From the Editor
A rise in substance use. Staff shortages and burnout. Waits for care.
The problems of the pandemic on mental health care have been clear and unfortunate. But how has care changed – and possibly improved – over the pandemic? In the first selection, Lewei Lin (of the University of Michigan) and her co-authors look at buprenorphine treatment before and during the pandemic. In a new paper for The American Journal of Psychiatry, they find a shift in care and a success story: “The number of patients receiving buprenorphine continued to increase after the COVID-19 policy changes, but the delivery of care shifted to telehealth visits…” We consider the paper and its clinical implications.
In the second selection, drawing on Canadian data, Chungah Kim (of Brock University) and her co-authors look at cannabis legalization and cannabis-related hospitalizations. In this new Canadian Journal of Psychiatry brief report, they find: “the initial legalization was followed by clinically significant increases in cannabis-related hospitalizations; however, the subsequent increase in retail stores, availability of cannabis edibles, and COVID-19 pandemic was not associated with a further increase in hospitalizations in Ontario.”
In the third selection, we consider the life and legacy of Dr. Leon E. Rosenberg with the obituary from The New York Times. Dr. Rosenberg had a storied career – a pioneer in genetics research, a dean of Yale, and the chief science officer at Bristol Myers Squibb. He’s also a person who had bipolar disorder and took lithium. “I am proof that it is possible to live a highly successful career in medicine and science, and to struggle with a complex, serious mental illness at the same time.”
Please note that there will be no Readings for the next two weeks.
Selection 1: “Impact of COVID-19 Telehealth Policy Changes on Buprenorphine Treatment for Opioid Use Disorder”
Lewei (Allison) Lin, Lan Zhang, Hyungjin Myra Kim, et al.
The American Journal of Psychiatry, 28 July 2022 Online First
The COVID-19 pandemic sparked a rapid, unprecedented expansion of telehealth-delivered care, including delivery of buprenorphine treatment for opioid use disorder (OUD), an effective treatment that can help reduce mortality in this vulnerable patient population. Key policy changes were implemented in March 2020, at the beginning of the pandemic, to decrease barriers to telehealth delivery of buprenorphine treatment in order to sustain treatment for patients with OUD across the United States…
At the same time, further acceleration of overdose mortality since the start of the COVID-19 pandemic suggests that there may either be an increase in treatment need or a decrease in treatment utilization in this population, which is one that may be particularly vulnerable to the impacts of the pandemic, underscoring the importance of examining trends in buprenorphine treatment since the start of the pandemic.
So begins a paper by Lin et al.
Here’s what they did:
“This was a national retrospective cohort study with interrupted time-series analyses to examine the impact of policy changes in March 2020 on buprenorphine treatment for OUD in the Veterans Health Administration, during the year before the start of the COVID-19 pandemic (March 2019 to February 2020) and during the first year of the pandemic (March 2020 to February 2021). The authors also examined trends in the use of telephone, video, and in-person visits for buprenorphine treatment and compared patient demographic characteristics and retention in buprenorphine treatment across the two periods.”
Here’s what they found:
- Patients. “The number of patients receiving buprenorphine increased from 13,415 in March 2019 to 15,339 in February 2021.”
- Types of visits. “By February 2021, telephone visits were used by the most patients (50.2%), followed by video visits (32.4%) and in-person visits (17.4%).”
- Increase. “During the pre-pandemic period, the number of patients receiving buprenorphine increased significantly by 103 patients per month. After the COVID-19 policy changes, there was an immediate increase of 265 patients in the first month, and the number continued to increase significantly, at a rate of 47 patients per month.”
- Retention and days. “The proportion of patients reaching 90-day retention on buprenorphine treatment decreased significantly from 49.6% to 47.7%, while days on buprenorphine increased significantly from 203.8 to 208.7.”
A few thoughts:
1. This is a good study.
2. How does the engagement in buprenorphine treatment compare to engagement in other substance use disorders? “During this same interval, the number of patients receiving any substance use disorder treatment in the VHA (not just OUD treatment) decreased from 138,745 to 129,806 (a 6% decrease).” !!
3. The story here: a shift to virtual options.
4. The implications? “[D]elivery of care changed dramatically during this period; the majority of visits shifted to telehealth, with telephone visits outnumbering video visits. These findings suggest that although the COVID-19 pandemic substantially changed the way OUD care is delivered, policy changes that were rapidly implemented in order to reduce barriers to telehealth allowed delivery of this life-saving treatment to be sustained during the pandemic.” Innovation resulted in better access. Nice. And as we consider rules and regulations around care delivery on both sides of the border in a post-pandemic future, this paper offers a reminder of the importance of recent changes.
5. This paper adds nicely to the literature by focusing on opioids and care. The pandemic has seen a rise in substance use, yes, but it has also allowed for experimentation in care delivery. Let’s not forget how important opioid agonist treatment is – a recent paper found that it led to a 50% lower risk of mortality. That study was discussed in a past Reading: https://davidgratzer.com/reading-of-the-week/reading-of-the-week-does-opioid-agonist-treatment-save-lives-also-the-problem-with-decriminalization-of-illicit-drugs-cjp/
The full AJP paper can be found here:
Selection 2: “Cannabis Legalization and Cannabis-Related Hospitalizations in Ontario, Canada”
Chungah Kim, Antony Chum, Andrew Nielsen, et al.
The Canadian Journal of Psychiatry, 27 July 2022 Online First
Canada legalized recreational cannabis on October 17, 2018. Since then, only one Canadian study (in Quebec) examined the impact of legalization on cannabis-related hospitalizations. That study focused on youth (0-19) using 5.5 months of post-legalization data, which precluded understanding the impact on trends over a longer period after legalization. While a number of recent studies have examined the impact of legalization on cannabis-related emergency department (ED) visits in Canada, cannabis-related hospitalizations should not be ignored since substance-related in-patient care is required in the most severe spectrum of cases and they contribute to significant healthcare costs.
So begins a brief report by Kim et al.
Here’s what they did:
- They drew from several Ontario databases, focusing on cannabis-related hospitalizations between October 2015 and May 2021.
- “We compared trends and characteristics of the hospitalizations over three periods: pre-legalization, Phase 1, and Phase 2.”
- “Negative binomial segmented regressions were used to estimate the incidence rate ratios (IRRs) for immediate and trend changes associated with each of the 3 periods in the monthly counts of hospitalizations, examining effects of age and gender identity.”
Here’s what they found:
- “Our study (focused on adults) found significant immediate increases for all adults, with stronger immediate and trend effects shown in men versus women; and among women, stronger effects in women 25 + vs. 18–24.”
- “In another prior study, cannabis-related ED visits increased in both phases, however, our study found significant increases in hospitalizations only after initial legalization.”
A couple of thoughts:
1. The Canadian experience with cannabis legalization (really, decriminalization, then legalization) is interesting, and this brief report offers nice data.
2. An obvious complicating factor: the pandemic.
The CJP brief report can be found here:
Selection 3: “Leon E. Rosenberg, Geneticist Who Wrote of His Depression, Dies at 89”
The New York Times, 5 August 2022
Dr. Leon E. Rosenberg, who after spending decades as a pioneer in the field of medical genetics revealed that he had spent just as long struggling with manic depression, and who then urged doctors to be more open about their own mental health, died on July 22 at his home in Lawrenceville, N.J. He was 89.
So begins an obituary by Risen.
The author notes that “Dr. Rosenberg straddled the worlds of clinical and laboratory medicine.”
“Beginning in the early 1960s, he specialized in inherited metabolic disorders – cases in which the body is unable to process certain compounds, which then accumulate and poison a patient.”
He was particularly moved by one patient. “Most of his patients were children, including one of his first, a 9-year-old boy named Steven, whose skeletal muscles were rapidly wasting away. Dr. Rosenberg, who was then a fellow at the National Institutes of Health, found nothing wrong except a high level of amino acids in Steven’s urine. He interviewed the boy’s parents, who said they had had two other children with similar conditions, both of whom had died. Steven died not long after.” Later, he wrote: “I was unable to change the course of Steven’s illness but he changed the course of my professional life.”
He took an appointment at Yale – and success followed him, as he became the founding chair of the department of human genetics, then served as dean of medicine, where “he made it easier for people of color and women to rise to senior faculty positions…” Risen writes: “He scaled the peaks of his profession, sitting on corporate boards and joining the National Academy of Sciences. In 1989 he was shortlisted to run the National Institutes of Health, alongside Dr. Anthony Fauci.”
The article notes his secret: he struggled with mental illness and episodes of depression for years. “Though similar episodes struck later, often around major career changes, he never talked about them, or sought treatment, until he attempted suicide in 1998. His doctor diagnosed bipolar II disorder, and Dr. Rosenberg underwent electroshock therapy and took lithium.”
“Doctors can suffer from depression just like anyone else, but Dr. Rosenberg was the rare physician who spoke openly about it – first in the classroom and in lectures, then in a series of articles and, ultimately, in a book, ‘Genes, Medicines, Moods: A Memoir of Success and Struggle’ (2020).”
He encouraged others to speak out, writing: “The list of writers who have described their suicidal attempts and suicidal thoughts is long and illustrious. “Yet physicians and scientists, who commit and attempt suicide at least as often as artists, writers, politicians and business leaders, have been remarkably silent.”
Dr. Rosenberg was born in Madison, Wisconsin, to Abraham and Celia (Mazursky) Rosenberg, who had fled pogroms. His father had owned a general store. An injury to his mother’s hand had sparked an interest in medicine.
A few thoughts:
1. Dr. Rosenberg had quite the career.
2. His decision to speak out about this mental illness – at the peak of his success – was brave and important.
3. For those who want to read about his journey, his 2002 essay is engaging and beautifully written. It begins: “More than four years ago – on May 26, 1998, to be exact – I awakened during another restless, dreadful night. The clock read 4:15 a.m., so I closed my eyes and tried to be calm. It didn’t work. I got out of bed. ‘This must end, today,’ I thought. ‘I can’t sleep. I can’t eat. I can’t teach. I can’t even read or write.’” The essay is here: https://dana.org/article/brainsick-a-physicians-journey-to-the-brink/
4. A quick thanks to Dr. David Goldbloom for suggesting this selection.
The full NYT article can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.