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Abatacept shows potential in refractory myositis
Abatacept could be a new treatment option for people with adult dermatomyositis and polymyositis refractory to conventional treatment, a small, randomized pilot study suggests.
The investigators, led by first author Anna Tjärnlund, PhD, of the Karolinska Institute in Stockholm, noted that the health-related quality of life for people with dermatomyositis (DM) and polymyositis (PM) is low, compared with the general population.
“The majority of commonly used drugs are not approved for myositis, and only [a] few randomized, controlled trials (RCTs) have been performed in this patient group. Thus, there is an unmet need for new therapies for these patients,” they wrote (Ann Rheum Dis. 2017 Oct 9. doi: 10.1136/annrheumdis-2017-211751).
According to the researchers, muscle biopsies of people with DM and PM show a predominance of T cells in inflammatory infiltrates, suggesting a role for T cells in the disease process. Abatacept (Orencia), a fully human fusion protein of CTLA-4 and the Fc portion of human IgG1 that inhibits the co-stimulation of T cells, has been shown in several case reports to have beneficial effects in myositis, but no RCT has been done.
Abatacept is approved by the Food and Drug Administration for the treatment of moderately to severely active rheumatoid arthritis, moderately to severely active polyarticular juvenile idiopathic arthritis, and active psoriatic arthritis in adults.
The aim of the current phase 2b pilot study was to investigate the efficacy and safety of abatacept in a randomized trial with a delayed start in one arm. The researchers randomized 19 patients with DM or PM with refractory disease to receive either immediate active treatment (n = 10) with intravenous abatacept (dosed according to body weight) or a 3-month delayed start (n = 9). Patients who weighed less than 60 kg received 500 mg abatacept, those who weighed 60-100 kg received 750 mg, and those with body weight greater than 100 kg received 1,000 mg.
The primary endpoint was the number of responders defined by the International Myositis Assessment and Clinical Studies (IMACS) Group definition of improvement (relative improvement of 20% or greater in three of any six core set measures, with no more than two core set measures worsening by 25% or more) after 6 months of treatment.
The researchers saw improvements in the active treatment arm, compared with the delayed-start arm. At 3 months, five patients in the active treatment arm were responders, compared with one patient in the delayed treatment arm. For example, the active treatment groups improved by a mean of 2.5 points on the Manual Muscle Testing–8 (one of the individual components of the IMACS core set), compared with –4.9 in the delayed treatment arm (P = .0375).
At 6 months, an intent-to-treat analysis revealed that 8 out of 19 patients responded (2 with DM, 6 with PM) and reached the definition of improvement, with the remaining patients classified as nonresponders.
In patients who had before and after muscle biopsies, the expression of anti-inflammatory Foxp3+ regulatory T cells was significantly greater after abatacept treatment, the researchers reported. They noted that they had previously seen a decrease in the number of Foxp3+ cells in the tissues of patients with myositis on treatment with glucocorticoids.
“This difference could be related to the different treatment targets as since tissue-resident Foxp3+ regulatory T cells have been implicated in muscle repair and regeneration.”
Overall, 36 adverse events were reported during the study. Eight were considered related to abatacept, of which four were considered “mild” and the remaining four “moderate.”
The researchers concluded that although their study was not powered to confirm efficacy, treatment with abatacept was “clinically efficacious in a subgroup of patients with DM or PM and has an acceptable safety profile in refractory patients.”
They cautioned that treatment with abatacept might provide a new treatment option in PM/DM, but it needs to be investigated in randomized, placebo-controlled trials in larger patient populations.
The study was funded by grants from Bristol-Myers Squibb, the Börje Dahlin Foundation, the Swedish Research Council, the Swedish Rheumatism Association, and the King Gustaf V 80-Year Foundation. Two authors reported receiving research grants from Bristol-Myers Squibb and one serves as an advisory board consultant to the company.
Abatacept could be a new treatment option for people with adult dermatomyositis and polymyositis refractory to conventional treatment, a small, randomized pilot study suggests.
The investigators, led by first author Anna Tjärnlund, PhD, of the Karolinska Institute in Stockholm, noted that the health-related quality of life for people with dermatomyositis (DM) and polymyositis (PM) is low, compared with the general population.
“The majority of commonly used drugs are not approved for myositis, and only [a] few randomized, controlled trials (RCTs) have been performed in this patient group. Thus, there is an unmet need for new therapies for these patients,” they wrote (Ann Rheum Dis. 2017 Oct 9. doi: 10.1136/annrheumdis-2017-211751).
According to the researchers, muscle biopsies of people with DM and PM show a predominance of T cells in inflammatory infiltrates, suggesting a role for T cells in the disease process. Abatacept (Orencia), a fully human fusion protein of CTLA-4 and the Fc portion of human IgG1 that inhibits the co-stimulation of T cells, has been shown in several case reports to have beneficial effects in myositis, but no RCT has been done.
Abatacept is approved by the Food and Drug Administration for the treatment of moderately to severely active rheumatoid arthritis, moderately to severely active polyarticular juvenile idiopathic arthritis, and active psoriatic arthritis in adults.
The aim of the current phase 2b pilot study was to investigate the efficacy and safety of abatacept in a randomized trial with a delayed start in one arm. The researchers randomized 19 patients with DM or PM with refractory disease to receive either immediate active treatment (n = 10) with intravenous abatacept (dosed according to body weight) or a 3-month delayed start (n = 9). Patients who weighed less than 60 kg received 500 mg abatacept, those who weighed 60-100 kg received 750 mg, and those with body weight greater than 100 kg received 1,000 mg.
The primary endpoint was the number of responders defined by the International Myositis Assessment and Clinical Studies (IMACS) Group definition of improvement (relative improvement of 20% or greater in three of any six core set measures, with no more than two core set measures worsening by 25% or more) after 6 months of treatment.
The researchers saw improvements in the active treatment arm, compared with the delayed-start arm. At 3 months, five patients in the active treatment arm were responders, compared with one patient in the delayed treatment arm. For example, the active treatment groups improved by a mean of 2.5 points on the Manual Muscle Testing–8 (one of the individual components of the IMACS core set), compared with –4.9 in the delayed treatment arm (P = .0375).
At 6 months, an intent-to-treat analysis revealed that 8 out of 19 patients responded (2 with DM, 6 with PM) and reached the definition of improvement, with the remaining patients classified as nonresponders.
In patients who had before and after muscle biopsies, the expression of anti-inflammatory Foxp3+ regulatory T cells was significantly greater after abatacept treatment, the researchers reported. They noted that they had previously seen a decrease in the number of Foxp3+ cells in the tissues of patients with myositis on treatment with glucocorticoids.
“This difference could be related to the different treatment targets as since tissue-resident Foxp3+ regulatory T cells have been implicated in muscle repair and regeneration.”
Overall, 36 adverse events were reported during the study. Eight were considered related to abatacept, of which four were considered “mild” and the remaining four “moderate.”
The researchers concluded that although their study was not powered to confirm efficacy, treatment with abatacept was “clinically efficacious in a subgroup of patients with DM or PM and has an acceptable safety profile in refractory patients.”
They cautioned that treatment with abatacept might provide a new treatment option in PM/DM, but it needs to be investigated in randomized, placebo-controlled trials in larger patient populations.
The study was funded by grants from Bristol-Myers Squibb, the Börje Dahlin Foundation, the Swedish Research Council, the Swedish Rheumatism Association, and the King Gustaf V 80-Year Foundation. Two authors reported receiving research grants from Bristol-Myers Squibb and one serves as an advisory board consultant to the company.
Abatacept could be a new treatment option for people with adult dermatomyositis and polymyositis refractory to conventional treatment, a small, randomized pilot study suggests.
The investigators, led by first author Anna Tjärnlund, PhD, of the Karolinska Institute in Stockholm, noted that the health-related quality of life for people with dermatomyositis (DM) and polymyositis (PM) is low, compared with the general population.
“The majority of commonly used drugs are not approved for myositis, and only [a] few randomized, controlled trials (RCTs) have been performed in this patient group. Thus, there is an unmet need for new therapies for these patients,” they wrote (Ann Rheum Dis. 2017 Oct 9. doi: 10.1136/annrheumdis-2017-211751).
According to the researchers, muscle biopsies of people with DM and PM show a predominance of T cells in inflammatory infiltrates, suggesting a role for T cells in the disease process. Abatacept (Orencia), a fully human fusion protein of CTLA-4 and the Fc portion of human IgG1 that inhibits the co-stimulation of T cells, has been shown in several case reports to have beneficial effects in myositis, but no RCT has been done.
Abatacept is approved by the Food and Drug Administration for the treatment of moderately to severely active rheumatoid arthritis, moderately to severely active polyarticular juvenile idiopathic arthritis, and active psoriatic arthritis in adults.
The aim of the current phase 2b pilot study was to investigate the efficacy and safety of abatacept in a randomized trial with a delayed start in one arm. The researchers randomized 19 patients with DM or PM with refractory disease to receive either immediate active treatment (n = 10) with intravenous abatacept (dosed according to body weight) or a 3-month delayed start (n = 9). Patients who weighed less than 60 kg received 500 mg abatacept, those who weighed 60-100 kg received 750 mg, and those with body weight greater than 100 kg received 1,000 mg.
The primary endpoint was the number of responders defined by the International Myositis Assessment and Clinical Studies (IMACS) Group definition of improvement (relative improvement of 20% or greater in three of any six core set measures, with no more than two core set measures worsening by 25% or more) after 6 months of treatment.
The researchers saw improvements in the active treatment arm, compared with the delayed-start arm. At 3 months, five patients in the active treatment arm were responders, compared with one patient in the delayed treatment arm. For example, the active treatment groups improved by a mean of 2.5 points on the Manual Muscle Testing–8 (one of the individual components of the IMACS core set), compared with –4.9 in the delayed treatment arm (P = .0375).
At 6 months, an intent-to-treat analysis revealed that 8 out of 19 patients responded (2 with DM, 6 with PM) and reached the definition of improvement, with the remaining patients classified as nonresponders.
In patients who had before and after muscle biopsies, the expression of anti-inflammatory Foxp3+ regulatory T cells was significantly greater after abatacept treatment, the researchers reported. They noted that they had previously seen a decrease in the number of Foxp3+ cells in the tissues of patients with myositis on treatment with glucocorticoids.
“This difference could be related to the different treatment targets as since tissue-resident Foxp3+ regulatory T cells have been implicated in muscle repair and regeneration.”
Overall, 36 adverse events were reported during the study. Eight were considered related to abatacept, of which four were considered “mild” and the remaining four “moderate.”
The researchers concluded that although their study was not powered to confirm efficacy, treatment with abatacept was “clinically efficacious in a subgroup of patients with DM or PM and has an acceptable safety profile in refractory patients.”
They cautioned that treatment with abatacept might provide a new treatment option in PM/DM, but it needs to be investigated in randomized, placebo-controlled trials in larger patient populations.
The study was funded by grants from Bristol-Myers Squibb, the Börje Dahlin Foundation, the Swedish Research Council, the Swedish Rheumatism Association, and the King Gustaf V 80-Year Foundation. Two authors reported receiving research grants from Bristol-Myers Squibb and one serves as an advisory board consultant to the company.
FROM ANNALS OF THE RHEUMATIC DISEASES
Key clinical point:
Major finding: Of 19 patients, 8 were classified as treatment responders, reaching the IMACS definition of improvement.
Data source: A phase 2b pilot study with a randomized delayed treatment arm.
Disclosures: The study was funded by grants from Bristol-Myers Squibb, the Börje Dahlin Foundation, the Swedish Research Council, the Swedish Rheumatism Association, and the King Gustaf V 80-Year Foundation. Two authors reported receiving research grants from Bristol-Myers Squibb and one serves as an advisory board consultant to the company.
Further evidence supports link between Zika and GBS
Newly identified risk factors add to the growing evidence of a causal association between Zika virus and Guillain-Barré Syndrome (GBS), according to a case-control study.
In a study conducted in Puerto Rico, GBS diagnosis was confirmed in 39 of 47 (83%) patients with clinical suspicion of the syndrome from nine hospitals from April 2016 to December 2016. They were compared with 78 control patients to identify GBS risk factors. Three risk factors were identified, Emilio Dirlikov, PhD, of the division of scientific education and professional development for the Centers for Disease Control and Prevention in San Juan, Puerto Rico, and his coauthors said in a research letter to JAMA (2017;318[15]:1498).
“During Zika virus outbreaks, clinical suspicion should be elevated to improve GBS patient prognosis through prompt diagnosis and treatment,” Dr. Dirlikov and his coauthors wrote. This was a small study. “The pathophysiology of Zika virus infection and risk factors for developing GBS require further investigation. Clinical trials of the Zika virus vaccine should monitor for GBS,” they said.
The study was supported with a grant from the National Institutes of Health. Carlos A. Luciano, MD, also reported grant funding from the University of Puerto Rico Medical Sciences, San Juan. No other authors reported any financial disclosures.
Newly identified risk factors add to the growing evidence of a causal association between Zika virus and Guillain-Barré Syndrome (GBS), according to a case-control study.
In a study conducted in Puerto Rico, GBS diagnosis was confirmed in 39 of 47 (83%) patients with clinical suspicion of the syndrome from nine hospitals from April 2016 to December 2016. They were compared with 78 control patients to identify GBS risk factors. Three risk factors were identified, Emilio Dirlikov, PhD, of the division of scientific education and professional development for the Centers for Disease Control and Prevention in San Juan, Puerto Rico, and his coauthors said in a research letter to JAMA (2017;318[15]:1498).
“During Zika virus outbreaks, clinical suspicion should be elevated to improve GBS patient prognosis through prompt diagnosis and treatment,” Dr. Dirlikov and his coauthors wrote. This was a small study. “The pathophysiology of Zika virus infection and risk factors for developing GBS require further investigation. Clinical trials of the Zika virus vaccine should monitor for GBS,” they said.
The study was supported with a grant from the National Institutes of Health. Carlos A. Luciano, MD, also reported grant funding from the University of Puerto Rico Medical Sciences, San Juan. No other authors reported any financial disclosures.
Newly identified risk factors add to the growing evidence of a causal association between Zika virus and Guillain-Barré Syndrome (GBS), according to a case-control study.
In a study conducted in Puerto Rico, GBS diagnosis was confirmed in 39 of 47 (83%) patients with clinical suspicion of the syndrome from nine hospitals from April 2016 to December 2016. They were compared with 78 control patients to identify GBS risk factors. Three risk factors were identified, Emilio Dirlikov, PhD, of the division of scientific education and professional development for the Centers for Disease Control and Prevention in San Juan, Puerto Rico, and his coauthors said in a research letter to JAMA (2017;318[15]:1498).
“During Zika virus outbreaks, clinical suspicion should be elevated to improve GBS patient prognosis through prompt diagnosis and treatment,” Dr. Dirlikov and his coauthors wrote. This was a small study. “The pathophysiology of Zika virus infection and risk factors for developing GBS require further investigation. Clinical trials of the Zika virus vaccine should monitor for GBS,” they said.
The study was supported with a grant from the National Institutes of Health. Carlos A. Luciano, MD, also reported grant funding from the University of Puerto Rico Medical Sciences, San Juan. No other authors reported any financial disclosures.
FROM JAMA
Key clinical point:
Major finding: Case patients saw higher rates of acute illness within the previous 2 months (82%), acute Zika virus infection (23%), and any laboratory evidence of Zika virus infection (69%), compared with controls.
Data source: A case-control study of 39 patients with GBS and 78 controls.
Disclosures: The study was supported with a grant from the National Institutes of Health. Carlos A. Luciano, MD, also reported grant funding from the University of Puerto Rico Medical Sciences, San Juan. No other authors reported any financial disclosures.
MRI brainstem volume loss predicts SUDEP
SAN DIEGO – Brainstem volume loss is extensive in sudden unexplained death in epilepsy, suggesting that loss of brainstem volume on MRI might predict who is at risk, according to investigators from the Center for SUDEP Research, a multicenter research collaborative.
The “MRI can detect potentially life threatening brainstem damage before SUDEP [sudden unexplained death in epilepsy] onset and ought to be further studied as a clinically useful biomarker to identify patients at risk for SUDEP,” said lead investigator Alica Goldman, MD, PhD, associate professor of neurology and neurophysiology at Baylor College of Medicine, Houston, and an investigator for the research collaborative.
It’s possible SUDEP is due to autonomic failure secondary to damage to areas of the brainstem that control autonomic functions such as breathing and heartbeat. Cardiorespiratory failure has been reported in cases of witnessed SUDEP, and the team previously reported structural mesencephalic and lower brainstem abnormalities in two SUDEP cases with temporal lobe epilepsy (Neuroimage Clin. 2014 Jul 9;5:208-16).
“It was a logical transition to have a larger study,” Dr. Goldman said at the annual meeting of the American Neurological Association.
The team compared findings from standardized 3T MRI exams in 18 patients with focal-onset epilepsy, 27 SUDEP cases that had focal-onset epilepsy and one or more MRIs within 10 years of death, and 11 controls without epilepsy.
They also looked at heart rate variability based on ECG readings, a proxy of autonomic control. Abnormal variability is a risk factor for arrhythmias and sudden cardiac death, and has been shown previously to correlate with epilepsy duration and frequency. It also seems worse at night, when SUDEP risk is highest.
In the living epilepsy patients, the team found structural volume loss in the dorsal mesencephalon and other brainstem areas, and the loss correlated with abnormal heart rate variability (P less than .001).
In the SUDEP cases, “we found that patients who died from SUDEP had widespread brainstem volume loss in their last MRI before death, and the extent of volume loss in the brainstem correlated with shorter survival time” from the final MRI (P = .03).
The SUDEP cases were a mean of 23 years old at their last MRI; the majority of the cases were men.
The National Institutes of Health and the Epilepsy Foundation supported the work. Dr. Goldman had no relevant disclosures.
SAN DIEGO – Brainstem volume loss is extensive in sudden unexplained death in epilepsy, suggesting that loss of brainstem volume on MRI might predict who is at risk, according to investigators from the Center for SUDEP Research, a multicenter research collaborative.
The “MRI can detect potentially life threatening brainstem damage before SUDEP [sudden unexplained death in epilepsy] onset and ought to be further studied as a clinically useful biomarker to identify patients at risk for SUDEP,” said lead investigator Alica Goldman, MD, PhD, associate professor of neurology and neurophysiology at Baylor College of Medicine, Houston, and an investigator for the research collaborative.
It’s possible SUDEP is due to autonomic failure secondary to damage to areas of the brainstem that control autonomic functions such as breathing and heartbeat. Cardiorespiratory failure has been reported in cases of witnessed SUDEP, and the team previously reported structural mesencephalic and lower brainstem abnormalities in two SUDEP cases with temporal lobe epilepsy (Neuroimage Clin. 2014 Jul 9;5:208-16).
“It was a logical transition to have a larger study,” Dr. Goldman said at the annual meeting of the American Neurological Association.
The team compared findings from standardized 3T MRI exams in 18 patients with focal-onset epilepsy, 27 SUDEP cases that had focal-onset epilepsy and one or more MRIs within 10 years of death, and 11 controls without epilepsy.
They also looked at heart rate variability based on ECG readings, a proxy of autonomic control. Abnormal variability is a risk factor for arrhythmias and sudden cardiac death, and has been shown previously to correlate with epilepsy duration and frequency. It also seems worse at night, when SUDEP risk is highest.
In the living epilepsy patients, the team found structural volume loss in the dorsal mesencephalon and other brainstem areas, and the loss correlated with abnormal heart rate variability (P less than .001).
In the SUDEP cases, “we found that patients who died from SUDEP had widespread brainstem volume loss in their last MRI before death, and the extent of volume loss in the brainstem correlated with shorter survival time” from the final MRI (P = .03).
The SUDEP cases were a mean of 23 years old at their last MRI; the majority of the cases were men.
The National Institutes of Health and the Epilepsy Foundation supported the work. Dr. Goldman had no relevant disclosures.
SAN DIEGO – Brainstem volume loss is extensive in sudden unexplained death in epilepsy, suggesting that loss of brainstem volume on MRI might predict who is at risk, according to investigators from the Center for SUDEP Research, a multicenter research collaborative.
The “MRI can detect potentially life threatening brainstem damage before SUDEP [sudden unexplained death in epilepsy] onset and ought to be further studied as a clinically useful biomarker to identify patients at risk for SUDEP,” said lead investigator Alica Goldman, MD, PhD, associate professor of neurology and neurophysiology at Baylor College of Medicine, Houston, and an investigator for the research collaborative.
It’s possible SUDEP is due to autonomic failure secondary to damage to areas of the brainstem that control autonomic functions such as breathing and heartbeat. Cardiorespiratory failure has been reported in cases of witnessed SUDEP, and the team previously reported structural mesencephalic and lower brainstem abnormalities in two SUDEP cases with temporal lobe epilepsy (Neuroimage Clin. 2014 Jul 9;5:208-16).
“It was a logical transition to have a larger study,” Dr. Goldman said at the annual meeting of the American Neurological Association.
The team compared findings from standardized 3T MRI exams in 18 patients with focal-onset epilepsy, 27 SUDEP cases that had focal-onset epilepsy and one or more MRIs within 10 years of death, and 11 controls without epilepsy.
They also looked at heart rate variability based on ECG readings, a proxy of autonomic control. Abnormal variability is a risk factor for arrhythmias and sudden cardiac death, and has been shown previously to correlate with epilepsy duration and frequency. It also seems worse at night, when SUDEP risk is highest.
In the living epilepsy patients, the team found structural volume loss in the dorsal mesencephalon and other brainstem areas, and the loss correlated with abnormal heart rate variability (P less than .001).
In the SUDEP cases, “we found that patients who died from SUDEP had widespread brainstem volume loss in their last MRI before death, and the extent of volume loss in the brainstem correlated with shorter survival time” from the final MRI (P = .03).
The SUDEP cases were a mean of 23 years old at their last MRI; the majority of the cases were men.
The National Institutes of Health and the Epilepsy Foundation supported the work. Dr. Goldman had no relevant disclosures.
AT ANA 2017
Key clinical point:
Major finding: Patients who died from SUDEP had widespread brainstem volume loss in their last MRI before death (P = .03).
Data source: Imaging review of 27 SUDEP cases, 18 patients with focal epilepsy, and 11 controls.
Disclosures: The National Institutes of Health and the Epilepsy Foundation supported the work. The lead investigator had no relevant disclosures.
Hospitalists struggle with opioid epidemic’s rising toll
It’s the stuff of doctors’ nightmares. In a recent analysis of attitudes, beliefs, and practices regarding opioid prescribing, one hospitalist described how a patient had overdosed: “She crushed up the oxycodone we were giving her in the hospital and shot it up through her central line and died.”1
Susan Calcaterra, MD, MPH, of the department of family medicine at the University of Colorado at Denver, Aurora; a hospitalist at Denver Health Hospital; and lead author of the recent study, says that the dramatic anecdotes don’t surprise her. “These are not uncommon events,” she said. “Across the country, you hear about overdose, you hear about people abusing fentanyl, and I think, when you have an addiction, your judgment of the dangers associated with your personal opioid use may be limited.”
Some critics have blamed the ubiquity of opioid prescriptions on the controversial movement to establish pain as a vital sign. Multiple investigations also have accused the pharmaceutical industry of aggressively promoting these prescription drugs while downplaying their risks. The CDC found that, in fact, so many opioid prescriptions were being written by 2012 that the 259 million scripts could have supplied every U.S. adult with his and her own bottle. In August 2017, President Trump declared the opioid crisis a national emergency, although opinions differ regarding the best ways forward.
Until recently, however, few studies had looked at how inpatient prescribing may be fueling a surging epidemic that already has exacted a staggering toll. So far, the early data paint a disturbing picture that suggests hospitals are both a part of the problem and a key to its solution.
Illuminating a ‘black box’
Changing the trajectory will be difficult. From 2002 to 2015, the nation’s overdose death rate from opioid analgesics, heroin, and synthetic opioids, such as fentanyl, nearly tripled, and studies suggest that prescription painkillers have become major gateway drugs for heroin.2 In the last 3 years alone, fentanyl-related deaths soared by more than 500%, and annual mortality from all drug overdoses has blown by the peak of the HIV/AIDS epidemic in 1995, when nearly 51,000 died from the disease.3
Amid the ringing alarm bells, hospitals have remained a largely neglected “regulatory dead zone” for opioids, said Shoshana Herzig, MD, MPH, of the department of medicine at Harvard Medical School, Boston, and director of hospital medicine research at Beth Israel Deaconess Medical Center, also in Boston. In an editorial accompanying the recent study of hospitalist perspectives, Dr. Herzig called the inpatient setting an opioid prescribing “black box.”4
In a previous analysis of 1.1 million nonsurgical hospital admissions, however, she and colleagues found that opioids were prescribed to 51% of all patients.5 More than half of those with inpatient exposure were still taking opioids on their discharge day. With other studies suggesting that such practices may be contributing to chronic opioid use long after hospitalization, Dr. Herzig wrote, “reigning in inpatient prescribing may be a crucial step in curbing the opioid epidemic as a whole.”
A recent study led by Anupam Jena, MD, PhD, a health care policy expert at Harvard Medical School, echoes the refrain. “It’s kind of remarkable that the hospital setting hasn’t really been studied, and it’s an important setting,” he said. When he and colleagues did their own analysis of hospitalized Medicare beneficiaries, they found that 15% of previously opioid-naive patients were discharged with a prescription.6 Of those patients, more than 40% remained on opioids three months after discharge. The research also revealed a nearly two-fold variation in prescription rates across hospitals.
Some hospitalists have asserted that the increase in opioid prescriptions may partially be tied to pressure to reduce 30-day readmission rates; Dr. Jena and Dr. Karaca-Mandic’s work leaves open the possibility that such prescriptions may increase readmissions instead. The researchers, however, say a bigger driving force may be financial pressure tied to discharging patients earlier or scoring higher on quality measures that gauge factors, such as pain management. Hospitals that scored better on HCAHPS measures of inpatient pain control, their study found, were slightly more likely to discharge patients on opioids.
Keri Holmes-Maybank, MD, MSCR, FHM, an academic hospitalist at the Medical University of South Carolina, Charleston, says a lack of clear evidence and guidelines, unrealistic expectations, and variable patient responses to opioids are compounding a “very frustrating and very scary” situation for hospital medicine. Hospitalists who conclude that a patient-requested antibiotic will do more harm than good, for example, usually feel comfortable saying no. “But a patient can talk you into an opioid,” she said. “It’s much harder to stand your ground with that, even though we need to be viewing it the same way.”
The pain paradox
The desire to alleviate pain, as doctors are discovering, often has replaced one harm with another inadvertently. Perhaps the single largest contributing factor, Dr. Herzig said, is the subjectivity of pain and the difficulty in discerning whether a patient’s self-reporting can be trusted. “We want to relieve suffering,” she said, “but we also don’t want to give a patient a drug to which they may develop an addiction or to which they may already be addicted, and so therein lies the conundrum.”
Some medical providers are also beginning to focus less on visual pain assessments and more on clinically meaningful functional improvements. “For example, instead of asking, ‘What level is your pain today?’ we might say, ‘Were you able to get up and work with physical therapy today?’ and ‘Were you able to get out of the bed to the chair while maintaining your pain at a tolerable level?’ ” Dr. Herzig said.
In addition, providers are recognizing that they should be clearer in telling patients that a complete absence of pain is not only unrealistic but also potentially harmful. “It takes time to have those discussions with patients, where you’re trying to explain to them, ‘Pain is the body’s way of telling you don’t do that, and you need to have some pain in order to know what your limitations are,’ ” Dr. Herzig said.
From talking with hospitalized patients, Dr. Mosher and her colleagues found that pain-related suffering can be manifested in or exacerbated by poor sleep or diet, boredom, physical discomfort, immobility, or inability to maintain comforting activities. In other words, how can the hospital improve sleeping conditions or address the understandable anxiety around health issues or being in a strange new environment and losing control? “One of the upsides of all this is that it may drive us to really think about, and make thoughtful investments in, changing the hospital to be a more therapeutic environment,” Dr. Mosher said.
Chronic use and discharge dilemmas
What about patients who already used opioids regularly before their hospital admission? In a 2014 study, Dr. Mosher and her colleagues found that among patients admitted to Veterans Affairs hospitals between 2009 and 2011, more than one in four were on chronic opioid therapy in the 6 months prior to their hospitalization.8 That subset of patients, the study suggested, was at greater risk for both 30-day readmission and death.
Determining whether an opioid prescription is appropriate or not, though, takes time. “Hospitalists are often terribly busy,” Dr. Mosher said. “There’s a lot of pressure to move people through the hospital. It’s a big ask to say, ‘How will hospitalists do what might be ideal?’ versus ‘What can we do?’ ” A workable solution, she said, may depend upon a cultural shift in recognizing that “pain is not something you measure by numbers,” but rather a part of a patient’s complex medical condition that may require consultations and coordination with specialists both within and beyond the hospital.
Sometimes, relatively simple questions can go a long way. When Dr. Mosher asks patients on opioids whether they help, she said, “I’ve had very few patients who will say it makes the pain go away.” Likewise, she contends that very few patients have been informed of potential side effects such as decreased muscle mass, osteoporosis, and endocrinopathy. Men on opioids can have a significant reduction in testosterone levels that negatively affects their sex life. When Dr. Mosher has talked to them about the downsides of long-term use, more than a few have requested her help in weaning them off the drugs.
If given the time to educate such patients and consider how their chronic pain and opioid use might be connected to the hospitalization, she said, “We can find opportunities to use that as a change moment.”
Discharging a patient with a well-considered opioid prescription can still present multiple challenges. The best-case scenario, Dr. Calcaterra said, is to coordinate a plan with the patient’s primary care provider. “A lot of patients that we take care of, though, don’t have a follow-up provider. They don’t have a primary care physician,” she said.
The opioid epidemic also has walloped many communities that lack sufficient resources for at-risk patients, whether it’s alternative pain therapy or a buprenorphine clinic. “If you look at access to medication-assisted therapies, the lights are out for a lot of America. There just isn’t access,” Dr. Mosher said. The limited options can set up a frustrating quandary: Hospitalists may be reluctant to wean patients off opioids and get them on buprenorphine if there’s no reliable resource to continue the therapy after a postdischarge handoff.
Until better safety nets and evidence-based protocols are woven together, hospitalists may need to make judgment calls based on their experience and available data and be creative in using existing resources to help their patients. Although electronic prescribing may help reduce the potential for tampering with a doctor’s script, Dr. Calcaterra said, diversion of opioid pills remains a “huge issue across the United States.” Several states now limit the amount of opioids that can be prescribed upon discharge, and hospitalists in many states can access prescription drug monitoring programs to determine whether patients are receiving opioids from other providers.
Pushing for proactive solutions
Kevin Vuernick, senior project manager of SHM’s Center for Hospital Innovation and Improvement, said the society’s Hospital Quality and Patient Safety Committee is actively exploring plans to develop pain prescribing guidelines for hospitalized patients based on the input of hospitalists and other medical specialists. The society also hopes to set up a website that compiles available resources, such as its own well-received Reducing Adverse Drug Events related to Opioids Mentored Implementation Program.
Dr. Mosher said SHM and other professional organizations also could assume leadership roles in setting a research agenda, establishing priorities for quality improvement efforts, and evaluating the utility of intervention programs. She and others have said additional help is sorely needed in educating providers, most of whom have never received formal training in pain management.
Talented and skilled physicians with the right language and approach could serve as role models in teaching providers how to appropriately bring up sensitive topics, such as concerns that a patient may be misusing opioids or that the pain may be more psychological than physical in nature. “We need a common language,” Dr. Herzig said.
More broadly, hospital medicine practitioners could serve as institutional role models. Many already sit on safety and quality improvement committees, meaning that they can help develop standardized protocols and help inform decisions regarding both prescribing and oversight to improve the appropriateness and safety of opioid prescriptions.
Matthew Jared, MD, a hospitalist at St. Anthony Hospital in Oklahoma City, said he and his colleagues have long worried about striking the right balance on opioids and about “trying to find an objective way to treat a subjective problem.” Because he and his hospitalist counterparts see 95% of St. Anthony’s inpatients, however, he said hospital medicine is uniquely positioned to help initiate a more holistic and consistent opioid management plan. “We’re key in the equation of trying to get this under control in a way that’s healthy and respectful to the patient and to the staff,” he said.
Bryn Nelson is a freelance writer in Seattle.
References
1. Calcaterra SL, Drabkin AD, Leslie SE, Doyle R, et al. The hospitalist perspective on opioid prescribing: A qualitative analysis. J Hosp Med. 2016 Aug;11(8):536-42.
2. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths – United States, 2010–2015. MMWR Morb Mortal Wkly Rep. 2016 Dec;65(50-51):1445-52; and https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates.
3. Katz, J. The First Count of Fentanyl Deaths in 2016: Up 540% in Three Years. New York Times, Sept. 2, 2017. https://www.nytimes.com/interactive/2017/09/02/upshot/fentanyl-drug-overdose-deaths.html?mcubz=1&_r=0
4. Herzig SJ. Opening the black box of inpatient opioid prescribing. J Hosp Med. 2016 Aug;11(8):595-6.
5. Herzig SJ, Rothberg MB, Cheung M, et al. Opioid utilization and opioid-related adverse events in nonsurgical patients in U.S. hospitals. J Hosp Med. 2014;9(2):73-81.
6. Jena AB, Goldman D, Karaca-Mandic P. Hospital prescribing of opioids to Medicare beneficiaries. JAMA Intern Med. 2016 July;176(7):990-7.
7. Jena AB, Goldman D, Weaver L, Karaca-Mandic P. Opioid prescribing by multiple providers in Medicare: Retrospective observational study of insurance claims. BMJ. 2014;348:g1393.
8. Mosher HJ, Jiang L, Vaughan Sarrazin MS, et al. Prevalence and characteristics of hospitalized adults on chronic opioid therapy. J Hosp Med. 2014 Feb;9(2):82-7.
It’s the stuff of doctors’ nightmares. In a recent analysis of attitudes, beliefs, and practices regarding opioid prescribing, one hospitalist described how a patient had overdosed: “She crushed up the oxycodone we were giving her in the hospital and shot it up through her central line and died.”1
Susan Calcaterra, MD, MPH, of the department of family medicine at the University of Colorado at Denver, Aurora; a hospitalist at Denver Health Hospital; and lead author of the recent study, says that the dramatic anecdotes don’t surprise her. “These are not uncommon events,” she said. “Across the country, you hear about overdose, you hear about people abusing fentanyl, and I think, when you have an addiction, your judgment of the dangers associated with your personal opioid use may be limited.”
Some critics have blamed the ubiquity of opioid prescriptions on the controversial movement to establish pain as a vital sign. Multiple investigations also have accused the pharmaceutical industry of aggressively promoting these prescription drugs while downplaying their risks. The CDC found that, in fact, so many opioid prescriptions were being written by 2012 that the 259 million scripts could have supplied every U.S. adult with his and her own bottle. In August 2017, President Trump declared the opioid crisis a national emergency, although opinions differ regarding the best ways forward.
Until recently, however, few studies had looked at how inpatient prescribing may be fueling a surging epidemic that already has exacted a staggering toll. So far, the early data paint a disturbing picture that suggests hospitals are both a part of the problem and a key to its solution.
Illuminating a ‘black box’
Changing the trajectory will be difficult. From 2002 to 2015, the nation’s overdose death rate from opioid analgesics, heroin, and synthetic opioids, such as fentanyl, nearly tripled, and studies suggest that prescription painkillers have become major gateway drugs for heroin.2 In the last 3 years alone, fentanyl-related deaths soared by more than 500%, and annual mortality from all drug overdoses has blown by the peak of the HIV/AIDS epidemic in 1995, when nearly 51,000 died from the disease.3
Amid the ringing alarm bells, hospitals have remained a largely neglected “regulatory dead zone” for opioids, said Shoshana Herzig, MD, MPH, of the department of medicine at Harvard Medical School, Boston, and director of hospital medicine research at Beth Israel Deaconess Medical Center, also in Boston. In an editorial accompanying the recent study of hospitalist perspectives, Dr. Herzig called the inpatient setting an opioid prescribing “black box.”4
In a previous analysis of 1.1 million nonsurgical hospital admissions, however, she and colleagues found that opioids were prescribed to 51% of all patients.5 More than half of those with inpatient exposure were still taking opioids on their discharge day. With other studies suggesting that such practices may be contributing to chronic opioid use long after hospitalization, Dr. Herzig wrote, “reigning in inpatient prescribing may be a crucial step in curbing the opioid epidemic as a whole.”
A recent study led by Anupam Jena, MD, PhD, a health care policy expert at Harvard Medical School, echoes the refrain. “It’s kind of remarkable that the hospital setting hasn’t really been studied, and it’s an important setting,” he said. When he and colleagues did their own analysis of hospitalized Medicare beneficiaries, they found that 15% of previously opioid-naive patients were discharged with a prescription.6 Of those patients, more than 40% remained on opioids three months after discharge. The research also revealed a nearly two-fold variation in prescription rates across hospitals.
Some hospitalists have asserted that the increase in opioid prescriptions may partially be tied to pressure to reduce 30-day readmission rates; Dr. Jena and Dr. Karaca-Mandic’s work leaves open the possibility that such prescriptions may increase readmissions instead. The researchers, however, say a bigger driving force may be financial pressure tied to discharging patients earlier or scoring higher on quality measures that gauge factors, such as pain management. Hospitals that scored better on HCAHPS measures of inpatient pain control, their study found, were slightly more likely to discharge patients on opioids.
Keri Holmes-Maybank, MD, MSCR, FHM, an academic hospitalist at the Medical University of South Carolina, Charleston, says a lack of clear evidence and guidelines, unrealistic expectations, and variable patient responses to opioids are compounding a “very frustrating and very scary” situation for hospital medicine. Hospitalists who conclude that a patient-requested antibiotic will do more harm than good, for example, usually feel comfortable saying no. “But a patient can talk you into an opioid,” she said. “It’s much harder to stand your ground with that, even though we need to be viewing it the same way.”
The pain paradox
The desire to alleviate pain, as doctors are discovering, often has replaced one harm with another inadvertently. Perhaps the single largest contributing factor, Dr. Herzig said, is the subjectivity of pain and the difficulty in discerning whether a patient’s self-reporting can be trusted. “We want to relieve suffering,” she said, “but we also don’t want to give a patient a drug to which they may develop an addiction or to which they may already be addicted, and so therein lies the conundrum.”
Some medical providers are also beginning to focus less on visual pain assessments and more on clinically meaningful functional improvements. “For example, instead of asking, ‘What level is your pain today?’ we might say, ‘Were you able to get up and work with physical therapy today?’ and ‘Were you able to get out of the bed to the chair while maintaining your pain at a tolerable level?’ ” Dr. Herzig said.
In addition, providers are recognizing that they should be clearer in telling patients that a complete absence of pain is not only unrealistic but also potentially harmful. “It takes time to have those discussions with patients, where you’re trying to explain to them, ‘Pain is the body’s way of telling you don’t do that, and you need to have some pain in order to know what your limitations are,’ ” Dr. Herzig said.
From talking with hospitalized patients, Dr. Mosher and her colleagues found that pain-related suffering can be manifested in or exacerbated by poor sleep or diet, boredom, physical discomfort, immobility, or inability to maintain comforting activities. In other words, how can the hospital improve sleeping conditions or address the understandable anxiety around health issues or being in a strange new environment and losing control? “One of the upsides of all this is that it may drive us to really think about, and make thoughtful investments in, changing the hospital to be a more therapeutic environment,” Dr. Mosher said.
Chronic use and discharge dilemmas
What about patients who already used opioids regularly before their hospital admission? In a 2014 study, Dr. Mosher and her colleagues found that among patients admitted to Veterans Affairs hospitals between 2009 and 2011, more than one in four were on chronic opioid therapy in the 6 months prior to their hospitalization.8 That subset of patients, the study suggested, was at greater risk for both 30-day readmission and death.
Determining whether an opioid prescription is appropriate or not, though, takes time. “Hospitalists are often terribly busy,” Dr. Mosher said. “There’s a lot of pressure to move people through the hospital. It’s a big ask to say, ‘How will hospitalists do what might be ideal?’ versus ‘What can we do?’ ” A workable solution, she said, may depend upon a cultural shift in recognizing that “pain is not something you measure by numbers,” but rather a part of a patient’s complex medical condition that may require consultations and coordination with specialists both within and beyond the hospital.
Sometimes, relatively simple questions can go a long way. When Dr. Mosher asks patients on opioids whether they help, she said, “I’ve had very few patients who will say it makes the pain go away.” Likewise, she contends that very few patients have been informed of potential side effects such as decreased muscle mass, osteoporosis, and endocrinopathy. Men on opioids can have a significant reduction in testosterone levels that negatively affects their sex life. When Dr. Mosher has talked to them about the downsides of long-term use, more than a few have requested her help in weaning them off the drugs.
If given the time to educate such patients and consider how their chronic pain and opioid use might be connected to the hospitalization, she said, “We can find opportunities to use that as a change moment.”
Discharging a patient with a well-considered opioid prescription can still present multiple challenges. The best-case scenario, Dr. Calcaterra said, is to coordinate a plan with the patient’s primary care provider. “A lot of patients that we take care of, though, don’t have a follow-up provider. They don’t have a primary care physician,” she said.
The opioid epidemic also has walloped many communities that lack sufficient resources for at-risk patients, whether it’s alternative pain therapy or a buprenorphine clinic. “If you look at access to medication-assisted therapies, the lights are out for a lot of America. There just isn’t access,” Dr. Mosher said. The limited options can set up a frustrating quandary: Hospitalists may be reluctant to wean patients off opioids and get them on buprenorphine if there’s no reliable resource to continue the therapy after a postdischarge handoff.
Until better safety nets and evidence-based protocols are woven together, hospitalists may need to make judgment calls based on their experience and available data and be creative in using existing resources to help their patients. Although electronic prescribing may help reduce the potential for tampering with a doctor’s script, Dr. Calcaterra said, diversion of opioid pills remains a “huge issue across the United States.” Several states now limit the amount of opioids that can be prescribed upon discharge, and hospitalists in many states can access prescription drug monitoring programs to determine whether patients are receiving opioids from other providers.
Pushing for proactive solutions
Kevin Vuernick, senior project manager of SHM’s Center for Hospital Innovation and Improvement, said the society’s Hospital Quality and Patient Safety Committee is actively exploring plans to develop pain prescribing guidelines for hospitalized patients based on the input of hospitalists and other medical specialists. The society also hopes to set up a website that compiles available resources, such as its own well-received Reducing Adverse Drug Events related to Opioids Mentored Implementation Program.
Dr. Mosher said SHM and other professional organizations also could assume leadership roles in setting a research agenda, establishing priorities for quality improvement efforts, and evaluating the utility of intervention programs. She and others have said additional help is sorely needed in educating providers, most of whom have never received formal training in pain management.
Talented and skilled physicians with the right language and approach could serve as role models in teaching providers how to appropriately bring up sensitive topics, such as concerns that a patient may be misusing opioids or that the pain may be more psychological than physical in nature. “We need a common language,” Dr. Herzig said.
More broadly, hospital medicine practitioners could serve as institutional role models. Many already sit on safety and quality improvement committees, meaning that they can help develop standardized protocols and help inform decisions regarding both prescribing and oversight to improve the appropriateness and safety of opioid prescriptions.
Matthew Jared, MD, a hospitalist at St. Anthony Hospital in Oklahoma City, said he and his colleagues have long worried about striking the right balance on opioids and about “trying to find an objective way to treat a subjective problem.” Because he and his hospitalist counterparts see 95% of St. Anthony’s inpatients, however, he said hospital medicine is uniquely positioned to help initiate a more holistic and consistent opioid management plan. “We’re key in the equation of trying to get this under control in a way that’s healthy and respectful to the patient and to the staff,” he said.
Bryn Nelson is a freelance writer in Seattle.
References
1. Calcaterra SL, Drabkin AD, Leslie SE, Doyle R, et al. The hospitalist perspective on opioid prescribing: A qualitative analysis. J Hosp Med. 2016 Aug;11(8):536-42.
2. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths – United States, 2010–2015. MMWR Morb Mortal Wkly Rep. 2016 Dec;65(50-51):1445-52; and https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates.
3. Katz, J. The First Count of Fentanyl Deaths in 2016: Up 540% in Three Years. New York Times, Sept. 2, 2017. https://www.nytimes.com/interactive/2017/09/02/upshot/fentanyl-drug-overdose-deaths.html?mcubz=1&_r=0
4. Herzig SJ. Opening the black box of inpatient opioid prescribing. J Hosp Med. 2016 Aug;11(8):595-6.
5. Herzig SJ, Rothberg MB, Cheung M, et al. Opioid utilization and opioid-related adverse events in nonsurgical patients in U.S. hospitals. J Hosp Med. 2014;9(2):73-81.
6. Jena AB, Goldman D, Karaca-Mandic P. Hospital prescribing of opioids to Medicare beneficiaries. JAMA Intern Med. 2016 July;176(7):990-7.
7. Jena AB, Goldman D, Weaver L, Karaca-Mandic P. Opioid prescribing by multiple providers in Medicare: Retrospective observational study of insurance claims. BMJ. 2014;348:g1393.
8. Mosher HJ, Jiang L, Vaughan Sarrazin MS, et al. Prevalence and characteristics of hospitalized adults on chronic opioid therapy. J Hosp Med. 2014 Feb;9(2):82-7.
It’s the stuff of doctors’ nightmares. In a recent analysis of attitudes, beliefs, and practices regarding opioid prescribing, one hospitalist described how a patient had overdosed: “She crushed up the oxycodone we were giving her in the hospital and shot it up through her central line and died.”1
Susan Calcaterra, MD, MPH, of the department of family medicine at the University of Colorado at Denver, Aurora; a hospitalist at Denver Health Hospital; and lead author of the recent study, says that the dramatic anecdotes don’t surprise her. “These are not uncommon events,” she said. “Across the country, you hear about overdose, you hear about people abusing fentanyl, and I think, when you have an addiction, your judgment of the dangers associated with your personal opioid use may be limited.”
Some critics have blamed the ubiquity of opioid prescriptions on the controversial movement to establish pain as a vital sign. Multiple investigations also have accused the pharmaceutical industry of aggressively promoting these prescription drugs while downplaying their risks. The CDC found that, in fact, so many opioid prescriptions were being written by 2012 that the 259 million scripts could have supplied every U.S. adult with his and her own bottle. In August 2017, President Trump declared the opioid crisis a national emergency, although opinions differ regarding the best ways forward.
Until recently, however, few studies had looked at how inpatient prescribing may be fueling a surging epidemic that already has exacted a staggering toll. So far, the early data paint a disturbing picture that suggests hospitals are both a part of the problem and a key to its solution.
Illuminating a ‘black box’
Changing the trajectory will be difficult. From 2002 to 2015, the nation’s overdose death rate from opioid analgesics, heroin, and synthetic opioids, such as fentanyl, nearly tripled, and studies suggest that prescription painkillers have become major gateway drugs for heroin.2 In the last 3 years alone, fentanyl-related deaths soared by more than 500%, and annual mortality from all drug overdoses has blown by the peak of the HIV/AIDS epidemic in 1995, when nearly 51,000 died from the disease.3
Amid the ringing alarm bells, hospitals have remained a largely neglected “regulatory dead zone” for opioids, said Shoshana Herzig, MD, MPH, of the department of medicine at Harvard Medical School, Boston, and director of hospital medicine research at Beth Israel Deaconess Medical Center, also in Boston. In an editorial accompanying the recent study of hospitalist perspectives, Dr. Herzig called the inpatient setting an opioid prescribing “black box.”4
In a previous analysis of 1.1 million nonsurgical hospital admissions, however, she and colleagues found that opioids were prescribed to 51% of all patients.5 More than half of those with inpatient exposure were still taking opioids on their discharge day. With other studies suggesting that such practices may be contributing to chronic opioid use long after hospitalization, Dr. Herzig wrote, “reigning in inpatient prescribing may be a crucial step in curbing the opioid epidemic as a whole.”
A recent study led by Anupam Jena, MD, PhD, a health care policy expert at Harvard Medical School, echoes the refrain. “It’s kind of remarkable that the hospital setting hasn’t really been studied, and it’s an important setting,” he said. When he and colleagues did their own analysis of hospitalized Medicare beneficiaries, they found that 15% of previously opioid-naive patients were discharged with a prescription.6 Of those patients, more than 40% remained on opioids three months after discharge. The research also revealed a nearly two-fold variation in prescription rates across hospitals.
Some hospitalists have asserted that the increase in opioid prescriptions may partially be tied to pressure to reduce 30-day readmission rates; Dr. Jena and Dr. Karaca-Mandic’s work leaves open the possibility that such prescriptions may increase readmissions instead. The researchers, however, say a bigger driving force may be financial pressure tied to discharging patients earlier or scoring higher on quality measures that gauge factors, such as pain management. Hospitals that scored better on HCAHPS measures of inpatient pain control, their study found, were slightly more likely to discharge patients on opioids.
Keri Holmes-Maybank, MD, MSCR, FHM, an academic hospitalist at the Medical University of South Carolina, Charleston, says a lack of clear evidence and guidelines, unrealistic expectations, and variable patient responses to opioids are compounding a “very frustrating and very scary” situation for hospital medicine. Hospitalists who conclude that a patient-requested antibiotic will do more harm than good, for example, usually feel comfortable saying no. “But a patient can talk you into an opioid,” she said. “It’s much harder to stand your ground with that, even though we need to be viewing it the same way.”
The pain paradox
The desire to alleviate pain, as doctors are discovering, often has replaced one harm with another inadvertently. Perhaps the single largest contributing factor, Dr. Herzig said, is the subjectivity of pain and the difficulty in discerning whether a patient’s self-reporting can be trusted. “We want to relieve suffering,” she said, “but we also don’t want to give a patient a drug to which they may develop an addiction or to which they may already be addicted, and so therein lies the conundrum.”
Some medical providers are also beginning to focus less on visual pain assessments and more on clinically meaningful functional improvements. “For example, instead of asking, ‘What level is your pain today?’ we might say, ‘Were you able to get up and work with physical therapy today?’ and ‘Were you able to get out of the bed to the chair while maintaining your pain at a tolerable level?’ ” Dr. Herzig said.
In addition, providers are recognizing that they should be clearer in telling patients that a complete absence of pain is not only unrealistic but also potentially harmful. “It takes time to have those discussions with patients, where you’re trying to explain to them, ‘Pain is the body’s way of telling you don’t do that, and you need to have some pain in order to know what your limitations are,’ ” Dr. Herzig said.
From talking with hospitalized patients, Dr. Mosher and her colleagues found that pain-related suffering can be manifested in or exacerbated by poor sleep or diet, boredom, physical discomfort, immobility, or inability to maintain comforting activities. In other words, how can the hospital improve sleeping conditions or address the understandable anxiety around health issues or being in a strange new environment and losing control? “One of the upsides of all this is that it may drive us to really think about, and make thoughtful investments in, changing the hospital to be a more therapeutic environment,” Dr. Mosher said.
Chronic use and discharge dilemmas
What about patients who already used opioids regularly before their hospital admission? In a 2014 study, Dr. Mosher and her colleagues found that among patients admitted to Veterans Affairs hospitals between 2009 and 2011, more than one in four were on chronic opioid therapy in the 6 months prior to their hospitalization.8 That subset of patients, the study suggested, was at greater risk for both 30-day readmission and death.
Determining whether an opioid prescription is appropriate or not, though, takes time. “Hospitalists are often terribly busy,” Dr. Mosher said. “There’s a lot of pressure to move people through the hospital. It’s a big ask to say, ‘How will hospitalists do what might be ideal?’ versus ‘What can we do?’ ” A workable solution, she said, may depend upon a cultural shift in recognizing that “pain is not something you measure by numbers,” but rather a part of a patient’s complex medical condition that may require consultations and coordination with specialists both within and beyond the hospital.
Sometimes, relatively simple questions can go a long way. When Dr. Mosher asks patients on opioids whether they help, she said, “I’ve had very few patients who will say it makes the pain go away.” Likewise, she contends that very few patients have been informed of potential side effects such as decreased muscle mass, osteoporosis, and endocrinopathy. Men on opioids can have a significant reduction in testosterone levels that negatively affects their sex life. When Dr. Mosher has talked to them about the downsides of long-term use, more than a few have requested her help in weaning them off the drugs.
If given the time to educate such patients and consider how their chronic pain and opioid use might be connected to the hospitalization, she said, “We can find opportunities to use that as a change moment.”
Discharging a patient with a well-considered opioid prescription can still present multiple challenges. The best-case scenario, Dr. Calcaterra said, is to coordinate a plan with the patient’s primary care provider. “A lot of patients that we take care of, though, don’t have a follow-up provider. They don’t have a primary care physician,” she said.
The opioid epidemic also has walloped many communities that lack sufficient resources for at-risk patients, whether it’s alternative pain therapy or a buprenorphine clinic. “If you look at access to medication-assisted therapies, the lights are out for a lot of America. There just isn’t access,” Dr. Mosher said. The limited options can set up a frustrating quandary: Hospitalists may be reluctant to wean patients off opioids and get them on buprenorphine if there’s no reliable resource to continue the therapy after a postdischarge handoff.
Until better safety nets and evidence-based protocols are woven together, hospitalists may need to make judgment calls based on their experience and available data and be creative in using existing resources to help their patients. Although electronic prescribing may help reduce the potential for tampering with a doctor’s script, Dr. Calcaterra said, diversion of opioid pills remains a “huge issue across the United States.” Several states now limit the amount of opioids that can be prescribed upon discharge, and hospitalists in many states can access prescription drug monitoring programs to determine whether patients are receiving opioids from other providers.
Pushing for proactive solutions
Kevin Vuernick, senior project manager of SHM’s Center for Hospital Innovation and Improvement, said the society’s Hospital Quality and Patient Safety Committee is actively exploring plans to develop pain prescribing guidelines for hospitalized patients based on the input of hospitalists and other medical specialists. The society also hopes to set up a website that compiles available resources, such as its own well-received Reducing Adverse Drug Events related to Opioids Mentored Implementation Program.
Dr. Mosher said SHM and other professional organizations also could assume leadership roles in setting a research agenda, establishing priorities for quality improvement efforts, and evaluating the utility of intervention programs. She and others have said additional help is sorely needed in educating providers, most of whom have never received formal training in pain management.
Talented and skilled physicians with the right language and approach could serve as role models in teaching providers how to appropriately bring up sensitive topics, such as concerns that a patient may be misusing opioids or that the pain may be more psychological than physical in nature. “We need a common language,” Dr. Herzig said.
More broadly, hospital medicine practitioners could serve as institutional role models. Many already sit on safety and quality improvement committees, meaning that they can help develop standardized protocols and help inform decisions regarding both prescribing and oversight to improve the appropriateness and safety of opioid prescriptions.
Matthew Jared, MD, a hospitalist at St. Anthony Hospital in Oklahoma City, said he and his colleagues have long worried about striking the right balance on opioids and about “trying to find an objective way to treat a subjective problem.” Because he and his hospitalist counterparts see 95% of St. Anthony’s inpatients, however, he said hospital medicine is uniquely positioned to help initiate a more holistic and consistent opioid management plan. “We’re key in the equation of trying to get this under control in a way that’s healthy and respectful to the patient and to the staff,” he said.
Bryn Nelson is a freelance writer in Seattle.
References
1. Calcaterra SL, Drabkin AD, Leslie SE, Doyle R, et al. The hospitalist perspective on opioid prescribing: A qualitative analysis. J Hosp Med. 2016 Aug;11(8):536-42.
2. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths – United States, 2010–2015. MMWR Morb Mortal Wkly Rep. 2016 Dec;65(50-51):1445-52; and https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates.
3. Katz, J. The First Count of Fentanyl Deaths in 2016: Up 540% in Three Years. New York Times, Sept. 2, 2017. https://www.nytimes.com/interactive/2017/09/02/upshot/fentanyl-drug-overdose-deaths.html?mcubz=1&_r=0
4. Herzig SJ. Opening the black box of inpatient opioid prescribing. J Hosp Med. 2016 Aug;11(8):595-6.
5. Herzig SJ, Rothberg MB, Cheung M, et al. Opioid utilization and opioid-related adverse events in nonsurgical patients in U.S. hospitals. J Hosp Med. 2014;9(2):73-81.
6. Jena AB, Goldman D, Karaca-Mandic P. Hospital prescribing of opioids to Medicare beneficiaries. JAMA Intern Med. 2016 July;176(7):990-7.
7. Jena AB, Goldman D, Weaver L, Karaca-Mandic P. Opioid prescribing by multiple providers in Medicare: Retrospective observational study of insurance claims. BMJ. 2014;348:g1393.
8. Mosher HJ, Jiang L, Vaughan Sarrazin MS, et al. Prevalence and characteristics of hospitalized adults on chronic opioid therapy. J Hosp Med. 2014 Feb;9(2):82-7.
VIDEO: IBD epidemiology provides clues into disease underpinnings
ORLANDO – The incidence of Crohn’s disease and ulcerative colitis has stabilized in the Western world, but is rising rapidly in newly industrialized countries, according to a systematic review of population-based studies.
The findings could provide important new insights into the environmental, genetic, and microbiome-related factors and interactions that form the underpinnings of IBD, Gilaad Kaplan, MD, of the University of Calgary (Alta.) said at the World Congress of Gastroenterology at ACG 2017.
In turn, that information could lead to approaches to reduce IBD incidence, he said in a video interview.
It has been known that Crohn’s disease and ulcerative colitis are “modern diseases of modern times,” but few studies have addressed the epidemiology of IBD in newly industrialized countries in Asia, Africa, and South America, he said.
“We see a pattern that as newly industrialized countries transition toward a westernized society, IBD emerges and its incidence rises, and there are many different explanations for that,” he said, noting that in part, the increase is due to improved health care infrastructure and advances in adoption of medical technology that lead to better identification of new cases.
“But probably one of the most important factors is that there are environmental exposures linked to the westernization of society that are creating this pressure that’s driving incidence of IBD up in many of the countries of the world,” he said. “I think if we do a lot more research focused on how environment influences microbiome, we might start to see things we could do that could potentially stem the tide of IBD.”
Dr. Kaplan reported having no relevant disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
ORLANDO – The incidence of Crohn’s disease and ulcerative colitis has stabilized in the Western world, but is rising rapidly in newly industrialized countries, according to a systematic review of population-based studies.
The findings could provide important new insights into the environmental, genetic, and microbiome-related factors and interactions that form the underpinnings of IBD, Gilaad Kaplan, MD, of the University of Calgary (Alta.) said at the World Congress of Gastroenterology at ACG 2017.
In turn, that information could lead to approaches to reduce IBD incidence, he said in a video interview.
It has been known that Crohn’s disease and ulcerative colitis are “modern diseases of modern times,” but few studies have addressed the epidemiology of IBD in newly industrialized countries in Asia, Africa, and South America, he said.
“We see a pattern that as newly industrialized countries transition toward a westernized society, IBD emerges and its incidence rises, and there are many different explanations for that,” he said, noting that in part, the increase is due to improved health care infrastructure and advances in adoption of medical technology that lead to better identification of new cases.
“But probably one of the most important factors is that there are environmental exposures linked to the westernization of society that are creating this pressure that’s driving incidence of IBD up in many of the countries of the world,” he said. “I think if we do a lot more research focused on how environment influences microbiome, we might start to see things we could do that could potentially stem the tide of IBD.”
Dr. Kaplan reported having no relevant disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
ORLANDO – The incidence of Crohn’s disease and ulcerative colitis has stabilized in the Western world, but is rising rapidly in newly industrialized countries, according to a systematic review of population-based studies.
The findings could provide important new insights into the environmental, genetic, and microbiome-related factors and interactions that form the underpinnings of IBD, Gilaad Kaplan, MD, of the University of Calgary (Alta.) said at the World Congress of Gastroenterology at ACG 2017.
In turn, that information could lead to approaches to reduce IBD incidence, he said in a video interview.
It has been known that Crohn’s disease and ulcerative colitis are “modern diseases of modern times,” but few studies have addressed the epidemiology of IBD in newly industrialized countries in Asia, Africa, and South America, he said.
“We see a pattern that as newly industrialized countries transition toward a westernized society, IBD emerges and its incidence rises, and there are many different explanations for that,” he said, noting that in part, the increase is due to improved health care infrastructure and advances in adoption of medical technology that lead to better identification of new cases.
“But probably one of the most important factors is that there are environmental exposures linked to the westernization of society that are creating this pressure that’s driving incidence of IBD up in many of the countries of the world,” he said. “I think if we do a lot more research focused on how environment influences microbiome, we might start to see things we could do that could potentially stem the tide of IBD.”
Dr. Kaplan reported having no relevant disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT THE 13TH WORLD CONGRESS OF GASTROENTEROLOGY
VIDEO: Mechanical colonoscope enhancements improve adenoma detection
ORLANDO – Mechanical enhancements to existing colonoscopes may be better than optical enhancements for improving adenoma detection, according to findings from a meta-analysis of data from 240 studies.
“Even though colonoscopy is felt to be our best test compared to others … we also recognize that we do not see every square inch of the colon,” Seth Gross, MD, of New York University Langone Medical Center said in a video interview at the World Congress of Gastroenterology at ACG 2017.
There has been a “tremendous drive” to improve the ability to inspect blind spots in the colon, and also to better recognize subtle precancerous lesions in visible areas of the colon, but it has been unclear whether optical or mechanical enhancements will better achieve that goal, Dr. Gross said.
Based on the findings of his meta-analysis, it appears that mechanical enhancements, including integrated balloons and single-use caps with finger-like projections or discs that clip on to the colonoscope to engage the colon wall and flatten areas to allow access to areas behind folds, are most effective.
The preliminary data should lead to more clinical questions about what can be done to improve exams, he said.
In fact, one four-arm study looking at standard colonoscopy vs. colonoscopy with various mechanical enhancements was just completed, and others looking at “deep learning” and computer assistance are underway.
The latter technology is intriguing, as “not every polyp that we’re missing is behind a fold,” Dr. Gross noted.
Preliminary findings from a study out of China demonstrated the feasibility of such computer assistance, and the researchers are now working on a prospective study of real-time cases to see if that type of integrated learning with computer assistance can improve polyp detection.
“Sometimes it’s just these subtle mucosal changes that we have to train our eye to identify,” he said. “So imagine having another set of eyes … where there’s a computer sort of highlighting an area that we should focus on.”
Dr. Gross reported having no relevant financial disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
ORLANDO – Mechanical enhancements to existing colonoscopes may be better than optical enhancements for improving adenoma detection, according to findings from a meta-analysis of data from 240 studies.
“Even though colonoscopy is felt to be our best test compared to others … we also recognize that we do not see every square inch of the colon,” Seth Gross, MD, of New York University Langone Medical Center said in a video interview at the World Congress of Gastroenterology at ACG 2017.
There has been a “tremendous drive” to improve the ability to inspect blind spots in the colon, and also to better recognize subtle precancerous lesions in visible areas of the colon, but it has been unclear whether optical or mechanical enhancements will better achieve that goal, Dr. Gross said.
Based on the findings of his meta-analysis, it appears that mechanical enhancements, including integrated balloons and single-use caps with finger-like projections or discs that clip on to the colonoscope to engage the colon wall and flatten areas to allow access to areas behind folds, are most effective.
The preliminary data should lead to more clinical questions about what can be done to improve exams, he said.
In fact, one four-arm study looking at standard colonoscopy vs. colonoscopy with various mechanical enhancements was just completed, and others looking at “deep learning” and computer assistance are underway.
The latter technology is intriguing, as “not every polyp that we’re missing is behind a fold,” Dr. Gross noted.
Preliminary findings from a study out of China demonstrated the feasibility of such computer assistance, and the researchers are now working on a prospective study of real-time cases to see if that type of integrated learning with computer assistance can improve polyp detection.
“Sometimes it’s just these subtle mucosal changes that we have to train our eye to identify,” he said. “So imagine having another set of eyes … where there’s a computer sort of highlighting an area that we should focus on.”
Dr. Gross reported having no relevant financial disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
ORLANDO – Mechanical enhancements to existing colonoscopes may be better than optical enhancements for improving adenoma detection, according to findings from a meta-analysis of data from 240 studies.
“Even though colonoscopy is felt to be our best test compared to others … we also recognize that we do not see every square inch of the colon,” Seth Gross, MD, of New York University Langone Medical Center said in a video interview at the World Congress of Gastroenterology at ACG 2017.
There has been a “tremendous drive” to improve the ability to inspect blind spots in the colon, and also to better recognize subtle precancerous lesions in visible areas of the colon, but it has been unclear whether optical or mechanical enhancements will better achieve that goal, Dr. Gross said.
Based on the findings of his meta-analysis, it appears that mechanical enhancements, including integrated balloons and single-use caps with finger-like projections or discs that clip on to the colonoscope to engage the colon wall and flatten areas to allow access to areas behind folds, are most effective.
The preliminary data should lead to more clinical questions about what can be done to improve exams, he said.
In fact, one four-arm study looking at standard colonoscopy vs. colonoscopy with various mechanical enhancements was just completed, and others looking at “deep learning” and computer assistance are underway.
The latter technology is intriguing, as “not every polyp that we’re missing is behind a fold,” Dr. Gross noted.
Preliminary findings from a study out of China demonstrated the feasibility of such computer assistance, and the researchers are now working on a prospective study of real-time cases to see if that type of integrated learning with computer assistance can improve polyp detection.
“Sometimes it’s just these subtle mucosal changes that we have to train our eye to identify,” he said. “So imagine having another set of eyes … where there’s a computer sort of highlighting an area that we should focus on.”
Dr. Gross reported having no relevant financial disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT THE WORLD CONGRESS OF GASTROENTEROLOGY
Debunking Acne Myths: Does Popping Pimples Resolve Acne Faster?
Myth: Popping pimples resolves acne faster
Acne patients may be compelled to squeeze or pop their pimples at home thinking it will clear their acne faster, but they should be advised that doing so without using the proper technique can actually make the condition worse.
When over-the-counter or prescription acne medications take too long to work, some patients may use their fingernails or even a physical instrument (eg, tweezers) to clear the contents of the pimple; however, this process often produces lesions that are inflamed and far more visible, slower to heal, and more likely to scar than lesions progressing through the natural disease course. According to the American Academy of Dermatology (AAD), unwanted side effects of popping pimples can include permanent acne scars, more noticeable and/or painful acne lesions, and infection from bacteria on the hands.
The AAD promotes that dermatologists know how to remove bothersome acne lesions safely. Also, the AAD guidelines of care for the management of acne vulgaris reported that comedo removal may be helpful for lesions resistant to other therapies. Acne extraction may be offered when standard treatments fail and involves the use of sterile instruments to clear comedones and microcomedones. For single lesions that are particularly painful, dermatologists may opt to inject the lesion with a corticosteroid to reduce inflammation, speed healing, and decrease the risk of scarring; the strength of this recommendation is level C, according to the AAD acne guidelines work group. Finally, incision and drainage using a sterile needle or surgical blade can be used to open and clear the contents of large or painful pimples, nodules, and cysts.
These procedures are not first-line acne therapies. To minimize the appearance of acne lesions and promote clearance while waiting to see results from prescribed treatment regimens, patients should be advised to keep their hands away from their face and avoid picking at lesions, to apply ice to painful lesions to reduce inflammation and relieve pain, and to be patient with the acne treatment prescribed by a dermatologist. If patients are prone to picking their acne lesions, a more aggressive approach to treatment may be necessary, as a reduced number of inflammatory lesions leaves the patient with fewer spots to manipulate.
Pimple popping: why only a dermatologist should do it. American Academy of Dermatology website. https://www.aad.org/public/diseases/acne-and-rosacea/pimple-popping-why-only-a-dermatologist-should-do-it. Accessed October 11, 2017.
Zaenglein AL, Pathy AL, Schlosser BJ, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016;74:945-973.
Myth: Popping pimples resolves acne faster
Acne patients may be compelled to squeeze or pop their pimples at home thinking it will clear their acne faster, but they should be advised that doing so without using the proper technique can actually make the condition worse.
When over-the-counter or prescription acne medications take too long to work, some patients may use their fingernails or even a physical instrument (eg, tweezers) to clear the contents of the pimple; however, this process often produces lesions that are inflamed and far more visible, slower to heal, and more likely to scar than lesions progressing through the natural disease course. According to the American Academy of Dermatology (AAD), unwanted side effects of popping pimples can include permanent acne scars, more noticeable and/or painful acne lesions, and infection from bacteria on the hands.
The AAD promotes that dermatologists know how to remove bothersome acne lesions safely. Also, the AAD guidelines of care for the management of acne vulgaris reported that comedo removal may be helpful for lesions resistant to other therapies. Acne extraction may be offered when standard treatments fail and involves the use of sterile instruments to clear comedones and microcomedones. For single lesions that are particularly painful, dermatologists may opt to inject the lesion with a corticosteroid to reduce inflammation, speed healing, and decrease the risk of scarring; the strength of this recommendation is level C, according to the AAD acne guidelines work group. Finally, incision and drainage using a sterile needle or surgical blade can be used to open and clear the contents of large or painful pimples, nodules, and cysts.
These procedures are not first-line acne therapies. To minimize the appearance of acne lesions and promote clearance while waiting to see results from prescribed treatment regimens, patients should be advised to keep their hands away from their face and avoid picking at lesions, to apply ice to painful lesions to reduce inflammation and relieve pain, and to be patient with the acne treatment prescribed by a dermatologist. If patients are prone to picking their acne lesions, a more aggressive approach to treatment may be necessary, as a reduced number of inflammatory lesions leaves the patient with fewer spots to manipulate.
Myth: Popping pimples resolves acne faster
Acne patients may be compelled to squeeze or pop their pimples at home thinking it will clear their acne faster, but they should be advised that doing so without using the proper technique can actually make the condition worse.
When over-the-counter or prescription acne medications take too long to work, some patients may use their fingernails or even a physical instrument (eg, tweezers) to clear the contents of the pimple; however, this process often produces lesions that are inflamed and far more visible, slower to heal, and more likely to scar than lesions progressing through the natural disease course. According to the American Academy of Dermatology (AAD), unwanted side effects of popping pimples can include permanent acne scars, more noticeable and/or painful acne lesions, and infection from bacteria on the hands.
The AAD promotes that dermatologists know how to remove bothersome acne lesions safely. Also, the AAD guidelines of care for the management of acne vulgaris reported that comedo removal may be helpful for lesions resistant to other therapies. Acne extraction may be offered when standard treatments fail and involves the use of sterile instruments to clear comedones and microcomedones. For single lesions that are particularly painful, dermatologists may opt to inject the lesion with a corticosteroid to reduce inflammation, speed healing, and decrease the risk of scarring; the strength of this recommendation is level C, according to the AAD acne guidelines work group. Finally, incision and drainage using a sterile needle or surgical blade can be used to open and clear the contents of large or painful pimples, nodules, and cysts.
These procedures are not first-line acne therapies. To minimize the appearance of acne lesions and promote clearance while waiting to see results from prescribed treatment regimens, patients should be advised to keep their hands away from their face and avoid picking at lesions, to apply ice to painful lesions to reduce inflammation and relieve pain, and to be patient with the acne treatment prescribed by a dermatologist. If patients are prone to picking their acne lesions, a more aggressive approach to treatment may be necessary, as a reduced number of inflammatory lesions leaves the patient with fewer spots to manipulate.
Pimple popping: why only a dermatologist should do it. American Academy of Dermatology website. https://www.aad.org/public/diseases/acne-and-rosacea/pimple-popping-why-only-a-dermatologist-should-do-it. Accessed October 11, 2017.
Zaenglein AL, Pathy AL, Schlosser BJ, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016;74:945-973.
Pimple popping: why only a dermatologist should do it. American Academy of Dermatology website. https://www.aad.org/public/diseases/acne-and-rosacea/pimple-popping-why-only-a-dermatologist-should-do-it. Accessed October 11, 2017.
Zaenglein AL, Pathy AL, Schlosser BJ, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016;74:945-973.
Ideal intubation position still unknown
In critically ill adults undergoing endotracheal intubation, the ramped position does not significantly improve oxygenation compared with the sniffing position, according to results of a multicenter, randomized trial of 260 patients treated in an intensive care unit.
Moreover, “[ramped] position appeared to worsen glottic view and increase the number of attempts required for successful intubation,” wrote Matthew W. Semler, MD, of Vanderbilt University Medical Center, Nashville, Tenn., and his coauthors (Chest. 2017 Oct. doi: 10.1016/j.chest.2017.03.061).
The ramped and sniffing positions are the two most common patient positions used during emergent intubation, according to investigators. The sniffing position is characterized by supine torso, neck flexed forward, and head extended, while ramped position involves elevating the torso and head.
Some believe the ramped position may offer superior anatomic alignment of the upper airway; however, only a few observational studies suggest it is associated with fewer complications than the sniffing position, the authors wrote.
Accordingly, they conducted a multicenter randomized trial with a primary endpoint of lowest arterial oxygen saturation, hypothesizing that the endpoint would be higher for the ramped position: “Our primary outcome of lowest arterial oxygen saturation is an established endpoint in ICU intubation trials, and is linked to periprocedural cardiac arrest and death,” they wrote.
The investigators instead found that median lowest arterial oxygen saturation was not statistically different between groups, at 93% for the ramped position, and 92% for the sniffing position (P = 0.27), published data show.
Further results showed that the ramped position appeared to be associated with poor glottic view and more difficult intubation. The incidence of grade III (only epiglottis) or grade IV (no visible glottis structures) views were 25.4% for ramped vs. 11.5% for sniffing (P = .01), while the rate of first-attempt intubation was 76.2% for ramped vs 85.4% for sniffing (P = .02).
While the findings are compelling, the authors were forthcoming about the potential limitations of the study and differences compared with earlier investigations. Notably, they said, all prior controlled trials of patient positioning during endotracheal intubation were conducted in the operating room, rather than in the ICU.
Also, the operators’ skill levels may further explain differences in this study’s outcomes from those of similar studies, the researchers noted. Earlier studies included patients intubated by one or two senior anesthesiologists from one center, while this trial involved 30 operators across multiple centers, with the average operator having performed 60 previous intubations. “Thus, our findings may generalize to settings in which airway management is performed by trainees, but whether results would be similar among expert operators remains unknown,” the investigators noted.
The authors reported no potential conflicts of interest. One coauthor reported serving on an advisory board for Avisa Pharma.
Editorialists praised the multicenter, randomized design of this study, and its total recruitment of 260 patients. They also noted several limitations of the study that “could shed some light” on the group’s conclusions (Chest. 2017 Oct. doi: 10.1016/j.chest.2017.06.002).
“The results diverge from [operating room] literature of the past 15 years that suggest that the ramped position is the preferred intubation position for obese patients or those with an anticipated difficult airway.” This may have been caused by shortcomings of this study’s design and differences between it and other research exploring the topic of patient positioning during endotracheal intubation, they wrote.
The study lacked a prespecified algorithm for preoxygenation and the operators had relatively low amounts of experience with intubations. Finally, the beds used in this study could contribute to the divergences between this intensive care unit experience and the operating room literature. The operating room table is narrower, firmer, and more stable, while by contrast, the ICU bed is wider and softer, they noted. This “may make initial positioning, maintenance of positioning, and accessing the patient’s head more difficult.”
Nevertheless, “[this] important study provides ideas for further study of optimal positioning in the ICU and adds valuable data to the sparse literature on the subject in the ICU setting,” they concluded.
James Aaron Scott, DO, Jens Matthias Walz, MD, FCCP, and Stephen O. Heard, MD, FCCP, are in the department of anesthesiology and perioperative medicine, UMass Memorial Medical Center, Worcester, Mass. The authors reported no conflicts of interest. These comments are based on their editorial.
Editorialists praised the multicenter, randomized design of this study, and its total recruitment of 260 patients. They also noted several limitations of the study that “could shed some light” on the group’s conclusions (Chest. 2017 Oct. doi: 10.1016/j.chest.2017.06.002).
“The results diverge from [operating room] literature of the past 15 years that suggest that the ramped position is the preferred intubation position for obese patients or those with an anticipated difficult airway.” This may have been caused by shortcomings of this study’s design and differences between it and other research exploring the topic of patient positioning during endotracheal intubation, they wrote.
The study lacked a prespecified algorithm for preoxygenation and the operators had relatively low amounts of experience with intubations. Finally, the beds used in this study could contribute to the divergences between this intensive care unit experience and the operating room literature. The operating room table is narrower, firmer, and more stable, while by contrast, the ICU bed is wider and softer, they noted. This “may make initial positioning, maintenance of positioning, and accessing the patient’s head more difficult.”
Nevertheless, “[this] important study provides ideas for further study of optimal positioning in the ICU and adds valuable data to the sparse literature on the subject in the ICU setting,” they concluded.
James Aaron Scott, DO, Jens Matthias Walz, MD, FCCP, and Stephen O. Heard, MD, FCCP, are in the department of anesthesiology and perioperative medicine, UMass Memorial Medical Center, Worcester, Mass. The authors reported no conflicts of interest. These comments are based on their editorial.
Editorialists praised the multicenter, randomized design of this study, and its total recruitment of 260 patients. They also noted several limitations of the study that “could shed some light” on the group’s conclusions (Chest. 2017 Oct. doi: 10.1016/j.chest.2017.06.002).
“The results diverge from [operating room] literature of the past 15 years that suggest that the ramped position is the preferred intubation position for obese patients or those with an anticipated difficult airway.” This may have been caused by shortcomings of this study’s design and differences between it and other research exploring the topic of patient positioning during endotracheal intubation, they wrote.
The study lacked a prespecified algorithm for preoxygenation and the operators had relatively low amounts of experience with intubations. Finally, the beds used in this study could contribute to the divergences between this intensive care unit experience and the operating room literature. The operating room table is narrower, firmer, and more stable, while by contrast, the ICU bed is wider and softer, they noted. This “may make initial positioning, maintenance of positioning, and accessing the patient’s head more difficult.”
Nevertheless, “[this] important study provides ideas for further study of optimal positioning in the ICU and adds valuable data to the sparse literature on the subject in the ICU setting,” they concluded.
James Aaron Scott, DO, Jens Matthias Walz, MD, FCCP, and Stephen O. Heard, MD, FCCP, are in the department of anesthesiology and perioperative medicine, UMass Memorial Medical Center, Worcester, Mass. The authors reported no conflicts of interest. These comments are based on their editorial.
In critically ill adults undergoing endotracheal intubation, the ramped position does not significantly improve oxygenation compared with the sniffing position, according to results of a multicenter, randomized trial of 260 patients treated in an intensive care unit.
Moreover, “[ramped] position appeared to worsen glottic view and increase the number of attempts required for successful intubation,” wrote Matthew W. Semler, MD, of Vanderbilt University Medical Center, Nashville, Tenn., and his coauthors (Chest. 2017 Oct. doi: 10.1016/j.chest.2017.03.061).
The ramped and sniffing positions are the two most common patient positions used during emergent intubation, according to investigators. The sniffing position is characterized by supine torso, neck flexed forward, and head extended, while ramped position involves elevating the torso and head.
Some believe the ramped position may offer superior anatomic alignment of the upper airway; however, only a few observational studies suggest it is associated with fewer complications than the sniffing position, the authors wrote.
Accordingly, they conducted a multicenter randomized trial with a primary endpoint of lowest arterial oxygen saturation, hypothesizing that the endpoint would be higher for the ramped position: “Our primary outcome of lowest arterial oxygen saturation is an established endpoint in ICU intubation trials, and is linked to periprocedural cardiac arrest and death,” they wrote.
The investigators instead found that median lowest arterial oxygen saturation was not statistically different between groups, at 93% for the ramped position, and 92% for the sniffing position (P = 0.27), published data show.
Further results showed that the ramped position appeared to be associated with poor glottic view and more difficult intubation. The incidence of grade III (only epiglottis) or grade IV (no visible glottis structures) views were 25.4% for ramped vs. 11.5% for sniffing (P = .01), while the rate of first-attempt intubation was 76.2% for ramped vs 85.4% for sniffing (P = .02).
While the findings are compelling, the authors were forthcoming about the potential limitations of the study and differences compared with earlier investigations. Notably, they said, all prior controlled trials of patient positioning during endotracheal intubation were conducted in the operating room, rather than in the ICU.
Also, the operators’ skill levels may further explain differences in this study’s outcomes from those of similar studies, the researchers noted. Earlier studies included patients intubated by one or two senior anesthesiologists from one center, while this trial involved 30 operators across multiple centers, with the average operator having performed 60 previous intubations. “Thus, our findings may generalize to settings in which airway management is performed by trainees, but whether results would be similar among expert operators remains unknown,” the investigators noted.
The authors reported no potential conflicts of interest. One coauthor reported serving on an advisory board for Avisa Pharma.
In critically ill adults undergoing endotracheal intubation, the ramped position does not significantly improve oxygenation compared with the sniffing position, according to results of a multicenter, randomized trial of 260 patients treated in an intensive care unit.
Moreover, “[ramped] position appeared to worsen glottic view and increase the number of attempts required for successful intubation,” wrote Matthew W. Semler, MD, of Vanderbilt University Medical Center, Nashville, Tenn., and his coauthors (Chest. 2017 Oct. doi: 10.1016/j.chest.2017.03.061).
The ramped and sniffing positions are the two most common patient positions used during emergent intubation, according to investigators. The sniffing position is characterized by supine torso, neck flexed forward, and head extended, while ramped position involves elevating the torso and head.
Some believe the ramped position may offer superior anatomic alignment of the upper airway; however, only a few observational studies suggest it is associated with fewer complications than the sniffing position, the authors wrote.
Accordingly, they conducted a multicenter randomized trial with a primary endpoint of lowest arterial oxygen saturation, hypothesizing that the endpoint would be higher for the ramped position: “Our primary outcome of lowest arterial oxygen saturation is an established endpoint in ICU intubation trials, and is linked to periprocedural cardiac arrest and death,” they wrote.
The investigators instead found that median lowest arterial oxygen saturation was not statistically different between groups, at 93% for the ramped position, and 92% for the sniffing position (P = 0.27), published data show.
Further results showed that the ramped position appeared to be associated with poor glottic view and more difficult intubation. The incidence of grade III (only epiglottis) or grade IV (no visible glottis structures) views were 25.4% for ramped vs. 11.5% for sniffing (P = .01), while the rate of first-attempt intubation was 76.2% for ramped vs 85.4% for sniffing (P = .02).
While the findings are compelling, the authors were forthcoming about the potential limitations of the study and differences compared with earlier investigations. Notably, they said, all prior controlled trials of patient positioning during endotracheal intubation were conducted in the operating room, rather than in the ICU.
Also, the operators’ skill levels may further explain differences in this study’s outcomes from those of similar studies, the researchers noted. Earlier studies included patients intubated by one or two senior anesthesiologists from one center, while this trial involved 30 operators across multiple centers, with the average operator having performed 60 previous intubations. “Thus, our findings may generalize to settings in which airway management is performed by trainees, but whether results would be similar among expert operators remains unknown,” the investigators noted.
The authors reported no potential conflicts of interest. One coauthor reported serving on an advisory board for Avisa Pharma.
FROM CHEST
Key clinical point: During endotracheal intubation of critically ill adults, use of the ramped position did not significantly improve oxygenation compared with the sniffing position, and it increased the number of attempts needed to achieve successful intubation.
Major finding: The median lowest arterial oxygen saturation was 93% for the ramped position and 92% for the sniffing position (P = .27).
Data source: Multicenter, randomized trial of 260 critically ill adults undergoing endotracheal intubation.
Disclosures: The authors reported no potential conflicts of interest. One coauthor reported serving on an advisory board for Avisa Pharma.
ACS Clinical Congress: Don’t miss these sessions
The ACS Clinical Congress will get underway on Saturday, Oct. 21, in San Diego. The vast array of sessions, presentations, and special events can be overwhelming. The best way to manage your time is to download the meeting app and start planning to attend must-see sessions and other events. The app lets you search by day, speaker, track, and type of session, so you can build your daily schedule and connect with colleagues. The ACS Surgery News editorial team, reporters, and videographers will be on site covering many sessions and posting stories and interviews daily on the web page.
Don’t miss these sessions
Acoustic gunshot sensor technology impacts trauma care.
Press Conference: TUESDAY, OCTOBER 24 - 10:30-11:00 a.m.
Location: Room 21 – San Diego Convention Center (Upper level)
~~~~
Lessons Learned from Las Vegas and other Major Intentional Mass Casualty Events.
Panel Session: TUESDAY, OCTOBER 24 – 8:00 – 9:30 a.m.
Location: 2, Upper Level of the San Diego Convention Center.
The ACS Surgery News editorial team offers the following picks among the hundreds of panels, sessions, and scientific forums:
•PS101: Controversies in the Management of Complicated Diverticulitis (Monday, Oct. 23, 9:45 am - 11:15 am, Hall F)
•PS104: The Gut Microbiome: Implications for Surgical Complications (Monday, Oct. 23, 9:45 am - 11:15 am, Room 20D)
•PS108: Management of Axilla in Breast Cancer (Monday, Oct. 23, 9:45 am - 11:15 am, 20A)
•PS109: Cholecystectomy: From Lap Chole to Open Common Duct Exploration (Monday, Oct. 23, 11:30 am - 1:00 pm, Hall F)
•PS200: The Impossible Gallbladder: Is Cholecystectomy Always the Answer? (Tuesday, Oct. 24, 8:00 am - 9:30 am, Hall F)
•PS204: What’s New in Hospital Acquired Infections? II (Tuesday, Oct. 24, 8:00 am - 9:30 am, Room 6E)
•PS218: Ergonomics for Surgeons: Preventing Work Related Injuries (Tuesday, Oct. 24, 9:45 am - 11:15 am)
•PS302: Shared Decision Making for Treatment of Uncomplicated Appendicitis (Wednesday, Oct. 25, 8:00 am - 9:30 am, Room 20C)
•PS313: Managing Bariatric Complications: The Role of the Non-Bariatric Surgeon (Wednesday, Oct. 25, 12:45 pm - 2:15 pm, Room 20D)
•PS332: Training Surgeons for Rural Practice (Wednesday, Oct. 25, 4:15 pm - 5:45 pm, Room 20D)
•PS400: Top Hot Topics in General Surgery (Thursday, Oct. 26, 8:00 am - 9:30 am, Room 20BC)
Social media
Follow Therese Borden on Twitter for live tweets during the meeting.
[email protected]
On Twitter @ThereseBorden
The ACS Clinical Congress will get underway on Saturday, Oct. 21, in San Diego. The vast array of sessions, presentations, and special events can be overwhelming. The best way to manage your time is to download the meeting app and start planning to attend must-see sessions and other events. The app lets you search by day, speaker, track, and type of session, so you can build your daily schedule and connect with colleagues. The ACS Surgery News editorial team, reporters, and videographers will be on site covering many sessions and posting stories and interviews daily on the web page.
Don’t miss these sessions
Acoustic gunshot sensor technology impacts trauma care.
Press Conference: TUESDAY, OCTOBER 24 - 10:30-11:00 a.m.
Location: Room 21 – San Diego Convention Center (Upper level)
~~~~
Lessons Learned from Las Vegas and other Major Intentional Mass Casualty Events.
Panel Session: TUESDAY, OCTOBER 24 – 8:00 – 9:30 a.m.
Location: 2, Upper Level of the San Diego Convention Center.
The ACS Surgery News editorial team offers the following picks among the hundreds of panels, sessions, and scientific forums:
•PS101: Controversies in the Management of Complicated Diverticulitis (Monday, Oct. 23, 9:45 am - 11:15 am, Hall F)
•PS104: The Gut Microbiome: Implications for Surgical Complications (Monday, Oct. 23, 9:45 am - 11:15 am, Room 20D)
•PS108: Management of Axilla in Breast Cancer (Monday, Oct. 23, 9:45 am - 11:15 am, 20A)
•PS109: Cholecystectomy: From Lap Chole to Open Common Duct Exploration (Monday, Oct. 23, 11:30 am - 1:00 pm, Hall F)
•PS200: The Impossible Gallbladder: Is Cholecystectomy Always the Answer? (Tuesday, Oct. 24, 8:00 am - 9:30 am, Hall F)
•PS204: What’s New in Hospital Acquired Infections? II (Tuesday, Oct. 24, 8:00 am - 9:30 am, Room 6E)
•PS218: Ergonomics for Surgeons: Preventing Work Related Injuries (Tuesday, Oct. 24, 9:45 am - 11:15 am)
•PS302: Shared Decision Making for Treatment of Uncomplicated Appendicitis (Wednesday, Oct. 25, 8:00 am - 9:30 am, Room 20C)
•PS313: Managing Bariatric Complications: The Role of the Non-Bariatric Surgeon (Wednesday, Oct. 25, 12:45 pm - 2:15 pm, Room 20D)
•PS332: Training Surgeons for Rural Practice (Wednesday, Oct. 25, 4:15 pm - 5:45 pm, Room 20D)
•PS400: Top Hot Topics in General Surgery (Thursday, Oct. 26, 8:00 am - 9:30 am, Room 20BC)
Social media
Follow Therese Borden on Twitter for live tweets during the meeting.
[email protected]
On Twitter @ThereseBorden
The ACS Clinical Congress will get underway on Saturday, Oct. 21, in San Diego. The vast array of sessions, presentations, and special events can be overwhelming. The best way to manage your time is to download the meeting app and start planning to attend must-see sessions and other events. The app lets you search by day, speaker, track, and type of session, so you can build your daily schedule and connect with colleagues. The ACS Surgery News editorial team, reporters, and videographers will be on site covering many sessions and posting stories and interviews daily on the web page.
Don’t miss these sessions
Acoustic gunshot sensor technology impacts trauma care.
Press Conference: TUESDAY, OCTOBER 24 - 10:30-11:00 a.m.
Location: Room 21 – San Diego Convention Center (Upper level)
~~~~
Lessons Learned from Las Vegas and other Major Intentional Mass Casualty Events.
Panel Session: TUESDAY, OCTOBER 24 – 8:00 – 9:30 a.m.
Location: 2, Upper Level of the San Diego Convention Center.
The ACS Surgery News editorial team offers the following picks among the hundreds of panels, sessions, and scientific forums:
•PS101: Controversies in the Management of Complicated Diverticulitis (Monday, Oct. 23, 9:45 am - 11:15 am, Hall F)
•PS104: The Gut Microbiome: Implications for Surgical Complications (Monday, Oct. 23, 9:45 am - 11:15 am, Room 20D)
•PS108: Management of Axilla in Breast Cancer (Monday, Oct. 23, 9:45 am - 11:15 am, 20A)
•PS109: Cholecystectomy: From Lap Chole to Open Common Duct Exploration (Monday, Oct. 23, 11:30 am - 1:00 pm, Hall F)
•PS200: The Impossible Gallbladder: Is Cholecystectomy Always the Answer? (Tuesday, Oct. 24, 8:00 am - 9:30 am, Hall F)
•PS204: What’s New in Hospital Acquired Infections? II (Tuesday, Oct. 24, 8:00 am - 9:30 am, Room 6E)
•PS218: Ergonomics for Surgeons: Preventing Work Related Injuries (Tuesday, Oct. 24, 9:45 am - 11:15 am)
•PS302: Shared Decision Making for Treatment of Uncomplicated Appendicitis (Wednesday, Oct. 25, 8:00 am - 9:30 am, Room 20C)
•PS313: Managing Bariatric Complications: The Role of the Non-Bariatric Surgeon (Wednesday, Oct. 25, 12:45 pm - 2:15 pm, Room 20D)
•PS332: Training Surgeons for Rural Practice (Wednesday, Oct. 25, 4:15 pm - 5:45 pm, Room 20D)
•PS400: Top Hot Topics in General Surgery (Thursday, Oct. 26, 8:00 am - 9:30 am, Room 20BC)
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When is technology ready for mainstream use for mental health care?
It is a daunting task for mental health providers to stay abreast with the current technology options available for mental health treatment. The past decade has seen the rise of multiple technology platforms with applications in mental health treatment (e.g., videoconferencing, mobile phones, web, patient-portals) along with specific interventions tailored to these platforms.
Traditional mechanisms for providers and mental health organizations, such as research papers and educational trainings, are unable to keep pace with both the technology available for providers and the technology being used by patients. How does a busy individual provider or mental health organization assess whether a technology is at a point to be considered a mainstream intervention and should be considered for routine use in clinical practice?
I proffer here the “middle caribou theory” for adapting “new” treatments and interventions. In a migrating caribou herd, animals leading the pack risk breaking through thin ice or getting pushed off unexpected cliffs by the masses behind them before the herd can institute a course correction. The caribou at the back of the herd are vulnerable to predation from wolves. The astute provider, like the caribou in the middle of the herd, has allowed others to test the path ahead and is less likely to be put at risk from antiquated methodologies found at the back of the herd.
There are now “base” technologies that every mental health provider and organization should be proficient in using and incorporating into clinical services where appropriate. These include email, videoconferencing, web-based technologies (e.g., patient education, patient portals) electronic medical records, and mobile phone-based applications. These are technologies that are relatively mature, and have reasonable track records in administrative and clinical psychiatry, in addition to growing or developed scientific literature supporting their use. “Emergent” technologies are those being deployed in clinical practice that have not reached widespread use and have underdeveloped literature and track records for their use. Examples of these include texting, virtual reality, and location technologies.1
Base vs. emergent technologies offer a framework for providers to determine which technologies they should be using in their practices. Often, it’s difficult to pinpoint when a technology has reached a “tipping point” into becoming a base/standard technology in the field and should be carefully considered by the middle caribou. Arguably, this occurs when a combination of a growing body of scientific evidence supporting a technology is coupled with wide adoption, although these two factors are not necessarily correlated. There are many examples in psychiatry of treatments coming into widespread practice with limited scientific support as well as scientifically robust treatments not being used in practice. Funding and reimbursement structures also play a role in facilitating and encouraging deployment and adoption of technology in mental health – and are not always driven by scientific best practices.
Finally, the temperament of individual providers and organizations determines when and how adoption might occur. Risk tolerance, novelty seeking, and capacity affect whether someone is an early or late adopter of an innovation.
Ultimately, clinical necessity drives the use of technologies in practice. Often, technology that has proved useful in other medical fields or in general use is translated into mental health, rather than being de novo developed for specific mental health treatments. This type of cross-pollination is not negative. Instead, it carries the risk of an initial “halo effect” where the promise of a technology used in other settings creates an unrealistic set of expectations about its potential in mental health treatments. This can lead to premature use and wider adoption that outpaces supporting scientific evidence.
So what should psychiatric providers and organizations consider in approaching these issues?
• Be proficient in base technologies, and stay up to date in their evolving uses and refinement.
• Stay informed about developing technologies, particularly those gaining broader use.
• Before considering adapting a new technology into clinical practice, make sure one is up to date on the scientific evidence supporting the technology. Providers should consider specialized training and orientation before piloting a new technology within a clinical setting.
• Take advantage of, and follow guidance of, reviews and best practices for assessing technology fit.
Dr. Shore chairs the American Psychiatric Association’s Committee on Telepsychiatry and is director of telemedicine at the Helen & Arthur E. Johnson Depression Center at the University of Colorado at Denver, Aurora. He also serves as associate professor of psychiatry at the university.
References
1 Telepsychiatry and Health Technologies: A Guide for Mental Health Professionals Arlington, Va.: American Psychiatric Association Publishing, 2017.
2 Telemed J E Health. 2015;21(12):1038-41.
3 Mil Med. 2014 Aug;179(8):865-78.
It is a daunting task for mental health providers to stay abreast with the current technology options available for mental health treatment. The past decade has seen the rise of multiple technology platforms with applications in mental health treatment (e.g., videoconferencing, mobile phones, web, patient-portals) along with specific interventions tailored to these platforms.
Traditional mechanisms for providers and mental health organizations, such as research papers and educational trainings, are unable to keep pace with both the technology available for providers and the technology being used by patients. How does a busy individual provider or mental health organization assess whether a technology is at a point to be considered a mainstream intervention and should be considered for routine use in clinical practice?
I proffer here the “middle caribou theory” for adapting “new” treatments and interventions. In a migrating caribou herd, animals leading the pack risk breaking through thin ice or getting pushed off unexpected cliffs by the masses behind them before the herd can institute a course correction. The caribou at the back of the herd are vulnerable to predation from wolves. The astute provider, like the caribou in the middle of the herd, has allowed others to test the path ahead and is less likely to be put at risk from antiquated methodologies found at the back of the herd.
There are now “base” technologies that every mental health provider and organization should be proficient in using and incorporating into clinical services where appropriate. These include email, videoconferencing, web-based technologies (e.g., patient education, patient portals) electronic medical records, and mobile phone-based applications. These are technologies that are relatively mature, and have reasonable track records in administrative and clinical psychiatry, in addition to growing or developed scientific literature supporting their use. “Emergent” technologies are those being deployed in clinical practice that have not reached widespread use and have underdeveloped literature and track records for their use. Examples of these include texting, virtual reality, and location technologies.1
Base vs. emergent technologies offer a framework for providers to determine which technologies they should be using in their practices. Often, it’s difficult to pinpoint when a technology has reached a “tipping point” into becoming a base/standard technology in the field and should be carefully considered by the middle caribou. Arguably, this occurs when a combination of a growing body of scientific evidence supporting a technology is coupled with wide adoption, although these two factors are not necessarily correlated. There are many examples in psychiatry of treatments coming into widespread practice with limited scientific support as well as scientifically robust treatments not being used in practice. Funding and reimbursement structures also play a role in facilitating and encouraging deployment and adoption of technology in mental health – and are not always driven by scientific best practices.
Finally, the temperament of individual providers and organizations determines when and how adoption might occur. Risk tolerance, novelty seeking, and capacity affect whether someone is an early or late adopter of an innovation.
Ultimately, clinical necessity drives the use of technologies in practice. Often, technology that has proved useful in other medical fields or in general use is translated into mental health, rather than being de novo developed for specific mental health treatments. This type of cross-pollination is not negative. Instead, it carries the risk of an initial “halo effect” where the promise of a technology used in other settings creates an unrealistic set of expectations about its potential in mental health treatments. This can lead to premature use and wider adoption that outpaces supporting scientific evidence.
So what should psychiatric providers and organizations consider in approaching these issues?
• Be proficient in base technologies, and stay up to date in their evolving uses and refinement.
• Stay informed about developing technologies, particularly those gaining broader use.
• Before considering adapting a new technology into clinical practice, make sure one is up to date on the scientific evidence supporting the technology. Providers should consider specialized training and orientation before piloting a new technology within a clinical setting.
• Take advantage of, and follow guidance of, reviews and best practices for assessing technology fit.
Dr. Shore chairs the American Psychiatric Association’s Committee on Telepsychiatry and is director of telemedicine at the Helen & Arthur E. Johnson Depression Center at the University of Colorado at Denver, Aurora. He also serves as associate professor of psychiatry at the university.
References
1 Telepsychiatry and Health Technologies: A Guide for Mental Health Professionals Arlington, Va.: American Psychiatric Association Publishing, 2017.
2 Telemed J E Health. 2015;21(12):1038-41.
3 Mil Med. 2014 Aug;179(8):865-78.
It is a daunting task for mental health providers to stay abreast with the current technology options available for mental health treatment. The past decade has seen the rise of multiple technology platforms with applications in mental health treatment (e.g., videoconferencing, mobile phones, web, patient-portals) along with specific interventions tailored to these platforms.
Traditional mechanisms for providers and mental health organizations, such as research papers and educational trainings, are unable to keep pace with both the technology available for providers and the technology being used by patients. How does a busy individual provider or mental health organization assess whether a technology is at a point to be considered a mainstream intervention and should be considered for routine use in clinical practice?
I proffer here the “middle caribou theory” for adapting “new” treatments and interventions. In a migrating caribou herd, animals leading the pack risk breaking through thin ice or getting pushed off unexpected cliffs by the masses behind them before the herd can institute a course correction. The caribou at the back of the herd are vulnerable to predation from wolves. The astute provider, like the caribou in the middle of the herd, has allowed others to test the path ahead and is less likely to be put at risk from antiquated methodologies found at the back of the herd.
There are now “base” technologies that every mental health provider and organization should be proficient in using and incorporating into clinical services where appropriate. These include email, videoconferencing, web-based technologies (e.g., patient education, patient portals) electronic medical records, and mobile phone-based applications. These are technologies that are relatively mature, and have reasonable track records in administrative and clinical psychiatry, in addition to growing or developed scientific literature supporting their use. “Emergent” technologies are those being deployed in clinical practice that have not reached widespread use and have underdeveloped literature and track records for their use. Examples of these include texting, virtual reality, and location technologies.1
Base vs. emergent technologies offer a framework for providers to determine which technologies they should be using in their practices. Often, it’s difficult to pinpoint when a technology has reached a “tipping point” into becoming a base/standard technology in the field and should be carefully considered by the middle caribou. Arguably, this occurs when a combination of a growing body of scientific evidence supporting a technology is coupled with wide adoption, although these two factors are not necessarily correlated. There are many examples in psychiatry of treatments coming into widespread practice with limited scientific support as well as scientifically robust treatments not being used in practice. Funding and reimbursement structures also play a role in facilitating and encouraging deployment and adoption of technology in mental health – and are not always driven by scientific best practices.
Finally, the temperament of individual providers and organizations determines when and how adoption might occur. Risk tolerance, novelty seeking, and capacity affect whether someone is an early or late adopter of an innovation.
Ultimately, clinical necessity drives the use of technologies in practice. Often, technology that has proved useful in other medical fields or in general use is translated into mental health, rather than being de novo developed for specific mental health treatments. This type of cross-pollination is not negative. Instead, it carries the risk of an initial “halo effect” where the promise of a technology used in other settings creates an unrealistic set of expectations about its potential in mental health treatments. This can lead to premature use and wider adoption that outpaces supporting scientific evidence.
So what should psychiatric providers and organizations consider in approaching these issues?
• Be proficient in base technologies, and stay up to date in their evolving uses and refinement.
• Stay informed about developing technologies, particularly those gaining broader use.
• Before considering adapting a new technology into clinical practice, make sure one is up to date on the scientific evidence supporting the technology. Providers should consider specialized training and orientation before piloting a new technology within a clinical setting.
• Take advantage of, and follow guidance of, reviews and best practices for assessing technology fit.
Dr. Shore chairs the American Psychiatric Association’s Committee on Telepsychiatry and is director of telemedicine at the Helen & Arthur E. Johnson Depression Center at the University of Colorado at Denver, Aurora. He also serves as associate professor of psychiatry at the university.
References
1 Telepsychiatry and Health Technologies: A Guide for Mental Health Professionals Arlington, Va.: American Psychiatric Association Publishing, 2017.
2 Telemed J E Health. 2015;21(12):1038-41.
3 Mil Med. 2014 Aug;179(8):865-78.