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Readers weigh in on opioid epidemic
I read Dr. Unger’s guest editorial, “Staring down the opioid epidemic” (J Fam Pract. 2017;66:8) and thought that he made some good points, but as an internist for 38 years and a detox addiction specialist for the past 7 years, I have seen too much “pendulum swinging” with regard to opioids.
The state of Pennsylvania is enforcing opioid prescription laws so intensely that I now see underprescribing of needed medications by physicians and dentists. For example, I recently had dental surgery and wasn’t prescribed a narcotic. I suffered for 24 hours with ineffective nonsteroidal anti-inflammatory drugs. And a relative of mine experienced excessive pain following gynecologic cancer surgery because the surgeon wouldn’t prescribe opioids for fear of reprisal.
I would like to see someone conduct a nationwide survey of primary care physicians regarding their views on narcotics for pain so that I can better understand my colleagues’ perspectives on this issue.
Don Sesso, DO, FCCP
Gwynedd Valley, PA
In his guest editorial, Dr. Unger urged family physicians to treat patients who are addicted to opioids with buprenorphine. It’s a shame that so few of us do so.
Patients who are addicted to opioids are no more difficult to treat than patients with diabetes, yet we, as family physicians, often fail to fulfill our basic duty to respond to their illness. Using buprenorphine to help a patient who is addicted to opioids achieve sobriety is highly effective. And treating these patients is amazingly satisfying, as you’ll never have more grateful patients than these.
I began integrating buprenorphine treatment into my family practice 10 years ago. It has made me much more effective in treating my patients who are addicted to alcohol, and it has provided me with a great deal of personal satisfaction in the latter part of my career.
I challenge all family physicians to step up and do their duty to help combat the opioid epidemic.
David A. Moore, MD
Salt Lake City, Utah
I read Dr. Unger’s guest editorial, “Staring down the opioid epidemic” (J Fam Pract. 2017;66:8) and thought that he made some good points, but as an internist for 38 years and a detox addiction specialist for the past 7 years, I have seen too much “pendulum swinging” with regard to opioids.
The state of Pennsylvania is enforcing opioid prescription laws so intensely that I now see underprescribing of needed medications by physicians and dentists. For example, I recently had dental surgery and wasn’t prescribed a narcotic. I suffered for 24 hours with ineffective nonsteroidal anti-inflammatory drugs. And a relative of mine experienced excessive pain following gynecologic cancer surgery because the surgeon wouldn’t prescribe opioids for fear of reprisal.
I would like to see someone conduct a nationwide survey of primary care physicians regarding their views on narcotics for pain so that I can better understand my colleagues’ perspectives on this issue.
Don Sesso, DO, FCCP
Gwynedd Valley, PA
In his guest editorial, Dr. Unger urged family physicians to treat patients who are addicted to opioids with buprenorphine. It’s a shame that so few of us do so.
Patients who are addicted to opioids are no more difficult to treat than patients with diabetes, yet we, as family physicians, often fail to fulfill our basic duty to respond to their illness. Using buprenorphine to help a patient who is addicted to opioids achieve sobriety is highly effective. And treating these patients is amazingly satisfying, as you’ll never have more grateful patients than these.
I began integrating buprenorphine treatment into my family practice 10 years ago. It has made me much more effective in treating my patients who are addicted to alcohol, and it has provided me with a great deal of personal satisfaction in the latter part of my career.
I challenge all family physicians to step up and do their duty to help combat the opioid epidemic.
David A. Moore, MD
Salt Lake City, Utah
I read Dr. Unger’s guest editorial, “Staring down the opioid epidemic” (J Fam Pract. 2017;66:8) and thought that he made some good points, but as an internist for 38 years and a detox addiction specialist for the past 7 years, I have seen too much “pendulum swinging” with regard to opioids.
The state of Pennsylvania is enforcing opioid prescription laws so intensely that I now see underprescribing of needed medications by physicians and dentists. For example, I recently had dental surgery and wasn’t prescribed a narcotic. I suffered for 24 hours with ineffective nonsteroidal anti-inflammatory drugs. And a relative of mine experienced excessive pain following gynecologic cancer surgery because the surgeon wouldn’t prescribe opioids for fear of reprisal.
I would like to see someone conduct a nationwide survey of primary care physicians regarding their views on narcotics for pain so that I can better understand my colleagues’ perspectives on this issue.
Don Sesso, DO, FCCP
Gwynedd Valley, PA
In his guest editorial, Dr. Unger urged family physicians to treat patients who are addicted to opioids with buprenorphine. It’s a shame that so few of us do so.
Patients who are addicted to opioids are no more difficult to treat than patients with diabetes, yet we, as family physicians, often fail to fulfill our basic duty to respond to their illness. Using buprenorphine to help a patient who is addicted to opioids achieve sobriety is highly effective. And treating these patients is amazingly satisfying, as you’ll never have more grateful patients than these.
I began integrating buprenorphine treatment into my family practice 10 years ago. It has made me much more effective in treating my patients who are addicted to alcohol, and it has provided me with a great deal of personal satisfaction in the latter part of my career.
I challenge all family physicians to step up and do their duty to help combat the opioid epidemic.
David A. Moore, MD
Salt Lake City, Utah
An overlooked Rx for nasal obstruction relief
In the article, “Improving your approach to nasal obstruction” (J Fam Pract. 2016;65:889-893,898-899), I noticed that ipratropium nasal spray was not mentioned in Table 2, which listed commonly used medications for nasal obstruction.
We frequently recommend ipratropium nasal spray in our office, as it is an effective, non-addictive nasal decongestant. It is available in 2 strengths, .03% and .06%, and we usually prescribe 2 sprays in each nostril, 2 to 3 times a day, as needed.
We have found this to be very effective for short-term use. Its value, of course, is that it acts rapidly and there is no limit on how long it may be used.
Walter D. Leventhal, MD
Summerville, SC
In the article, “Improving your approach to nasal obstruction” (J Fam Pract. 2016;65:889-893,898-899), I noticed that ipratropium nasal spray was not mentioned in Table 2, which listed commonly used medications for nasal obstruction.
We frequently recommend ipratropium nasal spray in our office, as it is an effective, non-addictive nasal decongestant. It is available in 2 strengths, .03% and .06%, and we usually prescribe 2 sprays in each nostril, 2 to 3 times a day, as needed.
We have found this to be very effective for short-term use. Its value, of course, is that it acts rapidly and there is no limit on how long it may be used.
Walter D. Leventhal, MD
Summerville, SC
In the article, “Improving your approach to nasal obstruction” (J Fam Pract. 2016;65:889-893,898-899), I noticed that ipratropium nasal spray was not mentioned in Table 2, which listed commonly used medications for nasal obstruction.
We frequently recommend ipratropium nasal spray in our office, as it is an effective, non-addictive nasal decongestant. It is available in 2 strengths, .03% and .06%, and we usually prescribe 2 sprays in each nostril, 2 to 3 times a day, as needed.
We have found this to be very effective for short-term use. Its value, of course, is that it acts rapidly and there is no limit on how long it may be used.
Walter D. Leventhal, MD
Summerville, SC
Medical marijuana: Irresponsible medical care?
As we know, the active ingredient of marijuana, delta-9 tetrahydrocannabinol (THC), has been available by prescription since 1985.1 The Food and Drug Administration (FDA) has allowed a pill form to be prescribed for wasting related to acquired immunodeficiency syndrome and for patients with terminal cancer.
And while the FDA can extend use of the pills to other conditions when scientific, evidence-based studies prove that they are effective, it has not done so. The reason? The evidence is lacking.
According to The Medical Letter on Drugs and Therapeutics (August 1, 2016), no adequate studies of cannabis (botanical marijuana) are available for such indications as cancer pain, multiple sclerosis, epilepsy, and neuropathic pain.1 Thus, I feel that there isn’t a need for “medical marijuana clinics,” which sell a product that isn’t regulated, is of unknown quality and strength, and may be dangerous or ineffective.
Illness should continue to be treated by health professionals employing scientific evidence. This is responsible policy. It is not appropriate or medically justified for family physicians to refer patients to medical marijuana clinics; instead, they should inform their patients that medical treatment must be based on scientific evidence.
Nayvin Gordon, MD
Oakland, Calif
1. Cannabis and cannabinoids. Med Lett Drugs Ther. 2016;58:97-98.
As we know, the active ingredient of marijuana, delta-9 tetrahydrocannabinol (THC), has been available by prescription since 1985.1 The Food and Drug Administration (FDA) has allowed a pill form to be prescribed for wasting related to acquired immunodeficiency syndrome and for patients with terminal cancer.
And while the FDA can extend use of the pills to other conditions when scientific, evidence-based studies prove that they are effective, it has not done so. The reason? The evidence is lacking.
According to The Medical Letter on Drugs and Therapeutics (August 1, 2016), no adequate studies of cannabis (botanical marijuana) are available for such indications as cancer pain, multiple sclerosis, epilepsy, and neuropathic pain.1 Thus, I feel that there isn’t a need for “medical marijuana clinics,” which sell a product that isn’t regulated, is of unknown quality and strength, and may be dangerous or ineffective.
Illness should continue to be treated by health professionals employing scientific evidence. This is responsible policy. It is not appropriate or medically justified for family physicians to refer patients to medical marijuana clinics; instead, they should inform their patients that medical treatment must be based on scientific evidence.
Nayvin Gordon, MD
Oakland, Calif
As we know, the active ingredient of marijuana, delta-9 tetrahydrocannabinol (THC), has been available by prescription since 1985.1 The Food and Drug Administration (FDA) has allowed a pill form to be prescribed for wasting related to acquired immunodeficiency syndrome and for patients with terminal cancer.
And while the FDA can extend use of the pills to other conditions when scientific, evidence-based studies prove that they are effective, it has not done so. The reason? The evidence is lacking.
According to The Medical Letter on Drugs and Therapeutics (August 1, 2016), no adequate studies of cannabis (botanical marijuana) are available for such indications as cancer pain, multiple sclerosis, epilepsy, and neuropathic pain.1 Thus, I feel that there isn’t a need for “medical marijuana clinics,” which sell a product that isn’t regulated, is of unknown quality and strength, and may be dangerous or ineffective.
Illness should continue to be treated by health professionals employing scientific evidence. This is responsible policy. It is not appropriate or medically justified for family physicians to refer patients to medical marijuana clinics; instead, they should inform their patients that medical treatment must be based on scientific evidence.
Nayvin Gordon, MD
Oakland, Calif
1. Cannabis and cannabinoids. Med Lett Drugs Ther. 2016;58:97-98.
1. Cannabis and cannabinoids. Med Lett Drugs Ther. 2016;58:97-98.
Dysmenorrhea and ginger
Up to 90% of reproductive women around the world describe experiencing painful menstrual periods (dysmenorrhea) at some point. Younger women struggle more than older women. Dysmenorrhea can lead to absenteeism and presenteeism to the tune of about $2 billion annually.
The next step was to find an alternate treatment method. Ginger root is used throughout the world as a seasoning, spice, and medicine. Ginger has been shown to inhibit COX-2 and has been studied for its potential role in reducing pain and inflammation. As a result, ginger may have a role in the treatment of dysmenorrhea.
James W. Daily, PhD, conducted a systematic review of the literature on the efficacy of ginger for treating primary dysmenorrhea (Pain Med. 2015 Dec;16[12]:2243-55).
It included all randomized trials investigating the effect of ginger powder on younger women. Included studies evaluated ginger efficacy on individuals aged 13-30 years. Most included studies excluded women with irregular menstrual cycles and individuals using hormonal medications, oral or intrauterine contraceptives, or a pregnancy history. Dosing was 750-2,000 mg ginger powder capsules per day for the first 3 days of the menstrual cycle.
Four studies were included in the meta-analysis, which suggested that ginger powder given during the first 3-4 days of the menstrual cycle was associated with significant reduction in the pain visual analog scale (risk ratio, –1.85; 95% confidence interval: –2.87 to –0.84; P = .0003).
I am not a consistent proponent of alternative therapies but mostly because it is difficult for me to keep up on the evidence for these treatment options. In this case, my bias is that individuals in this age group are much more willing to engage with alternative therapies and offering them may build trust.
For these patients, offering ginger powder may engage patients in self-help and help them appreciate you as a clinician willing to embrace alternative therapies. The hard part is recommending a brand that you know and trust, complicated by the lack of oversight and quality control for over-the-counter, nontraditional therapies.
Dr. Ebbert is a professor of medicine and general internist at the Mayo Clinic in Rochester, Minn. and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.
Up to 90% of reproductive women around the world describe experiencing painful menstrual periods (dysmenorrhea) at some point. Younger women struggle more than older women. Dysmenorrhea can lead to absenteeism and presenteeism to the tune of about $2 billion annually.
The next step was to find an alternate treatment method. Ginger root is used throughout the world as a seasoning, spice, and medicine. Ginger has been shown to inhibit COX-2 and has been studied for its potential role in reducing pain and inflammation. As a result, ginger may have a role in the treatment of dysmenorrhea.
James W. Daily, PhD, conducted a systematic review of the literature on the efficacy of ginger for treating primary dysmenorrhea (Pain Med. 2015 Dec;16[12]:2243-55).
It included all randomized trials investigating the effect of ginger powder on younger women. Included studies evaluated ginger efficacy on individuals aged 13-30 years. Most included studies excluded women with irregular menstrual cycles and individuals using hormonal medications, oral or intrauterine contraceptives, or a pregnancy history. Dosing was 750-2,000 mg ginger powder capsules per day for the first 3 days of the menstrual cycle.
Four studies were included in the meta-analysis, which suggested that ginger powder given during the first 3-4 days of the menstrual cycle was associated with significant reduction in the pain visual analog scale (risk ratio, –1.85; 95% confidence interval: –2.87 to –0.84; P = .0003).
I am not a consistent proponent of alternative therapies but mostly because it is difficult for me to keep up on the evidence for these treatment options. In this case, my bias is that individuals in this age group are much more willing to engage with alternative therapies and offering them may build trust.
For these patients, offering ginger powder may engage patients in self-help and help them appreciate you as a clinician willing to embrace alternative therapies. The hard part is recommending a brand that you know and trust, complicated by the lack of oversight and quality control for over-the-counter, nontraditional therapies.
Dr. Ebbert is a professor of medicine and general internist at the Mayo Clinic in Rochester, Minn. and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.
Up to 90% of reproductive women around the world describe experiencing painful menstrual periods (dysmenorrhea) at some point. Younger women struggle more than older women. Dysmenorrhea can lead to absenteeism and presenteeism to the tune of about $2 billion annually.
The next step was to find an alternate treatment method. Ginger root is used throughout the world as a seasoning, spice, and medicine. Ginger has been shown to inhibit COX-2 and has been studied for its potential role in reducing pain and inflammation. As a result, ginger may have a role in the treatment of dysmenorrhea.
James W. Daily, PhD, conducted a systematic review of the literature on the efficacy of ginger for treating primary dysmenorrhea (Pain Med. 2015 Dec;16[12]:2243-55).
It included all randomized trials investigating the effect of ginger powder on younger women. Included studies evaluated ginger efficacy on individuals aged 13-30 years. Most included studies excluded women with irregular menstrual cycles and individuals using hormonal medications, oral or intrauterine contraceptives, or a pregnancy history. Dosing was 750-2,000 mg ginger powder capsules per day for the first 3 days of the menstrual cycle.
Four studies were included in the meta-analysis, which suggested that ginger powder given during the first 3-4 days of the menstrual cycle was associated with significant reduction in the pain visual analog scale (risk ratio, –1.85; 95% confidence interval: –2.87 to –0.84; P = .0003).
I am not a consistent proponent of alternative therapies but mostly because it is difficult for me to keep up on the evidence for these treatment options. In this case, my bias is that individuals in this age group are much more willing to engage with alternative therapies and offering them may build trust.
For these patients, offering ginger powder may engage patients in self-help and help them appreciate you as a clinician willing to embrace alternative therapies. The hard part is recommending a brand that you know and trust, complicated by the lack of oversight and quality control for over-the-counter, nontraditional therapies.
Dr. Ebbert is a professor of medicine and general internist at the Mayo Clinic in Rochester, Minn. and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.
Palliative care ‘in my hands’
A randomized controlled multicenter study published by Carson et al. in JAMA concluded that, for patients with “chronic critical illness” (defined as requiring 7 days of mechanical ventilation), palliative care team-led informational and emotional support meetings did not reduce anxiety or depression for families and may have increased posttraumatic stress disorder symptoms (2016:316[1]:51-62. doi: 10.1001/jama.2016.8474).
This report may surprise surgeons, as well as practitioners in other specialties, as the disconnect between palliative care and critical care services has been previously perceived as an education and access issue, not an outcome problem.
Carson and colleagues point out that fidelity to some components of the meeting “templates” was low, suggesting that there was some flexibility baked into the study design. However, as Russ and Kaufman aptly described, patients and families vary greatly in their appetite for explicit information about prognosis (Cult Med Psychiatry 2005;29[1]:103-23). Conversely, the hypothesis that direct communication about prognosis will be welcomed by families is a core element of the Carson study. The manuscript supplement reports that discussion of the patient’s condition and prognosis took place in 100% of initial meetings. If the same variability in family receptiveness to this information exists in this population as was described by Russ and Kaufman, it is not hard to see why some families experienced negative consequences because of these discussions.
Furthermore, the authors of the Carson study point out that it was not intended to replicate the components of specialist palliative care (JAMA. 2016;316[15]:1598-9).
Essential elements of specialist palliative care include symptom management, a multidisciplinary approach, and fairly close contact in the acute care setting. These features were lacking in the study protocol. Experienced providers of palliative care will often use symptom assessment and symptom management optimization as a conduit for building rapport and to avoid focusing on prognosis until trust has been established. A period of delay before broaching challenging subjects also allows the palliative care team to develop an understanding of the patient’s or surrogates’ preferences regarding the amount and type of information communicated. Palliative care providers benefit from the deepening of relationships with patients and families over time, as much as or possibly more so than providers of other specialties.
The necessity of the multidisciplinary approach to successful palliative care outcomes cannot be overstated. In many programs, patients seen for specialist palliative care consultation are seen by a physician or advanced practitioner, a chaplain, and a social worker within 24-48 hours of initial referral, and these providers have key roles in addressing the sequelae of anxiety, depression, and stress that were the key outcomes in the JAMA study. In the study, the “support and information team” included a palliative care physician and an advanced practice nurse but not a chaplain or social worker, despite the significance of existential/spiritual and social consequences of ventilator withdrawal or progression to tracheostomy for long-term vent support.
Palliative care providers consider the family meeting to be the “procedure” of their field, a belief that may seem incongruous with a surgical understanding of the nature of procedures but is informative as a framework for understanding the results of the Carson study. Just as surgical procedures carry risk of complications or adverse outcomes, family meetings have risk for worsening instead of improving the coping of families and surrogates. And, as surgical technique can be connected to complications, the family meeting technique applied by Carson et al. may be related to its results. Although there was formalized communication between the ICU team and the palliative care team regarding the patient’s condition, prognosis, and treatment plan, there was not a representative from the critical care team present during the majority of the support and information team led family meetings. This represents a marked deviation from common practice at our institution and many others. Our usual practice is to have a member of the ICU team present for discussions focused on patient prognosis, in order to make sure that there is alignment between the messages of the ICU and palliative care teams and also to prevent the crippling of palliative support that occurs when it becomes the sole repository of unwelcome news.
Because the relief of suffering is a core value of surgery and palliative care, there are countless ways these disciplines can inform one another. The outcome of the Carson study is a cautionary tale about the fallibility of the integration of surgical and palliative care teams, both of which would acknowledge the importance of the multidisciplinary approach, relationships developed over time, and symptom management. As surgeons intuitively understand from their operative experience, the “procedure” (the family meeting) has the potential for both risk and benefit, the outcome of which may be determined “in my hands.”
Dr. Rivet is a colon and rectal surgeon with training and board certification in hospice and palliative medicine. She is an assistant professor, departments of surgery and internal medicine, Virginia Commonwealth University, Richmond. She has no disclosures.
A randomized controlled multicenter study published by Carson et al. in JAMA concluded that, for patients with “chronic critical illness” (defined as requiring 7 days of mechanical ventilation), palliative care team-led informational and emotional support meetings did not reduce anxiety or depression for families and may have increased posttraumatic stress disorder symptoms (2016:316[1]:51-62. doi: 10.1001/jama.2016.8474).
This report may surprise surgeons, as well as practitioners in other specialties, as the disconnect between palliative care and critical care services has been previously perceived as an education and access issue, not an outcome problem.
Carson and colleagues point out that fidelity to some components of the meeting “templates” was low, suggesting that there was some flexibility baked into the study design. However, as Russ and Kaufman aptly described, patients and families vary greatly in their appetite for explicit information about prognosis (Cult Med Psychiatry 2005;29[1]:103-23). Conversely, the hypothesis that direct communication about prognosis will be welcomed by families is a core element of the Carson study. The manuscript supplement reports that discussion of the patient’s condition and prognosis took place in 100% of initial meetings. If the same variability in family receptiveness to this information exists in this population as was described by Russ and Kaufman, it is not hard to see why some families experienced negative consequences because of these discussions.
Furthermore, the authors of the Carson study point out that it was not intended to replicate the components of specialist palliative care (JAMA. 2016;316[15]:1598-9).
Essential elements of specialist palliative care include symptom management, a multidisciplinary approach, and fairly close contact in the acute care setting. These features were lacking in the study protocol. Experienced providers of palliative care will often use symptom assessment and symptom management optimization as a conduit for building rapport and to avoid focusing on prognosis until trust has been established. A period of delay before broaching challenging subjects also allows the palliative care team to develop an understanding of the patient’s or surrogates’ preferences regarding the amount and type of information communicated. Palliative care providers benefit from the deepening of relationships with patients and families over time, as much as or possibly more so than providers of other specialties.
The necessity of the multidisciplinary approach to successful palliative care outcomes cannot be overstated. In many programs, patients seen for specialist palliative care consultation are seen by a physician or advanced practitioner, a chaplain, and a social worker within 24-48 hours of initial referral, and these providers have key roles in addressing the sequelae of anxiety, depression, and stress that were the key outcomes in the JAMA study. In the study, the “support and information team” included a palliative care physician and an advanced practice nurse but not a chaplain or social worker, despite the significance of existential/spiritual and social consequences of ventilator withdrawal or progression to tracheostomy for long-term vent support.
Palliative care providers consider the family meeting to be the “procedure” of their field, a belief that may seem incongruous with a surgical understanding of the nature of procedures but is informative as a framework for understanding the results of the Carson study. Just as surgical procedures carry risk of complications or adverse outcomes, family meetings have risk for worsening instead of improving the coping of families and surrogates. And, as surgical technique can be connected to complications, the family meeting technique applied by Carson et al. may be related to its results. Although there was formalized communication between the ICU team and the palliative care team regarding the patient’s condition, prognosis, and treatment plan, there was not a representative from the critical care team present during the majority of the support and information team led family meetings. This represents a marked deviation from common practice at our institution and many others. Our usual practice is to have a member of the ICU team present for discussions focused on patient prognosis, in order to make sure that there is alignment between the messages of the ICU and palliative care teams and also to prevent the crippling of palliative support that occurs when it becomes the sole repository of unwelcome news.
Because the relief of suffering is a core value of surgery and palliative care, there are countless ways these disciplines can inform one another. The outcome of the Carson study is a cautionary tale about the fallibility of the integration of surgical and palliative care teams, both of which would acknowledge the importance of the multidisciplinary approach, relationships developed over time, and symptom management. As surgeons intuitively understand from their operative experience, the “procedure” (the family meeting) has the potential for both risk and benefit, the outcome of which may be determined “in my hands.”
Dr. Rivet is a colon and rectal surgeon with training and board certification in hospice and palliative medicine. She is an assistant professor, departments of surgery and internal medicine, Virginia Commonwealth University, Richmond. She has no disclosures.
A randomized controlled multicenter study published by Carson et al. in JAMA concluded that, for patients with “chronic critical illness” (defined as requiring 7 days of mechanical ventilation), palliative care team-led informational and emotional support meetings did not reduce anxiety or depression for families and may have increased posttraumatic stress disorder symptoms (2016:316[1]:51-62. doi: 10.1001/jama.2016.8474).
This report may surprise surgeons, as well as practitioners in other specialties, as the disconnect between palliative care and critical care services has been previously perceived as an education and access issue, not an outcome problem.
Carson and colleagues point out that fidelity to some components of the meeting “templates” was low, suggesting that there was some flexibility baked into the study design. However, as Russ and Kaufman aptly described, patients and families vary greatly in their appetite for explicit information about prognosis (Cult Med Psychiatry 2005;29[1]:103-23). Conversely, the hypothesis that direct communication about prognosis will be welcomed by families is a core element of the Carson study. The manuscript supplement reports that discussion of the patient’s condition and prognosis took place in 100% of initial meetings. If the same variability in family receptiveness to this information exists in this population as was described by Russ and Kaufman, it is not hard to see why some families experienced negative consequences because of these discussions.
Furthermore, the authors of the Carson study point out that it was not intended to replicate the components of specialist palliative care (JAMA. 2016;316[15]:1598-9).
Essential elements of specialist palliative care include symptom management, a multidisciplinary approach, and fairly close contact in the acute care setting. These features were lacking in the study protocol. Experienced providers of palliative care will often use symptom assessment and symptom management optimization as a conduit for building rapport and to avoid focusing on prognosis until trust has been established. A period of delay before broaching challenging subjects also allows the palliative care team to develop an understanding of the patient’s or surrogates’ preferences regarding the amount and type of information communicated. Palliative care providers benefit from the deepening of relationships with patients and families over time, as much as or possibly more so than providers of other specialties.
The necessity of the multidisciplinary approach to successful palliative care outcomes cannot be overstated. In many programs, patients seen for specialist palliative care consultation are seen by a physician or advanced practitioner, a chaplain, and a social worker within 24-48 hours of initial referral, and these providers have key roles in addressing the sequelae of anxiety, depression, and stress that were the key outcomes in the JAMA study. In the study, the “support and information team” included a palliative care physician and an advanced practice nurse but not a chaplain or social worker, despite the significance of existential/spiritual and social consequences of ventilator withdrawal or progression to tracheostomy for long-term vent support.
Palliative care providers consider the family meeting to be the “procedure” of their field, a belief that may seem incongruous with a surgical understanding of the nature of procedures but is informative as a framework for understanding the results of the Carson study. Just as surgical procedures carry risk of complications or adverse outcomes, family meetings have risk for worsening instead of improving the coping of families and surrogates. And, as surgical technique can be connected to complications, the family meeting technique applied by Carson et al. may be related to its results. Although there was formalized communication between the ICU team and the palliative care team regarding the patient’s condition, prognosis, and treatment plan, there was not a representative from the critical care team present during the majority of the support and information team led family meetings. This represents a marked deviation from common practice at our institution and many others. Our usual practice is to have a member of the ICU team present for discussions focused on patient prognosis, in order to make sure that there is alignment between the messages of the ICU and palliative care teams and also to prevent the crippling of palliative support that occurs when it becomes the sole repository of unwelcome news.
Because the relief of suffering is a core value of surgery and palliative care, there are countless ways these disciplines can inform one another. The outcome of the Carson study is a cautionary tale about the fallibility of the integration of surgical and palliative care teams, both of which would acknowledge the importance of the multidisciplinary approach, relationships developed over time, and symptom management. As surgeons intuitively understand from their operative experience, the “procedure” (the family meeting) has the potential for both risk and benefit, the outcome of which may be determined “in my hands.”
Dr. Rivet is a colon and rectal surgeon with training and board certification in hospice and palliative medicine. She is an assistant professor, departments of surgery and internal medicine, Virginia Commonwealth University, Richmond. She has no disclosures.
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].