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Hickey TR, Meeks T, Oxentine H, Park DC, Abelleira A, Edens E, Gordon AJ, Acampora G. Perioperative Management of Extended-Release Buprenorphine: A Narrative Review and Case Series. Subst Abus 2023; 44:96-103. [PMID: 37226900 DOI: 10.1177/08897077231167043] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND Perioperative management of formulations of buprenorphine used for the treatment of opioid use disorder and/or pain are common clinical challenges. Care strategies are increasingly recommending continuation of buprenorphine while administering multimodal analgesia including full agonist opioids. While this "simultaneous strategy" is relatively simple for the shorter-acting sublingual buprenorphine formulation, best practices are needed for the increasingly prescribed extended-release buprenorphine (ER-buprenorphine). To our knowledge there are no prospective data to guide perioperative management of patients on ER-buprenorphine. Herein we provide a narrative review, report on the perioperative experiences of a series of patients maintained on ER-buprenorphine, and propose recommendations for perioperative ER-buprenorphine management based on best evidence, clinical experience, and our judgments. CASES Here we present clinical data describing the perioperative experiences of patients maintained on extended-release buprenorphine who recently underwent a variety of surgeries ranging from outpatient inguinal hernia repair to multiple inpatient surgeries for source control in sepsis, at different medical centers throughout the United States. These patients were identified via an email solicitation to substance use disorder treatment providers throughout a nationwide healthcare system, requesting cases of patients maintained on extended-release buprenorphine who had recently undergone surgery. We report here on all of the cases received. DISCUSSION Extrapolating from these and recently published case reports, we describe an approach to perioperative management of extended-release buprenorphine.
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Affiliation(s)
- Thomas R Hickey
- VA Connecticut Healthcare System, Yale University School of Medicine, West Haven, CT, USA
| | - Thomas Meeks
- VA Portland Health Care System, Oregon Health & Science University, Vancouver, WA, USA
| | - Heather Oxentine
- Substance Abuse Treatment Program, Bay Pines VA Healthcare System, Bay Pines, FL, USA
| | - Dong Chan Park
- Bedford VA Healthcare System, Boston University Medical School, Bedford, MA, USA
| | | | - Ellen Edens
- Yale School of Medicine, Department of Psychiatry, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Adam J Gordon
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA. Sciences Center, VA Salt Lake City Health Care System, Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Informatics, Decision-Enhancement, and Analytics Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Gregory Acampora
- MGH/Harvard Center for Addiction Medicine, Pain Management Center at MGH, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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Dawes SE, Palmer BW, Meeks T, Golshan S, Kasckow J, Mohamed S, Zisook S. Does antidepressant treatment improve cognition in older people with schizophrenia or schizoaffective disorder and comorbid subsyndromal depression? Neuropsychobiology 2012; 65:168-72. [PMID: 22456094 PMCID: PMC3701889 DOI: 10.1159/000331141] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Accepted: 02/03/2012] [Indexed: 01/07/2023]
Abstract
BACKGROUND Subsyndromal symptoms of depression (SSD) in patients with schizophrenia are common and clinically important. While treatment of depression in major depressive disorder may partially ameliorate cognitive deficits, the cognitive effects of antidepressant medications in patients with schizophrenia or schizoaffective disorder and SSD are unknown. METHODS The goal of this study was to assess the impact of SSD and their treatment on cognition in participants with schizophrenia or schizoaffective disorder aged ≥40 years. Participants were randomly assigned to a flexible dose treatment with citalopram or placebo augmentation of their current medication for 12 weeks. An ANCOVA compared improvement in the cognitive composite scores, and a linear model determined the moderation of cognition on treatment effects based on the Hamilton Depression Rating Scale and the Calgary Depression Rating Scale scores between treatment groups. RESULTS There were no differences between the citalopram and placebo groups in changes in cognition. Baseline cognitive status did not moderate antidepressant treatment response. CONCLUSIONS Although there are other cogent reasons why SSD in schizophrenia warrant direct intervention, treatment does not substantially affect the level of cognitive functioning. Given the effects of cognitive deficits associated with schizophrenia on functional disability, there remains an ongoing need to identify effective means of directly ameliorating them.
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Affiliation(s)
- Sharron E. Dawes
- Department of Psychiatry, UC San Diego, Veterans Affairs San Diego Healthcare System, San Diego, Calif., USA
| | - Barton W. Palmer
- Department of Psychiatry, UC San Diego, Veterans Affairs San Diego Healthcare System, San Diego, Calif., USA,San Diego Veterans Medical Research Foundation, Veterans Affairs San Diego Healthcare System, San Diego, Calif., USA
| | - Thomas Meeks
- Department of Psychiatry, UC San Diego, Veterans Affairs San Diego Healthcare System, San Diego, Calif., USA
| | - Shahrokh Golshan
- Department of Psychiatry, UC San Diego, Veterans Affairs San Diego Healthcare System, San Diego, Calif., USA,Department of Psychiatry, Veterans Affairs San Diego Healthcare System, San Diego, Calif., USA
| | - John Kasckow
- VA Pittsburgh Health Care System, Behavioral Health, MIRECC and CHERP, Pittsburgh, Pa., USA,UPMC Western Psychiatric Institute and Clinic, Pittsburgh, Pa., USA
| | - Somaia Mohamed
- Veterans Affairs New England Mental Illness Research, Education and Clinical Center, West Haven, Conn., USA,Department of Psychiatry, Yale School of Medicine, New Haven, Conn., USA
| | - Sidney Zisook
- Department of Psychiatry, UC San Diego, Veterans Affairs San Diego Healthcare System, San Diego, Calif., USA,San Diego Veterans Medical Research Foundation, Veterans Affairs San Diego Healthcare System, San Diego, Calif., USA,Department of Psychiatry, Veterans Affairs San Diego Healthcare System, San Diego, Calif., USA,*Prof. Sidney Zisook, MD, Division of Geriatric Psychiatry, Department of Psychiatry, University of California San Diego, 3350 La Jolla Village Drive, San Diego, CA 92161 (USA), Tel. +1 858 534 4040, E-Mail
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Meeks T, Vahia I, Lavretsky H, Kulkarni G, Jeste D. A tune in "a minor" can "b major": a review of epidemiology, illness course, and public health implications of subthreshold depression in older adults. J Affect Disord 2011; 129:126-42. [PMID: 20926139 PMCID: PMC3036776 DOI: 10.1016/j.jad.2010.09.015] [Citation(s) in RCA: 341] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2010] [Accepted: 09/15/2010] [Indexed: 01/04/2023]
Abstract
BACKGROUND With emphasis on dimensional aspects of psychopathology in development of the upcoming DSM-V, we systematically review data on epidemiology, illness course, risk factors for, and consequences of late-life depressive syndromes not meeting DSM-IV-TR criteria for major depression or dysthymia. We termed these syndromes subthreshold depression, including minor depression and subsyndromal depression. METHODS We searched PubMed (1980-Jan 2010) using the terms: subsyndromal depression, subthreshold depression, and minor depression in combination with elderly, geriatric, older adult, and late-life. Data were extracted from 181 studies of late-life subthreshold depression. RESULTS In older adults subthreshold depression was generally at least 2-3 times more prevalent (median community point prevalence 9.8%) than major depression. Prevalence of subthreshold depression was lower in community settings versus primary care and highest in long-term care settings. Approximately 8-10% of older persons with subthreshold depression developed major depression per year. The course of late-life subthreshold depression was more favorable than that of late-life major depression, but far from benign, with a median remission rate to non-depressed status of only 27% after ≥1 year. Prominent risk factors included female gender, medical burden, disability, and low social support; consequences included increased disability, greater healthcare utilization, and increased suicidal ideation. LIMITATIONS Heterogeneity of the data, especially related to definitions of subthreshold depression limit our ability to conduct meta-analysis. CONCLUSIONS The high prevalence and associated adverse health outcomes of late-life subthreshold depression indicate the major public health significance of this condition and suggest a need for further research on its neurobiology and treatment. Such efforts could potentially lead to prevention of considerable morbidity for the growing number of older adults.
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Affiliation(s)
- Thomas Meeks
- Department of Psychiatry, University of California, San Diego (UCSD),Sam and Rose Stein Institute for Research on Aging, UCSD
| | - Ipsit Vahia
- Department of Psychiatry, University of California, San Diego (UCSD),Sam and Rose Stein Institute for Research on Aging, UCSD
| | - Helen Lavretsky
- Department of Psychiatry, University of California, Los Angeles
| | | | - Dilip Jeste
- Department of Psychiatry, University of California, San Diego (UCSD),Sam and Rose Stein Institute for Research on Aging, UCSD
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Jeste DV, Palmer BW, Golshan S, Eyler LT, Dunn LB, Meeks T, Glorioso D, Fellows I, Kraemer H, Appelbaum PS. Multimedia consent for research in people with schizophrenia and normal subjects: a randomized controlled trial. Schizophr Bull 2009; 35:719-29. [PMID: 18245061 PMCID: PMC2696362 DOI: 10.1093/schbul/sbm148] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Limitations of printed, text-based, consent forms have long been documented and may be particularly problematic for persons at risk for impaired decision-making capacity, such as those with schizophrenia. We conducted a randomized controlled comparison of the effectiveness of a multimedia vs routine consent procedure (augmented with a 10-minute control video presentation) as a means of enhancing comprehension among 128 middle-aged and older persons with schizophrenia and 60 healthy comparison subjects. The primary outcome measure was manifest decisional capacity (understanding, appreciation, reasoning, and expression of choice) for participation in a (hypothetical) clinical drug trial, as measured with the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR) and the University of California San Diego (UCSD) Brief Assessment for Capacity to Consent (UBACC). The MacCAT-CR and UBACC were administered by research assistants kept blind to consent condition. Additional assessments included standardized measures of psychopathology and cognitive functioning. Relative to patients in the routine consent condition, schizophrenia patients receiving multimedia consent had significantly better scores on the UBACC and on the MacCAT-CR understanding and expression of choice subscales and were significantly more likely to be categorized as being capable to consent than those in the routine consent condition (as categorized with several previously established criteria). Among the healthy subjects, there were few significant effects of consent condition. These findings suggest that multimedia consent procedures may be a valuable consent aid that should be considered for use when enrolling participants at risk for impaired decisional capacity, particularly for complex and/or high-risk research protocols.
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Jeste DV, Blazer D, Casey D, Meeks T, Salzman C, Schneider L, Tariot P, Yaffe K. ACNP White Paper: update on use of antipsychotic drugs in elderly persons with dementia. Neuropsychopharmacology 2008; 33:957-70. [PMID: 17637610 PMCID: PMC2553721 DOI: 10.1038/sj.npp.1301492] [Citation(s) in RCA: 218] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
In elderly persons, antipsychotic drugs are clinically prescribed off-label for a number of disorders outside of their Food and Drug Administration (FDA)-approved indications (schizophrenia and bipolar disorder). The largest number of antipsychotic prescriptions in older adults is for behavioral disturbances associated with dementia. In April 2005, the FDA, based on a meta-analysis of 17 double-blind randomized placebo-controlled trials among elderly people with dementia, determined that atypical antipsychotics were associated with a significantly (1.6-1.7 times) greater mortality risk compared with placebo, and asked that drug manufacturers add a 'black box' warning to prescribing information for these drugs. Most deaths were due to either cardiac or infectious causes, the two most common immediate causes of death in dementia in general. Clinicians, patients, and caregivers are left with unclear choices of treatment for dementia patients with psychosis and/or severe agitation. Not only are psychosis and agitation common in persons with dementia but they also frequently cause considerable caregiver distress and hasten institutionalization of patients. At the same time, there is a paucity of evidence-based treatment alternatives to antipsychotics for this population. Thus, there is insufficient evidence to suggest that psychotropics other than antipsychotics represent an overall effective and safe, let alone better, treatment choice for psychosis or agitation in dementia; currently no such treatment has been approved by the FDA for these symptoms. Similarly, the data on the efficacy of specific psychosocial treatments in patients with dementia are limited and inconclusive. The goal of this White Paper is to review relevant issues and make clinical and research recommendations regarding the treatment of elderly dementia patients with psychosis and/or agitation. The role of shared decision making and caution in using pharmacotherapy for these patients is stressed.
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Affiliation(s)
- Dilip V Jeste
- Department of Psychiatry and Neurosciences, University of California, San Diego, CA 92161, USA.
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Jeste DV, Palmer BW, Appelbaum PS, Golshan S, Glorioso D, Dunn LB, Kim K, Meeks T, Kraemer HC. A new brief instrument for assessing decisional capacity for clinical research. ACTA ACUST UNITED AC 2007; 64:966-74. [PMID: 17679641 DOI: 10.1001/archpsyc.64.8.966] [Citation(s) in RCA: 312] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT There is a critical need for practical measures for screening and documenting decisional capacity in people participating in different types of clinical research. However, there are few reliable and validated brief tools that could be used routinely to evaluate individuals' capacity to consent to a research protocol. OBJECTIVE To describe the development, testing, and proposed use of a new practical instrument to assess decision-making capacity: the University of California, San Diego Brief Assessment of Capacity to Consent (UBACC). The UBACC is intended to help investigators identify research participants who warrant more thorough decisional capacity assessment and/or remediation efforts prior to enrollment. DESIGN, SETTING, AND PARTICIPANTS We developed the UBACC as a 10-item scale that included questions focusing on understanding and appreciation of the information concerning a research protocol. It was developed and tested among middle-aged and older outpatients with schizophrenia and healthy comparison subjects participating in research on informed consent. In an investigation of reliability and validity, we studied 127 outpatients with schizophrenia or schizoaffective disorder and 30 healthy comparison subjects who received information about a simulated clinical drug trial. Internal consistency, interrater reliability, and concurrent (criterion) validity (including correlations with an established instrument as well as sensitivity and specificity relative to 2 potential "gold standard" criteria) were measured. MAIN OUTCOME MEASURES Reliability and validity of the UBACC. RESULTS The UBACC was found to have good internal consistency, interrater reliability, concurrent validity, high sensitivity, and acceptable specificity. It typically took less than 5 minutes to administer, was easy to use and reliably score, and could be used to identify subjects with questionable capacity to consent to the specific research project. CONCLUSION The UBACC is a potentially useful instrument for screening large numbers of subjects to identify those needing more comprehensive decisional capacity assessment and/or remediation efforts.
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Affiliation(s)
- Dilip V Jeste
- Department of Psychiatry, University of California, San Diego, Veterans Affairs San Diego Healthcare System, Bldg 13, Fourth Floor, 3350 La Jolla Village Dr, San Diego, CA 92161, USA.
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Meeks T, Nwomeh B, Abdessalam S, Groner J. Paradoxical Missile Embolus to the Right Superficial Femoral Artery following Gunshot Wound to the Liver: A Case Report. ACTA ACUST UNITED AC 2004; 57:1338-40. [PMID: 15625473 DOI: 10.1097/01.ta.0000152311.84257.4d] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Thomas Meeks
- Columbus Children's Hospital, Columbus, Ohio, USA
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Lee RW, Raya TE, Michael U, Foster S, Meeks T, Goldman S. Captopril and ANP: changes in renal hemodynamics, glomerular-ANP receptors and guanylate cyclase activity in rats with heart failure. J Pharmacol Exp Ther 1992; 260:349-54. [PMID: 1346164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023] Open
Abstract
To define the renal effects of atrial natriuretic peptide (ANP) in heart failure, we studied rats with heart failure after coronary artery ligation. The rats received either captopril (2 milligrams drinking water) or placebo for 4 weeks. Glomerular filtration rate, renal plasma flow, filtration fraction, urine volume, urinary sodium excretion and the percent fractional excretion of sodium were measured before and after an infusion of ANP (0.3 microgram/kg/min). To determine whether changes in ANP receptor binding and responsiveness occur in heart failure and after captopril treatment, we performed radioreceptor binding studies and measured guanylate cyclase activity. Atrial natriuretic peptide in sham-operated rats decreased mean arterial pressure from 118 +/- 5 to 95 +/- 5 mm Hg (P less than .001), increased urine volume from 0.06 +/- 0.02 to 0.16 +/- 0.05 ml/min/kg (P less than .05), urinary sodium excretion, 14.2 +/- 3.1 to 41.4 +/- 8.9 mu eq/min/kg (P less than .02), filtration fraction from 0.30 +/- 0.03 to 0.40 +/- 0.4 (P less than .05), and the percent fractional excretion of sodium from 0.84 +/- 0.19 to 2.85 +/- 0.61 (P less than .02). Atrial natriuretic peptide in untreated rats with heart failure produced no significant systemic or renal hemodynamic effects. In rats with heart failure treated with captopril, ANP decreased mean arterial pressure from 93 +/- 4 to 86 +/- 4 mm Hg (P less than .05) and increased hematocrit from 50 +/- 2 to 52 +/- 1 (P less than .001).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- R W Lee
- Department of Internal Medicine, Veterans Administration Medical Center, Tucson 85723
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Abstract
The effect of frequency modulation on acoustic middle ear muscle reflex persistence was studied. Changes in impedance at the tympanic membrane were used as an indirect indication of reflex activity. Signals were a 2-kHz pure tone, a narrow band of noise centered at 2-kHz, and FM signals centered at 2-kHz modulated 70, 140, and 280 times per second.
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