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Bowman LA, Berger O, Nesbit S, Stoller KB, Buresh M, Stewart R. Operationalizing the new DEA exception: A novel process for dispensing of methadone for opioid use disorder at discharge from acute care settings. Am J Health Syst Pharm 2024; 81:204-218. [PMID: 38091380 DOI: 10.1093/ajhp/zxad288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024] Open
Abstract
PURPOSE To describe one strategy for dispensing of methadone at emergency department (ED) and hospital discharge implemented within 2 urban academic medical centers. SUMMARY Expanding access to medications for opioid use disorder (OUD) is a national priority. ED visits and hospitalizations offer an opportunity to initiate or continue these lifesaving medications, including methadone and buprenorphine. However, federal regulations governing methadone treatment and significant gaps in treatment availability have made continuing methadone upon ED or hospital discharge challenging. To address this issue, the Drug Enforcement Administration (DEA) granted an exception allowing hospitals, clinics, and EDs to dispense a 72-hour supply of methadone while continued treatment is arranged. Though this exception addresses a critical unmet need, guidance for operationalizing this service is limited. To facilitate expanded patient access to methadone on ED or hospital discharge at 2 Baltimore hospitals, key stakeholders within the parent health system were identified, and a workgroup was formed. Processes were established for requesting, approving, preparing, and dispensing the methadone supply using an electronic health record order set. Multidisciplinary educational materials were created to support end users of the workflow. In the first 3 months of implementation, 42 requests were entered, of which 36 were approved, resulting in 79 dispensed methadone doses. CONCLUSION This project demonstrates feasibility of methadone dispensing at hospital and ED discharge. Further work is needed to evaluate impact on patient outcomes, such as hospital and ED utilization, length of stay, linkage to treatment, and retention in treatment.
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Affiliation(s)
- Lindsay A Bowman
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Olivia Berger
- Department of Pharmacy, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Suzanne Nesbit
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Kenneth B Stoller
- Johns Hopkins Broadway Center for Addiction, Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Megan Buresh
- Bayview Medical Center Addiction Consult Service, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Rosalyn Stewart
- Johns Hopkins Hospital Addiction Consult Service, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
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2
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Abel S, Winans ARM, Jubran N, Nesbit S. Call to action: Clinical pharmacy and addressing the opioid crisis. J Am Coll Clin Pharm 2022. [DOI: 10.1002/jac5.1592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Stephanie Abel
- Office of Opioid Safety University of Kentucky HealthCare Lexington Kentucky USA
| | - Amanda R. M. Winans
- Department of Pharmaceutical Care Services Bassett Healthcare Cooperstown New York USA
| | - Nadia Jubran
- U.S. Department of Veterans Affairs, Veterans Integrated Services Networks (VISN) 5 Academic Detailing Washington District of Columbia USA
| | - Suzanne Nesbit
- Departments of Pharmacy and Oncology Center for Drug Safety and Effectiveness, The Johns Hopkins Hospital Baltimore Maryland USA
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3
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Akid I, Nesbit S, Nanavati J, Bienvenu OJ, Smith TJ. Prevention of Steroid-Induced Neuropsychiatric Complications With Neuroleptic Drugs: A Review. Am J Hosp Palliat Care 2021; 39:472-476. [PMID: 34387114 DOI: 10.1177/10499091211034771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Corticosteroids are used for a multitude of indications in palliative patients. In this narrative review, we aim to review literature on the treatment and prevention of neuropsychiatric complications of steroids. For prevention, only lamotrigine had a positive effect in a small number of studies. For treatment, olanzapine appears to be nearly universally effective at low doses, but randomized trial evidence is lacking. Further randomized clinical trials are necessary to elucidate data-driven guidelines for prevention and treatment of corticosteroid-induced neuropsychiatric symptoms. Until further data are available, it is reasonable to consider low dose olanzapine for any patient taking 40 mg of prednisone or its equivalent, especially those with a history of depression or neuropsychiatric symptoms.
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Affiliation(s)
- Ivy Akid
- Johns Hopkins Palliative Care Program, the Department of Internal Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Suzanne Nesbit
- Johns Hopkins Palliative Care Program, the Department of Internal Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Julie Nanavati
- Johns Hopkins Palliative Care Program, the Department of Internal Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Oscar Joseph Bienvenu
- Johns Hopkins Palliative Care Program, the Department of Internal Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Thomas J Smith
- Johns Hopkins Palliative Care Program, the Department of Internal Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA.,Harry J. Duffey Family Patient and Family Services Program of the Sidney Kimmel Comprehensive Cancer Program, 588543Johns Hopkins Medical Institutions, Baltimore, MD, USA
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4
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Swarm RA, Paice JA, Anghelescu DL, Are M, Bruce JY, Buga S, Chwistek M, Cleeland C, Craig D, Gafford E, Greenlee H, Hansen E, Kamal AH, Kamdar MM, LeGrand S, Mackey S, McDowell MR, Moryl N, Nabell LM, Nesbit S, O'Connor N, Rabow MW, Rickerson E, Shatsky R, Sindt J, Urba SG, Youngwerth JM, Hammond LJ, Gurski LA. Adult Cancer Pain, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2019; 17:977-1007. [PMID: 31390582 DOI: 10.6004/jnccn.2019.0038] [Citation(s) in RCA: 251] [Impact Index Per Article: 50.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In recent years, the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Adult Cancer Pain have undergone substantial revisions focusing on the appropriate and safe prescription of opioid analgesics, optimization of nonopioid analgesics and adjuvant medications, and integration of nonpharmacologic methods of cancer pain management. This selection highlights some of these changes, covering topics on management of adult cancer pain including pharmacologic interventions, nonpharmacologic interventions, and treatment of specific cancer pain syndromes. The complete version of the NCCN Guidelines for Adult Cancer Pain addresses additional aspects of this topic, including pathophysiologic classification of cancer pain syndromes, comprehensive pain assessment, management of pain crisis, ongoing care for cancer pain, pain in cancer survivors, and specialty consultations.
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Affiliation(s)
- Robert A Swarm
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | - Judith A Paice
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | - Doralina L Anghelescu
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | | | | | | | | | | | - Ellin Gafford
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Heather Greenlee
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | | | | | | | - Susan LeGrand
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
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- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | - Nina O'Connor
- Abramson Cancer Center at the University of Pennsylvania
| | | | | | | | - Jill Sindt
- Huntsman Cancer Institute at the University of Utah
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Zschoche JH, Nesbit S, Murtaza U, Sowell A, Waldfogel JM, Arwood N, Rush J, McNamara L, Swarthout M, Nesbit T, Ortmann M. Development and implementation of procedures for outpatient naloxone prescribing at a large academic medical center. Am J Health Syst Pharm 2018; 75:1812-1820. [DOI: 10.2146/ajhp170759] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - Suzanne Nesbit
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
| | - Umbreen Murtaza
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
| | - Amanda Sowell
- Department of Pharmacy, Palmetto Health Richland Hospital, Columbia, SC
| | | | - Nicole Arwood
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
| | - Jordan Rush
- Department of Pharmacy, University of North Carolina Hospitals, Chapel Hill, NC
| | - LeAnn McNamara
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
| | | | - Todd Nesbit
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
| | - Melinda Ortmann
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
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Waldfogel JM, Nesbit S, Cohen SP, Dy SM. Successful Treatment of Opioid-Refractory Cancer Pain with Short-Course, Low-Dose Ketamine. J Pain Palliat Care Pharmacother 2016; 30:294-297. [PMID: 27754734 DOI: 10.1080/15360288.2016.1231732] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Opioids remain the mainstay of treatment for severe cancer pain, but up to 20% of patients have persistent or refractory pain despite rapid and aggressive opioid titration, or develop refractory pain after long-term opioid use. In these scenarios, alternative agents and mechanisms for analgesia should be considered. This case report describes a 28-year-old man with metastatic pancreatic neuroendocrine cancer with severe, intractable pain despite high-dose opioids including methadone and a hydromorphone patient-controlled analgesia (PCA). After treatment with short-course, low-dose ketamine, his opioid requirements decreased by 99% and pain ratings by 50%, with the majority of this decrease occurring in the first 48 hours. As this patient's pain and opioid regimen escalated, he likely experienced some component of central sensitization and hyperalgesia. Administration of ketamine reduced opioid consumption by 99% and potentially "reset" neuronal hyperexcitability and reduced pain signaling, allowing for improved pain control.
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Bao T, Ye X, Skinner J, Cao B, Fisher J, Nesbit S, Grossman SA. The analgesic effect of magnetic acupressure in cancer patients undergoing bone marrow aspiration and biopsy: a randomized, blinded, controlled trial. J Pain Symptom Manage 2011; 41:995-1002. [PMID: 21306863 DOI: 10.1016/j.jpainsymman.2010.08.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Revised: 08/20/2010] [Accepted: 08/26/2010] [Indexed: 11/16/2022]
Abstract
CONTEXT Bone marrow aspiration and biopsy (BMAB) is a frequently performed and painful procedure. OBJECTIVES To evaluate the efficacy of magnetic acupressure in reducing pain in cancer patients undergoing BMAB. METHODS Cancer patients without previous acupuncture or acupressure experience were stratified by the number of prior BMAB and randomized to having magnetic acupressure delivered to either the large intestine 4 (LI4) acupoint or a sham site. The primary study endpoint was the patient's pain intensity rating during the procedure using a visual analogue scale (VAS). RESULTS Seventy-seven eligible patients received magnetic acupressure: 37 were randomized to treatment at the LI4 site arm and 40 at the designated sham site arm. There was no significant difference between the median pain scores of patients treated at the LI4 site and the sham site (P=0.87). However, severe pain (VAS ≥ 7) was reported in only one patient (2.7%) treated at the LI4 site compared with eight patients (20%) at the sham site (P=0.03). No patients experienced significant magnetic acupressure-related toxicities. CONCLUSION Magnetic acupressure at the LI4 acupoint requires minimal training and expense and is well tolerated. Although its use did not significantly reduce median pain scores in patients undergoing BMAB, it does appear to reduce the proportion of patients with severe pain associated with this invasive procedure.
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Affiliation(s)
- Ting Bao
- The University of Maryland Marlene and Stewart Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland 21212, USA.
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Lechtzin N, Busse AM, Smith MT, Grossman S, Nesbit S, Diette GB. A randomized trial of nature scenery and sounds versus urban scenery and sounds to reduce pain in adults undergoing bone marrow aspirate and biopsy. J Altern Complement Med 2011; 16:965-72. [PMID: 20799901 DOI: 10.1089/acm.2009.0531] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Bone marrow aspiration and biopsy (BMAB) is painful when performed with only local anesthetic. Our objective was to determine whether viewing nature scenes and listening to nature sounds can reduce pain during BMAB. DESIGN This was a randomized, controlled clinical trial. Adult patients undergoing outpatient BMAB with only local anesthetic were assigned to use either a nature scene with accompanying nature sounds, city scene with city sounds, or standard care. The primary outcome was a visual analog scale (0-10) of pain. Prespecified secondary analyses included categorizing pain as mild and moderate to severe and using multiple logistic regression to adjust for potential confounding variables. RESULTS One hundred and twenty (120) subjects were enrolled: 44 in the Nature arm, 39 in the City arm, and 37 in the Standard Care arm. The mean pain scores, which were the primary outcome, were not significantly different between the three arms. A higher proportion in the Standard Care arm had moderate-to-severe pain (pain rating ≥4) than in the Nature arm (78.4% versus 60.5%), though this was not statistically significant (p = 0.097). This difference was statistically significant after adjusting for differences in the operators who performed the procedures (odds ratio = 3.71, p = 0.02). CONCLUSIONS We confirmed earlier findings showing that BMAB is poorly tolerated. While mean pain scores were not significantly different between the study arms, secondary analyses suggest that viewing a nature scene while listening to nature sounds is a safe, inexpensive method that may reduce pain during BMAB. This approach should be considered to alleviate pain during invasive procedures.
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Affiliation(s)
- Noah Lechtzin
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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9
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Murinson BB, Nenortas E, Mayer RS, Mezei L, Kozachik S, Nesbit S, Haythornthwaite JA, Campbell JN. A new program in pain medicine for medical students: integrating core curriculum knowledge with emotional and reflective development. Pain Med 2011; 12:186-95. [PMID: 21276187 DOI: 10.1111/j.1526-4637.2010.01050.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Improvements in clinical pain care have not matched advances in scientific knowledge, and innovations in medical education are needed. Several streams of evidence indicate that pain education needs to address both the affective and cognitive dimensions of pain. Our aim was to design and deliver a new course in pain establishing foundation-level knowledge while comprehensively addressing the emotional development needs in this area. SETTING One hundred eighteen first-year medical students at Johns Hopkins School of Medicine. OUTCOME MEASURES Performance was measured by multiple-choice tests of pain knowledge, attendance, reflective pain portfolios, and satisfaction measures. RESULTS Domains of competence in pain knowledge included central and peripheral pain signalling, pharmacological management of pain with standard analgesic medications, neuromodulating agents, and opioids; cancer pain, musculoskeletal pain, nociceptive, inflammatory, neuropathic, geriatric, and pediatric pain. Socio-emotional development (portfolio) work focused on increasing awareness of pain affect in self and others, and on enhancing the commitment to excellence in pain care. Reflections included observations on a brief pain experience (cold pressor test), the multidimensionality of pain, the role of empathy and compassion in medical care, the positive characteristics of pain-care role models, the complex feelings engendered by pain and addiction including frustration and disappointment, and aspirations and commitments in clinical medicine. The students completing feedback expressed high levels of interest in pain medicine as a result of the course. DISCUSSION We conclude that a 4-day pain course incorporating sessions with pain specialists, pain medicine knowledge, and design-built elements to strengthen emotional skills is an effective educational approach. SUMMARY Innovations in medical education about pain are needed. Our aim was to design and deliver a new course for medical students addressing both the affective and cognitive dimensions of pain. Combining small-group sessions with pain specialists, active-learning approaches to pain knowledge, and design-built elements to strengthen emotional skills was highly effective.
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Affiliation(s)
- Beth B Murinson
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland 21287, USA.
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10
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Page RL, Hume AL, Trujillo JM, Leader WG, Vardeny O, Neuhauser MM, Dang D, Nesbit S, Cohen LJ. Interprofessional Education: Principles and Application A Framework for Clinical Pharmacy. Pharmacotherapy 2009. [DOI: 10.1592/phco.29.7.879] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Swarm R, Anghelescu DL, Benedetti C, Boston B, Cleeland C, Coyle N, Deleon-Casasola OA, Eidelman A, Eilers JG, Ferrell B, Grossman SA, Janjan NA, Levy MH, Lynch M, Montana GS, Nesbit S, Oakes L, Obbens EA, Paice J, Syrjala KL, Urba S, Weinstein SM. Adult cancer pain. J Natl Compr Canc Netw 2007; 5:726-751. [PMID: 17927930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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Abstract
Despite the reduced radiation exposure documented with E-speed film use, many clinicians still prefer D-speed radiographic film. The authors tested various storage factors and found that E-speed film is more sensitive to these variables than D-speed film.
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Affiliation(s)
- S Nesbit
- Department of Diagnostic Sciences, University of North Carolina, School of Dentistry, Chapel Hill 27599-7450
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