Well, things are changing quite drastically in the U.S. due to the ongoing pandemic. While first writing this article, things were actually looking good for the U.S. We thought we were seeing light at the end of the tunnel due to the numerous vaccines and a large number of Americans being vaccinated. COVID-19 cases were decreasing, many states were confident and had thus eased restrictions and regulations surrounding social distancing, allowing businesses to open up. Healthcare providers who have been ensuring patient care via virtual means were also opening up for in-person visits. Unfortunately, things did not remain positive for long – the pandemic is far from over.
COVID-19 cases in certain states are once again rising with increasing the pressure on healthcare providers. Once again, some hospitals are choosing to postpone elective procedures, whereas others are updating visitation policies for the patients. Moreover, hospitals are now getting filled with regular patients as well as COVID-19 patients. Thus, healthcare providers must focus on enhancing patient safety and risk management to reduce unwanted incidents and enhance healthcare outcomes.
COVID-19 has changed everything
The pandemic has changed everything for the entire world – one can say that it has shaken the word’s core, figuratively. For instance, many of us are still working remotely and practicing social distancing. However, the biggest changes, arguably, occurred in hospitals and health systems – telehealth became one of the only ways to ensure patient care during the pandemic and it looks like telehealth will become a permanent part of healthcare. Before diving into patient safety and risk management in the post-pandemic era, let’s see how it was before the pandemic.
1. In patient safety and risk management, patient misidentification is a common theme
Quite simply, patient safety focuses on preventing patient harm during the treatment process so that unwanted incidents don’t hamper healthcare outcomes.
Now patient safety incidents occur because several reasons, such as diagnostic testing errors, medication errors, patient falls, among other issues. While these topics have been widely discussed by experts, let’s take a look at a less discussed but crucial problem that causes patient safety incidents in many ways – patient misidentification.
Patient misidentification isn’t anything new – in fact, it has existed for decades due to a variety of reasons. However, a lot of patient safety incidents can be traced back to patient misidentification.
2. Patient misidentification causes patient record mix-ups
This one’s quite simple – when a patient comes for an in-person visit, s/he is assigned the wrong medical record due to misidentification. As a result, any subsequent action will most definitely lead to a patient safety incident as the patient will receive wrong treatment, medication, and so on.
However, if by some miracle, the patient who came in doesn’t face any harm – does it mean that future patient safety incidents won’t occur? What about the patient whose EHR was used?
3. Patient misidentification jeopardizes patient data integrity
This answers the question asked in the previous point. Whenever a medical record is used for someone else other than the actual patient, it leads to patient data integrity failure. Not only is the information in the EHR corrupt, but it also becomes quite dangerous. Just imagine that the patient who has heart disease is getting prescribed medication for chronic kidney disease – the consequences can be quite disastrous!
4. Patient misidentification generates preventable medical errors
This is closely tied to the previous points and is a consequence of them. When a patient is misidentified, they will be getting the wrong treatment, radiation overdoses, blood transfusion errors, wrong medication, and so on. While patients are usually misidentified during the registration process, it might also occur during treatment, and both of them lead to detrimental healthcare outcomes. However dangerous these events might seem, they are entirely preventable if patients are accurately identified.
While these were some of the patient safety and risk management issues in the pre-pandemic era, what do caregivers need to do in the post-pandemic one?
5. Improving patient safety in a post-pandemic world
To be honest, there are still many unresolved issues within healthcare facilities that jeopardize patient safety and risk management. However, the pandemic has added more issues into the mix – as a result, caregivers need to work on all of the problems simultaneously.
So, how can caregivers focus on patient safety as some of them are opening their doors to in-person visits?
Continue providing virtual healthcare sessions
Starting off, we all know how the pandemic has shown the many advantages of telehealth. Fortunately, a lot of patients have accepted telehealth and are even wanting to continue using it after the national health emergency is over.
If the caregivers continue to provide telehealth services, they can keep patient volumes down within their facilities and continue treating everyone. This ensures patient safety as lesser patients come in for in-person visits and keep HAIs (hospital-acquired infections) at bay.
6. Ensure everyone is properly wearing PPE
While it looked like the pandemic was waning in the U.S., COVID-19 cases have increased once again. We’re still at a critical stage, and as new infectious and dangerous variants are popping up, healthcare providers must ensure the safety of everyone that comes into their facilities.
Enforcing PPE usage on everyone is the only way to safeguard both patients and caregivers. While restrictions might have eased for other industries, enforcing PPE usage on people who visit the hospitals can reduce infections and even save lives in the process.
7. Utilize solutions that eliminate physical touch
Due to the pandemic, many organizations are working towards innovative solutions, one of which is making them contactless or at least reducing the number of physical interactions required. This is more applicable for healthcare facilities, as these are places where patients might become victims of HAIs.
While many organizations are coming up with contactless solutions, some already exist, for instance, many healthcare providers are using a touchless patient identification platform. Not only does such a solution help ensure positive patient identification, but it also reduces the risk of HAIs as it’s contactless.
Hospitals must protect patients at all costs
Patient safety incidents have always been an issue of the U.S. healthcare system, and with COVID-19 cases spiking once again, it looks like hospitals and health systems have their hands full. However, with careful planning, utilizing appropriate strategies, and making informed decisions, hospitals can prevent deaths, medication errors, mix-ups, and more – improving patient safety in the process.
My second grader’s almond-shaped brown eyes widened over the doubled-up N95 and cloth masks I’d instructed her and her older sister to wear that day. There, in the foyer of her school, stood her unmasked principal, greeting the hundreds of families who were flocking to a July 29 open house.
We passed by the front office staff, also mostly unmasked. In the crowds we observed, there were as many unmasked parents and children as masked ones.Families bumped into each other in hallways as they searched for classrooms. They lined up in the cafeteria to sign up for PTA and extracurricular activities. The cafeteria, we were told, would be back to full capacity the following Monday, the first day of school in Cobb County, Georgia. Unlike last school year, when my girls had attended virtually, there would be no more social distancing when it came time to eat.
We found my younger daughter’s classroom. The maskless homeroom teacher presented a slideshow of her family’s summer adventures. Her classroom partner, a Spanish-language teacher who was paired with her as part of the school’s dual-language immersion program, donned a mask that matched her outfit.“Will you be masked while teaching?” asked a masked parent from the back of the crowded classroom.
“I will not,” the homeroom teacher answered, emphasizing the “not.”
“I will,” her Spanish-language teaching partner answered.
A few miles away, at about the same time the doors to the open house swung open, Dr. Janet Memark, director of public health for Cobb and Douglas counties, sat down in a conference room to record a somber update.
“We are up to 235 cases per 100,000 since last night” for new infections over a two-week period, Memark said, delivering a message for community channels, news outlets and YouTube.
“So that has blown us past high transmission,” she said.
“And I heard today our numbers are looking even worse.”
Back in early May, when my family had to decide whether to send our daughters to their suburban Atlanta school for face-to-face learning in the upcoming school year, I was comfortable with the decision to let them go back. The coronavirus caseload in Cobb County at the time was low. Plus, the school had a mask mandate.
By the time of the open house, neither was true. Cobb County reversed course on its mask mandate in June and refused to budge even after the Centers for Disease Control and Prevention, whose headquarters is two counties over, on July 27 recommended masking for all K-12 students and teachers,even vaccinated ones.
Three days before the open house, we had requested to change our decision and return to virtual learning. The superintendent’s office denied our request. Too late, it said.
Cobb County Schools, the second largest school district in Georgia and among the first major metro districts nationwide to reopen for the 2021-22 school year, is one of only two of the eight districts in metro Atlanta’s five-county region without a mask mandate. The other is the city school system in Cobb’s county seat, Marietta, which operates as its own district and which ProPublica wrote about last year for its then-rare decision, among Georgia districts, to require masks.
“It’s disappointing that the districts are not implementing the strategies recommended by the CDC to keep these kids safe when there is moderate to high transmission,” said Elizabeth Stuart, a biostatistician at the Johns Hopkins Bloomberg School of Public Health, in reference to the metro Atlanta school districts that are not requiring masks. “It puts families into these really challenging situations.”
The school districts weren’t even heeding the warning of their county’s own public health director: “My best advice is that you go with the CDC recommendations. They are that everybody in K through 12 need to wear their mask,” Memark implored those watching her July 29 recording.
Asked why Cobb County Schools deviated from the CDC and its own county’s public health director on a mask mandate, a district spokesperson would only respond that its public health protocols “are intended to balance the importance of in-person learning and the frequent changes associated with COVID-19. This pandemic continues to impact students, staff, and families differently throughout Cobb County, and we will continue to update our school protocols accordingly.”
When I walked into that open house, I reminded myself of my husband’s words from earlier that morning: “Have an open mind.” When I walked out, I knew there was nothing that would make me feel safe sending my girls to school on Monday.
The car ride home from the open house was filled with excited back-to-school banter between the girls and my husband. I was silent, waiting for him to pull into the driveway and drop me off so he could take the kids for Happy Meals. He and I had planned to talk that night, after the girls and our toddler son went to bed. But I wasn’t sure I could wait that long.
I ignored the knot in my stomach and focused on figuring out Plan B.
Our immediate alternatives were private school (though we could scarcely afford it, and admissions had closed for most of them), home schooling (but what about our jobs?) or moving to another district (if we could find a house in this manic real estate market).
Waiting for my husband to come back from lunch, I threw up a prayer and tried to secure one more last-ditch option. I entered our daughters into a lottery for a virtual-only charter school that had just opened a few hundred additional slots statewide. It was the only free, accredited and teacher-led virtual alternative at the time.
Within five minutes, I received a response: They both got in.
When my husband got back, I intercepted him in the garage and sent the kids upstairs.
“Can we have a pre-meeting?” I begged, then launched right into it: “I don’t like what I saw at the school.”
He was less bothered by what he’d observed than by our girls forgoing another year of in-person learning, arguing that he hadn’t yet seen data to convince him they needed any more protection than their own masks. Besides, he said, if it got bad enough, wouldn’t the school have to go back to virtual learning, anyway?
I countered that the data we were reviewing was based on current behavior, noting that the transmission and hospitalization rates were rising before the kids even packed into the buildings.
That afternoon, between calls to my daughters’ pediatrician and their elementary school to get records that the virtual charter needed, I forwarded the virtual school information to other concerned parents. At least one of them tried to get in, two and a half hours after my attempt. It didn’t work: She was stuck on a waitlist.
The next morning, still locked in a stalemate with my husband, I stopped by the pediatrician’s office to pick up the immunization records I needed. “Am I the only one doing this?” I asked the receptionist.
“No, ma’am, you’re not alone,” she said, holding up a folder full of vaccine records awaiting other parents who’d changed course.
I then went to the elementary school to pick up my daughters’ report cards and un-enroll them. A staff member wrote their names alongside those of more than a dozen students who would not be showing up on the first day of school.
Later, I reached out to Cobb County Schools and other districts to determine how many parents had withdrawn their children in recent weeks. Most districts, including Cobb, said it was not a request they could immediately fulfill.
While I was out trying to handle the new school enrollment, my husband called to apologize. He thanked me for executing a new plan at a time when he was consumed with disappointment for the kids. He just wanted them to be happy, he said, and didn’t want them to feel defeated by the news of another year of virtual learning.
On Sunday, Aug. 1, the day before the first day of school, I wrote an email to Cobb County School District Superintendent Chris Ragsdale, Assistant Superintendent Ehsan Kattoula and the county school board, to let them know we were leaving the county school system for now. I noted that, as difficult as this process had been for us, I couldn’t imagine what other families in tougher spots with fewer resources must be facing.
School board member Charisse Davis, one of three members of the Democratic minority on the Cobb County School Board, wrote back: “With school starting tomorrow, we are hearing from so many parents who are flat out scared about what is going to happen. I have no answers as to why we are rejecting the public health guidelines.” She added, “It almost feels like the last 18 months didn’t happen. We are just back to normal because of what? Denial, fatigue, politics?”
Several parents I spoke with while reporting this story expressed skepticism that COVID-19 could harm them. “We go out to eat. We go to the grocery store. We’ve traveled all summer long,” said Ashley Gentile, a West Cobb mother of two elementary school students. She said that any member of her family could have gotten the virus anywhere, but none had. “For our family, it’s not alarming when we hear numbers have risen in certain schools and certain areas. It doesn’t make us want to keep our kids home.”
Sharon Abney, Gentile’s sister, who lives in East Cobb and is a physical therapist, said the data isn’t concerning to her.
“The kids, yeah, they’re gonna get it, but they’re probably going to be asymptomatic or have a really mild case,” she said. “There are people in our community who believe that because we’re choosing not to send our kids in a mask, we’re killing them. And that’s not what’s happening.”
The same day I sent my email to the district, screengrabs of a message to parents at Cobb County’s King Springs Elementary School, near my daughters’ now-former school, began circulating on social media and in my parent text groups. The message concerned the school’s open house three days earlier. Up top it said in bold red: “Covid-19 Low Risk Letter.”
“Good Evening Everyone,” it read. “We are super excited to get this school year started! Following our wonderful Sneak A Peek on Thursday, we’ve been notified that several families have positive cases of Covid and attended our event. Since this was a fluid event with people mingling throughout the building, we thought it best to send a low risk letter to all families.”
The alert prompted Cobb County school board member Dr. Jaha Howard to request, the day before school started, an emergency meeting for the board to consider the repercussions of the district’s COVID-19 protocols when it came to keeping students safe.
Howard, a pediatric dentist whose three children attend Cobb schools, said he had spoken with dozens of parents who expressed a broad spectrum of opinions on masking in the classroom.
“You have a good number of parents who fundamentally would like to see less people getting infected and less people getting into the hospital, and they’re willing to do what needs to be done so that people don’t get sick,” Howard told me. “You have another group in this county and in this country that fundamentally believe that this virus has to run its course. And they’re not saying it out loud, but what I’m hearing between the lines is: ‘People are going to get sick. Some people are going to have to go to the hospital. Some people might tragically pass, but the best way through it is to literally allow it to take its course.’”
Howard had made previous unsuccessful attempts to get the school board to meet about COVID-19 protocol, including a meeting he tried to call between the board and Cobb’s public health director in June.
Like those previous appeals, his Aug. 1 request also was denied. Board Chair Randy Scramihorn did not respond to a request for comment.
The board’s most publicized agenda item in recent months, which came to a vote in June, had nothing to do with the pandemic. Rather, the board voted to ban critical race theory from its curriculum.
On Aug. 4, the third day of school, Cobb County Schools emailed parents to let them know the district had updated its COVID-19 protocols. One change was that masks, though still optional, were now “strongly encouraged.”
https://cdfac1b64c06c4257b660078a3ccf7fa.safeframe.googlesyndication.com/safeframe/1-0-38/html/container.htmlA more significant change had to do with quarantining. The district’s new protocol allowed asymptomatic students and staff who’d been in close contact with a person who’d tested positive to return to school the next day, as long as they agreed to wear a mask for 10 days. The previous protocol was to follow CDC and Georgia Department of Public Health quarantine guidelines, which call for asymptomatic unvaccinated people to isolate at home for between seven and 14 days following a close contact with a coronavirus-infected person.
Not only is Cobb County one of two districts to fail to adopt a mask mandate among the eight in metro Atlanta, but, as of Aug. 4, Cobb has a far more lenient quarantine protocol, too.
Asked what precipitated the change, a Cobb County Schools spokesperson pointed to an Aug. 2 order signed by DPH Commissioner Dr. Kathleen Toomey, which states: “Following guidance from the Centers for Disease Control and Prevention on quarantine remains the safest way to protect teachers and students from the spread of COVID-19. However, recognizing the importance of in-person learning, schools may elect to adhere to different quarantine requirements as developed by the local school district to facilitate in-person learning.”
Yet the order clarifies that schools should adopt “such different quarantine requirements as long as the point of exposure occurred in the school setting” and as long as those exposed remain asymptomatic.
Cobb County Schools did not directly address ProPublica’s questions about how the district would distinguish point of contact or if there was a threshold at which it would adopt a mask mandate.
Over a 12-day period between my children’s school open house and Aug. 9, the second Monday of school, Cobb County and much of the rest of Georgia and the South saw rapid growth in coronavirus infections. In Cobb, cases per 100,000 nearly doubled in that time and the positivity rate went up, as well, a sign that the virus was spreading rapidly.
On Aug. 10, Memark, the Cobb-Douglas public health director, told the Cobb County Board of Commissioners that child cases had grown by 60 percent in the past week — the first week of school — for kids between the ages of 5 and 17. On Aug. 8, Georgia’s seven-day average number of cases among 5- to 9-year-olds reached a peak higher than at any previous point in the pandemic. As of Wednesday, it was higher still.
That first week of school, instead of posting pictures of the kids’ first day and sitting each afternoon in the carpool pickup line, my husband and I tried to come up with a schedule to fill their days in advance of virtual school starting later in the month.
I also attempted to turn off the notifications from my elementary school chat group. But for some reason, I kept getting them.
On Aug. 6, an alert popped up. A mom wanted us to know that her kindergartner, whose sibling is in the classroom where my second-grader would have been, tested positive. She said she doubted the school would notify us.
The next morning, another mother confirmed that she herself had tested positive; her kids were negative so far.
The day after, another family’s three-year-old tested positive. Their school-aged child remained negative.
That night, a fourth mother’s friend was rounding out a 24-hour hospital stay with her kindergartner who’d tested positive. So had multiple classmates.
“If you have a little one in that class,” she wrote, “I suggest you get them tested.”
Mesothelioma is an aggressive form of cancer that concentrates on the layer of tissues surrounding the internal organs. The disease is usually caused by asbestos exposure (according to theAmerican Cancer Society, eight out of 10 cases can be traced to asbestos inhalation). It is rare, hard to treat, and the survival rates are daunting, so a patient who receives a mesothelioma diagnosis needs as much support as you can provide.
As patient educators, nurses can help to significantly ease patients’ fears and uncertainties. Below are some strategies to help you support a newly diagnosed mesothelioma patient, prepare them for living with this cancer, and encourage them to be active participants in their own treatment.
Mesothelioma Basics: Causes, Symptoms, and Treatments
Symptoms: There are four types of mesothelioma, all of which affect different areas of the body. However, pleural mesothelioma is the most common and is found in the lining of the lungs. The most common symptoms of mesothelioma—regardless of the type—include:
Coughing and wheezing
Fatigue and muscle weakness
Fever and night sweats
Loss of appetite
Unexplained weight loss
Diagnosis: It could take anywhere from 10–20 years after being exposed to asbestos for mesothelioma to develop. This can make it difficult for patients to remember when and where they were exposed— in part because the disease is often detected in the later stages. Also, the prognosis for mesothelioma is poor, with a life expectancy anywhere between 18 to 31 months.
Treatment: Current treatment options for mesothelioma include surgery, chemotherapy, radiation therapy, or a mix of the three. However, there are clinical trials that are continually being done to make advancements to these treatments.
Starting on the Right Foot: Educate, Communicate, and Guard Against Misinformation
Nurses and health professionals are responsible for assessing how the patient is feeling physically and emotionally, educating them and their families about treatment plans and potential outcomes, being aware of the patient’s lab results and medical history, and instructing them on where they can find support groups and further information.
Before you start relaying information to your patient, you’ll want to figure out the patient’s health literacy—their ability to understand health information. It’s important for nurses to know about health literacy because it improves communication with the patient and can greatly improve the outcome of their disease. If your patient is constantly missing appointments, giving excuses for why they can’t fill out their forms or read materials or are behaving overly nervous or indifferent, then they may have a low health literacy.
A lot of the information associated with mesothelioma can be upsetting and confusing.
Listen to patients if they say that they’re done learning for the day, and avoid overloading them with information all at one time.
In explaining a cancer diagnosis, avoid polysyllabic medical terms and jargon (but do point patients to a good glossary, so they can “study up”). You should also try to answercommon questions about mesothelioma (even if the patient tells you they don’t have any) to steer them away from 2 am Google sessions leading to dubious sources. Key questions to cover are:
What other tests will they need before and during treatment?
What are the goals of the treatments? Are they palliative or do they aim to cure the cancer?
How will the patient know when treatments are working?
How will treatments affect their everyday activities?
Lastly, nurses and healthcare providers should utilize teach-back to ensure that the patient understands the information they were given. Have them explain their disease, treatments, and other information as if they were discussing it with a friend or family member. Use this time to clear up any misinformation that the patient may have.
Get a Handle on their Learning Style
Everyone has different learning styles, so your education efforts should align with how the patient learns best. Find out what sort of learning materials s/he finds easiest to absorb.
Ask them if they would rather have their information given to them via text, video, audio, or in person. You could also ask if pictures, charts, and models are more helpful than just written words. Often providing the same information in multiple formats is the most effective way to share information.
Lastly, make sure that the patient’s family and friends have access to this information as well. These people act as a support system for them and will be able to help them remember facts once they’re at home. Give them the opportunity to ask questions, and give them materials to study. Include them in demonstrations and instructions.
Practice Your Caritas Processes
Mesothelioma is an aggressive disease that has a low survival rate. This is a scary fact, and your patient may be having a difficult time accepting it. It’s important to be sensitive to their feelings and to allow them the time to absorb the gravity of their disease. Here, more than ever, you will want to practice the classicWatson Caring Science principles such as being present, compassionate, sensitive, coaching, and understanding a patient’s need to express both positive and negative feelings.
You want to give your patient realistic expectations on how mesothelioma will affect their lives. However, you don’t want to use fear tactics to encourage them to do treatment or follow medication instructions. Instead, focus on the positive outcomes of them following these instructions.
Be mindful that a lot of the information associated with mesothelioma can be upsetting and confusing. Listen to patients if they say that they’re done learning for the day, and avoid overloading them with information all at one time. Following these practices will ensure that your patients will are well informed about their condition and the treatment options that are available to them.
Resources on Mesothelioma
To learn more about mesothelioma, check out these additional sources:
Coming off a year of being worked to the bone, burnout is more common than ever among nurses everywhere, and it’s about time we begin feeling better again. Prioritizing self-care is not selfish. Your emotional wellbeing matters and will help you show up as your best self at work and at home. I invite you to take a moment to pause, regroup, and figure out what you need to operate in a state of sustainable wellness for the sake of yourself, your loved ones, and your patients.
Here are some of my go-to strategies for navigating this time and living a balanced life:
1. Use Your Resources (You May Have More than You Realize)
For nurses working in a hospital setting or at a larger institution, there are often resources available that promote mental health and wellness, even if they are not well advertised. At Hospital for Special Surgery (HSS), we offer coaching in both one on one and group settings to help nurses voice and face a variety of fears in a safe environment. Educate yourself about your options and take advantage of resources your employer provides. Joining committees or support groups will help new nurses in particular build a foundation and feel like an integrated part of the hospital community. You don’t have to go it alone. If you are struggling, raise your hand.
2. Leave Work at Work
Carving out time for yourself can be a challenge, especially when so many of us in the nursing workforce act as caretakers both in our personal and professional lives. Daily time to reflect, take stock of how you feel, and allow yourself to think about something that brings you joy, even if they are small moments, can make a world of difference. Whether it is listening to a good audiobook on your commute, meditating before bed, or (for me) bird watching on your days off, find the activities that replenish you and remember you cannot take care of others if you are not taking care of yourself.
3. Give Your Body What It Needs
Our minds and our bodies are inextricably linked. When one is unwell, often so is the other. Making sure you are exercising during the day, getting a full night’s sleep, drinking enough fluids, and eating in a way that promotes health is essential to overall wellness and will boost your mood and increase your energy levels. Personally, I monitor how many steps I take in a day to ensure I’m maintaining a high level of activity and turn to Pilates after work to keep my body strong. Giving our bodies what they need to function at their best has a domino effect on our ability to think clearly and process our feelings.
4. Focus on Gratitude
Emotional fatigue is common and not your fault. Caring for others both physically and feeling invested in their well-being emotionally can take a toll on your mental health. For me, one of the key components of weathering this experience is gratitude. Recognizing the pieces of my daily life I am grateful for, and expressing gratitude to my colleagues and peers for their contributions keeps my spirits up and promotes a work environment where people feel appreciated and valued for all their physical, mental and emotional labor. A little thank you can go a long way.
5. Talk It Out
In an emotionally draining job like nursing, the buddy system is not just comforting, it is essential to persevering. Processing your experiences and sharing them with others helps both you and your colleagues feel supported and provides opportunities to learn from each other. Figure out who you communicate best with at your organization, and check in with them weekly to discuss the challenges you are both facing. Don’t be afraid to ask questions, and be honest about your emotions. For young nurses, it is immensely beneficial to hear seasoned colleagues share their stories, and know that they are not alone.
6. Get Vaccinated
Wellness means doing everything in your power to promote a healthy life for yourself and those around you. Today, that means protecting yourself and others from COVID and the Delta variant by getting vaccinated if you are not already. A big concern for many nurses is compromising their own health and spreading disease to their families as a result of caring for infectious patients. Take that worry out of the equation, ease your mind, and increase your sense of security by getting your shot as soon as possible.
Opioid therapy is complex. In recent years, a rise in opioid-related deaths and changing prescribing guidelines and regulatory policies have led many physicians to reduce daily doses for patients prescribed stable opioid therapy for chronic pain.
Some patients have reported that this dose reduction process—called tapering –has been difficult, sometimes involving worsened pain, symptoms of opioid withdrawal and depressed mood.
In a study published Aug. 3 in JAMA, a team of UC Davis Health researchers examined the potential risks of opioid dose tapering. Their study found that patients on stable opioid therapy who had their doses tapered had significantly higher rates of overdose and mental health crisis, compared to patients without dose reductions.
“Prescribers are really in a difficult position. There are conflicting desires of ameliorating pain among patients while reducing the risk of adverse outcomes related to prescriptions,” said Alicia Agnoli, assistant professor of Family and Community Medicine at UC Davis School of Medicine and first author on the study. “Our study shows an increased risk of overdose and mental health crisis following dose reduction. It suggests that patients undergoing tapering need significant support to safely reduce or discontinue their opioids.”
De-prescribing opioids for patients on long-term therapy
The study used enrollment records and medical and pharmacy claims for 113,618 patients prescribed stable higher opioid doses (the equivalent of at least 50 morphine milligrams per day) for a one-year baseline period and at least two months of follow-up.
It looked at emergency department visits or inpatient hospital admissions for any drug overdose, alcohol intoxication, or drug withdrawal and for mental health crisis events such as depression, anxiety, or suicide attempts.
The researchers compared outcomes for patients after dose tapering to those for patients before or without tapering. They found a 68% increase in overdose events and a doubling of mental health crises among tapered as compared to non-tapered patients. The risks of tapering were greater in patients who had faster dose reductions and higher baseline doses.
To taper or not to taper
Guidelines from the Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC) advise clinicians to monitor patients carefully during tapering and provide psychosocial support. They caution about the potential hazards of rapid dose reduction, including withdrawal, transition to illicit opioids, and psychological distress.
“Our study results support the recent federal guidelines for clinicians considering opioid dose reduction for patients,” said Joshua Fenton, professor and Vice Chair of Research in the Department of Family and Community Medicine and senior author on the study. “But I fear that most tapering patients aren’t receiving close follow-up and monitoring to make sure they’re coping well on lower doses.”
The researchers emphasized the need for clinicians and patients to carefully weigh the risks and benefits of both opioid continuation and tapering in decisions regarding ongoing opioid therapy.
“We hope that this work will inform a more cautious and compassionate approach to decisions around opioid dose tapering,” Agnoli said. “Our study may help shape clinical guidelines on patient selection for tapering, optimal rates of dose reduction, and how best to monitor and support patients during periods of dose transition.”
People around the world dramatically changed their shopping behaviors at the start of the COVID-19 pandemic.
Faced with new uncertainty, shoppers began stocking up on basic household items – especially toilet paper – to account for the new unknown. This buying frenzy led to shortages, even though, in most cases, there was enough to go around if people only purchased what they needed.
According to a study led by UNSW Sydney, reactive behavior like this isn’t unusual, but a common way to handle unexpected uncertainty.
In fact, unexpected uncertainty is such a powerful motivator for change that it often prompts us to adjust our behavior – even when it’s not good for us.
“When people experience an unexpected change in their environment, they start looking for ways to lessen that uncertainty,” says lead author of the study Dr Adrian Walker, who completed this research as part of his PhD in psychology at UNSW Science. “They can change their behavior and decision-making strategies to try and find a way to regain some sense of control.
“Surprisingly, our study found that unexpected uncertainty caused people to change their behaviors even when they would have been better off sticking to an old strategy.”
The behavioral study, recently published in The Journal of Experimental Psychology: Learning, Memory, and Cognition, is the first to show the type of uncertainty we experience – that is, whether it is expected or unexpected – plays a key role in our reaction.
For example, a city worker who knows their morning commute takes anywhere from 30 to 50 minutes wouldn’t be surprised by a 50-minute trip. On the other hand, a country driver would be very surprised if their predictable 30-minute trip suddenly took 50 minutes.
To test how people respond to unexpected change, the researchers tasked study participants with selling a pair of objects to one of two subjects – in this scenario, aliens – in a virtual simulation. Their task was simple: get as many points (or ‘alien dollars’) as possible.
Participants needed to choose which alien to sell a pair of chemicals to, but only one of the chemicals determined how much the alien would pay. They needed to work out which chemical and alien combination would earn them the greatest rewards.
An initial group of 35 participants were familiarised with the task and quickly learnt that one strategy (say, Option A) gave the better offer of 15 points. But midway through the experiment, the reward pattern changed, and Option A now gave a random number between 8 and 22 points.
“As soon as we added an element of uncertainty, the participants started looking for new ways to complete the task,” says Dr Walker. “The kicker is that in all cases, the best thing they could do was use their old strategy.”
Dr Walker says the pandemic – and our different responses to it – is a large-scale example of unexpected uncertainty.
“Everything changed very suddenly at the start of COVID-19,” he says.
“Many of us were suddenly all working from home, changing how we shop, and changing how we socialize. The rules we were living by beforehand no longer applied, and there was – and still is – no clear answer about when or how the pandemic will end.
“Different people tried all sorts of things – like panic shopping – to reduce this new uncertainty and return to ‘normal’. But as we’ve seen, not all of these reactive strategies were good in the long run.”
Boiling frog syndrome
While unexpected uncertainty led to dramatic responses, expected uncertainty had the opposite effect.
During the second phase of the trial, the researchers introduced uncertainty in a gradual way to a different group of 35 participants. Option A’s usual 15 points changed to 14-16 points, then 13-17 points, until the uncertainty rose to 8-22 points.
“The participants’ behavior didn’t change dramatically, even though the uncertainty eventually reached the same levels as in the first experiment,” says Dr Walker.
“When uncertainty was introduced gradually, people were able to maintain their old strategies.”
While this specific experiment was designed for the original strategy to be the most beneficial, Dr Walker says other research has shown the harm in not changing behavior when faced with gradual change.
“We can see this pattern in a lot of real-world challenges, like the climate change crisis,” says Dr Walker.
“When change is slow and barely noticeable, there’s no sudden prompt to change our behavior, and so we hold to old behaviors.
“Trying to get action on climate change is a lot like the boiling frog fable. If you put a frog in a pot and boil the water, it won’t notice the threat because the water is warming gradually. When it finally notices, it is too late to jump out.”
Professor Ben Newell, the Deputy Head of UNSW School of Psychology, was one of the researchers involved in the project. He says an important next step in this research is translating insights about how people react to uncertainty in the lab to engaging people in climate action.
“If we can identify the triggers for exploring new alternatives, then we might overcome the inertia inherent in developing new, sustainable behaviors,” says Prof. Newell.
Being certain about uncertainty
Uncertainty is something humans face every day, whether it’s how bad traffic will be or what questions might be asked in an exam.
But the COVID-19 pandemic has thrown a new layer of uncertainty to major areas of our lives, like career, health, and living circumstances.
“While this study isn’t the whole picture for human behavior during the pandemic, it can help explain why so many people looked for new ways to add certainty to their lives,” says Dr Walker, who is now a researcher in the School of Psychiatry at UNSW Medicine and Health.
Co-author Dr Tom Beesley, formerly of UNSW and now based at Lancaster University, says “Dr Walker’s work really helps us understand how people develop a representation of the uncertainty they are facing, and how they might cope, or not cope, with that.
“My lab is trying to formalize this relationship in a computational model of behavior so that we can make clearer predictions about what we might expect to happen under different conditions of uncertainty.”
While Dr Walker’s research is now focused on psychiatric epidemiology, he is interested to see where future research in this area goes – especially in predicting individual responses to uncertainty.
“Given how many decisions we make under uncertainty in our everyday lives, the more we can understand about how these decisions are made, the more we hope to enable people to make good decisions,” says Dr Walker.