A&E Abstracts and Extracts

Authors: Zofia Kozak, MD, et al.

Abstract: Co-use of benzodiazepines and opioids significantly increases fatal overdose risk, yet few studies have examined co-use of these drugs when obtained both with and without a prescription.

The authors examined daily co-use of prescribed benzodiazepines/tranquilizers (BZD/TRQ) and prescribed and nonprescribed opioids among people who use street opioids (PWUO).

The study sample came from The Peer Harm Reduction of Maryland Outreach Tiered Evaluation, a mixed-methods, cross-sectional study of people who use drugs in Baltimore City, Maryland, and neighboring Anne Arundel County.

They concluded that clinicians working with PWUO, or who prescribe BZDs or opioids, should screen patients who use cocaine or synthetic cannabinoids, have low level of educational attainment, or who have recently accessed mental health services, as these patients may be at higher risk for daily co-use of BZD/TRQ and opioids, and therefore lethal overdose.

Importance: Poisoning deaths are the leading cause of unintentional death in the US, with the highest number of fatal overdoses ever recorded (100,306) occurring in the 12-month period ending in April 2021, constituting a 28.5% increase from the same period the year before.

Most of these fatalities involve opioids, and recent studies show mortality rates for opioid overdoses involving benzodiazepines increased 10-fold from 1999 to 2017. In addition to being used for their anxiolytic effects, BZDs are often used nonmedically in conjunction with other drugs to potentiate or prolong drug effects, or to mitigate withdrawal symptoms. When used specifically with opioids, BZDs are often used to enhance opioid intoxication, which may involve taking BZD doses that are greater than the typical therapeutic range. 

The interacting pharmacokinetics between BZDs and opioids are well established: co-use of the two substances together significantly increases the risk of fatal overdose due to respiratory drive suppression and increased sedation, increasing the risk for hypoxic respiratory failure. The contamination of the drug supply chain with fentanyl and fentanyl analogues poses an increasing risk of death for individuals using street opioids, not just because of their potency, but also because these compounds have longer half-lives relative to heroin.

Successfully identifying patients who co-use BZDs and opioids (both prescribed and nonprescribed) is critical in providing interventions to reduce risk of fatal overdose. The clinical encounter provides an opportunity to screen patients for co-use, and engage high-risk patients in harm reduction behaviors that reduce mortality, such as using with others and carrying naloxone.

Availability: Published by The American Journal on Addictions.

Authors: Joshua Franklin, MD, et al.

Abstract: The authors present the case of a 34-year-old Black patient with no significant psychiatric history who presented with catatonia and psychotic symptoms following a recent SARS-CoV-2 infection. His diagnosis of COVID encephalitis was delayed by premature attribution of his symptoms to a primary psychiatric etiology.

The authors provide guidance for this commonly encountered clinical case based on their experience and a review of available literature.

Key teaching topics include the diagnosis and management of COVID encephalitis, cognitive bias, and racial bias.

Importance: This case illustrates the role of the C-L psychiatrist in identifying medical conditions that may overlap with psychiatric presentations and in advocating for marginalized patients.

Availability: Published by the Journal of the Academy of Consultation-Liaison Psychiatry (JACLP).

Authors: Jennifer Erikson, DO, et al.

Abstract: The Academy’s Neuropsychiatry SIG increased its membership from 174 in 2015 to 972 in 2022. At the last count, it had 1,112 members—the second largest of 27 SIGs in ACLP. Here SIG members give an account of what they did to make it a success—and offer a potential model for SIG development.

“SIGs are an integral component of professional societies,” say the authors. “They offer opportunities to develop professional identities, coalesce around subspecialized interests, position academic clinicians for career development, and optimize networking connections. Innovative ideas can be discussed and executed through an expansive cohort of individuals assembled around a common theme of interest. For junior faculty and trainees, involvement in professional organizations can positively impact career development as they acquire institutional leadership positions, national recognition, and enhanced scholarly productivity, potentially leading to academic promotion.”

But effective SIG administration is challenging. “SIGs are generally unfunded and depend on members donating time and effort to contribute to the richness of the experience.”

The Neuropsychiatry SIG was established in 2008. “Over the years, however, interest waxed and waned, and ultimately dwindled.” Finally, in 2015, with only three attendees from the SIG at an ACLP meeting, two of them volunteered to revive it.

Virtual meetings were added between annual meetings. And three taskforces were created to focus on three common reasons clinicians engage with SIGs:

• SIG-sponsored presentations at national conferences.
• Development and dissemination of educational materials.
• Finding potential co-authors.

All members were asked to join one task force and encouraged to participate in as many as possible. As the size of each task force expanded, a lead person was appointed through whom activity was spearheaded.

“In addition to contributing to the growth of our membership, the three task forces have offered junior faculty and trainees leadership experience, as all three have been led or co-led by a junior person.”

Members also refined and completed project ideas in subtask groups, enabling senior members to progress additional opportunities. The SIG has now attracted the attention of Maudsley and Bethlem Hospital School, London, to create an international neuropsychiatry journal club. “This has led to international collaborations and allowed trainees and junior faculty to participate in invited presentations of cutting-edge literature in neuropsychiatry.”

Throughout, the model has focused on supporting distributed efforts while not overburdening leaders nor members. “This infrastructure has enabled the SIG to run independently without a sole leader’s dependence.”

Importance: Here is a potential blueprint for academic leaders seeking structure, and a way to engage trainees while providing them with early leadership opportunities.

Availability: Published by Springer Nature.

Authors: Tucker Hickox, BS, et al.

Abstract: The authors describe the case of a nine-year-old girl who presented to a tertiary-care academic children's hospital with acute onset of severe obsessive-compulsive symptoms, perseveration, grimacing, and personality changes with resultant agitation. Extensive multidisciplinary workup led to a diagnosis of seronegative autoimmune encephalitis. The clinical course included multiple general pediatric and inpatient psychiatric unit admissions that were complicated by severe affective dysregulation with physical aggression towards staff and family.

The authors provide guidance for this commonly encountered clinical case based on their experience and review of available literature. Key teaching points include assessment and management of seronegative autoimmune encephalitis and catatonia. Also discussed are the system-level challenges of management of aggression in health care settings and ways to improve care for patients presenting with behavioral manifestations (aggression) of physical illness.

Importance: The most striking aspect of the patient's clinical presentation, say the authors, was the severe aggression in multiple settings. Patients, families, and providers face challenges in managing psychiatric or behavioral symptoms as a result of fragmented care that often results from health care silos. The absence of a clear path to successfully manage aggression was overwhelming and further contributed to a sense of demoralization for the teams.

Availability: To be published by the Journal of the Academy of Consultation-Liaison Psychiatry (JACLP).