What Would Equitable Harm Reduction Look Like?

Structural determinants of health frameworks must express antiracism to be effective, but racial and ethnic inequities are widely documented, even in harm reduction programs that focus on person-centered interventions. Harm reduction strategies should express social justice and health equity, resist stigma and discrimination, and mitigate marginalization experiences among people who use drugs (PWUD). To do so, government and organizational policies that promote harm reduction must acknowledge historical and ongoing patterns of racializing drug use. This article gives examples of such racialization and offers recommendations about how harm reduction programming can most easily and effectively motivate equitable, antiracist care for PWUD.

Sociodemographic Attributes and Prevalence of Arrest With Possession of Substances in Incarcerated Population in the United States.

Background and objectives In recent years, there has been an increase in the US imprisonment rate. A substantial percentage of those incarcerations are for drug-related offenses. The authors investigated the relationship between the pattern of substance use and drug-related offenses across a broad spectrum of various sociodemographic attributes of the incarcerated population in the United States. Methods Cross-sectional data from the 2016 Survey of Prison Inmates conducted by the Bureau of Judicial Statistics were extracted with inmates who reported possession of a drug at the time of arrest as a primary outcome of interest. Using SAS 9.4 statistical software (SAS Institute Inc., Cary, USA), the authors used multivariate analyses to determine the odds ratios between various sociodemographic attributes of the inmates and possession of substance at the time of the arrest. Logistic regression analysis for age groups in relation to substance possession at the time of arrest is presented in the form of an adjusted odds ratio and their respective confidence interval at p ≤0.5. Results Out of the total 23,798 inmates who reported possession of a drug at the time of arrest, 34.07% were Non-Hispanic Whites, and 31.5% were within the age group of 25-34 years. Only 59.47% of inmates were employed 30 days before the arrest, and 58.02% had less than a high school education. Different patterns of drug use were linked with different types of drugs found in their possession at the time of the arrest. Possession of cannabis at the time of arrest was highest in the age group 18-24 years compared to other age groups (odds ratio: 1.362; 95% CI: 1.159 - 1.602). Inmates with a history of stimulant or hypnotic use were more likely to have another psychoactive substance during a time of the arrest. Only 8.46% of inmates had psychiatric and psychological treatment as part of their sentence. Conclusions A large proportion of incarcerations in the US is because of drug-related offenses, with most of the burden on the younger age group. Inmates should receive psychiatric and psychological treatments for substance use as part of their sentencing while in prison and after release as a form of targeted intervention for this vulnerable group.

Posterior Reversible Encephalopathy Syndrome (PRES) in a Patient with Opioid Use Disorder.

Posterior Reversible Encephalopathy Syndrome (PRES) is a characteristic clinical radiographic syndrome with diffuse structural alteration of cerebral white matter secondary to myelin damage with diverse and multifactorial etiologies. It can present with acutely altered mentation, somnolence or occasionally stupor, vision impairment, seizures, and sudden or chronic headaches that are not focal. The pathophysiology remains unclear, but mechanisms involving endothelial injury and dysregulation of cerebral autoregulation have been purported. We report the case of a 36-year-old male with a history of heroin use disorder, who was admitted to our hospital for opioid withdrawal. CT head without contrast and MRI with and without gadolinium showed significant white matter disease in both cerebral hemispheres and cerebellum. He was diagnosed with Posterior Reversible Encephalopathy Syndrome secondary to heroin use and managed on the medical floor in collaboration with the neurology team. His clinical symptoms improved and he was discharged after six weeks. To our knowledge, this case did not present with the risk factors for PRES reported in the literature. For patients with heroin use disorder who present with an altered mental status, PRES should be highly suspected. The diagnosis and management require collaboration between psychiatry and neurology.

Prevalence and Trends of Opioid Use in Patients With Depression in the United States.

Background Depression and prescription opioid use have a bi-directional relationship. Depression commonly co-occurs with chronic noncancer pain and is known to be associated with opioid use. Studies have found an increased risk of depression only in patients with opioid dependence. Other studies have found an increased risk of opioid misuse in depressed patients. In addition, chronic pain conditions can lead to depression without the use of opioids. Methods We used the National Health and Nutrition Examination Survey (NHANES) data collected over seven survey cycles spanning 14 years: 2005/2006-2017/2018. Included in our study were participants ≥18 years who completed the patient health (PHQ-9) questionnaire. Persons with documented use of opioids were considered to have chronic use of opioids. Relevant data files were merged, and analytical weights computed in keeping with the survey analytical guidelines. Prevalence measures are reported as proportions. Associations were assessed using the Chi-square test. Binary logistic regression was used to assess the trend in the prevalence of opioid use. We used STATA-16 for data analysis and p-values <0.05 were considered statistically significant. Results A total of 36,459 participants met the inclusion criteria. The prevalence of depression was 7.7% (95% CI: 7.3-8.2). The prevalence of any narcotic use was 6.0%. Among depressed individuals, Blacks: OR 0.71 (95% CI: 0.54-0.93) and Hispanics: OR 0.48 (95% CI: 0.34-0.67) were less likely to be on narcotics compared to non-Hispanic Whites. The prevalence of opioid use was stable over the first 12 years, followed by a significant drop in the last two years. Conclusion Beyond the risk for opioid misuse, and opioid use disorder, depression should also be considered when prescribing opioids. It is therefore important to implement a training to screen for depression in patients receiving opioids for pain management.

Opioid-Induced Psychosis in a Patient With Sickle Cell Disease.

Sickle cell disease (SCD) is a common inherited hemoglobin disorder in which people have atypical hemoglobin, known as hemoglobin S. It is highly prevalent in non-Hispanic Blacks and people of Arab descent. It causes a distortion of the shape of red blood cells, leading to occlusion of blood vessels and thus tissue hypoxia and injury. The resultant infarction/reperfusion, in turn, causes fatigue and pain. Patients with SCD require constant analgesic medications for pain management. In the general population, opioids are amongst the most prescribed medications for pain management and the trend has been gradually growing during the past two decades. Side effects commonly associated with opioids are gastrointestinal and central nervous system-related, with up to 80% of patients experiencing at least one adverse effect. We report the case of a 36-year-old male patient who has a history of cannabis use and no prior psychiatric history, who developed acute psychosis while receiving a high dose of hydromorphone for sickle cell pain crisis. This case contributes to the growing literature about opioid-induced psychosis and also explores psychosis in sickle cell disease. Understanding the pharmacology and potential side effects of opioids is critical given the increasing number of patients using prescribed and illicit opioids.

Levetiracetam Induced Behavioral Abnormalities in a Patient with Seizure Disorder: A Diagnostic Challenge.

Levetiracetam is a second-generation antiepileptic drug that is chemically unrelated to other antiepileptic drugs. Levetiracetam is a broad-spectrum antiseizure medication that is approved as an adjunctive therapy in the treatment of partial and generalized tonic-clonic seizures in children and adults with epilepsy. The mechanism by which Levetiracetam induces behavioral changes remains unknown. Its proposed mechanism of action involves binding to synaptic vesicle protein 2A (SV2A) and this leads to neuronal inhibition. Though, the drug has a convenient dosing regimen and is relatively well tolerated, neuropsychiatric side effects can emerge beyond the initial titration period and may be the most common reason for drug discontinuation. Levetiracetam has been reported to cause varying degrees of psychiatric adverse effects including behavioral disturbance such as agitation, hostility and psychosis, and mood symptoms and suicidality. It has been shown to induce psychiatric side effects in 13.3% of adults, with only 0.7% presenting with severe symptoms such as depression, agitation, or hostility. The prevalence rate of development of psychosis in these patients is estimated to be about 1.4%. A review of literature has demonstrated a relative correlation between Levetiracetam use and the development of neurobehavioral symptoms which is increased in predisposed individuals. This research describes the case of a 28-year-old woman with seizure disorder and a psychiatric history of schizoaffective disorder who developed aggressive behavior, paranoia, and severe hostility following administration of Levetiracetam 750 mg orally twice daily. She developed acute behavioral symptoms which were reversed with cessation of Levetiracetam. This report emphasizes the need for developing an appropriately high index of suspicion in promoting surveillance and prompt identification of behavioral adverse effects associated with Levetiracetam especially in high-risk patient population.

Persistent Tachycardia in a Patient on Clozapine.

Tachycardia emergent from clozapine treatment is usually transient, often missed, unreported, and therefore frequently goes untreated resulting in possible premature discontinuation of an otherwise effective treatment. Clozapine-induced tachycardia results from direct effects on the sympathetic nervous system including the blockade of cardiac muscarinic M2 receptors, presynaptic α 2 adrenoceptors, and indirect activation of the ß adrenoceptors. Unfortunately, there are no clear guidelines for monitoring or treating tachycardia induced by clozapine. We present a case of a 55-year-old man with treatment-resistant schizophrenia initiated on clozapine who developed persistent tachycardia and right bundle branch block in the course of treatment. Tachycardia persisted despite treatment with metoprolol and necessitated a transfer to the intensive care unit. A reduction in clozapine dose with the addition of adjunctive antipsychotic(lurasidone) stabilized the patient's heart rate. This case highlights the need for consistent physical examination and a multidisciplinary-based treatment approach for patients on clozapine. The case also suggests that clozapine dose reduction and combination antipsychotic treatments may preclude the need to discontinue clozapine in patients with persistent tachycardia.

Cannabis Use in Inpatients With Schizophrenia Spectrum Disorders at a Community Hospital.

BACKGROUND: Cannabis is the second most used recreational drug in the United States and one of the most used substances in patients with schizophrenia spectrum disorder (SSD). Unfortunately, the increased use is likely to continue as more states legalize recreational use of cannabis. Although the association between cannabis and schizophrenia has been studied extensively, the understanding of the relationship is still evolving. In this study, we sought to determine the prevalence and potential factors associated with cannabis use (CU) among inpatients with SSD at a community teaching hospital. METHODS: We performed a retrospective review of the electronic medical charts of patients discharged from the psychiatric unit of our hospital from July 1, 2017 through October 31, 2017. Patients were included in this study if: 1) They were ≥ 18 years old; 2) They had discharge diagnosis of SSD; and 3) They had urine drug testing performed. Pertinent sociodemographic and clinical variables, including substance use status and hospital length of stay (LOS), were abstracted. Univariate frequencies and summary statistics were performed. Odds ratios (ORs) were determined by logistic regression analysis of bivariate and multivariate analyses. RESULTS: Three hundred sixty-five (52.2%) patients had a discharge diagnosis of SSD, and only 322 had urine toxicology result for cannabinoids and were included in analysis. Of the 322 patients, 41.5% (n = 133) screened positive for cannabinoids. Of the 133 patients, 78% were African American, 15% were Hispanic and 5% were White; 77% were male and the median age was 36 years. Bivariate analyses showed tobacco use (OR: 2.8, 95% confidence interval (CI): 1.7 - 4.6), alcohol use (OR: 3.4, 95% CI: 2.9 - 7.0), younger age (OR: 2.8, 95% CI: 1.8 - 4.5), male gender (OR: 2.9, 95% CI: 2.2 - 3.2), unemployment (OR: 3.91, 95% CI: 3.49 - 7.35), homelessness (OR: 3.18, 95% CI: 2.76 - 3.84) and LOS (OR: 3.46, 95% CI: 2.93 - 4.31) were significantly associated with CU. Result of multivariate analysis was similar to that found in bivariate analysis. CONCLUSIONS: CU appears to be prevalent among patients with SSD. Clinicians and public health professionals are encouraged to understand the health implications of its use in patients with mental illness especially against the backdrop of current marijuana laws.

Substance Use Patterns and Schizophrenia Spectrum Disorders: A Retrospective Study of Inpatients at a Community Teaching Hospital.

BACKGROUND: Schizophrenia is one of the chronic mental illnesses, characterized by delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and cognitive decline. It frequently leads to a lifetime of impairment and disability that span the entire lifespan of the patients. Several epidemiologic studies have shown that schizophrenia spectrum disorders (SSDs) contribute significantly to years lived with disability. Additionally, substance use disorders have been reported to co-occur commonly among patients with SSD (a comorbidity also known as dual diagnosis), attracting notable attention over the past few decades. This dual diagnosis often requires treatment modifications to ensure for best patient outcomes. METHODS: This study was a retrospective review of the electronic medical charts. The patients included in the study were discharged from the psychiatric unit of our hospital between July 1, 2017 and October 31, 2017. Patients were included in the study using three inclusion criteria: 1) age ≥18 years; 2) had a diagnosis of SSD at discharge; and 3) had urine drug screen performed. Sociodemographic and clinical variables were abstracted. Univariate analysis and summary statistics were performed. Bivariate and multivariate analyses were done via logistic regression models to determine the odds ratios (ORs) and corresponding P values (P). RESULTS: A total of 365 (52.2%) patients had a diagnosis of SSD at discharge. Of these, 349 met the inclusion criteria. The age ranged from 19 to 79 years, with a mean age of 42.2 years, and 76.8% of the patients used substances. Out of the 269 patients who used substances, 199 (74%) used two or more substances. Tobacco use was most prevalent (62.3%), followed by cannabis use (41.5%), alcohol use (40.2%), and cocaine use (27.4%). Patients who reported using tobacco, were more likely to have comorbid alcohol use (OR = 7.24; P = 0.000), cannabis use (OR = 2.80; P = 0.000), cocaine use (OR = 5.00; P = 0.000), and synthetic cannabis (K2) use (OR = 4.62; P = 0.048). Results of the multivariate analyses supported the other findings. CONCLUSIONS: Our study found a high association between schizophrenia spectrum disorders and substance use, with three out of four patients with SSD using a substance. This prevalence is higher than previously reported by other studies. Among those who use substances, about three in four use multiple substances. These point to some interaction between the substances and appear to be heavily influenced by significant social determinants of mental health that continue to plague the community. It is important to establish if a patient with schizophrenia has a comorbid substance use disorder, because addressing both generally leads to better patient outcomes.