Management Of Withdrawal Research Articles

Incorporation of peer support in a novel community-based mobile withdrawal management program

Despite the sweeping and deep-rooted impacts of problematic substance use throughout Canada, services remain under-resourced and overwhelmed. Innovative approaches are required if meaningful change is to occur. In this paper, we examine the incorporation of peer support into a novel, community-based outreach withdrawal program which engages with participants where they are situated. Peer support is an evidence-based intervention utilized in a wide range of health care arenas. It employs lived experience as a skillset to address health care needs to complement other components in the therapeutic journey. In the context of an outreach withdrawal service, peer support holds potential to deconstruct the power dynamic that acts as a barrier in conventional withdrawal programs. Peer support promotes the concept of interdisciplinary care, while actively dismantling stigma. More research is required to evaluate outcomes, client satisfaction, and cost-effectiveness with regards to peer support interventions in community-based outreach detoxification programming.

Sublingual dexmedetomidine (BXCL501) reduces opioid withdrawal symptoms: findings from a multi-site, phase 1b/2, randomized, double-blind, placebo-controlled trial

ABSTRACT Background: Like other alpha-2-adrenergic receptor agonists, dexmedetomidine may reduce the severity of opioid withdrawal but with fewer adverse cardiovascular effects. Objective: This study assessed the safety of sublingual dexmedetomidine (BXCL501) and its preliminary efficacy in treating opioid withdrawal (ClinicalTrials.gov: NCT04470050). Methods: Withdrawal was induced among individuals with physiological dependence on opioids via discontinuation of oral morphine (Days 1–5). Participants were randomized to receive placebo or active BXCL501: 30, 60, 90, 120, 180, and 240 μg twice daily (Days 6–12). Treatment-emergent adverse events (TEAEs) were the primary outcome measure. Secondary outcomes included the Clinical and Subjective Opiate Withdrawal Scales (COWS and SOWS-Gossop, respectively), and the Agitation and Calmness Evaluation Scale (ACES). Results: Of 225 participants enrolled, 90 discontinued during morphine stabilization. Post-BXCL501 randomization (Day 6) data were available from 135 participants (73% male), with 33% completing thru Day 12. In total, 36 subjects reported 1 or more TEAE. Higher doses of BXCL501 (i.e. 180 and 240 µg, twice daily) increased the frequency of: hypotension, orthostatic hypotension, and somnolence. TEAEs related to BXCL501 were mild or moderate in severity, except for one participant in the 120 µg condition whose orthostatic hypotension and bradycardia were classified as severe. Higher BXCL501 dose conditions (120, 180, and 240 µg) resulted in statistically significant reductions in COWS & SOWS scores. Mean ratings on the ACES were between 3 (mild), 4 (normal), and 5 (mild calmness), with few significant differences as a function of dose. Conclusions: These findings support the continued development of BXCL501 for the management of opioid withdrawal.

Impact of an Educational Intervention on Hospital Pharmacists' Knowledge and Application of Substance Withdrawal Management.

Patients with substance use disorders are often encountered in an acute care setting and withdrawal management is important. Available literature reveals inadequate acute management of substance withdrawal due to lack of experience and knowledge of medications. A quality improvement project was implemented to improve hospital pharmacists' knowledge, application, and practice of inpatient opioid and alcohol withdrawal management through provision of didactic and case-based education and implementation of practice based prospective drug utilization review (PDUR). Pharmacists' knowledge of the management of alcohol and opioid withdrawal was assessed by a 10-item survey pre-and post-intervention. Twenty-one pharmacists completed the education and pre- and post-surveys. Scores for the 21 pharmacists improved significantly, with pre- and post-intervention scores of 7.33 ± 1.98 and 8.86 ± 0.91, respectively (P = .0035). Most pharmacists completed their required PDUR submission, and several pharmacist interventions were made and accepted post-education. Pharmacists indicated that the education increased their confidence and enabled them to learn new information that could be directly applied to their pharmacy practice. Providing education and requiring a PDUR improved pharmacists' knowledge, application, and practice of inpatient opioid and alcohol withdrawal management. Re-education or expanded education may be warranted to further increase pharmacists' competence.

Complicated opioid withdrawal presenting with delirium

Unlike alcohol or benzodiazepine withdrawal, delirium is extremely uncommon during opioid withdrawal. We describe a case of smack addiction and opioid withdrawal in which led to delirium during withdrawal management. There is no prior history of substance misuse and no relevant personal or family background. It is discussed if delirium could be a withdrawal sign in opioid dependence. Yawning, sweating, lacrimation, rhinorrhea, anxiety, restlessness, insomnia, dilated pupils, piloerection, chills, tachycardia, hypertension, nausea/vomiting, crampy abdominal pains, diarrhea, and muscle aches and pains are some of the withdrawal symptoms that are typically associated with opioid abuse.

Community Pharmacists' Views on the Early Stages of Implementation of a National Pilot Independent Prescribing Service in Wales: A Qualitative Study.

A pilot Independent Prescribers' Service (IPS) was introduced in 13 community pharmacies across Wales in June 2020. Independent Pharmacist Prescribers (IPPs) could prescribe in the areas of management of acute conditions, contraception, or opioid withdrawal, as agreed with local commissioners. Access to the patients' medical records was provided via Choose Pharmacy, the national community pharmacy IT platform. To explore the experiences of IPPs delivering the service and commissioners responsible for financial resources regarding the IPS in Wales. A qualitative methodology was employed, with purposive sampling, semi-structured interviews, and inductive thematic analysis. Five themes were constructed from 13 interviews (n=9 IPPs; n=4 commissioners): (i) patient experience and safety; (ii) professional enablement and rebalancing workload of GPs; (iii) role and limitations of remote consultations; (iv) funding and business model; (v) functionality on Choose Pharmacy to support patient care. The design of the service allowed pharmacists to determine how best to deliver the IPS, maximizing access for patients and promoting a sense of professional value amongst pharmacists. This study builds on the body of evidence on enhanced patient experience with prescribing services in the community, reinforcing that IPPs have a key role in rebalancing management of common conditions from GP surgeries to community pharmacies. Several considerations need to be addressed to ensure future success of the service implementation, delivery and enhanced sustainability, such as formal referral pathways and access to medical records. These can be used by other commissioning bodies in the UK and internationally to build a network of suitably supported IPPs, confident to appropriately deal with uncomplicated acute and chronic conditions; and liaise with primary and/or secondary care when referrals are needed.

Online Rights’ Withdrawal and Collective Management – Harmonizing the Online Music Rights Withdrawals for a Trans-Atlantic Streaming Economy

Online Rights’ Withdrawal and Collective Management – Harmonizing the Online Music Rights Withdrawals for a Trans-Atlantic Streaming Economy

C-L Case Conference: Applying Good Psychiatric Management for Borderline Personality Disorder in Hospitalized Patients With Co-occurring Substance Use Disorders.

We present a case illustrating common challenges in the hospital management and treatment of comorbid borderline personality disorder and substance use disorders. Experts in the field of personality disorders and substance use disorders discuss various topics and strategies for patient-centered management. Key learning points include evaluation and diagnosis of borderline personality disorder, good psychiatric management, withdrawal and pharmacologic management, harm reduction, team dynamics, and behavior planning all in the hospital setting. This paper provides actionable considerations with elements common to many clinical encounters that present challenges to the consultation-liaison psychiatrist in the general hospital setting.

Cannabis Use Disorder: A Review

Background: Cannabis use is rising and becoming a trending drug among youth. The drug is used in different forms, leading to intoxication, acute and long-term consequences. About 2.8% of Indians aged 10-75 years are current users of any cannabis product. Withdrawal from the drug use requires medical intervention and counselling. 
 Objectives: To identify existing evidence in homoeopathy on drug deaddiction and cannabis use disorder and to update the physicians on diagnosis, risk behaviours, treatment and investigations associated with cannabis use disorder. 
 Methods: A review of existing literature was conducted through internet sources and the CCRH headquarters library using keywords i.e. substance use, substance abuse, marijuana, cannabis abuse, drug abuse, cannabis use disorder etc. Data from studies reporting drug abuse to identify the type of drug use and homoeopathic treatment response in the withdrawal and long-term management and treatment of drug dependents was tabulated. 
 Results: Although some studies have been conducted on drug withdrawal, no studies have been conducted on cannabis use disorder. More case studies and research on treatment of cannabis use disorder using Homoeopathy are needed. 
 Interpretation: Physicians need to update themselves on diagnosis, risk behaviours, treatment and investigations to counter the condition and contribute to generating evidence-based literature on the homoeopathic approach for treating cannabis use disorder.

787: STANDARDIZING PHENOBARBITAL USE IN ALCOHOL WITHDRAWAL SYNDROME FOR A MULTIHOSPITAL SYSTEM

Introduction: Phenobarbital (PHB) use in the treatment of alcohol withdrawal syndrome (AWS) has become common in clinical practice despite the lack of dosing standardization and when to initiate PHB. Recently, clinical trials have evaluated PHB as a safe and effective alternative to benzodiazepines (BZD). The ASAM Guidelines on Alcohol Withdrawal Management recommend the use of PHB only by clinicians experienced in its use and where extensive monitoring may occur. PHB is listed as an alternative to BZDs for severe AWS, but otherwise is only recommended in patients with a contraindication to BZDs. The objective of this project is to assess PHB use to determine a standardized dosing recommendation for patients experiencing AWS, leading to an improved understanding of PHB resulting in improved outcomes. Methods: This retrospective, multicenter, observational cohort included patients ≥18 years of age admitted to 16 AAH hospitals in WI and IL between June 4, 2021 to August 30, 2021 who received PHB for the treatment of AWS. Clinical data was extracted from the electronic medical record by chart review including comorbid conditions, PHB form and dose, CIWA scores before and 24 hours after PHB administration, and total concomitant BZD use. The primary outcome was improvement in median CIWA score after PHB administration while secondary outcomes included admission to the ICU, intubation, and death. Results: 100 patients were included. Improvement in median CIWA score after PHB occurred in both moderate and severe initial CIWA scores. Median severe initial CIWA scores decreased from 23 to 7 about 24 hours after PHB and median moderate initial CIWA scores decreased from 12 to 4 about 24 hours after PHB. Looking at where PHB orders were placed, 56 orders were in the ICU, 15 orders were in the ED, and the remaining placed on a general medicine floor. Prior to PHB, 18 patients were intubated with only 3 patients needing intubation after PHB. Only 4 patients who received PHB died with 2 related to a cancer diagnosis and the remaining 2 unrelated to AWS. Conclusions: The project concluded there was a decrease in CIWA scores after PHB in both moderate and severe AWS with the largest reduction in CIWA scores seen in patients with severe AWS. Earlier phenobarbital was associated with lower BZD use.

818: THE IMPACT OF A BENZODIAZEPINE-SPARING STRATEGY ON ALCOHOL WITHDRAWAL MANAGEMENT

Introduction: The objective of this study was to assess the impact of a benzodiazepine-sparing strategy on overall benzodiazepine use in alcohol withdrawal management. Commonly utilized agents in benzodiazepine-sparing strategies include clonidine, gabapentin, and dexmedetomidine. These agents are less potent than benzodiazepines individually, but literature reveals using higher doses and combinations of these agents to target multiple pathways may provide similar efficacy with less adverse events. Methods: This is a chart review of trauma and surgical patients at a large, community hospital. Patients managed for alcohol withdrawal prior to implementation of a benzodiazepine-sparing protocol were compared to patients managed post-implementation of a protocol. Those included had a Prediction of Alcohol Withdrawal Severity Scale (PAWSS) score ≥ 4 or clinical suspicion of alcohol withdrawal. The primary outcome was decreased overall benzodiazepine use in lorazepam equivalents in milligrams. Secondary outcomes evaluated duration of alcohol withdrawal symptoms and adverse effects. Descriptive statistics were utilized to analyze primary and secondary outcomes as well as baseline characteristics. Propensity matching was performed using IBM SPSS Statistics version 25.0 (IBM Inc., Armonk, NY). Results: A total of 25 patients received a benzodiazepine-sparing strategy and 159 patients were in the control group. The intervention arm required a median of 2 mg [IQR: 0, 14] of benzodiazepines (lorazepam equivalents) compared to the control arm who required a median of 10 mg [IQR: 2, 28]. Propensity matching yielded similar results with the intervention arm receiving a median of 8 mg [IQR: 2, 25] of benzodiazepines (lorazepam equivalents) versus a median of 13 mg [IQR: 9, 37]) in the control arm. The intervention arm experienced alcohol withdrawal symptoms for a median of 1 day [IQR: 0,6]; whereas, the control arm experienced symptoms for a median of 5 days [IQR: 0, 4]. Conclusions: Utilization of a benzodiazepine-sparing strategy was associated with a reduction in overall benzodiazepine exposure. The results of this study implicate a need for further robust trials to establish the safety of benzodiazepine-sparing protocols and the ability to improve clinically meaningful outcomes.

Inpatient GHB withdrawal management in an inner-city hospital in Sydney, Australia: a retrospective medical record review

RationaleRegular consumption of gamma-hydroxybutyrate (GHB) may result in a dependence syndrome that can lead to withdrawal symptoms. There are limited data on medications to manage GHB withdrawal.ObjectivesTo examine characteristics associated with delirium and discharge against medical advice (DAMA), in the context of implementing a GHB withdrawal management protocol at an inner-city hospital in 2020.MethodsWe retrospectively reviewed records (01 January 2017–31 March 2021), and included admissions that were ≥ 18 years of age, admitted for GHB withdrawal, and with documented recent GHB use. Admissions were assessed for demographics, medications administered, features of delirium, ICU admission, and DAMA. Exploratory analyses were conducted to examine factors associated (p < 0.2) with features of delirium and DAMA.ResultsWe identified 135 admissions amongst 91 patients. Medications administered included diazepam (133 admissions, 98.5%), antipsychotics (olanzapine [70 admissions, 51.9%]), baclofen (114 admissions, 84%), and phenobarbital (8 admissions, 5.9%). Features of delirium were diagnosed in 21 (16%) admissions. Delirium was associated with higher daily GHB consumption prior to admission, while duration of GHB use, time from presentation to first dose of diazepam, and concomitant methamphetamine use were inversely associated with delirium. DAMA occurred amongst 41 (30%) admissions, and was associated with a longer time from presentation to first dose of baclofen, while being female and receiving a loading dose of diazepam were inversely associated.ConclusionsThis study adds to the literature in support of the safety and feasibility of diazepam and baclofen for the management of GHB withdrawal. Prospective, randomised trials are required.

Management of Tizanidine Abuse and Withdrawal in a 53-Year-Old Woman: a Case Report

Management of Tizanidine Abuse and Withdrawal in a 53-Year-Old Woman: a Case Report

Thermal response of a deep monomictic reservoir to selective withdrawal of the upstream reservoir

Selective withdrawal is an effective strategy to alleviate the adverse impact of reservoir construction on the downstream thermal regime. However, most studies mainly focus on the water temperature improvement effect of a single reservoir, while few studies focus on the impact of selective withdrawal of upstream cascade reservoirs on downstream reservoirs. This study combined measured data and a two-dimensional hydrodynamic model (CE-QUAL-W2) to analyze the response of the downstream reservoir to selective withdrawal of the upstream reservoir in the operation mode of cascade reservoirs. The purpose of this study was to optimize reservoir operation to minimize the impact of cold water and satisfy the water temperature requirements of downstream fish spawning and breeding. The results indicated that the proposed index of the response to selective withdrawal (IRSW) could reflect the response of the downstream reservoir to selective withdrawal of the upstream reservoir. There existed a statistically significant positive correlation between the improvement in the withdrawal water temperature (WWT) in the Xiangjiaba Reservoir and the IRSW value (R = 0.9257, P < 0.05). The impact of the Xiangjiaba Reservoir on the incoming water temperature during the selective withdrawal period of the upstream reservoir imposed a negative superposition effect, and the selective withdrawal effect of the upstream reservoir could be maintained at 87.0%. The negative superimposition effect could be alleviated via independent operation of the upper water intake and maintenance of a low water level, and the IRSW could be increased by 6.6% and 10.4%, respectively, compared to that under the designed scenario, which could even approach the equilibrium effect (100%) and could be helpful to improve the WWT. This study provided a helpful reference for the evaluation of selective withdrawal and reservoir management in similar cascade reservoirs.

A National Environmental Scan of Public Withdrawal Management Services in Canada

ABSTRACT Objectives: Withdrawal management services (WMS) are often a vital step in the continuum of support for substance use disorders. We conducted an environmental scan to provide an overview of current organizational practices and characteristics of WMS in Canadian substance use treatment systems to better inform evidence-based guidelines and other quality improvements. Methods: We developed an organizational-level national survey of public and private substance use treatment services providing either WMS on a residential or nonresidential basis. An online survey covering background information about WMS offerings and client demographics was then disseminated to program representatives. Data were analysed for key themes relevant to the project objective. Results: Eighty-five (59.4%) publicly funded programs completed the survey, with the best response rate emanating from the Atlantic Region (84.2%, n=16). Nearly every province and territory had a specialized WMS open to a diverse profile of clients accessing treatment for various substances, providing a mix of residential and nonresidential WMS, along with a range of clinical, psychosocial, and health professional supports extending beyond immediate substance detoxication. The scan also identified a significant lack of youth-specific beds in available WMS services. Conclusion: Findings suggest a strong national capacity for WMS, and available matching criteria to support client placement in a stepped-care approach. System planners are encouraged to continue exploring the value of offering appropriate combinations of WMS options to build a more robust and accessible system of care to support the specific needs of the communities they serve. Objectifs: Les services de gestion du sevrage (SGS) constituent souvent une étape essentielle dans le continuum de soutien des troubles liés à la consommation de substances. Nous avons effectué une analyse de l’environnement pour donner un aperçu des pratiques organisationnelles et des caractéristiques actuelles des SGS dans les systèmes canadiens de traitement de la toxicomanie afin de mieux informer sur les lignes directrices fondées sur des données probantes et d’autres améliorations de la qualité. Méthodes: Nous avons élaboré une enquête nationale au niveau organisationnel sur les services publics et privés de traitement de la toxicomanie qui offrent des SGS en établissement ou hors établissement. Nous avons ensuite diffusé aux représentants des programmes un questionnaire en ligne contenant des informations générales sur les services offerts par les SGS et les caractéristiques démographiques des clients. Les données ont été analysées à la recherche de thèmes clés correspondant à l’objectif du projet. Résultats: 85 (59,4%) programmes financés par l'État ont répondu au sondage, le meilleur taux de réponse émanant de la région de l’Atlantique (84,2%, n=16). Presque toutes les provinces et tous les territoires disposaient d’un programme spécialisé de SGS ouvert à un profil diversifié de clients accédant à un traitement pour diverses substances, où on offrait un mélange de SGS résidentiels et non résidentiels, ainsi qu’une gamme de soutiens cliniques, psychosociaux et professionnels de la santé allant au-delà de la désintoxication immédiate. L’analyse a également révélé un manque important de lits réservés aux jeunes dans les services de SGS disponibles. Conclusion: Les résultats suggèrent une forte capacité nationale en matière de SGS, et des critères de correspondance disponibles pour soutenir le placement des clients dans une approche de soins par étapes. Les planificateurs du système sont encouragés à continuer d’explorer l’intérêt d’offrir des combinaisons appropriées d’options de SGS afin de construire un système de soins plus solide et plus accessible pour répondre aux besoins spécifiques des communautés qu’ils servent.

Infective endocarditis in people who inject drugs: A scoping review of clinical guidelines.

The incidence of infective endocarditis (IE) among people who inject drugs (PWID) is rising worldwide. Multiple clinical guidelines differ on the management of this condition, and few guidelines comment on treatment for primary substance use disorder (SUD). A comprehensive comparison of these guidelines is lacking. To perform a critical review identifying key differences in clinical guideline recommendations for treating IE among PWID, focusing on the inclusion of recommendations for SUD treatment and the presence of stigmatizing language. Recently published, English-language, society-developed clinical guidelines for the treatment of IE among PWID. PubMed, Google Scholar, and CINAHL Plus databases. In line with Arksey and O'Malley's framework, a scoping review was adapted using Joanna Briggs Institute and PRISMA-ScR guidelines. Two reviewers independently performed database searches for clinical guidelines published between 2007 and 2020 that commented on the management of IE among PWID. Ten clinical guidelines were included in the final analysis. Treatment recommendations varied with some societies proposing nonstandard care due to concern for return to drug use. Three guidelines include reference to addiction treatment. Only one guideline specifies the use of opioid agonist therapy for treating opioid use disorder and identifies the benefits of an addiction specialist consultation. Acute withdrawal management is not mentioned in any guideline. All guidelines utilized stigmatizing language to describe PWID. Most guidelines do not address SUD treatment, despite its effectiveness in reducing adverse health outcomes. Future guidelines should address SUD treatment using patient-first language.

Alcohol use disorder with comorbid anxiety disorder: a case report and focused literature review

BackgroundAlcohol use disorder (AUD) and anxiety disorders (AnxD) are prevalent health concerns in clinical practice which frequently co-occur (AUD-AnxD) and compound one another. Concurrent AUD-AnxD poses a challenge for clinical management as approaches to treatment of one disorder may be ineffective or potentially counterproductive for the other disorder.Case PresentationWe present the case of a middle-aged man with anxiety disorder, AUD, chronic pain, and gamma-hydroxybutyrate use in context of tapering prescribed benzodiazepines who experienced severe alcohol withdrawal episodes during a complicated course of repeated inpatient withdrawal management. After medical stabilization, the patient found significant improvement in symptoms and no return to alcohol use with a regimen of naltrexone targeting his AUD, gabapentin targeting both his AUD and AnxD, and engagement with integrated psychotherapy, Alcoholics Anonymous, and addictions medicine follow-up.ConclusionProper recognition and interventions for AUD and AnxD, ideally with overlapping efficacy, can benefit individuals with comorbid AUD-AnxD. Gabapentin, tobacco cessation, and integrated psychotherapy have preliminary evidence of synergistic effects in AUD-AnxD. Meta-analysis evidence does not support serotoninergic medications (e.g. selective serotonin reuptake inhibitors) which are commonly prescribed in AnxD and mood disorders as their use has not been associated with improved outcomes for AUD-AnxD. Additionally, several double-blind placebo-controlled randomized trials have suggested that serotonergic medications may worsen alcohol-related outcomes in some individuals with AUD. Areas for future investigation are highlighted.

20 Eat Sleep Console: A Quality Improvement Initiative to Improve the Care of Opioid Exposed Newborns at a Community Hospital

Abstract Background As the opioid crisis continues in B.C., more infants are born to mothers using opioids during pregnancy. Many of these newborns experience neonatal opioid withdrawal syndrome (NOWS) and require specialized medical care and prolonged hospital stays. Objectives We sought to improve the care of opioid exposed newborns by replacing the Finnegan Neonatal Abstinence Scoring System (FNASS) with the Eat Sleep Console (ESC) protocol. Our aim was to reduce infant NICU length of stay (LOS) and morphine dosing required for withdrawal management. Design/Methods A multi-disciplinary team was formed in 2019 and standard quality improvement methodology was implemented using plan-do-study-act cycles. Interventions included NOWS education for maternity and newborn health care providers, pediatric antenatal consults, introduction of as needed morphine, and implementation of the Eat Sleep Console (ESC) assessment tool. Primary outcomes were number of NICU admission days and cumulative morphine dosing required for NOWS treatment. Data from chart reviews was obtained from 2017 to 2021. Qualitative survey data was collected from nursing staff pre and post ESC implementation. Results ESC successfully replaced the FNASS, and nursing staff reported overall satisfaction and confidence with the practice change. Forty-four infants were captured in our data analysis, including 21 from the baseline period (FNASS), 12 from intervention group 1 (PRN morphine and FNASS), and 9 from intervention group 2 (PRN morphine and ESC). Cumulative morphine dose decreased by 55% when comparing the two intervention groups (19.45 mg intervention group 1 vs 10.71 mg intervention group 2). Two infants were managed exclusively with ESC non-pharmacological strategies and did not require any morphine. Although NICU LOS increased over time in our project (10.79 days in the baseline group vs 19.64 in the intervention group 2), there were no differences in the LOS between the two intervention groups (18.49 days vs 19.64 days). Unstable maternal opioid use, defined as illicit opioid use two weeks prior to delivery increased as the project progressed and was unbalanced between groups, possibly affecting our overall outcomes (38% unstable mothers in the baseline period vs 78% intervention group 2). Stratified analysis between stable and unstable mothers showed a trend of increased LOS and morphine requirements for infants born to unstable mothers. In our center, the ability to provide 1:1 care by nurse or parent was the most prominent challenge. Conclusion ESC successfully replaced the FNASS at our community hospital and has shown a clinically significant decrease in morphine requirements for infants experiencing opioid withdrawal.

Associations Between Inpatient Induction on Medications for Opioid Use Disorder and Postdischarge Medications for Opioid Use Disorder Adherence, Overdose, and Service Use.

This study aimed to examine outcomes of a pilot program designed to increase inpatient medications for opioid use disorder (MOUD) induction and to support MOUD adherence after discharge. This retrospective cohort analysis examined Medicaid adults diagnosed with opioid use disorder discharged from 2 freestanding inpatient withdrawal management facilities between October 1, 2018, and December 31, 2019. Participants had ≥90 days of continuous Medicaid enrollment before and after admission. Odds ratios (ORs) examined associations of inpatient MOUD induction with discharge against medical advice, 7- and 30-day all-cause hospital readmission, and postdischarge MOUD adherence. Mixed-effect models examined changes associated with MOUD induction and postdischarge MOUD adherence in acute service utilization and opioid overdose in the 90-day postdischarge period. Of the 2332 patients discharged, 493 started MOUD inpatient care (21.1%), with most initiating buprenorphine (76.5%). Induction of MOUD was associated with a lower likelihood of discharge against medical advice (OR, 0.49; 95% confidence interval [CI], 0.37-0.64), 30-day all-cause hospital readmission (OR, 0.61; 95% CI, 0.47-0.80), and higher odds of postdischarge MOUD adherence (OR, 3.83; 95% CI, 3.06-4.81). In the 90 days after discharge, MOUD adherent patients had significant reductions in emergency department visits for behavioral health, inpatient days, withdrawal management episodes, and opioid overdoses compared with the 90-day preadmission period. Inpatient MOUD induction is associated with a higher likelihood of short-term MOUD adherence after discharge, which in turn is associated with significant reductions in short-term service utilization and opioid overdose after discharge.

Peer support to reduce readmission in Medicaid-enrolled adults with substance use disorder

IntroductionPeer support service in substance use disorder systems (PS SUD) is an optional supplement to treatment services for Medicaid-enrolled individuals across Pennsylvania. The value of PS SUD was defined through association with improved service utilization patterns. We examined service utilization in a subset of individuals receiving PS SUD following an acute service (hospitalization or withdrawal management) compared to utilization in propensity-score-matched controls via an observational analysis. MethodsWe identified all Medicaid-enrolled adults with receipt of PS SUD from 2016 to 2019 and included those with prior acute service (n = 349); the study successfully matched all to individuals receiving outpatient SUD services without peer support (n = 698). Individuals were matched on age, gender, race, ethnicity, diagnosis, and prior utilization of acute care. A large percentage of individuals receiving PS SUD (74 %) had co-occurring mental health diagnoses, which we included in matching. We examined service utilization rates via administrative paid claims data for both groups in the first 90 days following peer support/outpatient discharge. ResultsAcute service utilization differed between groups over time, p = .0014. We observed a larger reduction in the rate of acute care during PS SUD service (8.6 %) versus outpatient service (21.2 %), with lower rates remaining 90 days following PS SUD (13.8 %) or outpatient discharge (16.8 %). Individuals receiving PS SUD showed connection to community-based services in the 90 days following discharge from PS SUD, including 45.0 % receiving outpatient SUD and 31.8 % receiving outpatient mental health services. ConclusionsPeer support may help individuals to navigate the behavioral health system and reduce hospitalization or other restrictive levels of care.

Alterations of brain microstructures in a mouse model of prenatal opioid exposure detected by diffusion MRI

Growing opioid use among pregnant women is fueling a crisis of infants born with prenatal opioid exposure. A large body of research has been devoted to studying the management of opioid withdrawal during the neonatal period in these infants, but less substantive work has explored the long-term impact of prenatal opioid exposure on neurodevelopment. Using a translationally relevant mouse model of prenatal methadone exposure (PME), the aim of the study is to investigate the cerebral microstructural differences between the mice with PME and prenatal saline exposure (PSE). The brains of eight-week-old male offspring with either PME (n = 15) or PSE (n = 15) were imaged using high resolution in-vivo diffusion magnetic resonance imaging on a 9.4 Tesla small animal scanner. Brain microstructure was characterized using diffusion tensor imaging (DTI) and Bingham neurite orientation dispersion and density imaging (Bingham-NODDI). Voxel-based analysis (VBA) was performed using the calculated microstructural parametric maps. The VBA showed significant (p < 0.05) bilateral alterations in fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), radial diffusivity (RD), orientation dispersion index (ODI) and dispersion anisotropy index (DAI) across several cortical and subcortical regions, compared to PSE. Particularly, in PME offspring, FA, MD and AD were significantly higher in the hippocampus, dorsal amygdala, thalamus, septal nuclei, dorsal striatum and nucleus accumbens. These DTI-based results suggest widespread bilateral microstructural alterations across cortical and subcortical regions in PME offspring. Consistent with the observations in DTI, Bingham-NODDI derived ODI exhibited significant reduction in PME offspring within the hippocampus, dorsal striatum and cortex. NODDI-based results further suggest reduction in dendritic arborization in PME offspring across multiple cortical and subcortical regions. To our best knowledge, this is the first study of prenatal opioid exposure to examine microstructural organization in vivo. Our findings demonstrate perturbed microstructural complexity in cortical and subcortical regions persisting into early adulthood which could interfere with critical neurodevelopmental processes in individuals with prenatal opioid exposure.