Use of Prescription Drug Samples and Patient Assistance Programs,and the Role of Doctor–Patient Communication

BACKGROUND  

Cost-related underuse of medications is common among older adults, who seldom discuss medication costs with their physicians. Some older adults may use free drug samples or industry-sponsored patient assistance programs (PAP) in hopes of lowering out-of-pocket costs, although the long-term effect of these programs on drug spending is unclear.     

Screening and Follow-Up Monitoring for Substance Use in Primary Care: An Exploration of Rural–Urban Variations

BACKGROUND

Rates of substance use in rural areas are close to those of urban areas. While recent efforts have emphasized integrated care as a promising model for addressing workforce shortages in providing behavioral health services to those living in medically underserved regions, little is known on how substance use problems are addressed in rural primary care settings.

OBJECTIVE

To examine rural–urban variations in screening and monitoring primary care- based patients for substance use problems in a state-wide mental health integration program.

DESIGN

This was an observational study using patient registry.

SUBJECTS

The study included adult enrollees (n?=?15,843) with a mental disorder from 133 participating community health clinics.

MAIN OUTCOMES

We measured whether a standardized substance use instrument was used to screen patients at treatment entry and to monitor symptoms at follow-up visits.

KEY RESULTS

While on average 73.6 % of patients were screened for substance use, follow-up on substance use problems after initial screening was low (41.4 %); clinics in small/isolated rural settings appeared to be the lowest (13.6 %). Patients who were treated for a mental disorder or substance abuse in the past and who showed greater psychiatric complexities were more likely to receive a screening, whereas patients of small, isolated rural clinics and those traveling longer distances to the care facility were least likely to receive follow-up monitoring for their substance use problems.

CONCLUSIONS

Despite the prevalent substance misuse among patients with mental disorders, opportunities to screen this high-risk population for substance use and provide a timely follow-up for those identified as at risk remained overlooked in both rural and urban areas. Rural residents continue to bear a disproportionate burden of substance use problems, with rural–urban disparities found to be most salient in providing the continuum of services for patients with substance use problems in primary care.

     

What Factors Are Associated with High‐Frequency Drug Treatment Use among a Racially and Ethnically Diverse Population of Injection Drug Users?

This study explored the frequency of drug treatment utilization by 36,081 injection drug users (IDUs) in Massachusetts, 1996-2002. A number of multiple and logistic regression analyses examined the relationship between demographic characteristics, parental status, level of and type of drug use, history of mental health treatment use, types of drug treatment entered, and the number of times an IDU had entered drug treatment for the seven-year time period. Homelessness, using heroin as the primary drug of choice, and health insurance status were all associated with number of treatments entered. Logistic regression analysis identified that health insurance was a key factor associated with more frequent treatment: those with private health insurance were ten times more likely to be in the 90th percentile (12-107 entries) with respect to number of treatment entries.     

Drug Users’ Willingness to Encourage Social,Sexual, and Drug Network Members to Receive an HIV Vaccine: A Social Network Analysis

This study examined feasibility of peer-based promotion of HIV vaccination and dyadic correlates to vaccine encouragement in risk- and non-risk networks of drug users (n = 433) in the US. Data were collected on HIV vaccine attitudes, risk compensation intentions, likelihood of encouraging vaccination, and recent (past 6 months) risk (i.e. involving sex and/or injecting drugs) and non-risk (i.e. involving co-usage of noninjected drugs and/or social support) relationships. Willingness to encourage HIV vaccination was reported in 521 and 555 risk- and non-risk relationships, respectively. However, 37 % expressed hesitancy, typically due to fear of side effects or social concerns. Encouragement was often motivated by perceived HIV risk, though 9 % were motivated by risk compensation intentions. In non-risk partnerships, encouragement was associated with drug co-usage, and in risk relationships, with perceived vaccine acceptability and encouragement by the partner. Network-based HIV vaccine promotion may be a successful strategy, but risk compensation intentions should be explored.     

Classic and Recent Etiologies of Cushing’s Syndrome

Endogenous Cushing's syndrome can result from excess adrenocorticotropic hormone (ACTH; corticotropin) production by a pituitary adenoma (Cushing's disease) or by ectopic tumors secreting ACTH or corticotro- pin-releasing hormone (CRH). ACTH-independent Cushing's syndrome is caused by adrenocortical tumors or hyperplasias. Initial diagnosis is performed using 24-hour urinary free cortisol, low-dose dexamethasone tests, salivary cortisol, or night-time plasma cortisol values. A dexamethasone CRH test can discriminate between Cushing's syndrome and pseudo-Cushing's syndrome. If ACTH is elevated, combinations of high-dose dexamethasone tests, CRH/desmopressin tests, and pituitary magnetic resonance imaging can indicate a pituitary source. Discrimination from an ectopic ACTH tumor often requires inferior petrosal sinus sampling to confirm the ACTH source. If ACTH is low, adrenal computed tomography scan will identify the adrenal lesion(s) implicated. Some cortisol-producing adrenal tumors or, more frequently, bilateral macronodular hyperplasias, are under the control of aberrant membrane hormone receptors, or altered activity of eutopic receptors. The initial therapy of choice for patients with Cushing's disease is the selective transsphenoidal removal of the corticotroph adenoma; this induces remission in approximately 80% of patients, but long-term relapse occurs in up to 30% of these cases. The choice of second-line therapy remains controversial. Repeat surgery can be successful when residual tumor is detectable on magnetic resonance imaging, but carries a high risk of hypopituitarism. Bilateral adrenalectomy may be a better choice in patients without visible residual tumors, particularly in women desiring fertility. Radiotherapy combined with ketoconazole or radiosurgery was recently found effective, but longer-term evaluation of hypopituitarism and brain function is required. Current studies do not support the systematic use of prophylactic radiotherapy after bilateral adrenalectomy to decrease the risk of Nelson's syndrome; however, as soon as the residual tumor progresses, surgery and radiotherapy should be initiated. Various drugs which inhibit steroid synthesis (ketoconazole, metyrapone, aminoglutethimide, mitotane) are often effective for rapidly controlling hypercortisolism either in preparation for surgery, after unsuccessful removal of the etiologic tumor, or while awaiting the full effect of radiotherapy or more definitive therapy. Surgery is usually the treatment of choice for removal of cortisol-secreting adrenal tumors or ectopic ACTH/CRH-secreting tumors. The identification of aberrant adrenal receptors has recently allowed normalization of cortisol secretion by specific ligand receptor antagonists in limited cases of Cushing's syndrome secondary to bilateral macronodular adrenal hyperplasia. The long-term follow-up of patients treated for Cushing's syndrome should include the adequate replacement of glucocorticoids and other hormones, treatment of osteoporosis, and detection of long-term relapse of Cushing's syndrome.     

Drug Use Among Gay and Bisexual Men at Weekend Dance Parties: The Role of Intentions and Perceptions of Peers’ Behaviors

Substance use is high among gay and bisexual men attending weekend dance events, yet little research has investigated motivations for drug use and contextual factors influencing use in these settings. We hypothesized that beliefs about peer drug use interact with individuals’ own drug use intentions to predict use. 489 men attending weekend dance events completed an anonymous assessment asking about their own and their beliefs about other attendants’ drug use intentions—47 % completed a follow-up assessment after the event. Forty-four percent reported intending to use ecstasy at the event; intentions to use GHB, marijuana, cocaine, unprescribed erectile dysfunction drugs, and poppers were also high. Perceptions about other attendant’s drug use predicted use among those intending and those not intending to use drugs. Normative beliefs are important predictors of drug use at weekend dance events; event-specific prevention strategies should encompass messages that correct misperceptions of drug use among party attendants.     

New York City Injection Drug Users’ Memories of Syringe-Sharing Patterns and Changes During the Peak of the HIV/AIDS Epidemic

In this oral history, 23 injection drug users (IDUs) were interviewed about the mid-1970s to mid-1980s when they could not legally purchase or possess syringes, and the threat of AIDS began to loom large. Several themes emerged, including: abrupt changes in syringe-sharing patterns; the effects of illnesses or deaths of others on their understanding of AIDS; and, racial/ethnic differences in responses to the threat of AIDS. Settings, such as “shooting galleries,” helped HIV spread rapidly in the earliest stages of the city's AIDS epidemic. HIV entered the drug scene in the mid-1970s, just when IDUs were shifting from sharing homemade “works” (consisting of steel needles and syringes devised from rubber baby pacifiers and similar sources) among many IDUs to mass produced and distributed plastic, disposable needle and syringe sets. IDUs remember when they first became aware of AIDS and began to adjust their behaviors and social assumptions.     

The Rheology of Liquids: A Comparison of Clinicians’ Subjective Impressions and Objective Measurement

Texture-modified diets are commonly prescribed for patients with dysphagia; it is therefore important to demonstrate that clinicians form accurate impressions of the rheological (flow) properties of the items that they recommend for their clients. We explored the correlation between objective rheological measurement and clinicians subjective impressions of liquid consistency, rated on the bases of product labeling and sampling. Ten liquids, ranging from thin through nectar-thick and honey-thick to spoon-thick consistencies, were selected for study. Rheological analysis was conducted using a Carri-Med CSL Controlled Stress Rheometer. Fifty speech-language pathologists ranked the liquids in order of perceived viscosity, based on their interpretation of the product packaging and label. Product nomenclature proved insufficient to accurately represent the consistency class to which each liquid belonged. A second group of 16 speech-language pathologists rated the perceived relative viscosity and density of nectar-thick and honey-thick juice items in blinded two-point discrimination tests of stirring-resistance, oral manipulation, and vessel weight. Physical sampling of these two products enabled clinicians to reliably perceive relative viscosity and density differences between the nectar- and honey-thick items.     

A Cognitive–Behavioral Intervention to Reduce HIV Risk Behaviors in Crack and Injection Drug Users

This paper presents the results of a study evaluating the efficacy of a theory-based cognitive–behavioral intervention to reduce HIV risk among street-based crack and injection drug users not currently in drug treatment in Long Beach, California. A nine-session, 4-month enhanced intervention (including HIV counseling and testing) was compared to a two-session standard counseling and testing intervention developed by the National Institute on Drug Abuse (NIDA) in terms of their efficacy for reducing drug- and sex-related risk behaviors. The theory-based enhanced intervention rarely was found to be different from NIDA's standard counseling and testing intervention in reducing both drug- and sex-related risks, as indicated by cessation and/or reduction of drug use (measured by urine test and self-report), entry into drug treatment, and increased frequency of condom use. One of the few significant effects was that the enhanced intervention significantly increased injecting drug users' use of their own injection equipment. On the other hand, for both interventions, most risk behaviors were significantly reduced. It is concluded that the theory-based cognitive–behavioral intervention has limited advantage over the standard intervention in terms of both magnitude and frequency of HIV risk reduction achieved by high-risk, active drug users.     

Which Patient Characteristics Among Cocaine Users with HIV Relate to Drug Use and Adherence Outcomes Following a Dual-Focused Intervention?

This is a secondary analysis of data from a randomized trial of dually-focused interventions for nonadherent HIV patients with cocaine use disorders (Ingersoll et al. in Drug Alcohol Depend 116(1–3):177–187, 2011). We examined the relationships among baseline demographic, psychological, psychiatric, and behavioral characteristics and 6-months post-study ART adherence, log viral load (VL), ASI Drug Composite Score, and days using cocaine. We used the SAS GLMSELECT procedure to build multivariate models of each post-study outcome. Post-study ART adherence was related to 2 psychological variables; while logVL was related to 2 drug-related behaviors. ASI Drug Composite score was related to 2 psychiatric disorders, 1 demographic, and 1 psychological variable; in contrast, days using cocaine related to 1 behavioral and 3 psychological variables. Analyses show clear, robust relationships among behavioral, psychological and psychiatric diagnosis factors with post-study ART adherence and cocaine use outcomes. Future ART adherence interventions for cocaine users should consider tailoring to these patient characteristics.     

Detection of HCV-Specific IFN-γ Responses in HCV Antibody and HCV RNA Negative Injecting Drug Users

Background:

Detectable HCV-specific cellular immune responses in HCV antibody and RNA negative people who inject drugs (PWID) raise the question of whether some are resistant to HCV infection. Immune responses from people who have been exposed to hepatitis C virus (HCV) and remain anti-HCV negative are of interest for HCV vaccine development; however, limited research addresses this area.

Objectives:

In a cohort of HCV antibody and RNA negative PWID, we assessed whether the presence of HCV-specific IFN-γ responses or genetic associations provide any evidence of protection from HCV infection.

Patients and Methods:

One hundred and ninety-eight participants were examined longitudinally for clinical, behavioral, social, environmental and genetic characteristics (IFNL3 genotype [formally IL-28B] and HLA type). Sixty-one of the 198 participants were HCV antibody and RNA negative, with 53 able to be examined longitudinally for HCV-specific IFN-γ ELISpot T cell responses.

Results:

Ten of the 53 HCV antibody and RNA negative participants had detectable HCV-specific IFN-γ responses at baseline (18%). The magnitude of IFN-γ responses averaged 131 +/- 96 SFC/106 PBMC and the breadth was mean 1 +/- 1 pool positive. The specificity of responses were mainly directed to E2, NS4b and NS5b. Participants with (10) and without (43) HCV-specific IFN-γ responses did not differ in behavioral, clinical or genetic characteristics (P > 0.05). There was a larger proportion sharing needles (with 70%, without 49%, P = 0.320) and a higher incidence of HCV (with 35.1 per 100 py, 95% CI 14.6, 84.4, without 16.0 per 100 py, 95% CI 7.2, 35.6, P = 0.212) in those with IFN-γ responses, although not statistically significant. Half the participants with baseline IFN-γ responses became HCV RNA positive (5/10), with one of these participants spontaneously clearing HCV. The spontaneous clearer had high magnitude and broad Th1 responses, favorable IFNL3 genotype and favorable HLA types.

Conclusions:

This study demonstrated the detection of HCV-specific IFN-γ responses in HCV antibody and RNA negative individuals, with a tendency for HCV-specific IFN-γ responses to be associated with HCV exposure. The potential role of HCV-specific IFN-γ responses in those who remained HCV RNA negative is of value for the development of novel HCV therapeutics.     

A Comparison of the Psychosocial Functioning of Children with Drug‐Versus Alcohol‐Dependent Fathers

The present study compared the psychosocial functioning of children whose fathers primarily abused illicit drugs other than alcohol (n = 51) to children from a demographically matched sample of families whose fathers abused alcohol (n = 51). Children with drug‐abusing (DA) fathers exhibited significantly more negative child behaviors on a standardized child‐rating scale than did children from homes with alcohol‐abusing fathers. In addition, a significantly greater proportion of children with DA fathers met clinical cutoffs indicative of psychosocial impairment (n = 23; 45%) than did children whose fathers abused alcohol (n = 5; 10%). Mediation analyses indicated that severity of drug, legal, medical, employment, and family problems partially mediated the relationship between type of family (i.e., families with fathers who had an alcohol problem versus families with fathers who had a drug problem) and children's psychosocial adjustment.     

Extensions of Respondent-Driven Sampling: A New Approach to the Study of Injection Drug Users Aged 18–25

Researchers generally use nonprobability methods such as chain-referral sampling to study populations for which no sampling frame exists. Respondent-driven sampling is a new form of chain-referral sampling that was designed to reduce several sources of bias associated with this method, including those from the choice of initial participants, volunteerism, and masking. This study expands this method by introducing steering incentives, supplemental rewards for referral of members of a specific group, injection drug users (IDUs) aged 18–25. The results are based on an interrupted time series analysis in which 196 IDUs from Meriden, CT, were interviewed before introduction of the steering incentives, and another 190 were interviewed afterwards. The steering incentives increased the percentage of younger IDUs sampled by 70%. We compared recruitment patterns with institutional data and self-reported personal networks to determine representativeness and whether volunteerism or masking were present. The results indicated that steering incentives helped to increase recruitment of younger IDUs, that the sample was representative, and that both volunteerism and masking were modest.     

Trajectories of Drug Use and Mortality Outcomes Among Adults Followed Over 18?Years

BACKGROUND

For adults in general population community settings, data regarding long-term course and outcomes of illicit drug use are sparse, limiting the formulation of evidence-based recommendations for drug use screening of adults in primary care.

OBJECTIVE

To describe trajectories of three illicit drugs (cocaine, opioids, amphetamines) among adults in community settings, and to assess their relation to all-cause mortality.

DESIGN

Longitudinal cohort, 1987/88 ?C 2005/06.

SETTING

Community-based recruitment from four cities (Birmingham, Chicago, Oakland, Minneapolis).

PARTICIPANTS

Healthy adults, balanced for race (black and white) and gender were assessed for drug use from 1987/88??2005/06, and for mortality through 12/31/2008 (n?=?4301)

MEASUREMENTS

Use of cocaine, amphetamines, and opioids (last 30?days) was queried in the following years: 1987/88, 1990/91, 1992/93, 1995/96, 2000/01, 2005/06. Survey-based assessment of demographics and psychosocial characteristics. Mortality over 18?years.

RESULTS

Trajectory analysis identified four groups: Nonusers (n?=?3691, 85.8%), Early Occasional Users (n?=?340, 7.9%), Persistent Occasional Users (n?=?160, 3.7%), and Early Frequent/Later Occasional Users (n?=?110, 2.6%). Trajectories conformed to expected patterns regarding demographics, other substance use, family background and education. Adjusting for demographics, baseline health status, health behaviors (alcohol, tobacco), and psychosocial characteristics, Early Frequent/Later Occasional Users had greater all-cause mortality (Hazard Ratio, HR?=?4.94, 95% CI?=?1.58?C15.51, p?=?0.006).

LIMITATIONS

Study is restricted to three common drugs, and trajectory analyses represent statistical approximations rather than identifiable ??types??. Causal inferences are tentative.

CONCLUSIONS

Four trajectories describe illicit drug use from young adulthood to middle age. Two trajectories, representing over one third of adult users, continued use into middle age. These persons were more likely to continue harmful risk behaviors such as smoking, and more likely to die.     

Use of Hospitalists and Office-Based Primary Care Physicians’ Productivity

BACKGROUND

Growth in the care of hospitalized patients by hospitalists has the potential to increase the productivity of office-based primary care physicians (PCPs) by allowing them to focus on outpatient practice.

OBJECTIVE

Our aim was to examine the association between utilization of hospitalists and the productivity of office-based PCPs.

DESIGN/PARTICIPANTS

The cross-sectional study was conducted using the 2008 Health Tracking Physician Survey Restricted Use File linked to the Area Resource File. We analyzed a total of 1,158 office-based PCPs representing a weighted total of 97,355 physicians.

MAIN MEASURES

Utilization of hospitalists was defined as the percentage of a PCP’s hospitalized patients treated by a hospitalist. The measures of PCPs’ productivity were: (1) number of hospital visits per week, (2) number of office and outpatient clinic visits per week, and (3) direct patient care time per visit.

KEY RESULTS

We found that the use of hospitalists was significantly associated with a decreased number of hospital visits. The use of hospitalists was also associated with an increased number of office visits, but this was only significant for high users. Physicians who used hospitalists for more than three-quarters of their hospitalized patients had an extra 8.8 office visits per week on average (p = 0.05), which was equivalent to a 10 % increase in productivity over the predicted mean of 87 visits for physicians who did not use hospitalists. We did not find any significant differences in direct patient care time per visit.

CONCLUSIONS

Our study demonstrates that the increase in productivity for the one-third of PCPs who use hospitalists extensively may not be sufficient to offset the current loss of PCP workforce. However, our findings provide cautious optimism that if more PCPs effectively and efficiently used hospitalists, this could help mitigate a PCP shortage and improve access to primary care services.KEY WORDS: hospitalists, primary care physician shortage, productivity