O. Lee McCabe

Methadone/LAAM maintenance: A comparison study

NE MAJOR PROBLEM with methadone in the maintenance approach to treatment of addiction is its short duration of action, requiring daily administration and often entailing daily clinic attendance. When more than one day’s supply is given with take-home privileges, the likelihood of illegal dispersion and accidental ingestion by nonaddicted individuals is created. The requirements of daily clinic attendance become an interference with the patient’s way of life and might be considered a form of dependence in its own right. LAAM (I-alpha-acetylmethadol), a longer acting compound chemically similar to methadone, has the potential for preventing the problems associated with methadone. Since LAAM prevents withdrawal for more than 48 hr, it is necessary to administer it only three times weekly, thus limiting administration of medication to the clinic and requiring patients to report to the clinic less often. Consequently, the anticipated advantages of LAAM are that its use would curtail illegal dispersion of a drug of dependence and at the same time allow patients to lead more conventional lives, being less dependent on the clinic. According to Blachly, David, and Irwin, I the major advantages of LAAM are: (1) it will suppress abstinence symptoms for about twice as long as methadone: (2) its action is “smoother;” (3) there is less complaint of “nodding;” (4) it is more effective orally than parenterally, hence it is less likely to be abused; and (5) there is less subjective euphoria. Its major disadvantages are the occurrence of: (1) a subjective amphetamine-like effect and dysphoria in some patients; (2) occasional complaints of feeling less “mellow;” and (3) occasional complaints of abdominal cramps. In their comparison of methadone and LAAM, Blachly, David, and Irwin reported that EEG abnormalities were present in 53% of all patients, 63% of those on methadone, and 38.5% of those on LAAM, and that fasting hyperglycemia occurred in 62% of the LAAM patients as opposed to 2 1% of those on methadone. Only the latter difference was significant.

Crossing the quality chasm in behavioral health care: The role of evidence-based practice

The concept of evidence-based practice (EBP) is one receiving increasing attention from providers, managers, payers, and regulators of care, yet practical guidelines for professional psychologists who may be interested in incorporating EBPs into their own work settings are not available. The author explores the pragmatics of EBP adoption within the broad context of quality problems in American health care, particularly as described in a heralded 2001 publication by the Institute of Medicine. Concrete suggestions are offered to help practitioners locate EBP resources for specific clinical problems, use an evidence hierarchy to infer “best practices,” address the science-to-service management challenge, and generate outcomes data and feedback loops to continuously improve clinical effectiveness. Increasingly, clinical practitioners working in professional psychology, as well as in other areas of behavioral health care, are encountering the concept of evidence-based practice (EBP) along with implicit responsibility for assessing the applicability of EBPs for their own clinical setting. The context for these considerations is a health system with profound quality defects and a professional environment with little consensus about what role EBPs realistically might serve in overcoming quality problems.

Evaluation of clinic attendance schedules for LAAM and methadone: A controlled study

The authors randomly assigned 95 male narcotic addicts to one of four treatment conditions: either methadone or LAAM maintenance and one of two drug-appropriate clinic attendance schedules. Although no differences were observed among treatment conditions on any of the outcome measures employed, the conclusion that the drugs and attendance regimens were equally efficacious and acceptable was made cautiously due to the relatively small sample size and to the observed trend (p =. 10) in favor of methadone maintenance combined with the 3-day (LAMM-appropriate) attendance schedule. There was no evidence of untoward physical effects associated with any of the treatment approaches.

Psychological First Aid: A Consensus-Derived, Empirically Supported, Competency-Based Training Model

Surges in demand for professional mental health services occasioned by disasters represent a major public health challenge. To build response capacity, numerous psychological first aid (PFA) training models for professional and lay audiences have been developed that, although often concurring on broad intervention aims, have not systematically addressed pedagogical elements necessary for optimal learning or teaching. We describe a competency-based model of PFA training developed under the auspices of the Centers for Disease Control and Prevention and the Association of Schools of Public Health. We explain the approach used for developing and refining the competency set and summarize the observable knowledge, skills, and attitudes underlying the 6 core competency domains. We discuss the strategies for model dissemination, validation, and adoption in professional and lay communities.

A study of methadone failures in an abstinence program

The methadone maintenance approach to the treatment of chronic heroin addiction has become exceedingly popular. Evaluations of such programs, however, have been generally inadequate and are particularly remiss in delineating the profile and fate of the methadone dropout. The present report focuses on a group of chronic heroin abusers who: (1) previously had failed on a methadone program (2) subsequently were institutionalized in a correctional facility, and (3) were paroled to a community-based abstinence program. The study addresses itself to the following questions: What are some of the experiences (expectations, fears, drug effects, disappointments, etc) that ex-methadone patients retrospectively associate with their methadone participation? Do methadone dropouts differ on social-demographic and criminal history variables from addict-parolees who never participated in a methadone maintenance program ? What will be the adjustment course in an abstinence program of ex-methadone patients compared to a coh...

Guided preparedness planning with lay communities: enhancing capacity of rural emergency response through a systems-based partnership

INTRODUCTION Community disaster preparedness plans, particularly those with content that would mitigate the effects of psychological trauma on vulnerable rural populations, are often nonexistent or underdeveloped. The purpose of the study was to develop and evaluate a model of disaster mental health preparedness planning involving a partnership among three, key stakeholders in the public health system. METHODS A one-group, post-test, quasi-experimental design was used to assess outcomes as a function of an intervention designated Guided Preparedness Planning (GPP). The setting was the eastern-, northern-, and mid-shore region of the state of Maryland. Partner participants were four local health departments (LHDs), 100 faith-based organizations (FBOs), and one academic health center (AHC)-the latter, collaborating entities of the Johns Hopkins University and the Johns Hopkins Health System. Individual participants were 178 community residents recruited from counties of the above-referenced geographic area. Effectiveness of GPP was based on post-intervention assessments of trainee knowledge, skills, and attitudes supportive of community disaster mental health planning. Inferences about the practicability (feasibility) of the model were drawn from pre-defined criteria for partner readiness, willingness, and ability to participate in the project. Additional aims of the study were to determine if LHD leaders would be willing and able to generate post-project strategies to perpetuate project-initiated government/faith planning alliances (sustainability), and to develop portable methods and materials to enhance model application and impact in other health jurisdictions (scalability). RESULTS The majority (95%) of the 178 lay citizens receiving the GPP intervention and submitting complete evaluations reported that planning-supportive objectives had been achieved. Moreover, all criteria for inferring model feasibility, sustainability, and scalability were met. CONCLUSIONS Within the span of a six-month period, LHDs, FBOs, and AHCs can work effectively to plan, implement, and evaluate what appears to be an effective, practical, and durable model of capacity building for public mental health emergency planning.

The Development of a Model of Psychological First Aid for Non-Mental Health Trained Public Health Personnel: The Johns Hopkins RAPID-PFA

INTRODUCTION The Johns Hopkins Center for Public Health Preparedness, which houses the Centers for Disease Control and Prevention-funded Preparedness and Emergency Response Learning Center, has been addressing the challenge of disaster-caused behavioral health surge by conducting training programs in psychological first aid (PFA) for public health professionals. This report describes our approach, named RAPID-PFA, and summarizes training evaluation data to determine if relevant knowledge, skills, and attitudes are imparted to trainees to support effective PFA delivery. BACKGROUND/RATIONALE In the wake of disasters, there is an increase in psychological distress and dysfunction among survivors and first responders. To meet the challenges posed by this surge, a professional workforce trained in PFA is imperative. METHODS/ACTIVITY More than 1500 participants received a 1-day RAPID-PFA training. Pre-/postassessments were conducted to measure (a) required knowledge to apply PFA; (b) perceived self-efficacy, that is, belief in ones own ability, to apply PFA techniques; and (c) confidence in ones own resilience in a crisis context. Statistical techniques were used to validate the extent to which the survey successfully measured individual PFA constructs, that is, unidimensionality, and to quantify the reliability of the assessment tool. RESULTS/OUTCOME Statistically significant pre-/postimprovements were observed in (a) knowledge items supportive of PFA delivery, (b) perceived self-efficacy to apply PFA interventions, and (c) confidence about being a resilient PFA provider. Cronbach alpha coefficients ranging from 0.87 to 0.90 suggested that the self-reported measures possessed sufficient internal consistency. DISCUSSION Findings were consistent with our pilot work, and with our complementary research initiatives validating a variant of RAPID-PFA with faith communities. LESSONS LEARNED/NEXT STEPS The RAPID-PFA model promises to be a broadly applicable approach to extending community behavioral health surge capacity. Relevant next steps include evaluating the effectiveness of trained providers in real crisis situations, and determining if PFA training may have potential beyond the disaster context.

An academic-government-faith partnership to build disaster mental health preparedness and community resilience

Objectives. Faculty and affiliates of the Johns Hopkins Preparedness and Emergency Response Research Center partnered with local health departments and faith-based organizations to develop a dual-intervention model of capacity-building for public mental health preparedness and community resilience. Project objectives included (1) determining the feasibility of the tri-partite collaborative concept; (2) designing, delivering, and evaluating psychological first aid (PFA) training and guided preparedness planning (GPP); and (3) documenting preliminary evidence of the sustainability and impact of the model. Methods. We evaluated intervention effectiveness by analyzing pre- and post-training changes in participant responses on knowledge-acquisition tests administered to three urban and four rural community cohorts. Changes in percent of correct items and mean total correct items were evaluated. Criteria for model sustainability and impact were, respectively, observations of non-academic partners engaging in efforts to advance post-project preparedness alliances, and project-attributable changes in preparedness-related practices of local or state governments. Results. The majority (11 of 14) test items addressing technical or practical PFA content showed significant improvement; we observed comparable testing results for GPP training. Government and faith partners developed ideas and tools for sustaining preparedness activities, and numerous project-driven changes in local and state government policies were documented. Conclusions. Results suggest that the model could be an effective approach to promoting public health preparedness and community resilience.

Building a national model of public mental health preparedness and community resilience: validation of a dual-intervention, systems-based approach.

OBJECTIVE Working within a series of partnerships among an academic health center, local health departments (LHDs), and faith-based organizations (FBOs), we validated companion interventions to address community mental health planning and response challenges in public health emergency preparedness. METHODS We implemented the project within the framework of an enhanced logic model and employed a multi-cohort, pre-test/post-test design to assess the outcomes of 1-day workshops in psychological first aid (PFA) and guided preparedness planning (GPP). The workshops were delivered to urban and rural communities in eastern and midwestern regions of the United States. Intervention effectiveness was based on changes in relevant knowledge, skills, and attitudes (KSAs) and on several behavioral indexes. RESULTS Significant improvements were observed in self-reported and objectively measured KSAs across all cohorts. Additionally, GPP teams proved capable of producing quality drafts of basic community disaster plans in 1 day, and PFA trainees confirmed upon follow-up that their training proved useful in real-world trauma contexts. We documented examples of policy and practice changes at the levels of local and state health departments. CONCLUSIONS Given appropriate guidance, LHDs and FBOs can implement an effective and potentially scalable model for promoting disaster mental health preparedness and community resilience, with implications for positive translational impact.

Preparing for an Influenza Pandemic: Mental Health Considerations

There is a common belief that an influenza pandemic not only is inevitable, but that it is imminent. It is further believed by some, and dramatized by a 2006 made-for-television-movie, that such a pandemic will herald an end to life as we know it. Are such claims hyperboles, or does a pandemic represent the most significant threat to public health in the new millennium? Any potential effects of a disease on a population are mediated not only through the pathophysiological mechanisms of the disease itself, but through the psychological and behavioral reactions that such a disease might engender. It is the purpose of this paper to explore the potential psychological and behavioral reactions that may accompany an influenza pandemic.