Factors associated with frequent buprenorphine / naloxone initiation in a national survey of Canadian emergency physicians

OBJECTIVE

To identify individual and site-related factors associated with frequent emergency department (ED) buprenorphine/naloxone (BUP) initiation. BUP initiation, an effective opioid use disorder (OUD) intervention, varies widely across Canadian EDs.

METHODS

We surveyed emergency physicians in 6 Canadian provinces from 2018 to 2019 using bilingual paper and web-based questionnaires. Survey domains included BUP-related practice, demographics, attitudes toward BUP, and site characteristics. We defined frequent BUP initiation (the primary outcome) as at least once per month, high OUD prevalence as at least one OUD patient per shift, and high OUD resources as at least 3 out of the following 5 resources: BUP initiation pathways, BUP in ED, peer navigators, accessible addiction specialists, and accessible follow-up clinics. We excluded responses from sites with <50% participation (to minimize non-responder bias) and those missing the primary outcome. We used univariate analysis to identify associations between frequent BUP initiation and factors of interest, stratifying by OUD prevalence.

RESULTS

We excluded 3 responses for missing BUP initiation frequency and 9 for low response rate at one ED. Of the remaining 649 respondents from 34 EDs, 374 (58%) practiced in metropolitan areas, 384 (59%) reported high OUD prevalence, 312 (48%) had high OUD resources, and 161 (25%) initiated BUP frequently. Age, gender, board certification and years in practice were not associated with frequent BUP initiation. Site-specific factors were associated with frequent BUP initiation (high OUD resources [OR 6.91], high OUD prevalence [OR 4.45], and metropolitan location [OR 2.39],) as were individual attitudinal factors (willingness, confidence, and responsibility to initiate BUP.) Similar associations persisted in the high OUD prevalence subgroup.

CONCLUSIONS

Individual attitudinal and site-specific factors were associated with frequent BUP initiation. Training to increase physician confidence and increasing OUD resources could increase BUP initiation and benefit ED patients with OUD.

A cross-sectional survey on buprenorphine-naloxone practice and attitudes in 22 Canadian emergency physician groups: a cross-sectional survey

BACKGROUND

Buprenorphine-naloxone (BUP) initiation in emergency departments improves follow-up and survival among patients with opioid use disorder. We aimed to assess self-reported BUP-related practices and attitudes among emergency physicians.

METHODS

We designed a cross-sectional physician survey by adapting a validated questionnaire on opioid harm reduction practices, attitudes and barriers. We recruited physician leads from 6 Canadian provinces to administer surveys to the staff physicians in their emergency department groups between December 2018 and November 2019. We included academic and community non-locum emergency department staff physicians. We excluded responses from emergency department groups with response rates less than 50% to minimize nonresponse bias. Primary (BUP prescribing practices) and secondary (willingness and attitudes) outcomes were analyzed using descriptive statistics.

RESULTS

After excluding 1 group for low response (9/26 physicians), 652 of 798 (81.7%) physicians responded from 22 groups serving 34 emergency departments. Among respondents, 64.1% (95% confidence interval [CI] 60.4%-67.8%, emergency department group range 7.1%-100.0%) had prescribed BUP at least once in their career, 38.4% had prescribed it for home initiation and 24.8% prescribed it at least once a month. Overall, 68.9% (95% CI 65.3%-72.4%, emergency department group range 24.1%-97.6%) were willing to administer BUP, 64.2% felt it was a major responsibility and 37.1% felt they understood people who use drugs. Respondents most frequently rated lack of adequate training (58.2%) and lack of time (55.2%) as very important barriers to BUP initiation.

INTERPRETATION

Two-thirds of the emergency physicians surveyed prescribed BUP, although only one-quarter did so regularly and one-third prescribed it for home initiation; wide variation between emergency department groups existed. Strategies to increase BUP initiation must address physicians' lack of time and training for BUP initiation and improve their understanding of people who use drugs.

An analysis of knowledge and attitudes of hospice staff towards organ and tissue donation

BACKGROUND

Only a minority of hospice patients eligible to donate tissue and organs choose to do so. Hospice care staff play a key role in discussions about donation, but their willingness to engage in these discussions and their understanding of issues around tissue and organ donation is poorly understood.

AIMS

To (i) identify factors associated with the wish of hospice doctors, nurses and healthcare assistants to donate their own organs after death; (ii) survey the experience of discussing the subject with patients; (iii) determine staff members' knowledge of organ and tissue donation and (iv) identify factors associated with knowledge of organ and tissue donation.

DESIGN

Cross-sectional questionnaire survey of hospice care staff.

SETTING/PARTICIPANTS

76 of the 94 care staff of one large UK hospice completed and returned the questionnaire.

RESULTS

Staff wishing to donate their organs after death (43/76 56.6%) were more likely to be doctors or nurses than healthcare assistants (p=0.011) and more likely to have discussed organ or tissue donation with their family (p<0.001). Staff reporting ever having discussed donation with patients had more years' experience (p=0.045) and had similarly discussed donation with their own family (p=0.039). Those with greater knowledge were more likely to have discussed organ or tissue donation with a patient (p=0.042).

CONCLUSIONS

A reluctance to instigate discussions about organ and tissue donation may prevent palliative patients and their families being allowed the opportunity to donate. Suboptimal knowledge among hospice staff suggests the need for greater liaison between hospice staff, and the organ and tissue donation teams.

Sleep apnoea related hypoxia is associated with cognitive disturbances in patients with tetraplegia

Sleep disordered breathing is common in patients with tetraplegia. Nocturnal arterial hypoxemia and sleep fragmentation due to sleep apnoea may be associated with cognitive dysfunction. We therefore studied the influence of sleep disordered breathing on neuropsychological function in 37 representative tetraplegic patients (mean age 34 +/- 9.7 years). Thirty percent (11 of 37 patients) had clinically significant sleep disordered breathing, defined as apnoea plus hypopnoea index (AHI) greater than 15 per hour of sleep. Most apnoeas were obstructive in type. Seven patients (19%) desaturated to < 80% during the night. Neuropsychological variables were significantly correlated with measures of sleep hypoxia, but not with the AHI and the frequency of sleep arousals. The neuropsychological functions most affected by nocturnal desaturation were: verbal attention and concentration, immediate and short-term memory, cognitive flexibility, internal scanning and working memory. There appeared to be a weak association between the presence of severe sleep hypoxia and visual perception, attention and concentration but no association was found between sleep variables and depression scores. We concluded that sleep disordered breathing is common in patients with tetraplegia and may be accompanied with significant oxygen desaturation. The latter impairs daytime cognitive function in these patients, particularly attention, concentration, memory and learning skills. Cognitive disturbances resulting from sleep apnoea might adversely affect rehabilitation in patients with tetraplegia.

Pirenzepine blunts the pulmonary parenchymal response to inhaled methacholine

To determine the role of M1 muscarinic receptors in the response of the pulmonary parenchyma to inhaled methacholine (MCh), 20 mongrel, out-bred puppies, 8-10 weeks of age were challenged following pretreatment with either saline (control), UH-AH37 (a combined M1 & M3 receptor blocker), or pirenzepine (a relatively selective M1 receptor blocker). In addition, eight fox hound-beagle puppies, born and raised in a clean animal house, were studied. Relatively selective doses of pirenzepine produced a dose-dependent shift to the right of the parenchymal dose-response curves (P = 0.031), with no effect on the airway dose-response curve (P = 0.102). The fox hound-beagle puppies showed less parenchymal response (P <0.0005), but equivalent airway response (P = 0.468), to MCh compared with the mongrel puppies. High doses of pirenzepine (10 000 mu g/kg) and UH-AH37 (3 mg/kg) markedly inhibited both the parenchymal and airway responses to MCh. Data from the present study demonstrate that: (1) while both the airway and pulmonary parenchyma respond to inhaled MCh, the mechanisms by which they respond differ; (2) stimulation of M1 subtype muscarinic receptors are responsible, at least partly, for the parenchymal response; and (3) experimental conditions, such as the breed and housing conditions of animals, may have major influences on the parenchymal response to inhalational challenge tests.

The effect of illness duration on perceptual asymmetry in schizophrenia

Perceptual asymmetry in a group of schizophrenic subjects who were clinically stable and living in the community was compared with a group of normal control subjects matched for age and sex using a dichotic monitoring task of language processing. Schizophrenic subjects showed reduced target detection and slower reaction times for both left and right ear inputs. In relation to performance asymmetry, the schizophrenic subjects had a reduced speed of responding to left ear items compared to normal controls. Within the schizophrenic group differences in performance emerged according to duration of illness. Shorter duration of illness was associated with poorer target detection overall and comparatively greater magnitude of the normal right ear advantage. The latter was accounted for by a relative augmentation of the normal left ear performance decrement. These results were partly reflected in the reaction time measures. The findings suggest that as illness duration increases there may be a tendency for certain aspects of the information processing abnormality in schizophrenia to normalise, in spite of continued deficits as reflected in prolonged reaction times.

Differences in dichotic listening asymmetries in depression according to symptomatology

Subjects suffering from major depressive disorder were compared to normal controls on two verbal dichotic listening tasks. Although there were no significant differences between the groups on a task primarily of language perception, significant differences were obtained on a task with an attentional component. Overall performance was lower for the depressed group and ear asymmetry was reduced. Within the depressed group ear asymmetry varied according to symptomatology; withdrawal-retardation was associated with a lack of asymmetry and anxiety with a normal right ear advantage. The results were interpreted in terms of an interaction between affect and attention, and possible underlying mechanisms of cerebral hemisphere function were discussed.

Focused and divided attention in each half of space with disconnected hemispheres

The effects of spatial location and strategy of attention on the processing of speech messages were investigated in ten right-handed subjects and four persons with complete forebrain commissurotomy and one case of right hemispherectomy. Lists of simultaneous but different words, with one of each pair spoken by a male and the other by a female, were monitored for target words. The lists were presented to the left ear, the right ear and to both ears (central) in separate conditions. Unimanual responses were made to targets in either voice (divided attention) or to only one of the voices (focused attention). The performance of the clinical subjects was generally less efficient than that of the controls. In contrast to intact subjects, they responded to more distractor and unattended items. They also showed a nonsignificant tendency for better processing of right rather than centrally-presented words. With right-sided presentation two clinical subjects, with extracallosal damage to the right cortex, were unable to divide attention and responded to only one of the voices. These results implicate an intact corpus callosum for efficient use of attention strategies as well as hemispheric differences in the control of attention.

The effects of antipsychotic drugs and symptomatology on perceptual asymmetry in schizophrenia

Perceptual asymmetry was measured in acutely psychotic schizophrenic patients and normal controls using a dichotic monitoring task. Although the schizophrenic group differed from the controls in terms of accuracy and speed of response, there were no significant group differences with respect to asymmetries in these variables. The pattern of responding in the schizophrenic group was also examined in relation to differences in symptomatology and antipsychotic drug administration. These variables, in isolation and in interaction with each other, were found to have a number of effects on both asymmetry and overall level of responding. The results were interpreted in the context of an information processing model of functional hemisphere asymmetry in schizophrenia, and the implications regarding the nature of schizophrenic symptomatology and the effects of antipsychotic drugs were discussed.

Antibody response to outer-membrane antigens of Pseudomonas aeruginosa in human burn wound infection

There is little information about the local and systemic antibody response to surface antigens of bacteria growing in situ in infected lesions in man. In this study, Pseudomonas aeruginosa was obtained directly from the infected wounds of two patients with burns and studied without subculture. Outer-membrane proteins (OMPs) were investigated and compared with those of cells cultivated in the laboratory, with the aim of selecting defined growth conditions to give surface antigens more closely resembling those found in vivo. Several high-mol. wt (77,000-101,000) proteins were expressed in the outer membranes of the bacteria from the patients and could be phenotypically induced by cultivating the same isolate in iron-depleted conditions in vitro. Other major OMPs (D, E, F, G and H) were also observed in cells taken from the lesions. Immunoblotting demonstrated that proteins D and E were recognised by different classes of immunoglobulins in the sera of both patients as was flagellar antigen present in the outer-membrane preparation of the P. aeruginosa from patient 1. Iron-regulated membrane proteins (IRMPs) were similarly detected, but more strongly by IgM from patient 1. Furthermore, a marked antibody response to IRMPs was noted at the site of infection. Bands of a similar intensity were seen after absorption of the sera with lipopolysaccharide (LPS) purified from the infecting strain. This indicated that the response observed was directed against OMPs (including IRMPs) and not against contaminating LPS.

Dichotic listening asymmetries and psychotic symptoms in schizophrenia: a preliminary report

Schizophrenic subjects were compared with both psychiatric control and normal control groups on two verbal measures of functional hemispheric asymmetry on a dichotic listening task. One measure of language perception showed little variation in ear differences across groups. However, the task that contained both attentional and language-processing components showed variations in asymmetry according to symptomatology. Subjects with high scores on scales of hallucinations and delusions showed a pattern of ear differences that was not found in those with low scores on these symptom dimensions. The results may reflect cognitive factors in a dysfunctional information-processing system and, in particular, attentional disturbance rather than anomalies in the lateralization of language.

Schizophrenia: an information processing model

There is a wealth of literature associating schizophrenia with disorders of information processing and attention. This paper draws together knowledge from experimental cognitive psychology and examines how both research findings and the clinical manifestations of schizophrenia can be accommodated by an information processing paradigm. An attentional model of schizophrenia is proposed in which disorders in the perception of information are related to dysfunction at the level of preattentive processes. This is seen as one crucial difference between schizophrenia and bipolar disorder, both of which demonstrate failures of sensory gating and filter mechanisms in the acquisition and processing of inputs. Commonalities between the two disorders are thus addressed. Certain psychopathological phenomena in schizophrenia, particularly negative symptoms ('inhibition'), hallucinations and delusions, are seen as compensatory operations of a disordered information processing system. The model has heuristic value and is able to account for, and coherently organise, the variability which continues to confound research in schizophrenia.

Hemispheric specialization and attention: effects of complete and partial callosal section and hemispherectomy on dichotic monitoring

Dichotic word monitoring tasks were given to four cases with complete forebrain comissurotomy, three cases of partial section of the corpus callosum, one case of right hemispherectomy, and control subjects. The task involved a unimanual response to target words in either ear (divided attention, Experiment 1) or to target words in one voice that changed ears unpredictably (focused attention, Experiment 2). Left-ear extinction, defined as chance level (25%) detection of left-ear targets and 75% right-ear target detection, varied both between and within subjects during divided attention. No examples of extinction were obtained with focused attention. These results highlight attentional aspects of dichotic listening. Neither the structural, hemispheric asymmetry model (Cortex 3, 163-178, 1967), nor the cognitive, attention priming model (Attention and Performance V, pp. 87-97, Academic Press, New York) could account for the obtained results. We propose an alternative account in terms of the different processing modes and attentional capabilities of the two cerebral hemispheres.

The use of ECT for mania in childhood bipolar disorder

A case of childhood bipolar disorder, manic type, is presented in which electroconvulsive therapy was used for the acute manic episode. The pharmacological complications which led to this choice of treatment and the computerized tomography finding of ventricular enlargement, are discussed.

Dichotic monitoring as a test of hemispheric dominance in cases of epilepsy

The predictive validity and reliability of a dichotic monitoring test of speech lateralization was assessed in four cases of epilepsy. Speech dominance was subsequently determined by both the intracarotid amylobarbitone test and the results of neurosurgery. On the patients tested, faster reaction times (RT) to target words in one ear was an accurate and consistent indication of contralateral hemispheric dominance. The variability in performance associated with epileptic disorders was reflected in the inconsistent ear differences obtained using target detection rates, however the RT measures yielded stable ear differences.