Publications by authors named "Darius A Rastegar"

53 Publications

"I'm a Survivor": Perceptions of Chronic Disease and Survivorship Among Individuals in Long-Term Remission from Opioid Use Disorder.

J Gen Intern Med 2021 May 23. Epub 2021 May 23.

Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Background: While opioid use disorder (OUD) is prevalent, little is known about what patients with OUD in sustained remission think about the chronic disease model of OUD and their perspectives of the cause, course, and ongoing treatment needs of their OUD.

Objective: To (1) examine patient perceptions of the chronic disease model of addiction and disease identity and (2) use an explanatory model framework to explore how these perceptions inform ongoing treatment needs and help maintain abstinence.

Design: Qualitative study of a cross-sectional cohort of patients with OUD in long-term sustained remission currently receiving methadone or buprenorphine. Participants completed a single in-depth, semi-structured individual interview.

Participants: Twenty adults were recruited from two opioid treatment programs and two office-based opioid treatment programs in Baltimore, MD. Half of the participants were Black, had a median (IQR) age of 46.5 (43-52) years and the median (IQR) time since the last non-prescribed opioid was 12 (8-15) years.

Approach: Hybrid deductive-inductive thematic analysis of the transcribed interviews.

Key Results: Some participants described a chronic OUD disease identity where they continue to live with OUD. Participants who maintain an OUD identity describe inherent traits or predetermination of developing OUD. Maintaining a disease identity helps them remain vigilant against returning to drug use. Others described a post-OUD/survivor identity where they no longer felt they had OUD, but the experience remains. Each perspective informed attitudes about continued treatment with methadone or buprenorphine and strategies to remain in remission.

Conclusions: The identity that people with OUD in sustained remission maintain was the lens through which they viewed other aspects of their OUD including cause and ongoing treatment needs. An alternative, post-OUD/survivorship model emerged or was accepted by participants who did not identify as currently having OUD. Understanding patient perspectives of OUD identity might improve patient-centered care and improve outcomes.
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http://dx.doi.org/10.1007/s11606-021-06925-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8141362PMC
May 2021

Micro-dosing Intravenous Buprenorphine to Rapidly Transition From Full Opioid Agonists.

J Addict Med 2021 Mar 19. Epub 2021 Mar 19.

Department of Medicine, Division of Addiction Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (APT); Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD (LJ); Department of Medicine, Division of Addiction Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (JR); Johns Hopkins University School of Medicine, Department of Medicine, Division of Addiction Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (DAR).

For patients with opioid use disorder transitioning from methadone or requiring opioid analgesia, initiating buprenorphine for opioid use disorder can be difficult because of the risk of precipitated withdrawal. Low-dose initiation, also known as micro-dosing, is an alternative to standard initiation. Prior studies relied on nonstandard dosing of tablets or films, patches, or buccal formulations, all of which are unavailable in many hospitals. We report a novel approach to micro-dosing using intravenous buprenorphine. Two patients, one on methadone maintenance and another requiring postoperative opioid analgesia, were transitioned to buprenorphine with concurrent full-agonist opioids and without precipitated withdrawal.
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http://dx.doi.org/10.1097/ADM.0000000000000838DOI Listing
March 2021

Down the drain: Reconsidering routine urine drug testing during the COVID-19 pandemic.

J Subst Abuse Treat 2021 01 5;120:108155. Epub 2020 Oct 5.

Division of Addiction Medicine, Johns Hopkins Bayview Medical Center, 5200 Eastern Avenue, Mason Lord Building, East Tower, 2nd floor, Baltimore, MD 21224, United States of America. Electronic address:

The COVID-19 pandemic and the move to telemedicine for office-based opioid treatment have made the practice of routine urine drug tests (UDT) obsolete. In this commentary we discuss how COVID-19 has demonstrated the limited usefulness and possible harms of routine UDT. We propose that practitioners should stop using routine UDT and instead use targeted UDT, paired with clinical reasoning, as part of a patient-centered approach to care.
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http://dx.doi.org/10.1016/j.jsat.2020.108155DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7534596PMC
January 2021

Implementation of a Protocol Using the 5-Item Brief Alcohol Withdrawal Scale for Treatment of Severe Alcohol Withdrawal in Intensive Care Units.

J Intensive Care Med 2020 Aug 27:885066620952762. Epub 2020 Aug 27.

Division of Pulmonary and Critical Care Medicine, 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Background: There is variation in the treatment of patients with severe alcohol withdrawal and a need for effective protocols. The purpose of this study was to evaluate the implementation of a symptom-triggered benzodiazepine protocol using the 5-item Brief Alcohol Withdrawal Scale (BAWS) for treatment of alcohol withdrawal in intensive care units (ICUs).

Methods: This retrospective study included admissions to ICUs of 2 hospitals over 6 months who had an alcohol withdrawal protocol ordered and experienced severe withdrawal. Records were reviewed to collect demographic data, benzodiazepine exposure, duration of treatment, and withdrawal severity.

Results: The protocol was ordered and implemented in 279 admissions; 48 (17.9%) had severe withdrawal defined as a BAWS of 6 or more. The majority of the 48 patients were from the emergency department (79.2%); mean hospital length of stay was 11.2 days and mean ICU stay 6.6 days; 31.3% required mechanical ventilation. A little more than half were treated only with the protocol (53.2%); 25.0% received additional benzodiazepines, 20.8% dexmedetomidine, 10.4% propofol, 25.0% antipsychotics and 2.0% phenobarbital.

Conclusion: Among ICU patients treated for alcohol withdrawal with a symptom-triggered benzodiazepine protocol using a novel 5-item scale, most did not develop severe withdrawal, and of those who did, approximately half were treated with the protocol alone.
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http://dx.doi.org/10.1177/0885066620952762DOI Listing
August 2020

Transition From Methadone to Buprenorphine Using a Short-acting Agonist Bridge in the Inpatient Setting: A Case Study.

J Addict Med 2020 Sep/Oct;14(5):e274-e276

Johns Hopkins University School of Medicine, Baltimore, MD (JC, JP, JR, DAR); Addiction Medicine and General Internal Medicine Fellowships, Johns Hopkins University School of Medicine, Baltimore, MD (JP); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD (JR); Division of Addiction Medicine, Johns Hopkins Bayview Medical Campus, Baltimore, MD (DAR).

: Methadone and buprenorphine are the most common medications for opioid use disorder. Buprenorphine is often the preferred medication because of fewer drug-drug interactions and fewer regulatory barriers. For these reasons, patients often desire to transition from methadone to buprenorphine, but this can be difficult because of the risk of precipitated withdrawal. There are protocols designed to minimize withdrawal; however, these can be time-consuming or infeasible due to formulation and dosage availability of buprenorphine. We describe an inpatient transition from methadone to buprenorphine using a hydromorphone bridge over a 7-day period. This method used commonly available dosages and formulations of buprenorphine. To our knowledge, this is the first time a method has been described that transitions a patient from methadone to buprenorphine using a short-acting opioid agonist bridge and readily available opioid dosages and formulations. This case provides a viable alternative for rapidly transitioning a patient from methadone to buprenorphine that can be used as a template for an alternative method to transitions between these medications.
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http://dx.doi.org/10.1097/ADM.0000000000000623DOI Listing
June 2021

Fumer de la marijuana entraîne de la toux, des sibilances et de la dyspnée.

Rev Med Suisse 2019 Nov;15(672):2176

CHUV, Lausanne.

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November 2019

Evaluation of the Brief Alcohol Withdrawal Scale Protocol at an Academic Medical Center.

J Addict Med 2019 Sep/Oct;13(5):379-384

Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD (BKL, VTG, RMK, ASJ); Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (AAHA, TN); Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (ESC); Department of Medicine, The Johns Hopkins Hospital, Baltimore, MD (PM, KP); Center for Chemical Dependence, Johns Hopkins Bayview Medical Center, Baltimore, MD (DAR); Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD (SY).

Objectives: The standard of care for treatment of alcohol withdrawal is symptom-triggered dosing of benzodiazepines using a withdrawal scale. Abbreviated scales are desired for clinician efficiency. The objective of this study was to evaluate the use of the 5-item Brief Alcohol Withdrawal Scale (BAWS) protocol.

Methods: This single-center, retrospective, observational, cohort study assessed patients ordered the BAWS protocol between August 1, 2016 and July 31, 2017. Data were collected on benzodiazepine exposure, duration of treatment, withdrawal severity, agitation, over-sedation, and delirium while being treated for alcohol withdrawal. Comparisons were made to analyze predetermined patient subgroups.

Results: Seven hundred ninety-nine patients were initiated on the BAWS protocol. Patients received a median (IQR) of 0 (0-4) lorazepam equivalents (LEs) and were on the BAWS protocol for a median (IQR) of 44.9 (22.4-77.2) hours. Of the patients that received benzodiazepines while on the BAWS protocol, a median (IQR) of 4 (2-11) LEs were given. Seventeen (2.1%) patients had severe withdrawal. Days of agitation, over-sedation, and delirium were minimal, with the median (IQR) of 0 (0-0). Few patients received adjunctive medications for symptom management. Intensive care unit (ICU) patients had more severe withdrawal than non-ICU patients, but received the same cumulative benzodiazepine dose.

Conclusions: Most patients on the BAWS protocol received little-to-no benzodiazepines; severe withdrawal, agitation, delirium, or over-sedation were uncommon. This is the first evaluation of the BAWS protocol on a diverse population of hospitalized patients.
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http://dx.doi.org/10.1097/ADM.0000000000000510DOI Listing
July 2020

Brain Change in Addiction as Learning, Not Disease.

N Engl J Med 2019 01;380(3):301

Johns Hopkins University School of Medicine, Baltimore, MD

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http://dx.doi.org/10.1056/NEJMc1815144DOI Listing
January 2019

Who Leaves Early? Factors Associated With Against Medical Advice Discharge During Alcohol Withdrawal Treatment.

J Addict Med 2018 Nov/Dec;12(6):447-452

Bayview Internal Medicine Residency Program, Johns Hopkins University School of Medicine, Baltimore, MD (JDP); Center for Chemical Dependence, Johns Hopkins Bayview Medical Center, Baltimore, MD (DAR).

Objective: To determine if certain patient, clinical, and disease factors are associated with against medical advice (AMA) discharge among patients admitted for treatment of alcohol withdrawal.

Methods: Data from admissions to a dedicated unit for treatment of substance withdrawal were collected over a 6-month period. Patients with AMA and planned discharge were compared with regard to demographics, clinical data, and substance use disorder disease characteristics. A stepwise logistic regression was used to find the best model.

Results: The study population included 655 patient encounters. A total of 93 (14%) discharges were AMA. Bivariate analysis showed patients with AMA discharge were younger (mean age 43 vs 46 years; P < 0.05), more likely to leave on a Tuesday to Thursday, and to have an initial withdrawal score at or above the median (AMA 69% vs planned 56%; P = 0.02). Emergency department (ED) admissions had an AMA discharge rate of 21% compared with 10% of community admissions (P < 0.05). Regression analysis found AMA discharge was significantly associated with admission from the ED (odds ratio [OR] 2.03, confidence interval [CI] 1.27-3.25) and younger age (OR 0.97, CI 0.95-0.99). There was no significant difference in discharge disposition among patients with concurrent opioid use disorder who were on opioid agonist therapy.

Conclusions: AMA discharges occurred in 1 of every 7 admissions. Being admitted from the ED and younger age was associated with AMA discharge. No other patient or clinical factors were found to be associated with AMA discharge.
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http://dx.doi.org/10.1097/ADM.0000000000000430DOI Listing
November 2019

New and Emerging Illicit Psychoactive Substances.

Med Clin North Am 2018 Jul;102(4):697-714

Division of Chemical Dependence, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Suite D5W, Baltimore, MD 21224, USA. Electronic address:

Several novel psychoactive substances have emerged in recent years. Users are typically young men who use other substances. In the category of stimulants, cathinones ("bath salts") have predominated and can lead to agitation, psychosis, hyperthermia, and death. Synthetic cannabinoids ("spice") are more potent than marijuana and can lead to agitation, psychosis, seizures, and death. There are no rapid tests to identify these substances and general treatment includes benzodiazepines for agitation and supportive therapy. Many Synthetic opioids are potent analogues of fentanyl and carry a high risk of overdose. In addition, there are several designer benzodiazepines that have emerged.
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http://dx.doi.org/10.1016/j.mcna.2018.02.010DOI Listing
July 2018

Impact of a Mandated Change in Buprenorphine Formulation.

J Addict Med 2017 Nov/Dec;11(6):435-439

Division of Chemical Dependence, Department of Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD.

Objective: This study examines the impact of an insurance-mandated change in formulation of buprenorphine/naloxone (BNX) for patients with opioid use disorder treated in a primary care clinic.

Methods: A retrospective cohort study was conducted to determine the proportion of patients who were switched back to the previous BNX formulation and rates of aberrant urine drug tests for the 3 months before and 3 months after a mandated change in BNX from the sublingual film to the rapidly dissolving tablet (BNX-RDT). Aberrant urine drug tests were defined as the presence of cocaine, nonprescribed opioids/benzodiazepines, or the absence of buprenorphine.

Results: In all, 186 patients were included in the analysis. At 3 months after the change, 36.0% of patients remained on BNX-RDT at equivalent dose, 9.1% were prescribed a higher dose of BNX-RDT, 52.7% were switched back to their previous formulation after a trial of BNX-RDT, and 2.2% dropped out of care. There was no significant change in the rates of aberrant urine drug tests pre and postchange (36.6% vs 33.7%; P = 0.27) or in any individual component of urine drug testing. Age, sex, and starting dose were not associated with remaining on BNX-RDT at equivalent dose, compared with increasing dose or changing formulation.

Conclusions: Most patients were dissatisfied with the change in formulation and requested a return to the previous formulation. This change did not appear to impact drug use; however, the flexibility that permitted patients to switch back to their previous BNX formulation likely attenuated the policy's impact.
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http://dx.doi.org/10.1097/ADM.0000000000000341DOI Listing
June 2018

Development and implementation of an alcohol withdrawal protocol using a 5-item scale, the Brief Alcohol Withdrawal Scale (BAWS).

Subst Abus 2017 Oct-Dec;38(4):394-400. Epub 2017 Jul 12.

e Division of Pulmonary and Critical Care Medicine , Johns Hopkins University School of Medicine , Baltimore , Maryland , USA.

Background: The standard of care for management of alcohol withdrawal is symptom-triggered treatment using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar). Many items of this 10-question scale rely on subjective assessments of withdrawal symptoms, making it time-consuming and cumbersome to use. Therefore, there is interest in shorter and more objective methods to assess alcohol withdrawal symptoms.

Methods: A 6-item withdrawal scale developed at another institution was piloted. Based on comparison with the CIWA-Ar, this was adapted into a 5-item scale named the Brief Alcohol Withdrawal Scale (BAWS). The BAWS was compared with the CIWA-Ar and a withdrawal protocol utilizing the BAWS was developed. The new protocol was implemented on an inpatient unit dedicated to treating substance withdrawal. Data was collected on the first 3 months of implementation and compared with the 3 months prior to that.

Results: A BAWS score of 3 or more predicted CIWA-Ar score ≥8 with a sensitivity of 85.3% and specificity of 65.8%. The demographics of the patients in the 2 time periods were similar: the mean age was 45.9; 70.6% were male; 30.9% received concurrent treatment for opioid withdrawal; and 14.2% were receiving methadone maintenance. During the BAWS phase, patients received significantly less diazepam (mean dose 81.4 vs. 60.3 mg, P < .001). There was no significant difference in length of stay. No patients experienced a seizure, delirium, or required transfer to a higher level of care during any of the 664 admissions in either phase.

Conclusions: This simple protocol utilizing a 5-item withdrawal scale performed well in this setting. Its use in other settings, particularly with patients with concurrent medical illnesses or more severe withdrawal, needs to be explored further.
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http://dx.doi.org/10.1080/08897077.2017.1354119DOI Listing
June 2018

Change in Medical Student Attitudes Toward Patients with Substance Use Disorders After Course Exposure.

Acad Psychiatry 2018 Apr 6;42(2):283-287. Epub 2017 Apr 6.

Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Objective: Negative physician attitudes toward patients with substance use disorders (SUD) pose a significant barrier to treatment. This study tests the overall and intra-individual change in attitudes of second year medical students after exposure to a 15 hour SUD course.

Methods: Two cohorts of second year medical students (2014 and 2015) responded to an anonymous 13-item previously published survey exploring personal views regarding patients with SUD using a four-point Likert scale. Students were surveyed one day before and up to one month after course completion. Survey items were grouped into the following categories: treatment optimism/confidence in intervention, moralism, and stereotyping. The Wilcoxon nonparametric signed-rank test (α=0.05) was used to compare the pre- and post- survey responses.

Results: In 2014 and 2015 respectively, 118 and 120 students participated in the SUD course with pre- and post-response rates of 89.0% and 75.4% in 2014 and 95.8% and 97.5% in 2015. Of the 13 survey questions, paired responses to eight questions showed a statistically significant positive change in attitudes with a medium (d = 0.5) to large effect size (d = 0.8). Items focused on treatment optimism and confidence in treatment intervention reflected a positive attitude change, as did items associated with stereotyping and moralism.

Conclusions: These results support the hypothesis that exposure to a course on SUD was associated with positive change in medical students' attitudes toward patients with SUD.
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http://dx.doi.org/10.1007/s40596-017-0702-8DOI Listing
April 2018

AST: A Simplified 3-item Tool for Managing Alcohol Withdrawal.

J Addict Med 2016 May-Jun;10(3):190-5

Center for Chemical Dependence, Department of Medicine, Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD.

Aims: This study compared the Glasgow Modified Alcohol Withdrawal Scale (GMAWS) and a newly devised 3-item "Anxiety Sweats Tremor" Scale (AST) to the Revised Clinical Institute Withdrawal Assessment Scale (CIWA-Ar)-the standard of care for symptom-triggered management of alcohol withdrawal syndrome.

Methods: Our study took place over 2 separate 1-week observational periods, and included 332 serial evaluations from 85 unique patients. All study participants were treated per hospital protocol based on CIWA-Ar, with supplemental scoring initially by GMAWS and later by AST in tandem. Internal consistency, interitem correlation, and operational characteristics were explored.

Results: Median CIWA-Ar score across both phases was 6 (range 0-13), with a median GMAWS score of 2 (range 0-5) and an AST score of 3 (range 0-7). The internal consistency of CIWA-Ar and GMAWS were both poor, with Cronbach alpha scores of 0.46 (n = 156) and 0.41 (n = 156), respectively. The internal consistency of the AST scale was significantly better, with a Cronbach alpha of 0.68 (n = 176). AST identified individuals with CIWA-Ar ≥8 with an area under the receiver-operating characteristic curve of 0.83 (95% confidence interval 0.77-0.89), compared with 0.81 (95% confidence interval 0.74-0.88) for GMAWS. An AST score of ≥3 (out of a possible 9) predicted CIWA-Ar ≥8, with a sensitivity of 93% and a specificity of 63%, whereas the GMAWS had a sensitivity and specificity of 100% and 12%, respectively, based on previously defined cut-offs.

Conclusions: A simple 3-item scale demonstrated good internal consistency and reliably identified individuals experiencing significant alcohol withdrawal. This scale needs to be tested in other settings and among patients with a broader spectrum of withdrawal severity.
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http://dx.doi.org/10.1097/ADM.0000000000000215DOI Listing
February 2017

Criminal Charges Prior to and After Enrollment in Opioid Agonist Treatment: A Comparison of Methadone Maintenance and Office-based Buprenorphine.

Subst Use Misuse 2016 06 20;51(7):803-11. Epub 2016 Apr 20.

c Department of Psychiatry and Behavioral Science and Addiction Treatment Services , Johns Hopkins University , Baltimore , Maryland , USA.

Background: Entry into methadone maintenance is associated with a reduction in criminal activity; less is known about the effects of office-based buprenorphine.

Objective: To compare criminal charges before and after enrollment in methadone maintenance or office-based buprenorphine.

Methods: Subjects were opioid-dependent adults who initiated either methadone maintenance (n = 252) or office-based buprenorphine (n = 252) between 2003 and 2007. Medical records were reviewed to gather demographic data and a state-maintained web-based database to collect data on criminal charges. Overall charges and drug charges in the 2 years prior to and after treatment enrollment were compared. Multivariable analysis was used to examine risk factors for charges after treatment enrollment.

Results: In the 2 years after enrolling in treatment, subjects receiving methadone had a significant decline in the proportion of subjects with any charges (49.6% vs. 32.5%, p < .001) or drug charges (25.0% vs. 17.5%, p = .015), as well as the mean number of cases (0.97 vs. 0.63, p = .002) and drug cases (0.38 vs. 0.23, p = .008), while those who initiated buprenorphine did not have significant changes in any of these measures. On multivariable analysis, the strongest predictor of criminal charges in the 2 years after treatment enrollment was prior charges (adjusted odds ratio 3.35, 95% confidence interval, 2.24-5.01).

Conclusions: Enrollment in office-based buprenorphine treatment did not appear to have the same beneficial effect on subsequent criminal charges as methadone maintenance. If this observation is replicated in other settings, it may have implications for matching individuals to these treatment options.
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http://dx.doi.org/10.3109/10826084.2016.1155608DOI Listing
June 2016

The Effect of a Payer-Mandated Decrease in Buprenorphine Dose on Aberrant Drug Tests and Treatment Retention Among Patients with Opioid Dependence.

J Subst Abuse Treat 2016 Feb 1;61:74-9. Epub 2015 Oct 1.

Division of Chemical Dependence, Department of Internal Medicine, Johns Hopkins Bayview Medical Center, 5200 Eastern Ave, Mason F. Lord, West Tower 5th Floor, Baltimore, MD 21224.

Background: The optimal dose for office-based buprenorphine therapy is not known. This study reports on the effect of a change in payer policy, in which the insurer of a subset of patients in an office-based practice imposed a maximum sublingual buprenorphine dose of 16 mg/day, thereby forcing those patients on higher daily doses to decrease their dose. This situation created conditions for a natural experiment, in which treatment outcomes for patients experiencing this dose decrease could be compared to patients with other insurance who were not challenged with a dose decrease.

Methods: Subjects were 297 patients with opioid use disorder in a primary care practice who were prescribed buprenorphine continuously for at least 3 months. Medical records were retrospectively reviewed for urine drug test results and treatment retention. Rates of aberrant urine drug tests were calculated in the period before the dose decrease and compared to rate after it with patients serving as their own controls. Comparison groups were formed from patients with the same insurance on buprenorphine doses of 16 mg/day or lower, patients with different insurance on 16 mg/day or lower, and patients with different insurance on greater than 16 mg/day. Rates of aberrant drug tests and treatment retention of patients on 16 mg/day or less of buprenorphine were compared to that of patients on higher daily doses.

Results: The rate of aberrant urine drug tests among patients who experienced a dose decrease rose from 27.5% to 34.2% (p=0.043). No comparison group showed any significant change in aberrant drug test rates. Moreover, all groups who were prescribed buprenorphine doses greater than 16 mg/day displayed lower rates of aberrant urine drug tests than groups prescribed lower doses. Retention in treatment was also highest among those prescribed greater than 16 mg/day (100% vs. 86.8%, 90.1%, and 84.4% p=0.010).

Discussion: An imposed buprenorphine dose decrease was associated with an increase in aberrant drug tests. Patients in a control group with higher buprenorphine doses had greater retention in treatment. These findings suggest that buprenorphine doses greater than 16 mg/day are more effective for some patients and that dose limits at this level or lower are harmful.
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http://dx.doi.org/10.1016/j.jsat.2015.09.004DOI Listing
February 2016

Impact of hepatitis C status on 20-year mortality of patients with substance use disorders.

Addict Sci Clin Pract 2015 Oct 13;10:20. Epub 2015 Oct 13.

Johns Hopkins Bayview Medical Center, 5200 Eastern Ave, Mason F. Lord Bldg, West Tower 5th floor, Baltimore, MD, 21224, USA.

Background: The magnitude of the effect of hepatitis C viral infection on survival is still not fully understood. The objective of this study was to determine whether the presence of hepatitis C viral antibodies in 1991 was associated with increased mortality 20 years later within a cohort of patients with substance use disorders. Secondary objectives were to determine other factors that were associated with increased mortality in the cohort.

Methods: A subset of a 1991 study cohort of patients who had presented for detoxification was reexamined 20 years later. The Social Security Death Index was queried to identify which of the original patients had died. Attributes of survivors and non-survivors were compared, with special attention to their hepatitis C status in 1991. The original study and this analysis were conducted in the chemical detoxification unit at Johns Hopkins Bayview (previously Francis Scott Key Hospital), an academic urban hospital. All participants met the criteria for alcohol or opioid dependence at the time of admission in 1991. The primary study outcome was 20-year mortality after initial admission in 1991, with a planned analysis of hepatitis C status.

Results: Twenty years after admission, 362 patients survived and 82 had died. Of the 284 patients who were hepatitis C positive, 228 survived (80 %). Of the 160 patients who were hepatitis C negative, 134 survived (84 %). This absolute risk increase of 4 % was not statistically significant (p = 0.37). Factors associated with increased mortality included male sex, white race, older age, and reported use of alcohol, cocaine, and illicit methadone. Binary logistic regression including hepatitis C status and these other variables yielded an adjusted odds ratio of 0.87 (95 % CI 0.49-1.55); (p = 0.64) for hepatitis C positive 20-year survival.

Conclusions: Hepatitis C positivity was not associated with a statistically significant difference in 20-year survival. The effect of the virus on mortality, if present, is small, relative to the effect of substance use disorders alone.
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http://dx.doi.org/10.1186/s13722-015-0041-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4672505PMC
October 2015

A comparison of characteristics and outcomes of opioid-dependent patients initiating office-based buprenorphine or methadone maintenance treatment.

Subst Abus 2014 ;35(2):122-6

a Department of Medicine , The Johns Hopkins University , Baltimore , Maryland , USA.

Background: The purpose of this study was to compare demographic factors and 1-year treatment outcomes of patients treated with buprenorphine or methadone.

Methods: The study included 252 subjects who received a prescription for buprenorphine in an academic internal medicine practice and 252 subjects who enrolled in a methadone maintenance program located on the same campus over the same time frame. Data were collected retrospectively. Patients were classified as "opioid-positive" or "opioid-negative" each month for a year based on urine drug testing and provider assessment. Successful treatment was defined as remaining in treatment after 1 year and achieving 6 or more opioid-negative months.

Results: Buprenorphine patients were more likely to be male, have health insurance, be employed, abuse prescription opioids, and be human immunodeficiency virus (HIV) infected; they were less likely to abuse benzodiazepines. At 12 months, 140 (55.6%) of buprenorphine patients and 156 (61.9%) of methadone patients remained in treatment (P =.148). Patients on methadone had a higher mean number of opioid-negative months (6.96 vs. 5.43; P <.001) and mean number of months in treatment (9.38 vs. 8.59; P <.001). On multivariable analysis, methadone maintenance was significantly associated with successful treatment (adjusted odds ratio: 2.10; 95% confidence interval: 1.43-3.07).

Conclusions: Office-based buprenorphine and methadone maintenance programs serve very different populations. Both are effective, but patients on methadone had mildly better treatment outcomes.
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http://dx.doi.org/10.1080/08897077.2013.819828DOI Listing
April 2015

2012 Update in addiction medicine for the generalist.

Addict Sci Clin Pract 2013 Mar 13;8. Epub 2013 Mar 13.

Johns Hopkins School of Medicine, Baltimore, MD, USA.

This article presents an update on addiction-related medical literature for the calendar years 2010 and 2011, focusing on studies that have implications for generalist practice. We present articles pertaining to medical comorbidities and complications, prescription drug misuse among patients with chronic pain, screening and brief interventions (SBIs), and pharmacotherapy for addiction.
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http://dx.doi.org/10.1186/1940-0640-8-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3602093PMC
March 2013

Preventing prescription opioid overdose deaths.

J Gen Intern Med 2013 Oct;28(10):1258-9

Johns Hopkins Bayview Medical Center, Baltimore, MD, USA,

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http://dx.doi.org/10.1007/s11606-013-2390-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3785643PMC
October 2013

Entry into primary care-based buprenorphine treatment is associated with identification and treatment of other chronic medical problems.

Addict Sci Clin Pract 2012 Oct 29;7:22. Epub 2012 Oct 29.

Yale University School of Medicine, New Haven, CT, USA.

Background: Buprenorphine is an effective treatment for opioid dependence that can be provided in a primary care setting. Offering this treatment may also facilitate the identification and treatment of other chronic medical conditions.

Methods: We retrospectively reviewed the medical records of 168 patients who presented to a primary care clinic for treatment of opioid dependence and who received a prescription for sublingual buprenorphine within a month of their initial visit.

Results: Of the 168 new patients, 122 (73%) did not report having an established primary care provider at the time of the initial visit. One hundred and twenty-five patients (74%) reported at least one established chronic condition at the initial visit. Of the 215 established diagnoses documented on the initial visit, 146 (68%) were not being actively treated; treatment was initiated for 70 (48%) of these within one year. At least one new chronic medical condition was identified in 47 patients (28%) during the first four months of their care. Treatment was initiated for 39 of the 54 new diagnoses (72%) within the first year.

Conclusions: Offering treatment for opioid dependence with buprenorphine in a primary care practice is associated with the identification and treatment of other chronic medical conditions.
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http://dx.doi.org/10.1186/1940-0640-7-22DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3509402PMC
October 2012

Long-term opioid therapy, aberrant behaviors, and substance misuse: comparison of patients treated by resident and attending physicians in a general medical clinic.

J Opioid Manag 2012 May-Jun;8(3):153-60

Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Objective: To compare rates of opioid prescribing, aberrant behaviors, and indicators of substance misuse in patients prescribed long-term opioids by resident physicians or attending physicians in a general internal medicine practice.

Design: Medical records of 333 patients who were prescribed opioids for at least three consecutive months were reviewed. Aberrant behaviors over a 2-year period were documented, including reporting lost or stolen medications or receiving opioids from more than one provider. Indicators of substance misuse were also recorded, including positive urine drug testing for illicit substances, addiction treatment, overdose, and altering prescriptions.

Results: An estimated 13.6 percent of the patients followed by residents had been prescribed opioids for three or more months; this was significantly higher than the rate for attendings (5.9 percent, p < 0.001). Patients followed by residents were more likely to have reported lost or stolen prescriptions or medication (25.7 percent vs 12.2 percent, p = 0.03) or to have received opioids from another provider (17.8 percent vs 7.6 percent, p = 0.008); they were also more likely to exhibit an indicator of substance misuse (24.8 percent vs 7.6 percent, p < 0.001). However, in multivariate analyses, aberrant behaviors and indicators of substance misuse were not significantly associated with having a resident physician.

Conclusions: Resident physicians at our institution are following a disproportionate number of patients on long-term opioids, many of whom exhibit aberrant behaviors and indicators of substance misuse. This underscores a need for better resident training and supervision to provide effective and safe care for patients with chronic pain.
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http://dx.doi.org/10.5055/jom.2012.0111DOI Listing
August 2012

Learner feedback and educational outcomes with an internet-based ambulatory curriculum: a qualitative and quantitative analysis.

BMC Med Educ 2012 Jul 12;12:55. Epub 2012 Jul 12.

Department of Medicine, Johns Hopkins University, 1800 Orleans Street, Baltimore, MD 21205, USA.

Background: Online medical education curricula offer new tools to teach and evaluate learners. The effect on educational outcomes of using learner feedback to guide curricular revision for online learning is unknown.

Methods: In this study, qualitative analysis of learner feedback gathered from an online curriculum was used to identify themes of learner feedback, and changes to the online curriculum in response to this feedback were tracked. Learner satisfaction and knowledge gains were then compared from before and after implementation of learner feedback.

Results: 37,755 learners from 122 internal medicine residency training programs were studied, including 9437 postgraduate year (PGY)1 residents (24.4 % of learners), 9864 PGY2 residents (25.5 %), 9653 PGY3 residents (25.0 %), and 6605 attending physicians (17.0 %). Qualitative analysis of learner feedback on how to improve the curriculum showed that learners commented most on the overall quality of the educational content, followed by specific comments on the content. When learner feedback was incorporated into curricular revision, learner satisfaction with the instructive value of the curriculum (1 = not instructive; 5 = highly instructive) increased from 3.8 to 4.1 (p < 0.001), and knowledge gains (i.e., post test scores minus pretest scores) increased from 17.0 % to 20.2 % (p < 0.001).

Conclusions: Learners give more feedback on the factual content of a curriculum than on other areas such as interactivity or website design. Incorporating learner feedback into curricular revision was associated with improved educational outcomes. Online curricula should be designed to include a mechanism for learner feedback and that feedback should be used for future curricular revision.
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http://dx.doi.org/10.1186/1472-6920-12-55DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3418189PMC
July 2012

A collaborative approach to teaching medical students how to screen, intervene, and treat substance use disorders.

Subst Abus 2012 ;33(3):286-91

Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Few medical schools require a stand-alone course to develop knowledge and skills relevant to substance use disorders (SUDs). The authors successfully initiated a new course for second-year medical students that used screening, brief intervention, and referral to treatment (SBIRT) as the course foundation. The 15-hour course (39 faculty teaching hours) arose from collaboration between faculty in Departments of Medicine and Psychiatry and included 5 hours of direct patient interaction during clinical demonstrations and in small-group skills development. Pre- and post-exam results suggest that the course had a significant impact on knowledge about SUDs. The authors' experience demonstrates that collaboration between 2 clinical departments can produce a successful second-year medical student course based in SBIRT principles.
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http://dx.doi.org/10.1080/08897077.2011.640090DOI Listing
November 2012

Criminal charges prior to and after initiation of office-based buprenorphine treatment.

Subst Abuse Treat Prev Policy 2012 Mar 19;7:10. Epub 2012 Mar 19.

Albert Einstein College of Medicine/Montefiore Medical Center, 1621 Eastchester Road Bronx, New York 10461, USA.

Background: There is little data on the impact of office-based buprenorphine therapy on criminal activity. The goal of this study was to determine the impact of primary care clinic-based buprenorphine maintenance therapy on rates of criminal charges and the factors associated with criminal charges in the 2 years after initiation of treatment.

Methods: We collected demographic and outcome data on 252 patients who were given at least one prescription for buprenorphine. We searched a public database of criminal charges and recorded criminal charges prior to and after enrollment. We compared the total number of criminal cases and drug cases 2 years before versus 2 years after initiation of treatment.

Results: There was at least one criminal charge made against 38% of the subjects in the 2 years after initiation of treatment; these subjects were more likely to have used heroin, to have injected drugs, to have had any prior criminal charges, and recent criminal charges. There was no significant difference in the number of subjects with any criminal charge or a drug charge before and after initiation of treatment. Likewise, the mean number of all cases and drug cases was not significantly different between the two periods. However, among those who were opioid-negative for 6 or more months in the first year of treatment, there was a significant decline in criminal cases. On multivariable analysis, having recent criminal charges was significantly associated with criminal charges after initiation of treatment (adjusted odds ratio 3.92); subjects who were on opioid maintenance treatment prior to enrollment were significantly less likely to have subsequent criminal charges (adjusted odds ratio 0.52).

Conclusions: Among subjects with prior criminal charges, initiation of office-based buprenorphine treatment did not appear to have a significant impact on subsequent criminal charges.
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http://dx.doi.org/10.1186/1747-597X-7-10DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3359252PMC
March 2012

Safety and effectiveness of a fixed-dose phenobarbital protocol for inpatient benzodiazepine detoxification.

J Subst Abuse Treat 2012 Oct 28;43(3):331-4. Epub 2012 Jan 28.

Center for Chemical Dependence, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224, USA.

Benzodiazepine dependence is a common problem. However, there is limited data on safe and effective detoxification protocols for benzodiazepine-dependent patients. We reviewed the medical records of 310 patients treated with a 3-day fixed-dose phenobarbital taper for benzodiazepine dependence over a 5-year period between 2004 and 2009. We recorded the incidence of seizures, falls, delirium, and emergency department (ED) visits or readmission to our institution within 30 days as markers for safety; we also recorded how many patients had doses held because of sedation. The taper was well tolerated, although one quarter of the patients had at least one dose held because of sedation. There were no seizures, falls, or injuries reported. Six percent had a readmission, and 7% had an ED visit at our institution within 30 days of discharge, but only 3 patients required readmission for withdrawal symptoms. Overall, this protocol appears to be safe and effective.
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http://dx.doi.org/10.1016/j.jsat.2011.12.011DOI Listing
October 2012

Use of an internet-based curriculum to teach internal medicine residents about addiction.

J Addict Med 2010 Dec;4(4):233-5

From the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

Objectives: : Addiction is an important and common health problem. Many internal medicine training programs do not offer structured training in addiction; as a result, residents often report feeling unprepared in caring for patients with this problem. We developed an Internet-based curriculum to teach internal medicine residents about evaluating and treating patients with substance use disorders.

Methods: : Three educational modules on addiction were developed and posted on an established Web site that provides an internal medicine curriculum for training programs throughout the United States. Baseline and posttest questions were tested and validated by having house officers and addiction medicine faculty members complete the tests. We compared baseline pretest scores between first (PGY-1) and third year (PGY-3) residents to assess baseline knowledge and pretest and posttest scores for the entire cohort to assess the impact of the modules.

Results: : Each module was completed by over 1200 residents at 86 different training programs. Although overall baseline pretest scores were better among PGY-3 than PGY-1 residents (mean 58% vs 55%; P < 0.05), the difference between the 2 groups for individual modules was not significant. The mean baseline pretest score was 56.4% and posttest score was 74.8%, a difference that was statistically significant (P < 0.001). When asked to rate the educational value of the program, the residents gave it a mean score of 4.2 on a 5-point Likert scale (1 = not instructive; 5 = highly instructive).

Conclusions: : Internet-based curricula can be an effective tool to disseminate knowledge on addiction to trainees. Learners show an improvement in testing scores and rate these programs highly.
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http://dx.doi.org/10.1097/ADM.0b013e3181cc9fc7DOI Listing
December 2010

Safety of opioids in older adults.

Arch Intern Med 2011 Jun;171(12):1126

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http://dx.doi.org/10.1001/archinternmed.2011.264DOI Listing
June 2011
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