Addiction Medicine and Behavioral Health Issues in Primary Care with Adina Elise Bowe, MD
[Music] Welcome to Health Matters, where we explore key topics from a primary care perspective. I’m your host, Dr. Shay Spencer. Here at Vendelia Health, we are passionate about bridging the gap between primary care and specialty medicine, ensuring that complex medical topics are accessible and understandable for healthcare providers and patients alike. In each episode, we’ll dive deep into the latest advancements, best practices, and critical insights to help improve patient care. Thank you for joining me on this journey toward better health. Today, I’m pleased to announce that we have Dr. Adena Bo joining us. Dr. Dr. Bo went to medical school at the University of West Indies, Kingston, Jamaica. She completed meds residency at WVU Charleston Division and later went on to complete addiction medicine fellowship at Yale University School of Medicine. Dr. Bose’s special interests reside in treating medically complex duly diagnosed individuals with addiction disorders in rural communities. She’s an advocate for the integrated care model of health delivery. Dr. Bo is an active member of the American Academy of Addiction Psychiatry, the American Medical Association, and the American Psychiatric Association as she is passionate about integrated care and substance use disorders treatment. She has co-led workshops at the AA AAP and APA that are geared towards training psychiatrists in how to engage family physicians and internists in addiction treatment. Dr. Bo is an ASAM and PCSS Matt trainer for medical facilities in rural West Virginia. Dr. Bo, thank you so much for being here today. Um, your background is extremely impressive and I think our listeners are really going to benefit from um, the perspective you bring, especially when it comes to uh, treating patients with substance use disorder and mental health and uh, medically complex patients. Thank you. I’m really happy to be here. These are such important conversations and I’m excited to be a part of it. You know, as a family medicine resident, I can’t count how many times I’ve seen patients whose uh mental health and substance use disorders are either overlooked or just kind of siloed from the rest of their care. Um, so I’m really looking forward to talking about what integrated care actually looks like and how we as primary care providers uh can show up for these patients uh more effectively. Absolutely. This disconnect between mental and physical health is something we see all the time. Integrated care is not just a buzzword. is truly necessary if we want to get better outcomes especially for our vulnerable populations. You know, I know a lot of our listen listeners whether they’re trainees or practicing clinicians or just interested in the health systems probably run into some of these challenges. So, um let’s get into it. I’ve got a case here that I really think will get us into the heart of the discussion. Um our first patient is Mr. Marcus. Um he is a 22-year-old male um brought to the emergency department by his older sister. She’s concerned that over the past two weeks he’s become increasingly withdrawn. Um he’s actually been stopping going to class and rarely sleeps. Over the weekend he’s been um claiming that uh drones were following him and that his professors were part of a conspiracy to fail him. Um he’s visibly anxious. He avoids eye contact and occasionally mumbles to himself during the visit. He has no documented psychiatric history, no known substance use, and no medical coorbidities. He’s not on any medications. His sisters uh they’re also present and um they say there is a a family history of mental uh illness, but they’re not really sure uh what that entails. Uh his blood pressure is 130 over 72, heart rate’s 84. Um, the rest of his vitals look okay. On exam, he’s guarded but cooperative. He denies any suicidal or homicidal ideiation, but does say, “I know they’re watching me. I don’t want to talk about that here.” You know, Dr. Bo, when you first hear about Marcus’s story, what’s kind of running through your mind? What’s running through my mind? I’m thinking about this young man who comes to us with his sister. First of all, I’m so happy that he has engaged family members who seem to know about him and care about his health, but he’s bought in with very concerning symptoms that’s suggestive of psychosis, as if he’s having a mental or emotional breakdown. So, I’m wondering what’s going on here? How long has it been happening? Um, how strong is that family history and how we can help him? He said he was pretty scared and didn’t want to talk. So, I’m thinking, well, how can I engage him? How can I make him feel safe? Dr. Dr. Bo, what are some big um red flags that or key details that really just jump out to you? Well, some of them are first of all his age. We know when it comes to psychotic disorders, especially in men, they tend to present in that age group between 18 and 35. So, I’m wondering h is he now starting to present with the first episode of psychosis. Other things that jump out to me is that there’s his family history of some vague disorder. We’re not sure. We kind of have to get into that. But also, look at the dysfunction in his life. He’s had to stop school. he can’t do his classes. He’s withdrawn. He’s he’s locked into himself. So, I’m kind of wondering what’s going on here. And those are big signs and flags that things are not right and things have changed. That’s so good. Um, two weeks of these changes, how does that timeline shape uh the way you’re thinking about this? So, when I think about two weeks, I’m thinking, hm, is this something is more acute? Did something happen in his life? Did he have like a traumatic event? Did he go through a breakup? Um, and I’m also thinking, well, two weeks kind of gives us some information if he has some mood disorders along with it, like depression. You have to have symptoms for a long enough time to have a psychiatric diagnosis. So, I’m kind of thinking, is this a mood disorder or is it more of a primary sarcotic disorder or even is he just starting to use substances? Did he dabble at some party? Did something happen? Uh I think the question Vignette said that he’s uh withdrawn uh not sleeping and now paranoid. So uh you mentioned uh mood issues and a primary psychotic process. How do you kind of sort through those things? So when I look at those things I first of all try to get a timeline and baseline information on what his personality was like before. Um family members are important here. You just get that information. Then I think about symptoms. So when I know when I’m looking at a primary mood disorder such as depression with psychosis, I’m looking at like maybe two weeks of severe depressive symptoms and then you start to have some psychosis over time. If I’m thinking about a first episode psychotic disorder, those symptoms can develop pretty rapidly. So you’re in the emergency department. Um what are some things that you want to hear about in terms of like labs or tests um that are must haves before you could really uh call this psychiatric? Okay. So, it’s very important when we meet uh patients for the first time, they figure out is this a medical condition or is this a psychiatric condition? And so, we go ahead and look at things we call the basic metabolic profile. Um we look at the urine drug screen. We go ahead and look at their kidney function. Um we would do um other labs in terms of if there’s indications like ammonia, if there’s a change. Um we look for infections because sometimes something called delirium where you can be very confused, acute infections can cause that. So there’s a v a v variety of tests and also of course if he’s hearing voices seeing things a CT scan brain you mentioned substances and and things like talk screen what substances would we be suspicious for in someone presenting like Mr. mark us. So big in our population, things that would make me think about psychosis and paranoia are our stimulants. So that’s like methamphetamine, cocaine, but also our um our medications like THC because we have delta 8, delta 9, and delta 10. And depending on what’s in them, they can cause psychosis over time or even in the acute setting. Also was coming up in a lot of our um college age kids are like LSD and mushrooms. Depending on how you do them, that can cause psychosis. Also, I would look at him and see, are you a bodybuilder? Are you someone who’s recently been on steroids and now stop? Because sometimes using steroids and stopping can also cause psychosis or even high doses of steroids. So, it’s a variety of things. He mentioned um the drones and and conspiracy ideas. How do you kind of tease apart u true psychosis versus just odd or stronghold beliefs? That’s a very good question. So when we think about people who are maybe odd or eccentric, we think about a pervasive um pattern. All their life they’re this way. Um they wouldn’t have a presentation that two weeks there’s a change. They would say, “No, I believe in UFOs. I’ve been seeing them all my life.” They don’t really disrupt their thinking or their functioning. It’s just that they have odd beliefs. Whereas something has a psychiatric condition, you can see the abrupt change in behavior or thoughts. Uh the clinical vignette mentions that he’s um mumbling to himself. Uh can you kind of just walk us through your approach uh to kind of probe out whether uh these are hallucinations or not? Okay. So first of all when anyone is mumbling to themsself I kind of ask them. I’m say hey you seem to be having a conversation is there anyone around? I mean can I see that person not see that person? I’m also careful to ask is it okay if I ask you about the mumbling? Because sometimes when people are hearing voices that they’re engaged in, the voices actually say, “Don’t talk to anyone else.” So pretty much I kind of ask the patient, “You’re talking? Are you talking to anyone?” And just go by what they say. Thanks for kind of walking us through that. Um do you have any other like advice on like um how to really tease out insight um whenever you’re talking to a patient um just to uh try to avoid shutting them down more? Yeah. A lot of times patients feel very embarrassed by their symptoms particularly if they’re aware of them. So sometimes I like to normalize it. I say you know there are many people who hear voices or see things that are not there. Um have you ever encountered that? Do you have friends or family members like that? Um then I also say it doesn’t make you crazy because a lot of people need to hear that in order to go ahead because we don’t like to call our patients with psychotic disorders crazy, right? They’re having problems with reality and problems with cognition. And then I kind of asked him more questions about it. I’d be like, “hm, is it a male voice or is it a female voice? Is it in your head or outside your head?” And sometimes they ask me, “What do you mean by if it’s outside my head?” And I tell them, “H take your hands and cover up your ears and tell me if you can still hear those voices.” Okay? It’s just to get and I just get them kind of get them comfortable talking about it. Just remove the shame of it. So, we talked about um whether this is medical versus psychiatric. We talked about like the workup in terms of the BMP. um maybe a a talk screen if it’s necessary and then of course if there’s any neurological symptoms like talking about getting the the uh scan um can you kind of just walk us through like your differential in terms of like um uh if this were psychiatric what you would think about? Yeah, so for sure. So when I think about someone who comes to me the first time um kind of withdrawn, mumbling to themsself, being paranoid or psychotic, I think about a brief psychotic disorder versus a schizophrenia form disorder versus a schizophffective disorder or versus substance use mood disorder or even schizophrenia. And a lot of times the diagnosis is longitudinal. I usually tell my residents there’s no way you can absolutely know what’s going on with a patient the first time you meet them. to just kind of sit and have a broad list in your mind. Um, so people who I think more about brief psychotic disorder, they can happen at any age, right? Um, you have an event like maybe you lost your job, you found out something difficult and then you have a a snap and where you lose touch with reality. Those have a pretty good prognosis. Whereas someone maybe with schizophrenia form, they had these symptoms going on for maybe about one to six months, not quite reaching six months, but you hear voices, you see things, you’re withdrawn. Once you hit the six-month mark, we say you probably have schizophrenia or schizopeffective disorder. That’s uh so it’s kind of like timeline driven is what I’m hearing. Very much. Um what does um disposition look like for this patient? When would you think about like admission versus like a close um uh outpatient psychiatric or followup? Going to re-record that. So what does um disposition look like for this patient um versus admission versus like close followup? So disposition definitely depends on presentation as well as insight as well as severity of symptoms. So, if I have someone who comes to me and they’re hearing voices, they’re kind of withdrawn. They’re paranoid, but there’s nothing telling them to kill themselves. There’s no command hallucinations telling them to go burn down a house, go cut someone, go hurt someone, and if they’re able to not obey commands they’re given, I can offer them an outpatient um treatment plan. However, someone has lost touch with reality, can’t tell what’s real is not real. Um the voices are degrading, they feel guilty, they feel ashamed, they’re scared. I offer them inpatient admission and depending on what the patient wants, I we decide to start medicine then or not. If they’re in their right mind, they can make that decision themselves. If they want to start a med, we do it. If they don’t, we don’t. We just say follow up as an outpatient. But if they’re not um quite in their right mind or have capacity like how we the medical term, we have their surrogate decision maker make the decision for them. You mentioned medication. whenever you’re um looking for medication, can you kind of just walk us through how you decide which agent you’re going to use? Oh yeah. So usually when it comes to medications for all psychiatric disorders, it depends on what’s available, what’s covered, what patients preference and also their coorbidities. So for example, this person comes in, he has he’s hearing voices, seeing things, we call it psychosis, we want to give an antisycchotic. Well, we have a whole list and it all depends on the preparation whether you can swallow it, get an injection or get a long acting injection or whether um you have kidney issues or you have liver issues. So, for example, if you had kidney problems, I would stay away from we call the don’ts like respir. If you have liver issues, I stay away from quotopine. Um we stay away from so pretty much it’s based on availability, patients preference, side effect profile um and and pat and family’s response. also if they have another family member who’s on their medication responded well. So, uh that was just a beautiful way to to really walk us through um your thought process in terms of uh choosing agents. Um, what are some early psychosocial supporter going to re-record that? That was a beautiful way just kind of walking us through the pharmarmacology about um which agents you’re going to pick depending on whether there’s liver impairment versus kidney impairment. Really appreciate that. Uh when we’re thinking about psychosocial support, um what are you noticing that’s making the biggest difference for your patients? Okay. So when I think of in terms of psychosocial support, I think about family support. I think about education in um level. I think about home environment, social environment. I think about um extended family support. Um social circles such as is there a community around you can be engaged with? Do you have a um religious affiliation? Are there certain religious groups you’re um involved with? So those types of things. So what we find is very important with patients who might be experiencing psychosis. Is there family support? Family should know what’s going on, know what to anticipate, know how to get help, but also connectivity. Are they able to get their appointments? Do they have transportation? Um, do they have the financial means to to keep up with the help and to manage the help? Then what about that wider community around? Are there groups they can interact with to increase their social skills? Do they have the spiritual support that that they need or or may not need? Are there any pair groups around? When thinking about patients, uh, Dr. Bo with the first episode of psychosis. What’s one thing that you want listeners to take away um from Mr. Marcus’ story? I want them to know that they’re not alone. Many people experience it and help is there. Help is incredibly effective. And I just want to give a shout out for um this are a community mental health um program. They have this awesome program for first episode psychosis especially for young people. They would evaluate you. They try to get resources to your home. um they integrate social skills and they try to get you into an education programs. So there’s so much help and they also work along with us because we have patients who who we see both in our department CMC but if they have extensive needs we often refer to for that wraparound service as well. What amazing service. I I didn’t know that that existed. Thank you kind of for sharing that. Um it’s definitely something that um I think is beneficial for the community. [Music] Bandelia Healthc is proud to be an academic medical center, which means we’re training and preparing future doctors, nurses, and other health professionals to deliver the highest quality care through innovative research, advanced learning experiences, and more than 20 residency and fellowship programs. Medical professionals are elevating their academic journey at CAMC to bring you the best care. [Music] [Music] Stay connected with Vanelia Health for all the latest updates by liking us on Facebook and following us on Instagram and X. [Music] Um, so while Mr. Marcus showed us what a first episode of psychosis might look like, uh, Mike’s story is one that reflects really another crisis we’re facing today, uh, the opiate epidemic. Mhm. Um let’s take a closer look at his case. So Mike L, he’s a 34 year old male. Um he’s presented to uh your clinic for routine followup. He has a history of anxiety and chronic low back pain uh because of a workplace injury around 5 years ago. He was prescribed oxycodone at that time and he’s been intermittently using opioids since. Over the past year, Mike’s Mike has lost his job. He’s experienced some uh relationship strain with his partner and has become evicted from his apartment. He admits to using heroin and fentanyl a few times a week, mostly by snorting, but he does admit that recently he started injecting occasionally. He expressed ambivalence. Um I want to stop, but I’m not sure I can. He reports anxiety, fatigue, poor sleep, and daily cravings. He does say that he’s had one uh episode of overdose in the past 6 months. Um thankfully it was reversed with Nlloxxone administered by a friend. Currently not in treatment and is a little bit distrustful of rehab programs. He’s heard of Suboxone and he’s kind of curious about it. Um at this moment he’s denied any suicidal ideations. He’s alert. He’s cooperative and it appears that he’s appropriately dressed. Vitals are stable. Uh urine drug screen is positive for opioids. Um fentinil and bzzoazipines. Liver enzymes are mildly elevated. Um HIV and hepatitis C are pending. You know, Dr. Bo, uh can we just kind of talk about Mike? You know, he’s 34. He’s dealing with some both some anxiety and chronic pain. Um and he says he’s been using heroin and fentinyl pretty regularly. Um, where do you even begin when patients are, you know, kind of in that in between space of wanting help but not fully ready to commit? Well, first of all, um, I my approach to him would be just to encourage him and to thank him for even coming in and talking to us about it. It is awesome when a patient discloses how much they’re struggling with a substance because there’s so much shame um, surrounding that and so much helplessness. And so, usually with my patients, I just let them know I’m going to partner with them in it. I’m not here to force them to do anything. I just want to know where they’re at and what they would like for me to do. I and I would say most of my patients when I first see them, they have a lot of ambivalence. Um they’re they’re on the substance, hard to get away from it, not quite sure if they’re ready. And so I just meet them right there. I’m say, “Hey, you say you might want to stop, but what’s making you thinking about stop? What’s what’s getting you there? Why do you want Why is that important to you?” Because I always feel it’s important to partner with your patient. They figure out what’s important to them and what’s motivating them to get um to stop. and from there we can build. So I’m I’m hearing um some some good um education just about like forming a partnership and things like that. He mentioned he’s uh curious about Suboxone for people who don’t know what actually what actually is Suboxone and um how does it help someone like Mike? So um Suboxone is actually um a trade name for a medication. It’s called buprenorphine nlloxxone and it is awesome. It is one of the medications we use for people with opioid use disorder. And what I like about it is that it’s easy to use. Um, you can give week supply at a time for people who are first starting out. It brings down cravings. It brings it takes out withdrawal and man, it really helps get patients their life back. So medications um are super important, but so also is the support, right? The therapist support around them. Um we have a whole team here at CMC who really try to get around the patient, get them initiated on Suboxone both in the inpatient and outpatient unit. Um Suboxone we say is a partial agonist which means it works in the same area of the brain as heroin and fentinyl but it acts a little different. So it doesn’t get you high, not at all. But what it does do is bring you to a point where you can think rationally. You can um not crave the substance and this makes basically get you back to functioning. You know, I think it’s important to call out that Mike isn’t new to opiates. Um, he started on oxycodone after an injury. Um, how often do you see stories like this? You know, people starting out with prescribed medication and um, then he’s ending up here. I would say um, probably 80% of my my patients who are over um, 30 or 40 have been started off in prescription opioid medications. Um, in the younger age group, I don’t see it as much. they they actually start off on maybe street buprenorphine or a fental heroin, but it’s devastating because so many people were exposed to opioids um and appropriately so, but had difficulty getting off of it, right? So, you you really feel for patients who come to you with this problem knowing that, hey, as clinicians, we kind of we kind of got you there. One thing that really stood out to me was the overdose. You know, he said he survived because a friend had nlloxxone. Um, do you think we’re doing enough to make sure Nolloxxone is available and that people know how to use it? I think we have definitely doing more than we did in the past, but we can always improve. So, in different um parts, every pharmacy has nlloxxone that’s available for patients. You can get it a lot manyarmacies even without a prescription. But I always feel that every patient and every family member, if you have someone in your home who you know is using substances or prescribed prescription medicine, man, you should have that Narcan kit there. Naran is so easy to administer. You just need to get it and if you suspect an overdose, you just go ahead and put it in their nose. Um if you’re in a hospital system, we have a different way of getting it. But we definitely need a lot more um nlloxxone education for sure and availability. We talked about earlier um you mentioned Suboxone, how it’s a wonder drug. Um uh he’s also complaining of some emotional symptoms like anxiety, maybe some poor sleep and daily cravings. How much of that uh would you consider it being withdrawal versus how much of this could be like a mental health picture? Uh that’s a very good question. We know that maybe 40 to 60 70% of patients with opio use disorder also have comora psychiatric illness and that could be depression or anxiety, schizophrenia, bipolar disease. So, I would say it’s hard to tell right away. Um, almost everyone who’s in withdrawal from opioids will experience depression and anxiety. So, we kind of wait. We kind of wait till they get through that and then we keep evaluating them and then about four to six weeks later we do a re-evaluation of those symptoms. If they’re still there, we call it a primary mood disorder or primary psychotic disorder and we treat because if you don’t treat that, it’s not likely they will do as well in recovery. Dr. Bo, that’s a a beautiful piece. Um, last thing, I promise. Last thing. What would a realistic, compassionate um care plan uh look like for someone like Mike? Okay, you know, not a perfect one, but one that actually meets him where he is. So, we always say when it comes to patients in recovery, we have to use an individualized plan for them. Not every patient will respond the same way. So, a compassion approach would first of all to be the ask him, what do you want? What do you think is necessary? How can we be helpful? We would include medications. We will include therapy. We will include family therapy, family support. We will include vocational training if needed. Also case management, which means um if you’re suffering from housing insecurity or food insecurity, connect you through the right sources. For some people when they’re in in their um use, they have strong family support, they’re rich, they don’t need as much help. Other people, they’re financially devastated. And a good plan would be to encompass all of that. And of course, you have to adhere to their medical issues because there are many medical complications from substance use disorders as well as their psychiatric issues. You have to use the integrated care model managing patients with substance use disorders and all those with mental illness. What a beautiful piece. Dr. Bo, uh you walked us really through a challenging case. Um you’d mentioned earlier, you know, substance use disorders are such a critical part of psychiatry, um really family medicine as well. Um, this case I feel like it really highlights both the struggles and opportunities for us as uh, physicians uh, for intervention. If you don’t mind, we’ll just shift gears really to um, our last case. Um, this kind of explores really a different area of of mental health in general. Um, we have Miss Carter. Um, she’s an 82-year-old um, retired school teacher. Uh, she’s actually in the hospital setting. She’s diagnosed with community acquired pneumonia. Um really her past medical history, she’s got a little bit of hypertension, type 2 diabetes, some osteoarthritis, and um some mild cognitive impairment that’s listed. She lives alone, but she does have supportive care with her um her daughter who checks in daily. Um she’s actually on hospital day three, and the nursing staff notes that Miss Carter has become a little bit more confused and agitated. Um, the nurse says she actually tried to get out of bed this morning without assistance. Um, she also did that pretty much throughout the entire night. She’s been pulling at her IV lines during her morning rounds. Um, she’s disoriented to time and place. Um, intermittently moaning and really just trying to remove her oxygen. Um, I think maybe the nurse had reported earlier that uh, she accused her of stealing her purse. Um, vitals were stable. Labs show mild hypenetreia at 130 and her blood uh glucose was 65 overnight. Chest X-ray shows improvement actually. Um she’s a febral. Uh current medications include sephopramyin. She’s on a little bit of slides scale insulin and oxycodone PRN for pain. Uh I think um the overnight um resident might have given her some um dyen hydromeine last night for a little bit of itching. Um you know Dr. boat, you have a story like this. Um it’s an older patient who’s um seems like is experiencing a little bit of a sudden change in mentation. Um what’s the first thing that comes to your mind? Um a couple things come to mind. I guess one of the first things is just first of all normalizing it for the family and for the nurse. This looks like your your mom your your patient is going through delirium. Um and delirium is sort of like when you have a sudden change in your mental status and it’s because you’re sick. It’s because you’re getting different medications, your body is not well, you’re in a different environment. Um, but it can be frightening to see. It can be sometimes unsafe for staff to experience, but the patient needs a lot of reassurance and help. Dr. Bo, that’s um, you mentioned delirium. Um, she also has like a history of mild cognitive impairment. How do you kind of differentiate those two when you’re um, seeing that in a patient’s history? Okay, so the differentiation sometimes can be kind of complex because you can have both occurring at the same time, but usually it goes by family report. If and or patient report if the family tells you, man, they were fine at their baseline and then this with that shift with that inattentiveness with that disorientation is more likely delirium. Um, and what makes delirium more likely to happen for some patients are older age is a history of baseline um mild cognitive impairment. So it’s at times though it can be tricky because you can have chronic delirium where this process has been going on for one to three months and not just one or two days. You know for Miss U Carter what are some things that kind of pushes you to um going to re-record that Jason don’t put this in for Miss Carter um what were some big triggers that you think kind of pushed her into the state? So some of the big triggers that pushed her in likely the new onet of pneumonia that can cause it. Also she has a little bit of a low sodium. Her sodium is 130. Um usually we see big changes more at 125 but if she fell from like 137 to 130 that can definitely cause it. Also she’s on PRN as needed pain medications and when our patients are sick even their home dose of oxycodone can kind of build up in the system in terms of metabolites and make them not function as well. She also was noted to have a slightly low sugar. Her her glucose was 65. And for our older patients, we like to keep it above 80. All right. Um, she’s in a new environment. She’s not at home. Um, and as you know, in the hospital, you never sleep, right? Because the nurses come in and check on you every hour. So, there’s all kinds of things that can cause it. We also know she’s on a medicine benil, the dy hydromeine, the anticolinergic medicine, can make our patients very confused. good for sleep when you’re younger, not so good for the elderly person or the older person. What a great job. You really kind of um just summed summed up uh Miss Carter. We hear about an infectious cause, maybe the pneumonia, some metabolic in terms of her hyponetriia and hypoglycemia and then you talked about medications too like dyenhydramine and um um the the PR and oxycodone. Um in regards to like medications, what are some like big red flags you’d mentioned? anticolinergics. What are things that you’re seeing in the hospital in terms of like a myth list that kind of jump out to you? So things that really stand out to us are people we call on multiple CNS depressant medications and that just means things that can affect the way you think and the way you reason. So those medications can be things like bzzoizipines um barbituates I mean many people are on this medicine called neurontin for like peripheral neuropathy. We also see it in the anticolinergics. We can even see it in our medicines like the highdosese triccyclic anti-depressants. We see it a lot inside our pain medications um in particular narcotics as well as in muscle relaxants. There is so many medications we give our patients that can really really affect their cognition especially when they’re sick. So that’s actually something I’m going to take into practice whenever I’m prescribing medications. Thinking about um uh the patient’s age, thinking about things like the beers criteria. Um just stepping back really we know delirium happens pretty frequently in the hospital. Uh sometimes it’s missed. Um what are some things that we can do as physicians um to catch it early or even prevent it from happening in the first place? So in order to catch it early, we always like to say kind of risk stratify your patient. Who are our patients are more likely going to have problems with cognition? And then we and we kind of keep an eye on them. So the people who are more likely to have issues are maybe people who are very ill or ICU patients, people who are older age, people who are on multiple medications, people who are experiencing liver failure, um renal failure, heart failure. We look for people who’ve had strokes and seizures. Those type of people are more likely to have delirium. Um also for sure are persons who have seizure disorders or people who have mild cognitive changes, already have dementia, they’re more likely to develop delirium. Of course, people who are going to be exposed to anesthetic agents or changes in their pain medications are more likely to experience delirium. There are lots of things we can do to help prevent it or at least minimize it. And CMC nursing staff is fantastic at implementing those such as minimizing IV lines. Open those shades when it’s um when it’s light outside. Um if you can get them in a good sleepwake cycle, orient your patients every day, minimize catheterss, you know, bring blankets in from home. Have some music going in the room. encourage family support at the bed, avoid sedating medications, avoid anticolinergics. So, that’s one of the things um I really noticed here. The staff is awesome about implementing that. Thanks for sharing that. Um Dr. Bo, these are things that you you hear about. We call them delirium precautions. Um but you kind of just walked us through those um some non-farmacological things that we can do. Um when is it ever uh right to u jump to medications? Okay. So when we think about delirium, we put it in three different categories. We say you have hypoactive, it means you’re just kind of low in there. People think you’re depressed, but you’re actually delirious. Then you have mix where you can fluctuate between being excitable, kind of picking at the air, violent, and then going into the sleep. Then you have um hyperactive delirium where you’re just pulling at lines, you’re hitting people, you’re cussing, you’re having a really difficult time. So people who are disruptive to nursing staff and harmful to themselves in terms of pulling out lines, they probably benefit from medications because what those medications do is just help them sleep, help them rest. There’s actually no FDA approved medication for delirium. And what’s important to know is that when you start the medications, they take about 3 to 5 days to work. They’re not going to work right away. So patients who are hyperactive, who are maybe suicidal or hurting staff or pulling at lines, they’re good candidates for medications. And of course that’s done with shared decision-m with their family. When you’re reaching in your medication back, what medicines are you reaching for? Definitely Roserum. That’s number one because it sets your sleepwake cycle. And people who we want to prevent delirium or already delirious, we give them that unless you have formulate liver failure. Then when we think about treating delirium, our three main categories are the antiscychotics, the bzzoizipines, and the mood stabilizers. And when we say mood stabilizers, we in our hospital system, we’re thinking about depicote because you can give that um by IV or through oral route. Um in terms of antisycchotics, there’s a blackbox warning. So you have to talk to all family members. Hey, this can increase the risk of cardiovascular event after a year or so. Um we talk about our respols. And then when it’s indicated for people who have delirium because of drug reactions or drug withdrawal, we think about our benzoazipines. I guess big picture um would you say the mainstay of delirium treatment is more about treating the underlying cause and supporting the patient rather than just relying on medication itself? Absolutely. Because we know the delirious patient is responding to their internal environment responding to the medical issues that’s going on. So the first treatment is actually treat the underlying medical causes understanding that it’s going to take a while. Dr. Bo, I think this was extremely helpful. Um, I think this case with Miss Carter, um, really just a good reminder, kind of like you said earlier, delirium is common. It’s not normal, but if we can catch it early, um, we can often reverse it. Um, I think you highlighted some really important things in terms of treating the underlying cause. Um, you talked about the non-farmacological, um, strategies that we have here at CAMC and, um, still know that medications can still have a role in certain instances. Um really you’ve walked us through uh three challenging cases. Um we may come across from first episodes of psychosis to substance use disorder to delirium in older patients. I know our listeners are going to take a lot away from this discussion and hopefully feel a little bit more comfortable um when they come to these situations in their own practice. So thank you again for your time and insight and uh thank you for just coming here and being with us today. Um, thank you guys for tuning in to another episode of Health Matters. Thank you for inviting me. Health Matters Today is a podcast recorded at Vanelia Health Charleston Area Medical Center Studios in Charleston, West Virginia. Hosted by Dr. Shayen Spencer, directed by Dr. Amy Bruce, produced by Christopher Cobb and Jason Lyens.
Welcome to the ninth episode of the CAMC Institute for Academic Medicine’s Health Matters Podcast! In this episode, our host Sheylan Spencer, DO, will discuss bridging the gap between primary care and addiction medicine in behavioral health.
Adina Elise Bowe, MD, went to medical school at the University of the West Indies, Kingston, Jamaica. She completed the Vandalia Health CAMC Internal Medicine and Psychiatry Residency and later went on to complete an addiction medicine fellowship at the Yale University School of Medicine. Dr. Bowe’s special interests reside in treating medically complex, dually diagnosed individuals with addiction disorders in rural communities. She is an advocate for the integrated care model of health delivery. Dr. Bowe is an active member of the American Academy of Addiction Psychiatry, the American Medical Association and the American Psychiatric Association, as she is passionate about integrated care and substance use disorders treatment. She has co-led workshops at the AAAP and APA that are geared toward training psychiatrists in how to engage family physicians and internists in addiction treatment, and she is a Providers Clinical Support System and Medication-Assisted Treatment trainer for medical facilities in rural West Virginia.
Disclosure and Mitigation: The CAMC Institute for Academic Medicine controls the content and production of this CE activity and attempt to ensure the presentation of balanced, objective information. In accordance with the Standards for Integrity and Independence in Accredited Continuing Education established by the ACCME, faculty, abstract reviewers, paper presenters/authors, planning committee members, staff and any others involved in planning the educational content must disclose any relationship they or their co-authors have with ineligible companies which may be related to their content. The ACCME defines “relevant financial relationships” as financial relationships in any amount occurring within the past 24 months that create a conflict of interest. All presenters, planning committee and faculty have declared no financial interest with an ineligible company for this educational activity.
Accreditation: In support of improving patient care, this activity has been planned and implemented by the CAMC Institute for Academic Medicine. The CAMC Institute for Academic Medicine is accredited by the American Nurses Credentialing Center, the Accreditation Council for Pharmacy Education and the Accreditation Council for Continuing Medical Education to provide continuing education for the health care team.
Physicians – The CAMC Institute for Academic Medicine designates this enduring material activity for a maximum of .5 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
For CME credit, click here: https://ce.camcinstitute.org/camc/classes.cfm?func=viewclass&classid=20114&dateid=89225.