PARIS – Device thrombosis occurred nearly four times more frequently in recipients of the Absorb everolimus-eluting bioresorbable vascular scaffold than with the Xience everolimus-eluting metallic stent during 2 years of prospective follow-up in the randomized AIDA trial.

AIDA (the Amsterdam Investigator-Initiated Absorb Strategy All-Comers Trial) was the first randomized trial designed to compare the Absorb scaffold to a drug-eluting metallic stent in a broad patient population reflecting routine real-world clinical practice. The disturbing AIDA finding follows upon earlier serious concerns raised regarding an increased risk of scaffold thrombosis – and the particularly worrisome complication of late thrombosis – in the ABSORB Japan and ABSORB II trials, Joanna J. Wykrzykowska, MD, reported at the annual congress of the European Association of Percutaneous Cardiovascular Interventions.

[email protected]

PARIS – Device thrombosis occurred nearly four times more frequently in recipients of the Absorb everolimus-eluting bioresorbable vascular scaffold than with the Xience everolimus-eluting metallic stent during 2 years of prospective follow-up in the randomized AIDA trial.

AIDA (the Amsterdam Investigator-Initiated Absorb Strategy All-Comers Trial) was the first randomized trial designed to compare the Absorb scaffold to a drug-eluting metallic stent in a broad patient population reflecting routine real-world clinical practice. The disturbing AIDA finding follows upon earlier serious concerns raised regarding an increased risk of scaffold thrombosis – and the particularly worrisome complication of late thrombosis – in the ABSORB Japan and ABSORB II trials, Joanna J. Wykrzykowska, MD, reported at the annual congress of the European Association of Percutaneous Cardiovascular Interventions.

[email protected]

PARIS – Device thrombosis occurred nearly four times more frequently in recipients of the Absorb everolimus-eluting bioresorbable vascular scaffold than with the Xience everolimus-eluting metallic stent during 2 years of prospective follow-up in the randomized AIDA trial.

AIDA (the Amsterdam Investigator-Initiated Absorb Strategy All-Comers Trial) was the first randomized trial designed to compare the Absorb scaffold to a drug-eluting metallic stent in a broad patient population reflecting routine real-world clinical practice. The disturbing AIDA finding follows upon earlier serious concerns raised regarding an increased risk of scaffold thrombosis – and the particularly worrisome complication of late thrombosis – in the ABSORB Japan and ABSORB II trials, Joanna J. Wykrzykowska, MD, reported at the annual congress of the European Association of Percutaneous Cardiovascular Interventions.

[email protected]

WASHINGTON – A view of borderline personality disorder as neurobiological in nature can help clinicians extend their patience and empathy to these notoriously difficult-to-treat patients, according to an expert.

“Unfortunately, there are those who ... are just too frustrated by” [patients with borderline personality disorder], said Carmen V. Pinto, MD, an Elizabethtown, Ky.–based psychiatrist who specializes in treating patients with the disorder.

The diagnosis occurs in up to 2% of the population and is twice as common in women. About three-quarters of borderline personality disorder patients will attempt suicide at least once, and up to 1 in 10 complete suicide, said Dr. Pinto, assistant clinical professor of psychiatry at the University of Louisville (Ky.).

“There is an art to dealing with patients who are impulsive, and sometimes dangerous and scary,” Dr. Pinto said at Summit in Neurology & Psychiatry, held by Global Academy for Medical Education.

He emphasized the effect of unstable interpersonal relationships combined with frontolimbic brain abnormalities on the lives of patients with borderline personality disorder. In some cases, borderline personality disorder patients experienced traumatic events such as sexual abuse that was personal and ongoing – and occurred while the personality was being formed.

“These are normal people who have been exposed to abnormal stress,” Dr. Pinto said. “So you have to be careful, and see them not as victims but as survivors still suffering.”

Citing several lines of study into the neurobiochemical mechanisms of action in the disorder, Dr. Pinto discussed the role of disruption to the brain’s cortical-limbic circuit that serves as the brain’s basic stress response. In this population, an overactive amygdala and hypofunctioning frontal cortex continually signal threats even when none exist – exciting the sympathetic nervous system – as well as the endocrine and immune systems.

“The circuit gets overwhelmed, either because there really is too much to deal with, or there was poor functioning to start with, so the brain is going off like a pinball machine,” Dr. Pinto said. “If [the patients perceive] even the slightest offense, their limbic system lights up, and they have trouble turning it off, which is why it can be so difficult to deal with these folks in therapy.”

He explained the borderline personality patient’s typical negative valence as the result of this hyper-threat detection, often rooted in experiences in which people who professed to care for them acted contrary to their words, as in cases of incest. “They learn they can’t trust what is said, so they rely on nonverbal cues,” Dr. Pinto said. “They aren’t listening to what is said to them.”

Dr. Pinto cited a study of how this patient population had trouble distinguishing neutral faces from faces expressing anger or boredom, resulting in their believing that most people they encounter are unhappy with them in some way, causing them to retreat or have stressful relationships with others.

“Therapeutic neutrality is not the best way to approach this person, because they read it as ‘you are mad at me’ or ‘you’re bored with me’ or ‘you don’t like me,’ ” Dr. Pinto said, noting that he likes to reassure patients that they are doing the best they can with what they have. However, he warned against how often, in these patients’ quest to feel loved and accepted, they might ask for hugs or other contact. Rather than panic, use the opportunity to help the patient practice having healthy boundaries by explaining that not hugging them is designed to protect them, Dr. Pinto said.

Among the DSM-5 criteria for diagnosing this disorder is that the patient has an “enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture.” Because there are no imaging or laboratory tests to confirm a deviant inner experience, the clinician must turn to the patient for assessment while quelling the impulse to assign meanings to action and insight.

“You really have to be quiet and listen. They are the expert with their inner experience, and you have to let them tell you what that is,” he said, noting that the distortion of how they view themselves in relation to others is painful and pervasive, crossing all areas of their lives.

Because relationships are so difficult for these patients to develop, Dr. Pinto urged keeping in mind that it is possible they have no other therapeutic relationship in their lives. “That is a scary responsibility, to think they have no one else to talk to but you,” he said. This underscores the need for clinicians to protect themselves, too. “If I don’t feel safe, I can’t do a good job for them – and I tell them that,” Dr. Pinto said.

Global Academy and this news organization are owned by the same company. Dr. Pinto had no relevant disclosures, although he said he is a paid speaker for Otsuka, Lundbeck, Janssen, and other pharmaceutical companies.

[email protected]

On Twitter @whitneymcknight

WASHINGTON – A view of borderline personality disorder as neurobiological in nature can help clinicians extend their patience and empathy to these notoriously difficult-to-treat patients, according to an expert.

“Unfortunately, there are those who ... are just too frustrated by” [patients with borderline personality disorder], said Carmen V. Pinto, MD, an Elizabethtown, Ky.–based psychiatrist who specializes in treating patients with the disorder.

The diagnosis occurs in up to 2% of the population and is twice as common in women. About three-quarters of borderline personality disorder patients will attempt suicide at least once, and up to 1 in 10 complete suicide, said Dr. Pinto, assistant clinical professor of psychiatry at the University of Louisville (Ky.).

“There is an art to dealing with patients who are impulsive, and sometimes dangerous and scary,” Dr. Pinto said at Summit in Neurology & Psychiatry, held by Global Academy for Medical Education.

He emphasized the effect of unstable interpersonal relationships combined with frontolimbic brain abnormalities on the lives of patients with borderline personality disorder. In some cases, borderline personality disorder patients experienced traumatic events such as sexual abuse that was personal and ongoing – and occurred while the personality was being formed.

“These are normal people who have been exposed to abnormal stress,” Dr. Pinto said. “So you have to be careful, and see them not as victims but as survivors still suffering.”

Citing several lines of study into the neurobiochemical mechanisms of action in the disorder, Dr. Pinto discussed the role of disruption to the brain’s cortical-limbic circuit that serves as the brain’s basic stress response. In this population, an overactive amygdala and hypofunctioning frontal cortex continually signal threats even when none exist – exciting the sympathetic nervous system – as well as the endocrine and immune systems.

“The circuit gets overwhelmed, either because there really is too much to deal with, or there was poor functioning to start with, so the brain is going off like a pinball machine,” Dr. Pinto said. “If [the patients perceive] even the slightest offense, their limbic system lights up, and they have trouble turning it off, which is why it can be so difficult to deal with these folks in therapy.”

He explained the borderline personality patient’s typical negative valence as the result of this hyper-threat detection, often rooted in experiences in which people who professed to care for them acted contrary to their words, as in cases of incest. “They learn they can’t trust what is said, so they rely on nonverbal cues,” Dr. Pinto said. “They aren’t listening to what is said to them.”

Dr. Pinto cited a study of how this patient population had trouble distinguishing neutral faces from faces expressing anger or boredom, resulting in their believing that most people they encounter are unhappy with them in some way, causing them to retreat or have stressful relationships with others.

“Therapeutic neutrality is not the best way to approach this person, because they read it as ‘you are mad at me’ or ‘you’re bored with me’ or ‘you don’t like me,’ ” Dr. Pinto said, noting that he likes to reassure patients that they are doing the best they can with what they have. However, he warned against how often, in these patients’ quest to feel loved and accepted, they might ask for hugs or other contact. Rather than panic, use the opportunity to help the patient practice having healthy boundaries by explaining that not hugging them is designed to protect them, Dr. Pinto said.

Among the DSM-5 criteria for diagnosing this disorder is that the patient has an “enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture.” Because there are no imaging or laboratory tests to confirm a deviant inner experience, the clinician must turn to the patient for assessment while quelling the impulse to assign meanings to action and insight.

“You really have to be quiet and listen. They are the expert with their inner experience, and you have to let them tell you what that is,” he said, noting that the distortion of how they view themselves in relation to others is painful and pervasive, crossing all areas of their lives.

Because relationships are so difficult for these patients to develop, Dr. Pinto urged keeping in mind that it is possible they have no other therapeutic relationship in their lives. “That is a scary responsibility, to think they have no one else to talk to but you,” he said. This underscores the need for clinicians to protect themselves, too. “If I don’t feel safe, I can’t do a good job for them – and I tell them that,” Dr. Pinto said.

Global Academy and this news organization are owned by the same company. Dr. Pinto had no relevant disclosures, although he said he is a paid speaker for Otsuka, Lundbeck, Janssen, and other pharmaceutical companies.

[email protected]

On Twitter @whitneymcknight

WASHINGTON – A view of borderline personality disorder as neurobiological in nature can help clinicians extend their patience and empathy to these notoriously difficult-to-treat patients, according to an expert.

“Unfortunately, there are those who ... are just too frustrated by” [patients with borderline personality disorder], said Carmen V. Pinto, MD, an Elizabethtown, Ky.–based psychiatrist who specializes in treating patients with the disorder.

The diagnosis occurs in up to 2% of the population and is twice as common in women. About three-quarters of borderline personality disorder patients will attempt suicide at least once, and up to 1 in 10 complete suicide, said Dr. Pinto, assistant clinical professor of psychiatry at the University of Louisville (Ky.).

“There is an art to dealing with patients who are impulsive, and sometimes dangerous and scary,” Dr. Pinto said at Summit in Neurology & Psychiatry, held by Global Academy for Medical Education.

He emphasized the effect of unstable interpersonal relationships combined with frontolimbic brain abnormalities on the lives of patients with borderline personality disorder. In some cases, borderline personality disorder patients experienced traumatic events such as sexual abuse that was personal and ongoing – and occurred while the personality was being formed.

“These are normal people who have been exposed to abnormal stress,” Dr. Pinto said. “So you have to be careful, and see them not as victims but as survivors still suffering.”

Citing several lines of study into the neurobiochemical mechanisms of action in the disorder, Dr. Pinto discussed the role of disruption to the brain’s cortical-limbic circuit that serves as the brain’s basic stress response. In this population, an overactive amygdala and hypofunctioning frontal cortex continually signal threats even when none exist – exciting the sympathetic nervous system – as well as the endocrine and immune systems.

“The circuit gets overwhelmed, either because there really is too much to deal with, or there was poor functioning to start with, so the brain is going off like a pinball machine,” Dr. Pinto said. “If [the patients perceive] even the slightest offense, their limbic system lights up, and they have trouble turning it off, which is why it can be so difficult to deal with these folks in therapy.”

He explained the borderline personality patient’s typical negative valence as the result of this hyper-threat detection, often rooted in experiences in which people who professed to care for them acted contrary to their words, as in cases of incest. “They learn they can’t trust what is said, so they rely on nonverbal cues,” Dr. Pinto said. “They aren’t listening to what is said to them.”

Dr. Pinto cited a study of how this patient population had trouble distinguishing neutral faces from faces expressing anger or boredom, resulting in their believing that most people they encounter are unhappy with them in some way, causing them to retreat or have stressful relationships with others.

“Therapeutic neutrality is not the best way to approach this person, because they read it as ‘you are mad at me’ or ‘you’re bored with me’ or ‘you don’t like me,’ ” Dr. Pinto said, noting that he likes to reassure patients that they are doing the best they can with what they have. However, he warned against how often, in these patients’ quest to feel loved and accepted, they might ask for hugs or other contact. Rather than panic, use the opportunity to help the patient practice having healthy boundaries by explaining that not hugging them is designed to protect them, Dr. Pinto said.

Among the DSM-5 criteria for diagnosing this disorder is that the patient has an “enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture.” Because there are no imaging or laboratory tests to confirm a deviant inner experience, the clinician must turn to the patient for assessment while quelling the impulse to assign meanings to action and insight.

“You really have to be quiet and listen. They are the expert with their inner experience, and you have to let them tell you what that is,” he said, noting that the distortion of how they view themselves in relation to others is painful and pervasive, crossing all areas of their lives.

Because relationships are so difficult for these patients to develop, Dr. Pinto urged keeping in mind that it is possible they have no other therapeutic relationship in their lives. “That is a scary responsibility, to think they have no one else to talk to but you,” he said. This underscores the need for clinicians to protect themselves, too. “If I don’t feel safe, I can’t do a good job for them – and I tell them that,” Dr. Pinto said.

Global Academy and this news organization are owned by the same company. Dr. Pinto had no relevant disclosures, although he said he is a paid speaker for Otsuka, Lundbeck, Janssen, and other pharmaceutical companies.

[email protected]

On Twitter @whitneymcknight

The Food and Drug Administration has approved the Praxis Extended RAS Panel for the identification of metastatic colorectal cancer patients who can be treated with panitumumab.

The Praxis Extended RAS Panel is able to detect 56 specific mutations in the RAS genes of mCRC patients, and is the first next generation sequencing test approved by the FDA capable of testing more than one RAS gene mutation. If RAS mutations are not detected, then panitumumab is indicated, and if a mutation is detected, panitumumab is not indicated, according to the FDA statement.

[email protected]

The Food and Drug Administration has approved the Praxis Extended RAS Panel for the identification of metastatic colorectal cancer patients who can be treated with panitumumab.

The Praxis Extended RAS Panel is able to detect 56 specific mutations in the RAS genes of mCRC patients, and is the first next generation sequencing test approved by the FDA capable of testing more than one RAS gene mutation. If RAS mutations are not detected, then panitumumab is indicated, and if a mutation is detected, panitumumab is not indicated, according to the FDA statement.

[email protected]

The Food and Drug Administration has approved the Praxis Extended RAS Panel for the identification of metastatic colorectal cancer patients who can be treated with panitumumab.

The Praxis Extended RAS Panel is able to detect 56 specific mutations in the RAS genes of mCRC patients, and is the first next generation sequencing test approved by the FDA capable of testing more than one RAS gene mutation. If RAS mutations are not detected, then panitumumab is indicated, and if a mutation is detected, panitumumab is not indicated, according to the FDA statement.

[email protected]

ATHENS, OHIO – On April 5, Ciera Smith sat in a car parked on the gravel driveway of the Rural Women’s Recovery Program here with a choice to make: Go to jail or enter treatment for her addiction.

Ms. Smith, 22, started abusing drugs when she was 18 years old, enticed by the “good time” she and her friends found in smoking marijuana. She later turned to addictive painkillers, then antianxiety medications such as Xanax and eventually Suboxone, a narcotic often used to replace opioids when treating addiction.

Before stepping out of the car, she decided she needed one more high before treatment. She reached into her purse and then swallowed a handful of gabapentin pills.

Last December, Ohio’s Board of Pharmacy began reporting sales of gabapentin prescriptions in its regular monitoring of controlled substances. The drug, which is neither an opioid nor designated a controlled substance by federal authorities, is used to treat nerve pain. But the board found that it was the most prescribed medication on its list that month, surpassing oxycodone by more than 9 million doses. In February, the Ohio Substance Abuse Monitoring Network issued an alert regarding increasing misuse across the state.

And it’s not just in Ohio. Gabapentin’s ability to tackle multiple ailments has helped make it one of the most popular medications in the United States. In May, it was the fifth-most prescribed drug in the nation, according to GoodRx.

Gabapentin is approved by the Food and Drug Administration to treat epilepsy and pain related to nerve damage, called neuropathy. Also known by its brand name, Neurontin, the drug acts as a sedative. It is widely considered nonaddictive and touted by the federal Centers for Disease Control and Prevention as an alternative intervention to opiates for chronic pain. Generally, doctors prescribe no more than 1,800-2,400 mg of gabapentin per day, according to information on the Mayo Clinic’s website.

Gabapentin does not carry the same risk of lethal overdoses as opioids, but drug experts say the effects of using gabapentin for long periods of time or in very high quantities, particularly among such sensitive populations as pregnant women, are not well known.

As providers dole out the drug in mass quantities for conditions such as restless legs syndrome and alcoholism, it is being subverted to a drug of abuse. Gabapentin can enhance the euphoria caused by an opioid and stave off drug withdrawals. In addition, it can bypass the blocking effects of medications used for addiction treatment, enabling patients to get high while in recovery.

Athens, home to Ohio University, lies in the southeastern corner of the state, which has been ravaged by the opioid epidemic. Despite experience in combating illicit drug use, law enforcement officials and drug counselors say the addition of gabapentin adds a new obstacle.

“I don’t know if we have a clear picture of the risk,” said Joe Gay, executive director of Health Recovery Services, a network of substance abuse recovery centers headquartered in Athens.

‘Available to be abused’

A literature review published in 2016 in the journal Addiction found about a fifth of those who abuse opiates misuse gabapentin. A separate 2015 study of adults in Appalachian Kentucky who abused opiates found 15% of participants also misused gabapentin in the past 6 months “to get high.”

In the same year, the drug was involved in 109 overdose deaths in West Virginia, the Charleston Gazette-Mail reported.

Rachel Quivey, an Athens pharmacist, said she noticed signs of gabapentin misuse half a decade ago when patients began picking up the drug several days before their prescription ran out.

“Gabapentin is so readily available,” she said. “That, in my opinion, is where a lot of that danger is. It’s available to be abused.”

In May, Ms. Quivey’s pharmacy filled roughly 33 prescriptions of gabapentin per week, dispensing 90-120 pills for each client.

For customers who arrive with scripts demanding a high dosage of the drug, Ms. Quivey sometimes calls the doctor to discuss her concerns. But many of them aren’t aware of gabapentin misuse, she said.

Even as gabapentin gets restocked regularly on Ms. Quivey’s shelves, the drug’s presence is increasing on the streets of Athens. A 300-milligram pill sells for as little as 75 cents.

Yet, according to Chuck Haegele, field supervisor for the major crimes unit at the Athens City Police Department, law enforcement can do little to stop its spread. That’s because gabapentin is not categorized as a controlled substance. That designation places restrictions on who can possess and dispense the drug.

“There’s really not much we can do at this point,” he said. “If it’s not controlled … it’s not illegal for somebody that’s not prescribed it to possess it.”

Mr. Haegele said he heard about the drug less than 3 months ago when an officer accidentally received a text message from someone offering to sell it. The police force, he said, is still trying to assess the threat of gabapentin.

Little testing

Nearly anyone arrested and found to struggle with addiction in Athens is given the option to go through a drug-court program to get treatment. But officials said that some exploit the absence of routine exams for gabapentin to get high while testing clean.

Brice Johnson, a probation officer at Athens County Municipal Court, said participants in the municipal court’s substance abuse mentally ill program undergo gabapentin testing only when abuse is suspected. Screenings are not regularly done on every client because gabapentin abuse has not been a concern and the testing adds expense, he said.

The rehab program run through the county prosecutor’s office, called Fresh Start, does test for gabapentin. Its latest round of screenings detected the drug in 5 of its roughly 238 active participants, prosecutor Keller Blackburn said.

Linda Holley, a clinical supervisor at an Athens outpatient program run by the Health Recovery Services, said she suspects at least half of her clients on Suboxone treatment abuse gabapentin. But the center can’t afford to regularly test every participant.

Ms. Holley said she sees clients who are prescribed gabapentin but, because of health privacy laws, she can’t share their status as a person in recovery to an outside provider without written consent. The restrictions give clients in recovery an opportunity to get high using drugs they obtained legally and still pass a drug test.

“With the gabapentin, I wish there were more we could do, but our hands are tied,” she said. “We can’t do anything but educate the client and discourage” them from using such medications.

Ms. Smith visited two separate doctors to secure a prescription. As she rotated through drug court, Narcotics Anonymous meetings, jail for relapsing on cocaine, and house arrest enforced with an ankle bracelet, she said her gabapentin abuse wasn’t detected until she arrived at the residential recovery center.

Today, Ms. Smith sticks to the recovery process. Expecting a baby in early July, her successful completion of the program not only means sobriety but also allows her the opportunity to restore custody of her eldest daughter and raise her children.

She intends to relocate her family away from the friends and routines that helped lead her to addiction and said she will help guide her daughter away from making similar mistakes.

“All I can do is be there and give her the knowledge that I can about addiction,” Ms. Smith said, “and hope that she chooses to go on the right path.”
 

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

ATHENS, OHIO – On April 5, Ciera Smith sat in a car parked on the gravel driveway of the Rural Women’s Recovery Program here with a choice to make: Go to jail or enter treatment for her addiction.

Ms. Smith, 22, started abusing drugs when she was 18 years old, enticed by the “good time” she and her friends found in smoking marijuana. She later turned to addictive painkillers, then antianxiety medications such as Xanax and eventually Suboxone, a narcotic often used to replace opioids when treating addiction.

Before stepping out of the car, she decided she needed one more high before treatment. She reached into her purse and then swallowed a handful of gabapentin pills.

Last December, Ohio’s Board of Pharmacy began reporting sales of gabapentin prescriptions in its regular monitoring of controlled substances. The drug, which is neither an opioid nor designated a controlled substance by federal authorities, is used to treat nerve pain. But the board found that it was the most prescribed medication on its list that month, surpassing oxycodone by more than 9 million doses. In February, the Ohio Substance Abuse Monitoring Network issued an alert regarding increasing misuse across the state.

And it’s not just in Ohio. Gabapentin’s ability to tackle multiple ailments has helped make it one of the most popular medications in the United States. In May, it was the fifth-most prescribed drug in the nation, according to GoodRx.

Gabapentin is approved by the Food and Drug Administration to treat epilepsy and pain related to nerve damage, called neuropathy. Also known by its brand name, Neurontin, the drug acts as a sedative. It is widely considered nonaddictive and touted by the federal Centers for Disease Control and Prevention as an alternative intervention to opiates for chronic pain. Generally, doctors prescribe no more than 1,800-2,400 mg of gabapentin per day, according to information on the Mayo Clinic’s website.

Gabapentin does not carry the same risk of lethal overdoses as opioids, but drug experts say the effects of using gabapentin for long periods of time or in very high quantities, particularly among such sensitive populations as pregnant women, are not well known.

As providers dole out the drug in mass quantities for conditions such as restless legs syndrome and alcoholism, it is being subverted to a drug of abuse. Gabapentin can enhance the euphoria caused by an opioid and stave off drug withdrawals. In addition, it can bypass the blocking effects of medications used for addiction treatment, enabling patients to get high while in recovery.

Athens, home to Ohio University, lies in the southeastern corner of the state, which has been ravaged by the opioid epidemic. Despite experience in combating illicit drug use, law enforcement officials and drug counselors say the addition of gabapentin adds a new obstacle.

“I don’t know if we have a clear picture of the risk,” said Joe Gay, executive director of Health Recovery Services, a network of substance abuse recovery centers headquartered in Athens.

‘Available to be abused’

A literature review published in 2016 in the journal Addiction found about a fifth of those who abuse opiates misuse gabapentin. A separate 2015 study of adults in Appalachian Kentucky who abused opiates found 15% of participants also misused gabapentin in the past 6 months “to get high.”

In the same year, the drug was involved in 109 overdose deaths in West Virginia, the Charleston Gazette-Mail reported.

Rachel Quivey, an Athens pharmacist, said she noticed signs of gabapentin misuse half a decade ago when patients began picking up the drug several days before their prescription ran out.

“Gabapentin is so readily available,” she said. “That, in my opinion, is where a lot of that danger is. It’s available to be abused.”

In May, Ms. Quivey’s pharmacy filled roughly 33 prescriptions of gabapentin per week, dispensing 90-120 pills for each client.

For customers who arrive with scripts demanding a high dosage of the drug, Ms. Quivey sometimes calls the doctor to discuss her concerns. But many of them aren’t aware of gabapentin misuse, she said.

Even as gabapentin gets restocked regularly on Ms. Quivey’s shelves, the drug’s presence is increasing on the streets of Athens. A 300-milligram pill sells for as little as 75 cents.

Yet, according to Chuck Haegele, field supervisor for the major crimes unit at the Athens City Police Department, law enforcement can do little to stop its spread. That’s because gabapentin is not categorized as a controlled substance. That designation places restrictions on who can possess and dispense the drug.

“There’s really not much we can do at this point,” he said. “If it’s not controlled … it’s not illegal for somebody that’s not prescribed it to possess it.”

Mr. Haegele said he heard about the drug less than 3 months ago when an officer accidentally received a text message from someone offering to sell it. The police force, he said, is still trying to assess the threat of gabapentin.

Little testing

Nearly anyone arrested and found to struggle with addiction in Athens is given the option to go through a drug-court program to get treatment. But officials said that some exploit the absence of routine exams for gabapentin to get high while testing clean.

Brice Johnson, a probation officer at Athens County Municipal Court, said participants in the municipal court’s substance abuse mentally ill program undergo gabapentin testing only when abuse is suspected. Screenings are not regularly done on every client because gabapentin abuse has not been a concern and the testing adds expense, he said.

The rehab program run through the county prosecutor’s office, called Fresh Start, does test for gabapentin. Its latest round of screenings detected the drug in 5 of its roughly 238 active participants, prosecutor Keller Blackburn said.

Linda Holley, a clinical supervisor at an Athens outpatient program run by the Health Recovery Services, said she suspects at least half of her clients on Suboxone treatment abuse gabapentin. But the center can’t afford to regularly test every participant.

Ms. Holley said she sees clients who are prescribed gabapentin but, because of health privacy laws, she can’t share their status as a person in recovery to an outside provider without written consent. The restrictions give clients in recovery an opportunity to get high using drugs they obtained legally and still pass a drug test.

“With the gabapentin, I wish there were more we could do, but our hands are tied,” she said. “We can’t do anything but educate the client and discourage” them from using such medications.

Ms. Smith visited two separate doctors to secure a prescription. As she rotated through drug court, Narcotics Anonymous meetings, jail for relapsing on cocaine, and house arrest enforced with an ankle bracelet, she said her gabapentin abuse wasn’t detected until she arrived at the residential recovery center.

Today, Ms. Smith sticks to the recovery process. Expecting a baby in early July, her successful completion of the program not only means sobriety but also allows her the opportunity to restore custody of her eldest daughter and raise her children.

She intends to relocate her family away from the friends and routines that helped lead her to addiction and said she will help guide her daughter away from making similar mistakes.

“All I can do is be there and give her the knowledge that I can about addiction,” Ms. Smith said, “and hope that she chooses to go on the right path.”
 

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

ATHENS, OHIO – On April 5, Ciera Smith sat in a car parked on the gravel driveway of the Rural Women’s Recovery Program here with a choice to make: Go to jail or enter treatment for her addiction.

Ms. Smith, 22, started abusing drugs when she was 18 years old, enticed by the “good time” she and her friends found in smoking marijuana. She later turned to addictive painkillers, then antianxiety medications such as Xanax and eventually Suboxone, a narcotic often used to replace opioids when treating addiction.

Before stepping out of the car, she decided she needed one more high before treatment. She reached into her purse and then swallowed a handful of gabapentin pills.

Last December, Ohio’s Board of Pharmacy began reporting sales of gabapentin prescriptions in its regular monitoring of controlled substances. The drug, which is neither an opioid nor designated a controlled substance by federal authorities, is used to treat nerve pain. But the board found that it was the most prescribed medication on its list that month, surpassing oxycodone by more than 9 million doses. In February, the Ohio Substance Abuse Monitoring Network issued an alert regarding increasing misuse across the state.

And it’s not just in Ohio. Gabapentin’s ability to tackle multiple ailments has helped make it one of the most popular medications in the United States. In May, it was the fifth-most prescribed drug in the nation, according to GoodRx.

Gabapentin is approved by the Food and Drug Administration to treat epilepsy and pain related to nerve damage, called neuropathy. Also known by its brand name, Neurontin, the drug acts as a sedative. It is widely considered nonaddictive and touted by the federal Centers for Disease Control and Prevention as an alternative intervention to opiates for chronic pain. Generally, doctors prescribe no more than 1,800-2,400 mg of gabapentin per day, according to information on the Mayo Clinic’s website.

Gabapentin does not carry the same risk of lethal overdoses as opioids, but drug experts say the effects of using gabapentin for long periods of time or in very high quantities, particularly among such sensitive populations as pregnant women, are not well known.

As providers dole out the drug in mass quantities for conditions such as restless legs syndrome and alcoholism, it is being subverted to a drug of abuse. Gabapentin can enhance the euphoria caused by an opioid and stave off drug withdrawals. In addition, it can bypass the blocking effects of medications used for addiction treatment, enabling patients to get high while in recovery.

Athens, home to Ohio University, lies in the southeastern corner of the state, which has been ravaged by the opioid epidemic. Despite experience in combating illicit drug use, law enforcement officials and drug counselors say the addition of gabapentin adds a new obstacle.

“I don’t know if we have a clear picture of the risk,” said Joe Gay, executive director of Health Recovery Services, a network of substance abuse recovery centers headquartered in Athens.

‘Available to be abused’

A literature review published in 2016 in the journal Addiction found about a fifth of those who abuse opiates misuse gabapentin. A separate 2015 study of adults in Appalachian Kentucky who abused opiates found 15% of participants also misused gabapentin in the past 6 months “to get high.”

In the same year, the drug was involved in 109 overdose deaths in West Virginia, the Charleston Gazette-Mail reported.

Rachel Quivey, an Athens pharmacist, said she noticed signs of gabapentin misuse half a decade ago when patients began picking up the drug several days before their prescription ran out.

“Gabapentin is so readily available,” she said. “That, in my opinion, is where a lot of that danger is. It’s available to be abused.”

In May, Ms. Quivey’s pharmacy filled roughly 33 prescriptions of gabapentin per week, dispensing 90-120 pills for each client.

For customers who arrive with scripts demanding a high dosage of the drug, Ms. Quivey sometimes calls the doctor to discuss her concerns. But many of them aren’t aware of gabapentin misuse, she said.

Even as gabapentin gets restocked regularly on Ms. Quivey’s shelves, the drug’s presence is increasing on the streets of Athens. A 300-milligram pill sells for as little as 75 cents.

Yet, according to Chuck Haegele, field supervisor for the major crimes unit at the Athens City Police Department, law enforcement can do little to stop its spread. That’s because gabapentin is not categorized as a controlled substance. That designation places restrictions on who can possess and dispense the drug.

“There’s really not much we can do at this point,” he said. “If it’s not controlled … it’s not illegal for somebody that’s not prescribed it to possess it.”

Mr. Haegele said he heard about the drug less than 3 months ago when an officer accidentally received a text message from someone offering to sell it. The police force, he said, is still trying to assess the threat of gabapentin.

Little testing

Nearly anyone arrested and found to struggle with addiction in Athens is given the option to go through a drug-court program to get treatment. But officials said that some exploit the absence of routine exams for gabapentin to get high while testing clean.

Brice Johnson, a probation officer at Athens County Municipal Court, said participants in the municipal court’s substance abuse mentally ill program undergo gabapentin testing only when abuse is suspected. Screenings are not regularly done on every client because gabapentin abuse has not been a concern and the testing adds expense, he said.

The rehab program run through the county prosecutor’s office, called Fresh Start, does test for gabapentin. Its latest round of screenings detected the drug in 5 of its roughly 238 active participants, prosecutor Keller Blackburn said.

Linda Holley, a clinical supervisor at an Athens outpatient program run by the Health Recovery Services, said she suspects at least half of her clients on Suboxone treatment abuse gabapentin. But the center can’t afford to regularly test every participant.

Ms. Holley said she sees clients who are prescribed gabapentin but, because of health privacy laws, she can’t share their status as a person in recovery to an outside provider without written consent. The restrictions give clients in recovery an opportunity to get high using drugs they obtained legally and still pass a drug test.

“With the gabapentin, I wish there were more we could do, but our hands are tied,” she said. “We can’t do anything but educate the client and discourage” them from using such medications.

Ms. Smith visited two separate doctors to secure a prescription. As she rotated through drug court, Narcotics Anonymous meetings, jail for relapsing on cocaine, and house arrest enforced with an ankle bracelet, she said her gabapentin abuse wasn’t detected until she arrived at the residential recovery center.

Today, Ms. Smith sticks to the recovery process. Expecting a baby in early July, her successful completion of the program not only means sobriety but also allows her the opportunity to restore custody of her eldest daughter and raise her children.

She intends to relocate her family away from the friends and routines that helped lead her to addiction and said she will help guide her daughter away from making similar mistakes.

“All I can do is be there and give her the knowledge that I can about addiction,” Ms. Smith said, “and hope that she chooses to go on the right path.”
 

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

washington – As data mount confirming the neurodegenerative effects of psychotic episodes in schizophrenia, one expert urges psychiatrists to think of psychosis as a “brain attack” which, like heart attacks, must be prevented from recurring.

“Schizophrenia doesn’t have to be progressive neurodegenerative unless patients relapse again and again, but that happens all the time because we give our patients pills they don’t take as prescribed. There are many reasons for poor adherence,” Henry A. Nasrallah, MD, said at the meeting held by Global Academy for Medical Education.

[email protected]

On Twitter @whitneymcknight

washington – As data mount confirming the neurodegenerative effects of psychotic episodes in schizophrenia, one expert urges psychiatrists to think of psychosis as a “brain attack” which, like heart attacks, must be prevented from recurring.

“Schizophrenia doesn’t have to be progressive neurodegenerative unless patients relapse again and again, but that happens all the time because we give our patients pills they don’t take as prescribed. There are many reasons for poor adherence,” Henry A. Nasrallah, MD, said at the meeting held by Global Academy for Medical Education.

[email protected]

On Twitter @whitneymcknight

washington – As data mount confirming the neurodegenerative effects of psychotic episodes in schizophrenia, one expert urges psychiatrists to think of psychosis as a “brain attack” which, like heart attacks, must be prevented from recurring.

“Schizophrenia doesn’t have to be progressive neurodegenerative unless patients relapse again and again, but that happens all the time because we give our patients pills they don’t take as prescribed. There are many reasons for poor adherence,” Henry A. Nasrallah, MD, said at the meeting held by Global Academy for Medical Education.

[email protected]

On Twitter @whitneymcknight

Savolitinib, a highly selective inhibitor of c-Met receptor tyrosine kinase, improved progression-free survival in a small portion of patients with MET-driven advanced renal papillary cell cancer.

The molecule, being developed by Hutchison China MediTech Limited and AstraZeneca, extended progression-free survival by about 5 months in these patients, compared with those whose tumors were not MET driven (6.2 vs. 1.4 months, respectively), reported Toni Choueiri, MD, and his colleagues (J Clin Oncol 2017. doi: 10.1200/JCO.2017.72.2967).

[email protected]

On Twitter @Alz_gal

Savolitinib, a highly selective inhibitor of c-Met receptor tyrosine kinase, improved progression-free survival in a small portion of patients with MET-driven advanced renal papillary cell cancer.

The molecule, being developed by Hutchison China MediTech Limited and AstraZeneca, extended progression-free survival by about 5 months in these patients, compared with those whose tumors were not MET driven (6.2 vs. 1.4 months, respectively), reported Toni Choueiri, MD, and his colleagues (J Clin Oncol 2017. doi: 10.1200/JCO.2017.72.2967).

[email protected]

On Twitter @Alz_gal

Savolitinib, a highly selective inhibitor of c-Met receptor tyrosine kinase, improved progression-free survival in a small portion of patients with MET-driven advanced renal papillary cell cancer.

The molecule, being developed by Hutchison China MediTech Limited and AstraZeneca, extended progression-free survival by about 5 months in these patients, compared with those whose tumors were not MET driven (6.2 vs. 1.4 months, respectively), reported Toni Choueiri, MD, and his colleagues (J Clin Oncol 2017. doi: 10.1200/JCO.2017.72.2967).

[email protected]

On Twitter @Alz_gal

A retrospective cohort study of Clostridium difficile infection (CDI), the most common health care–associated infection, found that multiply recurrent CDI (mrCDI) is increasing in incidence, disproportionately to the overall increase in CDI.

Researchers from the University of Pennsylvania, Philadelphia, worked with a database of more than 38 million individuals with private health insurance between January 2001 and December 2012.

Cases of CDI and mrCDI in the study population were determined through ICD-9 diagnosis codes, and prescriptions for treatment. To meet the definition of mrCDI, there had to be at least three courses of treatment lasting at least 14 days each.

In the study population, 45,341 persons developed CDI, of whom 1,669 had mrCDI. The median age was 46 years, and 58.9% were female. Between 2001 and 2012, CDI incidence increased by 42.7% (P = .004), while mrCDI incidence increased by 188.8% (P less than .001).

With increases in CDI and mrCDI incidence, and with the effectiveness of standard antibiotic treatment decreasing with each recurrence, “demand for new antimicrobial therapies and FMT [fecal microbiota transplantation] can be expected to increase considerably in the coming years,” wrote Gene K. Ma, MD, and his coauthors.

As for FMT, the researchers noted that its likely greater demand in the future (as suggested by their study results) highlights the importance of establishing the long-term safety of the procedure (Ann Intern Med. 2017 Jul. doi: 10.7326/M16-2733).

[email protected]

A retrospective cohort study of Clostridium difficile infection (CDI), the most common health care–associated infection, found that multiply recurrent CDI (mrCDI) is increasing in incidence, disproportionately to the overall increase in CDI.

Researchers from the University of Pennsylvania, Philadelphia, worked with a database of more than 38 million individuals with private health insurance between January 2001 and December 2012.

Cases of CDI and mrCDI in the study population were determined through ICD-9 diagnosis codes, and prescriptions for treatment. To meet the definition of mrCDI, there had to be at least three courses of treatment lasting at least 14 days each.

In the study population, 45,341 persons developed CDI, of whom 1,669 had mrCDI. The median age was 46 years, and 58.9% were female. Between 2001 and 2012, CDI incidence increased by 42.7% (P = .004), while mrCDI incidence increased by 188.8% (P less than .001).

With increases in CDI and mrCDI incidence, and with the effectiveness of standard antibiotic treatment decreasing with each recurrence, “demand for new antimicrobial therapies and FMT [fecal microbiota transplantation] can be expected to increase considerably in the coming years,” wrote Gene K. Ma, MD, and his coauthors.

As for FMT, the researchers noted that its likely greater demand in the future (as suggested by their study results) highlights the importance of establishing the long-term safety of the procedure (Ann Intern Med. 2017 Jul. doi: 10.7326/M16-2733).

[email protected]

A retrospective cohort study of Clostridium difficile infection (CDI), the most common health care–associated infection, found that multiply recurrent CDI (mrCDI) is increasing in incidence, disproportionately to the overall increase in CDI.

Researchers from the University of Pennsylvania, Philadelphia, worked with a database of more than 38 million individuals with private health insurance between January 2001 and December 2012.

Cases of CDI and mrCDI in the study population were determined through ICD-9 diagnosis codes, and prescriptions for treatment. To meet the definition of mrCDI, there had to be at least three courses of treatment lasting at least 14 days each.

In the study population, 45,341 persons developed CDI, of whom 1,669 had mrCDI. The median age was 46 years, and 58.9% were female. Between 2001 and 2012, CDI incidence increased by 42.7% (P = .004), while mrCDI incidence increased by 188.8% (P less than .001).

With increases in CDI and mrCDI incidence, and with the effectiveness of standard antibiotic treatment decreasing with each recurrence, “demand for new antimicrobial therapies and FMT [fecal microbiota transplantation] can be expected to increase considerably in the coming years,” wrote Gene K. Ma, MD, and his coauthors.

As for FMT, the researchers noted that its likely greater demand in the future (as suggested by their study results) highlights the importance of establishing the long-term safety of the procedure (Ann Intern Med. 2017 Jul. doi: 10.7326/M16-2733).

[email protected]

Some things I’ve been thinking about:

• Physician well-being, morale, and burnout seem to be getting more attention in both the medical and the lay press.
• Leaders from 10 prestigious health systems and the CEO of the American Medical Association wrote a March 2017 post in the Health Affairs Blog titled “Physician Burnout is a Public Health Crisis: A Message To Our Fellow Health Care CEOs.”
• I’m now regularly hearing and reading mention of the “Quadruple Aim.” The “Triple Aim,” first described in 2008, is the pursuit of excellence in 1) patient experience – both quality of care and patient satisfaction; 2) population health; and 3) cost reduction. The November/December 2014 Annals of Family Medicine included an article recommending “that the Triple Aim be expanded to a Quadruple Aim by adding the goal of improving the work life of health care providers, including clinicians and staff.”¹
• The CEO at a community hospital near me chose to make addressing physician burnout one of his top priorities and tied success in the effort to his own compensation bonus.
• In the course of my consulting work with hospitalist groups across the country, I’ve noticed a meaningful increase in the number of our colleagues who seem deeply unhappy with their work and/or burned out. The “Hospitalist Morale Index” may be a worthwhile way for a group to conduct an assessment.²
• I’m concerned that many other hospital care givers, including RNs, social workers, and others, are experiencing levels of distress and/or burnout that might be similar to that of physicians. From where I sit, they seem to be getting less attention, and I can’t tell if that is just because I’m not as immersed in their world or if it reflects reality. It’s pretty disappointing if it’s the latter.

For the most part, I think the causes of hospitalist distress and burnout are very similar to that of doctors in other specialties, and interventions to address the problem can be similar across specialties. Yet, each specialty probably differs in ways that are important to keep in mind.

What to do?

An Internet search on physician burnout, or other terms related to well-being, will yield more articles with advice to address the problem than you’ll ever have time to read. Trying to read all of them would likely lead to burnout! I think interventions can be divided into two broad categories: organizational efforts and personal efforts.

Like the 10 CEOs mentioned above, health care leaders should acknowledge physician distress and burnout as a meaningful issue that can impede organizational performance and that investments to address it can have a meaningful return on investment. The Health Affairs Blog post listed 11 things the CEOs committed to doing. It’s a list anyone working on this issue should review.

Doctors at The Mayo Clinic have published a great deal of research on physician burnout. In the March 7, 2017, JAMA, (summarized in a YouTube video) they describe several worthwhile organizational changes, as well as some personal strategies.³ They wrote about their experiences with interventions such as a deliberate curriculum to train doctors in self-care (self-reflection, mindfulness, etc.) in a series of one-hour lectures over several months.⁴ In November 2016, they published a meta-analysis of interventions to address burnout.⁵

In total, all of the worthwhile recommendations to address burnout leave me feeling like they’re a lot of work, and any individual intervention may not be as helpful as hoped, so that the best way to approach this is with a collection of interventions. In many ways, it is similar to the problem of readmissions: There is a lot of research out there, it’s hard to prove that any single intervention really works, and success lies in implementing a broad set of interventions. And success doesn’t equate to eliminating readmissions, only reducing them.

Coda: Is a sabbatical uniquely valuable for hospitalists?

I think a sabbatical might be a good idea for hospitalists. It also seems practical for other doctors, such as radiologists, anesthesiologists, and ED doctors, who don’t have 1:1 continuity relationships with patients. However, it is problematic for primary care doctors and specialists who need to maintain continuity relationships with patients and referring doctors that could be disrupted by a lengthy absence.

I’m not sure a sabbatical would reduce burnout much on its own, but, if properly structured, it seems very likely to reduce staffing turnover, and the sabbatical could be spent in ways that help rejuvenate interest and satisfaction in our work rather than simply taking a long vacation to travel and play golf, etc. It should probably be at least 3 months and better if it lasts a year. A common arrangement is that a doctor becomes eligible for the sabbatical after 10 years and is paid half of her usual compensation while away. I’d like to see more hospitalist groups do this.

Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses. Write to [email protected].

References

1. Bodenheimer, T and Sninsky, C. From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. Ann Fam Med. Nov/Dec 2014.

2. Chandra, S et al. Introducing the Hospitalist Morale Index: A New Tool That May Be Relevant for Improving Provider Retention. JHM. June 2016.

3. Shanafelt, T, Dyrbye, L, West, C. Addressing Physician Burnout: The Way Forward. JAMA. March 7, 2017.

4. West, C et al. Intervention to Promote Physician Well-being, Job Satisfaction, and Professionalism: A Randomized Clinical Trial. JAMA Intern Med. 2014;174(4):527-33.

5. West, C et al. Interventions to prevent and reduce physician burnout: A systematic review and meta-analysis. The Lancet. Nov 5, 2016.

Some things I’ve been thinking about:

• Physician well-being, morale, and burnout seem to be getting more attention in both the medical and the lay press.
• Leaders from 10 prestigious health systems and the CEO of the American Medical Association wrote a March 2017 post in the Health Affairs Blog titled “Physician Burnout is a Public Health Crisis: A Message To Our Fellow Health Care CEOs.”
• I’m now regularly hearing and reading mention of the “Quadruple Aim.” The “Triple Aim,” first described in 2008, is the pursuit of excellence in 1) patient experience – both quality of care and patient satisfaction; 2) population health; and 3) cost reduction. The November/December 2014 Annals of Family Medicine included an article recommending “that the Triple Aim be expanded to a Quadruple Aim by adding the goal of improving the work life of health care providers, including clinicians and staff.”¹
• The CEO at a community hospital near me chose to make addressing physician burnout one of his top priorities and tied success in the effort to his own compensation bonus.
• In the course of my consulting work with hospitalist groups across the country, I’ve noticed a meaningful increase in the number of our colleagues who seem deeply unhappy with their work and/or burned out. The “Hospitalist Morale Index” may be a worthwhile way for a group to conduct an assessment.²
• I’m concerned that many other hospital care givers, including RNs, social workers, and others, are experiencing levels of distress and/or burnout that might be similar to that of physicians. From where I sit, they seem to be getting less attention, and I can’t tell if that is just because I’m not as immersed in their world or if it reflects reality. It’s pretty disappointing if it’s the latter.

For the most part, I think the causes of hospitalist distress and burnout are very similar to that of doctors in other specialties, and interventions to address the problem can be similar across specialties. Yet, each specialty probably differs in ways that are important to keep in mind.

What to do?

An Internet search on physician burnout, or other terms related to well-being, will yield more articles with advice to address the problem than you’ll ever have time to read. Trying to read all of them would likely lead to burnout! I think interventions can be divided into two broad categories: organizational efforts and personal efforts.

Like the 10 CEOs mentioned above, health care leaders should acknowledge physician distress and burnout as a meaningful issue that can impede organizational performance and that investments to address it can have a meaningful return on investment. The Health Affairs Blog post listed 11 things the CEOs committed to doing. It’s a list anyone working on this issue should review.

Doctors at The Mayo Clinic have published a great deal of research on physician burnout. In the March 7, 2017, JAMA, (summarized in a YouTube video) they describe several worthwhile organizational changes, as well as some personal strategies.³ They wrote about their experiences with interventions such as a deliberate curriculum to train doctors in self-care (self-reflection, mindfulness, etc.) in a series of one-hour lectures over several months.⁴ In November 2016, they published a meta-analysis of interventions to address burnout.⁵

In total, all of the worthwhile recommendations to address burnout leave me feeling like they’re a lot of work, and any individual intervention may not be as helpful as hoped, so that the best way to approach this is with a collection of interventions. In many ways, it is similar to the problem of readmissions: There is a lot of research out there, it’s hard to prove that any single intervention really works, and success lies in implementing a broad set of interventions. And success doesn’t equate to eliminating readmissions, only reducing them.

Coda: Is a sabbatical uniquely valuable for hospitalists?

I think a sabbatical might be a good idea for hospitalists. It also seems practical for other doctors, such as radiologists, anesthesiologists, and ED doctors, who don’t have 1:1 continuity relationships with patients. However, it is problematic for primary care doctors and specialists who need to maintain continuity relationships with patients and referring doctors that could be disrupted by a lengthy absence.

I’m not sure a sabbatical would reduce burnout much on its own, but, if properly structured, it seems very likely to reduce staffing turnover, and the sabbatical could be spent in ways that help rejuvenate interest and satisfaction in our work rather than simply taking a long vacation to travel and play golf, etc. It should probably be at least 3 months and better if it lasts a year. A common arrangement is that a doctor becomes eligible for the sabbatical after 10 years and is paid half of her usual compensation while away. I’d like to see more hospitalist groups do this.

Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses. Write to [email protected].

References

1. Bodenheimer, T and Sninsky, C. From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. Ann Fam Med. Nov/Dec 2014.

2. Chandra, S et al. Introducing the Hospitalist Morale Index: A New Tool That May Be Relevant for Improving Provider Retention. JHM. June 2016.

3. Shanafelt, T, Dyrbye, L, West, C. Addressing Physician Burnout: The Way Forward. JAMA. March 7, 2017.

4. West, C et al. Intervention to Promote Physician Well-being, Job Satisfaction, and Professionalism: A Randomized Clinical Trial. JAMA Intern Med. 2014;174(4):527-33.

5. West, C et al. Interventions to prevent and reduce physician burnout: A systematic review and meta-analysis. The Lancet. Nov 5, 2016.

Some things I’ve been thinking about:

• Physician well-being, morale, and burnout seem to be getting more attention in both the medical and the lay press.
• Leaders from 10 prestigious health systems and the CEO of the American Medical Association wrote a March 2017 post in the Health Affairs Blog titled “Physician Burnout is a Public Health Crisis: A Message To Our Fellow Health Care CEOs.”
• I’m now regularly hearing and reading mention of the “Quadruple Aim.” The “Triple Aim,” first described in 2008, is the pursuit of excellence in 1) patient experience – both quality of care and patient satisfaction; 2) population health; and 3) cost reduction. The November/December 2014 Annals of Family Medicine included an article recommending “that the Triple Aim be expanded to a Quadruple Aim by adding the goal of improving the work life of health care providers, including clinicians and staff.”¹
• The CEO at a community hospital near me chose to make addressing physician burnout one of his top priorities and tied success in the effort to his own compensation bonus.
• In the course of my consulting work with hospitalist groups across the country, I’ve noticed a meaningful increase in the number of our colleagues who seem deeply unhappy with their work and/or burned out. The “Hospitalist Morale Index” may be a worthwhile way for a group to conduct an assessment.²
• I’m concerned that many other hospital care givers, including RNs, social workers, and others, are experiencing levels of distress and/or burnout that might be similar to that of physicians. From where I sit, they seem to be getting less attention, and I can’t tell if that is just because I’m not as immersed in their world or if it reflects reality. It’s pretty disappointing if it’s the latter.

For the most part, I think the causes of hospitalist distress and burnout are very similar to that of doctors in other specialties, and interventions to address the problem can be similar across specialties. Yet, each specialty probably differs in ways that are important to keep in mind.

What to do?

An Internet search on physician burnout, or other terms related to well-being, will yield more articles with advice to address the problem than you’ll ever have time to read. Trying to read all of them would likely lead to burnout! I think interventions can be divided into two broad categories: organizational efforts and personal efforts.

Like the 10 CEOs mentioned above, health care leaders should acknowledge physician distress and burnout as a meaningful issue that can impede organizational performance and that investments to address it can have a meaningful return on investment. The Health Affairs Blog post listed 11 things the CEOs committed to doing. It’s a list anyone working on this issue should review.

Doctors at The Mayo Clinic have published a great deal of research on physician burnout. In the March 7, 2017, JAMA, (summarized in a YouTube video) they describe several worthwhile organizational changes, as well as some personal strategies.³ They wrote about their experiences with interventions such as a deliberate curriculum to train doctors in self-care (self-reflection, mindfulness, etc.) in a series of one-hour lectures over several months.⁴ In November 2016, they published a meta-analysis of interventions to address burnout.⁵

In total, all of the worthwhile recommendations to address burnout leave me feeling like they’re a lot of work, and any individual intervention may not be as helpful as hoped, so that the best way to approach this is with a collection of interventions. In many ways, it is similar to the problem of readmissions: There is a lot of research out there, it’s hard to prove that any single intervention really works, and success lies in implementing a broad set of interventions. And success doesn’t equate to eliminating readmissions, only reducing them.

Coda: Is a sabbatical uniquely valuable for hospitalists?

I think a sabbatical might be a good idea for hospitalists. It also seems practical for other doctors, such as radiologists, anesthesiologists, and ED doctors, who don’t have 1:1 continuity relationships with patients. However, it is problematic for primary care doctors and specialists who need to maintain continuity relationships with patients and referring doctors that could be disrupted by a lengthy absence.

I’m not sure a sabbatical would reduce burnout much on its own, but, if properly structured, it seems very likely to reduce staffing turnover, and the sabbatical could be spent in ways that help rejuvenate interest and satisfaction in our work rather than simply taking a long vacation to travel and play golf, etc. It should probably be at least 3 months and better if it lasts a year. A common arrangement is that a doctor becomes eligible for the sabbatical after 10 years and is paid half of her usual compensation while away. I’d like to see more hospitalist groups do this.

Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses. Write to [email protected].

References

1. Bodenheimer, T and Sninsky, C. From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. Ann Fam Med. Nov/Dec 2014.

2. Chandra, S et al. Introducing the Hospitalist Morale Index: A New Tool That May Be Relevant for Improving Provider Retention. JHM. June 2016.

3. Shanafelt, T, Dyrbye, L, West, C. Addressing Physician Burnout: The Way Forward. JAMA. March 7, 2017.

4. West, C et al. Intervention to Promote Physician Well-being, Job Satisfaction, and Professionalism: A Randomized Clinical Trial. JAMA Intern Med. 2014;174(4):527-33.

5. West, C et al. Interventions to prevent and reduce physician burnout: A systematic review and meta-analysis. The Lancet. Nov 5, 2016.

Taking into consideration the patient’s 2 predisposing risk factors (AIDS and dementia), the FP diagnosed seborrheic dermatitis. The FP also noted seborrheic dermatitis on the scalp. The scalp is frequently involved in cases of seborrheic dermatitis on the face.

Seborrheic dermatitis is a common, chronic, relapsing dermatitis affecting sebum-rich areas of the body. Its presentation may vary from mild erythema to greasy scale, and rarely, to erythroderma. Patients with seborrheic dermatitis may be colonized with certain species of lipophilic yeast of the genus Malassezia (also known as Pityrosporum). Malassezia, however, is considered normal skin flora because it is also found in unaffected people.

Some evidence suggests that an overgrowth of Malassezia may produce different irritants or metabolites on affected skin, leading to inflammation. It’s postulated that an overgrowth of Malassezia leads to the inflammatory dermatitis in seborrhea.

The goals of treatment are to diminish the fungal overgrowth and treat the inflammatory response. Thus, the mainstay of treatment is ongoing topical antifungals in shampoos and other preparations, along with a topical steroid to treat the inflammation.

The FP prescribed 2% ketoconazole shampoo to be used twice weekly and suggested that a selenium-containing shampoo be used on the other days of the week, as well as a 2.5% hydrocortisone cream to be applied twice daily to the face until the dermatitis resolved. The FP also prescribed a topical antifungal, cyclopirox 1% cream, to be applied twice daily on an ongoing basis to keep the Malassezia under control. At a one-month follow-up, the patient’s skin and scalp were cleared.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Hancock M, Bae Y, Usatine R. Seborrheic dermatitis. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 871-877.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

Taking into consideration the patient’s 2 predisposing risk factors (AIDS and dementia), the FP diagnosed seborrheic dermatitis. The FP also noted seborrheic dermatitis on the scalp. The scalp is frequently involved in cases of seborrheic dermatitis on the face.

Seborrheic dermatitis is a common, chronic, relapsing dermatitis affecting sebum-rich areas of the body. Its presentation may vary from mild erythema to greasy scale, and rarely, to erythroderma. Patients with seborrheic dermatitis may be colonized with certain species of lipophilic yeast of the genus Malassezia (also known as Pityrosporum). Malassezia, however, is considered normal skin flora because it is also found in unaffected people.

Some evidence suggests that an overgrowth of Malassezia may produce different irritants or metabolites on affected skin, leading to inflammation. It’s postulated that an overgrowth of Malassezia leads to the inflammatory dermatitis in seborrhea.

The goals of treatment are to diminish the fungal overgrowth and treat the inflammatory response. Thus, the mainstay of treatment is ongoing topical antifungals in shampoos and other preparations, along with a topical steroid to treat the inflammation.

The FP prescribed 2% ketoconazole shampoo to be used twice weekly and suggested that a selenium-containing shampoo be used on the other days of the week, as well as a 2.5% hydrocortisone cream to be applied twice daily to the face until the dermatitis resolved. The FP also prescribed a topical antifungal, cyclopirox 1% cream, to be applied twice daily on an ongoing basis to keep the Malassezia under control. At a one-month follow-up, the patient’s skin and scalp were cleared.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Hancock M, Bae Y, Usatine R. Seborrheic dermatitis. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 871-877.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

Taking into consideration the patient’s 2 predisposing risk factors (AIDS and dementia), the FP diagnosed seborrheic dermatitis. The FP also noted seborrheic dermatitis on the scalp. The scalp is frequently involved in cases of seborrheic dermatitis on the face.

Seborrheic dermatitis is a common, chronic, relapsing dermatitis affecting sebum-rich areas of the body. Its presentation may vary from mild erythema to greasy scale, and rarely, to erythroderma. Patients with seborrheic dermatitis may be colonized with certain species of lipophilic yeast of the genus Malassezia (also known as Pityrosporum). Malassezia, however, is considered normal skin flora because it is also found in unaffected people.

Some evidence suggests that an overgrowth of Malassezia may produce different irritants or metabolites on affected skin, leading to inflammation. It’s postulated that an overgrowth of Malassezia leads to the inflammatory dermatitis in seborrhea.

The goals of treatment are to diminish the fungal overgrowth and treat the inflammatory response. Thus, the mainstay of treatment is ongoing topical antifungals in shampoos and other preparations, along with a topical steroid to treat the inflammation.

The FP prescribed 2% ketoconazole shampoo to be used twice weekly and suggested that a selenium-containing shampoo be used on the other days of the week, as well as a 2.5% hydrocortisone cream to be applied twice daily to the face until the dermatitis resolved. The FP also prescribed a topical antifungal, cyclopirox 1% cream, to be applied twice daily on an ongoing basis to keep the Malassezia under control. At a one-month follow-up, the patient’s skin and scalp were cleared.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Hancock M, Bae Y, Usatine R. Seborrheic dermatitis. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 871-877.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

While low-dose aspirin has been shown for decades to decrease the risk of preterm preeclampsia, yet to be established are the optimal dose and time of day to administer aspirin; how preeclampsia risk is best assessed; and at what gestational week it is best to start aspirin.

New findings from a randomized, double-blind, placebo-controlled trial show that a daily 150-mg dose of aspirin, taken at night, significantly reduced incidence of preterm preeclampsia in women identified as being at high risk in the first trimester (N Engl J Med. 2017 June 28. doi: 10.1056/NEJMoa1704559).

copyright Darren Hester/Fotolia.com

copyright Sohel_Parvez_Haque/Thinkstock

While low-dose aspirin has been shown for decades to decrease the risk of preterm preeclampsia, yet to be established are the optimal dose and time of day to administer aspirin; how preeclampsia risk is best assessed; and at what gestational week it is best to start aspirin.

New findings from a randomized, double-blind, placebo-controlled trial show that a daily 150-mg dose of aspirin, taken at night, significantly reduced incidence of preterm preeclampsia in women identified as being at high risk in the first trimester (N Engl J Med. 2017 June 28. doi: 10.1056/NEJMoa1704559).

copyright Darren Hester/Fotolia.com

copyright Sohel_Parvez_Haque/Thinkstock

While low-dose aspirin has been shown for decades to decrease the risk of preterm preeclampsia, yet to be established are the optimal dose and time of day to administer aspirin; how preeclampsia risk is best assessed; and at what gestational week it is best to start aspirin.

New findings from a randomized, double-blind, placebo-controlled trial show that a daily 150-mg dose of aspirin, taken at night, significantly reduced incidence of preterm preeclampsia in women identified as being at high risk in the first trimester (N Engl J Med. 2017 June 28. doi: 10.1056/NEJMoa1704559).

copyright Darren Hester/Fotolia.com

copyright Sohel_Parvez_Haque/Thinkstock