Antipsychotic Prescribing in Older Adults after In-Hospital Initiation.

Background: In older adults, the use of antipsychotics to treat delirium or the behavioural and psychological symptoms of dementia is potentially inappropriate and may be associated with adverse effects. Antipsychotics newly initiated in hospital may be inadvertently continued after discharge. In the Saskatchewan Health Authority (SHA) - Regina area, the frequency and duration of antipsychotic continuation for older adults after initiation during a hospital stay is unknown. Objectives: To describe potentially inappropriate antipsychotic use in older adults after discharge from hospital, specifically rates of postdischarge antipsychotic therapy after initiation in hospital and continuation up to 180 days after discharge; prescribing regimens used; risk factors associated with continuation; pharmacist involvement; and plans for antipsychotic discontinuation, tapering, and/or follow-up. Methods: This retrospective chart review included inpatients 65 years of age or older who were discharged from medicine units at SHA - Regina area hospitals between September 30, 2021, and June 28, 2022. Outpatient dispensing histories were also gathered. Results: Of the 189 patients included in the analysis, 60 (31.7%) had continuation of antipsychotic therapy at discharge. Of these, 48 (80.0%), 33 (55.0%), and 24 (40.0%) had continuation of antipsychotic therapy at 30, 90, and 180 days after discharge, respectively. Of the patients with continuing antipsychotic therapy, 53 (88.3%) were 75 years of age or older, and 9 (15.0%) had documentation of an outpatient antipsychotic follow-up plan. Conclusions: Postdischarge continuation of antipsychotics was similar to that reported in the literature. Patients continued on antipsychotics after discharge were at a greater than 50% risk of continuation at 90 days and were unlikely to have a follow-up plan. Future quality improvement efforts should include standardized prioritization of medication reviews, documentation of indications, and regular reassessment of therapy.

Contexte: Chez les personnes âgées, l'utilisation d'antipsychotiques pour traiter le délire ou les symptômes comportementaux et psychologiques de la démence est potentiellement inappropriée et associée à des effets indésirables. Le traitement antipsychotique initié à l'hôpital pourrait se poursuivre par inadvertance après le congé. Dans la région de Regina de la Saskatchewan Health Authority (SHA), la fréquence et la durée du maintien d'antipsychotiques chez les personnes âgées après l'initiation au cours d'un séjour à l'hôpital sont inconnues. Objectifs: Décrire l'utilisation potentiellement inappropriée d'antipsychotiques chez les personnes âgées après le congé de l'hôpital, en particulier les taux de traitement antipsychotique initié à l'hôpital qui continue après le congé et son maintien jusqu'à 180 jours après le congé; les schémas de prescription utilisés; les facteurs de risque associés au maintien; l'implication du pharmacien; et les plans visant à arrêter, réduire progressivement et/ou à faire le suivi de la prise d'antipsychotiques. Méthodologie: Cet examen rétrospectif des dossiers comprenait des patients hospitalisés âgés d'au moins 65 ans qui étaient sortis des unités de médecine d'hôpitaux de la région de Regina de la SHA entre le 30 septembre 2021 et le 28 juin 2022. Les historiques de délivrance en ambulatoire ont également été recueillis. Résultats: Sur les 189 patients inclus dans l'analyse, 60 (31,7 %) ont continué leur traitement antipsychotique au moment du congé. Parmi eux, 48 (80,0 %), 33 (55,0 %) et 24 (40,0 %) continuaient leur traitement antipsychotique à 30, 90 et 180 jours après leur congé, respectivement. Parmi les patients recevant un traitement antipsychotique continu, 53 (88,3 %) étaient âgés d'au moins 75 ans et 9 (15,0 %) avaient un plan de suivi antipsychotique ambulatoire. Conclusions: Le maintien des antipsychotiques après le congé était similaire à celui rapporté dans la littérature. Les patients qui continuaient à prendre des antipsychotiques après leur congé couraient un risque supérieur à 50 % de continuer à 90 jours et étaient peu susceptibles de disposer d'un plan de suivi. Les futurs efforts d'amélioration de la qualité devraient comprendre une priorisation standardisée des examens des médicaments, la documentation des indications et une réévaluation régulière du traitement.

Clozapine clinical toolkit optimizes inpatient clozapine monitoring.

Introduction: Clozapine is the most effective antipsychotic in the management of treatment-resistant schizophrenia; however, its use is challenging due to the risk of severe adverse effects. Despite the risks associated with clozapine, there is no mandatory monitoring in Canada beyond hematologic testing for agranulocytosis surveillance. This study focuses on the development, implementation, and evaluation of a clozapine clinical toolkit (CTK) targeted at optimizing inpatient clozapine use. Methods: A comprehensive literature review was conducted to identify clozapine best practices, experts were consulted, and a comprehensive clozapine CTK was developed and implemented at a large Canadian tertiary hospital in December 2018. To evaluate the CTK, a retrospective chart review was conducted to assess for change in guideline-concordant monitoring pre- and post- CTK implementation. Patients were included if they were > 18 years of age and received clozapine during inpatient admission. Results were analyzed using descriptive and inferential statistics. Results: Among the charts reviewed, 185 and 113 admissions met the pre- and post-CTK inclusion criteria, respectively. Staff used the CTK in the care of 96% of clozapine patients post implementation, and its use resulted in improvements in guideline-concordant monitoring for agranulocytosis and myocarditis. Discussion: Implementation of the clozapine CTK increased the concordance of clozapine monitoring with best practice recommendations. Future research is necessary to assess the impact of the CTK on clinical outcomes and patient satisfaction.

Barriers and facilitators for family physicians prescribing opioid agonist therapy in Saskatchewan.

OBJECTIVE: To explore barriers and facilitators for family physicians in Saskatchewan prescribing opioid agonist therapy (OAT). DESIGN: Self-administered postal survey. SETTING: Family medicine practices in Saskatchewan. PARTICIPANTS: A total of 218 Saskatchewan family physicians who were not authorized to prescribe OAT as of June 2022. MAIN OUTCOME MEASURES: Descriptive and inferential statistics of physicians' self-reported barriers to and facilitators of prescribing OAT for opioid use disorder (OUD). RESULTS: Most respondents (84.8%) had some comfort with diagnosing OUD. However, more than half (58.3%) did not feel confident or knowledgeable about prescribing OAT. Barriers to OAT prescribing included lack of time, incomplete training requirements, lack of interest, insufficient funding or support, feeling overwhelmed, and perceiving that OAT does not work and thus is not necessary. Physicians working in core neighbourhoods and those receiving fee-for-service compensation reported the least available time to prescribe OAT. Conversely, physicians working in interdisciplinary team settings had increased time for OAT prescribing compared with physicians in other settings. Having a close personal relationship with someone with OUD was correlated with increased comfort in diagnosing OUD as well as with knowledge about and confidence in prescribing OAT. Themes identified as facilitators to increasing OAT prescribing included the addition of resources and supports, increased training, more awareness about OUD and OAT, enhanced compensation, and altered prescribing regulations. CONCLUSION: Despite the presence of several real and perceived barriers limiting OAT prescribing by Saskatchewan family physicians, there are family physicians interested in providing this therapy. Increased clinical resources and support, including increased interdisciplinary practice, are actionable steps that should be considered by policy decision makers to address this issue. Additionally, increased OUD and OAT education, which includes the perspectives of those with lived experience of OUD, would help address physician confidence, knowledge, and awareness in this area.

Low-dose Initiation of Buprenorphine/naloxone for the Management of Chronic Non-cancer Pain in Patients on Long-term Opioid Therapy: A Case Series.

Background: Buprenorphine may provide superior analgesia to full opioid agonist therapy and reverse the effects of opioid-induced hyperalgesia, while having a favorable safety profile and fewer adverse effects, in chronic non-cancer pain treatment. Low-dose initiation of buprenorphine is a useful strategy for patients on long-term opioid therapy because it avoids the need for moderate opioid withdrawal required for traditional buprenorphine initiations. However, there are few published reports of low-dose initiation regimens in the setting of chronic pain. Aims: The aim of the study was to describe a case series of individuals living with chronic pain who were transitioned from long-term full opioid agonist therapy onto sublingual buprenorphine/naloxone using low-dose initiation regimens. Methods: This study is a retrospective case series that included all patients who received care at an outpatient chronic pain clinic and were scheduled for low-dose initiation of buprenorphine/naloxone between March 2020 and December 2022. Data were collected through a retrospective review of electronic medical records and results were analyzed using descriptive statistics. Results: Eighteen patients underwent transitions from their baseline opioids onto buprenorphine/naloxone using a low-dose initiation regimen. Of those patients, 17 successfully completed the initiation (94.44%), 12 experienced adverse effects during the initiation (66.67%), with only one patient requiring treatment discontinuation, and all adverse effects resolved once maintenance doses of buprenorphine/naloxone were established. The mean Clinical Global Impression-Improvement score after initiation was 2 (1-5). Conclusion: Low-dose initiation is an effective approach to transition patients with chronic non-cancer pain from long-term opioid therapy to buprenorphine/naloxone without major complications or worsening pain.

Contexte: La buprénorphine peut offrir une analgésie supérieure à celle d'un traitement par agonistes opioïdes complet et inverser les effets de l'hyperalgésie induite par les opioïdes, tout en présentant un profil d'innocuité favorable et moins d'effets indésirables dans le traitement de la douleur chronique non cancéreuse. L'initiation à faible dose de la buprénorphine est une stratégie utile pour les patients sous traitement opioïde à long terme, car elle évite le besoin de sevrage des opioïdes modéré nécessaire pour les traitements traditionnels à base de buprénorphine. Cependant, il existe peu de rapports publiés sur les régimes d'initiation à faible dose dans le cadre de la douleur chronique.Objectifs: L'objectif de cette étude était de décrire une série de cas d'individus vivant avec une douleur chronique qui sont passés d'un traitement opioïde complet à long terme à un traitement par buprénorphine sublinguale/naloxone en ayant recours à des régimes d'initiation à faible dose.Méthodes: Cette étude est une série de cas rétrospective incluant tous les patients pris en charge dans une clinique externe de traitement de la douleur chronique et pour lesquels un schéma d'initiation à faible dose de buprénorphine/naloxone a été programmé entre mars 2020 et décembre 2022. Les données ont été collectées par le biais d'un examen rétrospectif des dossiers médicaux électroniques et les résultats ont été analysés à l'aide de statistiques descriptives.Résultats: Dix-huit patients ont fait la transition des opioïdes de base à la buprénorphine/naloxone en utilisant un régime d'initiation à faible dose. Parmi ces patients, 17 ont terminé l'initiation avec succès (94,44 %), 12 ont présenté des effets indésirables pendant l'initiation (66,67 %) et un seul patient a dû interrompre son traitement. Tous les effets indésirables ont disparu une fois les doses d'entretien de buprénorphine/naloxone établies. Le score d'impression clinique globale-amélioration moyen après le début du traitement était de 2 (1-5).Conclusion: L'initiation à faible dose est une approche efficace pour faire passer les patients souffrant de douleur chronique non cancéreuse d'un traitement opioïde à long terme à la buprénorphine/naloxone sans complications majeures ni aggravation de la douleur.

Take-Home Naloxone Access and Use among Older Adults Living with Pain: A Scoping Review.

Background: Opioids are a common treatment for older adults living with pain. Given high rates of polypharmacy and chronic comorbidities, older adults are at risk of opioid overdose. Evidence is now available that take-home naloxone (THN) supports reduction of opioid-related harms. It is unknown what THN initiatives are available for older adults, especially those living with chronic pain. Objective: To summarize the literature regarding THN, with a focus on older adults using opioids for pain, including facilitators of and barriers to THN access, knowledge gaps, and pharmacist-led initiatives. Data Sources: A scoping review, guided by an established framework and PRISMA-ScR guidelines, was performed. Methods involved searching 6 bibliographic databases (MEDLINE, Embase, Scopus, APA PsycINFO, Web of Science Core Collection, and PubMed), reference harvesting, and citation tracking. Searches were conducted up to March 2023, with no date limits applied; only English publications were included. Study Selection and Data Extraction: Study eligibility was determined according to preset criteria, including age; discrepancies were resolved by discussion and consensus. Data were extracted and categorized through thematic analysis. Data Synthesis: Four studies met the eligibility criteria. All 4 studies detailed THN programs in primary care settings involving older adults taking opioids for pain management. Two of the studies highlighted patient-specific risk factors for opioid overdose, including concomitant use of benzodiazepines and/or gabapentinoids, mean morphine milligram equivalents per day of at least 50, and previous opioid overdose. Two of the studies assessed patient knowledge of opioid overdose management and attitudes toward THN. Educational programs increased patients' interest in THN. Conclusions: The literature about THN for older adults living with pain is limited, and no literature was found on pharmacist-led initiatives in this area. Future research on THN provision for older adults, including pharmacist-led initiatives, could help to optimize care for older adults living with pain.

Contexte: Les opioïdes sont un traitement courant pour les personnes âgées souffrant de douleur. Compte tenu des taux élevés de polypharmacie et de comorbidités chroniques, les personnes âgées courent un risque de surdose d'opioïdes. Il est désormais prouvé que la distribution de trousses de naloxone contribue à la réduction des méfaits liés aux opioïdes. On ne sait pas quelles initiatives de distribution de trousses de naloxone existent pour les personnes âgées, en particulier celles souffrant de douleurs chroniques. Objectif: Résumer la documentation concernant la distribution des trousses de naloxone chez les personnes âgées qui utilisent des opioïdes contre la douleur, y compris les facilitateurs et les obstacles à l'accès aux trousses, les lacunes dans les connaissances et les initiatives menées par les pharmaciens. Sources des données: Un examen de la portée, guidé par un cadre éprouvé et les lignes directrices PRISMA-ScR, a été réalisé. Les méthodes impliquaient la recherche dans 6 bases de données bibliographiques (MEDLINE, Embase, Scopus, APA PsycINFO, Web of Science Core Collection et PubMed), la récolte de références et le suivi des citations. Les recherches ont été effectuées jusqu'en mars 2023, sans limites quant à la date; seules les publications en anglais ont été incluses. Sélection des études et extraction des données: L'admissibilité à l'étude a été déterminée selon des critères prédéfinis, notamment l'âge; les divergences ont été résolues par discussion et consensus. Les données ont été extraites et catégorisées grâce à une analyse thématique. Synthèse des données: Quatre études répondaient aux critères d'admissibilité. Les 4 études ont détaillé des programmes de distribution de trousses de naloxone dans des établissements de soins primaires chez les personnes âgées prenant des opioïdes pour gérer la douleur. Deux des études ont mis en évidence des facteurs de risque spécifiques aux patients en matière de surdosage aux opioïdes, notamment l'utilisation concomitante de benzodiazépines et/ou de gabapentinoïdes, une moyenne d'équivalents en milligrammes de morphine par jour d'au moins 50 et un surdosage antérieur aux opioïdes. Deux des études ont évalué les connaissances des patients en matière de gestion des surdosages aux opioïdes et leur attitude envers la distribution de trousses de naloxone. Les programmes éducatifs ont accru l'intérêt des patients pour les trousses de naloxone. Conclusions: La documentation sur la distribution de trousses de naloxone chez les personnes âgées souffrant de douleur est limitée et aucune littérature n'a été trouvée sur les initiatives menées par les pharmaciens dans ce domaine. Les recherches futures sur la distribution de trousses de naloxone aux personnes âgées, y compris les initiatives menées par des pharmaciens, pourraient contribuer à optimiser les soins aux personnes âgées souffrant de douleur.

Ligne directrice canadienne pour la prise en charge clinique de la consommation d'alcool à risque élevé et du trouble d'utilisation de l'alcool.

CONTEXTE: Au Canada, on note que les équipes soignantes et les personnes qui bénéficieraient de soins ciblés connaissent peu les interventions fondées sur des données probantes pour la prise en charge clinique du trouble d'utilisation de l'alcool. Pour combler cette lacune, l'Initiative canadienne de recherche sur l'abus de substances a créé un comité national dans le but d'élaborer une ligne directrice pour la prise en charge clinique de la consommation d'alcool à risque élevé et du trouble lié à la consommation d'alcool. MÉTHODES: L'élaboration de cette ligne directrice s'est faite selon le processus ADAPTE, et est inspirée par une ligne directrice britanno-colombienne de 2019 pour le trouble lié à la consommation d'alcool. Un comité national de rédaction de la ligne directrice (composé de 36 membres de divers horizons, notamment des universitaires, des médecins, des personnes ayant ou ayant eu des expériences de consommation d'alcool et des personnes s'identifiant comme Autochtones ou Métis) a choisi les thèmes prioritaires, a passé en revue les données probantes et atteint un consensus relatif aux recommandations. Nous avons utilisé l'outil AGREE II (Appraisal of Guidelines for Research and Evaluation Instrument II) et les principes de divulgation des intérêts et de gestion des conflits lors du processus de rédaction des lignes directrices (Principles for Disclosure of Interests and Management of Conflicts in Guidelines) publiés en anglais par le Réseau international des lignes directrices (Guidelines International Network) pour nous assurer que la ligne directrice répondait aux normes internationales de transparence, de qualité élevée et de rigueur méthodologique. Nous avons évalué les recommandations finales à l'aide de l'approche GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Les recommandations ont fait l'objet d'une revue externe par 13 spécialistes et parties prenantes d'ici et de l'étranger. RECOMMANDATIONS: La ligne directrice comprend 15 recommandations qui concernent le dépistage, le diagnostic, la prise en charge du sevrage et le traitement continu, y compris les interventions psychosociales, les pharmacothérapies et les programmes communautaires. Le comité de rédaction de la ligne directrice a reconnu la nécessité d'insister sur la sous-utilisation des interventions qui pourraient être bénéfiques et sur les modes de prescription et autres pratiques d'usage courant qui ne reposent pas sur des données probantes et pourraient aggraver les effets de la consommation d'alcool. INTERPRÉTATION: La ligne directrice se veut une ressource à l'intention des médecins, des responsables des orientations politiques et des membres des équipes cliniques et autres, de même que des personnes, des familles et des communautés affectées par la consommation d'alcool. Ces recommandations proposent un cadre fondé sur des données probantes pour alléger le lourd fardeau du trouble d'utilisation de l'alcool au Canada et combler les besoins en matière de traitements et de soins.

Intranasal ketamine as a treatment for psychiatric complications of long COVID: A case report.

Background: Neuropsychiatric symptoms associated with long COVID are a growing concern. A proposed pathophysiology is increased inflammatory mediators. There is evidence that typical serotonergic antidepressants have limited efficacy in the presence of inflammation. Although ketamine has shown promise in MDD, there is limited evidence supporting the use of ketamine to treat depressive symptoms associated with long COVID. Case Report: This case took place on an inpatient psychiatry unit in a Canadian hospital. The patient was admitted with a 10-month history of worsening depression and suicidality following infection with COVID-19. Depressive symptoms and suicidal ideation were assessed throughout treatment using the Montgomery-Asberg Depression Rating Scale (MADRS). Written informed consent was obtained prior to data collection. This patient received 4 doses of intranasal ketamine which resulted in rapid improvement of depressive symptoms and complete resolution of suicidality with no major adverse events. Discussion: There is evidence to support long COVID symptoms result from dysregulated inflammatory processes. The presence of inflammation in patients with MDD has correlated to poor outcomes with first-line antidepressants. It has been demonstrated that IV ketamine is associated with decreased inflammatory mediators and proportional decrease in depressive symptoms. Conclusions: Intranasal ketamine in this case was effective at treating depressive symptoms and suicidal ideation associated with long COVID. This is consistent with available data that demonstrates ketamine's efficacy in reducing inflammatory mediators associated with neuropsychiatric symptoms. Therefore, ketamine may be a potential therapeutic option to treat long COVID and persistent depressive symptoms.

Canadian guideline for the clinical management of high-risk drinking and alcohol use disorder.

BACKGROUND: In Canada, low awareness of evidence-based interventions for the clinical management of alcohol use disorder exists among health care providers and people who could benefit from care. To address this gap, the Canadian Research Initiative in Substance Misuse convened a national committee to develop a guideline for the clinical management of high-risk drinking and alcohol use disorder. METHODS: Development of this guideline followed the ADAPTE process, building upon the 2019 British Columbia provincial guideline for alcohol use disorder. A national guideline committee (consisting of 36 members with diverse expertise, including academics, clinicians, people with lived and living experiences of alcohol use, and people who self-identified as Indigenous or Métis) selected priority topics, reviewed evidence and reached consensus on the recommendations. We used the Appraisal of Guidelines for Research and Evaluation Instrument (AGREE II) and the Guidelines International Network's Principles for Disclosure of Interests and Management of Conflicts to ensure the guideline met international standards for transparency, high quality and methodological rigour. We rated the final recommendations using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) tool; the recommendations underwent external review by 13 national and international experts and stakeholders. RECOMMENDATIONS: The guideline includes 15 recommendations that cover screening, diagnosis, withdrawal management and ongoing treatment, including psychosocial treatment interventions, pharmacotherapies and community-based programs. The guideline committee identified a need to emphasize both underused interventions that may be beneficial and common prescribing and other practice patterns that are not evidence based and that may potentially worsen alcohol use outcomes. INTERPRETATION: The guideline is intended to be a resource for physicians, policymakers and other clinical and nonclinical personnel, as well as individuals, families and communities affected by alcohol use. The recommendations seek to provide a framework for addressing a large burden of unmet treatment and care needs for alcohol use disorder within Canada in an evidence-based manner.

Between what is and what could be: a survey of pharmacists' practices, attitudes, and beliefs in the provision of mental health care.

BACKGROUND: Pharmacists can have an essential role in providing care for patients with mental illness. There are gaps in the understanding of the current extent of pharmacists' involvement in caring for patients with mental illness and their readiness to effectively provide this care. AIM: To describe the current practices, attitudes, and beliefs of pharmacists in providing care to individuals with mental illness, and to assess factors that may impact these practices. METHOD: An electronic questionnaire was emailed to pharmacists in Saskatchewan, Canada. Likert scale questions were utilized, and data were analyzed using descriptive statistics and content analysis for free-text responses. RESULTS: The response rate was 9.1% (n = 146/1596). Fewer than 20% of respondents reported they were providing the clinical services listed to most or all patients with mental illness, except for providing basic medication education (61%). Almost all agreed it is a pharmacist's role to provide all the services (61-98% for different services) and many were motivated to provide them (47-91%). The factors most frequently selected as having the greatest impact on service provision were insufficient knowledge (27%, n = 34) and competing priorities (19%, n = 24). CONCLUSION: Consistent with international trends, Saskatchewan pharmacists reported low provision of clinical services for individuals with mental illness, despite a readiness to provide these services. There is an opportunity and a need to better utilize pharmacists internationally in the provision of mental health care.

Intranasal racemic ketamine for patients hospitalized with treatment-resistant depression: A retrospective analysis.

Most research describing ketamine as a treatment for depression has relied on intravenous dosing. There remains a need for more research to support this treatment with other routes of administration. This was a retrospective chart review of 30 patients hospitalized with unipolar or bipolar treatment-resistant depression who were treated with up to four doses of compounded intranasal racemic ketamine (50 mg or 75 mg). Treatment courses lasted up to 7 days. Symptom improvement was measured with either the Hamilton Depression Rating Scale or the Montgomery-Åsberg Depression Rating Scale. Ketamine was well tolerated with no severe adverse events or treatment discontinuations due to adverse effects. Blood pressures increased by 4-6 mmHg on average with no patients requiring medication to lower blood pressure. Twenty patients (66.7%) were classified as treatment responders based on depression scores decreasing by more than 50%. Among the 27 patients with moderate to severe suicidal ideation scores at baseline, these decreased by 68.5% on average. Overall, the results suggest that compounded intranasal racemic ketamine was safe and effective in the treatment of depressive symptoms and suicidal ideation in a real-world sample of patients hospitalized with treatment-resistant depression. Additional research comparing intranasal ketamine to esketamine and intravenous racemic ketamine is warranted. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Evaluation of a pharmacist-led interprofessional chronic pain clinic in Canada.

Background: Chronic noncancer pain (CNCP) is a common condition that affects individuals at a biopsychosocial level and can significantly impair function and quality of life. Referral to an interprofessional CNCP program is recommended for most patients; however, these clinics are limited in number and capacity. Expanding access by testing new service delivery models would be of value. The purpose of this study was to measure the impact of a new pharmacist-led, interprofessional model of care developed at the University of Saskatchewan Chronic Pain Clinic. Methods: A retrospective chart audit was conducted using data that included adult patients referred for CNCP management between May 2020 and December 2021. Medication use, overall health status (using the Clinical Global Impression of Change-Improvement [CGI-I] scale) and patient readiness to change (using the Transtheoretical Model) were measured 6 months after the initial appointment. Results: The study included 138 patients. Of the 80 patients taking an opioid, 22.5% were switched to buprenorphine/naloxone and the remainder had their mean morphine-equivalent dose reduced by a mean of 41.7 mg/d. Overall patient health status was minimally improved and many patients moved into the Action stage of change. Discussion: Changes in opioid use demonstrate a clinically important shift toward safer medication regimens that are less likely to lead to toxicity and unintended overdose. CGI-I data suggest that these patients, whose health status is typically very difficult to change, did not deteriorate but slightly improved after attending the clinic. Conclusion: The unique pharmacist-led, interprofessional model of care used by the University of Saskatchewan Chronic Pain Clinic may offer a viable alternative to traditional physician-led models.

The Time is Now for Mental Health Care: Evaluating the Impact of a Clinical Pharmacist on an Acute Mental Health Unit.

Background: Clinical pharmacists have a significant role in optimizing pharmacotherapy for patients admitted to acute care settings. Patients with mental health disorders are especially vulnerable to polypharmacy, adverse drug effects, medication nonadherence, and misconceptions about medication use. The Royal University Hospital in Saskatoon, Saskatchewan, currently lacks resources to provide optimal clinical pharmacy coverage for mental health inpatients. Objectives: To determine the optimal clinical role for a pharmacist providing specialized care to mental health inpatients and to evaluate the potential impact of the pharmacist on medication use and patient care. Methods: A pharmacist with 5 years of mental health-related pharmacy practice experience was temporarily assigned to the Mental Health Short Stay Unit as a practical component of a Master's program in pharmacy. Clinical activities to be completed by the pharmacist were defined on the basis of available evidence, existing performance and quality assurance indicators, and prior experience. The pharmacist's activities and recommendations during each shift were tracked and reported. Results: The pharmacist saw 94 patients over a total of 88 hours. The pharmacist made a total of 61 recommendations, of which 55 (90%) were accepted by the psychiatrist, and initiated 42 medication changes. Forty-one patients (44%) received a thorough medication assessment, and individualized, often specialized, education was provided to patients 39 times. The pharmacist was consulted by the psychiatrist 19 times. Conclusions: Pharmacists have an important role in medication management and patient education for psychiatric inpatients, and the health care team values pharmacists' unique expertise. Additional resources dedicated to defining and expanding clinical pharmacy services on inpatient psychiatry units could further optimize patient care.

Contexte: Les pharmaciens cliniciens jouent un rôle important dans l'optimisation de la pharmacothérapie pour les patients admis en milieu de soins aigus. Les patients souffrant de troubles de la santé mentale sont particulièrement vulnérables à la polypharmacie, aux effets indésirables des médicaments, au non-respect de la médication et aux idées fausses circulant sur leur utilisation. L'hôpital Royal University, à Saskatoon (Saskatchewan), manque actuellement de ressources pour offrir une couverture pharmaceutique clinique optimale aux patients hospitalisés en santé mentale. Objectifs: Déterminer le rôle clinique optimal du pharmacien fournissant des soins spécialisés aux patients hospitalisés en santé mentale et évaluer son impact potentiel sur l'utilisation des médicaments et les soins aux patients. Méthodes: Un pharmacien ayant 5 ans d'expérience dans la pratique de la pharmacie liée à la santé mentale a été temporairement affecté à l'unité de séjours de courte durée en santé mentale dans le cadre de la composante pratique d'un programme de maîtrise en pharmacie. Les activités cliniques qu'il devait réaliser ont été définies sur la base des données probantes à disposition, des indicateurs de performance et d'assurance de la qualité existants, ainsi que sur la base de son expérience antérieure. Les activités et les recommandations du pharmacien au cours de chaque quart de travail étaient suivies et signalées. Résultats: Le pharmacien a visité 94 patients sur un total de 88 heures. Au total, il a fait 61 recommandations, dont 55 (90 %) ont été acceptées par le psychiatre, et il a amorcé 42 changements de traitement. Quarante et un patients (44 %) ont reçu une évaluation approfondie concernant le traitement, et des patients ont reçu une explication individualisée, souvent spécialisée, 39 fois. Le psychiatre a consulté le pharmacien 19 fois. Conclusions: Les pharmaciens jouent un rôle important dans la gestion des médicaments et l'éducation des patients hospitalisés en psychiatrie, et l'équipe de soins de santé apprécie leur expertise unique. Des ressources supplémentaires consacrées à la définition et à l'élargissement des services de pharmacie clinique dans les unités de psychiatrie pour patients hospitalisés pourraient optimiser davantage les soins aux patients.

Successful conversion from butorphanol nasal spray to buprenorphine/naloxone using a low-dose regimen to assist with opioid tapering in the setting of chronic pain and migraine management in an older adult patient: A case report.

Background: Butorphanol is marketed as a treatment for migraines; however, evidence suggests that the harms of its use exceed the benefits. The short half-life of butorphanol places patients at high risk for opioid dependence and makes tapering a challenge. Buprenorphine/naloxone has unique pharmacological properties that are beneficial in chronic pain treatment. At this time there is limited published data on the use of micro-dosing initiation regimens in patients with chronic pain, especially in older adult patients. Aims: This article presents the case of an older adult patient for whom a buprenorphine/naloxone micro-dosing regimen was successfully utilized to aid discontinuation of butorphanol nasal spray, assist with opioid tapering, and manage chronic pain. Methods: This case took place in an outpatient setting while the patient was receiving care from an interprofessional chronic pain service. The electronic medical record was reviewed to obtain a summary of the case data. Informed patient consent was obtained. Results: We present a case of an older adult patient who had been using butorphanol nasal spray for migraine and general pain management for over 20 years. The risks of ongoing use of butorphanol (i.e., inter-dose-related pain, opioid dependence, possible opioid-induced hyperalgesia, and fall risk) no longer exceeded any perceived benefit. The patient was successfully transitioned onto sublingual buprenorphine/naloxone using a micro-dosing regimen. Conclusions: This case provides an example of the potential benefit buprenorphine/naloxone can have for patients with chronic pain and previous opioid exposure, especially older adults at risk of central adverse effects of opioids.

Contexte: Le butorphanol est commercialisé comme traitement des migraines; cependant, les données probantes indiquent que les méfaits de son utilisation dépassent les avantages. La courte demi-vie du butorphanol expose les patients à un risque élevé de dépendance aux opioïdes et rend la réduction progressive un défi. La buprénorphine/naloxone possède des propriétés pharmacologiques uniques qui sont bénéfiques dans le traitement de la douleur chronique. À l'heure actuelle, il existe peu de données publiées sur l'utilisation de programmes d'initiation de microdosage chez les patients souffrant de douleur chronique, en particulier chez les patients adultes âgés.Buts: Cet article présente le cas d'un patient adulte âgé pour lequel un programme de microdosage buprénorphine/naloxone a été utilisé avec succès pour aider à l'arrêt de la pulvérisation nasale de butorphanol, à la réduction progressive des opioïdes et à la prise en charge de la douleur chronique.Méthodes: Ce cas s'est produit dans un cadre ambulatoire alors que le patient recevait des soins d'un service interprofessionnel de traitement de la douleur chronique. Le dossier médical électronique a été examiné pour obtenir un résumé des données du cas. Le consentement éclairé du patient a été obtenu.Résultats: Nous présentons le cas d'un patient adulte âgé qui utilisait un vaporisateur nasal au butorphanol pour la migraine et la prise en charge générale de la douleur depuis plus de 20 ans. Les risques liés à l'utilisation continue du butorphanol (c.-à-d. la douleur interdose, la dépendance aux opioïdes, l'hyperalgésie possible induite par les opioïdes et le risque de chute) ne dépassaient plus les avantages perçus. Le patient a été transféré avec succès vers le buprénorphine/naloxone sublingual en utilisant un programme de microdosage.Conclusions: Ce cas fournit un exemple de l'avantage potentiel de la buprénorphine/naloxone pour les patients présentant une douleur chronique et une exposition antérieure aux opioïdes, en particulier les personnes âgées à risque d'effets indésirables centraux des opioïdes.

Development and validation of patient-community pharmacist encounter toolkit regarding substance misuse: Delphi procedure.

BACKGROUND: Pharmacists' roles and services for patients with substance use are not well defined and inconsistent from site to site. Several barriers have been identified that hinder pharmacists' care for people who use substances, such as a lack of training and resources. Clinical practice tools can aid in transferring evidence-based approaches to the practice sphere. OBJECTIVES: The aim of the study was to develop a substance misuse management toolkit for community pharmacists to help them manage their encounters with people who use substances. METHODS: A focused literature review was conducted and 2 needs assessment studies, one for community pharmacists and one for patients informed the development of the toolkit. The toolkit is an adaption of the screening, brief intervention, and referral to treatment (SBIRT) approach, which is one of the most well-defined and effective strategies for substance use management. However, SBIRT is a novel care model in community pharmacy settings. Therefore, a substance misuse management toolkit with 20 items was created for community pharmacists incorporating evidence-based strategies and clinical algorithms. Delphi procedure was used to validate the toolkit. RESULTS: Two rounds of questions were sent to experts in the field of substance misuse, some of whom were pharmacists. In both rounds, these experts were asked to rate the appropriateness and clarity of items in the toolkit and provide comments and suggestions. Items with a median rating of 7 or more out of 10 were included in the toolkit. In the second round, the experts were asked to rerate the revised version and provide additional feedback. After the second round, agreement was reached for almost all items of the toolkit. CONCLUSION: A Delphi procedure was successfully used to provide evidence of the validity of the new guiding toolkit for community pharmacists. The toolkit will be implemented and evaluated to provide additional evidence of validity in practice.

The role of pharmacists in opioid stewardship: A scoping review.

BACKGROUND: The opioid epidemic is an international public health concern. Pharmacists are in a strategic position to promote and implement effective opioid stewardship due to both their central role on health care teams and frequent interaction with patients. Despite this integral role, pharmacists do not have harmonized scopes of practice in opioid stewardship. OBJECTIVES: This scoping review was conducted to identify and critically review the role of pharmacists in opioid stewardship and identify future areas of study. METHODS: The scoping review was conducted according to the methodological framework proposed by Arksey and O'Malley, which was further modified by the Joanna Briggs Institute. Six databases were searched for original, peer-reviewed research; PubMed (MEDLINE), Ovid Embase, Ovid International Pharmaceutical Abstracts, Scopus, Cochrane Library, and APA PsycInfo. RESULTS: In 92% of the included studies (n = 77), opioid stewardship interventions led by either a pharmacist or in an interdisciplinary team resulted in improvements in at least one outcome measure, with education and medication therapy adjustments being the most predominant activities. Other areas supported by evidence include community stakeholder education, policy and guideline setting, and risk assessment. CONCLUSION: This scoping review provides valuable insight into the various roles pharmacists can have in opioid stewardship. The findings from this review identified opioid stewardship activities that can make significant contributions towards reducing the impact of the opioid crisis. This review informs future research and has the potential to influence pharmacy practice on a national and international scale.

The Academic Triathlete: Applying Triathlon Training Principles to Guide Academic Success.

INTRODUCTION: Academic faculty are evaluated on their service, teaching, and research performance with the reward of tenure, promotion, and self-fulfillment. Triathletes spend numerous hours building their swim, bike, and run endurance in aspiration of crossing the finish line on race day. Given the workload required for academic and triathlon success, effective time and task management is essential. In this commentary, the authors posit that academic faculty can effectively structure their day-to-day "training" to achieve their career ambitions similarly to how a triathlete structures their training plan in preparation for a race. PERSPECTIVE: Triathlon requires mastery of three disciplines - swimming, biking, and running - each of which requires specific training approaches, skills, and techniques. Likewise, the service, teaching, and research pillars of academia involve planning, development, and application of diverse knowledge, skills, and techniques. The authors apply the fundamental aspects and lessons learned of triathlon training to the planning and execution of faculty academic work. IMPLICATIONS: Through the adaptation of a triathlete training framework to an academic position, the reader will be prepared to cross the finish line and realize their career goals as an academic triathlete.