Methadone-Related Delirium: Prevalence, Causes, and Outcomes.

Goals consist of determining 5-year prevalence and recurrence of methadone-related delirium (MRD), along with causes, treatments, and outcomes. Sample comprised 81 patients in methadone maintenance treatment. Criteria for MRD encompassed delirium with high methadone serum levels plus alleviation of delirium upon lowering methadone serum levels. MRD occurred in 14 cases who had 25 episodes. MRD precipitants included physician prescribing (i.e., excessive methadone or medications slowing methadone metabolism), drug misuse, and renal-fluid alterations. Social affiliation (housing with family, intimate partner) reduced MRD; employment increased MRD. Recovery occurred in 23/25 episodes of MRD; two episodes progressed to dementia. Obtaining serum methadone levels fostered prompt recognition.

Closing the Classroom Theory to Practice Gap by Simulating a Psychiatric Pharmacy Practice Experience.

Objective. To examine the feasibility and effectiveness of combining whole-task and guided reflection educational design principles with cloud-based learning technologies to simulate the clinical psychiatric advanced pharmacy practice experience (APPE) in the classroom to begin to close the theory to practice gap. Methods. Components of the typical student experience while completing an APPE were integrated into the course experience, ie, patient case work-ups, facilitated sessions with a preceptor, personal statement of goals and progress with feedback, and intentional interaction with peer-learners. Multiple sources of quantitative and qualitative data were collected and analyzed. Results. Twelve third-year pharmacy students from two campuses participated in and successfully completed this one-credit elective advanced psychiatric pharmacotherapy course. Eleven board-certified psychiatric pharmacists (BCPP) served as visiting experts, some participating for multiple weeks, and provided preceptor-like feedback to the case presentations in spring 2017. All BCPP pharmacists plus an additional geriatric pharmacist specialist participated in the course in spring 2018. Results of the quantitative and qualitative analyses demonstrated that students progressed in their readiness for APPEs and gained additional psychiatric pharmacy knowledge and evidence-based medicine decision making skills. Conclusion. Pharmacy programs are challenged to find additional ways to improve student readiness for APPEs and expand psychiatric learning opportunities to meet the increasing mental health needs across clinical settings. This example provides a feasible and effective strategy to do both without the requirement to create extensive new learning materials or add significant faculty workload.

Integration of a clinical pharmacy specialist into a substance use disorder intensive outpatient treatment program to improve prescribing rates of alcohol use disorder pharmacotherapy.

BACKGROUND: Research has demonstrated that the combination of pharmacotherapy and psychological interventions in alcohol use disorder (AUD) treatment is superior to either alone. Despite this, medications remain highly underutilized in many outpatient treatment facilities. Pharmacists can serve as an excellent resource to aid in improving access to medications. METHODS: This study was a prospective, longitudinal evaluation of a pharmacist's role in a substance use disorder (SUD) clinic, specifically an intensive outpatient program (IOP). The primary objective was to determine if the addition of a clinical pharmacy specialist (CPS) as a bridge until next available provider appointment would improve access to AUD pharmacotherapy for patients in the IOP. RESULTS: A total of 43 patients were enrolled in the IOP during the study. Of these, 27 patients presented with a primary diagnosis of AUD, and only eight were receiving AUD pharmacotherapy at the start of the program. During this intervention, 11 patients expressed interest in initiating a medication for AUD while in the IOP. The average wait time for a medication evaluation appointment with the CPS was 1.4 days. By comparison, the average wait time for an addiction psychiatrist was approximately 44 days. Each patient was seen for an average of two 30-minute visits, including an initial medication evaluation and one follow-up. Upon completion of CPS services, patients were referred almost equally to an established non-addiction recovery services (ARS) mental health provider (36%), an ARS psychiatrist (36%), or a primary care provider (28%). CONCLUSION: Our study highlights the role that pharmacists can play in improving access to evidence-based AUD pharmacotherapy, as well as in providing medication education to patients and providers. Long-term prospective research and pharmacoeconomic analysis are needed to determine the sustainability of this service, both at our facility and in other similar practice settings.

Evaluation of Concurrent Oral and Long-Acting Injectable Antipsychotic Prescribing at the Minneapolis Veterans Affairs Health Care System.

BACKGROUND: Antipsychotic polypharmacy is defined as the concomitant prescribing of more than 1 antipsychotic medication for an individual patient. Despite clinical guideline recommendations, long-acting injectable antipsychotics (LAIAs) are often used together with oral antipsychotics (OAPs) to treat a variety of psychiatric illnesses. Little research exists to address this form of antipsychotic polypharmacy, and its role in therapy is poorly understood. The purpose of this evaluation was to determine the prevalence of this prescribing pattern at our facility, identify provider rationale for polypharmacy, and analyze trends. To our knowledge, this study is the first to describe the prevalence of and rationale for concomitant LAIA and OAP prescribing in the veteran population. METHODS: All patients receiving an LAIA at the time of study initiation were included. Long-acting injectable antipsychotics/oral antipsychotics polypharmacy was defined as the use of both agents outside the manufacturer's recommendations for titration and overlap. Statistical analysis was performed to further evaluate prescribing patterns by agent, dose, and indication. RESULTS: Long-acting injectable antipsychotics/oral antipsychotics polypharmacy occurred in 28% (22/79) of subjects. Of these, 50% (11/22) were prescribed the same antipsychotic in both dosage forms, of which 73% (8/11) were risperidone. Patients on LAIA/OAP polypharmacy were half as likely to be on a maximum dose LAIA compared with those on monotherapy (13% vs. 26%). CONCLUSIONS: Although LAIA/OAP polypharmacy occurred less frequently than reported in previous literature, this study highlights the need for further research to better understand this prescribing practice.

Implementing a Policy and Protocol on Managing Patients With Hypertensive Urgencies.

BACKGROUND: The use of short-acting agents, such as clonidine, for hypertensive urgency has been shown to worsen outcomes and, therefore, should be avoided in the office. OBJECTIVES: The primary objective was to achieve decreased rates of clonidine orders for immediate treatment of asymptomatic hypertension in the office. The secondary objective was to determine if reduced use leads to a decline in poor outcomes. METHODS: This was an observational cohort study evaluating a protocol and algorithm developed by clinical pharmacists on the appropriate management of hypertensive urgencies. The protocol included the provision of avoiding short-acting antihypertensives (ie, clonidine). Preintervention and postintervention reports were generated to determine the number of times clonidine was ordered in the office. Electronic health charts were also reviewed for documentation of poor outcomes related to clonidine administration within 1 week of the hypertensive urgency visit date. RESULTS: In the preintervention cohort, 106 (17.4%) orders of clonidine were captured compared with 73 (10.6%) in the postintervention group (P = 0.001). Of the patients who were administered clonidine, 7 patients in the preintervention group were advised to go to the emergency department (ED) for additional hypertensive management, 2 of whom were subsequently hospitalized; 9 patients were advised to go to the ED in the postintervention group, and no patient was subsequently hospitalized. No adverse effects were documented from in-office clonidine administration in either cohort of patients. CONCLUSION: The hypertensive urgency protocol and education reduced the number of clonidine orders and hospital admissions. The increase in ED referrals needs further assessment.