Background
Among health care providers, prescription of HIV pre-exposure prophylaxis (PrEP) has been low. Little is known specifically about primary care physicians (PCPs) with regard to PrEP ...awareness and adoption (i.e., prescription or referral), and factors associated with adoption.
Objective
To assess PrEP awareness, PrEP adoption, and factors associated with adoption among PCPs.
Design
Cross-sectional online survey conducted in April and May 2015.
Respondents
Members of a national professional organization for academic primary care physicians (
n
= 266).
Main Measures
PrEP awareness, PrEP adoption (ever prescribed or referred a patient for PrEP yes/no), provider and practice characteristics, and self-rated knowledge, attitudes, and beliefs associated with adoption.
Key Results
The survey response rate was 8.6 % (266/2093). Ninety-three percent of respondents reported prior awareness of PrEP. Of these, 34.9 % reported PrEP adoption. In multivariable analysis of provider and practice characteristics, compared with non-adopters, adopters were more likely to provide care to more than 50 HIV-positive patients (vs. 0, aOR = 6.82, 95 % CI 2.06–22.52). Compared with non-adopters, adopters were also more likely to report excellent, very good, or good self-rated PrEP knowledge (15.1 %, 33.7 %, 30.2 % vs. 2.5 %, 18.1 %, 23.8 %, respectively;
p
< 0.001) and to perceive PrEP as extremely safe (35.1 % vs. 10.7 %;
p
= 0.002). Compared with non-adopters, adopters were less likely to perceive PrEP as being moderately likely to increase risk behaviors (“risk compensation”) (12.8 % vs. 28.8 %,
p
= 0.02).
Conclusions
While most respondents were aware of PrEP, only one-third of PrEP-aware PCPs reported adoption. Adopters were more likely to have experience providing HIV care and to perceive PrEP as extremely safe, and were less likely to perceive PrEP use as leading to risk compensation. To enhance PCP adoption of PrEP, educational efforts targeting PCPs without HIV care experience should be considered, as well as training those with HIV care experience to be PrEP “clinical champions”. Concerns about safety and risk compensation must also be addressed.
Abstract Objective To determine the impact of cognitive behavioral therapy on outcomes in primary care, office-based buprenorphine/naloxone treatment of opioid dependence. Methods We conducted a ...24-week randomized clinical trial in 141 opioid-dependent patients in a primary care clinic. Patients were randomized to physician management or physician management plus cognitive behavioral therapy. Physician management was brief, manual guided, and medically focused; cognitive behavioral therapy was manual guided and provided for the first 12 weeks of treatment. The primary outcome measures were self-reported frequency of illicit opioid use and the maximum number of consecutive weeks of abstinence from illicit opioids, as documented by urine toxicology and self-report. Results The 2 treatments had similar effectiveness with respect to reduction in the mean self-reported frequency of opioid use, from 5.3 days per week (95% confidence interval, 5.1-5.5) at baseline to 0.4 (95% confidence interval, 0.1-0.6) for the second half of maintenance ( P <.001 for the comparisons of induction and maintenance with baseline), with no differences between the 2 groups ( P =. 96) or between the treatments over time ( P = .44). For the maximum consecutive weeks of opioid abstinence there was a significant main effect of time ( P <.001), but the interaction ( P = .11) and main effect of group ( P = .84) were not significant. No differences were observed on the basis of treatment assignment with respect to cocaine use or study completion. Conclusions Among patients receiving buprenorphine/naloxone in primary care for opioid dependence, the effectiveness of physician management did not differ significantly from that of physician management plus cognitive behavioral therapy.
Abstract A range of innovative computer-based interventions for psychiatric disorders have been developed and are promising for drug use disorders due to reduced cost and greater availability ...compared to traditional treatment. Electronic searches were conducted from 1966 to November 19, 2009, using MEDLINE, Psychlit, and EMBASE. Four hundred sixty-eight nonduplicate records were identified. Two reviewers classified abstracts for study inclusion, resulting in 12 studies of moderate quality. Eleven studies were pilot or full-scale trials compared to a control condition. Interventions showed high acceptability despite substantial variation in type and amount of treatment. Compared to treatment-as-usual, computer-based interventions led to less substance use and higher motivation to change, better retention, and greater knowledge of presented information. Computer-based interventions for drug use disorders have the potential to dramatically expand and alter the landscape of treatment. Evaluation of Internet- and telephone-based delivery that allows for treatment-on-demand in patients' own environment is needed.
To compare the microbiological efficacy of hydrogen peroxide vapor (HPV) and ultraviolet radiation (UVC) for room decontamination.
Prospective observational study.
500-bed teaching hospital.
HPV and ...UVC processes were performed in 15 patient rooms. Five high-touch sites were sampled before and after the processes and aerobic colony counts (ACCs) were determined. Carrier disks with ∼10(6) Clostridium difficile (CD) spores and biological indicators (BIs) with 10(4) and 10(6) Geobacillus stearothermophilus spores were placed in 5 sites before decontamination. After decontamination, CD log reductions were determined and BIs were recorded as growth or no growth.
93% of ACC samples that had growth before HPV did not have growth after HPV, whereas 52% of sites that had growth before UVC did not have growth after UVC (P < .0001). The mean CD log reduction was >6 for HPV and ∼2 for UVC. After HPV 100% of the 10(4) BIs did not grow, and 22% did not grow after UVC, with a range of 7%-53% for the 5 sites. For the 10(6) BIs, 99% did not grow after HPV and 0% did not grow after UVC. Sites out of direct line of sight were significantly more likely to show growth after UVC than after HPV. Mean cycle time was 153 (range, 140-177) min for HPV and 73 (range, 39-100) min for UVC (P < .0001).
Both HPV and UVC reduce bacterial contamination, including spores, in patient rooms, but HPV is significantly more effective. UVC is significantly less effective for sites that are out of direct line of sight.
IMPORTANCE: Prescription opioid dependence is increasing and creates a significant public health burden, but primary care physicians lack evidence-based guidelines to decide between tapering doses ...followed by discontinuation of buprenorphine hydrochloride and naloxone hydrochloride therapy (hereinafter referred to as buprenorphine therapy) or ongoing maintenance therapy. OBJECTIVE: To determine the efficacy of buprenorphine taper vs ongoing maintenance therapy in primary care–based treatment for prescription opioid dependence. DESIGN, SETTING, AND PARTICIPANTS: We conducted a 14-week randomized clinical trial that enrolled 113 patients with prescription opioid dependence from February 17, 2009, through February 1, 2013, in a single primary care site. INTERVENTIONS: Patients were randomized to buprenorphine taper (taper condition) or ongoing buprenorphine maintenance therapy (maintenance condition). The buprenorphine taper was initiated after 6 weeks of stabilization, lasted for 3 weeks, and included medications for opioid withdrawal, after which patients were offered naltrexone treatment. The maintenance group received ongoing buprenorphine therapy. All patients received physician and nurse support and drug counseling. MAIN OUTCOMES AND MEASURES: Illicit opioid use via results of urinanalysis and patient report, treatment retention, and reinitiation of buprenorphine therapy (taper group only). RESULTS: During the trial, the mean percentage of urine samples negative for opioids was lower for patients in the taper group (35.2% 95% CI, 26.2%-44.2%) compared with those in the maintenance group (53.2% 95% CI, 44.3%-62.0%). Patients in the taper group reported more days per week of illicit opioid use than those in the maintenance group once they were no longer receiving buprenorphine (mean use, 1.27 95% CI, 0.60-1.94 vs 0.47 95% CI, 0.19-0.74 days). Patients in the taper group had fewer maximum consecutive weeks of opioid abstinence compared with those in the maintenance group (mean abstinence, 2.70 95% CI, 1.72-3.75 vs 5.20 95% CI, 4.16-6.20 weeks). Patients in the taper group were less likely to complete the trial (6 of 57 11% vs 37 of 56 66%; P < .001). Sixteen patients in the taper group reinitiated buprenorphine treatment after the taper owing to relapse. CONCLUSIONS AND RELEVANCE: Tapering is less efficacious than ongoing maintenance treatment in patients with prescription opioid dependence who receive buprenorphine therapy in primary care. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00555425
Abstract To determine whether treatment outcomes differed for prescription opioid and heroin use disorder patients, we conducted a secondary analysis of a 24-week (N = 140) randomized trial of ...physician management (PM) or PM plus cognitive behavioral therapy (CBT) in primary care buprenorphine/naloxone treatment. Self-reported opioid use and urine toxicology analyses were obtained weekly. We examined baseline demographic differences between primary prescription opioid use patients (n = 49) and primary heroin use patients (n = 91) and evaluated whether treatment response differed by assigned condition. Compared to primary heroin use patients, primary prescription opioid use patients had marginally fewer years of opioid use, were less likely to have had a previous drug treatment or detoxification, and were less likely to report injection drug use. Although opioid abstinence only, and treatment retention did not differ by opioid use group, opioid category moderated the effect of CBT on urine samples negative for all drugs. Primary prescription opioid use patients assigned to PM-CBT had more than twice the mean number of weeks of abstinence for all drugs (7.6) than those assigned to PM only (3.6; p = .02), while primary heroin use patients did not differ by treatment. Findings suggest that examination of other factors that may predict response to behavioral interventions is warranted.
In a randomized trial involving 50 opioid users on a waiting list for detoxification, all 25 users who received interim self-administered buprenorphine pills had complete abstinence over 12 weeks, as ...compared with 3 of the 25 who did not receive buprenorphine.
To the Editor:
Opioid-use disorder has reached epidemic proportions, with high attendant costs in terms of increases in overdoses and infectious diseases and in economic costs.
1
Despite the demonstrated efficacy of maintaining abstinence by treating patients with opioid agonists, patients can remain on clinic waiting lists for months, during which time they are at risk of premature death.
2
The use of interim treatment with buprenorphine without formal counseling while patients remain on waiting lists may mitigate this risk during delays in treatment.
3
In a randomized pilot study (ClinicalTrials.gov number, NCT02360007), we evaluated the efficacy of an interim regimen of buprenorphine . . .
In this randomized trial of addiction treatment in the primary care setting for patients with opioid dependence, brief counseling with once-weekly dispensing of buprenorphine–naloxone did not result ...in different outcomes than extended counseling and thrice-weekly medication dispensing.
In patients with opioid dependence, brief counseling with once-weekly dispensing of buprenorphine–naloxone did not result in different outcomes than extended counseling and thrice-weekly medication dispensing.
Buprenorphine–naloxone treatment of patients dependent on heroin and prescription opioids is more efficacious than placebo and as efficacious as moderate doses of methadone.
1
–
4
Because of its low risk of respiratory depression and abuse, buprenorphine–naloxone is a Schedule III controlled medication.
5
Specially certified office-based physicians can provide this treatment.
6
Previous research has demonstrated the effectiveness of transferring patients from opioid-treatment programs to treatment through physicians' offices.
7
,
8
Buprenorphine–naloxone allows physicians to initiate and manage the treatment of opioid-dependent patients directly in the office.
The appropriate level of contact (e.g., the degree of counseling services and the frequency of prescriptions received) . . .
To determine the ability of a mobile UV light unit to reduce bacterial contamination of environmental surfaces in patient rooms.
An automated mobile UV light unit that emits UV-C light was placed in ...25 patient rooms after patient discharge and operated using a 1- or 2-stage procedure. Aerobic colony counts were calculated for each of 5 standardized high-touch surfaces in the rooms before and after UV light decontamination (UVLD). Clostridium difficile spore log reductions achieved were determined using a modification of the ASTM (American Society for Testing and Materials) International E2197 quantitative disk carrier test method. In-room ozone concentrations during UVLD were measured.
For the 1-stage procedure, mean aerobic colony counts for the 5 high-touch surfaces ranged from 10.6 to 98.2 colony-forming units (CFUs) per Dey/Engley (D/E) plate before UVLD and from 0.3 to 24.0 CFUs per D/E plate after UVLD, with significant reductions for all 5 surfaces (all Formula: see text). Surfaces in direct line of sight were significantly more likely to yield negative culture results after UVLD than before UVLD (all Formula: see text). Mean C. difficile spore log reductions ranged from 1.8 to 2.9. UVLD cycle times ranged from 34.2 to 100.1 minutes. For the 2-stage procedure, mean aerobic colony counts ranged from 10.0 to 89.2 CFUs per D/E plate before UVLD and were 0 CFUs per D/E plate after UVLD, with significant reductions for all 5 high-touch surfaces. UVLD cycle times ranged from 72.1 to 146.3 minutes. In-room ozone concentrations during UVLD ranged from undetectable to 0.012 ppm.
The mobile UV-C light unit significantly reduced aerobic colony counts and C. difficile spores on contaminated surfaces in patient rooms.
•Evaluated cognitive-behavioral therapy (CBT) for opioid use disorder and chronic pain.•CBT was found to be feasible and acceptable.•We found preliminary support for efficacy of CBT in reducing ...nonmedical opioid use.
The primary study aim was to evaluate the feasibility and acceptability of cognitive-behavioral therapy (CBT) for opioid use disorder and chronic pain. The secondary aim was to examine its preliminary efficacy.
In a 12-week pilot randomized clinical trial, 40 methadone-maintained patients were assigned to receive weekly manualized CBT (n = 21) or Methadone Drug Counseling (MDC) to approximate usual drug counseling (n = 19).
Twenty of 21 patients assigned to CBT and 18 of 19 assigned to MDC completed the pilot study. Mean (SD) sessions attended were 8.4 (2.9) for CBT (out of 12 possible) and 3.8 (1.1) for MDC (out of 4 possible); mean (SD) patient satisfaction ratings (scored on 1–7 Likert-type scales) were 6.6 (0.5) for CBT and 6.0 (0.4) for MDC (p < .001). The proportion of patients abstinent during the baseline and each successive 4-week interval was higher for patients assigned to CBT than for those assigned to MDC Wald χ2 (1) = 5.47, p = .02; time effects (p = .69) and interaction effects between treatment condition and time (p = .10) were not significant. Rates of clinically significant change from baseline to end of treatment on pain interference (42.9% vs. 42.1%, χ2 (1, N = 40) = 0.002, p = 0.96) did not differ significantly for patients assigned to CBT or MDC.
We found support for the feasibility, acceptability, and preliminary efficacy of cognitive-behavioral therapy relative to standard drug counseling in promoting abstinence from nonmedical opioid use among patients with opioid use disorder and chronic pain. Overall, patients exhibited improved pain outcomes, but these improvements did not differ significantly by treatment condition.
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