Medical Education About the Care of Addicted Incarcerated Persons: A National Survey of Residency Programs

In June 1998, there were 1.8 million inmates in correctional facilities for adults; 1.2 million in state and federal prisons and 600,000 in municipal/county jails (668 persons per 100,000 U.S. population). Rates of TB, AIDS, mental illness, and substance abuse are 2–13 times higher in persons living in jails and prisons. This study was designed to assess the level of training offered to residents in seven medical specialties in the care of addicted incarcerated persons. The study design involved two stages. The first entailed a mailed survey to 1,831 residency directors in family medicine, internal medicine, osteopathic medicine, pediatrics, obstetrics and gynecology, psychiatry, and emergency medicine. The second stage was a telephone interview, about substance use disorders, of faculty listed by the residency directors as teaching residents. The mailed survey was completed by 1,205 residency directors (66%). The 769 faculty from those identified programs, who participated in the telephone interview, reported that only 14% of their residency programs offered lectures or conferences on the care of incarcerated persons, yet 44% of the programs had residents caring for incarcerated persons with substance abuse problems, in a clinical setting. Only 22% offered clinical experiences for residents in a correctional facility. We recognize that our survey of correctional health and substance abuse training is limited, but as such, a greater number of respondents to our survey do not teach residents addiction medicine topics pertaining to prevention, evaluation, intervention, and management of the addicted criminal offender/patient in a correctional setting or give adequate clinical exposure to this special population. The data suggests a need to develop and implement educational programs on medical care for this high-risk and expanding population.     

Drug treatment services for adult offenders: the state of the state

We conducted a national survey of prisons, jails, and community correctional agencies to estimate the prevalence of entry into and accessibility of correctional programs and drug treatment services for adult offenders. Substance abuse education and awareness is the most prevalent form of service provided, being offered in 74% of prisons, 61% of jails, and 53% of community correctional agencies; at the same time, remedial education is the most frequently available correctional program in prisons (89%) and jails (59.5%), whereas sex offender therapy (57.2%) and intensive supervision (41.9%) dominate in community correctional programs. Most substance abuse services provided to offenders are offered through correctional programs such as intensive supervision, day reporting, vocational education, and work release, among others. Although agencies report a high frequency of providing substance abuse services, the prevalence rates are misleading because less than a quarter of the offenders in prisons and jails and less than 10% of those in community correctional agencies have daily access to these services through correctional agencies; in addition, these are predominantly drug treatment services that offer few clinical services. Given that drug-involved offenders are likely to have dependence rates that are four times greater than those among the general public, the drug treatment services and correctional programs available to offenders do not appear to be appropriate for the needs of this population. The National Criminal Justice Treatment Practices survey provides a better understanding of the distribution of services and programs across prisons, jails, and community correctional agencies and allows researchers and policymakers to understand some of the gaps in services and programs that may negatively affect recidivism reduction efforts.     

A national survey of training in substance use disorders in residency programs

OBJECTIVE: To determine the amount of formal training in substance use disorders that occurs in selected residency programs and to identify the perceived barriers to such training. METHOD: A national survey was conducted of program directors in emergency medicine, family medicine, internal medicine, obstetrics/gynecology, osteopathic medicine, pediatrics and psychiatry. In 1997, program directors were mailed a brief survey to determine the extent to which required training in substance use disorders occurred and the median number of hours devoted to substance use disorders training. Follow-up telephone surveys were conducted with faculty designated in the survey as responsible for substance-related disorders training to determine type of training and barriers to training. RESULTS: Of 1,831 program directors, 1,183 (64.6%) responded to the brief survey. The percentage of programs with required substance use disorders training ranged from 31.8% in pediatrics to 95.0% in psychiatry, with 56.3% for all programs combined. The median number of curricular hours ranged from 3 (emergency medicine and OB/GYN) to 12 (family medicine). Time was perceived to be the most common barrier to additional training. CONCLUSIONS: Consistent training for all residents in the initial diagnosis and management of substance use disorders has not been achieved. New strategies that integrate into existing residency structures are needed to improve substance use disorders training. Faculty development in substance use disorders and review of current substance use disorders training as part of the residency review process should facilitate this endeavor.     

Dual Diagnosis Among Incarcerated Populations: Exception or Rule?

ABSTRACT

Objectives: Over 2 million individuals were incarcerated in jails and prisons in the United States in 2004. Multiple studies indicate that the prevalence of mental illness and substance use disorders is substantially higher in correctional environments when compared with rates in the community. The objective of this paper is to provide information on the prevalence of dual diagnosis among those incarcerated and the importance of assessing comorbidity for determining treatment needs of inmates. For the purposes of this article, the definition of dual diagnosis includes mental disorders and coexisting substance use disorders, mental disorders and coexisting developmental disabilities, and developmental disabilities and coexisting substance abuse disorders.

Methods: An extensive electronic literature search was conducted through PubMed, Medline, Department of Justice, and the National Commission on Correctional Health Care. Studies examining the prevalence of mental illness and substance use in jails and prisons, female inmates, and inmates with developmental disabilities were reviewed.

Results: The literature reviewed indicated a high comorbidity of mental illness and substance use disorders in incarcerated individuals. Providers should be aware of issues regarding dual diagnosis in special populations among those incarcerated to include female offenders and offenders with developmental disabilities.

Conclusion: Providers who work in correctional environments must understand the significant prevalence of comorbid mental illness and substance use disorders in those incarcerated to more effectively assess and treat inmates.     

HIV in the epicenter of the epicenter: HIV and drug use among criminal justice populations in New York City, 1980-2007

During the 1990s, some of the highest rates of HIV infection in the United States were found among inmates in the New York City jail and prisons systems. This article traces the history of drug use and HIV infection among populations incarcerated in New York City jails and New York State prisons between 1980 and 2007. It describes and analyzes the policies and programs that were initiated to respond to these epidemics and assesses the lessons learned from almost three decades of experience with HIV among populations in New York's correctional facilities.     

An ethical analysis of medication treatment for opioid use disorder (MOUD) for persons who are incarcerated

Abstract

Opioid use disorder (OUD) is highly prevalent among persons who are incarcerated. Medication treatment for opioid use disorder (MOUD), methadone, buprenorphine, and naltrexone, is widely used to treat OUD in the community. Despite MOUD’s well-documented effectiveness in improving health and social outcomes, its use in American jails and prisons is limited.

Several factors are used to justify limited access to MOUD in jails and prisons including: “uncertainty” of MOUD’s effectiveness during incarceration, security concerns, risk of overdose from MOUD, lack of resources and institutional infrastructure, and the inability of people with OUD to provide informed consent. Stigma regarding MOUD also likely plays a role. While these factors are relevant to the creation and implementation of addiction treatment policies in incarcerated settings, their ethicality remains underexplored.

Using ethical principles of beneficence/non-maleficence, justice, and autonomy, in addition to public health ethics, we evaluate the ethicality of the above list of factors. There is a two-fold ethical imperative to provide MOUD in jails and prisons. Firstly, persons who are incarcerated have the right to evidence-based medical care for OUD. Secondly, because jails and prisons are government institutions, they have an obligation to provide that evidence-based treatment. Additionally, jails and prisons must address the systematic barriers that prevent them from fulfilling that responsibility. According to widely accepted ethical principles, strong evidence supporting the health benefits of MOUD cannot be subordinated to stigma or inaccurate assessments of security, cost, and feasibility. We conclude that making MOUD inaccessible in jails and prisons is ethically impermissible.     

HIV in the Epicenter of the Epicenter: HIV and Drug Use Among Criminal Justice Populations in New York City, 1980–2007

During the 1990s, some of the highest rates of HIV infection in the United States were found among inmates in the New York City jail and prisons systems. This article traces the history of drug use and HIV infection among populations incarcerated in New York City jails and New York State prisons between 1980 and 2007. It describes and analyzes the policies and programs that were initiated to respond to these epidemics and assesses the lessons learned from almost three decades of experience with HIV among populations in New York's correctional facilities.     

The atwood hall health promotion program,federal medical center,lexington, KY: Effects on drug-involved federal offenders

There is a critical need for the development of effective substance abuse and dependence treatment programs in prisons and jails. One aspect of treatment provision within this population that has received insufficient research attention is the inclusion of health promotion or Wellness programs, including exercise and other health-related lifestyle modification training. Little is known about either the physiological or psychological consequences of such lifestyle modification programs among prisoners with substance use disorders. This study reports the effectiveness of an experimental wellness program included as part of a residential treatment unit in a federal correctional institute in the United States. A sample of 43 female offenders with a history of polysubstance abuse or dependence, who had volunteered to be part of a residential drug treatment program, were evaluated. Changes in health status and perceived psychological well-being between entry into the program and exit after maintaining participation for a minimum of 9 months were assessed. Pretest-posttest comparisons on a variety of physiological parameters indicated that significant improvements had occurred in the physical fitness of the group. Thematic analysis of qualitative self-reports by inmates exiting the program suggested that participants had also experienced significant enhancements in a number of areas pertaining to psychological well-being, including self-esteem, health awareness and concerns, healthy lifestyle adoption, and relapse prevention skills. These results suggest that including health promotion training in drug treatment programs for incarcerated offenders may have beneficial results.     

Assessment of factors influencing community pharmacy residents' pursuit of academic positions

Objectives

To determine the percentage of residents accepting faculty positions following completion of a community pharmacy residency program (CPRP) and identify influences to pursue/not pursue an academic career.

Methods

CPRP directors and preceptors across the United States were contacted and 53 community pharmacy residents were identified. The residents were invited to participate in surveys at the beginning and end of the 2005-2006 residency year.

Results

Forty-five residents (85%) completed the preliminary survey instrument and 40 (75%) completed the follow-up survey instrument. Of these, 36 completed both survey instruments. Initially, 28 (62%) respondents indicated a faculty position as one of their potential job preferences. After completing their residency program, 3 (8%) residents accepted faculty positions; and 3 (8%) others were awaiting offers at follow-up. Reasons for accepting a faculty position were positive teaching experiences and the influence of a mentor or preceptor. Reasons for not pursuing a faculty position included lack of interest, geographic location, disliked teaching experiences, lack of preparedness, and non-competitive salary.

Conclusion

Many community pharmacy residents consider faculty positions early in their residency but few pursue faculty positions. CPRPs and colleges of pharmacy should work together to enhance residents'' experiences to foster interest in academia.     

HIV risk reduction and service delivery strategies in criminal justice settings

Because of the HIV risk behaviors of substance abusers, particularly injection drug users and those who exchange sex for drugs, and the large numbers who are already infected with HIV or showing symptoms of AIDS, significant service delivery issues are associated with their criminal justice processing. Many strategies have been implemented in correctional settings in an effort to prevent and control the transmission of HIV. A number of these are for the purpose of lowering transmission risk in institutions, whereas others have been structured for the sake of offering prevention/intervention to inmates before they return to the free community. As such, prisons and jails represent opportune settings for HIV prevention and education. The most common HIV control/prevention/education strategies include mandatory testing of inmates for HIV, segregating infected inmates from the general prison population, establishing special health care units for HIV positive and AIDS symptomatic inmates, offering HIV prevention and risk reduction programs, and granting medical parole for the terminally ill. Because drug abuse treatment results in substantial declines in the use of heroin, cocaine, and other drugs, treatment per se can play a significant role in reducing the spread of HIV and AIDS among those coming to the attention of the criminal justice system. Most promising are continuous and integrated treatment services that are tied to the stages of correctional supervision: primary treatment while incarcerated; secondary treatment while on work release, halfway house or community supervision; and, tertiary treatment in ongoing aftercare.     

Training experiences of current and former community pharmacy residents, 1986-2000

OBJECTIVE: To identify why current and former community pharmacy residents chose a community pharmacy residency program (CPRP), what factors in the program were emphasized and not emphasized, what opportunities were available to them postresidency, and, for former residents, what skills learned during their residency have been most useful in their careers to date. DESIGN: Mail survey. PARTICIPANTS: 1999-2000 residents and former residents dating back to 1986. MAIN OUTCOME MEASURES: Reasons residents chose a CPRP over other residency or employment opportunities and respondents' ratings of the emphasis placed on a variety of skills and activities in their training programs. RESULTS: A total of 44 surveys were included in the final analysis, 18 (41%) of which were completed by 1999-2000 CPRP residents performing their residency at the time of the survey. The most common reasons for choosing a CPRP over other types of programs were opportunities for developing innovative services and direct patient interaction. Communication skills, clinical skills, and level of patient interaction were reported as being most highly emphasized. Management of the distribution system was most frequently cited as having "low" or "no" emphasis in their residency. Respondents listed marketing skills as the most common area requiring improvement or additional focus in their residency. Former residents cited leadership skills and the development of patient care services as the factors in their residency having the greatest impact on their careers to date. Postresidency opportunities most frequently sought included faculty, staff pharmacist, and clinical pharmacist positions. CONCLUSION: Candidates are drawn to CPRPs because of the opportunities such residencies offer to develop innovative services and provide direct patient care. Residents feel that many programs fail to provide adequate training in the areas of marketing services and obtaining reimbursement. Residency program directors should consider these findings when evaluating and marketing their programs.     

Educational half day: an innovative way to incorporate substance abuse curriculum into residency training.

Internal medicine residents often come across substance use disorder (SUD) issues; however not all residency programs have curricula to educate residents on management of these issues. We hereby describe a curricular action plan incorporating an innovative method of Educational Half Day (EHD) to address SUD issues in small group settings. We believe that EHD is an effective way of addressing substance abuse issues in the residency curriculum and it has the potential to change the way residents manage their patients with SUD.     

Pharmacy Residents’ Pursuit of Academic Positions

Objective. To describe pharmacy residents’ interest in and pursuit of academic positions.Methods. An electronic presurvey and postsurvey were sent to pharmacy residents during the 2011-2012 residency year. The initial survey evaluated residents’ job preferences and interest in academia at the beginning of residency, and the follow-up survey focused on job selection and reasons for pursuing or not pursuing positions in academia.Results. Nine hundred thirty-six residents responded to the initial survey and 630 participated in both the initial and follow-up survey. Forty-eight percent of those responding to both surveys strongly considered a career in academia in the initial survey, 28% applied for an academic position, and 7% accepted a position. Second-year postgraduate residents were more likely than first-year postgraduate residents to apply for and be offered a faculty position.Conclusion. Pharmacy residents are interested in academia. While increasing interest among residents is encouraging for faculty recruitment, the academy should also encourage and develop adequate training experiences to prepare residents to succeed in these positions.     

Pharmacy resident participation in cardiopulmonary resuscitation events.

PURPOSE: An electronically administered cross-sectional survey was conducted to establish the rate of pharmacy resident participation in cardiopulmonary resuscitation (CPR) events at pharmacy residency programs throughout the United States and Puerto Rico. METHODS: A 46-item questionnaire was developed and sent by e-mail to pharmacy residency program directors. The recipients were given one month to complete the survey. Responses were screened for duplicate answers, and the most complete survey was included in the analysis. The survey dealt with residency program demographics and sought information about required life-support certifications for pharmacy personnel, institution-specific training methods for medical emergencies employed by pharmacy departments, responsibilities of pharmacy personnel who respond to CPR events, and evaluation methods used to assess resident performance in CPR events. RESULTS: A total of 745 pharmacy residency directors were surveyed. Responses were received from 190 residency program directors, which represented 221 residency programs. The three most common residency program settings were community (not-for- profit) hospitals, college and university hospitals, and government hospitals. Thirty percent of respondents required pharmacy resident response to CPR events, while 38% made this opportunity optional. In 85% of programs that required or offered resident response to CPR events, there was a formal CPR team. The three primary roles fulfilled by pharmacists in medical emergencies were provision of drug information, drug admixture, and documentation; pharmacy resident duties mirrored these roles. CONCLUSION: Pharmacy resident response to CPR events was required in approximately 30% of responding pharmacy residency programs. Various methods were used in educating, assessing, and evaluating pharmacy residents in this role.     

Redesign of a Statewide Teaching Certificate Program for Pharmacy Residents

Objectives. To identify and assess changes made to the Indiana Pharmacy Resident Teaching Certificate program over 10 years to adapt to the growing number and changing needs of pharmacy educators in the next generation.Design. In 2011, all resident program participants and directors were sent an electronic survey instrument designed to assess the perceived value of each program component.Assessment. Since 2003, the number of program participants has tripled, and the program has expanded to include additional core requirements and continuing education. Participants generally agreed that the speakers, seminar topics, seminar video recordings, and seminar offerings during the fall semester were program strengths. The program redesign included availability of online registration; a 2-day conference format; retention of those seminars perceived to be most important, according to survey results; implementation of a registration fee; electronic teaching portfolio submission; and establishment of teaching mentors.Conclusion. With the growing number of residents and residency programs, pharmacy teaching certificate programs must accommodate more participants while continuing to provide quality instruction, faculty mentorship, and opportunities for classroom presentations and student precepting. The Indiana Pharmacy Resident Teaching Certificate program has successfully evolved over the last 10 years to meet these challenges by implementing successful programmatic changes in response to residency program director and past program participant feedback.     

Training in office-based opioid treatment with buprenorphine in US residency programs: A national survey of residency program directors

Background: The prevalence of opioid use disorder (OUD) has increased sharply. Office-based opioid treatment with buprenorphine (OBOT) is effective but often underutilized because of physicians' lack of experience prescribing this therapy. Little is known about US residency training programs' provision of OBOT and addiction medicine training. Methods: The authors conducted a survey of residency program directors (RPDs) at all US residency programs in internal medicine, family medicine, and psychiatry to assess the frequency with which their residents provide care for OUD, presence and features of curricula in OBOT and addiction medicine, RPDs' beliefs about OBOT, and potential barriers to providing OBOT training. Results: The response rate was 49.5% (476 of 962). Although 76.9% of RPDs reported that residents frequently manage patients with OUD, only 23.5% reported that their program dedicates 12 or more hours of curricular time to addiction medicine, 35.9% reported that their program encourages/requires training in OBOT, and 22.6% reported that their program encourages/requires obtaining a Drug Enforcement Administration (DEA) waiver to prescribe buprenorphine. Most RPDs believe that OBOT is an important treatment option for OUD (88.1%) and that increased residency training in OBOT would improve access to OBOT (73.7%). The authors also found that programs whose RPD had favorable views of OBOT were more likely to provide OBOT and addiction medicine training. Psychiatry programs were most likely to provide OBOT training and their RPDs most likely to have beliefs about OBOT that were positive. Commonly cited barriers to implementing OBOT training include a lack of waivered preceptors (76.9%), competing curricular priorities (64.1%), and a lack of support (social work and counseling) services (54.0%). Conclusions: Internal medicine, family medicine, and psychiatry residents often care for patients with OUD, and most RPDs believe that increased residency training in OBOT would increase access to this treatment. Yet, only a minority of programs offer training in OBOT.     

A resident clerkship that combines inpatient and outpatient training in substance abuse and HIV care.

Substance abuse and HIV infection are important medical problems that receive comparatively little attention in residency training programs and residents often feel unprepared to deal with them. We developed a month-long rotation that combined outpatient care for patients with HIV infection and addiction, with inpatient care for medically-ill patients on a detoxification unit. At the end of the rotation, residents reported greater comfort with caring for these patients and improved self-rated competence. They also rated the rotation highly. Our experience shows that a rotation combining inpatient and outpatient substance abuse and HIV care was valued by residents and increased their comfort and proficiency with caring for these underserved and stigmatized populations.     

Survey of ASHP-accredited pharmacy residency programs.

The results of a survey of the requirements and features of pharmacy residency programs are reported. The survey was mailed on March 5, 1999, to the directors of 414 pharmacy practice and specialty residency programs with ASHP accreditation as of March 1, 1999. Included were questions on stipends, staffing requirements, and benefits. Information not typically included in the ASHP residency directories was also sought. Three hundred surveys were returned, for a 72% response rate. Of the responding programs, 174 (58%) were pharmacy practice programs and the rest specialty programs. The specialties with the largest number of respondents were primary care (30 of 126, or 24%) and drug information (23, or 18%). The practice setting varied widely, but a university-based practice site was most frequent (122 of 300 programs, or 41%). The overall median stipend range was $28,000-$28,999; stipends varied relatively little by geographic region but were highest in New York and New Jersey. Most residency programs had a staffing requirement, which averaged eight hours per week. A substantial part of residents' time was spent on drug distribution and patient care activities, such as medical rounds and patient counseling. The most common benefits reported were paid time off, health and medical coverage, and reimbursement for specific professional expenses. Ultimately, the creation of an Internet-accessible electronic database will maximize the availability and timeliness of such information and minimize the cost and labor involved in updating currently available resources. A survey of ASHP-accredited residency programs yielded data that provide a valuable supplement to the information in ASHP residency directories.     

Assessment of teaching experiences completed during accredited pharmacy residency programs

Objectives

To examine teaching experiences in residency programs accredited by the American Society of Health-System Pharmacists (ASHP) and how they relate to career choices of residents.

Methods

An online survey instrument was developed that asked former residents about the type of teaching experiences they completed during their residency and the effect of these experiences on the decision to pursue an academic career. Our target population was pharmacists completing accredited residencies from 2003-2006.

Results

Four hundred fifty-five (11% of the target population) pharmacists who had completed a residency responded. Former residents who completed 2 years of postgraduate training were significantly more likely to participate in all teaching experiences identified by this survey (p < 0.008). Former residents in college- or school-affiliated programs were significantly more likely to participate in all of the teaching experiences identified (p < 0.003). Former residents who went on to take a faculty position were more likely to have given lectures, participated in problem-based learning (PBL) or small group seminars (SGS), and served as a primary preceptor (p < 0.008) during their residency.

Conclusions

Residents who eventually became faculty members were more likely to have acquired training and experience in teaching during their residency programs.