Journal of General Internal Medicine最新文献

Background: With increased legalization and access, many Veterans are using cannabis for medical purposes, yet little is known about Veterans' motives for and experiences of using cannabis, how they make decisions about cannabis use, and if and how clinicians are involved in this decision-making.

Objective: To better understand and highlight Veterans' experiences using cannabis, including their perspectives, information needs, and interactions with clinicians.

Design: Qualitative interview study.

Participants: Twenty-three mostly rural Veterans with past 30-day medical cannabis use living in Connecticut, Michigan, or Oregon-where cannabis is legal.

Approach: In-depth, semi-structured interviews via Webex. We used a qualitative inductive thematic approach, developing an initial codebook then refining as new themes and subthemes emerged.

Key results: Many Veterans viewed cannabis as an important tool to cope with or alleviate symptoms from a variety of health conditions. They primarily relied on the experiences of trusted peers, recommendations from dispensaries, or their own trial-and-error process to gain information about cannabis. Many Veterans perceived few or no harms from cannabis use, and those who did felt that the benefits outweighed the potential risks. Participants described several reasons they were reluctant to engage with VA clinicians about their cannabis use but identified several strategies VA providers could employ to improve engagement including increasing their knowledge of cannabis and engaging patients in unbiased discussions about their use including seeking to understand patients' motivations for use.

Conclusions: Veterans use cannabis for a variety of health conditions. Veterans who use cannabis obtain information about it from sources other than healthcare professionals and may be reluctant to discuss their cannabis use with clinicians despite its relevance to their care. Clinicians can better support their patients who use cannabis by obtaining information and training on the health effects of cannabis and engaging with patients about their use non-judgmentally.

Guidelines recommend chlordiazepoxide or diazepam over lorazepam for alcohol withdrawal due to lorazepam's increased risk of breakthrough symptoms and rebound phenomena, including seizures and delirium. Additionally, diazepam has a shorter time to peak effect than lorazepam, enabling more rapid symptom control and accurate titration to avoid over-sedation. The efficacy of chlordiazepoxide and diazepam for alcohol withdrawal was well established by the mid-1970s, while lorazepam was not approved in the USA until 1977. Despite its inferiority and later approval, lorazepam is the most widely used benzodiazepine for Emergency Department and inpatient alcohol withdrawal management. Therefore, it is notable that the first three studies comparing lorazepam to chlordiazepoxide and diazepam, published in 1983 and 1984, all concluded lorazepam is the "drug of choice." This conclusion is anomalous, as some lorazepam-treated patients developed seizures or delirium tremens, complications not observed with chlordiazepoxide or diazepam. These adverse outcomes were not disclosed in abstracts or discussions but seemingly intentionally concealed within the text. Evidence reveals these studies were ghostwritten by Wyeth, the pharmaceutical company that originally marketed lorazepam. Wyeth sales representatives likely distributed reprint copies of these deceptive "drug of choice" papers to physicians and physicians-in-training, thereby initiating the widespread reiterative intergenerational use of lorazepam for alcohol withdrawal.

Background: Addiction medical care is a core competency for internal medicine residents, yet most hospital systems lack an addiction medicine consult service to provide residents with practice-based learning opportunities.

Aim: Provide medical residents with clinical training in evidence-based approaches to treating substance use disorders.

Setting: Large, urban, academic tertiary care internal medicine residency program PARTICIPANTS: Internal medicine residents on inpatient services PROGRAM DESCRIPTION: Creation of an "educational consult" program where residents caring for patients with substance use disorders discuss cases with an addiction medicine provider to learn patient-relevant addiction medicine principles and management techniques PROGRAM EVALUATION: Over one academic year, 44 educational consults for residents were completed involving 50 unique trainees, mostly focusing on opioid (37, 84%) and alcohol (11, 25%) related topics. Follow-up survey data showed high levels of satisfaction (average 4.9/5 using a Likert scale), with 70% of respondents (20 of 28) reporting that the consult resulted in changes to patient care and 50% of respondents (14 of 28) reporting that the consult changed their approach to future patients.

Discussion: Educational consults are a feasible tool to provide trainees at the graduate medical education level with advanced clinical exposures in settings lacking addiction medicine consult services.

Background: Low-threshold care (LTC) practices for prescribing medication for opioid use disorder (MOUD) systematically remove treatment barriers, increasing access to lifesaving MOUD. Despite its promise, LTC operationalization is unclear and heterogeneous, and lacks standardized measures.

Objective: To develop and test LTC composite measures as useful predictors of implementation outcomes.

Design: This prospective cohort study was embedded within a California state MOUD practice change collaborative involving safety-net primary care clinics.

Participants: Data were collected at baseline, midpoint, and endpoint from 20 clinics.

Intervention: Clinics received a multifaceted implementation-support package designed to improve MOUD delivery.

Main measures: Four LTC scales (LTC12, LTC5, LTC3, LTC2) were developed and tested using team-reported one to five Likert items. Implementation outcomes included Reach (monthly new MOUD patients), Retention (monthly new MOUD patients engaged in treatment after initial diagnosis), and Adoption (active MOUD prescribers). Analyses included repeated-measures ANOVA for LTC change and Poisson GEE for incidence rate ratios, adjusting for panel size, medically underserved area designation, and time.

Key results: Clinics showed significant improvements in LTC scores over time. The LTC12 scale demonstrated the largest effect size (d = 1.18, p = .003). A 1-point increase on the LTC3 index was associated with a 37% increase in new patients receiving MOUD (IRR = 1.37, 95% CI [1.01,1.86], p = .047). A 1-point increase on LTC2 was associated with a 24% increase (IRR = 1.24, 95% CI [1.01,1.53], p = 0.049).

Conclusions: Our findings provide preliminary empirical support for a replicable measure of LTC in primary care settings. Longer scales showed greater internal consistency and sensitivity to change, while brief scales predicted patient reach outcomes. These measures may be useful for clinical programs to gauge the extent to which their MOUD services align with low threshold care principles and to guide quality improvement efforts. Future research should validate these scales in larger, diverse cohorts and test causal impact.