Medical Student Attitudes Toward Patients With Substance Use Disorder After Experiential Learning on an Addiction Psychiatry Consultation-Liaison Service: A Pilot Study.

BACKGROUND: Stigma surrounding substance use disorder (SUD) is highly prevalent in health care. Negative attitudes toward patients with SUD have been shown to negatively impact patient care. Addressing SUD stigma in medical students is a promising approach, however, few curricula include experiential learning on addiction psychiatry clinical services. We describe a medical student rotation on an addiction psychiatry clinical service and examine its effect on attitudes toward patients with SUD. METHODS: Medical students were integrated onto an addiction psychiatry consultation-liaison service serving medically/surgically hospitalized patients with co-occurring SUD and other psychiatric disorders. Students learned and practiced in-person assessment of patients and received instruction on basic principles of psychiatry and evaluation and management of SUD. A targeted anti-stigma curriculum was included. Attitudes toward patients with SUD were measured with the Medical Condition Regard Scale (MCRS) before and after the experience. Each item of the MCRS and an overall composite attitude score were analyzed. RESULTS: Of the 36 students on the clinical rotation, 33 completed the survey. Attitudes showed widespread improvement toward patients with SUD. Mann-Whitney U tests showed significant improvement in most items of the MCRS. Further analysis of composite scores showed an improvement in overall attitudes toward patients with SUD. CONCLUSIONS: Inclusion of medical students on an addiction psychiatry consult service as part of the core psychiatry clerkship may hold promise for helping improve student attitudes and decrease stigma toward patients with SUD. Controlled study is needed to compare other clinical experiences and determine specific causative effects.

Phenobarbital Versus Benzodiazepines for the Treatment of Severe Alcohol Withdrawal.

BACKGROUND: Phenobarbital may offer advantages over benzodiazepines for severe alcohol withdrawal syndrome (SAWS), but its impact on clinical outcomes has not been fully elucidated. OBJECTIVE: The purpose of this study was to determine the clinical impact of phenobarbital versus benzodiazepines for SAWS. METHODS: This retrospective cohort study compared phenobarbital to benzodiazepines for the management of SAWS for patients admitted to progressive or intensive care units (ICUs) between July 2018 and July 2022. Patients included had a history of delirium tremens (DT) or seizures, Clinical Institute Withdrawal Assessment of Alcohol-Revised (CIWA-Ar) >15, or Prediction of Alcohol Withdrawal Severity Scale (PAWSS) score ≥4. The primary outcome was hospital length of stay (LOS). Secondary outcomes included progressive or ICU LOS, incidence of adjunctive pharmacotherapy, and incidence/duration of mechanical ventilation. RESULTS: The final analysis included 126 phenobarbital and 98 benzodiazepine encounters. Patients treated with phenobarbital had shorter median hospital LOS versus those treated with benzodiazepines (2.8 vs 4.7 days; P < 0.0001); a finding corroborated by multivariable analysis. The phenobarbital group also had shorter median progressive/ICU LOS (0.7 vs 1.3 days; P < 0.0001), and lower incidence of dexmedetomidine (P < 0.0001) and antipsychotic initiation (P < 0.0001). Fewer patients in the phenobarbital group compared to the benzodiazepine group received new mechanical ventilation (P = 0.045), but median duration was similar (1.2 vs 1.6 days; P = 1.00). CONCLUSION AND RELEVANCE: Scheduled phenobarbital was associated with decreased hospital LOS compared to benzodiazepines for SAWS. This was the first study to compare outcomes of fixed-dose, nonoverlapping phenobarbital to benzodiazepines in patients with clearly defined SAWS and details a readily implementable protocol.

Rewriting the Hidden Curriculum via Addiction Consult Services: Meeting Patients Where They Are At.

Addiction Consult Services (ACS) deliver evidence-based care for patients with substance use disorder (SUD) during the course of general hospital admissions. Stigma toward patients with SUD is a known phenomenon and is part of the "hidden curriculum" that permeates medical training and healthcare settings. ACS have the potential to rewrite the hidden curriculum around SUD and to teach medical students and other trainees how to compassionately care for this patient population. Here, the authors explore the role of stigma within the hidden curriculum of medical training and outline how ACS can successfully contribute to combatting this stigma. The authors highlight two institutions' approaches to educational initiatives that incorporate health professional trainees into ACS. The authors end by providing a vision of how expansion of ACS can promote interdisciplinary learning for healthcare providers amidst the changing landscape of SUD treatment in the USA.

Impact of Hospital-Administered Extended-Release Naltrexone on Readmission Rates in Patients With Alcohol Use Disorder: A Pilot Study.

Objective: To evaluate the impact of extended-release (ER) intramuscular naltrexone on readmission rates for hospitalized patients with alcohol use disorder (AUD).Methods: This was a single-center, retrospective before and after study. Adult patients with AUD who received ER naltrexone prior to discharge between June 29, 2020, and November 30, 2020, were included in the study. The primary outcome measure was alcohol-related readmission 90 days after ER naltrexone administration. Secondary outcomes were the number of emergency department visits, length of hospital stay, and time between hospital admissions. Patients served as their own controls before and after ER naltrexone administration, and data were collected from the electronic medical records. Comparative analysis was performed using descriptive statistics and paired Student t test.Results: 58 patients received ER naltrexone during the study period, with a mean (SD) pre and post 90-day admission rate of 0.60 (1.14) and 0.71 (1.27), respectively, P = .56. Number of emergency department visits before and after the intervention were 0.5 (1.06) and 0.48 (1.40), respectively, P = .93. Length of hospital stay decreased after naltrexone administration (2.92 [1.95] vs 1.18 [1.78] days, P < .005).Conclusion: There was no major difference in the number of hospitalizations or emergency department visits, but there was a decreased length of hospital stay in patients who received ER naltrexone prior to hospital discharge for the treatment of AUD.

A call for increased addiction psychiatrist engagement in medical student education.

BACKGROUND AND OBJECTIVES: Addiction psychiatrists are ideally trained to provide trainees with supervised clinical experiences in caring for patients with co-occurring substance use disorders and other complex psychiatric disorders. METHODS: This is a call for addiction psychiatrists to step up as clinical champions in medical student education. Our targeted audience is practicing addiction psychiatrists who do not currently have medical students on their clinical services. RESULTS: We suggest several approaches to incorporating learners into existing addiction psychiatry clinical services both at academic institutions and in the community. DISCUSSION AND CONCLUSIONS: For medical schools without addiction psychiatrists on faculty, we suggest unique solutions for collaborating with external educational venues. SCIENTIFIC SIGNIFICANCE: There is limited literature on the role of addiction psychiatrists in providing supervised experiential learning experiences for medical students. There has been no previous publication specifically advocating for increased addiction psychiatrist engagement in the clinical education of medical students.

A Proposal for Addiction and Infectious Diseases Specialist Collaboration to Improve Care for Patients With Opioid Use Disorder and Injection Drug Use-Associated Infective Endocarditis.

ABSTRACT: Patients with injection drug use-associated infective endocarditis and opioid use disorder often receive treatment for the infection that fails to address its underlying cause. People who inject drugs (PWID) and develop serious infections also face disparities in antibiotic management, particularly with regards to use of outpatient parenteral antimicrobial therapy (OPAT). We highlight literature on OPAT in PWID challenging the notion that PWID cannot be managed with OPAT. Given that OPAT use amongst PWID and non-PWID yields similar outcomes, we argue that a bias against OPAT use in PWID is unwarranted and may reflect stigma rather than data. We further note the proven value of comprehensive OUD treatment on endocarditis treatment outcomes, which also addresses the potential safety concerns of OPAT in PWID, and propose a treatment model in which Addiction and Infectious Disease specialists collaborate to integrate opioid use disorder treatment into injection drug use-associated infective endocarditis care.

Occult Untreated Alcohol Use Disorder in a Patient with Recurrent Pituitary Macroadenoma.

Alcohol use disorder (AUD) is a chronic relapsing and remitting psychiatric condition associated with adverse health outcomes. Although common, AUD is underdiagnosed, and treatment is often overlooked. At times of increased risk, such as the postoperative period, it is imperative to screen for and treat AUD to improve patient outcomes. Psychiatrists can play an important role in addressing AUD in this patient population through addiction psychiatry consultation services. We present the case of a patient with occult alcohol use disorder (AUD) leading to hospitalization in the setting of depressive mood symptoms and personality changes after a repeat pituitary macroadenoma resection and radiation five months earlier. AUD was noted months prior to hospitalization but was not addressed despite regular interactions with the healthcare system. Evaluation by addiction psychiatry specialists during hospitalization prompted recognition and treatment of AUD, resulting in cessation of alcohol use and resolution of mood symptoms and personality changes. The patient was discharged 3 days after admission and maintained abstinence from alcohol at two months postdischarge without recurrence of psychiatric symptoms.

Feelings and the Patient-Doctor Relationship.

In this autobiographical piece about conducting psychotherapy with a patient during residency training, a physician reflects on the shared humanity between patients and doctors and the feelings that unite them.