Outpatient Detoxification Program Research Articles

Circulating nociceptin and CGRP in medication-overuse headache.

Previous studies found low serum levels of nociceptin in migraine patients but high serum levels of calcitonin gene-related peptide (CGRP). CGRP can elicit migraine-like headache. Medication-Overuse Headache (MOH) often has migraine features and can mimic chronic migraine. We therefore hypothesized that as in migraine, serum levels of nociceptin would be lower and CGRP serum levels higher in MOH patients compared with those in healthy volunteers. We hypothesized that the serum levels would normalize after detoxification. Seventeen MOH patients, hereof 70.6% with chronic migraine and MOH, and 30 sex and age matched headache-free controls were included. MOH patients underwent a 2-month outpatient detoxification program and after 6months, 10 patients and 19 controls were retested. Blood samples were analyzed blinded. We found no differences in the levels of nociceptin and CGRP between MOH patients and controls (P=0.65 and P=0.59). The mean headache frequency reduction was 43% and 70% of patients reverted to episodic headache after 6months, but the levels of nociceptin and CGRP were unchanged (P=0.71 and P=0.82). In contrast to previous findings in migraine patients, we found normal serum levels of nociceptin and CGRP in MOH patients. Thus, we find no evidence that the increased headache frequency of MOH patients could be caused by altered nociceptin and CGRP levels. This underlines the importance of identifying medication overuse in chronic headache and treating the MOH.

217: Opiate detoxification in pregnancy: A cost-effectiveness analysis

It is common for women with opioid dependency in pregnancy to be managed with methadone or buprenorphine maintenance therapy. However, detoxification is generally avoided due to perceived unfavorable outcomes to the fetus. Recent literature shows improved neonatal outcomes compared to the initial data. This study is a cost-effectiveness analysis of three detoxification methods looking at neonatal and maternal outcomes. A decision-analytic model use TreeAge Pro was constructed for opioid-dependent patients with singleton pregnancies who were placed into one of three detoxification programs: a 1-week inpatient setting followed by inpatient rehabilitation for their remaining pregnancy (Group 1), a 1-week inpatient detoxification program (Group 2), or a 16-week outpatient detoxification program (Group 3). A comparison of these strategies was completed in a theoretical cohort of 10,000 women. Probabilities, utilities, and costs were approximated by the existing literature. Prenatal outcomes measured included intrauterine fetal demise (IUFD), neonatal death (NND), neonatal abstinence syndrome (NAS), major neurodevelopmental disorder (MNDD), and preterm deliveries (PTD). Maternal opiate relapse and quality life adjusted years (QALYs) were also assessed. Group 1 (in + out) produced the best outcomes. As compared to Group 2 (in only), it had 511 fewer women relapse and had fewer IUFDs and neonatal deaths (Table). Group 3 (out only) led to the worst outcomes overall (Table). With the lowest costs and best outcomes, Group 1 (in + out) was the dominant strategy. It remained the dominant strategy over both other groups until cost reached $23,950. Group 1 (in + out) had improved maternal QALYs of 0.53 greater than Group 3 (out only) and 5.56 over Group 2 (in only). Patients detoxified from opiates as an inpatient with placement in rehabilitation for their remaining pregnancy was most cost effective, and had the best neonatal outcomes of this study. The patients who were detoxified in the inpatient setting without follow up had a high rate of relapse of their drug use, leading to highest costs, lest maternal QALYs, and worst neonatal outcomes. If patients choose to be detoxified from opiates during pregnancy, an inpatient detoxification program followed by an inpatient rehabilitation center is the best strategy for maternal and fetal outcomes and cost-effectiveness.

A consensus protocol for the management of medication-overuse headache: Evaluation in a multicentric, multinational study

The management of medication-overuse headache (MOH) is often difficult and no specific guidelines are available as regards the most practical and effective approaches. In this study we defined and tested a consensus protocol for the management of MOH on a large population of patients distributed in different countries. The protocol was based on evidence from the literature and on consolidated expertise of the members of the consensus group. The study was conducted according to a multicentric interventional design with the enrolment of 376 MOH subjects in four centres from Europe and two centres in Latin America. The majority of patients were treated according to an outpatient detoxification programme. The post-detoxification follow-up lasted six months. At the final evaluation, two-thirds of the subjects were no longer overusers and in 46.5% of subjects headache had reverted back to an episodic pattern of headache. When comparing the subjects who underwent out-patient detoxification vs those treated with in-patient detoxification, both regimens proved effective, although the drop-out rate was higher in the out-patient approach. The present findings support the effectiveness and usability of the proposed consensus protocol in different countries with different health care modalities.

Treatment outcome predictors in flexible dose-duration methadone detoxification program.

Methadone detoxification is among the widely used treatment programs for opioid dependence. The aims of this study were to identify which patient baseline factors and treatment regimen features are predictors of the treatment outcome in an outpatient flexible dose-duration methadone detoxification program. We studied 126 opioid dependents in a naturalistic nonexperimental clinical setting. The patients were assessed for baseline demographic characteristics, and drug abuse characteristics. Treatment regimen features were recorded during the program. Successful treatment completion was defined as the last daily dose of methadone being less than 15 mg, negative urine analysis in the last two weeks of treatment, and based on the final clinician-client's decision. Out of 126 patients, 60 patients completed detoxification successfully. Younger age, longer duration of the opioid abuse, and higher subjective opiate intoxication severity before treatment entry were all significantly associated with negative treatment outcome. Among treatment regimen features, higher maximum methadone dose had a marginally significant independent effect on treatment failure. Patients with maximum methadone dose of more than 75 mg per day had around ten times worse success rate when compared to those who received lesser doses. The study findings could be used to predict treatment outcome and prognosis in a more individualized and patient-tailored approach in the real clinical setting. Guideline development for treatment selection and outcome monitoring in addiction medicine based on similar studies could enhance treatment outcome in clinical services.

Polydrug Abuse by Intravenous Use of Heroin and Tropicamide-Containing Eyedrops

Drug abuse is rarely limited to a single substance; polydrug use is the norm rather than the exception. In many cases, the misuse of potentially psychoactive substances can lead to serious intoxications and results in addictive behavior. A 22-year-old heroin-addicted woman presented in our clinic reporting a 2-year history of intravenous injection of an eyedrop solution containing 1% tropicamide, an antimuscarinic agent. She reported injecting tropicamide because it attenuated symptoms and signs of opiate withdrawal and it also has hallucinogenic and euphorigenic effects. Despite the large amounts (up to 1.5 g), the rapidity of injection, and the long-term use, tropicamide was relatively well tolerated, without life-threatening consequences.An outpatient detoxification program was performed without any sign or symptom caused by discontinuing tropicamide. The present case claims a role for pharmacological interactions, in addition to rewarding effects, in influencing drug association in polyabuse pattern. Moreover, this case underlines the need for physicians to be aware of the potential emergence of tropicamide as a drug of misuse, to prevent further harm.

One to One awardees build relationships with patients

Pharmacy Today honored pharmacists for their outstanding counseling and patient care at last month’s 2012 APhA Annual Meeting & Exposition in New Orleans. Student pharmacists and pharmacists received round-trip airfare to APhA2012 and 2 nights’ hotel and were recognized at an awards dinner. A full list of the 2012 One to One Patient Counseling Recognition Program recipients appeared in the March issue of Today. The program was made possible through the generous support of McNeil Consumer Healthcare. Today will profile each of the top 10 One to One pharmacist awardees through the spring. This month features two pharmacists who establish long-term relationships with their patients by providing ongoing care with frequent follow-up counseling sessions. Traci Brooks, PharmD, a clinical pharmacist at the Wounded Warrior and Pain Clinics at Womack Army Medical Center in Fort Bragg, NC, provides medication management to active duty men and women who have been wounded or injured or are ill. She keeps her patients safe by monitoring for drug-drug interactions and adverse effects. Counseling this patient population can be challenging because of physical and emotional injuries that patients incur from training missions and deployments. Brooks recently met with a patient who requested a refill for rizatriptan (Maxalt—Merk); she noticed that the prescription had been filled within the past 10 days. After further discussion. Brooks learned that the patient was taking the medication daily to prevent headaches, rather than on an as-needed basis at the onset of a headache. Brooks provided medication education and counseling, and the patient learned about the appropriate use of his medication, decreasing the chance of worsening his condition from medication overuse. Brooks was instrumental in developing an outpatient detoxification program for active duty personnel. Pain and Behavioral Health clinic providers asked Brooks to provide expertise in opening a buprenorphine/naloxone (Suboxone— Reckitt Benckiser) clinic. She took the lead in creating criteria for patients to be seen at the clinic, including weekly screenings, safety checks, and medication counseling. Once patients are enrolled in the Suboxone clinic, Brooks counsels them about the role of the drug in their treatment and any adverse effects they can expect. Through weekly interactions, she builds a rapport with her patients and they feel comfortable disclosing issues that may affect their treatment plan. Through these ongoing relationships with her patients, Brooks ensures that they are following their treatment plan and are evaluated for dose adjustments. One Special Forces soldier sought out Brooks after completing his treatment with Suboxone. He thanked her for saving his life and said that the program she manages enabled him to be a better husband and father. The personal goal of Patrick Devereux. PharmD. is to provide one-on-one counseling services to every patient who fills prescriptions at FMS Pharmacy in Bessemer, AL. As the vice president of the pharmacy, Devereux believes in building long-term relationships with his patients. He recently added in-depth patient follow-up procedures to the pharmacy’s standard patient counseling sessions. When a new medication is initiated or when an existing medication is changed, the patient is counseled as usual, and counseling points are noted in the patient’s chart. The patient is contacted 5 to 7 days later to assess if there are any adverse effects. Through this process. Devereux identifies patients who have stopped taking their medications because of adverse effects and works with prescribers to find alternative options for these patients. Devereux uses the follow-up consultation to sync medication refills for his patients. Typically, within 3 months, Devereux is able to formulate a strategy that allows patients to make only one trip to the pharmacy to refill chronic medications. The system is also useful in determining nonadherence, because patients are able to receive refills on all chronic medications at the same time each month. When patients come in to get all of their medications refilled. Devereux takes this opportunity to talk to them about any medication adherence problems. He also strategizes with patients and prescribers to ensure optimal medication use. Devereux established the only accredited diabetes education program in a community pharmacy in Alabama. He completed a pilot program in his pharmacy and has since marketed the program to additional contracted payers. “Of all the pharmacists I have worked with, Patrick far exceeds all the expectations of normal patient counseling,” wrote Devereux’s nominator, Lindsey Elmore, PharmD, BCPS, Assistant Professor of Pharmacy Practice and Residency Program Director for the Community Pharmacy Residency Program at the Samford University McWhorter School of Pharmacy.

Management of Medication Overuse Headache: 1-Year Randomized Multicentre Open-Label Trial

It is a general belief that patients with medication overuse headache (MOH) need withdrawal of acute headache medication before they respond to prophylactic medication. In this 1-year open-labelled, multicentre study intention-to-treat analyses were performed on 56 patients with MOH. These were randomly assigned to receive prophylactic treatment from the start without detoxification, undergo a standard out-patient detoxification programme without prophylactic treatment from the start, or no specific treatment (5-month follow-up). The primary outcome measure, change in headache days per month, did not differ significantly between groups. However, the prophylaxis group had the greatest decrease in headache days compared with baseline, and also a significantly more pronounced reduction in total headache index (headache days/month x headache intensity x headache hours) at months 3 (P = 0.003) and 12 (P = 0.017) compared with the withdrawal group. At month 12, 53% of patients in the prophylaxis group had > or = 50% reduction in monthly headache days compared with 25% in the withdrawal group (P = 0.081). Early introduction of preventive treatment without a previous detoxification programme reduced total headache suffering more effectively compared with abrupt withdrawal. (ClinicalTrials.gov number, NCT00159588).

Pancreatitis

To determine the prevalence of pancreatitis and associated risk factors among heavy-drinking veterans. At a large Veterans Administration Outpatient Detoxification Program (ODP) that systematically collects risk information, 1409 black and white male veterans with International Classification of Diseases, Ninth Revision codes for alcohol abuse enrolling in the ODP from January 2002 to December 2003 were identified. Among these patients, pancreatitis at any time (before the ODP admission or occurring through June 2005) was identified using International Classification of Diseases, Ninth Revision codes. Cases were verified by chart review. Logistic regression analyses were used for multivariable analyses. Overall, history of smoking (89.6%) and current or past drug use (90.1%) were very common, whereas intravenous drug use (22.3%) was less so. Although 87 (6.2%) subjects had pancreatitis codes (acute, 50; chronic, 15; both, 22), chart review verified only 42 cases (acute, 29; chronic, 5; both, 8) for a 3% prevalence. Alcohol appeared to be the definite etiology in 39 of these 42 patients. In bivariate analyses, patients with pancreatitis were older, had more substance abuse admissions, reported a significantly heavier current alcohol use, and lower drug dependence (each P < 0.05). In multivariable models, alcoholic pancreatitis was associated positively with age (odds ratio, 1.08; 95% confidence interval, 1.04-1.12) and number of substance abuse admissions (odds ratio, 1.08; 95% confidence interval, 0.995-1.18; P = 0.06). In this high-risk population of heavy drinkers, the prevalence of pancreatitis is at least 3%. Our study provides preliminary data regarding potential cofactors for pancreatitis in heavy drinkers.

PREVALENCE OF AND RISK-FACTOR PROFILE FOR PANCREATITIS IN MALE VETERANS WITH MIXED ALCOHOL AND DRUG ADDICTION

Background and Aims: To determine the prevalence of and risk factor profile for pancreatitis among high-risk veterans. Methods: The study population consisted of 1409 black or white men with alcohol-related ICD-9 codes (291, 303, 305.00, 305.01, 305.02, 305.03) attending a large VA Outpatient Detoxification Program (1/2002-12/2003) who had systematically collected risk-factor information on alcohol use, drug use and smoking. Pancreatitis (at anytime through 6/2005) among study subjects was identified using ICD-9 codes (acute pancreatitis [AP] - 577.0, chronic pancreatitis [CP] - 577.1). Clinical records of all subjects with pancreatitis codes (n = 87) and 214 controls within this population (no ICD-9 codes for pancreatitis) were reviewed in a blinded fashion to verify pancreatitis diagnosis. Definite AP was diagnosed by presence of typical abdominal pain with amylase ± lipase elevation ≥3 times normal or imaging evidence of pancreatitis, and alcoholic CP based on the International workshop on CP criteria for definite diagnosis (Pancreas 1997;14:215-221). Results: Most subjects were middle aged (median 48 yrs, IQR 44-53) and 43.5% were whites. History of smoking (90%), current or past drug use (90%) and IV-drug use (22.3%) was common. Although 6.2% subjects had pancreatitis codes (n = 87, AP-50, CP-15, both-22), chart review verified only 3% cases (n = 42, AP-29, CP-5, both-8). After excluding 3 patients who also had gallstones on imaging, definite alcoholic pancreatitis was present in 39 of these 42 patients. The prevalence of pancreatitis increased to 4.2% if milder criteria to diagnose AP (typical abdominal pain with any enzyme elevation and negative imaging study) and CP (clinical picture consistent with CP but no morphological changes of CP as included in the definite criteria) were used. On bivariate analyses, compared to controls (no pancreatitis), pancreatitis subjects were significantly older (median age 53 vs. 48 yrs, p < 0.001), had more admissions to substance abuse program (median 4 vs. 2, p < 0.01), reported higher current alcohol use (median 17 vs. 12 drinks/d, p < 0.05) and lower drug dependence (p < 0.05). In multivariable logistic regression analyses, alcoholic pancreatitis associated positively with age (OR = 1.08, 95% CI = 1.04-1.12, p < 0.001) and number of substance abuse admissions (OR = 1.08, 95% CI = 0.995-1.18, p = 0.06). Conclusions: Pancreatitis prevalence in this high-risk population is at least 3%, but likely ranges between 3-6%. Many behavioral factors associate with pancreatitis. Our study provides preliminary data for future studies focusing on risk factor associations for pancreatitis in high-risk populations.

Advice Alone Vs. Structured Detoxification Programmes for Medication Overuse Headache: A Prospective, Randomized, Open-Label Trial in Transformed Migraine Patients With Low Medical Needs

The aim of this study was to compare the effectiveness of strong advice to withdraw the overused medication with the effectiveness of two structured pharmacological detoxification strategies in a cohort of patients diagnosed with probable migraine overuse headache (MOH) plus migraine and presenting low medical needs. One hundred and twenty patients participated in the study. Exclusion criteria included: previous detoxification treatments, coexistent medical or psychiatric illnesses and overuse of agents containing opioids, benzodiazepines and barbiturates. Group A received only intensive advice to withdraw the overused medication. Group B underwent a standard out-patient detoxification programme (advice+prednisone+preventive treatment). Group C underwent a standard in-patient withdrawal programme (as in group B + fluid replacement and antiemetics). Withdrawal therapy was considered successful if, after 2 months, the patient had reverted to an episodic pattern of headache and to an intake of symptomatic medication on fewer than 10 days/month. We were able to detoxify 75.4% of the whole cohort, 77.5% of patients in group A, 71.7% of patients in group B and 76.9% of those in group C (P>0.05). In patients with migraine plus MOH and low medical needs, effective drug withdrawal may be obtained through the imparting of advice alone.

A comparison of clonidine and buprenorphine in the outpatient treatment of opiate withdrawal

The opiate withdrawal syndrome, although not life threatening, is a major obstacle in the treatment of opiate dependence. Over a 12 week period, 124 patients (63% female, 66% African American and mean age 32.6 years) underwent 5 day treatment for opiate withdrawal. Patients treated in the first 6 weeks (n = 69) received clonidine based treatment (0.1 mg every 6 h with one dose received on‐site each day and the others taken home), while patients treated in the latter 6 weeks (n = 65) received buprenorphine 0.3 mg IM daily. Both groups received supportive medications for diarrhea, cramps, aches, and nausea, had clonidine patches placed on day 4, and were offered naltrexone upon completion. Based on age, gender, and race the two treatment groups were similar. The completion rate was 75.4% for buprenorphine group and 47.5% for the clonidine group, p = .001. In conclusion, buprenorphine was superior to clonidine in enabling opiate dependent patients to successfully complete an outpatient detoxification program.

Outcomes of patients in a VA ambulatory detoxification program.

The study examined outcomes of patients enrolled in a Veterans Affairs ambulatory detoxification program. Descriptive statistical data were collected by routine clerical processes at a VA medical center. Patients' outcomes were operationally defined to include completion of the detoxification program, dropout or discharge, or re-enrollment in the program; admission to inpatient detoxification; and referral to, entry into, and completion of substance abuse rehabilitation after detoxification. Outcomes were determined for 517 of the 577 patients consecutively referred to the program during nine months in 1995. Patients met established criteria for mild to moderate alcohol withdrawal syndrome. Of the 517 patients, 453 successfully completed outpatient detoxification. Twenty patients dropped out, 19 were discharged, 37 re-enrolled, and 25 were admitted for inpatient detoxification. Of the 453 patients who completed outpatient detoxification, 434 were referred for further treatment; 415 entered and 322 completed the next treatment phase. The completion rate for patients in the outpatient detoxification program and rates for continuing and completing further treatment were higher than in previous studies. Measures of poor short-term outcome (dropout, re-enrollment, and admission to inpatient detoxification) also compared favorably with previous studies. Unique factors contributing to outcomes included systematic screening, medical protocols for detoxification, psychosocial therapies, program-supported housing, and attention to patient satisfaction.

Factors Associated with Relapse Among Opiate Addicts in an Out-patient Detoxification Programme

Relapse is a central problem in the treatment of addictive behaviour, and a specific problem in the out-patient treatment of the opiate withdrawal syndrome. This study investigated factors associated with relapse among 42 opiate addicts receiving out-patient detoxification treatment at a London drug-dependence clinic. All subjects completed a questionnaire about their social, psychological, and environmental circumstances in the week before interview, and were interviewed within the first two weeks of the programme. Forty per cent had lapsed to illicit heroin abuse within the previous week. Interpersonal factors and drug-related cues were associated with lapse to opiate use. Most subjects encountered a range of high-risk situations, such as regularly meeting other drug users and being offered drugs, and persistent negative mood states.

A Structured Programme for Out-patient Alcohol Detoxification

An out-patient alcohol detoxification service based in a psychiatric emergency clinic is described. Of 173 patients referred during the first year, 76 (44%) were accepted for the programme; 60 (79%) of these successfully completed detoxification with no medical complications. Compared with previous years, during the year of operation of the service there was a 50% fall in the number of in-patient admissions for detoxification to the local hospital. We conclude that a structured out-patient detoxification programme is safe and effective, and may obviate the need for many patients to be admitted, freeing psychiatric beds for other uses.

Contingent methadone delivery: Effects on illicit-opiate use

This study examined the effects of contingent vs. non-contingent delivery of a methadone dose supplement on relapse to illicit opiate use in the context of a methadone outpatient detoxification program. Following a 3-week methadone stabilization period on 30 mg, patients ( N = 39) were randomly assigned to a contingent, a non-contingent, or a control treatment group. All patients received identical gradual reductions in their assigned methadone dose. During the dose reduction period (weeks 4–11), members of the contingent ( N = 13) and non-contingent groups ( N = 13) could obtain daily methadone-dose supplements up to 20 mg, but contingent group members could obtain supplements only if their most recent urinalysis results were opiate negative. Control subjects ( N = 13) did not have dose increases available. The contingent group presented significantly lower opiate-positive urines during weeks 8–11 (14% positive) of the detox than the non-contingent (38% positive) or control (50% positive) groups. Additionally, the availability of extra methadone improved treatment retention and increased clinic attendance above levels observed in the control group. The potential for further use of methadone's reinforcing properties in the treatment of opiate dependence is discussed.

Chronic opiate use during methadone detoxification: Effects of a dose increase treatment

The effects of administering high methadone doses during detoxification treatment were examined on illicit opiate use and treatment retention in chronic opiate supplementors. Twenty-six applicants to a 90-day outpatient detoxification program who delivered 50% or more opiate-positive urine samples during treatment weeks 2 and 3 were randomly assigned to receive a constant 30-mg dose through treatment week 10 or an increase to 60 mg in week 4 with gradual reduction to 30 mg by week 10. Dosage for both groups was reduced to 0 mg during weeks 11–13. Treatment retention was better for experimental (median = 86 days) than for control (median = 41 days) subjects, but the difference was not statistically significant. In the dose increase group, percent opiate-positive urines decreased from 80% to 62% during the first two weeks of dose increase ( t = 2.39, P < 0.05); opiate positive rates for the control group remained above 80%. A 20% between group difference in percent of opiate positive urine tests persisted through study week 10 in subjects ( N = 5 control, 7 experimental) who remained in treatment this long. Although the blind dose increase did improve treatment outcome, we concluded that the magnitude of the effect in this population of chronic opiate supplementors was insufficient to judge the procedure clinically useful.

Treatment outcome in methadone detoxification: Relationship to initial levels of illicit opiate use

Two groups each of 10 patients enrolled in a 90-day outpatient detoxification program were classified on the basis of high (92.5% of tests) and low (7.5% of tests) rates of opiate-positive urine test results during two weeks of dosage stabilization. Pretreatment demographic variables did not differ between the two groups. Relapse to opiate use during the detoxification occurred in patients who were initially opiate free. By the end of the dose reduction period, opiate-positive rates were 60% and 87% of tests for the low and high opiate use groups, respectively. Sedative use and missed clinic days showed similar trends for both groups during the detoxification, although different patterns of drop-out from treatment were noted. Symptomatology increased during dose reduction for the low- but not for the high-frequency opiate group. In general, treatment outcome appeared equally poor for patients who showed low or high levels of illicit opiate drug use early in detoxification treatment.