The Necessity of a Trauma-Informed Paradigm in Substance Use Disorder Services.

OBJECTIVE: To raise awareness and understanding about the role of trauma in the development of substance use and to define and clarify the need for trauma-informed care within the treatment of patients with substance use disorders (SUDs). METHOD: This article reviews the up-to-date literature on how and why traumatic life experiences promote a neurobiological vulnerability to development of SUDs and combines this with a discussion of the principles of trauma-informed care for SUDs, as well as a review of the role of stigma and structural violence as foundational concepts in the implementation of trauma-informed care for people with SUDs. RESULTS: Shifting to a trauma-informed care paradigm in treating SUDs more effectively serves patients by improving patient experiences and accounting for a chronic disease model, wherein multiple episodes of SUD care are often necessary. CONCLUSIONS: This article reviews the ways in which nurses and other service providers can increase SUD patient retention and decrease recurrence by understanding the role of trauma in the development of SUDs, exploring the role of stigma, and identifying and interrupting structural violence as it relates to SUDs. This article also offers actionable steps that all nurses can take now as well as areas for further inquiry into trauma-informed care substance use services.

Lamotrigine extended-release as adjunctive therapy with optional conversion to monotherapy in older adults with epilepsy.

PURPOSE: To determine the tolerability and efficacy of lamotrigine extended-release (LTG XR) as adjunctive therapy with optional conversion to monotherapy in patients ages≥65 years with epilepsy. METHODS: This open-label study included the standard LTG XR dose escalation, an 8-week Adjunctive Maintenance Phase (AMP), a 13-week Adjunctive Optimization Phase or Conversion and Monotherapy Phase, and a Taper/Follow-Up Phase. At the end of the AMP, patients on a single concomitant antiepileptic drug (AED) were converted to LTG XR monotherapy over 5 weeks and then remained in the Monotherapy Maintenance Phase for 8 weeks. All other patients remained in the study on concomitant AEDs for an additional 13 weeks in the Adjunctive Optimization Phase. KEY FINDINGS: The number of patients who took ≥1 dose of study medication was 121. Of the 92 patients completing the AMP, 68 patients (74%) were deemed by their treating physician to be eligible to proceed with monotherapy; the remaining 24 patients (26%) continued in the Adjunctive Optimization Phase. The types of adverse events reported with LTG XR were similar to those in studies of LTG XR in younger adult patients with epilepsy and studies of LTG immediate-release (IR) across age groups with epilepsy. No serious rashes were reported. For subjects who were not seizure free at baseline (n=55), the median baseline seizure frequency was 0.5 seizures per week. During the entire treatment period, the median percent change from baseline was 90% (p<0.0001). Fifty-two (52) patients (76%) of the 68 who entered the monotherapy phase successfully converted to monotherapy. SIGNIFICANCE: In this small open label study, LTG-XR was safe and effective when added to the AED regimen of older patients with epilepsy. Many patients were able to be converted to LTG-XR monotherapy.

Pulmonary embolism after shoulder arthroscopy.

Deep venous thrombosis and pulmonary embolism events are common complications following lower-extremity orthopedic surgery. Conversely, deep venous thrombosis and pulmonary embolism events are rare following upper-extremity surgery, specifically shoulder arthroscopy. The purpose of this article is to emphasize the necessity of performing a thorough preoperative workup to uncover possible risk factors for deep venous thrombosis/pulmonary embolism despite the rare occurrence of developing a pulmonary embolism following shoulder arthroscopy. This article describes 3 patients who developed a nonfatal pulmonary embolism following elective shoulder arthroscopy. All 3 surgeries were performed with the patient in the lateral decubitus position. No complications were noted intraoperatively. Symptoms appeared at postoperative days 14, 29, and 2, respectively. One patient demonstrated no risk factors for developing a pulmonary embolism, whereas the other 2 exhibited risk factors for deep venous thrombosis and pulmonary embolism. Pulmonary embolism is a rare but serious complication following shoulder arthroscopy. Shoulder surgeons should be aware of the presenting signs and symptoms. Mechanical or chemical prophylaxis should be administered for patients with identified coagulopathic risk factors. Although it is rare for patients to develop a pulmonary embolism following upper-extremity shoulder arthroscopy, orthopedic surgeons must be aware of the possibility that a pulmonary embolism can occur after elective, uncomplicated shoulder arthroscopy. Surgeons should consider prophylactic measures for patients with identified coagulopathy disorders.

Lamotrigine in the acute treatment of bipolar depression: results of five double-blind, placebo-controlled clinical trials.

OBJECTIVES: The efficacy of lamotrigine as maintenance treatment for bipolar disorder (BD), particularly for delaying depressive episodes, is well established, but its efficacy in the acute treatment of bipolar depression is less clear. This paper reports the results of five randomized, double-blind, placebo-controlled trials of lamotrigine monotherapy for the acute treatment of bipolar depression. METHODS: Adult subjects with bipolar I or II disorder experiencing a depressive episode were randomized to placebo or lamotrigine monotherapy (after titration, at a fixed dose of 50 mg or 200 mg daily in Study 1; a flexible dose of 100-400 mg daily in Study 2; or a fixed dose of 200 mg daily in Studies 3, 4 and 5) for 7-10 weeks. RESULTS: Lamotrigine did not differ significantly from placebo on primary efficacy endpoints [17-item Hamilton Depression Rating Scale in Studies 1 and 2; Montgomery-Asberg Depression Rating Scale (MADRS) in Studies 3, 4 and 5]. In Study 1, lamotrigine significantly separated from placebo on some secondary measures of efficacy, including the MADRS, the Clinical Global Impressions-Severity (CGI-S) and the CGI-Improvement (CGI-I), but seldom differed on secondary efficacy endpoints for the other studies. CONCLUSIONS: Lamotrigine monotherapy did not demonstrate efficacy in the acute treatment of bipolar depression in four out of five placebo-controlled clinical studies. Lamotrigine was well tolerated in the acute treatment of bipolar depression.

A 52-week, open-label continuation study of lamotrigine in the treatment of bipolar depression.

BACKGROUND: Lamotrigine has demonstrated efficacy for the acute treatment of depression in bipolar I patients in a placebo-controlled, monotherapy study. We describe the results of a 52-week, open-label continuation of that trial. METHOD: Patients meeting DSM-IV criteria for bipolar I disorder with a current major depressive episode who completed a 7-week, double-blind study of bipolar depression were offered 1 year of open-label lamotrigine therapy (flexible doses of 100-500 mg/day) in a continuation study. To maintain the acute study blind, the first 3 weeks of the continuation study remained blinded while patients previously randomly assigned to placebo were titrated to a lamotrigine dose of 50 mg/day. Patients who had been randomly assigned to lamotrigine continued at their fixed doses. Beginning at week 4, all patients received open-label lamotrigine for up to 49 additional weeks. Concomitant psychotropic medications were permitted during the open-label phase. Effectiveness (Montgomery-Asberg Depression Rating Scale [MADRS], Clinical Global Impressions-Improvement scale) and safety assessments were administered at weeks 4, 12, 24, 36, and 52. The study was conducted from June 1996 to December 1998. RESULTS: Of 135 patients completing the acute study, 124 (92%) entered the continuation study: 77 had received lamotrigine and 47 had received placebo in the acute study. The mean duration of lamotrigine exposure was 10.4 months, with a mean modal dose of 187 mg/day. Sixty-nine patients (56%) completed 1 year of treatment. Significant and sustained improvement from baseline was seen in mean observed MADRS scores (p <.05). The proportion of patients achieving remission (MADRS score < or = 11) by week 4 of the study was 81.4%, and episodes of mania/hypomania occurred less frequently than in the preceding year. Headache was the most common drug-related adverse event. CONCLUSION: During 1 year of open-label therapy with lamotrigine as adjunctive therapy or monotherapy, bipolar I patients experienced sustained improvement in depressive symptoms without evidence of mood destabilization.