Faculty Bibliography

Background: Buprenorphine is a partial mu-opioid receptor agonist that is effective at reducing all-cause and overdose mortality in patients with opioid use disorder (OUD). Buprenorphine microinduction is a novel and clinically useful strategy in which very low doses of buprenorphine are titrated concurrently with full opioid agonists, allowing for initiation of buprenorphine without a period of opioid withdrawal (Ahmed, 2021), (De Aquino 2021). In 2021, NYU Langone Health adopted an inpatient buprenorphine microinduction protocol that was developed by Addiction Psychiatry and Clinical Pharmacy. In order to highlight its clinical applications in the hospital setting, we describe a series of patients on our Addiction Consultation-Liaison (C-L) Service who were successfully transitioned to buprenorphine using microinduction.
Method(s): Our microinduction protocol utilizes buprenorphine buccal films (Belbuca) with doses increased in a step-wise manner over several days prior to transitioning to buprenorphine-naloxone (Suboxone). A short and long titration schedule were created taking into consideration anticipated length of stay and milligram morphine equivalence (titration schedules to be included in poster). Case 1: A 77-year-old woman with a history of opioid misuse, anxiety, panic attacks, chronic back pain and a T12 compression fracture was seen for suicidal ideation in the context of pain and opioid withdrawal. A short schedule microinduction was administered, together with oxycodone, resolving her pain and suicidal ideation. Case 2: A 41-year-old man with a history of OUD, depression, and GAD was admitted with C7-T1 osteomyelitis requiring neurosurgical intervention. A long schedule microinduction was administered, along with postoperative hydromorphone, resulting in maintenance of buprenorphine without precipitating opioid withdrawal symptoms. Case 3: A 69-year-old man with a history of OUD admitted for an infected foot ulcer was found using fentanyl in the hospital and demonstrating signs of opioid withdrawal. He was started on low dose methadone in tandem with a short schedule microinduction, which resolved withdrawal symptoms with a therapeutic buprenorphine regimen.
Discussion(s): These cases demonstrate the clinical utility of buprenorphine microinduction in the hospital setting. This method is particularly useful for patients with co-occurring pain, methadone exposure, or a history of precipitated withdrawal with buprenorphine. By using microinduction protocols, C-L psychiatrists can overcome common barriers associated with conventional buprenorphine initiation.
Conclusion(s): Buprenorphine microinduction is a novel and effective way to initiate treatment for OUD in the hospital setting. By utilizing microinduction, C-L psychiatrists can play a greater role in offering life-saving medication for OUD. Future research should evaluate the impact of microinduction on OUD treatment retention. References: 1. Ahmed S, Bhivandkar S, Lonergan BB, Suzuki J. Microinduction of Buprenorphine/Naloxone: A Review of the Literature. Am J Addict. 2021;30(4):305-15. 2. De Aquino JP, Parida S, Sofuoglu M. The Pharmacology of Buprenorphine Microinduction for Opioid Use Disorder. Clin Drug Investig. 2021;41(5):425-36.
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Background: Consultation-Liaison (CL) psychiatrists frequently provide consultation for patients prescribed psychotropic medications who have complex cardiopulmonary disease, including prolonged QTc interval and risk for fatal ventricular arrhythmias, like torsades de pointes (TdP). CL Psychiatrists routinely utilize QTc measurements, along other risk factors, to inform risk-benefit analysis when recommending psychotropic medications known to prolong QTc. In order to assess the risk of certain psychotropic medications, the literature suggests relying on EKG parameters not routinely available on automated EKG interpretations. For example, in conditions where a ventricular conduction delay results in a widening of the QRS interval, different methods of correcting the QT interval are required. However, the methods most supported by the literature require complex calculations, limiting their clinical utility especially during behavioral emergencies, as there were no application based or online calculators that offer these formulas. (Funk et al, 2021) Method: Using the Calconic online interactive calculator platform, we created an online calculator that provides the CL psychiatrist with a point-of-care assessment of the QTc interval. This calculator includes the Hodges formula for correcting QTc; Hodges is thought to provide more accurate rate correction than the more commonly available Bazett formula which can overestimate QTc in tachycardic patients. (Beach et al, 2018). In addition, the calculator identifies prolonged QRS intervals and offers four methods for correction: the Bogossian formula with Hodges correction for QTc, the Rautaharju formula for QTc, corrected JT interval (JTc) and the JT prolongation index (JTi). The calculator is optimized for mobile devices, but can be accessed by any web browser (tinyurl.com/QTcCal). We present three cases derived from our clinical experiences to demonstrate the utility of the calculator. Cases: #1: Patient taking methadone and QTc -Bazett prolongation in setting of elevated heart rate. The online calculator recalculates the QTc interval using the Hodges correction supports a recommendation to continue methadone. #2: Patient on aripiprazole and QTc-Bazett prolongation in setting of widened QRS interval. The online calculator corrects for heart rate and widened QRS interval with multiple formulas, the results which support a recommendation to continue aripiprazole. #3: Acute agitation and QTc-Bazett prolongation in an elderly patient. The online calculator corrects for heart rate and widened QRS; however, with these corrections, the risk of TdP remained elevated and the clinician recommends using intravenous valproate for agitation instead of antipsychotics.
Conclusion(s): The interactive online calculator is an effective, point-of-care tool to assist CL psychiatrists in assessing the arrhythmia risk of QTc prolonging medication, including antipsychotics in medically ill patients. References: Beach SR, Celano CM, Sugrue AM, et al. QT Prolongation, Torsades de Pointes, and Psychotropic Medications: A 5-Year Update. Psychosomatics. 2018;59(2):105-122. Funk MC, Beach SR, Bostwick JR, et al. QTc Prolongation and Psychotropic Medications. Am J Psychiatry. 2020;177(3):273-274.
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Background: Rates of alcohol use disorder amongst women have increased markedly since the start of the Covid-19 Pandemic with some studies showing as much as a 41% increase in heavy drinking days (1). Among women with alcohol use disorder, there is a high degree of comorbidity with eating disorders (ED) with studies suggesting rates of co-occurring disease as high as 23-50%(2). However, there is little data on the assessment of transplant recipients presenting with co-occuring ED and AUD. Case: A 34-year-old woman with no known past psychiatric or substance use history presented to our hospital in acute hepatic failure (MELD Score 34) in the context of escalating alcohol use over the course of the COVID-19 Pandemic. As the patient did not respond to multiple medical therapies, evaluation for liver transplantation was initiated. The patient was assessed using the Stanford Integrated Psychosocial Assessment for Transplant (SIPAT), and found to be a high risk candidate. During the course of our evaluation, the patient demonstrated a lack of interest in eating food, refusing to eat food that required chewing, and expressed multiple consequences about the aversive consequences of eating. She described extremely restrictive eating patterns with her lowest weight being 95 lbs (BMI < 16), leading to nutritional deficiencies, peripheral neuropathy and anemia. Given the absence of excessive concern regarding appearance or body weight, a diagnosis of avoidant restrictive food intake disorder (ARFID) was made. Despite efforts to engage the patient, she demonstrated little understanding of her ED. The patient was declined for listing and medically stabilized. She was declined by all inpatient substance use programs given the extent of her ED and rejected recommendations for targeted ED treatment. She was ultimately discharged to an intensive outpatient program for AUD.
Discussion(s): There is a paucity of information regarding liver transplantation in patients with co-occurring AUD and EDs. However, there are many unique considerations in the management of this patient population in both the pre- and post- transplant period. Existing screening methods such as the SIPAT do little to evaluate transplant risk in patients with EDs relative to other psychiatric illnesses. And while predictive risk factors for recurrence of alcohol use after transplant have been identified, little is known about the risk factors for ED relapse. It appears that the emphasis on abstinence from alcohol in the post-transplant period can be a potent trigger for ED relapse(3). Post-transplant, patients with ED have an increased risk of relapse to alcohol and poorer retention in residential treatment(4).
Conclusion(s): Patients with co-occurring ED and AUD requiring liver transplantation are a challenging patient population with complex pre- and post-transplant considerations. References: 1. Pollard M, et al. "Changes in Adult Alcohol Use and Consequences During COVID-19 Pandemic in the US." JAMA Netw Open. 2020;3(9). 2. Bulik, Cynthia, et al. "Alcohol Use Disorder Comorbidity in Eating Disorders: A Multi-center Study." Journal of Clinical Psychiatry. 65:7, July 2004. 3. Coffman K L, et al. Treatment of the Postoperative Alcoholic Liver Transplant Recipient With Other Addictions." Liver Transpl Surg. 1997;3:322-327. 4. Elmquist, J. et al., "Eating Disorder Symptoms and Length of Stay in Residential Treatment for Substance Use: A Brief Report." Journal of Dual Diagnosis, 11(3-4), 233-237. https://doi.org/10.1080/15504263.2015.1104480.2015.
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Background/Significance: During the COVID-19 pandemic, people with substance use disorders have experienced increased rates of overdose, decreased access to substance use disorder treatment, and increased risk for adverse COVID outcomes (NIDA, 2020). Throughout the pandemic, NYU Langone Health has continued using the Tobacco, Alcohol, and Prescription Substance (TAPS) screening tool for all inpatient admissions in order to identify and provide proactive consultation to hospitalized patients at risk for substance use disorders.
Method(s): We conducted a retrospective review of adult inpatient medical and surgical admissions to NYU Langone Health, using data collected from a pre-defined Epic report based on TAPS documentation. We compared groups pre-COVID-19 pandemic (defined as 9/2018-9/2019) and during COVID-19 pandemic (defined as 3/2020-3/2021) for the following outcomes: (1) nursing compliance rate with TAPS administration, (2) prevalence of patients with substance use disorders as measured by positive TAPS screen, and (3) severity of alcohol use disorder among patients with TAPS positive for alcohol.
Result(s): During the pre-COVID-19 period, 24,057 patients were screened with a compliance rate of 90% and a positivity rate of 6% (N=1673). ICU compliance was 84%. Prevalence of patients at risk for various substance use disorders was as follows: 4.3% (N=1027) alcohol, 1.5% (N=357) cannabis, 0.32% (N=78) heroin, 0.24% (N=57) opiates, 0.15% (N=35) sedatives, 0.48% (N=116) stimulants, and 0.01% (N=3) prescription stimulants. Of positive alcohol screens, 26.7% (274/1027) represented the highest severity of use (Alcohol Score 4). During the COVID-19 period, 17,931 patients were screened with a compliance rate of 82% and positivity rate of 6% (N=1374). ICU compliance was 74%. Prevalence of patients at risk for various substance use disorders was as follows: 4.3% (N=772) alcohol, 1.5% (N=272) cannabis, 0.60% (N=108) heroin, 0.26% (N=46) opiates, 0.20% (N=35) sedatives, 0.69% (N=124) stimulants, and 0.04% (N=7) prescription stimulants. Of positive alcohol screens, 41.2% (318/772) were highest severity. We were unable to meaningfully test for significant given limitations of Epic datasets and variability in unit composition and staffing throughout COVID-19 period.
Discussion(s): There was decreased compliance with TAPS administration during COVID-19 as compared to pre-COVID-19, as well as overall low compliance in ICUs during both time periods. There were similar rates of positive screens for all substance use disorders pre-COVID-19 and during COVID-19, with an increase in positive heroin and other opiate screens during COVID-19. Among patients with positive alcohol screens, there was increased severity of alcohol scores during COVID-19 relative to pre-COVID-19. Conclusion/Implications: These results suggest a change in patterns of substance use during the COVID-19 pandemic, consistent with findings from prior studies of increased opioid overdoses (Slavova 2020, Georgia Department of Public Health 2020) and severity of substance use (NIDA 2020). Poor ICU compliance suggests increased barriers to TAPS administration in patients with critical illness and/or altered mental status, which may lead to decreased identification and treatment of patients at increased risk for substance use disorders. These results may inform clinical practice and future studies regarding utilization of TAPS screen and proactive addiction psychiatry consultation service in acute care settings. References: 1. NIDA. 2020, September 14. Addressing the Unique Challenges of COVID-19 for People in Recovery. Retrieved from https://www.drugabuse.gov/about-nida/noras-blog/2020/09/addressing-u nique-challenges-covid-19-people-in-recovery on 2021, March 15 2. Slavova, S., Rock, P., Bush, H. M., Quesinberry, D., & Walsh, S. L. (2020). Signal of increased opioid overdose during COVID-19 from emergency medical services data. Drug and alcohol dependence, 214, 108176. 3. Georgia Department of Public Health. 2020, June 19. Suspected Drug Overdose Increases in Georgia Amid COVID-19. Retrieved from https://www.drugabuse.gov/sites/default/files/suspected_drug_overdos e_increases_in_georgia_amid_covid-19_1.pdf
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