Opioid Use Disorder among Hospitalized Adults in North Carolina: Analysis from the 2000-2020 NC State Inpatient Database.

OBJECTIVES: Opioid use disorder (OUD) is characterized as a chronic condition that was first outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and now the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. It encompasses frequent opioid usage, cravings, the development of tolerance, withdrawal symptoms upon discontinuation, unsuccessful attempts to quit or reduce use, and recurrent use even when faced with negative consequences. Both national- and state-level data show that overdose deaths associated with prescription opioids are increasing at an alarming rate. The increasing overdose deaths from illicitly manufactured fentanyl and other synthetic opioids compound this epidemic's burden. The present study sought to determine the prevalence and potential factors associated with OUD in North Carolina. METHODS: Using the State Inpatient Database, a retrospective cross-sectional study was conducted to identify OUD-related discharges between 2000 and 2020. Descriptive statistics and rates of OUD per 1000 discharges were calculated. Simple and multivariable logistic regression models were used to identify factors associated with increased odds of having an opioid use disorder diagnosis at discharge. The deviance-Pearson goodness of fit statistic was also used. Variables were identified using International Classification of Diseases, Ninth Revision, Clinical Modification, and International Classification of Diseases, Tenth Revision, Clinical Modification, codes in the discharge records. RESULTS: Of 19,370,483 hospitalizations that occurred between 2000 and 2020 in North Carolina, 483,250 were associated with OUD, a prevalence rate of 24.9 cases per 1000 discharges. The highest OUD rates were seen among adults who self-paid for their hospitalization, those with Medicaid, and those with other types of payors such as Workers' Compensation and the Indian Health Service; individuals between 25 and 54 years old; tobacco and alcohol users; Native American patients; patients located in urban areas; patients with lower household income; White patients; and female patients. OUD also was associated with increased odds of having one or more comorbid psychiatric disorders when controlling for other factors. CONCLUSIONS: Although preventive measures are crucial, including policies that discourage prescribing opioids for noncancer pain and those that target the manufacturing and distribution of synthetic opioids, providing integrated care for patients with OUD and co-occurring psychiatric and/or physical disorders is equally important. These findings suggest the need for a system-wide public health response focused on the expansion of primary prevention and treatment efforts, including crisis services, harm reduction services, and recovery programs.

Substance Use Disorders among Adolescents in the United States: 2000-2019.

OBJECTIVES: Substance use disorders (SUDs) are characterized by impairment caused by the recurrent use of alcohol, illicit drugs, or both. SUDs are pervasive and endemic among US adolescents, with potentially negative health and social consequences. Although the term experimentation normalizes adolescent substance abuse, the long-term consequences of this behavior beginning in adolescence can be detrimental to not only the adolescent but also the adult into which he or she develops. Our objective was to examine the epidemiology of SUD among hospitalized US adolescents, 13 to 19 years of age, during the time period 2000-2019. METHODS: A case-control study was conducted using 5,260,104 hospital discharge records (394,952 SUD and 4,865,152 non-SUD) from the 2000-2019 Kids' Inpatient Database. SUD and clinical outcomes variables were identified based on the International Classification of Diseases, Ninth/Tenth Revisions, Clinical Modification, coding. SUD rates (per 1000 discharges) were calculated and adjusted odds ratios (aORs) with their 95% confidence intervals (CIs) were computed using logistic regression models for predictors of SUDs among hospitalized adolescents. RESULTS: The prevalence of SUDs was estimated to be 75.10 cases per 1000 discharges (95% CI 74.86-75.31). Demographically, the highest crude rates (per 1000 discharges) were seen among Native American (139.58) and White (91.97) patients. Adolescent patients who experienced SUD were twice as likely as nonusers to be 16 to 19 years of age (aOR 2.2, 95% CI 2.13-2.19) or to be male (aOR 2.2, 95% CI 2.22-2.27). SUD was significantly associated with cooccurring conditions, including anxiety (aOR 2.5, 95% CI 2.48-2.53), depression (aOR 2.3, 95% CI 2.30-2.35), mood disorder (aOR 2.17, 95% CI 2.14-2.20), schizophrenia (aOR 2.6, 95% CI 2.52-2.64), sexually transmitted infections (aOR 2.3, 95% CI 2.23-2.45), hepatitis (aOR 3.0, 95% CI 2.87-3.15), and suicide (aOR 1.33, 95% CI 1.30-1.35). CONCLUSIONS: The study examined the epidemiology, risk factors, and common characteristics of hospitalized adolescent patients with SUDs. The high burden of psychiatric and medical comorbidities observed among this patient group warrants designing effective and comprehensive substance use prevention and treatment programs for youths.

Nationwide Assessment of Chronic Pain among Hospitalized Individuals with Co-occurring Post Traumatic Stress Disorder and Substance Use Disorder in the United States.

Objective: Chronic pain (CP) is independently associated with substance use disorders (SUD) and posttraumatic stress disorder (PTSD). However, little is known about factors associated with CP among patients with co-occurring PTSD and SUD. Patterns of hospital resource usage should also be explored further. Methods: Using the 2019 National Inpatient Sample (NIS), we identified 216,125 hospital discharges with co-occurring diagnoses of PTSD and SUD in 2019 and examined their association with CP. Multivariable logistic regression models were used to identify factors associated with an increased likelihood of CP in this cohort. Results: Among those with co-occurring PTSD and SUD (N = 216,125), 35,450 had associated CP, a prevalence of 164.02 cases per 1,000 discharges (95% CI [160.54, 167.52]). Individuals aged 55-64 with co-occurring PTSD and SUD were approximately 7.2 times more likely to experience CP, compared to those aged 16-24 (OR = 7.2; 95% CI [6.09, 8.60]). Being in the CP group was associated with 50% increased odds of insomnia and obesity (OR = 1.5; 95% CI [1.12, 2.03] and OR = 1.5; 95% CI [1.38, 1.55], respectively), 30% increased odds of anxiety (OR = 1.3; 95% CI [1.24, 1.38]), 20% increased odds of attention deficit disorder (ADD;OR = 1.2; 95% CI [1.12, 1.38]) and 10% increased odds of depression (OR = 1.1; 95% CI [1.01, 1.14]). Compared with females, being male was associated with slightly decreased odds of CP (OR = 0.9; 95% CI [0.84, 0.94]). Conclusions: Among hospitalized Americans with co-occurring PTSD and SUD, advanced age, being female, and the presence other mental health disorders were associated with an increased risk of CP. Providers treating co-occurring PTSD/SUD should evaluate for and consider evidence-based management of CP if present.

Substance Use Disorder among Hospitalized Adolescents in North Carolina.

OBJECTIVES: Individuals who began using alcohol or other drugs before the age of 15 are 7 times more likely to develop a substance use disorder (SUD) in adulthood. This study sought to determine the common characteristics of SUD-related hospitalizations and patterns of discharge diagnoses among adolescents in North Carolina. METHODS: Using the 2014 State Inpatient Database (SID), discharge records associated with the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic codes for SUD were identified. Adolescents between the ages of 13 and 19 years were included. SUD and non-SUD groups were compared using the Student t test for continuous variables and the χ2 test for categorical variables. A total of 1.1 million hospital discharges were analyzed. A uniform and standardized coding system called Clinical Classifications Software was used to identify cases. The Clinical Classifications Software collapses the ICD-9-CM codes into 679 clinically meaningful categories. A cluster of 3900 ICD-9-CM procedure codes also was used to identify clinically relevant groups of procedures performed during hospitalization. RESULTS: An estimated 3276 adolescents associated with SUD were discharged from North Carolina hospitals during the study year. Discharged patients with a SUD spent a total of 21,242 inpatient days, at a cost of $62 million. Among the adolescents with a SUD, 53% were boys, 62% were White, 24% were Black, 8% were Hispanic (8%), and 6% were of other races. Compared with patients without a SUD, those with a SUD had longer mean hospital stays (6.5 days vs 4.7 days; P < 0.0001) and lower mean hospital charge per hospitalization ($18,932 vs 24,532; P < 0.0001). Adolescents with a SUD also were diagnosed primarily as having mood disorders (44.78%), followed by schizophrenia and other psychological disorders, upon discharge. Approximately 37% of the SUD-related discharges occurred in areas, denoted in this study using ZIP code designations, with mean household annual incomes <$38,999. A large proportion of the SUD-related hospitalizations (44%) were billed to Medicaid. Frequently observed diagnoses associated with adolescents with a SUD were mood disorders (45%), schizophrenia (7%), and poisoning by other medications and drugs (4%). In 16% of hospitalized adolescents with a SUD, there were at least 2 procedures performed. There was a statistically significant mean hospital charge difference of $5600 between SUD and non-SUD teens. CONCLUSIONS: The literature reflects the connection between adolescent use and the propensity for diagnosis with a SUD in adulthood; it is evident that this is a growing public health crisis. This study identified patterns of adolescent substance use that, based on the current literature, are indicative of problematic futures for these individuals. The concerning data and literature identify a significant need to address prevention, treatment, and recovery services for adolescents, not only in North Carolina but throughout the United States. The need for focused interventions, access to care, and funding of substance-specific adolescent education and services is greatly needed to change the trajectory of these adolescents' lives.

Patient and Hospital Characteristics of Newborns with Neonatal Withdrawal Syndrome.

OBJECTIVES: We sought to evaluate hospital resource usage patterns and determine risk factors for neonatal withdrawal syndrome (NWS) in the United States. METHODS: Using the 2016 Kids' Inpatient Database (KID), we conducted a retrospective cross-sectional analysis of a nationally representative sample of neonates with NWS. The KID is the largest publicly available pediatric (20 years of age and younger) inpatient care database in the United States. We analyzed a stratified probability sampling of 3.1 million pediatric hospital discharges weighted to 6.3 million national discharges. Descriptive statistics for hospital and patient characteristics were identified and binary variables were analyzed using the Student t test. Multivariate regression was performed to assess the predictors of NWS. We excluded discharges if total cost or hospital length of stay (LOS) exceeded mean values by >3 standard deviations. Hospitalizations with NWS diagnosis were identified using the International Classification of Diseases, 10th Revision, Clinical Modification code P96.1 in any 1 of 30 discharge diagnostic fields. RESULTS: We estimated that 25,394 pediatric discharges were associated with an NWS diagnosis, totaling 403,127 inpatient days at a cost of $1.8 billion. Compared with non-NWS newborns, neonates with NWS had higher mean hospital charges ($71,540 vs $15,765), longer mean hospital stays (16 days vs 3 days), and a significantly higher proportion of low birth weight (7.2% vs 1.9%), feeding problems (19.0% vs 3.5%), respiratory diagnoses (5.6% vs 2.5%), and seizure (0.3% vs 0.1%). Among newborns with NWS, 53% were boys, 80.0% were white, 7.2% were black, 7.4% were Hispanic, and 5.3% were of other races. Hispanic neonates had the highest mean hospital charges and LOS of any other ethnic group ($123,749, 21 days). The largest proportion (83.0%) of NWS-related hospital stays were billed to Medicaid, followed by private insurance (10.3%) and self-pay (4.8%). More than one-third of NWS-related discharges (39.3%) occurred in areas with the lowest mean household annual income (≤$42,999) compared with 28.4% of neonates without NWS. Most NWS cases (53%) had ≥5 diagnoses, compared with 11% of non-NWS neonates. In the multivariate analysis, neonates with a birth weight <2500 g, feeding problems, respiratory diagnoses, seizure, >4 diagnoses, LOS >5 days, rural hospitals, Medicaid, and low-income households were significantly associated with NWS. There was a statistically significant mean hospital charge difference of $55,775 between NWS and non-NWS neonates. CONCLUSIONS: Since 2000, the number of infants treated for NWS in the US neonatal intensive care units has increased fivefold, accounting for an estimated $1.5 billion in annual hospital expenditures. The high hospital resource usage among NWS neonates raises the possibility that care for expectant mothers who use opiates and their newborns may be able to be delivered in a more efficient and effective manner. Because the majority of the study population was covered by Medicaid programs, state policy makers should be mindful of the impact the opioid crises continue to have on expectant mothers and their infants.

Assessment of current occupational safety and health regulations and legislation in the Caribbean.

Neglecting occupational safety and health (OSH) can have adverse and even deadly consequences. While OSH is important in any nation, the issue is particularly concerning in developing countries, including ones in the Caribbean. The purpose of this study, which was carried out in 2012 and 2013, was to examine the reasons for an apparent fundamental lack of awareness of OSH in the Caribbean. We conducted a descriptive study, in which a questionnaire was administered, via telephone, to key policy-making representatives from six English-speaking Caribbean nations, in order to assess the current OSH environment in their countries. We also did a situational analysis of current OSH regulations and legislation within the six countries. We found that that some of the countries' OSH laws are out of date or are limited to a certain type of industry. We also found that there is very little documentation on research on exposure to and risks from hazards and on psychological and reproductive health as related to OSH. It is recommended that these Caribbean countries both increase national OSH awareness and strengthen enforcement of OSH regulations. Additionally, further assistance and a more coordinated effort from intergovernmental bodies could help build and fortify OSH systems in the Caribbean.

Severe Illness Associated with Reported Use of Synthetic Cannabinoids - Mississippi, April 2015.

On April 2, 2015, four patients were evaluated at the University of Mississippi Medical Center (UMMC) in Jackson, Mississippi, for agitated delirium after using synthetic cannabinoids. Over the next 3 days, 24 additional persons went to UMMC with illnesses suspected to be related to synthetic cannabinoid use; one patient died. UMMC notified the Mississippi State Department of Health, which issued a statewide alert via the Health Alert Network on April 5, requesting that health care providers report suspected cases of synthetic cannabinoid intoxication to the Mississippi Poison Control Center (MPCC). A suspected case was defined as the occurrence of at least two of the following symptoms: sweating, severe agitation, or psychosis in a person with known or suspected synthetic cannabinoid use. A second statewide alert was issued on April 13, instructing all Mississippi emergency departments to submit line lists of suspected patients to MPCC each day. By April 21, 16 days after the first alert was issued, MPCC had received reports of approximately 400 cases, including eight deaths possibly linked to synthetic cannabinoid use; in contrast, during April 2012­March 2015, the median number of telephone calls to MPCC regarding synthetic cannabinoid use was one per month (range = 0­11). The Mississippi State Department of Health, with the assistance of CDC, initiated an investigation to better characterize the outbreak, identify risk factors associated with severe illness, and prevent additional illnesses and deaths.

Association between pain and e-cigarette use stratified by cigarette smoking status: Results from National Health Interview Survey (NHIS) 2019-2020.

INTRODUCTION: Previous studies have shown frequent co-morbidities between pain and tobacco use. However, the investigation in use of e-cigarettes, a relatively new tobacco product, at the intersection of pain and cigarette smoking is still lacking. This study used a US national dataset to examine associations between pain experience (pain lasting 3 months) and e-cigarette use, stratified by cigarette smoking status. METHODS: This study used a pooled dataset of the 2019 and 2020 National Health Interview Survey (NHIS) (N = 63,565). We estimated multivariable binomial logistic regressions predicting current e-cigarette use by pain experience, after controlling for survey year, age, sex, race/ethnicity, sexual orientation, education level, health insurance status, other tobacco use, diagnosis of anxiety and depression, use of pain management methods (e.g., physical therapy, behavioral therapy), and prescribed opioid pain reliever use among the overall population, and stratified by cigarette smoking status - never, former, and current cigarette smoking. RESULTS: After controlling for covariates, past-3-month pain experience was associated with current e-cigarette use (aOR = 1.26; 95 % CI = 1.08, 1.46) in the overall population. When stratified by current cigarette smoking, pain experience was associated with current e-cigarette use among current combustible cigarette smokers (aOR = 1.62, 95 % CI = 1.20, 2.18). However, there was no significant difference in e-cigarette use by pain experience among non-current cigarette smokers (p = 0.103). CONCLUSIONS: We observed a higher likelihood of e-cigarette use among US adults experiencing pain. Future studies are needed to investigate mechanisms linking pain and e-cigarette use to inform smoking/vaping prevention and cessation interventions.

Prevalence and hospital resource usage associated with substance use disorder among hospitalized adolescents in the United States.

We sought to determine common characteristics of SUD-related hospitalizations and patterns of discharge diagnoses among adolescents in the United States. Using the 2016 KID, a cross-sectional study was conducted to identify discharge records associated with ICD-10-CM diagnostic codes for SUD. Adolescents between the ages of 13 and 19 were included. SUD and non-SUD groups were compared using the Student's t-test for continuous variables and the χ2 test for categorical variables. A total of 6.7 million hospital discharges were analyzed. A uniform and a standardized coding system were used to identify cases. Subgroup comparative analysis for length of stay, hospital charge, and common discharge diagnoses was performed. A weighted estimate of 94,732 adolescents associated with SUD was discharged from the U.S. hospitals during the study year. Teens with SUD accounted for 510,268 days of inpatient days in the U.S. community hospitals accounting for a total charge of $3,070,948,580. The average LOS for all SUD teens in the U.S. was 5.4 days with a mean charge per discharge of $32,754, indicating higher LOS but a significantly lower mean charge compared to non-SUD teens (4.1 days; $39,657). In 2016, more than 88% of SUD patients had ≥ 3 diagnoses compared to non-SUD patients (76%) (P < 0.0001 for all). The most frequently observed diagnosis associated with teens with SUD was psychoses, depressive neuroses, and alcohol use disorder. With one in ten teenagers found with an SUD, early substance initiation still appears to be an important public health issue. Unfortunately, the health and economic impact of substance use in adolescence on society are huge requiring effective strategies targeted to this population. The concerning data and literature identify a significant need to address prevention, treatment, and recovery services for adolescents throughout the United States.

Latent Class Analysis of Maternal Comorbid Conditions among Hospitalized Pregnant Women Diagnosed with Opioid Use Disorders in North Carolina.

BACKGROUND: Pregnant women are among the groups most affected by the United States opioid epidemic. OBJECTIVES: To determine latent classes of maternal comorbidities, examine their relationship to opioid use disorder (OUD), and how they can predict hospital discharge status among hospitalized pregnant women with and without OUD. STUDY DESIGN: This is a cross-sectional study. SETTING: Hospitals in North Carolina. METHODS: A latent class analysis (LCA) was performed using 929,085 hospital discharge records from the 2000-2014 State Inpatient Databases for North Carolina. We defined OUD status and 24 maternal comorbid conditions based on International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes and Clinical Classification Software codes, respectively. Discharge status was categorized as home, institution, or died. Binary and multinomial logistic regression models were constructed adjusting for demographic and hospital characteristics. RESULTS: LCA of maternal comorbid conditions resulted in 591,745 records belonging to Class 1 (birth complications) and 337,340 records belonging to Class 2 (pre-existing and pregnancy-related morbidities). Class 2 records less frequently belonged to patients with OUD than those without OUD, and more frequently to younger, Black/Hispanic/other race or ethnicity, and patients with a higher socioeconomic status who resided in large metropolitan areas. Non-Medicare primary payers were more likely among Class 2 records. Irrespective of OUD status, patients belonging to Class 2 were less likely to be discharged to an institution or be deceased, controlling for confounders. LIMITATIONS: Administrative database; data clustering; misclassification bias; confounding bias; temporality; data-driven approach; generalizability. CONCLUSIONS: Hospitalized pregnant women may be classified based on comorbid conditions into 2 latent classes ("birth complications" and "pre-existing and pregnancy-related morbidities"), with the former exhibiting greater OUD frequency than the latter. These findings can inform health care needs of populations with a high-risk for OUD.

Traumatic brain Injury related schizophrenia in individuals without family history: A case series.

Traumatic brain injury (TBI) related mental disorder has been hypothesized in the literature before 1969 as the etiology of schizophrenia. TBI has been described as a complex of multiple genetic factors and interacting non-genetic factor influence. Most research on non-genetic factors has focused on the period from conception through childhood. Thus far, there is no evidence suggestive of schizophrenic features for individuals without family history of mental health disorder following TBI in adulthood. Hence, we present these case series of three different TBI related schizophrenia with no past psychiatric history nor positive family psychiatric background. Though there are scientific reports suggesting association between TBI and schizophrenia, most of the links are either based on pre-teen exposure to TBI or positive family history of mental illness. Discussed in line of current literature, this case series adds to the body of evidence on adult TBI related schizophrenia in individuals with no family history of mental health disorder.

Characteristics of Hospitalized Adults with Opioid Use Disorder in the United States: Nationwide Inpatient Sample.

BACKGROUND: Although the clinical significance and treatment management of opioid use disorder (OUD) is sufficiently discussed, utilization of healthcare services associated with OUD has not been adequately studied in the United States. OBJECTIVE: To provide a descriptive assessment of the utilization of health care services for adults with OUD in the United States. STUDY DESIGN: A retrospective cross-sectional study design based on the National Inpatient Sample (NIS) developed by the Healthcare Cost and Utilization Project. SETTING: All OUD cases included in the 2016 NIS database. Adults aged 18 years or older were included in the study. METHODS: We analyzed a stratified probability sampling of 7.1 million hospital discharges weighted to 35.7 million national discharges. We used ICD-10-CM codes to identify OUD cases. Groups were compared using the Student's t-test for continuous variables and the chi-square test for categorical variables. Total cost per hospital discharge was determined by converting the total per case hospital charge to a hospital cost estimate (estimate = total charges X hospital cost-to-charge ratio). RESULTS: In 2016, an estimated 741,275 Americans were associated with OUD. Among patients with OUD, 73% were White, 12% were African-American, 8% were Hispanic, 0.6% Asian-American/Pacific Islander, 0.9% were Native Americans, and 2% were other race; 49% of patients with OUD were women. A large proportion (43%) of the OUD hospitalizations were billed to Medicaid. The average hospital length of stay for all OUD patients was 5.6 days, and the average cost per discharge was $11,233. A higher average LOS was observed for patients who died during hospitalization (8.4 days), Asian-American/Pacific Islander patients (6.8 days), patients covered by self-pay (6.8 days), patients with median household income of 71,000 or more (5.8 days), patients discharged from hospitals in the Northeast ($10,540) and patients discharged from hospitals in large hospitals ($12,570). The most frequently observed diagnosis associated with patients with OUD were alcohol/drug abuse or dependence, psychosis, and septicemia. LIMITATIONS: These data sources are comprised of hospital discharge records, originally collected for billing purposes, and may be subject to provider biases and variations in coding practices. CONCLUSIONS: In the United States, very few health issues have garnered the attention of such diverse sectors as the opioid crisis. Our analysis of 2016 NIS data found that patients with OUD accounted for approximately 740,000 discharges that year. This represents about a 55% increase over 2015. We also demonstrate that inpatient settings provide a unique opportunity for targeting evidence-based, comprehensive interventions at patients with OUD. Key words: Opioid use disorder, discharge diagnosis, hospital resource utilization, cost-to-charge ratio, HCUP, NIS, AHRQ.

Temporal trends in rates of opioid misuse among delivery-related hospitalizations in North Carolina from 2000 to 2014.

Opioid misuse during pregnancy is increasing at an alarming rate across the United States. To determine the prevalence, temporal trends, and resource usage of delivery-related hospitalizations of women who misuse opioids in North Carolina from 2000 to 2014. A retrospective, cross-sectional study was conducted using the State Inpatient Databases. Annual prevalence was calculated, and linear trends were assessed using logistic regression. Temporal trends in hospital charges and length of stay (LOS) were analyzed using ordinary least squares regression with a loge-transformed response. Of 1,937,455 delivery-related hospitalizations in NC, 6,084 were associated with opioid misuse, a prevalence of 3.14 cases per 1,000 delivery-related discharges. During the study period, the prevalence of opioid misuse during pregnancy in NC increased 955%, from 0.9 cases per 1,000 discharges in 2000 to 9.5 cases per 1,000 discharges in 2014, an average annual rate increase of 1.18 cases (95% CI, 1.16-1.21; P < 0.0001). Median LOS for women who misuse opioids remained stable at three days, whereas the median charge per delivery-related hospitalization significantly increased from $6,311 in 2000 to $9,019 in 2010 (annual average change [AAC], 282.2; 95% CI, 182.9-381.5; P < 0.0001) and from $8,908 in 2011 to $10,864 in 2014 (AAC, 667.5; 95% CI, 275.2-1059.9; P < 0.0001). Health care providers and policymakers in NC are advised to introduce system-wide public health responses focused on prevention and increased access to evidence-based treatment that improves the health of the mothers and neonates who are exposed to opioids.

Clozapine Response for Vocal Tics in Schizophrenic Patients: A Case Report With Literature Review.

Antipsychotics have been documented in the literature as the most effective pharmacological treatment for tics thus far. Additionally, evidence in the literature has shown that typical and atypical antipsychotics are effective for the treatment of tic disorders in patients who are diagnosed with schizophrenia and other psychiatric illnesses. This evidence is typified as atypical antipsychotic medications, such as risperidone, aripiprazole, and olanzapine, have been documented as being effective for motor tics, particularly in Tourette's syndrome. Despite the level of evidence with regard to antipsychotics, there is no published literature on the role of clozapine-based treatment for persistent vocal tics in schizophrenia. We present a case of severe adult-onset persistent vocal tics in a schizophrenic patient who was admitted for acute psychotic exacerbation. The patient's vocal tics as well as his comorbid psychotic symptoms were not responsive to risperidone and paliperidone. The combination of risperidone with clozapine for psychosis showed improvements in his symptoms. In addition, the patient's tics showed excellent response to risperidone and clozapine combination therapy. He was subsequently discharged to the community with clozapine 125 mg twice daily and paliperidone palmitate 156 mg every 28 days. The patient was psychiatrically stable without vocalization at the time of discharge. We suggest that clozapine augmentation therapy could be an approach in treatment-resistant vocal tics among schizophrenic patients who are refractory to atypical antipsychotics.

Catatonia Presentation as a Rare Alcohol Withdrawal Symptom in a Patient With No Past Psychiatry History: A Case Report.

A complicated alcohol withdrawal syndrome (AWS) includes epileptic seizures and/or delirium tremens (DT). However, there is still a dearth of literature for catatonia as a consequence of AWS especially in terms of clinical reports. Secondly, the few noted reported cases in the literature were mainly of non-American populations. Hence, we present the case of a middle-aged woman with no past psychiatric history admitted for psychosis and altered sensorium with delayed catatonic features in the context of a history of alcohol use disorder. Ms. M., a 44-year-old African American female with no past psychiatric history but a past medical history of gastric bypass surgery, presented to the psychiatric emergency department via emergency medical service due to roaming the street because of acute onset of altered mental status and psychotic features. She had a Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA) score of 33 following last alcohol use a few hours prior to presentation. While on the inpatient unit, the patient had an isolated episode of catatonic stupor despite being administered lorazepam 2mg every four hours as needed. Supportive medical staff should also be aware of catatonia as a rare manifestation of alcohol withdrawal. A persistent, thorough medical workup and evidence-based "investigative" history gathering can help elucidate the source of the presenting symptom in this patient population.

Opioid use disorder among hospitalized adults in North Carolina: Comparative analysis of national and statewide trends.

OBJECTIVE: Hospital resource utilization is reported to be higher among patients with opioid use disorder (OUD) compared with those without OUD at national and local levels. However, utilization of healthcare services associated with OUD in North Carolina (NC) has not been adequately characterized. We describe inpatient hospital resource utilization among adults with an OUD-diagnosed in NC and the United States (US). We hypothesize that hospitalized adults with OUD will have longer hospital stays, more frequent use of emergency services, a higher number of diagnoses, and comparable hospital charges compared with hospitalized adults without OUD. DESIGN: A retrospective cross-sectional study analyzing hospital discharge abstracts included in the 2016 NC State Inpatient Databases (SIDs) and the 2016 National Inpatient Sample (NIS). OUD and non-OUD groups were compared using the Student's t-test for continuous variables and the χ2 test for categorical variables. PARTICIPANTS: Adults 18 years and older from SID (n = 25,871) and NIS (n = 148,255) databases were included in the analysis. MAIN OUTCOME MEASURES: Length of stay (LOS), use of emergency services, discharge diagnosis, and hospital charge among hospitalized adults with OUD. RESULTS: In NC, patients with OUD were younger (age 18-35), more likely to be white, and more likely to be hospitalized in areas with the lowest median income compared with patients without OUD. Compared to the US, twice as many NC OUD patients were self-payers. Hispanic patients, Medicare beneficiaries, and those in the highest income areas experienced the longest LOS and highest hospital charge. Patients with OUD were more likely to have five or more diagnoses and those with five or more diagnoses had higher LOS and hospital charges. OUD hospitalizations were also associated with more frequent use of emergency services. The most common co-occurring diagnoses were psychoses, substance abuse or dependence, and septicemia or severe sepsis. CONCLUSION: High percentages of self-payers and lower-income OUD patients indicate the need for Medicaid eligibility outreach programs in NC. High LOS and hospital charges among Hispanic, Medicare-covered, and high-income OUD patients call for a more detailed examination to identify underlying causes of disproportionate resource utilization in NC hospitals.

Opioid use disorder among pregnant women in the 2000-2014 North Carolina state inpatient database.

Background: The opioid epidemic's impact reached an increasing portion of the United States population, including pregnant women.Objectives: We sought to determine the prevalence and factors associated with opioid use disorders during pregnancy in North Carolina.Study Design: Using North Carolina's State Inpatient Sample, a retrospective study was conducted to identify pregnancy-related discharges between 2000 and 2014. Hospital discharge records associated with ICD-9-CM diagnoses codes for the use of opioids for all eligible pregnancy-related discharges were extracted. Logistic regression models were used to estimate unadjusted and adjusted bivariate and multivariate relationships.Results: Of 1,937,455 pregnancy-related hospitalization in North Carolina, 6,084 were associated with opioid use, a prevalence of 3.14 cases per 1,000 discharge. Maternal opioid use was associated with an increased odds of early onset delivery, threatened preterm labor, premature rupture of membranes, postpartum depression, stillbirth and poor fetal growth. Women who used opioids during pregnancy had prolonged hospital stays (>5 days) and were 2 times as likely to have more than 4 procedures performed during hospitalization. Compared to other racial groups, non-Hispanic whites had a notably higher prevalence of opioid use disorders (5.8/1,000 pregnancy-related discharges) (P < 0.05 for all).Conclusions: Very few health issues have garnered the attention of such diverse sectors of our society as the opioid epidemic. As the first state-level analysis of opioid use disorders among delivery hospitalizations, these findings suggest the need for a system-wide public health response such as improved funding for Medicaid and child welfare systems to improve the health of the opioid-exposed mother-infant dyad.

Comorbid Depressive and Anxiety Symptoms in a Patient with Myasthenia Gravis.

INTRODUCTION: Myasthenia gravis (MG) is a chronic illness most commonly found in women under 40 years. The most common psychiatric comorbidities found in MG include depressive and anxiety disorders. CLINICAL PRESENTATION: We describe a case of a 43-year-old African American female with MG who was brought in for shortness of breath. History included MG diagnosed twelve years prior to the current presentation and a history of seven intubations. The patient was admitted to the ICU and intubated. She endorsed poor sleep, easy fatigability, and feeling hopeless in the context of psychosocial stressors-being single, homeless, and unemployed. The patient was started on Zoloft 50 mg per oral daily for depression and Atarax 50 mg per oral three times a day for anxiety. The patient responded well to the treatment and was discharged on day 10 after the resolution of her symptoms with appropriate aftercare in place. DISCUSSION: Depressive and anxiety symptoms usually develop as comorbidity during MG disease. Depressive and anxiety symptoms, besides motor symptoms, have a negative impact on the quality of life. Mental health must be a clinical focus during the treatment of somatic symptoms during MG.

Substance Use Patterns and Schizophrenia Spectrum Disorders: A Retrospective Study of Inpatients at a Community Teaching Hospital.

BACKGROUND: Schizophrenia is one of the chronic mental illnesses, characterized by delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and cognitive decline. It frequently leads to a lifetime of impairment and disability that span the entire lifespan of the patients. Several epidemiologic studies have shown that schizophrenia spectrum disorders (SSDs) contribute significantly to years lived with disability. Additionally, substance use disorders have been reported to co-occur commonly among patients with SSD (a comorbidity also known as dual diagnosis), attracting notable attention over the past few decades. This dual diagnosis often requires treatment modifications to ensure for best patient outcomes. METHODS: This study was a retrospective review of the electronic medical charts. The patients included in the study were discharged from the psychiatric unit of our hospital between July 1, 2017 and October 31, 2017. Patients were included in the study using three inclusion criteria: 1) age ≥18 years; 2) had a diagnosis of SSD at discharge; and 3) had urine drug screen performed. Sociodemographic and clinical variables were abstracted. Univariate analysis and summary statistics were performed. Bivariate and multivariate analyses were done via logistic regression models to determine the odds ratios (ORs) and corresponding P values (P). RESULTS: A total of 365 (52.2%) patients had a diagnosis of SSD at discharge. Of these, 349 met the inclusion criteria. The age ranged from 19 to 79 years, with a mean age of 42.2 years, and 76.8% of the patients used substances. Out of the 269 patients who used substances, 199 (74%) used two or more substances. Tobacco use was most prevalent (62.3%), followed by cannabis use (41.5%), alcohol use (40.2%), and cocaine use (27.4%). Patients who reported using tobacco, were more likely to have comorbid alcohol use (OR = 7.24; P = 0.000), cannabis use (OR = 2.80; P = 0.000), cocaine use (OR = 5.00; P = 0.000), and synthetic cannabis (K2) use (OR = 4.62; P = 0.048). Results of the multivariate analyses supported the other findings. CONCLUSIONS: Our study found a high association between schizophrenia spectrum disorders and substance use, with three out of four patients with SSD using a substance. This prevalence is higher than previously reported by other studies. Among those who use substances, about three in four use multiple substances. These point to some interaction between the substances and appear to be heavily influenced by significant social determinants of mental health that continue to plague the community. It is important to establish if a patient with schizophrenia has a comorbid substance use disorder, because addressing both generally leads to better patient outcomes.

Cannabis Use in Inpatients With Schizophrenia Spectrum Disorders at a Community Hospital.

BACKGROUND: Cannabis is the second most used recreational drug in the United States and one of the most used substances in patients with schizophrenia spectrum disorder (SSD). Unfortunately, the increased use is likely to continue as more states legalize recreational use of cannabis. Although the association between cannabis and schizophrenia has been studied extensively, the understanding of the relationship is still evolving. In this study, we sought to determine the prevalence and potential factors associated with cannabis use (CU) among inpatients with SSD at a community teaching hospital. METHODS: We performed a retrospective review of the electronic medical charts of patients discharged from the psychiatric unit of our hospital from July 1, 2017 through October 31, 2017. Patients were included in this study if: 1) They were ≥ 18 years old; 2) They had discharge diagnosis of SSD; and 3) They had urine drug testing performed. Pertinent sociodemographic and clinical variables, including substance use status and hospital length of stay (LOS), were abstracted. Univariate frequencies and summary statistics were performed. Odds ratios (ORs) were determined by logistic regression analysis of bivariate and multivariate analyses. RESULTS: Three hundred sixty-five (52.2%) patients had a discharge diagnosis of SSD, and only 322 had urine toxicology result for cannabinoids and were included in analysis. Of the 322 patients, 41.5% (n = 133) screened positive for cannabinoids. Of the 133 patients, 78% were African American, 15% were Hispanic and 5% were White; 77% were male and the median age was 36 years. Bivariate analyses showed tobacco use (OR: 2.8, 95% confidence interval (CI): 1.7 - 4.6), alcohol use (OR: 3.4, 95% CI: 2.9 - 7.0), younger age (OR: 2.8, 95% CI: 1.8 - 4.5), male gender (OR: 2.9, 95% CI: 2.2 - 3.2), unemployment (OR: 3.91, 95% CI: 3.49 - 7.35), homelessness (OR: 3.18, 95% CI: 2.76 - 3.84) and LOS (OR: 3.46, 95% CI: 2.93 - 4.31) were significantly associated with CU. Result of multivariate analysis was similar to that found in bivariate analysis. CONCLUSIONS: CU appears to be prevalent among patients with SSD. Clinicians and public health professionals are encouraged to understand the health implications of its use in patients with mental illness especially against the backdrop of current marijuana laws.