Understanding Clinician Knowledge, Attitudes, and Practices Relating to Nonpharmaceutical Fentanyl and Harm Reduction.

BACKGROUND: Nonpharmaceutical fentanyl (NPF) is driving the national epidemic of opioid overdose deaths. Clinicians can play a role in fostering awareness of this growing risk and delivering interventions to reduce mortality. However, there is limited research assessing clinician knowledge, attitudes, and practices relating to NPF and harm reduction strategies. METHODS: A 34-question survey was designed to assess knowledge, attitudes, and practices related to NPF and harm reduction strategies of adult and pediatric hospital-based and emergency clinicians at a single academic medical center. Results were summarized using descriptive statistics. Chi square and Fishers exact tests were used to compare groups. RESULTS: There were 136 survey responses. The majority (88%) of respondents correctly answered a question on NPF potency. Most respondents were aware that NPF exposure was very (84%) or somewhat likely (10%) for someone using illicit opioids and very (44%) or somewhat likely (46%) for nonopioid drugs. Respondents viewed overdose prevention as highly important for patients using illicit opioids (93%) and nonopioid drugs (86%) but few (21%) were very/extremely familiar with overdose prevention strategies and just over half (57%) were comfortable/very comfortable counseling about overdose prevention. There was wide variability in utilization of harm reduction/treatment strategies (7.3% frequently providing fentanyl test kits to 70% frequently prescribing naloxone). Higher levels of comfort and familiarity with overdose prevention were associated with more frequent counseling on harm reduction strategies. Pediatric-only clinicians had less familiarity (5% very/extremely familiar) and comfort (35% comfortable/very comfortable) with overdose prevention, and limited use of harm reduction strategies (0%-31% using each strategy frequently). CONCLUSIONS: While clinicians had knowledge and awareness of NPF and rated overdose prevention as highly important, utilization of harm reduction and treatment strategies was variable. This study highlights opportunities for education and system-based support to improve clinician-driven harm reduction practices for patients at risk of overdose.

A substance use disorder training curriculum for internal medicine residents using resident-empaneled patients.

BACKGROUND: Internal Medicine (IM) residents frequently encounter, but feel unprepared to diagnose and treat, patients with substance use disorders (SUD). This is compounded by negative regard for patients with SUD. Optimal education strategies are needed to empower IM residents to care for patients with SUD. The objective of this study was to evaluate a brief SUD curriculum for IM residents, using resident-empaneled patients as an engaging educational strategy. METHODS: Following a needs assessment, a 2-part SUD curriculum was developed for IM residents at the University of Chicago during the 2018-2019 academic year as part of the ambulatory curriculum. During sessions on Opioid Use Disorder (OUD) and Alcohol Use Disorder (AUD), a facilitator covered concepts about screening, diagnosis, and treatment. In session, residents completed structured worksheets applying concepts to one of their primary care patients. A post-session assessment included questions on knowledge, preparedness & attitudes. RESULTS: Resident needs assessment (n = 44/105, 42% response rate) showed 86% characterized instruction received during residency in SUD as none or too little, and residents did not feel prepared to treat SUD. Following the AUD session, all residents (n = 22) felt prepared to diagnose and treat AUD. After the OUD session, all residents (n = 19) felt prepared to diagnose, and 79% (n = 15) felt prepared to treat OUD. Residents planned to screen for SUD more or differently, initiate harm reduction strategies and increase consideration of pharmacotherapy. CONCLUSIONS: A brief curricular intervention for AUD and OUD using resident-empaneled patients can empower residents to integrate SUD diagnosis and management into practice.

Availability of Long-Acting Injectable Buprenorphine at Substance Use Treatment Facilities in 2021.

This study assesses the proportion of US substance use and mental health care facilities that offered any medications for opioid use disorder and, specifically, long-acting injectable buprenorphine in 2021.

Low dose IV buprenorphine inductions for patients with opioid use disorder and concurrent pain: a retrospective case series.

BACKGROUND: Hospitalizations are a vital opportunity for the initiation of life-saving opioid agonist therapy (OAT) for patients with opioid use disorder. A novel approach to OAT initiation is the use of IV buprenorphine for low dose induction, which allows patients to immediately start buprenorphine at any point in a hospitalization without stopping full agonist opioids or experiencing significant withdrawal. METHODS: This is a retrospective case series of 33 patients with opioid use disorder concurrently treated with full agonist opioids for pain who voluntarily underwent low dose induction at a tertiary academic medical center. Low dose induction is the process of initiating very low doses of buprenorphine at fixed intervals with gradual dose increases in patients who recently received or are simultaneously treated with full opioid agonists. Our study reports one primary outcome: successful completion of the low dose induction (i.e. transitioned from low dose IV buprenorphine to sublingual buprenorphine-naloxone) and three secondary outcomes: discharge from the hospital with buprenorphine-naloxone prescription, self-reported pain scores, and nursing-assessed clinical opiate withdrawal scale (COWS) scores over a 6-day period, using descriptive statistics. COWS and pain scores were obtained from day 0 (prior to starting the low dose induction) to day 5 to assess the effect on withdrawal symptoms and pain control. RESULTS: Thirty patients completed the low dose induction (30/33, 90.9%). Thirty patients (30/33, 90.9%) were discharged with a buprenorphine prescription. Pain and COWS scores remained stable over the course of the study period. Mean COWS scores for all patients were 2.6 (SD 2.8) on day 0 and 1.6 (SD 2.6) on day 5. Mean pain scores for all patients were 4.4 (SD 2.1) on day 0 and 3.5 on day 5 (SD 2.1). CONCLUSIONS: This study found that an IV buprenorphine low dose induction protocol was well-tolerated by a group of 33 hospitalized patients with opioid use disorder with co-occurring pain requiring full agonist opioid therapy. COWS and pain scores improved for the majority of patients. This is the first case series to report mean daily COWS and pain scores over an extended period throughout a low dose induction process.

ACR Appropriateness Criteria® Post-Treatment Follow-up of Prostate Cancer: 2022 Update.

Prostate cancer has a wide spectrum ranging between low-grade localized disease and castrate-resistant metastatic disease. Although whole gland and systematic therapies result in cure in the majority of patients, recurrent and metastatic prostate cancer can still occur. Imaging approaches including anatomic, functional, and molecular modalities are continuously expanding. Currently, recurrent and metastatic prostate cancer is grouped in three major categories: 1) Clinical concern for residual or recurrent disease after radical prostatectomy, 2) Clinical concern for residual or recurrent disease after nonsurgical local and pelvic treatments, and 3) Metastatic prostate cancer treated by systemic therapy (androgen deprivation therapy, chemotherapy, immunotherapy). This document is a review of the current literature regarding imaging in these settings and the resulting recommendations for imaging. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Association between wait time and behavioral health appointment attendance across patient characteristics.

Adequate access to behavioral health (BH) services is a critical issue. Many patients who are referred to BH care miss their appointments. One barrier to BH care is that longer wait times decrease the likelihood of appointment attendance. The present study examines the relationship between the wait time for BH services and appointment attendance, overall and by multiple patient characteristics. Logistic regression was performed to analyze the association between wait time and patient attendance for BH referrals made from March 1, 2016, to February 28, 2019, at an urban academic medical center. In total, 1,587 referrals were included. Most patients were female (72%) and of non-Hispanic/Latinx Black race (55%). Each additional week of waiting between the referral and scheduled appointment was associated with a 5% decrease in odds of attendance. In adjusted race/ethnicity-stratified analyses, Hispanic/Latinx patients had a 9% lower odds of attendance per week of waiting. Non-Hispanic/Latinx White and Black patients had a 5% lower odds of attendance per week of waiting. Patients with private insurance had a 7% lower odds of attendance per week of waiting, and patients with Medicare had a 6% lower odds of attendance per week of waiting. Limiting scheduling may improve BH care utilization by decreasing the rate of "no shows." (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Prescribing Opioids for Pain.

This JAMA Clinical Guidelines Synopsis summarizes the Centers for Disease Control and Prevention's 2022 clinical practice guideline for prescribing opioids for pain.

Impact of an opioid use disorder consult service on hospitalized trauma patients with opioid use disorder.

BACKGROUND: Opioid use disorder (OUD) is common in the hospitalized trauma population, being a comorbid diagnosis in approximately 1% of operative trauma cases. The impact of an addiction consult service in this population has been less well studied but may lead to increased provision of evidence-based OUD treatment and improved postdischarge outcomes. METHODS: One hundred thirteen patients with an International Classification of Diseases diagnosis of OUD who were admitted to the trauma service at a single academic hospital between January 2020 to December 2021 were included in a retrospective chart review. Wilcoxon rank-sum tests were used to evaluate differences between patients who received an OUD consult and those who did not. Regression analysis was used to assess differences in postdischarge acute care utilization, attendance of follow-up appointments, initiation of and discharge on medication for opioid use disorder (MOUD), naloxone prescribing at discharge, and length of stay (LOS) between the consult and no-consult groups. RESULTS: Eighty-one patients in the study population received a consult and 32 did not. Patients in the consult group were more likely to have started MOUD during their admission (odds ratio [OR], 2.09; p < 0.001), be discharged with naloxone (OR, 1.89; p < 0.001), have a plan in place for continued OUD treatment at discharge (OR, 1.43; p < 0.001), and attend scheduled follow-up appointments with the trauma team (OR, 1.76; p = 0.02). Differences in acute care utilization and LOS between the two groups were not statistically significant. CONCLUSION: An OUD consult service can provide benefit to hospitalized trauma patients by increasing likelihood of starting MOUD, of discharging with MOUD and naloxone, and of attending trauma follow-up appointments without increasing LOS or acute care utilization. Thus, addiction consult service interventions during hospital admissions for trauma may serve to facilitate both evidence-based OUD care and posthospitalization trauma care. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

A Model to Improve Care and Enhance the Physician-Patient Relationship for Hospitalized Patients With Opioid Use Disorder.

PROBLEM: Opioid-related morbidity and mortality continues to accelerate, with increasing acute care events for opioid-related causes. Most patients do not receive evidence-based treatment for opioid use disorder (OUD) during acute hospitalizations despite this being an invaluable moment to initiate substance use treatment. Inpatient addiction consult services can bridge this gap and improve patient engagement and outcomes, but varying models and approaches are needed to match institutional resources. APPROACH: To improve care for hospitalized patients with OUD, a work group was formed at the University of Chicago Medical Center in October 2019. An OUD consult service, run by generalists, was created as part of a series of process improvement interventions. Important collaborations with pharmacy, informatics, nursing, physicians, and community partners have occurred over the last 3 years. OUTCOMES: The OUD consult service completes 40-60 new inpatient consults monthly. Between August 2019 and February 2022, the service completed 867 consults from across the institution. Most consult patients were started on medications for opioid use disorder (MOUD), and many received MOUD and naloxone at discharge. Patients who were treated by our consult service experienced lower 30-day and 90-day readmission rates compared with patients who did not receive a consult. Length of stay for patients receiving a consult was not increased. NEXT STEPS: Adaptable models of hospital-based addiction care are needed to improve care for hospitalized patients with OUD. Continued work to reach a higher percentage of hospitalized patients with OUD and to improve linkage to care with community collaborators are important steps to strengthen the care received by individuals with OUD in all clinical departments.

Overcoming challenges in acute care hospitalizations for patients with opioid use disorder.

BACKGROUND: Hospitalized patients with opioid use disorder (OUD) present unique challenges and opportunities for inpatient medical teams. Having the ability to initiate medications for opioid use disorder (MOUD) and linkage to outpatient treatment are key to improve inpatient care of patients with OUD. OBJECTIVE: This study aimed to describe the process taken by a multidisciplinary work group to improve the acute care management of patients with OUD. PRACTICE DESCRIPTION: In 2018, we identified that inpatient care teams at the University of Chicago Medicine (UCM) lacked a standardized approach to the management of hospitalized patients with OUD and that the care typically did not include evidence-based therapies. Herein, we describe the process taken to develop the OUD workgroup and the work completed by the workgroup. PRACTICE INNOVATION: The OUD workgroup spearheaded the development of an OUD consult service, formulary revisions, education for health care workers (inpatient nurse training and X-waiver training for prescribers), and outpatient partnerships. Pharmacy-led initiatives included formulary management, electronic medication orders, naloxone co-prescribing decision support, and MOUD education. EVALUATION METHODS: The OUD consult service was granted an Institutional Review Board exemption for quality improvement analysis through UCM. A data analytics dashboard was built to track consult service volumes and outcomes. RESULTS: From July 2020 to April 2021, 296 OUD consults occurred. In total, 103 consult patients (35%) received and were discharged with buprenorphine. An additional 118 patients (40%) were managed with methadone and linked to outpatient care. Naloxone dispensing at discharge increased to over 65%, which did not include patients who opted out or were discharged to a facility. CONCLUSION: The ongoing OUD epidemic presents a need for the development of services to improve management of patients with OUD in the acute care setting. The OUD workgroup has improved the management of patients admitted with OUD. Pharmacy-based initiatives are key to the development of safe and effective management of OUD in hospitalized patients.

Improving the management of chronic pain, opioid use, and opioid use disorder in older adults: study protocol for I-COPE study.

BACKGROUND: Older adults with chronic pain, opioid use, and opioid use disorder (OUD) present complex management decisions in primary care. Clinical tools are needed to improve care delivery. This study protocol describes the planned implementation and evaluation of I-COPE (Improving Chicago Older Adult Opioid and Pain Management through Patient-centered Clinical Decision Support and Project ECHO®) to improve care for this population. METHODS: This study uses a pragmatic, expanding cohort stepped-wedge design to assess the outcomes. The study will be implemented in 35 clinical sites across metropolitan Chicago for patients aged ≥ 65 with chronic pain, opioid use, or OUD who receive primary care at one of the clinics. I-COPE includes the integration of patient-reported data on symptoms and preferences, clinical decision support tools, and a shared decision-making tool into routine primary care for more effective management of chronic pain, opioid prescribing, and OUD in older adults. Primary care providers will be trained through web-based videos and an optional Project ECHO® course, entitled "Pain Management and OUD in Older Adults." The RE-AIM framework will be used to assess the I-COPE implementation. Effectiveness outcomes will include an increased variety of recommended pain treatments, decreased prescriptions of higher-risk pain treatments, and decreased patient pain scores. All outcomes will be evaluated 6 and 12 months after implementation. PCPs participating in Project ECHO® will be evaluated on changes in knowledge, attitudes, and self-efficacy using pre- and post-course surveys. DISCUSSION: This study will provide evidence about the effectiveness of collecting patient-reported data on symptoms and treatment preferences and providing clinical decision support and shared decision-making tools to improve management for older adults with chronic pain, opioid use, and OUD. TRIAL REGISTRATION: ClinicalTrials.gov NCT04878562 .

Improving Primary Care Behavioral Health Integration in an Academic Internal Medicine Practice: 2-Year Follow-Up.

This report details ongoing efforts to improve integration in the 2 years following implementation of the Primary Care Behavioral Health model at a general internal medicine clinic of an urban academic medical center. Efforts were informed by a modified version of the validated Level of Integration Measure, sent to all faculty and staff annually. At baseline, results indicated that the domains of systems integration, training, and integrated clinical practices had the greatest need for improvement. Over the 2 years, the authors increased availability of behavioral medicine appointments, improved depression screening processes, offered behavioral health training for providers, disseminated clinical decision support tools, and provided updates about integration progress during clinic meetings. Follow-up survey results demonstrated that physicians and staff perceived improvements in integration overall and in targeted domains. However, the main ongoing barrier to integration was insufficient behavioral health staff to meet patient demand for behavioral health services.

Team-Based Learning in a Longitudinal Integrated Clerkship: an Opportunity for Integrated Multidisciplinary Learning and Curricular Focus on the Underserved.

Team-based learning (TBL) offers opportunities to tailor curricula to match specific aims and modalities of innovative medical education models. This paper describes a TBL curriculum developed for a longitudinal integrated clerkship (LIC) at an urban safety-net hospital. Similar to our LIC students' clinical training experience, which includes simultaneously meeting core competencies across specialties in an underserved setting, our TBL curriculum is multidisciplinary and integrates topics related to caring for vulnerable patients. TBL within our LIC avoids the limitations of teaching content in specialty specific silos, creating a cohesive didactic and clinical education model which is highly rated by our students.

Reflective Writing as a Window on Medical Students' Professional Identity Development in a Longitudinal Integrated Clerkship.

Phenomenon: Integral to the formation of a professional identity is the concept of professional identity construction, an essential part of becoming a competent physician. In this framework, identity is dynamic and shaped by experiences and relationships. Minimal work has addressed the impact that clinical care settings and relationships with patients have in the construction of professional identity for medical students. This study explores how patient interactions and intentional curriculum design support professional identity construction in students participating in a longitudinal integrated clerkship focused on care for the underserved. Approach: This qualitative analysis investigated students' professional identity construction as detailed in 45 reflective essays from 15 students while enrolled in an 11-month longitudinal integrated clerkship (LIC) in a safety-net hospital system. Researchers used an inductive analytic approach. Findings: Students provided rich and complex descriptions of their experiences. Six themes emerged: care for the underserved; therapeutic alliance; humility and gratitude; altruism; resilience; and aspirations. Insights: Professional identity construction was observable through students' reflective essays. Student interactions with patients provided rich material for professional identity construction, and role models in patient care enhanced this process. This study suggests that clinical learning in a safety-net hospital system, coupled with an LIC curriculum that prioritizes continuity with vulnerable patients, faculty role models, and ongoing reflection, supported the professional identity construction of students as patient-centered caregivers providing equitable care and advocacy for the underserved, described here as an Equity Identity.

Teaching Safe Opioid Prescribing During the Opioid Epidemic: Results of the 2018 Clerkship Directors in Internal Medicine Survey.

BACKGROUND: Educating medical trainees across the continuum is essential to a multifaceted strategy for addressing the opioid epidemic. OBJECTIVE: To assess the current state of internal medicine clerkship content on safe opioid prescribing and opioid use disorder, and barriers to curriculum implementation. DESIGN: National Annual (2018) Clerkship Directors in Internal Medicine (CDIM) cross-sectional survey. PARTICIPANTS: One hundred thirty-four clerkship directors at all Liaison Committee of Medical Education accredited US medical schools with CDIM membership as of October 1, 2018. MAIN MEASURES: The survey section on safe opioid prescribing and opioid use disorder education in the internal medicine clerkship addressed assessment of current curricula, perceived importance of curricula, barriers to implementation, and plans to start or expand curricula. Descriptive statistics were used to summarize responses, and Pearson's chi-square and Fisher's exact tests for statistical comparisons. KEY RESULTS: The survey response rate was 82% (110/134). Overall 54.1% of responding institutions reported covering one or more topics related to safe opioid prescribing or opioid use disorder in the internal medicine clerkship. A preponderance of clerkship directors (range 51-86%) reported that various opioid-related topics were important to cover in the internal medicine clerkship. Safe opioid prescribing topics were covered more frequently than topics related specifically to opioid use disorder. The main barriers identified included time (80.9%) and lack of faculty expertise (65.5%). CONCLUSIONS: Clerkship directors agreed that incorporating safe opioid prescribing and opioid use disorder topics in the internal medicine clerkship is important, despite wide variation in current curricula. Addressing curricular time constraints and lack of faculty expertise in internal medicine clerkships will be key to successfully integrating content to address the opioid epidemic.

The effects of growth hormone treatment on bone mineral density and body composition in girls with turner syndrome.

BACKGROUND: Many girls with Turner syndrome (TS) are treated with GH to increase adult height. In addition to promoting longitudinal bone growth, GH has effects on bone and body composition. OBJECTIVE: The objective was to determine how GH treatment affects bone mineral density (BMD) and body composition in girls with TS. METHOD: In a cross-sectional study, we compared measures of body composition and BMD by dual energy x-ray absorptiometry, and phalangeal cortical thickness by hand radiography in 28 girls with TS who had never received GH and 39 girls who were treated with GH for at least 1 yr. All girls were participants in a National Institutes of Health (NIH) Clinical Research Center (CRC) protocol between 2001 and 2006. RESULTS: The two groups were similar in age (12.3 yr, sd 2.9), bone age (11.5 yr, sd 2.6), and weight (42.8 kg, sd 16.6); but the GH-treated group was taller (134 vs. 137 cm, P = 0.001). The average duration of GH treatment was 4.2 (sd 3.2) yr (range 1-14 yr). After adjustment for size and bone age, there were no significant differences in BMD at L1-L4, 1/3 radius or cortical bone thickness measured at the second metacarpal. However, lean body mass percent was higher (P < 0.001), whereas body fat percent was lower (P < 0.001) in the GH-treated group. These effects were independent of estrogen exposure and were still apparent in girls that had finished GH treatment at least 1 yr previously. CONCLUSIONS: Although GH treatment has little effect on cortical or trabecular BMD in girls with TS, it is associated with increased lean body mass and reduced adiposity.