinical, and implementation research that diverse experts agree will have the greatest impact on improving care for hospitalized patients with SAWS.

The COVID-19 pandemic and the move to telemedicine for office-based opioid treatment have made the practice of routine urine drug tests (UDT) obsolete. In this commentary we discuss how COVID-19 has demonstrated the limited usefulness and possible harms of routine UDT. We propose that practitioners should stop using routine UDT and instead use targeted UDT, paired with clinical reasoning, as part of a patient-centered approach to care., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Psychiatric illness complicates the assessment of alcohol and sedative withdrawal (ASW). This study measured the diagnostic characteristics of the Revised Clinical Institute Withdrawal Alcohol Assessment (CIWA-Ar) and the Brief Alcohol Withdrawal Scale (BAWS) compared with a reference standard in patients with psychiatric illness and evaluated their administration time., Methods: This prospective quality improvement (QI) project conducted in November, 2016 evaluated 35 consecutive unique patients in psychiatric settings. Each patient was evaluated on 1 occasion, sequentially by 2 independent examiners with the CIWA-Ar and BAWS. A Diagnostic Statistical Manual of Mental Disorders, Fifth Edition diagnosis of ASW derived after medical record review by 2 psychiatrists blind to the screening results served as a reference standard. Psychometric properties of the CIWA-Ar and BAWS were measured against the reference., Results: Nineteen (54%) patients had ASW diagnosis by the reference standard. The sensitivity (95% confidence interval [CI]) of the CIWA-Ar was 47% (25%-71%) at a cut-off score ≥8; sensitivity of the BAWS was 79% (54%-94%) at a cut-off score ≥3. Specificity (95% CI) for CIWA-Ar and BAWS was 88% (62%-98%) and 88% (62%-98%), respectively. Administration times (interquartile range) for the CIWA-Ar and BAWS were 120 (60-180) and 65 (50-75) seconds, respectively. Receiver operator characteristic area under the curve for CIWA-Ar was 0.77 and for BAWS was 0.76 (P = 0.86)., Conclusion: Both instruments performed similarly in assessing for mild to moderate ASW in a sample of patients with psychiatric illness. The BAWS took 65 seconds to administer-almost half as much time as the CIWA-Ar.

: Methadone and buprenorphine are the most common medications for opioid use disorder. Buprenorphine is often the preferred medication because of fewer drug-drug interactions and fewer regulatory barriers. For these reasons, patients often desire to transition from methadone to buprenorphine, but this can be difficult because of the risk of precipitated withdrawal. There are protocols designed to minimize withdrawal; however, these can be time-consuming or infeasible due to formulation and dosage availability of buprenorphine. We describe an inpatient transition from methadone to buprenorphine using a hydromorphone bridge over a 7-day period. This method used commonly available dosages and formulations of buprenorphine. To our knowledge, this is the first time a method has been described that transitions a patient from methadone to buprenorphine using a short-acting opioid agonist bridge and readily available opioid dosages and formulations. This case provides a viable alternative for rapidly transitioning a patient from methadone to buprenorphine that can be used as a template for an alternative method to transitions between these medications.

Objectives: The standard of care for treatment of alcohol withdrawal is symptom-triggered dosing of benzodiazepines using a withdrawal scale. Abbreviated scales are desired for clinician efficiency. The objective of this study was to evaluate the use of the 5-item Brief Alcohol Withdrawal Scale (BAWS) protocol., Methods: This single-center, retrospective, observational, cohort study assessed patients ordered the BAWS protocol between August 1, 2016 and July 31, 2017. Data were collected on benzodiazepine exposure, duration of treatment, withdrawal severity, agitation, over-sedation, and delirium while being treated for alcohol withdrawal. Comparisons were made to analyze predetermined patient subgroups., Results: Seven hundred ninety-nine patients were initiated on the BAWS protocol. Patients received a median (IQR) of 0 (0-4) lorazepam equivalents (LEs) and were on the BAWS protocol for a median (IQR) of 44.9 (22.4-77.2) hours. Of the patients that received benzodiazepines while on the BAWS protocol, a median (IQR) of 4 (2-11) LEs were given. Seventeen (2.1%) patients had severe withdrawal. Days of agitation, over-sedation, and delirium were minimal, with the median (IQR) of 0 (0-0). Few patients received adjunctive medications for symptom management. Intensive care unit (ICU) patients had more severe withdrawal than non-ICU patients, but received the same cumulative benzodiazepine dose., Conclusions: Most patients on the BAWS protocol received little-to-no benzodiazepines; severe withdrawal, agitation, delirium, or over-sedation were uncommon. This is the first evaluation of the BAWS protocol on a diverse population of hospitalized patients.

Objective: To determine if certain patient, clinical, and disease factors are associated with against medical advice (AMA) discharge among patients admitted for treatment of alcohol withdrawal., Methods: Data from admissions to a dedicated unit for treatment of substance withdrawal were collected over a 6-month period. Patients with AMA and planned discharge were compared with regard to demographics, clinical data, and substance use disorder disease characteristics. A stepwise logistic regression was used to find the best model., Results: The study population included 655 patient encounters. A total of 93 (14%) discharges were AMA. Bivariate analysis showed patients with AMA discharge were younger (mean age 43 vs 46 years; P < 0.05), more likely to leave on a Tuesday to Thursday, and to have an initial withdrawal score at or above the median (AMA 69% vs planned 56%; P = 0.02). Emergency department (ED) admissions had an AMA discharge rate of 21% compared with 10% of community admissions (P < 0.05). Regression analysis found AMA discharge was significantly associated with admission from the ED (odds ratio [OR] 2.03, confidence interval [CI] 1.27-3.25) and younger age (OR 0.97, CI 0.95-0.99). There was no significant difference in discharge disposition among patients with concurrent opioid use disorder who were on opioid agonist therapy., Conclusions: AMA discharges occurred in 1 of every 7 admissions. Being admitted from the ED and younger age was associated with AMA discharge. No other patient or clinical factors were found to be associated with AMA discharge.

Several novel psychoactive substances have emerged in recent years. Users are typically young men who use other substances. In the category of stimulants, cathinones ("bath salts") have predominated and can lead to agitation, psychosis, hyperthermia, and death. Synthetic cannabinoids ("spice") are more potent than marijuana and can lead to agitation, psychosis, seizures, and death. There are no rapid tests to identify these substances and general treatment includes benzodiazepines for agitation and supportive therapy. Many Synthetic opioids are potent analogues of fentanyl and carry a high risk of overdose. In addition, there are several designer benzodiazepines that have emerged., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Negative physician attitudes toward patients with substance use disorders (SUD) pose a significant barrier to treatment. This study tests the overall and intra-individual change in attitudes of second year medical students after exposure to a 15 hour SUD course., Methods: Two cohorts of second year medical students (2014 and 2015) responded to an anonymous 13-item previously published survey exploring personal views regarding patients with SUD using a four-point Likert scale. Students were surveyed one day before and up to one month after course completion. Survey items were grouped into the following categories: treatment optimism/confidence in intervention, moralism, and stereotyping. The Wilcoxon nonparametric signed-rank test (α=0.05) was used to compare the pre- and post- survey responses., Results: In 2014 and 2015 respectively, 118 and 120 students participated in the SUD course with pre- and post-response rates of 89.0% and 75.4% in 2014 and 95.8% and 97.5% in 2015. Of the 13 survey questions, paired responses to eight questions showed a statistically significant positive change in attitudes with a medium (d = 0.5) to large effect size (d = 0.8). Items focused on treatment optimism and confidence in treatment intervention reflected a positive attitude change, as did items associated with stereotyping and moralism., Conclusions: These results support the hypothesis that exposure to a course on SUD was associated with positive change in medical students' attitudes toward patients with SUD.

Objective: This study examines the impact of an insurance-mandated change in formulation of buprenorphine/naloxone (BNX) for patients with opioid use disorder treated in a primary care clinic., Methods: A retrospective cohort study was conducted to determine the proportion of patients who were switched back to the previous BNX formulation and rates of aberrant urine drug tests for the 3 months before and 3 months after a mandated change in BNX from the sublingual film to the rapidly dissolving tablet (BNX-RDT). Aberrant urine drug tests were defined as the presence of cocaine, nonprescribed opioids/benzodiazepines, or the absence of buprenorphine., Results: In all, 186 patients were included in the analysis. At 3 months after the change, 36.0% of patients remained on BNX-RDT at equivalent dose, 9.1% were prescribed a higher dose of BNX-RDT, 52.7% were switched back to their previous formulation after a trial of BNX-RDT, and 2.2% dropped out of care. There was no significant change in the rates of aberrant urine drug tests pre and postchange (36.6% vs 33.7%; P = 0.27) or in any individual component of urine drug testing. Age, sex, and starting dose were not associated with remaining on BNX-RDT at equivalent dose, compared with increasing dose or changing formulation., Conclusions: Most patients were dissatisfied with the change in formulation and requested a return to the previous formulation. This change did not appear to impact drug use; however, the flexibility that permitted patients to switch back to their previous BNX formulation likely attenuated the policy's impact.

Background: The standard of care for management of alcohol withdrawal is symptom-triggered treatment using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar). Many items of this 10-question scale rely on subjective assessments of withdrawal symptoms, making it time-consuming and cumbersome to use. Therefore, there is interest in shorter and more objective methods to assess alcohol withdrawal symptoms., Methods: A 6-item withdrawal scale developed at another institution was piloted. Based on comparison with the CIWA-Ar, this was adapted into a 5-item scale named the Brief Alcohol Withdrawal Scale (BAWS). The BAWS was compared with the CIWA-Ar and a withdrawal protocol utilizing the BAWS was developed. The new protocol was implemented on an inpatient unit dedicated to treating substance withdrawal. Data was collected on the first 3 months of implementation and compared with the 3 months prior to that., Results: A BAWS score of 3 or more predicted CIWA-Ar score ≥8 with a sensitivity of 85.3% and specificity of 65.8%. The demographics of the patients in the 2 time periods were similar: the mean age was 45.9; 70.6% were male; 30.9% received concurrent treatment for opioid withdrawal; and 14.2% were receiving methadone maintenance. During the BAWS phase, patients received significantly less diazepam (mean dose 81.4 vs. 60.3 mg, P < .001). There was no significant difference in length of stay. No patients experienced a seizure, delirium, or required transfer to a higher level of care during any of the 664 admissions in either phase., Conclusions: This simple protocol utilizing a 5-item withdrawal scale performed well in this setting. Its use in other settings, particularly with patients with concurrent medical illnesses or more severe withdrawal, needs to be explored further.

Background: Entry into methadone maintenance is associated with a reduction in criminal activity; less is known about the effects of office-based buprenorphine., Objective: To compare criminal charges before and after enrollment in methadone maintenance or office-based buprenorphine., Methods: Subjects were opioid-dependent adults who initiated either methadone maintenance (n = 252) or office-based buprenorphine (n = 252) between 2003 and 2007. Medical records were reviewed to gather demographic data and a state-maintained web-based database to collect data on criminal charges. Overall charges and drug charges in the 2 years prior to and after treatment enrollment were compared. Multivariable analysis was used to examine risk factors for charges after treatment enrollment., Results: In the 2 years after enrolling in treatment, subjects receiving methadone had a significant decline in the proportion of subjects with any charges (49.6% vs. 32.5%, p < .001) or drug charges (25.0% vs. 17.5%, p = .015), as well as the mean number of cases (0.97 vs. 0.63, p = .002) and drug cases (0.38 vs. 0.23, p = .008), while those who initiated buprenorphine did not have significant changes in any of these measures. On multivariable analysis, the strongest predictor of criminal charges in the 2 years after treatment enrollment was prior charges (adjusted odds ratio 3.35, 95% confidence interval, 2.24-5.01)., Conclusions: Enrollment in office-based buprenorphine treatment did not appear to have the same beneficial effect on subsequent criminal charges as methadone maintenance. If this observation is replicated in other settings, it may have implications for matching individuals to these treatment options.

Aims: This study compared the Glasgow Modified Alcohol Withdrawal Scale (GMAWS) and a newly devised 3-item "Anxiety Sweats Tremor" Scale (AST) to the Revised Clinical Institute Withdrawal Assessment Scale (CIWA-Ar)-the standard of care for symptom-triggered management of alcohol withdrawal syndrome., Methods: Our study took place over 2 separate 1-week observational periods, and included 332 serial evaluations from 85 unique patients. All study participants were treated per hospital protocol based on CIWA-Ar, with supplemental scoring initially by GMAWS and later by AST in tandem. Internal consistency, interitem correlation, and operational characteristics were explored., Results: Median CIWA-Ar score across both phases was 6 (range 0-13), with a median GMAWS score of 2 (range 0-5) and an AST score of 3 (range 0-7). The internal consistency of CIWA-Ar and GMAWS were both poor, with Cronbach alpha scores of 0.46 (n = 156) and 0.41 (n = 156), respectively. The internal consistency of the AST scale was significantly better, with a Cronbach alpha of 0.68 (n = 176). AST identified individuals with CIWA-Ar ≥8 with an area under the receiver-operating characteristic curve of 0.83 (95% confidence interval 0.77-0.89), compared with 0.81 (95% confidence interval 0.74-0.88) for GMAWS. An AST score of ≥3 (out of a possible 9) predicted CIWA-Ar ≥8, with a sensitivity of 93% and a specificity of 63%, whereas the GMAWS had a sensitivity and specificity of 100% and 12%, respectively, based on previously defined cut-offs., Conclusions: A simple 3-item scale demonstrated good internal consistency and reliably identified individuals experiencing significant alcohol withdrawal. This scale needs to be tested in other settings and among patients with a broader spectrum of withdrawal severity.

Background: The optimal dose for office-based buprenorphine therapy is not known. This study reports on the effect of a change in payer policy, in which the insurer of a subset of patients in an office-based practice imposed a maximum sublingual buprenorphine dose of 16 mg/day, thereby forcing those patients on higher daily doses to decrease their dose. This situation created conditions for a natural experiment, in which treatment outcomes for patients experiencing this dose decrease could be compared to patients with other insurance who were not challenged with a dose decrease., Methods: Subjects were 297 patients with opioid use disorder in a primary care practice who were prescribed buprenorphine continuously for at least 3 months. Medical records were retrospectively reviewed for urine drug test results and treatment retention. Rates of aberrant urine drug tests were calculated in the period before the dose decrease and compared to rate after it with patients serving as their own controls. Comparison groups were formed from patients with the same insurance on buprenorphine doses of 16 mg/day or lower, patients with different insurance on 16 mg/day or lower, and patients with different insurance on greater than 16 mg/day. Rates of aberrant drug tests and treatment retention of patients on 16 mg/day or less of buprenorphine were compared to that of patients on higher daily doses., Results: The rate of aberrant urine drug tests among patients who experienced a dose decrease rose from 27.5% to 34.2% (p=0.043). No comparison group showed any significant change in aberrant drug test rates. Moreover, all groups who were prescribed buprenorphine doses greater than 16 mg/day displayed lower rates of aberrant urine drug tests than groups prescribed lower doses. Retention in treatment was also highest among those prescribed greater than 16 mg/day (100% vs. 86.8%, 90.1%, and 84.4% p=0.010)., Discussion: An imposed buprenorphine dose decrease was associated with an increase in aberrant drug tests. Patients in a control group with higher buprenorphine doses had greater retention in treatment. These findings suggest that buprenorphine doses greater than 16 mg/day are more effective for some patients and that dose limits at this level or lower are harmful., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: The magnitude of the effect of hepatitis C viral infection on survival is still not fully understood. The objective of this study was to determine whether the presence of hepatitis C viral antibodies in 1991 was associated with increased mortality 20 years later within a cohort of patients with substance use disorders. Secondary objectives were to determine other factors that were associated with increased mortality in the cohort., Methods: A subset of a 1991 study cohort of patients who had presented for detoxification was reexamined 20 years later. The Social Security Death Index was queried to identify which of the original patients had died. Attributes of survivors and non-survivors were compared, with special attention to their hepatitis C status in 1991. The original study and this analysis were conducted in the chemical detoxification unit at Johns Hopkins Bayview (previously Francis Scott Key Hospital), an academic urban hospital. All participants met the criteria for alcohol or opioid dependence at the time of admission in 1991. The primary study outcome was 20-year mortality after initial admission in 1991, with a planned analysis of hepatitis C status., Results: Twenty years after admission, 362 patients survived and 82 had died. Of the 284 patients who were hepatitis C positive, 228 survived (80 %). Of the 160 patients who were hepatitis C negative, 134 survived (84 %). This absolute risk increase of 4 % was not statistically significant (p = 0.37). Factors associated with increased mortality included male sex, white race, older age, and reported use of alcohol, cocaine, and illicit methadone. Binary logistic regression including hepatitis C status and these other variables yielded an adjusted odds ratio of 0.87 (95 % CI 0.49-1.55); (p = 0.64) for hepatitis C positive 20-year survival., Conclusions: Hepatitis C positivity was not associated with a statistically significant difference in 20-year survival. The effect of the virus on mortality, if present, is small, relative to the effect of substance use disorders alone.

Background: The purpose of this study was to compare demographic factors and 1-year treatment outcomes of patients treated with buprenorphine or methadone., Methods: The study included 252 subjects who received a prescription for buprenorphine in an academic internal medicine practice and 252 subjects who enrolled in a methadone maintenance program located on the same campus over the same time frame. Data were collected retrospectively. Patients were classified as "opioid-positive" or "opioid-negative" each month for a year based on urine drug testing and provider assessment. Successful treatment was defined as remaining in treatment after 1 year and achieving 6 or more opioid-negative months., Results: Buprenorphine patients were more likely to be male, have health insurance, be employed, abuse prescription opioids, and be human immunodeficiency virus (HIV) infected; they were less likely to abuse benzodiazepines. At 12 months, 140 (55.6%) of buprenorphine patients and 156 (61.9%) of methadone patients remained in treatment (P =.148). Patients on methadone had a higher mean number of opioid-negative months (6.96 vs. 5.43; P <.001) and mean number of months in treatment (9.38 vs. 8.59; P <.001). On multivariable analysis, methadone maintenance was significantly associated with successful treatment (adjusted odds ratio: 2.10; 95% confidence interval: 1.43-3.07)., Conclusions: Office-based buprenorphine and methadone maintenance programs serve very different populations. Both are effective, but patients on methadone had mildly better treatment outcomes.

This article presents an update on addiction-related medical literature for the calendar years 2010 and 2011, focusing on studies that have implications for generalist practice. We present articles pertaining to medical comorbidities and complications, prescription drug misuse among patients with chronic pain, screening and brief interventions (SBIs), and pharmacotherapy for addiction.

Background: Buprenorphine is an effective treatment for opioid dependence that can be provided in a primary care setting. Offering this treatment may also facilitate the identification and treatment of other chronic medical conditions., Methods: We retrospectively reviewed the medical records of 168 patients who presented to a primary care clinic for treatment of opioid dependence and who received a prescription for sublingual buprenorphine within a month of their initial visit., Results: Of the 168 new patients, 122 (73%) did not report having an established primary care provider at the time of the initial visit. One hundred and twenty-five patients (74%) reported at least one established chronic condition at the initial visit. Of the 215 established diagnoses documented on the initial visit, 146 (68%) were not being actively treated; treatment was initiated for 70 (48%) of these within one year. At least one new chronic medical condition was identified in 47 patients (28%) during the first four months of their care. Treatment was initiated for 39 of the 54 new diagnoses (72%) within the first year., Conclusions: Offering treatment for opioid dependence with buprenorphine in a primary care practice is associated with the identification and treatment of other chronic medical conditions.

Benzodiazepine dependence is a common problem. However, there is limited data on safe and effective detoxification protocols for benzodiazepine-dependent patients. We reviewed the medical records of 310 patients treated with a 3-day fixed-dose phenobarbital taper for benzodiazepine dependence over a 5-year period between 2004 and 2009. We recorded the incidence of seizures, falls, delirium, and emergency department (ED) visits or readmission to our institution within 30 days as markers for safety; we also recorded how many patients had doses held because of sedation. The taper was well tolerated, although one quarter of the patients had at least one dose held because of sedation. There were no seizures, falls, or injuries reported. Six percent had a readmission, and 7% had an ED visit at our institution within 30 days of discharge, but only 3 patients required readmission for withdrawal symptoms. Overall, this protocol appears to be safe and effective., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: To compare rates of opioid prescribing, aberrant behaviors, and indicators of substance misuse in patients prescribed long-term opioids by resident physicians or attending physicians in a general internal medicine practice., Design: Medical records of 333 patients who were prescribed opioids for at least three consecutive months were reviewed. Aberrant behaviors over a 2-year period were documented, including reporting lost or stolen medications or receiving opioids from more than one provider. Indicators of substance misuse were also recorded, including positive urine drug testing for illicit substances, addiction treatment, overdose, and altering prescriptions., Results: An estimated 13.6 percent of the patients followed by residents had been prescribed opioids for three or more months; this was significantly higher than the rate for attendings (5.9 percent, p < 0.001). Patients followed by residents were more likely to have reported lost or stolen prescriptions or medication (25.7 percent vs 12.2 percent, p = 0.03) or to have received opioids from another provider (17.8 percent vs 7.6 percent, p = 0.008); they were also more likely to exhibit an indicator of substance misuse (24.8 percent vs 7.6 percent, p < 0.001). However, in multivariate analyses, aberrant behaviors and indicators of substance misuse were not significantly associated with having a resident physician., Conclusions: Resident physicians at our institution are following a disproportionate number of patients on long-term opioids, many of whom exhibit aberrant behaviors and indicators of substance misuse. This underscores a need for better resident training and supervision to provide effective and safe care for patients with chronic pain.

Few medical schools require a stand-alone course to develop knowledge and skills relevant to substance use disorders (SUDs). The authors successfully initiated a new course for second-year medical students that used screening, brief intervention, and referral to treatment (SBIRT) as the course foundation. The 15-hour course (39 faculty teaching hours) arose from collaboration between faculty in Departments of Medicine and Psychiatry and included 5 hours of direct patient interaction during clinical demonstrations and in small-group skills development. Pre- and post-exam results suggest that the course had a significant impact on knowledge about SUDs. The authors' experience demonstrates that collaboration between 2 clinical departments can produce a successful second-year medical student course based in SBIRT principles.

Objectives: : Addiction is an important and common health problem. Many internal medicine training programs do not offer structured training in addiction; as a result, residents often report feeling unprepared in caring for patients with this problem. We developed an Internet-based curriculum to teach internal medicine residents about evaluating and treating patients with substance use disorders., Methods: : Three educational modules on addiction were developed and posted on an established Web site that provides an internal medicine curriculum for training programs throughout the United States. Baseline and posttest questions were tested and validated by having house officers and addiction medicine faculty members complete the tests. We compared baseline pretest scores between first (PGY-1) and third year (PGY-3) residents to assess baseline knowledge and pretest and posttest scores for the entire cohort to assess the impact of the modules., Results: : Each module was completed by over 1200 residents at 86 different training programs. Although overall baseline pretest scores were better among PGY-3 than PGY-1 residents (mean 58% vs 55%; P < 0.05), the difference between the 2 groups for individual modules was not significant. The mean baseline pretest score was 56.4% and posttest score was 74.8%, a difference that was statistically significant (P < 0.001). When asked to rate the educational value of the program, the residents gave it a mean score of 4.2 on a 5-point Likert scale (1 = not instructive; 5 = highly instructive)., Conclusions: : Internet-based curricula can be an effective tool to disseminate knowledge on addiction to trainees. Learners show an improvement in testing scores and rate these programs highly.

The purposes of this study were to assess outcomes of patients prescribed buprenorphine at a primary care practice and to identify factors associated with favorable outcomes. All 255 patients given at least one prescription for buprenorphine between August 2003 and September 1, 2007, at a primary care practice in Baltimore were included. Data regarding demographics and comorbidities were collected retrospectively. Patients were classified as "opioid-positive" or "opioid-negative" each month based on patient report, urine toxicology, and provider assessment. After 12 months, 145 (56.9%) patients remained in treatment, and 64.7% of their months were opioid-negative. Patients using heroin were less likely to be opioid-negative, whereas those using prescription opioids were more likely to be opioid-negative. Polysubstance use was associated with increased treatment retention. The prescription of buprenorphine for opioid dependence treatment can be incorporated into primary care practice, and many patients, including polysubstance users, benefit from this treatment.

Elite controllers or suppressors are untreated human immunodeficiency virus type 1 (HIV-1)-infected patients who maintain undetectable viral loads. In this study, we show that most elite suppressors do not experience significant changes in T cell counts over a 10-year period. Interestingly, treatment of an elite suppressor with highly active antiretroviral therapy (HAART) led to a marked decrease in immune activation.

Background: Antiretroviral prescribing errors are common among hospitalized patients. Inadequate medical knowledge is likely one of the factors leading to these errors. Our objective was to determine the proportion of hospital physicians with knowledge gaps about prescribing antiretroviral medications for hospitalized HIV-infected patients and to correlate knowledge with length and type of medical training and experience., Methods: We conducted an electronic survey comprising of ten clinical scenarios based on antiretroviral-prescribing errors seen at two community teaching hospitals. It also contained demographic questions regarding length and type of medical training and antiretroviral prescribing experience. Three hundred and forty three physicians at both hospitals were asked to anonymously complete the survey between February 2007 and April 2007., Results: One hundred and fifty-seven physicians (46%) completed at least one question. The mean percentage of correct responses was 33% for resident physicians, 37% for attending physicians, and 93% for Infectious Diseases or HIV (ID/HIV) specialist physicians. Higher scores were independently associated with ID/HIV specialty, number of outpatients seen per month and physician reported comfort level in managing HIV patients (P < .001)., Conclusion: Non-ID/HIV physicians had uniformly poor knowledge of common antiretroviral medication regimens. Involvement of ID/HIV specialists in the prescribing of antiretrovirals in hospitalized patients might mitigate prescribing errors stemming from knowledge deficits.

Background: The Accreditation Council of Graduate Medical Education (ACGME) is changing residency program assessment to include education outcomes assessment, challenging resources of residency training programs. The internet is a means of sharing education resources among training programs., Methods: A multicenter survey was distributed to leaders of 80 internal medicine residency training programs that shared an online medical knowledge curriculum that included education outcomes assessment. Program characteristics, curriculum implementation methods, and use of educational outcome assessment were analyzed to determine how implementation differed among programs., Results: Seventy-four programs (92%) completed the survey. The programs vary in medical school affiliation, number of house staff, and proportion of students who specialize on graduation. They most commonly use the curriculum to augment a preexisting curriculum (37 programs [50%]); 41 programs (56%) use the curriculum to comply with ACGME requirements. The programs differ in how they adapt the curriculum to their needs, most commonly by discussing modules with house staff (47 programs [63%]). In 61 programs (82%), module completion is mandatory. Thirty-five programs (47%) use penalties to encourage module completion, most commonly poor evaluation scores (15 programs [20%]) or withholding of promotion (12 programs [16%]). Nearly all programs (71 [97%]) track module completion; 34 programs (47%) track group performance on learning objectives; and 8 programs (11%) alter their educational curriculum based on group performance., Conclusions: A medical knowledge curriculum that includes education outcome assessment can be adapted at a range of residency training programs, helping them to comply with ACGME requirements. However, most residency training programs are not using outcomes data to their full potential.

Purpose: Buprenorphine is commonly used for opioid detoxification. The goal of this study was to determine whether a change from the intramuscular (IM) buprenorphine to the sublingual (SL) formulation of buprenorphine-naloxone was associated with improved treatment completion rates on an inpatient detoxification unit., Methods: This study was conducted at the Johns Hopkins Bayview Medical Center (JHBMC) Chemical Dependence Unit (CDU), a 26-bed, 3-day inpatient detoxification unit providing detoxification from opioids, alcohol, and sedatives. The opioid detoxification protocol was changed from IM buprenorphine (0.3 mg bid for 3 days) to SL buprenorphine-naloxone (8, 8, and 6 mg on sequential days, plus 2 mg on the morning of discharge). For the 3 months prior to and after the change in protocol, data were collected retrospectively on demographics, type of dependence being treated, and type of discharge., Findings: A total of 1,168 patients were admitted to the JHBMC CDU during the period studied. In the 3 months prior to the change in buprenorphine protocol, 353 of 483 patients admitted for treatment of opioid dependence (73.1%) completed treatment, compared with 407 of 473 patients admitted after the change (86.0%); this difference was highly significant (p < .0001). Among 212 patients who did not receive treatment for opioid dependence over the same period, the rates of treatment completion did not change significantly (89.8% before vs. 83.0% after; p = .208)., Conclusions: A change from IM buprenorphine to SL buprenorphine-naloxone for opioid detoxification was associated with a significant improvement in completion rates at this inpatient treatment program.

Background: Highly active antiretroviral therapy (HAART) has improved survival for persons living with human immunodeficiency virus (HIV) infection. However, effective therapy requires high levels of adherence over extended periods of time. Previous studies suggest that patients receiving long-term medication are at risk for unintended medication discrepancies at the time of hospital admission., Methods: We retrospectively identified every HIV-infected patient admitted to our hospital over a 1-year period who received an antiretroviral agent. We collected information on medications and renal function from the hospital computerized provider order entry system. We reviewed the medical records for those admissions for which a potential error was identified. We defined errors using Department of Health and Human Services guidelines and included only those errors that were not corrected within 24 h after initial entry., Results: There were a total of 209 admissions during a 1-year period in which an HIV-infected patient received antiretroviral therapy. After review of the medical records for 77 admissions with a potential error, 61 uncorrected errors from 54 admissions were identified (percentage of total admissions, 25.8%; 95% confidence interval, 20.1%-32.3%). The most common type of error was an error with respect to the amount or frequency of dosage, which occurred in 34 (16.3%) of the admissions; 18 of these errors were attributable to failure to appropriately adjust dosage for renal insufficiency. The next most common error was combining antiretroviral drugs with a contraindicated medication; this occurred in 12 (5.2%) of the admissions. Patients erroneously received