Perceptions of nonopioid treatment for pain in a homeless population.

CONTEXT: Opioid abuse has developed into a public health emergency within the last decade because opioid medications, while addictive, are effective and commonly used for pain management. In 2016, over 42,000 deaths were attributed to opioids. Chronic pain affects about 50% of people experiencing homelessness in the US, and they have a higher overall rate of chronic pain than the general population; opioids are among the methods they might use to manage that pain. Complementary and alternative therapies for pain management have largely gone unexplored in the homeless population. OBJECTIVES: To determine, among people experiencing homelessness, the willingness to use and current use of complementary and alternative treatments (physical and massage therapy, chiropractic treatments). A secondary objective was to investigate awareness and perception of osteopathic manipulative treatment (OMT) as a complementary treatment for chronic pain among the homeless population. METHODS: A 32 question survey was administered verbally to guests of True Worth Place Homeless Shelter in Fort Worth, Texas in three 4 hour sessions from February 2019 to April 2019. If participants gave verbal consent, a researcher read the questionnaire, one question at a time, and recorded the participant's responses. The survey included queries for opioid and nonopioid treatment modalities (physical and massage therapy, chiropractic, and OMT) to assess the perception of and current use of each among the population. Appropriate nonparametric statistical analysis was conducted to assess significance and correlations among the treatment groups. RESULTS: Of the 200 survey participants, 126 (91.3%) reported a history of opiate use for pain, but 136 (68.0%) believed that a nondrug pain intervention could better treat their pain. Additionally, 150 participants (75.0%) believed that regular manipulation, including OMT, would decrease their need for pain medications. Participants with a history of opioid use for pain were more likely to believe that the availability of regular manipulation, including OMT, at True Worth Place could decrease their need for pain medication (odds ratio=3.7143; 95% confidence interval=1.6122-8.5572; p=0.0009). Moreover, some participants (141; 70.5%) were already pursuing nondrug pain management modalities such as PT, massage therapy, and chiropractic care. The greatest barriers to receiving OMT were transportation and cost. CONCLUSIONS: This survey study was conducted to determine whether a homeless population would be willing to use nonopioid treatment, particularly OMT, for chronic pain management. Results revealed both a willingness to use and a previous use of nonopioid treatments for pain, along with a high prevalence of opiate use. Despite limited exposure to OMT, this population reported being potentially willing to pursue manipulation, including OMT, as a complementary treatment for pain relief alongside opioids if readily available.

Chronic psychological stress suppresses contact hypersensitivity: potential roles of dysregulated cell trafficking and decreased IFN-γ production.

Increasing evidence shows that psychological stress can have dramatic impacts on the immune system, particularly the cutaneous immune response in dermatological disorders. While there have been many studies examining the impact of acute psychological stress on contact hypersensitivity there are relatively few studies concerning the impact of chronic psychological stress. Furthermore, the local immunological mechanisms by which chronic psychological stress impacts contact hypersensitivity still remain to be explored. Here we show that restraint-induced chronic psychological stress stimulates activation of the hypothalamus-pituitary-adrenal axis and delays weight gain in female BALB/c mice. We observed that chronic psychological stress reduces the cutaneous immune response as evidence by reduced ear swelling. This correlated with a significant decrease in the inflammatory cell infiltrate. On the other hand, chronic psychological stress does not influence T cell proliferation, activation, or sensitivity to corticosterone but does increase CD4(+) and CD8(+) T cell percentages in draining lymph nodes during a contact hypersensitivity reaction. Chronic psychological stress induces a decrease in overall circulating white blood cells, lymphocytes, and monocytes during a contact hypersensitivity reaction suggesting extravasation from the circulation. Finally, we found markedly reduced local IFN-γ production in chronically stressed animals. Based on these findings we propose that chronic psychological stress reduces contact hypersensitivity due to dysregulated cell trafficking and reduced production of IFN-γ.

Psychological Stress and the Cutaneous Immune Response: Roles of the HPA Axis and the Sympathetic Nervous System in Atopic Dermatitis and Psoriasis.

Psychological stress, an evolutionary adaptation to the fight-or-flight response, triggers a number of physiological responses that can be deleterious under some circumstances. Stress signals activate the hypothalamus-pituitary-adrenal (HPA) axis and the sympathetic nervous system. Elements derived from those systems (e.g., cortisol, catecholamines and neuropeptides) can impact the immune system and possible disease states. Skin provides a first line of defense against many environmental insults. A number of investigations have indicated that the skin is especially sensitive to psychological stress, and experimental evidence shows that the cutaneous innate and adaptive immune systems are affected by stressors. For example, psychological stress has been shown to reduce recovery time of the stratum corneum barrier after its removal (innate immunity) and alters antigen presentation by epidermal Langerhans cells (adaptive immunity). Moreover, psychological stress may trigger or exacerbate immune mediated dermatological disorders. Understanding how the activity of the psyche-nervous -immune system axis impinges on skin diseases may facilitate coordinated treatment strategies between dermatologists and psychiatrists. Herein, we will review the roles of the HPA axis and the sympathetic nervous system on the cutaneous immune response. We will selectively highlight how the interplay between psychological stress and the immune system affects atopic dermatitis and psoriasis.

What the Joint Admission Medical Program (JAMP) can do for Texas physicians; what Texas physicians can do for JAMP.

Texas faces health challenges requiring a physician workforce with understanding of a broad range of issues -- including the role of culture, income level, and health beliefs -- that affect the health of individuals and communities. Building on previous successful physician workforce "pipeline" efforts, Texas established the Joint Admission Medical Program (JAMP), a first-of-its-kind program to encourage access to medical education by Texans who are economically disadvantaged. The program benefits those from racial and ethnic minority groups and involves all 31 public and 34 private Texas undergraduate colleges and universities offering life science degrees, as well as all 9 medical schools. Available program data indicate that JAMP has broadened enrollment diversity in Texas' medical schools. However, greater progress requires strengthened partnerships with professional colleagues practicing medicine in communities across Texas. This article explores how JAMP can help Texas physicians and how Texas physicians can help JAMP.

A review of current bipolar disorder treatment guidelines.

With the help of the Texas Implementation of Medication Algorithms (TIMA) and the American Psychiatric Association (APA) practice guidelines, primary care physicians can devise a treatment plan for their patients with bipolar disorder. Clinicians should keep in mind the goals of treatment, engage the patient in the treatment plan, and encourage the patient to keep a mood log and undertake psychoeducation or cognitive therapy. Patients who are unable to participate in treatment, who are suicidal, who have psychotic symptoms, or who require advanced treatments should be referred to a psychiatrist or hospital.

Diagnosing bipolar disorder: signs and symptoms.

Bipolar disorder occurs in up to 2% of the community, but the prevalence is much higher among first-degree relatives of individuals with bipolar disorder. Following Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria assists clinicians in making an accurate diagnosis of bipolar I or bipolar II disorder and in distinguishing bipolar disorders from other illnesses such as major depressive disorder, medical conditions, and substance use. Additionally, always asking depressed patients about mania and using mnemonics to check for symptoms of mania and major depression can help physicians accurately diagnose and treat bipolar disorder.

Learning outcomes from a biomedical research course for second year osteopathic medical students.

BACKGROUND: A ubiquitous dilemma in medical education continues to be whether and how to integrate research competencies into the predoctoral curriculum. Understanding research concepts is imbedded in the six core competencies for physicians, but predoctoral medical education typically does not explicitly include research education. In an effort to quickly report academic research findings to the field, this is the second in a series of articles reporting the outcomes of a research education initiative at one college of osteopathic medicine. The first article described the competency model and reported baseline performance in applied understanding of targeted research concepts. This second article reports on the learning outcomes from the inaugural year of a course in basic biomedical research concepts. METHODS: This course consisted of 24 total hours of classroom lectures augmented with web-based materials using Blackboard Vista, faculty moderated student presentations of research articles, and quizzes. To measure changes in applied understanding of targeted research concepts in the inaugural year of the course, we administered a pretest and a posttest to second year students who took the course and to first year students who took an informatics course in the same academic year. RESULTS: We analyzed 154 matched pretests and posttests representing 56% of the 273 first and second year students. On average, the first year (53) and second year students (101) did not differ in their mean pretest scores. At posttest the second year students showed significant improvement in their applied understanding of the concepts, whereas the first year students' mean posttest score was lower than their mean pretest score. CONCLUSIONS: This biomedical research course appears to have increased the second year students' applied understanding of the targeted biomedical research concepts. This assessment of learning outcomes has facilitated the quality improvement process for the course, and improved our understanding of how to measure the benefits of research education for medical students. Some of the course content and methods, and the outcome measures may need to be approached differently in the future to more effectively lay the foundation for osteopathic medical students to utilize these concepts in the clinical setting.

Family members of Hispanic military veterans: the risk of major depressive disorder.

The number of Hispanics serving in the US military is expected to grow substantially. Frequent deployments and combat assignments put significant stress on military families, increasing the risk of major depression. The family members of Hispanic military personnel may manifest depression differently than other ethnicities. Hispanics are also less likely to seek help, more likely to seek care from primary care physicians, and less likely to be appropriately diagnosed and treated. Thus, clinicians should be aware of the risk and presentation of major depressive disorder in family members of Hispanic US military veterans.

Treatment-resistant depression in Hispanic patients.

About one-third of patients treated with antidepressants do not respond to initial treatment, and Spanish-speaking Hispanic patients with major depression may exhibit a worse response to initial medication than English-speaking patients. Patients and clinicians should be resolute and patient as different regimens are tried throughout the course of treatment. Other options include electroconvulsive therapy, vagus nerve stimulation, transcranial magnetic stimulation, and the medicinal food L-methylfolate.

Psychotherapy for major depressive disorder in Latinos.

Latino patients often prefer psychotherapy to pharmacotherapy for the treatment of depression. Psychotherapies, such as cognitive-behavioral therapy and interpersonal therapy, have been found to be effective treatments for patients with depression, particularly for Latino patients. Clinicians should be respectful of the core values of family, respect, identity, and spirituality in Latino cultures and should modify psychotherapies accordingly.

Medical therapy for major depressive disorder in Latinos.

Latino patients require special considerations due to cultural beliefs, inadequate antidepressant response, increased placebo response, and adherence problems. Current evidence-based guidelines for the diagnosis and treatment of depression are generally applicable to a Hispanic population, but no separate recommendations for the treatment of major depressive disorder in Hispanic veterans or their families exist. More research is needed on depression in Hispanic patients in order to establish treatment guidelines specific to this population.

The Joint Admission Medical Program: a statewide approach to expanding medical education and career opportunities for disadvantaged students.

In 2003, Texas initiated an experiment to address enrollment disparities in its medical schools. With bipartisan support from key Texas legislators, funding was allocated in 2002 to establish the Joint Admission Medical Program (JAMP). Texas' then eight medical schools created, through JAMP, a partnership with the state's 31 public and 34 private undergraduate colleges and universities. Cognizant of legal prohibitions against reliance solely on race or ethnicity in promoting diversity, JAMP is designed to enhance opportunities for economically disadvantaged students from across the state, including those from (1) rural and remote areas of the state, and (2) institutions that have historically sent few students to medical school. Now in its seventh year of operation, JAMP is overseen by a council with representatives from all nine Texas medical schools. For the six years-2003 to 2008-for which data are available, indicators of JAMP performance can be seen in (1) the numbers of applicants to JAMP (1,230 applicants in the first six years), (2) levels of JAMP participation (480 participants), and (3) matriculation of JAMP participants into medical schools (164 of 288 of those accepted into the program in the years 2003-2006).The authors provide a brief history of JAMP, describe its structure and operation, summarize objective performance data, and identify some of the challenges still faced. These include increasing the participation of students from underrepresented minority groups within the legal structure for the program, and fostering substantive participation in JAMP by all of Texas' undergraduate institutions. A focused effort is under way to strengthen the evaluative aspects of JAMP so that more comprehensive data, including subjective evaluation data from participants, can be shared with colleagues in the future.

Biomedical research competencies for osteopathic medical students.

BACKGROUND: Without systematic exposure to biomedical research concepts or applications, osteopathic medical students may be generally under-prepared to efficiently consume and effectively apply research and evidence-based medicine information in patient care. The academic literature suggests that although medical residents are increasingly expected to conduct research in their post graduate training specialties, they generally have limited understanding of research concepts.With grant support from the National Center for Complementary and Alternative Medicine, and a grant from the Osteopathic Heritage Foundation, the University of North Texas Health Science Center (UNTHSC) is incorporating research education in the osteopathic medical school curriculum. The first phase of this research education project involved a baseline assessment of students' understanding of targeted research concepts. This paper reports the results of that assessment and discusses implications for research education during medical school. METHODS: Using a novel set of research competencies supported by the literature as needed for understanding research information, we created a questionnaire to measure students' confidence and understanding of selected research concepts. Three matriculating medical school classes completed the on-line questionnaire. Data were analyzed for differences between groups using analysis of variance and t-tests. Correlation coefficients were computed for the confidence and applied understanding measures. We performed a principle component factor analysis of the confidence items, and used multiple regression analyses to explore how confidence might be related to the applied understanding. RESULTS: Of 496 total incoming, first, and second year medical students, 354 (71.4%) completed the questionnaire. Incoming students expressed significantly more confidence than first or second year students (F = 7.198, df = 2, 351, P = 0.001) in their ability to understand the research concepts. Factor analyses of the confidence items yielded conceptually coherent groupings. Regression analysis confirmed a relationship between confidence and applied understanding referred to as knowledge. Confidence scores were important in explaining variability in knowledge scores of the respondents. CONCLUSION: Medical students with limited understanding of research concepts may struggle to understand the medical literature. Assessing medical students' confidence to understand and objectively measured ability to interpret basic research concepts can be used to incorporate competency based research material into the existing curriculum.

Practical strategies for diagnosing and treating depression in women at midlife and beyond: chronic depression.

Dysthymic disorder is a mild but chronic depression that can be difficult for physicians to treat because patients with dysthymic disorder have a high risk of relapse. Guidelines for treating dysthymic disorder suggest treatment with antidepressants, especially selective serotonin reuptake inhibitors, and psychotherapy. A variety of antidepressants and psychotherapies have shown efficacy in trials, and treatment must be tailored to the individual patient.

Do atypical antipsychotics effectively treat co-occurring bipolar disorder and stimulant dependence? A randomized, double-blind trial.

OBJECTIVES: The primary objective was to compare the efficacy and tolerability of quetiapine and risperidone in the treatment of mood symptoms, drug cravings, and drug use in outpatients with concurrent DSM-IV-defined bipolar I or II disorder and cocaine or methamphetamine dependence. METHOD: Men and women of all ethnic origins, 20 to 50 years of age, were eligible to participate. Persons were excluded if they were inpatients, met DSM-IV criteria for substance-induced mood disorder, had any other substance dependence, were euthymic or suicidal, had any life-threatening illnesses, or were currently receiving antipsychotic medications. Duration of the trial was 20 weeks. Study participants attended weekly visits and were evaluated for mood symptoms, drug cravings, drug use, and medication side effects. Treatment outcomes were analyzed using linear mixed models. Fixed-effects terms for medication group, study week, and group-by-study-week were included in the models. The study was conducted between October 2002 and November 2006. RESULTS: Of 124 consenting outpatients, an evaluable sample of 80 patients who attended baseline and at least 1 follow-up study visit was formed. The mean +/- SD exit dose for quetiapine was 303.6 +/- 151.9 mg/day and 3.1 +/- 1.2 mg/day for risperidone. Both quetiapine (N = 42) and risperidone (N = 38) significantly improved manic and depressive symptoms and reduced drug cravings (p < .0005) compared to baseline. Decreased drug cravings were related to less frequent drug use (p = .03). The 2 medications did not significantly differ in their effects on mood symptoms, drug craving, or drug use. CONCLUSIONS: Relative to baseline mood and drug-craving status, both quetiapine and risperidone were associated with manic, mixed, and depressive symptom improvement and reduced drug cravings. Both medications were well tolerated. The interpretation of these results is limited by the absence of a placebo control. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00227123.