Older patients readily understand prognostic information, which influences their preferences with respect to CPR. Most do not want to undergo CPR once a clinician explains the probability of survival after the procedure.

Integrated behavioral health services have positive outcomes for patients and providers, but little is known about providers' perspectives on implementing these services. This community-based participatory research collaboration with a Federally Qualified Health Center examined provider perspectives on implementing a collaborative psychiatry consultation program in pediatric primary care. We interviewed providers (N = 14) from psychiatry, social work, primary care, and psychology regarding their experiences implementing the program, and their recommendations for its sustainability. Providers described interdisciplinary integration arising from the program, with accompanying benefits (e.g., increased access to care for patients with complex diagnostic profiles, increased learning and role satisfaction among providers), and challenges (e.g., increased burden on primary care providers, potential patient discomfort with team-based care). Our results highlight the complexities of implementing collaborative psychiatry consultation in pediatric primary care, and suggest the importance of supporting primary care providers and patients within this context.

A case is presented of a fatal drug interaction caused by ingestion of oxycodone (Oxycontin®) and clonazepam (Klonapin®). Oxycodone is an opium alkaloid used in long-term pain management therapy. Clonazepam is a benzodiazepine used for the treatment of seizures and panic disorders. The Drug Abuse Warning Network (DAWN) has reported an increase of 108% in the last two years of emergency department episodes related to Oxycontin®. Six billion prescriptions were written for Oxycontin® in the year 2000, an 18-fold increase from four years previous (1). Oxycontin has recently gained enormous notoriety at the local and national levels; however, there are very few previously documented cases of lethal drug interactions between oxycodone and clonazepam. Synergistic effects between these two drugs are postulated to arise from different agonistic mechanisms producing similar physiological changes. It is also theorized that clonazepam may inhibit the metabolism of oxycodone. A 38-year-old white female was found dead in Jefferson County, Tennessee in March of 2001. The deceased had physical evidence of previous drug abuse and positive serological findings of hepatitis B and C. Prescription pill bottles filled under the name of the deceased, as well as another name, were found with the body. Serum, urine and gastric contents from the deceased were screened for numerous drugs and metabolites using a combination of thin layer chromatography and immunoassay techniques (EMIT and FPIA). Analysis of biological specimens from the deceased revealed the presence of: benzodiazepines, opiates (oxycodone), and trazodone metabolites in the serum; cannabinoids, benzodiazepines, opiates (oxycodone), trazodone, trazodone metabolites, nicotine, and nicotine metabolite in the urine; and benzodiazepines, opiates (oxycodone), nicotine, and nicotine metabolite in the gastric contents. Quantitative analyses for clonazepam was performed by high performance liquid chromatography (HPLC) and revealed a plasma concentration of 1.41 µg/mL. Plasma oxycodone and urine 11-nor-carboxy-delta-9-tetrahydrocannabinol concentrations were determined by gas chromatography/mass spectrometry and revealed concentrations of 0.60 µg/mL and 27.9 ng/mL, respectively. The deceased had pathologies consistent with severe central nervous system (CNS) and respiratory depression produced by high concentrations of clonazepam and oxycodone including collapsed lungs, aspirated mucus, and heart failure. The pathologies were sufficient to cause death, which was officially attributed to a drug overdose; however, the manner of death was unknown.

The estimated number of employees in the United Stated screened annually for illicit drugs is approximately 20 million, with marijuana being the most frequently abused drug. Urine adulterants provide an opportunity for illicit drug users to obtain a false-negative result on commonly used primary drug screening methods such as the enzyme multiplied immunoassay technique and the fluorescence polarized immunoassay technique (FPIA). Typical chemical adulterants such as nitrites are easily detected or render the urine specimen invalid as defined in the proposed SAMHSA guidelines for specimen validity testing based on creatinine, specific gravity, and pH. Papain is a cysteine protease with intrinsic ester hydrolysis capability. The primary metabolite of the psychoactive chemical in marijuana, 11-norcarboxy-Delta9-tetrahydrocannibinol (THC-COOH), was assayed by FPIA in concentrations ranging from 25 to 500 ng/mL, at pH values ranging from 4.5 to 8, over the course of 3 days with papain concentrations ranging from 0 to 10 mg/mL. FPIA analysis of other frequently abused drugs: amphetamines, barbiturates, benzodiazepines, cocaine, opiates, and phencyclidine, along with gas chromatography-mass spectrometry (GC-MS) of THC-COOH and high-pressure liquid chromatography-ultraviolet detection (HPLC-UV) of nordiazepam was performed in order to determine if the mechanism of urine adulteration by papain was analyte specific. Control and adulterated urine specimens (n = 30) were assayed for creatinine, specific gravity, and pH to determine if papain rendered the specimens invalid based on the proposed SAMHSA guidelines. There was a direct pH, temperature, and time-dependent correlate between the increase in papain concentration and the decrease in THC-COOH concentration from the untreated control groups (p < 0.01). The average 72-h THC-COOH concentration decrease at pH 6.2 with a papain concentration of 10 mg/mL was 50%. Papain did not significantly decrease the concentration of the other drugs analyzed with the exception of nordiazepam. GC-MS of THC-COOH and HPLC-UV of nordiazepam revealed a 66% and 24% decrease in concentration of the respective analyte with 10 mg/mL papain after 24 h at room temperature (approximately 23 degrees C). No adulterated specimens were rendered invalid based on the SAMHSA guidelines. Immediate FPIA analysis is suggested to minimize the interfering effects of papain with regards to primary drug screening.