Theodore V. Parran

Comparison of pregnancy-specific interventions to a traditional treatment program for cocaine-addicted pregnant women

Alcohol and drug use in pregnancy is a significant concern. There is a paucity of treatment programs for substance-abusing pregnant women, especially if indigent. Furthermore, treatment retention is compromised when the drug of choice is crack-cocaine. This paper reports the results of a study comparing treatment retention of cocaine-abusing indigent pregnant women before and after incorporating pregnancy-specific interventions. Audits were performed on 603 charts of women enrolled between 1988 and 1994 in either a traditional treatment program (n = 114) or in the Pregnancy Substance Abuse Program (PSAP) (n = 489). Differences in treatment retention were found between the two treatment groups. Drop-out rates from the inpatient component of treatment were significantly lower in the PSAP group than in the control group (11.3% vs. 38.6%, p < .001). There was a higher rate of completion of outpatient treatment in the PSAP compared to the control group (34.4% vs. 13.5%, p < .005). These results were achieved with a 2-day decreased inpatient stay. Treatment retention improved when specialized interventions were provided, at minimal additional cost. These results have implications for other publicly funded treatment programs.

Tramadol versus buprenorphine for the treatment of opiate withdrawal: a retrospective cohort control study.

Abstract Various drugs have been used for the treatment of opioid withdrawal, e.g., methadone, buprenorphine, and clonidine. Tramadol is a centrally acting synthetic analgesic agent with opiate activity due to low affinity binding of the parent compound and higher affinity binding of the Odemethylated metabolite M1 to opioid receptors. As a consequence, there may be a role for the use of tramadol in the treatment of opiate withdrawal. We attempt to assess the efficacy of tramadol in treating moderate heroin withdrawal through a retrospective cohort control study, conducted in a detoxification unit in a community teaching hospital. Out of 100 heroin abusers admitted for detoxification during the review period, 64 patients who were treated either with buprenorphine or tramadol, were included in this study, with 20 participants in the buprenorphine group and 44 in the tramadol group. Both groups were matched for age, sex, and self—reported average quantity of heroin used per day. In the tramadol group, the average CINA maximum was 9.0, and in the buprenorphine group it was 11.2 (P =0.07). The use of oral clonidine per patient in the tramadol group was 1.6 tablets, and in the buprenorphine group 0.1 tablets (P =0.002). The length of stay was 3.7 days in the tramadol group and 4.1 days in the buprenorphine group (P =0.5). Four participants in the tramadol group received three or more doses of buprenorphine because their symptoms were not controlled, and were considered as treatment failures. These preliminary data suggest that tramadol may be comparable to buprenorphine in the management of mild to moderately severe heroin withdrawal. These findings, if reproduced in larger studies with stronger research designs, have potentially great implications for the management of opioid withdrawal in both the inpatient and outpatient setting.

A teachable moment communication process for smoking cessation talk: description of a group randomized clinician-focused intervention

BackgroundEffective clinician-patient communication about health behavior change is one of the most important and most overlooked strategies to promote health and prevent disease. Existing guidelines for specific health behavior counseling have been created and promulgated, but not successfully adopted in primary care practice. Building on work focused on creating effective clinician strategies for prompting health behavior change in the primary care setting, we developed an intervention intended to enhance clinician communication skills to create and act on teachable moments for smoking cessation. In this manuscript, we describe the development and implementation of the Teachable Moment Communication Process (TMCP) intervention and the baseline characteristics of a group randomized trial designed to evaluate its effectiveness.Methods/DesignThis group randomized trial includes thirty-one community-based primary care clinicians practicing in Northeast Ohio and 840 of their adult patients. Clinicians were randomly assigned to receive either the Teachable Moments Communication Process (TMCP) intervention for smoking cessation, or the delayed intervention. The TMCP intervention consisted of two, 3-hour educational training sessions including didactic presentation, skill demonstration through video examples, skills practices with standardized patients, and feedback from peers and the trainers. For each clinician enrolled, 12 patients were recruited for two time points. Pre- and post-intervention data from the clinicians, patients and audio-recorded clinician‒patient interactions were collected. At baseline, the two groups of clinicians and their patients were similar with regard to all demographic and practice characteristics examined. Both physician and patient recruitment goals were met, and retention was 96% and 94% respectively.DiscussionFindings support the feasibility of training clinicians to use the Teachable Moments Communication Process. The next steps are to assess how well clinicians employ these skills within their practices and to assess the effect on patient outcomes.Trial RegistrationClinicalTrials.gov Identifier: NCT01575886

The Use of Tramadol for Acute Heroin Withdrawal: A Comparison to Clonidine.

Abstract Using a retrospective chart review, 59 patients detoxified with tramadol were compared to 85 patients detoxified with clonidine on rates of leaving against medical advice (AMA) and control of withdrawal symptoms. Patients detoxified with tramadol had 23% (95% CI, 0.09–0.59; P < .01) the risk of leaving AMA and scored an average of 0.24 points lower (95% CI, 0.08–0.41; P < .01) on a 0-3 point withdrawal symptom scale compared to patients detoxified with clonidine. This preliminary study indicates that tramadol is more effective in managing withdrawal than clonidine, and may be especially useful in outpatient detoxification.

A Buprenorphine Stabilization and Rapid-Taper Protocol for the Detoxification of Opioid-Dependent Patients

Management of hospitalized opioid-dependent patients can be problematic at times, especially when patients are medically unstable, elderly, or have acute or chronic pain syndromes. The authors report a case series of 65 patients detoxified on 74 separate occasions with the use of the partial μ-agonist buprenorphine. The buprenorphine was administered subcutaneously as an initial stabilization dose, after which patients received a rapid taper over approximately 6 days. Ninety-seven percent (n=72) of the 74 episodes of detoxification were successfully managed with buprenorphine; 62% (n = 40) of the patients bad no symptoms of opioid withdrawal. All patients reported that this detoxification protocol was as comfortable or more comfortable than any previously encountered withdrawal experience. The results of this case series provide strong support for further studies of the role of buprenorphine in the short-term detoxification of hospitalized opioid-dependent patients.

Is screening and brief advice for problem drinkers by clergy feasible? A survey of clergy

Routine screening for alcohol abuse in primary care, with brief advice to stop drinking for those screening positive, can detect individuals with alcohol problems and reduce alcohol use and alcohol induced problems in those detected. Not everyone with alcohol problems sees a physician regularly, however, and not all respond to a physicians brief advice. To explore the feasibility of expanding screening for alcohol problems to clergy, we did a mailed survey to 315 clergy at Christian churches in Cleveland, Ohio. Clergy reported a variety of views about alcohol use and abuse, but most agreed that alcoholism is a disease. They indicated counseling a significant number of parishioners, and were receptive to learning brief screening questions to detect alcohol problems. We conclude that many clergy would be interested in a strategy of screening and then giving brief advice or referral to individuals found to have alcohol problems.

The role of disabled physicians in the diversion of controlled drugs

Abstract To test the assertion that disabled physicians are loose prescribers and clinically meaningful contributors to the diversion of controlled prescriptions, an anonymous survey of physicians in a confidential treatment program in Ohio was conducted to compare pre- and post-recovery: (1) self-reported number of controlled drug prescriptions written, and (2) self-rated appropriateness of prescribing practices. Forty (50%) of the surveyed physicians responded. Opioids alone showed a post recovery reduction in the number of prescriptions (-4.5; 95% CI: −9.5 to −0.5). The volume of prescribing in all controlled drug categories was small from both a law enforcement and clinical perspective. Respondents self-assessment of prescribing practices indicated conservative pre-, and more conservative post-recovery prescribing, increasing from 2.0 in stimulants (CI: 1.0-4.0), to 3.5 in sedatives (CI: 1.0-6.0). Despite limitations, this initial data provides evidence to refute the assertion that disabled physicians are loose prescribers and meaningful contributors to the diversion of controlled prescriptions.

Access to and Payment for Office-Based Buprenorphine Treatment in Ohio:

Importance: Office-based opiate agonist therapy has dramatically expanded access to medication-assisted treatment over the past decade but has also led to increased buprenorphine diversion. Objective: Our study sought to characterize physicians who participate in office-based therapy (OBT) to assess patient access to OBT in Ohio 10 years after its introduction. Design/Setting/Participants: Cross-sectional telephone survey of Drug Addiction Treatment Act–waivered physicians in Ohio listed by the Center for Substance Abuse Treatment (CSAT). Main Outcomes: This study sought to determine what proportion of eligible physicians are actively prescribing buprenorphine, whether they accept insurance for OBT, and whether they accept insurance for non-OBT services. In addition, we evaluated what physician characteristics predicted those primary outcomes. We hypothesized that a significant minority of eligible physicians are not active prescribers of buprenorphine. In addition, we expected that a significant minority of OBT prescribers do not accept insurance, further restricting patient access. We further hypothesized that a large subset of OBT prescribers accept insurance in their regular practices but do not take insurance for OBT. Results: Of the 466 listed physicians, 327 (70.2%) practice representatives were reached for interview. Thirty-three physicians were excluded, with a true response rate of 75.5%. In total, 80.7% of providers reached were active OBT prescribers. Of these, 52.7% accepted insurance for OBT, 20.8% accepted insurance for non-OBT services but not for OBT, and 26.5% did not accept insurance for any services. Practices who did not accept insurance were more likely among dedicated addiction clinics located outside of Ohio’s 6 major cities. Practices who normally accepted insurance but did not for OBT services were more likely in urban locations and were not associated with dedicated addiction practices. Neither business practice was associated with physician specialty Conclusions and Relevance: Access to OBT in Ohio is far lower than what the 466 listed physicians suggests. Nearly 1 in 5 of those physicians are not active OBT prescribers, and 1 in 2 active prescribers do not accept insurance for OBT. Further research is needed to determine whether practices who do not accept insurance provide care consistent with CSAT guidelines and whether such practice patterns contribute to buprenorphine diversion.