Selection from the latest research impacting C-L Psychiatry
Opioids: Does Tapering Make Matters Worse Over the Following Two Years?
Research: Long-term Risk of Overdose or Mental Health Crisis After Opioid Dose Tapering
Author: Joshua Fenton, MD, MPH, et al.
Abstract: Is opioid dose tapering associated with reduced longer-term risks of overdose, withdrawal, or mental health crisis in patients who have been prescribed long-term opioids?
In this study of 19,377 patients, in both pre- and post-taper periods, the adjusted incidence rate ratios were 1.57 for overdose-withdrawal and 1.52 for a mental health crisis. Both were significant—suggesting that opioid dose tapering is associated with increased risks of overdose-withdrawal and mental health crisis that persist for up to two years after taper initiation.
“Given the observational study design, we cannot infer a causal connection between tapering and long-term risks of these events,” say the authors. “Nevertheless, our findings support guidelines advising careful monitoring and psychosocial support for patients undergoing opioid dose reduction and suggest that this support continue for at least two years after taper initiation, particularly among patients who were prescribed higher baseline doses.”
Over the past two decades, millions of Americans have been prescribed opioids to manage chronic pain. Although supported by limited evidence, medical educators encouraged the practice of initiating and escalating opioid dosages to address uncontrolled chronic pain, and drug companies aggressively marketed opioids, leading to increases in opioid prescriptions and the number of patients prescribed long-term opioid therapy (LTOT).
As opioid overdose deaths subsequently increased, state and regional policies have encouraged opioid deprescribing and dose reduction, or tapering, among patients prescribed LTOT. The frequency of tapering among patients increased substantially after publication of a Centers for Disease Control and Prevention (CDC) opioid prescribing guideline in 2016.
According to a US Department of Health and Human Services guideline, dose tapering in patients prescribed LTOT should be considered when the risks of dose continuation outweigh the benefits in terms of pain relief and functional improvement.
A dose-response association has been observed between long-term opioids and overdose risk, prompting the CDC to caution clinicians about escalating daily opioid doses greater than 50 morphine milligram equivalents. On the other hand, say the authors, opioid tapering may also confer patient risks, including precipitated withdrawal, worsening pain, use of illicit opioids, depression, anxiety, and suicide.
Importance: Research to date documenting tapering risks has generally examined periods near the time of initial dose reduction or discontinuation. This research, among patients prescribed long-term opioid therapy, highlights risks of substance misuse, overdose, and mental health crisis during the two years from initiation—when follow-up health care is needed. However, lowering opioid dosage can reduce risks of adverse events in the longer term.
Availability: Published by JAMA Network
Earlier Psychiatric Consultation Results in Fewer Readmissions
Research: Early Liaison Psychiatry Consultations and General Hospital Readmission: A retrospective cohort study
Author: Victoria Lanvin, et al.
Abstract: In this retrospective study conducted in a general Parisian hospital, earlier psychiatric consultation was associated with fewer 30-day and seven-day readmissions.
“Interventional studies are needed to show that proactive C-L Psychiatry teams could help general hospitals to improve quality of care and make significant economic savings,” say the authors.
All adult inpatients referred for the first time to C-L Psychiatry from January 2008 to December 2016 were included in the study.
The objective was to determine whether the timing of psychiatric consultations is associated with 30-day and seven-day readmissions.
A total of 4,498 inpatients (51.1% women) were referred to C-L Psychiatry. Adjusting for age, sex, place of residence, year of admission, type of ward, psychiatric diagnosis and disease severity, later consultation was associated with higher 30-day and seven-day readmission rates.
Importance: Readmissions are under growing scrutiny as an indicator of quality of care as much as a potential source of savings. Patients with comorbid psychiatric conditions are more likely to be readmitted, so C-L Psychiatry may play a role in lowering readmission rates.
Availability: Published in General Hospital Psychiatry
Ramelteon Ineffective in Reducing Delirium Incidence
Research: Prophylactic Use of Ramelteon for Delirium in Hospitalized Patients: A systematic review and meta-analyses
Author: Vanessa Dang, MD, et al.
Abstract: This systematic review and meta-analyses of five randomized placebo-controlled trials, which included data from recent studies, did NOT find that ramelteon was effective in reducing delirium incidence in adult hospitalized patients.
The review follows smaller studies, case reports, and randomized placebo-controlled trials and previous meta-analyses that have shown that ramelteon, a melatonin agonist, may reduce the risk of developing delirium.
This latest research assessed current evidence by including data from larger (> 100 subjects) and more recent trials since the most recent meta-analyses were published in 2019.
“Current evidence suggests that ramelteon is ineffective as a prophylactic drug in reducing the incidence of delirium in hospitalized patients,” say the authors.
Importance: Delirium is associated with longer lengths of hospitalization, higher rates of mortality, and subsequent cognitive decline over a 12-month period. The financial burden of delirium in postoperative elderly patients can reach as high as an additional $44,000 per-patient-per-year.
Management of delirium includes identifying and correcting the underlying etiology, ameliorating sleep-wake disturbances, and managing behavioral manifestations, including agitation. Both pharmacologic and non-pharmacologic interventions are used, although not consistently in all patients, such as reducing use of medications capable of inducing or worsening delirium, re-orientation via verbal and visual cues (e.g., with nursing support, clocks, calendars, bright light exposure, and the use of family photos and/or visits), optimizing hearing and vision (e.g., with hearing aids, ear plugs, and glasses), and ensuring adequate hydration and nutrition.
A recent Cochrane review of non-pharmacologic interventions for delirium, however, found low quality evidence in support of probable reduction of delirium incidence, and possible reduction of hospital length of stay and delirium duration. Current pharmacologic interventions do not appear to shorten the duration of delirium or reduce its sequalae.
Ramelteon is used as an agent to prevent the onset of delirium—but, it seems, that too has little effect.
Availability: Pre-publication in the Journal of the Academy of Consultation-Liaison Psychiatry (JACLP)
Why We Should Shift Government Dollars Outside the Health Care System
Research: The Role of Health Care Systems in Bolstering the Social Safety Net to Address Health Inequities in the Wake of the COVID-19 Pandemic
Author: Rita Hamad, MD, et al.
Abstract: For hundreds of years, US health has been characterized by vast inequities in health achievement across groups. For example, at least since the 1800s, disparities in tuberculosis were known to be associated with overcrowded housing, poor ventilation, and malnutrition. The earliest evaluations of the Framingham Heart Study documented disparities in cardiovascular disease by educational attainment.
Today, advantaged groups in the US have a 20-year greater life expectancy than disadvantaged groups, while racial and ethnic minority populations and those with lower income and education (among other types of disadvantage) have a greater burden of disease than more advantaged groups.
As the scholarship examining these health outcomes has evolved, it has become clearer that these inequities are caused by foundational social and structural forces, stemming from historical structural conditions that carry to the present day.
Despite this understanding, the US is unique among high-income nations in approaching disease as a problem to be solved almost exclusively by health care systems. This has resulted in an underinvestment in resources to address social and structural determinants such as poverty and housing, such that the US spends more on health care than any high-income country but has the least to show for it in terms of health.
Not only does the US have worse outcomes on average than other high-income nations, but also greater inequities between those of higher and lower socioeconomic position.
Historically, the national health care conversation has sidestepped addressing the broader social conditions in which patients live, seeing these conditions as outside the remit of what health care systems can achieve. In the past two years, however, the COVID-19 pandemic has further brought to light and exacerbated socioeconomic and racial disparities in disease, pushing organizational leaders in the health care system and academic medicine to recognize that the usual approaches need to change, and greater attention must be paid to social and structural determinants.
Detailing proposals to address this phenomenon, the authors say: “Ultimately, the most effective of these proposed solutions may require health care systems to encourage the shifting of dollars to government budgets outside of the health care system. This would require great humility from health care systems, recognizing that a society in which health care is less needed because of a shift toward a more holistic view of health is a better society in which to live. Such a view would also recognize that overall health and health inequities are inseparable from the social and structural factors that have been recognized for decades but in which the US has long underinvested.”
Importance: Nearly 20% of people in the US do not see a physician in a given year, and it may not be feasible for clinicians to address social needs in their limited time during health care visits. Consequently, and particularly for larger health care systems and academic medical centers that are anchor institutions in their communities, engagement with nonprofit organizations is needed, say the authors, to invest in communities at a population level rather than on an individual basis.
Availability: Published by JAMA Network
What We Can Offer to Gunshot Injury Victims
Research: Consultation-Liaison Case Conference: Psychiatric Evaluation and Management Following Gunshot Injury
Author: Rafael Tamargo, MD, et al.
Abstract: The authors describe the case of a 23-year-old female presenting to C-L Psychiatry after admission for multiple gunshot wounds. Experts in C-L Psychiatry provide guidance for this commonly encountered clinical case based on their experience and a review of available literature.
Key teaching topics include risk factors for gun violence victimization, assessment of psychiatric diagnoses associated with gunshot injury, and management challenges including access to psychiatric care.
“Specifically,” say the authors, “we highlight the high prevalence of trauma-related disorders, substance use disorders, and functional impairment after gunshot injury. We also provide practical guidance on issues of lethality assessment, trauma-informed care, psychiatric management, and community resources that support recovery.”
Importance (from Priya Gopalan, MD, FACLP): “C-L psychiatrists can advocate for what remains a highly marginalized group of patients in medicine. Limitations placed on the study of firearm injury provide significant barriers to the care of patients with gun violence injury, but research on the subject is growing. Social determinants of health play a significant role in mediating gun violence, and systemic racism likely precludes additional funding or attention to this important area of work. C-L psychiatrists must utilize trauma-informed care principles.”
Availability: Pre-publication in the Journal of the Academy of Consultation Liaison Psychiatry (JACLP)