Purpose Strategies for deploying clinical pharmacists to increase access to buprenorphine in inpatient, outpatient and transitional care, and community practice settings are described. Summary Access to medications for opioid use disorder (MOUD) is essential, but patients face many barriers when pursuing treatment and MOUD. The coronavirus disease 2019 (COVID-19) pandemic has compounded the opioid crisis and worsened outcomes by introducing new barriers to MOUD access. Many strategies to ensure continued access to MOUD have been described, but the role of leveraging pharmacists during the opioid/COVID-19 syndemic to improve medication access and outcomes remains underappreciated. Pharmacists, while both qualified and capable of liberalizing access to all forms of MOUD, may have the strongest impact by increasing access to buprenorphine. Herein we present progressive strategies to maintain and extend buprenorphine access for patients with OUD through deployment of clinical pharmacists, particularly in the context of the COVID-19 pandemic, during which access may be further restricted. Conclusion Leveraging pharmacists to extend access to MOUD, particularly buprenorphine, remains an underutilized strategy that should be implemented, particularly during the concurrent COVID-19 global pandemic.
IntroductionSuicidality and self-injurious behavior afflict patients with a wide variety of psychiatric illnesses. Currently, there are few pharmacologic treatments for suicidality and self-injurious behavior and none that treat these conditions emergently. Recently, ketamine has demonstrated efficacy in treating both depression and acute suicidal ideation. An increasing usage of ketamine, of a variety of formulations, has been studied for these indications. This article reviews the evidence for use of ketamine in self-injurious behavior and suicidality.MethodsA review of the MEDLINE database for articles relating to ketamine, self-injurious behavior, suicidality, and self-harm was conducted. Additional articles were assessed via cross-reference.ResultsA total of 24 articles that included clinical trials, meta-analyses, case series, and case reports were analyzed. The majority of studies of ketamine for suicidal ideation include the intravenous route using a dose of 0.5 mg/kg over 40 minutes. These studies suggest that intravenous ketamine may be effective at reducing suicidal ideation acutely. Data on use of ketamine in the intramuscular, intranasal, and oral forms are limited and of poorer quality. Studies on these formulations contain greater variability of positive and negative results of ketamine for reducing suicidality and self-injurious behavior. The durability of the antisuicidal effects across all formulations is limited.DiscussionKetamine may be an effective option for the treatment of suicidal ideation in patients across inpatient, outpatient, or emergent settings. At this time, more research is needed on the efficacy of ketamine across all formulations being used in clinical practice.
Background During the COVID-19 pandemic, federal agencies relaxed buprenorphine prescribing restrictions including for incarcerated individuals. The impact of COVID-19 on the supply of MOUD in U.S. prisons and jails is not known. Methods We used cross-sectional national monthly data from the IQVIA National Sales Perspective (NSP) for the total volume of medicines supplied to city, county and state prisons and jails and other types of institutional facilities in the U.S. We measured the total monthly supply (or volume) as extended units (EUs) for MOUDs overall and by type. We used interrupted time series analysis to evaluate changes in monthly volume of MOUDs in prisons and jails and other types of facilities (hospitals, clinics and long-term care) before (January 2018-February 2020) and during the COVID-19 (March 2020-October 2020) pandemic. Results The availability of MOUD in jails and prisons increased by 471.3% between January 2018 (52,784 EU) and October 2020 (333,226 EU). This increase was largely driven by increased volume of buprenorphine/naloxone and was not observed in other institutional facilities, including hospitals, clinics and long-term care, and. Specifically, the mean monthly volume of buprenorphine/naloxone at prisons/jails increased every month before the pandemic by 1,860 EU (95% CI, 1,110-2,360). In March 2020, the mean volume of buprenorphine/naloxone increased by 81,930 EU (95% CI, 59,040-104,820) per month, followed by a significant increase of 24,010 EU (95% CI 19,530-28,490) per month during the pandemic vs before the pandemic. Conclusion These findings may indicate increased availability of buprenorphine/naloxone, a safe and effective MOUD, in prisons and jails since the start of the COVID-19 pandemic in the U.S. despite previous barriers in its use.
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