Sarah E. Wakeman

Medicine and the Epidemic of Incarceration in the United States

Mental illness and substance use and dependence, among other medical conditions, are highly prevalent in the vast incarcerated population of the United States. But correctional facilities are fundamentally designed to confine and punish, not to treat disease.

Filling the Gap: The Importance of Medicaid Continuity for Former Inmates

ABSTRACTDespite no federal law mandating Medicaid termination for prisoners, 90 percent of states have implemented policies that withdraw inmates’ enrollment upon incarceration. This leaves a medically and psychiatrically vulnerable population uninsured during the months following release, a time period during which former inmates have been shown to have an increased risk of medical problems and death. We believe it is of critical importance for the 10 million Americans who cycle in and out of corrections each year, as well as the communities they return to, that Medicaid be suspended rather than terminated during incarceration.

Preventing Death Among the Recently Incarcerated: An Argument for Naloxone Prescription Before Release

ABSTRACT Death from opiate overdose is a tremendous source of mortality, with a heightened risk in the weeks following incarceration. The goal of this study is to assess overdose experience and response among long-term opiate users involved in the criminal justice system. One hundred thirty-seven subjects from a project linking opiate-dependent individuals being released from prison with methadone maintenance programs were asked 73 questions regarding overdose. Most had experienced and witnessed multiple overdoses; 911 was often not called. The majority of personal overdoses occurred within 1 month of having been institutionalized. Nearly all participants expressed an interest in being trained in overdose prevention with Naloxone. The risk of death from overdose is greatly increased in the weeks following release from prison. A pre-release program of overdose prevention education, including Naloxone prescription, for inmates with a history of opiate addiction would likely prevent many overdose deaths.

Stop Talking ‘Dirty’: Clinicians, Language, and Quality of Care for the Leading Cause of Preventable Death in the United States

A patient with diabetes has “an elevated glucose” level. A patient with cardiovascular disease has “a positive exercise tolerance test” result. A clinician within the health care setting addresses the results. An “addict” is not “clean”—he has been “abusing” drugs and has a “dirty” urine sample. Someone outside the system that cares for all other health conditions addresses the results. In the worst case, the drug use is addressed by incarceration. On December 9, 2013, the first ever national drug policy reform summit was held at the White House. A major thrust of this summit was to mark a philosophical shift away from the “war on drugs” and toward a broader public health approach. Much of the summit was devoted to addressing the stigma surrounding addiction and the under-recognized importance of language. Stigma is defined as an attribute, behavior, or condition that is socially discrediting. It is important because of the 23 million Americans who meet criteria for a substance use disorder each year, only 10% access treatment, and stigma is a major barrier to seeking help. A World Health Organization study of the 18 most stigmatized social problems (including criminal behavior) in 14 countries found that drug addiction was ranked number 1, and alcohol addiction was ranked number 4. There are 2 main factors that influence stigma: cause and controllability. Stigma decreases when people perceive that the individual is not responsible for causing his/her problem (ie, “It’s not his fault”) and when he or she is unable to control it (ie, “She can’t help it”). Research has taught us that half the risk for addiction is conferred by genetics. In addition, the chronic effects of substances on the central nervous system produce profound changes in brain structure and function that radically impair efforts to control use,

Internal Medicine Residents’ Training in Substance Use Disorders: A Survey of the Quality of Instruction and Residents’ Self-Perceived Preparedness to Diagnose and Treat Addiction

ABSTRACT Background: Resident physicians are the direct care providers for many patients with addiction. This study assesses residents’ self-perceived preparedness to diagnose and treat addiction, measures residents’ perceptions of the quality of addictions instruction, and evaluates basic knowledge of addictions. Methods: A survey was e-mailed to 184 internal medicine residents at Massachusetts General Hospital in May 2012. Results: Responses were obtained from 55% of residents. Residents estimated that 26% of inpatients they cared for met criteria for a substance use disorder (SUD). Twenty-five percent of residents felt unprepared to diagnose and 62% felt unprepared to treat addiction. Only 13% felt very prepared to diagnose addiction. No residents felt very prepared to treat addiction. Preparedness to diagnose or treat addiction did not differ significantly across postgraduate year (PGY) level. Fifty-five percent rated the overall instruction in addictions as poor or fair. Seventy-two percent of residents rated the quality of addictions training as poor or fair in the outpatient clinical setting, and 56% in the inpatient setting. No resident answered all 6 knowledge questions correctly. Slightly more than half correctly identified the mechanism of buprenorphine and 19% correctly answered a question about naltrexone. Nine percent of residents responded that someone had expressed concern about the respondents substance use. Conclusions: Despite providing care for a substantial population with addiction, the majority of internal medicine residents in this study feel unprepared to treat SUDs. More than half rate the quality of addictions instruction as fair or poor. Structured and comprehensive addictions curriculum and faculty development are needed to address the deficiencies of the current training system.

HIV-2 diagnosis and quantification in high-risk patients

Current diagnostic assays for HIV-1 do not always test for the presence of HIV-2 in the United States. We present the case of a patient from Cape Verde, who was admitted to our hospital with rapidly deteriorating neurological function and multiple white matter lesions on MRI likely secondary to progressive multifocal leukoencephalopathy (PML). Initially, the patient had a positive EIA for HIV, but a negative HIV-1 Western Blot and no viral load detected on a branched-DNA assay. A repeat viral load by reverse transcriptase methodology (RT-DNA) detected 121,000 copies and an HIV-2 Western Blot was positive. The case highlights an extremely rare presentation of HIV-2 with severe neurological disease. We discuss the different tests available for the diagnosis and monitoring of HIV-2 in the United States.

Language, Substance Use Disorders, and Policy: The Need to Reach Consensus on an “Addiction-ary”

ABSTRACT The language used to describe health conditions reflects and influences our attitudes and approaches to addressing them, even to the extent of suggesting that a health condition is a moral, social, or criminal issue. The language and terminology we use is particularly important when it comes to highly stigmatized and life-threatening conditions, such as those relating to alcohol and other drugs. Scientific research has demonstrated that, whether we are aware of it, the use of certain terms implicitly generates biases that can influence the formation and effectiveness of our social and public health policies in addressing them. Such research has made it difficult to trivialize or dismiss the terminology debate as merely “semantics” or a linguistic preference for “political correctness.” Furthermore, given that alcohol and other drug-related conditions are among the top public health concerns in the United States and in most English speaking countries globally (e.g., United Kingdom, Australia, Ireland), this is no trivial matter. In this article, the authors detail the conceptual and empirical basis for the need to avoid using certain terms and to reach consensus on an “addiction-ary.” The authors conclude that consistent use of agreed-upon terminology will aid precise and unambiguous clinical and scientific communication and help reduce stigmatizing and discriminatory public health and social policies.

Attitudes, practices, and preparedness to care for patients with substance use disorder: Results from a survey of general internists.

ABSTRACT Background: Previous research demonstrates that most primary care physicians feel unprepared to diagnose and treat substance use disorder (SUD). Confidence in SUD management has been associated with improved clinical practices. Methods: A cross-sectional survey of 290 inpatient and outpatient general internists in an academic medical center evaluating attitudes, preparedness, and clinical practice related to SUD. Results: 149 general internists responded, a response rate of 51%. Forty-six percent frequently cared for patients with SUD. Sixteen percent frequently referred patients to treatment and 6% frequently prescribed a medication to treat SUD. Twenty percent felt very prepared to screen for SUD, 9% to provide a brief intervention, 7% to discuss behavioral treatments, and 9% to discuss medication treatments. Thirty-one percent felt that SUD is different from other chronic diseases because they believe using substances is a choice. Fourteen percent felt treatment with opioid agonists was replacing one addiction with another. Twelve percent of hospitalists and 6% of PCPs believe that someone who uses drugs is committing a crime and deserves punishment. Preparedness was significantly associated with evidence-based clinical practice and favorable attitudes. Frequently caring for patients with SUD was significantly associated with preparedness, clinical practice, and favorable attitudes. Conclusions: SUD is a treatable and prevalent disease, yet a majority of general internists do not feel very prepared to screen, diagnose, provide a brief intervention, refer to treatment, or discuss treatment options with patients. Very few frequently prescribe medications to treat SUD. Some physicians view substance use as a crime and a choice. Physician preparedness and exposure to SUD is associated with improved clinical practice and favorable attitudes towards SUD. Physicians need education and support to provide better care for patients with SUD.

Medications For Addiction Treatment: Changing Language to Improve Care

The term medication-assisted treatment has been widely adopted in reference to the use of opioid agonist therapy. Although it is arguably better than the older terms of replacement or substitution therapy, medication-assisted treatment implies that medications are a corollary to whatever the main part of treatment is. No other medication for other health conditions is referred to this way. It has finally been recognized that to improve care and reduce stigma, we must use medically accurate and person-first language, describing those with the disease of addiction as people with substance use disorder. However, to truly change outcomes, we must also alter the language of treatment.

The opioid epidemic and new legislation in Massachusetts: Time for a culture change in surgery?

B etween 1999 and 2008, the rate of overdose deaths from prescription opioid pain relievers (OPR) in the United States increased 4-fold. This alarming increase in OPR-related death rate was paralleled by a simultaneous increase in the sales of OPR, and also an increase in the rate of admissions for opioid use disorder treatment nationally. Since then, the OPR overdose epidemic continued to worsen, with unintentional drug overdose now becoming the leading cause of accidental death in the United States, killing more Americans than motor vehicle crashes or firearms. Prescription opioids account for the greatest number of drug-related deaths in the United States: of 47,055 drug overdose deaths in 2014, 18,893 were related to OPR and 10,574 to heroin. Among individuals who have used an OPR for a nonmedical reason, 69% report getting the medication from a friend or relative, the majority of whom received the original prescriptions from a single physician. Massachusetts has been hit particularly hard by the opioid epidemic. In 2013, poisoning and overdoses were the leading cause of injury in the state, accounting for 37% of deaths, compared with falls and motor vehicle crashes that accounted for 20% and 11% of injury deaths, respectively. Examination of this trend reveals the driving role opioids have played in these trends: from 2009 to 2013, the rate of opioid overdoses in Massachusetts increased from 9.6 per 100,000 people to 14.2 per 100,000 people. In addition to the death toll, for every opioid overdose death in Massachusetts, there were twice as many hospitalizations and 4 times as many emergency room visits for nonfatal opioid overdose, resulting in a substantial burden on the healthcare system. In response to the opioid epidemic, Massachusetts Governor Baker proposed a comprehensive legislation in late 2015. After multiple revisions, The STEP Act, an act relative to Substance use, Treatment, Education, and Prevention, was signed into effect in March 2016. The law detailed several components focused on OPR prescription. Table 1 illustrates some of the key parts of the law that surgeons in Massachusetts not only need to understand but also need to legally abide by. Although it is likely too early to fully understand the new opioid law in Massachusetts, interpret its mandates, or even get a sense of the degree to which it will be strictly enforced, 1 thing is now clear: our current approach to acute perioperative pain relief, as surgeons, needs to change. The predominant opioid-centric habits and traditions of OPR prescriptions in surgical fields have partially contributed to the epidemic, and a culture change in perioperative pain management is needed. Such a change will not be fast or easy and will require funds and resources, as it will probably affect multiple aspects of the surgical patient care that we cannot yet fathom, including current surgical and clinic workflow, patient expectations for perioperative pain, and the patient’s care satisfaction. Patientcentered outcomes including patients’ perception of the quality of care they receive [eg, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores] might be negatively affected by limiting OPR use unless patients’ expectations are addressed and managed a priori. Several experts understandably debate the misconception that prescribing more opioids creates better patient satisfaction, but the message remains clear either way: preoperative empathetic discussions with the patients to optimize their coping mechanisms and the design of pathways for pain management that are not opioid-centric are both essential. The Massachusetts General Hospital (MGH) is one of the 2 major hospitals of Partners Healthcare, the largest private employer and the biggest healthcare provider in the Boston Metropolitan area, serving more than a third of its population. MGH and its physician organization, the Massachusetts General Physicians Organization (MGPO), recognizing the need for a comprehensive strategy to support patients and prescribing physicians alike, established a multidisciplinary opioid task force in late 2015 with one of its goals being to provide guidance regarding the use of opioid