The use of an integrated opioid and medical marijuana prescription drug monitoring program.

OBJECTIVES: To (1) identify the reasons for which pharmacists in Connecticut use the CPMRS when dispensing opioid medications and medical marijuana products, (2) determine pharmacists' perceived value of the CPMRS when dispensing opioids or medical marijuana, and (3) compare practices and the perceived value of the CPMRS among community-based pharmacists (CBPs) and medical marijuana dispensary pharmacists (MMDPs). METHODS: An online survey was administered from May 2019 to June 2019 to CBPs (n = 178) and MMDPs (n = 12). The survey included items about background, use, and attitudes about current and future use of the CPMRS. RESULTS: Both pharmacist groups indicated that opioid use information was the most useful aspect of the CPMRS. Ninety percent of both groups checked patients' use of opioids using the CPMRS, and 81.2% of the MMDPs compared with 38.4% of the CBPs indicated that they checked for patients' use of medical marijuana. A greater percentage of MMDPs than CBPs felt that access to the marijuana use information was useful and needed for counseling. Several pharmacists recommended improvements in marijuana use information in the CPMRS and greater efficiencies for users of the system. CONCLUSION: Access to both marijuana and opioid use information can allow pharmacists to make specific recommendations on the basis of potential drug interactions and dose adjustments. The results from the present study highlight how integrated systems of opioid and marijuana dispensing information can be further enhanced by resolving existing pharmacy barriers involving technology, workflow, and need for systems with more detailed marijuana product information.

Differences in the prevalence of musculoskeletal symptoms among female and male custodians.

BACKGROUND: The prevalence of musculoskeletal symptoms among custodians is high. We sought to compare musculoskeletal symptoms between female and male custodians and to explore how task might affect this relationship. METHODS: A cross-sectional study was performed among 712 custodians who completed a survey assessing upper extremity, back, and lower extremity musculoskeletal symptoms and exposure to cleaning tasks. Chi-square tests and logistic regression analyses were used to test for associations between gender, cleaning tasks, and musculoskeletal symptoms. RESULTS: Gender was significantly (P < 0.05) associated with musculoskeletal symptoms in χ(2) tests and multivariate analyses. The prevalence ratio of symptoms among women was roughly 50% higher than men, regardless of the tasks that workers performed. CONCLUSIONS: The prevalence of musculoskeletal symptoms differed for female and male custodians and appeared to be consistent across a range of job tasks. Am. J. Ind. Med. 59:841-852, 2016. © 2016 Wiley Periodicals, Inc.

Characterization of Urinary Phthalate Metabolites Among Custodians.

Phthalates, a ubiquitous class of chemicals found in consumer, personal care, and cleaning products, have been linked to adverse health effects. Our goal was to characterize urinary phthalate metabolite concentrations and to identify work and nonwork sources among custodians using traditional cleaning chemicals and 'green' or environmentally preferable products (EPP). Sixty-eight custodians provided four urine samples on a workday (first void, before shift, end of shift, and before bedtime) and trained observers recorded cleaning tasks and types of products used (traditional, EPP, or disinfectant) hourly over the work shifts. Questionnaires were used to assess personal care product use. Four different phthalate metabolites [monoethyl phthalate (MEP), monomethyl phthalate (MMP), mono (2-ethylhexyl) phthalate (MEHP), and monobenzyl phthalate (MBzP)] were quantified using liquid chromatography mass spectrometry. Geometric means (GM) and 95% confidence intervals (95% CI) were calculated for creatinine-adjusted urinary phthalate concentrations. Mixed effects univariate and multivariate modeling, using a random intercept for each individual, was performed to identify predictors of phthalate metabolites including demographics, workplace factors, and personal care product use. Creatinine-adjusted urinary concentrations [GM (95% CI)] of MEP, MMP, MEHP, and MBzP were 107 (91.0-126), 2.69 (2.18-3.30), 6.93 (6.00-7.99), 8.79 (7.84-9.86) µg g(-1), respectively. An increasing trend in phthalate concentrations from before to after shift was not observed. Creatinine-adjusted urinary MEP was significantly associated with frequency of traditional cleaning chemical intensity in the multivariate model after adjusting for potential confounding by demographics, workplace factors, and personal care product use. While numerous demographics, workplace factors, and personal care products were statistically significant univariate predictors of MMP, MEHP, and MBzP, few associations persisted in multivariate models. In summary, among this population of custodians, we identified both occupational and nonoccupational predictors of phthalate exposures. Identification of phthalates as ingredients in cleaning chemicals and consumer products would allow workers and consumers to avoid phthalate exposure.

Traditional and environmentally preferable cleaning product exposure and health symptoms in custodians.

BACKGROUND: We investigated the associations between traditional and environmentally preferable cleaning product exposure and dermal, respiratory, and musculoskeletal symptoms in a population of custodians. METHODS: We analyzed associations between symptoms and exposure to traditional and environmentally preferable cleaning product exposure among 329 custodians. RESULTS: We observed increased odds of dermal (P < 0.01), upper (P = 0.01) and lower respiratory (P = 0.01), and upper extremity (P < 0.01), back (P < 0.01), and lower extremity (P = 0.01) musculoskeletal symptoms associated with increased typical traditional cleaning product exposure. We observed significant trends for increased odds of dermal (P = 0.03) and back (P = 0.04) and lower (P = 0.02) extremity musculoskeletal symptoms associated with increased typical environmentally preferable cleaning product exposure. CONCLUSIONS: Fewer positive associations and reduced odds of health symptoms associated with environmentally preferable cleaning product exposure suggest that these products may represent a safer alternative to traditional cleaning products.

Development of an assessment of functioning scale for prison environments.

This paper reports the development of a global assessment of functioning (GAF), modified from the DSM Axis V GAF for the prison environment. Focus groups, which were conducted with 36 correctional officers and clinicians in two prisons, provided descriptions of behavior in prison settings to re-align the GAF scale. Face validity was established. It was found that Habitation/Behavior, Social, and Symptoms emerged as important domains of functioning in prison. Gender differences were noted with regard to cleanliness, relationships and coping strategies. The cut-off score was identified at a score where offenders were unable to participate in a disciplinary process due to their mental illness. The structure of prison alters human functioning, requiring different assessment language and ratings to measure perceived behavioral norms and/or expectations. Front-line staff need the ability to observe and communicate behavioral changes quickly and accurately in a prison environment without undue burden upon their workload. This assessment was modified by front-line staff specifically for the prison environment to document quick and frequent assessments of observed changes over time in the offender population.

A pilot test of the CM-GAF among offenders with mental disorders.

A pilot test of clinician-rated validity of scores on a Correction Modified-Global Assessment of Functioning (CM-GAF) scale was performed by assessing a random sample of 60 adult male and female offenders at two correctional facilities. Pairs of trained clinicians assessed the offenders with the CM-GAF and GAF instruments. Regression analyses were conducted. Variables included in the analysis were demographic characteristics (age, gender, and race), criminal history (number of incarcerations, violent/non-violent offense, year of current incarceration), number of disciplinary reports (tickets), and Connecticut Department of Corrections (CDOC) risk scores. The model for the CM-GAF yielded one significant predictor variable, Presence of Pending Charges Risk Score (B = -7.25, p = .003), predicting 44.4% of the variance. This finding suggests that higher functioning offenders tend not to have pending charges, which may be a proxy for length of incarceration. Newly admitted offenders are more likely to have pending charges and more likely to exhibit disruptive and disorganized behaviors. Management of mentally ill persons who are incarcerated is facilitated when inter-professional frontline staff can communicate using a common language. Frequent assessment with an instrument that is understandable across disciplines has the potential to improve care, and as few standardized mental health instruments are modified and tested for use in the prison environment. Additional studies, refining scoring across subsamples by age, race, gender, diagnosis, and levels of security, are still needed.

A process evaluation of START NOW Skills Training for inmates with impulsive and aggressive behaviors.

AIM: To conduct a formative evaluation of a treatment program designed for inmates with impulsive and aggressive behavior disorders in high-security facilities in Connecticut correctional facilities. METHOD: Pencil-and-paper surveys and in-person inmate interviews were used to answer four evaluation questions. Descriptive statistics and content analyses were used to assess context, input, process, and products. FINDINGS: A convenience sample of 26 adult male (18) and female (8) inmates participated in the study. Inmates were satisfied with the program (4-point scale, M = 3.38, SD = 0.75). Inmate hospital stays were reduced by 13.6%, and psychotropic medication use increased slightly (0.40%). Improved outcomes were noted for those inmates who attended more sessions. CONCLUSIONS: The findings of the formative evaluation were useful for moving the START NOW Skills Training treatment to the implementation phase. Recommendations for implementation modifications included development of an implementation team, reinforcement of training, and attention applied to uniform collection of outcome data to demonstrate its evidence base.

Suicide prevention skills, confidence and training: Results from the Zero Suicide Workforce Survey of behavioral health care professionals.

INTRODUCTION: In behavioral health care settings, a workforce well trained in suicide prevention is critically important for behavioral health care professionals across different disciplines and service sectors who are likely to have considerable exposure to patients at risk for suicidal behavior. This study examined the types of training behavioral health care professionals received, their self-reported skills, comfort level and confidence related to suicide prevention, the association of types and length of training with skills, comfort level and confidence, and areas in which participants would like more training. METHODS: The Zero Suicide Workforce Survey was administered electronically to behavioral health care professionals at six behavioral health treatment centers with both inpatient and ambulatory programs in Connecticut, USA. Item numbers and percentages were calculated for 847 respondents with behavioral health care roles. The chi-square tests were performed to determine the statistical significance of group differences. Non-parametric sign tests were performed to determine the statistical significance of the collective differences in direction among items between groups. RESULTS: Suicide prevention training is associated with increased levels of behavioral health care professionals' skills and confidence, but one-third of behavioral health care professionals in the sample received no formal training in suicide prevention/intervention. Even brief training appears to have a positive impact on behavioral health care professionals' assessment of their skills and confidence. Prominent topics for additional training include suicide-specific treatment approaches, suicide prevention and awareness, and identification of risk factors and warning signs. CONCLUSION: Although behavioral health care professionals may often encounter patients at risk for suicide, many have not obtained any relevant training. The findings highlight the need to strengthen suicide identification, assessment and treatment within behavioral health care treatment settings as part of an effort to prevent suicide.

Conducting research in corrections: challenges and solutions.

Research in correctional settings has progressed from the exploitation of a vulnerable population in the years prior to 1978 to its current overly protective and restrictive state. With the considerable growth in the numbers of inmates with medical and mental health care needs, developing effective interventions to serve this population is paramount. There now appear to be signs of interest in and support for research with inmates by correctional agencies, academia, and health care organizations. Innes (2003) has articulated the following strategies for implementing research in prison: (1) gather stakeholders; (2) include one or more experienced research collaborators; (3) consider obtaining technical assistance from a university or the National Institute of Corrections (NIC); (4) define potential opportunities/interests that support the institution's mission; (5) develop a relationship with an IRB; (6) pilot a small proposal that is of interest and potential value to the organization. The authors illustrate the implementation of a study in a correctional system that uses these strategies.

Adaptation of the Texas Implementation Medication Algorithm for Bipolar Disorder in Adult Female Offenders.

Use of medication algorithms in the correctional setting may facilitate clinical decision making, improve consistency of care, and reduce polypharmacy. The objective of the present study was to evaluate effectiveness of algorithm (Texas Implementation of Medication Algorithm [TIMA])-driven treatment of bipolar disorder (BD) compared with Treatment as Usual (TAU) in the correctional environment. A total of 61 women inmates with BD were randomized to TIMA (n = 30) or TAU (n = 31) and treated over a 12-week period. The outcome measures included measures of BD symptoms, comorbid symptomatology, quality of life, and psychotropic medication utilization. In comparison with TAU, TIMA-driven treatment reduced polypharmacy, decreased overall psychotropic medication utilization, and significantly decreased use of specific classes of psychotropic medication (antipsychotics and antidepressants). This pilot study confirmed the feasibility and benefits of algorithm-driven treatment of BD in the correctional setting, primarily by enhancing appropriate use of evidence-based treatment.

Algorithm-driven pharmacological management of bipolar disorder in Connecticut prisons.

The objective of this study was to assess adaptation of the Texas Implementation of Medication Algorithm (TIMA) for bipolar disorder (BD) in the Connecticut Department of Correction. A nonrandomized sample of 20 males and 20 females, with diagnoses of BD Type I or II, was enrolled in the study. Two TIMA-trained psychiatrists treated the participants over a 12-week period following the TIMA protocol. The primary outcome measure was the Bipolar Disorder Symptom Scale. Secondary outcome measures evaluated global clinical status, comorbid symptomatology, and quality of life. Significant improvement was seen with the primary and secondary outcome measures (p < .001). Subanalyses showed differences in outcomes based on gender and whether a manic or depression algorithm was used. Antidepressant and antipsychotic medication use decreased, with increase in anticonvulsant and anxiolytic medication usage. This pilot study confirmed the effectiveness and benefits of TIMA for BD adaptation in the correctional setting.

Transitioning from traditional to green cleaners: an analysis of custodian and manager focus groups.

Custodians represent one of the largest occupational groups using cleaning agents, and yet their voices are infrequently heard in relation to the introduction of "green" cleaners and the laws regarding environmentally preferable products (EPP). This study reflects worker voices on use and effectiveness of chemicals, as well as incentives and obstacles for green cleaning programs. Sixty-four custodians and staff participated in 10 focus groups. Data were entered into Atlas Ti and the constant comparative method of qualitative data analysis was used to identify themes. Themes included satisfaction in a "well-done" job, more effort required for job, lack of involvement in EPP selection process, EPP's ease of use for workers with English as a Second Language (ESL), misuse of disinfectants, health complaints, and need for training. This study shows that custodians have a voice, and that improved communication and feedback among all the stakeholders are needed to make the transition to green cleaning more effective.

Best practices: disseminating best practices for bipolar disorder treatment in a correctional population.

Use of medication treatment algorithms may facilitate clinical decision making, improve consistency, and reduce polypharmacy in the correctional setting. A feasibility study was conducted investigating use of Texas Implementation of Medication Algorithms (TIMA) guidelines for bipolar disorder in the Connecticut Department of Correction. Forty inmates with diagnoses of bipolar disorder were treated over a 12-week period adhering to the TIMA algorithm for bipolar disorder. Significant improvement was seen in the primary and secondary outcome measures (p<.001). This pilot project confirmed the feasibility of algorithm adaptation to the correctional setting and provided specific recommendations for successful dissemination of the TIMA algorithm for bipolar disorder in correctional settings.