Maintaining abstinence through the opioid withdrawal period is a substantial barrier to treatment for patients with opioid use disorder. The alpha-2 agonist lofexidine has demonstrated efficacy and safety in clinical trials, but pragmatic studies describing its use in clinical practice are lacking. This case series describes the use of lofexidine for opioid withdrawal symptoms in an inpatient addiction treatment facility. Seventeen patients receiving at least 1 dose of lofexidine during inpatient treatment for opioid withdrawal were included in this study. A retrospective chart review was conducted for clinical, subjective, and objective data. Adverse events, total daily dose, clinical opioid withdrawal scale (COWS) scores, vital signs, and reasons for early discontinuation of lofexidine are reported. Patients treated with lofexidine experienced mild withdrawal symptoms throughout treatment. Most patients (65%) experienced a decrease in their average daily COWS scores from intake to discharge. Two patients (12%) left treatment against medical advice, and 5 patients (29%) discontinued treatment prior to day 7 due to resolution of symptoms. Average daily blood pressure readings remained stable, and daily average heart rate decreased over time. Lofexidine can be successfully incorporated into a conventional withdrawal management protocol. The cost of lofexidine and its recent introduction to the market remain barriers to accessibility in the United States. Studies evaluating patient-reported outcomes as well as direct comparisons with other alpha-2 agonists are needed to inform optimal clinical use of lofexidine.Abstract
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Many psychiatric, long-acting injectable (LAI) medications are available, and each product comes with its own unique challenges. Improper administration can lead to pain, decreased efficacy, and loss of trust in the patient-provider relationship. This study was conducted to determine if a pharmacist-led, 1-hour training was successful in increasing psychiatric LAI medication knowledge through a pretest and posttest. The study also assessed staff satisfaction, confidence, and relevance to practice through a feedback questionnaire. Four 1-hour live trainings took place in November 2019. Thirty-five nurses and 8 medical assistants attended 1 of the trainings. A pretest and posttest was administered to determine the training's efficacy, and then a final assessment was administered 4 to 6 weeks after the training. Additionally, a participant feedback questionnaire was given to determine the perceived benefits of the training. The primary outcome was to compare pretest and posttest scores. The pretest average score was 67%, the posttest average score was 97%, and the average score 4 to 6 weeks after the training was 97%. The secondary outcome was to review feedback questionnaires to determine the perceived benefit and effectiveness of the training. Ninety-five percent of participants selected that they were very satisfied with the training, 88% selected they would definitely use the information presented in their work, and 93% selected that they had a lot of confidence in the topic after the training. A psychiatric LAI medication training administered to nursing staff and medical assistants improved knowledge scores and was perceived as being useful.Abstract
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Opioid overdose is highly prevalent among veterans. The Opioid Safety Initiative (OSI) and Centers for Disease Control and Prevention (CDC) issued prescribing guidelines for managing chronic pain. The purpose of this study was to investigate the impact of the 2013 OSI and 2016 CDC guidelines on opioid-prescribing trends in the emergency department and dental clinic within the Veterans Affairs Salt Lake City Health Care System. In this retrospective, cohort study, opioid prescriptions were queried from January 1, 2013, through March 31, 2017, and separated into 3 groups: pre-OSI, post-OSI, and post-CDC. The primary outcome was to determine a decrease in opioid prescribing. Secondary outcomes included changes in concurrent benzodiazepine and naloxone prescriptions and prescriber status. Analysis of variance was used to determine a difference between study periods. There were 7339 opioid prescriptions identified. A statistically significant difference was found between the 3 groups in average number of opioids prescribed, morphine milligram equivalents per prescription, days' supplied, and medication quantity per prescription (P < .01). There was no significant difference between the 3 groups regarding morphine milligram equivalents per day (P = .24). Benzodiazepine prescribing remained the same. Concurrent naloxone prescriptions increased. The results demonstrate that days' supply, quantity, and morphine milligram equivalent per day in the post-CDC group were consistent with guideline recommendations. Concurrent naloxone prescribing increased throughout all time periods. Implementation of guidelines impacted opioid-prescribing trends, ultimately lessening potential for misuse and abuse. However, there is still need for improvement with reducing concurrent benzodiazepine prescriptions.Abstract
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Antipsychotics are commonly used to treat psychotic symptoms and severe mental illnesses. Treatment guidelines recommend antipsychotics be titrated quickly to therapeutic effect in the acute setting but acknowledge that determining the optimal dose is complicated by a delay between treatment initiation and therapeutic response. The purpose of this study was to evaluate antipsychotic titration patterns in an inpatient psychiatric hospital. This study is a retrospective chart review of adult patients admitted to a teaching hospital and initiated on an antipsychotic for treatment of psychosis between January and December 2018. Patients were excluded if they had substance-induced psychosis, delirium, were prescribed >1 antipsychotic, or had no antipsychotic dose changes. The primary outcome was the average titration rate of the newly initiated antipsychotic. Secondary outcomes included differences in titration rate between involuntary and voluntary admissions and other antipsychotic characteristics. Of 149 patients included, the majority had a primary diagnosis of schizophrenia. Antipsychotics were titrated on average every 2 days regardless of admission type. Eighteen percent of patients were titrated to guideline-recommended maximum doses, and it took, on average, 3 days for patients to reach their final dose during hospitalization. Average length of stay was 9 days, and 43.6% of patients were readmitted within 1 year. Antipsychotics are titrated rapidly in the inpatient setting despite a lack of evidence regarding the impact of titration rate on clinical outcomes. Further studies comparing slow versus rapid titration strategies are needed to elucidate the impact of this on patient outcomes.Abstract
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Up to a third of patients seen by home-based primary care (HBPC) providers suffer from mental health problems. These conditions tend to be underrecognized and undertreated for patients receiving HBPC. The purpose of this scoping review is to evaluate current psychotropic use patterns for patients receiving HBPC services. The following databases were searched for articles reporting on studies conducted in HBPC settings that identified patterns of psychotropic medication prescription and use: Ovid/MEDLINE, Cochrane Library, Embase, Scopus, Web of Science, CINAHL, and PsycInfo. Studies that only reported on patients in hospice, rehabilitation, or long-term care facilities were excluded as were drug trials, opinion pieces, case studies, case series, meeting abstracts, and other reviews. Of 4542 articles initially identified, 74 were selected for full text screening. Of these, only 2 met full criteria and were included in the data extraction and analysis. In 1 study, 41.7% patients enrolled were prescribed an antidepressant, 21.5% were prescribed an antipsychotic (12.7% prescribed both), and 5% to 7% of patients were prescribed benzodiazepines/hypnotics. In the other study, 9% of patients were prescribed an antipsychotic, and 7% were prescribed a benzodiazepine. There are extremely limited data on psychotropic prescribing patterns in HBPC in published studies. Because a significant number of HBPC patients suffer from mental health conditions in addition to other chronic illnesses, treatment can be complex. More studies are needed on current psychotropic prescribing trends to help determine what type of interventions are needed to promote patient safety in this setting.Abstract
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Olanzapine is a second-generation antipsychotic (SGA) that has been shown to promote disease remission in persons with treatment-resistant depression when used in combination with fluoxetine. However, tolerability of treatment augmentation with SGAs may be limited because of common adverse effects, such as weight gain, hypertriglyceridemia, and elevated glucose. Data exist pertaining to rare localized edematous reactions or angioedema with use of SGAs, but diffuse whole-body edema has yet to be documented. A 47-year-old white female with treatment-resistant depression presented with a 5-day history of weight gain and swelling of her torso and extremities. Five days prior, she had initiated olanzapine/fluoxetine 6/50 mg daily following failure of fluoxetine 40 mg daily monotherapy. The patient was noted to have gained 3.6 kg since her last appointment and exhibited profuse pitting edema on her forearms, lower limbs, hands, and chest. Olanzapine/fluoxetine was discontinued and the patient was prescribed a 3-day course of a loop diuretic for symptomatic management. A follow-up visit 5 days later noted complete resolution of symptoms. Because of the temporal relationship of symptoms with initiation of olanzapine, we recommend monitoring for edema with initiation and/or titration of therapy.Abstract
Pharmacist-psychiatrist collaborative clinic models in specialty mental health clinics are limited, and there has been only 1 report of a clinic focused on adult attention-deficit hyperactivity disorder (ADHD). In this article, we describe the successful implementation of a pharmacist-psychiatrist collaborative practice agreement in an adult ADHD clinic at an academic medical center. Adult patients diagnosed with ADHD after a comprehensive assessment, including a full neuropsychological evaluation, were enrolled in the collaborative treatment clinic. The collaboration was a partnership between a psychiatry department and a school of pharmacy at a public university. We report the details of 58 patients and 774 patient encounters at the collaborative pharmacist-psychiatrist practice from March 2015 through June 2018. The visits were billed using traditional medical billing codes for follow-up visits. Pharmacist practice opportunities included psychiatric evaluation, medication management, counseling, and referral to auxiliary services. Challenges to the clinic's success included limited pharmacist time, prescriptive authority, and reimbursement for services from payors. A collaborative practice model targeted at adult ADHD patients may be a unique clinic setting for psychiatric pharmacists.Abstract
The objective of this data analysis was to assess the impact of the addition of a clinical psychiatric pharmacist to a community hospital inpatient psychiatric consult liaison team. Consult liaison psychiatry deals with medically ill patients in general hospital settings and involves the timely recognition and treatment of mental health conditions while coordinating with other medical providers. Each patient consulted to the psychiatry team was reviewed by the clinical pharmacist. Recommendations made by the clinical pharmacist were tracked over a 9-month period. During that time frame, 596 opportunities for intervention were identified. The largest proportion of identified opportunities for intervention were related to admission medication reconciliation, equating to roughly 30%. Optimization of safe medication use had the second largest number of opportunities for intervention at approximately 27%. Additional data, such as time spent on patient care, reason for consultation, and number of accepted recommendations based on medication class/type of intervention, were collected.Abstract
According to the World Health Organization, prior to the pandemic, 50% of people with chronic disease in developed countries did not take their prescribed medication.1 Two studies by Mishra et al2,3 found that patients diagnosed with bipolar disorder and schizophrenia receiving pharmacist-led education had improved medication adherence and quality of life. Patient medication education groups (PMEGs) as defined by the College of Psychiatric and Neurologic Pharmacists allow patients the unique opportunity to interact with individuals who may share similar life experiences during the educational session.4 The PMEGs have been shownDear Editor: