Galit Sacajiu

Providers' experiences treating chronic pain among opioid-dependent drug users.

BACKGROUNDSuccessful management of chronic pain with opioid medications requires balancing opioid dependence and addiction with pain relief and restoration of function. Evaluating these risks and benefits is difficult among patients with chronic pain and pre-existing addiction, and the ambiguity is increased for patients on methadone maintenance therapy for opioid dependence. Providers treating both chronic pain and addiction routinely make diagnostic and therapeutic decisions, but decision-making strategies in this context have not been well described.OBJECTIVEOur objective was twofold. We sought first to explore providers’ perceptions of ambiguity, and then to examine their strategies for making diagnostic and treatment decisions to manage chronic pain among patients on methadone maintenance therapy.DESIGNQualitative semi-structured interviews.SETTING AND PARTICIPANTSWe interviewed health-care providers delivering integrated medical care and substance abuse treatment to patients in a methadone maintenance program.RESULTSProviders treating pain and co-morbid addiction described ambiguity in all diagnostic and therapeutic decisions. To cope with this inherent ambiguity, most providers adopted one of two decision-making frameworks, which determined clinical behavior. One framework prioritized addiction treatment by emphasizing the destructive consequences of abusing illicit drugs or prescription medications; the other prioritized pain management by focusing on the destructive consequences of untreated pain. Identification with a decision-making framework shaped providers’ experiences, including their treatment goals, perceptions of treatment risks, pain management strategies, and tolerance of ambiguity. Adherence to one of these two frameworks led to wide variation in pain management practices, which created tension among providers.CONCLUSIONSProviders delivering integrated medical care and substance abuse treatment to patients in a methadone maintenance program found tremendous ambiguity in the management of chronic pain. Most providers adopted one of the two divergent heuristic frameworks we identified, which resulted in significant variations in pain management. To reduce variation and determine best practices, studies should examine clinically relevant endpoints, including pain, illicit drug use, prescription drug abuse, and functional status. Until then, providers managing chronic pain in patients with co-morbid addiction should attempt to reduce tension by acknowledging ambiguity and engaging in open discourse.

Home- versus office-based buprenorphine inductions for opioid-dependent patients

Recent legislation permits the treatment of opioid-dependent patients with buprenorphine in the primary care setting, opening doors for the development of new treatment models for opioid dependence. We modified national buprenorphine treatment guidelines to emphasize patient self-management by giving patients the opportunity to choose to have buprenorphine inductions at home or the physicians office. We examined whether patients who had home-based inductions achieved greater 30-day retention than patients who had traditional office-based inductions in a study of 115 opioid-dependent patients treated in an inner-city health center. Retention was similar in both groups: 50 (78.1%) in office-based group versus 40 (78.4%) in home-based group, p = .97. Several patient characteristics were associated with choosing office- versus home-based inductions, which likely influenced these results. We conclude that opioid dependence can be successfully managed in the primary care setting. Approaches that encourage patient involvement in treatment for opioid dependence can be beneficial.

Conceptual Models of Psychological Distress Among Low-income Patients in an Inner-city Primary Care Clinic

Although depression and anxiety syndromes are common in primary care, many depressed and anxious patients fail to receive effective treatment. Little attention has been given to the role of illness beliefs in shaping these patients’ treatment preferences and decisions. Using semistructured interviews, this study examined conceptual models of depressive symptoms among patients in an inner-city clinic. A theoretical taxonomy of patients’ conceptual models of distress was developed: each category was associated with a unique pattern of treatment preferences. We conclude that patients’ models of distress may play an important role in treatment-seeking decisions, and deserve further investigation.

Factors associated with complicated buprenorphine inductions

Despite data supporting its efficacy, barriers to implementation of buprenorphine for office-based treatment are present. Complications can occur during buprenorphine inductions, yet few published studies have examined this phase of treatment. To examine factors associated with complications during buprenorphine induction, we conducted a retrospective chart review of the first 107 patients receiving buprenorphine treatment in an urban community health center. The primary outcome, defined as complicated induction (precipitated or protracted withdrawal), was observed in 18 (16.8%) patients. Complicated inductions were associated with poorer treatment retention (than routine inductions) and decreased over time. Factors independently associated with complicated inductions included recent use of prescribed methadone, recent benzodiazepine use, no prior experience with buprenorphine, and a low initial dose of buprenorphine/naloxone. Findings from this study and further investigation of patient characteristics and treatment characteristics associated with complicated inductions can help guide buprenorphine treatment strategies.

Description of a research-based health activism curriculum for medical students.

INTRODUCTION: Few curricula train medical students to engage in health system reform. AIM: To develop physician activists by teaching medical students the skills necessary to advocate for socially equitable health policies in the U.S. health system. SETTING: Montefiore Medical Center, the University Hospital of the Albert Einstein College of Medicine, Bronx, NY. PROGRAM DESCRIPTION: We designed a 1-month curriculum in research-based health activism to develop physician activists. The annual curriculum includes a student project and 4 course sections; health policy, research methods, advocacy, and physician activists as role models; taught by core faculty and volunteers from academic institutions, government, and nongovernmental organizations. PROGRAM EVALUATION: From 2002 to 2005, 47 students from across the country have participated. Students reported improved capabilities to generate a research question, design a research proposal, and create an advocacy plan. DISCUSSION: Our curriculum demonstrates a model for training physician activists to engage in health systems reform.

Family Planning Knowledge: The Role of Social Networks and Primary Care Providers as Information Sources for African American Women.

Disparities in the rates of unintended pregnancy have increased for low-income African American women as compared to other groups due, in part, to declining contraception use. Women obtain family planning information from diverse sources, which may ultimately influence contraceptive decision making. For this qualitative study, we conducted in-depth interviews with urban-dwelling low-income African American women to explore, within the framework of the theory of planned behavior, how family planning information is acquired from two distinct knowledge sources: social networks and primary care providers. We present thematic analysis and model interpretation, and offer approaches to preventing unintended pregnancy.

Inquiries About and Initiation of Buprenorphine Treatment in an Inner-City Clinic

ABSTRACT Despite increases in opioid dependence, availability of buprenorphine treatment remains limited. Reasons may include health center concerns about becoming overwhelmed or attracting patients who differ from the local community. This study documents inquiries about and initiation of buprenorphine treatment in an inner-city health center. From 2006–2008, we collected demographic information and subsequent treatment data for everyone who inquired about treatment. Of the 324 people who inquired, 55.6% initiated treatment. The number of inquiries increased gradually over time, and most came from local community residents (80.4%). These results may allay health center concerns, and can help planning for buprenorphine treatment.