NC #1 in naloxone distribution

The Guardian  published an article today (Timothy Pratt, June 10, 2016) about naloxone rescue kit distribution efforts in NC. The state claims national leadership status in the number of lives saved with naloxone in the shortest period of time (not by police, ERs, or other medical first responders). Key to that effort has been getting the rescue kits into the hands of opiate users and their peersThe NC Harm Reduction Coalition (NCHRC) is the organization responsible for this monumental undertaking. Most states are making similar efforts but some advocates have expressed frustration about the lack of cohesive plans to reach those in need.

Peter Davidson, a professor at the UC San Diego School of Medicine who has studied opioid deaths said it’s “frustrating” to see that other states haven’t yet adopted North Carolina’s methods, which he believes should be a national model.

“We have a really good … public health response that works, and seeing it not being done more comprehensively is infuriating,” he said. “You’re watching the death reports come in, and you know they don’t need to be that high.”

Let’s all learn from each other with the common goal of not just saving lives but treating addiction adequately in the first place.



June 10 CPI Keynote John Kane, MD



Dr. John Kane at APNA CPI conference. Photo by Mary Ann Nihart, 6/10/2016


John Kane, MD
Schizophrenia treatment and how far we’ve come.
No slides available. No disclosures were available but feels like there might be.

This post includes my notes about this session.

only 1 in 7 recover. best outcomes are early diagnosis and treatment.

RAISE study:

Methods of reaching the youngest that aren’t yet treated — using social media, trying to connect with them.

Teen/young adults themselves don’t want to accept it and their parents don’t either.

At risk for many comorbid conditions both physically/medically, mentally, socially.

at 23yoa already have HTN, are pre-diabetic, and have dyslipidemia. 50% of tobacco users in the US have mental illness.

Don’t start with the known to be biggest offenders (zyprexa eg). The youngest of them can do well on lower doses in general.

RAISE goal is recovery, not management or maintenance. Takes a team but you can’t bill for a team meeting and we have to figure out how to do that.

Train “navigators”

four components: psychopharm : COMPASS decision support stytem; family education, supported employment/education; individual resiliency training (IRT).

RAISE has various manuals on their website.

RCT: navigators vs. community care, or treatment as usual


relapse fuels the progression of illness

LAI and concerns about not selecting them:

side effects concerns as a reason not to use: NMS was the only one he mentioned and he said that the rate of developing that is no higher than PO med.

patients can’t afford, non feasible combo, fewer choices of SGA, mare EPS than oral meds
impossible to discontinue/reduce, low reimbursement for hospitals, relatively short ink interval, hard to link to next care, hassle of injections.

Clozapine efficacy

Technology: 90% of worlds data created in the last 2 yrs, etc. slide closed too soon. Technology efforts have potential to be a game changer. He mentioned a project they’re working on to see outcomes.

E-health to address problem areas of in-person services: online CBT, web based psycho ed for families,

RAISIN SYSTEM: Raisin Data Recorder impeded chip that monitors activity.

Q: Haldol causes brain cancer?… A: he denied it.
Q: Depot injections, do you have a bill of rights, do you do home visits for the injections? A: No home injections. No bill of rights.
Q: is anyone developing protocols to identify first breaks when they present in the ER; not enough mental health providers in the ER? Basically they’re being snowed and probably sent back out. A: no protocols.
Q: Trinza is knocking my patients out. A: he hasn’t used Trinza yet.



Thursday 5/9/16 Preconference: Benzo pitfalls

Benzo discussion Dr. Limandri:


My impression: great info, so much material to cover though so she mostly skimmed the surface. Lots of the info seemed to come from her own experience (lots!). There was also material that came from the UK — Ashton Manual which I refer to often and it’s full of good info. I’d like to have seen links about the issue at the end (maybe there were at the end, under references?).

At one of my locations I’m working with a therapist to put together a CBT class for our clients that we’re working with to get off benzos. I have an article/reference I’m using for that and tomorrow I’ll try to scan it to my email in the business office to upload to this site with a link. I’ll also try and upload it the APNA CPI site.

If anyone is interested in furthering the discussions from this session today please hit me up! I want to network and talk more about it.

Below are my mostly unedited notes from this session along with some lyrics from a famous Rolling Stones song relevant to subject.

why are women taking them more than men? 25-50 yr age range is highest; multitasking; middle aged, white, wealthier. The rolling stones wrote a famous song about women using Valium, “mother’s little helper” in the 60s — here are the lyrics:

What a drag it is getting old
“Kids are different today, ”
I hear ev’ry mother say
Mother needs something today to calm her down
And though she’s not really ill
There’s a little yellow pill
She goes running for the shelter of a mother’s little helper
And it helps her on her way, gets her through her busy day

“Things are different today, ”
I hear ev’ry mother say
Cooking fresh food for a husband’s just a drag
So she buys an instant cake and she burns her frozen steak
And goes running for the shelter of a mother’s little helper
And two help her on her way, get her through her busy day

Doctor please, some more of these
Outside the door, she took four more
What a drag it is getting old

“Men just aren’t the same today”
I hear ev’ry mother say
They just don’t appreciate that you get tired
They’re so hard to satisfy, You can tranquilize your mind
So go running for the shelter of a mother’s little helper
And four help you through the night, help to minimize your plight

Doctor please, some more of these
Outside the door, she took four more
What a drag it is getting old

“Life’s just much too hard today, ”
I hear ev’ry mother say
The pusuit of happiness just seems a bore
And if you take more of those, you will get an overdose
No more running for the shelter of a mother’s little helper
They just helped you on your way, through your busy dying day

Notes con’t:

more deaths for those who were regular daily users v the infrequent.

3 weeks (no more than 90 days!) is the longest time they should be prescribed. Most long term users stay at same dosages, but they have rebound anxiety and end up raising the dose over time. When your patient c/o anxiety while on a benzo — and you choose to up the dose — you’ve done opposite of what you were supposed to do.

Primary care providers are the bigger offenders. they feel pressured to solve all the problems.

studies are reporting on stats by psychiatrists and not NPs. Add the NPs and the stats would be different. get out of my emergency room, GOMER. quicker to write the script than do MI or other counseling. There are providers out the that will write for benzos with no intent to stop because it’s lucrative work.

GAD has so many somatic c/o so they end up in primary care.

best anxiolytics are SSRIs. take a bzd to bridge until they kick in, for 2-3 weeks and then stop without taper.

DSM5: MDD with anxious distress… emphasize the last part and that it’s linked to the first.

why do people with trauma not take bzd? loss of control.

used in dementia and causes falls.

expensive to treat all the collateral damage, eg, falls, car accidents, etc.

2.5 x higher rate of suicide attempts: from a big study in Taiwan.

anterograde amnesia (use midazolam in your teaching and why it’s used in medical procedures), dissociation, cognitive impairment, paradoxical anxiety that is proven in PET scans. It makes you not care about the anxiety. They don’t care about possible risks. hinders fight/flight — exactly what trauma survivors don’t want.

cognitive impairment makes it hard to learn the skills needed to curb anxiety.

dependence of psychological nature can be stronger than physical.

Mechanism of Action:

gaba works on all chloride ion channels. Gaba A and chloride channel:


CBT to get people off benzos: you question why you think it’s helping your anxiety.

Q: state hospitals and violent patients and use of bzd’s: increases impulsivity but they’re slower and we can catch them. Use a different gabaergic that’s not the benzo receptor: lamictal and gabapentin. both slow the firing and gives staff time to think. State hospitals may want to use benzo cause it’s cheaper.

56% of letter recipients got off them on their own just with some education, the letter gave them the info.

DBT in schizophrenia works but it’s expensive

Alternative anxiolytics: Effexor — more adrenergic at higher doses. 75mg is antidepressant. Fetzima has more adrenergic at lower doses so better tolerated. Buspar opens the receptor; celexa releases serotonin. other gabaergics: lamitical and gabapentin. alpha and betas: trauma does better on these and feel it right away.

Q: schizophrenia and benzos: no indication but had been used for akathisia.


APNA 14th Annual Clinical Psychopharm Conference

Yes! It’s conference time in Baltimore! I’m excited to be here at the 14th Annual CPI. The program this year includes many important topics and I’m going to try my best to write a little about the sessions at the end of the day. Conference registration is downstairs in 29 minutes so I better get ready to head down there.



Recovering From Rotator Cuff Surgery 1.3

Yesterday was my last follow-up visit with my surgeon. He told me that PT was now optional, and that over the next month or so I could ease into regular life with a new shoulder.

That came as a surprise because I’m still going to PT and am only on 1 or 2 lb weights with strength training. He said I could resume mountain biking (only gravel roads for the next month). When I asked him what would happen to my shoulder if I fell while biking. His answer was that the operative shoulder (my right) is now stronger than my left, even at this stage of recovery.

I still have pain but it’s not constant, and I still only take prn Advil (no ibuprofen as naproxen apparently is the preferred musculoskeletal anti-inflammary) plus prn Tylenol  and that’s plenty sufficient. I’m able to get through an entire workday of hand writing all my notes (no EMR) — something I couldn’t do in the days leading up to surgery.


GET THE BEST RECLINER YOU CAN AFFORD —  I opted for a lesser model with the thinking that I wouldn’t be using it for too long. That was wrong — I’ve used this recliner so much that it’s starting to lose it’s comfy luster of newness.

DON’T BELIEVE EVERYTHING YOU READ ONLINE ABOUT HOW PAINFUL IT IS! Yes, it hurts, but not like I was led to believe from almost every post I read.


That’s all I want to say, mostly because my pizza just arrived and I need to eat.

Contact me if you have questions about RC surgery. I am happy to answer.

Be well!