Management Of Withdrawal Research Articles

Iatrogenic Withdrawal Syndrome in the Pediatric Cardiac Intensive Care Unit: Incidence, Risk Factors and Outcome.

ObjectivesCritically ill children and neonates routinely receive opioids and benzodiazepines for analgesia and sedation in the pediatric intensive care unit (PICU). Prolonged opioid therapy often leads to tolerance and is associated with iatrogenic withdrawal syndrome (IWS) when opioids and benzodiazepines are weaned or discontinued. Our aim is to study the incidence, risk factors and outcome of IWS following use of a withdrawal protocol on pediatric patients after cardiac surgery.MethodsWe prospectively included all postoperative pediatric patients who developed IWS after being assessed by the Withdrawal Assessment Tool (WAT-1) score (WAT-1 ≥3) over 9 months. Unit-based withdrawal management protocol was used. Patients’ outcome was assessed by duration to be completely off opioids & benzodiazepines, duration of ICU and hospital stay.Results432 patients were admitted during study period. Twenty-five patients (5.8%) developed IWS. The mean age and weight was 15.2 ± 31.4 months and 6.9 ± 7.7 kg respectively. 60% of the patients who developed withdrawal had previous ICU admissions with exposure to sedatives. In the IWS group the mean duration for use of fentanyl and midazolam infusions was 8.6 ± 5.1 & 9.6 ± 6 days respectively. The mean duration for completely stopping opioids and benzodiazepines was 17.2 ± 6.8 days with a mean duration of ventilation of 8.2 ± 6.8 days. The mean ICU and hospital stay for IWS patients was 26.5 ± 21.9 and 31.5 ± 21.1 days respectively. There was statistically significant difference in the mean age, and duration of use of sedatives between the patients who developed IWS and those who did not with P-value of 0.003 and < 0.0001, respectively.ConclusionWithdrawal syndrome after pediatric cardiac surgery prolongs ICU and hospital stay. Our data shows that younger age and longer duration for use of sedatives seem to be risk factors for developing withdrawal syndrome.

Integration of Patient-reported Outcomes Assessment Into Routine Care for Patients Receiving Residential Treatment for Alcohol and/or Substance Use Disorder.

More than 3 million individuals receive treatment for alcohol use disorder (AUD) and/or substance use disorder each year, yet there exists no standardized method for measuring patient success in treatment. Quantifying a more comprehensive assessment of treatment outcomes could identify the relative efficacy of different treatment strategies for individuals with AUD/substance use disorders, and help patients to identify, in advance, appropriate treatment options. This study developed and embedded patient-reported outcome measures into the routine clinical operations of a residential treatment program. Surveys assessed demographics, drug use history, physical and mental health, and quality of life. Outcomes were assessed among participants at admission (n = 961) and in patients who completed the survey at time of discharge (n = 633). Past 30-day alcohol and/or opioid use at admission were correlated with worse self-reported physical and mental health, sleep, and quality of life, and greater negative affect and craving ( P s < 0.05). Previous history of treatment and/or withdrawal management were associated with worse self-reported physical and mental health, quality of life, and increased craving ( P s < 0.05). Physical and mental health improved across timepoints and was most pronounced when comparing persons receiving treatment for opioid use disorder versus AUD, wherein persons with opioid use disorder had worse physical health at all time points, and greater sleep disturbance and negative affect at discharge ( P s < 0.05). It is feasible to embed patient outcome monitoring into routine clinic operations, which could be used in the future to tailor treatment plans.

New Australian guidelines for the treatment of alcohol problems: an overview of recommendations.

New Australian guidelines for the treatment of alcohol problems: an overview of recommendations.

66.2 THE ART OF THE START: CLINICAL READINESS FOR SUCCESSFUL INITIATION OF BUPRENORPHINE IN ADOLESCENTS AND YOUNG ADULTS

Initiation of buprenorphine for the pharmacologic treatment of opioid use disorder in adolescents and young adults is a key step in overall opioid use disorder treatment, which requires clinical caution and careful timing. If unsuccessfully done, precipitated withdrawal can be acutely uncomfortable and distressing, and failed initiation may represent a missed opportunity for acceptance of this life-saving treatment. When following clinical guidelines, buprenorphine can be started successfully in a variety of settings, including at home, an increasingly common practice among addiction providers. The aim of this presentation is to help attendees increase clinical confidence and competence for initiating buprenorphine treatment. A review of current literature on strategies and procedures for buprenorphine induction in youth and young adults, including an emphasis on strategies for both home and clinic initiation of buprenorphine, has been completed and findings will be presented. A review of clinical management of precipitated withdrawal will also be provided. Clinical case scenarios representing important decision points regarding timing and strategy for buprenorphine induction have been created for audience participation. Standard protocols and guidelines have been created and used widely to successfully start buprenorphine treatment in youth and young adults with opioid use disorder. With correct clinical utilization of validated tools such as withdrawal scales, the risks associated with buprenorphine initiation can be minimized. Barriers to utilization of this potentially life-saving treatment are decreasing. The initiation phase of buprenorphine treatment is a key step in providing this potentially life-saving treatment for youth and young adults with opioid use disorders. Adequate education can decrease a discomfort barrier that prevents physicians from utilizing their buprenorphine waiver training to begin treating this clinical population.

GROUND GLASS OPACITIES: IT'S NOT ALL COVID

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: During the COVID-19 pandemic, superimposed infections with both bacterial and fungal organisms have been shown to complicate the viral process. Aspergillus and candida are the most common fungal organisms reported [2];but there have also been a few case reports with co-infection from Pneumocystis jirovecii pneumonia (PJP) [1,3]. We present a COVID patient with lymphopenia and diffuse ground glass opacities who was also diagnosed with PJP. CASE PRESENTATION: A 58-year-old male with past medical history of emphysema liver cirrhosis presented to the hospital with nausea, vomiting and abdominal distention. On examination he was afebrile, hypotensive with a blood pressure of 88/56, SpO2 was 96% on room air. His lungs were clear on auscultation and abdominal exam was notable for moderate ascites. There was 2+ pedal edema bilaterally. Laboratory work-up showed a WBC count of 12000/µL, only 7% of which were lymphocytes. Chest X-ray did not reveal any acute pathology and screening COVID-19 PCR was negative. He was admitted to the medical ward for management of alcohol withdrawal and decompensated liver cirrhosis. He developed hypoxic respiratory failure within 24 hours of presentation. CT chest (Figure 1) showed multifocal ground glass opacities along with bilateral pleural effusions and consolidative airspace disease at bases. A repeat COVID PCR resulted positive. His respiratory failure progressively worsened over the next two weeks despite being treated with remdesivir, dexamethasone and empiric broad spectrum antibiotics. He was intubated and placed on mechanical ventilation. Repeat imaging (Figure 2) showed worsening diffuse ground glass opacities now with more predominant cystic changes. Bronchoscopy with broncho-alveolar lavage (BAL) was performed, PCR testing of the BAL sample detected Pneumocystis jirovecii. He was then started on Bactrim in conjunction with steroids for the high A-a gradient. HIV antibody was negative, CD4 lymphocyte count was low at 304/µL and CD8 counts were normal at 311/µL. The patient slowly started to improve and was successfully extubated after three weeks. However, he later on developed septic shock from candidemia and was placed on hospice care by family due to his poor functional status. DISCUSSION: As with many viral infections, patient's with COVID-19 have demonstrated considerable risk for developing concomitant bacterial and fungal infections. We speculate that lymphopenia with low absolute CD4 count, combined with the use of corticosteroids may play a role in susceptibility to opportunistic infections in otherwise immunocompetent hosts. CONCLUSIONS: When critically ill COVID patient's fail to improve and have persistent lymphopenia, co-infections should be considered and appropriately worked up. REFERENCE #1: A case of COVID-19 and Pneumoncystis jirovecii Coinfection. A. Menon et al. Am J Respir Crit Care Med. 2020 Jul REFERENCE #2: Invasive Fungal Disease Complicating Coronavirus Disease 2019: When It Rains, It Spores. M.Hoenigl. Clinical infectious diseases. 2020 September REFERENCE #3: Pneumocystis and Severe Acute Respiratory Syndrome Coronavirus 2 Coinfection: A Case Report and Review of an Emerging Diagnostic Dilemma. C. Rubiano. Open Forum Infectious Diseases. January 2021. DISCLOSURES: No relevant relationships by Ahmed Mahgoub, source=Web Response No relevant relationships by Joseph Meharg, source=Web Response No relevant relationships by Leandro Ramirez, source=Web Response No relevant relationships by Ajit Thota, source=Web Response

PHENOBARBITAL VS BENZODIAZEPINES FOR ALCOHOL WITHDRAWAL MANAGEMENT IN MEDICAL ICU: PRELIMINARY RESULTS OF PRE-POST PROTOCOL STUDY

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: Phenobarbital (PB) has been suggested as an alternative to benzodiazepines (BZD) for alcohol withdrawal (AW) management. Few studies have examined the efficacy of different PB regimens for the management of AW in the medical intensive care unit (ICU). METHODS: Retrospective, pre-post protocol, cohort study for patients with AW syndrome admitted to the medical ICU at Cleveland Clinic, Fairview Hospital, during the period from January 2019 through April 2021. Historically a symptom-triggered BZD based protocol utilizing CIWA-Ar has been employed. In September 2020, a PB-based protocol was implemented for AW management. The protocol included PB 260 mg intravenous (IV) followed by 130 mg IV repeated doses every 15 - 30 minutes as needed up to a total of 15 mg/kg (ideal body weight) to maintain CIWA-Ar score below 10. We included adult patients who were admitted to medical ICU primarily for AW management. We excluded patients intubated before ICU admission or the presence of a serious medical or surgical diagnosis that would have otherwise dictated admission to the ICU. The primary outcome is ICU length of stay (LOS). Secondary outcomes include hospital LOS, intubation rate, the number of adjunctive agents, medication side effects, requirement for sitter, restraining, ICU readmission and mortality rate. RESULTS: A total of 270 patients were screened, of which only 62 patients with AW were enrolled, 15 in the PB arm and 47 in the BZD arm. Overall, 32% of all patients presented as uncomplicated AW, 42% as delirium tremens, and 13% as AW seizure. No significant differences in basic characteristics between arms were observed. Compared to BZD arm, patients who received PB had significant shorter ICU LOS (median [IQR], 28 hours [24 – 37] vs 59 hours [34 – 115]; P=<.001) and hospital LOS (median [IQR] 4 days [3 – 5] vs 6 days [4 – 10]; P=.006). PB arm required less number of adjunctive agents to control AW (1 [0 – 1] vs 3 [2 – 4]; p=<.001) including less utilization of dexmedetomidine (1 [7%] vs 22 [47%]; p=<.001). None of the patients in the PB arm required restraint use (0 vs 27 [57%]; p=<.001). No significant difference between arms with regards to medication side effects, sitter requirement, ICU readmission, intubation rate, and mortality rate. CONCLUSIONS: The initial findings from our study are suggesting that our proposed PB-AW management protocol is associated with shorter ICU and hospital LOS. It may be considered as an effective and safe alternative to BZD. CLINICAL IMPLICATIONS: Our results will help in evolving AW management guidelines in ICU. DISCLOSURES: No relevant relationships by Saira Afzal, source=Web Response No relevant relationships by BASSEL AKBIK, source=Web Response No relevant relationships by Dina alayan, source=Web Response No relevant relationships by Sura Alqaisi, source=Web Response No relevant relationships by Mahmoud Alwakeel, source=Web Response No relevant relationships by Ellen Immler, source=Web Response No relevant relationships by Talha Saleem, source=Web Response No relevant relationships by Xiaofeng Wang, source=Web Response

JSAT call for papers for special issue: Stimulant use disorder

The Journal of Substance Abuse Treatment seeks articles on the changing epidemiology and treatment of stimulant use disorder for a planned Special Issue. JSAT prefers empirical research, however, we will also consider systematic reviews and meta analyses. Recent reports from CDC and other sources has documented that cocaine and methamphetamine play an increasing role in the overdose death crisis in the US. We think a special issue presenting new information on a variety of stimulant-related research topics is merited. We invite high quality research manuscripts on topics related to stimulant use disorder, such as:•Behavioral and pharmacotherapy innovations•Implementation and dissemination science•Treatment in medical and specialty care settings•Assessment and treatment of co-occurring psychiatric symptoms (psychosis, depression)•Withdrawal management•Overdose prevention and overdose treatment•Epidemiological and treatment studies addressing racial, ethnic, sexual, and/or gender minority populations, as well as rural communities To facilitate manuscript development, authors should submit an abstract (maximum of one page) of the proposed paper to Michael McDonell, [email protected] . Authors of selected manuscripts will be invited to submit a full manuscript. When a manuscript is ready for submission, it must be submitted directly to the JSAT Editorial Manager: (https://www.editorialmanager.com/josat/default.aspx). The first step is to indicate “article type.” In the drop-down menu, select “Stimulant Use Disorder” so the paper will be routed to the editors. Articles should follow the outline provided in the guide for authors (https://www.elsevier.com/journals/journal-of-substance-abusetreatment/0740-5472/guide-for-authors). We advise authors to consult the EQUATOR Network for guidance on standardized reporting guidelines (https://www.equator-network.org/) and follow the appropriate guidelines. The due date for abstracts is 1st January 2022. Abstracts will be peer-reviewed and decisions will be announced no later than 1st February 2022. Papers invited for submission will be due on 1st May 2022. All submitted manuscripts will go through a rigorous peer-reviewed process, thus acceptance of your abstract does not guarantee publication. Accepted manuscripts will be published online on a rolling basis (prior to the full special issue being published in late 2022). Please email any questions to the guest editors below. We look forward to receiving your abstracts!

In Support of Initial Parenteral Medical Management of Intrathecal Baclofen Withdrawal in Spasticity Patients.

Background: Spasticity may present as a wide range of symptoms and conditions. With this protean presentation, a consensus regarding the best course of treatment does not exist. Those patients most severely affected may receive significant benefit from intrathecal baclofen delivery. However, this therapy may itself lead to patient injury in the event of withdrawal. Objective: Withdrawal from intrathecal baclofen may devolve rapidly into a situation in which the patient may incur significant morbidity and even death. A focused, prompt treatment plan would afford the patient the best possible outcome. Methods: The medical literature was reviewed for reports of plans of treatment of baclofen withdrawal and the results obtained. The nature of this problem does not lend itself to a typical study design, depending on case reports and basic pharmacological science application. The paucity of such reports severely limits categorical comparison of patient characteristics and clinical circumstances. Clinical situations, patient characteristics, and therapies were considered and compared. Outcomes of the varied treatments were evaluated for efficacy. Results: Inaccurate diagnoses, delayed correct diagnoses, and the absence of a consistent, treatment plan contributed to widely disparate outcomes. Prompt, correct diagnosis and intensive care unit-based continuous benzodiazepine infusion with titration led to a controlled clinical situation and maximized patient outcomes. Conclusions: Patients going through withdrawal from intrathecal baclofen achieved best outcomes when treated with a continuous infusion and titration of an intravenous benzodiazepine. A well-defined treatment protocol employing this management, reporting serial outcomes, would enable further refinement of the treatment of this clinical problem.

Percutaneous electrical nerve field stimulation to reduce clincial opiate withdrawal: a case series

ABSTRACT Background Medication-assisted treatment can reduce mortality and withdrawal symptoms, yet treatments can have side effects and are cost ineffective. Research has supported alternative approaches to withdrawal symptoms, specifically percutaneous nerve field stimulator (PNFS); yet, to date, there is a lack of understanding of the initial acceptability within treatment programs. Methods A retrospective case series evaluated PNFS to reduce opioid withdrawal symptoms for five adult patients participating in an in-home withdrawal management program. The device was worn for five consecutive days, in which a licensed practical nurses monitored their care. Evaluation included the clinical opiate withdrawal scale (COWS) and clinical reviews based on self-report and clinician interview. Results Significant reductions were noted for all five participants, with the average COWS score for Day 1 at 19.1 reducing to 2.6 at Day 5. In addition, 2-day post-COWS scores demonstrated a continual reduction to 1.4. Qualitative feedback from the patients was recorded, and generalized themes were recorded and addressed. Conclusions Future controlled, prospective studies should investigate the possibility that PNFS can significantly reduce negative symptoms of opiate withdrawal symptoms, along with providing alternatives to medication-assisted treatments for those who are suffering from opiate use disorder.

Characterizing Baclofen Withdrawal: A National Survey of Physician Experience

ObjectiveWe studied physicians’ opinions and experiences concerning clinical concerns, perceived severity, occurrence, and management of baclofen withdrawal due to abrupt discontinuation. MethodsA nationwide 26-question electronic survey was distributed via e-mail to physicians (N = 952) representing varying specialties who manage spasticity with baclofen. A total of 110 physicians provided responses to the survey (response rate = 11.6%). Results were evaluated using descriptive statistics. ResultsWithdrawal from both oral and intrathecal (IT) baclofen was recognized as a significant concern and was observed by most respondents. However, approximately 75% and 35% of respondents or their clinic sites lack established management protocols for managing anticipated interruption of oral or IT baclofen, respectively. ConclusionsThese findings highlight the need for further research on and the development of guidelines for the prevention and treatment of baclofen withdrawal. The results of this survey, along with a systematic literature review and multidisciplinary stakeholder input, may be helpful in establishing guidelines for the treatment and prevention of baclofen withdrawal.

A multifaceted quality improvement intervention to improve management of alcohol withdrawal on a general medicine ward: impact on benzodiazepine use

Objective: To measure the effects of a quality improvement intervention on length of stay and benzodiazepine use among patients admitted for alcohol use disorder. Methods: This retrospective cohort study was performed at the Salt Lake City Veterans Affairs Medical Center. Patients 18 years and older admitted to a general medical ward with a diagnosis of alcohol related disorders who were treated for alcohol withdrawal were included. The baseline cohort included patients admitted over 12 months. The post-intervention cohort included patients admitted over 12 months. Primary outcomes were total benzodiazepine dose and length of stay. Secondary outcomes included episodes of delirium tremens and seizures. Results: Total benzodiazepine dose decreased significantly over the intervention period. Length of stay also decreased. No episodes of delirium tremens or seizures were observed. Conclusions: A quality improvement intervention directed at general medicine inpatients admitted for alcohol withdrawal was associated with reductions in total benzodiazepine administration and length of stay.

The impact of the opioid crisis on U.S. state prison systems

BackgroundPrior studies have documented limited use of medications to treat opioid use disorders (OUD) for people incarcerated within state prisons in the United States. Using the framework of the criminal justice OUD service cascade, this study interviewed representatives of prison systems in states most heavily impacted by opioid overdose regarding the provision of medications for OUD (MOUD). MethodsA stratified sampling strategy included states with high indicators of opioid-overdose deaths. Two sampling strata targeted states with: 1) OUD overdose rates significantly higher than the per capita national average; or 2) high absolute number of OUD overdose fatalities. Interviews were completed with representatives from 21 of the 23 (91%) targeted states in 2019, representing 583 prisons across these states. Interviews assessed service provision across the criminal justice OUD service cascade, including OUD screening, withdrawal management, MOUD availability and provision, overdose prevention, re-entry services, barriers, and needs for training and technical assistance.ResultsMOUD (buprenorphine, methadone, or naltrexone) was available in at least one prison in approximately 90% of the state prison systems and all three medications were available in at least one prison in 62% of systems. However, MOUD provision was limited to subsets of prisons within these systems: 15% provided buprenorphine, 9% provided methadone, 36% provided naltrexone, and only 7% provided all three. Buprenorphine and methadone were most frequently provided to pregnant women or individuals already receiving these at admission, whereas naltrexone was primarily used at release. Funding was the most frequently cited barrier for all medications.ConclusionStudy findings yield a complex picture of how, when, and to whom MOUD is provided across prisons within prison systems in states most heavily impacted by opioid overdose in the United States and have implications for expanding availability.

Patient characteristics predicting attendance for elective in-patient treatment of substance use disorder.

Consumption of alcohol and other drugs constitutes a significant health burden. Treatment access is poor, and a number of barriers are recognised. The objective of this retrospective cohort study is to examine patient characteristics of those attending/not attending for elective in-patient withdrawal management (IWM). Records of all elective admissions for IWM between 1 March and 30 June 2019 were reviewed. Data were extracted on attendance, age, substance(s) used, pre-arranged rehabilitation admissions following discharge, wait time, legal issues and child welfare agency involvement. Of 274 planned admissions, 193 (70%) attended. Attendance was predicted by residential treatment planned after withdrawal management and older age. People using amphetamines were less likely to attend. There are low attendance rates for elective IWM. Patient characteristics predicting lower attendance include younger age, amphetamine use and not planning rehabilitation. Further research is required to improve attendance.

A clinical research priority setting study for issues related to the use of methamphetamine and emerging drugs of concern in Australia.

IntroductionThis study aimed to gather a range of opinions, including those of affected people (consumers, concerned others) to identify clinical research priorities for methamphetamine and emerging drugs of concern in Australia, to guide the work of the National Centre for Clinical Research on Emerging Drugs (NCCRED).MethodsA priority setting study was conducted (February–March 2019) in four phases: online stakeholder survey, thematic analysis of responses, rapid literature review, expert panel ranking of priorities against predetermined criteria.ResultsForty‐seven respondents completed the survey, including people identifying as one or more of: researcher (53%, n = 25), clinician (45%; n = 21), family/friend/caregiver of someone who uses methamphetamine/emerging drugs (15%, n = 7) and consumer of methamphetamine/emerging drugs (13%, n = 6). Expert panel, evidence‐informed top‐ranked clinical research priorities for methamphetamine were: strategies to overcome barriers to intervention uptake, pilot medication trials for adults seeking treatment, and communication strategies regarding evidence‐based treatments. For emerging drugs of concern, top‐ranked priorities were: piloting community‐located drug checking, feasibility of social media/other opportunities to alert consumers of emerging risks, GHB overdose and withdrawal management, and impacts of an early warning information system on reducing harms.Discussion and ConclusionsWe demonstrate feasibility of a structured, collaborative clinical research priority setting process. Results have informed the establishment of NCCRED; using the identified priorities to guide seed funding, fellowships/scholarships and research programs. Broader uptake of this methodology by policymakers/research funders would assist to embed areas of concern identified by affected communities and other stakeholders in research prioritisation.

Treatment Programs for Substance Use Disorder

&#x0D; Moderate to weak evidence suggests that patients with substance use disorders who received residential treatment were more likely than outpatients to complete treatment and be considered abstinent. Comparisons between residential treatment and outpatient programs for other outcomes were unclear.&#x0D; Strong- to weak-quality evidence showed that residential treatment services for patients with substance use disorders was effective in improving various outcomes including substance use, social, criminal activity, and mental health outcomes. However, residential treatment was likely associated with poorest survival outcomes after discharge compared to other treatments.&#x0D; Managed alcohol programs in hospital settings appeared to be effective and safe in preventing and treating alcohol withdrawal syndrome in surgical patients, trauma patients, or hospitalized patients. The level of evidence was not assessed.&#x0D; There was evidence that managed alcohol programs in community settings improved drinking patterns, alcohol-related harm, criminal activity, mental health, and social and physical well-being. The level of evidence was not assessed.&#x0D; The American Society of Addiction Medicine clinical practice guideline provides recommendations for the identification and management of alcohol withdrawal in inpatient and ambulatory settings. Patients’ current signs and symptoms, levels of risk for developing severe or complicated withdrawal or complications of withdrawal, and other dimensions should be taken into consideration in the assessment process to determine the appropriate level of care. Strength of recommendations was not assessed.&#x0D; The Canadian Coalition for Seniors’ Mental Health recommends that patients with cannabis use disorder should be considered for residential treatment if they are unable to effectively reduce or cease their cannabis use (level of evidence: Low; strength of recommendation: Strong).&#x0D;

Use of clonidine in the management of opiate withdrawal in community patients

AimsClonidine has been used to alleviate symptoms of opiate withdrawal. No validated prescribing schedules exist for the use of Clonidine in opiate detoxification in community patients. We have devised a Clonidine prescribing schedule for adult outpatients seeking opiate detoxification.BackgroundOpiate cessation following prolonged use produces a central noradrenergic (NA) response in the locus coeruleus (LC), causing symptoms that can result in reinstatement of use. Pharmacotherapies for withdrawal are thought to work through decreased NA release in the LC by agonising pre-synaptic alpha-2 adrenoceptors. Clonidine has been used since the 1970s. However, it is off-license in the UK, and superseded by Lofexidine. Though both cause hypotension, this is less marked with Lofexidine, which may be anxiolytic and considered better tolerated. Lofexidine is no longer available in the UK. Specialists may need to resort to Clonidine for those seeking opiate detoxification.MethodWe performed a feasibility study with the primary outcome being tolerability of an outpatient clonidine schedule. Patients (n = 7) were aged between 18 and 65 years (mean 32). Six were prescribed buprenorphine as opiate substitution (OST), and one methadone.Exclusion criteria were in keeping with BNF contraindications.An ECG was obtained for each patient before treatment. A urine drug screen and Clinical Opiate Withdrawal Scale were taken to confirm opiate dependence and withdrawal. Patients self-monitored withdrawal using the Subjective Opiate Withdrawal Scale and daily blood pressure measurements. Standard adjuvants for withdrawal were prescribed.A test dose of 100mcg Clonidine was given to assess for hypotension. If tolerant they received 100mcg QDS, reducing over eight days.Patients were contacted by their recovery worker twice during the period.ResultFive of the seven completed the course, two dropped out due to hypotension. No other adverse effects warranting discontinuation were encountered. Patients reported fatigue and light-headedness as their most troublesome side-effects. Of 3 patients who returned SOWS scores, 2 reported decline by 21/64 and 14/64 respectively. One reported an increase of 49/64 over 8 days. 3 of the 5 subjects who completed the course were not abstinent at completion, citing opiate withdrawal symptoms as causative.ConclusionThere is scope for the safe use of clonidine in the community for motivated individuals. Adequate monitoring of heart rate and blood pressure is required. Starting doses at 100mcg QDS appear well tolerated. Prescribers may wish to reduce this over a longer period to encourage completion and improve tolerability. Further research is needed.

Therapeutic Approaches to Opioid Use Disorder: What is the Current Standard of Care?

Opioid use disorder is a frequent cause of suffering to communities worldwide. Therapeutic approaches to opioid use disorder include screening, appropriate assessment and diagnosis, consideration of level of care, acute management of overdose or withdrawal, treatment with medications, psychotherapeutic approaches, and community support. People who struggle with addiction to opioids often suffer deeply from direct and indirect consequences of use. Subsequently, it is critical that all medical providers understand the appropriate treatment options for opioid use disorder. This paper provides a comprehensive overview of the therapeutic options available for treatment of this chronic disease.

Modernizing Withdrawal Management Services

ABSTRACT Alcohol, opioid, and stimulant withdrawal syndromes are serious clinical presentations, some of which can be life-threatening if untreated. Patients presenting with withdrawal syndromes offer an important opportunity for healthcare providers to ally in deciding the most appropriate treatment setting, safely treating withdrawal symptoms, preventing potentially severe medical complications, and facilitating a transition to longer-term low-barrier substance use care including, where available, psychosocial interventions, evidence-based pharmacotherapies, and referrals for primary care-based or specialist-led services. Given that substance use disorders are chronic biopsychosocial disorders commonly characterized by periods of relapse and remission, patients presenting in substance withdrawal deserve a long-term and holistic approach to management that cannot be simply achieved in short-term withdrawal management siloed and separate from a continuum of ongoing substance use care. With this in mind, this narrative review of withdrawal management literature describes recent advances and challenges in clinical care for patients in withdrawal from alcohol, opioids, and stimulants. Les syndromes de sevrage liés à l’alcool, aux opioïdes et aux stimulants sont des manifestations cliniques graves, dont certaines peuvent mettre la vie en danger si elles ne sont pas traitées. Les patients présentant des syndromes de sevrage offrent aux fournisseurs de soins de santé une occasion importante de s’allier pour décider du cadre de traitement le plus approprié, traiter en toute sécurité les symptômes de sevrage, prévenir les complications médicales potentiellement graves et faciliter la transition vers des soins de consommation de substances à faible barrière à long terme, y compris, lorsque disponibles, interventions psychosociales, pharmacothérapies fondées sur des données probantes et aiguillage vers des services de soins primaires ou dirigés par des spécialistes. Étant donné que les troubles liés à l’usage de substances sont des troubles biopsychosociaux chroniques généralement caractérisés par des périodes de rechute et de rémission, les patients se présentant en sevrage de substances méritent une approche à long terme et holistique de la prise en charge qui ne peut être simplement réalisée dans une gestion du sevrage à court terme cloisonnée et séparée d’un continuum des soins continus liés à l’usage de substances. Dans cet esprit, cette revue narrative de la littérature sur la gestion du sevrage décrit les progrès récents et les défis dans les soins cliniques pour les patients en sevrage d’alcool, d’opioïdes et de stimulants.

Predictors of and reasons for early discharge from inpatient withdrawal management settings: A scoping review.

Early discharges, also known as 'against medical advice' discharges, frequently occur in inpatient withdrawal management settings and can result in negative outcomes for patients. The purpose of this scoping review is to identify what is known about predictors of and reasons for the early discharge among adults accessing inpatient withdrawal management settings. MEDLINE, CINAHL, PsycINFO, ASSIA and EMBASE were searched, resulting in 2587 articles for screening. Title and abstract screening and full-text review were completed by two independent reviewers. Results were synthesised in quantitative and qualitative formats. Sixty-two studies were included in this scoping review. All studies focused on predictors of early discharge, except one which only described reasons for the early discharge. Forty-eight percent of studies involved retrospective review of health records data. The most frequently examined variables were demographics. Variables related to the treatment setting, such as referral source and treatment received, were examined less frequently but were more consistently associated with early discharge compared to demographics. Only six studies described patient reasons for the early discharge, which were retrieved via clinical documentation. The most common reasons for early discharge were dissatisfaction with treatment and family issues. Most demographic variables do not consistently predict early discharge, and reasons for early discharge are not well understood. Future studies should focus on the predictive value of non-patient-level variables, or conduct analyses to account for predictors of early discharge among different subgroups of people (e.g. by gender or ethnicity). Qualitative research exploring patient perspectives is needed.

Facilitating rapid access to addiction treatment: a randomized controlled trial

BackgroundObtaining timely access to addiction medicine treatment for patients with substance use disorders is challenging and patients often have to navigate complex referral pathways. This randomized controlled trial examines the effect of providing an expedited pathway to addiction medicine treatment on initial treatment engagement and health care utilization.MethodsIndividuals with possible alcohol or opioid use disorder were recruited from three residential withdrawal management services (WMS). Subjects randomized to the Delayed Intervention (DI) group were given contact information for a nearby addiction medicine clinic; those randomized to the Rapid Intervention (RI) group were given an appointment at the clinic within 2 days and were accompanied to their first appointment.ResultsOf the 174 individuals who were screened, 106 were randomized to either the DI or RI group. The two groups were similar in demographics, housing status, and substance use in the last 30 days. In the 6-month period following randomization, 85% of the RI group attended at least one clinic appointment, compared to only 29% in the DI group (p < 0.0001). The RI group had a mean of 6.39 ED visits per subject in the 12 months after randomization, while the DI group had a mean of 13.02 ED visits per subject in the same 12-month period (p = 0.0469). Other health utilization measures did not differ between the two groups.ConclusionProviding immediate facilitated access to an addiction medicine service resulted in greater initial engagement and reduced emergency department visits at 6 months.Trial registration This trial is registered at the National Institutes of Health (ClinicalTrials.gov) under identifier #NCT01934751.