Analysis of psychiatrists' prescription of opioid, benzodiazepine, and buprenorphine in Medicare Part D in the United States

Abstract Introduction The opioid epidemic is a severe problem in the world, especially in the United States, where prescription opioid overdose accounts for a quarter of drug overdose deaths. Objective To describe psychiatrists' prescription of opioid, benzodiazepine, and buprenorphine in the United States. Methods We conducted a retrospective cross-sectional study of the 2016 Medicare Part D claims data and analyzed psychiatrists' prescriptions of: 1) opioids; 2) benzodiazepines, whose concurrent prescription with opioids can cause overdose death; 3) buprenorphine, a partial opioid agonist for treating opioid addiction; 4) and naltrexone microsphere, a once-monthly injectable opioid antagonist to prevent relapse to opioid dependence. Prescribers with 11 or more claims were included in the analysis. Results In Medicare Part D in 2016, there were a total of 1,131,550 prescribers accounting for 1,480,972,766 total prescriptions and 78,145,305 opioid prescriptions, including 25,528 psychiatrists (2.6% of all prescribers) accounting for 44,684,504 total prescriptions (3.0% of all prescriptions) and 131,115 opioid prescriptions (0.2% of all opioid prescriptions). Psychiatrists accounted for 17.3% of benzodiazepine, 16.3% of buprenorphine, and 33.4% of naltrexone microsphere prescriptions. The opioid prescription rate of psychiatrists was much lower than that of all prescribers (0.3 vs 5.3%). The buprenorphine prescription rate of psychiatrists was much higher than that of all prescribers (2.3 vs. 0.1%). There was a substantial geographical variation across the United States. Conclusions The results show that, proportionally, psychiatrists have lower rates of opioid prescription and higher rates of benzodiazepine and buprenorphine prescription.

Intrathecal tramadol may cause respiratory depression

Opioids such as morphine and fentanyl have been used in neuraxial anesthesia to prolong the analgesic effects since long, but these have frequently been associated with few adverse effects e.g. nausea, vomiting, pruritus and rarely respiratory depression. Tramadol has also been used in epidural as well as spinal anesthesia, and respiratory depression has not been reported with its intrathecal use. We present a case in which 20 mg of intrathecal tramadol produced signs of opioid overdose including respiratory depression. The side effects were reversed with naloxone confirming our suspicion that these were caused by tramadol. We recommend adequate monitoring and vigilance for tramadol as is used for other intrathecal opioids

Vértigo con nistagmo vertical por administración de morfina intratecal y reversión con naloxona / Vertigo and vertical nystagmus associated with intrathecal morphine administration and resolution by naloxone

La anestesia regional combinada es utilizada frecuentemente como herramienta para el tratamiento del dolor postoperatorio. Los efectos secundarios de los opioides utilizados por esta vía son similares a los que se presentan luego de la administración sistémica. La aparición de vértigo con nistagmo vertical es un efecto adverso muy pocas veces descripto con el uso de morfina por vía intratecal, epidural o endovenosa. Comunicamos el caso de un paciente que presentó esta complicación en el postoperatorio de una nefrectomía parcial, luego de la administración de morfina intratecal, con resolución completa mediante el uso de naloxona endovenosa.

Combined regional anesthesia is frequently used as a tool for management of postoperative pain. The profile of side effects of the opioids used via this route is similar to those occurring after systemic administration. The onset of vertigo with vertical nystagmus is an adverse effect rarely described after the use of intrathecal, epidural or intravenous morphine. We report the case of a patient who presented this complication in the postoperative period of a partial nephrectomy, after the administration of intrathecal morphine, with complete resolution by intravenous naloxone.

DOTS in drug addicts with TB : Delhi experience.

BACKGROUND: Drug abuse is on the rise. Drug addiction lowers the general immunity of the body. Tuberculosis is known to be one of the major infectious diseases with a high incidence among drug addicts. Treatment of drug addicts suffering from tuberculosis is a challenge to the treating physician. METHODS: An interventional prospective study which involved free de-addiction drugs and motivation along with free anti tubercular drugs under Revised National Tuberculosis Programme was undertaken among drug addicts. Sixty drug addicts suffering from tuberculosis, registered under RNTCP in SPM marg TB Clinic (Pili Kothi) between 2002-2007 and treated under DOTS along with de-addiction treatment by an NGO (Sharan) formed the study sample. OBJECTIVES: Objectives of the study were: a) To study the profile of drug addicts with tuberculosis, b) To assess the success results of DOTS in drug addicts with tuberculosis (along with de-addiction treatment). RESULTS: Extensive counselling for de-addiction and motivation of the study patients along with nutritional food supplements improved the compliance and adherence to treatment with equal success rates as in non-addict tuberculosis patients. The overall success rate in drug addicts was 83.3%. The default rate of 3.3% and failure rate of just 1.7% among study group were also within the permissible range of RNTCP (< 4%). CONCLUSION: DOTS along with supplementary intervention was observed to be quite effective in drug addicts with TB.

Ludomania: avaliação transcultural do jogo de azar por dinheiro e seu tratamento / Ludomania: cross-cultural examinations of gambling and its treatment

O jogo patológico é um transtorno do controle do impulso que está ganhando mais e mais atenção. Este artigo revisa os critérios diagnósticos e os instrumentos de rastreamento para o jogo patológico, bem como os índices de prevalência desse transtorno ao redor do mundo, com ênfase na situação do jogo de azar no Brasil. Os tratamentos para o jogo patológico são também descritos, incluindo tanto as abordagens psicossociais como as farmacológicas. O jogo patológico é altamente comórbido com outros transtornos psiquiátricos, incluindo abuso de substâncias e depressão e poucos jogadores patológicos buscam tratamento para seus problemas com o jogo de azar. Portanto, recomenda-se a procura direta de problemas com o jogo de azar. É necessário melhorar a educação sobre o transtorno, tanto sob a perspectiva do cuidador como da sociedade, a fim de reduzir as conse-qüências pessoais e sociais desse transtorno.

Pathological gambling is a disorder of impulse control that is gaining more and more attention. This paper reviews diagnostic criteria and screening instruments for pathological gambling, as well as the prevalence rates of this disorder worldwide, with an emphasis on gambling in Brazil. Treatments for pathological gambling are also described, including both psychosocial and pharmacological approaches. Pathological gambling is highly comorbid with other psychiatric disorders, including substance abuse and depression, and few pathological gamblers seek treatment for their gambling problems. Therefore, direct screening for gambling problems is recommended. Increasing education about the disorder, from both the provider and societal perspective, is necessary to reduce the personal and societal consequences of this disorder.

Compras compulsivas: uma revisão e um relato de caso / Compulsive buying disorder: a review and a Case Vignette

OBJETIVO: O transtorno do comprar compulsivo foi descrito pela primeira vez como uma síndrome psiquiátrica no começo do século XX. Sua classificação permanece incerta e os investigadores têm debatido uma correlação potencial com transtornos do humor, transtorno obsessivo-compulsivo e transtornos do impulso. O objetivo deste estudo é apresentar uma revisão de transtorno do comprar compulsivo e um relato de caso. MÉTODO: Duas bases de dados foram investigadas (Medline e PsycINFO) em busca de artigos publicados nos últimos 40 anos. Os unitermos selecionados foram "oniomania" e "compras compulsivas". Outros artigos relevantes também foram identificados por meio das listas de referências. RESULTADOS: O transtorno do comprar compulsivo é uma condição crônica e prevalente encontrada ao redor do mundo, que divide características comuns com transtornos do controle do impulso. Em amostras clínicas, mulheres perfazem mais de 80 por cento dos sujeitos. Sua etiologia é desconhecida, mas mecanismos neurobiológicos e genéticos têm sido propostos. O transtorno apresenta altas taxas de comorbidade com transtornos do humor, abuso de substâncias, transtornos alimentares e transtornos do controle do impulso. CONCLUSÃO: As recomendações terapêuticas derivadas da literatura e da experiência clínica sugerem que compradores compulsivos podem se beneficiar de intervenções psicossociais. Modelos de intervenção cognitivo-comportamental de grupo parecem promissores. Ensaios farmacológicos relatam resultados conflitantes. A identificação e o tratamento das comorbidades psiquiátricas são também um aspecto chave do tratamento. Para determinar a validade do transtorno do comprar compulsivo, os futuros trabalhos devem enfocar os achados psicopatológicos e neurobiológicos específicos à síndrome.

OBJECTIVE: Compulsive buying disorder was first described as a psychiatric syndrome in the early twentieth century. Its classification remains elusive, and investigators have debated its potential relationship to mood, substance use, obsessive-compulsive, and impulse control disorders. The objective of this study is to present a review of compulsive buying disorder and present a case vignette. METHOD: Two databases were reviewed (Medline and PsycINFO) in search for articles published in the last 40 years. Selected terms included oniomania, compulsive buying, and compulsive shopping. Other relevant articles were also identified through reference lists. RESULTS: Compulsive buying disorder is a prevalent and chronic condition that is found worldwide, sharing commonalities with impulse control disorders. In clinical samples, women make up more than 80 percent of subjects. Its etiology is unknown, but neurobiologic and genetic mechanisms have been proposed. The disorder is highly comorbid with mood, substance use, eating and impulse control disorders. CONCLUSIONS: Treatment recommendations derived from the literature and clinical experience suggest that problem shoppers can benefit from psychosocial interventions. Cognitive-behavioral group models appear promising. Medication trials have reported mixed results. The identification and treatment of psychiatric comorbidity is also a key aspect of treatment. In order to determine the validity of compulsive buying disorder, future work should focus on psychopathology and neurobiological findings unique to the syndrome.

Cleptomania: características clínicas e tratamento / Kleptomania: clinical characteristics and treatment

OBJECTIVES: Kleptomania, a disabling impulse control disorder, is characterized by the repetitive and uncontrollable theft of items that are of little use to the afflicted person. Despite its relatively long history, kleptomania remains poorly understood to the general public, clinicians, and sufferers. METHOD: This article reviews the literature for what is known about the clinical characteristics, family history, neurobiology, and treatment options for individuals with kleptomania. RESULTS: Kleptomania generally has its onset in late adolescence or early adulthood and appears to be more common among women. Lifetime psychiatric comorbidity is frequent, mainly with other impulse control (20-46 percent), substance use (23-50 percent) and mood disorders (45-100 percent). Individuals with kleptomania suffer significant impairment in their ability to function socially and occupationally. Kleptomania may respond to cognitive behavioral therapy and various pharmacotherapies (lithium, anti-epileptics, and opioid antagonists). CONCLUSIONS: Kleptomania is a disabling disorder that results in intense shame, as well as legal, social, family, and occupational problems. Large scale treatment studies are needed.

OBJETIVOS: A cleptomania, um transtorno incapacitante do controle dos impulsos, caracteriza-se pelo furto repetitivo e incontrolável de itens que são de pequena utilidade para a pessoa acometida por esse transtorno. Apesar de seu histórico relativamente longo, a cleptomania continua sendo pouco entendida pelo público geral, pelos clínicos e pelos que dela sofrem. MÉTODO: Este artigo revisa a literatura sobre o que se sabe a respeito das características clínicas, histórico familiar, neurobiologia e opções de tratamento para indivíduos com cleptomania. RESULTADOS: A cleptomania geralmente tem seu início no final da adolescência ou no início da vida adulta, e parece ser mais comum em mulheres. A comorbidade psiquiátrica ao longo da vida com outros transtornos de controle de impulsos (20-46 por cento), de uso de substâncias (23-50 por cento) e de humor (45-100 por cento) é freqüente. Indivíduos com cleptomania sofrem de prejuízo significativo em sua capacidade de funcionamento social e ocupacional. A cleptomania pode responder ao tratamento com terapia cognitivo-comportamental e com várias farmacoterapias (lítio, antiepilépticos e antagonistas de opióides). CONCLUSÕES: A cleptomania é um transtorno incapacitante que resulta em uma vergonha intensa, bem como problemas legais, sociais, familiares e ocupacionais. São necessários estudos de tratamento em ampla escala.

Experiencia interdisciplinaria en la problemática del alcoholismo / Interdisciplinary experience in the problematic one of the alcoholism

El presente estudio de investigación enuncia los resultados de la aplicación de un tratamiento integral a pacientes afectados por el alcoholismo. Realizado por un equipo interdisciplinario perteneciente a la Universidad Nacional de Santiago del Estero.

Ultra-rapid opioid detoxification: current status and controversies.

Opioid dependence is a major health problem and a cause of increasing concern to physicians and other health professionals worldwide. A crucial first step in intervention is detoxification. Recent trends in medical practice have seen the emergence of newer techniques that claim to accelerate the detoxification procedure and ensure prevention of relapse by rapid induction onto maintenance treatment with opioid antagonists such as naltrexone. This review delves into the theoretical and methodological aspects related to ultra-rapid opioid detoxification (opioid detoxification procedure using opioid antagonists, performed under general anaesthesia or heavy sedation) and discusses the status of the same in light of the available evidence regarding its applicability, safety and effectiveness. Although useful in some respects (especially in completion rates for detoxification and subsequent induction onto naltrexone maintenance), the justification of this procedure lies in (a) the resolution of the ethical conflicts surrounding the procedure and (b) conduction of methodologically sound long-term studies to demonstrate greater efficacy over routine/standard detoxification procedures beyond the short-term detoxification period.

Tratamento farmacológico da dependência do álcool / The pharmacologic treatment of the alcohol dependence

As intervencões farmacológicas podem ter um papel crucial na reducão do craving, consumo de álcool e manutencão da abstinência. Este artigo revisa a farmacoterapia para a dependência de álcool com ênfase na naltrexona, dissulfiram e acamprosato. O antagonista opióide naltrexona diminui taxas de recaída, reduz dias de consumo e prolonga períodos de abstinência. Acamprosato restaura a atividade normal dos sistemas glutamato e GABA. Dissulfiram tem demonstrado ser mais efetivo para pacientes que acreditam em sua eficácia e permanecam aderentes ao tratamento. Ondansetron tem-se mostrado promissor na dependência de álcool de início precoce, mas necessita estudos mais extensivos. Topiramato (até 300 mg/dia) foi mais eficaz do que placebo no tratamento da dependência de álcool.

Analgesia in phasic and tonic pain tests in a pharmacological model of autotomy.

Self-mutilation or self-injurious behaviour is a well known behavioural disorder in humans. The proposition that this behaviour in animals is a response to chronic pain of peripheral nerve injury has been met with controversy. In the present study a pharmacological model, which produces no sensory or motor loss was used to study how autotomy is related to pain. In a group of rats autotomy was induced by amphetamine in phenoxybenzamine and reserpine treated animals. The pain tests, both phasic and tonic were then performed. The results of this study showed that a total analgesia was produced in both phasic and tonic pain tests, in animals that exhibited autotomy. Injection of naloxone in these animals prevented autotomy. A correlation between autotomy and no pain is suggested in this pharmacological model of autotomy.

Neuroprotective agents in acute ischemic stroke.

The concept of neuroprotection relies on the principle that delayed neuronal injury occurs after ischemia. The phenomenon of the "ischemic cascade" has been described, and each step along this cascade provides a target for therapeutic intervention. A wide variety of drugs have been studied in humans. Ten classes of neuroprotective agents have reached phase III efficacy trials but have shown mixed results. They included calcium channel antagonists, NMDA receptor antagonists, lubeluzole, CDP-choline, the free radical scavenger tirilazad and ebselen, enlimomab, GABA agonist clomethiazole, the sodium channel antagonist fosphenytoin, magnesium, glycine site antagonist GV150526 and piracetam. Furthermore, the mechanisms that underlie the development of focal ischemic injury continue to be discovered, opening new therapeutic perspective for neuroprotection that might clinically be applicable in the future.

Role of ketamine in convulsions.

It can be concluded from the present study that ketamine showed dose-dependent anticonvulsant effect on MES in mice. It is presumed that this anticonvulsant effect of ketamine could be due to blockade of excitatory amino acid NMDA receptors. It was potentiated by anticonvulsants like diazepam and DPH but was found to be insensitive to naloxone. These findings suggest the involvement of NMDA receptors and their antagonists in epilepsy. Ketamine thus can be given as add-on therapy in refractory cases, and may prove to be useful as an anticonvulsant in future.

The effect of baclofen on spontaneous and evoked behavioral expression of experimental neuropathic chronic pain

Baclofen (Beta-p-chlorophenyl-GABA) has been used in humans to treat spasticity, as well as trigeminal neuralgia Since GABA (gamma-aminobutyric acid) has been implicated in inhibitory and analgesic effects in the nervous system, it was of interest to study the effect of baclofen in experimental neuropathic pain. With this purpose, experiments were carried out in 17 neuropathic rats with constrictive sciatic injury, as described by Bennet and Xie (1988), taking as pain parameters scratching behaviour and the latency to the thermal nociceptive stimulus. The results showed that baclofen induces, in a dose-dependent manner, significant decrease (p<0.05) of scratching behaviour and significant increase (p<0.05) of the latency to the nociceptive thermal stimulus. The absence of antagonism of naloxone suggested a non-participation of an opioid-mediated mechanism in this analgesic effect of baclofen on experimental neuropathic pain.

Opioid receptor mediated anticonvulsant effect of pentazocine.

Intraperitoneal (i.p.) administration of (+/-) pentazocine (10, 30 & 50 mg/kg), a Sigma opioid agonist, resulted in a dose dependent anticonvulsant action against maximal electroshock seizures in mice. This anticonvulsant effect of pentazocine was not antagonized by both the doses of naloxone (1 and 10 mg/kg) suggesting thereby that its anticonvulsant action is probably mediated by Sigma opiate binding sites. Its anticonvulsant effect was potentiated by both the anticonvulsant drugs viz. diazepam and diphenylhydantoin. Morphine, mu opioid agonist, on the other hand, failed to protect the animals against maximal electroshock seizures when it was given in doses of 10-40 mg/kg body wt.

Intervençöes farmacológicas no trauma raquimedular: uma nova visäo terapêutica / Pharmacological interventions in spinal cord trauma: a therapeutic approach

O imenso déficit neurológico decorrente da lesao da medula espinhal advém do somatório de dois eventos distintos: a lesao mecânica inicial e a lesao endógena secundária conseqüente à primeira. A lesao secundária da medula espinhal envolve complexas mudanças bioquímicas, que podem ser minimizadas pela introduçao de agentes farmacológicos recentes. Para limitar o dano tecidual e promover o reparo funcional, essas alteraçoes teciduais patológicas devem ser interrompidas. Avanços clínicos e científicos indicam que as lesoes agudas na medula espinhal podem ser manipuladas por terapêuticas farmacológicas utilizadas em curto espaço de tempo. A metilprednisolona administrada dentro das primeiras oito horas pós-trauma é o primeiro agente farmacológico a demonstrar melhora significativa na recuperaçao do trauma raquimedular em seres humanos. Outras drogas, como tilirazade e o GM-1, ainda sob investigaçao clínica, apresentam excelentes resultados preliminares. Esses avanços podem representar grande melhora na qualidade de vida de pacientes com lesao da medula espinhal, desde que sejam adotados pela prática clínica.