Saturday, January 26, 2019

Anxiety: What it is, what to do

The crushing toll of the opioid crisis is daily news, including stories about ways to “fix” it. A wide array of initiatives has been brought forward in an attempt to curb this epidemic and the damage it causes. Prescription monitoring programs (PMPs) are one of them. The goal of PMPs is a good one — to identify patients who are being prescribed multiple medications by multiple clinicians. It is a means to introduce some stewardship for preventing overuse and misuse of prescription drugs.
How prescription monitoring programs work

Prescription monitoring programs are state-based electronic databases that provide a way to track prescriptions, specifically controlled substances including opioids, benzodiazepines, and amphetamines. They are intended to support access to legitimate medical use of these drugs, and to help identify and deter drug misuse and diversion (when medications are not used by the person for whom they were prescribed). Currently 49 states, the District of Columbia, and Guam have PMPs, and in many states providers must access the PMP before prescribing a controlled substance.

PMPs have had some success, with several states demonstrating an overall decrease in prescription opioid overdose after implementation. At the same time, there are several challenges hindering effective use of prescription monitoring programs, including issues of lag time, state to state variability, and important privacy concerns. These issues need to be addressed as this tool is used more and more frequently.
Prescription monitoring programs in medical practice

I work in emergency medicine, and the emergency department (ED) is on the front line of this epidemic in many ways. Not only do we treat people who overdose, but many patients who come through our doors are in pain and need our help. But there are some patients who come to the ED with the sole intention of getting a prescription for an opioid pain medicine, either for illicit use or with the intention of selling it. These same individuals may go to multiple EDs, obtaining several prescriptions in a single day. The ED isn’t the only place this sort of thing happens; some patients are prescribed the same opioid medication by two or sometimes even three different doctors.

The PMP should help “weed out” patients with this risky behavior, and allow the prescriber to identify such individuals and ideally get them help. Good intentions aside, there are some unintended and negative consequences of PMPs. The PMP can incorrectly target some patients. And for those people the system may actually do more harm than good, including taking away much needed medications. The results include poorly managed pain, inadequate palliative therapy, and in some cases driving patients to turn to illicitly obtained prescriptions or street drugs like heroin and fentanyl.
Unintended harms of prescription monitoring programs

I like to use a case as an example. I had a young woman who came to my ED one day with thoughts of self-harm. She said that she felt hopeless and lost. She had suffered from a chronic, painful condition for many years. A small daily dose of oxycodone managed her pain and allowed her to live a normal life. Other treatments hadn’t worked for her and she had never misused this drug. When she changed primary care doctors, her new doctor, who had accessed the PMP, stopped the prescription. While the concerns were legitimate, that left the patient in pain and this eventually led her to buying oxycodone from friends, then on the street, and eventually she started using heroin. She was now homeless, addicted, and contemplating suicide. This example is extreme, but illustrative. As we navigate the opioid epidemic, we must attend to appropriate use as well as misuse. Opioids have a place, such as when treating people with cancer pain or those receiving palliative or end-of-life care. The deep concerns among prescribers about misuse and diversion are completely justified, yet we must make sure that the pendulum doesn’t swing too far and cause harm to those patients who need these medications.
Beyond prescription monitoring programs: Prescribing stewardship

The PMP is a valuable tool, and it has helped to identify patients who may need help with substance misuse. However, as with any tool it needs to be used with caution. Not every patient who gets an opioid is misusing it, and there are many for whom opioids mean the difference between suffering and being able to manage pain. There is certainly a lot of room for prescribers to do a better job addressing pain, discussing both drug and nondrug options as well as early referral to pain clinics. Prescribers, policy makers, and the public need to ensure that these medications are available to the people who truly need them, for the short or long term. The opioid epidemic is a crisis, and we need to develop strategies to reduce harm and the loss of life. At the same time, we need to be vigilant that our approach doesn’t cause unintended harm.
What’s your “cheer up” song? That question popped up on a recent text thread among a few of my longtime friends. It spurred a list of songs from the ‘70s and ‘80s, back when we were in high school and college. But did you know that music may actually help boost your health as well as your mood?

Music engages not only your auditory system but many other parts of your brain as well, including areas responsible for movement, language, attention, memory, and emotion. “There is no other stimulus on earth that simultaneously engages our brains as widely as music does,” says Brian Harris, certified neurologic music therapist at Harvard-affiliated Spaulding Rehabilitation Hospital. This global activation happens whether you listen to music, play an instrument, or sing — even informally in the car or the shower, he says.
Make my heart sing

Music can also alter your brain chemistry, and these changes may produce cardiovascular benefits, as evidenced by a number of different studies. For example, studies have found that listening to music may

    enable people to exercise longer during cardiac stress testing done on a treadmill or stationary bike
    improve blood vessel function by relaxing arteries
    help heart rate and blood pressure levels to return to baseline more quickly after physical exertion
    ease anxiety in heart attack survivors
    help people recovering from heart surgery to feel less pain and anxiety.

Notable effects

Like other pleasurable sensations, listening to or creating music triggers the release of dopamine, a brain chemical that makes people feel engaged and motivated. As Harris points out, “An exercise class without music is unimaginable.” Sound processing begins in the brainstem, which also controls the rate of your heartbeat and respiration. This connection could explain why relaxing music may lower heart rate, breathing rate, and blood pressure — and also seems to ease pain, stress, and anxiety.
What music resonates for you?

But preference matters. Research suggests that patient-selected music shows more beneficial effects than music chosen by someone else, which makes sense. According to the American Music Therapy Association, music “provokes responses due to the familiarity, predictability, and feelings of security associated with it.”

In the cardiac stress test study (done at a Texas university), most of the participants were Hispanic, so the researchers chose up-tempo, Latin-inspired music. In the artery relaxation study, which tested both classical and rock music, improvements were greater when classical aficionados listened to classical music than when they listened to rock, and vice versa. Someone who loves opera might find a soaring aria immensely calming. “But quite frankly, if you don’t care for opera, it could have the opposite effect!” says Harris.

There’s no downside to using music either to relax or to invigorate your exercise routine, provided you keep the decibel level in a safe range. You might even consider using your heart health as an excuse to splurge on a new sound system. The availability of home genealogy testing has made exploring genealogy popular and easy to do. This has led to many interesting stories of people meeting long lost relatives, learning that their heritage is not what they thought, and even discovering that they are not genetically related to people they thought were blood relatives.

While much has been written about privacy concerns related to DNA genealogy testing and how that information is shared, it seems there is little attention paid to preparing people for the emotions they may experience in reaction to what they may discover. This preparation includes considering what people’s expectations are for the testing, and how best to handle surprising results (“good” or “bad”).
Genealogy testing and family connections

Discovering “new” family members through DNA genealogy testing can trigger a wide range of emotions, including happiness, anxiety, sadness, or even anger. In fact, the emotional experience may be so intense that many genealogy sites state they are not liable for any “emotional distress” that may result from using the service.

If you are considering consumer  genealogy testing, think carefully about your motivation for your search. What do you hope to learn? What are you curious about? What will you do if you receive unexpected results (for example, your DNA suggests that your roots are not in Ireland as you thought, or that it is unlikely that you are biologically related to your family)? Do you anticipate trying to connect with relatives you never knew you had? What will you do if you can’t make those connections? What will you do if you can? How will these new people fit into your life and the family you’ve always known?

What happens if the results are disappointing?
Don’t go genealogy testing alone

Whatever you hope to learn, ground your search in the life you have. Consider talking with family members about your interest in testing before you take the plunge. Share your goals for exploring your family tree, and invite family members to share their thoughts as well. Provide space for family members to express their worries and fears as well as curiosity. This conversation offers the opportunity to explore family history in a new way. Be prepared for it to also raise information that was previously undisclosed or difficult to talk about.
Prepare for genealogy testing results

It can take weeks to months to process the test and get results, so think about how you will manage the time waiting for the results. You may choose to spend the time gathering data about your family. Continue to reflect on the reasons for your interest in your family history, and plan ahead for how you will view the results. Alone? With family? With friends?

Take time to consider whether or not you want your results to be shared with others on the genealogy site. Think about whether or not you would like to be contacted by strangers with whom you may share some DNA, and whether you would want to reach out to others.

Proactively make a plan to cope with potential strong emotional responses. Plan how much time you will allocate when you log on to the genealogy site. Make sure you have other activities scheduled for your day, and do not ignore other plans you have made to spend additional time on the genealogy site.
Getting (and acting on) the results of genealogy testing

Once you receive your results, you may at first find the amount of data you receive overwhelming. For example, you might receive information about your ethnicity, and hundreds (or thousands) of people with whom you share a significant amount of DNA. Make a point to tend to the emotions you experience. Are you happy? Anxious? Sad? Is this what you expected to find? If it starts to feel like too much to process, take a break from mining the data. Update family and friends on how you are doing, and let them know if you need support.

For some people, the results of genealogy testing prompt them to reach out to strangers with whom they share DNA. This may lead to a new and positive connection. This may also lead to a connection that is disappointing. And perhaps it may be hardest to cope with no response. Some people you attempt to contact on the site will not write back to you. Consider how many times you will reach out to someone who does not respond.
Moving forward after genealogy testing

DNA genealogy testing can yield information about your heritage that you never knew and never even thought about. This can be exciting and can broaden your thinking. It can also be disconcerting to learn about discrepancies between what you thought you knew about your family and what the results from the testing provided. And for some people, it may not bring the insight and direction they had hoped for, or may raise issues around family relationships that are hard to handle.

In the end, the results of genealogy testing do not change who you are as a person. But it may provide interesting information about your family tree and result in a powerful emotional experience. Be prepared with a plan and a support system.  Recently the FDA approved a medication called lofexidine (Lucemyra) for the treatment of opioid withdrawal. Lofexidine is in a class of medications called alpha-2-adrenergic agonists, which act on the nervous system and can cause sedation, mild pain relief, and relaxation. This class of medications has been used to treat common medical conditions like high blood pressure or anxiety. They have also been used for decades to ameliorate the symptoms of opioid withdrawal. The more commonly used medication in this group is called clonidine and has been a staple for medically supervised withdrawal. Lofexidine is very similar to clonidine, with one exception: clonidine can cause low blood pressure, which can be a limiting side effect, whereas lofexidine has less of an impact on blood pressure.

How does lofexidine compare to other medications used for withdrawal?

So lofexidine is slightly safer, but does it work? Well, that depends on what you compare it to. Compared to no medication or a placebo, both lofexidine and clonidine are more effective at relieving withdrawal symptoms. However, being better than no treatment is not exactly a winning endorsement. The real question is whether lofexidine is better than standard of care treatment with medications like buprenorphine or methadone. Buprenorphine and methadone are both opioid agonists, meaning they exert activity at the same receptor that all opioids do. This makes them effective at resolving withdrawal symptoms, and also at relieving cravings and reducing the likelihood of relapse and overdose if used in an ongoing way.

When compared to tapering doses of methadone used for medically supervised withdrawal, peak withdrawal severity was worse with lofexidine, meaning people treated with lofexidine instead of methadone were more likely to have severe withdrawal, and reported higher peak scores for withdrawal symptoms. However, overall the withdrawal symptoms resolved sooner with lofexidine compared to methadone, and treatment was shorter.

Can this medication help reduce overdose deaths or help people stay in treatment?

The rub here is that medically supervised withdrawal with methadone or buprenorphine is also not standard of care. A majority of people will relapse after medically supervised withdrawal (often referred to as “detox”). In contrast, being treated long-term with either methadone or buprenorphine as a maintenance medication treatment reduces the risk of relapse and overdose death by more than 50% while increasing the likelihood of staying engaged in treatment.

For example, one seminal paper published in the Lancet randomly assigned a small group of individuals with opioid use disorder to either medically supervised withdrawal followed by a year of intensive psychosocial treatment, or a year of buprenorphine with psychosocial treatment. In the group assigned to medically supervised withdrawal, no one stayed in treatment and 20% were dead at the end of the year. In contrast, in the group assigned to buprenorphine, 75% were abstinent and no one died. These are dramatic differences calling into question any practice of medically supervised withdrawal as an effective intervention for opioid use disorder.

Lofexidine may be an option before starting extended-release naltrexone

One group of patients who do require medically supervised withdrawal are those who want to start extended-release naltrexone, a third FDA-approved medication for the treatment of opioid use disorder. Unlike methadone and buprenorphine, naltrexone does not activate the opioid receptor, but rather blocks it to prevent the effects of other opioids. People have to be opioid-free for seven to 10 days prior to starting naltrexone, which leads to fewer people being able to successfully start treatment. This is one of the main reasons that extended-release naltrexone is less effective than buprenorphine treatment. However, for patients who choose extended-release naltrexone, effective non-opioid options for withdrawal management are important, and this may be where lofexidine is particularly helpful.

So what’s the bottom line? The most effective treatments we have for opioid use disorder treatment are long-term medication maintenance with methadone or buprenorphine, and for select patients extended-release naltrexone. For patients choosing medically supervised withdrawal, methadone and buprenorphine are still the most effective, but lofexidine may be an important option for patients undergoing withdrawal with the intent of starting extended-release naltrexone.

No comments:

Leave a comment