Treating Opioid Use Disorder in the Hospital: A Trauma Informed Approach (Strickland, 11/17/2021)

Many thanks to Dr. Tiffani Strickland, who gave an action packed Grand Rounds this week on Treating Opioid Use Disorder in the Hospital. She covered a ton of ground on this important topic-- from opioid use trends to adverse child experiences to trauma informed care to  micro-dosing of buprenorphine in the hospital.

To see a full recording of Dr. Strickland's excellent presentation click HERE.

My notes:

• Overdose deaths from opioids are off the charts and continue to increase in the US and in our own Sonoma County (see graphs below, including local data)
• If you only have 5 minutes, watch this video about our current understanding of addiction and social isolation: "Everything you know about addiction is wrong". It challenges our traditional framework for addiction and substance use disorder.
• Also consider reading this book: Chasing the Scream (by Johann Hari)
• 

SoCo DPH opioid overdose rates (Death and ED visits)

Racism and the opioid epidemic

• Despite similar rates of drug use, Black Americans (who make up 13% of the population) make up 27% of drug arrests (2018)
• Disparities in incarceration have affected generations of communities of color
• African American and Hispanic Americans are 7.5 and 2.3 times more likely to have an incarcerated parent (than white children)
• having an incarcerated parent puts children at increased risk for future substance use

Adverse Childhood Events (ACES)

We know that ACES (childhood abuse, neglect and household dysfunction)are associated with risk for substance use disorder. I.e. the more ACES you have, the higher risk you have to have issues with substances, including IVDU.

Trauma Informed Care

• It is our job to care for patients with a hx of trauma by influencing healthy coping mechanisms and helping patients build resiliency
• The Substance Abuse and Mental Health Service Administration (SAMSHA) decribes 6 principles of a trauma-informed approach. These are SO important to consider in how to engage with all patients, but particularly those with high ACE scores
1. Safety
2. Trustworthiness and transparency
3. Peer support
4. Collaboration and mutuality
5. Empowerment, voice and control
6. Cultural, historical and gender issues

• Again, providers should consider how to help patients focus on RESILIENCE and COPING
• Examples of how to do this include
• Openly discussing harm reduction methods (prevent dying and suffering)
• Person first language, welcoming, non-discriminatory, non stigmatizing language
• i.e. person with substance use disorder, person in recovery
• i.e. avoid "clean" and "dirty" when talking about drug screen results
• Put up signage offering treatment for opioid use disorder in hospitals and clinics

Words Matter! Check out these tables to make sure that you are using language that is non-stigmatizing.

https://www.drugabuse.gov/sites/default/files/nidamed_wordsmatter3_508.pdf 

Treatment of acute pain and management of withdrawal 

• If a patient is on BUP, don't STOP it when treating acute pain
• patients can safely get acute pain meds on top of their BUP
• you will only precipitate withdrawal at initiation of BUP
• split dosing to BID for pain management in the acute setting
• provide sense of calm and comfort (help patient feel safe and connected)
• Also, schedule tylenol and/or ibuprofen (or toradol) in setting of acute pain
• consider gabapentinoids, SSRI, TCA, regional block
• can increase up to 32 mg/day for acute pain
• add opioids with higher Mu affinity: morphine, hydromorphone, fentanyl

Buprenorphine (BUP) inductions in the hospital (simplified from CA Bridge: https://cabridge.org/tools/resources).

• Very simple! For uncomplicated withdrawal (COWS>8), start with 8mg BUP SL, recheck in 1 hour, give second dose of 8mg
• Subsequent days, titrate from 16mg with additional 4-8mg prn cravings
• Labs to consider (but don't need results to start): UDOA, CBC, HIV, HCV, RPR, HCG, HAV and HBV immunity
• Adjunctive medications: acetaminophen (pain, headache), clonidine (w/d symptoms), diphenhydramine (anxiety), loperamide (diarrhea), ondansetron (n/v), trazodone, melatonin (sleep)

Microdose inductions of BUP

• Very slow start of BUP to decrease or even eliminate withdrawal symptoms 
• Consider: if patient taking methadone, history difficulty BUP start, transitioning from prescription opioids, intentionally taking fentanyl daily
• Avoid: if already significant withdrawal (it's too slow), don't want to continue full opiate agonist, risk for respiratory depression/sedation, prefer rapid start

Harm reduction refers to a set of policies, programs and practices that aim to reduce health, social and economic consequences of drug and alcohol use. 

• Reduce stigma by being a safe place, regardless of ongoing substance use
• Offer clean needles (available at Face to Face, DAAC, but also on PHP formulary (see image below)
• Always give Narcan Rx
• Give Fentanyl test strips (available at Face to Face)
• Resource support
• If patient leaving AMA, give direct phone # to outpatient MAT care:
• Marla Pfohl MAT program manager SRCH 707-890-0375
• Erick Hill, Matt Clinic supervisor SRCH 707-867-8690
• Never Use Alone phone # 800-484-3731
• Connect to outpatient MAT, give bridge Rx to outpatient MAT (x-license no longer required)

Gender Affirming Healthcare: Beyond Pronouns and Hormones (Kohli, 11/10/2021)

 Many thanks to local expert, Dr. Arunima Kohli, for her excellent Grand Rounds this week on Gender Affirming Care: Beyond Pronouns and Hormones. 

A recording of her presentation can be found HERE.

My notes:

Transgender Awareness Week, observed November 13th to November 19th, is a one-week celebration leading up to the Transgender Day of Remembrance (TDoR), which memorializes victims of transphobic violence. In Santa Rosa, TDoR will be honored during an event at Brew Coffee House Saturday 11/20/21 5pm. More information click HERE.  All are welcome.

Of note, in talking about gender affirming care it is important to acknowledge who we are and what our biases are.

No lecture on gender affirming care is complete without going over terminology and definitely not a presentation without the Gender Unicorn. Take a look at the unicorn and try to identify where you would place yourself. 

• gender is a construct AND a spectrum
• gender identity is different than gender expression, physical and emotional attraction are also separate (sexual orientation)

In addition to the gender unicorn, Dr. Kohli likes to think of gender as a multi-dimensional ball-- everybody is kind of fluid-- we are all constantly figuring out our identity, especially when we are younger. This is not isolated to people who identify as trans.  

Language keeps evolving in this field. Very quickly.

• gender diversity and gender expansiveness: umbrella terms that capture the full spectrum (including gender binary people)
• transgender: person whose gender does not correspond to sex assigned at birth based on traditional expectations
• cisgender: person whose gender does correspond to sex assigned at birth
• non-binary (enby): person whose gender does not fit into typical binary norms, based on traditional expectations
• intersex: people with unique variations in reproductive/sexual anatomy, may or may not need to talk about hormones, pronouns, etc

Terms to avoid: transgendered, transgenderism, trans-sexual, biologically/genetically/born as, gender reconstruction surgery. Instead use assignation, designation, and socialization. 

What is gender affirming care? "Health care that holistically attends to transgenders people physical, mental and social needs and well being while respectfully affirming their gender identity."

• social: pronouns, clothing, gender expression, community support
• legal: name change, sex designation, gender marker or legal documents
• medical: gender affirming HRT, surgery, laser tx, voice therapy, pelvic floor therapy
• mental: medication management, mental health service

Professional Guidelines for gender affirming care

• World Professional Association Transgender Healthcare Standards of Care (v7, 2013, v8 may be coming soon)
• UCSF Guidelines for Primary and Gender Affirming Care of Transgender and Gender non-binary People (good for hormone doses, lab monitoring, etc)
• Endocrine Society: Endocrine Treatment of Gender Dysphoric/Gender Incongruent People: Clinical Practice Guidelines (2017)

Health disparities in the gender expansive population are marked

• 1/2 of trans people had to teach their healthcare provider about trans care
• 20% of people don't access health care for fear of mistreatment
• 62% (or more) of gender expansive people suffer depression
• High rates smoking and alcohol
• Higher rates of HIV infection, particularly in black trans women population

Data specific to teens (CDC data)

• Nearly 2% of high schoolers identify as transgender (number increasing)
• 27% of trans-identified high schoolers feel unsafe at school
• 35% of trans-identified high schoolers report being bullied at school
• 35% of trans teenagers attempt suicide
• Higher rates of early sex, multiple partners, having sex without contraception or STD prevention

cdc mmwr 2017

It is INCREDIBLY effective to have supportive parents for trans kids. Check out this graphic to understand why! Markedly improved rates of depression, suicide attempts. . .

https://transstudent.org/graphics/youthsupport/

Gender affirming care is life saving care

• Well documented improved mental health in adults and children with gender affirming care (including psychotherapy, gender affirming surgery, hormones, even proper use of pronouns)
• decreased depression, anxiety, SI
• Decreased rates of suicide attempts by 40% if there is ANY gender affirming person in a trans person's life
• increased engagement with health care system
• improved school performance, improved social skills

. . .But affirmation isn't everything. 

Discrimination

• 65% of trans-people experience discrimination (DMV, nursing homes, gym/health club)
• 59% of trans people avoid using public restroom because of fear of discrimination, 1/3 limit food and drink so they can avoid bathrooms
• 3x higher unemployment rate, worse in BIPOC
• 2/3 of states coverage cover gender affirming hormone therapy
• Few states have Medicaid protections for transgender people
• Being undocumented is additional risk factor; high rates of anti-trans violence in Latin America, have 
• Higher rates of incarceration, higher rates of assaults in prisons, many denied medically necessary gender affirming healthcare while incarcerated

Safety is a real issue

• Sexual assault, sexual violence
• 2021 

https://transrespect.org/en/tmm-update-tdor-2021/

What do we do as health care providers?

• Advocate for change in health systems
• EMR
• Ask EVERY one who comes into your system SOGI (sexual orientation, gender identity), not just those who you assume are different
• organ inventories (so you don't assume gender tells you screening needs)
• formulary
• education and trainings for staff
• hiring people who are transgender
• Do the work before you signal you are safe!
• Learn the language and vocabulary
• Learn insurance rules: sometimes insurance will initially decline but they are not allowed
• Think beyond your own panel
• specialists, other providers--> improve access 
• In CA, all medically necessary care MUST be covered for transition (this includes everything in WPATH of what is medical necessity and what procedures, e.g. laser, body contouring)
• Know your State and National Laws, Legal rights about restroom, Sports participation, etc
• Know local referral providers (e.g. surgeons for gender affirming surgeries)
• Advocacy with schools and workplaces

Additional resources

WPATH Global Education Institute

Transline

Fenway Institute

U Michigan OB/Gyn modules

Trans Student Educational Resources (TSER)
William's Institute UCLA

What Every Health Provider Needs to Know about Drowning (Hoffman, 11/3/2021)

 Thank you to Dr. Ben Hoffman who gave a profoundly moving talk on Drowning Prevention in Children. What an honor to host the national expert on accident prevention!

A recording of the excellent presentation is HERE. 

I consider this presentation a MUST for all of us that care for children. This is PRACTICE CHANGING.

Here are our notes:

Drowning is the leading cause of unintentional injuries in children 1-18 from data collected between 2009-2018-- that’s over 9,000 children. 

• Imagine 9 school buses of children-- 72 kiddos in each bus-- that die every year from drowning.
• Drowning is the single leading cause of death in children ages 1-4, and the 2^nd leading cause in children 15-19.
• We must remember the BIPOC community who suffer disproportionately from incidents of drowning.
• we can trace this reality back to systemic racism and lack of access to pools, swimming lessons, etc.

 PREVENTION: the AAP has created both a toolkit https://www.aap.org/drowning and a policy (attached) to help providers educate family’s on drowning prevention. The toolkit has both general information and patient handouts and posters for your office.

https://www.aap.org/drowning

The bottom line: LAYERS OF PROTECTION to prevent drownings, and we should focus particularly on new parents of children <4, teens, BIPOC families, and children with disabilities and epilepsy.

                *infants: never leave unsupervised – even a second- in water.

                *toddlers: their curiosity is dangerous. Never leave a toddler unsupervised around any water. They can get into tubs, toilets, wading pools. Lock or empty these when not in use.

                *swimming lessons: no evidence that they protect infants, but there IS evidence that they work for children 1-4 yrs old and shows a significant reduction in drownings.

                *water competence: we should teach our families that learning to swim is a life skill. Many BIPOC parents were never taught to swim so consider the water dangerous.

                *erect barriers: particularly pools – 70% of pool drownings are when it’s not “swim time”. Pool fences that have 4 sides with a locking gate reduce drownings by 50%.

                *supervision: constant, close and capable supervision-at arm’s length if a child can’t swim competently. Don’t rely on lifeguards – children still drown in their presence.

*life jackets: only coast guard approved life jackets are appropriate (and a must when our families visit the Russian River or the Sonoma Coast). Never rely on anything inflatable. The coast guard approved life jackets are more expensive than the inflatables.

*advocacy: some cities have life jacket loaner programs. Dr Hoffman will be glad to speak to anyone who is interested in starting a program locally (for example Spring Lake loans them with boat rentals).

 A great big thank you for years of ethics support in the hospital AND for a great Grand Rounds on How to Mitigate Moral Distress among Providers by our very own Sutter Senior Bioethicist, Dr.Shilpa Shashidhara. 

A recording of her presentation is available HERE. Please watch it if you can!

And here are my notes:

What is moral distress? 

Moral Distress was first defined by Dr. Andrew Jameton (1984) as a natural response to violation of one's core values. In healthcare, it is a feeling of uncomfortableness that arise when providers are unable to do the thing they believe is the "right" thing to do. It is an inability to act within our individual and/or professional values. 

These are ethically challenging situations, where providers feel powerless. 

Moral Distress can lead to disengagement and burnout, can have negative impact on patient care. Prevalent in high stress environments (e.g. ICU: critically ill patients, family members in distress, etc). Has been magnified by the pandemic: challenging clinical situations, managing really ill patients, not having PPE, concerns about allocating resources in stressed healthcare system

• "I don't know if this is the right thing to do"
• "I feel stuck"
• "Both options are equally bad"
• "I feel like I am causing harm to someone"

If not addressed, moral distress takes toll on personal and professional well-being

3 areas that cause moral distress

• clinical situations (e.g. non-beneficial treatments that family is requesting, sense false hope with discordant prognosis by different providers, unrepresented patients that cannot make decisions for self and we don't know their values and acceptable quality of life)
• internal constraints (e.g. fear of speaking up, self doubt, anxiety, wish to not cause conflict, lack of confidence, feeling "stuck" in the middle)
• external constraints (e.g. power imbalance: RN vs. MD, resident vs. attending; fear of legal action,  poor communication)

Moral distress is a root cause of burnout. 

• 42% physicians experience burnout (long hours, overwhelming workload, lack of support)
• 54% of nurses experience moderate burnout with emotional exhaustion,28% high burnout
• significant role of burnout in organizational turnover

How do we mitigate moral distress to best support providers to reduce burnout?

Identify the problem--> Express a concern

Use debriefing sessions, specifically interdisciplinary debriefing sessions

• mitigate negative effects
• normalize and validate experience of negative emotions
• supports providers
• uncovers gaps
• promotes team cohesion
• opportunity to explore systemic problems

Debriefing sessions: goal is NOT just venting session, but also action planning. Both together are more effective

Part 1: Preparatory: identify needs of healthcare provider, gather relevant information, set goals, plan logistics

Part 2: Implemental: 8 step method

4 As to Rise Above Moral Distress (Developed by the American Academy of Critical Care Nurses)

Can be done as individual or ina group

What else can we do?

Targeted education training for providers, promoting provider ethical decision-making. What is appropriate in a complex situation?

Communication skills and practice

Don't forget to take concerns to hospital/clinic administration to be sure they understand what is happening and look at systems-based solutions