Supervised Disulfiram Should Be Considered First-line Treatment for Alcohol Use Disorder.

Despite the prevalence of alcohol use disorder (AUD) in the United States, the armamentarium of FDA-approved medications available for AUD treatment is remarkably small. Disulfiram, 1 of only 3 approved medications, is consistently designated as a second-line option in national treatment guidelines, citing inconsistent evidence, lack of patient preference, and safety concerns. These concerns, however, stem from a misguided interpretation of the evidence that exclusively relies upon double-blind randomized controlled trials (RCT).

Shared Medical Appointment: A Novel Model for Incorporating Group Visits Into Residency Training for Substance Use Disorders.

Background: Shared medical appointments (SMAs) are a novel modality for treating patients with similar conditions, together, by a team of interdisciplinary providers. SMAs benefit patients with substance use disorder (SUD), but no research has focused on the feasibility of implementation of SMAs in a teaching clinic.

Methods: Primary care residents rotated in a half-day ambulatory addiction clinic for 4 weeks where a third-year resident co-facilitated 4 SMAs.

Preparing Physicians to Treat Addiction: Inclusion of Dedicated Addiction Training During Internal Medicine Residency.

Background: Physicians in internal medicine lack comfort and skills required to diagnose and treat substance use disorder (SUD). Formal training in substance use treatment within primary care training has traditionally been inconsistent and sparse. The purpose of this study is to assess the impact of a longitudinal experiential addiction curriculum on the attitudes and experiences of graduates from a primary care/internal medicine residency program that included formal addiction didactics, rotations in an outpatient addiction clinic embedded within the resident primary care clinic, and exposure to addiction medicine faculty across treatment settings.

Chief resident behaviors that lead to effective morning reports, a multisite qualitative study.

Background: Morning report is a fundamental component of internal medicine training and often represents the most significant teaching responsibility of Chief Residents. We sought to define Chief Resident behaviors essential to leading a successful morning report.

Methods: In 2016, we conducted a multi-site qualitative study using key informant interviews of morning report stakeholders.

The Spectrum of Alcohol Use: Epidemiology, Diagnosis, and Treatment.

In the United States, alcohol is the most common substance used and the spectrum of unhealthy alcohol use is highly prevalent. Complications of unhealthy alcohol use affect nearly every organ system. One of the most frequent and potentially life-threatening of these complications is alcohol withdrawal syndrome for which benzodiazepines remain first-line therapy.

Computerized Cognitive Behavioral Therapy for Substance Use Disorders in a Specialized Primary Care Practice: A Randomized Feasibility Trial to Address the RT Component of SBIRT.

Objectives: Screening, Brief Intervention, and Referral to Treatment (SBIRT) has demonstrated efficacy for addressing unhealthy alcohol use in primary care, yet recent research indicates weaker efficacy for drug use as well as very limited success in referral to specialty care for patients with substance use disorder (SUD). Technology-based interventions for SUD delivered in primary care settings are a potential strategy of efficiently delivering treatment to those who need it.

Methods: We conducted a randomized clinical trial evaluating feasibility, satisfaction, and substance use outcomes for 58 individuals with SUD.

A scalable, automated warm handoff from the emergency department to community sites offering continued medication for opioid use disorder: Lessons learned from the EMBED trial stakeholders.

Background: In order to streamline the emergency department (ED) referral process in a multi-network automated opioid treatment referral program, we performed a needs assessment of community providers for Medication for Opioid Use Disorder (MOUD) in the EMergency department-initiated BuprenorphinE for opioid use Disorder (EMBED) trial network.

Methods: A needs assessment was conducted in two phases: (1) key stakeholder meetings and (2) a survey of community sites offering MOUD. Stakeholder meetings were conducted with five key stakeholder groups: 1) ED clinicians and staff, 2) community sites offering MOUD, 3) the investigative team, 4) health system IT staff, and 5) medical ethics experts.

Physicians Should Play a Role in Ensuring Safe Firearm Ownership.

The USA is unique among industrialized nations in its dramatic rate of firearm violence. Unfortunately, firearm-related issues in America are politically divisive and fraught with controversy, thus impeding the study and implementation of safety strategies. Despite the lack of consensus, there is agreement that firearms should be kept away from individuals with criminal intent and those who are dangerous due to medical impairment.

Efficacy of Extended-Release Naltrexone on HIV-Related and Drinking Outcomes Among HIV-Positive Patients: A Randomized-Controlled Trial.

We sought to test the efficacy of extended-release naltrexone (XR-NTX) on HIV-related and drinking outcomes. From April 2011-February 2015, we conducted a 4-site randomized double-blind placebo controlled clinical trial involving 51 HIV-positive patients with heavy drinking and < 95% antiretroviral (ART) adherence. All participants received counseling.

Pharmacotherapy for Alcohol Use Disorder.

Alcohol use disorder is a common, destructive, and undertreated disease. As understanding of alcohol use disorder has evolved, so has our ability to manage patients with pharmacotherapeutic agents in addition to nondrug therapy, including various counseling strategies. Providers now have a myriad of medications, both approved and not approved by the US Food and Drug Administration, to choose from and can personalize care based on treatment goals, comorbidities, drug interactions, and drug availability.

Addressing discordant quantitative urine buprenorphine and norbuprenorphine levels: Case examples in opioid use disorder.

Introduction: Urine adulteration is a concern among patients treated for opioid use disorder. Quantitative urine testing for buprenorphine (B) and norbuprenorphine (NB), and the appropriate interpretation of B and NB levels, can facilitate constructive conversations with patients that may lead to modifications in the treatment plan, and strengthening of the patient-provider relationship.

Case Summary: Three cases are presented in which discordant urine B and NB levels were recognized.

Objective Structured Clinical Examination-Based Teaching of the Musculoskeletal Examination.

Objectives: Musculoskeletal complaints are the most common presenting illnesses in primary care settings, yet physicians often are underprepared to manage such complaints. We sought to create and evaluate an objective structured clinical examination (OSCE)-based musculoskeletal workshop designed to simultaneously educate medical students and internal medicine residents, enlisting volunteer medical students as standardized patients (SPs).

Methods: The setting for the study was the Yale Primary Care Residency Program.

Interpreting quantitative urine buprenorphine and norbuprenorphine levels in office-based clinical practice.

Background: Quantitative urine buprenorphine testing is used to monitor patients receiving buprenorphine for the treatment of opioid use disorder (OUD), however the interpretation of urine buprenorphine testing is complex. Currently, interpretation of quantitative buprenorphine testing is guided by data from drug assay development studies and forensic labs rather than clinical treatment cohorts.

Methods: In this retrospective study, we describe the patterns of urine buprenorphine and norbuprenorphine levels in patients prescribed sublingual buprenorphine for OUD in an office-based addiction treatment clinic.

The Addiction Recovery Clinic: A Novel, Primary-Care-Based Approach to Teaching Addiction Medicine.

Problem: Substance use is highly prevalent in the United States, but little time in the curriculum is devoted to training internal medicine residents in addiction medicine.

Approach: In 2014, the authors developed and launched the Addiction Recovery Clinic (ARC) to address this educational gap while also providing outpatient clinical services to patients with substance use disorders. The ARC is embedded within the residency primary care practice and is staffed by three to four internal medicine residents, two board-certified addiction medicine specialists, one chief resident, and one psychologist.

Resident and Faculty Perceptions of Chart-Stimulated Recall.

Objectives: Chart-stimulated recall (CSR) is a case-based interviewing technique advocated by the Accreditation Council for Graduate Medical Education as an assessment tool across a variety of clinical competencies, yet resident and faculty perceptions of this exercise have not been reported previously. The authors incorporated a CSR exercise into an internal medicine residency program and sought to assess the perceptions of residents and faculty participants.

Methods: Faculty met weekly with night float residents at the end of their shift.

Instruments to assess patient-reported safety, efficacy, or misuse of current opioid therapy for chronic pain: a systematic review.

The purpose of this systematic review was to summarize and critically appraise research developing or validating instruments to assess patient-reported safety, efficacy, and/or misuse in ongoing opioid therapy for chronic pain. Our search included the following datasets: OvidSP MEDLINE (1946-August 2012), OvidSP PsycINFO (1967-August 2012), Elsevier Scopus (1947-August 2012), OvidSP HaPI (1985-August 2012), and EBSCO CINAHL (1981-August 2012). Eligible studies were published in English and pertained to adult, nonsurgical/interventional populations.

Physician detection of unhealthy substance use on inpatient teaching and hospitalist medical services.

Background: Screening, brief intervention, and referral to treatment for substance use depends on reliable identification. The goal of this study was to determine the rate of detection of unhealthy substance use by physicians on teaching and nonteaching medical services at a community teaching hospital.

Methods: This cross-sectional study was conducted from February to June 2009.

Prevalence of unhealthy substance use on teaching and hospitalist medical services: implications for education.

The prevalence of unhealthy substance use (USU) among medical inpatients can vary, and prior research has not characterized the prevalence of USU among patients cared for by a teaching service (TS) and a nonteaching hospitalist service (NTHS). The objective of this study was to compare the prevalence of USU among patients cared for by a TS and an NTHS. We conducted a cross-sectional study from February to June 2009 at a community teaching hospital.

Temperature dependent modulation of lobster neuromuscular properties by serotonin.

In cold-blooded species the efficacy of neuromuscular function depends both on the thermal environmental of the animal's habitat and on the concentrations of modulatory hormones circulating within the animal's body. The goal of this study is to examine how temperature variation within an ecologically relevant range affects neuromuscular function and its modulation by the neurohormone serotonin (5-HT) in Homarus americanus, a lobster species that inhabits a broad thermal range in the wild. The synaptic strength of the excitatory and inhibitory motoneurons innervating the lobster dactyl opener muscle depends on temperature, with the strongest neurally evoked muscle movements being elicited at cold (<5 degrees C) temperatures.