Angeline Prabhu, MD

CASE

Dr. Peter D is a mid-career family physician in a group practice that recently adopted an electronic health record system. Although he realizes he is now competent at computerized medicine, he has far less of the one-on-one patient contact that he once found so gratifying about the field of medicine.

Others in the practice have similar concerns, but they suggest that everyone ought to “go along to get along.” To manage the increasing demands of his case load and the required documentation, Dr. D has begun staying late to finish charting, which is negatively impacting his family life.

Dr. D finds himself burdened by record keeping that is increasingly complicated and insurance company demands that are onerous. Pharmaceutical prior authorizations that previously had been mildly bothersome are now a full-on burden. More often than not, he finds himself becoming irritable over extra requests and administrative demands, impatient with some patients and staff, and extremely fatigued at the end of workdays. Simply put, he finds that practicing medicine is far less enjoyable than it once was. He takes the Maslach Burnout Inventory, and his score indicates that he has moderate burnout.

©Joe Gorman/Shutterstock

Physician burnout has been a growing concern in recent decades.¹ Characterized by varying degrees of job dissatisfaction, cynicism, emotional exhaustion, clinical inefficiency, and depression, physician burnout can impede effective patient care, cause significant health issues among physicians, diminish professional gratification and feelings of accomplishment, and financially burden society as a whole. Here we present the information you need to recognize burnout in yourself and colleagues and address the problem on personal, organizational, and legislative levels.

A problem that affects physicians of all ages

Physician burnout has been recognized to present anywhere on a spectrum, manifesting as ineffectiveness, overextension, disengagement, and/or an inability to practice.² Such features may lead to feelings of professional inadequacy among even the highest functioning physicians.

In 2018, the Medscape National Physician Burnout and Depression Report indicated that 42% of physicians admitted to some burnout, while 12% said they were unhappy at work, and 3% reported being clinically depressed.

Burnout occurs in all stages of medical life—as students, residents, and practicing physicians.^3-6 Due to pressures in excess of coping capacity, some physicians will suffer from alcohol or other drug abuse, depression, and/or suicidal thinking.⁷ Stress and burnout can also result in musculoskeletal disorders, immune system dysfunction, cardiac pathology, and a shorter lifespan.⁸

Not only do individual practitioners suffer consequences from burnout, but it also compromises health care delivery. In 2018, the Medscape National Physician Burnout and Depression Report surveyed 15,000 physicians from 29 specialties; 33% of the respondents said that they were more easily frustrated by patients, and 32% reported less personal engagement.⁹ Burnout adversely impacts care, patient satisfaction, productivity, physician retention, retirement, and income, as well.⁶ Safety during clinical practice deteriorates because of an increase in medical error rates.¹⁰ Resultant emotional distress for physicians creates a vicious cycle.¹⁰

[polldaddy:10427848]

Continue to: These issues negatively impact...

These issues negatively impact practice enthusiasm and may engender self-doubt.¹¹ They may lead to absenteeism or, worse, to abandoning the profession, further contributing to physician shortages.¹² The financial impact of physician burnout in lost revenue in 2018 was about $17 billion, according to the National Taskforce for Humanity in ­Medicine.¹³

How prevalent is physician burnout?

Between October 2012 and March 2013, the American Society of Clinical Oncology surveyed US oncologists and found that 45% had evidence of burnout.¹⁴ In another survey of US physicians from all specialties conducted in 2011, at least 1 symptom of burnout was documented in nearly 46% of respondents.¹⁵ By 2014, this percentage increased to 54%.¹⁶

In 2018, the Medscape National Physician Burnout and Depression Report indicated that 42% of physicians admitted to some burnout, while 12% said they were unhappy at work, and 3% reported being clinically depressed.⁹ About 48% of female practitioners reported burnout vs 38% of male peers.⁹ Work-related distress varies between specialties, with internists, family physicians, intensivists, neurologists, and gynecologists more affected than those from other specialties.⁹

Causes and contributing factors

Job stress generally increases with changes in the workplace. This can be heightened in the health care workplace, which demands perfection and leaves little room for emotional issues. Loss of autonomy, time constraints associated with clinical care, electronic health record (EHR) documentation, and disorganized workflow tend to contribute to provider dissatisfaction and stress, as do ethical disagreements about patient care between physicians and leadership.^10,17 Fear of reprisal for speaking up about such issues can further exacerbate the problem. Some older physicians may have difficulty with technology and computerized record keeping. Reduced patient contact due to increasing reliance on computers can diminish physicians’ job satisfaction. And managing recurrent or difficult-to-treat ailments can result in compassion fatigue, diminished empathy, and emotional disengagement.

Burnout in the health care workplace is inconsistently addressed, despite negative professional and personal ramifications. The reasons include denial, uncertainty about monetary implications, and lack of corrective programs by decision-making organizations and/or employers.⁶ American medicine has lacked the political and financial will to implement strategies to mitigate burnout. Improvement requires changes on the part of government, physician groups, and the population at large.

The answer?

A multipronged approach

Identifying burnout is the first step in management. The 22-item Maslach Burnout Inventory (MBI) is a self-reporting questionnaire, reliable at detecting and assessing burnout severity.¹⁸ It screens 3 main domains: emotional exhaustion, depersonalization, and diminished feelings of accomplishment. The American Medical Association recommends the 10-item Zero Burnout Program—the “Mini Z Survey”—as being quicker and more convenient.¹⁹

Once the problem is recognized, experts suggest adopting a multipronged approach to prevention and intervention by using personal, organizational, and legislative strategies.²⁰

Continue to: On a personal level...

On a personal level, it’s important to identify stressors and employ stress-reduction and coping skills, such as mindfulness and/or reflection.²¹ Mindfulness programs may help to minimize exhaustion, increase compassion, and improve understanding of other people’s feelings.²² Such programs are widely available and may be accessed through the Internet, mental health centers, or by contacting psychiatric or psychological services.

Other self-care methods include ensuring adequate sleep, nutrition, exercise, and enjoyable activities. If a physician who is suffering from burnout is taking any prescription or over-the-counter drugs or supplements, it is important to be self-aware of the potential for misuse of medications. Of course, one should never self-prescribe controlled drugs, such as opiates and sedatives. Consumption of alcohol must be well-controlled, without excesses, and drinking near bedtime is ill-advised. The use of illegal substances should be avoided.

Pursuing aspects of health care that are meaningful and that increase patient contact time can boost enthusiasm, as can focusing on the positives aspects of one’s career.²³ Continuing medical education can enhance self-esteem and promote a sense of purpose.²⁴

Peer support. Practice partners may assist their colleagues by alerting them to signs of burnout, offering timely intervention suggestions, and monitoring the effectiveness of strategies. Physicians should discuss stress and burnout with their peers; camaraderie within a practice group is helpful.

Professional coaches or counselors may be engaged to mitigate workplace distress. Coaching is best instituted collegially with pre-identified goals in order to minimize stigmatization.

Continue to: Professional societies and medical boards

Professional societies and medical boards. Reporting requirements by medical boards tend to stigmatize those seeking professional assistance. But that could change if all of us—through our participation in these organizations—pursue change.

Specifically, organizations and related societies could assist with better guidance and policy adjustment (see “Resources”). State medical boards could, for example, increase education of, and outreach to, physicians about mental health issues, while maintaining confidentiality.²⁵ Medical organizations could regularly survey their membership to identify burnout early and identify personal, social, and institutional shortcomings that contribute to physician burnout. In addition, hospital quality improvement committees that monitor health care delivery appropriateness could take steps toward change as well.

The American Medical Association (AMA) just recently announced that they are launching a new effort to fight the causes of physician burnout. The AMA’s Practice Transformation Inititative²⁶ seeks to fill the knowledge gaps regarding effective interventions to reduce burnout. AMA’s leadership indicates that the initiative will focus on “improving joy in medicine by using validated assessment tools to measure burnout; field-testing interventions that are designed to improve workflows, applying practice science research methodology to evaluate impact, and sharing best practices within an AMA-facilitated learning community.”²⁶

Stanford’s example. Stanford University instituted a ‘time bank’ program, to help their academic medical faculty balance work and life and reduce stress. They essentially offer services, such as home food delivery and house cleaning, in return for hours spent in the clinic.²⁷

Reorganizing and reprioritizing. Prioritizing physician wellness as a quality indicator and instituting a committee to advocate for wellness can help attenuate burnout.^28,29 Specific measures include minimizing rushed, overloaded scheduling and allowing more clinical contact time with patients. Using nursing and office staff to streamline workflow is also helpful.²⁹ The University of Colorado’s “Ambulatory Process Excellence Model” strives to assist doctors by increasing the medical assistant-to-clinician ratio, yielding better productivity.²³ Medical assistants are increasingly handling tasks such as data entry, medication reconciliation, and preventive care, to allow physicians more time to focus on medical decision-making.²³

Continue to: The role of the EHR

The role of the EHR. One important way to boost professional morale is to simplify and shorten the EHR. The complexity of and reduced patient contact caused by today’s record-keeping systems is the source of great frustration among many physicians. In addition, many patients dislike the disproportionate attention paid by physicians to the computer during office visits, further compromising physician-patient relationships. Improving documentation methodology and/or employing medical assistant scribes can be helpful.^30,31 (See “Advanced team-based care: How we made it work” at http://bit.ly/2lNaB5Q.)

Legislation with physician input can mandate policies for more appropriate work environments. A good way to initiate improvement and reform strategies is to contact local medical societies and political representatives. Federal and state collaboration to reduce physician shortages in selected specialties or geographic regions can improve work-related stress. This might be attained by expanding residency programs, using telemedicine in underserved regions, and employing more physician assistants.³²

Health insurance. Enhancing universal access to affordable medical care, including pharmaceutical coverage, would alleviate stress for physicians and patients alike.³³ Health insurance regulation to decrease paperwork and simplify coverage would decrease physician workload. Standardized policy requirements, fewer exclusionary rules, and simplified prescribing guidelines (including having less cumbersome prescription pre-authorizations and greater standardization of drug formularies by different payer sources or insurance plans) would facilitate better clinical management.

CASE

Dr. D begins by discussing his concerns with his colleagues in the group practice and finds he is not alone. Many of the concerns of the group center around brief, rushed appointments that diminish relationships with patients, a lack of autonomy, and the fear of medical malpractice. Several older physicians acknowledge that they just want to retire.

Stanford University instituted a "time bank" program that offers home food delivery and house cleaning in return for hours spent in the clinic.

To address the patient contact and documentation issues, the group decides to hire scribes. They also decide to bring their concerns to the next county medical society meeting. The end result: They petitioned their state medical association to host presentations about mitigating burnout, to hold roundtable discussions, and to establish panels focused on remedying the situation.

Continue to: With this accomplished...

With this accomplished, Dr. D’s anxieties lessened. He surveyed relevant literature and shared tips for improving professional time management with his partners. In a hopeful mood, he volunteered to address burnout prevention at the next statewide medical meeting. He felt it was a good start.

CORRESPONDENCE
Steven Lippmann, MD, 401 E. Chestnut Street, Suite 610, Louisville, KY 40202; steven.lippmann@louisville.edu.

CASE

Dr. Peter D is a mid-career family physician in a group practice that recently adopted an electronic health record system. Although he realizes he is now competent at computerized medicine, he has far less of the one-on-one patient contact that he once found so gratifying about the field of medicine.

Others in the practice have similar concerns, but they suggest that everyone ought to “go along to get along.” To manage the increasing demands of his case load and the required documentation, Dr. D has begun staying late to finish charting, which is negatively impacting his family life.

Dr. D finds himself burdened by record keeping that is increasingly complicated and insurance company demands that are onerous. Pharmaceutical prior authorizations that previously had been mildly bothersome are now a full-on burden. More often than not, he finds himself becoming irritable over extra requests and administrative demands, impatient with some patients and staff, and extremely fatigued at the end of workdays. Simply put, he finds that practicing medicine is far less enjoyable than it once was. He takes the Maslach Burnout Inventory, and his score indicates that he has moderate burnout.

©Joe Gorman/Shutterstock

Physician burnout has been a growing concern in recent decades.¹ Characterized by varying degrees of job dissatisfaction, cynicism, emotional exhaustion, clinical inefficiency, and depression, physician burnout can impede effective patient care, cause significant health issues among physicians, diminish professional gratification and feelings of accomplishment, and financially burden society as a whole. Here we present the information you need to recognize burnout in yourself and colleagues and address the problem on personal, organizational, and legislative levels.

A problem that affects physicians of all ages

Physician burnout has been recognized to present anywhere on a spectrum, manifesting as ineffectiveness, overextension, disengagement, and/or an inability to practice.² Such features may lead to feelings of professional inadequacy among even the highest functioning physicians.

In 2018, the Medscape National Physician Burnout and Depression Report indicated that 42% of physicians admitted to some burnout, while 12% said they were unhappy at work, and 3% reported being clinically depressed.

Burnout occurs in all stages of medical life—as students, residents, and practicing physicians.^3-6 Due to pressures in excess of coping capacity, some physicians will suffer from alcohol or other drug abuse, depression, and/or suicidal thinking.⁷ Stress and burnout can also result in musculoskeletal disorders, immune system dysfunction, cardiac pathology, and a shorter lifespan.⁸

Not only do individual practitioners suffer consequences from burnout, but it also compromises health care delivery. In 2018, the Medscape National Physician Burnout and Depression Report surveyed 15,000 physicians from 29 specialties; 33% of the respondents said that they were more easily frustrated by patients, and 32% reported less personal engagement.⁹ Burnout adversely impacts care, patient satisfaction, productivity, physician retention, retirement, and income, as well.⁶ Safety during clinical practice deteriorates because of an increase in medical error rates.¹⁰ Resultant emotional distress for physicians creates a vicious cycle.¹⁰

[polldaddy:10427848]

Continue to: These issues negatively impact...

These issues negatively impact practice enthusiasm and may engender self-doubt.¹¹ They may lead to absenteeism or, worse, to abandoning the profession, further contributing to physician shortages.¹² The financial impact of physician burnout in lost revenue in 2018 was about $17 billion, according to the National Taskforce for Humanity in ­Medicine.¹³

How prevalent is physician burnout?

Between October 2012 and March 2013, the American Society of Clinical Oncology surveyed US oncologists and found that 45% had evidence of burnout.¹⁴ In another survey of US physicians from all specialties conducted in 2011, at least 1 symptom of burnout was documented in nearly 46% of respondents.¹⁵ By 2014, this percentage increased to 54%.¹⁶

In 2018, the Medscape National Physician Burnout and Depression Report indicated that 42% of physicians admitted to some burnout, while 12% said they were unhappy at work, and 3% reported being clinically depressed.⁹ About 48% of female practitioners reported burnout vs 38% of male peers.⁹ Work-related distress varies between specialties, with internists, family physicians, intensivists, neurologists, and gynecologists more affected than those from other specialties.⁹

Causes and contributing factors

Job stress generally increases with changes in the workplace. This can be heightened in the health care workplace, which demands perfection and leaves little room for emotional issues. Loss of autonomy, time constraints associated with clinical care, electronic health record (EHR) documentation, and disorganized workflow tend to contribute to provider dissatisfaction and stress, as do ethical disagreements about patient care between physicians and leadership.^10,17 Fear of reprisal for speaking up about such issues can further exacerbate the problem. Some older physicians may have difficulty with technology and computerized record keeping. Reduced patient contact due to increasing reliance on computers can diminish physicians’ job satisfaction. And managing recurrent or difficult-to-treat ailments can result in compassion fatigue, diminished empathy, and emotional disengagement.

Burnout in the health care workplace is inconsistently addressed, despite negative professional and personal ramifications. The reasons include denial, uncertainty about monetary implications, and lack of corrective programs by decision-making organizations and/or employers.⁶ American medicine has lacked the political and financial will to implement strategies to mitigate burnout. Improvement requires changes on the part of government, physician groups, and the population at large.

The answer?

A multipronged approach

Identifying burnout is the first step in management. The 22-item Maslach Burnout Inventory (MBI) is a self-reporting questionnaire, reliable at detecting and assessing burnout severity.¹⁸ It screens 3 main domains: emotional exhaustion, depersonalization, and diminished feelings of accomplishment. The American Medical Association recommends the 10-item Zero Burnout Program—the “Mini Z Survey”—as being quicker and more convenient.¹⁹

Once the problem is recognized, experts suggest adopting a multipronged approach to prevention and intervention by using personal, organizational, and legislative strategies.²⁰

Continue to: On a personal level...

On a personal level, it’s important to identify stressors and employ stress-reduction and coping skills, such as mindfulness and/or reflection.²¹ Mindfulness programs may help to minimize exhaustion, increase compassion, and improve understanding of other people’s feelings.²² Such programs are widely available and may be accessed through the Internet, mental health centers, or by contacting psychiatric or psychological services.

Other self-care methods include ensuring adequate sleep, nutrition, exercise, and enjoyable activities. If a physician who is suffering from burnout is taking any prescription or over-the-counter drugs or supplements, it is important to be self-aware of the potential for misuse of medications. Of course, one should never self-prescribe controlled drugs, such as opiates and sedatives. Consumption of alcohol must be well-controlled, without excesses, and drinking near bedtime is ill-advised. The use of illegal substances should be avoided.

Pursuing aspects of health care that are meaningful and that increase patient contact time can boost enthusiasm, as can focusing on the positives aspects of one’s career.²³ Continuing medical education can enhance self-esteem and promote a sense of purpose.²⁴

Peer support. Practice partners may assist their colleagues by alerting them to signs of burnout, offering timely intervention suggestions, and monitoring the effectiveness of strategies. Physicians should discuss stress and burnout with their peers; camaraderie within a practice group is helpful.

Professional coaches or counselors may be engaged to mitigate workplace distress. Coaching is best instituted collegially with pre-identified goals in order to minimize stigmatization.

Continue to: Professional societies and medical boards

Professional societies and medical boards. Reporting requirements by medical boards tend to stigmatize those seeking professional assistance. But that could change if all of us—through our participation in these organizations—pursue change.

Specifically, organizations and related societies could assist with better guidance and policy adjustment (see “Resources”). State medical boards could, for example, increase education of, and outreach to, physicians about mental health issues, while maintaining confidentiality.²⁵ Medical organizations could regularly survey their membership to identify burnout early and identify personal, social, and institutional shortcomings that contribute to physician burnout. In addition, hospital quality improvement committees that monitor health care delivery appropriateness could take steps toward change as well.

The American Medical Association (AMA) just recently announced that they are launching a new effort to fight the causes of physician burnout. The AMA’s Practice Transformation Inititative²⁶ seeks to fill the knowledge gaps regarding effective interventions to reduce burnout. AMA’s leadership indicates that the initiative will focus on “improving joy in medicine by using validated assessment tools to measure burnout; field-testing interventions that are designed to improve workflows, applying practice science research methodology to evaluate impact, and sharing best practices within an AMA-facilitated learning community.”²⁶

Stanford’s example. Stanford University instituted a ‘time bank’ program, to help their academic medical faculty balance work and life and reduce stress. They essentially offer services, such as home food delivery and house cleaning, in return for hours spent in the clinic.²⁷

Reorganizing and reprioritizing. Prioritizing physician wellness as a quality indicator and instituting a committee to advocate for wellness can help attenuate burnout.^28,29 Specific measures include minimizing rushed, overloaded scheduling and allowing more clinical contact time with patients. Using nursing and office staff to streamline workflow is also helpful.²⁹ The University of Colorado’s “Ambulatory Process Excellence Model” strives to assist doctors by increasing the medical assistant-to-clinician ratio, yielding better productivity.²³ Medical assistants are increasingly handling tasks such as data entry, medication reconciliation, and preventive care, to allow physicians more time to focus on medical decision-making.²³

Continue to: The role of the EHR

The role of the EHR. One important way to boost professional morale is to simplify and shorten the EHR. The complexity of and reduced patient contact caused by today’s record-keeping systems is the source of great frustration among many physicians. In addition, many patients dislike the disproportionate attention paid by physicians to the computer during office visits, further compromising physician-patient relationships. Improving documentation methodology and/or employing medical assistant scribes can be helpful.^30,31 (See “Advanced team-based care: How we made it work” at http://bit.ly/2lNaB5Q.)

Legislation with physician input can mandate policies for more appropriate work environments. A good way to initiate improvement and reform strategies is to contact local medical societies and political representatives. Federal and state collaboration to reduce physician shortages in selected specialties or geographic regions can improve work-related stress. This might be attained by expanding residency programs, using telemedicine in underserved regions, and employing more physician assistants.³²

Health insurance. Enhancing universal access to affordable medical care, including pharmaceutical coverage, would alleviate stress for physicians and patients alike.³³ Health insurance regulation to decrease paperwork and simplify coverage would decrease physician workload. Standardized policy requirements, fewer exclusionary rules, and simplified prescribing guidelines (including having less cumbersome prescription pre-authorizations and greater standardization of drug formularies by different payer sources or insurance plans) would facilitate better clinical management.

CASE

Dr. D begins by discussing his concerns with his colleagues in the group practice and finds he is not alone. Many of the concerns of the group center around brief, rushed appointments that diminish relationships with patients, a lack of autonomy, and the fear of medical malpractice. Several older physicians acknowledge that they just want to retire.

Stanford University instituted a "time bank" program that offers home food delivery and house cleaning in return for hours spent in the clinic.

To address the patient contact and documentation issues, the group decides to hire scribes. They also decide to bring their concerns to the next county medical society meeting. The end result: They petitioned their state medical association to host presentations about mitigating burnout, to hold roundtable discussions, and to establish panels focused on remedying the situation.

Continue to: With this accomplished...

With this accomplished, Dr. D’s anxieties lessened. He surveyed relevant literature and shared tips for improving professional time management with his partners. In a hopeful mood, he volunteered to address burnout prevention at the next statewide medical meeting. He felt it was a good start.

CORRESPONDENCE
Steven Lippmann, MD, 401 E. Chestnut Street, Suite 610, Louisville, KY 40202; steven.lippmann@louisville.edu.

CASE

Dr. Peter D is a mid-career family physician in a group practice that recently adopted an electronic health record system. Although he realizes he is now competent at computerized medicine, he has far less of the one-on-one patient contact that he once found so gratifying about the field of medicine.

Others in the practice have similar concerns, but they suggest that everyone ought to “go along to get along.” To manage the increasing demands of his case load and the required documentation, Dr. D has begun staying late to finish charting, which is negatively impacting his family life.

Dr. D finds himself burdened by record keeping that is increasingly complicated and insurance company demands that are onerous. Pharmaceutical prior authorizations that previously had been mildly bothersome are now a full-on burden. More often than not, he finds himself becoming irritable over extra requests and administrative demands, impatient with some patients and staff, and extremely fatigued at the end of workdays. Simply put, he finds that practicing medicine is far less enjoyable than it once was. He takes the Maslach Burnout Inventory, and his score indicates that he has moderate burnout.

©Joe Gorman/Shutterstock

Physician burnout has been a growing concern in recent decades.¹ Characterized by varying degrees of job dissatisfaction, cynicism, emotional exhaustion, clinical inefficiency, and depression, physician burnout can impede effective patient care, cause significant health issues among physicians, diminish professional gratification and feelings of accomplishment, and financially burden society as a whole. Here we present the information you need to recognize burnout in yourself and colleagues and address the problem on personal, organizational, and legislative levels.

A problem that affects physicians of all ages

Physician burnout has been recognized to present anywhere on a spectrum, manifesting as ineffectiveness, overextension, disengagement, and/or an inability to practice.² Such features may lead to feelings of professional inadequacy among even the highest functioning physicians.

In 2018, the Medscape National Physician Burnout and Depression Report indicated that 42% of physicians admitted to some burnout, while 12% said they were unhappy at work, and 3% reported being clinically depressed.

Burnout occurs in all stages of medical life—as students, residents, and practicing physicians.^3-6 Due to pressures in excess of coping capacity, some physicians will suffer from alcohol or other drug abuse, depression, and/or suicidal thinking.⁷ Stress and burnout can also result in musculoskeletal disorders, immune system dysfunction, cardiac pathology, and a shorter lifespan.⁸

Not only do individual practitioners suffer consequences from burnout, but it also compromises health care delivery. In 2018, the Medscape National Physician Burnout and Depression Report surveyed 15,000 physicians from 29 specialties; 33% of the respondents said that they were more easily frustrated by patients, and 32% reported less personal engagement.⁹ Burnout adversely impacts care, patient satisfaction, productivity, physician retention, retirement, and income, as well.⁶ Safety during clinical practice deteriorates because of an increase in medical error rates.¹⁰ Resultant emotional distress for physicians creates a vicious cycle.¹⁰

[polldaddy:10427848]

Continue to: These issues negatively impact...

These issues negatively impact practice enthusiasm and may engender self-doubt.¹¹ They may lead to absenteeism or, worse, to abandoning the profession, further contributing to physician shortages.¹² The financial impact of physician burnout in lost revenue in 2018 was about $17 billion, according to the National Taskforce for Humanity in ­Medicine.¹³

How prevalent is physician burnout?

Between October 2012 and March 2013, the American Society of Clinical Oncology surveyed US oncologists and found that 45% had evidence of burnout.¹⁴ In another survey of US physicians from all specialties conducted in 2011, at least 1 symptom of burnout was documented in nearly 46% of respondents.¹⁵ By 2014, this percentage increased to 54%.¹⁶

In 2018, the Medscape National Physician Burnout and Depression Report indicated that 42% of physicians admitted to some burnout, while 12% said they were unhappy at work, and 3% reported being clinically depressed.⁹ About 48% of female practitioners reported burnout vs 38% of male peers.⁹ Work-related distress varies between specialties, with internists, family physicians, intensivists, neurologists, and gynecologists more affected than those from other specialties.⁹

Causes and contributing factors

Job stress generally increases with changes in the workplace. This can be heightened in the health care workplace, which demands perfection and leaves little room for emotional issues. Loss of autonomy, time constraints associated with clinical care, electronic health record (EHR) documentation, and disorganized workflow tend to contribute to provider dissatisfaction and stress, as do ethical disagreements about patient care between physicians and leadership.^10,17 Fear of reprisal for speaking up about such issues can further exacerbate the problem. Some older physicians may have difficulty with technology and computerized record keeping. Reduced patient contact due to increasing reliance on computers can diminish physicians’ job satisfaction. And managing recurrent or difficult-to-treat ailments can result in compassion fatigue, diminished empathy, and emotional disengagement.

Burnout in the health care workplace is inconsistently addressed, despite negative professional and personal ramifications. The reasons include denial, uncertainty about monetary implications, and lack of corrective programs by decision-making organizations and/or employers.⁶ American medicine has lacked the political and financial will to implement strategies to mitigate burnout. Improvement requires changes on the part of government, physician groups, and the population at large.

The answer?

A multipronged approach

Identifying burnout is the first step in management. The 22-item Maslach Burnout Inventory (MBI) is a self-reporting questionnaire, reliable at detecting and assessing burnout severity.¹⁸ It screens 3 main domains: emotional exhaustion, depersonalization, and diminished feelings of accomplishment. The American Medical Association recommends the 10-item Zero Burnout Program—the “Mini Z Survey”—as being quicker and more convenient.¹⁹

Once the problem is recognized, experts suggest adopting a multipronged approach to prevention and intervention by using personal, organizational, and legislative strategies.²⁰

Continue to: On a personal level...

On a personal level, it’s important to identify stressors and employ stress-reduction and coping skills, such as mindfulness and/or reflection.²¹ Mindfulness programs may help to minimize exhaustion, increase compassion, and improve understanding of other people’s feelings.²² Such programs are widely available and may be accessed through the Internet, mental health centers, or by contacting psychiatric or psychological services.

Other self-care methods include ensuring adequate sleep, nutrition, exercise, and enjoyable activities. If a physician who is suffering from burnout is taking any prescription or over-the-counter drugs or supplements, it is important to be self-aware of the potential for misuse of medications. Of course, one should never self-prescribe controlled drugs, such as opiates and sedatives. Consumption of alcohol must be well-controlled, without excesses, and drinking near bedtime is ill-advised. The use of illegal substances should be avoided.

Pursuing aspects of health care that are meaningful and that increase patient contact time can boost enthusiasm, as can focusing on the positives aspects of one’s career.²³ Continuing medical education can enhance self-esteem and promote a sense of purpose.²⁴

Peer support. Practice partners may assist their colleagues by alerting them to signs of burnout, offering timely intervention suggestions, and monitoring the effectiveness of strategies. Physicians should discuss stress and burnout with their peers; camaraderie within a practice group is helpful.

Professional coaches or counselors may be engaged to mitigate workplace distress. Coaching is best instituted collegially with pre-identified goals in order to minimize stigmatization.

Continue to: Professional societies and medical boards

Professional societies and medical boards. Reporting requirements by medical boards tend to stigmatize those seeking professional assistance. But that could change if all of us—through our participation in these organizations—pursue change.

Specifically, organizations and related societies could assist with better guidance and policy adjustment (see “Resources”). State medical boards could, for example, increase education of, and outreach to, physicians about mental health issues, while maintaining confidentiality.²⁵ Medical organizations could regularly survey their membership to identify burnout early and identify personal, social, and institutional shortcomings that contribute to physician burnout. In addition, hospital quality improvement committees that monitor health care delivery appropriateness could take steps toward change as well.

The American Medical Association (AMA) just recently announced that they are launching a new effort to fight the causes of physician burnout. The AMA’s Practice Transformation Inititative²⁶ seeks to fill the knowledge gaps regarding effective interventions to reduce burnout. AMA’s leadership indicates that the initiative will focus on “improving joy in medicine by using validated assessment tools to measure burnout; field-testing interventions that are designed to improve workflows, applying practice science research methodology to evaluate impact, and sharing best practices within an AMA-facilitated learning community.”²⁶

Stanford’s example. Stanford University instituted a ‘time bank’ program, to help their academic medical faculty balance work and life and reduce stress. They essentially offer services, such as home food delivery and house cleaning, in return for hours spent in the clinic.²⁷

Reorganizing and reprioritizing. Prioritizing physician wellness as a quality indicator and instituting a committee to advocate for wellness can help attenuate burnout.^28,29 Specific measures include minimizing rushed, overloaded scheduling and allowing more clinical contact time with patients. Using nursing and office staff to streamline workflow is also helpful.²⁹ The University of Colorado’s “Ambulatory Process Excellence Model” strives to assist doctors by increasing the medical assistant-to-clinician ratio, yielding better productivity.²³ Medical assistants are increasingly handling tasks such as data entry, medication reconciliation, and preventive care, to allow physicians more time to focus on medical decision-making.²³

Continue to: The role of the EHR

The role of the EHR. One important way to boost professional morale is to simplify and shorten the EHR. The complexity of and reduced patient contact caused by today’s record-keeping systems is the source of great frustration among many physicians. In addition, many patients dislike the disproportionate attention paid by physicians to the computer during office visits, further compromising physician-patient relationships. Improving documentation methodology and/or employing medical assistant scribes can be helpful.^30,31 (See “Advanced team-based care: How we made it work” at http://bit.ly/2lNaB5Q.)

Legislation with physician input can mandate policies for more appropriate work environments. A good way to initiate improvement and reform strategies is to contact local medical societies and political representatives. Federal and state collaboration to reduce physician shortages in selected specialties or geographic regions can improve work-related stress. This might be attained by expanding residency programs, using telemedicine in underserved regions, and employing more physician assistants.³²

Health insurance. Enhancing universal access to affordable medical care, including pharmaceutical coverage, would alleviate stress for physicians and patients alike.³³ Health insurance regulation to decrease paperwork and simplify coverage would decrease physician workload. Standardized policy requirements, fewer exclusionary rules, and simplified prescribing guidelines (including having less cumbersome prescription pre-authorizations and greater standardization of drug formularies by different payer sources or insurance plans) would facilitate better clinical management.

CASE

Dr. D begins by discussing his concerns with his colleagues in the group practice and finds he is not alone. Many of the concerns of the group center around brief, rushed appointments that diminish relationships with patients, a lack of autonomy, and the fear of medical malpractice. Several older physicians acknowledge that they just want to retire.

Stanford University instituted a "time bank" program that offers home food delivery and house cleaning in return for hours spent in the clinic.

To address the patient contact and documentation issues, the group decides to hire scribes. They also decide to bring their concerns to the next county medical society meeting. The end result: They petitioned their state medical association to host presentations about mitigating burnout, to hold roundtable discussions, and to establish panels focused on remedying the situation.

Continue to: With this accomplished...

With this accomplished, Dr. D’s anxieties lessened. He surveyed relevant literature and shared tips for improving professional time management with his partners. In a hopeful mood, he volunteered to address burnout prevention at the next statewide medical meeting. He felt it was a good start.

CORRESPONDENCE
Steven Lippmann, MD, 401 E. Chestnut Street, Suite 610, Louisville, KY 40202; steven.lippmann@louisville.edu.

More than 64,000 people in the United States died of drug overdoses in 2016.¹ Of those overdose deaths, more than 34,000 were related to the use of natural (eg, codeine, morphine); synthetic (eg, fentanyl); and semisynthetic (eg, oxycodone, hydrocodone) opioids.¹ The number of drug-overdose fatalities (driven largely by opioids) has increased so dramatically in recent years that drug overdose is now the leading cause of intentional and unintentional injury-related death in the United States.² Furthermore, opioid use is increasing among college students, with many injecting these agents.³ Those injecting (as opposed to other routes of delivery) have the highest death rate.⁴

The Department of Health and Human Services has identified 3 important issues to address with regard to the opioid epidemic: prescriber education, community naloxone access, and better interventions (such as naloxone overdose-reversal take-home kits) for people with opioid use disorders and/or a history of overdoses.⁵ (For more on overdose reversal kits, see “What FPs need to know about naloxone kits,” a 3-in-3 video.) With these goals in mind, we provide the following review of naloxone dosing and postoverdose treatment.

Steps FPs can take to reverse the overdose

Opioids act on delta, kappa, and mu receptors in the brain to produce analgesic effects,⁶ but, in large quantities, their mu receptor activity can cause fatal respiratory depression.⁷ Some of the most commonly abused opioids are heroin and the prescription opioids fentanyl, oxycodone, and hydrocodone.⁸

People who have overdosed on opioids generally present with evidence of obtundation, miosis, and difficulty breathing. Respiratory failure is the most common cause of death.⁹ Hypothermia, compartment syndrome, rhabdomyolysis, renal failure, and acute pulmonary edema are less common complications. Overdoses and these medical issues can potentially be reversed and/or mitigated by naloxone administration.^10,11

Naloxone and its routes of administration. Naloxone is the agent of choice in overdose situations.¹² It works as an antagonist of the delta, kappa, and mu receptors,^6,13 has a rapid onset of action, and is associated with minimal adverse effects.¹⁴

Naloxone can be administered via the intravenous (IV), intranasal, intramuscular, subcutaneous, intraosseous, or endotracheal routes.⁶ Although IV administration has been the most common and is still generally preferred in the hospital setting, the intranasal route has gained favor, partly because it can be difficult to establish an IV in IV drug users and partly because it is easier for nonmedical people to administer.⁶

In addition, the nasal mucosa has an abundant blood supply resulting in rapid absorption. The drug reaches the systemic circulation quickly and avoids first-pass hepatic metabolism.⁶ Intranasal route absorption is enhanced by deep inhalation and patient cooperation, but it can still be effective in an unconscious patient. Response time is nearly the same as that with IV administration (both act within 1-2 mins).⁶

Naloxone has a short duration of action (shorter than that of some opiates), and its duration of action is influenced by the pharmacology and toxicity of the overdose drug.¹⁵ The serum half-life in adults ranges from 30 to 81 mins, and clinical impact varies from minutes to an hour.¹⁵ Thus, even if a patient initially improves after administration, close observation is mandatory due to the frequent need for repeat naloxone dosing.

Adverse effects. Naloxone is considered safe, with relatively few adverse effects and doesn’t have any effects on someone who isn’t experiencing an opioid overdose or currently on opioids.¹⁵ The only downside is that naloxone administration to an opioid-dependent person often precipitates an acute withdrawal event, characterized by global pain, agitation, generalized distress, and gastrointestinal complaints, including vomiting and diarrhea. Although withdrawal is not life-threatening, it can cause great discomfort.

Getting a handle on naloxone dosing

The starting dose of naloxone used to be 0.04 mg, but this was later increased to 0.4 mg. The advent and high overdose lethality of more potent drugs like fentanyl and carfentanil has made low-dose naloxone less effective.¹² 

Currently, 1 mg is often the initial recommendation, but doses of 2 to 4 mg are not uncommon, and multiple administrations or continuous IV administration are frequently needed to reverse severe toxicities, such as those involving fentanyl or longer-action opioids like methadone. Anyone exhibiting difficulty breathing mandates a starting naloxone dose of at least 1 to 2 mg.^12,16 In addition to breathing, additional doses are indicated clinically by medical parameters such as vital signs, ocular pupil diameter, and/or alertness.⁶

Intranasal administration often utilizes up to 4 mg of naloxone in one nostril, followed by a titrated additional administration in the other nostril. In life-threatening circumstances, especially those in which a patient is exhibiting respiratory depression, a much larger quantity of naloxone—up to 10 mg—may be administered by trained medical personnel.^12,16 In the end, all dosing varies and must be individualized to the patient’s signs and symptoms. Those who have overdosed require prolonged monitoring to treat potential complications.

Emergency assistance and transport. Because of the dangers that can result from opioid toxicities, any hint or evidence of physiologic compromise merits a 911 call for emergency medical assistance and transport to a hospital emergency department (ED). Hospitalization is at the physician’s discretion. 

Expanding the availability of naloxone in the community

The availability of naloxone overdose-reversal kits is growing among hospitals, other types of health care facilities, first responders, medical offices, and the general public. Distributing the kits to opioid users and their families has wide support but remains controversial (more on this in a bit).

Opioids are responsible for 61% of drug-overdose deaths.

Support even includes that from the current US Surgeon General, Jerome Adams, MD, MPH, who noted in a statement on April 5, 2018, the lifesaving success of opioid-overdose reversal naloxone kits by medical personnel, first responders, and other people. As a result, he formally recommended that more Americans keep such kits available in order to be able to quickly diminish opioid toxicities.^17,18 His advice was especially directed toward people at risk for an opioid overdose or anyone associated with opioid drug users.

Prehospital management of overdoses is ideally managed by emergency medical service (EMS) personnel,¹⁰ but even nonmedical people can safely administer naloxone. About 10,000 overdose cases were documented to have been reversed by nonmedical providers between 1996 and 2010.¹⁰ Many states have laws limiting the civil and criminal liability for naloxone administrators. New Mexico was the first state to legally allow naloxone administration by individuals without a prescription.⁷ Pharmacists often participate in efforts to counter opioid drug overdose deaths by offering naloxone administration kits, along with training about techniques of use, to people filling opioid prescriptions and to household members and/or other individuals in the social support network of an opioid user.⁶ Some physicians co-prescribe naloxone to patients along with opioid therapies during long-term pain management. Such dual prescribing is encouraged by many clinics.¹⁹ This method has decreased opioid overdose deaths in North Carolina,²⁰ in its army base at Fort Bragg,¹⁹ and in California.²¹

The issue of “risk compensation”

About 10,000 overdose cases were documented to have been reversed by nonmedical providers between 1996 and 2010.

To those who say that having naloxone available to users of opioids or those in their social network promotes even riskier behavior resulting in increased overdoses, research points to just the opposite. A nonrandomized study that examined co-prescribing naloxone to patients on chronic opioid therapy for non-cancer-related pain, documented fewer opioid-related ED visits following use by prescribers and patients at community health centers.²² Other research has demonstrated a reduced number of community-level opioid overdose deaths once opioid overdose education and community naloxone distribution were implemented.^23,24

After the overdose: Getting patients into treatment

After reversing initial toxicities, a protracted period of assessment is required to assure patient safety. Beyond prolonged observation after an overdose, it is critical to recommend and provide long-term substance abuse therapies. Simply reversing the overdose is not medically sufficient, even if postoverdose patients refuse such treatment referrals. The fact that many of these people subsequently die is evidence of the importance of adhering to a formal, long-term chemical dependence intervention program.

Persistent diligence is usually needed to convince a patient who has recovered from an acute drug overdose event to accept a treatment referral. Some EDs institute special teams to facilitate such referrals, using a multidisciplinary approach, including substance abuse counselors and social workers. Referral agencies are also sometimes included to aid patient acceptance and retention in drug abuse treatment interventions. (See "Resources" below for more information.)

CORRESPONDENCE
Steven Lippmann, MD, 401 East Chestnut Street, Suite 610, Louisville, KY 40202; Steven.lippmann@louisville.edu.

More than 64,000 people in the United States died of drug overdoses in 2016.¹ Of those overdose deaths, more than 34,000 were related to the use of natural (eg, codeine, morphine); synthetic (eg, fentanyl); and semisynthetic (eg, oxycodone, hydrocodone) opioids.¹ The number of drug-overdose fatalities (driven largely by opioids) has increased so dramatically in recent years that drug overdose is now the leading cause of intentional and unintentional injury-related death in the United States.² Furthermore, opioid use is increasing among college students, with many injecting these agents.³ Those injecting (as opposed to other routes of delivery) have the highest death rate.⁴

The Department of Health and Human Services has identified 3 important issues to address with regard to the opioid epidemic: prescriber education, community naloxone access, and better interventions (such as naloxone overdose-reversal take-home kits) for people with opioid use disorders and/or a history of overdoses.⁵ (For more on overdose reversal kits, see “What FPs need to know about naloxone kits,” a 3-in-3 video.) With these goals in mind, we provide the following review of naloxone dosing and postoverdose treatment.

Steps FPs can take to reverse the overdose

Opioids act on delta, kappa, and mu receptors in the brain to produce analgesic effects,⁶ but, in large quantities, their mu receptor activity can cause fatal respiratory depression.⁷ Some of the most commonly abused opioids are heroin and the prescription opioids fentanyl, oxycodone, and hydrocodone.⁸

People who have overdosed on opioids generally present with evidence of obtundation, miosis, and difficulty breathing. Respiratory failure is the most common cause of death.⁹ Hypothermia, compartment syndrome, rhabdomyolysis, renal failure, and acute pulmonary edema are less common complications. Overdoses and these medical issues can potentially be reversed and/or mitigated by naloxone administration.^10,11

Naloxone and its routes of administration. Naloxone is the agent of choice in overdose situations.¹² It works as an antagonist of the delta, kappa, and mu receptors,^6,13 has a rapid onset of action, and is associated with minimal adverse effects.¹⁴

Naloxone can be administered via the intravenous (IV), intranasal, intramuscular, subcutaneous, intraosseous, or endotracheal routes.⁶ Although IV administration has been the most common and is still generally preferred in the hospital setting, the intranasal route has gained favor, partly because it can be difficult to establish an IV in IV drug users and partly because it is easier for nonmedical people to administer.⁶

In addition, the nasal mucosa has an abundant blood supply resulting in rapid absorption. The drug reaches the systemic circulation quickly and avoids first-pass hepatic metabolism.⁶ Intranasal route absorption is enhanced by deep inhalation and patient cooperation, but it can still be effective in an unconscious patient. Response time is nearly the same as that with IV administration (both act within 1-2 mins).⁶

Naloxone has a short duration of action (shorter than that of some opiates), and its duration of action is influenced by the pharmacology and toxicity of the overdose drug.¹⁵ The serum half-life in adults ranges from 30 to 81 mins, and clinical impact varies from minutes to an hour.¹⁵ Thus, even if a patient initially improves after administration, close observation is mandatory due to the frequent need for repeat naloxone dosing.

Adverse effects. Naloxone is considered safe, with relatively few adverse effects and doesn’t have any effects on someone who isn’t experiencing an opioid overdose or currently on opioids.¹⁵ The only downside is that naloxone administration to an opioid-dependent person often precipitates an acute withdrawal event, characterized by global pain, agitation, generalized distress, and gastrointestinal complaints, including vomiting and diarrhea. Although withdrawal is not life-threatening, it can cause great discomfort.

Getting a handle on naloxone dosing

The starting dose of naloxone used to be 0.04 mg, but this was later increased to 0.4 mg. The advent and high overdose lethality of more potent drugs like fentanyl and carfentanil has made low-dose naloxone less effective.¹² 

Currently, 1 mg is often the initial recommendation, but doses of 2 to 4 mg are not uncommon, and multiple administrations or continuous IV administration are frequently needed to reverse severe toxicities, such as those involving fentanyl or longer-action opioids like methadone. Anyone exhibiting difficulty breathing mandates a starting naloxone dose of at least 1 to 2 mg.^12,16 In addition to breathing, additional doses are indicated clinically by medical parameters such as vital signs, ocular pupil diameter, and/or alertness.⁶

Intranasal administration often utilizes up to 4 mg of naloxone in one nostril, followed by a titrated additional administration in the other nostril. In life-threatening circumstances, especially those in which a patient is exhibiting respiratory depression, a much larger quantity of naloxone—up to 10 mg—may be administered by trained medical personnel.^12,16 In the end, all dosing varies and must be individualized to the patient’s signs and symptoms. Those who have overdosed require prolonged monitoring to treat potential complications.

Emergency assistance and transport. Because of the dangers that can result from opioid toxicities, any hint or evidence of physiologic compromise merits a 911 call for emergency medical assistance and transport to a hospital emergency department (ED). Hospitalization is at the physician’s discretion. 

Expanding the availability of naloxone in the community

The availability of naloxone overdose-reversal kits is growing among hospitals, other types of health care facilities, first responders, medical offices, and the general public. Distributing the kits to opioid users and their families has wide support but remains controversial (more on this in a bit).

Opioids are responsible for 61% of drug-overdose deaths.

Support even includes that from the current US Surgeon General, Jerome Adams, MD, MPH, who noted in a statement on April 5, 2018, the lifesaving success of opioid-overdose reversal naloxone kits by medical personnel, first responders, and other people. As a result, he formally recommended that more Americans keep such kits available in order to be able to quickly diminish opioid toxicities.^17,18 His advice was especially directed toward people at risk for an opioid overdose or anyone associated with opioid drug users.

Prehospital management of overdoses is ideally managed by emergency medical service (EMS) personnel,¹⁰ but even nonmedical people can safely administer naloxone. About 10,000 overdose cases were documented to have been reversed by nonmedical providers between 1996 and 2010.¹⁰ Many states have laws limiting the civil and criminal liability for naloxone administrators. New Mexico was the first state to legally allow naloxone administration by individuals without a prescription.⁷ Pharmacists often participate in efforts to counter opioid drug overdose deaths by offering naloxone administration kits, along with training about techniques of use, to people filling opioid prescriptions and to household members and/or other individuals in the social support network of an opioid user.⁶ Some physicians co-prescribe naloxone to patients along with opioid therapies during long-term pain management. Such dual prescribing is encouraged by many clinics.¹⁹ This method has decreased opioid overdose deaths in North Carolina,²⁰ in its army base at Fort Bragg,¹⁹ and in California.²¹

The issue of “risk compensation”

About 10,000 overdose cases were documented to have been reversed by nonmedical providers between 1996 and 2010.

To those who say that having naloxone available to users of opioids or those in their social network promotes even riskier behavior resulting in increased overdoses, research points to just the opposite. A nonrandomized study that examined co-prescribing naloxone to patients on chronic opioid therapy for non-cancer-related pain, documented fewer opioid-related ED visits following use by prescribers and patients at community health centers.²² Other research has demonstrated a reduced number of community-level opioid overdose deaths once opioid overdose education and community naloxone distribution were implemented.^23,24

After the overdose: Getting patients into treatment

After reversing initial toxicities, a protracted period of assessment is required to assure patient safety. Beyond prolonged observation after an overdose, it is critical to recommend and provide long-term substance abuse therapies. Simply reversing the overdose is not medically sufficient, even if postoverdose patients refuse such treatment referrals. The fact that many of these people subsequently die is evidence of the importance of adhering to a formal, long-term chemical dependence intervention program.

Persistent diligence is usually needed to convince a patient who has recovered from an acute drug overdose event to accept a treatment referral. Some EDs institute special teams to facilitate such referrals, using a multidisciplinary approach, including substance abuse counselors and social workers. Referral agencies are also sometimes included to aid patient acceptance and retention in drug abuse treatment interventions. (See "Resources" below for more information.)

CORRESPONDENCE
Steven Lippmann, MD, 401 East Chestnut Street, Suite 610, Louisville, KY 40202; Steven.lippmann@louisville.edu.

More than 64,000 people in the United States died of drug overdoses in 2016.¹ Of those overdose deaths, more than 34,000 were related to the use of natural (eg, codeine, morphine); synthetic (eg, fentanyl); and semisynthetic (eg, oxycodone, hydrocodone) opioids.¹ The number of drug-overdose fatalities (driven largely by opioids) has increased so dramatically in recent years that drug overdose is now the leading cause of intentional and unintentional injury-related death in the United States.² Furthermore, opioid use is increasing among college students, with many injecting these agents.³ Those injecting (as opposed to other routes of delivery) have the highest death rate.⁴

The Department of Health and Human Services has identified 3 important issues to address with regard to the opioid epidemic: prescriber education, community naloxone access, and better interventions (such as naloxone overdose-reversal take-home kits) for people with opioid use disorders and/or a history of overdoses.⁵ (For more on overdose reversal kits, see “What FPs need to know about naloxone kits,” a 3-in-3 video.) With these goals in mind, we provide the following review of naloxone dosing and postoverdose treatment.

Steps FPs can take to reverse the overdose

Opioids act on delta, kappa, and mu receptors in the brain to produce analgesic effects,⁶ but, in large quantities, their mu receptor activity can cause fatal respiratory depression.⁷ Some of the most commonly abused opioids are heroin and the prescription opioids fentanyl, oxycodone, and hydrocodone.⁸

People who have overdosed on opioids generally present with evidence of obtundation, miosis, and difficulty breathing. Respiratory failure is the most common cause of death.⁹ Hypothermia, compartment syndrome, rhabdomyolysis, renal failure, and acute pulmonary edema are less common complications. Overdoses and these medical issues can potentially be reversed and/or mitigated by naloxone administration.^10,11

Naloxone and its routes of administration. Naloxone is the agent of choice in overdose situations.¹² It works as an antagonist of the delta, kappa, and mu receptors,^6,13 has a rapid onset of action, and is associated with minimal adverse effects.¹⁴

Naloxone can be administered via the intravenous (IV), intranasal, intramuscular, subcutaneous, intraosseous, or endotracheal routes.⁶ Although IV administration has been the most common and is still generally preferred in the hospital setting, the intranasal route has gained favor, partly because it can be difficult to establish an IV in IV drug users and partly because it is easier for nonmedical people to administer.⁶

In addition, the nasal mucosa has an abundant blood supply resulting in rapid absorption. The drug reaches the systemic circulation quickly and avoids first-pass hepatic metabolism.⁶ Intranasal route absorption is enhanced by deep inhalation and patient cooperation, but it can still be effective in an unconscious patient. Response time is nearly the same as that with IV administration (both act within 1-2 mins).⁶

Naloxone has a short duration of action (shorter than that of some opiates), and its duration of action is influenced by the pharmacology and toxicity of the overdose drug.¹⁵ The serum half-life in adults ranges from 30 to 81 mins, and clinical impact varies from minutes to an hour.¹⁵ Thus, even if a patient initially improves after administration, close observation is mandatory due to the frequent need for repeat naloxone dosing.

Adverse effects. Naloxone is considered safe, with relatively few adverse effects and doesn’t have any effects on someone who isn’t experiencing an opioid overdose or currently on opioids.¹⁵ The only downside is that naloxone administration to an opioid-dependent person often precipitates an acute withdrawal event, characterized by global pain, agitation, generalized distress, and gastrointestinal complaints, including vomiting and diarrhea. Although withdrawal is not life-threatening, it can cause great discomfort.

Getting a handle on naloxone dosing

The starting dose of naloxone used to be 0.04 mg, but this was later increased to 0.4 mg. The advent and high overdose lethality of more potent drugs like fentanyl and carfentanil has made low-dose naloxone less effective.¹² 

Currently, 1 mg is often the initial recommendation, but doses of 2 to 4 mg are not uncommon, and multiple administrations or continuous IV administration are frequently needed to reverse severe toxicities, such as those involving fentanyl or longer-action opioids like methadone. Anyone exhibiting difficulty breathing mandates a starting naloxone dose of at least 1 to 2 mg.^12,16 In addition to breathing, additional doses are indicated clinically by medical parameters such as vital signs, ocular pupil diameter, and/or alertness.⁶

Intranasal administration often utilizes up to 4 mg of naloxone in one nostril, followed by a titrated additional administration in the other nostril. In life-threatening circumstances, especially those in which a patient is exhibiting respiratory depression, a much larger quantity of naloxone—up to 10 mg—may be administered by trained medical personnel.^12,16 In the end, all dosing varies and must be individualized to the patient’s signs and symptoms. Those who have overdosed require prolonged monitoring to treat potential complications.

Emergency assistance and transport. Because of the dangers that can result from opioid toxicities, any hint or evidence of physiologic compromise merits a 911 call for emergency medical assistance and transport to a hospital emergency department (ED). Hospitalization is at the physician’s discretion. 

Expanding the availability of naloxone in the community

The availability of naloxone overdose-reversal kits is growing among hospitals, other types of health care facilities, first responders, medical offices, and the general public. Distributing the kits to opioid users and their families has wide support but remains controversial (more on this in a bit).

Opioids are responsible for 61% of drug-overdose deaths.

Support even includes that from the current US Surgeon General, Jerome Adams, MD, MPH, who noted in a statement on April 5, 2018, the lifesaving success of opioid-overdose reversal naloxone kits by medical personnel, first responders, and other people. As a result, he formally recommended that more Americans keep such kits available in order to be able to quickly diminish opioid toxicities.^17,18 His advice was especially directed toward people at risk for an opioid overdose or anyone associated with opioid drug users.

Prehospital management of overdoses is ideally managed by emergency medical service (EMS) personnel,¹⁰ but even nonmedical people can safely administer naloxone. About 10,000 overdose cases were documented to have been reversed by nonmedical providers between 1996 and 2010.¹⁰ Many states have laws limiting the civil and criminal liability for naloxone administrators. New Mexico was the first state to legally allow naloxone administration by individuals without a prescription.⁷ Pharmacists often participate in efforts to counter opioid drug overdose deaths by offering naloxone administration kits, along with training about techniques of use, to people filling opioid prescriptions and to household members and/or other individuals in the social support network of an opioid user.⁶ Some physicians co-prescribe naloxone to patients along with opioid therapies during long-term pain management. Such dual prescribing is encouraged by many clinics.¹⁹ This method has decreased opioid overdose deaths in North Carolina,²⁰ in its army base at Fort Bragg,¹⁹ and in California.²¹

The issue of “risk compensation”

About 10,000 overdose cases were documented to have been reversed by nonmedical providers between 1996 and 2010.

To those who say that having naloxone available to users of opioids or those in their social network promotes even riskier behavior resulting in increased overdoses, research points to just the opposite. A nonrandomized study that examined co-prescribing naloxone to patients on chronic opioid therapy for non-cancer-related pain, documented fewer opioid-related ED visits following use by prescribers and patients at community health centers.²² Other research has demonstrated a reduced number of community-level opioid overdose deaths once opioid overdose education and community naloxone distribution were implemented.^23,24

After the overdose: Getting patients into treatment

After reversing initial toxicities, a protracted period of assessment is required to assure patient safety. Beyond prolonged observation after an overdose, it is critical to recommend and provide long-term substance abuse therapies. Simply reversing the overdose is not medically sufficient, even if postoverdose patients refuse such treatment referrals. The fact that many of these people subsequently die is evidence of the importance of adhering to a formal, long-term chemical dependence intervention program.

Persistent diligence is usually needed to convince a patient who has recovered from an acute drug overdose event to accept a treatment referral. Some EDs institute special teams to facilitate such referrals, using a multidisciplinary approach, including substance abuse counselors and social workers. Referral agencies are also sometimes included to aid patient acceptance and retention in drug abuse treatment interventions. (See "Resources" below for more information.)

CORRESPONDENCE
Steven Lippmann, MD, 401 East Chestnut Street, Suite 610, Louisville, KY 40202; Steven.lippmann@louisville.edu.