Journal Article Annotations
2024, 2nd Quarter
Annotations by Clayton Barnes, MD, MPH
July, 2024
The finding:
Notable distinctions in psychotic symptoms exist between those suffering from short- and long-term methamphetamine use relative to those suffering from other psychotic disorders unrelated to stimulate use. However, diagnostic classifications have not kept pace with this clinical gestalt. Investigators established a panel of experts familiar with methamphetamine intoxication, withdrawal, and addiction by way of recruitment through national listservs. Clinicians were screened for knowledge base and experiential diversity. The assembled panel then utilized the Delphi technique with a threshold of 80% agreement to develop the clinical guidelines.
Strength and weaknesses:
One strength of the panel was the requirement that experts have at least five years of experience and board certification, which is likely sufficient for a clinician to treat a variety of methamphetamine-related presentations. However, while the panel represented broad diversity in location of practice and academic affiliation, only 18% of experts were board certified in Addiction Medicine and most experts represented urban centers. Finally, the use of email as a recruitment tool and the time investment required to participate potentially excluded many busy expert clinicians with valuable experience.
Relevance:
This research further refines the clinical and diagnostic differences between those suffering from a primary psychotic disorder and those experiencing a methamphetamine-induced psychotic disorder. The diagnostic criteria put forth encourages ongoing research and validation into how these entities are similar and distinct. Codifying these differences in diagnostic terms will facilitate ongoing research into epidemiological trends, treatment modalities, and effective public policies.
The finding:
Inspired by the success of naloxone in preventing opioid overdose deaths, investigators provided 92 participants treated for methamphetamine-induced psychosis at a psychiatric emergency department with olanzapine, medication administration information, and referral information (termed Methamphetamine Assist Packs or Chill Packs) at the time of discharge. Readmission rates at two months (0.68) and six months (0.87) were reduced relative to the time period before intervention (p<0.001), with no statistical difference at 12 months. Twenty-four of the 92 participants received multiple Assist Packs during the 12 months.
Strength and weaknesses:
The strength of this study lies in its practicality; this protocol could be implemented in most emergency settings relatively quickly. The potential benefits of reducing symptoms of psychosis and aggression likely outweigh potential side effects for most patients. Primary weaknesses included the exclusion of patient presentations to outside hospitals, the inability to understand the patient perspective, and no follow-up after receiving the Assist Packs.
Relevance:
The Methamphetamine Assist Pack offers an agency-promoting method of potentially decreasing the severity of the methamphetamine intoxication syndrome. An important aspect of the study design was the provision of medication and referral information prior to discharge; medication nonadherence (caused by financial, mobility, and other factors) is a primary cause of symptom recurrence. Providing medications before discharge, rather than requiring pharmacy pick up, undoubtedly supported adherence to treatment recommendations. Hospital and health system administrators should view these study results as a test of Methamphetamine Assist Packs specifically, but also as a confirmation of the utility of dispensing medications at the time of discharge, particularly for high-risk patients such as those with recent substance use or suffering from housing insecurity. Furthermore, future research should explore the use of additional antipsychotic medications, as many patients who are unhoused are unwilling to take sedating medications so as not to risk victimization. To this end, risperidone or ziprasidone would be interesting comparison medications for this intervention.
This is a retrospective dataset analysis of a large sample of health care encounters, and
compared data on total adult visits, and visits associated with opioid use disorder (OUD), opioid-related visits (including overdose), opioid or buprenorphine prescription, and naloxone at discharge. During the period of study2016-2021, 407 sampled medical visits (representing 2.4 million health care encounters) were for an OUD diagnosis, out of a total 83,941 sampled medical visits 9655 million encounters). Visits diagnosed with OUD during 2020-2021 declined significantly compared with 2016-2017 but there was no significant decline in opioid-related visits over this time. The study additionally observed a statistically significant decline in opioid prescription visits, and a 3-fold increase in buprenorphine prescriptions within the sample population; however, while the proportion of buprenorphine visits within overall opioid visits increased from 0.4% to 0.8% this was not a statistically significant increase. Additionally, only a minority–19 out of 407–OUD visits had naloxone prescribed at discharge. The authors conclude that the findings of declining ED visits for OUD during 2016-2021 contrasted with increase in opioid overdose fatalities during this time, possibly due to less efficacious OUD screenings in the ED during this time, as well as that all-cause ED visits and SUD-related visits decreased during the pandemic. The data indicated that OUD-specific visits decreased, opioid-related visits, including opioid overdose, did not significantly decline.
This is dataset analysis of a large sample set, likely misses many undiagnosed/uncoded visits, lacks information on clinical characteristics of patient visits (is not a chart-based review), and is unable to be controlled for confounders including indications for prescriptions; buprenorphine dosages are unknown, and methadone is not captured. The sample demographics limit generalizability to an urban population. Patients with OUD are increasingly presenting to the ED with varying opioid-related chief concerns including overdose and MAT prescriptions, yet OUD outcomes remain poor; this calls for a need for enhanced OUD screening, detoxification and treatment initiation protocols in the ED.