Experienced Withdrawal Symptoms Research Articles

A multicentric survey among patients with substance use disorders during the COVID-19 lockdown in India.

Background:The unprecedented first wave of the COVID-19 pandemic severely impacted mental health services globally. However, the negative impact of such disruptions on people with substance use disorders (SUD) seeking treatment remains unclear. We aim to explore the behaviors adopted by these individuals to overcome the service disruptions.Materials and Methods:We explored the changes related to substance use behavior (quit attempts, withdrawal experienced, treatment-seeking, and risky behaviors), and behavioral changes in response to COVID-19 lockdown. A cross-sectional survey was conducted among 404 people with SUD seeking treatment from seven centers across India. They were assessed by a specially designed structured questionnaire during the first wave (June–September) of the pandemic.Results:An overwhelming majority experienced withdrawal symptoms, with close to half making quit attempts and seeking treatment during the lockdown. Three-fourth of the sample reported difficulty in accessing treatment services and medications. Patients with opioid use were significantly more likely to think about quitting (χ2 = 20.408, P = 0.000), make attempts (χ2 = 12.436, P = 0.000), seek treatment (χ2 = 7.536, P = 0.006), and self-medicate for withdrawal symptoms (χ2 = 5.885, P = 0.015). In turn, those with alcohol use were more likely to use telepsychiatry services (χ2 = 35.143, P = 0.000) and experience stigma by family members (χ2 = 29.951, P = 0.000) and neighbors (χ2 = 17.725, P = 0.000). Among COVID-19 safety precautions, majority practised wearing masks and social distancing but not others.Conclusion:COVID-19 lockdown led a significant proportion of substance users, especially opioid users, to make quit attempts and seek help. However, these could not be sustained due to difficulty in accessing treatment services. Further, significant proportion failed to adhere to COVID-19 safety precautions.

Ensuring buprenorphine access in rural community pharmacies to prevent overdoses

BackgroundOpioid-related drug overdoses have been rapidly increasing in the United States, especially in rural Southern and Appalachian regions. The use of buprenorphine-containing medications to treat opioid use disorder (OUD) is an evidence-based approach proven to reduce overdose death risks. Access to such treatment is uneven, with less access in parts of the United States where overdose rates are higher. Pharmacy dispensing of buprenorphine is a key component of access, yet barriers related to perceived and actual regulatory constraints, training gaps, stigma, and challenges to prescriber-pharmacist communication limit dispensing of this life-saving medication. ObjectivesThe objectives of this study were to explore the experiences of rural patients with OUD filling prescriptions for buprenorphine-containing medications at community pharmacies. Practice DescriptionRural community pharmacies, both commercial chain and independent, in 2 rural South-Central Appalachian counties where the local health departments prescribe buprenorphine-containing medications. Practice InnovationThe local county health departments each entered into dedicated dispensing arrangements with a local independent community pharmacy to ensure a stable supply of medication for their patients with OUD who were prescribed buprenorphine. Evaluation MethodsQualitative interviews (n =16) with patients prescribed buprenorphine from their county health department; county health department staff, local harm reduction program staff, and harm reduction program participants prescribed buprenorphine. Transcripts were analyzed using thematic analysis. ResultsParticipants reported problems with buprenorphine dispensing at rural community pharmacies, dispensing delays that resulted in experiencing withdrawal symptoms and hesitation to continue in treatment, high medication costs, and stigmatizing treatment by some pharmacists. Participants also reported that access improved after dedicated dispensing arrangements began. ConclusionAgreements between prescribing health departments and community pharmacies could increase access to buprenorphine, especially in rural areas.

Cannabinoid Hyperemesis Syndrome Survey and Genomic Investigation.

Background:Cannabinoid hyperemesis syndrome (CHS) is a diagnosis of exclusion with intractable nausea, cyclic vomiting, abdominal pain, and hot bathing behavior associated with ongoing tetrahydrocannabinol (THC) exposure. Increasing cannabis use may elevate CHS prevalence, exacerbating a public health issue with attendant costs and morbidity.Objective, Design, and Data Source:This study, the largest contemporaneous database, investigated genetic mutations underlying CHS. Patients with CHS diagnosis and ongoing symptoms were compared with current cannabis users lacking symptoms.Target Population:A screening questionnaire was posted online. Of 585 respondents, 205 qualified as the CHS pool and 54 as controls; a reduced pool of 28 patients and 12 controls ultimately completed genomic testing.Results:Patients and controls were high-frequency users of cannabis flower or concentrates (93%), using multiple grams/day of THC-predominant material. Among patients, 15.6% carried diagnoses of cannabis dependency or addiction, and 56.6% experienced withdrawal symptoms. About 87.7% of patients improved after cannabis cessation, most suffering recurrence rapidly after resumption. Findings in patients included mutations in genes COMT {odds ratio, 12 (95% confidence limit [CL], 1.3–88.1) p=0.012}, transient receptor potential vanilloid receptor 1 (TRPV1) (odds ratio, 5.8 [95% CL, 1.2–28.4] p=0.015), CYP2C9 (odds ratio, 7.8 [95% CL, 1.1–70.1] p=0.043), gene coding dopamine-2 receptor (DRD2) (odds ratio, 6.2 [95% CL, 1.1–34.7] p=0.031), and ATP-binding cassette transporter gene (ABCA1) (odds ratio, 8.4 [95% CL, 1.5–48.1] p=0.012).Limitations:Some participants were reluctant to undergo genetic testing; only 28 of 99 CHS patients who agreed to testing ultimately returned a kit.Conclusion:This is the largest patient cohort of CHS examined to date, and first to note associated mutations in genes affecting neurotransmitters, the endocannabinoid system, and the cytochrome P450 complex associated with cannabinoid metabolism. Although the sample size was smaller than desired, these preliminary findings may contribute to the growing body of knowledge, stimulate additional investigation, help elucidate the pathophysiology of CHS, and, ultimately, direct future treatment.

Patient-Reported Symptoms during Ibrutinib Holds: A Withdrawal Syndrome

Background:The Bruton tyrosine kinase (BTK) inhibitor ibrutinib recently became the first approved therapy for patients with symptomatic Waldenström macroglobulinemia (WM). The management of ibrutinib-related toxicities, such as bleeding and others, are often managed with temporary interruption of therapy. We observed that some WM patients who held ibrutinib developed symptoms during the time they were holding ibrutinib, which then resolved promptly after ibrutinib reinitiation. Our study aims at describing this “ibrutinib withdrawal” phenomenon.Methods: We identified patients seen at our institution between May 2012 and April 2017 who met clinicopathological criteria for WM, and received ibrutinib therapy. Medical files were manually reviewed to identify patients who reported new-onset symptoms occurring during a temporary hold of ibrutinib therapy. Pertinent clinical data were gathered. Patient characteristics are summarized descriptively. Univariate association with withdrawal symptoms was evaluated with logistic regression models.Results: A total of 189 patients with WM who started ibrutinib were identified; 100 patients (53%) have not held ibrutinib, and 89 (47%) held ibrutinib at some point during therapy. The median time on ibrutinib therapy in patients who held ibrutinib was 23 months (95% CI 13-30 months) and 10 months (95% CI 7-12 months) in patients who did not hold ibrutinib. There were no differences between the patients who held and did not hold ibrutinib with regards to age at WM diagnosis, age at ibrutinib initiation, sex, hemoglobin, platelet count, beta-2-microglobulin (B2M), serum IgM, bone marrow involvement, CXCR4 status, prior treatment and time between WM diagnosis and ibrutinib initiation (p≥0.05 for all factors). From the patients who held ibrutinib, 69 (78%) did not experience withdrawal symptoms and 20 (22%) did. Of the patients who experienced withdrawal symptoms, 17 (85%) were receiving ibrutinib in the relapsed/refractory setting. All patients were holding ibrutinib for the first time since treatment initiation. The median drug hold length was 7 days (range 3-33 days). Reasons for holding ibrutinib included: procedure/surgery (n=12; 60%), toxicity (n=6; 30%), drug interaction (n=1; 5%), and patient choice (n=1; 5%). The median time to symptom development was 2 days (range 0-5 days) from the start of the drug hold. Patient-reported symptoms included: fever (n=16; 80%), body aches (n=6; 30%), chills (n=5; 20%), night sweats (n=5; 20%), headache (n=4; 20%), fatigue (n=2; 10%), arthralgias (n=2; 10%), and weakness (n=1; 5%). There were no differences between patients who became symptomatic and remained asymptomatic during ibrutinib hold with regards to age at WM diagnosis, age at ibrutinib initiation, sex, hemoglobin, platelet count, B2M, bone marrow involvement, CXCR4 status, prior treatment, time from WM diagnosis and ibrutinib initiation and time on ibrutinib (p≥0.05 for all factors). Patients with serum IgM >4,000 mg/dl had a lower proportion of withdrawal symptoms than patients with serum IgM <4,000 mg/dl (9% vs. 30%; p=0.02). The rates of very good partial response (VGPR), partial response (PR), minor response (MR) and no response (NR) to ibrutinib were 16% (n=13), 57% (n=108), 22% (n=41) and 5% (n=9), respectively. No withdrawal symptoms were reported in patients with MR or NR. The proportion of patients with withdrawal symptoms was higher in patients who achieved VGPR (46%) than in patients who achieved PR (25%). Four patients with fever were admitted to the hospital; no infectious etiology was identified. All patients reported resolution of symptoms the same day ibrutinib was restarted following the drug hold. Nine patients had subsequent drug holds, and reported recurrence of the same symptoms during the hold period. Two patients known to develop these symptoms were treated with corticosteroids during a subsequent hold and reported symptomatic relief.Conclusion: We describe patient-reported symptoms that develop in about 20% of WM patients who held ibrutinib therapy. The rate of withdrawal symptoms is lower in patients who started ibrutinib with IgM levels >4,000 mg/dl (9%), and higher in patients who had achieved VGPR on ibrutinib (46%). Such symptoms ensue within 2 days of hold and resolve rapidly following reinitiation of therapy. Clinicians should be aware of this phenomenon which may represent an ibrutinib withdrawal syndrome. DisclosuresCastillo:Millennium: Research Funding; Abbvie: Research Funding; Pharmacyclics: Consultancy, Research Funding; Janssen: Consultancy, Research Funding. Treon:Pharmacyclics: Consultancy, Research Funding.

Pregabalin addiction caracteristics at oran: A cohort study

IntroductionPregabalin is an analogue of gamma-aminobutyric acid (GABA). Recent reports suggest illicit pregabalin use may be increasing among youth, however its addictive potential has not been well established (1).ObjectivesDrug seeking behavior and chronic drug use are associated with defcits in glutamate clearance and activation of postsynaptic glutamatergic receptors (2). Based upon multiple studies, we compare here the addiction and misuse risks of pregabalin with those of traditional psychoactive substances (3).MethodsUsers of pregabalin were identified from 1st January 2019 to 31 December 2019 in Oran Addictology service, at west Algeria. The aim of the study was to establish the addictive potential of pregabalin and to compare the addiction risks of pregabalin with traditional psychoactive substances in west Algerian population. Clinical diagnosis was established according DSM-5 diagnosis criteria.ResultsA total of 92 cases of pregabalin abuse or dependence were identified. The principal population at risk consists of patients with other current or past substance use disorders, for the most part opioid and multi-drug users, the age group were between 17-38 years old, mostly single men. The mean daily dose of pregabalin was 1200 mg. Almost all patients experienced withdrawal symptoms when pregabalin was discontinued.ConclusionsThe misuse of pregabalin often leads to abuse and dependence, mostly in the context of multiple drug addiction, especially in youth population.

Maternal and iatrogenic neonatal opioid withdrawal syndrome: Differences and similarities in recognition, management, and consequences.

Opioids are potent analgesics used to manage pain in both young and old, but the increased use in the pregnant population has significant individual and societal implications. Infants dependent on opioids, either through maternal or iatrogenic exposure, undergo neonatal opioid withdrawal syndrome (NOWS), where they may experience withdrawal symptoms ranging from mild to severe. We present a detailed and original review of NOWS caused by maternal opioid exposure (mNOWS) and iatrogenic opioid intake (iNOWS). While these two entities have been assessed entirely separately, recognition and treatment of the clinical manifestations of NOWS overlap. Neonatal risk factors such as age, genetic predisposition, drug type, and clinical factors like type of opioid, cumulative dose of opioid exposure, and disease status affect the incidence of both mNOWS and iNOWS, as well as their severity. Recognition of withdrawal is dependent on clinical assessment of symptoms, and the use of clinical assessment tools designed to determine the need for pharmacotherapy. Treatment of NOWS relies on a combination of non-pharmacological therapies and pharmacological options. Long-term consequences of opioids and NOWS continue to generate controversy, with some evidence of anatomic brain changes, but conflicting animal and human clinical evidence of significant cognitive or behavioral impacts on school-age children. We highlight the current knowledge on clinically relevant recognition, treatment, and consequences of NOWS, and identify new advances in clinical management of the neonate. This review brings a unique clinical perspective and critically analyzes gaps between the clinical problem and our preclinical understanding of NOWS.

Comparing rapid micro-induction and standard induction of buprenorphine/naloxone for treatment of opioid use disorder: protocol for an open-label, parallel-group, superiority, randomized controlled trial

BackgroundBuprenorphine/naloxone (Suboxone) is a current first-line treatment for opioid use disorder (OUD). The standard induction method of buprenorphine/naloxone requires patients to be abstinent from opioids and therefore experience withdrawal symptoms prior to induction, which can be a barrier in starting treatment. Rapid micro-induction (micro-dosing) involves the administration of small, frequent does of buprenorphine/naloxone and removes the need for a period of withdrawal prior to the start of treatment. This study aims to compare the effectiveness and safety of rapid micro-induction versus standard induction of buprenorphine/naloxone in patients with OUD.MethodsThis is a randomized, open-label, two-arm, superiority, controlled trial comparing the safety and effectiveness of rapid micro-induction versus standard induction of buprenorphine/naloxone for the treatment of OUD. A total of 50 participants with OUD will be randomized at one Canadian hospital. The primary outcome is the completion of buprenorphine/naloxone induction with low levels of withdrawal. Secondary outcomes are treatment retention, illicit drug use, self-reported drug use behaviour, craving, pain, physical health, safety, and client satisfaction.DiscussionThis is the first randomized controlled trial to compare the effectiveness and safety of rapid micro-induction versus standard induction of buprenorphine/naloxone. This study will thereby generate evidence for a novel induction method which eliminates substantial barriers to the use of buprenorphine/naloxone in the midst of the ongoing opioid crisis.Trial registration ClinicalTrials.gov, NCT04234191; date of registration: January 21, 2020; https://clinicaltrials.gov/ct2/show/NCT04234191

Barriers to treatment for opioid use disorder in Colombia

ABSTRACT Background: In Colombia, the rapid rise of illicit opioid use has become a major public health concern. Medications for opioid use disorder (MOUD) are well established and effective. However, access to MOUD remains suboptimal in this country. This paper aims to understand barriers to accessing MOUD in Colombia to inform the integration of this treatment modality in health systems. Methods: This study is a cross-sectional survey among persons with opioid use disorder (OUD) not enrolled in MMT in four Colombian cities with high known OUD prevalence. Survey domains consisted of the Barriers to Treatment Inventory, attitudes pertaining to MOUD treatments, and perceptions regarding interventions to ease access to Methadone. Results: A total of 84 subjects completed the survey. The most commonly endorsed barriers were related to admission difficulties, including concerns with “too many steps to get into treatment” (84.3%), experiencing withdrawal symptoms (78.1%), being placed on waiting lists (48.2%), and cost (44.6%). Nearly all participants were receptive to Methadone dispensation in primary care (96.4%) or mobile vans (91.6%). Conclusions: Findings from this study highlight persistent barriers to linking with MOUD among adults with OUD in Colombia requiring increased outpatient treatment programs, flexible methadone dosing, and administrative and financial support for patients.

Ambulatory detoxification in alcohol use disorder and opioid use disorder

Ambulatory detoxification in alcohol use disorder and opioid use disorder is an important component in the management of patients experiencing withdrawal symptoms from alcohol or opioids. The goal of withdrawal management is ultimately to provide each patient with comfort and safety. Having the knowledge of the possible signs and symptoms of intoxication and withdrawal assists providers to institute the most appropriate treatment protocol and setting for the patient. Pharmacists play a vital role in choosing appropriate therapeutic management options for common or complex clinical situations involving ambulatory detoxification from alcohol and opioids. Ambulatory detoxification serves as an appealing option to many patients and helps save the limited inpatient resources that many institutions have for those patients with more severe withdrawal presentations.

Benzodiazepine withdrawal in older people: what is the prevalence, what are the signs, and which patients?

Benzodiazepines (BZDs) and related drugs (Z-drugs) are mainly taken chronically, and older people are much more likely to take them on a chronic basis despite recommendations. Withdrawal symptoms could be an obstacle to stopping BZD/Z-drug administration. The main objective of this study is to estimate the prevalence of withdrawal symptoms in patients aged 65years and older who have experience a stop of BZD/Z-drug. The secondary objectives are to describe the withdrawal symptoms and identify factors associated. This ancillary study was based on a national observational study in patients with chronic BZD/Z-drug consumption. Patients who made at least one BZD/Z-drug stop experience were selected. Withdrawal symptoms are described, and a logistic regression was carried out to identify the variables most associated with withdrawal symptoms. In total, 697 patients were selected: 78% experienced at least one withdrawal symptom after a stop administering BZDs or Z-drugs; most of the withdrawal symptoms were psychological disorders. Our study identifies a specific population experiencing withdrawal symptoms and who cannot stop administering BZD/Z-drug. We assume that withdrawal symptoms in patients with chronic use play an essential role in the nonstop use of BZD/Z-drugs.

Identification of Substance-Exposed Newborns and Neonatal Abstinence Syndrome Using ICD-10-CM - 15 Hospitals, Massachusetts, 2017.

Opioid use disorder and neonatal abstinence syndrome (NAS) increased in Massachusetts from 1999 to 2013 (1,2). In response, in 2016, the state passed a law requiring birth hospitals to report the number of newborns who were exposed to controlled substances to the Massachusetts Department of Public Health (MDPH)* by mandating monthly reporting of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnostic codes related to maternal dependence on opioids (F11.20) or benzodiazepines (F13.20) and to newborns affected by maternal use of drugs of addiction (P04.49) or experiencing withdrawal symptoms from maternal drugs of addiction (P96.1) separately.† MDPH uses these same codes for monthly, real-time crude estimates of NAS and uses P96.1 alone for official NAS state reporting.§ MDPH requested CDC's assistance in evaluating the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of either maternal or newborn codes to identify substance-exposed newborns, and of newborn exposure codes (both exposure [P04.49] or withdrawal [P96.1]) and the newborn code for withdrawal alone (P96.1) to identify infants with NAS cases related to three exposure scenarios: 1) opioids, 2) opioids or benzodiazepines, and 3) any controlled substance. Confirmed diagnoses of substance exposure and NAS abstracted from linked clinical records for 1,123 infants born in 2017 and their birth mothers were considered the diagnostic standard and were compared against hospital-reported ICD-10-CM codes. For identifying substance-exposed newborns across the three exposure scenarios, the newborn exposure codes had higher sensitivity (range=31%-61%) than did maternal drug dependence codes (range=16%-41%), but both sets of codes had high PPV (≥74%). For identifying NAS, for all exposure scenarios, the sensitivity for either newborn code (P04.49 or P96.1) was ≥92% and the PPV was ≥64%; for P96.1 alone the sensitivity was ≥79% and the PPV was ≥92% for all scenarios. Whereas ICD-10-CM codes are effective for NAS surveillance in Massachusetts, they should be applied cautiously for substance-exposed newborn surveillance. Surveillance for substance-exposed newborns using ICD-10-CM codes might be improved by increasing the use of validated substance-use screening tools and standardized facility protocols and improving communication between patients and maternal health and infant health care providers.

Subcutaneous Extended-Release Buprenorphine Use in Pregnancy

Background Opioid use disorder (OUD) in pregnancy is managed by medication-assisted treatment. Sublingual buprenorphine is one option, but subcutaneous extended-release buprenorphine (Sublocade®) is an alternate form administered in monthly injections. Through an extensive literature search, we did not find any prior publication on the use of Sublocade in pregnancy. Case Two patients with OUD switched from sublingual buprenorphine to Sublocade. One patient received a total of eight injections and then discovered she was pregnant. Based on ultrasound dating, the last 5 administrations occurred during her pregnancy. The second patient received 6 injections with the last occurring at the time of her last menstrual period. Both declined further injections, as well as oral buprenorphine. Serial urine drug screens remained positive for buprenorphine through delivery in both cases. Neither the mothers nor the neonates experienced withdrawal symptoms or adverse outcomes. No birth anomalies were found. Discussion. Though further research is needed regarding the use of Sublocade in pregnancy, it is likely that other pregnancies will occur during this treatment modality. If this long-acting form of buprenorphine medication is found to be safe, it might play a role in managing some pregnant patients with OUD.

Characteristics of tianeptine effects reported to a poison control center: a growing threat to public health

Background Tianeptine is an antidepressant structurally similar to tricyclic antidepressants which is approved abroad but is currently a drug of abuse in the United States since at least 2000. In 2019, our poison center experienced an increase in calls relating to this xenobiotic. The goal of this report is to describe the characteristics of acute tianeptine intoxication and withdrawal. Methods All calls to a statewide poison center regarding tianeptine were reviewed from January 1, 2015 to March 15, 2020. Cases were identified using the American Association of Poison Control Centers’ substance code for “other types of tricyclic antidepressants.” Cases were excluded if they did not involve tianeptine. Date of call, patient demographics, symptoms, cardiac intervals if available, and disposition were recorded. Results Eighty-four cases of atypical tricyclic antidepressants were identified in the study period. Forty-eight cases involving tianeptine met inclusion criteria and were reviewed. Of these, 37 (77%) occurred from May 2019 to March 2020. Twenty-seven (56%) required medical admission including 17 cases (35%) that were managed in an intensive care unit. Seventeen of the 48 cases resulted from acute tianeptine intoxication. Lethargy was the most common presentation, but some patients also presented with agitation. Thirty-one (65%) of the cases resulted from tianeptine withdrawal, which usually exhibited agitation, anxiety, gastrointestinal distress. Naloxone was used in 4 cases (24%) of the acute intoxication cohort and benzodiazepines were frequently used both in acutely intoxicated patients and in patients experiencing tianeptine withdrawal. No patients in either cohort had cardiac conduction disturbances. Conclusion Our center observed a dramatic rise in tianeptine toxicity, particularly in patients experiencing withdrawal symptoms, beginning in May 2019. More than half of the cases required medical admission including a third who were treated in the intensive care unit. Health care practitioners should be increasingly aware of this xenobiotic as usage may be on the rise.

Treatment-free remission in chronic myeloid leukemia: the patient perspective and areas of unmet needs

In CML, treatment-free remission (TFR) refers to having a stable deep molecular response without the need for ongoing tyrosine kinase inhibitor treatment. Whilst recommendations exist about the technical management of stopping and re-starting therapy, much is still unknown about the experiences of those considering and undertaking TFR. This study sought to obtain the patient perspective, identify areas of unmet needs and create recommendations for improvements. Fifty-six percent of patients reported fear or anxiety during treatment discontinuation, whereas only 7% of patients were asked if they needed psychological support during this period. Where patients re-initiated treatment; 59% felt scared or anxious, and 56% felt depressed. Twenty-six percent of re-initiated patients received psychological and/or emotional support at this time. Sixty percent of patients experienced withdrawal symptoms whilst discontinuing treatment, however, 40% of patients who experienced withdrawal symptoms reported that they were not fully supported by their doctor in managing all the symptoms. Healthcare professionals should further consider how they monitor the psychological well-being of patients who are discontinuing or re-initiating treatment, and review what support is offered in response to identified concerns. Surveillance of withdrawal symptoms should be a priority during treatment discontinuation, along with how healthcare professionals assist in the management of these.

Prégabaline et risque d’addiction : une nouvelle demande de soin ?

PurposePregabalin (PRG) is a gamma-aminobutyric acid (GABA) analogue used for treatment of epilepsy, neuropathic pain, generalised anxiety disorder and currently being studied for other indications. Supported by the results of case studies and a limited number of studies, there is an ongoing debate about the addictive potential of PRG. However, evidence is scarce and no definitive assessment on the potential for abuse and dependence to PRG is available. The objective of our study was to identify the number of cases of abuse or dependence to PRG published and to study potential risk factors of addiction to PRG. MethodsWe have identified on PubMed and ScienceDirect published case studies of PRG abuse or dependence and analysed these cases on the basis of several clinical parameters. ResultsA total of 118 cases of PRG abuse or dependence were identified, including 21 isolated cases (mean age 33 years, 67 % men). The mean daily dose of PRG was 2,9 g. Current or past polydrug abuse was present in the majority of cases. Psychiatric diagnoses, other than substance-related disorders, were reported in as many patients, and almost all patients experienced withdrawal symptoms when PRG was discontinued. ConclusionCurrent literature suggests an important and growing concern for the abuse of PRG. Male sex, psychiatric and/or addiction history, including opioid addiction, may be potential risk factors for the development of addictive behaviours associated with PRG.

The long and winding road of discontinuing long-term use of antidepressants: Learning from my experience.

WHAT IS KNOWN ON THE SUBJECT?: More people experience withdrawal symptoms when weaning off antidepressants than previously thought; particularly after taking them for a long time. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: I explore my own experience of weaning off antidepressants; detailing conflicting advice I have received from healthcare professionals, and the mental and physical withdrawal symptoms I experienced. I relate my experiences to a growing body of research, which have important implications for improving care. WHAT ARE THE IMPLICATIONS FOR MENTAL HEALTH NURSING?: Healthcare professionals should make patients aware of potential withdrawal symptoms they may experience before they wean off antidepressants; regularly review their progress; consider helping them access psychological support whilst weaning off; and engage in open and collaborative conversations with patients throughout. Clinical guidance needs to be updated to provide appropriate evidence-based information/advice/recommendations for how best to support patients when coming off of antidepressants. ABSTRACT: A significant proportion of the UK population are taking antidepressants, and have been taking them for at least a year. Clinical guidelines have controversially stated that withdrawal symptoms when weaning off antidepressants are mild and resolve after one week, with the proviso that they can be severe only if the drug is stopped abruptly. However, recent evidence suggests this is not the case. I describe my own experiences of tapering the dose of my antidepressants after several years of taking them. I describe my encounters with healthcare professionals throughout this period, detailing conflicting advice I have received, along with describing the mental and physical withdrawal symptoms I have experienced. My experiences relate to a growing body of research, which have important implications for improving care. Potential learning outcomes are that healthcare professionals should make patients aware of potential withdrawal symptoms they may experience before they wean off antidepressants; regularly review their progress; consider helping them access psychological support whilst weaning off; and engage in open and collaborative conversations with patients throughout the process. Clinical guidance needs to be updated to provide appropriate evidence-based information, advice, and recommendations for how best to support patients when coming off of antidepressants.

Comparison of the efficacy of an infusion pump or standard IV push injection to deliver naloxone in treatment of opioid toxicity

Background:The optimal goal of naloxone infusion in intensive care units is to ameliorate opioid-induced side effects in therapy or eliminate the symptoms of opioid toxicity in overdoses. Accurately monitoring and regulating the doses is critical to prevent adverse effects related to naloxone administration. The present study aimed to compare treatment outcomes when using two methods of intravenous naloxone infusion: an infusion pump or the standard method. Methods:This study involved 80 patients with signs and symptoms of opioid overdose. The patients were randomly assigned into two groups with respect to intravenous infusion of naloxone by either an infusion pump or the standard method. Results:Comparison of study parameters between the two groups at 12 and 24 hours after intervention showed significantly more compensatory acid-base imbalance in the naloxone infusion pump group. In the group that received naloxone by pump, only one patient experienced withdrawal symptoms, but withdrawal symptoms appeared in 12 patients (30.0%) in the standard intravenous infusion group within 12 hours and in seven additional patients (17.5%) within 24 hours of intervention. In the group receiving pump-based naloxone infusion therapy, no another complications were reported; however in the standard infusion group, the 12-hour and 24-hour complication rates were 55.0% and 32.5%, respectively. The length of hospital stay was 2.85±1.05 and 4.22±0.92 days for the pump and standard infusion groups, respectively (P<0.001). Conclusions:Naloxone infusion using an infusion pump may be safer with regard to hemodynamic stability, resulting in shorter hospitalization periods, and fewer posttreatment complications.

The role of negative affect in the persistence of nicotine dependence among alternative high school students: A latent growth curve analysis

BackgroundPrevious research has demonstrated how negative affect (i.e., depression, anxiety, stress) is often a correlate of and precursor to nicotine dependence. Although recent evidence shows a gradual decline in tobacco use in the United States, subgroups that report higher levels of negative affect may continue to be at risk of becoming dependent on nicotine. One high-risk subgroup is students who attend alternative high schools. The current longitudinal investigation examined the effect of negative affect on nicotine dependence in this youth population. Methods1060 students from 29 alternative high schools in Southern California completed a series of attitudinal and behavioral measures once per year over a three-year period. The main outcome was nicotine dependence i.e., feeling a strong urge to use nicotine products or experiencing withdrawal symptoms after a period of abstinence, measured using a version of the Fagerstrom Tolerance Questionnaire designed for adolescents. A latent growth curve model was utilized to examine the effect of negative affect on nicotine dependence during this timeframe. ResultsThe analysis revealed that negative affect had both a concurrent and prospective relationship with nicotine dependence. Moreover, the association between negative affect and nicotine dependence in the present was not statistically significant once the influence of negative affect reported one year earlier was accounted for. ConclusionsNegative affect may play a critical role in the persistence of nicotine dependence among high-risk youth. Providing resources to help manage negative affect may be critical to curtailing nicotine dependence in this population.

High-dose zolpidem abuse in a patient with insomnia comorbid with major depressive disorder

A 39-year-old married woman was referred to a psychiatry outpatient clinic for treatment of major depressive disorder (MDD). The dose of zolpidem she had been taking had increased to more than 500 mg/day and, therefore, she was hospitalized with the aim of zolpidem detoxification. On admission, her serum zolpidem level was 1550 ng/mL, and this dropped to less than one (ng/mL) within 50 h. However, after discontinuation of zolpidem, she experienced withdrawal symptoms. Though a few cases of high-dose zolpidem abuse have been reported in Japan, physicians should be aware that zolpidem has the potential for abuse and dependence.

Commentary on Cairns et al. (2020): Codeine rescheduling-where to from here?

Commentary on Cairns et al. (2020): Codeine rescheduling-where to from here?