Prescription monitoring, families in the ICU, and more

Summaries from ACP Hospitalist Weekly.

Evidence lacking on efficacy of prescription drug monitoring programs

There isn't enough evidence to determine whether prescription drug monitoring programs (PDMPs) increase or decrease overdoses, a study found.

Photo by Thinkstock
Photo by Thinkstock

To examine whether such programs were associated with changes in nonfatal and fatal overdoses, to identify features of programs associated with those outcomes, and to investigate unintended consequences of the programs, researchers reviewed the published literature for observational studies. Seventeen articles met the inclusion criteria. Articles examined PDMP implementation only (n=8), program features only (n=2), PDMP implementation and program features (n=5), PDMP implementation with mandated clinician review combined with pain clinic laws (n=1), and PDMP robustness (n=1). Results were published online May 8 by Annals of Internal Medicine and appeared in the June 5 issue.

Of the 17 included studies, evidence from three was insufficient to draw conclusions about an association between PDMP implementation and nonfatal overdoses. Another 10 studies linked PDMP implementation to reductions in fatal opioid overdoses. Features associated with reductions included mandatory review of PDMP data by clinicians before writing prescriptions, frequent (at least weekly) updates of PDMP data, clinician authorization to access PDMP data, and monitoring of nonscheduled drugs.

Of the six studies examining the relationship between PDMP enactment and heroin-related overdoses, three found a statistically significant post-implementation increase in these events. The authors noted that heroin substitution may have increased after PDMP-inspired restrictions on opioid prescribing and cautioned that programs aimed at reducing prescription opioids should also address the supply and demand of illicit opioids.

Research is needed to identify a set of best practices and complementary initiatives to address potential consequences of PDMPs, the authors wrote. Programs that have adopted best practices, such as real-time reporting and proactive provision of unsolicited patient reports to clinicians, may reduce “doctor shopping,” as well as the overall supply of prescription opioids on the illicit market, they said.

“A PDMP's ability to influence population health probably arises from its unique set of administrative features,” the authors wrote. “Future studies will have to consider this variation in features to develop a set of empirically based best practices that result in the greatest reduction in prescription opioid-related harm and mitigate any potential unintended consequences of PDMPs, such as heroin-related harms.”

An accompanying editorial noted that PDMPs are not a panacea, but just one program among many initiatives to curb opioid abuse. “The basis for PDMP development was the reasonable idea that stricter monitoring of prescribing would deter overprescribing, diversion, and prescription opioid misuse and result in fewer adverse outcomes, such as overdose,” the editorial stated. “Yet, we should not automatically assume that PDMPs are effective.”

A separate research letter published May 1 by JAMA found a significant increase in synthetic opioid involvement in overdose deaths involving prescription opioids, heroin, and all other illicit or psychotherapeutic drugs from 2010 through 2016.

Among the 42,249 opioid-related overdose deaths in 2016, 19,413 involved synthetic opioids, 17,087 involved prescription opioids, and 15,469 involved heroin. Synthetic opioid involvement in these deaths increased significantly from 14.3% of opioid-related deaths in 2010 to 45.9% in 2016 (P<0.01 for trend).

“Lack of awareness about synthetic opioid potency, variability, availability, and increasing adulteration of the illicit drug supply poses substantial risks to individual and public health,” the research letter stated. “Widespread public health messaging is needed, and clinicians, first responders, and lay persons likely to respond to an overdose should be trained on synthetic opioid risks and equipped with multiple doses of naloxone.”

Also, the CDC announced on April 23 that clinicians should maintain a high index of suspicion for vitamin K-dependent antagonist coagulopathy in patients with a history of using synthetic cannabinoids such as K2, Spice, and AK47. Patients may present with symptoms unrelated to bleeding, such as appendicitis, or be asymptomatic and have numerical coagulopathy.

Since an index case was identified on March 8, 2018, in Illinois, at least 160 people may have been anticoagulated without clinical signs of coagulopathy and presented to health care facilities with serious unexplained bleeding, mostly in Illinois but also in Florida, Indiana, Kentucky, Maryland, Missouri, Pennsylvania, Virginia, and Wisconsin. There have been at least three fatalities. Laboratory investigations confirmed exposure to brodifacoum (a vitamin-K dependent antagonist used in pesticides) in at least 60 patients.

The CDC said that all patients should be asked about history of illicit drug use and that all synthetic cannabinoids users, regardless of presentation, should be screened for vitamin K-dependent antagonist coagulopathy by checking their coagulation profile (e.g., international normalized ratio and prothrombin time).

Family participation in ICU rounds may yield benefit, study finds

Family attendance in ICU rounds may increase their duration but improve communication, according to recent research.

In an observational study, researchers in Canada looked at the association between family participation in ICU rounds and rounding processes. Rounds were conducted by 33 attending physicians at seven hospitals in Canada, and 302 rounds involving 210 patients were observed. Patients' family members were defined as people participating on rounds who had any relation to the patient, including biological, legal, or emotional. Patient data were obtained from a regional database, while observational quantitative and qualitative data were collected via a separately tested form. A checklist assessing the quality of rounds on a 10-point scale, 1 being lowest and 10 being highest, was also completed. The study results were published online May 7 by Critical Care Medicine.

Thirty-eight days of observation were conducted between May 5, 2016, and Aug. 26, 2016. Family members attended 68 rounds (23%), were in the ICU during but did not attend 59 rounds (20%), and were not in the ICU during 175 rounds (58%). Family members who attended rounds were introduced 62% of the time and were given a summary of the discussion 87% of the time. The median duration of rounds was 20 minutes, 16 minutes, and 16 minutes, respectively (P=0.01). Discussion of prognostic information (35% vs. 36% vs. 36%; P=0.99) and bedside teaching (35% vs. 37% vs. 34%; P=0.88) did not differ among groups. No significant association was seen between the scored quality of rounds and family attendance or presence in the ICU (median score, 8 vs. 7 vs. 7, respectively; P=0.11). Qualitative analyses suggested that family attendance on ICU rounds may influence relationship building, information gathering, patient and family education, team dynamics, and shared clinical decision making.

The researchers noted that their study observed care only during rounds and that their results may reflect intrinsic bias and may not be generalizable. However, they concluded that while family attendance during ICU rounds may slightly increase their duration, it may help improve relationship building and promote shared decision making while having little effect on trainee teaching. “Family attendance in rounds enhances communication and is complementary to family conferences,” the researchers wrote. “Methods to identify individual family member preferences for participating in rounds, as well as barriers and facilitators to participation, warrants further study.”

Addiction medicine consult service improved hospital staff perceptions of care

Implementation of an addiction medicine consultation service improved hospital staff members' perceptions of hospital care for patients with substance use disorder (SUD), a recent qualitative study found.

Between February and July 2016, researchers at one hospital in Portland, Ore., interviewed staff after implementation of an Improving Addiction Care Team (IMPACT), which included an interprofessional hospital-based addiction medicine service with rapid-access pathways to postdischarge treatment for SUD. IMPACT involves SUD assessments, management of withdrawal, medications such as methadone and buprenorphine, counseling and behavioral SUD treatment, peer engagement and support, and linkages to community-based addiction care.

Researchers interviewed a total of 34 hospital staff members (including physicians, nurses, social workers, residents, patient advocates, case managers, and pharmacists) who had experience caring for patients with SUD as well as exposure to IMPACT. Results were published online on April 25 by the Journal of Hospital Medicine.

Before IMPACT, staff members reported that hospital care ignored or avoided addressing addiction, and clinicians reported limited expertise and scarce treatment options. One attending said, “I would ask those questions [about SUD] before, but then . . . I had the information, but I couldn't do anything with it.” Failure to address addiction adversely affected patient care and clinician experience, as it led to untreated withdrawal, disruptive behaviors, and patients leaving against medical advice, respondents said.

After implementation of IMPACT, hospital staff reported that having hospital-based systems to address SUD reframed addiction as “a medical condition that actually has a treatment,” not a moral failing. The new system improved patient engagement and humanized care by treating withdrawal and directly communicating about SUD, they said. One attending emphasized the importance of using medications to treat hospitalized patients with addiction, stating that “Starting them on [methadone or buprenorphine-naloxone] and then making the next step in the outpatient world happen has been huge. That transition is so critical . . . that's been probably the biggest impact.”

Despite the success of IMPACT, survey respondents noted several key limitations, including that hospital-based interventions do not address poverty and have limited ability to address socioeconomic factors. They also noted that IMPACT had limited ability to ease the boredom and isolation patients feel during prolonged hospitalization.

The authors also noted limitations of the study, such as its single-center design and the possibility that staff perspectives on care before IMPACT were influenced by the intervention. Despite its limitations, the study has important implications, they said.

“For clinical practice, our findings highlight the importance of treating withdrawal to address challenging patient behaviors and the value of integrating [medications for addiction] into the hospital setting. . . . By implementing SUD improvements, hospitals can support staff and reduce burnout, better engage patients, improve care, and reduce stigma from this devastating disease,” the authors wrote.