Geographic access to buprenorphine prescribers for patients who use public transit.

OBJECTIVE: Urban Medicaid enrollees with opioid use disorder often rely on public transit to reach buprenorphine prescribers. Research has not shown whether public transit provides this population with adequate geographic access to buprenorphine prescribers. We examined travel times to buprenorphine prescribers by car and public transit in urban areas, and determined whether car-based Medicaid regulatory standards produce their intended geographic coverage. METHODS: We obtained data for this study from the Substance Abuse and Mental Health Services Administration's Buprenorphine Practitioner Locator, Microsoft Bing Maps, and the American Community Survey. We examined four urban counties at the centers of the metropolitan statistical areas with the highest 2017 accidental drug poisoning death rates: Kanawha, WV; Montgomery, OH; Philadelphia, PA; and St. Louis City, MO. These counties comprised 696 census tracts representing 1,038,564 households. We calculated travel times from each census tract center to the nearest buprenorphine prescribers by car and public transit, and compared that to 30-min regulatory standards and by whether census tracts had below median levels of car access. We calculated Global Moran's I statistics to determine whether spatial clustering was present among census tracts with limited access to buprenorphine prescribers. RESULTS: Households in all but two census tracts could access a buprenorphine prescriber within 30 min by car. However, households in 12.1% (84) of census tracts could not do so by public transit. The correlation between car- and public transit-based travel times to the nearest buprenorphine prescriber was 0.11 (95% CI = 0.07-0.22). More than 15% (47,918) of households in the two less densely populated counties could not travel to the nearest prescriber in 30 min and resided in census tracts where access to cars was relatively low. There was no evidence of spatial clustering among census tracts with public transit travel times exceeding 30 min, or among census tracts with public transit travel times exceeding 30 min and below median values of access to cars. CONCLUSIONS: Geographic access to buprenorphine prescribers is overestimated by regulatory standards that apply car-based travel time estimates, which are a weak proxy for public transit-based travel times. Since geographic areas with limited access to buprenorphine prescribers do not tend to cluster near one another, individually targeted interventions may be necessary to improve buprenorphine access and utilization.

Three questions can detect hazardous drinkers.

OBJECTIVE: The researchers evaluated the Alcohol Use Disorders Identification Test (AUDIT), the first 3 questions of the AUDIT (AUDIT-C), the third AUDIT question (AUDIT-3), and quantity-frequency questions for identifying hazardous drinkers in a large primary care sample. STUDY DESIGN: Cross-sectional survey. POPULATION: Patients waiting for care at 12 primary care sites in western Pennsylvania from October 1995 to December 1997. OUTCOMES MEASURED: Sensitivity, specificity, likelihood ratios, and predictive values for the AUDIT, AUDIT-C, and AUDIT-3. RESULTS: A total of 13,438 patients were surveyed. Compared with a quantity-frequency definition of hazardous drinking (> or =16 drinks/week for men and > or =12 drinks/week for women), the AUDIT, AUDIT-C, and AUDIT-3 had areas under the receiver-operating characteristic curves (AUROC) of 0.940, 0.949, and 0.871, respectively. The AUROCs of the AUDIT and AUDIT-C were significantly different (P=.004). The AUROCs of the AUDIT-C (P<.001) and AUDIT (P <.001) were significantly larger than the AUDIT-3. When compared with a positive AUDIT score of 8 or higher, the AUDIT-C (score > or =3) and the AUDIT-3 (score > or =1) were 94.9% and 99.6% sensitive and 68.8% and 51.1% specific in detecting individuals as hazardous drinkers. CONCLUSIONS: In a large primary care sample, a 3-question version of the AUDIT identified hazardous drinkers as well as the full AUDIT when such drinkers were defined by quantity-frequency criterion. This version of the AUDIT may be useful as an initial screen for assessing hazardous drinking behavior.

Managing alcohol withdrawal in the elderly.

The alcohol withdrawal syndrome is common in elderly individuals who are alcohol dependent and who decrease or stop their alcohol intake. While there have been few clinical studies to directly support or refute the hypothesis that withdrawal symptom severity, delirium and seizures increase with advancing age, several observational studies suggest that adverse functional and cognitive complications during alcohol withdrawal do occur more frequently in elderly patients. Most elderly patients with alcohol withdrawal symptoms should be considered for admission to an inpatient setting for supportive care and management. However, elderly patients with adequate social support and without significant withdrawal symptoms at presentation, comorbid illness or past history of complicated withdrawal may be suitable for outpatient management. Although over 100 drugs have been described for alcohol withdrawal treatment, there have been no studies assessing the efficacy of these drugs specifically in elderly patients. Studies in younger patients support benzodiazepines as the most efficacious therapy for reducing withdrawal symptoms and the incidence of delirium and seizure. While short-acting benzodiazepines, such as oxazepam and lorazepam, may be appropriate for elderly patients given the risk for excessive sedation from long-acting benzodiazepines, they may be less effective in preventing seizures and more prone to produce discontinuation symptoms if not tapered properly. To ensure appropriate benzodiazepine treatment, dose and frequency should be individualised with frequent monitoring, and based on validated alcohol withdrawal severity measures. Selected patients who have a history of severe or complicated withdrawal symptoms may benefit from a fixed schedule of benzodiazepine provided that medication is held for sedation. beta-Blockers, clonidine, carbamazepine and haloperidol may be used as adjunctive agents to treat symptoms not controlled by benzodiazepines. Lastly, the age of the patient should not deter clinicians from helping the patient achieve successful alcohol treatment and rehabilitation.

Impact of age on the severity, course, and complications of alcohol withdrawal.

BACKGROUND: Early identification of alcohol-dependent patients at increased risk for severe or complicated alcohol withdrawal would improve triage and treatment. However, the role of age in predicting alcohol withdrawal outcomes has not been well studied. OBJECTIVE: To assess the impact of age on the severity, course, and complications of alcohol withdrawal. METHODS: We performed a retrospective cohort study of 284 inpatients admitted for alcohol withdrawal between September 1992 and August 1994. Outcomes included alcohol withdrawal severity measured by the revised Clinical Institute Withdrawal Assessment for Alcohol scale, quantity and duration of benzodiazepine therapy, and complications during withdrawal. RESULTS: Initial and maximal withdrawal severity scores, amount of benzodiazepine administered, and duration of benzodiazepine treatment for elevated withdrawal severity scores did not change significantly with age. However, patients aged 60 years and older had increased risk for delirium (adjusted odds ratio [OR], 4.7; 95% confidence interval [CI], 1.5-15.0; P = .008), falls (OR, 3.1; 95% CI, 0.9-11.2; P = .08), and transient dependency in 2 or more activities of daily living (OR, 5.8; 95% CI, 2.9-11.7; P < .001). As age increased, there were significant increases in length of stay (P < .001) and frequency of discharge to an extended care facility (P < .001). CONCLUSIONS: Although alcohol withdrawal severity scores and benzodiazepine requirements were similar across age groups, patients aged 60 years and older were at increased risk for cognitive and functional impairment during withdrawal. These findings support recommendations that older patients with alcohol withdrawal are best treated in closely supervised settings.

Pulmonary edema associated with the treatment of preterm labor: what critical care nurses need to know.

Knowledge of the physiologic changes, conditions, and therapies of pregnancy that increase the risk of pulmonary edema enables nurses to influence the outcome of their patients who develop medical complications while undergoing tocolytic therapy. Cooperation between perinatal and critical care nurses ensures optimal care of both the mother and the fetus.

Clinical correlates of secondary meningitis in HIV-infected adults.

BACKGROUND: Neurologic complaints are common in adults infected with the human immunodeficiency virus, but little is known about which clinical features are associated with secondary causes of meningitis. METHODS: A retrospective cross-sectional study of adults infected with the human immunodeficiency virus who received a diagnostic lumbar puncture (LP) in the infectious disease clinic, emergency department, and inpatient wards of the Deaconess Hospital, Boston, Mass, from 1989 through 1992 to determine which clinical features available at the time of LP are correlated with definite or probable secondary meningitis. RESULTS: Of the 491 LPs, 90% were performed in whites, 93% in men, and 11% in injection drug users. Cerebrospinal fluid test results revealed secondary meningitis in 39 (7.9%) of 491 LPs performed on 322 individuals. Cryptococcal meningitis was the predominant type (27 cases); no bacterial or tuberculous meningitis was found. In multivariate analyses, a history of non-Hodgkin's lymphoma (adjusted odds ratio [OR], 4.3; 95% confidence interval [CI], 1.5 to 12.5), a history of herpes simplex virus infection (OR, 2.5; 95% CI, 1.2 to 5.0), nausea and/or vomiting (OR, 2.0; 95% CI, 1.03 to 4.0), headache in a person with the acquired immunodeficiency syndrome (OR, 2.1; 95% CI, 1.03 to 4.4), and cranial nerve abnormalities (OR, 5.1; 95% CI, 1.8 to 14.1) were positive correlates of opportunistic meningitis; current fluconazole use (OR, 0.3; 95% CI, 0.1 to 0.8) conferred a lower risk. CONCLUSION: In similar clinical settings, physicians and their human immunodeficiency virus-infected patients should consider these features when assessing the risk of secondary meningitis and the necessity for immediate LP.