Sublingual Buprenorphine/Naloxone and Multi-Modal Management for High-Risk Chronic Pain Patients

Patients with chronic pain managed with opioid medications are at high risk for opioid overuse or misuse. West Virginia University (WVU) established a High-Risk Pain Clinic to use sublingual buprenorphine/naloxone (bup/nal) plus a multimodal approach to help chronic pain patients with history of Substance Use Disorder (SUD) or aberrant drug-related behavior. The objective of this study was to report overall retention rates and indicators of efficacy in pain control from approximately six years of High-Risk Pain Clinic data. A retrospective chart review was conducted for a total of 78 patients who enrolled in the High-Risk Pain Clinic between 2014 and 2020. Data gathered include psychiatric diagnoses, prescribed medications, pain score, buprenorphine/naloxone dosing, time in clinic, and reason for dismissal. A linear mixed effects model was used to assess the pain score from the Defense and Veterans Pain Rating Scale (DVPRS) and daily bup/nal dose across time. The overall retention of the High-Risk Pain Clinic was 41%. The mean pain score demonstrated a significant downward trend across treatment time (p \u3c 0.001), while the opposite trend was seen with buprenorphine dose (p \u3c 0.001). With the benefit of six years of observation, this study supports buprenorphine/naloxone as a safe and efficacious component of comprehensive chronic pain treatment in patients with SUD or high-risk of opioid overuse or misuse

Amnesia Associated with Bilateral Hippocampal and Bilateral Basal Ganglia Lesions in Anoxia with Stimulant Use

We report a case of a 55-year-old man with ischemic lesions of the bilateral hippocampus and bilateral basal ganglia following a myocardial infarction during an episode of multiple drug use with subsequent anoxia requiring resuscitation. He presented for a neuropsychological evaluation with an anterograde amnesia for both explicit and procedural memory. There are two main points to this case, the unique aspects of the bilateral multifocal lesions and the functional, cognitive impact of these lesions. We hypothesize that his rare focal bilateral lesions of both the hippocampus and basal ganglia are a result of anoxia acting in synergy with his stimulant drug use (cocaine and/or 3,4-methylenedioxy-methamphetamine). Second, his unique lesions produced an explicit and implicit/procedural anterograde amnesia

Off-Label Use of Transmucosal Ketamine as a Rapidacting Antidepressant: A Retrospective Chart Review

Objective: This study evaluated the effectiveness and safety of subanesthetic doses of ketamine using an off-label, transmucosal administration route in patients with treatment-resistant depression. Methods: A retrospective chart review was conducted to identify patients who met the inclusion criteria for treatment-resistant major depressive disorder. Seventeen such patients who received subanesthetic doses of ketamine were included. Patient demographics, efficacy (drug refill, clinician notes), side effects, and concurrent medications were assessed. Results: Benefit from low-dose transmucosal ketamine was noted in 76% of subjects (average age 48 years, 88% female), with a dose duration lasting 7–14 days. No notable side effects were noted. The most common classes of concurrent medications to which ketamine was added were serotonin–norepinephrine reuptake inhibitors (59%), stimulants (47%), folate replacement (47%), and benzodiazepines (47%). Conclusion: Our results provide preliminary evidence of the effectiveness and safety of lowdose transmucosal ketamine in treatment-resistant patients. A controlled, prospective pilot study is warranted to validate these findings

Off-label use of transmucosal ketamine as a rapid-acting antidepressant: a retrospective chart review

Objective: This study evaluated the effectiveness and safety of subanesthetic doses of ketamine using an off-label, transmucosal administration route in patients with treatment-resistant depression. Methods: A retrospective chart review was conducted to identify patients who met the inclusion criteria for treatment-resistant major depressive disorder. Seventeen such patients who received subanesthetic doses of ketamine were included. Patient demographics, efficacy (drug refill, clinician notes), side effects, and concurrent medications were assessed. Results: Benefit from low-dose transmucosal ketamine was noted in 76% of subjects (average age 48 years, 88% female), with a dose duration lasting 7–14 days. No notable side effects were noted. The most common classes of concurrent medications to which ketamine was added were serotonin–norepinephrine reuptake inhibitors (59%), stimulants (47%), folate replacement (47%), and benzodiazepines (47%). Conclusion: Our results provide preliminary evidence of the effectiveness and safety of lowdose transmucosal ketamine in treatment-resistant patients. A controlled, prospective pilot study is warranted to validate these findings

Treating women with opioid use disorder during pregnancy in Appalachia: Initial neonatal outcomes following buprenorphine + naloxone exposure

Background and Objectives—Rising concerns regarding diversion and misuse of monobuprenorphine for treatment of pregnant women with opioid use disorders have sparked interest in the use of buprenorphine +naloxone to reduce misuse and diversion rates. Examined the relationship of prenatal buprenorphine +naloxone exposure to neonatal outcomes. Methods—This is a retrospective chart review of 26 mother infant dyads in comprehensive medication-assisted treatment with buprenorphine +naloxone during pregnancy. Results—All neonatal birth outcome parameters were within normal ranges, albeit on the lower side of normal for gestational age and birth weight. Only 19% of neonates required morphine pharmacology for NAS. Conclusions—Use of buprenorphine +naloxone shows relative safety in pregnancy. Scientific Significance—These findings can help better guide prescribing practices for pregnant patients at risk for misuse or diversion of buprenorphine

Measurement-based care training curriculum in psychiatry residency programs: I: Description of the curriculum and demonstration of implementation.

BACKGROUND: Recent literature shows that most practicing psychiatrists do not receive training in measurement-based care (MBC). Among the primary barriers to MBC implementation are the lack of formal training and curriculums. We present the first comprehensive MBC curriculum for use in adult psychiatric practice, and describe how the curriculum is adapted and implemented in psychiatry residency training programs. METHODS: The Standard for Clinicians\u27 Interview in Psychiatry (SCIP) was developed as a measurement-based care tool for clinicians\u27 use. The SCIP is the only instrument that includes 18 reliable and validated clinician-rated scales covering most adult psychiatric disorders. The SCIP has simple, unified rules of measurement that apply to the 18 scales. The MBC curriculum includes 2 instruction manuals, 4 didactic lectures, and 12 videotaped interviews. We describe the annual learning and implementation of MBC curriculum in residency programs. RESULTS: The curriculum implementation at West Virginia University and Delaware Psychiatric Center began in 2019 and is ongoing. We present 3 case demonstrations of the implementation of MBC in clinical settings. CONCLUSIONS: Comprehensive implementation of MBC curriculum in residency programs has the potential to facilitate research and create a culture of MBC in future generations of psychiatrists