User login
The merits of buprenorphine for pregnant women with opioid use disorder
Several medication-assisted treatments (MATs) for opioid use disorder were highlighted in “What clinicians need to know about treating opioid use disorder,” (Evidence-Based Reviews,
The landmark study, the Maternal Opioid Treatment: Human Experimental Research, a 2010 multicenter randomized controlled trial compared buprenorphine with methadone in pregnant women with opioid use disorder. The results revealed that neonates exposed to buprenorphine needed 89% less morphine to treat neonatal abstinence syndrome (NAS), 43% shorter hospital stay, and 58% shorter duration of medical treatment for NAS compared with those receiving methadone. Other advantages of buprenorphine over methadone are lower risk of overdose, fewer drug–drug interactions, and the option of receiving treatment in an outpatient setting, rather than a licensed treatment program, such as a methadone maintenance treatment program, which is more tightly controlled.1-3
The previous recommendation was to consider buprenorphine for patients who refused methadone or were unable to take it, or when a methadone treatment program wasn’t available. This study highlighted some clear advantages for treating this subpopulation with methadone instead of buprenorphine: only 18% of patients receiving methadone discontinued treatment, compared with 33% of those receiving buprenorphine,1-3 and methadone had a lower risk of diversion.3 The accepted practice has been to recommend methadone treatment for patients with mental, physical, or social stressors because of the structure of opioid treatment programs (OTP) (also known as methadone maintenance treatment programs). However, buprenorphine can be dispensed through an OTP, following the same stringent rules and regulations.4
The single agent, buprenorphine—not buprenorphine/naloxone—is recommended to prevent prenatal exposure to naloxone. It is thought that exposure to naloxone in utero might produce hormonal changes in the fetus.1,5 O'Connor et al5 noted methadone’s suitability during breast-feeding because of its low concentration in breast milk. Buprenorphine is excreted at breast milk to plasma ratio of 1:1, but because of buprenorphine’s poor oral bioavailability, infant exposure has little impact on the NAS score, therefore it’s suitable for breast-feeding mothers.5
Adegboyega Oyemade, MD, FAPA
Addiction Psychiatrist
Kaiser Permanente
Baltimore, Maryland
References
1. Lori W. Buprenorphine during pregnancy reduces neonate distress. https://www.drugabuse.gov/news-events/nida-notes/2012/07/buprenorphine- during-pregnancy-reduces-neonate-distress. Published July 6, 2016. Accessed September 9, 2016.
2. Jones HE, Kaltenbach K, Heil SH, et al. Neonatal abstinence syndrome after methadone or buprenorphine exposure. N Engl J Med. 2010;363(24):2320-2331.
3. ACOG Committee on Health Care for Underserved Women; American Society of Addiction Medicine. ACOG Committee Opinion No. 524: Opioid abuse, dependence, and addiction in pregnancy. Obest Gynecol. 2012;119(5):1070-1076.
4. Addiction Treatment Forum. Methadone vs. buprenorphine: how do OTPs and patients make the choice? http://atforum.com/2013/11/methadone-vs-buprenorphine-how-do-otps-and-patients-make-the-choice. Published November 15, 2013. Accessed September 9, 2016.
5. O’Connor A, Alto W, Musgrave K, et al. Observational study of buprenorphine treatment of opioid-dependent pregnancy women in a family medicine residency: reports on maternal and infant outcomes. J Am Board Fam Med. 2011;24(2):194-201.
A possible solution to the 'shrinking' workforce
I would like to offer another pragmatic, easy, and quick solution for dealing with the shrinking psychiatrist workforce (The psychiatry workforce pool is shrinking. What are we doing about it? From the Editor.
The United States is short approximately 45,000 psychiatrists.1 Burnout—a silent epidemic among physicians—is prevalent in psychiatry. What consumes time and leads to burn out? “Scut work.”
There are thousands of unmatched residency graduates.2 Most of these graduates have clinical experience in the United States. Psychiatry residency programs should give these unmatched graduates 6 months of training in psychiatry and use them as our primary workforce. These assistant physicians could be paired with 2 to 3 psychiatrists to perform the menial tasks, including, but not limited to, phone calls, prescriptions, prior authorizations, chart review, and other clinical and administrative paper work. This way, psychiatrists can focus on the interview, diagnoses, and treatment, major medical decision-making, and see more patients.
Employing assistant physicians to provide care has been suggested as a solution.3 Arkansas, Kansas, and Missouri have passed laws that allow medical school graduates who did not match with a residency program to work in underserved areas with a collaborating physician.
Because 1 out of 4 individuals have a mental illness and more of them are seeking help because of increasing awareness and the Affordable Care Act, the construct of “assistant physicians” could ease psychiatrists’ workload allowing them to deliver better care to more people.
Maju Mathew Koola, MD
Associate Professor
Department of Psychiatry and Behavioral Sciences
George Washington University
School of Medicine and Health Sciences
Washington, DC
References
1. Carlat D. 45,000 More psychiatrists, anyone? Psychiatric Times. http://www.psychiatrictimes.com/articles/45000-more-psychiatrists-anyone-0.Published August 3, 2010. Accessed November 11, 2016.
2. The Match: National Resident Matching Program. results and data: 2016 main residency match. http://www.nrmp.org/wp-content/uploads/2016/04/Main-Match-Results-and-Data-2016.pdf. Published April 2016. Accessed November 11, 2016.
3. Miller JG, Peterson DJ. Employing nurse practitioners and physician assistants to provide access to care as the psychiatrist shortage continues. Acad Psychiatry. 2015;39(6):685-686.
Concerns in psychiatry
The August 2016 editorial (Unresolved questions about the specialty lurk in the cortext of psychiatrists.
Denis F. Darko, MD
CEO
NeuroSci R&D Consultancy, LLC
Maple Grove, Minnesota
The merits of buprenorphine for pregnant women with opioid use disorder
Several medication-assisted treatments (MATs) for opioid use disorder were highlighted in “What clinicians need to know about treating opioid use disorder,” (Evidence-Based Reviews,
The landmark study, the Maternal Opioid Treatment: Human Experimental Research, a 2010 multicenter randomized controlled trial compared buprenorphine with methadone in pregnant women with opioid use disorder. The results revealed that neonates exposed to buprenorphine needed 89% less morphine to treat neonatal abstinence syndrome (NAS), 43% shorter hospital stay, and 58% shorter duration of medical treatment for NAS compared with those receiving methadone. Other advantages of buprenorphine over methadone are lower risk of overdose, fewer drug–drug interactions, and the option of receiving treatment in an outpatient setting, rather than a licensed treatment program, such as a methadone maintenance treatment program, which is more tightly controlled.1-3
The previous recommendation was to consider buprenorphine for patients who refused methadone or were unable to take it, or when a methadone treatment program wasn’t available. This study highlighted some clear advantages for treating this subpopulation with methadone instead of buprenorphine: only 18% of patients receiving methadone discontinued treatment, compared with 33% of those receiving buprenorphine,1-3 and methadone had a lower risk of diversion.3 The accepted practice has been to recommend methadone treatment for patients with mental, physical, or social stressors because of the structure of opioid treatment programs (OTP) (also known as methadone maintenance treatment programs). However, buprenorphine can be dispensed through an OTP, following the same stringent rules and regulations.4
The single agent, buprenorphine—not buprenorphine/naloxone—is recommended to prevent prenatal exposure to naloxone. It is thought that exposure to naloxone in utero might produce hormonal changes in the fetus.1,5 O'Connor et al5 noted methadone’s suitability during breast-feeding because of its low concentration in breast milk. Buprenorphine is excreted at breast milk to plasma ratio of 1:1, but because of buprenorphine’s poor oral bioavailability, infant exposure has little impact on the NAS score, therefore it’s suitable for breast-feeding mothers.5
Adegboyega Oyemade, MD, FAPA
Addiction Psychiatrist
Kaiser Permanente
Baltimore, Maryland
References
1. Lori W. Buprenorphine during pregnancy reduces neonate distress. https://www.drugabuse.gov/news-events/nida-notes/2012/07/buprenorphine- during-pregnancy-reduces-neonate-distress. Published July 6, 2016. Accessed September 9, 2016.
2. Jones HE, Kaltenbach K, Heil SH, et al. Neonatal abstinence syndrome after methadone or buprenorphine exposure. N Engl J Med. 2010;363(24):2320-2331.
3. ACOG Committee on Health Care for Underserved Women; American Society of Addiction Medicine. ACOG Committee Opinion No. 524: Opioid abuse, dependence, and addiction in pregnancy. Obest Gynecol. 2012;119(5):1070-1076.
4. Addiction Treatment Forum. Methadone vs. buprenorphine: how do OTPs and patients make the choice? http://atforum.com/2013/11/methadone-vs-buprenorphine-how-do-otps-and-patients-make-the-choice. Published November 15, 2013. Accessed September 9, 2016.
5. O’Connor A, Alto W, Musgrave K, et al. Observational study of buprenorphine treatment of opioid-dependent pregnancy women in a family medicine residency: reports on maternal and infant outcomes. J Am Board Fam Med. 2011;24(2):194-201.
A possible solution to the 'shrinking' workforce
I would like to offer another pragmatic, easy, and quick solution for dealing with the shrinking psychiatrist workforce (The psychiatry workforce pool is shrinking. What are we doing about it? From the Editor.
The United States is short approximately 45,000 psychiatrists.1 Burnout—a silent epidemic among physicians—is prevalent in psychiatry. What consumes time and leads to burn out? “Scut work.”
There are thousands of unmatched residency graduates.2 Most of these graduates have clinical experience in the United States. Psychiatry residency programs should give these unmatched graduates 6 months of training in psychiatry and use them as our primary workforce. These assistant physicians could be paired with 2 to 3 psychiatrists to perform the menial tasks, including, but not limited to, phone calls, prescriptions, prior authorizations, chart review, and other clinical and administrative paper work. This way, psychiatrists can focus on the interview, diagnoses, and treatment, major medical decision-making, and see more patients.
Employing assistant physicians to provide care has been suggested as a solution.3 Arkansas, Kansas, and Missouri have passed laws that allow medical school graduates who did not match with a residency program to work in underserved areas with a collaborating physician.
Because 1 out of 4 individuals have a mental illness and more of them are seeking help because of increasing awareness and the Affordable Care Act, the construct of “assistant physicians” could ease psychiatrists’ workload allowing them to deliver better care to more people.
Maju Mathew Koola, MD
Associate Professor
Department of Psychiatry and Behavioral Sciences
George Washington University
School of Medicine and Health Sciences
Washington, DC
References
1. Carlat D. 45,000 More psychiatrists, anyone? Psychiatric Times. http://www.psychiatrictimes.com/articles/45000-more-psychiatrists-anyone-0.Published August 3, 2010. Accessed November 11, 2016.
2. The Match: National Resident Matching Program. results and data: 2016 main residency match. http://www.nrmp.org/wp-content/uploads/2016/04/Main-Match-Results-and-Data-2016.pdf. Published April 2016. Accessed November 11, 2016.
3. Miller JG, Peterson DJ. Employing nurse practitioners and physician assistants to provide access to care as the psychiatrist shortage continues. Acad Psychiatry. 2015;39(6):685-686.
Concerns in psychiatry
The August 2016 editorial (Unresolved questions about the specialty lurk in the cortext of psychiatrists.
Denis F. Darko, MD
CEO
NeuroSci R&D Consultancy, LLC
Maple Grove, Minnesota
The merits of buprenorphine for pregnant women with opioid use disorder
Several medication-assisted treatments (MATs) for opioid use disorder were highlighted in “What clinicians need to know about treating opioid use disorder,” (Evidence-Based Reviews,
The landmark study, the Maternal Opioid Treatment: Human Experimental Research, a 2010 multicenter randomized controlled trial compared buprenorphine with methadone in pregnant women with opioid use disorder. The results revealed that neonates exposed to buprenorphine needed 89% less morphine to treat neonatal abstinence syndrome (NAS), 43% shorter hospital stay, and 58% shorter duration of medical treatment for NAS compared with those receiving methadone. Other advantages of buprenorphine over methadone are lower risk of overdose, fewer drug–drug interactions, and the option of receiving treatment in an outpatient setting, rather than a licensed treatment program, such as a methadone maintenance treatment program, which is more tightly controlled.1-3
The previous recommendation was to consider buprenorphine for patients who refused methadone or were unable to take it, or when a methadone treatment program wasn’t available. This study highlighted some clear advantages for treating this subpopulation with methadone instead of buprenorphine: only 18% of patients receiving methadone discontinued treatment, compared with 33% of those receiving buprenorphine,1-3 and methadone had a lower risk of diversion.3 The accepted practice has been to recommend methadone treatment for patients with mental, physical, or social stressors because of the structure of opioid treatment programs (OTP) (also known as methadone maintenance treatment programs). However, buprenorphine can be dispensed through an OTP, following the same stringent rules and regulations.4
The single agent, buprenorphine—not buprenorphine/naloxone—is recommended to prevent prenatal exposure to naloxone. It is thought that exposure to naloxone in utero might produce hormonal changes in the fetus.1,5 O'Connor et al5 noted methadone’s suitability during breast-feeding because of its low concentration in breast milk. Buprenorphine is excreted at breast milk to plasma ratio of 1:1, but because of buprenorphine’s poor oral bioavailability, infant exposure has little impact on the NAS score, therefore it’s suitable for breast-feeding mothers.5
Adegboyega Oyemade, MD, FAPA
Addiction Psychiatrist
Kaiser Permanente
Baltimore, Maryland
References
1. Lori W. Buprenorphine during pregnancy reduces neonate distress. https://www.drugabuse.gov/news-events/nida-notes/2012/07/buprenorphine- during-pregnancy-reduces-neonate-distress. Published July 6, 2016. Accessed September 9, 2016.
2. Jones HE, Kaltenbach K, Heil SH, et al. Neonatal abstinence syndrome after methadone or buprenorphine exposure. N Engl J Med. 2010;363(24):2320-2331.
3. ACOG Committee on Health Care for Underserved Women; American Society of Addiction Medicine. ACOG Committee Opinion No. 524: Opioid abuse, dependence, and addiction in pregnancy. Obest Gynecol. 2012;119(5):1070-1076.
4. Addiction Treatment Forum. Methadone vs. buprenorphine: how do OTPs and patients make the choice? http://atforum.com/2013/11/methadone-vs-buprenorphine-how-do-otps-and-patients-make-the-choice. Published November 15, 2013. Accessed September 9, 2016.
5. O’Connor A, Alto W, Musgrave K, et al. Observational study of buprenorphine treatment of opioid-dependent pregnancy women in a family medicine residency: reports on maternal and infant outcomes. J Am Board Fam Med. 2011;24(2):194-201.
A possible solution to the 'shrinking' workforce
I would like to offer another pragmatic, easy, and quick solution for dealing with the shrinking psychiatrist workforce (The psychiatry workforce pool is shrinking. What are we doing about it? From the Editor.
The United States is short approximately 45,000 psychiatrists.1 Burnout—a silent epidemic among physicians—is prevalent in psychiatry. What consumes time and leads to burn out? “Scut work.”
There are thousands of unmatched residency graduates.2 Most of these graduates have clinical experience in the United States. Psychiatry residency programs should give these unmatched graduates 6 months of training in psychiatry and use them as our primary workforce. These assistant physicians could be paired with 2 to 3 psychiatrists to perform the menial tasks, including, but not limited to, phone calls, prescriptions, prior authorizations, chart review, and other clinical and administrative paper work. This way, psychiatrists can focus on the interview, diagnoses, and treatment, major medical decision-making, and see more patients.
Employing assistant physicians to provide care has been suggested as a solution.3 Arkansas, Kansas, and Missouri have passed laws that allow medical school graduates who did not match with a residency program to work in underserved areas with a collaborating physician.
Because 1 out of 4 individuals have a mental illness and more of them are seeking help because of increasing awareness and the Affordable Care Act, the construct of “assistant physicians” could ease psychiatrists’ workload allowing them to deliver better care to more people.
Maju Mathew Koola, MD
Associate Professor
Department of Psychiatry and Behavioral Sciences
George Washington University
School of Medicine and Health Sciences
Washington, DC
References
1. Carlat D. 45,000 More psychiatrists, anyone? Psychiatric Times. http://www.psychiatrictimes.com/articles/45000-more-psychiatrists-anyone-0.Published August 3, 2010. Accessed November 11, 2016.
2. The Match: National Resident Matching Program. results and data: 2016 main residency match. http://www.nrmp.org/wp-content/uploads/2016/04/Main-Match-Results-and-Data-2016.pdf. Published April 2016. Accessed November 11, 2016.
3. Miller JG, Peterson DJ. Employing nurse practitioners and physician assistants to provide access to care as the psychiatrist shortage continues. Acad Psychiatry. 2015;39(6):685-686.
Concerns in psychiatry
The August 2016 editorial (Unresolved questions about the specialty lurk in the cortext of psychiatrists.
Denis F. Darko, MD
CEO
NeuroSci R&D Consultancy, LLC
Maple Grove, Minnesota
