Context: Interpersonal communication is inherent in a majority of strategies seeking to engage prescriber and dispenser health care professionals (HCPs) in the reduction and prevention of prescription drug abuse (PDA). However, research is lacking on HCP PDA communicative behavioral engagement and factors that influence it. Objective: To describe PDA-related communicative behaviors and perceptions of primary care prescribers and community pharmacists. Design: Qualitative, semi-structured interprofessional and profession-specific focus groups were conducted, transcribed, coded, and thematically analyzed by two researchers. Established communication domains (communication apprehension, self-perceived communication competence, and willingness to communicate) guided focus group interviews. Setting: Appalachian Research Network (AppNET) PBRN clinics and communities. Participants: AppNET primary care prescribers (N=19) and community pharmacists (N=16). Main and Secondary Outcome Measures: Inductively derived themes resulting from focus groups. Results: Twelve themes were noted across two communication domains: HCP-patient communication (N=6) and HCP-HCP communication (N=6). HCP-patient communication engagement was influenced by multiple patient factors, with objective data (e.g., urine drug screens, distance travelled to practice) weighed heavily. Multiple practice barriers to communication were noted, including time pressures and a lack of screening resources. Difficult or uncomfortable conversations were often avoided by HCPs and substituted with simplified prescribing/dispensing conversations or policies. Dispenser to prescriber and prescriber to dispenser communication was described as rare and often perceived to be ineffective. Counter-intuitively, prescriber to dispenser communication was reported to have decreased after implementation of state prescription drug monitoring programs. Dispensers reported not being perceived as colleagues or teammates to prescribers in prescription drug abuse prevention and treatment. Prescribing behaviors were often questioned by dispensers, and some prescribers questioned dispensing behaviors. Conclusions: HCP prescription drug abuse communication is situational and influenced by patient, practice, and HCP characteristics. Identified themes will inform development of PDA-specific communication assessments that can be used to target and evaluate PDA communication interventions.

No description available.

For patients afflicted with symptoms of anxiety and insomnia, benzodiazepines are generally a safe and effective short-term pharmacological treatment option. Although considered safer than other sedative-hypnotic medications, substantial concern exists regarding the addictive nature and abuse potential of benzodiazepines along with potentially inappropriate prescribing and utilization in clinically vulnerable populations. These medication misadventures can have a significant impact on public health. Examples of medication misadventures as they pertain to benzodiazepines include the prescribing and use in clinically vulnerable populations for whom they are contraindicated or their efficacy has not been evaluated, the development of tolerance or addiction, abuse of the medication, and the manifestation of negative health outcomes including cognitive impairment, withdrawal symptoms upon discontinuation, or the reoccurrence of a preexisting substance use disorder. In order to better understand medication misadventures associated with benzodiazepines retrospective analyses using populations extracted from large health claims databases are employed. To understand how benzodiazepine use may lead to adverse events causing patient harm, the risk of exacerbations in benzodiazepine users diagnosed with chronic obstructive pulmonary disease was estimated. The inherent risk of benzodiazepine addiction and abuse was estimated in an HIV-infected population, a population with a high prevalence of substance use disorders. This risk was estimated by first determining whether HIV-infected individuals are more likely to have any benzodiazepine use compared to their uninfected counterparts, and secondly, by examining the association between HIV-infection and potentially problematic benzodiazepine use. Finally, in an effort to mitigate unexpected and undesirable consequences to public health associated with the prescription drug abuse epidemic in the US, states have implemented prescription drug monitoring programs (PDMPs) to track the prescribing and dispensing of controlled substance medications. The effect of these programs on benzodiazepine dispensing is evaluated on a state and national level. Findings will provide healthcare professionals a better understanding regarding the risk of medication misadventures involving benzodiazepines when evaluating their appropriateness in patients with anxiety, depression, and insomnia. Additionally, policymakers will understand the implications of PDMPs on the dispensing of benzodiazepines as they become a more widely used tool to combat prescription drug abuse and diversion.

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal

Thesis (Ph. D.)--RAND Graduate School, 2005. / Includes bibliographical references.

La prescription extinctive a fait l’objet de nombreuses études en droit privé ou en droit pénal. Elle constitue à l’inverse un angle mort de la recherche en droit public. La réforme opérée en matière civile par la loi du 17 juin 2008, ainsi que le renouveau contemporain du débat sur l’existence d’une théorie générale des obligations publiques, justifient pourtant une analyse approfondie en droit public. Prenant ses racines dans le Code civil, la prescription extinctive tient une place non négligeable dans les rapports obligataires des personnes publiques. La multiplication des prescriptions propres au droit public, notamment en raison d’impératifs budgétaires, oblige toutefois à identifier ce qu’elle recouvre précisément. Fondée sur la sécurité juridique, elle se distingue d’autres mécanismes similaires en emportant l’extinction de l’exigibilité de l’obligation. De ce fait, elle connaît un essor important et s’étend à la plupart des obligations publiques, même si elle doit être conciliée avec la nécessité d’intérêt général d’obtenir le paiement des obligations.Si la prescription extinctive existe bien en droit public, elle a toutefois été adaptée aux caractéristiques propres de cette matière. Bien que le Code civil ait longtemps imposé le recours aux règles du droit privé, le juge administratif n’en avait pas moins conservé une certaine autonomie. En supprimant l’application du droit privé aux rapports obligataires des personnes publiques, la réforme du 17 juin 2008 a rendu le droit public de la prescription autonome. Cette autonomie devrait néanmoins être consolidée par la voie d’une réforme législative, réorganisant les prescriptions disparates, et comblant les lacunes existantes. Une telle intervention serait également l’occasion de constater l’originalité de la prescription extinctive en droit public. Son fonctionnement (point de départ, suspension, interruption, opposition, renonciation, etc.) reste gouverné par de nombreuses spécificités dues à la double appartenance de la prescription aux règles de la légalité administrative et financière. Elle souligne en définitive l’irréductible spécificité du droit public. / Extinctive prescription has been the subject of numerous studies both in public and private laws. In contrast it is a dead angle in Public Law research. The reform put in place in the civil domain by the June 17, 2008 Act, as well as a renewed interest in the debate about the existence of a general theory of public obligations, warrant a deep analysis. Having its roots in the civil code, the extinctive prescription holds an important place among the contractual or legal relationship of public persons. The significant increase of prescriptions specific to public law, partly due to budgetary need, however requires identifying what it exactly entails. Based on legal certainty, it differs from other mechanisms that are close to it, by leading to the termination of liability for payment. Hence, it sees a significant expansion and now extends to most public obligations, even though it has to be reconciled with the need of general interest to get payment of obligations.If the extinctive prescription does exist in public law, it has however been adapted to the inherent characteristics of this subject. Even though the Civil Code has imposed the use of private law rules for long, the administrative judge had retained some autonomy. By removing the use of private law from contractual or legal relationship of public persons, the June 17, 2008 reform has made prescription in public law independent. This autonomy should be enhanced through a legislative reform, both reorganizing the existing prescriptions and filling existing gaps. Such intervention would be an opportunity to observe the originality of extinctive prescription in public law. Its operation (starting point, suspension, interruption, waiver, etc.) remains governed by numerous characteristics due to dual ownership of prescription to the rules of administrative and financial legality. It eventually highlights the undeniable specificity of public law.

Notre thèse s’inscrit dans la lignée d’un premier travail de recherche durant lequel nous avions mis en évidence le recours par les préventeurs à l’accommodation de certaines consignes au cours des visites de sécurité. Ce résultat a suscité de nouveaux questionnements quant aux conséquences de ce phénomène sur leur santé mais aussi sur les performances du système de management de la sécurité. Notre travail de thèse s’est ainsi centré sur la caractérisation des difficultés rencontrées par les préventeurs lors des séquences de résolution de problèmes initiées par la mise en évidence d’écarts à la prescription au cours de la visite de sécurité mais aussi sur l’identification des déterminants méthodologiques qui en sont à l’origine. Trois méthodes ont été utilisées : des relevés des traces de l’activité à l’aide de la méthode de l’agenda, des observations ouvertes de l’activité d’un échantillon préventeurs en entreprise et des observations systématiques des phases de visites de sécurité couplées à des techniques de verbalisations. Les principaux résultats de cette thèse sont que : (i) les préventeurs en entreprise ne consacrent que très peu de temps aux visites de sécurité, (ii) ce phénomène de "désertion" du terrain ne peut être uniquement expliqué par le poids des tâches administratives, (iii) le contexte temporel dans lequel sont réalisées les visites de sécurité et l’absence d’artefact support pour les échanges ne favorisent pas le développement du phénomène de synchronisation cognitive puisque tous les écarts ne sont pas levés par des solutions explicitement approuvées par l’ensemble des interlocuteurs, (iv) les préventeurs développent des stratégies de défense pour réduire les effets de ce manque de performance sur leur santé, (v) les modifications du contexte temporel et l’intégration de l’artefact vidéo facilitant les échanges permettent d’améliorer les performances en matière de résolution de problèmes et de développer dans quelques mesures la santé des préventeurs; les solutions produites sont alors plus nombreuses ou plus complexes, les échanges plus riches et les contraintes mieux gérées. Les résultats de cette thèse permettent à la fois de poursuivre la caractérisation du travail des préventeurs en entreprise, de rendre compte des effets de l’autoconfrontation sur les interviewers mais aussi de proposer une méthode de conception d’artefact basée sur l’approche instrumentale qui facilite l’appropriation. / Our thesis is in line with a first research work in which we highlighted the use by OSH to accommodation of some instructions during safety inspections. This has raised new questions about the consequences of this phenomenon on the health of the OSH but also on the performance of the safety management system. Our thesis then focused on the characterization of the difficulties encountered by OSH during problem solving sequences initiated by the detection of deviations from the prescription safety during the visit, but also on identifying methodological determinants that are at the origin. Three methods were used: statement traces of the activity using the method of the agenda, open observations of the activity of a sample of OSH enterprises and systematic observations visit phases security coupled with verbalisation techniques. The main results of this thesis are: (i) OSH in companies only spend very little time for safety inspections, (ii) the phenomenon of "desertion" of the land can’t be solely explained by the weight of administrative tasks (iii) the temporal context in which are carried out safety inspections and the lack of media artifact exchanges, do not favor the development of cognitive synchronization phenomenon, since all differences are not explicitly approved by surveying the solutions of all interlocutors, (iv) OSH develop defense strategies reducing the effects of this lack of performance on their health, (v) changes in the temporal context and the integration of video artifacts facilitating trade, allows improved performance in terms of deviations lifted; the solutions produced are then more numerous and more complex, exchanges are richer and constraints are better managed. The results of this thesis allow both to continue with the characterization of the work of OHS in companies, to account for the effects of self-confrontation on interviewers but also to offer an artifact design method based on the instrumental approach which facilitates ownership.

La contraception hormonale combinée (CHC) est la contraception la plus utilisée en France. La maladie veineuse thromboembolique (MVTE), constitue le principal effet délétère de ces CHC. Des recommandations de bonnes pratiques sont publiées pour guider les prescripteurs. La meilleure compréhension des modifications biologiques associées aux différents types de CHC, les caractéristiques cliniques des femmes ayant eu une MVTE, la place de la recherche d’antécédents familiaux de MVTE (AFVTE) et d’une thrombophilie biologique avant la prescription d’une CHC constituent des pistes de recherche qui permettrait potentiellement d’optimiser la balance bénéfice-risque des CHC. Enfin l’impact de l’utilisation d’une contraception hormonale après un 1er épisode de MVTE reste peu évalué. Ce travail de thèse a été réalisé à la fois à l’aide de données biologiques d’utilisatrices de contraceptions hormonales (Etude EDGAR) et aussi à partir des données de l’étude de cohorte française COREVE (COntraception and REcurrent Venous Event). Cette étude a inclus 3121 femmes de moins de 45 ans au moment de leur 1er épisode de MVTE. Nous nous sommes particulièrement intéressés à l’analyse des caractéristiques de ces femmes en fonction du type de contraception utilisée, à la prévalence des facteurs de risque vasculaires et notamment les AFVTE. La fréquence d’épisode de MVTE associé à une prescription inadaptée de CHC, variait ainsi de 8.8 à 25.9 %. Par ailleurs, à l’aide d’une méthodologie de type cas versus cas, l’interaction entre l’utilisation d’une CHC et la présence d’une mutation du facteur V Leiden sur le risque de MVTE diffère significativement en fonction du progestatif combiné des CHC. / Combined hormonal contraception (CHC) is the most widely used contraception in France in which venous thrombosis embolism (VTE) is the main deleterious effect. Best practice recommendations are published in order to guide prescribers.The better understanding of the biological changes associated with different types of CHC, the clinical characteristics of women with VTE, the place of family history of VTE (FHVTE) and for biological thrombophilia before prescribing a CHC constitute research paths that could potentially optimize the risk-benefit balance of CHCs. Finally, the impact of hormonal contraception use after a first episode of VTE remains rarely evaluated.This work was carried out both using biological data from hormonal contraception users (EDGAR study) and also using data from the French cohort study COREVE (COntraception and REcurrent Venous Event).This study included 3121 women under 45 at the time of their 1st episode of VTE. We were particularly interested in analyzing the characteristics of these women according to the type of contraception used, the prevalence of vascular risk factors and especially the FHVTE.The frequency of VTE episode associated with an inadequate CHC prescription varied from 8.8 to 25.9%. Moreover, using a case-only methodology, the interaction between the use of CHC and the presence of a mutation of the factor V Leiden on the risk of VTE differs significantly depending on the progestin combined of the CHCs.

Background: Prescription drug abuse is a major public health concern in the United States, associated with dramatic increases in morbidity and mortality over the past two decades. In recent years, disposal of unwanted, unused, and expired medications has been a pillar of national prevention efforts. Acknowledging increased policy and advocacy emphasis on improving prescription drug disposal behaviors of consumers, the purpose of this study was to evaluate the impacts of a targeted promotional campaign on participation in community-based drug take back events (TBE) in NE Tennessee. Methods: Between October 2013 and October 2017, 45 drug take-back events were held in 5 municipalities across NE Tennessee. A region-wide, promotional campaign including direct to consumer advertising (television, print, radio, etc) initiated spring 2014. Two methods of data collection were implemented: 1) donor surveys; and 2) drug donation weights (pounds) and dosage units collected. Controlled substance (CS) donations with identifiable dispensing dates were used to calculate donors’ possession time in months. One-way ANOVA, paired t-tests, and chi-square procedures were utilized to assess trends in donation weights, time to donation, and donor characteristics across the study period. Results: Total Disposal donations increased by 2.35 times (CS 2.61 times) from baseline after the initial promotional campaign. A total of 2300 CS donations were collected, with a spike in total pounds collected observed in spring of 2014 following initial marketing interventions. Donor possession time hdecreased by approximately one year during the length of the study (62.01 to 50.5 months). More than 1500 donor surveys were administered during the study. Half of all participants reported hearing about TBE through television promotions. Participants at urban events were 52.6% more likely than rural participants to hear about the event through newspaper promotion. Conclusion: Collaborative marketing across a TBE concentrated region increases CS disposal weight and decreases donor possession time.

Background: Interpersonal communication is inherent in a majority of strategies seeking to engage prescriber and pharmacist health care professionals (HCPs) in the reduction and prevention of prescription drug abuse (PDA). However, research on HCP PDA communication behavioral engagement and factors that influence it is limited. Objectives This study quantitatively examined communication behaviors and trait-level communication metrics, and qualitatively described prescription drug abuse-related communication perceptions and behaviors among primary care prescribers and community pharmacists. Methods: Five focus groups (N = 35) were conducted within the Appalachian Research Network (AppNET), a rural primary care practice-based research network (PBRN) in South Central Appalachia between February and October, 2014. Focus groups were structured around the administration of three previously validated trait-level communication survey instruments, and one instrument developed by the investigators to gauge HCP prescription drug abuse communication engagement and perceived communication importance. Using a grounded theory approach, focus group themes were inductively derived and coded independently by study investigators. Member-checking interviews were conducted to validate derived themes. Results: Respondents' trait-level communication self-perceptions indicated low communication apprehension, high self-perceived communication competence, and average willingness to communicate as compared to instrument specific criteria and norms. Significant variation in HCP communication behavior engagement was noted specific to PDA. Two overarching themes were noted for HCP-patient communication: 1) influencers of HCP communication and prescribing/dispensing behaviors, and 2) communication behaviors. Multiple sub-themes were identified within each theme. Similarities were noted in perceptions and behaviors across both prescribers and pharmacists. Conclusions: Despite the perceived importance of engaging in PDA communication, HCPs reported that prescription drug abuse communication is uncomfortable, variable, multifactorial, and often avoided. The themes that emerged from this analysis support the utility of communication science and health behavior theories to better understand and improve PDA communication behaviors of both prescribers and pharmacists, and thereby improve engagement in PDA prevention and treatment.