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Reframing views of patients who malinger advised
WASHINGTON – Imagine desperately wanting addiction treatment while living in a homeless shelter with many people who were using drugs. Could you remain sober for 6 weeks until treatment was available at an outpatient clinic – or would you bluff your way into treatment in an emergency department, where you would receive follow-up care within a week?
This is the kind of challenge that Margaret Balfour, MD, PhD, said she puts to her staff – and to anyone who treats patients they suspect are lying about this medical conditions. “Could [you], as a well-adjusted professional with reasonably good coping skills tolerate the things we ask our patients to do in order to help ‘appropriately’ ” asked Dr. Balfour, chief clinical officer at the Crisis Response Center in Tucson, Ariz., and a vice president for clinical innovation and quality at ConnectionsAZ in Tucson and Phoenix.
Signs of malingering
On average, 13% of the people presenting in the ED malinger, according to panelist Scott A. Simpson, MD, MPH, of the department of psychiatry at the University of Colorado at Denver, Aurora, and the medical director of psychiatric emergency services at Denver Health. So, how can a clinician differentiate whether a patient’s story is fact or fiction, and what can be done to get the real story?
Classic signs of malingering include a notable discrepancy between observed and reported symptoms, reports of atypical psychosis, and inexplicable cognitive symptoms. “Watch for things that seem odd, such as late-in-life onset of psychosis, Dr. Simpson said.
Patients who grow increasingly irritated during the patient interview, even to the point of threatening suicide if their treatment demands aren’t met, also can be patients who malinger However, some data do not necessarily support this as cause for alarm, according to Dr. Simpson, who cited a study showing that among 137 patients who endorsed suicidality, the 7-year suicide rate among those who did so conditionally was 0.0%, compared with 11% in those who did not have conditional suicidality (Psychiatr Serv. 2002 Jan;53[1]:92-4). The overall 7-year mortality in the first cohort was 4%, compared with 20% in the latter.
Rather than panic in such a situation, go deeper, said panelist John S. Rozel, MD, of the department of psychiatry at the University of Pittsburgh, where he also completed a master of studies in law program and serves as an adjunct professor of law. Dr. Rozel also is the medical director of the university’s re:solve Crisis Network.
“Maybe the person is worried they won’t be taken seriously,” said Dr. Rozel, explaining why some patients will escalate their claims and often are oblivious to their deceit. He shared an anecdote of having been called to treat a 14-year-old trauma patient with suicidality but who didn’t endorse any thoughts of self-harm during the patient interview. Instead, she told him that being suicidal is“what you say when you need more support, and the staff aren’t paying enough attention to you.”
Documenting the behavior
Even when clinicians are sure their patient is malingering, they often are reluctant to document it, according to Rachel Rodriguez, MD, an inpatient/emergency attending psychiatrist at Bellevue Hospital Center in New York.
“Malingering is lying, and lying is distasteful. It’s difficult to talk about,” Dr. Rodriguez said. “It’s also making a judgment about someone’s intentions, which is outside the bounds of what we are trained to do.”
Clinicians are reluctant to formally identify malingering for many reasons, Dr. Rodriguez said in an interview. Those reasons include:
• Future denial of necessary care.
• Fear of retaliation.
• Concerns about making a judgment about motives/intentions.
• Risk of misidentification.
• Fear of liability.
• Feeling sorry for the patient and helpless to address the patient’s actual needs.
Dr. Rodriguez said the underidentification and overidentification of malingering also include unique sets of risks.
At the session, Dr. Rozel agreed that an unwillingness to address malingering head-on does have its risks.
“Documentation is very important in medical malpractice. If we [record] our thinking in our notes, it’s kind of like high school math; you at least get partial credit if you show the work.” Thorough note taking includes recording the observations of all the personnel involved in the patient’s case, according to Dr. Rozel. As an example, he shared an anecdote of a patient endorsing suicidal symptoms in the interview with the clinician, but flirting with others in the waiting area, as witnessed by the admitting nurse.
Based on your observation and on a review of your patient’s prior history, Dr. Rozel suggested this partial list of notes and phrasing can be effective at establishing a “clear paper trail” should there need to be one:
• “Records show an established pattern of seeking inpatient services for ... and delaying discharge during admissions of [include dates].”
• “Review of prior records indicates no evidence of clinical improvement for brief or extended admissions similar to her current presentation.”
• “A second opinion obtained from ... concurs with ...”
• “This case has been reviewed in detail with ...”
• “Formulation and plan have been discussed with patient and other [relevant] providers, including ...”
Dr. Rozel offered this caveat: “I am not a lawyer. The only thing I promise that your lawyer and I will agree on is that they would rather you get your legal advice from them and not from me.”
Reframing the situation
Understanding yourself first will help you understand the patient better, according to Dr. Balfour: “What underlies all this is how you are feeling. Being aware of this is important.”
The range of emotional experiences when dealing with a patient who malingers can run from anger at being lied to, frustration with wasted time and resources, helplessness that nothing seems to make a difference, fear of making the wrong decision, and even hatred borne of constantly experiencing all the other emotions, she said.
Being honest about your own emotions helps keep them out of the way of delivering better care, as does being mindful of the language you use to describe patients. Describing a patient to other staff in words that connote negativity, such as “manipulative,” “attention seeking,” or “high maintenance,” might influence others to see the patient as problematic rather than someone to be helped, said Dr. Balfour, who is with the department of psychiatry at the University of Arizona, Tucson.
Instead of labeling patients, “I find using the techniques of dialectical behavioral training very effective in dealing with [this population],” Dr. Balfour said. A more effective approach includes reframing your view of patients not as liars, but as people who are doing the best they can with what they have in a system that is often set up in ways that prevent, more than augment, care.
In that case, a person who lives in a homeless shelter and who wants help with a drug addiction, for example, will “understandably come to the emergency department to try and get admitted to the inpatient unit where they can get into rehab,” Dr. Balfour said. “Sometimes, our system makes people do things we find annoying in order to get the help they need.”
Instead of making the prevention of unnecessary admissions the goal, find a way to create a rapport with patients to determine their actual problem and see what can be done to solve it. This might take several engagements with the patient, often with more than one staff member. Using the statement, “I don’t feel like I’m getting the whole story” in the patient interview is an effective way to engage patients without accusing them of lying, Dr. Balfour said. “It’s like a magic phrase. Its effectiveness is predicated on the idea that all people, even those who dissemble or embellish, have a wish on some level to reveal sensitive, personal material.”
Remembering not to take malingering personally and that your role is “to be a detective not a bouncer” will help de-escalate untruths, and can lead to a partnership with the patient rather than enmity, Dr. Balfour said.
Dr. Balfour disclosed that she is a consultant for Connections Health Solutions and Otsuka. Dr. Simpson, Dr. Rozel, and Dr. Rodriguez had no relevant disclosures.
[email protected]
On Twitter @whitneymcknight
WASHINGTON – Imagine desperately wanting addiction treatment while living in a homeless shelter with many people who were using drugs. Could you remain sober for 6 weeks until treatment was available at an outpatient clinic – or would you bluff your way into treatment in an emergency department, where you would receive follow-up care within a week?
This is the kind of challenge that Margaret Balfour, MD, PhD, said she puts to her staff – and to anyone who treats patients they suspect are lying about this medical conditions. “Could [you], as a well-adjusted professional with reasonably good coping skills tolerate the things we ask our patients to do in order to help ‘appropriately’ ” asked Dr. Balfour, chief clinical officer at the Crisis Response Center in Tucson, Ariz., and a vice president for clinical innovation and quality at ConnectionsAZ in Tucson and Phoenix.
Signs of malingering
On average, 13% of the people presenting in the ED malinger, according to panelist Scott A. Simpson, MD, MPH, of the department of psychiatry at the University of Colorado at Denver, Aurora, and the medical director of psychiatric emergency services at Denver Health. So, how can a clinician differentiate whether a patient’s story is fact or fiction, and what can be done to get the real story?
Classic signs of malingering include a notable discrepancy between observed and reported symptoms, reports of atypical psychosis, and inexplicable cognitive symptoms. “Watch for things that seem odd, such as late-in-life onset of psychosis, Dr. Simpson said.
Patients who grow increasingly irritated during the patient interview, even to the point of threatening suicide if their treatment demands aren’t met, also can be patients who malinger However, some data do not necessarily support this as cause for alarm, according to Dr. Simpson, who cited a study showing that among 137 patients who endorsed suicidality, the 7-year suicide rate among those who did so conditionally was 0.0%, compared with 11% in those who did not have conditional suicidality (Psychiatr Serv. 2002 Jan;53[1]:92-4). The overall 7-year mortality in the first cohort was 4%, compared with 20% in the latter.
Rather than panic in such a situation, go deeper, said panelist John S. Rozel, MD, of the department of psychiatry at the University of Pittsburgh, where he also completed a master of studies in law program and serves as an adjunct professor of law. Dr. Rozel also is the medical director of the university’s re:solve Crisis Network.
“Maybe the person is worried they won’t be taken seriously,” said Dr. Rozel, explaining why some patients will escalate their claims and often are oblivious to their deceit. He shared an anecdote of having been called to treat a 14-year-old trauma patient with suicidality but who didn’t endorse any thoughts of self-harm during the patient interview. Instead, she told him that being suicidal is“what you say when you need more support, and the staff aren’t paying enough attention to you.”
Documenting the behavior
Even when clinicians are sure their patient is malingering, they often are reluctant to document it, according to Rachel Rodriguez, MD, an inpatient/emergency attending psychiatrist at Bellevue Hospital Center in New York.
“Malingering is lying, and lying is distasteful. It’s difficult to talk about,” Dr. Rodriguez said. “It’s also making a judgment about someone’s intentions, which is outside the bounds of what we are trained to do.”
Clinicians are reluctant to formally identify malingering for many reasons, Dr. Rodriguez said in an interview. Those reasons include:
• Future denial of necessary care.
• Fear of retaliation.
• Concerns about making a judgment about motives/intentions.
• Risk of misidentification.
• Fear of liability.
• Feeling sorry for the patient and helpless to address the patient’s actual needs.
Dr. Rodriguez said the underidentification and overidentification of malingering also include unique sets of risks.
At the session, Dr. Rozel agreed that an unwillingness to address malingering head-on does have its risks.
“Documentation is very important in medical malpractice. If we [record] our thinking in our notes, it’s kind of like high school math; you at least get partial credit if you show the work.” Thorough note taking includes recording the observations of all the personnel involved in the patient’s case, according to Dr. Rozel. As an example, he shared an anecdote of a patient endorsing suicidal symptoms in the interview with the clinician, but flirting with others in the waiting area, as witnessed by the admitting nurse.
Based on your observation and on a review of your patient’s prior history, Dr. Rozel suggested this partial list of notes and phrasing can be effective at establishing a “clear paper trail” should there need to be one:
• “Records show an established pattern of seeking inpatient services for ... and delaying discharge during admissions of [include dates].”
• “Review of prior records indicates no evidence of clinical improvement for brief or extended admissions similar to her current presentation.”
• “A second opinion obtained from ... concurs with ...”
• “This case has been reviewed in detail with ...”
• “Formulation and plan have been discussed with patient and other [relevant] providers, including ...”
Dr. Rozel offered this caveat: “I am not a lawyer. The only thing I promise that your lawyer and I will agree on is that they would rather you get your legal advice from them and not from me.”
Reframing the situation
Understanding yourself first will help you understand the patient better, according to Dr. Balfour: “What underlies all this is how you are feeling. Being aware of this is important.”
The range of emotional experiences when dealing with a patient who malingers can run from anger at being lied to, frustration with wasted time and resources, helplessness that nothing seems to make a difference, fear of making the wrong decision, and even hatred borne of constantly experiencing all the other emotions, she said.
Being honest about your own emotions helps keep them out of the way of delivering better care, as does being mindful of the language you use to describe patients. Describing a patient to other staff in words that connote negativity, such as “manipulative,” “attention seeking,” or “high maintenance,” might influence others to see the patient as problematic rather than someone to be helped, said Dr. Balfour, who is with the department of psychiatry at the University of Arizona, Tucson.
Instead of labeling patients, “I find using the techniques of dialectical behavioral training very effective in dealing with [this population],” Dr. Balfour said. A more effective approach includes reframing your view of patients not as liars, but as people who are doing the best they can with what they have in a system that is often set up in ways that prevent, more than augment, care.
In that case, a person who lives in a homeless shelter and who wants help with a drug addiction, for example, will “understandably come to the emergency department to try and get admitted to the inpatient unit where they can get into rehab,” Dr. Balfour said. “Sometimes, our system makes people do things we find annoying in order to get the help they need.”
Instead of making the prevention of unnecessary admissions the goal, find a way to create a rapport with patients to determine their actual problem and see what can be done to solve it. This might take several engagements with the patient, often with more than one staff member. Using the statement, “I don’t feel like I’m getting the whole story” in the patient interview is an effective way to engage patients without accusing them of lying, Dr. Balfour said. “It’s like a magic phrase. Its effectiveness is predicated on the idea that all people, even those who dissemble or embellish, have a wish on some level to reveal sensitive, personal material.”
Remembering not to take malingering personally and that your role is “to be a detective not a bouncer” will help de-escalate untruths, and can lead to a partnership with the patient rather than enmity, Dr. Balfour said.
Dr. Balfour disclosed that she is a consultant for Connections Health Solutions and Otsuka. Dr. Simpson, Dr. Rozel, and Dr. Rodriguez had no relevant disclosures.
[email protected]
On Twitter @whitneymcknight
WASHINGTON – Imagine desperately wanting addiction treatment while living in a homeless shelter with many people who were using drugs. Could you remain sober for 6 weeks until treatment was available at an outpatient clinic – or would you bluff your way into treatment in an emergency department, where you would receive follow-up care within a week?
This is the kind of challenge that Margaret Balfour, MD, PhD, said she puts to her staff – and to anyone who treats patients they suspect are lying about this medical conditions. “Could [you], as a well-adjusted professional with reasonably good coping skills tolerate the things we ask our patients to do in order to help ‘appropriately’ ” asked Dr. Balfour, chief clinical officer at the Crisis Response Center in Tucson, Ariz., and a vice president for clinical innovation and quality at ConnectionsAZ in Tucson and Phoenix.
Signs of malingering
On average, 13% of the people presenting in the ED malinger, according to panelist Scott A. Simpson, MD, MPH, of the department of psychiatry at the University of Colorado at Denver, Aurora, and the medical director of psychiatric emergency services at Denver Health. So, how can a clinician differentiate whether a patient’s story is fact or fiction, and what can be done to get the real story?
Classic signs of malingering include a notable discrepancy between observed and reported symptoms, reports of atypical psychosis, and inexplicable cognitive symptoms. “Watch for things that seem odd, such as late-in-life onset of psychosis, Dr. Simpson said.
Patients who grow increasingly irritated during the patient interview, even to the point of threatening suicide if their treatment demands aren’t met, also can be patients who malinger However, some data do not necessarily support this as cause for alarm, according to Dr. Simpson, who cited a study showing that among 137 patients who endorsed suicidality, the 7-year suicide rate among those who did so conditionally was 0.0%, compared with 11% in those who did not have conditional suicidality (Psychiatr Serv. 2002 Jan;53[1]:92-4). The overall 7-year mortality in the first cohort was 4%, compared with 20% in the latter.
Rather than panic in such a situation, go deeper, said panelist John S. Rozel, MD, of the department of psychiatry at the University of Pittsburgh, where he also completed a master of studies in law program and serves as an adjunct professor of law. Dr. Rozel also is the medical director of the university’s re:solve Crisis Network.
“Maybe the person is worried they won’t be taken seriously,” said Dr. Rozel, explaining why some patients will escalate their claims and often are oblivious to their deceit. He shared an anecdote of having been called to treat a 14-year-old trauma patient with suicidality but who didn’t endorse any thoughts of self-harm during the patient interview. Instead, she told him that being suicidal is“what you say when you need more support, and the staff aren’t paying enough attention to you.”
Documenting the behavior
Even when clinicians are sure their patient is malingering, they often are reluctant to document it, according to Rachel Rodriguez, MD, an inpatient/emergency attending psychiatrist at Bellevue Hospital Center in New York.
“Malingering is lying, and lying is distasteful. It’s difficult to talk about,” Dr. Rodriguez said. “It’s also making a judgment about someone’s intentions, which is outside the bounds of what we are trained to do.”
Clinicians are reluctant to formally identify malingering for many reasons, Dr. Rodriguez said in an interview. Those reasons include:
• Future denial of necessary care.
• Fear of retaliation.
• Concerns about making a judgment about motives/intentions.
• Risk of misidentification.
• Fear of liability.
• Feeling sorry for the patient and helpless to address the patient’s actual needs.
Dr. Rodriguez said the underidentification and overidentification of malingering also include unique sets of risks.
At the session, Dr. Rozel agreed that an unwillingness to address malingering head-on does have its risks.
“Documentation is very important in medical malpractice. If we [record] our thinking in our notes, it’s kind of like high school math; you at least get partial credit if you show the work.” Thorough note taking includes recording the observations of all the personnel involved in the patient’s case, according to Dr. Rozel. As an example, he shared an anecdote of a patient endorsing suicidal symptoms in the interview with the clinician, but flirting with others in the waiting area, as witnessed by the admitting nurse.
Based on your observation and on a review of your patient’s prior history, Dr. Rozel suggested this partial list of notes and phrasing can be effective at establishing a “clear paper trail” should there need to be one:
• “Records show an established pattern of seeking inpatient services for ... and delaying discharge during admissions of [include dates].”
• “Review of prior records indicates no evidence of clinical improvement for brief or extended admissions similar to her current presentation.”
• “A second opinion obtained from ... concurs with ...”
• “This case has been reviewed in detail with ...”
• “Formulation and plan have been discussed with patient and other [relevant] providers, including ...”
Dr. Rozel offered this caveat: “I am not a lawyer. The only thing I promise that your lawyer and I will agree on is that they would rather you get your legal advice from them and not from me.”
Reframing the situation
Understanding yourself first will help you understand the patient better, according to Dr. Balfour: “What underlies all this is how you are feeling. Being aware of this is important.”
The range of emotional experiences when dealing with a patient who malingers can run from anger at being lied to, frustration with wasted time and resources, helplessness that nothing seems to make a difference, fear of making the wrong decision, and even hatred borne of constantly experiencing all the other emotions, she said.
Being honest about your own emotions helps keep them out of the way of delivering better care, as does being mindful of the language you use to describe patients. Describing a patient to other staff in words that connote negativity, such as “manipulative,” “attention seeking,” or “high maintenance,” might influence others to see the patient as problematic rather than someone to be helped, said Dr. Balfour, who is with the department of psychiatry at the University of Arizona, Tucson.
Instead of labeling patients, “I find using the techniques of dialectical behavioral training very effective in dealing with [this population],” Dr. Balfour said. A more effective approach includes reframing your view of patients not as liars, but as people who are doing the best they can with what they have in a system that is often set up in ways that prevent, more than augment, care.
In that case, a person who lives in a homeless shelter and who wants help with a drug addiction, for example, will “understandably come to the emergency department to try and get admitted to the inpatient unit where they can get into rehab,” Dr. Balfour said. “Sometimes, our system makes people do things we find annoying in order to get the help they need.”
Instead of making the prevention of unnecessary admissions the goal, find a way to create a rapport with patients to determine their actual problem and see what can be done to solve it. This might take several engagements with the patient, often with more than one staff member. Using the statement, “I don’t feel like I’m getting the whole story” in the patient interview is an effective way to engage patients without accusing them of lying, Dr. Balfour said. “It’s like a magic phrase. Its effectiveness is predicated on the idea that all people, even those who dissemble or embellish, have a wish on some level to reveal sensitive, personal material.”
Remembering not to take malingering personally and that your role is “to be a detective not a bouncer” will help de-escalate untruths, and can lead to a partnership with the patient rather than enmity, Dr. Balfour said.
Dr. Balfour disclosed that she is a consultant for Connections Health Solutions and Otsuka. Dr. Simpson, Dr. Rozel, and Dr. Rodriguez had no relevant disclosures.
[email protected]
On Twitter @whitneymcknight
Medication-assisted treatment in group settings may result in greater job satisfaction, more reimbursements
WASHINGTON – For practices that offer medication-assisted treatment but perhaps are struggling to balance follow-up appointments with new patient inductions, Leah K. Bauer, MD, has a suggestion: group sessions.
“It’s a lot of fun, and makes my practice more dynamic. It gets me out of the grind of ‘see a patient; write a note; repeat,’ ” Dr. Bauer said at the American Psychiatric Association’s Institute on Psychiatric Services.
Compressing 26.5 hours of individual clinical time into 12 hours of monthly group sessions held twice a week for 90 minutes each, Dr. Bauer said, resulted in an additional $41,000 of revenue annually, with inductions doubling from 8 to 16 per month.
One reason is that despite the sessions taking place in a group setting, she and her staff bill for a series of individual appointments using the CPT code 99212. “It is perfectly legal, and not very recognized,” Dr. Bauer said, noting that the sessions are in a group context, but that she does get to have one-on-one interaction with her patients with the added therapeutic value that peer support brings.
Modeling appropriate behavior is easier in the group setting, she said: “Patients don’t all have to test the same limits.” Instead, they can learn from the interaction of another patient with Dr. Bauer as the therapist. The group setting also helps her deliver more consistent care to all her patients, she said. “I am more conscious of what I am saying.”
A hospitalist and psychiatrist, Dr. Bauer leads group MAT with the help of a clinician cofacilitator who she says reinforces what is being said in the group and acts as a scribe, reducing Dr. Bauer’s administrative burden. “This improves my job satisfaction tremendously,” she said.
Patients sign a “check-in” sheet that also serves as their treatment plan that includes their goals and objectives. It includes the patients’ written self-reflections, what their week was like, and other entries about their mood and struggles with their recovery. The information also is recorded in their patient records. “The sheet is problem focused, and has a lot of counseling and coordination of care built in,” Dr. Bauer said.
If a patient comes to the session late, there is no lost time or productivity for the MAT team, because the group meets regardless of who attends. Patients can come as much or as little as they like every 1-4 weeks. “It’s very flexible,” Dr. Bauer said.
She does not have data on her patient outcomes in the group setting vs. the individual one, but Dr. Bauer said in an interview that she believes it is as effective and allows more people who need MAT to receive it, because few clinics in her state offer it.
The group structure does place more demand on the hospital’s pharmacy, she said, in that, after the sessions, patients arrive en masse to fill their buprenorphine prescriptions.
Questions about confidentiality do arise, although each session begins with a reminder to keep private what is shared during the meetings. However, Dr. Bauer said, she thinks some patients remain reluctant to speak their minds for fear of what they say not remaining confidential. “This can limit the depth of what’s discussed,” she said.
Dr. Bauer said she did not have any relevant financial disclosures.
[email protected]
On Twitter @whitneymcknight
WASHINGTON – For practices that offer medication-assisted treatment but perhaps are struggling to balance follow-up appointments with new patient inductions, Leah K. Bauer, MD, has a suggestion: group sessions.
“It’s a lot of fun, and makes my practice more dynamic. It gets me out of the grind of ‘see a patient; write a note; repeat,’ ” Dr. Bauer said at the American Psychiatric Association’s Institute on Psychiatric Services.
Compressing 26.5 hours of individual clinical time into 12 hours of monthly group sessions held twice a week for 90 minutes each, Dr. Bauer said, resulted in an additional $41,000 of revenue annually, with inductions doubling from 8 to 16 per month.
One reason is that despite the sessions taking place in a group setting, she and her staff bill for a series of individual appointments using the CPT code 99212. “It is perfectly legal, and not very recognized,” Dr. Bauer said, noting that the sessions are in a group context, but that she does get to have one-on-one interaction with her patients with the added therapeutic value that peer support brings.
Modeling appropriate behavior is easier in the group setting, she said: “Patients don’t all have to test the same limits.” Instead, they can learn from the interaction of another patient with Dr. Bauer as the therapist. The group setting also helps her deliver more consistent care to all her patients, she said. “I am more conscious of what I am saying.”
A hospitalist and psychiatrist, Dr. Bauer leads group MAT with the help of a clinician cofacilitator who she says reinforces what is being said in the group and acts as a scribe, reducing Dr. Bauer’s administrative burden. “This improves my job satisfaction tremendously,” she said.
Patients sign a “check-in” sheet that also serves as their treatment plan that includes their goals and objectives. It includes the patients’ written self-reflections, what their week was like, and other entries about their mood and struggles with their recovery. The information also is recorded in their patient records. “The sheet is problem focused, and has a lot of counseling and coordination of care built in,” Dr. Bauer said.
If a patient comes to the session late, there is no lost time or productivity for the MAT team, because the group meets regardless of who attends. Patients can come as much or as little as they like every 1-4 weeks. “It’s very flexible,” Dr. Bauer said.
She does not have data on her patient outcomes in the group setting vs. the individual one, but Dr. Bauer said in an interview that she believes it is as effective and allows more people who need MAT to receive it, because few clinics in her state offer it.
The group structure does place more demand on the hospital’s pharmacy, she said, in that, after the sessions, patients arrive en masse to fill their buprenorphine prescriptions.
Questions about confidentiality do arise, although each session begins with a reminder to keep private what is shared during the meetings. However, Dr. Bauer said, she thinks some patients remain reluctant to speak their minds for fear of what they say not remaining confidential. “This can limit the depth of what’s discussed,” she said.
Dr. Bauer said she did not have any relevant financial disclosures.
[email protected]
On Twitter @whitneymcknight
WASHINGTON – For practices that offer medication-assisted treatment but perhaps are struggling to balance follow-up appointments with new patient inductions, Leah K. Bauer, MD, has a suggestion: group sessions.
“It’s a lot of fun, and makes my practice more dynamic. It gets me out of the grind of ‘see a patient; write a note; repeat,’ ” Dr. Bauer said at the American Psychiatric Association’s Institute on Psychiatric Services.
Compressing 26.5 hours of individual clinical time into 12 hours of monthly group sessions held twice a week for 90 minutes each, Dr. Bauer said, resulted in an additional $41,000 of revenue annually, with inductions doubling from 8 to 16 per month.
One reason is that despite the sessions taking place in a group setting, she and her staff bill for a series of individual appointments using the CPT code 99212. “It is perfectly legal, and not very recognized,” Dr. Bauer said, noting that the sessions are in a group context, but that she does get to have one-on-one interaction with her patients with the added therapeutic value that peer support brings.
Modeling appropriate behavior is easier in the group setting, she said: “Patients don’t all have to test the same limits.” Instead, they can learn from the interaction of another patient with Dr. Bauer as the therapist. The group setting also helps her deliver more consistent care to all her patients, she said. “I am more conscious of what I am saying.”
A hospitalist and psychiatrist, Dr. Bauer leads group MAT with the help of a clinician cofacilitator who she says reinforces what is being said in the group and acts as a scribe, reducing Dr. Bauer’s administrative burden. “This improves my job satisfaction tremendously,” she said.
Patients sign a “check-in” sheet that also serves as their treatment plan that includes their goals and objectives. It includes the patients’ written self-reflections, what their week was like, and other entries about their mood and struggles with their recovery. The information also is recorded in their patient records. “The sheet is problem focused, and has a lot of counseling and coordination of care built in,” Dr. Bauer said.
If a patient comes to the session late, there is no lost time or productivity for the MAT team, because the group meets regardless of who attends. Patients can come as much or as little as they like every 1-4 weeks. “It’s very flexible,” Dr. Bauer said.
She does not have data on her patient outcomes in the group setting vs. the individual one, but Dr. Bauer said in an interview that she believes it is as effective and allows more people who need MAT to receive it, because few clinics in her state offer it.
The group structure does place more demand on the hospital’s pharmacy, she said, in that, after the sessions, patients arrive en masse to fill their buprenorphine prescriptions.
Questions about confidentiality do arise, although each session begins with a reminder to keep private what is shared during the meetings. However, Dr. Bauer said, she thinks some patients remain reluctant to speak their minds for fear of what they say not remaining confidential. “This can limit the depth of what’s discussed,” she said.
Dr. Bauer said she did not have any relevant financial disclosures.
[email protected]
On Twitter @whitneymcknight
2016 a big year for mental health legislation
• The Comprehensive Addiction and Recovery Act. Signed into law in July, CARA is primarily intended, as its name indicates, to comprehensively address the opioid addiction crisis. The law includes components aimed at prevention, treatment, recovery, law enforcement, criminal justice reform, and overdose treatment. It also has provisions aimed at expanded prescription drug monitoring programs and other drug abuse prevention mechanisms.
Another important part of this law is the expansion of buprenorphine prescribing rights to nurse practitioners and physician assistants who obtain the necessary training. Public comment is being taken through Nov. 1, on what the requirements should be. This provision will be revisited in 2021.
In all, the law allocates $25 million annually from 2017 through 2021 to expand medication-assisted treatment (MAT). An abundance of evidence shows that MAT – the use of opioid agonists and partial opioid agonists such as methadone, naltrexone, and buprenorphine, in combination with psychosocial therapies – is more effective than either modality alone.
• The Helping Families in Mental Health Crisis Act. Originating in 2013 in response to the Newtown, Conn., massacre, this bill (H.R. 2646) is focused on serious mental illness. It passed the House in July with near unanimous support, but awaits the Senate to sort out its own version of the bill. If this bill is passed, HIPAA laws would loosen, allowing practices to share all but psychotherapy notes with caregivers and guardians of people with serious mental illness. Practices also could bill Medicaid and Medicare for medical and mental health services delivered on the same day, and there would be support for the better integration of medical and mental health electronic medical records. The current 30-day limit on inpatient psychiatric facility services paid for by Medicaid would be lifted, and $20 million in grants would be made available for assisted outpatient treatment of this population. Grants for expanded use of telepsychiatry also would be available.
• The Mental Health Reform Act of 2016. Essentially the companion bill to the one passed in the House, this bill (S. 2680) also calls for the expansion of telepsychiatry, especially for pediatric and adolescent mental and behavioral health needs. If it becomes law, grant money would be made available for better integration of primary and behavioral health care services. This bill calls for strengthening current mental health parity laws by requiring additional federal guidance to help insurance plans comply. The bill currently is stalled on the Senate floor and is not expected to be revisited until after the presidential election.
• The Medication Assisted Treatment for Opioid Use Disorders final rule. As of August, the rule allows addiction medicine specialists to treat up to 275 patients using buprenorphine for substance use disorder annually. Previously, they were held to treating no more than 100 such patients per year. For practices not already licensed to provide MAT, this rule doesn’t have much direct impact. However, for practices with patients on their panels who are struggling with substance use disorders, this could expand available referral resources.
• The Quality Payment Program final rule. While this rule – borne of the MACRA (Medicare Access and CHIP Reauthorization Act) law that is now referred to as the Quality Payment Program – does not directly address mental and behavioral health, it directly affects delivery of these services when it goes into effect in 2017. Because mental and behavioral health outcomes of patient panels that include Medicare populations will be assessed as part of overall patient outcomes, providing effective, integrated services will be imperative. How severely a practice will be penalized for poor outcomes will depend upon how that practice chooses to set up its reimbursement structures and quality metrics over the next few years.
[email protected]
On Twitter @whitneymcknight
• The Comprehensive Addiction and Recovery Act. Signed into law in July, CARA is primarily intended, as its name indicates, to comprehensively address the opioid addiction crisis. The law includes components aimed at prevention, treatment, recovery, law enforcement, criminal justice reform, and overdose treatment. It also has provisions aimed at expanded prescription drug monitoring programs and other drug abuse prevention mechanisms.
Another important part of this law is the expansion of buprenorphine prescribing rights to nurse practitioners and physician assistants who obtain the necessary training. Public comment is being taken through Nov. 1, on what the requirements should be. This provision will be revisited in 2021.
In all, the law allocates $25 million annually from 2017 through 2021 to expand medication-assisted treatment (MAT). An abundance of evidence shows that MAT – the use of opioid agonists and partial opioid agonists such as methadone, naltrexone, and buprenorphine, in combination with psychosocial therapies – is more effective than either modality alone.
• The Helping Families in Mental Health Crisis Act. Originating in 2013 in response to the Newtown, Conn., massacre, this bill (H.R. 2646) is focused on serious mental illness. It passed the House in July with near unanimous support, but awaits the Senate to sort out its own version of the bill. If this bill is passed, HIPAA laws would loosen, allowing practices to share all but psychotherapy notes with caregivers and guardians of people with serious mental illness. Practices also could bill Medicaid and Medicare for medical and mental health services delivered on the same day, and there would be support for the better integration of medical and mental health electronic medical records. The current 30-day limit on inpatient psychiatric facility services paid for by Medicaid would be lifted, and $20 million in grants would be made available for assisted outpatient treatment of this population. Grants for expanded use of telepsychiatry also would be available.
• The Mental Health Reform Act of 2016. Essentially the companion bill to the one passed in the House, this bill (S. 2680) also calls for the expansion of telepsychiatry, especially for pediatric and adolescent mental and behavioral health needs. If it becomes law, grant money would be made available for better integration of primary and behavioral health care services. This bill calls for strengthening current mental health parity laws by requiring additional federal guidance to help insurance plans comply. The bill currently is stalled on the Senate floor and is not expected to be revisited until after the presidential election.
• The Medication Assisted Treatment for Opioid Use Disorders final rule. As of August, the rule allows addiction medicine specialists to treat up to 275 patients using buprenorphine for substance use disorder annually. Previously, they were held to treating no more than 100 such patients per year. For practices not already licensed to provide MAT, this rule doesn’t have much direct impact. However, for practices with patients on their panels who are struggling with substance use disorders, this could expand available referral resources.
• The Quality Payment Program final rule. While this rule – borne of the MACRA (Medicare Access and CHIP Reauthorization Act) law that is now referred to as the Quality Payment Program – does not directly address mental and behavioral health, it directly affects delivery of these services when it goes into effect in 2017. Because mental and behavioral health outcomes of patient panels that include Medicare populations will be assessed as part of overall patient outcomes, providing effective, integrated services will be imperative. How severely a practice will be penalized for poor outcomes will depend upon how that practice chooses to set up its reimbursement structures and quality metrics over the next few years.
[email protected]
On Twitter @whitneymcknight
• The Comprehensive Addiction and Recovery Act. Signed into law in July, CARA is primarily intended, as its name indicates, to comprehensively address the opioid addiction crisis. The law includes components aimed at prevention, treatment, recovery, law enforcement, criminal justice reform, and overdose treatment. It also has provisions aimed at expanded prescription drug monitoring programs and other drug abuse prevention mechanisms.
Another important part of this law is the expansion of buprenorphine prescribing rights to nurse practitioners and physician assistants who obtain the necessary training. Public comment is being taken through Nov. 1, on what the requirements should be. This provision will be revisited in 2021.
In all, the law allocates $25 million annually from 2017 through 2021 to expand medication-assisted treatment (MAT). An abundance of evidence shows that MAT – the use of opioid agonists and partial opioid agonists such as methadone, naltrexone, and buprenorphine, in combination with psychosocial therapies – is more effective than either modality alone.
• The Helping Families in Mental Health Crisis Act. Originating in 2013 in response to the Newtown, Conn., massacre, this bill (H.R. 2646) is focused on serious mental illness. It passed the House in July with near unanimous support, but awaits the Senate to sort out its own version of the bill. If this bill is passed, HIPAA laws would loosen, allowing practices to share all but psychotherapy notes with caregivers and guardians of people with serious mental illness. Practices also could bill Medicaid and Medicare for medical and mental health services delivered on the same day, and there would be support for the better integration of medical and mental health electronic medical records. The current 30-day limit on inpatient psychiatric facility services paid for by Medicaid would be lifted, and $20 million in grants would be made available for assisted outpatient treatment of this population. Grants for expanded use of telepsychiatry also would be available.
• The Mental Health Reform Act of 2016. Essentially the companion bill to the one passed in the House, this bill (S. 2680) also calls for the expansion of telepsychiatry, especially for pediatric and adolescent mental and behavioral health needs. If it becomes law, grant money would be made available for better integration of primary and behavioral health care services. This bill calls for strengthening current mental health parity laws by requiring additional federal guidance to help insurance plans comply. The bill currently is stalled on the Senate floor and is not expected to be revisited until after the presidential election.
• The Medication Assisted Treatment for Opioid Use Disorders final rule. As of August, the rule allows addiction medicine specialists to treat up to 275 patients using buprenorphine for substance use disorder annually. Previously, they were held to treating no more than 100 such patients per year. For practices not already licensed to provide MAT, this rule doesn’t have much direct impact. However, for practices with patients on their panels who are struggling with substance use disorders, this could expand available referral resources.
• The Quality Payment Program final rule. While this rule – borne of the MACRA (Medicare Access and CHIP Reauthorization Act) law that is now referred to as the Quality Payment Program – does not directly address mental and behavioral health, it directly affects delivery of these services when it goes into effect in 2017. Because mental and behavioral health outcomes of patient panels that include Medicare populations will be assessed as part of overall patient outcomes, providing effective, integrated services will be imperative. How severely a practice will be penalized for poor outcomes will depend upon how that practice chooses to set up its reimbursement structures and quality metrics over the next few years.
[email protected]
On Twitter @whitneymcknight
USPSTF gives breastfeeding support a ‘B’ grade
The U.S. Preventive Services Task Force (USPSTF) has issued a B-level recommendation for interventions given during pregnancy and after birth to support breastfeeding.
The Task Force cites “adequate” evidence that breastfeeding provides substantial health benefits for children and moderate health benefits for women. While they found evidence to support individual-level interventions, such as education and psychosocial support, system-level interventions were not shown to be effective. The recommendation appears online in JAMA (2016 Oct 25;316[16]:1688-93).
The recommendation updates a previous one issued in 2008, in which the USPSTF also recommended breastfeeding support interventions with a grade of B. The new recommendation is based on a review of 43 studies of individual-level primary care interventions in support of breastfeeding, and nine system-level interventions. The authors evaluated the available evidence on breastfeeding initiation, duration, and exclusivity, as well as breastfeeding’s effects on child and maternal health outcomes. They determined that support from a professional lactation consultant or a peer group was effective in producing any or exclusive breastfeeding, while systemwide interventions, such as the World Health Organization’s Baby-Friendly Hospital Initiative offered inconsistent benefits. The evidence review was also published in JAMA (2016;316[16]:1694-1705).
The Initiative’s “Ten Steps to Successful Breastfeeding” program, in particular, presents a potential risk, they noted. The program recommends counseling parents to avoid use of pacifiers in the newborn period to support breastfeeding, but evidence is growing that avoiding pacifiers is not associated with any breastfeeding outcomes and pacifier use may be protective against sudden infant death syndrome.
“U.S. institutions will need to disengage from the Ten Steps if they conclude that the scientific evidence that conflicts with them is valid,” Dr. Flaherman and Dr. Von Kohorn wrote.
The practice of recommending that mothers do not supplement breast-milk feedings with formula is also of concern, based on mixed evidence. Since not all mothers produce adequate milk supplies during the first week postpartum, not supplementing with formula could run the risk that the infant suffers dehydration, hyperbilirubinemia, or other complications. With up to 2% of all newborns in the United States requiring hospital readmission – the risk is doubled for breastfed infants – Dr. Flaherman and Dr. Von Kohorn suggest that strict adherence to a “breast-milk only” policy has the potential to be harmful, especially given that current evidence doesn’t show that exclusive breastfeeding in the newborn period improves breastfeeding duration.
“Individual clinical judgment may be more valuable than a single rigid rule for exclusive breastfeeding for the first 6 months,” Dr. Flaherman and Dr. Von Kohorn wrote.
Based on the evidence, the USPSTF advised clinicians that they can support women before and after childbirth by promoting the benefits of breastfeeding during monthly visits, providing practical guidance on how to breastfeed, and offering psychosocial support.
“Although there is moderate certainty that breastfeeding is of moderate net benefit to women and their infants and children, not all women choose to or are able to breastfeed. Clinicians should, as with any preventive service, respect the autonomy of women and their families to make decisions that fit their specific situation, values, and preferences,” the USPSTF members wrote.
The USPSTF members reported receiving travel reimbursement and honorarium for participating in USPSTF meetings. Dr. Flaherman and Dr. Von Kohorn reported having no relevant financial disclosures.
[email protected]
On Twitter @whitneymcknight
The key to successful office-based health promotion and prevention programs is to prioritize evidence-based practices and recommendations that parents already have a predilection to follow. That is, of the myriad of topics one might discuss, why not start with the ones that caregivers are most interested in. Breastfeeding is surely one of those.
The USPSTF estimates the number needed to treat when offering breastfeeding support is 30. That is, if 30 women are offered it, 1 additional woman will breastfeed for 6 full months. This compares favorably with the NNT for antibiotics for otitis media for fever and pain reduction at 48 hours in children older than 2 years, (NNT, 20) especially when one considers the comparable benefits of each. And the breastfeeding NNT could be reduced even further if there were structural changes to workplaces and communities that helped support breastfeeding mothers.
Dimitri A. Christakis, MD, MPH , of Seattle Children’s Research Institute, is an associate editor for JAMA Pediatrics. His comments are adapted from an editorial published in JAMA Pediatrics (2016 Oct 25. doi: 10.1001/jamapediatrics.2016.3390). He reported having no relevant financial disclosures.
The key to successful office-based health promotion and prevention programs is to prioritize evidence-based practices and recommendations that parents already have a predilection to follow. That is, of the myriad of topics one might discuss, why not start with the ones that caregivers are most interested in. Breastfeeding is surely one of those.
The USPSTF estimates the number needed to treat when offering breastfeeding support is 30. That is, if 30 women are offered it, 1 additional woman will breastfeed for 6 full months. This compares favorably with the NNT for antibiotics for otitis media for fever and pain reduction at 48 hours in children older than 2 years, (NNT, 20) especially when one considers the comparable benefits of each. And the breastfeeding NNT could be reduced even further if there were structural changes to workplaces and communities that helped support breastfeeding mothers.
Dimitri A. Christakis, MD, MPH , of Seattle Children’s Research Institute, is an associate editor for JAMA Pediatrics. His comments are adapted from an editorial published in JAMA Pediatrics (2016 Oct 25. doi: 10.1001/jamapediatrics.2016.3390). He reported having no relevant financial disclosures.
The key to successful office-based health promotion and prevention programs is to prioritize evidence-based practices and recommendations that parents already have a predilection to follow. That is, of the myriad of topics one might discuss, why not start with the ones that caregivers are most interested in. Breastfeeding is surely one of those.
The USPSTF estimates the number needed to treat when offering breastfeeding support is 30. That is, if 30 women are offered it, 1 additional woman will breastfeed for 6 full months. This compares favorably with the NNT for antibiotics for otitis media for fever and pain reduction at 48 hours in children older than 2 years, (NNT, 20) especially when one considers the comparable benefits of each. And the breastfeeding NNT could be reduced even further if there were structural changes to workplaces and communities that helped support breastfeeding mothers.
Dimitri A. Christakis, MD, MPH , of Seattle Children’s Research Institute, is an associate editor for JAMA Pediatrics. His comments are adapted from an editorial published in JAMA Pediatrics (2016 Oct 25. doi: 10.1001/jamapediatrics.2016.3390). He reported having no relevant financial disclosures.
The U.S. Preventive Services Task Force (USPSTF) has issued a B-level recommendation for interventions given during pregnancy and after birth to support breastfeeding.
The Task Force cites “adequate” evidence that breastfeeding provides substantial health benefits for children and moderate health benefits for women. While they found evidence to support individual-level interventions, such as education and psychosocial support, system-level interventions were not shown to be effective. The recommendation appears online in JAMA (2016 Oct 25;316[16]:1688-93).
The recommendation updates a previous one issued in 2008, in which the USPSTF also recommended breastfeeding support interventions with a grade of B. The new recommendation is based on a review of 43 studies of individual-level primary care interventions in support of breastfeeding, and nine system-level interventions. The authors evaluated the available evidence on breastfeeding initiation, duration, and exclusivity, as well as breastfeeding’s effects on child and maternal health outcomes. They determined that support from a professional lactation consultant or a peer group was effective in producing any or exclusive breastfeeding, while systemwide interventions, such as the World Health Organization’s Baby-Friendly Hospital Initiative offered inconsistent benefits. The evidence review was also published in JAMA (2016;316[16]:1694-1705).
The Initiative’s “Ten Steps to Successful Breastfeeding” program, in particular, presents a potential risk, they noted. The program recommends counseling parents to avoid use of pacifiers in the newborn period to support breastfeeding, but evidence is growing that avoiding pacifiers is not associated with any breastfeeding outcomes and pacifier use may be protective against sudden infant death syndrome.
“U.S. institutions will need to disengage from the Ten Steps if they conclude that the scientific evidence that conflicts with them is valid,” Dr. Flaherman and Dr. Von Kohorn wrote.
The practice of recommending that mothers do not supplement breast-milk feedings with formula is also of concern, based on mixed evidence. Since not all mothers produce adequate milk supplies during the first week postpartum, not supplementing with formula could run the risk that the infant suffers dehydration, hyperbilirubinemia, or other complications. With up to 2% of all newborns in the United States requiring hospital readmission – the risk is doubled for breastfed infants – Dr. Flaherman and Dr. Von Kohorn suggest that strict adherence to a “breast-milk only” policy has the potential to be harmful, especially given that current evidence doesn’t show that exclusive breastfeeding in the newborn period improves breastfeeding duration.
“Individual clinical judgment may be more valuable than a single rigid rule for exclusive breastfeeding for the first 6 months,” Dr. Flaherman and Dr. Von Kohorn wrote.
Based on the evidence, the USPSTF advised clinicians that they can support women before and after childbirth by promoting the benefits of breastfeeding during monthly visits, providing practical guidance on how to breastfeed, and offering psychosocial support.
“Although there is moderate certainty that breastfeeding is of moderate net benefit to women and their infants and children, not all women choose to or are able to breastfeed. Clinicians should, as with any preventive service, respect the autonomy of women and their families to make decisions that fit their specific situation, values, and preferences,” the USPSTF members wrote.
The USPSTF members reported receiving travel reimbursement and honorarium for participating in USPSTF meetings. Dr. Flaherman and Dr. Von Kohorn reported having no relevant financial disclosures.
[email protected]
On Twitter @whitneymcknight
The U.S. Preventive Services Task Force (USPSTF) has issued a B-level recommendation for interventions given during pregnancy and after birth to support breastfeeding.
The Task Force cites “adequate” evidence that breastfeeding provides substantial health benefits for children and moderate health benefits for women. While they found evidence to support individual-level interventions, such as education and psychosocial support, system-level interventions were not shown to be effective. The recommendation appears online in JAMA (2016 Oct 25;316[16]:1688-93).
The recommendation updates a previous one issued in 2008, in which the USPSTF also recommended breastfeeding support interventions with a grade of B. The new recommendation is based on a review of 43 studies of individual-level primary care interventions in support of breastfeeding, and nine system-level interventions. The authors evaluated the available evidence on breastfeeding initiation, duration, and exclusivity, as well as breastfeeding’s effects on child and maternal health outcomes. They determined that support from a professional lactation consultant or a peer group was effective in producing any or exclusive breastfeeding, while systemwide interventions, such as the World Health Organization’s Baby-Friendly Hospital Initiative offered inconsistent benefits. The evidence review was also published in JAMA (2016;316[16]:1694-1705).
The Initiative’s “Ten Steps to Successful Breastfeeding” program, in particular, presents a potential risk, they noted. The program recommends counseling parents to avoid use of pacifiers in the newborn period to support breastfeeding, but evidence is growing that avoiding pacifiers is not associated with any breastfeeding outcomes and pacifier use may be protective against sudden infant death syndrome.
“U.S. institutions will need to disengage from the Ten Steps if they conclude that the scientific evidence that conflicts with them is valid,” Dr. Flaherman and Dr. Von Kohorn wrote.
The practice of recommending that mothers do not supplement breast-milk feedings with formula is also of concern, based on mixed evidence. Since not all mothers produce adequate milk supplies during the first week postpartum, not supplementing with formula could run the risk that the infant suffers dehydration, hyperbilirubinemia, or other complications. With up to 2% of all newborns in the United States requiring hospital readmission – the risk is doubled for breastfed infants – Dr. Flaherman and Dr. Von Kohorn suggest that strict adherence to a “breast-milk only” policy has the potential to be harmful, especially given that current evidence doesn’t show that exclusive breastfeeding in the newborn period improves breastfeeding duration.
“Individual clinical judgment may be more valuable than a single rigid rule for exclusive breastfeeding for the first 6 months,” Dr. Flaherman and Dr. Von Kohorn wrote.
Based on the evidence, the USPSTF advised clinicians that they can support women before and after childbirth by promoting the benefits of breastfeeding during monthly visits, providing practical guidance on how to breastfeed, and offering psychosocial support.
“Although there is moderate certainty that breastfeeding is of moderate net benefit to women and their infants and children, not all women choose to or are able to breastfeed. Clinicians should, as with any preventive service, respect the autonomy of women and their families to make decisions that fit their specific situation, values, and preferences,” the USPSTF members wrote.
The USPSTF members reported receiving travel reimbursement and honorarium for participating in USPSTF meetings. Dr. Flaherman and Dr. Von Kohorn reported having no relevant financial disclosures.
[email protected]
On Twitter @whitneymcknight
Cigna drops preauthorization for buprenorphine in treatment for opioid dependency
Health insurer Cigna will no longer require preauthorization for the opioid partial agonist buprenorphine in patients with opioid use disorder.
Although the change in policy applies to plans nationwide, the announcement came not long after New York State Attorney General Eric T. Schneiderman requested information from the insurer about its medication-assisted treatment policies as part of an investigation into barriers to treatment.
“Under our commercial plans, we have agreed to voluntarily remove prior authorization from all medications used in medication-assisted treatment for opioid use disorder. This will help make it easier for our customers to access coverage for the medications they need,” she said.
Medication-assisted treatment (MAT) employs a combination of psychosocial therapies and full or partial opioid agonists such as methadone, naltrexone, or buprenorphine to treat opioid dependency. The Substance Abuse and Mental Health Services Administration and the Centers for Disease Control and Prevention both endorse the use of MAT, as numerous studies have shown it is significantly more effective than either medication or psychosocial support alone.
Because providers of MAT are federally required to specialize in addiction medicine and obtain a license from the Drug Enforcement Agency to prescribe buprenorphine, the new policy will not affect most clinical practices. For those who treat people with opioid use disorder, however, the impact could be powerful.
“I can tell you in my 10 years or so of prescribing buprenorphine, I have never had a preauthorization turned down,” Margaret Chaplin, MD, a psychiatrist and addiction medicine specialist in New Britain, Conn., said in an interview. “It was really just a hoop we had to jump through that seemed designed to discourage treatment more than to insure appropriate treatment.
“At our clinic, we are thrilled to see this barrier coming down,” said Dr. Chaplin, who also serves as director of Community Mental Health Affiliates in New Britain.
Cheers also went up from others who treat this patient population. American Society of Addiction Medicine President-Elect Kelly J. Clark, MD, MBA, said in a statement: “There is often a small window of opportunity for a person seeking help to engage in treatment. Waiting for days to obtain medication to treat this condition represents an unnecessary risk for a deadly outcome. Hopefully, other payers will follow Cigna’s lead.”
Dr. Chaplin did not have any relevant disclosures.
[email protected]
On Twitter @whitneymcknight
Health insurer Cigna will no longer require preauthorization for the opioid partial agonist buprenorphine in patients with opioid use disorder.
Although the change in policy applies to plans nationwide, the announcement came not long after New York State Attorney General Eric T. Schneiderman requested information from the insurer about its medication-assisted treatment policies as part of an investigation into barriers to treatment.
“Under our commercial plans, we have agreed to voluntarily remove prior authorization from all medications used in medication-assisted treatment for opioid use disorder. This will help make it easier for our customers to access coverage for the medications they need,” she said.
Medication-assisted treatment (MAT) employs a combination of psychosocial therapies and full or partial opioid agonists such as methadone, naltrexone, or buprenorphine to treat opioid dependency. The Substance Abuse and Mental Health Services Administration and the Centers for Disease Control and Prevention both endorse the use of MAT, as numerous studies have shown it is significantly more effective than either medication or psychosocial support alone.
Because providers of MAT are federally required to specialize in addiction medicine and obtain a license from the Drug Enforcement Agency to prescribe buprenorphine, the new policy will not affect most clinical practices. For those who treat people with opioid use disorder, however, the impact could be powerful.
“I can tell you in my 10 years or so of prescribing buprenorphine, I have never had a preauthorization turned down,” Margaret Chaplin, MD, a psychiatrist and addiction medicine specialist in New Britain, Conn., said in an interview. “It was really just a hoop we had to jump through that seemed designed to discourage treatment more than to insure appropriate treatment.
“At our clinic, we are thrilled to see this barrier coming down,” said Dr. Chaplin, who also serves as director of Community Mental Health Affiliates in New Britain.
Cheers also went up from others who treat this patient population. American Society of Addiction Medicine President-Elect Kelly J. Clark, MD, MBA, said in a statement: “There is often a small window of opportunity for a person seeking help to engage in treatment. Waiting for days to obtain medication to treat this condition represents an unnecessary risk for a deadly outcome. Hopefully, other payers will follow Cigna’s lead.”
Dr. Chaplin did not have any relevant disclosures.
[email protected]
On Twitter @whitneymcknight
Health insurer Cigna will no longer require preauthorization for the opioid partial agonist buprenorphine in patients with opioid use disorder.
Although the change in policy applies to plans nationwide, the announcement came not long after New York State Attorney General Eric T. Schneiderman requested information from the insurer about its medication-assisted treatment policies as part of an investigation into barriers to treatment.
“Under our commercial plans, we have agreed to voluntarily remove prior authorization from all medications used in medication-assisted treatment for opioid use disorder. This will help make it easier for our customers to access coverage for the medications they need,” she said.
Medication-assisted treatment (MAT) employs a combination of psychosocial therapies and full or partial opioid agonists such as methadone, naltrexone, or buprenorphine to treat opioid dependency. The Substance Abuse and Mental Health Services Administration and the Centers for Disease Control and Prevention both endorse the use of MAT, as numerous studies have shown it is significantly more effective than either medication or psychosocial support alone.
Because providers of MAT are federally required to specialize in addiction medicine and obtain a license from the Drug Enforcement Agency to prescribe buprenorphine, the new policy will not affect most clinical practices. For those who treat people with opioid use disorder, however, the impact could be powerful.
“I can tell you in my 10 years or so of prescribing buprenorphine, I have never had a preauthorization turned down,” Margaret Chaplin, MD, a psychiatrist and addiction medicine specialist in New Britain, Conn., said in an interview. “It was really just a hoop we had to jump through that seemed designed to discourage treatment more than to insure appropriate treatment.
“At our clinic, we are thrilled to see this barrier coming down,” said Dr. Chaplin, who also serves as director of Community Mental Health Affiliates in New Britain.
Cheers also went up from others who treat this patient population. American Society of Addiction Medicine President-Elect Kelly J. Clark, MD, MBA, said in a statement: “There is often a small window of opportunity for a person seeking help to engage in treatment. Waiting for days to obtain medication to treat this condition represents an unnecessary risk for a deadly outcome. Hopefully, other payers will follow Cigna’s lead.”
Dr. Chaplin did not have any relevant disclosures.
[email protected]
On Twitter @whitneymcknight
Experts: Fewer opioids, more treatment laws mean nothing without better access to care
WASHINGTON – Pressure on physicians to prescribe fewer opioids could have unintended consequences in the absence of adequate access to treatment, according to experts.
“There is mixed evidence that, when medication-assisted treatment is lacking, there are higher rates of transition from prescription opioids to heroin,” Gary Tsai, MD, said during a presentation at the American Psychiatric Association’s Institute on Psychiatric Services.
“As we constrict our prescribing, we want to make sure that there is ready access to these interventions, so that those who are already dependent on opioids can transition to something safer,” said Dr. Tsai, medical director and science officer of Substance Abuse Prevention and Control, a division of Los Angeles County’s public health department.
Medication-assisted treatment (MAT) uses methadone, buprenorphine, or naltrexone in combination with appropriate behavioral and other other psychosocial therapies to help achieve opioid abstinence. Despite MAT’s well-established superiority to either pharmacotherapy or psychosocial interventions alone, the use of MAT has, in some cases, declined. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), MAT was used in 35% of heroin-related treatment admissions in 2002, compared with 28% in 2010.
Reasons for MAT’s difficult path to acceptance are manifold, ranging from lack of certified facilities to administer the medications to misunderstanding about how the medications work, Dr. Tsai said.
A law passed earlier this year and the issuance of a final federal rule that increases the legal patient load that certified MAT providers can treat annually were designed to expand access to MAT. These, however, are only partial solutions, according to Margaret Chaplin, MD, a psychiatrist and program director of Community Mental Health Affiliates in New Britain, Conn.
“Can you imagine if endocrinologists were the only doctors who were certified to prescribe insulin and that each of them was only limited to prescribing to 100 patients?” Dr. Chaplin said in an interview. The final rule brought the number from 100 to 275 patients per year that a certified addiction specialist can treat. This might expand access to care, but “it sends a message that either the people with [addiction] don’t deserve treatment or that they don’t have a legitimate illness,” said Dr. Chaplin, who also was a presenter at the meeting.
Viewing people with opioid addiction through a lens of moral failing only compounds the nation’s addiction crisis, Dr. Chaplin believes. “Not to say that a person with a substance use disorder doesn’t have a responsibility to take care of their illness, [but] our [leaders] haven’t been well educated on the scientific evidence that addiction is a brain disease.”
It is true that, until the Comprehensive Addiction and Recovery Act was signed into law over the summer, nurse practitioners and physician assistants could have prescribed controlled substances such as acetaminophen/oxycontin but not the far less dangerous – and potentially life-saving – partial opioid agonist buprenorphine. Under the new law, those health care professions now have the same buprenorphine prescribing rights as physicians.
New legislation does not guarantee access to treatment, however. “Funding for MAT programs varies throughout the states, and the availability of these medications on formularies often determines how readily accessible MAT interventions are,” said Dr. Tsai, who emphasized the role of collaboration in ensuring the laws take hold.
“Addiction specialists comprise a minority of the work force. To scale MAT up, we need to engage other prescribers from other systems, including those in primary care and mental health,” Dr. Tai said. To wit, the three primary MAT facilities in Los Angeles County offer learning collaboratives with primary care clinicians who want to incorporate these services into their practice, even if they are not certified addiction specialists themselves. This helps increase referrals to the treatment facilities, he explained.
Overcoming resistance to offering MAT ultimately will depend on educating leaders about the costs of not doing so, Dr. Tsai and Dr. Chaplin said.
“Our system has been slow to adopt a disease model of addiction,” Dr. Chaplin said. “Buprenorphine and methadone are life-saving medical treatments that are regulated in ways that you don’t see for any other medical condition.”
SAMHSA currently is requesting comments through Nov. 1, 2016, on what should be required of MAT providers under the new law.
Neither Dr. Tsai nor Dr. Chaplin had any relevant disclosures.
[email protected]
On Twitter @whitneymcknight
WASHINGTON – Pressure on physicians to prescribe fewer opioids could have unintended consequences in the absence of adequate access to treatment, according to experts.
“There is mixed evidence that, when medication-assisted treatment is lacking, there are higher rates of transition from prescription opioids to heroin,” Gary Tsai, MD, said during a presentation at the American Psychiatric Association’s Institute on Psychiatric Services.
“As we constrict our prescribing, we want to make sure that there is ready access to these interventions, so that those who are already dependent on opioids can transition to something safer,” said Dr. Tsai, medical director and science officer of Substance Abuse Prevention and Control, a division of Los Angeles County’s public health department.
Medication-assisted treatment (MAT) uses methadone, buprenorphine, or naltrexone in combination with appropriate behavioral and other other psychosocial therapies to help achieve opioid abstinence. Despite MAT’s well-established superiority to either pharmacotherapy or psychosocial interventions alone, the use of MAT has, in some cases, declined. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), MAT was used in 35% of heroin-related treatment admissions in 2002, compared with 28% in 2010.
Reasons for MAT’s difficult path to acceptance are manifold, ranging from lack of certified facilities to administer the medications to misunderstanding about how the medications work, Dr. Tsai said.
A law passed earlier this year and the issuance of a final federal rule that increases the legal patient load that certified MAT providers can treat annually were designed to expand access to MAT. These, however, are only partial solutions, according to Margaret Chaplin, MD, a psychiatrist and program director of Community Mental Health Affiliates in New Britain, Conn.
“Can you imagine if endocrinologists were the only doctors who were certified to prescribe insulin and that each of them was only limited to prescribing to 100 patients?” Dr. Chaplin said in an interview. The final rule brought the number from 100 to 275 patients per year that a certified addiction specialist can treat. This might expand access to care, but “it sends a message that either the people with [addiction] don’t deserve treatment or that they don’t have a legitimate illness,” said Dr. Chaplin, who also was a presenter at the meeting.
Viewing people with opioid addiction through a lens of moral failing only compounds the nation’s addiction crisis, Dr. Chaplin believes. “Not to say that a person with a substance use disorder doesn’t have a responsibility to take care of their illness, [but] our [leaders] haven’t been well educated on the scientific evidence that addiction is a brain disease.”
It is true that, until the Comprehensive Addiction and Recovery Act was signed into law over the summer, nurse practitioners and physician assistants could have prescribed controlled substances such as acetaminophen/oxycontin but not the far less dangerous – and potentially life-saving – partial opioid agonist buprenorphine. Under the new law, those health care professions now have the same buprenorphine prescribing rights as physicians.
New legislation does not guarantee access to treatment, however. “Funding for MAT programs varies throughout the states, and the availability of these medications on formularies often determines how readily accessible MAT interventions are,” said Dr. Tsai, who emphasized the role of collaboration in ensuring the laws take hold.
“Addiction specialists comprise a minority of the work force. To scale MAT up, we need to engage other prescribers from other systems, including those in primary care and mental health,” Dr. Tai said. To wit, the three primary MAT facilities in Los Angeles County offer learning collaboratives with primary care clinicians who want to incorporate these services into their practice, even if they are not certified addiction specialists themselves. This helps increase referrals to the treatment facilities, he explained.
Overcoming resistance to offering MAT ultimately will depend on educating leaders about the costs of not doing so, Dr. Tsai and Dr. Chaplin said.
“Our system has been slow to adopt a disease model of addiction,” Dr. Chaplin said. “Buprenorphine and methadone are life-saving medical treatments that are regulated in ways that you don’t see for any other medical condition.”
SAMHSA currently is requesting comments through Nov. 1, 2016, on what should be required of MAT providers under the new law.
Neither Dr. Tsai nor Dr. Chaplin had any relevant disclosures.
[email protected]
On Twitter @whitneymcknight
WASHINGTON – Pressure on physicians to prescribe fewer opioids could have unintended consequences in the absence of adequate access to treatment, according to experts.
“There is mixed evidence that, when medication-assisted treatment is lacking, there are higher rates of transition from prescription opioids to heroin,” Gary Tsai, MD, said during a presentation at the American Psychiatric Association’s Institute on Psychiatric Services.
“As we constrict our prescribing, we want to make sure that there is ready access to these interventions, so that those who are already dependent on opioids can transition to something safer,” said Dr. Tsai, medical director and science officer of Substance Abuse Prevention and Control, a division of Los Angeles County’s public health department.
Medication-assisted treatment (MAT) uses methadone, buprenorphine, or naltrexone in combination with appropriate behavioral and other other psychosocial therapies to help achieve opioid abstinence. Despite MAT’s well-established superiority to either pharmacotherapy or psychosocial interventions alone, the use of MAT has, in some cases, declined. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), MAT was used in 35% of heroin-related treatment admissions in 2002, compared with 28% in 2010.
Reasons for MAT’s difficult path to acceptance are manifold, ranging from lack of certified facilities to administer the medications to misunderstanding about how the medications work, Dr. Tsai said.
A law passed earlier this year and the issuance of a final federal rule that increases the legal patient load that certified MAT providers can treat annually were designed to expand access to MAT. These, however, are only partial solutions, according to Margaret Chaplin, MD, a psychiatrist and program director of Community Mental Health Affiliates in New Britain, Conn.
“Can you imagine if endocrinologists were the only doctors who were certified to prescribe insulin and that each of them was only limited to prescribing to 100 patients?” Dr. Chaplin said in an interview. The final rule brought the number from 100 to 275 patients per year that a certified addiction specialist can treat. This might expand access to care, but “it sends a message that either the people with [addiction] don’t deserve treatment or that they don’t have a legitimate illness,” said Dr. Chaplin, who also was a presenter at the meeting.
Viewing people with opioid addiction through a lens of moral failing only compounds the nation’s addiction crisis, Dr. Chaplin believes. “Not to say that a person with a substance use disorder doesn’t have a responsibility to take care of their illness, [but] our [leaders] haven’t been well educated on the scientific evidence that addiction is a brain disease.”
It is true that, until the Comprehensive Addiction and Recovery Act was signed into law over the summer, nurse practitioners and physician assistants could have prescribed controlled substances such as acetaminophen/oxycontin but not the far less dangerous – and potentially life-saving – partial opioid agonist buprenorphine. Under the new law, those health care professions now have the same buprenorphine prescribing rights as physicians.
New legislation does not guarantee access to treatment, however. “Funding for MAT programs varies throughout the states, and the availability of these medications on formularies often determines how readily accessible MAT interventions are,” said Dr. Tsai, who emphasized the role of collaboration in ensuring the laws take hold.
“Addiction specialists comprise a minority of the work force. To scale MAT up, we need to engage other prescribers from other systems, including those in primary care and mental health,” Dr. Tai said. To wit, the three primary MAT facilities in Los Angeles County offer learning collaboratives with primary care clinicians who want to incorporate these services into their practice, even if they are not certified addiction specialists themselves. This helps increase referrals to the treatment facilities, he explained.
Overcoming resistance to offering MAT ultimately will depend on educating leaders about the costs of not doing so, Dr. Tsai and Dr. Chaplin said.
“Our system has been slow to adopt a disease model of addiction,” Dr. Chaplin said. “Buprenorphine and methadone are life-saving medical treatments that are regulated in ways that you don’t see for any other medical condition.”
SAMHSA currently is requesting comments through Nov. 1, 2016, on what should be required of MAT providers under the new law.
Neither Dr. Tsai nor Dr. Chaplin had any relevant disclosures.
[email protected]
On Twitter @whitneymcknight
EXPERT ANALYSIS FROM INSTITUTE ON PSYCHIATRIC SERVICES
Best practices discussed for using naloxone
WASHINGTON – More than 20 patients recently were admitted into New Haven, Conn., hospitals for overdoses of fentanyl on the same night – and many of them required multiple naloxone injections to stabilize, according to Margaret H. Chaplin, MD.
“We’re still going to lose people, but naloxone is obviously very important,” Dr. Chaplin, a psychiatrist who serves as program director of Community Mental Health Affiliates in New Britain, Conn., said during a presentation at the American Psychiatric Association’s Institute on Psychiatric Services.
The two ways it is most commonly prescribed, Dr. Chaplin said, is either to write a standing order for the drug to be shipped to the practice from the manufacturer, which is what community mental health and addiction service providers tend to do, or to write the prescription as needed when seeing patients. The former scenario means patients who are in the midst of an overdose do not need to wait for emergency personnel to arrive on the scene, Dr. Chaplin said.
There are three formulations: a nasal application, an intramuscular auto-injector version, and a syringe application; Dr. Chaplin said the nasal formulation is easier to store and to administer. The nasal version comes in a two-pack of 4 mg/0.1 mL doses, and the manufacturer also offers an app that gives video instructions for how to administer it.
“It’s incredibly easy to use. You stick it in a person’s nose and push,” Dr. Chaplin said. Do not prime the dose first, however. “If you do, you’ve lost the dose. Don’t push [the applicator] until it is in the nose.”
The auto-injectable formulation (Evzio) comes in a 0.4mg/0.4mL dose and is packaged with clear voice instructions recorded in the device.
Generic versions of naloxone are available. However, Dr. Chaplin said the branded versions are far easier to prescribe and administer because generics need additional scripts for the applicator. Until recently, the prices of generics and brand names were relatively similar. The auto-injectable version recently spiked considerably in price, Dr. Chaplin said.
Think of naloxone for people abusing opioids in the way that epinephrine for people susceptible to anaphylactic shock can save lives, Dr. Chaplin said. “Naloxone should be widely prescribed. There is no harm in administering it to a person who doesn’t need it.”
Naloxone really is effective only if it is administered at the time of the overdose, and it does not necessarily counteract the entire effect of the opioids. Therefore, people at risk of overdosing should have naloxone with them at all times, and 911 should be called at the time of naloxone’s administration.
“I always tell my patients that it will precipitate withdrawal, because I don’t want them to think of this as just a ‘morning after’ pill,” Dr. Chaplin said. Because most people with opioid addiction “fear withdrawal more than anything,” she said that usually helps prevent her patients from seeing naloxone as a tool to keep using opioids.
All people with a history of opioid overdose, anyone currently taking high doses of opioids, and anyone who has been coprescribed opioids with benzodiazepines also should be coprescribed naloxone, Dr. Chaplin said.
One dose of naloxone is not a 100% guarantee that a person will rebound from an overdose, Dr. Chaplin warned. Opioid overuse is evolving, particularly as the dangers posed by powerful street drugs, such as fentanyl and carfentanil, emerge.
Dr. Chaplin did not disclose any relevant financial information.
[email protected]
On Twitter @whitneymcknight
WASHINGTON – More than 20 patients recently were admitted into New Haven, Conn., hospitals for overdoses of fentanyl on the same night – and many of them required multiple naloxone injections to stabilize, according to Margaret H. Chaplin, MD.
“We’re still going to lose people, but naloxone is obviously very important,” Dr. Chaplin, a psychiatrist who serves as program director of Community Mental Health Affiliates in New Britain, Conn., said during a presentation at the American Psychiatric Association’s Institute on Psychiatric Services.
The two ways it is most commonly prescribed, Dr. Chaplin said, is either to write a standing order for the drug to be shipped to the practice from the manufacturer, which is what community mental health and addiction service providers tend to do, or to write the prescription as needed when seeing patients. The former scenario means patients who are in the midst of an overdose do not need to wait for emergency personnel to arrive on the scene, Dr. Chaplin said.
There are three formulations: a nasal application, an intramuscular auto-injector version, and a syringe application; Dr. Chaplin said the nasal formulation is easier to store and to administer. The nasal version comes in a two-pack of 4 mg/0.1 mL doses, and the manufacturer also offers an app that gives video instructions for how to administer it.
“It’s incredibly easy to use. You stick it in a person’s nose and push,” Dr. Chaplin said. Do not prime the dose first, however. “If you do, you’ve lost the dose. Don’t push [the applicator] until it is in the nose.”
The auto-injectable formulation (Evzio) comes in a 0.4mg/0.4mL dose and is packaged with clear voice instructions recorded in the device.
Generic versions of naloxone are available. However, Dr. Chaplin said the branded versions are far easier to prescribe and administer because generics need additional scripts for the applicator. Until recently, the prices of generics and brand names were relatively similar. The auto-injectable version recently spiked considerably in price, Dr. Chaplin said.
Think of naloxone for people abusing opioids in the way that epinephrine for people susceptible to anaphylactic shock can save lives, Dr. Chaplin said. “Naloxone should be widely prescribed. There is no harm in administering it to a person who doesn’t need it.”
Naloxone really is effective only if it is administered at the time of the overdose, and it does not necessarily counteract the entire effect of the opioids. Therefore, people at risk of overdosing should have naloxone with them at all times, and 911 should be called at the time of naloxone’s administration.
“I always tell my patients that it will precipitate withdrawal, because I don’t want them to think of this as just a ‘morning after’ pill,” Dr. Chaplin said. Because most people with opioid addiction “fear withdrawal more than anything,” she said that usually helps prevent her patients from seeing naloxone as a tool to keep using opioids.
All people with a history of opioid overdose, anyone currently taking high doses of opioids, and anyone who has been coprescribed opioids with benzodiazepines also should be coprescribed naloxone, Dr. Chaplin said.
One dose of naloxone is not a 100% guarantee that a person will rebound from an overdose, Dr. Chaplin warned. Opioid overuse is evolving, particularly as the dangers posed by powerful street drugs, such as fentanyl and carfentanil, emerge.
Dr. Chaplin did not disclose any relevant financial information.
[email protected]
On Twitter @whitneymcknight
WASHINGTON – More than 20 patients recently were admitted into New Haven, Conn., hospitals for overdoses of fentanyl on the same night – and many of them required multiple naloxone injections to stabilize, according to Margaret H. Chaplin, MD.
“We’re still going to lose people, but naloxone is obviously very important,” Dr. Chaplin, a psychiatrist who serves as program director of Community Mental Health Affiliates in New Britain, Conn., said during a presentation at the American Psychiatric Association’s Institute on Psychiatric Services.
The two ways it is most commonly prescribed, Dr. Chaplin said, is either to write a standing order for the drug to be shipped to the practice from the manufacturer, which is what community mental health and addiction service providers tend to do, or to write the prescription as needed when seeing patients. The former scenario means patients who are in the midst of an overdose do not need to wait for emergency personnel to arrive on the scene, Dr. Chaplin said.
There are three formulations: a nasal application, an intramuscular auto-injector version, and a syringe application; Dr. Chaplin said the nasal formulation is easier to store and to administer. The nasal version comes in a two-pack of 4 mg/0.1 mL doses, and the manufacturer also offers an app that gives video instructions for how to administer it.
“It’s incredibly easy to use. You stick it in a person’s nose and push,” Dr. Chaplin said. Do not prime the dose first, however. “If you do, you’ve lost the dose. Don’t push [the applicator] until it is in the nose.”
The auto-injectable formulation (Evzio) comes in a 0.4mg/0.4mL dose and is packaged with clear voice instructions recorded in the device.
Generic versions of naloxone are available. However, Dr. Chaplin said the branded versions are far easier to prescribe and administer because generics need additional scripts for the applicator. Until recently, the prices of generics and brand names were relatively similar. The auto-injectable version recently spiked considerably in price, Dr. Chaplin said.
Think of naloxone for people abusing opioids in the way that epinephrine for people susceptible to anaphylactic shock can save lives, Dr. Chaplin said. “Naloxone should be widely prescribed. There is no harm in administering it to a person who doesn’t need it.”
Naloxone really is effective only if it is administered at the time of the overdose, and it does not necessarily counteract the entire effect of the opioids. Therefore, people at risk of overdosing should have naloxone with them at all times, and 911 should be called at the time of naloxone’s administration.
“I always tell my patients that it will precipitate withdrawal, because I don’t want them to think of this as just a ‘morning after’ pill,” Dr. Chaplin said. Because most people with opioid addiction “fear withdrawal more than anything,” she said that usually helps prevent her patients from seeing naloxone as a tool to keep using opioids.
All people with a history of opioid overdose, anyone currently taking high doses of opioids, and anyone who has been coprescribed opioids with benzodiazepines also should be coprescribed naloxone, Dr. Chaplin said.
One dose of naloxone is not a 100% guarantee that a person will rebound from an overdose, Dr. Chaplin warned. Opioid overuse is evolving, particularly as the dangers posed by powerful street drugs, such as fentanyl and carfentanil, emerge.
Dr. Chaplin did not disclose any relevant financial information.
[email protected]
On Twitter @whitneymcknight
Suicide risk factors differ for women in military than in civilian population
WASHINGTON – Women service personnel face different suicide risks from their civilian counterparts, according to a Department of Defense appointee.
Data are few about suicide among women in the military – in part because not much research has been conducted over the years into service women’s health outcomes – according to Jacqueline Garrick, but insights gleaned from the reports of military women, both active duty and veterans, who survived suicide attempts, shed light on what to look for as risk factors. Ms. Garrick, special assistant, Manpower and Reserve Affairs in the Department of Defense, made her comments during a panel discussion at the American Psychiatric Association’s Institute on Psychiatric Services.*
One of the most salient of suicide risks can emerge when a service woman’s intimate relationship ends. This loss is compounded by the absence of social support that results from the military’s inherently masculine environment where “fitting in is definitely harder for women,” according to Ms. Garrick, a licensed clinical social worker, U.S. Army veteran, and policy analyst.
Deployment and combat zone traumas, whether physical, mental, or both, are other risk factors. Horrors witnessed in war can have psychological implications for men and women personnel. But for women, who also possibly face additional concerns of sexual assault and lack of social support, the traumas can become debilitating and lead to risk of suicide, Ms. Garrick said.
Women in the military overlap with civilians in their suicide risk factors where mental health history, abuse, and exposure to suicide are concerned, but where the two cohorts particularly diverge, Ms. Garrick said, is access to lethal means, particularly among women veterans. Civilian women who attempt suicide are more likely to cut themselves or overdose on drugs, whereas, “Military women have firearms, and they know how to use them,” Ms. Garrick said. “So, if you’re screening [for suicide in this population], pay close attention to whether there are weapons in the home.”
Traumatic brain injury is another area in which risks for suicide in military women could exist, but not enough is known at this point, Ms. Garrick said.
A suicide risk intervention called “safety planning” is one that Ms. Garrick said she has been developing in her work with the DOD. This includes asking these women what makes them feel “safe” at home, determining what their families know about the whereabouts and the safety features of their firearms, and learning what level of peer support exists for them and how to build it if it is lacking. Building resilience is another area, including finding military women opportunities to use their experiences in positive ways, such as through mentoring others.
For more information on suicide prevention for these women, Ms. Garrick referred clinicians to the suicide risk assessment and prevention clinical guidelines issued by the DOD and the Department of Veterans Affairs.
For patients at acute risk, Ms. Garrick said, “I recommend sitting with them as you watch them put this number into their phone: 800-273-8255. That’s the lifeline number that will connect you directly with the VA if you press 1.”
Because there has been a historic lack of interest on behalf of the military in women’s health outcomes related to their service compared with that of men, there is a need to create a database going forward to better inform DOD health and disability policies for women in the military, Ms. Garrick said. This places the onus on psychiatrists who evaluate this cohort to “tease out any potential psychological stressors that might not be obvious from their personnel file.” Some women have been exposed to the same levels of traumatic combat experiences as their male colleagues, even though it wasn’t until earlier this year that women became eligible for the same combat roles as men.
“If you look in their files, they might not have the same awards and titles as men, but they might have seen the same people being killed or the same number of dead bodies,” she said.
Ms. Garrick’s views are her own and do not represent those of the Department of Defense.
*Correction 10/14/16: An earlier version of this story misstated Ms. Garrick's position.
[email protected]
On Twitter @whitneymcknight
WASHINGTON – Women service personnel face different suicide risks from their civilian counterparts, according to a Department of Defense appointee.
Data are few about suicide among women in the military – in part because not much research has been conducted over the years into service women’s health outcomes – according to Jacqueline Garrick, but insights gleaned from the reports of military women, both active duty and veterans, who survived suicide attempts, shed light on what to look for as risk factors. Ms. Garrick, special assistant, Manpower and Reserve Affairs in the Department of Defense, made her comments during a panel discussion at the American Psychiatric Association’s Institute on Psychiatric Services.*
One of the most salient of suicide risks can emerge when a service woman’s intimate relationship ends. This loss is compounded by the absence of social support that results from the military’s inherently masculine environment where “fitting in is definitely harder for women,” according to Ms. Garrick, a licensed clinical social worker, U.S. Army veteran, and policy analyst.
Deployment and combat zone traumas, whether physical, mental, or both, are other risk factors. Horrors witnessed in war can have psychological implications for men and women personnel. But for women, who also possibly face additional concerns of sexual assault and lack of social support, the traumas can become debilitating and lead to risk of suicide, Ms. Garrick said.
Women in the military overlap with civilians in their suicide risk factors where mental health history, abuse, and exposure to suicide are concerned, but where the two cohorts particularly diverge, Ms. Garrick said, is access to lethal means, particularly among women veterans. Civilian women who attempt suicide are more likely to cut themselves or overdose on drugs, whereas, “Military women have firearms, and they know how to use them,” Ms. Garrick said. “So, if you’re screening [for suicide in this population], pay close attention to whether there are weapons in the home.”
Traumatic brain injury is another area in which risks for suicide in military women could exist, but not enough is known at this point, Ms. Garrick said.
A suicide risk intervention called “safety planning” is one that Ms. Garrick said she has been developing in her work with the DOD. This includes asking these women what makes them feel “safe” at home, determining what their families know about the whereabouts and the safety features of their firearms, and learning what level of peer support exists for them and how to build it if it is lacking. Building resilience is another area, including finding military women opportunities to use their experiences in positive ways, such as through mentoring others.
For more information on suicide prevention for these women, Ms. Garrick referred clinicians to the suicide risk assessment and prevention clinical guidelines issued by the DOD and the Department of Veterans Affairs.
For patients at acute risk, Ms. Garrick said, “I recommend sitting with them as you watch them put this number into their phone: 800-273-8255. That’s the lifeline number that will connect you directly with the VA if you press 1.”
Because there has been a historic lack of interest on behalf of the military in women’s health outcomes related to their service compared with that of men, there is a need to create a database going forward to better inform DOD health and disability policies for women in the military, Ms. Garrick said. This places the onus on psychiatrists who evaluate this cohort to “tease out any potential psychological stressors that might not be obvious from their personnel file.” Some women have been exposed to the same levels of traumatic combat experiences as their male colleagues, even though it wasn’t until earlier this year that women became eligible for the same combat roles as men.
“If you look in their files, they might not have the same awards and titles as men, but they might have seen the same people being killed or the same number of dead bodies,” she said.
Ms. Garrick’s views are her own and do not represent those of the Department of Defense.
*Correction 10/14/16: An earlier version of this story misstated Ms. Garrick's position.
[email protected]
On Twitter @whitneymcknight
WASHINGTON – Women service personnel face different suicide risks from their civilian counterparts, according to a Department of Defense appointee.
Data are few about suicide among women in the military – in part because not much research has been conducted over the years into service women’s health outcomes – according to Jacqueline Garrick, but insights gleaned from the reports of military women, both active duty and veterans, who survived suicide attempts, shed light on what to look for as risk factors. Ms. Garrick, special assistant, Manpower and Reserve Affairs in the Department of Defense, made her comments during a panel discussion at the American Psychiatric Association’s Institute on Psychiatric Services.*
One of the most salient of suicide risks can emerge when a service woman’s intimate relationship ends. This loss is compounded by the absence of social support that results from the military’s inherently masculine environment where “fitting in is definitely harder for women,” according to Ms. Garrick, a licensed clinical social worker, U.S. Army veteran, and policy analyst.
Deployment and combat zone traumas, whether physical, mental, or both, are other risk factors. Horrors witnessed in war can have psychological implications for men and women personnel. But for women, who also possibly face additional concerns of sexual assault and lack of social support, the traumas can become debilitating and lead to risk of suicide, Ms. Garrick said.
Women in the military overlap with civilians in their suicide risk factors where mental health history, abuse, and exposure to suicide are concerned, but where the two cohorts particularly diverge, Ms. Garrick said, is access to lethal means, particularly among women veterans. Civilian women who attempt suicide are more likely to cut themselves or overdose on drugs, whereas, “Military women have firearms, and they know how to use them,” Ms. Garrick said. “So, if you’re screening [for suicide in this population], pay close attention to whether there are weapons in the home.”
Traumatic brain injury is another area in which risks for suicide in military women could exist, but not enough is known at this point, Ms. Garrick said.
A suicide risk intervention called “safety planning” is one that Ms. Garrick said she has been developing in her work with the DOD. This includes asking these women what makes them feel “safe” at home, determining what their families know about the whereabouts and the safety features of their firearms, and learning what level of peer support exists for them and how to build it if it is lacking. Building resilience is another area, including finding military women opportunities to use their experiences in positive ways, such as through mentoring others.
For more information on suicide prevention for these women, Ms. Garrick referred clinicians to the suicide risk assessment and prevention clinical guidelines issued by the DOD and the Department of Veterans Affairs.
For patients at acute risk, Ms. Garrick said, “I recommend sitting with them as you watch them put this number into their phone: 800-273-8255. That’s the lifeline number that will connect you directly with the VA if you press 1.”
Because there has been a historic lack of interest on behalf of the military in women’s health outcomes related to their service compared with that of men, there is a need to create a database going forward to better inform DOD health and disability policies for women in the military, Ms. Garrick said. This places the onus on psychiatrists who evaluate this cohort to “tease out any potential psychological stressors that might not be obvious from their personnel file.” Some women have been exposed to the same levels of traumatic combat experiences as their male colleagues, even though it wasn’t until earlier this year that women became eligible for the same combat roles as men.
“If you look in their files, they might not have the same awards and titles as men, but they might have seen the same people being killed or the same number of dead bodies,” she said.
Ms. Garrick’s views are her own and do not represent those of the Department of Defense.
*Correction 10/14/16: An earlier version of this story misstated Ms. Garrick's position.
[email protected]
On Twitter @whitneymcknight
VIDEO: DNA-derived Zika vaccine in humans holds promise
BALTIMORE – Hope is high right now for a genetically engineered Zika virus vaccine currently being tested in humans.
“If we saw something, even early on, that we were concerned about, we would stop the trial and re-evaluate it. And that hasn’t happened, so that’s good news,” said Kathleen M. Neuzil, MD, lead investigator of the trial and a professor at the University of Maryland in Baltimore, where she is also director of the Center for Vaccine Development.
Testing of the DNA-based Zika vaccine began in early August. Now that Congress has approved a $1.1 billion funding package, Dr. Neuzil said investigators can rest assured that there is enough funding for the duration of this trial, which ultimately could take 2 years or longer.
Sponsored by the National Institutes of Health, phase I of the trial is being conducted at three U.S. sites, including the University of Maryland’s Vaccine Development Center, the NIH Clinical Center in Bethesda, Md., and Emory University in Atlanta.
Safety and tolerability results from all three sites are expected by year’s end and will inform how to construct phase II, currently set to begin in early 2017. That phase is expected to include a much larger population than the 80 current participants, although the exact numbers are still to be determined, Dr. Neuzil said. Also still unknown is whether phase II will be conducted internationally.
If the vaccine proves effective, it will be a high point in the annals of maternal-fetal medicine, said Christopher Harman, MD, chair of obstetrics and gynecology and director of the division of maternal-fetal medicine at the University of Maryland. “It’s going to become a story where the power of modern medicine has defeated an epidemic that had enormous potential for harm.”
Dr. Harman also predicted that a viable vaccine, combined with infectious disease prevention services globally, will mitigate Zika’s threat to the population, particularly developing fetuses.
In the meantime, there needs to be continued public education about preventing the spread of Zika, as well as rigorous attention to family planning, Dr. Harman said.
“Planned pregnancy is essential,” he said. “This puts the burden on the couple or the woman. Don’t get pregnant if you’re in an endemic area.”
For more about the vaccine trial and how clinicians can counsel patients about the threat of Zika, watch this video recorded at the University of Maryland.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @whitneymcknight
BALTIMORE – Hope is high right now for a genetically engineered Zika virus vaccine currently being tested in humans.
“If we saw something, even early on, that we were concerned about, we would stop the trial and re-evaluate it. And that hasn’t happened, so that’s good news,” said Kathleen M. Neuzil, MD, lead investigator of the trial and a professor at the University of Maryland in Baltimore, where she is also director of the Center for Vaccine Development.
Testing of the DNA-based Zika vaccine began in early August. Now that Congress has approved a $1.1 billion funding package, Dr. Neuzil said investigators can rest assured that there is enough funding for the duration of this trial, which ultimately could take 2 years or longer.
Sponsored by the National Institutes of Health, phase I of the trial is being conducted at three U.S. sites, including the University of Maryland’s Vaccine Development Center, the NIH Clinical Center in Bethesda, Md., and Emory University in Atlanta.
Safety and tolerability results from all three sites are expected by year’s end and will inform how to construct phase II, currently set to begin in early 2017. That phase is expected to include a much larger population than the 80 current participants, although the exact numbers are still to be determined, Dr. Neuzil said. Also still unknown is whether phase II will be conducted internationally.
If the vaccine proves effective, it will be a high point in the annals of maternal-fetal medicine, said Christopher Harman, MD, chair of obstetrics and gynecology and director of the division of maternal-fetal medicine at the University of Maryland. “It’s going to become a story where the power of modern medicine has defeated an epidemic that had enormous potential for harm.”
Dr. Harman also predicted that a viable vaccine, combined with infectious disease prevention services globally, will mitigate Zika’s threat to the population, particularly developing fetuses.
In the meantime, there needs to be continued public education about preventing the spread of Zika, as well as rigorous attention to family planning, Dr. Harman said.
“Planned pregnancy is essential,” he said. “This puts the burden on the couple or the woman. Don’t get pregnant if you’re in an endemic area.”
For more about the vaccine trial and how clinicians can counsel patients about the threat of Zika, watch this video recorded at the University of Maryland.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
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BALTIMORE – Hope is high right now for a genetically engineered Zika virus vaccine currently being tested in humans.
“If we saw something, even early on, that we were concerned about, we would stop the trial and re-evaluate it. And that hasn’t happened, so that’s good news,” said Kathleen M. Neuzil, MD, lead investigator of the trial and a professor at the University of Maryland in Baltimore, where she is also director of the Center for Vaccine Development.
Testing of the DNA-based Zika vaccine began in early August. Now that Congress has approved a $1.1 billion funding package, Dr. Neuzil said investigators can rest assured that there is enough funding for the duration of this trial, which ultimately could take 2 years or longer.
Sponsored by the National Institutes of Health, phase I of the trial is being conducted at three U.S. sites, including the University of Maryland’s Vaccine Development Center, the NIH Clinical Center in Bethesda, Md., and Emory University in Atlanta.
Safety and tolerability results from all three sites are expected by year’s end and will inform how to construct phase II, currently set to begin in early 2017. That phase is expected to include a much larger population than the 80 current participants, although the exact numbers are still to be determined, Dr. Neuzil said. Also still unknown is whether phase II will be conducted internationally.
If the vaccine proves effective, it will be a high point in the annals of maternal-fetal medicine, said Christopher Harman, MD, chair of obstetrics and gynecology and director of the division of maternal-fetal medicine at the University of Maryland. “It’s going to become a story where the power of modern medicine has defeated an epidemic that had enormous potential for harm.”
Dr. Harman also predicted that a viable vaccine, combined with infectious disease prevention services globally, will mitigate Zika’s threat to the population, particularly developing fetuses.
In the meantime, there needs to be continued public education about preventing the spread of Zika, as well as rigorous attention to family planning, Dr. Harman said.
“Planned pregnancy is essential,” he said. “This puts the burden on the couple or the woman. Don’t get pregnant if you’re in an endemic area.”
For more about the vaccine trial and how clinicians can counsel patients about the threat of Zika, watch this video recorded at the University of Maryland.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @whitneymcknight
VIDEO: What will be the NIMH’s focus under Dr. Joshua Gordon?
NEW YORK – “Most clinicians probably don’t have problems identifying patients who are depressed and giving them a trial of an antidepressant or a second antidepressant, but where do they run into stumbling blocks?” That’s a question Joshua A. Gordon, MD, PhD, the new director of the National Institute of Mental Health, said he is pondering as he steps into his new role.
Both a practicing clinical psychiatrist and a neuroscientist with a lab chiefly dedicated to optogenetics, Dr. Gordon shared his thoughts about what the priorities of the world’s largest mental health research institute should be, and how to balance immediate patient needs with the development of future interventions.
Conducted in New York City, where Dr. Gordon saw patients, maintained a lab, and was an associate professor of psychiatry at Columbia University for nearly 2 decades, this is the last installment in a series of interviews.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @whitneymcknight
NEW YORK – “Most clinicians probably don’t have problems identifying patients who are depressed and giving them a trial of an antidepressant or a second antidepressant, but where do they run into stumbling blocks?” That’s a question Joshua A. Gordon, MD, PhD, the new director of the National Institute of Mental Health, said he is pondering as he steps into his new role.
Both a practicing clinical psychiatrist and a neuroscientist with a lab chiefly dedicated to optogenetics, Dr. Gordon shared his thoughts about what the priorities of the world’s largest mental health research institute should be, and how to balance immediate patient needs with the development of future interventions.
Conducted in New York City, where Dr. Gordon saw patients, maintained a lab, and was an associate professor of psychiatry at Columbia University for nearly 2 decades, this is the last installment in a series of interviews.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @whitneymcknight
NEW YORK – “Most clinicians probably don’t have problems identifying patients who are depressed and giving them a trial of an antidepressant or a second antidepressant, but where do they run into stumbling blocks?” That’s a question Joshua A. Gordon, MD, PhD, the new director of the National Institute of Mental Health, said he is pondering as he steps into his new role.
Both a practicing clinical psychiatrist and a neuroscientist with a lab chiefly dedicated to optogenetics, Dr. Gordon shared his thoughts about what the priorities of the world’s largest mental health research institute should be, and how to balance immediate patient needs with the development of future interventions.
Conducted in New York City, where Dr. Gordon saw patients, maintained a lab, and was an associate professor of psychiatry at Columbia University for nearly 2 decades, this is the last installment in a series of interviews.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @whitneymcknight
