Patrick Marshalek

Guidelines for the Management of Pregnant Women With Substance Use Disorders

BACKGROUND Women of reproductive potential with substance use disorders, especially those who are pregnant, present many clinical challenges to healthcare providers, including comorbid psychiatric disorders, a history of trauma and abuse, avoidance of or poor access to prenatal care, fear of legal consequences, and countertransference reactions. METHODS In November 2013, members of the Womens Mental Health Special Interest Group of the Academy of Psychosomatic Medicine presented a Workshop reviewing substance abuse in pregnancy, highlighting the specific contributions that psychosomatic medicine specialists can make in the care of these patients. The discussion focused on epidemiology; maternal and fetal risks; and screening and treatment considerations for tobacco, alcohol, cannabis, opioids, benzodiazepines, stimulants, and several other substances. OBJECTIVE Our purpose in publishing this review is to provide clinicians and educators with the most up-to-date summary in this field to better engage these patients in care and break the intergenerational cycle of abuse and addiction.

Treatment Outcome Comparison Between Telepsychiatry and Face-to-face Buprenorphine Medication-assisted Treatment for Opioid Use Disorder: A 2-year Retrospective Data Analysis

Objectives: To retrospectively review clinic records to assess the difference between face-to-face and telepsychiatry buprenorphine medication-assisted treatment (MAT) programs for the treatment of opioid use disorder on 3 outcomes: additional substance use, average time to achieve 30 and 90 consecutive days of abstinence, and treatment retention rates at 90 and 365 days. Methods: Medical records of patients (N = 100) who were participating in telepsychiatry and in face-to-face group-based outpatient buprenorphine MAT programs were reviewed and assessed using descriptive statistical analysis. Results: In comparison with the telepsychiatry MAT group, the face-to-face MAT group showed no significant difference in terms of additional substance use, time to 30 days (P = 0.09) and 90 days of abstinence (P = 0.22), or retention rates at 90 and 365 days (P = 0.99). Conclusions: We did not find any significant statistical difference between telepsychiatry buprenorphine MAT intervention through videoconference and face-to-face MAT treatment in our Comprehensive Opioid Addiction Treatment model for individuals diagnosed with opioid use disorder in terms of additional substance use, average time to 30 and 90 days of abstinence, and treatment retention rates.

Off-label use of transmucosal ketamine as a rapid- acting antidepressant: a retrospective chart review

Objective This study evaluated the effectiveness and safety of subanesthetic doses of ketamine using an off-label, transmucosal administration route in patients with treatment-resistant depression. Methods A retrospective chart review was conducted to identify patients who met the inclusion criteria for treatment-resistant major depressive disorder. Seventeen such patients who received subanesthetic doses of ketamine were included. Patient demographics, efficacy (drug refill, clinician notes), side effects, and concurrent medications were assessed. Results Benefit from low-dose transmucosal ketamine was noted in 76% of subjects (average age 48 years, 88% female), with a dose duration lasting 7–14 days. No notable side effects were noted. The most common classes of concurrent medications to which ketamine was added were serotonin–norepinephrine reuptake inhibitors (59%), stimulants (47%), folate replacement (47%), and benzodiazepines (47%). Conclusion Our results provide preliminary evidence of the effectiveness and safety of low-dose transmucosal ketamine in treatment-resistant patients. A controlled, prospective pilot study is warranted to validate these findings.

Amnesia Associated with Bilateral Hippocampal and Bilateral Basal Ganglia Lesions in Anoxia with Stimulant Use

We report a case of a 55-year-old man with ischemic lesions of the bilateral hippocampus and bilateral basal ganglia following a myocardial infarction during an episode of multiple drug use with subsequent anoxia requiring resuscitation. He presented for a neuropsychological evaluation with an anterograde amnesia for both explicit and procedural memory. There are two main points to this case, the unique aspects of the bilateral multifocal lesions and the functional, cognitive impact of these lesions. We hypothesize that his rare focal bilateral lesions of both the hippocampus and basal ganglia are a result of anoxia acting in synergy with his stimulant drug use (cocaine and/or 3,4-methylenedioxy-methamphetamine). Second, his unique lesions produced an explicit and implicit/procedural anterograde amnesia.

Medication-Assisted Treatment for Pregnant Women: An Interdisciplinary Group Based Model

ABSTRACT The treatment needs of pregnant women with opioid use disorders are increasing drastically. Medication-assisted treatment with buprenorphine is emerging as relatively a safe and effective treatment for pregnant women. New comprehensive models of treatment need to be developed to engage this high-risk, highly stigmatized population. The group modality is ideal for increasing access to treatment and addressing the specialized clinical needs experienced by pregnant women with substance use disorders while promoting interpersonal connection. A group-based model of treatment delivery for pregnant women with substance use disorders is presented here with preliminary outcomes data.

Treating women with opioid use disorder during pregnancy in Appalachia: Initial neonatal outcomes following buprenorphine + naloxone exposure: Buprenorphine + Naloxone in Mat During Pregnancy

BACKGROUND AND OBJECTIVES Rising concerns regarding diversion and misuse of mono-buprenorphine for treatment of pregnant women with opioid use disorders have sparked interest in the use of buprenorphine + naloxone to reduce misuse and diversion rates. Examined the relationship of prenatal buprenorphine + naloxone exposure to neonatal outcomes. METHODS This is a retrospective chart review of 26 mother infant dyads in comprehensive medication-assisted treatment with buprenorphine + naloxone during pregnancy. RESULTS All neonatal birth outcome parameters were within normal ranges, albeit on the lower side of normal for gestational age and birth weight. Only 19% of neonates required morphine pharmacology for NAS. CONCLUSIONS Use of buprenorphine + naloxone shows relative safety in pregnancy. SCIENTIFIC SIGNIFICANCE These findings can help better guide prescribing practices for pregnant patients at risk for misuse or diversion of buprenorphine. (Am J Addict 2018;27:92-96).