Apr 6, 2018

Scripts ablaze

The story

Your red eyes and incipient paranoia are from 24-hour call, but be aware that people on the subway may think otherwise. We've got the latest on the role of medical marijuana laws in the opioid epidemic. 

The background

You've heard plenty about opioids throughout your education, but we bet the info on medical marijuana has been sparse. California approved the first medical cannabis law (MCL) in 1996, and since then 29 states and DC have approved varying degrees of access to marijuana. Cannabis use is rising fastest in patients over age 50, and a 2017 review from the National Academies of Sciences, Engineering, and Medicine concluded that marijuana is safe and effective for chronic pain. 

The study

If marijuana treats pain, do permissive laws reduce opioid use? A longitudinal analysis of opioid prescriptions filled through Medicare Part D found that fewer opioid scripts were written and filled in states with MCLs than in states without them. On the whole, states with dispensary MCLs saw a 14% drop in opioid prescriptions from 2010 - 2015, while states with home cultivation-only laws saw a 7% drop. Hydrocodone, by far the most commonly prescribed opioid, saw 17% fewer prescriptions in dispensary states, equivalent to 2.3 million daily doses.  
JAMA Int Med

The takeaway

There's a lot written about marijuana as a gateway drug, but at least as it pertains to opioids marijuana appears to decrease use. The results may give cannabis a larger role in the national opioid conversation.

Say it on rounds

When you copy the admission note from your patient's last visit

It helps to look back at old charts. A retrospective cohort study of 155,000 patients from a national Veterans Affairs dataset found that prompt initiation of a high-intensity statin within one year of diagnosis of peripheral artery disease (PAD) was associated with a 33% lower risk of amputation and a 26% lower risk of mortality. Since indications for statin use come primarily from studies of coronary artery disease and ischemic stroke, the study boosts the case for statins in PAD.

When you and the discharge care coordinator get into a shouting match

Better patch things up. The same applies to indwelling catheters for pleural effusions, where an RCT of 150 patients with PleurXs placed for malignant pleural effusion found that outpatient talc administration doubled pleurodesis (lung repair) at 35 days compared to placebo. Talc infusion has typically required an inpatient stay of 4 - 7 days, so the combination of PleurX and outpatient talc infusion can give these often very sick patients more time at home. 

When the hospital basement is a poorly lit maze

It helps to have a navigator, especially if you happen to be wheeling an unstable patient to CT. Peer navigators are also an effective resource for HIV-positive inmates awaiting release: an RCT of 350 men and transgender women found that use of trained peer navigators before and after release from prison increased viral suppression at 12 months compared to usual care (49% vs. 36%, respectively). Navigators are among the first interventions to improve the drop-off seen in viral suppression when incarcerated patients leave prison.
JAMA Int Med

Brush up


Just like endless vent alarms haunt your ears, up to 25% of adults will experience tinnitus. Classic risk factors are hearing loss and occupational noise exposure. Send affected patients for audiology testing, and make sure to ask about vertiginous symptoms to identify Meniere’s disease or acoustic neuromas. While many with tinnitus aren't bothered, treatment for those who need it includes hearing aids and acoustic simulation. Education and cognitive behavioral therapy help relieve associated anxiety. 

What's the evidence

For risk factors in tinnitus? A 2010 cross-sectional survey of 15,000 adults found that hypertension and former smoking were associated with increased odds of frequent tinnitus, along with loud leisure-time, firearm use, and occupational noise exposure. Tinnitus was also associated with low-mid and high frequency hearing impairment. 

What your neuro friends are talking about

With the amount we forget each day, it's hard to imagine that our brains aren't dormant. But a new autopsy study found that contrary to previous belief, humans produce new hippocampal neurons throughout adulthood.  
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