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Year of Publication
1.  Opioid Prescribing: Can the Art Become More Science? 
Journal of General Internal Medicine  2013;28(10):1253-1254.
doi:10.1007/s11606-013-2493-2
PMCID: PMC3785648  PMID: 23681844
2.  Low Vitamin D Status of Patients in Methadone Maintenance Treatment 
Journal of addiction medicine  2009;3(3):134-138.
Aim
To examine the prevalence and risk factors of low vitamin D status (vitamin D deficiency or insufficiency) among patients in a methadone maintenance treatment (MMT) program.
Design
Cross-sectional study of subjects recruited from an MMT program in a higher latitude (Boston, MA).
Measurements
Standardized survey and medical record review were used to assess patient characteristics. Serum was tested to determine vitamin D deficiency (25-hydroxyvitamin D <20 ng/mL) and insufficiency (25-hydroxyvitamin D between 20 and 30 ng/mL). Multivariable analyses were used to assess risk factors associated with vitamin D deficiency.
Findings
Low vitamin D status was found in 52% of the subjects (48 of 93), deficiency in 36%, and insufficiency in an additional 16%. Older age (OR = 3.47; 95% CI 1.31–9.22) and black or Hispanic race/ethnicity (OR 3.34; 95% CI 1.30–8.58) were significantly associated with higher risk of vitamin D deficiency.
Conclusion
Low vitamin D status was present in a majority of patients recruited from an MMT program. This raises the question as to whether this is a generalizable phenomenon and whether these patients are at higher risk of complications of low vitamin D status including bone pain, periodontal disease, osteomalacia, and cardiovascular disease.
doi:10.1097/ADM.0b013e31819b736d
PMCID: PMC4059827  PMID: 21769009
methadone maintenance; vitamin D; drug dependence; medical complications
3.  Methadone Dose, Take Home Status and Hospital Admission among Methadone Maintenance Patients 
Journal of addiction medicine  2012;6(3):186-190.
Objectives
Among patients receiving methadone maintenance treatment (MMT) for opioid dependence, receipt of unobserved dosing privileges (take homes) and adequate doses (i.e. ≥ 80mg) are each associated with improved addiction treatment outcomes, but the association with acute care hospitalization is unknown. We studied whether take-home dosing and adequate doses (i.e. ≥ 80 mg) were associated with decreased hospital admission among patients in a MMT program.
Methods
We reviewed daily electronic medical records of patients enrolled in one MMT program to determine receipt of take home doses, methadone dose ≥ 80mg and hospital admission date. Non-linear mixed effects logistic regression models were used to evaluate whether take home doses or dose ≥ 80mg on a given day were associated with hospital admission on the subsequent day. Covariates in adjusted models included age, gender, race/ethnicity, HIV status, medical illness, mental illness, and polysubstance use at program admission.
Results
Subjects (n=138) had the following characteristics: mean age 43 years; 52% female; 17% HIV-infected; 32% medical illness; 40% mental illness; and 52% polysubstance use. During a mean follow-up of 20 months, 42 patients (30%) accounted for 80 hospitalizations. Receipt of take homes was associated with significantly lower odds of a hospital admission (AOR 0.26; 95%CI: 0.11-0.62), whereas methadone dose ≥ 80mg was not (AOR 1.01; 95% CI: 0.56-1.83).
Conclusions
Among MMT patients, receipt of take homes, but not dose of methadone, was associated with decreased hospital admission. Take home status may reflect not only patients’ improved addiction outcomes, but also reduced healthcare utilization.
doi:10.1097/ADM.0b013e3182584772
PMCID: PMC3416958  PMID: 22694929
Methadone maintenance treatment; dose; take home status; hospital admission
5.  Safe Opioid Prescribing: A Long Way to Go 
doi:10.1007/s11606-011-1797-3
PMCID: PMC3157526  PMID: 21735346
6.  The genetic basis of early T-cell precursor acute lymphoblastic leukaemia 
Nature  2012;481(7380):157-163.
Early T-cell precursor acute lymphoblastic leukaemia (ETP ALL) is an aggressive malignancy of unknown genetic basis. We performed whole-genome sequencing of 12 ETP ALL cases and assessed the frequency of the identified somatic mutations in 94 T-cell acute lymphoblastic leukaemia cases. ETP ALL was characterized by activating mutations in genes regulating cytokine receptor and RAS signalling (67% of cases; NRAS, KRAS, FLT3, IL7R, JAK3, JAK1, SH2B3 and BRAF), inactivating lesions disrupting haematopoietic development (58%; GATA3, ETV6, RUNX1, IKZF1 and EP300) and histone-modifying genes (48%; EZH2, EED, SUZ12, SETD2 and EP300). We also identified new targets of recurrent mutation including DNM2, ECT2L and RELN. The mutational spectrum is similar to myeloid tumours, and moreover, the global transcriptional profile of ETP ALL was similar to that of normal and myeloid leukaemia haematopoietic stem cells. These findings suggest that addition of myeloid-directed therapies might improve the poor outcome of ETP ALL.
doi:10.1038/nature10725
PMCID: PMC3267575  PMID: 22237106
7.  Five Year Experience with Collaborative Care of Opioid Addicted Patients using Buprenorphine in Primary Care 
Archives of internal medicine  2011;171(5):425-431.
Background
Opioid addiction is a chronic disease treatable in primary care settings with buprenorphine, but this treatment remains underutilized. We describe a collaborative care model for managing opioid addiction with buprenorphine.
Methods
This is a cohort study of patients treated for opioid addiction utilizing collaborative care between nurse care managers and generalist physicians in an urban academic primary care practice over 5 years. We examine patient characteristics, 12-month treatment success (i.e., retention or taper after 6 months), and predictors of successful outcomes.
Results
From 2003 to 2008, 408 patients with opioid addiction were treated with buprenorphine. Twenty-six patients were excluded from analysis as they left treatment due to preexisting legal or medical conditions or a need for transfer to another buprenorphine program. At 12 months 51% of patients (196/382) underwent successful treatment. Of patients remaining in treatment at 3-, 6-, 9- and 12 months, 93% were no longer using illicit opioids or cocaine based on urine drug tests. On admission, patients who were older, employed, and used illicit buprenorphine had significantly higher odds of treatment success; those of African American or Hispanic race had significantly lower odds of treatment success. These outcomes were achieved with a model that facilitated physician involvement.
Conclusions
Collaborative care with nurse care managers in an urban primary care practice is an alternative and successful method of service delivery for the majority of patients with opioid addiction while effectively utilizing the time of physicians prescribing buprenorphine.
doi:10.1001/archinternmed.2010.541
PMCID: PMC3059544  PMID: 21403039
opioid dependence; buprenorphine; addiction; primary care; collaborative care
9.  Physician Introduction to Opioids for Pain Among Patients with Opioid Dependence and Depressive Symptoms 
This study determined the frequency of reporting being introduced to opioids by a physician among opioid dependent patients. Cross-sectional analyses were performed using baseline data from a cohort of opioid addicts seeking treatment with buprenorphine. The primary outcome was response to the question: “Who introduced you to opiates?” Covariates included sociodemographics, depression, pain, current and prior substance use. Of 140 participants, 29% reported that they had been introduced to opioids by a physician. Of those who were introduced to opioids by a physician, all indicated that they had initially used opioids for pain, versus only 11% of those who did not report being introduced to opioids by a physician (p<0.01). There was no difference in current pain (78% vs. 85%, p=0.29), however participants who were introduced to opioids by a physician were more likely to have chronic pain (63% vs. 43%, p=0.04). A substantial proportion of individuals with opioid dependence seeking treatment may have been introduced to opioids by a physician.
doi:10.1016/j.jsat.2010.06.012
PMCID: PMC3129653  PMID: 20727704
10.  Update in Pain Medicine 
Journal of General Internal Medicine  2010;25(11):1222-1226.
doi:10.1007/s11606-010-1452-4
PMCID: PMC2947651  PMID: 20632120
primary care; chronic pain; analgesics; opioids; complementary and alternative medicine
11.  Screening and Brief Intervention for Unhealthy Drug Use in Primary Care Settings: Randomized Clinical Trials Are Needed 
Journal of addiction medicine  2010;4(3):123-130.
The efficacy of screening and brief intervention (SBI) for drug use in primary care patients is largely unknown. Because of this lack of evidence, US professional organizations do not recommend it. Yet, a strong theoretical case can be made for drug SBI. Drug use is common and associated with numerous health consequences, patients usually do not seek help for drug abuse and dependence, and SBI has proven efficacy for unhealthy alcohol use. On the other hand, the diversity of drugs of abuse and the high prevalence of abuse and dependence among those who use them raise concerns that drug SBI may have limited or no efficacy. Federal efforts to disseminate SBI for drug use are underway, and reimbursement codes to compensate clinicians for these activities have been developed. However, the discrepancies between science and policy developments underscore the need for evidence-based research regarding the efficacy of SBI for drug use. This article discusses the rationale for drug SBI and existing research on its potential to improve drug-use outcomes and makes the argument that randomized controlled trials to determine its efficacy are urgently needed to bridge the gap between research, policy, and clinical practice.
doi:10.1097/ADM.0b013e3181db6b67
PMCID: PMC2950314  PMID: 20936079
addiction; drug use; primary care; drug screening; brief intervention
12.  Clinical Case Discussion: Screening and Brief Intervention for Drug Use in Primary Care 
Journal of addiction medicine  2010;4(3):131-136.
doi:10.1097/ADM.0b013e3181f59777
PMCID: PMC2989621  PMID: 21113433
primary care; drug use; substance use; screening; brief intervention; motivational interviewing
13.  A Transitional Opioid Program to Engage Hospitalized Drug Users 
BACKGROUND
Many opioid-dependent patients do not receive care for addiction issues when hospitalized for other medical problems. Based on 3 years of clinical practice, we report the Transitional Opioid Program (TOP) experience using hospitalization as a “reachable moment” to identify and link opioid-dependent persons to addiction treatment from medical care.
METHODS
A program nurse identified, assessed, and enrolled hospitalized, out-of-treatment opioid-dependent drug users based on their receipt of methadone during hospitalization. At discharge, patients transitioned to an outpatient interim opioid agonist program providing 30-day stabilization followed by 60-day taper. The nurse provided case management emphasizing HIV risk reduction, health education, counseling, and medical follow-up. Treatment outcomes included opioid agonist stabilization then taper or transfer to long-term opioid agonist treatment.
RESULTS
From January 2002 to January 2005, 362 unique hospitalized, opioid-dependent drug users were screened; 56% (n = 203) met eligibility criteria and enrolled into the program. Subsequently, 82% (167/203) presented to the program clinic post-hospital discharge; for 59% (119/203) treatment was provided, for 26% (52/203) treatment was not provided, and for 16% (32/203) treatment was not possible (pursuit of TOP objectives precluded by medical problems, psychiatric issues, or incarceration). Program patients adhered to a spectrum of medical recommendations (e.g., obtaining prescription medications, medical follow-up).
CONCLUSIONS
The Transitional Opioid Program (TOP) identified at-risk hospitalized, out-of-treatment opioid-dependent drug users and, by offering a range of treatment intensity options, engaged a majority into addiction treatment. Hospitalization can be a “reachable moment” to engage and link drug users into addiction treatment.
doi:10.1007/s11606-010-1311-3
PMCID: PMC2896583  PMID: 20237960
harm reduction; opioid dependence; methadone; addiction treatment
14.  Is unhealthy substance use associated with failure to receive cancer screening and flu vaccination? A retrospective cross-sectional study 
BMJ Open  2011;1(1):e000046.
Objective
To compare cancer screening and flu vaccination among persons with and without unhealthy substance use.
Design
The authors analysed data from 4804 women eligible for mammograms, 4414 eligible for Papanicolou (Pap) smears, 7008 persons eligible for colorectal cancer (CRC) screening and 7017 persons eligible for flu vaccination. All patients were screened for unhealthy substance use. The main outcome was completion of cancer screening and flu vaccination.
Results
Among the 9995 patients eligible for one or more of the preventive services of interest, 10% screened positive for unhealthy substance use. Compared with women without unhealthy substance use, women with unhealthy substance use received mammograms less frequently (75.4% vs 83.8%; p<0.0001), but Pap smears no less frequently (77.9% vs 78.1%). Persons with unhealthy substance use received CRC screening no less frequently (61.7% vs 63.4%), yet received flu vaccination less frequently (44.7% vs 50.4%; p=0.01). In multivariable analyses, women with unhealthy substance use were less likely to receive mammograms (adjusted odds ratio 0.68; 95% CI 0.52 to 0.89), and persons with unhealthy substance use were less likely to receive flu vaccination (adjusted odds ratio 0.81; 95% CI 0.67 to 0.97).
Conclusions
Unhealthy substance use is a risk factor for not receiving all appropriate preventive health services.
Article summary
Article focus
Do persons with unhealthy substance use receive breast, cervical and colorectal cancer screening less frequently than persons without unhealthy substance use?
Do persons with unhealthy substance use receive flu vaccination less frequently than persons without unhealthy substance use?
Key messages
Women with unhealthy substance use are less likely to receive mammograms than women without unhealthy substance use.
Persons with unhealthy substance use are less likely to receive flu vaccination than persons without unhealthy substance use.
Unhealthy substance use is not a risk factor for not receiving cervical or colorectal cancer screening.
Strengths and limitations of this study
Strengths: the study used validated measures of unhealthy substance use and encompassed a wide range of substance-use severity.
Limitations: the findings from our sample of an inner-city patient population with health insurance and access to care who receive primary care at an urban safety-net hospital may not be generalisable to other patient populations. The study cannot determine whether unhealthy substance use causes patients not to receive certain services, or whether screening, brief intervention and substance-use treatment led some patients to complete screenings or vaccination. The study did not obtain records of services performed outside Boston Medical Center, and relied on patient self-report of substance use.
doi:10.1136/bmjopen-2010-000046
PMCID: PMC3191402  PMID: 22021737
15.  Are Opioid Dependence and Methadone Maintenance Treatment (MMT) Documented in the Medical Record? A Patient Safety Issue 
Journal of General Internal Medicine  2009;24(9):1007-1011.
ABSTRACT
BACKGROUND
Opioid-dependent patients often have co-occurring chronic illnesses requiring medications that interact with methadone. Methadone maintenance treatment (MMT) is typically provided separately from medical care. Hence, coordination of medical care and substance use treatment is important to preserve patient safety.
OBJECTIVE
To identify potential safety risks among MMT patients engaged in medical care by evaluating the frequency that opioid dependence and MMT documentation are missing in medical records and characterizing potential medication-methadone interactions.
METHODS
Among patients from a methadone clinic who received primary care from an affiliated, but separate, medical center, we reviewed electronic medical records for documentation of methadone, opioid dependence, and potential drug-methadone interactions. The proportions of medical records without opioid dependence and methadone documentation were estimated and potential medication-methadone interactions were identified.
RESULTS
Among the study subjects ( = 84), opioid dependence documentation was missing from the medical record in 30% (95% CI, 20%–41%) and MMT documentation was missing from either the last primary care note or the last hospital discharge summary in 11% (95% CI, 5%-19%). Sixty-nine percent of the study subjects had at least 1 medication that potentially interacted with methadone; 19% had 3 or more potentially interacting medications.
CONCLUSION
Among patients receiving MMT and medical care at different sites, documentation of opioid dependence and MMT in the medical record occurs for the majority, but is missing in a substantial number of patients. Most of these patients are prescribed medications that potentially interact with methadone. This study highlights opportunities for improved coordination between medical care and MMT.
doi:10.1007/s11606-009-1043-4
PMCID: PMC2726880  PMID: 19578820
methadone; medication interactions; patient safety; care coordination
16.  Internal medicine residency training for unhealthy alcohol and other drug use: recommendations for curriculum design 
BMC Medical Education  2010;10:22.
Background
Unhealthy substance use is the spectrum from use that risks harm, to use associated with problems, to the diagnosable conditions of substance abuse and dependence, often referred to as substance abuse disorders. Despite the prevalence and impact of unhealthy substance use, medical education in this area remains lacking, not providing physicians with the necessary expertise to effectively address one of the most common and costly health conditions. Medical educators have begun to address the need for physician training in unhealthy substance use, and formal curricula have been developed and evaluated, though broad integration into busy residency curricula remains a challenge.
Discussion
We review the development of unhealthy substance use related competencies, and describe a curriculum in unhealthy substance use that integrates these competencies into internal medicine resident physician training. We outline strategies to facilitate adoption of such curricula by the residency programs. This paper provides an outline for the actual implementation of the curriculum within the structure of a training program, with examples using common teaching venues. We describe and link the content to the core competencies mandated by the Accreditation Council for Graduate Medical Education, the formal accrediting body for residency training programs in the United States. Specific topics are recommended, with suggestions on how to integrate such teaching into existing internal medicine residency training program curricula.
Summary
Given the burden of disease and effective interventions available that can be delivered by internal medicine physicians, teaching about unhealthy substance use must be incorporated into internal medicine residency training, and can be done within existing teaching venues.
doi:10.1186/1472-6920-10-22
PMCID: PMC2848062  PMID: 20230607
17.  Promoting Substance Use Education Among Generalist Physicians: An Evaluation of the Chief Resident Immersion Training (CRIT) Program 
ABSTRACT
BACKGROUND
Education about substance use (SU) disorders remains inadequate in medical training.
OBJECTIVE
To describe the Chief Resident Immersion Training (CRIT) program in addiction medicine and to evaluate its impact on chief resident (CR) physicians’ substance use knowledge, skills, clinical practice, and teaching.
DESIGN
A controlled educational study of CRIT programs (2003, 2004, and 2005) for incoming CRs in generalist disciplines. Intervention CRs were trained to diagnose, manage, and teach about SU. The control CRs sought but did not receive the intervention.
PARTICIPANTS
Eighty-six CR applicants to the CRIT program.
MEASUREMENTS
Baseline and 6-month questionnaires assessing substance use knowledge, skills, clinical practice, and teaching. Outcomes were compared within groups from baseline to follow-up and between groups at follow-up.
RESULTS
The intervention (n = 64) and control (n = 22) CRs were similar demographically. At 6-month follow-up, the intervention CRs reported a significant increase in SU knowledge, confidence, and preparedness to diagnose, manage, and teach and an increase in SU clinical and teaching practices compared to their baseline and control CRs.
CONCLUSIONS
This intensive training for chief residents (CRs) improved knowledge, confidence, and preparedness to diagnose, manage, and teach about substance use (SU), affecting both the CRs’ SU clinical and teaching practices. The CRIT program was an effective model for dissemination of SU knowledge and skills to educators in a key position to share this training with a broader audience of medical trainees. This model holds potential to address other high priority medical, yet under-addressed, content areas as well.
doi:10.1007/s11606-008-0819-2
PMCID: PMC2607502  PMID: 18937015
medical education; addiction; chief resident training; substance-related disorders
18.  Office-Based Management of Opioid Dependence with Buprenorphine: Clinical Practices and Barriers 
Journal of General Internal Medicine  2008;23(9):1393-1398.
Background
Buprenorphine is a safe, effective and underutilized treatment for opioid dependence that requires special credentialing, known as a waiver, to prescribe in the United States.
Objective
To describe buprenorphine clinical practices and barriers among office-based physicians.
Design
Cross-sectional survey.
Participants
Two hundred thirty-five office-based physicians waivered to prescribe buprenorphine in Massachusetts.
Measurements
Questionnaires mailed to all waivered physicians in Massachusetts in October and November 2005 included questions on medical specialty, practice setting, clinical practices, and barriers to prescribing. Logistic regression analyses were used to identify factors associated with prescribing.
Results
Prescribers were 66% of respondents and prescribed to a median of ten patients. Clinical practices included mandatory counseling (79%), drug screening (82%), observed induction (57%), linkage to methadone maintenance (40%), and storing buprenorphine notes separate from other medical records (33%). Most non-prescribers (54%) reported they would prescribe if barriers were reduced. Being a primary care physician compared to a psychiatrist (AOR: 3.02; 95% CI: 1.48–6.18) and solo practice only compared to group practice (AOR: 3.01; 95% CI: 1.23–7.35) were associated with prescribing, while reporting low patient demand (AOR: 0.043, 95% CI: 0.009–0.21) and insufficient institutional support (AOR: 0.37; 95% CI: 0.15–0.89) were associated with not prescribing.
Conclusions
Capacity for increased buprenorphine prescribing exists among physicians who have already obtained a waiver to prescribe. Increased efforts to link waivered physicians with opioid-dependent patients and initiatives to improve institutional support may mitigate barriers to buprenorphine treatment. Several guideline-driven practices have been widely adopted, such as adjunctive counseling and monitoring patients with drug screening.
doi:10.1007/s11606-008-0686-x
PMCID: PMC2518016  PMID: 18592319
opioid dependence; buprenorphine; medication assisted treatment
19.  Update in Pain Medicine 
doi:10.1007/s11606-008-0570-8
PMCID: PMC2517889  PMID: 18330653
primary care; chronic pain; opioids; complementary and alternative medicine
20.  Update in Addiction Medicine for the Generalist 
Journal of General Internal Medicine  2007;22(8):1190-1194.
doi:10.1007/s11606-007-0133-4
PMCID: PMC2305747  PMID: 17492327
primary health care; substance-related disorders; review literature
21.  A web-based Alcohol Clinical Training (ACT) curriculum: Is in-person faculty development necessary to affect teaching? 
Background
Physicians receive little education about unhealthy alcohol use and as a result patients often do not receive efficacious interventions. The objective of this study is to evaluate whether a free web-based alcohol curriculum would be used by physician educators and whether in-person faculty development would increase its use, confidence in teaching and teaching itself.
Methods
Subjects were physician educators who applied to attend a workshop on the use of a web-based curriculum about alcohol screening and brief intervention and cross-cultural efficacy. All physicians were provided the curriculum web address. Intervention subjects attended a 3-hour workshop including demonstration of the website, modeling of teaching, and development of a plan for using the curriculum. All subjects completed a survey prior to and 3 months after the workshop.
Results
Of 20 intervention and 13 control subjects, 19 (95%) and 10 (77%), respectively, completed follow-up. Compared to controls, intervention subjects had greater increases in confidence in teaching alcohol screening, and in the frequency of two teaching practices – teaching about screening and eliciting patient health beliefs. Teaching confidence and teaching practices improved significantly in 9 of 10 comparisons for intervention, and in 0 comparisons for control subjects. At follow-up 79% of intervention but only 50% of control subjects reported using any part of the curriculum (p = 0.20).
Conclusion
In-person training for physician educators on the use of a web-based alcohol curriculum can increase teaching confidence and practices. Although the web is frequently used for disemination, in-person training may be preferable to effect widespread teaching of clinical skills like alcohol screening and brief intervention.
doi:10.1186/1472-6920-8-11
PMCID: PMC2329623  PMID: 18325102
22.  Treating Homeless Opioid Dependent Patients with Buprenorphine in an Office-Based Setting 
Context
Although office-based opioid treatment with buprenorphine (OBOT-B) has been successfully implemented in primary care settings in the US, its use has not been reported in homeless patients.
Objective
To characterize the feasibility of OBOT-B in homeless relative to housed patients.
Design
A retrospective record review examining treatment failure, drug use, utilization of substance abuse treatment services, and intensity of clinical support by a nurse care manager (NCM) among homeless and housed patients in an OBOT-B program between August 2003 and October 2004. Treatment failure was defined as elopement before completing medication induction, discharge after medication induction due to ongoing drug use with concurrent nonadherence with intensified treatment, or discharge due to disruptive behavior.
Results
Of 44 homeless and 41 housed patients enrolled over 12 months, homeless patients were more likely to be older, nonwhite, unemployed, infected with HIV and hepatitis C, and report a psychiatric illness. Homeless patients had fewer social supports and more chronic substance abuse histories with a 3- to 6-fold greater number of years of drug use, number of detoxification attempts and percentage with a history of methadone maintenance treatment. The proportion of subjects with treatment failure for the homeless (21%) and housed (22%) did not differ (P = .94). At 12 months, both groups had similar proportions with illicit opioid use [Odds ratio (OR), 0.9 (95% CI, 0.5–1.7) P = .8], utilization of counseling (homeless, 46%; housed, 49%; P = .95), and participation in mutual-help groups (homeless, 25%; housed, 29%; P = .96). At 12 months, 36% of the homeless group was no longer homeless. During the first month of treatment, homeless patients required more clinical support from the NCM than housed patients.
Conclusions
Despite homeless opioid dependent patients’ social instability, greater comorbidities, and more chronic drug use, office-based opioid treatment with buprenorphine was effectively implemented in this population comparable to outcomes in housed patients with respect to treatment failure, illicit opioid use, and utilization of substance abuse treatment.
doi:10.1007/s11606-006-0023-1
PMCID: PMC1824722  PMID: 17356982
buprenorphine; drug dependence; primary care; homelessness
23.  Acute Pain Management for Patients Receiving Maintenance Methadone or Buprenorphine Therapy 
Annals of internal medicine  2006;144(2):127-134.
More patients with opioid addiction are receiving opioid agonist therapy (OAT) with methadone and buprenorphine. As a result, physicians will more frequently encounter patients receiving OAT who develop acutely painful conditions, requiring effective treatment strategies. Undertreatment of acute pain is suboptimal medical treatment, and patients receiving long-term OAT are at particular risk. This paper acknowledges the complex interplay among addictive disease, OAT, and acute pain management and describes 4 common misconceptions resulting in suboptimal treatment of acute pain. Clinical recommendations for providing analgesia for patients with acute pain who are receiving OAT are presented. Although challenging, acute pain in patients receiving this type of therapy can effectively be managed.
PMCID: PMC1892816  PMID: 16418412
24.  Treating Homeless Opioid Dependent Patients with Buprenorphine in an Office-Based Setting 
Context
Although office-based opioid treatment with buprenorphine (OBOT-B) has been successfully implemented in primary care settings in the US, its use has not been reported in homeless patients.
Objective
To characterize the feasibility of OBOT-B in homeless relative to housed patients.
Design
A retrospective record review examining treatment failure, drug use, utilization of substance abuse treatment services, and intensity of clinical support by a nurse care manager (NCM) among homeless and housed patients in an OBOT-B program between August 2003 and October 2004. Treatment failure was defined as elopement before completing medication induction, discharge after medication induction due to ongoing drug use with concurrent nonadherence with intensified treatment, or discharge due to disruptive behavior.
Results
Of 44 homeless and 41 housed patients enrolled over 12 months, homeless patients were more likely to be older, nonwhite, unemployed, infected with HIV and hepatitis C, and report a psychiatric illness. Homeless patients had fewer social supports and more chronic substance abuse histories with a 3- to 6-fold greater number of years of drug use, number of detoxification attempts and percentage with a history of methadone maintenance treatment. The proportion of subjects with treatment failure for the homeless (21%) and housed (22%) did not differ (P = .94). At 12 months, both groups had similar proportions with illicit opioid use [Odds ratio (OR), 0.9 (95% CI, 0.5–1.7) P = .8], utilization of counseling (homeless, 46%; housed, 49%; P = .95), and participation in mutual-help groups (homeless, 25%; housed, 29%; P = .96). At 12 months, 36% of the homeless group was no longer homeless. During the first month of treatment, homeless patients required more clinical support from the NCM than housed patients.
Conclusions
Despite homeless opioid dependent patients’ social instability, greater comorbidities, and more chronic drug use, office-based opioid treatment with buprenorphine was effectively implemented in this population comparable to outcomes in housed patients with respect to treatment failure, illicit opioid use, and utilization of substance abuse treatment.
doi:10.1007/s11606-006-0023-1
PMCID: PMC1824722  PMID: 17356982
buprenorphine; drug dependence; primary care; homelessness

Results 1-24 (24)