Impact of California Statute on Naloxone Availability and Opioid Overdose Rates.

Introduction: Ensuring that people at risk of overdosing on opioids have easy access to naloxone is an essential part of the fight against the opioid crisis. This study evaluates the impact of the 2016 California law (CA AB1535) permitting pharmacies to dispense this life-saving medication without a physician's prescription. Methods: California counties were categorized on the basis of population density (rural, suburban, urban), rate of opioid-related deaths by population density (high, medium, low), and rate of opioid prescriptions by population density (high, medium, low). Ten diverse pharmacies from each category were selected for inclusion. In a brief 1-minute interview conducted between July and August 2021, pharmacists from 146 California pharmacies were surveyed regarding their knowledge of CA AB1535, their practice of dispensing naloxone without a physician's prescription, and whether they normally stock naloxone. Chi-square tests were used to compare responses. Results: Although almost all pharmacies interviewed (94%) were aware of the law and most of them (64%) dispensed naloxone without a physician's prescription, few statistically significant differences were found between surveyed categories. There were no significant relationships between naloxone availability at pharmacies and overdose death rates. Conclusions: Our results suggest that the number of California pharmacies dispensing naloxone without a physician's prescription has continued to increase since the implementation of CA AB1535. However, despite increased access to naloxone at pharmacies, opioid overdose rates have continued to rise since 2016, indicating the need for a multifaceted harm reduction approach.

Self-care habits among people who inject drugs with skin and soft tissue infections: a qualitative analysis.

BACKGROUND: Injection drug use is on the rise in the USA, and skin and soft tissue infections (SSTI) are a common complication, resulting in significant morbidity and mortality. Due to structural barriers to care-seeking, many people who inject drugs avoid formal care and resort to self-care techniques, but little is known about the nature of these techniques, or more generally about the accuracy or breadth of this population's knowledge of SSTIs. METHODS: Semi-structured qualitative interviews were conducted with 12 people who inject heroin in two metropolitan areas: Sacramento and Boston, USA. RESULTS: These interviews reveal a robust and accurate knowledge base regarding skin infections, including the progression from simple cellulitis to an abscess, and acknowledgment of the possibility of serious infections. Nonetheless, there remains a reticence to seek care secondary to past traumatic experiences. A step-wise approach to self-care of SSTI infections was identified, which included themes of whole-body health, topical applications, use of non-prescribed antibiotics, and incision and drainage by non-medical providers. CONCLUSIONS: The reported SSTI self-care strategies demonstrate resilience and ingenuity, but also raise serious concerns about inappropriate antibiotic consumption and complications of invasive surgical procedures performed without proper training, technique, or materials. Harm reduction agencies and health care providers should work to obviate the need for these potentially dangerous practices by improving healthcare access for this population. In the absence of robust solutions to meet the needs of this population, education materials should be developed to optimize the efficacy and minimize the harms of these practices, while empowering and supporting the autonomy of people who use drugs and providing clear guidance on when self-care should be abandoned in favor of formal medical care.

Evidence for successful implementation of exposure and response prevention in a naturalistic group format for pediatric OCD.

BACKGROUND: Although exposure and response prevention (ERP) is an effective treatment for youth with obsessive-compulsive disorder (OCD), the majority of studies, randomized clinical trials of individual therapy, find variability in treatment response. We evaluated the potential role of individual differences in OCD presentation, comorbid disorders, age, and gender on treatment effects. Moreover, we examined these potential effects in a group format in a naturalistic, clinic-based sample of patients. METHODS: Pediatric patients with a DSM-IV diagnosis of OCD (n=41) were treated with ERP in an intensive outpatient community-based program. OCD, mood, and anxiety symptom severity was measured at baseline, during treatment, and at discharge. Trajectories and predictors of treatment outcome were measured using linear growth models. RESULTS: We found that group-based ERP was effective in reducing pediatric OCD symptom severity in a naturalistic treatment setting irrespective of age or gender. Furthermore, ERP was found to be effective at reducing depressive symptoms but not other anxiety symptoms. We also found inter-individual variability in the discharge levels of contamination, symmetry, and intrusive sexual thoughts and in the rate of severity reduction of intrusive sexual thoughts. CONCLUSION: Group-based ERP is an effective treatment for children and adolescents with OCD. Several factors, including symptom dimensions and comorbid psychopathology, are associated with treatment response and outcome in this pediatric population.

Neural correlates of symptom dimensions in pediatric obsessive-compulsive disorder: a functional magnetic resonance imaging study.

OBJECTIVE: Neuroimaging studies have identified distinct neural correlates of obsessive-compulsive disorder (OCD) symptom dimensions in adult subjects and may be related to functional abnormalities in different cortico-striatal-thalamic neural systems underlying cognition and affective processing. Similar symptom dimensions are apparent in childhood and adolescence, but their functional neural correlates remain to be elucidated. METHOD: Pediatric subjects with OCD (n = 18) and matched controls (n = 18), ages 10 to 17 years, were recruited for two functional magnetic resonance imaging experiments. They were scanned while viewing alternating blocks of symptom provocation (contamination-related or symmetry-related) and neutral pictures and imagining scenarios related to the content of each picture type. RESULTS: The subjects with OCD demonstrated reduced activity in the right insula, putamen, thalamus, dorsolateral prefrontal cortex, and left orbitofrontal cortex (contamination experiment) and in the right thalamus and right insula (symmetry experiment). Higher scores on OCD symptom-related measures (contamination and total severity) were significantly predictive of reduced neural activity in the right dorsolateral prefrontal cortex during the contamination experiment. CONCLUSIONS: Our findings indicate reduced activity in neural regions underlying emotional processing, cognitive processing, and motor performance in pediatric subjects with OCD compared with the controls. These between-group differences are present during both contamination and symmetry provocation experiments and during symptom provocation as well as viewing neutral pictures. The direction of activity is in contrast to adult findings in the insula and in components of cortico-striatal-thalamic neural systems. Our findings suggest developmental effects on neural systems underlying symptom dimensions in pediatric OCD.

Pediatric obsessive-compulsive disorder: management priorities in primary care.

PURPOSE OF REVIEW: Obsessive-compulsive disorder (OCD) is a severe neuropsychiatric condition with a substantial prevalence in childhood and adolescence. Our understanding of the etiopathogenesis of pediatric OCD continues to grow, along with diagnostic and treatment approaches. The present study attempts to provide a parsimonious review of important studies of pediatric OCD with particular emphasis on studies over the last year. RECENT FINDINGS: Consistent with many other pediatric conditions, OCD in childhood and adolescence has distinct yet overlapping features with the adult-onset type. It appears that OCD is a multidimensional disorder with substantial comorbidity with other neuropsychiatric disorders that may affect its course and treatment. Although its pathophysiology remains to be fully elucidated, evidence suggests that OCD likely results from a complex interaction between multiple genetic variants and nongenetic factors. Meanwhile, evidence supporting the efficacy of selective serotonin reuptake inhibitors, augmentation strategies affecting other neurotransmitter systems, and cognitive behavioral therapy for the treatment of pediatric OCD continues to emerge. SUMMARY: Results from the studies reviewed here reflect the heterogeneity of pediatric OCD. It is clear that clinicians need to consider specific symptoms, comorbid conditions, and the rapidly evolving clinical research when working with children and adolescents with OCD.

Brain structure and symptom dimension relationships in obsessive-compulsive disorder: a voxel-based morphometry study.

BACKGROUND: Obsessive-compulsive disorder (OCD) is a clinically heterogenous disorder characterized by temporally stable symptom dimensions. Past inconsistent results from structural neuroimaging studies of OCD may have resulted from the effects of these specific symptom dimensions as well as other socio-demographic and clinical variables upon gray matter (GM) volume. METHODS: GM volume was measured in 25 adult OCD patients and 20 adult healthy controls using voxel-based morphometry (VBM), controlling for age and total brain GM volume. Univariate and multivariate regression analyses were carried out between regions of GM difference and age, age of onset, medication load, OCD severity, depression severity, and separate symptom dimension scores. RESULTS: Significant GM volumetric differences in OCD patients relative to controls were found in dorsal cortical regions, including bilateral BA6, BA46, BA9 and right BA8 (controls>patients), and bilateral midbrain (patients>controls). Stepwise regression analyses revealed highly significant relationships between greater total OCD symptom severity and smaller GM volumes in dorsal cortical regions and larger GM volumes in bilateral midbrain. Greater age was independently associated with smaller GM volumes in right BA6, left BA9, left BA46 and larger GM volumes in right midbrain. Greater washing symptom severity was independently associated with smaller GM volume in right BA6, while there was a trend association between greater hoarding symptom severity and lower GM volume in left BA6. LIMITATIONS: The sample was relatively small to examine the relationship between symptom scores and GM volumes. Multiple patients were taking medication and had comorbid disorders. CONCLUSIONS: These analyses suggest dorsal prefrontal cortical and bilateral midbrain GM abnormalities in OCD that appear to be primarily driven by the effects of total OCD symptom severity. The results regarding the relationship between GM volumes and symptom dimension scores require examination in larger samples.

Gray matter differences between pediatric obsessive-compulsive disorder patients and high-risk siblings: a preliminary voxel-based morphometry study.

Neuroimaging studies have identified alterations in frontostriatal circuitry in obsessive-compulsive disorder (OCD). Voxel-based morphometry (VBM) allows for the assessment of differences in gray matter density across the whole brain. VBM has not previously been used to examine regional gray matter density in pediatric OCD patients and the siblings of pediatric OCD patients. Volumetric magnetic resonance imaging (MRI) studies were conducted in 10 psychotropic naïve pediatric patients with OCD, 10 unaffected siblings of pediatric patients with OCD, and 10 healthy controls. VBM analysis was conducted using SPM2. Statistical comparisons were performed with the general linear model, implementing small volume random field corrections for a priori regions of interest (anterior cingulate cortex or ACC, striatum and thalamus). VBM analysis revealed significantly lower gray matter density in OCD patients compared to healthy in the left ACC and bilateral medial superior frontal gyrus (SFG). Furthermore, a small volume correction was used to identify a significantly greater gray matter density in the right putamen in OCD patients as compared to unaffected siblings of OCD patients. These findings in patients, siblings, and healthy controls, although preliminary, suggest the presence of gray matter structural differences between affected subjects and healthy controls as well as between affected subjects and individuals at risk for OCD.

Brief report: abnormal association between the thalamus and brain size in Asperger's disorder.

The objective of this study was to examine the relationship between thalamic volume and brain size in individuals with Asperger's disorder (ASP). Volumetric measurements of the thalamus were performed on MRI scans obtained from 12 individuals with ASP (age range: 10-35 years) and 12 healthy controls (age range: 9-33 years). A positive correlation was found between total brain volume and thalamic size in controls, but not in ASP subjects. This occurred in the absence of differences in mean thalamic volumes between the study groups. Findings from this investigation point to an abnormal relationship between the thalamus and its projection areas in ASP and are consistent with similar studies in autism, supporting that these disorders are qualitatively similar and possibly quantitatively different.

Abnormal brain size effect on the thalamus in autism.

This study was conducted to examine the volume of the thalamus in autism and to investigate the effect of brain size on this structure in an attempt to replicate, in a larger sample, findings from a previous study reporting the existence of a relationship between brain volume and thalamus in healthy controls but not in individuals with autism. Additionally, the relationships between thalamic volumes and clinical features were examined. Volumetric measurements of the right and left thalamic nuclei were performed on MRI scans obtained from 40 high-functioning individuals with autism (age range: 8-45 years) and 41 healthy controls (age range: 9-43 years). No differences were observed between the two groups for unadjusted thalamic volumes. However, the expected linear relationship between TBV and thalamic volume was not observed in individuals with autism. Furthermore, no correlations were observed between thalamic volumes and clinical features. Findings from this larger study are consistent with the previous report of an abnormal brain size effect on the thalamus in autism and support the possibility of abnormal connections between cortical and subcortical structures in this disorder.

A developmental model for enhancing research training during psychiatry residency.

OBJECTIVE: The authors describe a developmental model for enhancing residency research training for careers in academic psychiatry. Over the past 10 years, the University of Pittsburgh Department of Psychiatry has developed a research track (RT) for its residents. While the Department's plan has been to address the critical need of training physician-scientists in psychiatry, the RT continues to evolve as a structured extension of the University's residency-training program. Recently, the University's departmental leadership has taken several steps that address regulatory, institutional, and personal barriers to residency research training put forth by the 2003 Institute of Medicine (IOM) report. METHODS: The authors outline a model of residency research training, elements of which should be exportable to the majority of U.S. psychiatry residency programs. RESULTS: For residents in the RT, up to 50% of time in PGY-3 and up to 75% of time in PGY-4 can be devoted to research-related activities. The authors currently have 13 residents and fellows in their track. Over the past 10 years, 15 of 33 RT residents have become research postdocs or full-time grant-funded researchers in academic positions. CONCLUSION: The authors' experience suggests that it is possible to organize and implement an RT during psychiatry residency within the parameters presented by the Psychiatry Residency Review Committee (RRC).

Obstetric complications correlate with neurobehavioral and brain structural alterations in young relatives at risk for schizophrenia.

As complications of pregnancy and birth may be important risk factors for the development of schizophrenia, studying the "roots" of schizophrenia in high-risk offspring may better elucidate the interface between biology, environment, and susceptibility to illness. Using magnetic resonance imaging (MRI), neurobehavioral assessments and obstetric histories, we found several significant correlations between these multiple factors, suggesting that birth complications may be a nonspecific etiopathogenic risk factor for psychopathology in young relatives at risk for schizophrenia.