It's not just the money: The role of treatment ideology in publicly funded substance use disorder treatment.

Medications for opioid use disorder (MOUD) are a first-line treatment for opioid use disorder, yet national surveys indicate that most substance use treatment facilities do not offer MOUD. This article presents the results of a qualitative analysis of interviews with leaders from 25 treatment organizations in Philadelphia, Pennsylvania, that investigated attitudes and barriers toward MOUD. Most treatment organizations that we interviewed are adopting at least one MOUD, suggesting that Philadelphia exceeds the national average of organizations with MOUD capacity. Leaders indicated that both practical resources and ideological barriers thwart adoption and implementation of MOUD in publicly funded substance use disorder treatment agencies. Organizations that had recently adopted MOUDs revealed facilitators to MOUD adoption, such as strong leadership that champions the implementation to staff and redefining recovery from substance use disorders throughout the organization. This study's findings highlight that clients, clinicians, and leadership need to address both practical and ideological barriers to expanding MOUD use.

Treating Fentanyl Withdrawal.

Fentanyl withdrawal is common, but pharmacological management has largely mirrored traditional approaches to opioid withdrawal. Observations in a large urban center suggest alternative approaches, including the need for dose modification, should be considered.

Diffusion-weighted imaging predicts cognitive impairment in multiple sclerosis.

Following a previous study with diffusion tensor imaging, we investigated the correlation between diffusion-weighted imaging (DWI) and cognitive dysfunction in multiple sclerosis (MS). We studied 60 MS patients (mean age 45.8+/-9.0 years) using 1.5-T MRI. Disease course was RR=40 and SP = 20. Mean disease duration was 12.8+/-8.7 years. Mean EDSS was 3.4+/-1.7. Whole brain, gray and white matter normalized volumes were calculated on 3D SPGR T1-WI using a fully automated Hybrid SIENAX method. Parenchymal mean diffusivity (PMD) maps were created after automated segmentation of the brain parenchyma and cerebrospinal fluid using T2-WI and DW images. Histogram analysis was performed and DWI indices of peak position (PP), peak height (PH), mean parenchymal diffusivity (MPD) and entropy were obtained. Neuropsychological (NP) evaluation emphasized auditory/verbal and visual/spatial memory, as well as processing speed and executive function. We found significant correlations between DWI and performance in all cognitive domains. Overall, stronger correlations emerged for MPD and entropy than other DWI measures, although all correlations were in the expected direction. The strongest association was between DWI entropy and performance on the Symbol Digit Modalities Test, which assesses processing speed and working memory (r = -0.54). Fisher r to z transformations revealed that DWI, gray matter (GMF) and whole brain (BPF) atrophy, T1-lesion volume (LV) and T2-LV all accounted for similar amounts of variance in NP testing. Stepwise regression models determined whether multiple MRI measures predicted unique additive variance in test performance. GMF (R2 = 0.35, F =30.82, P <0.01) and entropy (DeltaR2 =0.06, DeltaF=5.47, P <0.05) both accounted for unique variance in processing speed. Our data make a stronger case for the clinical validity of DWI in MS than heretofore reported. DWI has very short acquisition times, and the segmentation method applied in the present study is reliable and fully automated. Given its overall simplicity and moderate correlation with cognition, DWI may offer several logistic advantages over more traditional MRI measures when predicting the presence of NP impairment.