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

Publications (104)

Article
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-b...
Article
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 medi...
Article
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 c...
Article
Full-text available
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 in...
Article
Background Many national guidelines recommend the use of patient provider agreements (PPAs) when prescribing opioids for chronic pain. There are no standards for PPA content, readability, or administration processes.Objective Conduct a national survey of providers who use PPAs to describe the process of administering them, assess views on their uti...
Article
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Background The number of opioid-involved overdose deaths in the United States remains a national crisis. The HEALing Communities Study (HCS) will test whether Communities That HEAL (CTH), a community-engaged intervention, can decrease opioid-involved deaths in intervention communities (n = 33), relative to wait-list communities (n = 34), from four...
Preprint
Full-text available
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 nonpharmacologic treatment aligned with international clinical practice guidelines. Although DCs practice in at least 90 countries, chiropractic care is often not available with...
Article
Background: Many health professionals lack adequate training needed to effectively address alcohol and other drug (AOD)-related problems. Building upon our previously successful in-person faculty training programs, we designed and pilot tested the brief online Faculty Education in Addiction Training (FEAT) Program for social work and internal medic...
Article
Aims The efficacy of screening and brief intervention for lower-risk drug use is unknown. This pilot study tested the efficacy of two brief interventions (BIs) for drug use compared to no BI in primary care patients with lower-risk drug use identified by screening. Methods We randomly assigned participants identified by screening with Alcohol Smok...
Article
On March 6, 2019, a self-designated committee sent a public letter to the Centers for Disease Control and Prevention (CDC) urging the agency to address the widespread misapplication of its 2016 guideline on prescribing opioids. Three hundred and eighteen health care professionals, and three former Directors of the White House Office of National Dru...
Article
Objective: To implement a skills-based faculty development program (FDP) to improve Internal Medicine faculty's clinical skills and resident teaching about safe opioid prescribing. Design: An FDP for Internal Medicine attendings that included a one-hour didactic presentation followed immediately by an Objective Structured Clinical Examination (O...
Article
Background: A national crisis of opioid-related morbidity, mortality, and misuse has led to initiatives to address the appropriate role of opioids to treat pain. Deployment of a guideline from the Centers for Disease Control and Prevention to reduce the risks of opioid therapy has raised substantial clinical and public policy challenges. The agenc...
Article
Objectives: To assess national trends in selected prescription opioid risk mitigation practices and associations with prescriber type, state-specific opioid overdose severity, and required pain education. Methods: Analysis of the national SCOPE of Pain registrants' baseline self-report of five safer opioid prescribing practices over three years...
Article
In the United States, there is a prescription medication misuse crisis including increases in unintentional drug overdose deaths, medications obtained on the illicit market (i.e., diversion), and in the number of individuals seeking treatment for addiction to prescription medications. Neurologists manage patients suffering from conditions (e.g., pa...
Article
Background: Urine drug tests (UDTs) are recommended to monitor patients treated for opioid use disorder in primary care. The aims are to (1) estimate the frequency of self-report and UDT results of opioid and cocaine use and (2) evaluate the association between treatment time with non-disclosure of opioid or cocaine use and having a positive UDT....
Article
This study is an educational evaluation of participants (N = 50) in a 4-day immersion training program funded by the National Institute on Alcohol Abuse and Alcoholism. Using a pretest–posttest design, clinical social work faculty participants showed statistically significant (p < .001) improvement in overall alcohol and other drug-related knowledg...
Article
This study provides up-to-date information on the practices and barriers faced by 50 clinical faculty from 29 Council on Social Work Education-accredited master’s in social work programs across the United States in the integration of alcohol and other drug (AOD) content into social work education. Faculty report that AOD-related content is covered...
Article
This article presents the Alcohol and Other Drugs Education Program (ADEP) as a model for faculty training in evidence-based alcohol and other drug (AOD) identification and treatment. We make the case that AOD use is a serious social and public health issue and highlight faculty training as a strategic approach for addressing the pressing demand fo...
Article
Background: Generalist physicians should play a vital role in identifying and managing individuals with substance use but are inadequately trained to do so. Methods: This 5 year (2008-2012) controlled educational study assessed whether internal medicine and family medicine chief residents’ (CRs) addiction medicine teaching increased by co-training...
Article
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Objective: To develop consensus recommendations on urine drug monitoring (UDM) in patients with chronic pain who are prescribed opioids. Methods: An interdisciplinary group of clinicians with expertise in pain, substance use disorders, and primary care conducted virtual meetings to review relevant literature and existing guidelines and share the...
Article
Importance Prescription opioid misuse is a national crisis. Few interventions have improved adherence to opioid-prescribing guidelines. Objective To determine whether a multicomponent intervention, Transforming Opioid Prescribing in Primary Care (TOPCARE; http://mytopcare.org/), improves guideline adherence while decreasing opioid misuse risk. De...
Article
Objective: Buprenorphine is a highly effective treatment for opioid use disorders, but its continuation in the perioperative setting remains controversial, unlike the accepted practice of perioperative methadone continuation. Methods: We conducted a retrospective cohort study from 2006 to 2014 comparing post-cesarean section opioid analgesic req...
Article
Background: Due to the high prevalence of prescription opioid misuse, the US Food and Drug Administration (FDA) mandated a Risk Evaluation and Mitigation Strategy (REMS) requiring manufacturers of extended-release/long-acting (ER/LA) opioids to fund continuing education based on an FDA curricular Blueprint. This paper describes the Safe and Compet...
Article
Background: Residents feel unprepared to care for patients with chronic pain on long-term opioids who exhibit signs of prescription opioid misuse. Objective: Describe an educational intervention for internal medicine residents to improve confidence, practices, attitudes, and self-reported knowledge of resources for chronic pain and opioid misuse...
Article
Background: In 2012, the US Food and Drug Administration (FDA) responded to the opioid crisis with a Risk Evaluation and Mitigation Strategy, requiring manufacturers of extended-release/long-acting opioids to fund continuing medical education based on the "FDA Blueprint for Prescriber Education." Topics in the Blueprint are "Assessing Patients for...
Article
The increase in overdose deaths from prescription opioids and heroin in the United States over the past 20 years is believed to have resulted from increases in prescription of opioids for management of acute and chronic pain. Managing chronic pain is challenging for primary care clinicians for many reasons, including the lack of evidence to guide p...
Article
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The publication of Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health presents an historic moment not only for the field of addiction medicine, but also for the United States as a nation. The Board of Directors of the Association for Medical Education and Research in Substance Abuse (AMERSA), on behalf of our or...
Article
Aims: In a sample of patients receiving opioid agonist therapy, we evaluated whether having chronic pain was associated with (a) craving for opioids and (b) illicit opioid use. Methods: In a cross-sectional study of adults on buprenorphine or methadone maintenance recruited from an urban medical center, we examined any craving for opioids (prima...
Article
Background: Internal medicine residents care for a sizable number of patients with chronic pain. Programs need educational strategies to promote safe opioid prescribing. Objective: To describe a safe opioid prescribing education program utilizing an objective structured clinical examination (OSCE) and report the resulting impact on residents' kn...
Article
Groups advocating quick fixes to the opioid-misuse epidemic seek regulations limiting opioid availability, but prescriber education is a more finely tuned approach, allowing us to individualize care appropriately after a careful benefit-risk assessment.
Article
BACKGROUND Chronic pain is common among patients with drug use disorders. The prevalence of chronic pain and its consequences in primary care patients who use drugs is unknown. OBJECTIVES To examine: 1) the prevalence of chronic pain and pain-related dysfunction among primary care patients who screen positive for drug use, and 2) the prevalence of...
Article
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Background: The use of brief intervention for decreasing frequent marijuana use holds potential, but its efficacy in primary care is not known. Methods: Objective: To assess the impact of two brief interventions on marijuana use among daily/ or almost daily marijuana users. Design: Subgroup analysis of a 3-arm randomized clinical trial of two...
Article
Full-text available
Due to the high prevalence of prescription opioid misuse, the US Food and Drug Administration (FDA) mandated a Risk Evaluation and Mitigation Strategy (REMS) requiring manufacturers of extended-release/long-acting (ER/LA) opioid analgesics to fund continuing education based on a FDA Blueprint. This article describes the Safe and Competent Opioid Pr...
Article
Patients with opioid use disorders on opioid agonist therapy (OAT) have lower pain tolerance compared to controls. While chronic viral infections such as HCV and HIV have been associated with chronic pain in this population, no studies have examined their impact on pain sensitivity. We recruited 106 adults (41 uninfected controls; 40 HCV mono-infec...
Article
Symptomatic androgen deficiency is common in patients taking opioid analgesics, as these drugs potently suppress the hypothalamic-pituitary-gonadal axis. However, the efficacy of testosterone replacement in this setting remains unclear. The objective of this trial was to evaluate the efficacy of testosterone replacement on pain perception and other...
Article
Importance The United States has invested substantially in screening and brief intervention for illicit drug use and prescription drug misuse, based in part on evidence of efficacy for unhealthy alcohol use. However, it is not a recommended universal preventive service in primary care because of lack of evidence of efficacy.Objective To test the...
Article
This manuscript reviews peer-reviewed literature published from 2010-2012 relevant to the management of chronic pain in the primary care setting. Narrative review of peer-reviewed literature. We searched MEDLINE, PubMed, and reference lists and queried expert contacts for English-language studies related to the management of chronic noncancer pain...
Chapter
Surgery may be required for complications of alcohol use such as the management of traumatic injuries and cancers. Patients with unhealthy alcohol use will also be among those who are planning to undergo surgery for conditions that are unrelated to alcohol use. Alcohol use disorders (AUDs), alcohol-associated chronic medical conditions, and even he...
Chapter
For the primary care clinician treating patients with unhealthy alcohol use, pain syndromes are frequently clinical issues that pose unique challenges relative to the management of low risk or non-alcohol users with pain. Unhealthy alcohol use and its consequences may impact both the assessment and management of pain. Such considerations are partic...
Conference Paper
The MASBIRT program was a federally (SAMHSA) funded cooperative agreement to the Massachusetts Department of Public Health, Bureau of Substance Abuse Services and implemented by Boston Medical Center. Methods: MASBIRT was implemented in 3 medical centers and 5 community health centers in the greater Boston area. Health Promotion Advocates conducted...
Article
It is estimated that approximately 100 million US residents have chronic pain, costing more than $600 billion per year in direct medical treatment and lost productivity costs.1 In the 1980s, several reports began to support use of opioid therapy for chronic noncancer pain.2 Over the ensuing decades, a 4-fold increase in opioid prescribing has occur...
Article
Objectives: Health educators are increasingly being used to deliver preventive care including screening and brief intervention (SBI) for unhealthy substance use (SU) (alcohol or drug). There are few data, however, about the "handoff" of information from health educator to primary care clinician (PCC). Among patients identified with unhealthy SU an...
Article
Data on the effectiveness and safety of long-term opioid therapy for chronic pain are limited. Opioid adherence monitoring includes urine drug testing. Determining whether a patient's opioid prescription should be discontinued after an unexpected urine test result can be clinically complex. To review safe opioid prescribing practices and appropriat...
Article
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We describe universal screening in a large urban hospital-based primary care practice. Trained staff aimed to screen all adult patients presenting for primary care visits between July 2010 and February 2011. Screening included three items about past three-month drug use: frequency of heavy drinking (>3 standard drinks in a day for women and >4 for...
Article
Objectives: Among patients receiving methadone maintenance treatment (MMT) for opioid dependence, receipt of unobserved dosing privileges (take homes) and adequate doses (ie, ≥ 80 mg) are each associated with improved addiction treatment outcomes, but the association with acute care hospitalization is unknown. We studied whether take-home dosing a...
Article
Opioid addiction affects over 2 million patients in the United States. The advent of buprenorphine and the passage of the Drug Addiction Treatment Act in 2000 have revolutionized the opioid treatment delivery system by granting physicians the ability to administer office-based opioid treatment (OBOT), thereby giving patients greater access to treat...
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Objective To compare cancer screening and flu vaccination among persons with and without unhealthy substance use. Design The authors analysed data from 4804 women eligible for mammograms, 4414 eligible for Papanicolou (Pap) smears, 7008 persons eligible for colorectal cancer (CRC) screening and 7017 persons eligible for flu vaccination. All patient...
Article
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Opioid addiction is a chronic disease treatable in primary care settings with buprenorphine hydrochloride, but this treatment remains underused. We describe a collaborative care model for managing opioid addiction with buprenorphine hydrochloride-naloxone hydrochloride dihydrate sublingual tablets. Ours is a cohort study of patients treated for opi...
Article
This study determined the frequency of reporting being introduced to opioids by a physician among opioid-dependent patients. Cross-sectional analyses were performed using baseline data from a cohort of opioid addicts seeking treatment with buprenorphine. The primary outcome was a response to the question: "Who introduced you to opiates?" Covariates...
Article
Abstract Education in substance use disorders remains inadequate in medical training curricula. Although it is a growing health problem, prescription drug abuse is specifically addressed even less comprehensively. This curriculum module provides an overview of prescription drug abuse framed within the common clinical scenario of chronic pain manage...
Conference Paper
MAssachusetts SBIRT screens healthcare patients for unhealthy substance use; those screening positive get a brief intervention, those whose scores indicate possible abuse/dependence are either referred to Brief Treatment (6-12 sessions of manualized treatment based on motivational interviewing and cognitive behavioral therapy) or to more traditiona...
Article
Full-text available
More than 75 million Americans have chronic or recurrent pain.1 Pain accounts for 20% of all outpatient visits2 and more than $100 billion dollars per year in direct (i.e., health care services) and indirect costs (i.e., lost productivity)3; analgesics account for 12% of all prescriptions.4 Chronic pain is a leading cause of work loss, and disabili...
Article
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Article
The efficacy of screening and brief intervention (SBI) for drug use in primary care patients is largely unknown. Because of this lack of evidence, US professional organizations do not recommend it. Yet, a strong theoretical case can be made for drug SBI. Drug use is common and associated with numerous health consequences, patients usually do not se...
Article
Full-text available
Experts recommend opioid treatment agreements and urine drug testing to reduce opioid analgesia misuse, but evidence of their effectiveness has not been systematically reviewed. To synthesize studies of the association of treatment agreements and urine drug testing with opioid misuse outcomes in outpatients with chronic noncancer pain. MEDLINE, Psy...
Article
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Many opioid-dependent patients do not receive care for addiction issues when hospitalized for other medical problems. Based on 3 years of clinical practice, we report the Transitional Opioid Program (TOP) experience using hospitalization as a "reachable moment" to identify and link opioid-dependent persons to addiction treatment from medical care....
Article
Full-text available
Unhealthy substance use is the spectrum from use that risks harm, to use associated with problems, to the diagnosable conditions of substance abuse and dependence, often referred to as substance abuse disorders. Despite the prevalence and impact of unhealthy substance use, medical education in this area remains lacking, not providing physicians wit...
Article
Aim: : To examine the prevalence and risk factors of low vitamin D status (vitamin D deficiency or insufficiency) among patients in a methadone maintenance treatment (MMT) program. Design: : Cross-sectional study of subjects recruited from an MMT program in a higher latitude (Boston, MA). Measurements: : Standardized survey and medical record...