Reasons for Optimism About Academic Medicine's Actions Against Climate Change.

Since the first mention of climate change in Academic Medicine in 2009, the pace of the climate crisis has accelerated, its impacts on every facet of planetary health have grown more severe, and the urgency for humans to act has become more dire. Medical schools, teaching hospitals and health systems, universities, affiliated organizations, and the millions of people who traverse the halls of these institutions as leaders, physicians, scientists, educators, learners, patients and families, and community members have an obligation to respond. In this commentary, the authors describe 3 reasons they are optimistic that academic medicine will continue to act against climate change. First, the mission of academic medicine, inherently aligned with climate action, propels teaching hospitals and health systems to address climate change to improve the health of patients, families, and communities. Second, younger generations of learners, faculty, and staff who populate the workforce increasingly desire, and often demand, to work at institutions that are aligned with their personal values for climate action. Third, broader forces are pushing academic medicine forward in action against climate change. Economic factors will continue to reduce the cost and increase the return on investment of climate-smart facilities, purchased goods and services, fuel, transportation, food systems, and waste management. The authors are optimistic but not complacent. Current levels of climate action in academic medicine are not nearly enough. Faculty, staff, learners, leaders, patients and families, and community partners can and must apply a "climate lens" to everything they do: weave climate solutions into education, patient care, research, community collaborations, operations, and supply chain and facility management; integrate climate actions into strategic thinking, planning, and doing; address health inequities and climate injustice; and leverage their trusted voices to press for climate action and climate justice in the health sector and in society.

Risk for Substance Use Disorders in young adulthood: Associations with developmental experiences of homelessness, foster care, and adverse childhood experiences.

BACKGROUND: Multiple developmental risk factors for Substance Use Disorders (SUDs) during young adulthood have been identified. In this investigation, we examined the impact of homelessness, foster care, and adverse childhood experiences (ACEs) prior to 12th grade on the development of three common SUDs during young adulthood-Alcohol Use Disorder (AUD), Tobacco Use Disorder (TUD) and Cannabis Use Disorder (CUD). Our hypothesis was that while both homelessness and ACEs are significant risk factors for young adult SUDs, foster care involvement might convey protection. METHODS: Using nationally representative data from the National Longitudinal Study of Adolescent to Adult Health, measures of ACEs were derived from the CDC-Kaiser ACE study, and DSM-V SUD diagnoses were derived from items originally based on DSM-IV. SUD diagnoses were binned into "mild", "moderate", and "severe" groupings. Survey-based logistic models were used to estimate risks of SUDs while controlling for demographics. RESULTS: The results suggest that the experience of homelessness prior to 12th grade in addition to ACEs were significantly associated with the development in young adulthood of the most severe forms of AUD and TUD and all severity levels of CUD. Foster care was not associated with either risk or protection from SUDs. CONCLUSIONS: The experience of homelessness during development may be viewed as another detrimental ACE that is a risk factor for the most common SUDs in young adulthood. Given the magnitude of the current epidemic of homelessness in the U.S., these results should raise substantial concern.

Engaging Stakeholders in the Healthy Campus Movement.

BACKGROUND: Institutions of higher education are increasingly attending to the health of their campus community. This article reports on a Healthy Campus Initiative (HCI) to build a culture of health. OBJECTIVES: Evaluate the applicability of the four action areas of the Robert Wood Johnson Foundation Culture of Health Framework to campus health and discuss challenges and lessons learned. METHODS: Observational, qualitative, and quantitative data were collected to describe partnership development, key stakeholder engagement, and stakeholder perceptions of healthy campus activity between 2016 and fall 2018. RESULTS: This initiative aligned with 3 of the four action areas of the Culture of Health Framework by making campus health as a shared value, fostering campus and local community collaborations, and creating a healthier and more equitable campus community. CONCLUSIONS: For institutions of higher education, the Culture of Health Framework is ideal to engage stakeholders to take action to create and build cultures of health.

Carbohydrate deficient transferrin (CDT) predicts heavy drinking in adolescents with alcohol dependence.

A biomarker that could indicate problematic drinking in adolescents and/or reflect changes in heavy drinking would be a valuable addition to prevention, treatment, and research efforts. Carbohydrate deficient transferrin (CDT) is a valid biomarker of heavy drinking in adults; however, it is not well examined in adolescents. Adolescents with alcohol dependence (AD) (n = 21; 9 females) and non-dependent controls (ND) (n = 6; 3 females), ages 14-20, were interviewed to determine drinks per drinking day, peak number of drinks, and percent days heavy drinking (≥4 standard drinks/day). Blood samples from participants were assayed for percent of transferrin that was carbohydrate deficient (%CDT). Analyses compared groups on drinking and %CDT, examined the relationship between %CDT and indices of drinking, and provided preliminary estimates of the test validity of %CDT for heavy drinking in adolescents. Among adolescents with AD, %CDT was significantly and strongly correlated (r = .54) with percent heavy drinking days, and this relationship was consistent for both males and females. AD adolescents did not differ from ND on mean %CDT levels, despite significantly greater alcohol use. Indicators of test validity showed that %CDT had low sensitivity (33%) but adequate specificity (83%) for heavy drinking. Results provide proof of concept that %CDT is a potentially valuable tool to use in alcohol treatment and research in adolescents. Even if %CDT does not discriminate between adolescents with and without alcohol dependence, it could be an effective monitoring tool to indicate changes over time in binge drinking. Improved %CDT measurement methods might enhance its utility.

An Internet-Based Radiology Course in Medical School: Comparison of Academic Performance of Students on Campus Versus Those With Absenteeism Due to Residency Interviews.

BACKGROUND: Imaging and its optimal use are imperative to the practice of medicine, yet many students don't receive a formal education in radiology. Concurrently, students look for ways to take time away from medical school for residency interviewing. Web-based instruction provides an opportunity to combine these imperatives using online modalities. OBJECTIVE: A largely Web-based course in radiology during the 4th year of medical school was evaluated both for its acceptance to students who needed to be away from campus for interviews, and its effectiveness on a nationally administered standardized test. METHODS: All students were placed into a structured program utilizing online videos, online modules, online textbook assignments, and live interactive online lectures. Over half of the course could be completed away from campus. The Alliance of Medical Student Educators in Radiology test exam bank was used as a final exam to evaluate medical knowledge. RESULTS: Positive student feedback included the freedom to travel for interviews, hands-on ultrasound training, interactive teaching sessions, and quality Web-based learning modules. Negative feedback included taking quizzes in-person, a perceived outdated online textbook, and physically shadowing hospital technicians. Most students elected to take the course during the interview months of October through January. The Alliance of Medical Student Educators in Radiology final exam results (70.5%) were not significantly different than the national cohort (70%) who took the course in-person. Test scores from students taking the course during interview travel months were not significantly different from students who took the course before (P=.30) or after (P=.34) the interview season. CONCLUSIONS: Students desire to learn radiology and often choose to do so when they need to be away from campus during the fall of their 4th year of study to accomplish their residency interviews. Web-based education in radiology allows students' interview traveling and radiology course objectives to be successfully met without adversely affecting the outcomes on a nationally normed examination in radiology. A curriculum that includes online content and live Web-based teleconference access to faculty can accomplish both imperatives.

Improving diversity through strategic planning: a 10-year (2002-2012) experience at theMedical University of South Carolina.

The Medical University of South Carolina launched a systematic plan to infuse diversity among its students, resident physicians, and faculty in 2002. The dean and stakeholders of the College of Medicine (COM) embraced the concept that a more population-representative physician workforce could contribute to the goals of providing quality medical education and addressing health care disparities in South Carolina. Diversity became a central component of the COM's strategic plan, and all departments developed diversity plans consistent with the overarching plan of the COM. Liaisons from the COM diversity committee facilitated the development of the department's diversity plans. By 2011, the efforts resulted in a doubling of the number of underrepresented-in-medicine (URM, defined as African American, Latino, Native American) students (21% of student body); matriculation of 10 African American males as first-year medical students annually for four consecutive years; more than a threefold increase in URM residents/fellows; expansion of pipeline programs; expansion of mentoring programs; almost twice as many URM faculty; integration of cultural competency throughout the medical school curriculum; advancement of women and URM individuals into leadership positions; and enhanced learning for individuals from all backgrounds. This article reports the implementation of an institutional plan to create a more racially representative workforce across the academic continuum. The authors emphasize the role of the stakeholders in promoting diversity, the value of annual assessment to evaluate outcomes, and the positive benefits for individuals of all backgrounds.

Bupropion SR and contingency management for adolescent smoking cessation.

There is a significant need for evidence-based treatments for adolescent smoking cessation. Prior research, although limited, has suggested potential roles for bupropion sustained-release (SR) and contingency management (CM), but no previous studies have assessed their combined effect. In a double-blind, placebo-controlled design, 134 adolescent smokers were randomized to receive a 6-week course of bupropion SR + CM, bupropion SR + non-CM, placebo + CM, or placebo + non-CM, with final follow-up at 12 weeks. The primary outcome was 7-day cotinine-verified point prevalence abstinence, allowing for a 2-week grace period. Combined bupropion SR + CM treatment yielded significantly superior abstinence rates during active treatment when compared with placebo + non-CM treatment. In addition, combined treatment showed greater efficacy at multiple time points than did either bupropion SR + non-CM or placebo + CM treatment. Combined bupropion SR and CM appears efficacious, at least in the short-term, for adolescent smoking cessation and may be superior to either intervention alone.

Stimulant formulation and motivation for nonmedical use of prescription attention-deficit/hyperactivity disorder medications in a college-aged population.

There is relatively little research examining motives for nonmedical use (NMU) of attention-deficit/hyperactivity disorder (ADHD) medications and predictors of motivation. We present results of a secondary analysis of an Internet-based epidemiological survey to explore the relationship between stimulant formulation and motivation for NMU of ADHD stimulant medications in a college-aged population. Demographic predictors of motivation to engage in NMU were also explored to investigate the potential correlates of recreational versus performance-enhancement motivations. Respondents scoring higher on the Adult ADHD Self-Report Scale were significantly more likely to engage in NMU of ADHD stimulant medications. Those using extended release (ER) stimulant formulations were less likely to endorse "staying awake" as a reason for NMU compared to those using immediate release (IR) stimulant formulations.

Current state of treatment for alcohol and other drug use disorders in adolescents.

Over the past decade, treatment programs have been developed specifically for adolescents with alcohol and other drug (AOD) use disorders. The vast majority of these programs use psychosocial approaches, which can be further classified into family-based interventions and multisystemic therapy, motivational enhancement therapy, behavioral therapy, and cognitive-behavioral therapy. Outcome studies have evaluated the effectiveness of the different approaches. The results indicate that all of these strategies can improve an adolescent's outcome on a variety of measures. Pharmacotherapy rarely is used in the treatment of adolescents with AOD use disorders, and existing studies only have assessed the effectiveness of agents aimed at treating coexisting psychiatric conditions. Future studies should use more consistent, state-of-the-art assessment instruments developed specifically for adolescents and also pay greater attention to an adolescent's developmental status and its impact on treatment outcome.

Evidence-based treatments for alcohol use disorders in adolescents.

The prevalence of adolescent alcohol use and its related consequences underscore the need for evidenced-based treatments in this population. During the past decade, much progress has been made in treating adolescent alcohol use disorders with evidenced-based modalities developed specifically for adolescents. Controlled treatment outcome studies that compared > or = 1 modality, used random assignment to treatment conditions, and were published between 1990 and 2004 are discussed in this review. Psychosocial treatments such as family-based interventions, motivational enhancement therapy (motivational interviewing), behavioral therapy, and cognitive-behavioral therapy, as well as the limited pharmacotherapy studies, are discussed. All of the studies used assessment tools validated for use in adolescent populations. Overall, great strides have been made in the area of adolescent alcohol treatment, and the treatment modalities presented have more than adequate potential for replication.

Adolescent substance abuse and psychiatric comorbidities.

The use and abuse of substances-including alcohol, nicotine, marijuana, inhalants, and other drugs-are commonly found to be comorbid with psychiatric conditions in adolescents. This dual diagnosis requires special attention and treatment, especially as substance use often begins during this developmental period. Adolescents may be diagnosed with substance abuse, substance dependence, or substance use disorder not otherwise specified, which indicates a developing substance use problem that includes symptoms of but does not meet criteria for substance dependence. Psychiatric comorbidity in adolescents who abuse substances is the rule rather the exception, and common comorbidities include depression, anxiety, bipolar disorder, conduct disorder, and attention-deficit/hyperactivity disorder. Treatment of the psychiatric disorder often helps to alleviate the substance use disorder as well. This activity discusses the epidemiology, assessment, and treatment of this dual diagnosis.

Adolescent substance abuse and psychiatric comorbidities.

Substance use disorders have a serious impact on adolescents because these disorders have high prevalence rates and frequent associations with psychiatric disorders. Surveys of adolescent behaviors and substance use show that alcohol is the most common substance abused by adolescents. Despite the high rates of current alcohol use and binge drinking among adolescents, current diagnostic criteria are problematic. Adolescents may have a developing problem with substance dependence but not meet criteria for either substance abuse or dependence. At-risk adolescents, called "diagnostic orphans," may meet only 1 or 2 criteria for alcohol dependence and no abuse criteria and therefore do not receive an alcohol use disorder diagnosis from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Adolescents with substance use disorders tend to have higher rates of comorbid psychiatric disorders and are more likely to report a history of trauma and physical and/or sexual abuse than adolescents without a substance use disorder. In addition, psychiatric disorders in adolescents often predate the substance use disorder. Once the substance use disorder develops, the psychiatric disorder may be further exacerbated.

Advances in diagnosis of adolescent substance abuse.

Screening and diagnosis of adolescent substance abuse is a challenging but achievable component of primary care practice. Successful integration of these procedures into office visits requires an understanding of prevalence, risk factors, and strategies for prevention and treatment. The authors provide a synopsis of recent advances and important issues in this area and propose a stepwise, evidence-based approach to evaluation of substance abuse in adolescents.

Naltrexone treatment of adolescent alcoholics: an open-label pilot study.

OBJECTIVE: This 6-week open-label trial of naltrexone was conducted in a preliminary fashion to determine whether naltrexone would be safe, well tolerated, and lead to a reduction in alcohol consumption in adolescents with alcohol dependence. METHOD: Five outpatient treatment-seeking adolescents who met Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria for alcohol dependence were recruited. The Child Schedule for Schizophrenia and Affective Disorders (K-SADS), Structured Clinical Interview for DSM (SCID), and the Family History Questionnaire were administered at baseline. The Time-Line Follow-Back (TLFB) and two craving scales (Adolescent Obsessive Compulsive Drinking Scale [A-OCDS] and a craving analog scale) were administered at baseline and weekly thereafter. Each subject received a 10-day supply of naltrexone (50 mg) and a 100-mg riboflavin capsule. Subjects were instructed to take naltrexone and riboflavin simultaneously. RESULTS: Overall, the average drinks per drinking day (DDD) decreased significantly from baseline to the end of week 6 with an average reduction of 7.61 standard drinks. There was a significant reduction in the average A-OCDS total score, A-OCDS Irresistibility subscale score, and craving analog score. Nausea was the only side-effect reported, and there were no elevations of liver enzymes. Naltrexone was well tolerated by the alcohol-dependent adolescent. CONCLUSIONS: Our data suggest that naltrexone is safe and well tolerated in adolescent alcoholics. Naltrexone may lead to a significant reduction in alcohol consumption and craving in adolescent alcoholics, but larger, randomized, controlled trials are needed.

Attention-deficit/hyperactivity disorder, medication treatment, and substance use patterns among adolescents and young adults.

OBJECTIVE: The aim of this study was to examine the relationship between current active attention-deficit/hyperactivity disorder (ADHD) symptoms, medication treatment, and substance use patterns among college students. METHOD: Three hundred and thirty-four students at a local college were surveyed for current ADHD symptoms and psychopharmacological treatment. The survey was conducted in conjunction with an annual national survey that probes students about their substance use patterns and attitudes. RESULTS: Participants with ADHD as ascertained by medication treatment of ADHD had greater past-year tobacco and marijuana use. Among those with ADHD, participants with active ADHD symptoms were more likely to have past-year tobacco and other drug (besides tobacco, alcohol, and marijuana) use as compared to those without active ADHD symptoms. In addition, participants with active ADHD symptoms were more likely to have past-month "other" drug use as compared to those without active ADHD symptoms. Among those prescribed medications for ADHD, 25% reported ever using their medication to "get high" and almost 29% reported ever giving or selling their medication to someone else. CONCLUSIONS: Results of our preliminary study indicated that ADHD symptom control may be important to protect against increased risk of substance use (particularly tobacco and drugs other than alcohol and marijuana) among college-age students with ADHD. Further studies of misuse/diversion of prescription stimulant medication among college students are needed.

The A-OCDS predicts both craving and alcohol cue reactivity in adolescent alcoholics.

Adolescents with alcohol dependence may experience marked craving and physiologic reactivity in the presence of alcohol cues which could undermine treatment gains. The Adolescent Obsessive Compulsive Drinking Scale (A-OCDS) was developed to help quantify the severity of alcohol craving in adolescents with alcohol use disorders. The A-OCDS is a relatively new instrument, and empirical data are needed to support its value in clinical trials. The present investigation uses data collected as part of a clinical laboratory study examining alcohol craving and cue reactivity in adolescents with and without alcohol dependence. A-OCDS total and subscale scores from adolescent alcoholics (N = 28) were examined regarding their relationship to drinking and several indices of craving and alcohol cue reactivity. In addition, regression analyses were performed to characterize the predictive ability of A-OCDS total scores and drinking indices (drinks per drinking day and percent days abstinent) on two measures of alcohol craving and cue reactivity. Results showed that the A-OCDS total scores, but not drinks per drinking day or percent days abstinent, predicted scores on both indices of craving. The study uses a small but well-defined sample of adolescents with alcohol dependence and supports the construct validity of the A-OCDS and suggests that, as in adults, alcohol craving and drinking behavior are related but separate elements of alcohol dependence. The results are intended to guide future studies in which the A-OCDS may be employed to measure craving and changes in craving over the course of treatment for adolescents with alcohol dependence.