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.     

Do Words Matter? Incongruent Responses to Inconsistently Worded AUDIT-C Alcohol Screening Instruments

ABSTRACT

The first 3 questions of the Alcohol Use Disorders Identification Test (AUDIT-C) are often used as a brief alcohol screening instrument. However, the implications of common modifications made to the original AUDIT questions and response options have not been considered. The authors examined existing data from a randomized controlled trial of 310 persons with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) that was testing the efficacy of 2 antiretroviral medication adherence interventions. Logistic regression was used to model the probability of participants having inconsistent AUDIT-C item responses. Three patterns of conflicting responses to the AUDIT-C items were identified. Common item modifications resulted in 14% (n = 48) of the parent study sample reporting conflicting responses across related AUDIT-C items. The odds of having conflicting data were 3 times greater in opioid users (odds ratio [OR] = 3.139, 95% confidence interval [CI] = 1.267–7.777, P = .01) and greater in persons with higher levels of conscientiousness (OR = 1.053, 95% CI = 1.006–1.103, P = .03). Inconsistent question format and response options may impede proper scoring and interpretation of the AUDIT-C. Further discussion and consensus building are needed on the psychometrically ideal version of the AUDIT-C.     

Psychotherapeutic Benefits of Opioid Agonist Therapy

ABSTRACT

Opioids have been used for centuries to treat a variety of psychiatric conditions with much success. The so-called “opium cure” lost popularity in the early 1950s with the development of non-addictive tricyclic antidepressants and monoamine oxidase inhibitors. Nonetheless, recent literature supports the potent role of methadone, buprenorphine, tramadol, morphine, and other opioids as effective, durable, and rapid therapeutic agents for anxiety and depression. This article reviews the medical literature on the treatment of psychiatric disorders with opioids (notably, methadone and buprenorphine) in both the non-opioid-dependent population and in the opioid-dependent methadone maintenance population. The most recent neurotransmitter theories on the origin of depression and anxiety will be reviewed, including current information on the role of serotonin, N-Methyl d-Aspartate, glutamate, cortisol, catecholamine, and dopamine in psychiatric disorders. The observation that methadone maintenance patients with co-existing psychiatric morbidity (so called dual diagnosis patients) require substantially higher methadone dosages by between 20% and 50% will be explored and qualified. The role of methadone and other opioids as beneficial psychiatric medications that are independent of their drug abuse mitigating properties will be discussed. The mechanisms by which methadone and other opioids can favorably modulate the neurotransmitter systems controlling mood will also be discussed.     

Predictive Utility of Brief Alcohol Use Disorders Identification Test (AUDIT) for Human Immunodeficiency Virus Antiretroviral Medication Nonadherence

ABSTRACT

Alcohol use negatively affects adherence to antiretroviral therapy (ART), thus human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) care providers need accurate, efficient assessments of alcohol use. Using existing data from an efficacy trial of 2 cognitive-behavioral ART adherence interventions, the authors sought to determine if results on 2 common alcohol screening tests (Alcohol Use Disorders Identification Test—Consumption [AUDIT-C] and its binge-related question [AUDIT-3]) predict ART nonadherence. Twenty-seven percent of the sample (n = 308) were positive on the AUDIT-C and 34% were positive on the AUDIT-3. In multivariate analyses, AUDIT-C–positive status predicted ART nonadherence after controlling for race, age, conscientiousness, and self-efficacy (P = .036). Although AUDIT-3–positive status was associated with ART nonadherence in unadjusted analyses, this relationship was not maintained in the final multivariate model. The AUDIT-C shows potential as an indirect screening tool for both at-risk drinking and ART nonadherence, underscoring the relationship between alcohol and chronic disease management.     

False-Positive Buprenorphine EIA Urine Toxicology Results Due To High Dose Morphine: A Case Report

In monitoring a patient with chronic pain who was taking high-dose morphine and oxycodone with weekly urine enzymatic immunoassay (EIA) toxicology testing, the authors noted consistent positives for buprenorphine. The patient was not taking buprenorphine, and gas chromatography/mass spectroscopy (GCMS) testing on multiple samples revealed no buprenorphine, indicating a case of false-positive buprenorphine EIAs in a high-dose opiate case. The authors discontinued oxycodone for a period of time and then discontinued morphine. Urine monitoring with EIAs and GCMS revealed false-positive buprenorphine EIAs, which remained only when the patient was taking morphine. When taking only oxycodone and no morphine, urine samples became buprenorphine negative. When morphine was reintroduced, false-positive buprenorphine results resumed. Medical practitioners should be aware that high-dose morphine (with morphine urine levels turning positive within the15,000 to 28,000 mg/mL range) may produce false-positive buprenorphine EIAs with standard urine EIA toxicology testing.