Journal of the Academy of Consultation-Liaison Psychiatry最新文献

Background: Buprenorphine is an effective treatment for opioid use disorder but may be difficult to initate among hospitalized patients due to concerns about acute pain and withdrawal risks.

Objective: We sought to evaluate the safety and effectiveness of a novel approach for initiating buprenorphine treatment that did not require patients to first discontinue full-agonist opioids or experience an acute opioid withdrawal syndrome. This approach, referred to as low-dose initiation with opioid continuation (LDI), involved applying a transdermal patch which delivered microgram-level doses of buprenorphine for 24 h or longer, allowing for a gradual cross-titration of patients from full-agonist opioids to sublingual buprenorphine during their hospital stay.

Methods: Individuals who attempted LDI between April 2021 and July 2022 at a large urban academic hospital and an affiliated community hospital were included in the analysis. A LDI was deemed successful for patients receiving nontransdermal buprenorphine at the date of their discharge. Precipitated opioid withdrawal was defined as a relative score increase from pretreatment baseline of 5 or more on the Clinical Opiate Withdrawal Scale assessment, as long as the score exceeded 8 and occurred within 48 h of the patient receiving buprenorphine as part of the LDI. Descriptive statistics were performed comparing the characteristics of persons who did complete the LDI protocol to those who did not, and those who did experience precipitated opioid withdrawal to those who did not.

Results: A total of 67 patients were assessed. 79.1% completed the LDI successfully. Precipitated withdrawal occurred in 16.4% of patients. Morphine-milligram equivalents of opioids administered pre-LDI did not predict LDI completion. Surprisingly, persons who experienced precipitated withdrawal were more likely to complete LDI. Persons who completed the LDI were more likely to attend an outpatient or bridge clinic follow-up visit within 30 days of discharge.

Conclusions: LDI with transdermal buprenorphine was found to be generally safe and well-tolerated in these hospitalized patients. Compared to other published studies of LDI, rates of successful initiation of buprenorphine were largely equivalent. Further research is needed on predictors of unsuccessful and successful LDI.

Introduction: Delirium is a common disorder in patients with serious illness with prevalence ranging between 9% and 57% at the time of initial palliative care (PC) consultation. If detected early, morbidity and mortality from delirium can be reduced significantly. This study aims to evaluate the performance of the Months of the Year Backwards (MOTYB) test as a promising screening tool for delirium in the acute PC setting.

Methods: This multi-site cross-sectional study included patients who received PC consultation at our institutions over 6 months. Recruiting PC professionals determined delirium status, including definite and possible diagnosis, using DSM-5-TR criteria. We assessed the ease of administration and predictive performance of the MOTYB test by comparing logistic regression models on sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the receiving operating characteristic (ROC) curve (AUC).

Results: In total, 147 patients (59.2% women, 58.5% African American, mean age 65.9 years) WERE INCLUDED: 34 patients (23%) were designated with having delirium by DSM-5-TR criteria. Not reaching January or reaching January in over 90 seconds provided the highest sensitivity (93.8%) and NPV (95.7%).

Discussion: Different models of the MOTYB test demonstrated high prediction of delirium on initial PC consultation, with consistently high sensitivity, NPV, and AUC of the ROC. These findings support its utility as an effective screening tool for delirium in this context. The MOTYB test can be seamlessly integrated into the initial biopsychosocial and spiritual assessment in PC, significantly enhancing providers' ability to address the complex challenge of delirium in serious illness.