Reducing opioid use for chronic pain in older adults.

PURPOSE: Implementation of the SAFE PAIN algorithm for reducing opioid use for chronic pain in older adults is described. SUMMARY: A multidisciplinary team at Sheppard Pratt Health System, the largest private provider of psychiatric care in Maryland, used lean methodology to identify the root causes for noncompliance to evidence-based practices for patients in the geropsychiatry unit treated for osteoarthritis or chronic back pain. The team collaborated to develop a facility-specific treatment algorithm, called SAFE PAIN (Sheppard Pratt Health System Algorithm For Elderly Patient Centered Analgesia Interdisciplinary Nagara), was based on the Center for Disease Control and Prevention's evidence-based recommendations that included nonpharmacologic interventions as a first-line therapy for patients with osteoarthritis or chronic back pain. Rates of prescribing new opioids and prescribing evidence-based alternative medications via the SAFE PAIN algorithm were evaluated from March 1 to September 30, 2017 and compared with baseline (2012-2016). The lean methodology interventions led to zero new opioid orders during the study period, a significant decrease compared with previous years (p < 0.01). The rates of prescribing evidence-based alternative medications increased significantly from the baseline period to postimplementation (p < 0.01). Lean methodology interventions also decreased waste in several processes. CONCLUSION: The prescribing rate of new opioids for osteoarthritis and chronic back pain decreased and the prescribing rate for evidence-based medications increased after implementation of the SAFE PAIN algorithm in a geropsychiatry unit.

Adjunctive probiotic microorganisms to prevent rehospitalization in patients with acute mania: A randomized controlled trial.

OBJECTIVE: Immunological abnormalities play a role in the pathophysiology of mania and have been associated with relapse. Probiotic organisms such as Lactobacilli and Bifidobacteria modulate inflammation in humans and animal models. The trial examined whether the administration of probiotic organisms prevents psychiatric rehospitalizations in patients recently discharged following hospitalization for mania. METHODS: Patients hospitalized for mania (N = 66) were randomized after discharge to receive 24 weeks of adjunctive probiotics (Lactobacillus rhamnosus strain GG and Bifidobacterium animalis subsp. lactis strain Bb12) or adjunctive placebo in a parallel two-group design format. The effect of treatment group on the risk of rehospitalization was calculated using Cox regression models. The modulating effect of systemic inflammation was measured employing an inflammation score based on immunoglobulin levels directed at previously defined antigens. RESULTS: During the 24-week observation period there were a total of 24 rehospitalizations in the 33 individuals who received placebo and eight rehospitalizations in the 33 individuals who received the probiotics (z = 2.63, P = .009). Hazard functions indicated that the administration of the probiotics was associated with a significant advantage in time to all psychiatric rehospitalizations (hazard ratio [HR] = 0.26, 95% confidence interval [CI] 0.10, .69; P = .007). Probiotic treatment also resulted in fewer days rehospitalized (mean 8.3 vs 2.8 days for placebo and probiotic treatment, respectively; χ2  = 5.17, P = .017). The effect of the probiotic treatment on the prevention of rehospitalization was increased in individuals with elevated levels of systemic inflammation at baseline. CONCLUSION: Probiotic supplementation is associated with a lower rate of rehospitalization in patients who have been recently discharged following hospitalization for mania.

Optimizing Pain Management Through Opioid Deprescribing.

The use of opioid drug therapy in older adults has increased over the past decade. Although use of opioid drugs may be clinically warranted, ongoing use needs to be monitored closely to evaluate risks and benefits, especially with the potential for adverse events and misuse. An opioid drug deprescribing protocol would provide clinicians with a method to assess an individual's need for opioid agents, as well as a systematic process to taper opioid drug therapy when deemed appropriate. Although more than 60 studies have reported methods for deprescribing, there is currently no established guideline for discontinuing opioid medications. The U.S. Department of Veterans Affairs has developed an algorithm to assist clinicians with opioid drug discontinuation decision making. As efforts to discontinue opioid drugs for chronic non-cancer pain in older adults continue to expand, nurses, as an integral part of the inter-professional team, will play a key role in monitoring and assessing patients' pain and care plans. [Journal of Gerontological Nursing, 44(1), 9-14.].

Lean Methodology Reduces Inappropriate Use of Antipsychotics for Agitation at a Psychiatric Hospital.

OBJECTIVE: To Evaluate the Effects of Applying Lean Methodology-Improving Quality Increasing Efficiency by Eliminating Waste and Reducing Costs-An Approach To Decrease the Prescribing Frequency of Antipsychotics for The Indication of Agitation. DESIGN: Historically Controlled Study. SETTING: Bheppard Pratt Health System is the Largest Private Provider of Psychiatric Care in Maryland With a Total Bed Capacity of 300. There Were 4 337 Patient Days From November 1 2012 to October 31 2013 on the Dementia Unit. PATIENTS: All Patients Admitted on the Dementia Unit Were 65 Years of Age and Older with a Primary Diagnosis of Dementia. INTERVENTION: our Multidisciplinary Team Used Lean Methodology to Identify the Root Causes and Interventions Necessary to Reduce Inappropriate Antipsychotic Use. MAIN OUTCOME MEASURES: The Primary Outcome Was Rate of Inappropriately Indicating Agitation as the Rationale When Prescribing Antipsychotic Medications. RESULTS: There Was a 90% (P < 0.001) Reduction in Rate Of Antipsychotic Prescribing with an Indication of Agitation. CONCLUSION: The Lean Methodology Interventions Led To A 90% (P < 0.001) Reduction in the Rate of Antipsychotic Prescribing with an Indication of Agitation and a 10% Rate Reduction in Overall Antipsychotic Prescribing. Key Words: Agitation Alzheimer's Antipsychotics Behavioral and Psychological Symptoms of Dementia Centers For Medicare & Medicaid Services Dementia Root-cause Analysis. ABBREVIATIONS: BPSD = Behavioral and Psychological Symptoms of Dementia CATIE-AD = Clinical Antipsychotic Trials of Intervention Effectiveness in Alzheimer's Disease EMR = Electronic Medical Records GAO = Government Accountability Office GNCIS = Geriatric Neuropsychiatric Clinical Indicator Scale.

Management of migraine headaches in a chronic pain patient: A case report.

Managing migraines complicated with medication overuse headaches and opioid-induced hyperalgesia can be challenging, especially within the geriatric and chronic pain population. A 65-year-old woman with a degenerative spine condition and chronic migraine headaches, along with other comorbidities, was admitted to the geriatric psychiatry unit for extreme mood swings and paranoia. Prior to admission, she had been taking extended-release morphine sulfate twice daily for more than a month and was unable to determine triggers to her frequent migraine headaches. She had a history of medication overuse and severe migraine episodes within 4 weeks prior to admission. This case report reviews the challenges of treating a geriatric patient with probable chronic migraines in addition to other pain conditions and comorbidities.

Effect of probiotic supplementation on schizophrenia symptoms and association with gastrointestinal functioning: a randomized, placebo-controlled trial.

OBJECTIVE: A range of immune system abnormalities have been associated with schizophrenia. Probiotic compounds modulate the immune response and offer a potential treatment strategy for schizophrenia. Probiotic compounds have also been observed to improve gastrointestinal dysfunction, which is a common problem in individuals with schizophrenia. We performed a randomized, double-blind, placebo-controlled trial to examine whether probiotic supplementation can reduce symptom severity in patients with schizophrenia receiving antipsychotic treatment and also whether probiotics are associated with bowel functioning. METHODS: Outpatients with schizophrenia (N = 65) meeting DSM-IV criteria and with at least moderately severe psychotic symptoms were enrolled in the study from December 2010-August 2012. Following a 2-week placebo run-in period, patients were randomly assigned to 14 weeks of double-blind adjunctive probiotic (combined Lactobacillus rhamnosus strain GG and Bifidobacterium animalis subsp. lactis strain Bb12) or placebo therapy. Psychiatric symptoms were assessed biweekly with the Positive and Negative Syndrome Scale (PANSS), and patients were queried weekly about their gastrointestinal functioning. RESULTS: Repeated-measures analysis of variance showed no significant differences in the PANSS total score between probiotic and placebo supplementation (F = 1.28, P = .25). However, patients in the probiotic group were less likely to develop severe bowel difficulty over the course of the trial (hazard ratio = 0.23; 95% CI, 0.09-0.61, P = .003). CONCLUSIONS: Probiotic supplementation may help prevent a common somatic symptom associated with schizophrenia. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01242371.

Understanding clinician perception of common presentations in South Asians seeking mental health treatment and determining barriers and facilitators to treatment.

BACKGROUND: Little is known about the presentation of mental health symptoms among South Asians living in the US. OBJECTIVE: To explore mental health symptom presentation in South Asians in the US and to identify facilitators and barriers to treatment. DESIGN: Focus group study. PARTICIPANTS: Four focus groups were conducted with 7-8 participants in each group. All participants (N = 29) were clinicians who had been involved in the care of South Asian patients with emotional problems and/or mental illness in the US. APPROACH: Qualitative content analysis. RESULTS: Key themes identified included: generational differences in symptom presentation, stress was the most common symptom for younger South Asians (<40 years of age), while major mental illnesses such as severe depression, psychosis and anxiety disorder were the primary symptoms for older South Asians (>40 years of age). Substance abuse and verbal/physical/sexual abuse were not uncommon but were often not reported spontaneously. Stigma and denial of mental illness were identified as major barriers to treatment. Facilitators for treatment included use of a medical model and conducting systematic but patient-centered evaluations. CONCLUSIONS: South Asians living in the US present with a variety of mental health symptoms ranging from stress associated with acculturation to major mental illnesses. Facilitating the evaluation and treatment of South Asians with mental illness requires sensitivity to cultural issues and use of creative solutions to overcome barriers to treatment.

Artemisinin reduces the level of antibodies to gliadin in schizophrenia.

OBJECTIVE: To investigate if adjunctive artemisinin, an anti-malarial compound with in vivo activity against Toxoplasma gondii, reduces symptoms or antibodies in schizophrenia. METHOD: N=66 outpatients with schizophrenia were randomized to receive 100mg of artemisinin twice a day or placebo for 10 weeks after a 2 week placebo run-in in addition to their usual psychiatric medications. Symptoms were assessed biweekly. Antibodies to toxoplasma and to gliadin, a food antigen, were assessed at the beginning and end of the trial. RESULTS: A total of 57 participants (26 in the artemisinin arm and 31 in the placebo arm) completed the 12 weeks of the trial. The medication was well tolerated and there were no significant side effects associated with the treatment regimen. There was no significant difference in the change of positive, negative, general, or total PANSS symptoms between groups for all of the randomized patients or for just the completers. However, individuals in the artemisinin arm but not in the placebo arm had significant decreases in the levels of antibodies to gliadin (p<.0005, p>.2, respectively by paired t-test). Neither group had significant changes in antibodies to T. gondii. CONCLUSIONS: The study did not demonstrate clinical benefit of adjunctive artemisinin for schizophrenia symptoms. The finding of reduced levels of antibodies to gliadin in the artemisinin group merits further study.