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CORK Bibliography: Protocols

103 citations. January 2010 to present

Prepared: September 2012

Albright B; de la Torre L; Skipper B; Price S; Abbott P; Rayburn W. Changes in methadone maintenance therapy during and after pregnancy. Journal of Substance Abuse Treatment 41(4): 347-353, 2011. (31 refs.)

Objective: The aim of this study is to better understand anticipated changes in daily methadone doses as a guide for prescription during pregnancy. Methods: This retrospective case series involved a single cohort longitudinal design of 139 consecutively chosen women who began methadone therapy before 26 completed gestational weeks. Changes in the single daily dose were based on a standard opiate withdrawal scale and determined from early pregnancy until 6 weeks postpartum. Results: As gestation advanced, the methadone dose increased (86%) rather than remained the same (8%) or decreased (7%). This gradual increase in daily dose during pregnancy (mean increase = 24 mg, 95% confidence level = 20-28 mg) was statistically significant (p < .001) regardless of the initial maintenance dose. By the sixth postpartum week, most subjects (85%) took within 10 mg of their dose at delivery (mean change in dose = -4 mg, 95% confidence interval = -6 to -2 mg). Conclusions: Daily doses of methadone increased until the third trimester, then remained essentially unchanged through the sixth postpartum week.

Ames GM; Bennett JB. Prevention interventions of alcohol problems in the workplace: A review and guiding framework. Alcohol Research & Health 34(2): 175-+, 2011. (60 refs.)

The workplace offers advantages as a setting for interventions that result in primary prevention of alcohol abuse. Such programs have the potential to reach broad audiences and populations that would otherwise not receive prevention programs and, thereby, benefit both the employee and employer. Researchers have implemented and evaluated a variety of workplace alcohol problem prevention efforts in recent years, including programs focused on health promotion, social health promotion, brief interventions, and changing the work environment. Although some studies reported significant reductions in alcohol use outcomes, additional research with a stronger and integrated methodological approach is needed. The field of workplace alcohol prevention also might benefit from a guiding framework, such as the one proposed in this article.

Baldus C; Miranda A; Weymann N; Reis O; More K; Thomasius R. "CAN Stop" - Implementation and evaluation of a secondary group prevention for adolescent and young adult cannabis users in various contexts study protocol. BMC Health Services Research 11: e80, 2011. (36 refs.)

Background: Current research shows that overall numbers for cannabis use among adolescents and young adults dropped in recent years. However, this trend is much less pronounced in continuous cannabis use. With regard to the heightened risk for detrimental health- and development-related outcomes, adolescents and young adults with continuous cannabis use need special attention. The health services structure for adolescents and young adults with substance related problems in Germany, is multifaceted, because different communal, medical and judicial agencies are involved. This results in a rather decentralized organizational structure of the help system. This and further system-inherent characteristics make the threshold for young cannabis users rather high. Because of this, there is a need to establish evidence-based low-threshold help options for young cannabis users, which can be easily disseminated. Therefore, a training programme for young cannabis users (age 14-21) was developed in the "CAN Stop" project. Within the project, we seek to implement and evaluate the training programme within different institutions of the help system. The evaluation is sensitive to the different help systems and their specific prerequisites. Moreover, within this study, we also test the practicability of a training provision through laypersons. Methods/Design: The CAN Stop study is a four-armed randomized wait-list controlled trial. The four arms are needed for the different help system settings, in which the CAN Stop training programme is evaluated: (a) the drug addiction aid and youth welfare system, (b) the out-patient medical system, (c) the in-patient medical system and (d) prisons for juvenile offenders. Data are collected at three points, before and after the training or a treatment as usual, and six months after the end of either intervention. Discussion: The CAN Stop study is expected to provide an evidence-based programme for young cannabis users seeking to reduce or quit their cannabis use. Moreover, we seek to gain knowledge about the programme's utility within different settings of the German help system for young cannabis users and information about the settings' specific clientele. The study protocol is discussed with regard to potential difficulties within the different settings.

Bart G. CSAT's QT Interval Screening in Methadone Report: Outrageous fortune or sea of troubles? (editorial). Journal of Addictive Diseases 30(4): 313-317, 2011. (25 refs.)

Battersby CLF; Jermin PJ; Haigh GA; Towers TM. Clinical experience of smoking cessation advice in hospital trauma units. European Journal of Orthopaedic Surgery and Traumatology 21(6): 453-456, 2011. (18 refs.)

Cigarette smoking is increasingly well recognized as an inhibiting factor in fracture healing, and risk factor for non-union. We assessed whether adequate smoking cessation advice and support was given to cigarette smokers undergoing fracture management, based upon the United States Public Health Service 'Five As' Smoking Cessation Guidelines-evidence-based guidelines outlining effective strategy to promote smoking cessation, by taking a smoking history, advising the patient to stop smoking, assessing motivation to stop and facilitating cessation via support groups and pharmacological interventions (Ask, Advise, Assess, Assist, Arrange). Our study was conducted within three large orthopaedic units in the Mersey deanery, UK. A questionnaire was completed by 156 cigarette smokers-inpatients and outpatients-undergoing fracture management (87 M, 69 F, 18-89 years, mean age 48.2 years). All patients included within the study had been seen by an orthopaedic practitioner prior to completing the questionnaire. We assessed whether a member of the orthopaedic team had addressed each patient's smoking habits based upon the 'Five As' approach. A smoking history had been taken from 66% of smokers, 54% of those patients (36% of smokers) were advised to stop smoking. Motivation to stop smoking was assessed in only 4% of patients, whilst assistance and support relating to smoking cessation was offered to only 2.5% of patients. The assessment of smoking prevalence, and subsequent promotion of smoking cessation amongst trauma patients, is clearly suboptimal. We suggest highlighting the significance of smoking as a risk factor for impaired fracture healing amongst all healthcare professionals treating trauma patients, and the incorporation of smoking cessation advice and support into the management of orthopaedic trauma in order to promote improved fracture healing.

Baxter S; Everson-Hock E; Messina J; Guillaume L; Burrows J; Goyder E. Factors relating to the uptake of interventions for smoking cessation among pregnant women: A systematic review and qualitative synthesis. (review). Nicotine & Tobacco Research 12(7): 685-694, 2010. (49 refs.)

The review had the aim of investigating factors enabling or discouraging the uptake of smoking cessation services by pregnant women smokers. The literature was searched for papers relating to the delivery of services to pregnant or recently pregnant women who smoke. No restrictions were placed on study design. A qualitative synthesis strategy was adopted to analyze the included papers. Analysis and synthesis of the 23 included papers suggested 10 aspects of service delivery that may have an influence on the uptake of interventions. These were whether or not the subject of smoking is broached by a health professional, the content of advice and information provided, the manner of communication, having service protocols, follow-up discussion, staff confidence in their skills, the impact of time and resource constraints, staff perceptions of ineffectiveness, differences between professionals, and obstacles to accessing interventions. The findings suggest variation in practice between services and different professional groups, in particular regarding the recommendation of quitting smoking versus cutting down but also in regard to procedural aspects, such as recording status and repeat advice giving. These differences offer the potential for a pregnant woman to receive contradicting advice. The review suggests a need for greater training in this area and the greater use of protocols, with evidence of a perception of ineffectiveness/pessimism toward intervention among some service providers.

Beaulieu S; Saury S; Sareen J; Tremblay J; Schutz CG; McIntyre RS et al. The Canadian Network for Mood and Anxiety Treatments (CANMAT) Task Force recommendations for the management of patients with mood disorders and comorbid substance use disorders. (review). Annals of Clinical Psychiatry 24(1): 38-55, 2012. (128 refs.)

Background: Mood disorders, especially bipolar disorder (BD), frequently are associated with substance use disorders (SUDs). There are well-designed trials for the treatment of SUDs in the absence of a comorbid condition. However, one cannot generalize these study results to individuals with comorbid mood disorders, because therapeutic efficacy and/or safety and tolerability profiles may differ with the presence of the comorbid disorder. Therefore, a review of the available evidence is needed to provide guidance to clinicians facing the challenges of treating patients with comorbid mood disorders and SUDs. Methods: We reviewed the literature published between January 1966 and November 2010 by using the following search strategies on PubMed. Search terms were bipolar disorder or depressive disorder, major (to exclude depression, postpartum; dysthymic disorder; cyclothymic disorder; and seasonal affective disorder) cross-referenced with alcohol or drug or substance and abuse or dependence or disorder. When possible, a level of evidence was determined for each treatment using the framework of previous Canadian Network for Mood and Anxiety Treatments recommendations. The lack of evidence-based literature limited the authors' ability to generate treatment recommendations that were strictly evidence based, and as such, recommendations were often based on the authors' opinion. Results: Even though a large number of treatments were investigated for alcohol use disorder (AUD), none have been sufficiently studied to justify the attribution of level 1 evidence in comorbid AUD with major depressive disorder (MDD) or BD. The available data allows us to generate first-choice recommendations for AUD comorbid with MDD and only third-choice recommendations for cocaine, heroin, and opiate SUD comorbid with MOD. No recommendations were possible for cannabis, amphetamines, methamphetamines, or polysubstance SUD comorbid with MDD. First-choice recommendations were possible for alcohol, cannabis, and cocaine SUD comorbid with BD and only second-choice recommendations for heroin, amphetamine, methamphetamine, and polysubstance SUD comorbid with BD. No recommendations were possible for opiate SUD comorbid with BD. Finally, psychotherapies certainly are considered an essential component of the overall treatment of SUDs comorbid with mood disorders. However, further well-designed studies are needed in order to properly assess their potential role in specific SUDs comorbid with a mood disorder. Conclusions: Although certain treatments show promise in the management of mood disorders comorbid with SUDs, additional well-designed studies are needed to properly assess their potential role in specific SUDs comorbid with a mood disorder.

Bell J. The global diversion of pharmaceutical drugs. Addiction 105(9): 1531-1537, 2010. (41 refs.)

Aim: To provide a clinician's perspective on the problem of diversion of prescribed pharmaceuticals. Methods: The paper provides a personal account of working in a treatment context where diversion from opioid substitution treatment (OST) became a political issue potentially compromising the continued delivery of OST. It summarizes evidence on the impact of diversion, and measures to contain it, from the United Kingdom 1986-2006, Australia 1996-2008 and the United States and France from the mid-1990s. Results: Opioid diversion to the black market occurs in proportion to the amount of opioids prescribed to be taken without supervision, and in inverse proportion to the availability of heroin. Diversion for OST programmes using supervision of dosing is less than diversion of opioids prescribed for pain, which is now a growing public health problem. Adverse consequences of diversion include opioid overdose fatalities, an increased incidence of addiction (particularly in jurisdictions where heroin is scarce) and compromising the public acceptance of long-term opioid prescribing. All long-term opioid prescribing requires monitoring of risk and appropriate dispensing arrangements-including dilution of methadone take-aways, supervision of administration for high-risk patients and random urine testing. Clinical guidelines influence practice, although prescribing often deviates from guidelines. Conclusion: Clinical guidelines and clinical audit to enhance compliance with guidelines are helpful in maintaining the quality and integrity of the treatment system, and can contribute to keeping diversion within acceptable levels.

Bernardy NC; Hamblen JL; Friedman MJ; Kivlahan DR. Co-occurring posttraumatic stress disorder and substance use disorder: Recommendations for management and implementation in the Department of Veterans Affairs. Journal of Dual Diagnosis 7(4, special issue): 242-261, 2011. (81 refs.)

The recently revised Department of Veterans Affairs (VA) and Department of Defense Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder (PTSD) offers guidance to treat co-occurring PTSD and substance use disorder. The release of the guideline occurred at a time of cultural shifts in recognizing and managing substance use disorders and when major changes were made in the VA to address co-occurring PTSD and substance use disorders. The release also coincided with an increasing number of veterans returning from the wars in Afghanistan and Iraq who were coming to the VA for PTSD treatment. A key augmentation in mental health staffing has brought many new clinicians to the VA and has made it more feasible to address the two disorders in a coordinated way. In this article the authors describe the recommendations in the revised 2010 PTSD clinical practice guideline to address co-occurring PTSD and substance use disorder, review the supporting research evidence behind the recommendations, and examine methods of new VA programs to address the two disorders. A description of what is working and where obstacles still exist is provided. The new recommendations have moved the field forward by offering clinical guidance to practitioners who are working with patients with the commonly observed co-occurring PTSD and substance use disorder.

Brass EP; Lofstedt R; Renn O. Improving the decision-making process for nonprescription drugs: A framework for benefit-risk assessment. Clinical Pharmacology and Therapeutics 90(6): 791-803, 2011. (75 refs.)

Nonprescription drugs pose unique challenges to regulators. The fact that the barriers to access are lower for nonprescription drugs as compared with prescription drugs may permit additional consumers to obtain effective drugs. However, the use of these drugs by consumers in the absence of supervision by a health-care professional may result in unacceptable rates of misuse and suboptimal clinical outcomes. A value-tree method is proposed that defines important benefit and risk domains relevant to nonprescription drugs. This value tree can be used to comprehensively identify product-specific attributes in each domain and can also support formal benefit-risk assessment using a variety of tools. This is illustrated here, using a modification of the International Risk Governance Council (IRGC) framework, a flexible tool previously applied in a number of fields, which systematizes an approach to issue review, early alignment of stakeholders, evaluation, and risk mitigation/management. The proposed approach has the potential to provide structured, transparent tools for regulatory decision making for nonprescription drugs.

Brown RL. Configuring health care for systematic behavioral screening and intervention. Population Health Management 14(6): 299-305, 2011. (58 refs.)

The United States Preventive Services Task Force recommends universal screening and intervention for tobacco use, excessive drinking, and depression. These services improve health outcomes, decrease health care costs, enhance public safety, and generate substantial return on investment. Given the prevalence rates of these behavioral conditions and the time necessary for evidence-based interventions, it will be challenging to integrate behavioral screening and intervention (BSI) into busy health care settings. Therefore, consistent with the principles of the medical home and the chronic care model, the health care team must be expanded to systematically provide BSI. A 2-tiered, stepped-care model is proposed. The first tier of services-consisting of assessment, intervention, and follow-up services-would address most mild-to-moderate behavioral risks or conditions. The second tier would include various specialty-based resources, which would be conserved for patients with greatest need and potential to benefit. With slight enhancement of their training, health educators would be excellent candidates to serve as cost-efficient providers of first-tier services. The proposed model would help the United States realize improved health outcomes and cost savings as health care benefits are expanded to a greater proportion of its population.

Caplan L; Stout C; Blumenthal DS. Training physicians to do office-based smoking cessation increases adherence to PHS Guidelines. Journal of Community Health 36(2): 238-243, 2011. (23 refs.)

Cigarette smoking is the leading cause of preventable mortality and morbidity in the United States. Healthcare providers can contribute significantly to the war against tobacco use; patients advised to quit smoking by their physicians are 1.6 times more likely to quit than patients not receiving physician advice. However, most smokers do not receive this advice when visiting their physicians. The Morehouse School of Medicine Tobacco Control Research Program was undertaken to develop best practices for implementing the "2000 Public Health Services Clinical Practice Guidelines on Treating Tobacco Use and Dependence" and the "Pathways to Freedom" tobacco cessation program among African American physicians in private practice and healthcare providers at community health centers. Ten focus groups were conducted; 82 healthcare professionals participated. Six major themes were identified as barriers to the provision of smoking cessation services. An intervention was developed based on these results and tested among Georgia community-based physicians. A total of 308 charts were abstracted both pre- and post-intervention. Charts were scored using a system awarding one point for each of the five "A's" recommended by the PHS guidelines (Ask, Advise, Assess, Assist, Arrange) employed during the patient visit. The mean pre-intervention five "A's" score was 1.29 compared to 1.90 post-intervention (P < 0.001). All charts had evidence of the first "A" ("asked") both pre- and post-intervention, and the other four "A's" all had statistically significant increases pre-to post-intervention. Conclusions: The results demonstrate that, with training of physicians, compliance with the PHS tobacco guidelines can be greatly improved.

Carroll KM; Ball SA; Jackson R; Martino S; Petry NM; Stitzer ML et al. Ten take home lessons from the first 10 years of the CTN and 10 recommendations for the future. American Journal of Drug and Alcohol Abuse 37(5): 275-282, 2011. (77 refs.)

Background: The first 10 years of the National Institute on Drug Abuse's Clinical Trials Network (CTN) yielded a wealth of data on the effectiveness of a number of behavioral, pharmacological, and combined approaches in community-based settings. Methods: We summarize some of the methodological contributions and lessons learned from the behavioral trials conducted during its first ten years, including the capacity and enormous potential of this national research infrastructure. Results: The CTN made contributions to the methodology of effectiveness research; new insights from secondary analyses; the extent to which approaches with strong evidence bases, such as contingency management, extend their effectiveness to real world clinical settings; new data on 'standard treatment' as actually practiced in community programs, the extent to which retention remains a major issue in the field; important data on the safety of specific behavioral therapies for addiction; and heightened the importance of continued sustained attention to bridging the gap between treatment and research. Conclusions: Areas of focus for the CTN's future include defining common outcome measures to be used in treatment outcome studies for illicit drugs; incorporating performance indicators and measures of clinical significance; conducting comparative outcome studies; contributing to the understanding of effective treatments of comorbidity; reaching underserved populations; building implementation science; understanding long-term outcomes of current treatments and sustaining treatment effects; and conducting future trials more efficiently.

Caulkins JP; Reuter P; Coulson C. Basing drug scheduling decisions on scientific ranking of harmfulness: False promise from false premises. Addiction 106(11): 1886-1890, 2011. (20 refs.)

In recent years a number of studies have attempted to rank drugs by a single measure of harmfulness as the basis for decisions about scheduling and classification. These efforts are fundamentally flawed, both conceptually and methodologically. The effort to provide a single measure masks the variety of non-comparable dimensions that are relevant, the fact that benefits are ignored for most, but not all, drugs and that the harms of a drug are not invariant to the policy regime chosen. Methodologically, the most prominent recent effort ignores drug interactions and mixes aggregate and individual harms inappropriately. Instead we suggest that multiple dimensions of harm need to be displayed to inform human judgments of what drugs should be scheduled. Harm is not usefully reducible to a single dimension, and even perfect rankings would not constitute a 'sufficient statistic' for determining scheduling decisions.

Caulkins JP; Reuter P; Coulson C. Scales and blinkers, motes and beams: Whose view is obstructed on drug scheduling? (response). Addiction 106(11): 1896-1898, 2011. (7 refs.)

Cheatle MD; O'Brien CP. Opioid therapy in patients with chronic noncancer pain: Diagnostic and clinical challenges. Chronic Pain and Addiction, Advances in Psychosomatic Medicine 30: 61-91, 2011. (194 refs.)

Chronic opioid therapy for patients with chronic noncancer pain has become controversial, given the rising prevalence of opioid abuse. The prevailing literature suggests that the rate of addiction in chronic noncancer pain patients exposed to opioid therapy is relatively low, especially in those patients without significant concomitant psychiatric disorders and personal and family history of addiction. However, the escalating rate of misuse of prescription opioids has resulted in many clinicians caring for these patients to be more judicious in prescribing opioids. Accurately diagnosing addiction in chronic pain patients receiving opioids is complex. Managing the patient with pain and co-occurring opioid abuse is equally challenging. Diagnostic issues, current guidelines for the appropriate use of plods in the chronic pain population and risk stratification models are examined. Pharmacologic and nonpharmacologic treatment strategies for the patient with pain and opioid addiction are reviewed

Clark DB; Gordon AJ; Ettaro LR; Owens JM; Moss HB. Screening and brief intervention for underage drinkers. Mayo Clinic Proceedings 85(4): 380-391, 2010. (59 refs.)

In a 2007 report, the US Surgeeon General called for health care professionals to renew efforts to reduce underage drinking. Focusing on the adolescent patient, this review provides health care professionals with recommendations for alcohol-related screening, brief intervention, and referral to treatment. MEDLINE and published reviews were used to identify relevant literature. Several brief screening methods have been shown to effectively identify underage drinkers likely to have alcohol use disorders. After diagnostic assessment when germane, the initial intervention typically focuses on education, motivation for change, and consideration of treatment options. Internet-accessible resources providing effective brief interventions are available, along with supplemental suggestions for parents. Recent changes in federal and commercial insurance reimbursement policies provide some fiscal support for these services, although rate increases and expanded applicability may be required to prompt the participation of many practitioners. Nevertheless, advances in clinical methods and progress on reimbursement policies have made screening and brief intervention for underage drinking more feasible In general health care practice.

Demirkol A; Conigrave K; Haber P. Problem drinking: Management in general practice. Australian Family Physician 40(8): 576-+, 2011. (25 refs.)

Background: Management of problem drinking presents the general practitioner with similar challenges and rewards to those associated with the management of other chronic conditions. Objective: This article presents a framework for managing alcohol problems in general practice based on national guidelines for the treatment of alcohol problems. Discussion: General practitioners are well placed to undertake the management of drinking problems following an assessment of the amount of alcohol taken and the risks this poses for the individual and the people around them. This assessment starts the process of engagement and reflection on drinking habits and will inform the appropriate management approach. Brief interventions can result in reduction in drinking in nondependent drinkers. For dependent drinkers, treatment steps include assessing need for withdrawal management and developing a comprehensive management plan, which includes consideration of relapse prevention pharmacotherapy and psychosocial interventions. The patient's right to choose what they drink must be respected, and those who continue to drink in a problematic way can still be assisted, with compassion, within a harm reduction framework.

Demirkol A; Haber P; Conigrave K. Problem drinking: Detection and assessment in general practice. Australian Family Physician 40(8): 570-574, 2011. (27 refs.)

Background: Alcohol has long been an integral part of the social life of many Australians However, alcohol is associated with significant harm to drinkers, and also to nondrinkers. Objective: This article explores the role of the general practitioner in the detection and assessment of problem drinking. Discussion: Excessive alcohol use is a major public health problem and the majority of people who drink excessively go undetected. General practitioners are in a good position to detect excessive alcohol consumption; earlier intervention can help improve outcomes. AUDIT-C is an effective screening tool for the detection of problem drinking. National Health and Medical Research Council guidelines suggest that no more than two standard drinks on each occasion will keep lifetime risk of death from alcohol related disease or injury at a low level. Once an alcohol problem is detected it is important to assess for alcohol dependence, other substance use, motivation to change, psychiatric comorbidities and examination and investigation findings that may be associated with excessive alcohol use. A comprehensive assessment of the impact and risk of harm of the patient's drinking to themselves and others is vital, and may require several consultations.

Dickson-Spillmann M; Kraemer T; Rust K; Schaub M. Group hypnotherapy versus group relaxation for smoking cessation: An RCT study protocol. BMC Public Health 12: article 271, 2012. (39 refs.)

Background: A significant number of smokers would like to stop smoking. Despite the demonstrated efficacy of pharmacological smoking cessation treatments, many smokers are unwilling to use them; however, they are inclined to try alternative methods. Hypnosis has a long-standing reputation in smoking cessation therapy, but its efficacy has not been scientifically proven. We designed this randomised controlled trial to evaluate the effects of group hypnosis as a method for smoking cessation, and we will compare the results of group hypnosis with group relaxation. Methods/Design: This is a randomised controlled trial (RCT) to compare the efficacy of a single session of hypnosis with that of relaxation performed in groups of 8-15 smokers. We intend to include at least 220 participants in our trial. The inclusion criteria include smoking at least 5 cigarettes per day, not using other cessation methods and being willing to quit smoking. The intervention is performed by a trained hypnotist/relaxation therapist. Both groups first receive 40 min of mental preparation that is based on motivational interviewing. Then, a state of deep relaxation is induced in the hypnosis condition, and superficial relaxation is induced in the control condition. Suggestions are made in the hypnosis condition that aim to switch the mental self-image of the participants from that of smokers to that of non-smokers. Each intervention lasts for 40 min. The participants also complete questionnaires that assess their smoking status and symptoms of depression and anxiety at baseline, 2 weeks and 6 months post-intervention. In addition, saliva samples are collected to assess cotinine levels at baseline and at 6 months post-intervention. We also assess nicotine withdrawal symptoms at 2 weeks post-intervention. Discussion: To the best of our knowledge, this RCT is the first to test the efficacy of group hypnosis versus group relaxation. Issues requiring discussion in the outcome paper include the lack of standardisation of hypnotic interventions in smoking cessation, the debriefing of the participants, the effects of group dynamics and the reasons for dropouts.

Dom G; Francque S; Michielsen P. Risk for relapse of alcohol use after liver transplantation for alcoholic liver disease: A review and proposal of a set of risk assessment criteria. (review)18. Acta Gastro-Enterologica Belgica Acta Gastro-Enterologica Belgica(2): 247-251, 2010. (18 refs.)

Background : Liver transplantation for end stage alcoholic liver disease is becoming an increasingly frequent procedure. Within this context assessing the risk on relapse in alcohol use is a major issue. However, up to now, there is a clear lack in validated criteria that can be used to assess future relapse risk. Method : Literature review based upon Medline search identifying all new studies that have been published after the latest meta-analysis on this subject (2007-2009). Results : Five new original studies were identified. They provide new evidence for the prospective validity of different criteria; pre-transplant abstinence duration, diagnosis of alcohol dependence versus abuse, level of social support, additional psychiatric co-morbidity. Conclusions: These criteria seem promising as to the prediction of relapse in alcohol after liver transplantation. Based upon these results a new comprehensive assessment scale is proposed.

Donovan DM; Daley DC; Brigham GS; Hodgkins CC; Perl HI; Floyd AS. How practice and science are balanced and blended in the National Institute on Drug Abuse Clinical Trials Network: The bidirectional process in the development of the stage-12 protocol as an example. American Journal of Drug and Alcohol Abuse 37(5): 408-416, 2011. (59 refs.)

Background: Bidirectional, collaborative partnerships between academic researchers and practitioners have been a fundamental vehicle to achieve the National Institute on Drug Abuse (National Institute on Drug Abuse) Clinical Trials Network (CTN) goal of improving outcomes of community-based drug treatment. These partnerships blend clinical perspectives of practitioners and methodological expertise of researchers working together to address clinically meaningful issues through randomized clinical trials conducted in community treatment settings. Objectives: Bidirectionality is a guiding principle of the CTN, but its operationlization at the practical level in protocol development and implementation has not been articulated. This descriptive article presents the development of one protocol as an example and model of this bidirectional, collaborative, iterative partnership between researchers and practitioners. Methods: This article illuminates several specific issues encountered while developing STAGE-12, a behavioral intervention to facilitate 12-step mutual support group involvement, as well as the rationale for decisions taken to resolve each. Results: The STAGE-12 protocol was successfully developed through a series of decisions taking into account both design factors and clinical practice needs and realities, thus maintaining a balance between methodological rigor and generalizability. Conclusion: The review demonstrates the process by which research and practice have been blended in protocol development, exemplifying the underlying principle of bidirectionality, a key element in the success of the National Institute on Drug Abuse CTN. Scientific Significance: Bidirectional partnerships as derived in the CTN, employing a hybrid model of efficacy-effectiveness research, are capable of designing and implementing protocols that are both methodologically rigorous and clinically meaningful, thus increasing likelihood of adoption and eventual improvement in public health.

Doran D; Paterson J; Clark C; Srivastava R; Goering PN; Kushniruk AW et al. A pilot study of an electronic interprofessional evidence-based care planning tool for clients with mental health problems and addictions. Worldviews on Evidence-Based Nursing 7(3): 174-184, 2010. (14 refs.)

Background: The health system must develop effective solutions to the growing challenges it faces with respect to individuals who suffer with mental health disorders and addictions. The purpose of this study was to evaluate the usability and potential impact on outcomes of a knowledge translation system aimed at improving client-centered, evidence-based care for hospitalized individuals with schizophrenia. Methodology: A pre-posttest design was used. The e-Volution-TREAT system was implemented on two inpatient units at a large mental health facility. Thirty-seven nurses, allied health workers, and physicians participated from two units. Data collection involved questionnaires, semistructured interviews, and observations. Thirty-eight consenting clients' outcome data were collected from organizational records. Results: Overall, staff participants were very satisfied with the functions of the e-Volution-TREAT system. Barriers to using the system were identified by participants related to the work environment, to understaffing, equipment problems, discomfort with technology, and a focus on short-term rather than long-term goals. There was moderate uptake of guidelines related to social issues, and low uptake of guidelines related to family support and addictions. There were significant improvements in four client outcomes over time, specifically aggressive behavior, depression, withdrawal, and psychosis. Conclusions: In conclusion, users were overall satisfied with the e-Volution-TREAT system, although expressed challenges related to workload that interfered with time to utilize the system. It would be premature to conclude the change in client outcomes was related to the e-Volution-TREAT system without a randomized controlled trial with outcomes compared to a control group. Future research needs to incorporate strategies for modifying the context and engage clinicians who are in a position of influence to model change.

El-Guebaly N; Sareen J; Stein MB. Are there guidelines for the responsible prescription of benzodiazepines? (editorial). Canadian Journal of Psychiatry 55(11): 709-714, 2010. (27 refs.)

Ellis TE; Goldston DB. Special Series. Working with suicidal clients: Not business as usual (Introduction). Cognitive and Behavioral Practice 19(2): 205-208, 2012. (21 refs.)

In this introduction to a special series of articles on working with suicidal clients, we note that much of the recent growth in theory and research pertaining to suicidal individuals has been contributed by cognitive-behavioral theorists and researchers. This work has established that suicidal people manifest important cognitive vulnerabilities that can be addressed in therapeutic interventions specifically designed for them. Studies to date have produced outcomes that support this framework. We provide brief previews of the collection of articles that follow, which cover safety planning, protocols for evaluating risk, the utility of health behavior theory for informing treatment, mindfulness-based approaches for suicidality, developmental and family considerations, intensive inpatient CBT for individuals in the military, integrated interventions for substance abuse and suicidal behaviors, and coping with the impact of client suicide. We conclude that clinicians are now in a position to begin moving beyond a "therapy as usual" mindset in working with suicidal clients.

Feigelman S; Dubowitz H; Lane W; Grube L; Kim J. Training pediatric residents in a primary care clinic to help address psychosocial problems and prevent child maltreatment. Academic Pediatrics 11(6): 474-480, 2011. (33 refs.)

OBJECTIVE: The objectives of this study were to determine whether 1) residents trained in the SEEK (A Safe Environment for Every Kid) model would report improved attitudes, knowledge, comfort, competence, and practice regarding screening for psychosocial risk factors (parental depression, parental substance abuse, intimate partner violence, stress, corporal punishment, and food insecurity); 2) intervention residents would be more likely to screen for and assess those risk factors; and 3) families seen by intervention residents would report improved satisfaction with their child's doctor compared to families receiving standard care from control residents. METHODS: Pediatric residents in a university-based pediatrics continuity clinic were enrolled onto a randomized controlled trial of the SEEK model. The model included resident training about psychosocial risk factors, a Parent Screening Questionnaire, and a study social worker. Outcome measures included: 1) residents' baseline, 6-month, and 18-month post-training surveys, 2) medical record review, and 3) parents' satisfaction regarding doctor-parent interaction. RESULTS: Ninety-five residents participated. In 4 of 6 risk areas, intervention residents scored higher on the self-assessment compared to control subjects, with sustained improvement at 18 months. Intervention residents were more likely than control subjects to screen and assess parents for targeted risk factors. Parents seen by intervention residents responded favorably regarding interactions with their doctor. CONCLUSIONS: The SEEK model helped residents become more comfortable and competent in screening for and addressing psychosocial risk factors. The benefits were sustained. Parents viewed the intervention doctors favorably. The model shows promise as a way of helping address major psychosocial problems in pediatric primary care.

Fine PG; Finnegan T; Portenoy RK. Protect your patients, protect your practice. Practical risk assessment in the structuring of opioid therapy in chronic pain. Journal of Family Practice 59(9, supplement 2): S1-S16, 2010. (42 refs.)

Primary care clinicians play a crucial role in the assessment and management of chronic pain. As many as one-third of primary care patients report having chronic pain. Unfortunately, the increased availability and prescription of opioid analgesics in recent years have been accompanied by a parallel increase in prescription opioid abuse and misuse and related morbidity and mortality.3-5 Prescription drug abuse is an increasingly serious public health problem, and this reality has reinforced the view that primary care clinicians must possess skills in risk assessment and management, as well as the ability to optimize the potentially favorable effects of opioid drugs on pain and function. To help address the problem of prescription drug abuse while still allowing for the prescription of opioids for pain relief, policy makers involved in the development of health care regulations have started adopting the principle of balance. The key principles for assessment and management of the risks associated with misuse, abuse, addiction, and diversion are described, as are indications for referral to pain/addiction specialists.

Finnell DS. A clarion call for nurse-led SBIRT across the continuum of care. Alcoholism: Clinical and Experimental Research 36(7): 1134-1138, 2012. (26 refs.)

This commentary discusses the impact of the study by Broyles and colleagues (2012) that reported on hospitalized patients acceptability of nurse-delivered screening, brief intervention, and referral to treatment (SBIRT). This cross-sectional survey study assessed patient acceptability for and comfort with nurse-delivered SBIRT. The majority (95%) of inpatients found it acceptable for the nurse to ask about and/or discuss alcohol use during their hospitalization. This is a significant finding, as hospitals in the United States consider whether and how to implement The Joint Commission's performance measures related to SBIRT for hospitalized patients. The findings related to subgroups of patients who are more accepting of SBIRT and those who expressed some degree of discomfort highlight the importance for individualized patient-centered approaches. This study raises several important implications for nurse-delivered SBIRT. First, intensive efforts must be directed to enhancing the knowledge and competence of healthcare providers in general, and the current and future nursing workforce in particular, related to alcohol use and evidence-based care for patients who are drinking alcohol above recommended limits. Second, registered nurses, working to the full extent of their education and licensure are in key roles as members of the interdisciplinary team to provide cost-effective care at the bedside and across the continuum of care. Nurse-led SBIRT implementation models could help bridge the curricular gap and promote widespread and sustained integration of SBIRT as standard nursing care across all specialties and practice settings.

Fishbain DA; Lewis JE; Gao JR. Medical malpractice allegations of iatrogenic addiction in chronic opioid analgesic therapy: Forensic case reports. (editorial). Pain Medicine 11(10): 1537-1545, 2010. (41 refs.)

Objectives. The objectives for presenting these medico-legal forensic case reports are the following: 1) detail three cases where chronic opioid analgesic therapy (COAT) was alleged to cause iatrogenic addiction and/or re-addiction; 2) detail the plaintiff's and defendant's medical experts' opinions on these allegations; and 3) through analyzing these cases, develop some recommendations for future prevention of such allegations during COAT. Methods. Case Reports. Results. Medico-legal issues surrounding the allegation of iatrogenic addiction were identified in each case. Conclusions. Before starting COAT, physicians should obtain and document patient informed consent for the risk of addiction/re-addiction with COAT treatment. Patients with a history of addictions pre-COAT should be placed on adherence monitoring immediately on beginning COAT.

Franklin GM; Mai J; Turner J; Sullivan M; Wickizer T; Fulton-Kehoe D. Bending the prescription opioid dosing and mortality curves: Impact of the Washington State opioid dosing guideline. American Journal of Industrial Medicine 55(4): 325-331, 2012. (29 refs.)

Background: Opioid use and dosing for patients with chronic non-cancer pain have dramatically increased over the past decade, resulting in a national epidemic of mortality associated with unintentional overdose, and increased risk of disability among injured workers. We assessed changes in opioid dosing patterns and opioid-related mortality in the Washington State (WA) workers' compensation system following implementation of a specific WA opioid dosing guideline in April, 2007. Methods: Using detailed computerized billing data from WA workers' compensation, we report overall prevalence of opioid prescriptions, average morphine-equivalent dose (MED)/day, and proportion of workers on disability compensation receiving opioids and high-dose (>= 120 mg/day MED) opioids over the past decade. We also report the trend of unintentional opioid deaths during the same time period. Results: Compared to before 2007, there has been a substantial decline in both the MED/day of long-acting DEA Schedule II opioids (by 27%) and the proportion of workers on doses >= 120 md/day MED (by 35%). There was a 50% decrease from 2009 to 2010 in the number of deaths. Conclusions: The introduction in WA of an opioid dosing guideline appears to be associated temporally with a decline in the mean dose for long-acting opioids, percent of claimants receiving opioid doses >= 120 mg MED per day, and number of opioidrelated deaths among injured workers.

Fussell HE; Kunkel LE; McCarty D; Lewy CS. Standardized patient walkthroughs in the National Drug Abuse Treatment Clinical Trials Network: Common challenges to protocol implementation. American Journal of Drug and Alcohol Abuse 37(5): 434-439, 2011. (20 refs.)

Background: Training research staff to implement clinical trials occurring in community-based addiction treatment programs presents unique challenges. Standardized patient walkthroughs of study procedures may enhance training and protocol implementation. Objectives: Examine and discuss cross-site and cross-study challenges of participant screening and data collection procedures identified during standardized patient walkthroughs of multi-site clinical trials. Method: Actors portrayed clients and "walked through" study procedures with protocol research staff. The study completed 57 walkthroughs during implementation of 4 clinical trials. Results: Observers and walkthrough participants identified three areas of concern (consent procedures, screening and assessment processes, and protocol implementation) and made suggestions for resolving the concerns. Conclusions and Scientific Significance: Standardized patient walkthroughs capture issues with study procedures previously unidentified with didactic training or unscripted rehearsals. Clinical trials within the National Drug Abuse Treatment Clinical Trials Network are conducted in addiction treatment centers that vary on multiple dimensions. Based on walkthrough observations, the national protocol team and local site leadership modify standardized operating procedures and resolve cross-site problems prior to recruiting study participants. The standardized patient walkthrough improves consistency across study sites and reduces potential site variation in study outcomes.

Gan QA; Lu W; Xu JY; Li XJ; Goniewicz M; Benowitz NL et al. Chinese 'low-tar' cigarettes do not deliver lower levels of nicotine and carcinogens. Tobacco Control 19(5): 374-379, 2010. (20 refs.)

Background Low tar cigarette smoking is gaining popularity in China. The China National Tobacco Corporation (CNTC) promotes low tar cigarettes as safer than regular cigarettes. Methods: A total of 543 male smokers smoking cigarettes with different tar yields (15 mg regular cigarettes 10-13 mg low tar cigarettes and <10 mg low tar cigarettes) were recruited in Shanghai China who then completed a questionnaire on smoking behaviour and provided a urine sample for analysis of the nicotine metabolites cotinine and trans 3 hydroxycotinine. A total of 177 urine samples were selected at random for the analysis of the carcinogens polycyclic aromatic hydrocarbon metabolites (PAHs) (1 hydroxypyrene naphthols hydroxyfluorenes and hydroxyphenanthrenes) and the tobacco specific nitrosamine 4 (methylnitrosamino) 1 (3 pyridyl) butanone (NNK) metabolites 4 (methylnitrosamino) 1 (3 pyridyl) butanol (NNAL) and NNAL glucuronide .Values were normalised by creatinine to correct for possible distortions introduced by dilution or concentration of the urine. Results: Smokers of low tar cigarettes smoked fewer cigarettes per day (p=0 001) compared to smokers of regular cigarettes. Despite this lower reported consumption levels of cotinine trans 3 hydroxycotinine and PAHs in urine of people smoking low tar cigarettes were not correlated with nominal tar delivery of the cigarettes they smoked. Urine concentrations of NNAL were higher in smokers of lower tar than higher tar cigarettes. Conclusions: Chinese low tar cigarettes do not deliver lower doses of nicotine and carcinogens than regular cigarettes therefore it is unlikely that there would be any reduction in harm CNTC s promotion of low tar cigarettes as less harmful is a violation of the World Health Organization Framework Convention on Tobacco Control which China ratified in 2005

Garfield JM; Garfield FB; Holzman R; Mitani AA; Tsen LC. Practice policies for older anesthesiologists in academic departments: A national survey of academic departmental chairpersons. Journal of Clinical Anesthesia 24(5): 357-363, 2012. (21 refs.)

Study Objectives: To determine 1) which proportion of academic departments have policies concerning older anesthesiologists, 2) whether departments with such policies, particularly those related to call, had characteristics such as departmental size and proportions of older anesthesiologists that differed from departments without these policies, 3) if departments routinely screened their older members for problem behaviors, and 4) if departments provided nonclinical roles for older anesthesiologists. Design: Survey instrument. Setting: Academic medical centers. Measurements: An anonymous, web-based questionnaire that included questions on demographics and specific policy-related issues was sent to chairpersons of all academic anesthesia departments in the ASA database. Main Results: No department directly addressed every issue listed in the survey. Department size and the number of anesthesiologists over 60 years of age were unrelated to whether that department had one or more policies for older anesthesiologists. Twenty percent of programs stopped night call at age 60 years. Most departments did not exempt older anesthesiologists of any age from call responsibilities. Almost all departments tracked critical incidents and errors in technique and/or judgment. Almost three quarters tracked substance abuse, and over half of the responding departments tracked physical and emotional impairment and fixation errors. A third of departments tracked all 6 types of problem behavior. Only 12% had specific assessment tools for tracking problem behaviors in the clinic, and no department used these tools specifically for older anesthesiologists. While only 17% of departments directed older anesthesiologists into nonclinical roles, older clinicians had teaching, mentoring, and administrative roles within most of the departments. Conclusions: Relatively few departments had specific policies for older anesthesiologists that addressed the issues raised in the survey. Further research is needed to determine whether departments should decrease ambiguity of their policies, formulate explicit policies for older anesthesiologists, especially in regard to call, and assess problem behaviors more directly.

Gifford AE; Farkas KJ; Jackson LW; Molteno CD; Jacobson JL; Jacobson SW et al. Assessment of benefits of a universal screen for maternal alcohol use during pregnancy. Birth Defects Research. Part A: Clinical and Molecular Teratology 88(10, special issue): 838-846, 2010. (40 refs.)

INTRODUCTION: The objective of this report is to estimate the benefits of universal meconium screening for maternal drinking during pregnancy. Fetal alcohol spectrum disorder (FASD), including its most severe manifestation fetal alcohol syndrome (FAS), is preventable and remains a public health tragedy. The incidences of FAS and FASD have been conservatively estimated to be 0.97 and 10 per 1000 births, respectively. Meconium testing has been demonstrated to be a promising at-birth method for detection of drinking during pregnancy. METHODS: The current costs of FAS and FASD, alcohol treatment programs, and meconium screening were estimated by literature review. Monetary values were converted roughly to equal dollars in 2006. RESULTS: Costs of adding meconium analysis to the current newborn screening program and of treatment for the identified mothers were estimated and compared to potential averted costs that may result from identification and intervention for mothers and affected infants. Three potential maternal treatment strategies are analyzed. Depending on the treatment type, the savings may range from $6 to $97 for every $1 spent on screening and treatment. DISCUSSION: It needs to be emphasized, however, that such screening is premature and that to be effective this screening can be implemented only if there is a societal willingness to institute prevention and intervention programs to improve both women's and children's health. Future research should be directed at improving detection and developing in-depth prevention and remedial intervention programs. A thorough consideration of the ethical issues involved in such a screening program is also needed.

Glass JE; Perron BE; Ilgen MA; Chermack ST; Ratliff S; Zivin K. Prevalence and correlates of specialty substance use disorder treatment for Department of Veterans Affairs Healthcare System patients with high alcohol consumption. Drug and Alcohol Dependence 112(1-2): 150-155, 2010. (31 refs.)

Objective: Current substance use disorder (SUD) treatment guidelines suggest that SUD treatment may be indicated for individuals with elevated levels of alcohol consumption. The Department of Veterans Affairs (VA) considers patients with AUDIT-C scores of >= 8 as candidates for specialty care, however rates of SUD treatment based on AUDIT-C cutoffs remain understudied. We sought to identify SUD treatment rates and to identify patient characteristics that were associated with SUD treatment for VA patients with elevated AUDIT-C scores. Methods: The study sample included 10,384 ambulatory care VA patients with AUDIT-C scores of >= 8, who had not received SUD treatment in the past 60 days. Data were ascertained from the 2005 Survey of Health Experiences of Patients, a confidential mailed patient satisfaction survey (results were not available to providers). The outcome variable was the receipt of VA specialty SUD treatment in the year after the survey completion, as ascertained by VA administrative data. We identified rates of SUD treatment, and conducted unadjusted F tests and adjusted logistic regression analyses to identify patient characteristics that were associated with treatment entry. Results: Approximately 3.9% of veterans with AUDIT-C scores of >= 8 received SUD treatment in the year after being surveyed. Adjusted analyses revealed that treatment was more likely among persons with a mental health diagnosis (OR = 3.31, CI = 2.30-4.76) and among racial/ethnic minority groups. Conclusions: Very few veterans who reported elevated alcohol consumption on SHEP received specialty SUD treatment in the year after being surveyed. Increased efforts should be made to intervene with patients who have elevated levels of alcohol consumption.

Glynn TJ. Commentary on Bitton, et al. (2010): 'Yes, but will it work?'-the need for a formal evaluation process for the Framework Convention on Tobacco Control. (commentary). Addiction 105(12): 2192-2194, 2010. (6 refs.)

Goldade K; Whembolua GL; Thomas J; Eischen S; Guo HF; Connett J et al. Designing a smoking cessation intervention for the unique needs of homeless persons: A community-based randomized clinical trial. Clinical Trials 8(6): 744-754, 2011. (41 refs.)

Background: Although smoking prevalence remains strikingly high in homeless populations (similar to 70% and three times the US national average), smoking cessation studies usually exclude homeless persons. Novel evidence-based interventions are needed for this high-risk subpopulation of smokers. Purpose: To describe the aims and design of a first-ever smoking cessation clinical trial in the homeless population. The study was a two-group randomized community-based trial that enrolled participants (n = 430) residing across eight homeless shelters and transitional housing units in Minnesota. The study objective was to test the efficacy of motivational interviewing (MI) for enhancing adherence to nicotine replacement therapy (NRT; nicotine patch) and smoking cessation outcomes. Methods: Participants were randomized to one of the two groups: active (8 weeks of NRT + 6 sessions of MI) or control (NRT + standard care). Participants attended six in-person assessment sessions and eight retention visits at a location of their choice over 6 months. Nicotine patch in 2-week doses was administered at four visits over the first 8 weeks of the 26-week trial. The primary outcome was cotinine-verified 7-day point-prevalence abstinence at 6 months. Secondary outcomes included adherence to nicotine patch assessed through direct observation and patch counts. Other outcomes included the mediating and/or moderating effects of comorbid psychiatric and substance abuse disorders. Results: Lessons learned from the community-based cessation randomized trial for improving recruitment and retention in a mobile and vulnerable population included: (1) the importance of engaging the perspectives of shelter leadership by forming and convening a Community Advisory Board; (2) locating the study at the shelters for more visibility and easier access for participants; (3) minimizing exclusion criteria to allow enrollment of participants with stable psychiatric comorbid conditions; (4) delaying the baseline visit from the eligibility visit by a week to protect against attrition; and (5) regular and persistent calls to remind participants of upcoming appointments using cell phones and shelter-specific channels of communication. Limitations; The study's limitations include generalizability due to the sample drawn from a single Midwestern city in the United States. Since inclusion criteria encompassed willingness to use NRT patch, all participants were motivated and were ready to quit smoking at the time of enrollment in the study. Findings from the self-select group will be generalizable only to those motivated and ready to quit smoking. High incentives may limit the degree to which the intervention is replicable. Conclusions: Lessons learned reflect the need to engage communities in the design and implementation of community-based clinical trials with vulnerable populations.

Green SM; Roback MG; Kennedy RM; Krauss B. Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update. (review). Annals of Emergency Medicine 57(5): 449- 461, 2011. (112 refs.)

We update an evidence-based clinical practice guideline for the administration of the dissociative agent ketamine for emergency department procedural sedation and analgesia. Substantial new research warrants revision of the widely disseminated 2004 guideline, particularly with respect to contraindications, age recommendations, potential neurotoxicity, and the role of coadministered anticholinergics and benzodiazepines. We critically discuss indications, contraindications, personnel requirements, monitoring, dosing, coadministered medications, recovery issues, and future research questions for ketamine dissociative sedation.

Gudin JA. Clinical strategies for the primary health care professional to minimize prescription opioid abuse. Postgraduate Medicine 124(3): 131-138, 2012. (69 refs.)

Prescription opioid analgesic therapy can be effective in managing chronic noncancer pain in appropriately selected patients. However, the risks and benefits of prescription opioids should be carefully considered when treating this patient population. A dramatic increase in opioid-related morbidity and mortality has been observed in the United States in the past decade. Therefore, health care providers must balance the treatment of chronic pain with the need to minimize the risks of opioid misuse, abuse, addiction, and diversion. Current literature suggests that most patients with chronic pain are managed at the primary care level. However, many of these practitioners are not skilled in risk assessment, stratification, and monitoring. This article reviews strategies and tools that providers may implement to help identify appropriate patients for chronic opioid therapy and recognize signs of drug-related aberrant behaviors and abuse. In addition, the potential role of abuse-deterrent, extended-release opioid formulations to reduce risk in patients and nonmedical users of opioids is introduced. Collectively, these preventative measures may effectively reduce opioid misuse, abuse, and diversion without denying adequate analgesia in appropriate patients.

Gudin JA. The changing landscape of opioid prescribing: long-acting and extended-release opioid class-wide risk evaluation and mitigation strategy. Therapeutics and Clinical Risk Management 8(209-217), 2012. (39 refs.)

Prescriptions for opioid analgesics to manage moderate-to-severe chronic noncancer pain have increased markedly over the last decade, as have postmarketing reports of adverse events associated with opioids. As an unintentional consequence of greater prescription opioid utilization, there has been the parallel increase in misuse, abuse, and overdose, which are serious risks associated with all opioid analgesics. In response to these concerns, the Food and Drug Administration announced the requirement for a class-wide Risk Evaluation and Mitigation Strategy (REMS) for long-acting and extended-release (ER) opioid analgesics in April 2011. An understanding of the details of this REMS will be of particular importance to primary care providers. The class-wide REMS is focused on educating health care providers and patients on appropriate prescribing and safe use of ER opioids. Support from primary care will be necessary for the success of this REMS, as these clinicians are the predominant providers of care and the main prescribers of opioid analgesics for patients with chronic pain. Although currently voluntary, future policy will likely dictate that providers undergo mandatory training to continue prescribing medications within this class. This article outlines the elements of the class-wide REMS for ER opioids and clarifies the impact on primary care providers with regard to training, patient education, and clinical practice.

Guo FR; Hung LY; Chang CJ; Leung KK; Chen CY. The evaluation of a Taiwanese training program in smoking cessation and the trainees' adherence to a practice guideline. BMC Public Health 10: 77, 2010. (32 refs.)

Background: The Taiwanese government began reimbursement for smoking cessation in 2002. Certification from a training program was required for physicians who wanted reimbursement. The program certified 6,009 physicians till 2007. The objective of this study is to evaluate the short-and long term efficacy of the training program. Methods: For short term evaluation, all trainees in 2007 were recruited. For long term evaluation, computer randomly selected 2,000 trainees who received training from 2002 to 2006 were recruited. Course satisfaction, knowledge, confidence in providing smoking cessation services and the adherence to a practice guideline were evaluated by questionnaires. Results: Trainees reported high satisfaction with the training program. There was significant difference between pre- and post-test scores in knowledge. Confidence in providing services was lower in the long term evaluation compared to short term evaluation. For adherence to a practice guideline, 86% asked the status of smoking, 88% advised the smokers to quit, 76% assessed the smoker's willingness to quit, 59% assisted the smokers to quit, and 60% arranged follow-up visits for smokers. The incentive of reimbursement was the most significant factor affecting confidence and adherence. Conclusions: The training program was satisfactory and effective. Adherence to a practice guideline in our study was better than studies without physician training in other countries.

Hauli KA; Ndetei DM; Jande MB; Kabangila R. The prevalence of substance use among psychiatric patients: The case study of Bugando Medical Centre, Mwanza (Northern Tanzania). Substance Abuse 32(4): 238-241, 2011. (10 refs.)

World Health Organization (2004) documented that substance use or abuse and mental disorders are important causes of disease burden accounting for 8.8% and 16.6% of the total burden of disease in low income and lower middle-income countries, respectively. Alcohol use/abuse disorders alone contribute to 0.6%-2.6% of the total burden of disease in these countries. This cross-sectional descriptive study recruited 184 psychiatric patients seen at Bugando Medical centre and assessed them for substance involvement using the WHO Alcohol, Smoking and Substance Involvement Screening Test. The most frequently used substances among respondents were alcohol (59.3%), tobacco (38.6%), and cannabis (29.3%), while heroin and cocaine were least used (2.1% and 1.6%, respectively). Statistical significant difference existed between substance use and participants: level of education, formal employment, marital status, gender, family history of mental illness, and family history of substance use. About a third attributed their involvement into substance exclusively to peer pressure, 8.7 to both peer pressure and curiosity while 7.1% exclusively to curiosity. This result represents one of the most important risks to mental health, and is a leading factor that causes high rates of admission or reason to be seen by a psychiatrist, this cannot be ignored when managing psychiatric disorders and therefore calls for routing screening for substance involvement among clients seeking psychiatric treatment. It also calls for appropriate standard operation policy procedures that can be operationlized as a matter of clinical practice by mental health workers in their routine medical practice.

Havard A; Shakeshaft AP; Conigrave KM. Prevalence and characteristics of patients with risky alcohol consumption presenting to emergency departments in rural Australia. Emergency Medicine Australasia 24(3): 266-276, 2012. (38 refs.)

Objective: This study measures the prevalence of problematic alcohol consumption in patients of EDs in rural areas of Australia, relative to the general population in the same rural communities. It also identifies the characteristics associated with risky drinking in rural ED patients. Methods: Surveys containing the Alcohol Use Disorders Identification Test (AUDIT) and questions corresponding to the 2001 Australian Alcohol Guidelines were completed by 1056 patients presenting to five EDs in rural areas of New South Wales, and 756 residents of the same five communities. Results: Relative to the general community, ED patients were statistically significantly more likely to engage in risky alcohol consumption according to the AUDIT (39% vs 20%), alcohol consumption posing a high risk of short-term harm (26% vs 18%) and alcohol consumption posing a high risk of long-term harm (7% vs 3%). Although being aged under 40 years of age, being unmarried, not completing school and being assigned less urgent triage categories were associated with risky alcohol use among ED patients, rates of risky consumption were high across all patient subgroups. Conclusions: Risky drinking, across a number of measures, is overrepresented in patients of rural Australian EDs relative to the general community, and this type of consumption is not limited to certain subgroups of patients. There is a need for interventions that address both heavy single occasion drinking and excessive regular consumption in patients of rural Australian EDs, with universal interventions recommended rather than targeted programmes.

Hawkins EJ; Malte CA; Imel ZE; Saxon AJ; Kivlahan DR. Prevalence and trends of benzodiazepine use among Veterans Affairs patients with posttraumatic stress disorder, 2003-2010. Drug and Alcohol Dependence 124(1-2): 154-161, 2012. (52 refs.)

Background: Although the Veterans Affairs and Department of Defense (VA/DoD) clinical guidelines for management of posttraumatic stress disorder (PTSD) recommend against routine benzodiazepine use, little is known about the trends and clinical and prescription profiles of benzodiazepine use since these guidelines were released in 2004. Methods: This retrospective study included 64,872 patients with a PTSD diagnosis received from care at facilities in VA Northwest Veterans Integrated Service Network (VISN 20) during 2003-2010. Annual prevalence of any use was defined as any prescription for benzodiazepines, and long-term use was defined as >90 days' supply, in a year. Gender-specific logistic regressions were fit to estimate any and long-term benzodiazepine use, test for linear trends over 8-years and explore factors associated with trends. Results: The trend of age-adjusted benzodiazepine use over 8-years rose significantly from 25.0 to 26.8% among men and 31.2 to 38.8% among women. Long-term use in men and women increased from 15.4 to 16.4% and 18.0 to 22.7%, respectively. Comorbid psychiatric and alcohol use disorders (AUD) were associated with a greater increase in long-term use of benzodiazepines. In 2010, 61% of benzodiazepine users received >90 days' supply. Among those prescribed benzodiazepines long-term, 11% had AUD and 47% were also prescribed opioids long-term. Conclusion: Despite VA/DoD clinical guidelines recommending against routine use of benzodiazepines for PTSD, the adjusted prevalence of long-term use increased among men and women with PTSD in VISN 20. Widespread concomitant use of benzodiazepines and opioids suggests risk management systems and research on the efficacy and safety of these medications are needed.

Hillhouse M; Canamar CP; Doraimani G; Thomas C; Hasson A; Ling W. Participant characteristics and buprenorphine dose. American Journal of Drug and Alcohol Abuse 37(5): 453-459, 2011. (27 refs.)

Background: Clinical parameters for determining buprenorphine dose have not been adequately examined in treatment outcome research. Objectives: This study is a secondary analysis of data collected in a recently completed comparison of buprenorphine taper schedules conducted as part of the National Institute on Drug Abuse's Clinical Trials Network to assess whether participant baseline characteristics are associated with buprenorphine dose. Methods: After 3 weeks of flexible dosing, 516 participants were categorized by dose provided in the final dosing week (9.3% received a final week dose of 8 mg buprenorphine, 27.3% received 16 mg, and 63.4% received 24 mg). Results: Findings show that final week dose groups differed in baseline demographic and drug use characteristics including education, heroin use, route of drug administration, withdrawal symptoms, and craving. These groups also differed in opioid use during the four dosing weeks, with the lowest use in the 8 mg group and highest use in the 24 mg group (p < .0001). Additional analyses address withdrawal symptoms and craving. Conclusions and Scientific Significance: Final week dose groups differed in demographic and drug use characteristics, and the group receiving the largest final week dose had the highest rate of continued opioid use. These findings may contribute to the development of clinical guidelines regarding buprenorphine dose in the treatment of opioid dependence; however, further investigations that include random assignment to dose by baseline characteristics are needed.

Hilton TC. Breastfeeding considerations of opioid dependent mothers and infants. American Journal of Maternal-Child Nursing 37(4): 236-240, 2012. (29 refs.)

The American Academy of Pediatrics (AAP) has a long-standing recommendation against breastfeeding if the maternal methadone dose is above 20 mg/day. In 2001, the AAP lifted the dose restriction of maternal methadone allowing methadone-maintained mothers to breastfeed. The allowance of breastfeeding among mothers taking methadone has been met with opposition due to the uncertainty that exists related to methadone exposure of the suckling infant. Methadone-maintained mothers are at higher risk for abuse, concomitant psychiatric disorders, limited access to healthcare, and financial hardship. Breastfeeding rates among methadone-maintained women tend to be low compared to the national average. This manuscript will discuss the implications for healthcare practitioners caring for methadone-maintained mothers and infants and associated risks and benefits of breastfeeding. This population of mothers and infants stands to obtain particular benefits from the various well-known advantages of breastfeeding.

Jacobson FL; Austin JHM; Field JK; Jett JR; Keshavjee S; MacMahon H et al. Development of The American Association for Thoracic Surgery guidelines for low-dose computed tomography scans to screen for lung cancer in North America: Recommendations of The American Association for Thoracic Surgery Task Force for Lung Cancer Screening and Surveillance. Journal of Thoracic and Cardiovascular Surgery 144(1): 25-32, 2012. (15 refs.)

Objective: The study objective was to establish The American Association for Thoracic Surgery (AATS) lung cancer screening guidelines for clinical practice. Methods: The AATS established the Lung Cancer Screening and Surveillance Task Force with multidisciplinary representation including 4 thoracic surgeons, 4 thoracic radiologists, 4 medical oncologists, 1 pulmonologist, 1 pathologist, and 1 epidemiologist. Members have engaged in interdisciplinary collaborations regarding lung cancer screening and clinical care of patients with, and at risk for, lung cancer. The task force reviewed the literature, including screening trials in the United States and Europe, and discussed local best clinical practices in the United States and Canada on 4 conference calls. A reference library supported the discussions and increased individual study across disciplines. The task force met to review the literature, state of clinical practice, and recommend consensus-based guidelines. Results: Nine of 14 task force members were present at the meeting, and 3 participated by telephone. Two absent task force members were polled afterward. Six unanimous recommendations and supporting work-up algorithms were presented to the Council of the AATS at the 2012 annual meeting in San Francisco, California. Conclusions: Annual lung cancer screening and surveillance with low-dose computed tomography is recommended for smokers and former smokers with a 30 pack-year history of smoking and long-term lung cancer survivors aged 55 to 79 years. Screening may begin at age 50 years with a 20 pack-year history of smoking and additional comorbidity that produces a cumulative risk of developing lung cancer of 5% or greater over the following 5 years. Screening should be undertaken with a subspecialty qualified interdisciplinary team. Patient risk calculator application and intersociety engagement will provide data needed to refine future lung cancer screening guidelines.

Jaklitsch MT; Jacobson FL; Austin JHM; Field JK; Jett JR; Keshavjee S et al. The American Association for Thoracic Surgery guidelines for lung cancer screening using low-dose computed tomography scans for lung cancer survivors and other high-risk groups. Journal of Thoracic and Cardiovascular Surgery 144(1): 33-38, 2012. (15 refs.)

Objective: Lung cancer is the leading cause of cancer death in North America. Low-dose computed tomography screening can reduce lung cancer-specific mortality by 20%. Method: The American Association for Thoracic Surgery created a multispecialty task force to create screening guidelines for groups at high risk of developing lung cancer and survivors of previous lung cancer. Results: The American Association for Thoracic Surgery guidelines call for annual lung cancer screening with low-dose computed tomography screening for North Americans from age 55 to 79 years with a 30 pack-year history of smoking. Long-term lung cancer survivors should have annual low-dose computed tomography to detect second primary lung cancer until the age of 79 years. Annual low-dose computed tomography lung cancer screening should be offered starting at age 50 years with a 20 pack-year history if there is an additional cumulative risk of developing lung cancer of 5% or greater over the following 5 years. Lung cancer screening requires participation by a subspecialty-qualified team. The American Association for Thoracic Surgery will continue engagement with other specialty societies to refine future screening guidelines. Conclusions: The American Association for Thoracic Surgery provides specific guidelines for lung cancer screening in North America.

Jansson LM; Bunik M; Chantry CJ; Howard CR; Lawrence RA; Marinelli KA. ABM Clinical Protocol #21: Guidelines for breastfeeding and the drug-dependent woman. Breastfeeding Medicine 4(4): 225-228, 2010. (29 refs.)

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Kahan M; Mailis-Gagnon A; Wilson L; Srivastava A. Canadian guideline for safe and effective use of opioids for chronic noncancer pain. Clinical summary for family physicians. Part 1: general population. (review). Canadian Family Physician 57(11): 1257-1266, 2011. (71 refs.)

Objective To provide family physicians with a practical clinical summary of the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain, developed by the National Opioid Use Guideline Group. Quality of evidence Researchers for the guideline conducted a systematic review of the literature on the effectiveness and safety of opioids for chronic noncancer pain, and drafted a series of recommendations. A panel of 49 clinicians from across Canada reviewed the draft and achieved consensus on 24 recommendations. Main message Screening for addiction risk is recommended before prescribing opioids. Weak opioids (codeine and tramadol) are recommended for mild to moderate pain that has not responded to first-line treatments. Oxycodone, hydromorphone, and morphine can be tried in patients who have not responded to weaker opioids. A low initial dose and slow upward titration is recommended, with patient education and close monitoring. Physicians should watch for the development of complications such as sleep apnea. The optimal dose is one which improves function or decreases pain ratings by at least 30%. For by far most patients, the optimal dose will be well below a 200-mg morphine equivalent dose per day. Tapering is recommended for patients who have not responded to an adequate opioid trial. Conclusion: Opioids play an important role in the management of chronic noncancer pain, but careful prescribing is needed to limit potential harms. The new Canadian guideline provides much-needed guidance to help physicians achieve a balance between optimal pain control and safety.

Kahan M; Wilson L; Mailis-Gagnon A; Srivastava A. Canadian guideline for safe and effective use of opioids for chronic noncancer pain. Clinical summary for family physicians. Part 2: special populations. (review). Canadian Family Physician 57(11): 1269-1276, 2011. (66 refs.)

Objective: To provide family physicians with a practical clinical summary of opioid prescribing for specific populations based on recommendations from the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain. Quality of evidence: Researchers for the guideline conducted a systematic review of the literature, focusing on reviews of the effectiveness and safety of opioids in specific populations. Main message: Family physicians can minimize the risks of overdose, sedation, misuse, and addiction through the use of strategies tailored to the age and health status of patients. For patients at high risk of addiction, opioids should be reserved for well-defined nociceptive or neuropathic pain conditions that have not responded to first-line treatments. Opioids should be titrated slowly, with frequent dispensing and close monitoring for signs of misuse. Suspected opioid addiction is managed with structured opioid therapy, methadone or buprenorphine treatment, or abstinence-based treatment. Patients with mood and anxiety disorders tend to have a blunted analgesic response to opioids, are at higher risk of misuse, and are often taking sedating drugs that interact adversely with opioids. Precautions similar to those for other high-risk patients should be employed. The opioid should be tapered if the patient's pain remains severe despite an adequate trial of opioid therapy. In the elderly, sedation, falls, and overdose can be minimized through lower initial doses, slower titration, benzodiazepine tapering, and careful patient education. For pregnant women taking daily opioid therapy, the opioids should be slowly tapered and discontinued. If this is not possible, they should be tapered to the lowest effective dose. Opioid-dependent pregnant women should receive methadone treatment. Adolescents are at high risk of opioid overdose, misuse, and addiction. Patients with adolescents living at home should store their opioid medication safely. Adolescents rarely require long-term opioid therapy. Conclusion: Family physicians must take into consideration the patient's age, psychiatric status, level of risk of addiction, and other factors when prescribing opioids for chronic pain.

Kaner E. NICE work if you can get it: Development of national guidance incorporating screening and brief intervention to prevent hazardous and harmful drinking in England. Drug and Alcohol Review 29(6): 589-595, 2010. (54 refs.)

This paper describes the development of the first set of national guidance focused on the prevention of alcohol problems in England. These guidelines were produced by the National Institute for Health and Clinical Excellence (NICE) working with a multidisciplinary program development group of scientists, practitioners and lay members. In this work, screening and brief alcohol interventions represent a key element of a comprehensive public health strategy to prevent alcohol-related risk and harm across the population. The first controlled trials of brief alcohol intervention were published in the mid to late 1980's and there are now around 60 published trials in this field. After 25 years of accumulated evidence in this field, brief alcohol interventions have yet to make a significant impact on routine clinical practice. While it is imperative to have good science to make the case for brief intervention delivery, this work is in vain if practitioners are unwilling or unable to use these interventions with their patients. Evidence from the alcohol field and other clinical areas indicates that national prioritisation of brief alcohol intervention activity, by a body, such as NICE, is likely to be a key driver of implementation by practitioners. This paper summarises a suite of complementary system-level and practice recommendations, which were published by NICE in June 2010, and considers their likely impact on screening and brief alcohol in England.

King B; Borland R; Abdul-Salaam S; Polzin G; Ashley D; Watson C; O'Connor RJ. Divergence between strength indicators in packaging and cigarette engineering: A case study of Marlboro varieties in Australia and the USA. Tobacco Control 19(5): 398-402, 2010. (27 refs.)

Objectives: To investigate how the tobacco industry is adapting to regulatory action in accordance with provisions of the Framework Convention on Tobacco Control that targets misleading packaging and labelling. To relate the packaging and labelling of new cigarette varieties to their construction and performance. Methods: The principal design features and tar nicotine and carbon monoxide yields of the Marlboro brand family in Australia were measured and compared with those of the US equivalents. Results: Marlboro Red and Blue/Medium could not be differentiated in preliminary tests in Australia but were different in the USA. However, yield testing showed Marlboro Blue/Medium did not have lower tar and nicotine yields in either country indeed being higher in Australia. Conclusions: Colour can be used to market cigarettes as milder independently of ISO yields and Light/Mild descriptors. Banning of Light and Mild brand descriptors may be inadequate to end belief in less harmful cigarettes so long as the tobacco industry remains free to engineer mildness and to use colours other descriptors and design features to characterise varieties it wants to market as milder

Kingston AH; Morgan AJ; Jorm AF; Hall K; Hart LM; Kelly CM. Helping someone with problem drug use: A delphi consensus study of consumers, carers, and clinicians. BMC Psychiatry 11: e-article 3, 2011. (20 refs.)

Background: Problem use of illicit drugs (i.e. drug abuse or dependence) is associated with considerable health and social harms, highlighting the need for early intervention and engagement with health services. Family members, friends and colleagues play an important role in supporting and assisting individuals with problem drug use to seek professional help, however there are conflicting views about how and when such support should be offered. This paper reports on the development of mental health first aid guidelines for problem drug use in adults, to help inform community members on how to assist someone developing problem drug use or experiencing a drug-related crisis. Methods: A systematic review of the scientific and lay literature was conducted to develop a 228-item survey containing potential first-aid strategies to help someone developing a drug problem or experiencing a drug-related crisis. Three panels of experts (29 consumers, 31 carers and 27 clinicians) were recruited from Australia, Canada, New Zealand, the United Kingdom, and the United States. Panel members independently rated the items over three rounds, with strategies reaching consensus on importance written into the guidelines. Results: The overall response rate across three rounds was 80% (86% consumers, 81% carers, 74% clinicians). 140 first aid strategies were endorsed as essential or important by 80% or more of panel members. The endorsed strategies provide information and advice on what is problem drug use and its consequences, how to approach a person about their problem drug use, tips for effective communication, what to do if the person is unwilling to change their drug use, what to do if the person does (or does not) want professional help, what are drug-affected states and how to deal with them, how to deal with adverse reactions leading to a medical emergency, and what to do if the person is aggressive. Conclusions: The guidelines provide a consensus-based resource for community members who want to help someone with a drug problem. It is hoped that the guidelines will lead to better support and understanding for those with problem drug use and facilitate engagement with professional help.

Koyyalagunta D; Burton AW; Toro MP; Driver L; Novy DM. Opioid abuse in cancer pain: Report of two cases and presentation of an algorithm of multidisciplinary care. (review). Pain Physician 14(4): E361-E371, 2011. (37 refs.)

Background: The growing awareness of opioid abuse and addiction in the chronic pain population, along with increasing cancer survivorship, has heightened our awareness of this potential problem in the cancer patient. An increasing number of patients who abuse opioids have been identified in our clinical setting. Objective: We present an algorithm of multidisciplinary care for the treatment of cancer patients at risk for abusing opioids. Setting: Two illustrative patient examples were identified recently from our clinic. Results: These 2 patient examples demonstrate our multidisciplinary approach to treatment. A discussion of safe prescribing principles adapted from the literature is presented. Also, a brief point of added complexity is introduced; specifically, ethical considerations due to the unique nature of cancer pain. Limitations: Although validation studies exist for the use of screening tools in patients with chronic noncancer pain, there have been no instrument validation studies on patients with cancer pain. The educational treatment model that we refer to regarding facilitating safe use of opioids also has not been studied on patients with cancer pain. Lastly, we express caution in generalizing our guidelines to patients with noncancer pain. Our patient population differs in the multiple co-existing stressors and symptom burden associated with cancer. Conclusions: We have become increasingly aware of the problem of opioid abuse in the cancer pain population. With an approach to using safe prescribing principles adapted from chronic pain literature, and an ethically based multidisciplinary approach, clinicians can continue to treat pain successfully in the opioid-misusing cancer patient. We outline our approach in this article.

Krebs EE; Ramsey DC; Miloshoff JM; Bair MJ. Primary care monitoring of long-term opioid therapy among veterans with chronic pain. Pain Medicine 12(5): 740- 746, 2011. (27 refs.)

Objective. To characterize long-term opioid prescribing and monitoring practices in primary care. Design:. Retrospective medical record review. Setting. Primary care clinics associated with a large Veterans Affairs (VA) medical center. Patients. Adult patients who filled >= 6 prescriptions for opioid medications from the outpatient VA pharmacy between May 1, 2006 and April 30, 2007. Outcome Measures. Indicators of potential opioid misuse, documentation of guideline-recommended opioid-monitoring processes. Results. Ninety-six patients (57%) received a long-acting opioid, 122 (72%) received a short-acting opioid, and 50 (30%) received two different opioids. Indicators of some form of potential opioid misuse were present in the medical records of 55 (33%) patients. Of the seven guideline-recommended opioid-monitoring practices we examined, the mean number documented within 6 months was 1.7 (standard deviation [SD] 1.5). Pain reassessment was the most frequently documented process (N = 105, 52%), and use of an opioid treatment agreement was the least frequent (N = 19, 11%). Patients with indicators of potential opioid misuse had more documented opioid-monitoring processes than those without potential misuse indicators (2.4 vs 1.3, P < 0.001). After adjustment, potential opioid misuse was positively associated with the number of documented guideline-recommended processes (mean = 1.0 additional process, 95% confidence interval [CI] 0.4, 1.5). Conclusions. Guideline-recommended opioid management practices were infrequently documented overall but were documented more often for higher risk patients who had indicators of potential opioid misuse. The relationship between guideline-concordant opioid management and high-quality care has not been established, so our findings should not be interpreted as evidence of poor quality opioid management. Research is needed to determine optimal methods of monitoring opioid therapy in primary care.

Lewis ET; Trafton JA. Opioid use in primary care: Asking the right questions. (review). Current Pain and Headache Reports 15(2): 137-143, 2011. (55 refs.)

Pain is one of the most common reasons that patients seek treatment from health care professionals, often their primary care providers. One tool for treating pain is opioid therapy, and opioid prescriptions have increased dramatically in recent years in the United States. This article will review recent research about opioids that is most relevant to treating chronic pain in the context of a typical primary care practice. It will focus on four key practices that providers can engage in before and during the course of opioid therapy that we believe will enhance the likelihood that opioids, when used, are an effective tool for pain management: avoiding sole reliance on opioids; using adequate opioid doses to address pain; mitigating the risk of opioid misuse by patients; and fostering collaborative relationships for treating complex patients.

Liangpunsakul S; Chalasani N. What should we recommend to our patients with NAFLD (non-alcoholic fattly liver disease) regarding alcohol use? American Journal of Gastroenterology 107(7): 976-978, 2012. (28 refs.)

It is generally recommended that patients with nonalcoholic fatty liver disease (NAFLD) not consume alcohol. However, because these patients are at increased cardiovascular risk, and light to moderate alcohol consumption may have hepatic benefits in people with or at risk for NAFLD, this recommendation may be ill-advised. We reviewed the literature on alcohol consumption and NAFLD and conclude that (i) heavy consumption has many harmful effects, including those on the liver, and should be discouraged whether a person has NAFLD or not; (ii) it is unknown whether cardiovascular and metabolic benefits of light to moderate consumption observed in the general population extend to those with NAFLD; (iii) epidemiological and cohort studies suggesting that light to moderate drinking may have hepatic benefits are largely cross-sectional and used surrogate end points; and (iv) until further data from rigorous prospective studies become available, people with NAFLD should avoid alcohol of any type or amount.

Lingford-Hughes AR; Welch S; Peters L; Nutt DJ; Ball D; Buntwal N et al. BAP updated Guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP. Journal of Psychopharmacology 26(7): 899-952, 2012. (583 refs.)

The British Association for Psychopharmacology guidelines for the treatment of substance abuse, harmful use, addiction and comorbidity with psychiatric disorders primarily focus on their pharmacological management. They are based explicitly on the available evidence and presented as recommendations to aid clinical decision making for practitioners alongside a detailed review of the evidence. A consensus meeting, involving experts in the treatment of these disorders, reviewed key areas and considered the strength of the evidence and clinical implications. The guidelines were drawn up after feedback from participants. The guidelines primarily cover the pharmacological management of withdrawal, short- and long-term substitution, maintenance of abstinence and prevention of complications, where appropriate, for substance abuse or harmful use or addiction as well management in pregnancy, comorbidity with psychiatric disorders and in younger and older people.

Lo CF. FCTC guidelines on tobacco industry foreign investment would strengthen controls on tobacco supply and close loopholes in the tobacco treaty. Tobacco Control 19(4): 306-310, 2010. (18 refs.)

The Framework Convention on Tobacco Control (FCTC) contains no provisions covering tobacco industry investments. This creates the potential for tobacco companies to benefit from investment liberalisation by using foreign investments to avoid tobacco tariffs, increase tobacco consumption and otherwise impair the implementation of FCTC-style measures. Reducing and ultimately eliminating foreign investment activities by tobacco companies can be justified on health grounds, even though it runs counter to current investment liberalisation trends. Through the FCTC process, nonbinding guidelines can be elaborated to assist parties in recognising and responding to foreign investment strategies of tobacco companies, to support efforts to exclude the tobacco sector from investment liberalisation and otherwise would improve all countries' awareness of the threat from foreign investment strategies of tobacco companies and provide them with approaches to handle the problems.

Lv J; Su M; Hong ZH; Zhang T; Huang XM; Wang B et al. Implementation of the WHO Framework Convention on Tobacco Control in mainland China. Tobacco Control 20(4): 309-314, 2011. (56 refs.)

As per China's ratification of the WHO Framework Convention on Tobacco Control (FCTC), it should have implemented effective packaging and labelling measures prior to 9 January 2009 and enacted a comprehensive ban on all tobacco advertising, promotion and sponsorship prior to 9 January 2011. In addition, universal protection against secondhand tobacco smoke should have been implemented before 9 January 2011 by ensuring that all indoor workplaces, all indoor public places, all public transportation and possibly other (outdoor or quasi-outdoor) public places are free of secondhand smoke. The authors conducted a review of various sources of information to determine the current status of FCTC implementation in mainland China. Even though China has made considerable efforts to implement the FCTC, there is still a significant gap between the current state of affairs in China and the requirements of the FCTC. The Chinese tobacco monopoly under which commercial and other vested interests of the tobacco industry are jeopardising tobacco control efforts is thought to be the most crucial obstacle to the effective implementation of the FCTC across the country.

Mackay J. Implementing tobacco control policies. British Medical Bulletin 102(1): 5-16, 2012. (29 refs.)

Tobacco currently kills 6 million people each year, increasingly in the low- and middle-income countries, which will bear the economic brunt of this epidemic. Tobacco control takes health professionals to very new destinations, away from the traditional curative medical model to mastering the corridors of power, using the media, and political lobbying and advocacy. None of these skills is taught in medical schools. The magnitude and future expansion of the tobacco epidemic is beyond controversy, as is the fact that the economic costs of tobacco outweigh any benefits. The tools needed to reduce the epidemic are also known and accepted, and these are virtually identical in all countries. It only requires political will to implement these. All countries should ratify and implement the WHO Framework Convention on Tobacco Control and commit adequate funding to counter this global pandemic. Action must be based on the science of epidemiology, prevalence, health effects, economic burden, success of action taken and tracking the tobacco industry.

Mamudu HM; Gonzalez M; Glantz S. The nature, scope, and development of the global tobacco control epistemic community. (editorial). American Journal of Public Health 101(11): 2044-2054, 2011. (109 refs.)

Over the past 50 years, tobacco control has been transformed from a national to a global issue, becoming institutionalized in the World Health Organization (WHO) Framework Convention on Tobacco Control, the first international public health treaty negotiated under the auspices of the WHO. The global tobacco control epistemic community, a worldwide network of professionals with a common interpretation of the science in tobacco use and control, has contributed to this transformation. We investigated the development, structure, and function of this community through interviews and archival documents. Professionals in the community are bound by values and consensual knowledge developed after years of contentious debates undergirded their activities. Although these professionals play multiple roles, they recognize that scientific evidence should inform advocacy and policy activities. Public health professionals should continue to strengthen the links between science and advocacy for policy while being vigilant against industry efforts to undermine the scientific evidence on tobacco use and control.

Mamudu HM; Hammond R; Glantz SA. International trade versus public health during the FCTC negotiations, 1999-2003. Tobacco Control 20(1): e-article 3, 2011. (147 refs.)

Objective To examine why the Framework Convention on Tobacco Control did not include an explicit trade provision and delineate the central arguments in the debate over trade provision during the negotiations. Methods Triangulate interviews with participants in the FCTC negotiations, the FCTC negotiations documents, and tobacco industry documents. Results An explicit FCTC trade provision on relation between international trade and public health became a contentious issue during the negotiations. As a result, two conflicting positions, health-over-trade and opposition to health-over-trade emerged. Opposition to explicit trade language giving health priority was by both tobacco industry and countries that generally supported strong FCTC provisions because of concerns over 'disguised protectionism' and setting a precedent whereby governments could forfeit their obligations under pre-existing treaties. Owing to lack of consensus among political actors involved in the negotiations, a compromise position eliminating any mention of trade emerged, which was predicated on belief among some in the public health community that public health would prevail in future trade versus health conflicts. Conclusion: The absence of an explicit FCTC trade provision was due to a political compromise rather than the impact of international trade agreements and decisions on public health and lack of consensus among health advocates. This failure to include an explicit trade provision in the FCTC suggests that the public health community should become more involved in trade and health issues at all levels of governance and press the FCTC Conference of the Parties for clarification of this critical issue.

Manubay JM; Muchow C; Sullivan MA. Prescription drug abuse: Epidemiology, regulatory issues, chronic pain management with narcotic analgesics. Primary Care 38(1): 71+, 2011. (52 refs.)

The epidemic of prescription drug abuse has reached a critical level, which has received national attention. This article provides insight into the epidemiology of prescription drug abuse, explains regulatory issues, and provides guidelines for the assessment and management of pain, particularly with long-term opioid therapy. Using informed consent forms, treatment agreements, and risk documentation tools and regularly monitoring the 4 A's help to educate patients and guide management based on treatment goals. By using universal precautions, and being aware of aberrant behaviors, physicians may feel more confident in identifying and addressing problematic behaviors.

Markowitz JD; Francis EM; Gonzales-Nolas C. Managing acute and chronic pain in a substance abuse treatment program for the addicted individual early in recovery: A current controversy. Journal of Psychoactive Drugs 42(2): 193-198, 2010. (42 refs.)

Patients early in recovery from addictive disorders are in a tenuous position and when these individuals are stressed from acute or chronic pain they face even more challenges. Physicians are often conflicted by the desire to help the patient achieve pain control and maintain sobriety. While there have been a handful of studies examining patients in either active addiction with pain or with a more remote history of addiction with pain, there have been very few, if any, that look at treating patients during their addiction recovery process who suffer from pain. This article will examine the issue of whether it is ever appropriate to use opioid pain medications on such patients and, if so, what guidelines can be used to maximize the chances of a good outcome while minimizing the chances of causing a recurrence or exacerbation of addiction.

Marley JV; Atkinson D; Nelson C; Kitaura T; Gray D; Metcalf S. The protocol for the Be Our Ally Beat Smoking (BOABS) study, a randomised controlled trial of an intensive smoking cessation intervention in a remote Aboriginal Australian health care setting. BMC Public Health 12: e-article 232, 2012. (33 refs.)

Background: Australian Aboriginal peoples and Torres Strait Islanders (Indigenous Australians) smoke at much higher rates than non-Indigenous people and smoking is an important contributor to increased disease, hospital admissions and deaths in Indigenous Australian populations. Smoking cessation programs in Australia have not had the same impact on Indigenous smokers as on non-Indigenous smokers. This paper describes the protocol for a study that aims to test the efficacy of a locally-tailored, intensive, multidimensional smoking cessation program. Methods/Design: This study is a parallel, randomised, controlled trial. Participants are Aboriginal and Torres Strait Islander smokers aged 16 years and over, who are randomly allocated to a 'control' or 'intervention' group in a 2: 1 ratio. Those assigned to the 'intervention' group receive smoking cessation counselling at face-to-face visits, weekly for the first four weeks, monthly to six months and two monthly to 12 months. They are also encouraged to attend a monthly smoking cessation support group. The 'control' group receive 'usual care' (i.e. they do not receive the smoking cessation program). Aboriginal researchers deliver the intervention, the goal of which is to help Aboriginal peoples and Torres Strait Islanders quit smoking. Data collection occurs at baseline (when they enrol) and at six and 12 months after enrolling. The primary outcome is self-reported smoking cessation with urinary cotinine confirmation at 12 months. Discussion: Stopping smoking has been described as the single most important individual change Aboriginal and Torres Strait Islander smokers could make to improve their health. Smoking cessation programs are a major priority in Aboriginal and Torres Strait Islander health and evidence for effective approaches is essential for policy development and resourcing. A range of strategies have been used to encourage Aboriginal peoples and Torres Strait Islanders to quit smoking however there have been few good quality studies that show what approaches work best. More evidence of strategies that could work more widely in Indigenous primary health care settings is needed if effective policy is to be developed and implemented. Our project will make an important contribution in this area.

Martin JA; Campbell A; Killip T; Kotz M; Krantz MJ; Kreek MJ et al. QT Interval screening in methadone maintenance treatment: Report of a SAMHSA expert panel. (editorial). Journal of Addictive Diseases 30(4): 283-306, 2011. (108 refs.)

In an effort to enhance patient safety in opioid treatment programs, the Substance Abuse and Mental Health Services Administration convened a multi-disciplinary Expert Panel on the Cardiac Effects of Methadone. Panel members (Appendix A) reviewed the literature, regulatory actions, professional guidances, and opioid treatment program experiences regarding adverse cardiac events associated with methadone. The Panel concluded that, to the extent possible, every opioid treatment program should have a universal Cardiac Risk Management Plan (incorporating clinical assessment, electrocardiogram assessment, risk stratification, and prevention of drug interactions) for all patients and should strongly consider patient-specific risk minimization strategies (such as careful patient monitoring, obtaining electrocardiograms as indicated by a particular patient's risk profile, and adjusting the methadone dose as needed) for patients with identified risk factors for adverse cardiac events. The Panel also suggested specific modifications to informed consent documents, patient education, staff education, and methadone protocols.

Mayet S; Manning V; Sheridan J; Best D; Strang J. The virtual disappearance of injectable opioids for heroin addiction under the 'British System'. Drugs: Education, Prevention and Policy 17(5): 496-506, 2010. (25 refs.)

Aims: Injectable opioids were prescribed unsupervised under the 'British System' for heroin dependence. National guidelines (1999 and 2003) confirmed that injectable opioids have a legitimate 'limited clinical place' and should be dispensed daily, with 'mechanisms for supervision'. This study assesses whether national guidelines impacted on prescriptions of injectable opioids. Methods: A 25% random sample of community pharmacists (n = 2473) in England were surveyed by a questionnaire in 2005, with 95% response (n = 2349). Opioid maintenance prescription data for anonymous patients (n = 9620) were compared to the prescription data in 1995 (n = 3721) from a matched survey. Findings: Injectable opioid prescriptions reduced significantly from 10.5% (1995) to 1.8% (2005) of all opioid maintenance prescriptions. Daily doses significantly increased, as did daily dispensing from 28.8% (1995) to 57.8% (2005), whilst weekly dispensing reduced from 39.5% (1995) to 14.5% (2005). In 2005, injectable opioids accounted for 27.2% of private opioid prescriptions, versus 1.5% National Health Service (NHS) prescriptions. Private prescriptions were for larger take-home doses than NHS prescriptions. Regional variation was present. Conclusions: Injectable opioid maintenance treatment for heroin dependence under the unsupervised 'British System' is disappearing, although not extinct. If injectable opioids are prescribed, this is more in line with national guidelines. However, many prescriptions are less than daily instalments.

McMenamin SB; Bellows NM; Halpin HA; Rittenhouse DR; Casalino LP; Shortell SM. Adoption of policies to treat tobacco dependence in U.S. medical groups. American Journal of Preventive Medicine 39(5): 449-456, 2010. (23 refs.)

Background: There remains an ongoing need to reduce tobacco use in the U.S. Physician organizations, such as medical groups, can support healthcare providers to be more effective in their delivery of tobacco cessation by adopting practices recommended in the Public Health Service Clinical Practice Guideline for Treating Tobacco Use and Dependence (PHS Guideline). Purpose: To document the extent to which activities to reduce tobacco use, as recommended in the PHS Guideline as system-level interventions, are provided within large medical groups in the U.S. Methods: During 2006-2007, data were collected on 339 medical groups operating in the U.S., with 20 or more physicians treating at least one of four chronic conditions. Organizations were surveyed regarding activities to reduce tobacco use as recommended in the PHS Guideline as system-level interventions (i.e., tobacco-use status documentation, policies to promote provider interventions, and staff dedicated to treating tobacco dependence). Between 2008 and 2009, bivariate associations and multivariate logistic regression models assessed the relationship of organizational characteristics and external incentives with adoption of systems strategies for treating tobacco dependence. Results: Nearly 83% of medical groups with 20 or more physicians operating in the U.S. in 2006-2007 have adopted one or more strategies recommended as effective to support the treatment of tobacco dependence. However, only 5.6% of medical groups engage in all eight tobacco control activities examined in this study. The two factors that were associated most consistently with medical group policies to treat tobacco dependence were the patient-centeredness of the organization and participation in a quality demonstration program. Conclusions: There is much room for improvement in increasing medical group adoption of systems strategies to reduce tobacco use. The findings in this paper suggest recommendations to achieve these improvements.

McNally L; Todd C; Ratschen E. The prevalence of mental health problems among users of NHS stop smoking services: Effects of implementing a routine screening procedure. BMC Health Services Research 11: article 190, 2011. (8 refs.)

Background: Tobacco dependence among people with mental health problems is an issue that deserves attention both from a clinical and from a public health perspective. Research suggests that Stop Smoking Services often fail to ask clients about underlying mental health problems and thus fail to put in place the treatment adaptations and liaison procedures often required to meet the needs of clients with a mental health condition who want to stop smoking. This study assesses the recording of mental health problems in a large NHS stop smoking service in England and examines the effect of implementing a short screening procedure on recording mental health conditions. Methods: Treatment records from the Stop Smoking Service covering a period of 13 months were audited. The prevalence of reported mental health problems in the six month period before the implementation of the mental health screening procedure was compared with that of the six month period following implementation. The screening procedure was only implemented in the support services directly provided by the Stop Smoking Service. Comparisons were also made with third-party sections of the service where no such screening procedure was introduced. Results: The prevalence of reported mental health problems among a total of n = 4999 clients rose from less than 1% before implementation of the screening procedure to nearly 12% in the period following implementation, with the change being statistically significant. No significant rise was observed over the same period in the sections of the service where no screening procedure was implemented. Conclusions: The absence of standard procedures to record mental health problems among service users in many stop smoking services is currently likely to prevent the detection of co morbidity. Implementing a simple screening procedure appears suitable to increase the routine recording of mental health problems in a stop smoking service, which is an essential step to ensure services can be tailored and delivered appropriately to the client group.

Miller WR; Carroll KM. Drawing the science together: Ten principles, ten recommendations. IN: Miller WR; Carroll KM, eds. Rethinking Substance Abuse: What Science Shows, and What We Should Do About It. New York: Guilford Press, 2010

This concluding chapter in the final section (Section V) considers factors related to intervention with substance use and misuse, sets forth both principles and recommendation for moving toward providing treatment based on best scientific practices.

Morasco BJ; Duckart JP; Dobscha SK. Adherence to clinical guidelines for opioid therapy for chronic pain in patients with substance use disorder. Journal of General Internal Medicine 26(9): 965-971, 2011. (42 refs.)

BACKGROUND: Patients with chronic non-cancer pain (CNCP) have high rates of substance use disorders (SUD). SUD complicates pain treatment and may lead to worse outcomes. However, little information is available describing adherence to opioid treatment guidelines for CNCP generally, or guideline adherence for patients with comorbid SUD. OBJECTIVE: Examine adherence to clinical guidelines for opioid therapy over 12 months, comparing patients with SUD diagnoses made during the prior year to patients without SUD. DESIGN: Cohort study. PARTICIPANTS: Administrative data were collected from veterans with CNCP receiving treatment within a Veterans Affairs regional healthcare network who were prescribed chronic opioid therapy in 2008 (n = 5814). KEY RESULTS: Twenty percent of CNCP patients prescribed chronic opioid therapy had a prior-year diagnosis of SUD. Patients with SUD were more likely to have pain diagnoses and psychiatric comorbidities. In adjusted analyses, patients with SUD were more likely than those without SUD to have had a mental health appointment (29.7% versus 17.2%, OR = 1.49, 95% CI = 1.26-1.77) and a urine drug screen (UDS) (47.0% versus 18.2%, OR = 3.53, 95% CI = 3.06-4.06) over 12 months. There were no significant differences between groups on receiving more intensive treatment in primary care (63.4% versus 61.0%), long-acting opioids (26.9% versus 26.0%), prescriptions for antidepressants (88.2% versus 85.8%, among patients with depression), or participating in physical therapy (30.6% versus 28.6%). Only 35% of patients with SUD received substance abuse treatment. CONCLUSIONS: CNCP patients with SUD were more likely to have mental health appointments and receive UDS monitoring, but not more likely to participate in other aspects of pain care compared to those without SUD. Given data suggesting patients with comorbid SUD may need more intensive treatment to achieve improvements in pain-related function, SUD patients may be at high risk for poor outcomes.

Moreira M; Buchanan J; Heard K. Validation of a 6-hour observation period for cocaine body stuffers. American Journal of Emergency Medicine 29(3): 299-303, 2011. (13 refs.)

Often, patients are brought in to the emergency department after ingesting large amounts of cocaine in an attempt to conceal it. This act is known as body staffing. The observation period required to recognize potential toxic adverse effects in these patients is not well described in the literature. We sought to validate a treatment algorithm for asymptomatic cocaine body stuffers using a 6-hour observation period by observing the clinical course of cocaine body stuffers over a 24-hour period. A retrospective chart review was performed on all patients evaluated for witnessed or suspected stuffing over 2 years using a standardized protocol. One hundred six patients met final inclusion criteria as adult cocaine stuffers. No patients developed life-threatening symptoms, and no patients died during observation. In our medical setting, starers could be discharged after a 6-hour observation period if there was either complete resolution or absence of clinical symptoms.

Moriarty HJ; Stubbe MH; Chen L; Tester RM; Macdonald LM; Dowell AC et al. Challenges to alcohol and other drug discussions in the general practice consultation. Family Practice 29(2): 213-222, 2012. (38 refs.)

Background. There is a widely held expectation that GPs will routinely use opportunities to provide opportunistic screening and brief intervention for alcohol and other drug (AOD) abuse, a major cause of preventable death and morbidity. Aim. To explore how opportunities arise for AOD discussion in GP consultations and how that advice is delivered. Design. Analysis of video-recorded primary care consultations. Setting. New Zealand General Practice. Methods. Interactional content analysis of AOD consultations between 15 GP's and 56 patients identified by keyword search from a bank of digital video consultation recordings. Results. AOD-related words were found in almost one-third (56/171) of the GP consultation transcripts (22 female and 34 male patients). The AOD dialogue varied from brief mention to pertinent advice. Tobacco and alcohol discussion featured more often than misuse of anxiolytics, night sedation, analgesics and caffeine, with only one direct enquiry about other (unspecified) recreational drug use. Discussion was associated with interactional delicacy on the part of both doctor and patient, manifested by verbal and non-verbal discomfort, use of closed statements, understatement, wry humour and sudden topic change. Conclusions. Mindful prioritization of competing demands, time pressures, topic delicacy and the acuteness of the presenting complaint can impede use of AOD discussion opportunities. Guidelines and tools for routine screening and brief intervention in primary care do not accommodate this reality. Possible responses to enhance AOD conversations within general practice settings are discussed.

Morrison KN; Naegle MA. An evidence-based protocol for smoking cessation for persons with psychotic disorders. Journal of Addictions Nursing 21(2-3): 79-86, 2010. (26 refs.)

Consequences of the use of tobacco products claim the lives of 443,000 Americans and 5.4 million persons worldwide every year. Persons with diagnosed psychiatric illnesses, including addiction, have the highest prevalence of smoking of any population, and smoke more intensely and heavily than others. In preparation for developing a step-wide protocol for a nursing intervention, recent literature on smoking cessation with smokers and those with psychiatric diagnoses was searched. A total of 16 related or specific studies and reviews were identified and critiqued, seeking support for interventions specific to the needs and attributes of this population. Few studies either included or focused on the smoking cessation with those having diagnoses of addiction and/or other psychiatric disorders, although study populations may have included such individuals. The results of research critiques suggest that standard approaches to smoking cessation have comparable success with the general population and persons with psychiatric disorders. The need to tailor interventions to achieve continued smoking cessation, however, remains an important need. The protocol steps are supported by the evidence drawn from the research literature and best practice guidelines.

Murin S; Rafii R; Bilello K. Smoking and smoking cessation in pregnancy. Clinics in Chest Medicine 32(1): 75-+, 2011. (90 refs.)

Smoking during pregnancy is among the leading preventable causes of adverse maternal and fetal outcomes. Smoking prevalence among young women is the primary determinant of smoking prevalence during pregnancy. Smoking among women of childbearing age is associated with reduced fertility, increased complications of pregnancy, and a variety of adverse fetal outcomes. There is increasing evidence of lasting adverse effects on offspring. Guidelines for smoking cessation during pregnancy have been developed. This article reviews the epidemiology of smoking during pregnancy, the adverse effects of smoking on the mother, fetus, and offspring, and recommended approaches to smoking cessation for pregnant women.

Nicolich RS; Padilha MC; Neto FRD. Study of the endogenous steroid profile of male athletes from the Brazilian National Soccer Championship 2009. Drug Testing and Analysis 2(11-12, special issue): 599-602, 2010. (19 refs.)

Changes in the endogenous profile of androgenic anabolic steroids (AAS) may be interpreted as markers of doping. The objective of this study was to evaluate the endogenous profile of AAS in male athletes of the 2009 Brazilian National Soccer Championship, in normal conditions, particularly in the light of the revision of World Anti-Doping Agency's (WADA) Technical Document on the Interpretation of Endogenous AAS in athletes for doping control drafted in that year, as well as comparing these results to profiles already published in the literature. The upper limit of the 95% central reference interval of the following parameters for the studied population were estimated to be significantly higher than WADA's criteria, with a confidence of 90%: DHEA (about 2.3 times higher), Adiol (1.2 times higher), Bdiol (2.7 times higher), and Adiol/E (6 times higher). These findings seem to imply that WADA's criteria proposed in 2009 for DHEA, Adiol, Bdiol, and Adiol/E may not have been applicable to the studied population. Moreover, their comparison to previously published studies pointed to the need to evaluate in detail the appropriateness of adopting these criteria as universal, since there seems to be variations among different populations of athletes.

Peppin JF; Passik SD; Couto JE; Fine PG; Christo PJ; Argoff C et al. Recommendations for urine drug monitoring as a component of opioid therapy in the treatment of chronic pain. (review). Pain Medicine 13(7): 886-896, 2012. (50 refs.)

Objective. Several prominent guidelines recommend that patients on long-term opioid therapy have periodic urine drug monitoring (UDM) for appropriate use; however, none address the specific questions of which patients to test, which substances to test for, how often to test, and how to act on the results. Design. In the absence of adequate scientific evidence in the literature, a panel of experts in the field of pain and addiction medicine was convened to develop consensus UDM recommendations. The panel met three times between March 2010 and April 2011, and reviewed several drafts of the recommendations document between meetings. Results. The group was able to achieve consensus on a set of UDM recommendations addressing test selection, test frequency, interpretation of results, and how to handle discrepancies based on specific results. Conclusion. While the participating panel members recognize that there currently is a limited evidence base to support the expert panel's recommendations, primary care providers and pain specialists are largely acting today based on anecdote, intuition, and individual experience. The recommendations are meant to begin to provide a framework for standardizing practices for UDM in the treatment of chronic pain, and to serve as a catalyst to advance research that quantifies the effects of UDM on opioid therapy management and patient outcomes.

Resko SM; Walton MA; Chermack ST; Blow FC; Cunningham RM. Therapist competence and treatment adherence for a brief intervention addressing alcohol and violence among adolescents. Journal of Substance Abuse Treatment 42(4): 429-437, 2012. (49 refs.)

This study examines therapist competency and treatment adherence for a brief intervention addressing alcohol misuse and violent behaviors among adolescents aged 14-18 years. Three observational measures of fidelity were used by independent raters to evaluate 60 therapist-delivered sessions (M = 32.5 minutes). Individual items from the Content Adherence scale, the Global Rating of Competence (Global Rating of Motivational Interviewing Therapist [GROMIT]), and the Self Exploration and Change Talk (SECT) demonstrated fair to excellent interrater reliability (intraclass correlations ranged from .40 to 1.0). Principal components analysis was used to identify the underlying factor structure of the Content Adherence and the GROMIT. Parallel analysis suggested the extraction of three components for the Content Adherence reflecting the three distinct goals for each segment of the intervention. Two components were identified for the GROMIT representing the general spirit of motivational interviewing and empowerment. Findings provide support for the fidelity instruments adapted for this study and offer direction for future training and clinical supervision.

Rieckmann T; Fuller BE; Saedi GA; McCarty D. Adoption of practice guidelines and assessment tools in substance abuse treatment. Substance Abuse Treatment, Prevention and Policy 5(e-journal 4), 2010. (38 refs.)

Background: The gap between research and practice limits utilization of relevant, progressive and empirically validated strategies in substance abuse treatment. Methods: Participants included substance abuse treatment programs from the Northeastern United States. Structural equation models were constructed with agency level data to explore two outcome variables: adoption of practice guidelines and assessment tools at two points in time; models also included organizational, staffing and service variables. Results: In 1997, managed care involvement and provision of primary care services had the strongest association with increased use of assessment tools, which, along with provision of counseling services, were associated with a greater use of practice guidelines. In 2001, managed care involvement, counseling services and being a stand-alone drug treatment agency were associated with a greater use of assessment tools, which was in turn related to an increase in the use of practice guidelines. Conclusions: This study provides managers, clinicians and policy-makers with a framework for understanding factors related to the adoption of new technologies in substance abuse treatment.

Robbins MS; Feaster DJ; Horigian VE; Puccinelli MJ; Henderson C; Szapocznik J. Therapist adherence in brief strategic family therapy for adolescent drug abusers. Journal of Consulting and Clinical Psychology 79(1): 43-53, 2011. (44 refs.)

Objective: Therapist adherence has been shown to predict clinical outcomes in family therapy. In prior studies, adherence has been represented broadly by core principles and a consistent family (vs. individual) focus. To date, these studies have not captured the range of clinical skills that are represented in complex family-based approaches or examined how variations in these skills predict different clinically relevant outcomes over the course of treatment. In this study, the authors examined the reliability and validity of an observational adherence measure and the relationship between adherence and outcome in a sample of drug-using adolescents who received brief strategic family therapy within a multisite effectiveness study. Method: Participants were 480 adolescents (age 12-17) and their family members, who were randomized to the Brief Strategic Family Therapist treatment condition (J. Szapocznik, U. Hervis. & S. Schwartz, 2003) or treatment as usual. The adolescents were mostly male (377 vs. 103 female) and Hispanic (213), whereas 148 were White, and 110 were Black. Therapists were also randomly assigned to treatment condition within agencies. Results: Results supported the proposed factor structure of the adherence measure, providing evidence that it is possible to capture and discriminate between distinct dimensions of family therapy. Analyses demonstrated that the mean levels of the factors varied over time in theoretically and clinically relevant ways and that therapist adherence was associated with engagement and retention in treatment, improvements in family functioning, and reductions in adolescent drug use. Conclusions: Clinical implications and future research directions are discussed, including the relevance of these findings on training therapists and studies focusing on mechanisms of action in family therapy.

Rossow I. Can harm ratings be useful? (editorial). Addiction 106(11): 1893-1894, 2011. (13 refs.)

Saitz R. Candidate performance measures for screening for, assessing, and treating unhealthy substance use in hospitals: Advocacy or evidence-based practice? Annals of Internal Medicine 153(1): 40-43, 2010. (18 refs.)

The Joint Commission recently proposed candidate performance measures addressing unhealthy substance use in hospitalized patients. The proposed measures of screening and brief intervention (SBI) assume that interventions that work in one setting (primary care outpatient practice) would work in another (hospital); treatment would have the same benefits for persons identified by screening as for those with symptoms who seek help; treatments that work for persons less severely affected by substance use would also work for those with more severe illness; and an approach that works for nondependent, unhealthy alcohol use would work for drug use. However, these assumptions extrapolate evidence of the effectiveness of SBI for primary care outpatients with nondependent, unhealthy alcohol use to the inpatient setting, persons with dependence, and other substances. Although quality of care for unhealthy substance use in all medical settings needs to improve, the evidence base for SBI in the hospital is too limited for the implementation of performance measures assessing this care.

Sanyal C; Asbridge M; Kisely S; Sketris I; Andreou P. The utilization of antidepressants and benzodiazepines among people with major depression in Canada. Canadian Journal of Psychiatry 56(11): 667-676, 2011. (53 refs.)

Objective: Although clinical guidelines recommend monotherapy with antidepressants (ADs) for major depression, polypharmacy with benzodiazepines (BDZs) remains an issue. Risks associated with such treatments include tolerance and dependence, among others. We assessed the prevalence and determinants of AD and BDZ utilization among Canadians who experienced a major depressive episode (MDE) in the previous 12 months, and determined the association of seeing a psychiatrist on the utilization of ADs and BDZs. Method: Data were drawn from the 2002 Canadian Community Health Survey: Health and Well-Being, a nationally representative sample of Canadians aged 15 years and older. Descriptive statistics quantified utilization, while logistic regression identified factors associated with utilization, such as sociodemographic characteristics or type of physician seen. Sampling weights and bootstrap variance estimations were used for all analysis. Results: The overall prevalence of AD and BDZ utilization was 49.3% of respondents who experienced an MDE in the past 12 months and reported AD use. Key determinants of utilization were younger age and unemployment in the past week (OR 2.6; P < 0.001). Being seen by a psychiatrist increased utilization (OR 2.5; P < 0.001), possibly because psychiatrists were seeing patients with severe depression. Conclusion: A large proportion of people with past-year MDEs utilized ADs and BDZs. It is unclear how much of this is appropriate given that evidence-based clinical guidelines recommend monotherapy with ADs in the treatment of major depression.

Shawcross DL; O'Grady JG. The 6-month abstinence rule in liver transplantation. (editorial). Lancet 376(9737): 216-217, 2010. (12 refs.)

Singh I; Kendall T; Taylor C; Mears A; Hollis C; Batty M et al. Young people's experience of ADHD and stimulant medication: A qualitative study for the NICE Guideline. Child and Adolescent Mental Health 15(4): 186-192, 2010. (18 refs.)

Background: The NICE ADHD Guideline Group found a lack of research evidence on young people's experiences with stimulant medications. The present study was commissioned to help fill this gap in the evidence base and to inform the Guideline. Method: Focus groups and 1: 1 interviews with 16 UK young people with ADHD. Results: Young people were positive about taking medication, feeling that it reduced their disruptive behaviour and improved their peer relationships. Young people experienced stigma but this was related more to their symptomatic behaviours than to stimulant drug medication. Conclusions: The study's findings helped to inform the NICE guideline on ADHD by providing evidence that young people's experiences of medication were in general more positive than negative. All NICE Guidelines involving recommendations for the treatment of young people should draw on research evidence of young people's experiences of treatments.

Smith AJ; Tett SE. Improving the use of benzodiazepines-Is it possible? A non-systematic review of interventions tried in the last 20 years. BMC Health Services Research 10: e-article 321, 2010. (69 refs.)

Background: Benzodiazepines are often used on a long term basis in the elderly to treat various psychological disorders including sleep disorders, some neurological disorders and anxiety. This is despite the risk of dependence, cognitive impairment, and falls and fractures. Guidelines, campaigns and prescribing restrictions have been used to raise awareness of potentially inappropriate use, however long term use of benzodiazepine and related compounds is currently increasing in Australia and worldwide. The objective of this paper is to explore interventions aimed at improving the prescribing and use of benzodiazepines in the last 20 years. Methods: Medline, EMBASE, PsychINFO, IPA were searched for the period 1987 to June 2007. Results: Thirty-two articles met the study eligibility criteria (interventions solely focusing on increasing appropriate prescribing and reducing long term use of benzodiazepines) and were appraised. Insufficient data were presented in these studies for systematic data aggregation and synthesis, hence critical appraisal was used to tabulate the studies and draw empirical conclusions. Three major intervention approaches were identified; education, audit and feedback, and alerts. Conclusions: Studies which used a multi-faceted approach had the largest and most sustained reductions in benzodiazepines use. It appears that support groups for patients, non-voluntary recruitment of GPs, and oral delivery of alerts or feedback may all improve the outcomes of interventions. The choice of outcome measures, delivery style of educational messages, and requests by GPs to stop benzodiazepines, either in a letter or face to face, showed no differences on the success rates of the intervention.

Spanou C; Simpson SA; Hood K; Edwards A; Cohen D; Rollnick S et al. Preventing disease through opportunistic, rapid engagement by primary care teams using behaviour change counselling (PRE-EMPT): Protocol for a general practice-based cluster randomised trial. BMC Family Practice 11: e-article 11, 2010. (80 refs.)

Background: Smoking, excessive alcohol consumption, lack of exercise and an unhealthy diet are the key modifiable factors contributing to premature morbidity and mortality in the developed world. Brief interventions in health care consultations can be effective in changing single health behaviours. General Practice holds considerable potential for primary prevention through modifying patients' multiple risk behaviours, but feasible, acceptable and effective interventions are poorly developed, and uptake by practitioners is low. Through a process of theoretical development, modeling and exploratory trials, we have developed an intervention called Behaviour Change Counselling (BCC) derived from Motivational Interviewing (MI). This paper describes the protocol for an evaluation of a training intervention (the Talking Lifestyles Programme) which will enable practitioners to routinely use BCC during consultations for the above four risk behaviours. Methods/Design: This cluster randomised controlled efficacy trial (RCT) will evaluate the outcomes and costs of this training intervention for General Practitioners (GPs) and nurses. Training methods will include: a practice-based seminar, online self-directed learning, and reflecting on video recorded and simulated consultations. The intervention will be evaluated in 29 practices in Wales, UK; two clinicians will take part (one GP and one nurse) from each practice. In intervention practices both clinicians will receive training. The aim is to recruit 2000 patients into the study with an expected 30% drop out. The primary outcome will be the proportion of patients making changes in one or more of the four behaviours at three months. Results will be compared for patients seeing clinicians trained in BCC with patients seeing non-BCC trained clinicians. Economic and process evaluations will also be conducted. Discussion: Opportunistic engagement by health professionals potentially represents a cost effective medical intervention. This study integrates an existing, innovative intervention method with an innovative training model to enable clinicians to routinely use BCC, providing them with new tools to encourage and support people to make healthier choices. This trial will evaluate effectiveness in primary care and determine costs of the intervention. Trial Registration: ISRCTN22495456/

Stanger C; Budney AJ. Contingency management approaches for adolescent substance use disorders. Child and Adolescent Psychiatric Clinics of North America 19(3): 547-+, 2010. (44 refs.)

The addition of contingency management (CM) to the menu of effective treatments for adolescent substance abuse has generated excitement in the research and treatment communities. CM interventions are based on extensive basic science and clinical research evidence demonstrating that drug use is sensitive to systematically applied consequences. This article provides (a) a review of basic CM principles, (b) implementation guidelines, (c) a review of the clinical CM research targeting adolescent substance abuse, and (d) a discussion of implementation successes and challenges. Although the research base for CM with adolescents is in its infancy, there are multiple reasons for high expectations.

Teeuw AH; Derkx BHF; Koster WA; van Rijn RR. Educational paper. Detection of child abuse and neglect at the emergency room. (review). European Journal of Pediatrics 171(6): 877-885, 2012. (102 refs.)

The emergency room (ER) represents the main system entry for crises-based health care visits. It is estimated that 2% to 10% of children visiting the ER are victims of child abuse and neglect (CAN). Therefore, ER personnel may be the first hospital contact and opportunity for CAN victims to be recognised. Early diagnosis of CAN is important, as without early identification and intervention, about one in three children will suffer subsequent abuse. This educational paper provides the reader with an up-to-date and in-depth overview of the current screening methods for CAN at the ER. Conclusion: We believe that a combined approach, using a checklist with risk factors for CAN, a structured clinical assessment and inspection of the undressed patient (called 'top-toe' inspection) and a system of standard referral of all children from parents who attend the ER because of alcohol or drugs intoxication, severe psychiatric disorders or with injuries due to intimate partner violence, is the most promising procedure for the early diagnosis of CAN in the ER setting.

Tetzlaff J; Collins GB; Brown DL; Leak BC; Pollock G; Popa D. A strategy to prevent substance abuse in an academic anesthesiology department. Journal of Clinical Anesthesia 22(2): 143-150, 2010. (18 refs.)

Substance abuse is the most serious occupational safety issue associated with the practice of anesthesiology, with an incidence as high as 1% per year of training. The Cleveland Clinic's Anesthesiology Institute approached the process from the perspective of active prevention, including specific mandatory education programs for all department personnel on a recurring basis, strengthened procedures for the detection and prevention of diversion of controlled substances, enhanced skill building for detection of impairment, and implemented a multi-faceted drug testing program, including random and for cause" urine screens, for prevention and early detection of abused anesthetic drugs and other substances of abuse. After 18 months of preparation, a Substance Abuse Prevention Protocol was created, which has been fully implemented as of September 1, 2007.

Thevis M; Kuuranne T; Geyer H; Schanzer W. Annual banned-substance review: Analytical approaches in human sports drug testing. (review). Drug Testing and Analysis 3(1): 1-14, 2011. (122 refs.)

The timely update of the list of prohibited substances and methods of doping (as issued by the World Anti-Doping Agency) is an essential aspect of international anti-doping efforts and represents consensual agreement by expert panels regarding substances and the methods of performance manipulation in sports. The annual banned-substance review for human doping controls critically summarizes recent innovations in analytical approaches; its purpose is to improve the quality of doping controls by reporting emerging and advancing methods that focus on detecting known and recently outlawed substances. This review surveys new and/or enhanced procedures and techniques of doping analysis together with information relevant to doping control that has been published in the literature between October 2009 and September 2010.

Thomson NC; Spears M. Asthma guidelines and smokers: It's time to be inclusive. (editorial). Chest 141(2): 286, 2012. (12 refs.)

Tompkins-Dobbs K; Schiefelbein J. Emergency department policies and procedures for treatment of patients abusing methamphetamine. Journal of Emergency Nursing 37(5): 437-443, 2011. (13 refs.)

An investigative descriptive research case study design was used to explore the following questions: �Do hospital emergency departments in 2 rural, 2 suburban, and urban Kansas hospitals address a patient�s drug abuse even when the presenting complaint is unrelated to drug abuse?" and "Do emergency departments in 2 rural, 2 suburban, and 2 urban Kansas hospitals have policies and procedures available to their staff that provide guidance in caring for patients addicted to methamphetamine?" Telephone survey interviews were conducted. Consistency in themes was found among rural, suburban, and urban Kansas hospital emergency departments without regard to the size and location of the facilities. Data show that policies and procedures are not available and that treatment of patients addicted to methamphetamine is inconsistent within a single facility and across facilities in the same state. Treatment of methamphetamine addicts in the absence of policies and procedures set in place by the facility is based on the individual determination of the primary care provider and is subject to individual bias or lack of knowledge

Tsemberis S. Housing First: The Pathways Model to End Homelessness for People with Mental Illness and Addiction. Center City: Hazelden, 2011

There is a growing body of research demonstrating that in treating homeless persons with for those with multiple problems, be they psychiatric and/or substance the best clinical outcomes are associated with making permanent housing the priority. Housing First is a model that embodies this philosophy and which has been implemented in diverse communities. This model grew out of the experiences of working with homeless clients. This book offers a step-by-step guide for introducing the evidence-based Housing First approach - i.e., to provide housing first, followed by supportive treatment services . It provides a framework for structuring both policies and programs, and includes easy-to-follow checklists and other tools. It begins by outlining the program's philosophy, operations, and administration, including discussion of staffing in respect to staff composition and administrative structures. It outlines an assessment process and efforts to engage clients. It deals with property management. There are also protocols for working with landlords, the structure and support for clients in search of housing, and the process for the "settling in" process. The book also reviews the research evidence that the effectiveness of the Housing First model.

Tumwine J. Implementation of the Framework Convention on Tobacco Control in Africa: Current status of legislation. International Journal of Environmental Research and Public Health 8(11): 4312-4331, 2011. (27 refs.)

Objective: To describe, as of July 2011, the status of tobacco control legislation in Africa in three key areas of the Framework Convention on Tobacco Control (FCTC)-(1) Protection from exposure to tobacco smoke, (2) Packaging and labelling of tobacco products, and (3) Tobacco advertising, promotion and sponsorship. Methods: Review and analysis of tobacco control legislation in Africa, media reports, journal articles, tobacco industry documents and data published in the 2011 WHO Report on the Global Tobacco Epidemic. Results: Modest progress in FCTC implementation in Africa with many countries having legislation or policies on the protection from exposure to tobacco smoke, however, only a handful of countries meet the standards of the FCTC Article 8 and its Guidelines particularly with regards to designated smoking areas. Little progress on packaging and labelling of tobacco products, with few countries having legislation meeting the minimum standards of the FCTC Article 11 and its Guidelines. Mauritius is the only African country with graphic or pictorial health warnings in place and has the largest warning labels in Africa. Slightly better progress in banning tobacco advertising, promotion and sponsorship has been shown by African countries, although the majority of legislation falls short of the standards of the FCTC Article 13 and its Guidelines. Despite their efforts, African countries' FCTC implementation at national level has not matched the strong regional commitment demonstrated during the FCTC treaty negotiations. Conclusion: This study highlights the need for Africa to step up efforts to adopt and implement effective tobacco control legislation that is fully compliant with the FCTC. In order to achieve this, countries should prioritize resources for capacity building for drafting strong FCTC compliant legislation, research to inform policy and boost political will, and countering the tobacco industry which is a major obstacle to FCTC implementation in Africa.

Ulmer A; Lamy D; Reisinger M; Haraldsen M; Maremmani I; Newman R. How should methadone and buprenorphine treatment be organized and regulated? A comparison between two systems in the context of a EUROPAD Conference in Brussels. Heroin Addiction and Related Clinical Problems 14(1): 5-9, 2012. (0 refs.)

Opiate Agonist Treatment (OAT-providing) physicians and pharmacists from the southwest region of Germany and the Wallonian part of Belgium came together with international experts to compare their two different sets of OAT regulations. Both countries mostly rely on methadone, but with an increasing use of buprenorphine, besides a much less frequent recourse to other opioids. German OAT is rather strictly regulated. The aim of these regulations was to ensure quality. That effect is, however, questionable. The regulations make it difficult and legally dangerous to provide OAT. Physicians and patients suffer from these regulations. Most doctors avoid getting involved. No successors are available. The future scenario will be OAT provision at only a few clinics, with a large array of controls and with a customary setting of crowds of addicted people. The Belgian system runs without these regulations. The consequence is not greater chaos, but a much more normal integration of patients into normal medical practice and into society itself. The take-home message of the conference held under the auspices of EUROPAD was that most special regulations point in the wrong direction, and lead into a costly dead end. The whole treatment procedure works better and much more effectively if we treat the patients as normally as possible, with nothing more complicated than normal diligence. Connection with a good support system, networking, regular education and periodic evaluation of how the system functions - all these factors go to constitute a guarantee of the best possible outcome for patients.

Volk ML; Biggins SW; Huang MA; Argo CK; Fontana RJ; Anspach RR. Decision making in Liver Transplant Selection Committees: A multicenter study. Annals of Internal Medicine 155(8): 503-508, 2011. (18 refs.)

Background: To receive a liver transplant, patients must first be placed on a waiting list-a decision made at most transplant centers by a multidisciplinary committee. The function of these committees has never been studied. Objective: To describe decision making in liver transplant committees and identify opportunities for process improvement. Design: Observational multicenter study. Setting: 4 liver transplant centers in the United States. Participants: 68 members of liver transplant committees across the 4 centers. Measurements: 63 meetings were observed, and 50 committee members were interviewed. Recorded transcripts and field notes were analyzed by using standard qualitative sociologic methods. Results: Although the structure of the meetings varied by center, the process was uniform and primarily involved inductive reasoning to review possible reasons for patient exclusion. Patients were excluded if they were too well, too sick (in the setting of advanced liver disease), or too old or had nonhepatic comorbid conditions, substance abuse problems, or other psychosocial barriers. Dominant themes in the discussions included member angst over deciding who lived or died, a high correlation between psychosocial barriers to transplantation and the patient's socioeconomic status, and the influence of external forces on decision making. Unwritten center policies and confusion regarding advocacy versus stewardship roles were consistently identified as barriers to effective group decision making. Limitations: The use of qualitative methods provides broad understanding but limits specific inferences. The 4 centers may not reflect the practices of every transplant center nationwide. Conclusion: The difficult decisions made by liver transplant committees are reasonably consistent and well-intentioned, but the process might be improved by having more explicit written policies and clarifying roles. This may inform resource allocation in other areas of medicine.

Wasserman D; Rihmer Z; Rujescu D; Sarchiapone M; Sokolowski M; Titelman D et al. The European Psychiatric Association (EPA) guidance on suicide treatment and prevention. (review). European Psychiatry 27(2): 129-141, 2012. (166 refs.)

Suicide is a major public health problem in the WHO European Region accounting for over 150,000 deaths per year. Suicidal crisis: Acute intervention should start immediately in order to keep the patient alive. Diagnosis: An underlying psychiatric disorder is present in up to 90% of people who completed suicide. Comorbidity with depression, anxiety, substance abuse and personality disorders is high. In order to achieve successful prevention of suicidality, adequate diagnostic procedures and appropriate treatment for the underlying disorder are essential. Treatment: Existing evidence supports the efficacy of pharmacological treatment and cognitive behavioural therapy (CBT) in preventing suicidal behaviour. Some other psychological treatments are promising, but the supporting evidence is currently insufficient. Studies show that antidepressant treatment decreases the risk for suicidality among depressed patients. However, the risk of suicidal behaviour in depressed patients treated with antidepressants exists during the first 10-14 days of treatment, which requires careful monitoring. Short-term supplementary medication with anxiolytics and hypnotics in the case of anxiety and insomnia is recommended. Treatment with antidepressants of children and adolescents should only be given under supervision of a specialist. Long-term treatment with lithium has been shown to be effective in preventing both suicide and attempted suicide in patients with unipolar and bipolar depression. Treatment with clozapine is effective in reducing suicidal behaviour in patients with schizophrenia. Other atypical antipsychotics are promising but more evidence is required. Treatment team: Multidisciplinary treatment teams including psychiatrist and other professionals such as psychologist, social worker, and occupational therapist are always preferable, as integration of pharmacological, psychological and social rehabilitation is recommended especially for patients with chronic suicidality. Family: The suicidal person independently of age should always be motivated to involve family in the treatment. Social support: Psychosocial treatment and support is recommended, as the majority of suicidal patients have problems with relationships, work, school and lack functioning social networks. Safety: A secure home, public and hospital environment, without access to suicidal means is a necessary strategy in suicide prevention. Each treatment option, prescription of medication and discharge of the patient from hospital should be carefully evaluated against the involved risks. Training of personnel: Training of general practitioners (GPs) is effective in the prevention of suicide. It improves treatment of depression and anxiety, quality of the provided care and attitudes towards suicide. Continuous training including discussions about ethical and legal issues is necessary for psychiatrists and other mental health professionals.

Wesson DR; Smith DE. Buprenorphine in the treatment of opiate dependence. (review). Journal of Psychoactive Drugs 42(2): 161-175, 2010. (113 refs.)

Compelling clinical evidence establishes that buprenorphine is similar to methadone in efficacy for opiate detoxification and maintenance but safer than methadone in an overdose situation. The Drug Abuse Treatment Act of 2000 (DATA 2000) enabled US physicians with additional training to prescribe buprenorphine to a limited number of opiate-dependent patients. The sublingual tablets Subutex (R) (buprenorphine alone) and Suboxone (R) (a combination of buprenorphine and naloxone) meet the specifications of DATA 2000. Suboxone is intended to discourage intravenously administration and has less abuse potential than buprenorphine alone. Suboxone is generally recommended for maintenance treatment except for women who are pregnant. Subutex is recommended in treatment of pregnant women. A buprenorphine opiate withdrawal syndrome can occur in newborns. Although intravenous buprenorphine abuse is a significant public health problem in some countries, buprenorphine alone or in combination with naloxone has less potential for abuse than heroin and some prescription opiates, such as oxycodone. Pharmacotherapy from physicians' offices makes buprenorphine treatment acceptable to some opiate-dependent patients who would not accept treatment in traditional opiate-maintenance clinics. For reasons not adequately understood, some patients find discontinuation of buprenorphine following long-term use difficult. This article reviews the pharmacology of buprenorphine, summarizes evidence supporting the safety and efficacy of buprenorphine and provides clinical guidelines for treatment.

Wieser K; Zingg PO; Betz M; Neubauer G; Dora C. Total hip replacement in patients with history of illicit injecting drug use. Archives of Orthopaedic and Trauma Surgery 132(7): 1037-1044, 2012. (22 refs.)

A history of illicit injecting drug use makes indication of total hip arthroplasty (THA) in patients with end stage hip osteoarthritis difficult, as the risk of infection with colonized strains is multiplied if the patient continues to inject or inhale illicit drugs. A retrospective survivorship analysis of a consecutive series of 27 THA in patients with a history of illicit drug use was performed. Follow-up evaluation consisted of (1) a WOMAC score, (2) a standardized interview including queries on drug habits and eventual additional medico-surgical treatments of the affected hip, (3) a clinical examination in order to complete a Harris Hip Score, (4) radiological examination and (5) blood tests (blood sedimentation rates and C-reactive protein). Defined endpoints were death, implant revised or awaiting revision for deep infection or any other reason and lost to follow-up or follow-up after at least 2 years. Overall, 5- and 10-year implant survival rates with failure for any reason were 61 % (CI: 41;81) and 52.3 % (CI: 29;76) and for septic reasons 70.6 % (CI: 52;89) and 60.5 % (CI: 36;85), respectively. Even if at the time of THA all patients and respective health care professionals confirmed abstinence of illicit injecting drug use, five patients reported occasional use. Declared abstinence of less than 1 year before THA was associated with higher recurrence rates (p = 0.001) and both with higher septic failure rates (p = 0.023, p = 0.061). Positive serology for human deficiency virus did not increase implant failure rates. We use this unacceptable high failure rate as evidence when counseling patients and their health care professionals about the appropriate treatment of osteoarthritis in patients with a history of illicit drug use. Furthermore, we support the request of hair analysis for drugs documenting abstinence of at least 1 year before indicating THA.

Williamson L. 'For Debate': NICE but Needy: English guidance on managing alcohol dependence is not backed up by government alcohol policy. (editorial). Alcohol and Alcoholism 46(6): 647-650, 2011. (36 refs.)