Daniel P Alford’s research while affiliated with Boston Medical Center and other places

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Publications (110)


Delivering Education Through a Podcast to Change Provider Practice: A Mixed Methods Evaluation of a Fetal Alcohol Spectrum Disorders Podcast
  • Article

November 2024

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9 Reads

Pedagogy in Health Promotion

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Daniel P. Alford

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Jacqueline German

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[...]

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Education delivery through multi-media such as podcasts has become more common yet impacts on behavior change are understudied. To address this, we evaluated an educational podcast available for continuing education (CE) credit to all providers but specifically tailored for children and/or women-focused specialties (i.e., family medicine, OBGYN, pediatric, prenatal, primary care). The podcast consisted of three 20-minute episodes focused on: (1) prevalence of Fetal Alcohol Spectrum Disorders (FASDs); (2) perspectives from those with lived experience; and (3) treatment and prevention of FASDs at the provider level. Podcast effectiveness to educate providers was assessed using a mixed-methods evaluation. Participants completed registration information and an immediate post-test, which examined provider knowledge, self-efficacy, and practice behaviors related to FASD prevention. Qualitative data was collected from a sample of those who completed the post-test via focus groups conducted 6 months later. From March 2021 to March 2022 there were 579 listeners with 103 claiming CE credit (the evaluation sample) who participated in the evaluation. Participants reported high FASD-related knowledge; more than 85% were better able to educate patients about prenatal alcohol use risk and FASDs post-podcast. The majority (59.3%) intended to change practice based on what they learned. Qualitative results contextualized the benefits and challenges to changing practice, including structural barriers, and suggestions for enhancing the podcast in future seasons. Education delivered through podcasts can be effective in improving provider knowledge and self-efficacy and in promoting practice change. Podcasts offer broad reach and accessibility providing an opportunity to educate on topics including FASD.





Fig. 1. Monthly Alcohol Screening Rates and COVID-19 Case Counts, Boston MA, July 2019-May 2022.
Alcohol Screening During COVID-19 Surges in an Urban Health System the United States
  • Article
  • Full-text available

April 2023

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17 Reads

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2 Citations

Preventive Medicine Reports

In 2021, over 50% of U.S. adults drank alcohol in the past month with over 25% reporting binge drinking, an increase over previous years. Alcohol use is associated with increased risk of accidents, poor birth outcomes, cancer, chronic diseases, and mortality. During the COVID-19 pandemic alcohol consumption and alcohol-related deaths increased. National organizations recommend screening for unhealthy alcohol use in general health care settings as a prevention strategy. This observational study examined alcohol screening rates in primary care practices in Boston, MA in the context of the COVID-19 pandemic, from July 2019 through May 2022. Screening rates were mapped, by month, to the number of COVID-19 cases. Alcohol screening dropped substantially during the first COVID-19 surge but steadily increased to baseline between the second and third surges. This decline was likely due to competing pandemic-related priorities (e.g., testing, urgent care) and the transition to telemedicine. While some health screening cannot be completed virtually, screening for alcohol is possible. Innovative workflow strategies (e.g., pre-visit screening via patient portals, support staff screening using virtual rooming processes) should be considered to avoid future interruptions of screening for unhealthy alcohol use in primary care.

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Publications by 2007-2019 CARE MSSRP Participants with their faculty mentor.
Continued.
Evaluation of a student clinical research education program in addiction medicine

January 2023

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58 Reads

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7 Citations

Objective To evaluate an experiential student clinical addiction research program by analyzing its components, evaluation survey data, and scientific outputs. Methods In 1995, we established a summer research program supporting trainees to gain exposure to clinical addiction research careers. This curriculum employed a three-pronged approach that combined mentored research training, didactic education, and clinical observerships for medical students and other trainees to acquire experience with addiction medicine and research. Utilizing the Kirkpatrick model as program evaluation framework, we analyzed evaluation data from programmatic surveys (didactic seminar evaluations, overall program surveys) and conducted qualitative feedback exploration. Results Between 2007 and 2019, 56 trainees and 26 faculty mentors participated in the curriculum. To date, 25 students published 38 papers with their faculty mentor. Analysis of the past 12 years of program evaluation data demonstrated that students highly valued individually-mentored research experiences. They indicated that seminars familiarized them with the foundations of different clinical care models and career trajectories in addiction medicine. Clinical observerships provided students with patient contacts in various multidisciplinary addiction treatment settings. These experiences, perhaps most importantly hearing about patients’ lived experiences, meaningfully informed various research and didactic activities. Conclusions This summer student research program successfully introduced students to addiction medicine and research, manifested by high peer-reviewed publication productivity. While our program engaged and involved committed mentors and inspired mentees to pursue professional paths in addiction research, it did not specifically incorporate attention to equity and diversity into program planning and implementation. Going forward, the program will improve equity by increasing the recruitment of trainees from disadvantaged groups and engaging underrepresented faculty. KEY MESSAGES Summer programs can be effective in engaging medical students and trainees in research early in their trajectory and inspire them to incorporate research into their careers. Programs that integrate experiential addiction research learning, i.e. mentored research activities, didactic sessions, and clinical observerships, can provide trainees with a profound understanding of substance use disorder treatment and research.


Exploring perspectives on changing opioid prescribing practices: A qualitative study of community stakeholders in the HEALing Communities Study

February 2022

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37 Reads

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12 Citations

Drug and Alcohol Dependence

Background Community-based perspectives are needed to more broadly inform policy-makers, public health practitioners, prescribers, and pharmacists about community-led and broader efforts to reduce opioid overprescribing, and ultimately reduce prescription opioid use disorder, overdoses and fatalities. The aim of this study is to explore community-based perspectives on efforts to change opioid prescribing practices in their communities. Methods Semi-structured interviews were conducted with 388 community stakeholders across four states (Kentucky, Massachusetts, New York, Ohio) from November 2019 to January 2020 about community approaches and goals of community-led responses to the opioid crisis. Data analysis combined deductive and inductive approaches to identify themes and sub-themes related to improving opioid prescribing practices. Results Three major themes and different subthemes were characterized: (1) acknowledging progress (i.e., healthcare providers being part of the solution, provider education, and prescription drug monitoring programs); (2) emergent challenges (i.e., physician nonadherence with safer opioid prescribing guidelines, difficulty identifying appropriate use of opioids, and concerns about accelerating the progression from opioid misuse to drug abuse); and (3) opportunities for change (i.e., educating patients about safer use and proper disposal of opioids, expanding prescriber and pharmacist education, changing unrealistic expectations around eliminating pain, expanding and increasing insurance coverage for alternative treatment options). Conclusions Community stakeholders appeared to support specific opportunities to reduce prescription opioid misuse and improve safer prescribing. The opportunities included culture change around pain expectations, awareness of safe disposal, additional provider education, and increased coverage and acceptability of non-opioid treatments.


Prevalence and Correlates of Positive Follow-up Screens in Primary Care for Unhealthy Alcohol and Other Drug Use After a Negative Screen

November 2021

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9 Reads

Journal of Addiction Medicine

Objective: To determine the proportion and characteristics of adults in primary care (PC) who screen positive for unhealthy substance use (SU) (alcohol and/or other drug) 1 year or more after screening negative. Methods: Screening consisted of single-item questions for unhealthy use of alcohol and other drugs (illicit drugs and prescription medications). Health educators conducted in-person screening of patients presenting for a PC appointment. SU severity (low, moderate, high) was assessed with the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). Multivariate logistic regression models estimated predictors of a positive follow-up screen. Results: Among 9215 patients who previously screened negative, 237 (2.6%) screened positive for unhealthy SU (42% alcohol only, 43% other drug only, 15% alcohol and other drug). The mean interval between screens was 19 months. Most alcohol use was low risk (ASSIST score ≤ 10) (81%), whereas most drug use was moderate risk (ASSIST score 4-26) (77%). Patients between ages of 18 to 25 had a higher proportion of positive follow-up screens (7.4% [33/443]) as well as those with a self-identified history of SU problems (9.4% [40/421]). Patients with a higher odds of a positive follow-up screen were male (adjusted odds ratio [AOR] 2.64; 95% CI: 2.02-3.45), used tobacco (AOR 2.38; 95% CI: 1.75-3.23), had a longer interval between screenings (AOR 3.26; 95% CI: 1.84-5.75). Conclusions: Screening for unhealthy SU 1 year or more after screening negative identified additional patients at-risk. These findings highlight the need to empirically determine the incremental benefits of screening all PC patients annually.


Operational Definition and Illustrative Examples of UDT Outcome Classification as Not Concerning, Uncertain, and Concerning by UDT Test Result
Do Urine Drug Tests Reveal Substance Misuse Among Patients Prescribed Opioids for Chronic Pain?

August 2021

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47 Reads

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6 Citations

Journal of General Internal Medicine

Background Urine drug testing (UDT) is a recommended risk mitigation strategy for patients prescribed opioids for chronic pain, but evidence that UDT supports identification of substance misuse is limited.Objective Identify the prevalence of UDT results that may identify substance misuse, including diversion, among patients prescribed opioids for chronic pain.DesignRetrospective cohort study.SubjectsPatients (n=638) receiving opioids for chronic pain who had one or more UDTs, examining up to eight substances per sample, during a one 1-year period.Main MeasuresExperts adjudicated the clinical concern that UDT results suggest substance misuse or diversion as not concerning, uncertain, or concerning.Key ResultsOf 638 patients, 48% were female and 49% were over age 55 years. Patients had a median of three UDTs during the intervention year. We identified 37% of patients (235/638) with ≥1 concerning UDT and a further 35% (222/638) having ≥1 uncertain UDT. We found concerning UDTs due to non-detection of a prescribed substance in 24% (156/638) of patients and detection of a non-prescribed substance in 23% (147/638). Compared to patients over 65 years, those aged 18–34 years were more likely to have concerning UDT results with an adjusted odds ratio (AOR) of 4.8 (95% confidence interval [CI] 1.9–12.5). Patients with mental health diagnoses (AOR 1.6 [95% CI 1.1–2.3]) and substance use diagnoses (AOR 2.3 [95% CI 1.5–3.7]) were more likely to have a concerning UDT result.Conclusions Expert adjudication of UDT results identified clinical concern for substance misuse in 37% of patients receiving opioids for chronic pain. Further research is needed to determine if UDTs impact clinical practice or patient-related outcomes.


Figure 1 Key concepts for scoping review organised by sudy question and the three domains of the proctor conceptual model for implementation research.
Doctors of chiropractic working with or within integrated healthcare delivery systems: A scoping review protocol

January 2021

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101 Reads

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2 Citations

BMJ Open

Introduction Back and neck pain are the leading causes of disability worldwide. Doctors of chiropractic (DCs) are trained to manage these common conditions and can provide non-pharmacological treatment aligned with international clinical practice guidelines. Although DCs practice in over 90 countries, chiropractic care is rarely available within integrated healthcare delivery systems. A lack of DCs in private practice, particularly in low-income communities, may also limit access to chiropractic care. Improving collaboration between medical providers and community-based DCs, or embedding DCs in medical settings such as hospitals or community health centres, will improve access to evidence-based care for musculoskeletal conditions. Methods and analyses This scoping review will map studies of DCs working with or within integrated healthcare delivery systems. We will use the recommended six-step approach for scoping reviews. We will search three electronic data bases including Medline, Embase and Web of Science. Two investigators will independently review all titles and abstracts to identify relevant records, screen the full-text articles of potentially admissible records, and systematically extract data from selected articles. We will include studies published in English from 1998 to 2020 describing medical settings that have established formal relationships with community-based DCs (eg, shared medical record) or where DCs practice in medical settings. Data extraction and reporting will be guided by the Proctor Conceptual Model for Implementation Research, which has three domains: clinical intervention, implementation strategies and outcome measurement. Stakeholders from diverse clinical fields will offer feedback on the implications of our findings via a web-based survey. Ethics and dissemination Ethics approval will not be obtained for this review of published and publicly accessible data, but will be obtained for the web-based survey. Our results will be disseminated through conference presentations and a peer-reviewed publication. Our findings will inform implementation strategies that support the adoption of chiropractic care within integrated healthcare delivery systems.


Citations (69)


... A model that can be applied is similar to that used for the treatment of OUD and includes a combination of methadone, buprenorphine, and naltrexone. 83 De novo initiation or changing dosing of these medications should be done in consultation with either an acute pain service or the patient's prescribing physician. ...

Reference:

Current Practices and Recent Advances in Perioperative Pain Management for Liver Transplantation Living Donors and Recipients
Treatment of opioid use disorder in patients with liver disease
  • Citing Article
  • May 2024

Clinical Liver Disease

... Thus, a variety of education initiatives and training programs in medicine during summer or winter holidays have been developed in recent years, with the objective being to complement traditional academic curricula (13)(14)(15)(16)(17)(18)(19). ...

Evaluation of a student clinical research education program in addiction medicine

... These meetings were held between July 2022 and December 2022 by the second author, trained in conducting semi-structured interviews using an interview guide drawn from the literature (Appendix S1). 23,27 The first part of the guide aimed to explore the habits and daily practices of pain physicians. The second part explored pain physicians' perceptions of opioid deprescribing. ...

Exploring perspectives on changing opioid prescribing practices: A qualitative study of community stakeholders in the HEALing Communities Study
  • Citing Article
  • February 2022

Drug and Alcohol Dependence

... [1][2][3] However, evidence to support the clinical utility of UDT in monitoring patients on LTOT is lacking. [3][4][5] Testing based on perceived aberrant behaviors alone has been shown to be ineffective, prone to clinician biases, and can result in decision making based on stereotypes. [6][7][8] Routine periodic screening for potential opioid misuse-where patients on LTOT undergo UDT 1 to 3 or more times per year-is now recommended in national care guidelines with the aim of providing standardized and more equitable monitoring. ...

Do Urine Drug Tests Reveal Substance Misuse Among Patients Prescribed Opioids for Chronic Pain?

Journal of General Internal Medicine

... Conventionally, chiropractic care is delivered in a monodisciplinary environment separate from allopathic medical clinics or integrated primary care centres [19], which further contributes to the uncertainty and concern of the chiropractic professional from other health providers [20]. In Australia, most people with LBP will access a medical practitioner first, with only 19% seeking chiropractic care as a first point of contact [21]. ...

Doctors of chiropractic working with or within integrated healthcare delivery systems: A scoping review protocol

BMJ Open

... Some healthcare providers who actually use consent forms question whether they reduce the risk of opioid analgesic misuse because their content is difficult to understand and they require a reading comprehension level above that of most patients [127]. A survey in the United States also reported that the percentage of primary care physicians who used consent forms when prescribing opioid analgesics for non-cancer chronic pain varied widely, with an average of 48% (9%-84%) [128]. ...

A National Survey on Patient Provider Agreements When Prescribing Opioids for Chronic Pain
  • Citing Article
  • January 2021

Journal of General Internal Medicine

... Communities were randomized to either receive the CTH first (Wave 1; n = 34) or serve as the wait-list control group (Wave 2; n = 33) to receive the CTH after the HCS comparison period was completed [7]. The CTH intervention includes three components: (a) a process for community coalition-driven decision making around the deployment/ of EBPs guided by a data-driven approach to reduce opioid overdose deaths [8], (b) a set of EBPs with demonstrated efficacy and effectiveness in reducing overdoses and treating OUD [9], and (c) health campaigns to drive demand for EBPs, reduce stigma toward OUD treatment, and inform people about availability of OUD-related services [2]. Priority target groups for the campaigns included community leaders, people at risk for an overdose or with OUD, and family and friends of those at risk. ...

The Opioid-overdose Reduction Continuum of Care Approach (ORCCA): Evidence-based practices in the HEALing Communities Study

Drug and Alcohol Dependence

... This simple measure will also potentially divert patients away from waiting lists for government addiction clinics (in-patient). There is evidence which supports the effectiveness of delivering brief interventions in primary care contexts to reduce alcohol, tobacco and drug use (Bertholet et al., 2020;Mattoo et al., 2018;Pilowsky & Wu, 2012). Other adjunct modalities to support physicians when managing SUD in primary care include effective technology-based interventions which promote work-place learning, adherence, routine urine and blood-borne virus screening, self-management and substance use abstinence (Van Hout et al., 2018a). ...

Screening and brief intervention for lower-risk drug use in primary care: A pilot randomized trial
  • Citing Article
  • April 2020

Drug and Alcohol Dependence

... [24][25][26][27] Generally, these projects intended to identify core clinical competences required when caring for these patients. [28][29][30][31][32] Current addiction clinical practices and related clinical difficulties have been scarcely studied to explore resistance. Existing research has mainly focused on the perception of working with these patients using standard scales 8,33 or the experience of care from the patient perspective. ...

Medicine, with a focus on physicians: Addressing substance use in the 21st century
  • Citing Article
  • November 2019

Substance Abuse

... While these policies have been associated with decreased prescribing, 4 there is concern that they have also resulted in negative consequences for the estimated 5-8 million patients receiving opioid therapy for chronic pain, 5 including limited access to primary care and specialty pain care. [6][7][8][9][10] Recent secret shopper studies have found that approximately 40% of primary care clinics were unwilling to schedule a new primary care appointment for simulated patients seeking a provider to manage an existing opioid prescription, 11,12 and that nearly a quarter of specialty pain clinics in the state of Michigan (23%) did not offer patients medication management. 13 Moreover, 48% of these pain clinics did not accept Medicaid and 55% required a referral from a primary care provider, further limiting access to pain care for a patient population that struggles to access primary care. ...

Opioid discontinuation as an institutional mandate: Questions and answers on why we wrote to the Centers for Disease Control and Prevention
  • Citing Article
  • July 2019

Substance Abuse