John A. Renner

Factors affecting willingness to provide buprenorphine treatment

Buprenorphine is an effective long-term opioid agonist treatment. As the only pharmacological treatment for opioid dependence readily available in office-based settings, buprenorphine may facilitate a historic shift in addiction treatment from treatment facilities to general medical practices. Although many patients have benefited from the availability of buprenorphine in the United States, almost half of current prescribers are addiction specialists suggesting that buprenorphine treatment has not yet fully penetrated general practice settings. We examined factors affecting willingness to offer buprenorphine treatment among physicians with different levels of prescribing experience. Based on their prescribing practices, physicians were classified as experienced, novice, or as a nonprescriber and asked to assess the extent to which a list of factors impacted their prescription of buprenorphine. Several factors affected willingness to prescribe buprenorphine for all physicians: staff training; access to counseling and alternate treatment; visit time; buprenorphine availability; and pain medications concerns. Compared with other physicians, experienced prescribers were less concerned about induction logistics and access to expert consultation, clinical guidelines, and mental health services. They were more concerned with reimbursement. These data provide important insight into physician concerns about buprenorphine and have implications for practice, education, and policy change that may effectively support widespread adoption of buprenorphine.

The Physician Clinical Support System-Buprenorphine (PCSS-B): A Novel Project to Expand/Improve Buprenorphine Treatment

ABSTRACTOpioid dependence is largely an undertreated medical condition in the United States. The introduction of buprenorphine has created the potential to expand access to and use of opioid agonist treatment in generalist settings. Physicians, however, often have limited training and experience providing this type of care. Some physicians believe having a mentoring relationship with an experienced provider during their initial introduction to the use of buprenorphine would ease implementation. Our goal was to describe the development, implementation, resources, and evaluation of the Physician Clinical Support System-Buprenorphine (PCSS-B), a federally funded program to improve access to and quality of treatment with buprenorphine. We provide a description of the PCSS-B, a national network of 88 trained physician mentors with expertise in buprenorphine treatment and skills in clinical education. We provide information regarding the use the PCSS-B core services including telephone, email and in-person support, a website, clinical guidances, a warmline and outreach to primary care and specialty organizations. Between July 2005 and July 2009, 67 mentors and 4 clinical experts reported providing mentoring services to 632 participants in 48 states, Washington DC and Puerto Rico. A total of 1,455 contacts were provided through email (45%), telephone (34%) and in-person visits (20%). Seventy-six percent of contacts addressed a clinical issue. Eighteen percent of contacts addressed a logistical issue. The number of contacts per participant ranged from 1–125. Between August 2005 and April 2009 there were 72,822 visits to the PCSS-B website with 179,678 pages viewed. Seven guidances were downloaded more than 1000 times. The warmline averaged more than 100 calls per month. The PCSS-B model provides support for a mentorship program to assist non-specialty physicians in the provision of buprenorphine and may serve as a model for dissemination of other types of care.

Substance Abuse and Depression

Depression, complicated by substance abuse, is a common clinical problem and is often associated with poor clinical outcomes. Clinicians need to understand the relationship between these two conditions and must adjust their treatment plans to address both disorders simultaneously. It is critical that the clinician not confuse a substance-induced mood disorder with an independent depressive disorder. Unfortunately, the relationship between substance abuse and depression is not well understood, and there are relatively few well controlled studies to help guide the treatment of these patients.

Clinician Beliefs and Attitudes about Buprenorphine/Naloxone Diversion

BACKGROUND AND OBJECTIVES Concern about diversion of buprenorphine/naloxone (B/N) in the United States may affect prescribing patterns and policy decisions. This study examines addiction treatment clinician beliefs and attitudes regarding B/N diversion. METHODS Participants (n = 369) completed a 34-item survey in 2010 during two national symposia on opioid dependence. We conducted multivariable regression, examining the relationship of perceived danger from B/N diversion with clinician characteristics and their beliefs about B/N treatment and diversion. We compared causal beliefs about diversion among clinicians with and without B/N treatment experience. RESULTS Forty percent of clinicians believed that B/N diversion is a dangerous problem. The belief that B/N diversion increases accidental overdoses in the community was strongly associated with perceived danger from B/N diversion. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE Attitudes and beliefs, not education level, were associated with clinicians perceived danger from B/N diversion. Clinicians with greater B/N patient experience were more likely to believe treatment access barriers are the major cause of B/N diversion.

The changing patterns of psychiatric problems in Vietnam

Abstract I contend that military psychiatrists have been premature in suggesting that the Vietnam conflict has produced fewer psychiatric casualties than previous wars. While the number of men hospitalized and evacuated because of psychiatric problems has decreased, there has been a concurrent increase in disciplinary problems, drug abuse, and in the number of men diagnosed as character disorders. For some of our troops, duty in Vietnam has produced significant feelings of depression and guilt and has led to a rejection of any identification with the military. Other soldiers have turned to drug abuse as an escape from their distress. Men with character disorders sometimes act out their conflicts in antisocial behavior. The varying patterns of group formation in combat and support units determine whether this behavior will be directed towards Vietnamese or U.S. personnel. Antisocial behavior and drug abuse are symptomatic of emotional distress and have replaced combat fatigue as the predominant psychiatric syndromes among United States troops in Vietnam.

Preliminary survey of office-based opioid treatment practices and attitudes among psychiatrists never receiving buprenorphine training to those who received training during residency.

OBJECTIVE To compare the characteristics, attitudes, and current prescribing practices of recently graduating psychiatrists who completed buprenorphine training during residency to those who never completed any training. METHODS A total of 359 psychiatrists completing residency training between 2008 and 2011 were recruited to complete an on-line survey. RESULTS Responses from 93 psychiatrists were included for a response rate of 25.9%. Psychiatrists completing any buprenorphine training during residency were more likely to be male and report more favorable views of OBOT with buprenorphine than compared to those who never completed any training. Twenty (38.5%) of those psychiatrists who completed training during residency reported the current prescribing of buprenorphine. CONCLUSIONS Completion of buprenorphine training during residency may be a factor in shaping future attitudes towards OBOT and buprenorphine prescribing practices. Further research is needed to clarify the impact of buprenorphine training during residency. SCIENTIFIC SIGNIFICANCE Buprenorphine training during residency training may be a contributing factor in shaping future physician attitudes towards office-based opioid treatment and buprenorphine prescribing practices.

What Do Psychiatric Residents Think of Addiction Psychiatry as a Career

ObjectiveThe authors attempt to better understand the recent decline in the number of applicants to addiction psychiatry training.MethodsThe Corresponding Committee on Training and Education in Addiction Psychiatry of APA’s Council on Addiction Psychiatry sent out a 14-question anonymous e-mail survey to all postgraduate-year 2 (PGY-2) through PGY-4 APA Members-in-Training. The questions explored residents’ beliefs and attitudes toward addiction psychiatry and sought their opinion on how training in addiction psychiatry can be made more attractive to them.ResultsOf 2,511 eligible psychiatric residents surveyed nationally, 276 (10.6%) residents responded to the survey. Residents who responded had a generally positive impression of addiction psychiatrists but expressed much less favorable attitudes toward the practice of addiction psychiatry. Respondents provided three major subsets of suggestions: employment security and compensation, optimize PGY-1–4 addiction training, and fellowship training issues.ConclusionThese findings may be used to improve addiction psychiatry training and recruitment.

Clinical case discussion: treating opioid dependence with buprenorphine.

Monday You received a frantic phone call from a nurse colleague because her 26-year-old daughter, Susan, was addicted to heroin and relapsed immediately after being discharged from a 5-day inpatient detoxification program. Susan was eager to try treatment with buprenorphine but was unable to find a physician accepting new patients. You arranged for Susan to see you in your office the following day.

A Public Dual Diagnosis Detoxification Unit: Part I: Organization and Structure

A significant proportion of the nearly 1 million individuals with chronic mental illness in this country have problems with chemical dependency (CD), This problem is particularly germane among the almost 3 million homeless individuals in the United States. Traditional models for treating CD and psychiatric illness autonomously are not adequate for this population. This two-part article describes a cost-efficient detoxification, stabilization treatment unit, primarily for a homeless or homeless-prone population with comorbid CD and mental illness. In Part I, the authors discuss the overall treatment philosophy, staffing requirements, and specialized approaches designed for this heterogeneous population.

Training Psychiatrists to Treat Dual Diagnosis Patients

ABSTRACT Despite the high incidence of dual diagnosis patients in most treatment settings, psychiatrists have not been adequately trained to care for patients with substance use disorders and co-occurring psychiatric disorders. Brief rotations on detoxification or substance abuse rehabilitation units do not provide the type of training that is needed to develop the long-term management skills required to successfully treat these patients. Boston University Medical Center has developed an expanded addiction psychiatry curriculum that is coupled with a 2-year longitudinal rotation on a dual diagnosis outpatient unit. Residents receive in-depth training in cognitive behavioral and harm reduction therapy, motivational enhancement treatment, and addiction pharmacotherapy. Trainees need to work with psychiatrists who respect these patients and are willing to take responsibility to manage both SUD and co-occurring disorders. A longitudinal training experience is an ideal model for learning appropriate addiction treatment skills and for gaining confidence in the efficacy of these treatments.