Opioid Prescribing Rate for Nonoperative Distal Radius Fractures and Clinician Response to a Clinical Decision Support Alert.

BACKGROUND: Opioids are commonly prescribed for the management of acute orthopedic trauma pain, including nonoperative distal radius fractures. OBJECTIVES: This prospective study aimed to determine if a clinical decision support intervention influenced prescribing decisions for patients with known risk factors. We sought to quantify frequency of opioid prescriptions for acute nonoperative distal radius fractures treated. METHODS: We performed a prospective study at one large health care system. Utilizing umbrella code S52.5, we identified all distal radius fractures treated nonoperatively, and the encounters were merged with the Prescription Reporting with Immediate Medication Mapping (PRIMUM) database to identify encounters with opioid prescriptions and patients with risk factors for opioid use disorder. We used multivariable logistic regression to determine patient characteristics associated with the prescription of an opioid. Among encounters that triggered the PRIMUM alert, we calculated the percentage of encounters where the PRIMUM alert influenced the prescribing decision. RESULTS: Of 2984 encounters, 1244 (41.7%) included an opioid prescription. Age increment is a significant factor to more likely receive opioid prescriptions (p < 0.0001) after adjusting for other factors. Among encounters where the physician received an alert, those that triggered the alert for early refill were more likely to influence physicians' opioid prescribing when compared with other risk factors (p = 0.0088). CONCLUSION: Over 90% of patients (106/118) continued to receive an opioid medication despite having a known risk factor for abuse. Additionally, we found older patients were more likely to be prescribed opioids for nonoperatively managed distal radius fractures.

Adherence to legislation limiting opioid prescription duration following musculoskeletal injury.

OBJECTIVES: North Carolina had implemented legislation (Strengthen Opioid Misuse Prevention (STOP) Act) limiting opioid prescriptions to 5 days for acute pain and 7 days for post-operative pain. This study aimed to identify patient, prescriber, and facility characteristics associated with STOP Act adherence for patients with acute or post-surgical musculoskeletal (MSK) conditions. DESIGN: A three-level hierarchical logistic regression model was used to predict odds of adherence with STOP Act duration limits, accounting for fixed and random effects at the patient, prescriber, and facility levels. SETTING: A large healthcare system in North Carolina. PATIENTS AND PARTICIPANTS: Patients (N = 6,849) presenting from 2018 to 2020 with a diagnosis of an acute MSK injury. INTERVENTIONS: The STOP Act limited the duration of opioid prescriptions in North Carolina. MAIN OUTCOME MEASURE: Prescriptions adhering to the STOP Act duration limits of 5 days (nonoperative) or 7 days (operative) were the primary outcome. RESULTS: Opioids were compliant with STOP Act duration limits in 69.3 percent of encounters, with 33 percent of variation accounted for by clinician and 29 percent by facility. Patients prescribed >1 opioid (odds ratio (OR) 0.46, 95 percent confidence interval (CI): 0.36, 0.58) had reduced odds of a compliant prescription; surgical patients had increased odds of a compliant prescription (outpatient surgery: OR 5.89, 95 percent CI: 2.43-14.29; inpatient surgery: OR 7.71, 95 percent CI: 3.04-19.56). Primary care sports medicine clinicians adhered to legislation less frequently than orthopedic surgeons (OR 0.38, 95 percent CI: 0.15, 0.97). CONCLUSIONS: Most prescriptions adhered to STOP Act legislation. Tailored interventions to improve adherence among targeted groups of prescribers, eg, those treating nonoperative injuries and sport medicine clinicians, could be useful.

Safe Spaces: Mitigating Potential Aggression in Acute Care Psychiatry.

Awareness of potential aggression and violence is crucial when treating patients experiencing mental health crises in psychiatric emergency and inpatient settings. To provide a practical overview for health care workers in acute care psychiatry, the authors summarize relevant literature and clinical considerations on this important topic. Clinical contexts of violence in these settings, possible impact on patients and staff, and approaches to mitigating risk are reviewed. Considerations for early identification of at-risk patients and situations, and nonpharmacological and pharmacological interventions, are highlighted. The authors conclude with key points and future scholarly and practical directions that may further assist those entrusted with providing psychiatric care in these situations. Although working in these often high-paced, high-pressured settings can be challenging, effective violence-management strategies and tools can help staff optimize the focus on patient care while maintaining safety, their own well-being, and overall workplace satisfaction.

Impact of an opioid prescribing alert system on patients with posttraumatic stress disorder.

BACKGROUND AND OBJECTIVES: Posttraumatic stress disorder (PTSD) is associated with higher rates of chronic pain and increased risk of developing Opioid use disorder. This paper evaluates the impact of PRIMUM, an electronic health record-embedded (EHR) clinical decision support intervention on opioid prescribing patterns for patients with diagnosis of PTSD. METHODS: Inpatient, emergency department (ED), urgent care, and outpatient encounters with ICD-10 codes F43.1 (PTSD), F43.10 (PTSD, unspecified), F43.11 (PTSD, acute), and F43.12 (PTSD, chronic) at Atrium Health between 1/1/2016 and 12/29/2018 were included in the study. RESULTS: A total of 3121 patients with a diagnosis of PTSD were seen in 37,443 encounters during the study period. Ten percent (n = 3761) of the encounters resulted in prescriptions for opioids and PRIMUM alerts were triggered in 1488 of these encounters. These alerts resulted in "decision influenced" for 17% of patients (n = 255) or no prescriptions for opioids or benzodiazepines for 5.8% (n = 86). The majority of the prescriptions were below 50 Morphine milligram equivalents (MME)/day, but there were 570 (15.5%) prescriptions for doses of 50-90 MME and 721 (19.6%) prescriptions for >90 MME/day. DISCUSSION AND CONCLUSION: The PRIMUM alert system helps improve patient safety. PRIMUM affected clinician decisions 17% of the time, and the effect was greater in patients with opioid overdose history and those presenting for early refills. SCIENTIFIC SIGNIFICANCE: The effectiveness of clinical support interventions for opioid prescribing for patients with PTSD has not been documented previously. Our findings provide novel evidence that the EHR can be used to improve patient safety among patients with PTSD in the context of substance use.

Screening of Acute Traumatic Stress Disorder and Posttraumatic Stress Disorder in Pediatric Trauma Patients: A Pilot Study.

BACKGROUND: Children who experience traumatic physical injuries are at risk of developing acute stress disorder and posttraumatic stress disorder (PTSD). Early identification and treatment of these high-risk children can lead to improved mental health outcomes in this population. OBJECTIVE: This study assesses the feasibility of a study protocol that compares 3 screening tools for identifying patients at a high risk of later development of acute stress disorder or PTSD among pediatric trauma patients. METHODS: This pilot study compared 3 questionnaires used as screening tools for predictors of later development of PTSD in a convenience sample of pediatric trauma patients aged 7-17 years. Patients were randomized to one of 3 screening tools. Families were contacted at 30, 60, and 90-120 days postinjury to complete the Child Report of Post-Traumatic Symptoms questionnaire. The sensitivity and negative predictive value of the screening tools were compared for the diagnosis of PTSD defined using the Child Report of Post-Traumatic Symptoms questionnaire. RESULTS: Of the 263 patients identified for possible enrollment, 52 patients met full inclusion criteria and agreed to participate. Only 29 (55.7%) patients completed at least one follow-up questionnaire. The prevalence of acute stress disorder and PTSD in our population was 41% (95% CI [24, 61]) and 31% (95% CI [15, 51]), respectively. CONCLUSIONS: In this pilot study, we sought to determine the utility of the 3 commonly used screening instruments for measuring traumatic stress symptoms in pediatric trauma patients to predict the diagnosis of acute stress disorder or PTSD. Limitations include the use of the Child Report of Post-Traumatic Symptoms screening tool as the gold standard for calculating test characteristics and lack of 24/7 enrollment capabilities. As such, a significant portion of patients were discharged prior to our teams' engagement for enrollment.

Effect of a Virtual Patient Navigation Program on Behavioral Health Admissions in the Emergency Department: A Randomized Clinical Trial.

IMPORTANCE: The number of patients presenting to emergency departments (EDs) for psychiatric care continues to increase. Psychiatrists often make a conservative recommendation to admit patients because robust outpatient services for close follow-up are lacking. OBJECTIVE: To assess whether the availability of a 45-day behavioral health-virtual patient navigation program decreases hospitalization among patients presenting to the ED with a behavioral health crisis or need. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial enrolled 637 patients who presented to 6 EDs spanning urban and suburban locations within a large integrated health care system in North Carolina from June 12, 2017, through February 14, 2018; patients were followed up for up to 45 days. Eligible patients were aged 18 years or older, with a behavioral health crisis and a completed telepsychiatric ED consultation. The availability of the behavioral health-virtual patient navigation intervention was randomly allocated to specific days (Monday through Friday from 7 am to 7 pm) so that, in a 2-week block, there were 5 intervention days and 5 usual care days; 323 patients presented on days when the program was offered, and 314 presented on usual care days. Data analysis was performed from March 7 through June 13, 2018, using an intention-to-treat approach. INTERVENTIONS: The behavioral health-virtual patient navigation program included video contact with a patient while in the ED and telephonic outreach 24 to 72 hours after discharge and then at least weekly for up to 45 days. MAIN OUTCOMES AND MEASURES: The primary outcome was the conversion of an ED encounter to hospital admission. Secondary outcomes included 45-day follow-up encounters with a self-harm diagnosis and postdischarge acute care use. RESULTS: Among 637 participants, 358 (56.2%) were men, and the mean (SD) age was 39.7 (16.6) years. The conversion rates were 55.1% (178 of 323) in the intervention group vs 63.1% (198 of 314) in the usual care group (odds ratio, 0.74; 95% CI, 0.54-1.02; P = .06). The percentage of patient encounters with follow-up encounters having a self-harm diagnosis was significantly lower in the intervention group compared with the usual care group (36.8% [119 of 323] vs 45.5% [143 of 314]; P = .03). CONCLUSIONS AND RELEVANCE: Although the primary result did not reach statistical significance, there is a strong signal of potential positive benefit in an area that lacks evidence, suggesting that there should be additional investment and inquiry into virtual behavioral health programs. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03204643.

The Walking Wounded: Emerging Treatments for PTSD.

PURPOSE OF REVIEW: We review the published literature over the last 24 months in the treatment of PTSD for our military men and women. We examined the updated clinical practice guidelines published in June 2017 by the Veteran's administration and Department of Defense and contrasted the guidelines with the most recent literature. We also discuss new directions in PTSD research. RECENT FINDINGS: Psychotherapy remains one of the most effective treatments for PTSD; unfortunately, few participants remain in treatment to completion. Many of the emerging therapies target NMDA receptor antagonists, cannabinoid receptor modulators, glucocorticoid receptor agonists, non-SSRI antidepressants, and opioid receptor agonists. The newer therapies fall into the drug classes of anti-hypertensives, glutamate modulators, oxytocin, and medication targeting insomnia/hyperarousal. PTSD symptoms are often chronic in our veteran population. While current treatments are helpful, there are often significant residual symptoms. We reviewed the most recent improvements in treatment and discuss therapies that are in the research phase.

Emergency Department Medical Clearance of Patients with Psychiatric or Behavioral Emergencies, Part 1.

Patients presenting to the emergency department with mental illness or behavioral complaints merit workup for underlying physical conditions that can trigger, mimic, or worsen psychiatric symptoms. However, interdisciplinary consensus on medical clearance is lacking, leading to wide variations in quality of care and, quite often, poor medical care. Psychiatry and emergency medicine specialty guidelines support a tailored, customized approach. This article summarizes best-practice approaches to the medical clearance of patients with psychiatric illness, tips on history taking, system reviews, clinical or physical examination, and common pitfalls in the medical clearance process.

Emergency Department Medical Clearance of Patients with Psychiatric or Behavioral Emergencies, Part 2: Special Psychiatric Populations and Considerations.

Patients who present to the emergency department (ED) with mental illness or behavioral complaints merit workup for underlying physical conditions that can trigger, mimic, or worsen psychiatric symptoms. However, there are wide variations in quality of care for these individuals. Psychiatry and emergency medicine specialty guidelines support a tailored, customized approach to patients. Our group has long advocated a dynamic comanagement approach for medical clearance in the ED, and this article summarizes best-practice approaches to the medical clearance of patients with psychiatric illness, tips on history taking, system reviews, clinical/physical examination, and common pitfalls in the medical clearance process.

Highlight in Telepsychiatry and Behavioral Health Emergencies.

Carolinas HealthCare System is one of the largest freestanding psychiatric emergency departments in the country. It has grown from a small community mental health center in the 1930s, to one of the largest providers of emergency mental health services in the country. It offers services in person and via telepsychiatry to other emergency departments and primary care clinics. It decreased emergency room wait times and revolutionized where and how patients get their care. This has been the work of several groups from many disciplines. The transition from community mental health center to large-scale mental health emergency department has been a model for the rest of the country.

Military family physician attitudes toward treating obesity.

OBJECTIVE: The goal was to examine current knowledge, attitudes, and treatment practices of family practitioners regarding obesity. METHODS: A cross-sectional, anonymous, self-report survey of active members of the Uniformed Services Chapter of the American Academy of Family Physicians was performed. Measures included demographic information, attitudes toward obese patients, knowledge of associated health risks, and treatment recommendations, rated on a 5-point Likert scale. Results were compared with previous similar studies, and associations between demographic variables, physician body mass index, and attitudes and behaviors were examined by using multivariate regression analysis. RESULTS: Of the 1,186 members invited to participate, 477 (40.2%) responded. Compared with previous studies, there was increased awareness of obesity-associated health risks and physicians' sense of obligation to counsel patients. There were minimal changes in physician comfort and gratification with obesity counseling. Stereotypical attitudes of physicians toward obese patients were increased. Treatment recommendations were increased in all fields, including exercise, diet/nutrition counseling, and behavioral modification, but the most notable increases were seen in the use of prescription medications, diet center programs, and surgical referrals. Age, physician gender, physician weight status, practice location, and current training status were each associated with some aspect of physician attitudes and treatment practices. CONCLUSION: Physicians are better able to identify obesity and its associated health risks, but some negative stereotypical attitudes persist. These attitudes affect current treatment practices. Increased awareness, training, and study are required to combat the continuing increase in obesity rates.

Depression in entry-level military personnel.

OBJECTIVE: The goal was to determine the prevalence of, and risk factors for, depression in an entry-level U.S. Army population. METHOD: A cross-sectional survey of U.S. Army soldiers in advanced individual training was performed by using an anonymous self-report survey including demographic data, history (including abuse and psychiatric treatment), and the Patient Health Questionnaire-9. RESULTS: Soldiers in advanced individual training (n = 1,184) were approached, and 1,090 (91.2%; 955 male soldiers and 135 female soldiers) voluntarily chose to participate. Eleven percent reported a psychiatric history, 26% reported a history of abuse, and 15.9% endorsed moderate or more severe current depressive symptoms (male, 15.0%; female, 22.2%). A history of psychiatric treatment (odds ratio, 2.08; 95% confidence interval, 1.21-3.59; p = 0.009) and a history of verbal abuse (odds ratio, 4.11; 95% confidence interval, 2.45-6.90; p = 0.000) placed soldiers at higher risk for depression. CONCLUSIONS: Our study shows a higher than expected rate of depression in entry-level training soldiers and identifies some risk factors for depression. This indicates an important need for further study, effective screening, preventive counseling, and early intervention.

Current perspectives on chief residents in psychiatry.

OBJECTIVE: The authors examine qualitative data from outgoing chief residents in psychiatry from the 2004-2005 academic year to 1) determine common characteristics between programs, 2) examine the residents' perspectives on their experiences, and 3) determine their common leadership qualities. METHOD: The authors sent out self-report surveys via e-mail to 89 outgoing chief residents who attended the APA/Lilly Chief Resident Executive Leadership Program. RESULTS: Fifty-three (60%) chief residents responded. Although most chief residents are senior residents, over 20% are in their third postgraduate year. Two-thirds of programs have more than one chief resident each year. Most chief residents believe that their "participating" leadership style, existing leadership skills, and interpersonal skills contributed to their overall positive experiences. CONCLUSIONS: Successfully performing duties as a chief resident entails functioning in a variety of roles and demands attention to leadership qualities of the individual. Developing existing leadership skills, clarifying expectations, and providing mentorship to chief residents will ensure successful transition into practice, and the advancement of the field of psychiatry.

Perceptions and practices of graduates of combined family medicine-psychiatry residency programs: a nationwide survey.

OBJECTIVE: The authors evaluate the current practices and perceptions of graduates of combined family medicine-psychiatry residency programs in the following areas: preparation for practice, boundary formation, and integration of skills sets. METHOD: The authors conducted an electronic cross-sectional survey of all nationwide combined family medicine-psychiatry training graduates in the spring of 2005. RESULTS: Twenty-seven (62.8%) graduates participated. Nearly 30% worked in positions designed specifically for combined trained physicians, though only 11.1% participated in fully integrated practice. The mean time spent practicing psychiatry and family medicine is 70% and 16%, respectively. CONCLUSIONS: Combined trained graduates felt well prepared for practice in both specialties but somewhat less comfortable providing integrated care. Most are in positions that underutilize their ability to integrate family medicine and psychiatry in one practice. Contributing factors may include limited preparation for integration during residency training and lack of integrated job opportunities. Enhancing combined residents' training in the provision of integrated services may optimize their utilization.

Disordered eating in entry-level military personnel.

OBJECTIVE: The goal was to determine the prevalence of and risk factors for disordered eating in an entry-level U.S. Army population. METHODS: A cross-sectional survey of advanced individual training U.S. Army soldiers at Aberdeen Proving Ground, Maryland, was performed with an anonymous self-report survey containing demographic factors, history (including abuse and psychiatric treatment), and Eating Attitudes Test-26. RESULTS: Of 1,184 advanced individual training soldiers approached, 1090 participated. The response rate was 91.2% (955 men and 135 women). Forty percent were overweight (body mass index of > or =25), 11% reported a psychiatric history, 26% reported a history of abuse, and 9.8% endorsed disordered eating (male, 7.0%; female, 29.6%), as defined by Eating Attitudes Test-26. Factors that placed soldiers at higher risk for disordered eating were female gender (odds ratio, 5.63; 95% confidence interval, 3.32-9.57; p < 0.00005), overweight (odds ratio, 3.06; 95% confidence interval, 1.92-4.89; p < 0.00005), previous psychiatric treatment (odds ratio, 1.87; 95% confidence interval, 1.04-3.36; p = 0.035), and history of verbal abuse (odds ratio, 2.02; 95% confidence interval, 1.16-3.51; p = 0.014). CONCLUSIONS: Our study shows a higher than expected rate of disordered eating in advanced individual training soldiers with identifiable risk factors. This indicates an important need for further study, effective screening, preventive counseling, and early intervention for treatment.

Antidepressant discontinuation syndrome.

Antidepressant discontinuation syndrome occurs in approximately 20 percent of patients after abrupt discontinuation of an antidepressant medication that was taken for at least six weeks. Typical symptoms of antidepressant discontinuation syndrome include flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances, and hyperarousal. These symptoms usually are mild, last one to two weeks, and are rapidly extinguished with reinstitution of antidepressant medication. Antidepressant discontinuation syndrome is more likely with a longer duration of treatment and a shorter half-life of the treatment drug. A high index of suspicion should be maintained for the emergence of discontinuation symptoms, which should prompt close questioning regarding accidental or purposeful self-discontinuation of medication. Before antidepressants are prescribed, patient education should include warnings about the potential problems associated with abrupt discontinuation. Education about this common and likely underrecognized clinical phenomenon will help prevent future episodes and minimize the risk of misdiagnosis.

Characteristics of combined family practice-psychiatry residency programs.

OBJECTIVE: To evaluate how family practice-psychiatry residency programs meet the challenges of rigorous accreditation demands, clinical supervision, and boundaries of practice. METHOD: A 54-question survey of program directors of family practice-psychiatry residency programs outlining program demographic data, curricula, coordination, resident characteristics, integration, and overall satisfaction was mailed to 11 combined family practice psychiatry-residency programs. RESULTS: Programs surveyed were meeting residency review committee (RRC) requirements, and a majority of the program directors believe that the training is as good as or better than categorical programs, and categorical residents benefited from training alongside combined residents. CONCLUSIONS: Training programs are growing in size and producing quality physicians.

Teaching psychiatry to family practice residents.

OBJECTIVE: This article outlines a psychiatry curriculum developed for family practice residents by family practice-psychiatry residents. METHODS: A literature review, needs assessment, planning, implementation, and initial assessment were conducted. CONCLUSION: Early results demonstrated improved general psychiatric knowledge and a high level of satisfaction.