A novel non-opioid protocol for medically supervised opioid withdrawal and transition to antagonist treatment.

BACKGROUND: The clinical feasibility of a novel non-opioid and benzodiazepine-free protocol was assessed for the treatment of medically supervised opioid withdrawal and transition to subsequent relapse prevention strategies. METHODS: A retrospective chart review of DSM-IV diagnosed opioid-dependent patients admitted for inpatient medically supervised withdrawal examined 84 subjects (52 males, 32 females) treated with a 4-day protocol of scheduled tizanidine, hydroxyzine, and gabapentin. Subjects also received ancillary medications as needed, and routine counseling. Primary outcomes were completion of medically supervised withdrawal, and initiation of injectable extended release (ER) naltrexone treatment. Secondary outcomes included the length of hospital stay, Clinical Opiate Withdrawal Scale (COWS) scores, and facilitation to substance use disorder treatment intervention. Ancillary medication use and adverse effects were also assessed. RESULTS: A total of 79 (94%) of subjects completed medically supervised withdrawal. A total of 27 (32%) subjects chose to pursue transition to ER naltrexone, and 24 of the 27 (89%) successfully received the injection prior to hospital discharge. The protocol subjects had a mean length of hospital stay of 3.6 days, and the mean COWS scores was 3.3, 3.4, 2.8, and 2.4 on Day 1, 2, 3, and 4, respectively. Furthermore, 71 (85%) engaged in an inpatient or outpatient substance use disorder (SUD) treatment program following protocol completion. CONCLUSION: This retrospective chart review suggests the feasibility of a novel protocol for medically supervised opioid withdrawal and transition to relapse prevention strategies, including injectable ER naltrexone. This withdrawal protocol does not utilize opioid agonists or other controlled substances.‬‬‬‬.

Maternal Buprenorphine Dose at Delivery and Its Relationship to Neonatal Outcomes.

BACKGROUND/AIMS: To determine whether there is a dose-response relationship between maternal dose of buprenorphine at delivery and neonatal outcomes. METHODS: This retrospective cohort study of 155 maternal-infant dyads exposed to buprenorphine during pregnancy examines the relationship between maternal dose of buprenorphine at delivery and gestational age, birthweight, method of delivery, Apgar scores at 1 and 5 min, duration of infant hospital stay, peak neonatal abstinence syndrome (NAS) score, duration of NAS and incidence of pharmacologic treatment of NAS. RESULTS: Analyses failed to support any relationship between maternal dose of buprenorphine at delivery and any of the 9 clinical outcomes (all p values >0.093). CONCLUSIONS: This study failed to provide any evidence to support limiting or reducing maternal dose of buprenorphine during pregnancy in order to reduce possible adverse outcomes to the infant. Findings suggest that healthcare providers can focus medication decisions on maternal opioid cravings to reduce the risk of relapse to illicit opioid use rather than out of concern for adverse infant outcomes.

Exploring the barriers and facilitators to use of point of care tests in family medicine clinics in the United States.

BACKGROUND: Point-of-care tests (POCTs) are increasingly used in family medicine clinics in the United States. While the diagnostics industry predicts significant growth in the number and scope of POCTs deployed, little is known about clinic-level attitudes towards implementation of these tests. We aimed to explore attitudes of primary care providers, laboratory and clinic administrative/support staff to identify barriers and facilitators to use of POCTs in family medicine. METHODS: Seven focus groups and four semi-structured interviews were conducted with a total of 52 clinic staff from three family medicine clinics in two US states. Qualitative data from this exploratory study was analyzed using the constant comparison method. RESULTS: Five themes were identified which included the impact of POCTs on clinical decision-making; perceived inaccuracy of POCTs; impact of POCTs on staff and workflow; perceived patient experience and patient-provider relationship, and issues related to cost, regulation and quality control. Overall, there were mixed attitudes towards use of POCTs. Participants believed the added data provided by POCT may facilitate prompt clinical management, diagnostic certainty and patient-provider communication. Perceived barriers included inaccuracy of POCT, shortage of clinic staff to support more testing, and uncertainty about their cost-effectiveness. CONCLUSIONS: The potential benefits of using POCTs in family medicine clinics are countered by several barriers. Clinical utility of many POCTs will depend on the extent to which these barriers are addressed. Engagement between clinical researchers, industry, health insurers and the primary care community is important to ensure that POCTs align with clinic and patient needs.

Are there gender related differences in neonatal abstinence syndrome following exposure to buprenorphine during pregnancy?

AIM: To determine whether infant gender influences the course of neonatal abstinence syndrome (NAS) following exposure to buprenorphine during pregnancy. METHODS: A retrospective cohort study was performed in which maternal and infant data were collected for 46 male and 44 female infants. All infants were born to women enrolled in a buprenorphine treatment program from December 2007 until October 2012. Maternal and infant characteristics and outcomes were compared by infant gender. RESULTS: Male infants had a significantly higher mean peak NAS score (10.04 vs. 7.98, P=0.028) and were more likely to require pharmacologic treatment for NAS (39.1% vs. 11.4%, P=0.005). CONCLUSIONS: These data indicate that, following exposure to buprenorphine during pregnancy, male infants experience a more severe withdrawal syndrome and are more likely to require pharmacologic treatment for NAS.

Management of women treated with buprenorphine during pregnancy.

The management of pregnancy and delivery of a woman on opiate-substitution therapy with buprenorphine requires a coordinated team approach by social services, addiction medicine, obstetrics, and pediatrics. Her obstetrical care is further complicated by the unique pharmacology of buprenorphine and the issues of pain management. Obstetrical providers should be familiar with the complex issues surrounding the optimal care of these women.

Room for Improvement: Rates of Birth Cohort Hepatitis C Screening in Primary Care Practices-A WWAMI Region Practice and Research Network Study.

Introduction: An estimated 2.4 million people in the United States live with hepatitis C. Though there are effective treatments for chronic hepatitis C, many infected individuals remain untreated because 40% to 50% of individuals with chronic hepatitis C are unaware of their hepatitis C status. In 2013, the United States Preventive Services Task Force (USPSTF) recommended that adults born between 1945 and 1965 should be offered one-time hepatitis C screening. The purpose of this study is to describe rates of birth cohort hepatitis C screening across primary care practices in the WWAMI region Practice and Research Network (WPRN). Methods: Cross-sectional observational study of adult patients born between 1945 and 1965 who also had a primary care visit at 1 of 9 participating health systems (22 primary care clinics) between July 31, 2013 and September 30, 2015. Data extracted from the electronic health record systems at each clinic were used to calculate the proportion of birth cohort eligible patients with evidence of hepatitis C screening as well as proportions of screened patients with positive hepatitis C screening test results. Results: Of the 32 139 eligible patients, only 10.9% had evidence of hepatitis C screening in the electronic health record data (range 1.2%-49.1% across organizations). Among the 4 WPRN sites that were able to report data by race and ethnicity, the rate of hepatitis C screening was higher among African Americans (39.9%) and American Indians/Alaska Natives (23.2%) compared with Caucasians (10.7%; P < .001). Discussion: Rates of birth cohort hepatitis C screening are low in primary care practices. Future research to develop and test interventions to increase rates of birth cohort hepatitis C screening in primary care settings are needed.

Which Point-of-Care Tests Would Be Most Beneficial to Add to Clinical Practice?: Findings From a Survey of 3 Family Medicine Clinics in the United States.

BACKGROUND: Point-of-care tests (POCTs) are increasingly used in family medicine to facilitate screening, diagnosis, monitoring, treatment, and referral decisions for a variety of conditions. Point-of-care tests that clinicians believe might be beneficial to add to clinical practice and the conditions for which they would be most useful in family medicine remain poorly understood in the United States. METHODS: Forty-two clinicians at 3 family medicine residency clinics completed a brief survey asking which POCTs they believed would be beneficial to add to their clinical practice and the conditions POCTs would be most useful for. We calculated frequencies of reported POCTs and conditions using descriptive statistics. RESULTS: Clinicians identified 34 POCTs that would be beneficial to add to family medicine, of which hemoglobin A1c, chemistry panels, and human immunodeficiency virus and gonococcal and/or chlamydia were most frequently reported and anticipated would be used weekly. Clinicians reported 30 conditions for which they considered POCTs would be useful. Diabetes mellitus, sexually transmitted infections, and respiratory tract infections were the most often reported and were identified as benefiting diagnosis, monitoring, and treatment decisions. CONCLUSIONS: Clinicians identified a number of POCTs they viewed as being beneficial to add to their routine clinical practice, mostly to inform diagnosis and treatment planning. Some POCTs identified are available in the United States; thus, understanding barriers to implementation of these POCTs in primary care settings is necessary to optimize adoption.

Qualitative study of primary care clinicians' views on point-of-care testing for C-reactive protein for acute respiratory tract infections in family medicine.

OBJECTIVE: To explore clinicians views of the barriers and facilitators to use of C-reactive protein (CRP) point-of-care tests (POCT) in US family medicine clinics for the management of acute respiratory tract infections (ARTIs) in adults. SETTING: Five family medicine clinics across two US states. PARTICIPANTS: 30 clinicians including 18 physicians, 9 physician residents, 2 physician assistants and 1 nurse practitioner, took part in the study. DESIGN: A qualitative study using a grounded theory approach to thematically analyse focus group interviews. RESULTS: These clinicians had limited access to diagnostic tests for patients with ARTI, and very little knowledge of CRP POCT. Three major themes were identified and included the potential clinical role of CRP POCT, concerns related to implementing CRP POCT and evidence needed prior to wider adoption in family medicine. Clinicians believed CRP POCT could support decision-making for some presentations of ARTIs and patient populations when used in conjunction with clinical criteria. Clinicians had concerns about possible overuse and inaccuracy of CRP POCT which they believed might increase antibiotic prescribing rates. Other concerns identified included integration of the test with clinic workflows and cost-effectiveness. CONCLUSIONS: Clinicians stand at the forefront of antibiotic stewardship efforts, but have few diagnostic tests to help them confidently manage ARTIs. CRP POCT may facilitate some aspects of clinical practice. Incorporating CRP POCT with clinical guidelines may strengthen utility of this test, when there is diagnostic uncertainty.

Patient Willingness to Have Tests to Guide Antibiotic Use for Respiratory Tract Infections: From the WWAMI Region Practice and Research Network (WPRN).

INTRODUCTION: The majority of consultations for acute respiratory tract infections (RTIs) lead to prescriptions for antibiotics, which have limited clinical benefit. We explored patients' willingness to have blood tests as part of the diagnostic work-up for RTIs, and patient knowledge about antibiotics. METHODS: Patients at 6 family medicine clinics were surveyed. Regression modeling was used to determine independent predictors of willingness to have venous and point-of-care (POC) blood tests, and knowledge of the value of antibiotics for RTIs. RESULTS: Data were collected from 737 respondents (response rate 83.8%), of whom 65.7% were women, 60.1% were white, and 25.1% were current smokers; patients' mean age was 46.9 years. Sex (female), race (white), and a preference to avoid antibiotics were independent predictors of greater level of antibiotic knowledge. A total of 63.1% were willing to have a venous draw and 79% a POC blood test, to help guide antibiotic decision-making. Non-American Indian/Alaskan Native race, current smoking, and greater knowledge of antibiotics were independent predictors of willingness to have a POC test. CONCLUSION: A large majority of patients seemed willing to have POC tests to facilitate antibiotic prescribing decisions for RTIs. Poor knowledge about antibiotics suggests better education regarding antibiotic use might influence patient attitudes towards use of antibiotics for RTIs.

Does concurrent in utero exposure to buprenorphine and antidepressant medications influence the course of neonatal abstinence syndrome?

OBJECTIVE: To determine whether concurrent in utero exposure to buprenorphine and antidepressants impacts the course of neonatal abstinence syndrome (NAS) in infants. METHODS: A retrospective cohort study of 148 infants who were exposed to buprenorphine during pregnancy. Univariate and bivariate analyses were used to examine associations between concurrent maternal use of buprenorphine and antidepressants as compared to maternal use of buprenorphine alone. RESULTS: The time to onset of NAS resolution was significantly longer in infants exposed to both buprenorphine and antidepressants during pregnancy when compared to those exposed to buprenorphine alone (129.8 h versus 70.2 h, p = 0.042). CONCLUSIONS: Women who are prescribed both antidepressants and buprenorphine during pregnancy should be counseled about the possibility of a prolonged course of neonatal abstinence syndrome.

No need for glycosuria/proteinuria screen in pregnant women.

OBJECTIVE: More than 22 million prenatal visits occur in the US each year. Each pregnant woman averages 7 visits. Most include urine testing for glucose and protein to screen for gestational diabetes and preeclampsia. Is there sufficient scientific evidence to support this routine practice? METHODS: We searched Medline (1966-2004), the Cochrane review, AHRQ National Guideline Clearinghouse, the Institute for Clinical Systems Improvement, and Google, searching for studies on proteinuria or glycosuria in pregnancy. The reference list of each article reviewed was examined for additional studies, but none were identified. We found 6 studies investigating glycosuria as a predictor for gestational diabetes mellitus, or proteinuria as a predictor for preeclampsia (1 examined both). Because every study used different dipstick methods of determining results, or definitions of abnormal, each was evaluated separately. RESULTS: Glycosuria is found at some point in about 50% of pregnant women; it is believed to be due to an increased glomerular filtration rate. The renal threshold for glucose is highly variable and may lead to a positive test result for glycosuria despite normal blood sugar. High intake of ascorbic acid or high urinary ketone levels may result in false-positive results. Four published studies assessed the value of glycosuria as a screen for gestational diabetes. All used urine dipsticks. Three of the 4 most likely overestimate the sensitivity of glycosuria for predicting gestational diabetes. CONCLUSIONS: Routine dipstick screening for protein and glucose at each prenatal visit should be abandoned. Women who are known or perceived to be at high risk for gestational diabetes or preeclampsia should continue to be monitored closely at the discretion of their clinician.

Evaluating the Development, Implementation and Dissemination of a Multisite Card Study in the WWAMI Region Practice and Research Network.

BACKGROUND: Practice-based research networks (PBRNs) promote the conduct of research in real-world settings by engaging primary care clinicians as champion research collaborators. Card studies are brief surveys administered to patients or clinicians at the point of care. The objective of this paper is to describe the design and evaluation of a card study methodology that the WWAMI Region Practice and Research Network (WPRN) used to develop research partnerships across multiple member sites. METHODS: We used a collaborative model to develop, implement and disseminate the results of a network-wide card study to assess patient preferences for weight loss in primary care. After the card study data collection was completed, we conducted individual and focus group interviews and a brief survey of participating practice champions. RESULTS: Increased research engagement and personal and professional developments were the primary motivators for participating in the development of the card study. Increasing research activity at practices and learning information about patients were motivators for implementing the study. Their participation resulted in champions reporting increased confidence in collaborating on research projects as well as the development of new clinical services for patients. DISCUSSION: This collaborative model positively influenced research capacity in the WPRN and may be a useful strategy for helping PBRNs conducted translational research.

Breastfeeding rates and the relationship between breastfeeding and neonatal abstinence syndrome in women maintained on buprenorphine during pregnancy.

INTRODUCTION: Although a growing body of evidence suggests that buprenorphine is a safe alternative to methadone in the treatment of opioid-dependent pregnant women, little is known about breastfeeding in this population. The first objective of this study was to describe breastfeeding rates among opioid-dependent pregnant women maintained on buprenorphine in an integrated medical and behavioral health program. The second objective was to determine whether breastfeeding is related to the duration, severity, and frequency of pharmacologic treatment for neonatal abstinence syndrome (NAS). METHODS: A retrospective chart review was conducted for all infants born to opioid-dependent pregnant women treated in the integrated buprenorphine program between December 2007 and August 2012. RESULTS: Eighty-five maternal-infant pairs were identified. Sixty-five women (76%) chose to breastfeed their infants after birth; of the women who initiated breastfeeding in the hospital, 66% were still breastfeeding 6 to 8 weeks postpartum. Although the data suggest that infants who were breastfed had less severe NAS (mean peak NAS, 8.83 vs 9.65 on a modified Finnegan Scoring System) and were less likely to require pharmacologic treatment (23.1% vs 30.0%) than infants who were not breastfed, these results were not statistically significant. DISCUSSION: More than three-quarters of the opioid-dependent pregnant women in this case series chose to breastfeed after birth. Although a direct comparison of care models is not possible, the integrated model of care potentially reduced some of the barriers to breastfeeding as the women accessed all their care in a single, infant-friendly setting. Further work is needed to definitively determine whether breastfeeding mitigates NAS.

Observational study of buprenorphine treatment of opioid-dependent pregnant women in a family medicine residency: reports on maternal and infant outcomes.

PURPOSE: Within a family medicine residency, an outpatient buprenorphine treatment program was provided for pregnant women who were dependent on opioids. The purpose of this study was to investigate the outcomes of infants who were exposed to a range of doses of buprenorphine in utero and to determine how closely observed maternal/fetal outcomes (eg, method of delivery and infants requiring treatment for neonatal abstinence syndrome [NAS]) match those previously reported in the literature. METHODS: This study consists of a retrospective case series of 23 infants born to 22 pregnant women who were dependent on opioids and who were treated with buprenorphine during a 31-month period. RESULTS: Thirty-five percent of infants (8 of 23) required treatment for NAS. There was no significant relationship between maternal dose of buprenorphine and birth weight, NAS severity (ie, peak NAS score), or time to first peak NAS score. Infants born to tobacco users had a significantly lower birth weight (P = .0136) than infants born to nonusers. Seventy percent of infants (16 of 23) were breastfeeding at the time of discharge from the hospital. CONCLUSIONS: The observations made in this case series are consistent with data previously reported in the literature. Infants in this study were more likely to be breastfed than those previously described by others, but further analysis is necessary to determine whether this finding is significant.

Human metapneumovirus: a newly described respiratory tract pathogen.

Human metapneumovirus is an emerging human respiratory pathogen first discovered in 2001. It clinically resembles respiratory syncytial virus, can cause both upper and lower tract disease, and has been associated with serious illness in the young, among the immunosuppressed, and in the chronically ill. Cough and congestion are frequently reported, and respiratory failure may occur. Initial infection occurs during early childhood, and repeated infections throughout life impart only transient immunity. Diagnosis is by reverse transcription-polymerase chain reaction or rising serologic titers. No commercial laboratory tests or treatments are available. Primary care physicians should maintain vigilance for outbreaks of newly discovered and emerging respiratory illnesses.

Assuring the accuracy of home glucose monitoring.

BACKGROUND: An estimated 2.5 million diabetic patients in the United States practice self-monitoring of blood glucose (SMBG). The validity of the glucose values they obtain is in doubt. An American Diabetes Association consensus panel reported that up to 50% of SMBG determinations might vary more than 20% from their true value. Accurate glucose values are an integral part of intensive treatment and reduction of long-term complications. The objective of this study was to determine the technical skill and accuracy of SMBG in an outpatient population. METHODS: This study was conducted in two family practice residency sites where 111 patients with type 1 and type 2 adult diabetes were observed testing their blood glucose values on their own glucose monitors. Patient-measured glucose levels were immediately compared with a laboratory value obtained from a calibrated hand-held glucose monitor. RESULTS: Fifty-three percent of patient glucose values were within 10% of the control value, 84% were within 20% of the control value, and 16% varied 20% or more from the control value. Two patients had dangerously inaccurate glucose determinations. Four glucose monitors required replacement. The patients were observed using a 13-point checklist of critical steps in calibration and operation of their glucose monitor. Only 1 patient made no errors in testing. CONCLUSIONS: Despite multiple technical errors when using SMBG, most patients obtained clinically useful values. This project can be easily introduced into a medical office.