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Older recreational endurance athletes face sky-high AF risk
SNOWMASS, COLO. – , N. A. Mark Estes III, MD, said at the Annual Cardiovascular Conference at Snowmass.
“I see a very large number of former collegiate or professional athletes who come to me in their 40s, 50s, and 60s having recently developed A-fib. These are mainly men who’ve been doing high-intensity endurance exercise,” said Dr. Estes, professor of medicine and director of the New England Cardiac Arrhythmia Center at Tufts University in Boston.
This is an aspect of the athletic heart syndrome that has gone understudied and underappreciated, according to Dr. Estes, who asserted, “The best available evidence suggests that exercise, if excessive, is probably harmful. I know that’s heresy.”
He is coauthor of a forthcoming review on this topic to be published in the Journal of the American College of Cardiology – Electrophysiology. In it, he and his coauthors analyzed more than a half dozen published observational epidemiologic studies and concluded that the collective data show a classic J-shaped curve describes the relationship between physical activity level and risk of developing AF, but only in men. The risk is roughly 25% lower in men who regularly engage in moderate physical activity as defined in American Heart Association/American College of Cardiology guidelines, compared with that of sedentary men. But the AF risk shoots up dramatically in men who focus on intense exercise.
“As you get into the high-intensity/high-endurance end of the spectrum – typically more than 5 hours per week at greater than 80% of peak heart rate – the risk of A-fib increases up to 10-fold,” according to Dr. Estes.
“These are new data. They are important data. I think these data should impact the way we counsel people about exercise, particularly men who like to get into that high-intensity/high-endurance range,” the cardiologist continued.
This J-curve doesn’t apply to women, for reasons unclear. The analysis by Dr. Estes and his colleagues documented that women who engage in moderate physical activity have a lower risk of developing AF than do sedentary women, but unlike in men, the AF risk is lower still in women who favor high-intensity exercise.
“Maybe the explanation is in part endocrinologic differences, maybe in part due to women having smaller left atria and therefore less left atrial wall stress, less fibrosis. We really don’t know, but I think the observation, based on epidemiologic data, is valid,” he said.
Proposed multifactorial mechanisms for the increased incidence of AF in aging endurance athletes hinge in part upon basic science studies. These mechanisms include atrial inflammation and fibrosis, atrial enlargement, increased vagal tone, sympathetic nervous system stimulation, pulmonary vein triggers, genetic predisposition, and use of performance-enhancing substances.
Dr. Estes’ presentation struck a responsive chord with the audience. Numerous cardiologists rose to chime in that they, too, have encountered new-onset AF in middle-aged patients, friends, and medical colleagues who are serious cyclists, marathoners, and devotees of other forms of high-intensity endurance exercise to the tune of 10-20 hours per weekly.
“I know an electrophysiologist in his 60s who probably does 20 hours per week of spin and Cross-Fit classes and who is just now going into A-fib. How should I counsel him about this?” one audience member asked.
“You can’t tell these people to stop exercising,” Dr. Estes replied. “It’s so much a part of their identity. Their endorphin levels go down, and they feel depressed.”
For these patients he stresses what he called “the virtue of moderation.”
“If they have clinically important symptoms, many times we’ll decondition them. Often their symptoms will improve, and, in some instances, the A-fib will actually clear up and we don’t even need to go to any medical therapy,” Dr. Estes said.
His exercise prescription for deconditioning such patients is “basically nothing more than a moderate jog, a 10-minute mile. They should be able to carry on a conversation, with a peak heart rate no more than 60% of their maximum.”
If drug therapy is required, he favors rate control with beta blockers, as these patients generally don’t tolerate antiarrhythmic agents very well.
“Our threshold for AF ablation in these people is quite low because the response rate is high in paroxysmal AF in the absence of underlying structural heart disease,” he added.
Dr. Robert A. Vogel, who has been a consultant to the National Football League for a decade, commented, “I agree that you can exercise too much. These are the super-elite triathletes and so forth. A few of these folks not only get A-fib, but we’ve shown they can get accelerated atherosclerosis due to pervasive endothelial dysfunction caused by excessive athletics.”
“However, nothing here should be construed as saying exercise is bad for you. Athletes, even drug-taking cyclists and football players, actually live longer than similar nonathletes,” said Dr. Vogel, a cardiologist at the University of Colorado, Denver.
Dr. Estes was quick to agree.
“The cardiovascular benefits of exercise resoundingly overwhelm the adverse effects in that small group that experiences adverse effects,” he said.
Dr. Estes reported serving as a consultant to Boston Scientific, Medtronic, and St. Jude Medical.
SNOWMASS, COLO. – , N. A. Mark Estes III, MD, said at the Annual Cardiovascular Conference at Snowmass.
“I see a very large number of former collegiate or professional athletes who come to me in their 40s, 50s, and 60s having recently developed A-fib. These are mainly men who’ve been doing high-intensity endurance exercise,” said Dr. Estes, professor of medicine and director of the New England Cardiac Arrhythmia Center at Tufts University in Boston.
This is an aspect of the athletic heart syndrome that has gone understudied and underappreciated, according to Dr. Estes, who asserted, “The best available evidence suggests that exercise, if excessive, is probably harmful. I know that’s heresy.”
He is coauthor of a forthcoming review on this topic to be published in the Journal of the American College of Cardiology – Electrophysiology. In it, he and his coauthors analyzed more than a half dozen published observational epidemiologic studies and concluded that the collective data show a classic J-shaped curve describes the relationship between physical activity level and risk of developing AF, but only in men. The risk is roughly 25% lower in men who regularly engage in moderate physical activity as defined in American Heart Association/American College of Cardiology guidelines, compared with that of sedentary men. But the AF risk shoots up dramatically in men who focus on intense exercise.
“As you get into the high-intensity/high-endurance end of the spectrum – typically more than 5 hours per week at greater than 80% of peak heart rate – the risk of A-fib increases up to 10-fold,” according to Dr. Estes.
“These are new data. They are important data. I think these data should impact the way we counsel people about exercise, particularly men who like to get into that high-intensity/high-endurance range,” the cardiologist continued.
This J-curve doesn’t apply to women, for reasons unclear. The analysis by Dr. Estes and his colleagues documented that women who engage in moderate physical activity have a lower risk of developing AF than do sedentary women, but unlike in men, the AF risk is lower still in women who favor high-intensity exercise.
“Maybe the explanation is in part endocrinologic differences, maybe in part due to women having smaller left atria and therefore less left atrial wall stress, less fibrosis. We really don’t know, but I think the observation, based on epidemiologic data, is valid,” he said.
Proposed multifactorial mechanisms for the increased incidence of AF in aging endurance athletes hinge in part upon basic science studies. These mechanisms include atrial inflammation and fibrosis, atrial enlargement, increased vagal tone, sympathetic nervous system stimulation, pulmonary vein triggers, genetic predisposition, and use of performance-enhancing substances.
Dr. Estes’ presentation struck a responsive chord with the audience. Numerous cardiologists rose to chime in that they, too, have encountered new-onset AF in middle-aged patients, friends, and medical colleagues who are serious cyclists, marathoners, and devotees of other forms of high-intensity endurance exercise to the tune of 10-20 hours per weekly.
“I know an electrophysiologist in his 60s who probably does 20 hours per week of spin and Cross-Fit classes and who is just now going into A-fib. How should I counsel him about this?” one audience member asked.
“You can’t tell these people to stop exercising,” Dr. Estes replied. “It’s so much a part of their identity. Their endorphin levels go down, and they feel depressed.”
For these patients he stresses what he called “the virtue of moderation.”
“If they have clinically important symptoms, many times we’ll decondition them. Often their symptoms will improve, and, in some instances, the A-fib will actually clear up and we don’t even need to go to any medical therapy,” Dr. Estes said.
His exercise prescription for deconditioning such patients is “basically nothing more than a moderate jog, a 10-minute mile. They should be able to carry on a conversation, with a peak heart rate no more than 60% of their maximum.”
If drug therapy is required, he favors rate control with beta blockers, as these patients generally don’t tolerate antiarrhythmic agents very well.
“Our threshold for AF ablation in these people is quite low because the response rate is high in paroxysmal AF in the absence of underlying structural heart disease,” he added.
Dr. Robert A. Vogel, who has been a consultant to the National Football League for a decade, commented, “I agree that you can exercise too much. These are the super-elite triathletes and so forth. A few of these folks not only get A-fib, but we’ve shown they can get accelerated atherosclerosis due to pervasive endothelial dysfunction caused by excessive athletics.”
“However, nothing here should be construed as saying exercise is bad for you. Athletes, even drug-taking cyclists and football players, actually live longer than similar nonathletes,” said Dr. Vogel, a cardiologist at the University of Colorado, Denver.
Dr. Estes was quick to agree.
“The cardiovascular benefits of exercise resoundingly overwhelm the adverse effects in that small group that experiences adverse effects,” he said.
Dr. Estes reported serving as a consultant to Boston Scientific, Medtronic, and St. Jude Medical.
SNOWMASS, COLO. – , N. A. Mark Estes III, MD, said at the Annual Cardiovascular Conference at Snowmass.
“I see a very large number of former collegiate or professional athletes who come to me in their 40s, 50s, and 60s having recently developed A-fib. These are mainly men who’ve been doing high-intensity endurance exercise,” said Dr. Estes, professor of medicine and director of the New England Cardiac Arrhythmia Center at Tufts University in Boston.
This is an aspect of the athletic heart syndrome that has gone understudied and underappreciated, according to Dr. Estes, who asserted, “The best available evidence suggests that exercise, if excessive, is probably harmful. I know that’s heresy.”
He is coauthor of a forthcoming review on this topic to be published in the Journal of the American College of Cardiology – Electrophysiology. In it, he and his coauthors analyzed more than a half dozen published observational epidemiologic studies and concluded that the collective data show a classic J-shaped curve describes the relationship between physical activity level and risk of developing AF, but only in men. The risk is roughly 25% lower in men who regularly engage in moderate physical activity as defined in American Heart Association/American College of Cardiology guidelines, compared with that of sedentary men. But the AF risk shoots up dramatically in men who focus on intense exercise.
“As you get into the high-intensity/high-endurance end of the spectrum – typically more than 5 hours per week at greater than 80% of peak heart rate – the risk of A-fib increases up to 10-fold,” according to Dr. Estes.
“These are new data. They are important data. I think these data should impact the way we counsel people about exercise, particularly men who like to get into that high-intensity/high-endurance range,” the cardiologist continued.
This J-curve doesn’t apply to women, for reasons unclear. The analysis by Dr. Estes and his colleagues documented that women who engage in moderate physical activity have a lower risk of developing AF than do sedentary women, but unlike in men, the AF risk is lower still in women who favor high-intensity exercise.
“Maybe the explanation is in part endocrinologic differences, maybe in part due to women having smaller left atria and therefore less left atrial wall stress, less fibrosis. We really don’t know, but I think the observation, based on epidemiologic data, is valid,” he said.
Proposed multifactorial mechanisms for the increased incidence of AF in aging endurance athletes hinge in part upon basic science studies. These mechanisms include atrial inflammation and fibrosis, atrial enlargement, increased vagal tone, sympathetic nervous system stimulation, pulmonary vein triggers, genetic predisposition, and use of performance-enhancing substances.
Dr. Estes’ presentation struck a responsive chord with the audience. Numerous cardiologists rose to chime in that they, too, have encountered new-onset AF in middle-aged patients, friends, and medical colleagues who are serious cyclists, marathoners, and devotees of other forms of high-intensity endurance exercise to the tune of 10-20 hours per weekly.
“I know an electrophysiologist in his 60s who probably does 20 hours per week of spin and Cross-Fit classes and who is just now going into A-fib. How should I counsel him about this?” one audience member asked.
“You can’t tell these people to stop exercising,” Dr. Estes replied. “It’s so much a part of their identity. Their endorphin levels go down, and they feel depressed.”
For these patients he stresses what he called “the virtue of moderation.”
“If they have clinically important symptoms, many times we’ll decondition them. Often their symptoms will improve, and, in some instances, the A-fib will actually clear up and we don’t even need to go to any medical therapy,” Dr. Estes said.
His exercise prescription for deconditioning such patients is “basically nothing more than a moderate jog, a 10-minute mile. They should be able to carry on a conversation, with a peak heart rate no more than 60% of their maximum.”
If drug therapy is required, he favors rate control with beta blockers, as these patients generally don’t tolerate antiarrhythmic agents very well.
“Our threshold for AF ablation in these people is quite low because the response rate is high in paroxysmal AF in the absence of underlying structural heart disease,” he added.
Dr. Robert A. Vogel, who has been a consultant to the National Football League for a decade, commented, “I agree that you can exercise too much. These are the super-elite triathletes and so forth. A few of these folks not only get A-fib, but we’ve shown they can get accelerated atherosclerosis due to pervasive endothelial dysfunction caused by excessive athletics.”
“However, nothing here should be construed as saying exercise is bad for you. Athletes, even drug-taking cyclists and football players, actually live longer than similar nonathletes,” said Dr. Vogel, a cardiologist at the University of Colorado, Denver.
Dr. Estes was quick to agree.
“The cardiovascular benefits of exercise resoundingly overwhelm the adverse effects in that small group that experiences adverse effects,” he said.
Dr. Estes reported serving as a consultant to Boston Scientific, Medtronic, and St. Jude Medical.
EXPERT ANALYSIS FROM THE CARDIOVASCULAR CONFERENCE AT SNOWMASS
How to discuss Vivitrol with the ambivalent patient
As our nation faces an unprecedented opioid epidemic, mental health clinicians must communicate to patients options for treatment for opioid use disorders (OUDs). A small subset of patients who suffer from an OUD will be consistently motivated in their willingness to accept and fully engage in medically assisted treatment (MAT). However, most patients will display fluctuating degrees of intrinsic motivation in their perceived abilities, needs, and desires for MAT. As of 2017, the MAT agents that are approved for use in OUD by the Food and Drug Administration are methadone, buprenorphine, and naltrexone.
An obvious first step in treating these patients is to forge a therapeutic alliance that allows the patient to feel comfortable expressing myriad emotions, including shame, sadness, fear, anger, guilt, relief, hopefulness, and hopelessness. It is important for the clinician to have a nonjudgmental, kind, open, and empathic approach. We also must be able to specifically empathize with the ambivalence many patients feel regarding MAT. This column will review common questions and concerns that patients voice when contemplating the use of the long-acting injectable naltrexone (Vivitrol). In addition, this article will attempt to provide clinicians with possible responses to these questions, and aim to increase the likelihood that patients will be willing to accept treatment with Vivitrol.
Patient: “If I’m sober, then I should be completely sober, and that includes abstaining from Vivitrol.”
Here, this patient has expressed his/her point of view on what it means to be sober. This view is not uncommon. The clinician should explore the origin of this belief. This particular response may be internalized from an experience in a 12-step program. Or it may be a personal feeling. Engage in a conversation about what sobriety means to the patient, his or her personal goals, and thoughts related to how opiates might interfere with these goals. Clinicians should resist the urge to persuade a patient to use Vivitrol, regardless of how strongly the clinician feels about its effectiveness, in order to address the patient’s ambivalence. Join in with the patient to acknowledge and shed light on his or her perspective and ultimately support a well-informed decision that incorporates a patient’s individual values.
Patient: “Others will judge me and say that I can’t handle life without Vivitrol and I need a crutch.”
The truth is, others may think this. Clinicians should acknowledge that the influential people in the lives of our patients may very well be judgmental. But it is a potential barrier for this patient to be too concerned with others’ reaction to Vivitrol. Stay with the patient’s concern about being judged in order to move into a discussion about ways to tolerate that response. Maybe this is a time to ask whether it would be helpful to educate family members about Vivitrol or to problem-solve ways to handle interactions with others when they say this. It also might be a time to explore questions such as “Why is needing a crutch a sign of weakness to you?” Take a moment to understand the patient’s feelings about using “crutches.” This may open up the dialogue and the potential for seeing Vivitrol as a helpful resource rather than a sign of weakness.
Patient: “If I am doing so well, why introduce another medication?”
That is a valid question, especially if the patient has experienced real change and doesn’t see a need to mix things up. You can tell them that they may be right. However, this also is an opportunity to engage in a meaningful discussion with the patient about the nature of addiction and the nature of motivation. It may be helpful to review the triggers and patterns of use for this particular patient. Remind him or her that motivation to stay sober is fluid. People in the process of change typically are in regular dialogue with themselves about what they want, why they want it, and what they need to do. It is a natural part of the process to sometimes favor sobriety, while other times want to use. Vivitrol is ONE way to manage the relationship between these fluctuations and the desire to act on urges. This may be an appropriate time to tell the patient about other patients’ experiences with Vivitrol and how they experienced relief from not having to work through the costs and benefits of using on a constant basis.
Patient: “I feel controlled by Vivitrol, and it brings up a lot of emotions for me.”
For the most part, Vivitrol will remove the person’s day-to-day participation in their decision to use drugs. This is unsettling for many of our patients who find that using a substance of their own volition makes them feel more in control than does taking a prescribed medicine. The decision to use Vivitrol to treat their addiction is asking patients to think ahead and face what comes up day to day in ways they may not have. Clients can experience fear and sadness when attempting to manage life without the “escape hatch.” It’s natural to want to fight against any feelings of being controlled. To work through ambivalence, allow the patient to air these concerns, acknowledge that feeling controlled understandably is an uncomfortable experience, and then move into ways the patient may see Vivitrol as giving them more control. It is in this kind of conversation about the pros and cons that we can help a patient recognize what feels “wise” in the long term.
Patient: “If I take Vivitrol, I could imagine using many more opioids to override the blockade.”
This thought is a kind of hopeless, automatic one, such as “This won’t work for me,” or “I will just use on it.” We can remind our patient that a thought is simply a thought. Mindfulness can be used to help this patient identify and label his/her thoughts. The task is then to figure out whether it is wise to act on those thoughts. It is crucial to be able to monitor and track this kind of thinking to help a patient identify and manage cravings. These thoughts will happen, but the behavior does not have to follow. In dialectical behavior therapy, we help patients identify thoughts that come mostly from emotions, which are, for the most part, about having short-term relief rather than thoughts that are more balanced by emotion and reason. We call the latter kinds of thoughts “wise mind”; they are more focused on long-term goals. Clinicians should help the patient discern the difference between these different types of thoughts. Remember, if the patients are sitting in your office, there must have been some “wise mind thinking” that led them there, and you should highlight and explore why they made that choice in the first place.
Patient: “I want to have the ability to use opioids if things get really bad.”
Opioids can become a source of security and a reliable resource that doesn’t fail the patient when he or she is struggling. Most of the time, patients have gotten to a place in which opioids are the only coping skill they have to manage life’s difficulties. These clients need to relearn alternative coping skills. Using Vivitrol gives them the ability to be sober enough to practice distress tolerance skills and realize the benefits of not using opioids. Learning how to distract, soothe, and use relaxation strategies are the only ways they are going to be able to build a satisfying life again without substance use. If we can hold up the dilemma facing this person by saying “On the one hand, you are scared not to have your usual go-to; and on the other hand, you want things to change.” It may be helpful to have an in-depth discussion of what patients imagine might happen if they don’t have opioids to fall back on. This discussion may uncover the patients’ lack of confidence about being able to cope and a way to introduce some of the alternative coping strategies. It also may leave them with some concrete ways to manage the difficult feelings they are experiencing.
Patient: “What if I get in an accident and really need opioids?”
Some patients who have developed a dependence on opioids did so as a result of a past prescription for pain medication. They know very well the relationship between opioids and pain relief and the concern that they won’t have this option may be a real obstacle for them. Clinicians are in a position here to explain that, in most cases, patients can be treated with alternatives to opiate medication such as regional analgesia, nonopioid analgesics, and general anesthesia. In an emergency situation, a trained anesthesia provider is able to reverse the Vivitrol blockade so that the client can receive adequate pain management.
Patient: “I’m worried about side effects … ”
The most common side effects of Vivitrol are headache, nausea, somnolence, and vomiting. A serious but very rare complication is hepatocellular injury, but this is really only seen at extremely high doses of naltrexone (five times the approved dosage). If the patient is pregnant or planning pregnancy, she should consider alternative relapse-prevention medications, such as buprenorphine or methadone. If the patient has a proven allergy to naltrexone, polylactide-co-glycolide, carboxymethylcellulose, or any other component of the injection, Vivitrol should be avoided. As for the injection site, the client may experience some pain, tenderness, swelling, bruising. In very few cases, the site reaction can be severe. Again, here is an opportunity for a valuation of pros and cons of both continued opioid use and a Vivitrol trial.
Dr. Ascher is a board-certified general and addiction psychiatrist who serves as a clinical assistant professor in psychiatry at the University of Pennsylvania, Philadelphia, and is in private practice. Dr. Rosof is a clinical psychologist in Philadelphia with a specialty in addiction and extensive training in motivational approaches. Dr. Schack is a clinical psychologist who serves as an expert consultant with the Center for Motivation and Change and is private practice in Philadelphia and New York City. None of them have conflicts of interest to disclose.
As our nation faces an unprecedented opioid epidemic, mental health clinicians must communicate to patients options for treatment for opioid use disorders (OUDs). A small subset of patients who suffer from an OUD will be consistently motivated in their willingness to accept and fully engage in medically assisted treatment (MAT). However, most patients will display fluctuating degrees of intrinsic motivation in their perceived abilities, needs, and desires for MAT. As of 2017, the MAT agents that are approved for use in OUD by the Food and Drug Administration are methadone, buprenorphine, and naltrexone.
An obvious first step in treating these patients is to forge a therapeutic alliance that allows the patient to feel comfortable expressing myriad emotions, including shame, sadness, fear, anger, guilt, relief, hopefulness, and hopelessness. It is important for the clinician to have a nonjudgmental, kind, open, and empathic approach. We also must be able to specifically empathize with the ambivalence many patients feel regarding MAT. This column will review common questions and concerns that patients voice when contemplating the use of the long-acting injectable naltrexone (Vivitrol). In addition, this article will attempt to provide clinicians with possible responses to these questions, and aim to increase the likelihood that patients will be willing to accept treatment with Vivitrol.
Patient: “If I’m sober, then I should be completely sober, and that includes abstaining from Vivitrol.”
Here, this patient has expressed his/her point of view on what it means to be sober. This view is not uncommon. The clinician should explore the origin of this belief. This particular response may be internalized from an experience in a 12-step program. Or it may be a personal feeling. Engage in a conversation about what sobriety means to the patient, his or her personal goals, and thoughts related to how opiates might interfere with these goals. Clinicians should resist the urge to persuade a patient to use Vivitrol, regardless of how strongly the clinician feels about its effectiveness, in order to address the patient’s ambivalence. Join in with the patient to acknowledge and shed light on his or her perspective and ultimately support a well-informed decision that incorporates a patient’s individual values.
Patient: “Others will judge me and say that I can’t handle life without Vivitrol and I need a crutch.”
The truth is, others may think this. Clinicians should acknowledge that the influential people in the lives of our patients may very well be judgmental. But it is a potential barrier for this patient to be too concerned with others’ reaction to Vivitrol. Stay with the patient’s concern about being judged in order to move into a discussion about ways to tolerate that response. Maybe this is a time to ask whether it would be helpful to educate family members about Vivitrol or to problem-solve ways to handle interactions with others when they say this. It also might be a time to explore questions such as “Why is needing a crutch a sign of weakness to you?” Take a moment to understand the patient’s feelings about using “crutches.” This may open up the dialogue and the potential for seeing Vivitrol as a helpful resource rather than a sign of weakness.
Patient: “If I am doing so well, why introduce another medication?”
That is a valid question, especially if the patient has experienced real change and doesn’t see a need to mix things up. You can tell them that they may be right. However, this also is an opportunity to engage in a meaningful discussion with the patient about the nature of addiction and the nature of motivation. It may be helpful to review the triggers and patterns of use for this particular patient. Remind him or her that motivation to stay sober is fluid. People in the process of change typically are in regular dialogue with themselves about what they want, why they want it, and what they need to do. It is a natural part of the process to sometimes favor sobriety, while other times want to use. Vivitrol is ONE way to manage the relationship between these fluctuations and the desire to act on urges. This may be an appropriate time to tell the patient about other patients’ experiences with Vivitrol and how they experienced relief from not having to work through the costs and benefits of using on a constant basis.
Patient: “I feel controlled by Vivitrol, and it brings up a lot of emotions for me.”
For the most part, Vivitrol will remove the person’s day-to-day participation in their decision to use drugs. This is unsettling for many of our patients who find that using a substance of their own volition makes them feel more in control than does taking a prescribed medicine. The decision to use Vivitrol to treat their addiction is asking patients to think ahead and face what comes up day to day in ways they may not have. Clients can experience fear and sadness when attempting to manage life without the “escape hatch.” It’s natural to want to fight against any feelings of being controlled. To work through ambivalence, allow the patient to air these concerns, acknowledge that feeling controlled understandably is an uncomfortable experience, and then move into ways the patient may see Vivitrol as giving them more control. It is in this kind of conversation about the pros and cons that we can help a patient recognize what feels “wise” in the long term.
Patient: “If I take Vivitrol, I could imagine using many more opioids to override the blockade.”
This thought is a kind of hopeless, automatic one, such as “This won’t work for me,” or “I will just use on it.” We can remind our patient that a thought is simply a thought. Mindfulness can be used to help this patient identify and label his/her thoughts. The task is then to figure out whether it is wise to act on those thoughts. It is crucial to be able to monitor and track this kind of thinking to help a patient identify and manage cravings. These thoughts will happen, but the behavior does not have to follow. In dialectical behavior therapy, we help patients identify thoughts that come mostly from emotions, which are, for the most part, about having short-term relief rather than thoughts that are more balanced by emotion and reason. We call the latter kinds of thoughts “wise mind”; they are more focused on long-term goals. Clinicians should help the patient discern the difference between these different types of thoughts. Remember, if the patients are sitting in your office, there must have been some “wise mind thinking” that led them there, and you should highlight and explore why they made that choice in the first place.
Patient: “I want to have the ability to use opioids if things get really bad.”
Opioids can become a source of security and a reliable resource that doesn’t fail the patient when he or she is struggling. Most of the time, patients have gotten to a place in which opioids are the only coping skill they have to manage life’s difficulties. These clients need to relearn alternative coping skills. Using Vivitrol gives them the ability to be sober enough to practice distress tolerance skills and realize the benefits of not using opioids. Learning how to distract, soothe, and use relaxation strategies are the only ways they are going to be able to build a satisfying life again without substance use. If we can hold up the dilemma facing this person by saying “On the one hand, you are scared not to have your usual go-to; and on the other hand, you want things to change.” It may be helpful to have an in-depth discussion of what patients imagine might happen if they don’t have opioids to fall back on. This discussion may uncover the patients’ lack of confidence about being able to cope and a way to introduce some of the alternative coping strategies. It also may leave them with some concrete ways to manage the difficult feelings they are experiencing.
Patient: “What if I get in an accident and really need opioids?”
Some patients who have developed a dependence on opioids did so as a result of a past prescription for pain medication. They know very well the relationship between opioids and pain relief and the concern that they won’t have this option may be a real obstacle for them. Clinicians are in a position here to explain that, in most cases, patients can be treated with alternatives to opiate medication such as regional analgesia, nonopioid analgesics, and general anesthesia. In an emergency situation, a trained anesthesia provider is able to reverse the Vivitrol blockade so that the client can receive adequate pain management.
Patient: “I’m worried about side effects … ”
The most common side effects of Vivitrol are headache, nausea, somnolence, and vomiting. A serious but very rare complication is hepatocellular injury, but this is really only seen at extremely high doses of naltrexone (five times the approved dosage). If the patient is pregnant or planning pregnancy, she should consider alternative relapse-prevention medications, such as buprenorphine or methadone. If the patient has a proven allergy to naltrexone, polylactide-co-glycolide, carboxymethylcellulose, or any other component of the injection, Vivitrol should be avoided. As for the injection site, the client may experience some pain, tenderness, swelling, bruising. In very few cases, the site reaction can be severe. Again, here is an opportunity for a valuation of pros and cons of both continued opioid use and a Vivitrol trial.
Dr. Ascher is a board-certified general and addiction psychiatrist who serves as a clinical assistant professor in psychiatry at the University of Pennsylvania, Philadelphia, and is in private practice. Dr. Rosof is a clinical psychologist in Philadelphia with a specialty in addiction and extensive training in motivational approaches. Dr. Schack is a clinical psychologist who serves as an expert consultant with the Center for Motivation and Change and is private practice in Philadelphia and New York City. None of them have conflicts of interest to disclose.
As our nation faces an unprecedented opioid epidemic, mental health clinicians must communicate to patients options for treatment for opioid use disorders (OUDs). A small subset of patients who suffer from an OUD will be consistently motivated in their willingness to accept and fully engage in medically assisted treatment (MAT). However, most patients will display fluctuating degrees of intrinsic motivation in their perceived abilities, needs, and desires for MAT. As of 2017, the MAT agents that are approved for use in OUD by the Food and Drug Administration are methadone, buprenorphine, and naltrexone.
An obvious first step in treating these patients is to forge a therapeutic alliance that allows the patient to feel comfortable expressing myriad emotions, including shame, sadness, fear, anger, guilt, relief, hopefulness, and hopelessness. It is important for the clinician to have a nonjudgmental, kind, open, and empathic approach. We also must be able to specifically empathize with the ambivalence many patients feel regarding MAT. This column will review common questions and concerns that patients voice when contemplating the use of the long-acting injectable naltrexone (Vivitrol). In addition, this article will attempt to provide clinicians with possible responses to these questions, and aim to increase the likelihood that patients will be willing to accept treatment with Vivitrol.
Patient: “If I’m sober, then I should be completely sober, and that includes abstaining from Vivitrol.”
Here, this patient has expressed his/her point of view on what it means to be sober. This view is not uncommon. The clinician should explore the origin of this belief. This particular response may be internalized from an experience in a 12-step program. Or it may be a personal feeling. Engage in a conversation about what sobriety means to the patient, his or her personal goals, and thoughts related to how opiates might interfere with these goals. Clinicians should resist the urge to persuade a patient to use Vivitrol, regardless of how strongly the clinician feels about its effectiveness, in order to address the patient’s ambivalence. Join in with the patient to acknowledge and shed light on his or her perspective and ultimately support a well-informed decision that incorporates a patient’s individual values.
Patient: “Others will judge me and say that I can’t handle life without Vivitrol and I need a crutch.”
The truth is, others may think this. Clinicians should acknowledge that the influential people in the lives of our patients may very well be judgmental. But it is a potential barrier for this patient to be too concerned with others’ reaction to Vivitrol. Stay with the patient’s concern about being judged in order to move into a discussion about ways to tolerate that response. Maybe this is a time to ask whether it would be helpful to educate family members about Vivitrol or to problem-solve ways to handle interactions with others when they say this. It also might be a time to explore questions such as “Why is needing a crutch a sign of weakness to you?” Take a moment to understand the patient’s feelings about using “crutches.” This may open up the dialogue and the potential for seeing Vivitrol as a helpful resource rather than a sign of weakness.
Patient: “If I am doing so well, why introduce another medication?”
That is a valid question, especially if the patient has experienced real change and doesn’t see a need to mix things up. You can tell them that they may be right. However, this also is an opportunity to engage in a meaningful discussion with the patient about the nature of addiction and the nature of motivation. It may be helpful to review the triggers and patterns of use for this particular patient. Remind him or her that motivation to stay sober is fluid. People in the process of change typically are in regular dialogue with themselves about what they want, why they want it, and what they need to do. It is a natural part of the process to sometimes favor sobriety, while other times want to use. Vivitrol is ONE way to manage the relationship between these fluctuations and the desire to act on urges. This may be an appropriate time to tell the patient about other patients’ experiences with Vivitrol and how they experienced relief from not having to work through the costs and benefits of using on a constant basis.
Patient: “I feel controlled by Vivitrol, and it brings up a lot of emotions for me.”
For the most part, Vivitrol will remove the person’s day-to-day participation in their decision to use drugs. This is unsettling for many of our patients who find that using a substance of their own volition makes them feel more in control than does taking a prescribed medicine. The decision to use Vivitrol to treat their addiction is asking patients to think ahead and face what comes up day to day in ways they may not have. Clients can experience fear and sadness when attempting to manage life without the “escape hatch.” It’s natural to want to fight against any feelings of being controlled. To work through ambivalence, allow the patient to air these concerns, acknowledge that feeling controlled understandably is an uncomfortable experience, and then move into ways the patient may see Vivitrol as giving them more control. It is in this kind of conversation about the pros and cons that we can help a patient recognize what feels “wise” in the long term.
Patient: “If I take Vivitrol, I could imagine using many more opioids to override the blockade.”
This thought is a kind of hopeless, automatic one, such as “This won’t work for me,” or “I will just use on it.” We can remind our patient that a thought is simply a thought. Mindfulness can be used to help this patient identify and label his/her thoughts. The task is then to figure out whether it is wise to act on those thoughts. It is crucial to be able to monitor and track this kind of thinking to help a patient identify and manage cravings. These thoughts will happen, but the behavior does not have to follow. In dialectical behavior therapy, we help patients identify thoughts that come mostly from emotions, which are, for the most part, about having short-term relief rather than thoughts that are more balanced by emotion and reason. We call the latter kinds of thoughts “wise mind”; they are more focused on long-term goals. Clinicians should help the patient discern the difference between these different types of thoughts. Remember, if the patients are sitting in your office, there must have been some “wise mind thinking” that led them there, and you should highlight and explore why they made that choice in the first place.
Patient: “I want to have the ability to use opioids if things get really bad.”
Opioids can become a source of security and a reliable resource that doesn’t fail the patient when he or she is struggling. Most of the time, patients have gotten to a place in which opioids are the only coping skill they have to manage life’s difficulties. These clients need to relearn alternative coping skills. Using Vivitrol gives them the ability to be sober enough to practice distress tolerance skills and realize the benefits of not using opioids. Learning how to distract, soothe, and use relaxation strategies are the only ways they are going to be able to build a satisfying life again without substance use. If we can hold up the dilemma facing this person by saying “On the one hand, you are scared not to have your usual go-to; and on the other hand, you want things to change.” It may be helpful to have an in-depth discussion of what patients imagine might happen if they don’t have opioids to fall back on. This discussion may uncover the patients’ lack of confidence about being able to cope and a way to introduce some of the alternative coping strategies. It also may leave them with some concrete ways to manage the difficult feelings they are experiencing.
Patient: “What if I get in an accident and really need opioids?”
Some patients who have developed a dependence on opioids did so as a result of a past prescription for pain medication. They know very well the relationship between opioids and pain relief and the concern that they won’t have this option may be a real obstacle for them. Clinicians are in a position here to explain that, in most cases, patients can be treated with alternatives to opiate medication such as regional analgesia, nonopioid analgesics, and general anesthesia. In an emergency situation, a trained anesthesia provider is able to reverse the Vivitrol blockade so that the client can receive adequate pain management.
Patient: “I’m worried about side effects … ”
The most common side effects of Vivitrol are headache, nausea, somnolence, and vomiting. A serious but very rare complication is hepatocellular injury, but this is really only seen at extremely high doses of naltrexone (five times the approved dosage). If the patient is pregnant or planning pregnancy, she should consider alternative relapse-prevention medications, such as buprenorphine or methadone. If the patient has a proven allergy to naltrexone, polylactide-co-glycolide, carboxymethylcellulose, or any other component of the injection, Vivitrol should be avoided. As for the injection site, the client may experience some pain, tenderness, swelling, bruising. In very few cases, the site reaction can be severe. Again, here is an opportunity for a valuation of pros and cons of both continued opioid use and a Vivitrol trial.
Dr. Ascher is a board-certified general and addiction psychiatrist who serves as a clinical assistant professor in psychiatry at the University of Pennsylvania, Philadelphia, and is in private practice. Dr. Rosof is a clinical psychologist in Philadelphia with a specialty in addiction and extensive training in motivational approaches. Dr. Schack is a clinical psychologist who serves as an expert consultant with the Center for Motivation and Change and is private practice in Philadelphia and New York City. None of them have conflicts of interest to disclose.
A familiar face
A friend of mine recently fell and sustained a complex wrist fracture. She is more than a month post injury, and her forearm, with all its external hardware, looks like an 11-year-old’s science project gone horribly wrong. As she related the story of her fall, the surgery, and her recovery, she mentioned that, since the surgery, she has had four follow-up visits, none of them with the same provider.
Two visits were with nurse practitioners and two with physicians’ assistants. Each of the folks that she saw was pleasant and courteous and appeared genuinely concerned about how she was doing. From a purely economic standpoint, I can understand why a surgeon feels he can be more productive in the operating room than when he is doing follow-ups in the office. Personally, I would have preferred to have at least a quick look at my handiwork. What I found most troubling, however, was the fact that my friend’s injury hadn’t received even the smallest dose of continuity during her recovery.
Does not seeing the same provider at each visit make a difference? In my friend’s case it may have been important because it wasn’t until the last visit that she discovered that she was supposed to be wiggling her fingers. Continuity may not have prevented this oversight, but the discontinuity didn’t help.
People feel more comfortable in situations in which they see a familiar face, whether it’s a bank teller, a barber, or the person at the check-out counter in the grocery store. This calming effect of familiarity can be even more important when it comes to transmitting bad news or supporting a patient through a challenging illness.
If you find that argument for continuity a little too touchy-feely, consider it instead as an effective efficiency booster. Does it take you longer to see one of your colleague’s patients whom you may not have seen before or a 5-year-old patient you have seen several times a year since she was born? The time-saving advantage of continuity increases exponentially with the complexity of the patient’s presenting problem.
When you are seeing patients with whom you aren’t familiar, there are always those extra minutes with your eyes on the computer screen trying to get some sense of context. There are those time-gobbling ventures down therapeutic paths that are going to blind ends, simply because the patient doesn’t know you well enough to trust your advice.
These are just some of the reasons that make continuity important and why it should be one of the driving principles behind scheduling in every physician’s office. Where does continuity sit on the priority list in the practice where you work? Do providers leave enough time in their schedules to allow for same day visits and follow-ups? Are the providers flexible enough to allow their patients to see them for almost every visit?
You may agree with me on the importance of continuity, but you may also be struggling with that quality of life/professional responsibility thing. If, like an increasing number of pediatricians, you would like to work part time, but you realize that cutting back your hours also will mean that maintaining continuity with your patients will be more difficult, careful use of a mid-level provider might help soften the transition. Would 2 full days and 2 half-days a week be more continuity-friendly than 3 full days? You’d be working the same number of hours, but the first option may create the illusion that your familiar face is in the office more often than it is. Regardless of where your practice trajectory is going, don’t discount the value of continuity.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
A friend of mine recently fell and sustained a complex wrist fracture. She is more than a month post injury, and her forearm, with all its external hardware, looks like an 11-year-old’s science project gone horribly wrong. As she related the story of her fall, the surgery, and her recovery, she mentioned that, since the surgery, she has had four follow-up visits, none of them with the same provider.
Two visits were with nurse practitioners and two with physicians’ assistants. Each of the folks that she saw was pleasant and courteous and appeared genuinely concerned about how she was doing. From a purely economic standpoint, I can understand why a surgeon feels he can be more productive in the operating room than when he is doing follow-ups in the office. Personally, I would have preferred to have at least a quick look at my handiwork. What I found most troubling, however, was the fact that my friend’s injury hadn’t received even the smallest dose of continuity during her recovery.
Does not seeing the same provider at each visit make a difference? In my friend’s case it may have been important because it wasn’t until the last visit that she discovered that she was supposed to be wiggling her fingers. Continuity may not have prevented this oversight, but the discontinuity didn’t help.
People feel more comfortable in situations in which they see a familiar face, whether it’s a bank teller, a barber, or the person at the check-out counter in the grocery store. This calming effect of familiarity can be even more important when it comes to transmitting bad news or supporting a patient through a challenging illness.
If you find that argument for continuity a little too touchy-feely, consider it instead as an effective efficiency booster. Does it take you longer to see one of your colleague’s patients whom you may not have seen before or a 5-year-old patient you have seen several times a year since she was born? The time-saving advantage of continuity increases exponentially with the complexity of the patient’s presenting problem.
When you are seeing patients with whom you aren’t familiar, there are always those extra minutes with your eyes on the computer screen trying to get some sense of context. There are those time-gobbling ventures down therapeutic paths that are going to blind ends, simply because the patient doesn’t know you well enough to trust your advice.
These are just some of the reasons that make continuity important and why it should be one of the driving principles behind scheduling in every physician’s office. Where does continuity sit on the priority list in the practice where you work? Do providers leave enough time in their schedules to allow for same day visits and follow-ups? Are the providers flexible enough to allow their patients to see them for almost every visit?
You may agree with me on the importance of continuity, but you may also be struggling with that quality of life/professional responsibility thing. If, like an increasing number of pediatricians, you would like to work part time, but you realize that cutting back your hours also will mean that maintaining continuity with your patients will be more difficult, careful use of a mid-level provider might help soften the transition. Would 2 full days and 2 half-days a week be more continuity-friendly than 3 full days? You’d be working the same number of hours, but the first option may create the illusion that your familiar face is in the office more often than it is. Regardless of where your practice trajectory is going, don’t discount the value of continuity.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
A friend of mine recently fell and sustained a complex wrist fracture. She is more than a month post injury, and her forearm, with all its external hardware, looks like an 11-year-old’s science project gone horribly wrong. As she related the story of her fall, the surgery, and her recovery, she mentioned that, since the surgery, she has had four follow-up visits, none of them with the same provider.
Two visits were with nurse practitioners and two with physicians’ assistants. Each of the folks that she saw was pleasant and courteous and appeared genuinely concerned about how she was doing. From a purely economic standpoint, I can understand why a surgeon feels he can be more productive in the operating room than when he is doing follow-ups in the office. Personally, I would have preferred to have at least a quick look at my handiwork. What I found most troubling, however, was the fact that my friend’s injury hadn’t received even the smallest dose of continuity during her recovery.
Does not seeing the same provider at each visit make a difference? In my friend’s case it may have been important because it wasn’t until the last visit that she discovered that she was supposed to be wiggling her fingers. Continuity may not have prevented this oversight, but the discontinuity didn’t help.
People feel more comfortable in situations in which they see a familiar face, whether it’s a bank teller, a barber, or the person at the check-out counter in the grocery store. This calming effect of familiarity can be even more important when it comes to transmitting bad news or supporting a patient through a challenging illness.
If you find that argument for continuity a little too touchy-feely, consider it instead as an effective efficiency booster. Does it take you longer to see one of your colleague’s patients whom you may not have seen before or a 5-year-old patient you have seen several times a year since she was born? The time-saving advantage of continuity increases exponentially with the complexity of the patient’s presenting problem.
When you are seeing patients with whom you aren’t familiar, there are always those extra minutes with your eyes on the computer screen trying to get some sense of context. There are those time-gobbling ventures down therapeutic paths that are going to blind ends, simply because the patient doesn’t know you well enough to trust your advice.
These are just some of the reasons that make continuity important and why it should be one of the driving principles behind scheduling in every physician’s office. Where does continuity sit on the priority list in the practice where you work? Do providers leave enough time in their schedules to allow for same day visits and follow-ups? Are the providers flexible enough to allow their patients to see them for almost every visit?
You may agree with me on the importance of continuity, but you may also be struggling with that quality of life/professional responsibility thing. If, like an increasing number of pediatricians, you would like to work part time, but you realize that cutting back your hours also will mean that maintaining continuity with your patients will be more difficult, careful use of a mid-level provider might help soften the transition. Would 2 full days and 2 half-days a week be more continuity-friendly than 3 full days? You’d be working the same number of hours, but the first option may create the illusion that your familiar face is in the office more often than it is. Regardless of where your practice trajectory is going, don’t discount the value of continuity.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
Antibiotic prophylaxis for artificial joints
A 66-year-old woman 3 years status post hip replacement is seen for dental work. The dentist contacts the clinic for an antibiotic prescription. The patient has a penicillin allergy (rash). What do you recommend?
A. Clindamycin one dose before dental work.
B. Amoxicillin one dose before dental work.
C. Amoxicillin one dose before, one dose 4 hours after dental work.
D. Clindamycin one dose before dental work, one dose 4 hours after dental work.
E. No antibiotics.
Many patients with prosthetic joints will request antibiotics to take prior to dental procedures. Sometimes this request comes from the dental office.
When I ask patients why they feel they need antibiotics, they often reply that they were told by their orthopedic surgeons or their dentist that they would need to take antibiotics before dental procedures.
In an era when Clostridium difficile infection is a common and dangerous complication in the elderly, avoidance of unnecessary antibiotics is critical. In the United States, it is estimated that there are 240,000 patients infected with C. difficile annually, with 24,000 deaths at a cost of $6 billion.1
Is there compelling evidence to justify giving antibiotic prophylaxis for dental procedures to patients with prosthetic joints?
This information has called into question the wisdom of giving antibiotic prophylaxis for dental procedures when the same patients have transient bacteremias as a regular part of day-to-day life, and mouth organisms were infrequent causes of prosthetic joint infections.
The American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association (ADA) released an advisory statement 20 years ago on antibiotic prophylaxis for patients with dental replacements, which concluded: “Antibiotic prophylaxis is not indicated for dental patients with pins, plates, and screws, nor is it routinely indicated for most dental patients with total joint replacements.”4
In 2003, the AAOS and the ADA released updated guidelines that stated: “Presently, no scientific evidence supports the position that antibiotic prophylaxis to prevent hematogenous infections is required prior to dental treatment in patients with total joint prostheses. The risk/benefit and cost/effectiveness ratios fail to justify the administration of routine antibiotics.”5
Great confusion arose in 2009 when the AAOS published a position paper on its website that reversed this position.6 Interestingly, the statement was done by the AAOS alone, and not done in conjunction with the ADA.
In this position paper, the AAOS recommended that health care providers consider antibiotic prophylaxis prior to invasive procedures on all patients who had prosthetic joints, regardless of how long those joints have been in place. This major change in recommendations was not based on any new evidence that had been reviewed since the 2003 guidelines.
There are two studies that address outcome of patients with prosthetic joints who have and have not received prophylactic antibiotics.
Elie Berbari, MD, and colleagues reported on the results of a prospective case-control study comparing patients with prosthetic joints hospitalized with hip or knee infections with patients who had prosthetic joints hospitalized at the same time who did not have hip or knee infections.7
There was no increased risk of prosthetic hip or knee infection for patients undergoing a dental procedure who were not receiving antibiotic prophylaxis (odds ratio, 0.8; 95% confidence interval, 0.4-1.6), compared with the risk for patients not undergoing a dental procedure (OR, 0.6; 95% CI, 0.4-1.1). Antibiotic prophylaxis in patients undergoing high and low risk dental procedures did not decrease the risk of prosthetic joint infections.
In 2012, the AAOS and the ADA published updated guidelines with the following summary recommendation: “The practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures.”8 They referenced the Berbari study as the best available evidence.
Feng-Chen Kao, MD, and colleagues published a study this year with a design very similar to the Berbari study, with similar results.9 All Taiwanese residents who had received hip or knee replacements over a 12-year period were screened. Those who had received dental procedures were matched with individuals who had not had dental procedures. The dental procedure group was subdivided into a group that received antibiotics and one that didn’t.
There was no difference in infection rates between the group that had received dental procedures and the group that did not, and no difference in infection rates between those who received prophylactic antibiotics and those who didn’t.
I think this myth can be put to rest. There is no evidence to give patients with joint prostheses prophylactic antibiotics before dental procedures.
References
1. Steckelberg J.M., Osmon D.R. Prosthetic joint infections. In: Bisno A.L., Waldvogel F.A., eds. Infections associated with indwelling medical devices. Third ed., Washington, D.C.: American Society of Microbiology Press, 2000:173-209.
2. J Dent Res. 2004 Feb;83(2):170-4.
3. J Clin Periodontol. 2006 Feb;33(6):401-7.
4. J Am Dent Assoc. 1997 Jul;128(7):1004-8.
5. J Am Dent Assoc. 2003 Jul;134(7):895-9.
6. Spec Care Dentist. 2009 Nov-Dec;29(6):229-31.
7. Clin Infect Dis. 2010 Jan 1;50(1):8-16.
8. J Dent (Shiraz). 2013 Mar;14(1):49-52.
9. Infect Control Hosp Epidemiol. 2017 Feb;38(2):154-61.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].
A 66-year-old woman 3 years status post hip replacement is seen for dental work. The dentist contacts the clinic for an antibiotic prescription. The patient has a penicillin allergy (rash). What do you recommend?
A. Clindamycin one dose before dental work.
B. Amoxicillin one dose before dental work.
C. Amoxicillin one dose before, one dose 4 hours after dental work.
D. Clindamycin one dose before dental work, one dose 4 hours after dental work.
E. No antibiotics.
Many patients with prosthetic joints will request antibiotics to take prior to dental procedures. Sometimes this request comes from the dental office.
When I ask patients why they feel they need antibiotics, they often reply that they were told by their orthopedic surgeons or their dentist that they would need to take antibiotics before dental procedures.
In an era when Clostridium difficile infection is a common and dangerous complication in the elderly, avoidance of unnecessary antibiotics is critical. In the United States, it is estimated that there are 240,000 patients infected with C. difficile annually, with 24,000 deaths at a cost of $6 billion.1
Is there compelling evidence to justify giving antibiotic prophylaxis for dental procedures to patients with prosthetic joints?
This information has called into question the wisdom of giving antibiotic prophylaxis for dental procedures when the same patients have transient bacteremias as a regular part of day-to-day life, and mouth organisms were infrequent causes of prosthetic joint infections.
The American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association (ADA) released an advisory statement 20 years ago on antibiotic prophylaxis for patients with dental replacements, which concluded: “Antibiotic prophylaxis is not indicated for dental patients with pins, plates, and screws, nor is it routinely indicated for most dental patients with total joint replacements.”4
In 2003, the AAOS and the ADA released updated guidelines that stated: “Presently, no scientific evidence supports the position that antibiotic prophylaxis to prevent hematogenous infections is required prior to dental treatment in patients with total joint prostheses. The risk/benefit and cost/effectiveness ratios fail to justify the administration of routine antibiotics.”5
Great confusion arose in 2009 when the AAOS published a position paper on its website that reversed this position.6 Interestingly, the statement was done by the AAOS alone, and not done in conjunction with the ADA.
In this position paper, the AAOS recommended that health care providers consider antibiotic prophylaxis prior to invasive procedures on all patients who had prosthetic joints, regardless of how long those joints have been in place. This major change in recommendations was not based on any new evidence that had been reviewed since the 2003 guidelines.
There are two studies that address outcome of patients with prosthetic joints who have and have not received prophylactic antibiotics.
Elie Berbari, MD, and colleagues reported on the results of a prospective case-control study comparing patients with prosthetic joints hospitalized with hip or knee infections with patients who had prosthetic joints hospitalized at the same time who did not have hip or knee infections.7
There was no increased risk of prosthetic hip or knee infection for patients undergoing a dental procedure who were not receiving antibiotic prophylaxis (odds ratio, 0.8; 95% confidence interval, 0.4-1.6), compared with the risk for patients not undergoing a dental procedure (OR, 0.6; 95% CI, 0.4-1.1). Antibiotic prophylaxis in patients undergoing high and low risk dental procedures did not decrease the risk of prosthetic joint infections.
In 2012, the AAOS and the ADA published updated guidelines with the following summary recommendation: “The practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures.”8 They referenced the Berbari study as the best available evidence.
Feng-Chen Kao, MD, and colleagues published a study this year with a design very similar to the Berbari study, with similar results.9 All Taiwanese residents who had received hip or knee replacements over a 12-year period were screened. Those who had received dental procedures were matched with individuals who had not had dental procedures. The dental procedure group was subdivided into a group that received antibiotics and one that didn’t.
There was no difference in infection rates between the group that had received dental procedures and the group that did not, and no difference in infection rates between those who received prophylactic antibiotics and those who didn’t.
I think this myth can be put to rest. There is no evidence to give patients with joint prostheses prophylactic antibiotics before dental procedures.
References
1. Steckelberg J.M., Osmon D.R. Prosthetic joint infections. In: Bisno A.L., Waldvogel F.A., eds. Infections associated with indwelling medical devices. Third ed., Washington, D.C.: American Society of Microbiology Press, 2000:173-209.
2. J Dent Res. 2004 Feb;83(2):170-4.
3. J Clin Periodontol. 2006 Feb;33(6):401-7.
4. J Am Dent Assoc. 1997 Jul;128(7):1004-8.
5. J Am Dent Assoc. 2003 Jul;134(7):895-9.
6. Spec Care Dentist. 2009 Nov-Dec;29(6):229-31.
7. Clin Infect Dis. 2010 Jan 1;50(1):8-16.
8. J Dent (Shiraz). 2013 Mar;14(1):49-52.
9. Infect Control Hosp Epidemiol. 2017 Feb;38(2):154-61.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].
A 66-year-old woman 3 years status post hip replacement is seen for dental work. The dentist contacts the clinic for an antibiotic prescription. The patient has a penicillin allergy (rash). What do you recommend?
A. Clindamycin one dose before dental work.
B. Amoxicillin one dose before dental work.
C. Amoxicillin one dose before, one dose 4 hours after dental work.
D. Clindamycin one dose before dental work, one dose 4 hours after dental work.
E. No antibiotics.
Many patients with prosthetic joints will request antibiotics to take prior to dental procedures. Sometimes this request comes from the dental office.
When I ask patients why they feel they need antibiotics, they often reply that they were told by their orthopedic surgeons or their dentist that they would need to take antibiotics before dental procedures.
In an era when Clostridium difficile infection is a common and dangerous complication in the elderly, avoidance of unnecessary antibiotics is critical. In the United States, it is estimated that there are 240,000 patients infected with C. difficile annually, with 24,000 deaths at a cost of $6 billion.1
Is there compelling evidence to justify giving antibiotic prophylaxis for dental procedures to patients with prosthetic joints?
This information has called into question the wisdom of giving antibiotic prophylaxis for dental procedures when the same patients have transient bacteremias as a regular part of day-to-day life, and mouth organisms were infrequent causes of prosthetic joint infections.
The American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association (ADA) released an advisory statement 20 years ago on antibiotic prophylaxis for patients with dental replacements, which concluded: “Antibiotic prophylaxis is not indicated for dental patients with pins, plates, and screws, nor is it routinely indicated for most dental patients with total joint replacements.”4
In 2003, the AAOS and the ADA released updated guidelines that stated: “Presently, no scientific evidence supports the position that antibiotic prophylaxis to prevent hematogenous infections is required prior to dental treatment in patients with total joint prostheses. The risk/benefit and cost/effectiveness ratios fail to justify the administration of routine antibiotics.”5
Great confusion arose in 2009 when the AAOS published a position paper on its website that reversed this position.6 Interestingly, the statement was done by the AAOS alone, and not done in conjunction with the ADA.
In this position paper, the AAOS recommended that health care providers consider antibiotic prophylaxis prior to invasive procedures on all patients who had prosthetic joints, regardless of how long those joints have been in place. This major change in recommendations was not based on any new evidence that had been reviewed since the 2003 guidelines.
There are two studies that address outcome of patients with prosthetic joints who have and have not received prophylactic antibiotics.
Elie Berbari, MD, and colleagues reported on the results of a prospective case-control study comparing patients with prosthetic joints hospitalized with hip or knee infections with patients who had prosthetic joints hospitalized at the same time who did not have hip or knee infections.7
There was no increased risk of prosthetic hip or knee infection for patients undergoing a dental procedure who were not receiving antibiotic prophylaxis (odds ratio, 0.8; 95% confidence interval, 0.4-1.6), compared with the risk for patients not undergoing a dental procedure (OR, 0.6; 95% CI, 0.4-1.1). Antibiotic prophylaxis in patients undergoing high and low risk dental procedures did not decrease the risk of prosthetic joint infections.
In 2012, the AAOS and the ADA published updated guidelines with the following summary recommendation: “The practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures.”8 They referenced the Berbari study as the best available evidence.
Feng-Chen Kao, MD, and colleagues published a study this year with a design very similar to the Berbari study, with similar results.9 All Taiwanese residents who had received hip or knee replacements over a 12-year period were screened. Those who had received dental procedures were matched with individuals who had not had dental procedures. The dental procedure group was subdivided into a group that received antibiotics and one that didn’t.
There was no difference in infection rates between the group that had received dental procedures and the group that did not, and no difference in infection rates between those who received prophylactic antibiotics and those who didn’t.
I think this myth can be put to rest. There is no evidence to give patients with joint prostheses prophylactic antibiotics before dental procedures.
References
1. Steckelberg J.M., Osmon D.R. Prosthetic joint infections. In: Bisno A.L., Waldvogel F.A., eds. Infections associated with indwelling medical devices. Third ed., Washington, D.C.: American Society of Microbiology Press, 2000:173-209.
2. J Dent Res. 2004 Feb;83(2):170-4.
3. J Clin Periodontol. 2006 Feb;33(6):401-7.
4. J Am Dent Assoc. 1997 Jul;128(7):1004-8.
5. J Am Dent Assoc. 2003 Jul;134(7):895-9.
6. Spec Care Dentist. 2009 Nov-Dec;29(6):229-31.
7. Clin Infect Dis. 2010 Jan 1;50(1):8-16.
8. J Dent (Shiraz). 2013 Mar;14(1):49-52.
9. Infect Control Hosp Epidemiol. 2017 Feb;38(2):154-61.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].
Adverse childhood experiences
Adverse childhood experiences (ACEs) are the traumatic experiences in a person’s life occurring before the age of 18 years that the person remembers as an adult and that have consequences on a diverse set of outcomes. ACEs include physical abuse, sexual abuse, emotional abuse, mental illness of a household member, problematic drinking or alcoholism of a household member, illegal street or prescription drug use by a household member, divorce or separation of a parent, domestic violence toward a parent, and incarceration of a household member. Each of these experiences before the age of 18 years increases the likelihood of not only adulthood depression, suicide, and substance use disorders, but also a range of nonpsychiatric outcomes such as heart disease and chronic lung disease.
Case summary
Ellie is a 16-year-old girl with a past history of ADHD and oppositionality who arrives on her own in a walk-in clinic to be seen for a sports physical. Ellie has been generally healthy and was previously on a stable medical regimen of methylphenidate but has not been taking it for about 1 year. The oppositionality that she previously experienced in her early school-age years has slowly decreased. She generally does well in school and is in several clubs. In the course of the history, Ellie reveals that her mother’s depression has been worse lately to the point where her mother has resumed her drinking and illegal opiate use. You discuss safety with Ellie, and she reveals that, while she has never been threatened or injured, there has been domestic violence in the home that Ellie felt responsible to try to stop by calling the police. This led to the one and only time that Ellie was physically struck. Her father is now incarcerated, and Ellie feels guilty. After a discussion with Ellie, you report this situation to social services, who already has the case on file. Ellie’s mental status exam, including a thorough examination of symptoms of mood disorders, anxiety, substance use, and PTSD, is within normal limits.
Case discussion
Ellie has suffered a set of ACEs. Specifically, her mother has a mental illness, has a drinking problem, and uses illegal drugs; Ellie has witnessed domestic violence toward her mother, has a family member who is incarcerated, and has suffered from physical abuse. This ACEs score of 6 puts her at markedly increased risk for multiple psychiatric and nonpsychiatric medical outcomes. Individuals with scores of 4 or above on the simple ACEs questionnaire have demonstrated a 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempts. Further, studies have shown a twofold to fourfold increase in smoking, poor self-rated health, increased numbers of sexual partners and sexually transmitted disease, and 1.4- to 1.6-fold increase in physical inactivity and severe obesity (Am J Prev Med. 1998 May;14[4]:245-58). In Ellie’s case, her history of ADHD and family history of substance use puts her at even further increased risk for later substance use disorders.
While there is no pharmacotherapy or psychotherapy specific to the treatment of having suffered adversity, it is critical for the clinician to note her increased risk. Ellie would be an individual for whom health promotion and prevention would be critical. It is excellent that she is exercising and participating in sports, which appear to be protective. Careful counseling and follow-up with regard to her increased risk for psychiatric and nonpsychiatric disorders is paramount.
Dr. Althoff is associate professor of psychiatry, psychology, and pediatrics at the University of Vermont, Burlington. He is director of the division of behavioral genetics and conducts research on the development of self-regulation in children. Email him at [email protected].
Adverse childhood experiences (ACEs) are the traumatic experiences in a person’s life occurring before the age of 18 years that the person remembers as an adult and that have consequences on a diverse set of outcomes. ACEs include physical abuse, sexual abuse, emotional abuse, mental illness of a household member, problematic drinking or alcoholism of a household member, illegal street or prescription drug use by a household member, divorce or separation of a parent, domestic violence toward a parent, and incarceration of a household member. Each of these experiences before the age of 18 years increases the likelihood of not only adulthood depression, suicide, and substance use disorders, but also a range of nonpsychiatric outcomes such as heart disease and chronic lung disease.
Case summary
Ellie is a 16-year-old girl with a past history of ADHD and oppositionality who arrives on her own in a walk-in clinic to be seen for a sports physical. Ellie has been generally healthy and was previously on a stable medical regimen of methylphenidate but has not been taking it for about 1 year. The oppositionality that she previously experienced in her early school-age years has slowly decreased. She generally does well in school and is in several clubs. In the course of the history, Ellie reveals that her mother’s depression has been worse lately to the point where her mother has resumed her drinking and illegal opiate use. You discuss safety with Ellie, and she reveals that, while she has never been threatened or injured, there has been domestic violence in the home that Ellie felt responsible to try to stop by calling the police. This led to the one and only time that Ellie was physically struck. Her father is now incarcerated, and Ellie feels guilty. After a discussion with Ellie, you report this situation to social services, who already has the case on file. Ellie’s mental status exam, including a thorough examination of symptoms of mood disorders, anxiety, substance use, and PTSD, is within normal limits.
Case discussion
Ellie has suffered a set of ACEs. Specifically, her mother has a mental illness, has a drinking problem, and uses illegal drugs; Ellie has witnessed domestic violence toward her mother, has a family member who is incarcerated, and has suffered from physical abuse. This ACEs score of 6 puts her at markedly increased risk for multiple psychiatric and nonpsychiatric medical outcomes. Individuals with scores of 4 or above on the simple ACEs questionnaire have demonstrated a 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempts. Further, studies have shown a twofold to fourfold increase in smoking, poor self-rated health, increased numbers of sexual partners and sexually transmitted disease, and 1.4- to 1.6-fold increase in physical inactivity and severe obesity (Am J Prev Med. 1998 May;14[4]:245-58). In Ellie’s case, her history of ADHD and family history of substance use puts her at even further increased risk for later substance use disorders.
While there is no pharmacotherapy or psychotherapy specific to the treatment of having suffered adversity, it is critical for the clinician to note her increased risk. Ellie would be an individual for whom health promotion and prevention would be critical. It is excellent that she is exercising and participating in sports, which appear to be protective. Careful counseling and follow-up with regard to her increased risk for psychiatric and nonpsychiatric disorders is paramount.
Dr. Althoff is associate professor of psychiatry, psychology, and pediatrics at the University of Vermont, Burlington. He is director of the division of behavioral genetics and conducts research on the development of self-regulation in children. Email him at [email protected].
Adverse childhood experiences (ACEs) are the traumatic experiences in a person’s life occurring before the age of 18 years that the person remembers as an adult and that have consequences on a diverse set of outcomes. ACEs include physical abuse, sexual abuse, emotional abuse, mental illness of a household member, problematic drinking or alcoholism of a household member, illegal street or prescription drug use by a household member, divorce or separation of a parent, domestic violence toward a parent, and incarceration of a household member. Each of these experiences before the age of 18 years increases the likelihood of not only adulthood depression, suicide, and substance use disorders, but also a range of nonpsychiatric outcomes such as heart disease and chronic lung disease.
Case summary
Ellie is a 16-year-old girl with a past history of ADHD and oppositionality who arrives on her own in a walk-in clinic to be seen for a sports physical. Ellie has been generally healthy and was previously on a stable medical regimen of methylphenidate but has not been taking it for about 1 year. The oppositionality that she previously experienced in her early school-age years has slowly decreased. She generally does well in school and is in several clubs. In the course of the history, Ellie reveals that her mother’s depression has been worse lately to the point where her mother has resumed her drinking and illegal opiate use. You discuss safety with Ellie, and she reveals that, while she has never been threatened or injured, there has been domestic violence in the home that Ellie felt responsible to try to stop by calling the police. This led to the one and only time that Ellie was physically struck. Her father is now incarcerated, and Ellie feels guilty. After a discussion with Ellie, you report this situation to social services, who already has the case on file. Ellie’s mental status exam, including a thorough examination of symptoms of mood disorders, anxiety, substance use, and PTSD, is within normal limits.
Case discussion
Ellie has suffered a set of ACEs. Specifically, her mother has a mental illness, has a drinking problem, and uses illegal drugs; Ellie has witnessed domestic violence toward her mother, has a family member who is incarcerated, and has suffered from physical abuse. This ACEs score of 6 puts her at markedly increased risk for multiple psychiatric and nonpsychiatric medical outcomes. Individuals with scores of 4 or above on the simple ACEs questionnaire have demonstrated a 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempts. Further, studies have shown a twofold to fourfold increase in smoking, poor self-rated health, increased numbers of sexual partners and sexually transmitted disease, and 1.4- to 1.6-fold increase in physical inactivity and severe obesity (Am J Prev Med. 1998 May;14[4]:245-58). In Ellie’s case, her history of ADHD and family history of substance use puts her at even further increased risk for later substance use disorders.
While there is no pharmacotherapy or psychotherapy specific to the treatment of having suffered adversity, it is critical for the clinician to note her increased risk. Ellie would be an individual for whom health promotion and prevention would be critical. It is excellent that she is exercising and participating in sports, which appear to be protective. Careful counseling and follow-up with regard to her increased risk for psychiatric and nonpsychiatric disorders is paramount.
Dr. Althoff is associate professor of psychiatry, psychology, and pediatrics at the University of Vermont, Burlington. He is director of the division of behavioral genetics and conducts research on the development of self-regulation in children. Email him at [email protected].
Mycobacterium tuberculosis: Overcoming one obstacle on the road to elimination
March 24 is World TB Day. It was on this date in 1882 that physician Robert Koch announced the discovery of Mycobacterium tuberculosis, the causative agent of tuberculosis. Worldwide, activities are planned to raise awareness of TB and to support initiatives for prevention, better control, and ultimately the elimination of this disease.
Globally in 2015, the World Health Organization estimated there were 10.4 million new cases of TB, including 1 million in children. Data from the United States reveal that after 20 years of annual decline, the incidence of TB has plateaued. In 2015, 9,563 cases of TB disease were reported, including 440 cases in children less than 15 years of age. While the overall incidence was 3 cases per 100,000, the incidence among foreign-born persons was 15.1 cases per 100,000. There were 3,201 cases (33.5%) among U.S.-born individuals. Foreign-born persons accounted for 66.2% of cases; however, the majority of those cases were diagnosed several years after their arrival in the United States. The top five countries of origin of these individuals were China, India, Mexico, the Philippines, and Vietnam. In contrast, only one-quarter of all pediatric cases occurred in foreign-born children. Four states (California, Florida, New York, and Texas) reported more than 500 cases each in 2015, as they have for the last 7 consecutive years. In 2015, these states accounted for slightly more than half (4,839) of all cases (MMWR 2016 Mar 25;65[11]:273-8).
Why as pediatricians should we be concerned? TB in a child is a sentinel event and represents recent or ongoing transmission. Young children who are infected are more likely to progress to TB disease and develop severe manifestations such as miliary TB or meningitis. Children less than 4 years old and those with certain underlying disorders, including those with an immunodeficiency or who are receiving immunosuppressive agents, also are at greater risk for progression from infection to disease. Other predictors of disease progression include diagnosis of the infection within the past 2 years, use of chemotherapy and high-dose corticosteroids, as well as certain cancers, diabetes, and chronic renal failure.
Once infected, most children and adolescents remain asymptomatic. If disease occurs, symptoms develop 1-6 months after infection and include fever, cough, weight loss or failure to thrive, night sweats, and chills. Chest radiographic findings are nonspecific. Infiltrates and intrathoracic lymph node enlargement may or may not be present. However, our goal is to diagnose at-risk children with infection, treat them, and avoid their progression to TB disease.
Screening tests
The interferon-gamma release assay is a blood test that has a greater specificity than TST and requires only one visit. A positive test is seen in both latent TB infection and TB disease. There is no cross-reaction with BCG. This is the ideal test for prior BCG recipients and others who are unlikely to return for TST readings and are at least 5 years of age.
A chest radiograph is required to differentiate latent TB infection from TB disease. Latent TB infection is diagnosed when there is an absence of parenchymal disease, opacification, or intrathoracic adenopathy.
Treatment of latent TB infection versus TB disease is beyond the scope of this article. Consultation with an infectious disease expert is recommended.
For additional information and resources, go to www.cdc.gov/tb, and for a sample TB risk assessment tool, go to www.cdc.gov/tb/publications/ltbi/appendixa.htm.
As we mark the passing of another World TB Day, we have one goal – to identify, screen, and treat children and adolescents at risk for latent TB infection and help eliminate future cases of TB disease.
Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She said she had no relevant financial disclosures.
March 24 is World TB Day. It was on this date in 1882 that physician Robert Koch announced the discovery of Mycobacterium tuberculosis, the causative agent of tuberculosis. Worldwide, activities are planned to raise awareness of TB and to support initiatives for prevention, better control, and ultimately the elimination of this disease.
Globally in 2015, the World Health Organization estimated there were 10.4 million new cases of TB, including 1 million in children. Data from the United States reveal that after 20 years of annual decline, the incidence of TB has plateaued. In 2015, 9,563 cases of TB disease were reported, including 440 cases in children less than 15 years of age. While the overall incidence was 3 cases per 100,000, the incidence among foreign-born persons was 15.1 cases per 100,000. There were 3,201 cases (33.5%) among U.S.-born individuals. Foreign-born persons accounted for 66.2% of cases; however, the majority of those cases were diagnosed several years after their arrival in the United States. The top five countries of origin of these individuals were China, India, Mexico, the Philippines, and Vietnam. In contrast, only one-quarter of all pediatric cases occurred in foreign-born children. Four states (California, Florida, New York, and Texas) reported more than 500 cases each in 2015, as they have for the last 7 consecutive years. In 2015, these states accounted for slightly more than half (4,839) of all cases (MMWR 2016 Mar 25;65[11]:273-8).
Why as pediatricians should we be concerned? TB in a child is a sentinel event and represents recent or ongoing transmission. Young children who are infected are more likely to progress to TB disease and develop severe manifestations such as miliary TB or meningitis. Children less than 4 years old and those with certain underlying disorders, including those with an immunodeficiency or who are receiving immunosuppressive agents, also are at greater risk for progression from infection to disease. Other predictors of disease progression include diagnosis of the infection within the past 2 years, use of chemotherapy and high-dose corticosteroids, as well as certain cancers, diabetes, and chronic renal failure.
Once infected, most children and adolescents remain asymptomatic. If disease occurs, symptoms develop 1-6 months after infection and include fever, cough, weight loss or failure to thrive, night sweats, and chills. Chest radiographic findings are nonspecific. Infiltrates and intrathoracic lymph node enlargement may or may not be present. However, our goal is to diagnose at-risk children with infection, treat them, and avoid their progression to TB disease.
Screening tests
The interferon-gamma release assay is a blood test that has a greater specificity than TST and requires only one visit. A positive test is seen in both latent TB infection and TB disease. There is no cross-reaction with BCG. This is the ideal test for prior BCG recipients and others who are unlikely to return for TST readings and are at least 5 years of age.
A chest radiograph is required to differentiate latent TB infection from TB disease. Latent TB infection is diagnosed when there is an absence of parenchymal disease, opacification, or intrathoracic adenopathy.
Treatment of latent TB infection versus TB disease is beyond the scope of this article. Consultation with an infectious disease expert is recommended.
For additional information and resources, go to www.cdc.gov/tb, and for a sample TB risk assessment tool, go to www.cdc.gov/tb/publications/ltbi/appendixa.htm.
As we mark the passing of another World TB Day, we have one goal – to identify, screen, and treat children and adolescents at risk for latent TB infection and help eliminate future cases of TB disease.
Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She said she had no relevant financial disclosures.
March 24 is World TB Day. It was on this date in 1882 that physician Robert Koch announced the discovery of Mycobacterium tuberculosis, the causative agent of tuberculosis. Worldwide, activities are planned to raise awareness of TB and to support initiatives for prevention, better control, and ultimately the elimination of this disease.
Globally in 2015, the World Health Organization estimated there were 10.4 million new cases of TB, including 1 million in children. Data from the United States reveal that after 20 years of annual decline, the incidence of TB has plateaued. In 2015, 9,563 cases of TB disease were reported, including 440 cases in children less than 15 years of age. While the overall incidence was 3 cases per 100,000, the incidence among foreign-born persons was 15.1 cases per 100,000. There were 3,201 cases (33.5%) among U.S.-born individuals. Foreign-born persons accounted for 66.2% of cases; however, the majority of those cases were diagnosed several years after their arrival in the United States. The top five countries of origin of these individuals were China, India, Mexico, the Philippines, and Vietnam. In contrast, only one-quarter of all pediatric cases occurred in foreign-born children. Four states (California, Florida, New York, and Texas) reported more than 500 cases each in 2015, as they have for the last 7 consecutive years. In 2015, these states accounted for slightly more than half (4,839) of all cases (MMWR 2016 Mar 25;65[11]:273-8).
Why as pediatricians should we be concerned? TB in a child is a sentinel event and represents recent or ongoing transmission. Young children who are infected are more likely to progress to TB disease and develop severe manifestations such as miliary TB or meningitis. Children less than 4 years old and those with certain underlying disorders, including those with an immunodeficiency or who are receiving immunosuppressive agents, also are at greater risk for progression from infection to disease. Other predictors of disease progression include diagnosis of the infection within the past 2 years, use of chemotherapy and high-dose corticosteroids, as well as certain cancers, diabetes, and chronic renal failure.
Once infected, most children and adolescents remain asymptomatic. If disease occurs, symptoms develop 1-6 months after infection and include fever, cough, weight loss or failure to thrive, night sweats, and chills. Chest radiographic findings are nonspecific. Infiltrates and intrathoracic lymph node enlargement may or may not be present. However, our goal is to diagnose at-risk children with infection, treat them, and avoid their progression to TB disease.
Screening tests
The interferon-gamma release assay is a blood test that has a greater specificity than TST and requires only one visit. A positive test is seen in both latent TB infection and TB disease. There is no cross-reaction with BCG. This is the ideal test for prior BCG recipients and others who are unlikely to return for TST readings and are at least 5 years of age.
A chest radiograph is required to differentiate latent TB infection from TB disease. Latent TB infection is diagnosed when there is an absence of parenchymal disease, opacification, or intrathoracic adenopathy.
Treatment of latent TB infection versus TB disease is beyond the scope of this article. Consultation with an infectious disease expert is recommended.
For additional information and resources, go to www.cdc.gov/tb, and for a sample TB risk assessment tool, go to www.cdc.gov/tb/publications/ltbi/appendixa.htm.
As we mark the passing of another World TB Day, we have one goal – to identify, screen, and treat children and adolescents at risk for latent TB infection and help eliminate future cases of TB disease.
Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She said she had no relevant financial disclosures.
Hot Threads in ACS Communities
Your colleagues already have a lot to say in 2017. Here are the top discussion threads in ACS Communities just prior to press time (communities in which the threads appear are listed in parentheses):
1. Music in the OR. (General Surgery)
2. Nephrologist to surgeon in 3 months! (General Surgery)
3. MACRA. (Advocacy)
4. Mini-fellowship – or how to “brush up” on trauma? (General Surgery)
5. Trauma/PEG for intubated polytrauma patient. (Trauma Surgery)
6. Students observing in OR. (General Surgery)
7. Pediatric appendectomy. (General Surgery)
8. Call-bladders. (General Surgery)
9. Physician rehabilitation. (General Surgery)
10. Letters to ACS Fellows, Members and Members of Congress. (Vascular Surgery)
To join communities, log in to ACS Communities at http://acscommunities.facs.org/home, go to “Browse All Communities” near the top of any page, and click the blue “Join” button next to the community you’d like to join. If you have any questions, please send them to [email protected].
Your colleagues already have a lot to say in 2017. Here are the top discussion threads in ACS Communities just prior to press time (communities in which the threads appear are listed in parentheses):
1. Music in the OR. (General Surgery)
2. Nephrologist to surgeon in 3 months! (General Surgery)
3. MACRA. (Advocacy)
4. Mini-fellowship – or how to “brush up” on trauma? (General Surgery)
5. Trauma/PEG for intubated polytrauma patient. (Trauma Surgery)
6. Students observing in OR. (General Surgery)
7. Pediatric appendectomy. (General Surgery)
8. Call-bladders. (General Surgery)
9. Physician rehabilitation. (General Surgery)
10. Letters to ACS Fellows, Members and Members of Congress. (Vascular Surgery)
To join communities, log in to ACS Communities at http://acscommunities.facs.org/home, go to “Browse All Communities” near the top of any page, and click the blue “Join” button next to the community you’d like to join. If you have any questions, please send them to [email protected].
Your colleagues already have a lot to say in 2017. Here are the top discussion threads in ACS Communities just prior to press time (communities in which the threads appear are listed in parentheses):
1. Music in the OR. (General Surgery)
2. Nephrologist to surgeon in 3 months! (General Surgery)
3. MACRA. (Advocacy)
4. Mini-fellowship – or how to “brush up” on trauma? (General Surgery)
5. Trauma/PEG for intubated polytrauma patient. (Trauma Surgery)
6. Students observing in OR. (General Surgery)
7. Pediatric appendectomy. (General Surgery)
8. Call-bladders. (General Surgery)
9. Physician rehabilitation. (General Surgery)
10. Letters to ACS Fellows, Members and Members of Congress. (Vascular Surgery)
To join communities, log in to ACS Communities at http://acscommunities.facs.org/home, go to “Browse All Communities” near the top of any page, and click the blue “Join” button next to the community you’d like to join. If you have any questions, please send them to [email protected].
Your colleagues already have a lot to say in 2017. Here are the top discussion threads in ACS Communities just prior to press time
Cooperation must overcome polarization
Each profession has its own core set of knowledge, skills, and values. For physicians, the core set of knowledge is anatomy, pathophysiology, and pharmacology. Skills include taking a history, the physical exam, and surgical procedures. The core values traditionally have been compassion and altruism. For modern medical practice, I urge adding cooperation as a core value. Medical school and the apprenticeship of residency are designed to teach, role model, foster, develop, and groom these core competencies.
Getting into medical school is highly competitive. Medical training uses methods that are very different than those used to train elite Olympic and professional athletes. Some competitiveness persists in medical school, but in general the faculty emphasizes cooperation rather than competition. The metric is not whether one student or resident is better than another. Gold and silver medals are not awarded. It is about whether each physician-to-be has passed the milestones needed to practice medicine.
But American health care is threatened by the continued polarization of our government and our society. For years both Cleveland Clinic and Dana Farber have held annual fundraising events at Mar-a-Lago. In February 2017, because of that location’s association with President Trump, some people associated with the organizations advocated boycotting those important fund-raisers. These past few months, it seems every action and every purchase has become a political statement. One restaurant mentioned immigrants on its receipt. The action went viral and caused other people to advocate boycotting the restaurant or not tipping the wait staff (“The new political battleground: Your restaurant receipt,” The Washington Post, by Maura Judkis, Feb. 14, 2017).
Secondary boycotts are an ethical quandary. In labor disputes, organized unions can go on strike. In the 1970s, Japanese cars were not welcome in the employee parking lot of a Ford assembly plant. People do vote with their pocketbook. But in labor disputes, there are legal restrictions on secondary boycotts against other companies. People do need to get along with their neighbors and so do businesses. Politics is the art of encouraging cooperation on one project amongst people who disagree about the goals of many other proposed projects. The Preamble to the United States Constitution enumerates the benefits of cooperation.
In any large-scale human endeavor, conflicts arise that may limit cooperation. Accommodating conscientious objection is the safety valve that permits cooperation when dealing with contested government endeavors such as war, abortion, and physician-assisted suicide. It is meant as a last ditch effort to maintain cohesion of both societal and individual moral integrity. But if every proposed action is met with votes divided along party lines, conscientious objection loses its moral high ground.
Judge Neil Gorsuch, the nominee for the U.S. Supreme Court, has a record of supporting religious freedom in Yellowbear v. Lambert (10th Cir. 2014). He would likely support conscientious objection in relation to assisted dying by physicians, contrary to the arguments made recently by bioethicists Julian Savulescu and Udo Schuklenk. In related news, the liberty of physicians to address gun safety was affirmed when a Florida appeals court upheld the overturning of the state’s Privacy of Firearm Owners Act.
Summing up a tumultuous month of medical ethics, I leave you with the words of Voltaire: “Cherish those who seek the truth but beware of those who find it.”
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].
Each profession has its own core set of knowledge, skills, and values. For physicians, the core set of knowledge is anatomy, pathophysiology, and pharmacology. Skills include taking a history, the physical exam, and surgical procedures. The core values traditionally have been compassion and altruism. For modern medical practice, I urge adding cooperation as a core value. Medical school and the apprenticeship of residency are designed to teach, role model, foster, develop, and groom these core competencies.
Getting into medical school is highly competitive. Medical training uses methods that are very different than those used to train elite Olympic and professional athletes. Some competitiveness persists in medical school, but in general the faculty emphasizes cooperation rather than competition. The metric is not whether one student or resident is better than another. Gold and silver medals are not awarded. It is about whether each physician-to-be has passed the milestones needed to practice medicine.
But American health care is threatened by the continued polarization of our government and our society. For years both Cleveland Clinic and Dana Farber have held annual fundraising events at Mar-a-Lago. In February 2017, because of that location’s association with President Trump, some people associated with the organizations advocated boycotting those important fund-raisers. These past few months, it seems every action and every purchase has become a political statement. One restaurant mentioned immigrants on its receipt. The action went viral and caused other people to advocate boycotting the restaurant or not tipping the wait staff (“The new political battleground: Your restaurant receipt,” The Washington Post, by Maura Judkis, Feb. 14, 2017).
Secondary boycotts are an ethical quandary. In labor disputes, organized unions can go on strike. In the 1970s, Japanese cars were not welcome in the employee parking lot of a Ford assembly plant. People do vote with their pocketbook. But in labor disputes, there are legal restrictions on secondary boycotts against other companies. People do need to get along with their neighbors and so do businesses. Politics is the art of encouraging cooperation on one project amongst people who disagree about the goals of many other proposed projects. The Preamble to the United States Constitution enumerates the benefits of cooperation.
In any large-scale human endeavor, conflicts arise that may limit cooperation. Accommodating conscientious objection is the safety valve that permits cooperation when dealing with contested government endeavors such as war, abortion, and physician-assisted suicide. It is meant as a last ditch effort to maintain cohesion of both societal and individual moral integrity. But if every proposed action is met with votes divided along party lines, conscientious objection loses its moral high ground.
Judge Neil Gorsuch, the nominee for the U.S. Supreme Court, has a record of supporting religious freedom in Yellowbear v. Lambert (10th Cir. 2014). He would likely support conscientious objection in relation to assisted dying by physicians, contrary to the arguments made recently by bioethicists Julian Savulescu and Udo Schuklenk. In related news, the liberty of physicians to address gun safety was affirmed when a Florida appeals court upheld the overturning of the state’s Privacy of Firearm Owners Act.
Summing up a tumultuous month of medical ethics, I leave you with the words of Voltaire: “Cherish those who seek the truth but beware of those who find it.”
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].
Each profession has its own core set of knowledge, skills, and values. For physicians, the core set of knowledge is anatomy, pathophysiology, and pharmacology. Skills include taking a history, the physical exam, and surgical procedures. The core values traditionally have been compassion and altruism. For modern medical practice, I urge adding cooperation as a core value. Medical school and the apprenticeship of residency are designed to teach, role model, foster, develop, and groom these core competencies.
Getting into medical school is highly competitive. Medical training uses methods that are very different than those used to train elite Olympic and professional athletes. Some competitiveness persists in medical school, but in general the faculty emphasizes cooperation rather than competition. The metric is not whether one student or resident is better than another. Gold and silver medals are not awarded. It is about whether each physician-to-be has passed the milestones needed to practice medicine.
But American health care is threatened by the continued polarization of our government and our society. For years both Cleveland Clinic and Dana Farber have held annual fundraising events at Mar-a-Lago. In February 2017, because of that location’s association with President Trump, some people associated with the organizations advocated boycotting those important fund-raisers. These past few months, it seems every action and every purchase has become a political statement. One restaurant mentioned immigrants on its receipt. The action went viral and caused other people to advocate boycotting the restaurant or not tipping the wait staff (“The new political battleground: Your restaurant receipt,” The Washington Post, by Maura Judkis, Feb. 14, 2017).
Secondary boycotts are an ethical quandary. In labor disputes, organized unions can go on strike. In the 1970s, Japanese cars were not welcome in the employee parking lot of a Ford assembly plant. People do vote with their pocketbook. But in labor disputes, there are legal restrictions on secondary boycotts against other companies. People do need to get along with their neighbors and so do businesses. Politics is the art of encouraging cooperation on one project amongst people who disagree about the goals of many other proposed projects. The Preamble to the United States Constitution enumerates the benefits of cooperation.
In any large-scale human endeavor, conflicts arise that may limit cooperation. Accommodating conscientious objection is the safety valve that permits cooperation when dealing with contested government endeavors such as war, abortion, and physician-assisted suicide. It is meant as a last ditch effort to maintain cohesion of both societal and individual moral integrity. But if every proposed action is met with votes divided along party lines, conscientious objection loses its moral high ground.
Judge Neil Gorsuch, the nominee for the U.S. Supreme Court, has a record of supporting religious freedom in Yellowbear v. Lambert (10th Cir. 2014). He would likely support conscientious objection in relation to assisted dying by physicians, contrary to the arguments made recently by bioethicists Julian Savulescu and Udo Schuklenk. In related news, the liberty of physicians to address gun safety was affirmed when a Florida appeals court upheld the overturning of the state’s Privacy of Firearm Owners Act.
Summing up a tumultuous month of medical ethics, I leave you with the words of Voltaire: “Cherish those who seek the truth but beware of those who find it.”
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].
Medication for life
Some areas of psychiatry would benefit from more controversy. One of them is the prescription of antidepressants to young people dealing with romantic disappointments.
I have seen many young men and women given an antidepressant for the very painful, but ordinary, romantic break-ups characteristic of this phase of life, who then become habituated to the drug. They take the medication indefinitely, their brains accommodate neurophysiologically to the presence of the chemical, and they become unable to discontinue it without intolerable withdrawal symptoms that look like an underlying illness. A parallel phenomenon occurs not infrequently with the use of amphetamines (and other stimulants) for attention-deficit hyperactivity disorder that is at times mistakenly diagnosed in this age group.
Antidepressants for early romantic disappointments
Mr. A, now in his 30s, became sullen and withdrawn at age 16 after a girl refused his romantic approaches. His well-intentioned parents took him to a psychiatrist, who, after a brief evaluation, prescribed fluoxetine. Mr. A is now well adjusted and happily married but unable to get off fluoxetine. Even when it is carefully tapered, 2 or 3 months after it is discontinued, he becomes anxious and depressed. This is an iatrogenic problem. It is not related to goings-on in his mind or his life; rather it is the result of his brain’s accommodation to a medication, producing a serious withdrawal syndrome.
His original psychiatrist made only a descriptive diagnosis. He did not inquire about what was going on in Mr. A’s mind and thus could not make a dynamic diagnosis (that is, a diagnosis of a patient’s central emotional conflicts, ability to function in relation to other people, strengths, and weaknesses). Mr. A, like many adolescents, had a lot of anxiety and guilt about sexual and romantic involvement, and potential success. He defended against his anxiety and guilt by assuring himself life would never work out for him. When the girl he admired rebuffed him, he immediately concluded this would perpetually be his fate, so the girl’s refusal was particularly painful. Mr. A feels that had this dynamic been discussed with him at the time, he may well not have needed medication at all.
Ms. B, like Mr. A, was prescribed antidepressants for depressive reactions to early romantic disappointments. Likewise, she self-punitively convinced herself, despite easily attracting men’s attentions, that these disappointments meant a lifetime alone. Ms. B has a family history of depression (although neither of her brothers struggles with it), and she felt that she needed the medications to help negotiate difficult periods. But should she have been on them for extended periods of time? Therapeutic attention to her emotional conflicts helped her to form lasting relationships, marry, and have children. Unable to get off the medications, she had to deal with the risks of their use during pregnancy, which she then subjected to the same sort of guilty self-accusations as she previously had used to limit her romantic prospects.
Ms. C came to me on three medications – one for each of her significant romantic break-ups. She, too, was depressively self-diminishing, beginning therapy by letting me know all the things she could think of that might make me think less of her. Understanding some of the reasons for her self-deprecation helped her toward better romantic relationships but did not give her the courage to get off her medications. Pregnancy, however, led her to promptly and successfully discontinue an antidepressant and a mood stabilizer (she has never had any symptoms suggestive of manic depression). She remained on a low dose of a selective serotonin reuptake inhibitor, had an uneventful pregnancy, and then fell in love with a charming baby.
Principles for consideration
• Psychiatrists (and other mental health professionals and primary care physicians treating mental illness) should always make a dynamic, and not merely a descriptive, diagnosis. Even with a more clearly biologically driven problem, such as bipolar disorder, the patient’s personality and conflicts matter.
• Psychiatrists should be very judicious about prescribing medications in adolescence and young adulthood, especially for difficulties adapting to the typical events of those phases of life. Expert psychotherapy should be the first choice in these instances.
• Medication, when necessary, should be prescribed for as limited a time as possible. It is important for young people to advance their own development, not feel needlessly beholden to medications, not get iatrogenically dependent on them, and not feel that they have “diseases” they don’t have.
Amphetamines for misdiagnosed ADHD
When Ms. D’s family moved to a new house, she, her brother, and her sister, each attended a new school. Unlike her siblings, Ms. D, who was in high school, had a difficult adjustment. Her grades fell. She was taken to a psychiatrist who diagnosed ADHD and prescribed amphetamines. The psychiatrist paid little attention to her prior lack of difficulty in school or her struggles making new friends. Nor did the psychiatrist learn that Ms. D had to ward off the seductive advances of an older teacher (although Ms. D would likely not have been immediately forthcoming about this at the time).
When Ms. D came to me as a college student, for troubles with anger, anxiety, and some depression, she was religiously taking 70 mg of amphetamines daily. After I learned a bit about her and raised the question of whether she actually had ADHD, and whether it might make sense to consider tapering the amphetamines, she was appalled and looked like a toddler who was afraid I was about to steal her candy. Helping her to get off the unneeded medication was a multiyear process.
First, she had to recognize that it was prescribed to treat a problem she probably didn’t have, and second, that it was failing to help her with the problems she did have. As we attended to some of her actual emotional conflicts, she became willing to experiment with lower doses. She was able to see that her work was little changed as the dose was lowered, and that her difficulties with school had more to do with feelings toward classmates and teachers than with the presence or absence of amphetamines. After a protracted struggle, finally off the medication, she felt in charge of her life and no longer believed there was something inherently wrong with her mind or her brain.
Mr. E was the only son in a high-powered academic family. His older sisters were all intellectual standouts. Early in high school, he received his first B as a grade in a course. He was taken to a pediatrician, diagnosed with ADHD, and put on stimulants. Like Ms. D, he came to believe that he needed them. In college, he began to develop some magical aspects to his thinking, a potential side effect of the stimulants. It was very difficult to help him see either that he had a problem with his thinking or that it might be attributable to the medication.
Principles to consider
• If the ADHD wasn’t there in elementary school or before, it is unlikely that an adolescent or young adult has new-onset ADHD. A new or newly amplified conflict is occurring in the person’s mind and life A dynamic diagnosis, as always, is essential.
• When medication is prescribed for actual ADHD, as with anything else, the question of how long it will be taken must be asked. For life? Until other means of adaptation are accomplished? Until adequate outcome studies of long-term use of the medication are performed?
Helping patients to get off unneeded, or no longer needed, medications can be a difficult task. Their emotional attachments to the medications can be intense and varied. For some, the prescription is a sign of being loved and cared for. For others, it represents a certification of a deficit, appeases guilt about success, and/or attests to the need for special consideration. Insofar as the medication has been helpful, it may have come to be regarded as a dearly loved friend, or even a part of the self.
When medication has been helpful, there is also, of course, concern about the potential return of the difficulties for which it was prescribed. Few patients are told at the time of first prescription that there is potential risk of habituation and return of, or potential exaggeration of, symptoms with discontinuation. This type of discussion is more difficult to have in situations in which a prescription is urgently needed and the patient is reluctant, but is still not often done in those instances in which a prescription is more optional than essential. The picture is seldom simple.
These few comments only scratch the surface of the difficulties doctors and patients face in helping patients to discontinue their medications. Residency programs pay a lot of attention to helping trainees learn to prescribe medications; rarely do they sufficiently educate residents how to help patients discontinue them. The fact that so many residencies currently pay limited attention to interventions apart from medication contributes further to the difficulty.
Medications have saved the life of many a psychiatric patient. Some patients need medication for life. But some end up on medication for life, even in some instances when the medication may not have been needed in the first place. Although it is often a difficult task, we need to do a better job of distinguishing which patients are which.
Dr. Blum is a psychiatrist and psychoanalyst in private practice in Philadelphia. He teaches in the departments of anthropology and psychiatry at the University of Pennsylvania and at the Psychoanalytic Center of Philadelphia.
Some areas of psychiatry would benefit from more controversy. One of them is the prescription of antidepressants to young people dealing with romantic disappointments.
I have seen many young men and women given an antidepressant for the very painful, but ordinary, romantic break-ups characteristic of this phase of life, who then become habituated to the drug. They take the medication indefinitely, their brains accommodate neurophysiologically to the presence of the chemical, and they become unable to discontinue it without intolerable withdrawal symptoms that look like an underlying illness. A parallel phenomenon occurs not infrequently with the use of amphetamines (and other stimulants) for attention-deficit hyperactivity disorder that is at times mistakenly diagnosed in this age group.
Antidepressants for early romantic disappointments
Mr. A, now in his 30s, became sullen and withdrawn at age 16 after a girl refused his romantic approaches. His well-intentioned parents took him to a psychiatrist, who, after a brief evaluation, prescribed fluoxetine. Mr. A is now well adjusted and happily married but unable to get off fluoxetine. Even when it is carefully tapered, 2 or 3 months after it is discontinued, he becomes anxious and depressed. This is an iatrogenic problem. It is not related to goings-on in his mind or his life; rather it is the result of his brain’s accommodation to a medication, producing a serious withdrawal syndrome.
His original psychiatrist made only a descriptive diagnosis. He did not inquire about what was going on in Mr. A’s mind and thus could not make a dynamic diagnosis (that is, a diagnosis of a patient’s central emotional conflicts, ability to function in relation to other people, strengths, and weaknesses). Mr. A, like many adolescents, had a lot of anxiety and guilt about sexual and romantic involvement, and potential success. He defended against his anxiety and guilt by assuring himself life would never work out for him. When the girl he admired rebuffed him, he immediately concluded this would perpetually be his fate, so the girl’s refusal was particularly painful. Mr. A feels that had this dynamic been discussed with him at the time, he may well not have needed medication at all.
Ms. B, like Mr. A, was prescribed antidepressants for depressive reactions to early romantic disappointments. Likewise, she self-punitively convinced herself, despite easily attracting men’s attentions, that these disappointments meant a lifetime alone. Ms. B has a family history of depression (although neither of her brothers struggles with it), and she felt that she needed the medications to help negotiate difficult periods. But should she have been on them for extended periods of time? Therapeutic attention to her emotional conflicts helped her to form lasting relationships, marry, and have children. Unable to get off the medications, she had to deal with the risks of their use during pregnancy, which she then subjected to the same sort of guilty self-accusations as she previously had used to limit her romantic prospects.
Ms. C came to me on three medications – one for each of her significant romantic break-ups. She, too, was depressively self-diminishing, beginning therapy by letting me know all the things she could think of that might make me think less of her. Understanding some of the reasons for her self-deprecation helped her toward better romantic relationships but did not give her the courage to get off her medications. Pregnancy, however, led her to promptly and successfully discontinue an antidepressant and a mood stabilizer (she has never had any symptoms suggestive of manic depression). She remained on a low dose of a selective serotonin reuptake inhibitor, had an uneventful pregnancy, and then fell in love with a charming baby.
Principles for consideration
• Psychiatrists (and other mental health professionals and primary care physicians treating mental illness) should always make a dynamic, and not merely a descriptive, diagnosis. Even with a more clearly biologically driven problem, such as bipolar disorder, the patient’s personality and conflicts matter.
• Psychiatrists should be very judicious about prescribing medications in adolescence and young adulthood, especially for difficulties adapting to the typical events of those phases of life. Expert psychotherapy should be the first choice in these instances.
• Medication, when necessary, should be prescribed for as limited a time as possible. It is important for young people to advance their own development, not feel needlessly beholden to medications, not get iatrogenically dependent on them, and not feel that they have “diseases” they don’t have.
Amphetamines for misdiagnosed ADHD
When Ms. D’s family moved to a new house, she, her brother, and her sister, each attended a new school. Unlike her siblings, Ms. D, who was in high school, had a difficult adjustment. Her grades fell. She was taken to a psychiatrist who diagnosed ADHD and prescribed amphetamines. The psychiatrist paid little attention to her prior lack of difficulty in school or her struggles making new friends. Nor did the psychiatrist learn that Ms. D had to ward off the seductive advances of an older teacher (although Ms. D would likely not have been immediately forthcoming about this at the time).
When Ms. D came to me as a college student, for troubles with anger, anxiety, and some depression, she was religiously taking 70 mg of amphetamines daily. After I learned a bit about her and raised the question of whether she actually had ADHD, and whether it might make sense to consider tapering the amphetamines, she was appalled and looked like a toddler who was afraid I was about to steal her candy. Helping her to get off the unneeded medication was a multiyear process.
First, she had to recognize that it was prescribed to treat a problem she probably didn’t have, and second, that it was failing to help her with the problems she did have. As we attended to some of her actual emotional conflicts, she became willing to experiment with lower doses. She was able to see that her work was little changed as the dose was lowered, and that her difficulties with school had more to do with feelings toward classmates and teachers than with the presence or absence of amphetamines. After a protracted struggle, finally off the medication, she felt in charge of her life and no longer believed there was something inherently wrong with her mind or her brain.
Mr. E was the only son in a high-powered academic family. His older sisters were all intellectual standouts. Early in high school, he received his first B as a grade in a course. He was taken to a pediatrician, diagnosed with ADHD, and put on stimulants. Like Ms. D, he came to believe that he needed them. In college, he began to develop some magical aspects to his thinking, a potential side effect of the stimulants. It was very difficult to help him see either that he had a problem with his thinking or that it might be attributable to the medication.
Principles to consider
• If the ADHD wasn’t there in elementary school or before, it is unlikely that an adolescent or young adult has new-onset ADHD. A new or newly amplified conflict is occurring in the person’s mind and life A dynamic diagnosis, as always, is essential.
• When medication is prescribed for actual ADHD, as with anything else, the question of how long it will be taken must be asked. For life? Until other means of adaptation are accomplished? Until adequate outcome studies of long-term use of the medication are performed?
Helping patients to get off unneeded, or no longer needed, medications can be a difficult task. Their emotional attachments to the medications can be intense and varied. For some, the prescription is a sign of being loved and cared for. For others, it represents a certification of a deficit, appeases guilt about success, and/or attests to the need for special consideration. Insofar as the medication has been helpful, it may have come to be regarded as a dearly loved friend, or even a part of the self.
When medication has been helpful, there is also, of course, concern about the potential return of the difficulties for which it was prescribed. Few patients are told at the time of first prescription that there is potential risk of habituation and return of, or potential exaggeration of, symptoms with discontinuation. This type of discussion is more difficult to have in situations in which a prescription is urgently needed and the patient is reluctant, but is still not often done in those instances in which a prescription is more optional than essential. The picture is seldom simple.
These few comments only scratch the surface of the difficulties doctors and patients face in helping patients to discontinue their medications. Residency programs pay a lot of attention to helping trainees learn to prescribe medications; rarely do they sufficiently educate residents how to help patients discontinue them. The fact that so many residencies currently pay limited attention to interventions apart from medication contributes further to the difficulty.
Medications have saved the life of many a psychiatric patient. Some patients need medication for life. But some end up on medication for life, even in some instances when the medication may not have been needed in the first place. Although it is often a difficult task, we need to do a better job of distinguishing which patients are which.
Dr. Blum is a psychiatrist and psychoanalyst in private practice in Philadelphia. He teaches in the departments of anthropology and psychiatry at the University of Pennsylvania and at the Psychoanalytic Center of Philadelphia.
Some areas of psychiatry would benefit from more controversy. One of them is the prescription of antidepressants to young people dealing with romantic disappointments.
I have seen many young men and women given an antidepressant for the very painful, but ordinary, romantic break-ups characteristic of this phase of life, who then become habituated to the drug. They take the medication indefinitely, their brains accommodate neurophysiologically to the presence of the chemical, and they become unable to discontinue it without intolerable withdrawal symptoms that look like an underlying illness. A parallel phenomenon occurs not infrequently with the use of amphetamines (and other stimulants) for attention-deficit hyperactivity disorder that is at times mistakenly diagnosed in this age group.
Antidepressants for early romantic disappointments
Mr. A, now in his 30s, became sullen and withdrawn at age 16 after a girl refused his romantic approaches. His well-intentioned parents took him to a psychiatrist, who, after a brief evaluation, prescribed fluoxetine. Mr. A is now well adjusted and happily married but unable to get off fluoxetine. Even when it is carefully tapered, 2 or 3 months after it is discontinued, he becomes anxious and depressed. This is an iatrogenic problem. It is not related to goings-on in his mind or his life; rather it is the result of his brain’s accommodation to a medication, producing a serious withdrawal syndrome.
His original psychiatrist made only a descriptive diagnosis. He did not inquire about what was going on in Mr. A’s mind and thus could not make a dynamic diagnosis (that is, a diagnosis of a patient’s central emotional conflicts, ability to function in relation to other people, strengths, and weaknesses). Mr. A, like many adolescents, had a lot of anxiety and guilt about sexual and romantic involvement, and potential success. He defended against his anxiety and guilt by assuring himself life would never work out for him. When the girl he admired rebuffed him, he immediately concluded this would perpetually be his fate, so the girl’s refusal was particularly painful. Mr. A feels that had this dynamic been discussed with him at the time, he may well not have needed medication at all.
Ms. B, like Mr. A, was prescribed antidepressants for depressive reactions to early romantic disappointments. Likewise, she self-punitively convinced herself, despite easily attracting men’s attentions, that these disappointments meant a lifetime alone. Ms. B has a family history of depression (although neither of her brothers struggles with it), and she felt that she needed the medications to help negotiate difficult periods. But should she have been on them for extended periods of time? Therapeutic attention to her emotional conflicts helped her to form lasting relationships, marry, and have children. Unable to get off the medications, she had to deal with the risks of their use during pregnancy, which she then subjected to the same sort of guilty self-accusations as she previously had used to limit her romantic prospects.
Ms. C came to me on three medications – one for each of her significant romantic break-ups. She, too, was depressively self-diminishing, beginning therapy by letting me know all the things she could think of that might make me think less of her. Understanding some of the reasons for her self-deprecation helped her toward better romantic relationships but did not give her the courage to get off her medications. Pregnancy, however, led her to promptly and successfully discontinue an antidepressant and a mood stabilizer (she has never had any symptoms suggestive of manic depression). She remained on a low dose of a selective serotonin reuptake inhibitor, had an uneventful pregnancy, and then fell in love with a charming baby.
Principles for consideration
• Psychiatrists (and other mental health professionals and primary care physicians treating mental illness) should always make a dynamic, and not merely a descriptive, diagnosis. Even with a more clearly biologically driven problem, such as bipolar disorder, the patient’s personality and conflicts matter.
• Psychiatrists should be very judicious about prescribing medications in adolescence and young adulthood, especially for difficulties adapting to the typical events of those phases of life. Expert psychotherapy should be the first choice in these instances.
• Medication, when necessary, should be prescribed for as limited a time as possible. It is important for young people to advance their own development, not feel needlessly beholden to medications, not get iatrogenically dependent on them, and not feel that they have “diseases” they don’t have.
Amphetamines for misdiagnosed ADHD
When Ms. D’s family moved to a new house, she, her brother, and her sister, each attended a new school. Unlike her siblings, Ms. D, who was in high school, had a difficult adjustment. Her grades fell. She was taken to a psychiatrist who diagnosed ADHD and prescribed amphetamines. The psychiatrist paid little attention to her prior lack of difficulty in school or her struggles making new friends. Nor did the psychiatrist learn that Ms. D had to ward off the seductive advances of an older teacher (although Ms. D would likely not have been immediately forthcoming about this at the time).
When Ms. D came to me as a college student, for troubles with anger, anxiety, and some depression, she was religiously taking 70 mg of amphetamines daily. After I learned a bit about her and raised the question of whether she actually had ADHD, and whether it might make sense to consider tapering the amphetamines, she was appalled and looked like a toddler who was afraid I was about to steal her candy. Helping her to get off the unneeded medication was a multiyear process.
First, she had to recognize that it was prescribed to treat a problem she probably didn’t have, and second, that it was failing to help her with the problems she did have. As we attended to some of her actual emotional conflicts, she became willing to experiment with lower doses. She was able to see that her work was little changed as the dose was lowered, and that her difficulties with school had more to do with feelings toward classmates and teachers than with the presence or absence of amphetamines. After a protracted struggle, finally off the medication, she felt in charge of her life and no longer believed there was something inherently wrong with her mind or her brain.
Mr. E was the only son in a high-powered academic family. His older sisters were all intellectual standouts. Early in high school, he received his first B as a grade in a course. He was taken to a pediatrician, diagnosed with ADHD, and put on stimulants. Like Ms. D, he came to believe that he needed them. In college, he began to develop some magical aspects to his thinking, a potential side effect of the stimulants. It was very difficult to help him see either that he had a problem with his thinking or that it might be attributable to the medication.
Principles to consider
• If the ADHD wasn’t there in elementary school or before, it is unlikely that an adolescent or young adult has new-onset ADHD. A new or newly amplified conflict is occurring in the person’s mind and life A dynamic diagnosis, as always, is essential.
• When medication is prescribed for actual ADHD, as with anything else, the question of how long it will be taken must be asked. For life? Until other means of adaptation are accomplished? Until adequate outcome studies of long-term use of the medication are performed?
Helping patients to get off unneeded, or no longer needed, medications can be a difficult task. Their emotional attachments to the medications can be intense and varied. For some, the prescription is a sign of being loved and cared for. For others, it represents a certification of a deficit, appeases guilt about success, and/or attests to the need for special consideration. Insofar as the medication has been helpful, it may have come to be regarded as a dearly loved friend, or even a part of the self.
When medication has been helpful, there is also, of course, concern about the potential return of the difficulties for which it was prescribed. Few patients are told at the time of first prescription that there is potential risk of habituation and return of, or potential exaggeration of, symptoms with discontinuation. This type of discussion is more difficult to have in situations in which a prescription is urgently needed and the patient is reluctant, but is still not often done in those instances in which a prescription is more optional than essential. The picture is seldom simple.
These few comments only scratch the surface of the difficulties doctors and patients face in helping patients to discontinue their medications. Residency programs pay a lot of attention to helping trainees learn to prescribe medications; rarely do they sufficiently educate residents how to help patients discontinue them. The fact that so many residencies currently pay limited attention to interventions apart from medication contributes further to the difficulty.
Medications have saved the life of many a psychiatric patient. Some patients need medication for life. But some end up on medication for life, even in some instances when the medication may not have been needed in the first place. Although it is often a difficult task, we need to do a better job of distinguishing which patients are which.
Dr. Blum is a psychiatrist and psychoanalyst in private practice in Philadelphia. He teaches in the departments of anthropology and psychiatry at the University of Pennsylvania and at the Psychoanalytic Center of Philadelphia.