Implementation of smoking cessation treatment in substance use disorder treatment settings: a review

ABSTRACT

Background: The high prevalence of smoking among individuals receiving treatment for substance use disorder (SUD) has led to repeated calls for integrating smoking cessation treatment into these settings. Objectives: This review summarizes key findings from the research on the implementation of smoking cessation in SUD treatment. Methods: PubMed searches of articles published from 2000 to 2015 yielded 48 empirical studies that focused on the delivery of smoking cessation in the US specialty SUD treatment settings in which organizations and counselors were the unit of analysis. Most studies used observational designs to gather data from organizations and counselors. Organizational studies show that few SUD treatment programs offer cessation counseling or pharmacotherapy. Organizational barriers include limited training, inadequate resources, and cultural norms that do not recognize smoking cessation as part of the organization’s mission. Smoking cessation services are more likely to be available in medically oriented treatment settings, larger treatment programs, those offering a broader array of comprehensive services, and those that are more reliant on fee-for-service reimbursement (e.g., insurance, Medicaid). Surveys of counselors also show very low implementation. Counselors’ personal skills and attitudes, their perceptions of managerial and coworker support for smoking cessation, and the availability of resources and reimbursement to support these services are correlated with implementation. State policies requiring treatment programs to offer tobacco treatment increase both adoption and implementation, yet these services continue to reach only modest percentages of the patients. Conclusions: Few studies have tested specific implementation strategies. Such research is needed to determine how to accelerate the diffusion of these evidence-based practices to the SUD treatment field.     

Drug treatment and the conditionality of HIV treatment access: a qualitative study in a Russian city

Aims We explored social factors affecting access to antiretroviral HIV treatment (ART) among people who inject drugs (PWID) in a Russian city with a large HIV burden. Design Qualitative interview study. Setting Community settings in Ekaterinburg, Russian Federation. Participants 42 PWID living with HIV and 11 health practitioners. Measurements Thematic analyses of in-depth qualitative interviews. Findings Access to ART was felt by participants to be contingent upon their capacity to demonstrate a commitment to becoming 'drug free'. We identify, across interview accounts, a treatment access narrative of 'treat drugs before HIV'. This narrative is upheld by ART providers' concerns to maximize clinical outcome in the face of adherence doubts, as well as by would-be patients' perceptions of expectations placed upon them by the treatment system and their own doubts regarding treatment engagement. This has the effect of reproducing a habit of ART delay and disengaging people from the treatment system. Difficulties accessing ART, and the perceived rationing of treatment on account of untreated drug use, were experienced as 'moral discipline' for falling short of treatment 'deservedness'. Participants describe a 'Catch 22' system, where they are invited to treat their drug use in a setting where effective drug treatment was perceived as unavailable. Conclusions Inadequate drug treatment practices act as structural obstacles to realizing HIV treatment. Evidence internationally suggests that effective drug treatment, including opioid substitution therapy, improves access and adherence to antiretroviral treatment among people who inject drugs. Policy shifts are urgently needed in this setting to enable systemic improvements to drug treatment, especially given large HIV treatment demand.     

1例初诊酒精性肝病患者的循证治疗

目的借助循证医学的方法为1例初诊酒精性肝病患者确定治疗方案。方法根据患者情况提出临床问题,在Cochrane图书馆、PubMed、Embase、维普资讯上检索,并对相关证据进行评价,结合医生经验及患者意愿制定治疗方案。结果共纳入相关文献16篇,分析后对该患者确定治疗方案:水飞蓟宾(利加隆胶囊140 mg,tid)降转氨酶+泼尼松龙(40 mg/d,28 d)非特异性抗炎治疗。经10个月的随访,证实该方案对患者安全有效。结论采用循证治疗的方法,为初诊酒精性肝病患者确定合理的治疗方案,可有效提高治疗效果。     

Evaluation of a day treatment programme for eating disorders

A day hospital treatment programme is described for eating disordered patients who would otherwise require inpatient treatment. The characteristics at presentation of 106 consecutive patients are described. Of patients completing the programme, 65 could be recruited for the outcome study. At presentation, 26 per cent fulfilled DSM-IV criteria for anorexia nervosa, 65 per cent for bulimia nervosa and 9 per cent had an eating disorder not otherwise specified. The average length of treatment of all patients was 13 weeks. There was significant weight gain among the anorectic patients and a significant decrease in the average number of binges among the bulimic patients. Statistically significant improvements over time for psychological, sexual and socioeconomic adjustment were also obtained. © 1998 John Wiley & Sons, Ltd and Eating Disorders Association.     

Non-variceal upper gastrointestinal bleeding: Rescue treatment with a modified cyanoacrylate

AIM To evaluate the safety and efficacy of a modified cyanoacrylate [N-butyl-2-cyanoacrylate associated with methacryloxysulfolane(NBCA + MS)] to treat nonvariceal upper gastrointestinal bleeding(NV-UGIB).METHODS In our retrospective study we took into account 579 out of 1177 patients receiving endoscopic treatment for NV-UGIB admitted to our institution from 2008 to 2015; the remaining 598 patients were treated with other treatments. Initial hemostasis was not achieved in 45 of 579 patients; early rebleeding occurred in 12 of 579 patients. Thirty-three patients were treated with modified cyanoacrylate: 27 patients had duodenal, gastric or anastomotic ulcers, 3 had post-mucosectomy bleeding, 2 had Dieulafoy's lesions, and 1 had duodenal diverticular bleeding.RESULTS Of the 45 patients treated endoscopically without initialhemostasis or with early rebleeding, 33(76.7%) were treated with modified cyanoacrylate glue, 16(37.2%) underwent surgery, and 3(7.0%) were treated with selective transarterial embolization. The mean age of patients treated with NBCA + MS(23 males and 10 females) was 74.5 years. Modified cyanoacrylate was used in 24 patients during the first endoscopy and in 9 patients experiencing rebleeding. Overall, hemostasis was achieved in 26 of 33 patients(78.8%): 19 out of 24(79.2%) during the first endoscopy and in 7 out of 9(77.8%) among early rebleeders. Two patients(22.2%) not responding to cyanoacrylate treatment were treated with surgery or transarterial embolization. One patient had early rebleeding after treatment with cyanoacrylate. No late rebleeding during the follow-up or complications related to the glue injection were recorded.CONCLUSION Modified cyanoacrylate solved definitively NV-UGIB after failure of conventional treatment. Some reported life-threatening adverse events with other formulations, advise to use it as last option.     

NIDDM: a rapid progressive disease Results from a long-term,randomised, comparative study of insulin or sulphonylurea treatment

Summary The objective of the present study was to assess the relative efficacy of insulin or glibenclamide treatment for non-insulin-dependent diabetes mellitus (NIDDM) over 42 months. We performed a randomised, controlled trial allocating patients treated with diet and oral antihyperglycaemic agents to treatment with glibenclamide or insulin to achieve HbA_1c levels under 7.5 %. We included 36 subjects with established NIDDM of more than 2 years' duration. Mean HbA_1c levels were significantly reduced in patients allocated to insulin treatment from 9.1 ± 1.4 % before the start to 7.8 ± 1.3 % (p< 0.05) after 1 year, and did not change significantly thereafter throughout the study period. Mean HbA_1c levels increased during the study in the patients allocated to glibenclamide treatment, and 11 of 18 patients had to be switched to insulin treatment due to increasing hyperglycaemia (HbA_1c > 10 %). Mean body weight increased in the subjects allocated to insulin by 7.2 ± 4.1 kg during the study period. In conclusion, insulin was more effective than glibenclamide treatment in obtaining control over hyperglycaemia in these patients, and once improved, glycaemic control did not deteriorate over 42 months in the insulin-treated group. Two thirds of the patients allocated to glibenclamide treatment had to be given insulin due to inadequate glycaemic control. [Diabetologia (1996) 39: 1629–1633]     

VERITAS-PRN: a new measure of adherence to episodic treatment regimens in haemophilia

Summary.  Episodic treatment of bleeding disorders is defined as utilization of clotting factor concentrates in response to acute bleeding episodes to achieve haemostasis. Non-adherence to prescribed episodic regimens can limit treatment effectiveness and result in target joint formation, pain and disability. Evaluation of and interventions to promote adherence may improve health outcomes. The purpose of this study was to validate a new adherence scale developed for individuals with bleeding disorders treated on episodic infusion regimens, entitled VERITAS-PRN [Validated Hemophilia Reg i men Treatment Adherence Scale – PRN]. Participants were recruited from the Indiana Hemophilia and Thrombosis Center patient population. Participants completed the scale for psychometric development and analysis. Subjective ratings of adherence from participants and providers were used for validation. The study sample included 51 male and three female patients. Twenty-seven participants (50.0%) were diagnosed with FVIII deficiency, 21 (38.9%) with FIX deficiency and six (11.1%) with von Willebrand's disease (VWD). Internal consistency reliability for the total VERITAS-PRN score and the majority of subscales was good-to-excellent, with the one exception being the 'Plan' subscale. Test-retest reliability correlations were good-to-excellent for the total scale and all subscales. The VERITAS-PRN total scale had moderate-to-strong and statistically significant correlations with validity measures. The VERITAS-PRN is a reliable and valid measure of adherence to episodic treatment regimens for bleeding disorders. This tool may be utilized as a standard measure of adherence to increase sensitivity to adherence problems and promote targeted interventions to enhance adherence and health outcomes     

Combining medically assisted treatment and Twelve-Step programming: a perspective and review

Background: People with severe substance use disorders require long-term rehabilitative care after the initial treatment. There is, however, a deficit in the availability of such care. This may be due both to inadequate medical coverage and insufficient use of community-based Twelve-Step programs in many treatment facilities. In order to address this deficit, rehabilitative care for severe substance use disorders could be promoted through collaboration between practitioners of medically assisted treatment, employing medications, and Twelve-Step-oriented practitioners. Objective: To describe the limitations and benefits in applying biomedical approaches and Twelve-Step resources in the rehabilitation of persons with severe substance use disorders; and to assess how the two approaches can be employed together to improve clinical outcome. Method: Empirical literature focusing on clinical and manpower issues is reviewed with regard (a) to limitations in available treatment options in ambulatory and residential addiction treatment facilities for persons with severe substance use disorders, (b) problems of long-term rehabilitation particular to opioid-dependent persons, associated with the limitations of pharmacologic approaches, (c) the relative effectiveness of biomedical and Twelve-Step approaches in the clinical context, and (d) the potential for enhanced use of these approaches, singly and in combination, to address perceived deficits. Results: The biomedical and Twelve-Step-oriented approaches are based on differing theoretical and empirically grounded models. Research-based opportunities are reviewed for improving addiction rehabilitation resources with enhanced collaboration between practitioners of these two potentially complementary practice models. This can involve medications for both acute and chronic treatment for substances for which such medications are available, and Twelve-Step-based support for abstinence and long-term rehabilitation. Clinical and Scientific Significance: Criteria for developing evidence-based approaches for combined treatment should be developed, and research for evidence-based treatment on this basis can be undertaken in order to develop improved clinical outcome.     

Agonist substitution—a treatment alternative for high‐dose benzodiazepine‐dependent patients?

There is vast evidence for the superiority of agonist treatments (methadone, buprenorphine) over a withdrawal approach in opioid‐dependent populations. Little research, however, has been conducted on the same approach for the treatment of high‐dose benzodiazepine (BZD) dependence. Even large‐scale reviews and meta‐analyses discussing treatment strategies for benzodiazepine‐dependent patients focus solely upon approaches that aim at achieving abstinence, namely on complete BZD withdrawal. While the types of interventions differ (e.g. gradual benzodiazepine taper with a long or a short half‐life benzodiazepine, switching to non‐benzodiazepine anxiolytics or prescribing adjunctive medications such as antidepressants or anticonvulsants on an in‐ or out‐patient basis), the common aim of treatment still is total abstinence from benzodiazepines. However, the majority of patients suffering from high‐dose BZD dependence do not succeed with long‐term abstinence, irrespective of the procedure, and clinicians have been using BZD ‘substitution’ treatment in such cases for decades. Therefore, we suggest the evaluation of a substitution approach in this group, consisting of maintenance treatment with a slow‐onset, long‐acting BZD. Advantages of such a procedure may be improved health, less craving, fewer withdrawal complications, reduced anxiety, increased treatment retention, improvements in social functioning and less illegal activity. Cognitive impairments, the most problematic side effects of substitution treatment with benzodiazepines, could possibly be minimized by using an optimal agonist.     

Conservative treatment for brucella endocarditis

Endocarditis is the most devastating complication of brucellosis. The accepted treatment for Brucella endocarditis (BE) is a combination of valve replacement and antibiotics. Conservative antibiotic treatment alone is not recommended by most authors, as it is considered ineffective, risking fatality. We describe a patient with BE, in whom antibiotic treatment alone resulted in complete recovery. On reviewing the literature, we found 12 additional such cases. We compared this group of 13 patients with data from 49 published cases treated with a combination of surgery and antibiotics, with afavorable outcome. Absence of congestive heart failure or a prosthetic valve, relatively mild extravalvular cardiac involvement, and a somewhat shorter disease history until initiation of treatment were characteristic of the group treated conservatively in comparison with patients who underwent surgery. In selected patients with BE, conservative antibiotic treatment may be a valid alternative to surgery.     

血红素氧化酶系统: 高血压治疗的新靶点

本文介绍了血红素氧化酶系统在高血压中的调节作用,从针对自发高血压大鼠模型的研究和血管紧张素Ⅱ依赖的高血压/肾血管性高血压的研究两个角度分析了血红素氧化酶系统调节血压的机制,认为血红素氧化酶系统可以通过抗氧化、抗炎、抗凋亡、改善内皮功能以及舒张血管等方面降低血压。此外,还介绍了脂联素与血红素氧化酶系统的关系及其在调节血压中的作用,提出针对HO-1-脂联素轴的策略可能是一种有前景的控制高血压的治疗方法。     

毒性结节性甲状腺肿的外科治疗(附66例报告)

目的总结毒性结节性甲状腺肿的治疗体会。方法对1990～2006年收治的66例毒性结节性甲状腺肿行手术治疗的临床资料进行回顾性分析。结果66例中42例采用硫脲类药物加碘剂进行术前准备,10例采用心得安加碘剂准备,14例单用碘剂准备。除1例病人因甲状腺癌外都采用甲状腺次全切除术,术后无甲状腺危象,无永久性喉返神经损伤及甲状旁腺功能减低等并发症。结论手术治疗毒性甲状腺肿是安全有效的,须行合理的术前准备及选择适当的手术方式。     

Clinical correlates of desire for treatment for current alcohol dependence among patients with a primary psychiatric disorder

Background and Objectives: Rates of treatment-seeking for alcohol use disorders are notably low. To elucidate the clinical correlates of treatment-seeking for alcoholism, this study compared patients with current alcohol dependence and a primary psychiatric diagnosis who endorsed a desire for alcoholism treatment to patients who refused treatment or who were unsure.

Method: A total of 131 (54 females) psychiatric outpatients with current alcohol dependence completed an intake assessment at a large hospital-based psychiatric clinic and at the end of the intake were asked whether they would like to receive treatment for alcohol problems.

Results: Compared with alcohol-dependent patients who refused treatment for alcoholism or who were unsure (n = 46), patients who expressed a desire for treatment (n = 85) were older, were more likely to be female, reported higher levels of social impairments, and were more likely to endorse the following alcohol dependence symptoms: (i) multiple unsuccessful efforts or persistent desire to stop or cut down on their drinking; and (ii) drinking more than intended.

Conclusions: Approximately, 35% of patients who met current DSM-IV criteria for alcohol dependence reported no interest (or were unsure) in alcoholism treatment despite being engaged in treatment-seeking for another psychiatric disorder.

Scientific Significance: These findings extend previous epidemiological studies documenting treatment-seeking patterns for alcoholism by identifying clinical features associated with interest in treatment for this disorder among psychiatric outpatients.     

消化道大出血金属钛夹治疗与外科手术治疗的效价比较

目的通过观察金属钛夹及外科手术对消化道大出血的治疗效果及治疗费用，探讨内镜下金属钛夹治疗急性消化道大出血的临床应用价值及经济学价值。方法钛夹止血组（A组）采用经内镜对出血病灶放置金属钛夹止血；外科手术组（B组）采用“病灶切除术或胃大部切除术”。结果金属钛夹治疗组止血率100．0％，并发症发生率为0，平均住院时间17．82天，平均总住院费用5698．76元；外科手术治疗组止血率100．0％，术后并发症发生率42．86％，平均住院时间23．65天，平均总住院费用15831．56元。结论金属钛夹治疗消化道大出血具有止血效果确切、操作安全、简便、无并发症，费用低等优点，具有良好的效价比。