Outbreak of Locally Acquired Mosquito-Transmitted (Autochthonous) Malaria - Florida and Texas, May-July 2023.

Eight cases of locally acquired, mosquito-transmitted (i.e., autochthonous) Plasmodium vivax malaria, which has not been reported in the United States since 2003, were reported to CDC from state health departments in Florida and Texas during May 18-July 17, 2023. As of August 4, 2023, case surveillance, mosquito surveillance and control activities, and public outreach and education activities continue in both states. U.S. clinicians need to consider a malaria diagnosis in patients with unexplained fever, especially in areas where autochthonous malaria has been recently reported, although the risk for autochthonous malaria in the United States remains very low. Prompt diagnosis and treatment of malaria can prevent severe disease or death and limit ongoing transmission to local Anopheles mosquitoes and other persons. Preventing mosquito bites and controlling mosquitoes at home can prevent mosquitoborne diseases, including malaria. Before traveling internationally to areas with endemic malaria, travelers should consult with a health care provider regarding recommended malaria prevention measures, including potentially taking malaria prophylaxis. Malaria is a nationally notifiable disease; continued reporting of malaria cases to jurisdictional health departments and CDC will also help ensure robust surveillance to detect and prevent autochthonous malaria in the United States.

Twelve-Month Retention in Opioid Agonist Treatment for Opioid Use Disorder Among Patients With and Without HIV.

Although opioid agonist therapy (OAT) is associated with positive health outcomes, including improved HIV management, long-term retention in OAT remains low among patients with opioid use disorder (OUD). Using data from the Veterans Aging Cohort Study (VACS), we identify variables independently associated with OAT retention overall and by HIV status. Among 7,334 patients with OUD, 13.7% initiated OAT, and 27.8% were retained 12-months later. Likelihood of initiation and retention did not vary by HIV status. Variables associated with improved likelihood of retention included receiving buprenorphine (relative to methadone), receiving both buprenorphine and methadone at some point over the 12-month period, or diagnosis of HCV. History of homelessness was associated with a lower likelihood of retention. Predictors of retention were largely distinct between patients with HIV and patients without HIV. Findings highlight the need for clinical, systems, and research initiatives to better understand and improve OAT retention.

Substance use-related continuing education course objectives: Alignment with professional competencies.

Background: Novel educational efforts are needed to prepare the current and future interprofessional health care workforce to address the range of substance use-related health problems. A 6-module massive open online course (MOOC) was developed to provide education to health professionals of various disciplines on the fundamentals of substance use-related treatment. The purpose of this project was to match course objectives to substance use-related competencies for 5 disciplines: nurses, pharmacists, physicians, physician assistants (PA), and social workers. Methods: Content expert raters within each discipline determined what Association for Multidisciplinary Education and Research in Substance use and Addiction (AMERSA) core competencies were matched to each objective for the 6 modules of the MOOC. The number of objectives across the 6 modules was summated. Results: All nursing and social work competencies were mapped to the course objectives. For physicians, PAs, and pharmacists, the proportions of knowledge-based competencies that mapped to the course objective were 58%, 76%, and 80%, respectively, and proportions of skill-based competencies that mapped to the course objective were 88%, 83%, and 75%, respectively. For those 3 groups, 100% of attitude-based competencies mapped to the course objective. Conclusions: The competency-based mapping with the MOOC objectives supports the interprofessional design of the course and discipline-specific competencies needed to promote the best outcomes for patients.

Efficacy of Extended-Release Naltrexone on HIV-Related and Drinking Outcomes Among HIV-Positive Patients: A Randomized-Controlled Trial.

We sought to test the efficacy of extended-release naltrexone (XR-NTX) on HIV-related and drinking outcomes. From April 2011-February 2015, we conducted a 4-site randomized double-blind placebo controlled clinical trial involving 51 HIV-positive patients with heavy drinking and < 95% antiretroviral (ART) adherence. All participants received counseling. The primary outcome was proportion with ≥ 95% ART adherence. Secondary outcomes included HIV biomarkers, VACS Index score, and past 30-day heavy drinking days. Based on receipt of ≥ 5 injections, 23 participants were retained at 24 weeks. We did not detect an effect of XR-NTX on ART adherence (p = 0.38); undetectable HIV viral load (p = 0.26); CD4 cell count (p = 0.75) or VACS Index score (p = 0.70). XR-NTX was associated with fewer heavy drinking days (p = 0.03). While XR-NTX decreases heavy drinking days, we did not detect improvements in ART adherence or HIV outcomes. Strategies to improve retention in alcohol treatment and HIV-related outcomes among heavy drinking HIV-positive patients are needed.

Evaluation of an Integrated, Multidisciplinary Program to Address Unsafe Use of Opioids Prescribed for Pain.

Objectives: Unsafe use of opioids prescribed for pain is a common challenge in primary care. We aimed to describe a novel clinical program designed to address this issue-the Opioid Reassessment Clinic-and evaluate preliminary efficacy. Methods: The Opioid Reassessment Clinic is a multidisciplinary care team staffed by an internist, addiction psychiatrist, advanced practice nurse, and health psychologist designed to perform enhanced assessment and longitudinal treatment of patients with unsafe use of opioids prescribed for pain. We assessed preliminary efficacy of the clinic using a priori-defined metrics at the patient, provider, clinic process, and health system levels. Results: Of referred patients (N = 87), 84% had a history of substance abuse/dependence and 70% had current misuse of prescribed opioids; 22% received a new substance use disorder diagnosis, each of whom engaged in addiction treatment. Among primary care physicians, 48% referred a patient to the clinic. In terms of process metrics, high fidelity to structured clinical assessments was assisted by templated electronic progress notes. Wait time averaged 22.1 days while length of treatment averaged 137 days. Urine drug testing was performed on 91% of patients an average of 6.4 times, while assessing out-of-system opioid receipt occurred universally. Systems-level findings included evidence of institutional support: hiring a nurse case manager to help with care coordination. Conclusions: Results suggest the Opioid Reassessment Clinic was effective in the management of a small group of high-complexity patients. Wide-scale dissemination may require adapted care models.

Project STEP: Implementing the Veterans Health Administration's Stepped Care Model of Pain Management.

Objective: The "stepped care model of pain management" (SCM-PM) prioritizes the role of primary care providers in optimizing pharmacological management and timely and equitable access to patient-centered, evidence-based nonpharmacological approaches, when indicated. Over the past several years, the Veterans Health Administration (VHA) has supported implementation of SCM-PM, but few data exist regarding changes in pain care resulting from implementation. We examined trends in prescribing and referral practices of primary care providers with hypotheses of decreased opioid prescribing, increased nonopioid prescribing, and increased referrals to specialty care for nonpharmacological services. Design: An initiative was designed to foster implementation and systematic evaluation of the SCM-PM over a five-year period at the VA Connecticut Healthcare System (VACHS) while fostering collaborative, partnered initiatives to promote organizational improvements in the delivery of pain care. Subjects: Participants were veterans receiving care at VACHS with at least one pain intensity rating ≥4/10 over the course of the study period (7/2008-6/2013). Methods: We used electronic health record data to examine changes in indicators of pain care including pharmacy and health care utilization data. Results: We observed hypothesized changes in long-term opioid and nonopioid analgesic prescribing and increased utilization of nonpharmacological treatments such as physical therapy, occupational therapy, and clinical health psychology. Conclusions: Through a multifaceted comprehensive implementation approach, primary care providers demonstrated increases in guideline-concordant pain care practices. Findings suggest that engagement of interdisciplinary teams and partnerships to promote organizational improvements is a useful strategy to increase the use of integrated, multimodal pain care for veterans, consistent with VHA's SCM-PM.

Multiple Sources of Prescription Payment and Risky Opioid Therapy Among Veterans.

BACKGROUND: Opioid overdose and other related harms are a major source of morbidity and mortality among US Veterans, in part due to high-risk opioid prescribing. OBJECTIVES: We sought to determine whether having multiple sources of payment for opioids-as a marker for out-of-system access-is associated with risky opioid therapy among veterans. RESEARCH DESIGN: Cross-sectional study examining the association between multiple sources of payment and risky opioid therapy among all individuals with Veterans Health Administration (VHA) payment for opioid analgesic prescriptions in Kentucky during fiscal year 2014-2015. MEASURES: Source of payment categories: (1) VHA only source of payment (sole source); (2) sources of payment were VHA and at least 1 cash payment [VHA+cash payment(s)] whether or not there was a third source of payment; and (3) at least one other noncash source: Medicare, Medicaid, or private insurance [VHA+noncash source(s)]. Our outcomes were 2 risky opioid therapies: combination opioid/benzodiazepine therapy and high-dose opioid therapy, defined as morphine equivalent daily dose ≥90 mg. RESULTS: Of the 14,795 individuals in the analytic sample, there were 81.9% in the sole source category, 6.6% in the VHA+cash payment(s) category, and 11.5% in the VHA+noncash source(s) category. In logistic regression, controlling for age and sex, persons with multiple payment sources had significantly higher odds of each risky opioid therapy, with those in the VHA+cash having significantly higher odds than those in the VHA+noncash source(s) group. CONCLUSIONS: Prescribers should examine the prescription monitoring program as multiple payment sources increase the odds of risky opioid therapy.

A Cross-Sectional Online Survey of HIV Pre-Exposure Prophylaxis Adoption Among Primary Care Physicians.

BACKGROUND: Among health care providers, prescription of HIV pre-exposure prophylaxis (PrEP) has been low. Little is known specifically about primary care physicians (PCPs) with regard to PrEP awareness and adoption (i.e., prescription or referral), and factors associated with adoption. OBJECTIVE: To assess PrEP awareness, PrEP adoption, and factors associated with adoption among PCPs. DESIGN: Cross-sectional online survey conducted in April and May 2015. RESPONDENTS: Members of a national professional organization for academic primary care physicians (n = 266). MAIN MEASURES: PrEP awareness, PrEP adoption (ever prescribed or referred a patient for PrEP [yes/no]), provider and practice characteristics, and self-rated knowledge, attitudes, and beliefs associated with adoption. KEY RESULTS: The survey response rate was 8.6 % (266/2093). Ninety-three percent of respondents reported prior awareness of PrEP. Of these, 34.9 % reported PrEP adoption. In multivariable analysis of provider and practice characteristics, compared with non-adopters, adopters were more likely to provide care to more than 50 HIV-positive patients (vs. 0, aOR = 6.82, 95 % CI 2.06-22.52). Compared with non-adopters, adopters were also more likely to report excellent, very good, or good self-rated PrEP knowledge (15.1 %, 33.7 %, 30.2 % vs. 2.5 %, 18.1 %, 23.8 %, respectively; p < 0.001) and to perceive PrEP as extremely safe (35.1 % vs. 10.7 %; p = 0.002). Compared with non-adopters, adopters were less likely to perceive PrEP as being moderately likely to increase risk behaviors ("risk compensation") (12.8 % vs. 28.8 %, p = 0.02). CONCLUSIONS: While most respondents were aware of PrEP, only one-third of PrEP-aware PCPs reported adoption. Adopters were more likely to have experience providing HIV care and to perceive PrEP as extremely safe, and were less likely to perceive PrEP use as leading to risk compensation. To enhance PCP adoption of PrEP, educational efforts targeting PCPs without HIV care experience should be considered, as well as training those with HIV care experience to be PrEP "clinical champions". Concerns about safety and risk compensation must also be addressed.

Primary Care Physicians' Willingness to Prescribe HIV Pre-exposure Prophylaxis for People who Inject Drugs.

Pre-exposure prophylaxis for HIV (PrEP) is recommended for people who inject drugs (PWID). Despite their central role in disease prevention, willingness to prescribe PrEP to PWID among primary care physicians (PCPs) is largely understudied. We conducted an online survey (April-May 2015) of members of a society for academic general internists regarding PrEP. Among 250 respondents, 74% (n = 185) of PCPs reported high willingness to prescribe PrEP to PWID. PCPs were more likely to report high willingness to prescribe PrEP to all other HIV risk groups (p's < 0.03 for all pair comparisons). Compared with PCPs delivering care to more HIV-infected clinic patients, PCPs delivering care to fewer HIV-infected patients were more likely to report low willingness to prescribe PrEP to PWID (Odds Ratio [95% CI] = 6.38 [1.48-27.47]). PCP and practice characteristics were not otherwise associated with low willingness to prescribe PrEP to PWID. Interventions to improve PCPs' willingness to prescribe PrEP to PWID are needed.

A Remotely-Delivered CBT and Contingency Management Therapy for Substance Using People with HIV.

Substance using HIV patients are at risk for non-adherence, and most prior interventions in this population have had only modest effects on adherence. Contingency management (CM) is a promising intervention. The Centralized Off-site Adherence Enhancement (CARE) program involved 12 telephone-delivered substance and adherence-targeted cognitive behavior therapy sessions coupled with CM for adherence to antiretroviral therapy (ART) and counseling participation. CM involved 6 weeks of escalating reinforcement for taking prescribed doses followed by 6 weeks of tapering variable rate reinforcement, and separate reinforcement for counseling ($806 possible). Participants' adherence was measured by devices which wirelessly provided real-time notification of device-opening. HIV infected patients on ART (N = 10) with recent stimulant or alcohol use completed 10.2 of 12 possible telephone sessions, spent 42.8 min/call, and rated the counseling 6.2 on a 1-7 scale. Medication adherence improved from 81 to 93 % (p = 0.04). CARE appears to be acceptable and engaging.

Evaluation of a telementoring intervention for pain management in the Veterans Health Administration.

OBJECTIVE: Half of all Veterans experience chronic pain yet many face geographical barriers to specialty pain care. In 2011, the Veterans Health Administration (VHA) launched the Specialty Care Access Network-ECHO (SCAN-ECHO), which uses telehealth technology to provide primary care providers with case-based specialist consultation and pain management education. Our objective was to evaluate the pilot SCAN-ECHO pain management program (SCAN-ECHO-PM). DESIGN AND SETTING: This was a longitudinal observational evaluation of SCAN-ECHO-PM in seven regional VHA healthcare networks. METHODS: We identified the patient panels of primary care providers who submitted a consultation to one or more SCAN-ECHO-PM sessions. We constructed multivariable Cox proportional hazards models to assess the association between provider SCAN-ECHO-PM consultation and 1) delivery of outpatient care (physical medicine, mental health, substance use disorder, and pain medicine) and 2) medication initiation (antidepressants, anticonvulsants, and opioid analgesics). RESULTS: Primary care providers (N = 159) who presented one or more SCAN-ECHO-PM sessions had patient panels of 22,454 patients with chronic noncancer pain (CNCP). Provider consultation to SCAN-ECHO-PM was associated with utilization of physical medicine [hazard ratio (HR) 1.10, 95% confidence interval (CI) 1.05-1.14] but not mental health (HR 0.99, 95% CI 0.93-1.05), substance use disorder (HR 0.93, 95% CI 0.84-1.03) or specialty pain clinics (HR 1.01, 95% CI 0.94-1.08). SCAN-ECHO-PM consultation was associated with initiation of an antidepressant (HR 1.09, 95% CI 1.02-1.15) or anticonvulsant medication (HR 1.13, 95% CI 1.06-1.19) but not an opioid analgesic (HR 1.05, 0.99-1.10). CONCLUSIONS: SCAN-ECHO-PM was associated with increased utilization of physical medicine services and initiation of nonopioid medications among patients with CNCP. SCAN-ECHO-PM may provide a novel means of building pain management competency among primary care providers.

A partnered approach to opioid management, guideline concordant care and the stepped care model of pain management.

BACKGROUND: Pain is the most common presenting problem in primary care. Opioid therapy (OT) for chronic pain has increased dramatically over the past decade, as have related negative outcomes. Despite the development and dissemination of policy and clinical practice guidelines for pain management and OT, adoption has been variable. The Veterans Health Administration (VHA) has established a Stepped Care Model of Pain Management (SCM-PM) as an evidence-based framework and single standard of pain care to promote guideline-concordant care, but to date its adoption and related outcomes have not been systematically examined. OBJECTIVE: Our aim was to examine changes in care for Veterans receiving long-term OT for management of chronic pain over a four-year study period. DESIGN: As part of a comprehensive implementation evaluation of performance improvements, the current evaluation reports performance improvement outcomes related to pain management and OT over a four-year period. SUBJECTS: We studied Veterans receiving long-term (90+ consecutive days) OT through primary care. INTERVENTIONS: We engaged an interdisciplinary clinical-research team to develop and implement a multifaceted performance improvement approach that included interactive educational strategies and other organizational initiatives. MAIN MEASURES: We measured the proportion of patients receiving long-term OT; use of opioid risk mitigation strategies; referrals to pain-related specialty services; and use of non-opioid analgesics. KEY RESULTS: The proportion of patients receiving high-dose opioids decreased over four years (27.7 % to 24.7 %). The use of opioid risk mitigation strategies increased significantly. Referrals to physical therapy and chiropractic care and prescriptions for topical analgesics increased significantly, while referrals to the pain medicine specialty clinic decreased. CONCLUSIONS: We demonstrate improvements in the management of veterans receiving OT that are consistent with the SCM-PM and published practice guidelines. We highlight how partnerships among funders, researchers, clinicians, and administrators contributed to the project's design and implementation, and to the dissemination strategy and future directions for improving opioid management and pain care.

National Addiction Workshop: A Virtual Adaptation to Support Competency Development in Opioid Use Disorder Management.

BACKGROUND: Accessible, manualized, skill-based training ready for wide dissemination is needed to prepare healthcare staff to meet the needs of people impacted by the opioid epidemic. METHODS: A 2-day workshop and simulation training was designed by an interprofessional substance use disorder (SUD) specialty care team, adapted to a virtual platform, manualized, and offered to healthcare staff and trainees from a large healthcare system. The workshop was offered 6 times over the course of 10 months with a total of 177 participants from across the United States enrolled in the training. Interactive experiential learning strategies including games designed to test knowledge, small-group case discussions, video demonstrations of skills, patient panels, and 3 simulations of a patient with chronic pain who developed opioid use disorder in the context of long-term opioid therapy were utilized in efforts to build skills and confidence managing SUDs in primary care and general mental health settings. RESULTS: Of those who completed the post-workshop survey, most found both content and training structure useful, particularly content related to medication management, stigma, and collaborative care. In addition, overall confidence scores in assessing, diagnosing, and treating SUD increased. Skill building exercises, such as interprofessional team simulations, were highlighted as most beneficial. The workshop received national attention leading to a partnership with the healthcare system's simulation center for wider dissemination. CONCLUSION: Expanding access to SUD treatment requires training healthcare staff to effectively change attitudes, increase knowledge, and improve key skills. This 2-day interprofessional workshop was well-received by participants who reported high acceptability and satisfaction scores and demonstrated improved confidence in the management of SUDs. This type of manualized, collaborative, skill-based learning experience can foster staff preparedness and willingness to conceptualize SUD as a chronic condition amenable to treatment in different healthcare settings.

Pain and associated substance use among opioid dependent individuals seeking office-based treatment with buprenorphine-naloxone: a needs assessment study.

BACKGROUND AND OBJECTIVES: A paucity of studies has examined the pain experiences of opioid dependent individuals seeking office-based buprenorphine-naloxone treatment (BNT). We set out to examine, among those seeking BNT: (a) the prevalence of pain types (i.e., recent pain, chronic pain), (b) the characteristics of pain (intensity, frequency, duration, interference, location, and genesis), and (c) substance use to alleviate pain. METHOD: We surveyed 244 consecutive individuals seeking office-based BNT for opioid dependence about physical pain and associated substance use. RESULTS: Thirty-six percent of respondents reported chronic pain (CP) (i.e., pain lasting at least 3 months) and 36% reported "some pain" (SP) (i.e., past week pain not meeting the threshold for CP). In comparison to SP respondents, those with CP were, on average, older; reported greater current pain intensity, pain frequency, typical pain duration, typical pain intensity, and typical pain interference; were more likely to report shoulder or pelvis and less likely to report stomach or arms as their most bothersome pain location; and were more likely to report accident or nerve damage and less likely to report opioid withdrawal as the genesis of their pain. Both pain subgroups reported similarly high rates of past-week substance use to alleviate pain. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: The high rates of pain and self-reported substance use to manage pain suggest the importance of assessing and addressing pain in BNT patients.

Video-telecare collaborative pain management during COVID-19: a single-arm feasibility study.

BACKGROUND: Chronic pain is among the most common conditions presenting to primary care and guideline-based care faces several challenges. A novel pain management program, Video-Telecare Collaborative Pain Management (VCPM), was established to support primary care providers and meet new challenges to care presented by the COVID-19 pandemic. METHODS: The present single-arm feasibility study aimed to evaluate the feasibility and acceptability of VCPM and its components among U.S. veterans on long-term opioid therapy for chronic pain at ≥ 50 mg morphine equivalent daily dose (MEDD). VCPM consists of evidence-based interventions, including opioid reassessment and tapering, rotation to buprenorphine and monitoring, and encouraging behavioral pain and opioid-use disorder self-management. RESULTS: Of the 133 patients outreached for VPCM, 44 completed an initial intake (33%) and 19 attended multiple VCPM appointments (14%). Patients were generally satisfied with VCPM, virtual modalities, and provider interactions. Nearly all patients who attended multiple appointments maintained a buprenorphine switch or tapered opioids (16/19; 84%), and buprenorphine switches were generally reported as acceptable by patients. Patients completing an initial intake with VCPM had reduced morphine equivalent daily dose after three months (means = 109 mg MEDD vs 78 mg), with greater reductions among those who attended multiple appointments compared to intake only (ΔMEDD = -58.1 vs. -8.40). Finally, 29 referrals were placed for evidence-based non-pharmacologic interventions. CONCLUSION: Pre-defined feasibility and acceptability targets for VCPM and its components were broadly met, and preliminary data are encouraging. Novel strategies to improve enrollment and engagement and future directions are discussed.

Cost-effectiveness of long-term outpatient buprenorphine-naloxone treatment for opioid dependence in primary care.

BACKGROUND: Primary care physicians with appropriate training may prescribe buprenorphine-naloxone (bup/nx) to treat opioid dependence in US office-based settings, where many patients prefer to be treated. Bup/nx is off patent but not available as a generic. OBJECTIVE: We evaluated the cost-effectiveness of long-term office-based bup/nx treatment for clinically stable opioid-dependent patients compared to no treatment. DESIGN, SUBJECTS, AND INTERVENTION: A decision analytic model simulated a hypothetical cohort of clinically stable opioid-dependent individuals who have already completed 6 months of office-based bup/nx treatment. Data were from a published cohort study that collected treatment retention, opioid use, and costs for this population, and published quality-of-life weights. Uncertainties in estimated monthly costs and quality-of-life weights were evaluated in probabilistic sensitivity analyses, and the economic value of additional research to reduce these uncertainties was also evaluated. MAIN MEASURES: Bup/nx, provider, and patient costs in 2010 US dollars, quality-adjusted life years (QALYs), and incremental cost-effectiveness (CE) ratios ($/QALY); costs and QALYs are discounted at 3% annually. KEY RESULTS: In the base case, office-based bup/nx for clinically stable patients has a CE ratio of $35,100/QALY compared to no treatment after 24 months, with 64% probability of being < $100,000/QALY in probabilistic sensitivity analysis. With a 50% bup/nx price reduction the CE ratio is $23,000/QALY with 69% probability of being < $100,000/QALY. Alternative quality-of-life weights result in CE ratios of $138,000/QALY and $90,600/QALY. The value of research to reduce quality-of-life uncertainties for 24-month results is $6,400 per person eligible for treatment at the current bup/nx price and $5,100 per person with a 50% bup/nx price reduction. CONCLUSIONS: Office-based bup/nx for clinically stable patients may be a cost-effective alternative to no treatment at a threshold of $100,000/QALY depending on assumptions about quality-of-life weights. Additional research about quality-of-life benefits and broader health system and societal cost savings of bup/nx therapy is needed.

Microbial burden on environmental surfaces in patient rooms before daily cleaning-Analysis of multiple confounding variables.

OBJECTIVES: Estimated levels of microbial burden on hospital environmental surfaces vary substantially among published studies. Cultures obtained during a cluster-controlled crossover trial of a quaternary ammonium (Quat) disinfectant versus an improved hydrogen peroxide (IHP) disinfectant provided additional data on the amount of microbial burden on selected surfaces. METHODS: RODAC plates containing D/E neutralizing agar were used to sample a convenience sample of 5-8 high-touch surfaces in patient rooms on 2 medical wards, an intensive care unit, and a step-down unit at a large hospital. Before routine daily cleaning, samples were obtained in varying rooms over an 11-month period. RODAC plates (1 per surface sampled) were incubated for 72 hours, and aerobic colony counts per plate (ACCs) were determined. Statistical analysis was used to determine the potential impact on ACCs of study period, cleaning compliance rate, disinfectant used, ward, surface sampled, and isolation room status. RESULTS: Overall, 590 cultures were obtained on Quat wards and 589 on IHP wards. Multivariable regression analysis revealed that mean ACCs differed significantly by site (P < .001), type of ward (P < .001), isolation room status (P = .039), and study period (P = .036). The highest mean ACCs per RODAC plate were on toilet seats (112.8), bedside rails (92.0), and bathroom grab bars (79.5). CONCLUSIONS: The combination of factors analyzed revealed that estimating microbial burden is complex and is affected by multiple factors. Additional studies should evaluate individual sites, ward types, cleaning and disinfection practices, and isolation room status.

Opioid tapering support using a web-based app: Development and protocol for a pilot randomized controlled trial.

BACKGROUND: Given limited efficacy and potential harms of long-term opioid therapy, it is patient-centered and guideline-concordant to offer patients the opportunity to engage in a supportive, patient-centered tapering program. The goal of this study was to develop and pilot an interactive web-based program designed to support patients willing to consider an opioid taper; this manuscript describes the development and the protocol for a pilot randomized trial of Summit. METHODS: We used intervention mapping to develop the Summit program; during the development period we engaged multiple stakeholder groups and conducted usability testing to refine the interactive, theory-informed, multi-component mobile website program which includes education, video testimonials, self-management skills, and access to a peer specialist. We will evaluate the Summit program in a two-arm, 9 month randomized-controlled trial where 64 individuals will be assigned either to the Summit program or to a control group (pain tracking app). As a pilot trial, the primary outcomes are feasibility and acceptability; we will also measure patient-reported outcomes related to pain, quality of life, and opioid use. IMPLICATIONS: We developed an interactive program; results of the pilot trial are pending. If shown to be effective, Summit would be useful both in augmenting care for patients who are engaged in a taper with primary care.

Personality disorders and retention in a therapeutic community for substance dependence.

Although therapeutic community (TC) treatment is a promising intervention for substance use disorders, a primary obstacle to successful treatment is premature attrition. Because of their prevalence within substance use treatment facilities, personality disorder (PD) diagnoses have been examined as predictors of treatment completion. Prior research on TC outcomes has focused almost exclusively on antisocial personality disorder (ASPD), and the results have been mixed. This study extends previous research by examining the impact of the 10 Axis II PDs on early (first 30 days) attrition as well as overall time to dropout in a 9-month residential TC. Survival analyses indicated that borderline was the only PD negatively related to overall program retention. In contrast, ASPD, as well as histrionic PD, were related to very early attrition, but not to overall program retention. Early assessment and identification of at-risk individuals may improve treatment retention and outcome for TC treatment.