Psychiatry – Page 23 – Go Retire Psychiatrist

Back in the Saddle

Well, I’m pretty tapped out, so it’ll be a short post today. I’m back in the saddle, running around the hospital on the psychiatry consult service. This is my last year of phased retirement and in 11 months—I’ll be fully retired.

I put 36 floors and 3 miles on the step counter. I’m feeling every one of those. Sena bought me some banded collar shirts and I’m wearing those instead of a shirt with a necktie. I don’t need a tie bar.

And I don’t worry about a delirious, violent patient strangling me with my necktie.

We had a small scare tonight. We were looking at my total compensation statement (the last one) and got the Sharp Elsi Mate EL-505 vintage calculator out to crunch some figures. The calculator went dead.

I put some new batteries in it, hopeful. It still didn’t work. We’ve had this calculator for over 30 years and it ran more than a decade on the first set of AA batteries.

I tried another pair of batteries. It worked! The vintage calculator lasted longer than the batteries. It’s nice to know that just because something’s old doesn’t mean it’s useless.

That’s all I got.

Informal Bedside Tests for Delirium

Most of this post is an updated redux from years ago about an informal bedside test for delirium called the oral trails test. I learned about it from my senior resident when I was a junior psychiatry resident in training at the VA Medical Center.

There was an elderly patient admitted to the psychiatry unit who was thought to be psychiatrically ill but who actually seemed confused to me and the senior resident. We consulted medicine in order to get him transferred to the general medicine unit but it was tough going. I think the medicine resident disagreed with our clinical impression that he was confused and didn’t think medical transfer was necessary.

Anyway, my senior resident showed me her version of the oral version of the mixed Trails A and B Test for executive function. There is a written form which is part of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). First, she asked him to count from 1 to 7; then she asked him to recite the letters of the alphabet from A to J. She then asked him to try reciting those letters in alternating sequence. Of course, he failed miserably and was eventually transferred to internal medicine. The Trails actually is a paper and pencil test and it looks like a dot to dot game, like the example below:

My senior resident told me she learned the oral Trails test from her senior resident and couldn’t remember anything else about it. I used the test for years but a neuropsychologist criticized the practice, questioning the test’s validity, and rightly so.

Of course, I’d been doing it wrong. You’re supposed to have the patient count to 25, then recite the letters of the alphabet, then recite the numbers and letters in alternating sequence from 1 to 13 and A to M. More than two errors in pairings indicate cognitive impairment.

There are limitations to the verbal Trails and caution is advised in more recent literature, indicating that there are moderate education effects in older patients and that it may be wiser to use both paper and pencil and oral versions together.

Still the search goes on for quick and dirty ways to screen for cognitive impairment in the elderly because this and advanced age are two main risk factors for delirium.

Nowadays, I do the Mini-Cog (shown in the video below) or the Single Question in Delirium (SQiD) test, which just involves asking a family member if the patient seems confused lately.

References:

Mrazik, M., Millis, S., & Drane, D. L. (2010). The oral trail making test: effects of age and concurrent validity. Archives of clinical neuropsychology: the official journal of the National Academy of Neuropsychologists, 25(3), 236–243. doi:10.1093/arclin/acq006

Ricker, J. H., & Axelrod, B. N. (1994). Analysis of an Oral Paradigm for the Trail Making Test. Assessment, 1(1), 47–51. https://doi.org/10.1177/1073191194001001007

Sands, M., Dantoc, B., Hartshorn, A., Ryan, C., & Lujic, S. (2010). Single Question in Delirium (SQiD): testing its efficacy against psychiatrist interview, the Confusion Assessment Method and the Memorial Delirium Assessment Scale. Palliative Medicine, 24(6), 561–565. https://doi.org/10.1177/0269216310371556

Quiz Show versus Grand Rounds for Delirium Education Redux

Here’s a redux of one of my blog posts from years ago. There’s not been much change in the data or clinical practice regarding delirium, except we’re even less enthusiastic about using any kind of psychotropic medication to treat delirium, even hypoactive delirium. Try the puzzle.

“So, you want to put on a game show contest to educate clinicians about delirium? Contact David Meagher, a psychiatrist in (where else?) Limerick, Ireland. He reported on this innovative educational workshop in the November 2010 Vol. 3 issue of the Annals of Delirium, the newsletter for the European Delirium Association (EDA). He also published the study which describes the contest in International Psychogeriatrics [1].

The workshop focused on clinician attitudes toward drug therapy for distressed delirious patients. It explored pre-existing attitudes and practice toward the use of medications to manage delirium and exposed participants to a very interactive educational event modeled after a popular TV quiz show. There were two teams (skeptics versus neuroleptics) furnished with a list of statements about delirium pharmacotherapy. The participants later completed a post-workshop questionnaire that explored changes in attitudes as a result of the workshop.

The participants were all experts on the subject and there was a good deal of variability in attitudes and practice. Some of the questions put to the teams involved using antipsychotics prophylactically to prevent delirium, the mechanism of action of antipsychotics, and what role benzodiazepines play in the treatment of non-alcohol withdrawal delirium.

One of the more puzzling findings was that the frequency of antipsychotic use was inversely proportional to the perception of the strength of supporting evidence. In other words, the less they knew about antipsychotics, the more often they used them. Most participants seemed to believe that the principal mechanism of action of antipsychotics is sedation, despite the lack of supporting evidence.

Some clinicians used antipsychotics to relieve the stress of caregivers rather than that of delirious patients, an example of patients getting the right treatment for the wrong reasons as observed by Meagher—and many of us in the field.

The workshop also highlighted the tendency of clinicians to focus on risk management rather than effective therapeutic intervention in the management of delirious patients with disruptive behavior and severe distress. This mainly relates to focus on the potential adverse effects of antipsychotics such as extrapyramidal side effects, metabolic, and cerebrovascular effects.

The quiz show activity was fun and challenging. The device of dividing the participants into two small teams with larger audience participation cut down on the anxiety that could be provoked by giving the “wrong answer”. The questions were true/false and didn’t always have clear right or wrong answers. It was highly interactive, a component of continuing medical educational (CME) activities that is increasingly encouraged because it’s more likely to lead to changes in clinician attitude and practice. The one time Grand Rounds CME “seat time” is going the way of the dinosaur.

So a couple of findings from the quiz show post-activity questionnaire were that clinicians were more likely to use antipsychotics prophylactically and to use antipsychotics to manage hypoactive delirium.

Our delirium intervention project group members are not quite as enthusiastic yet about these two interventions. We’re a bit more inclined at least initially to focus on non-pharmacologic multicomponent strategies such as the example below:

Minimize the use of immobilizing catheters, intravenous lines, and physical restraints
Avoid immobility, early mobilization
Monitor nutrition
Provide visual and hearing aids
Monitor closely for dehydration
Control pain
Monitor fluid-electrolyte balance
Monitor bowel and bladder functioning
Review medications
Reorient communications with the patient
Place an orientation board, clock, or familiar objects (i.e., family photographs) in patient rooms
Encourage cognitively stimulating activities such as word puzzles
Facilitate sleep hygiene measures, including relaxation music or tapes at bedtime, warm drinks, and gentle massage
Minimize noise and interventions at bedtime, e.g., by rescheduling medication times

But I’m just as enthusiastic about interactive educational methods to engage learners in order to build a culture more likely to produce champions who will lead the delirium prevention effort—try the delirium multicomponent crisscross puzzle below. The clues are contained in the list of multicomponent tactics above.”

Meagher, D.J., Impact of an educational workshop upon attitudes towards pharmacotherapy for delirium. Int Psychogeriatr, 2010. 22(6): p. 938-46.

SQiD vs CAM Redux

This was a blog post I wrote back in 2011 on another blog, The Practical C-L Psychiatrist. SQiD is short for Single Question in Delirium and it’s a very short and effective screen for delirium, if you have a reliable informant. I also mention the Edinburgh Delirium Test Box (EDTB). It has been further developed into a smartphone app.

“The November Vol. 3 issue of the Annals of Delirium published a summary of an interesting study of a Single Question in delirium (SQiD) as a screen for delirium compared to the Confusion Assessment Method (CAM), the Memorial Delirium Assessment Scale (MDAS) and a psychiatrist interview[1].

The question “Do you think (name of patient) has been more confused lately?” was put to a friend or relative of 21 patients. Compared with psychiatric interview, the SQiD achieved a sensitivity and specificity of 80% (95% CI 28.3-99.49%) and 71% (41.90-91.61%) respectively. The CAM demonstrated a negative predictive value (NPV) of 80% (51.91-95.67%) and the SQiD showed an NPV of 91% (58.72-99.77%). The CAM in the study had only a 40% sensitivity used by minimally trained clinical users.

The negative predictive value of a test tells you how likely it is that you actually don’t have the condition or disease. It’s defined as the number of true negatives (people who test negative who are not affected) divided by the total number of patients who test negative and it varies with test sensitivity, test specificity, and disorder prevalence. The sensitivity of a test is how accurately it detects patients who are positive for the disorder (in this case delirium). If 100 patients are positive for the disorder, then a test that is 80% sensitive will detect 80 of those cases and miss 20 actual cases of the disorder. Specificity is defined as how accurately a test detects patients who do not have the disorder. In our delirium example, if 100 patients are free of the disorder, then a test that is 71% specific will correctly tell 71 of those people that they are not affected and will incorrectly tell 29 that they have the disorder when they don’t.

This seems to suggest that a single question screening question packs a fair punch compared to screening instruments and psychiatric interview for identifying delirium. The CAM takes a few minutes to complete and requires training to achieve optimal identification rates.

The authors suggest the SQiD deserves further study and their results seem to support the conclusion. The study is limited by small sample size, but intuitively the premise is appealing. This is one of the quickest tests for delirium applicable and can be applied by almost anyone.

Single question screening exams for depression are not unheard of so there is precedence for the SQiD. You just have to be careful about what you say in front of patients and families. “Go ahead and run the squid on Mr. Jones” could raise a few eyebrows.

This is possibly a low tech solution in a pinch when the CAM forms file is empty or the battery is low on the Edinburgh Delirium Test Box (EDTB)[2]. The EDTB is a more high-tech solution to testing for what neuropsychologists believe what one of the main abnormalities is in delirium—lack of sustained attention. It’s a computerized neuropsychological testing device.

And that face-off would be called SQiD versus Box.”

References:

1. Sands, M., et al., Single Question in Delirium (SQiD): testing its efficacy against psychiatrist interview, the Confusion Assessment Method and the Memorial Delirium Assessment Scale. Palliative Medicine, 2010. 24(6): p. 561-565.

2. Brown, L.J.E., et al., Detecting deficits of sustained visual attention in delirium. Journal of Neurology, Neurosurgery & Psychiatry.

Coach’s Corner: Somatoform Illness

This is a short Coach’s Corner video on somatoform and related abnormal illness behaviors which prompt physicians to request psychiatric consultation. Medically unexplained physical symptoms are not rare in the hospital and in medical clinics.

The general idea is to remember Stephen Covey’s caution about effectiveness and efficiency, which is that you have a lot better chance being effective rather than efficient with people.

“With people, slow is fast and fast is slow.”
Stephen Covey

The point is that it’s very important to listen for understanding and to validate pain and suffering. That means sitting with patients and taking time to hear what they tell you.

There is an excellent presentation on conversion disorder (also known as functional neurological disorder) on the National Neuroscience Curriculum Initiative (NNCI) web site. It’s very helpful for clinicians and patients.

Coach’s Corner On Delirium

I’m anticipating a busy time next month on the psychiatry consultation service. I suspect delirium will be the main event, as it is most of the time.

So I made a very short YouTube video on delirium. It’s cast in the style of a coach’s corner because I was one of the many clinicians who won the Excellence in Clinical Coaching Award this year.

I’m honored to be in such distinguished company and congratulate all the winners.

Coach’s Corner on Delirium

Time for July Psychiatry Consults

It’s getting close to the busiest time of the academic year in a teaching hospital–July. The residents have a steep learning curve during that month. Some hospitals have a sort of boot camp to get the upcoming first year internal medicine residents prepared for July.

I’m looking at my retirement countdown timer and it’s showing I have 12 months to go. I’ll be back in the saddle July 1st.

July is usually the time for the most interesting psychiatry consultation questions. Many years ago, the psychiatry residents used to keep a list of the weirdest ones. At least that’s what they claimed. Actually, I think most of them were simply made up–maybe all of them. Even though there is no way to know for sure, there is very low probability that any item on the list below could identify any patient.

We used to call it the “wailing wall” of strange and difficult to answer psychiatry consultation questions sometimes asked by our non-psychiatry colleagues from internal medicine and surgery. Questions have been and still are sometimes ambiguous (worse in July) and often need to be reframed so that the psychiatric consultant can be helpful to both customers—the patient and the consult requester. Here are some “quotes” from probably fictitious consultation requests tacked to wailing wall in the distant past, certainly embellished in some cases by frustrated psychiatry residents:

1. “EEG shows no brain activity.”

2. “The patient doesn’t like me.”

3. “We want to know if the patient who believes they are Sponge Bob and wants to leave the MICU to start filming a new movie—is competent.”

4. “I’m a humanitarian but can you transfer this patient to Mexico?”

5. “The patient looked at me funny.”

6. “We are wondering whether to discharge to their own apartment a patient who is oriented only to self, cannot perform activities of daily living, and is actively hallucinating?”

7. “I prefer not to speak with my patients.”

8. “I prefer not to speak with families.”

9. “Patient gets irritable during “that time of the month.”

10. “We are wondering if the patient should be taken off sedation before getting a history from them?”

11. “Patient swallowed their narcotic sobriety pin and is upset that morphine was discontinued.”

12. “The patient is eating their fingers off.”

13. “Cardiac arrest.”

14. “Consult for bilateral disorder or generalized panic disorder.”

15. “Anxiety and agitation 5 minutes before Code Blue.”

16. “Please evaluate for catatonia versus brain death on intubated patient.”

17. “Patient was fine yesterday but now unresponsive. Please rule out catatonia before we work up. If catatonia ruled out, we’ll then get a head CT and labs.”

18. “We want the consult for our own safety.”

19. “We need psychiatry’s blessing before we can feel comfortable discharging the patient.”

20. “Patient admitted for renal failure after being gored by a bull at a rodeo, please evaluate if this was a suicide attempt.”

Some are humorous and a few are mind-boggling. What they all speak to is the omnipresent opportunity for the C-L psychiatrist to excel as an educator. Reframing the question is a skill that requires patience, diplomacy, and credibility as an expert in this field.

What this may also indicate is the necessity to include a bit more about psychiatry in medical school clerkship programs.

Transplantation Psychiatry

Transplantation psychiatry is a special setting for consultation-liaison psychiatrists. Mainly, they work in organ transplant centers. The democratization of health care over many years, along with the relative scarcity of transplantation psychiatrists, has led to many other professionals conducting the psychosocial assessments for evaluating organ transplant candidates.

It’s a complicated field with many stakeholders. The scarcity of organs often leads to great anxiety in patients and their supporters. Anxiety can complicate the assessment phase, the waiting phase, and the post-transplant phase as well.

The most frequent question that consultees from the transplant team ask is whether the candidate is a good risk for receiving an organ that is in short supply, which therefore must be allocated carefully, and of which the candidate must be prepared to be a good steward. Psychosocial screening is a feature of most transplant programs. Rather than seeing one’s self as a gatekeeper, most experts agree that the most useful part of the psychosocial screening process is to identify psychosocial factors that would interfere with the candidate’s successful adaptation to life posttransplant, and to develop a plan for managing them using available resources.

The Medical-Psychiatry Unit

I guess I’m incorrigible; there are now 4 eggs in the robins’ nest. Progress there reminded me of another kind of progress–in integrated health care.

On that note, this is just a brief update on the Medical-Psychiatry Unit (MPU). I thought it would be a good time to do this since a hard-working Pennsylvania psychiatrist notified me of the very successful Medical Complexity Unit (MCU) in operation at Reading Hospital. See my post from May 23, 2019.

I co-attended on our MPU for 17 years before I chose to concentrate on the Consultation-Liaison Psychiatry (CLP) service. The health insurance payer system challenges have probably not changed much. I still believe that the MPU is a great place to teach trainees to appreciate the rewards and challenges of caring for patients with complex, comorbid psychiatric and medical issues.

I hope the video makes the case for that. I decided it didn’t need a voice over. I welcome any comments and questions.

Opinions on Cannabis for Neuropathic Pain

I just saw the Clinical Psychiatry News article “Evidence poor on medical marijuana for neuropathic pain,” by Andrew D. Bowen. It was published May 2019, Vol. 47, No. 5 and I couldn’t find it on line yet.

I should also hasten to add that there are a couple of other important articles on management of pain in this issue of Clinical Psychiatry News. One of them expresses a similar opinion about the lack of clear evidence pointing to a clear best choice for a medication for neuropathic pain, “No clear winner emerges for treating for chronic pain” also by Andrew D. Bosen, who interviewed a neurologist, Dr. Raymond Price, associate professor of neurology at the University of Pennsylvania, Philadelphia about his review of the evidence for treatment of neuropathic pain.

In addition, on a more hopeful note, there is good evidence for the effectiveness of cognitive behavioral therapy (CBT) for chronic pain, “In chronic pain, catastrophizing tied to disrupted circuitry,” by Kari Oakes, who interviewed Drs. Robert R. Edwards, PhD, psychologist at Brigham and Women’s Hospital/Harvard Medical School (Boston) Pain Management Center, and Vitaly Napadow, PhD. Connectivity between certain areas of the brain can lead to the perception that pain is a part of who we are. This can even interfere with the effectiveness of pain medications.

Dr. Ellie Grossman, MD, MPH said at the annual meeting of the American College of Physicians that there’s “a lot of the Wild West” in medical marijuana research regarding its use in neuropathic pain. I got the impression she was being as diplomatic as she could when she described the level of evidence as being marked by a lot of “squishiness.”

It’s a frankly cautious comment compared with the more positive opinions expressed just a month ago in Clinical Psychiatry News. Dr. Grossman is quoted, “The upshot here is that there may be some evidence for neuropathic pain, but the evidence is generally of poor quality and kind of mixed.” Dr. Grossman is an instructor at Harvard Medical School and Primary Care Lead for Behavior Health Integration, Cambridge Health Alliance, Somerville, Massachusetts.

In fact, as the author points out, the research in this area is marked by inconsistencies in the medical marijuana formulations, small numbers of patients enrolled in studies, and equivocal results from meta-analyses.

The title of the article says it all and it’s really no surprise. I have little to add except the following very short opinion based on a very superficial scan of PubMed.

First, I happened to find a couple of papers from the mid-1970s about cannabis and pain in cancer patients. They were written by Russell Noyes, MD and Art Canter, Ph.D. and colleagues. Dr. Noyes has retired for the second time from the Psychiatry Dept at University of Iowa and Dr. Canter was enjoying his retirement until his death in October, 2018; he was in his late 90s.

Even in 1975, there was very little reason for enthusiasm about the analgesic effect of cannabis in cancer patients. Admittedly, the number of subjects were low in each study but the side effects of cannabis were severe in a few cases.

The summary from the first Noyes et al paper is essentially that, why analgesic effect was demonstrable at high dose levels, so was “…substantial sedation and mental clouding…”

In the second paper by Noyes et al, the concluding remarks are telling— “Finally, particular difficulty was experienced in evaluating the pain of patients after receiving THC. In many instances they appeared exceptionally peaceful while, at the same time, reporting little pain relief. In other instances, they claimed that, though the pain was unchanged, it bothered them less.”

There seems to be nothing new under the sun in this setting although most of the studies involved patient with chronic non-cancer pain. One study found some benefit and modest tolerability—see the caveat below (Ware et al 2015).

“In conclusion, this study suggests that the AEs of medical cannabis are modest and comparable quantitatively and qualitatively with prescription cannabinoids. The results suggest that cannabis at average doses of 2.5 g/d in current cannabis users may be safe as part of a carefully monitored pain management program when conventional treatments have been considered medically inappropriate or inadequate. However, safety concerns in naive users cannot be addressed. Moreover, long-term effects on pulmonary functions and neurocognitive functions beyond 1 year cannot be determined. Further studies with systematic follow-up are required to characterize safety issues among new cannabis users and should be extended to allow estimation of longer-term risks.”

See the abstracts below. They tend to echo Dr. Grossman’s impressions. I wonder whether the quality of the research in this area will ever be strengthened.

References:

NOYES, R., et al. (1975). “Analgesic Effect of Delta‐9‐Tetrahydrocannabinol.” The Journal of Clinical Pharmacology 15(2‐3): 139-143.

Noyes, R., et al. (1975). “The analgesic properties of delta‐9‐tetrahydrocannabinol and codeine.” Clinical Pharmacology & Therapeutics 18(1): 84-89.

The administration of single oral doses of delta‐9‐tetrahydrocannabinol (THC) to patients with cancer pain demonstrated a mild analgesic effect. At a dose of 20 mg, however, THC induced side effects that would prohibit its therapeutic use including somnolence, dizziness, ataxia, and blurred vision. Alarming adverse reactions were also observed at this dose. THC, 10 mg, was well tolerated and, despite its sedative effect, may have analgesic potential.

Ware, M. A., et al. (2015). “Cannabis for the Management of Pain: Assessment of Safety Study (COMPASS).” The Journal of Pain 16(12): 1233-1242.

Cannabis is widely used as a self-management strategy by patients with a wide range of symptoms and diseases including chronic non-cancer pain. The safety of cannabis use for medical purposes has not been systematically evaluated. We conducted a prospective cohort study to describe safety issues among individuals with chronic non-cancer pain. A standardized herbal cannabis product (12.5% tetrahydrocannabinol) was dispensed to eligible individuals for a 1-year period; controls were individuals with chronic pain from the same clinics who were not cannabis users. The primary outcome consisted of serious adverse events and non-serious adverse events. Secondary safety outcomes included pulmonary and neurocognitive function and standard hematology, biochemistry, renal, liver, and endocrine function. Secondary efficacy parameters included pain and other symptoms, mood, and quality of life. Two hundred and fifteen individuals with chronic pain were recruited to the cannabis group (141 current users and 58 ex-users) and 216 controls (chronic pain but no current cannabis use) from 7 clinics across Canada. The median daily cannabis dose was 2.5 g/d. There was no difference in risk of serious adverse events (adjusted incidence rate ratio = 1.08, 95% confidence interval = .57–2.04) between groups. Medical cannabis users were at increased risk of non-serious adverse events (adjusted incidence rate ratio = 1.73, 95% confidence interval = 1.41–2.13); most were mild to moderate. There were no differences in secondary safety assessments. Quality-controlled herbal cannabis, when used by patients with experience of cannabis use as part of a monitored treatment program over 1 year, appears to have a reasonable safety profile. Longer-term monitoring for functional outcomes is needed. Study registration The study was registered with http://www.controlled-trials.com (ISRCTN19449752). Perspective This study evaluated the safety of cannabis use by patients with chronic pain over 1 year. The study found that there was a higher rate of adverse events among cannabis users compared with controls but not for serious adverse events at an average dose of 2.5 g herbal cannabis per day.

Andreae, M. H., et al. (2015). “Inhaled Cannabis for Chronic Neuropathic Pain: A Meta-analysis of Individual Patient Data.” The Journal of Pain 16(12): 1221-1232.

Chronic neuropathic pain, the most frequent condition affecting the peripheral nervous system, remains underdiagnosed and difficult to treat. Inhaled cannabis may alleviate chronic neuropathic pain. Our objective was to synthesize the evidence on the use of inhaled cannabis for chronic neuropathic pain. We performed a systematic review and a meta-analysis of individual patient data. We registered our protocol with PROSPERO CRD42011001182. We searched in Cochrane Central, PubMed, EMBASE, and AMED. We considered all randomized controlled trials investigating chronic painful neuropathy and comparing inhaled cannabis with placebo. We pooled treatment effects following a hierarchical random-effects Bayesian responder model for the population-averaged subject-specific effect. Our evidence synthesis of individual patient data from 178 participants with 405 observed responses in 5 randomized controlled trials following patients for days to weeks provides evidence that inhaled cannabis results in short-term reductions in chronic neuropathic pain for 1 in every 5 to 6 patients treated (number needed to treat = 5.6 with a Bayesian 95% credible interval ranging between 3.4 and 14). Our inferences were insensitive to model assumptions, priors, and parameter choices. We caution that the small number of studies and participants, the short follow-up, shortcomings in allocation concealment, and considerable attrition limit the conclusions that can be drawn from the review. The Bayes factor is 332, corresponding to a posterior probability of effect of 99.7%. Perspective This novel Bayesian meta-analysis of individual patient data from 5 randomized trials suggests that inhaled cannabis may provide short-term relief for 1 in 5 to 6 patients with neuropathic pain. Pragmatic trials are needed to evaluate the long-term benefits and risks of this treatment.

Ashrafioun, L., et al. (2015). “Characteristics of substance use disorder treatment patients using medical cannabis for pain.” Addictive Behaviors 42: 185-188.

Background This study was designed to assess the prevalence and correlates of self-reported medical cannabis use for pain in a substance use disorder (SUD) treatment program. Method Participants (n=433) aged 18years and older were recruited from February 2012 to July 2014 at a large residential SUD treatment program. They completed a battery of questionnaires to assess demographics, usual pain level in the past three months (using the 11-point Numeric Rating Scale for pain), depression (using the Beck Depression Inventory), previous types of pain treatments, and lifetime and past-year use of substances (using the Addiction Severity Index). Using both adjusted and unadjusted logistic regression models, we compared those who reported medical cannabis use for pain with those who did not report it. Results Overall, 15% of the sample (n=63) reported using medical cannabis for pain in the past year. After adjusting for age, medical cannabis use for pain was significantly associated with past-year use of alcohol, cocaine, heroin, other opioids, and sedatives, but was not associated with usual pain level or depression. It was also associated with past year treatment of pain using prescription pain relievers without prescriptions. Conclusions These results indicate that medical cannabis use for pain is relatively common and is associated with more extensive substance use among SUD patients. Future work is needed to develop and evaluate strategies to assess and treat individuals who report medical cannabis for pain in SUD treatment settings.

Hefner, K., et al. (2015). “Concomitant cannabis abuse/dependence in patients treated with opioids for non‐cancer pain.” The American Journal on Addictions 24(6): 538-545.

Background and Objectives Cannabis use is common among patients taking prescription opioids, although rates of concomitant cannabis use disorder (CUD) have been largely unexamined. CUD may increase safety risks in those taking opioid pain medications but it is unknown whether cannabis and opioids function as substitutes (cannabis use is associated with less prescription opioid use), or rather as complements (cannabis is associated with increased use of prescription opioids). Methods We examined rates of CUD in a national sample of Veterans Health Administration (VHA) patients (n = 1,316,464) with non‐cancer pain diagnoses receiving opioid medications in fiscal year 2012. Using bivariate analysis to identify potentially confounding variables associated with CUD (eg, psychotropic medication, other substance use disorders) in this population, we then utilized logistic regression to examine rates of cannabis use disorder among individuals receiving different numbers of opioid prescriptions (0, 1–2, 3–10, 11–19, 20+). Results Descriptive analysis, largely confirmed by logistic regression, demonstrated that greater numbers of prescription opioid fills were associated with greater likelihood of CUD. This relationship was reduced somewhat for those receiving the most opioid prescriptions (20+) in the logistic regression, which controlled for potentially confounding variables. Discussion and Conclusions These results warrant increased attention to CUDs among patients receiving numerous opioid prescriptions. Increasing legalization of cannabis is likely to further increase use and abuse of cannabis in patients prescribed opioids. Scientific Significance These findings suggest that clinicians should be alert to concomitant CUD and prescription opioid use, as these substances appear to complement each other. (Am J Addict 2015;24:538–545)