Unfilled prescriptions: Surveying patients' experiences with buprenorphine treatment in Massachusetts before and during the COVID-19 pandemic.

BACKGROUND AND OBJECTIVES: We explored potential challenges to accessing office-based opioid treatment (OBOT) with buprenorphine during the COVID-19 pandemic. METHODS: Using Facebook advertisements, we recruited a sample of N = 72 participants and conducted four repeated-measures analysis of variance comparing ratings of participants' abilities to access aspects of OBOT treatment. RESULTS: Participants reported increased difficulty filling buprenorphine prescriptions during the pandemic than before, p = .011, partial η2 = 0.092, and this was correlated with past month opioid use, r = .236, p = .042. DISCUSSION, CONCLUSIONS, AND SCIENTIFIC SIGNIFICANCE: This is the first investigation to report unfilled prescriptions during the pandemic and an association with opioid use. Unfilled prescriptions may contribute to relapse and partially explain increased overdose deaths during COVID-19.

Implementing group visits for opioid use disorder: A case series.

Background: Group-based models of Office-Based Opioid Treatment with buprenorphine-naloxone (B/N) are increasingly being implemented in clinical practice to increase access to care and provide additional therapeutic benefits. While previous studies reported these Group-Based Opioid Treatment (GBOT) models are feasible for providers and acceptable to patients, there has been no literature to help providers with the more practical aspects of how to create and maintain GBOT in different outpatient settings. Case series: We present 4 cases of GBOT implementation across a large academic health care system, highlighting various potential approaches for providers who seek to implement GBOT and demonstrate "success" based on feasibility and sustainability of these models. For each case, we describe the pros and cons and detail the personnel and resources involved, patient mix and group format, workflow logistics, monitoring and management, and sustainability components. Discussion: The implementation details illustrate that there is no one-size-fits-all approach, although feasibility is commonly supported by a team-based, patient-centered medical home. This approach includes the capacity for referral to higher levels of mental health and addiction support services and is bolstered by ongoing provider communication and shared resources across the health system. Future research identifying the core and malleable components to implementation, their evidence base, and how they might be influenced by site-specific resources, culture, and other contextual factors can help providers better understand how to implement a GBOT model in their unique clinical environment.

Progress testing: critical analysis and suggested practices.

Educators have long lamented the tendency of students to engage in rote memorization in preparation for tests rather than engaging in deep learning where they attempt to gain meaning from their studies. Rote memorization driven by objective exams has been termed a steering effect. Progress testing (PT), in which a comprehensive examination sampling all of medicine is administered repeatedly throughout the entire curriculum, was developed with the stated aim of breaking the steering effect of examinations and of promoting deep learning. PT is an approach historically linked to problem-based learning (PBL) although there is a growing recognition of its applicability more broadly. The purpose of this article is to summarize the salient features of PT drawn from the literature, provide a critical review of these features based upon the same literature and psychometric considerations drawn from the Standards for Educational and Psychological Testing and provide considerations of what should be part of best practices in applying PT from an evidence-based and a psychometric perspective.

Using educational prescriptions to teach medical students evidence-based medicine.

PURPOSE: To evaluate feasibility and impact of evidence-based medicine (EBM) educational prescriptions (EPs) in medical student clerkships. METHODS: Students answered clinical questions during clerkships using EPs, which guide learners through the "four As" of EBM. Epidemiology fellows graded EPs using a rubric. Feasibility was assessed using descriptive statistics and student and fellow end-of-study questionnaires, which also measured impact. In addition, for each EP, students reported patient impact. Impact on EBM skills was assessed by change in EP scores over time and scores on an EBM objective structured clinical exam (OSCE) that were compared to controls from the prior year. RESULTS: 117 students completed 402 EPs evaluated by 24 fellows. Average score was 7.34/9.00 (SD 1.58). 69 students (59%) and 21 fellows (88%) completed questionnaires. Most students thought EPs improved "Acquiring" and "Appraising". Almost half thought EPs improved "Asking" and "Applying". Fellows did not value grading EPs. For 18% of EPs, students reported a "change" or "potential change" in treatment. 56% "confirmed" treatment. EP scores increased by 1.27 (95% CI: 0.81-1.72). There were no differences in OSCE scores between cohorts. CONCLUSIONS: Integrating EPs into clerkships is feasible and has impact, yet OSCEs were unchanged, and research fellows had limitations as evaluators.

Blood pressure response to extended-release naltrexone in heroin and prescription opioid users and its implications for cardiovascular morbidity.

BACKGROUND: Consuming opioid agonists is a risk factor for cardiovascular disease particularly in intravenous heroin users. The monthly injectable extended-release opioid antagonist, naltrexone (XR-NTX) is an effective treatment for opioid use disorder. The impact of opioid receptor blockade through XR-NTX on blood pressure, a critical risk factor for cardiovascular morbidity, has not yet been characterized. METHODS: The study evaluated the change in blood pressure during XR-NTX treatment among 14 patients who predominately used intravenous heroin and 24 patients who used prescription oral opioids, all with opioid use disorder. Blood pressure was measured in each patient immediately before the first XR-NTX injection and ∼two weeks after the first injection. The change in diastolic and systolic pressure was compared between the heroin users and the prescription opioids users using analysis of variance. RESULTS: XR-NTX treatment was associated with significant decreases in diastolic blood pressure in the heroin group, but not in the prescription opioids group. Systolic blood pressure values in the heroin users showed a decline at trend level only. CONCLUSIONS: Further research is warranted to replicate our findings and to determine whether XR-NTX effect is relatively specific to blood pressure or generalizes to other components of metabolic syndrome. Distinguishing between heroin and prescription opioid users could shed light on the unique clinical and pharmacological profiles of opioid drugs, particularly regarding their cardiovascular safety. This information can be useful in developing personalized therapeutic strategies based on the route of opioid administration.

Single and Multiple Ability Estimation in the SEM Framework: A Non-Informative Bayesian Estimation Approach.

Latent variable models with many categorical items and multiple latent constructs result in many dimensions of numerical integration, and the traditional frequentist estimation approach, such as maximum likelihood (ML), tends to fail due to model complexity. In such cases, Bayesian estimation with diffuse priors can be used as a viable alternative to ML estimation. The present study compares the performance of Bayesian estimation to ML estimation in estimating single or multiple ability factors across two types of measurement models in the structural equation modeling framework: a multidimensional item response theory (MIRT) model and a multiple-indicator multiple-cause (MIMIC) model. A Monte Carlo simulation study demonstrates that Bayesian estimation with diffuse priors, under various conditions, produces quite comparable results to ML estimation in the single- and multi-level MIRT and MIMIC models. Additionally, an empirical example utilizing the Multistate Bar Examination is provided to compare the practical utility of the MIRT and MIMIC models. Structural relationships among the ability factors, covariates, and a binary outcome variable are investigated through the single- and multi-level measurement models. The paper concludes with a summary of the relative advantages of Bayesian estimation over ML estimation in MIRT and MIMIC models and suggests strategies for implementing these methods.

Psychiatry in the Harvard Medical School-Cambridge Integrated Clerkship: an innovative, year-long program.

OBJECTIVE: The authors present what is to their knowledge the first description of a model for longitudinal third-year medical student psychiatry education. METHOD: A longitudinal, integrated psychiatric curriculum was developed, implemented, and sustained within the Harvard Medical School-Cambridge Integrated Clerkship. Curriculum elements include longitudinal mentoring by attending physicians in an outpatient psychiatry clinic, exposure to the major psychotherapies, psychopharmacology training, acute psychiatry "immersion" experiences, and a variety of clinical and didactic teaching sessions. RESULTS: The longitudinal psychiatry curriculum has been sustained for 8 years to-date, providing effective learning as demonstrated by OSCE scores, NBME shelf exam scores, written work, and observed clinical work. The percentage of students in this clerkship choosing psychiatry as a residency specialty is significantly greater than those in traditional clerkships at Harvard Medical School and greater than the U.S. average. CONCLUSION: Longitudinal integrated clerkship experiences are effective and sustainable; they offer particular strengths and opportunities for psychiatry education, and may influence student choice of specialty.

Building a competency-based curriculum: the agony and the ecstasy.

Physician competencies have increasingly been a focus of medical education at all levels. Although competencies are not a new concept, when the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) jointly agreed on six competencies for certification and maintenance of certification of physicians in 1999, it brought about renewed interest. This article gives a brief overview of how a competency-based curriculum differs from other approaches and then describes the issues that need to be considered in the design and implementation of such a curriculum. In order to achieve success, a competency-based curriculum requires careful planning, preparation and a long-term commitment from everyone involved in the educational process. Building a competency-based curriculum is really about maintaining quality control and relinquishing control to those who care the most about medical education, our students. In the face of the many challenges that are facing undergraduate medical education (UME), including declining availability of teaching patients and over-burdened faculty, instituting quality control and relinquishing control will be necessary to maintain high quality.

Mechanisms Underlying Unconscious Processing and Their Alterations in Post-traumatic Stress Disorder: Neuroimaging of Zero Monetary Outcomes Contextually Framed as "No Losses" vs. "No Gains".

Although unconscious processing is a key element of mental operation, its neural correlates have not been established. Also, clinical observations suggest that unconscious processing may be involved in the pathophysiology of post-traumatic stress disorder (PTSD), but the neurobiological mechanisms underlying such impairments remain unknown. The purpose of the present study was to examine putative mechanisms underlying unconscious processing by healthy participants and to determine whether these mechanisms may be altered in PTSD patients. Twenty patients with PTSD and 27 healthy individuals were administered a validated wheel of fortune-type gambling task during functional magnetic resonance imaging (fMRI). Unconscious processing was elicited using unconscious contextual framing of the zero monetary outcomes as "no loss," "no gain" or as "neutral." Brief passive visual processing of the "no loss" vs. "no gain" contrast by healthy participants yielded bilateral frontal-, temporal- and insular cortices and striatal activations. Between-group comparison revealed smaller activity in the left anterior prefrontal-, left dorsolateral prefrontal-, right temporal- and right insular cortices and in bilateral striatum in PTSD patients with the left dorsolateral prefrontal cortex activity been more pronounced in those with greater PTSD severity. These observations implicate frontal-, temporal-, and insular cortices along with the striatum in the putative mechanisms underlying unconscious processing of the monetary outcomes. Additionally, our results support the hypothesis that PTSD is associated with primary cortical and subcortical alterations involved in the above processes and that these alterations may be related to some aspects of PTSD symptomatology.

Author Correction: Metabolic and Addiction Indices in Patients on Opioid Agonist Medication-Assisted Treatment: A Comparison of Buprenorphine and Methadone.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Metabolic and Addiction Indices in Patients on Opioid Agonist Medication-Assisted Treatment: A Comparison of Buprenorphine and Methadone.

Metabolic hormones stabilize brain reward and motivational circuits, whereas excessive opioid consumption counteracts this effect and may impair metabolic function. Here we addressed the role of metabolic processes in the course of the agonist medication-assisted treatment for opioid use disorder (OUD) with buprenorphine or methadone. Plasma lipids, hemoglobin A1C, body composition, the oral glucose tolerance test (oGTT) and the Sweet Taste Test (STT) were measured in buprenorphine- (n = 26) or methadone (n = 32)- treated subjects with OUD. On the whole, the subjects in both groups were overweight or obese and insulin resistant; they displayed similar oGTT and STT performance. As compared to methadone-treated subjects, those on buprenorphine had significantly lower rates of metabolic syndrome (MetS) along with better values of the high-density lipoproteins (HDL). Subjects with- vs. without MetS tended to have greater addiction severity. Correlative analyses revealed that more buprenorphine exposure duration was associated with better HDL and opioid craving values. In contrast, more methadone exposure duration was associated with worse triglycerides-, HDL-, blood pressure-, fasting glucose- and hemoglobin A1C values. Buprenorphine appears to produce beneficial HDL- and craving effects and, contrary to methadone, its role in the metabolic derangements is not obvious. Our data call for further research aimed at understanding the distinctive features of buprenorphine metabolic effects vis-à-vis those of methadone and their potential role in these drugs' unique therapeutic profiles.

Building a Group-Based Opioid Treatment (GBOT) blueprint: a qualitative study delineating GBOT implementation.

BACKGROUND: Group-Based Opioid Treatment (GBOT) has recently emerged as a mechanism for treating patients with opioid use disorder (OUD) in the outpatient setting. However, the more practical "how to" components of successfully delivering GBOT has received little attention in the medical literature, potentially limiting its widespread implementation and utilization. Building on a previous case series, this paper delineates the key components to implementing GBOT by asking: (a) What are the core components to GBOT implementation, and how are they defined? (b) What are the malleable components to GBOT implementation, and what conceptual framework should providers use in determining how to apply these components for effective delivery in their unique clinical environment? METHODS: To create a blueprint delineating GBOT implementation, we integrated findings from a previously conducted and separately published systematic review of existing GBOT studies, conducted additional literature review, reviewed best practice recommendations and policies related to GBOT and organizational frameworks for implementing health systems change. We triangulated this data with a qualitative thematic analysis from 5 individual interviews and 2 focus groups representing leaders from 5 different GBOT programs across our institution to identify the key components to GBOT implementation, distinguish "core" and "malleable" components, and provide a conceptual framework for considering various options for implementing the malleable components. RESULTS: We identified 6 core components to GBOT implementation that optimize clinical outcomes, comply with mandatory policies and regulations, ensure patient and staff safety, and promote sustainability in delivery. These included consistent group expectations, team-based approach to care, safe and confidential space, billing compliance, regular monitoring, and regular patient participation. We identified 14 malleable components and developed a novel conceptual framework that providers can apply when deciding how to employ each malleable component that considers empirical, theoretical and practical dimensions. CONCLUSION: While further research on the effectiveness of GBOT and its individual implementation components is needed, the blueprint outlined here provides an initial framework to help office-based opioid treatment sites implement a successful GBOT approach and hence potentially serve as future study sites to establish efficacy of the model. This blueprint can also be used to continuously monitor how components of GBOT influence treatment outcomes, providing an empirical framework for the ongoing process of refining implementation strategies.

Diagnostic radiology resident compliance with recommended health guidelines: effect of resident work environment.

RATIONALE AND OBJECTIVES: To determine diagnostic radiology resident compliance with recommended health guidelines for physical activity, body weight, diet, related health indicators, and the effects of the resident work environment on compliance. MATERIALS AND METHODS: A request was electronically mailed to members of the Association of Program Directors in Radiology and the Association of Program Coordinators in Radiology in May 2007 and again in June 2007, asking members to forward to their radiology residents an invitation to complete an online health survey. Frequency counts and Fisher's exact test, respectively, were used to summarize results and to determine statistically significant relationships between survey variables. RESULTS: A total of 811 radiology residents completed the survey, representing 18% of 4,412 diagnostic radiology residents. Five hundred forty-five (67.2%) of 811 were male and 264 (32.6%) female. Two hundred ten (25.9%) were first-year, 239 (29.5%) second-year, 201 (24.8%) third-year, and 161 (19.9%) fourth-year residents. Three hundred two (37.2%) engaged in recommended guidelines for physical activity and < or =465 (57.3%) complied with each of multiple federal dietary guidelines (excluding alcohol intake). Up to 329 (40.6%) residents did not know whether they were in compliance with various dietary guidelines. A total of 426 (52.5%) residents reported working > or =60 hours/week, which significantly correlated with less physical activity (P = .013). CONCLUSION: A substantial number of residents are out of compliance with federal guidelines for physical activity and diet and are not knowledgeable about their personal dietary intake. Long work hours are related to a lack of physical activity. Radiology programs may be able to influence resident health practices by modifying work hours and the working environment, encouraging healthy dietary intake and physical activity, and instituting campaigns to inform residents and faculty about health guidelines and available wellness programs.

Defining characteristics of educational competencies.

CONTEXT: Doctor competencies have become an increasing focus of medical education at all levels. However, confusion exists regarding what constitutes a competency versus a goal, objective or outcome. OBJECTIVES: This article attempts to identify the characteristics that define a competency and proposes criteria that can be applied to distinguish between competencies, goals, objectives and outcomes. METHODS: We provide a brief overview of the history of competencies and compare competencies identified by international medical education organisations (CanMEDS 2005, Institute for International Medical Education, Dundee Outcome Model, Accreditation Council for Graduate Medical Education/American Board of Medical Specialties). Based upon this review and comparisons, as well as on definitions of competencies from the literature and theoretical and conceptual analyses of the underpinnings of competencies, the authors develop criteria that can serve to distinguish competencies from goals, objectives and outcomes. RESULTS: We propose 5 criteria which can be used to define a competency: it focuses on the performance of the end-product or goal-state of instruction; it reflects expectations that are external to the immediate instructional programme; it is expressible in terms of measurable behaviour; it uses a standard for judging competence that is not dependent upon the performance of other learners, and it informs learners, as well as other stakeholders, about what is expected of them. CONCLUSIONS: Competency-based medical education is likely to be here for the foreseeable future. Whether or not these 5 criteria, or some variation of them, become the ultimate defining criteria for what constitutes a competency, they represent an essential step towards clearing the confusion that reigns.

Reward and aversion processing in patients with post-traumatic stress disorder: functional neuroimaging with visual and thermal stimuli.

In patients with post-traumatic stress disorder (PTSD), a decrease in the brain reward function was reported in behavioral- and in neuroimaging studies. While pathophysiological mechanisms underlying this response are unclear, there are several lines of evidence suggesting over-recruitment of the brain reward regions by aversive stimuli rendering them unavailable to respond to reward-related content. The purpose of this study was to juxtapose brain responses to functional neuroimaging probes that reliably produce rewarding and aversive experiences in PTSD subjects and in healthy controls. The stimuli used were pleasant, aversive and neutral images selected from the International Affective Picture System (IAPS) along with pain-inducing heat applied to the dorsum of the left hand; all were administered during 3 T functional magnetic resonance imaging. Analyses of IAPS responses for the pleasant images revealed significantly decreased subjective ratings and brain activations in PTSD subjects that included striatum and medial prefrontal-, parietal- and temporal cortices. For the aversive images, decreased activations were observed in the amygdala and in the thalamus. PTSD and healthy subjects provided similar subjective ratings of thermal sensory thresholds and each of the temperatures. When 46 °C (hot) and 42 °C (neutral) temperatures were contrasted, voxelwise between-group comparison revealed greater activations in the striatum, amygdala, hippocampus and medial prefrontal cortex in the PTSD subjects. These latter findings were for the most part mirrored by the 44 vs. 42 °C contrast. Our data suggest different brain alterations patterns in PTSD, namely relatively diminished corticolimbic response to pleasant and aversive psychosocial stimuli in the face of exaggerated response to heat-related pain. The present findings support the hypothesis that brain sensitization to pain in PTSD may interfere with the processing of psychosocial stimuli whether they are of rewarding or aversive valence.

The epidemiology of psychiatric disorders among repeat DUI offenders accepting a treatment-sentencing option.

Psychiatric comorbidity likely contributes to driving under the influence (DUI) of alcohol among repeat offenders. This study presents one of the first descriptions of the prevalence and comorbidity of psychiatric disorders among repeat DUI offenders in treatment. Participants included all consenting eligible admissions (N = 729) to a 2-week inpatient treatment facility for court-sentenced repeat DUI offenders (i.e., offenders electing treatment in place of prison time) from April 17, 2005, to April 23, 2006. Participants completed the Composite International Diagnostic Interview, which assessed the following disorders using criteria from the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994): alcohol use and drug use, bipolar, generalized anxiety, posttraumatic stress, intermittent explosive, conduct, attention deficit, nicotine dependence, pathological gambling, and major depressive. Repeat DUI offenders evidenced higher lifetime and 12-month prevalence of alcohol use and drug use disorders, conduct disorder, posttraumatic stress disorder, generalized anxiety disorder, and bipolar disorder compared with the general population. Almost half qualified for lifetime diagnoses of both addiction (i.e., alcohol, drug, nicotine, and/or gambling) and a psychiatric disorder. Lifetime and past-year comorbidity rates were higher among participants than in the general population. These results suggest that clinicians should consider multimorbidity within DUI treatment protocols.

Missing in action: care by physician assistants and nurse practitioners in national health surveys.

OBJECTIVE: To assess applicability of national health survey data for generalizable research on outpatient care by physician assistants (PAs) and nurse practitioners (NPs). DATA SOURCES: Methodology descriptions and 2003 data files from the National Ambulatory Medical Care Survey, the National Hospital Ambulatory Medical Care Survey, the Medical Expenditure Panel Survey, and the Community Tracking Study. STUDY DESIGN: Surveys were assessed for utility for research on PA and NP patient care, with respect to survey coverage, structure, content, generalizability to the U.S. population, and validity. National estimates of patient encounters, statistically adjusted for survey design and nonresponse, were compared across surveys. DATA COLLECTION/EXTRACTION METHODS: Surveys were identified through literature review, selected according to inclusion criteria, and analyzed based on methodology descriptions. Quantitative analyses used publicly available data downloaded from survey websites. PRINCIPAL FINDINGS: Surveys varied with respect to applicability to PA and NP care. Features limiting applicability included (1) sampling schemes that inconsistently capture nonphysician practice, (2) inaccurate identification of provider type, and (3) data structure that does not support analysis of team practice. CONCLUSIONS: Researchers using national health care surveys to analyze PA and NP patient interactions should account for design features that may differentially affect nonphysician data. Workforce research that includes NPs and PAs is needed for national planning efforts, and this research will require improved survey methodologies.

Substance use disorder and other predictors of antidepressant-induced mania: a retrospective chart review.

OBJECTIVE: To determine if substance use disorder (SUD) is a predictor of antidepressant-induced mania (ADM) in bipolar disorder, correcting for confounding factors in a regression model. METHOD: 335 antidepressant trials were identified in 98 patients treated in an academic bipolar specialty clinic from 2000 to 2004. Patient charts were reviewed, and histories of SUD and ADM (primary outcome; defined as a hypomanic or manic episode within 12 weeks of beginning an antidepressant trial) were identified. Mood disorder diagnoses were made using the Structured Clinical Interview for DSM-IV mood module, and SUD diagnoses were defined using DSM-IV criteria. Potential confounding variables were also examined and included in a multivariable regression model. Concomitant mood stabilizer, antimanic, and antidepressant use was adjusted for in the regression model. RESULTS: In univariate analyses, there was no evidence of an association between ADM and past SUD. However, after adjustment for confounding variables in a multivariable regression model, there was a strong relationship (OR = 5.06, 95% CI = 1.31 to 19.64, p < .05). Other statistically significant predictors of ADM in the regression model were type II subtype of bipolar illness, female gender, and tricyclic antidepressant (TCA) use (vs. bupropion). CONCLUSIONS: Along with other factors, a history of SUD was a strong predictor of ADM. Possible underestimation of ADM in randomized clinical trials may occur due to the exclusion of subjects with SUD. Type II illness, female gender, and TCA use also appeared to be predictors of ADM, while bupropion use appeared to predict lower likelihood of ADM.

Risperidone in cocaine-dependent patients with comorbid psychiatric disorders.

BACKGROUND: : A high percentage of individuals with cocaine dependence have a comorbid psychiatric illness, which complicates treatment of the substance abuse. This report will describe clinical experience using risperidone in cocaine-dependent patients with psychiatric disorders. METHOD: : Sixteen male patients with cocaine dependence and comorbid psychiatric disorder (DSM-III-R) diagnoses, who were admitted to a voluntary, post-detoxification, intermediate-care inpatient substance abuse program, were started on risperidone (mean starting dose 2.3 mg/day) in an open-label, naturalistic trial. Patients were assessed weekly using the Clinical Global Impressions scale to assess overall functioning, a Likert scale for craving, the Abnormal Involuntary Movement Scale, interviews with substance abuse counselors and patients, and laboratory tests. All patients had at least one other substance use diagnosis besides cocaine dependence, and 13 patients were taking another psychiatric medication. RESULTS: : Of the 16 patients, 13 (81%) were rated improved or much improved on the CGI scale, and all patients reported mild or no craving at the last assessment (after a mean of 32.6 days of risperidone treatment). No patient developed extrapyramidal symptoms or hypomania. Compared to a 32% historical completion rate for patients receiving treatment as usual, fourteen (88%) of these patients completed the program, and 9 moved on to the next level of care. CONCLUSION: : The results of this naturalistic trial suggest that risperidone is safe and well tolerated in patients with cocaine dependence and comorbid psychiatric illness. In the short term, risperidone may also be effective in reducing cocaine craving and use and may increase the likelihood of completing substance abuse treatment.

Underdiagnosis of bipolar disorder in men with substance use disorder.

OBJECTIVE: Recent reports indicate that bipolar disorder is frequently underdiagnosed in the clinical population, leading to overuse of antidepressants and underuse of mood stabilizers. This study assessed rates of diagnosis of bipolar disorder in a substance abuse population. METHOD: The study involved a retrospective chart review of data from 295 patients admitted to an inpatient substance abuse program for men. Data were then analyzed from the 85 patients in the sample who were diagnosed as meeting DSM-IV criteria for bipolar disorder on intake into the program. Charts were reviewed for relevant clinical and demographic data. The primary outcome measure was the rate of previous misdiagnosis. RESULTS: Of the 85 patients diagnosed with bipolar disorder upon intake, 42 (49%) had not been previously diagnosed with bipolar disorder; of these 42, 6 (14%) patients had not been assessed previously, while 36 (86%) had been assessed previously and had received many other psychiatric diagnoses, including major depression (77%), attention-deficit/hyperactivity disorder (20%), and panic disorder (3%). Among the comorbid substance use disorders in these patients, alcohol dependence was the most common (62%), followed by cocaine (38%), opioid (26%), polysubstance (12%), and sedative-hypnotic (2%) dependence. Other comorbid Axis I disorders included posttraumatic stress disorder (14%), attention-deficit/hyperactivity disorder (10%), panic disorder (2%), and generalized anxiety disorder (2%). CONCLUSION: This study found that bipolar disorder had not been previously diagnosed in approximately 50% of a sample of Caucasian males in a substance abuse population who were diagnosed with bipolar disorder upon admission to an inpatient substance abuse program.