Severe Withdrawal Research Articles

A Retrospective Comparison of the Effectiveness of Buprenorphine Versus Baclofen for Acute Opioid Withdrawal.

A significant impediment to opioid cessation or dose reduction is mitigating withdrawal severity that has been shown to affect the course of opioid dependence. Current guidelines recommend the use of buprenorphine and methadone over alpha-2 adrenergic agonists. Baclofen, a GABA-B agonist, has promising results as an adjunct agent for opioid withdrawal but has not been compared to buprenorphine. This study compared the ability of buprenorphine and baclofen to mitigate acute opioid withdrawal. This was a single-center, retrospective chart review of 63 patients with diagnosed opioid use disorder that received scheduled buprenorphine or baclofen for 3 days, in addition to as-needed medications during 2 distinct time periods (pre-2017 and 2017-2020). Patients were admitted to the inpatient detoxification unit at Gateway Community Services in Jacksonville, FL. The results showed that patients achieving detoxification success were 11.2 times more likely to be exposed to baclofen than buprenorphine (95% CI 3.32 - 37.83, P < .001). Completion of detoxification protocol (baclofen 63.2% vs buprenorphine 72%, P = .649) and incidence of orthostatic hypotension (15.8% versus 0%, P = .073) were not significantly different between the 2 groups. Patients treated with baclofen had a lower frequency of secondary medication use for acute opioid withdrawal than patients treated with buprenorphine. This raises an interesting question of whether baclofen is comparable to buprenorphine for treating opioid withdrawal. A prospective, randomized, controlled trial in a larger patient population is warranted to determine this difference.

Study of Socio-economic, Biochemical and Clinical Predictors of Alcohol Withdrawal and Delirium Tremens in Patients of Alcohol Dependence in Indian Population

Abstract Background: Alcohol withdrawal syndrome (AWS) is associated with morbidity and mortality. Assessment of factors affecting AWS will help in early diagnosis and initiation of appropriate treatment, hence improving the prognosis. Aim: The present study was conceived and planned to assess the socioeconomic, biochemical, and clinical predictors of alcohol withdrawal and delirium tremens with alcohol dependence patients in the Indian population. Study Design: Longitudinal study. Methodology: The study includes 100 patients admitted for alcohol withdrawal. Participants were assessed for detailed history, physical and mental state examination, CAGE scale (Cut down, Annoyed, Guilty, Eye-opener), AUDIT scale (Alcohol Use Disorders Identification Test), PAWSS scale (Prediction of Alcohol withdrawal severity Score), MINIPLUS (Mini-International Neuropsychiatric Interview) scale and CIWA scale (Clinical Institute withdrawal Assessment of Alcohol) scoring along-with biochemical and hematological investigations. Statistical analysis was done by using SPSS version 20. Results: Mean age of the patients observed was 33.91 years (19-70 years). A significant association between increase of mean corpuscular volume (MCV) and total bilirubin levels (P= 0.208); highly significant association between low platelet counts, low potassium levels, serum glutamic pyruvic transaminase (SGPT), serum glutamic oxaloacetic transaminase (SGOT), alkaline phosphatase (ALP) and the development of delirium tremens and severity of alcohol withdrawal was observed (P&lt;0.05). CAGE (P&lt;0.014), AUDIT (P&lt;0.001), and CIWA scores has significant association (P&lt;0.001) with development of delirium and PAWSS showed good prediction (P&lt;0.007) with patients having severe alcohol withdrawal. Conclusion: Our study recommends that socioeconomic and biochemical factors and predictors can be considered for early diagnosis of severity of alcohol withdrawal and delirium tremens.

Operational definition of precipitated opioid withdrawal.

Opioid withdrawal can be expressed as both a spontaneous and precipitated syndrome. Although spontaneous withdrawal is well-characterized, there is no operational definition of precipitated opioid withdrawal. People (N = 106) with opioid use disorder maintained on morphine received 0.4 mg intramuscular naloxone and completed self-report (Subjective Opiate Withdrawal Scale, SOWS), visual analog scale (VAS), Bad Effects and Sick, and observer ratings (Clinical Opiate Withdrawal Scale, COWS). Time to peak severity and minimal clinically important difference (MCID) in withdrawal severity were calculated. Principal component analysis (PCA) during peak severity were conducted and analyzed with repeated measures analyses of variance (ANOVA). Within 60 min, 89% of people reported peak SOWS ratings and 90% of people had peak COWS scores as made by raters. Self-reported signs of eyes tearing, yawning, nose running, perspiring, hot flashes, and observed changes in pupil diameter and rhinorrhea/lacrimation were uniquely associated with precipitated withdrawal. VAS ratings of Bad Effect and Sick served as statistically significant severity categories (0, 1-40, 41-80, and 81-100) for MCID evaluations and revealed participants' identification with an increase of 10 [SOWS; 15% maximum percent effect (MPE)] and 6 (COWS; 12% MPE) points as meaningful shifts in withdrawal severity indicative of precipitated withdrawal. Data suggested that a change of 10 (15% MPE) and 6 (12% MPE) points on the SOWS and COWS, respectively, that occurred within 60 min of antagonist administration was identified by participants as a clinically meaningful increase in symptom severity. These data provide a method to begin examining precipitated opioid withdrawal.

An innovative inpatient protocol for alcohol withdrawal prevention in a 16-year-old adolescent: a case report

BackgroundAlcohol cessation in youth with daily drinking poses a risk of severe and life-threatening alcohol withdrawal. If unsupervised, alcohol withdrawal in heavy users can cause severe complications, such as seizures, delirium tremens, and death. We present the case of a teenager admitted at our pediatric center for the prevention of alcohol withdrawal using an innovative protocol, including a fixed-dosage benzodiazepine regimen.Case descriptionA 16-year-old Caucasian male, known to have anxiety and an attention deficit disorder, was electively admitted for medical stabilization and surveillance of alcohol withdrawal. He had been previously diagnosed with alcohol use disorder and had a past history of withdrawal symptoms. He was prescribed a course of thiamine, folic acid, as well as a fixed-dosage benzodiazepine taper over 5 days. His withdrawal symptoms were evaluated using a standardized Clinical Institute Withdrawal Assessment for Alcohol scale. During his stay, he reported minimal symptoms, as well as a score on the Clinical Institute Withdrawal Assessment for Alcohol scale consistently lower than 5. His mood, motivation, eating habits and sleeping patterns significantly improved during his stay. He developed no medical complications and demonstrated pride in his successes. He was successfully transferred to a long-term rehabilitation center.ConclusionsA withdrawal prevention protocol was developed on the basis of existing literature. It included a soothing environment, basic laboratory work evaluating the medical complications of alcohol use, as well as medication aiming to prevent and reduce potential withdrawal symptoms. The patient responded well to the fixed-dosage taper with minimal symptoms and discomfort. Although alcohol use in adolescents is frequent, alcohol withdrawal in this population is rarely seen in a pediatric hospital setting. Nonetheless, given the lack of existing guidelines regarding alcohol withdrawal in adolescents, standardized protocols could be greatly beneficial for the prevention of this condition in this population.

289 Heart Rate Variability in Opioid Use Disordered Participants Undergoing Buprenorphine-Assisted Detoxification

OBJECTIVES/GOALS: This study explored whether gabapentin (GBN) differentially impacted heart rate variability (HRV) and whether HRV was associated with opioid withdrawal ratings among participants with opioid use disorder (OUD) undergoing a randomized, double blind placebo-controlled, trial (RCT) of GBN during a buprenorphine (BUP)-assisted taper. METHODS/STUDY POPULATION: Participants (ages 18-64) with OUD, no recent use of benzodiazepines/barbiturates, and no major psychiatric disorders or unstable medical conditions were enrolled in the RCT, inducted onto BUP starting week 1 day 1 and randomly assigned to receive adjunct GBN or placebo starting week 1 day 3. All participants began a 10-day BUP-taper beginning week 2 day 3. HRV measures were assessed on week 1 day 2 (before GBN/placebo induction), week 2 day 2, and week 3 day 5 (end of BUP taper). HRV metrics were analyzed using Two Sample T-Test to determine differences between GBN vs. Placebo. Correlations between HRV metrics and opioid withdrawal ratings administered at the above timepoints will be analyzed using Spearman correlation. RESULTS/ANTICIPATED RESULTS: 28 participants underwent at least 1 HRV session that resulted in usable data. Preliminary statistical analyses revealed that HRV trended lower for GBN subjects during PB exercises than Placebo subjects, demonstrated by a higher mean heart rate for GBN subjects compared to Placebo subjects (p=0.0506) at the end of the BUP-taper (week 3 day 5). We expect future analyses to demonstrate a negative correlation between certain HRV metrics indicative of parasympathetic tone and opioid withdrawal rating assessment scores indicative of withdrawal severity. Such findings would demonstrate an association between opioid withdrawal severity and lower parasympathetic tone and HRV. DISCUSSION/SIGNIFICANCE: Individuals with OUD have previously been shown to have a lower parasympathetic tone than individuals without OUD. Additionally, opioid withdrawal has been shown to be associated with reduced parasympathetic tone. Our initial findings suggest that adjunct GBN administration was not associated with lower parasympathetic tone during PB exercises.

Association of Urine Fentanyl Concentration With Severity of Opioid Withdrawal Among Patients Presenting to the Emergency Department.

Fentanyl is involved in most US drug overdose deaths and its use can complicate opioid withdrawal management. Clinical applications of quantitative urine fentanyl testing have not been demonstrated previously. The aim of this study was to determine whether urine fentanyl concentration is associated with severity of opioid withdrawal. This is a retrospective cross-sectional study. This study was conducted in 3 emergency departments in an urban, academic health system from January 1, 2020, to December 31, 2021. This study included patients with opioid use disorder, detectable urine fentanyl or norfentanyl, and Clinical Opiate Withdrawal Scale (COWS) recorded within 6 hours of urine drug testing. The primary exposure was urine fentanyl concentration stratified as high (>400 ng/mL), medium (40-399 ng/mL), or low (<40 ng/mL). The primary outcome was opioid withdrawal severity measured with COWS within 6 hours before or after urine specimen collection. We used a generalized linear model with γ distribution and log-link function to estimate the adjusted association between COWS and the exposures. For the 1127 patients in our sample, the mean age (SD) was 40.0 (10.7), 384 (34.1%) identified as female, 332 (29.5%) reported their race/ethnicity as non-Hispanic Black, and 658 (58.4%) reported their race/ethnicity as non-Hispanic White. For patients with high urine fentanyl concentrations, the adjusted mean COWS (95% confidence interval) was 4.4 (3.9-4.8) compared with 5.5 (5.1-6.0) among those with medium and 7.7 (6.8-8.7) among those with low fentanyl concentrations. Lower urine fentanyl concentration was associated with more severe opioid withdrawal, suggesting potential clinical applications for quantitative urine measurements in evolving approaches to fentanyl withdrawal management.

Low-dose Initiation of Buprenorphine in Hospitalized Patients Using Buccal Buprenorphine: A Case Series.

To describe a low-dose buprenorphine initiation strategy with buccal buprenorphine. This is a case series of hospitalized patients with opioid use disorder (OUD) and/or chronic pain who underwent low-dose buprenorphine initiation with buccal buprenorphine to sublingual buprenorphine. Results are descriptively reported. Forty-five patients underwent low-dose buprenorphine initiation from January 2020 to July 2021. Twenty-two (49%) patients had OUD only, 5 (11%) patients had chronic pain only, and 18 (40%) patients had both OUD and chronic pain. Thirty-six (80%) patients had documented history of heroin or non-prescribed fentanyl use before admission. Acute pain in 34 (76%) patients was the most commonly documented rationale for low-dose buprenorphine initiation. Methadone was the most common outpatient opioid utilized before admission (53%). The addiction medicine service consulted on 44 (98%) cases and median length of stay was approximately 2 weeks. Thirty-six (80%) patients completed the transition to sublingual buprenorphine with a median completion dose of 16 mg daily. Of the 24 patients (53%) with consistently documented Clinical Opiate Withdrawal Scale scores, no patients experienced severe opioid withdrawal. Fifteen (62.5%) experienced mild or moderate withdrawal and 9 (37.5%) experienced no withdrawal (Clinical Opiate Withdrawal Scale score <5) during the entire process. Continuity of postdischarge prescription refills ranged from 0 to 37 weeks and the median number of buprenorphine refills was 7 weeks. Low-dose buprenorphine initiation with buccal buprenorphine to sublingual buprenorphine was well tolerated and can be safely and effectively utilized for patients whose clinical scenario precludes traditional buprenorphine initiation strategies.

Which assessment tools are most useful for identifying hospitalized patients at risk of developing severe alcohol withdrawal syndrome?

Which assessment tools are most useful for identifying hospitalized patients at risk of developing severe alcohol withdrawal syndrome?

Prescription drug abuse in migrants from Middle Eastern and North African countries: a review

IntroductionIn recent years, there has been a rise in misuse of low-cost prescription pills across Middle Eastern and North African (MENA) countries. In Algeria, Tunisia and Morocco, for example, the consumption of prescription medications has dramatically increased, particularly amongst young and marginalized groups. Drugs such as clonazepam and pregabalin are extremely popular in these regions, as they are relatively inexpensive and perceived as safe. With the migration of MENA citizens to Europe, it is likely that mental health services will come across substance use disorders related to these medications.ObjectivesThe authors aim to analyse prescription medication misuse reports from MENA countries, specifically pregabalin and clonazepam, and review the pharmacological, neurobiological and social factors that contribute to their potential for abuse.MethodsNarrative review of articles referenced on PubMed and Google Scholar.ResultsPregabalin and clonazepam are widely used in psychiatry and neurology. Pregabalin is an alpha 2 omega ligand with supposed GABA-mimetic properties. Anecdotal reports suggest that pregabalin, used recreationally in amounts up to 3-20 times the therapeutic doses, possesses both sedative and psychedelic effects. Experimenters are mainly individuals with a history of recreational polydrug use, who are aware that pregabalin is not included in standard drug monitoring tests, with this molecule being used in some instances as a legal substitute of common illegal drugs. Clonazepam is a benzodiazepine that combines high potency and a long duration of action and is said to cause euphoria at doses over 8mg. It is very popular and affordable, placing consistently in the top three of benzodiazepines sales across the globe. Clonazepam has potential for tolerance build up and severe withdrawal symptoms. These medications are frequently used together and in combination with other substances such as alcohol and opiates, increasing the risk for respiratory failure and death.ConclusionsPrescription medications such as pregabalin and clonazepam are extremely accessible, inexpensive and highly addictive substances, whose abuse is well disseminated across MENA countries. With migratory flows from this region, the prevalence of misuse of these drugs in Europe is expected to increase. Therefore, physicians should be aware of their potential for abuse and carefully evaluate patients’ previous history before prescribing these medications.Disclosure of InterestNone Declared

High-potency benzodiazepine misuse in opioid-dependent patients: use naloxone with care

The misuse of highly potent benzodiazepines is increasing in the UK, particularly among the opioid-using population in Scotland. Differentiating opioid from benzodiazepine toxicity is not always straightforward in patients with...

Does tobacco dependence worsen cannabis withdrawal in people with and without schizophrenia-spectrum disorders?

Rates of cannabis use disorder (CUD) are higher in people with schizophrenia than in the general population. Irrespective of psychiatric diagnosis, tobacco co-use is prevalent in those with CUD and leads to poor cannabis cessation outcomes. The cannabis withdrawal syndrome is well-established and increases cannabis relapse risk. We investigated whether cannabis withdrawal severity differed as a function of high versus no/low tobacco dependence and psychiatric diagnosis in individuals with CUD. Men with CUD (N = 55) were parsed into four groups according to schizophrenia diagnosis and tobacco dependence severity using the Fagerstrom Test for Nicotine Dependence (FTND): men with schizophrenia with high tobacco dependence (SCT+, n = 13; FTND ≥ 5) and no/low tobacco dependence (SCT-, n = 22; FTND ≤ 4), and nonpsychiatric controls with high (CCT+, n = 7; FTND ≥ 5) and no/low (CCT-, n = 13; FTND ≤ 4) tobacco dependence. Participants completed the Marijuana Withdrawal Checklist following 12-h of cannabis abstinence. There was a significant main effect of tobacco dependence on cannabis withdrawal severity (p < .001). Individuals with high tobacco dependence had significantly greater cannabis withdrawal severity (M = 13.85 [6.8]) compared to individuals with no/low tobacco dependence (M = 6.49, [4.9]). Psychiatric diagnosis and the interaction effects were not significant. Lastly, cannabis withdrawal severity positively correlated with FTND (r = .41, p = .002). Among individuals with CUD and high tobacco dependence, cannabis withdrawal severity was elevated twofold, irrespective of diagnosis, relative to individuals with CUD and no/low tobacco dependence. Findings from this study emphasize the importance of addressing tobacco co-use when treating CUD.

Clinical Impact of the CYP2C19 Gene on Diazepam for the Management of Alcohol Withdrawal Syndrome.

Diazepam is a benzodiazepine widely prescribed for the management of patients with severe alcohol withdrawal syndrome to prevent agitation, withdrawal seizures, and delirium tremens. Despite standard dosing of diazepam, a subset of patients experience refractory withdrawal syndromes or adverse drug reactions, such as impaired motor coordination, dizziness, and slurred speech. The CYP2C19 and CYP3A4 enzymes play a key role in the biotransformation of diazepam. Given the highly polymorphic nature of the CYP2C19 gene, we reviewed the clinical impact of variants in the CYP2C19 gene on both the pharmacokinetics of diazepam and treatment outcomes related to the management of alcohol withdrawal syndrome.

Alcohol Biomarker Phosphatidylethanol as a Predictor of the Severity of Alcohol Withdrawal Syndrome.

to investigate the relationship between phosphatidylethanol (PEth) and withdrawal severity in patients with alcohol use disorder (AUD). in 34 patients with AUD admitted for treatment of acute alcohol withdrawal, data were available for initial blood PEth concentrations and scores throughout detoxification of symptoms of withdrawal assessed by trained medical staff using the alcohol withdrawal syndrome (AWS)-scale, a validated scale consisting of 11 items in the alcohol withdrawal syndrome (two subscales with seven physiological and five psychological symptoms). a significant positive correlation between PEth and the severity of alcohol withdrawal was found. When the sample was divided into two groups, according to whether or not AWS score at some point in the treatment reached 6 or more, the median PEth score was higher in those whose peak score had been 6 or more (score of 6 being the suggested cutoff to start medicating the withdrawal syndrome). Although there was a trend for some aspects of the clinical history to be more 'severe' in those with higher AWS, no differences reached significance. blood PEth on admission could have a role in identifying patients at risk of more severe AWS.

Antidepressant Tapering Is Not Routine But Could Be.

When antidepressants are discontinued, severe withdrawal symptoms are possible. Some patients have few or no problems stopping, whereas others struggle. That struggle can be minimized or prevented with careful dose tapering. How often is that done? Using 7 years of medical records, we determined the percentage of patients who received a prescription for the lowest available dose of their antidepressant before it was discontinued, as an indicator of a deliberate taper. Over that period, 8.9% of patients had evidence of tapering. The percentage increased from 4.9% in 2014 to a plateau around 10% in the past 4 years. While reports of severe withdrawal are increasingly recognized and must be addressed, our data suggest that many patients can discontinue their antidepressants without a taper through the lowest dose. However, it is difficult to identify which patients will struggle without a careful taper. A "one-size-fits-all" taper approach is recommended, balancing the need for withdrawal prevention with the need to avoid unnecessary complexity for the majority of patients. The first decrement is key for all patients: it must go well. Thereafter many patients may accelerate but all should receive a prescription for the lowest available dose of their antidepressant.

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.

Severe alcohol withdrawal in an adolescent male

Ethanol remains one of the most frequently abused agents by adolescents, exceeding all others except for vaping nicotine, and use is rising. With increased ethanol use comes a greater risk for dependence and potential for alcohol withdrawal syndromes (AWS). Pediatric AWS is extremely rare and poorly characterized in the literature. Pediatric acute care practitioners may have limited exposure to AWS. We report the case of a 16-year-old male with a history of polysubstance abuse who presented with mild AWS and progressed rapidly to delirium tremens. His withdrawal was initially refractory to high dose benzodiazepine therapy but responded well to phenobarbital. This case highlights how rapidly and dangerously AWS can progress if not aggressively treated. Given the rise in adolescent alcohol use and potential for life threatening symptoms, practitioners, especially in acute care specialties such as emergency medicine, critical care, and hospital medicine, would benefit from additional familiarity with AWS diagnoses and management strategies.

Inflamatuar markers as a predictor of severe alcohol withdrawal

Inflamatuar markers as a predictor of severe alcohol withdrawal

Choice and adequacy of sedation in critically ill mechanically ventilated children

Background: Sedation management is a crucial element of pediatric critical care medicine, aiming at reducing children's anxiety, distress, and oxygen demand. Prolonged administration of sedatives may result in drug tolerance and physical dependency. Abrupt discontinuation of these drugs in children may cause withdrawal symptoms. Our study aims to evaluate the choice and adequacy of sedation in ventilated children using the University of Michigan Sedation Scale score. Subjects and Methods: All the children aged between 1 and 12 years who were subjected to invasive ventilation during the time period October 2019 to June 2021 in the tertiary care pediatric intensive care unit (PICU) were included in the study. Results: Of the 35 children enrolled in the study, most of them spend the majority of their time in adequate sedation which accounts for around 87.1% of the total time of ventilation. Fentanyl and midazolam were the most frequently used drug combination. Oversedation and undersedation accounted for 7.9% and 5% of total ventilation hours, respectively. Out of 35 children, 10 (28%) developed iatrogenic withdrawal symptoms and 4 (11%) developed severe withdrawal symptoms. Conclusions: Fentanyl and midazolam were the most frequently used drug combination for attaining adequate sedation in our PICU. Irrespective of adequate sedation, no increase in the incidence of iatrogenic withdrawal syndrome, undersedation, or oversedation was noted in our study population.

Severe Neonatal Opioid Withdrawal Requiring Pharmacotherapy: Impact of Region of Residence.

Our objective was to evaluate the trend and to assess the impact of maternal region of residence in Western New York (WNY), on severe neonatal opioid withdrawal syndrome (NOWS). Term infants' born at gestational age greater than or equal to 37 weeks with severe NOWS, defined as withdrawal resulting in the receipt of pharmacologic therapy from WNY admitted to our neonatal intensive care unit (NICU) from January 1, 2008 to December 31, 2016, were included. Severe NOWS admissions to our NICU from the following five regions were controlled with birth and insurance data: (1) Urban North, (2) Erie Coastal, (3) Niagara Frontier, (4) Southern Tier, and (5) Urban South. "Urban South" residence was associated with an increased risk of severe NOWS (adjusted odds ratio = 1.8, 97.5% confidence interval: 1.1-2.9). The trend in admission for severe NOWS doubled between 2008 to 2010 and 2014 to 2016 (p = 0.01). More infants born to maternal nonprescribed opioid users were placed in foster care at discharge (36.5 vs. 1.9%, p < 0.001). In WNY, neonates born to mothers from the "Urban South" were twice at risk of being admitted for severe NOWS. One-third of infants with severe NOWS after nonprescribed opioid use were placed in foster care. Implementing targeted strategies at the community level may help improve outcomes in NOWS. · Maternal region of residence is a risk factor for severe neonatal opioid withdrawal.. · Admissions for severe neonatal opioid withdrawal trended up from 2008 to 2010 to 2014 to 2016.. · One-third of the infants born to mothers on nonprescribed opioids were discharged to foster care..

I Want to Quit! Exploring Individual, Job and Organization-related Determinants of Turnover Intention among Employees of Microfinance Institutions

Employee turnover is a crucial Human Resource (HR) challenge faced by Microfinance Institutions (MFIs), which are labour-intensive businesses providing financial services to the poor and underprivileged section of society. Despite the extreme attrition rate, there is limited empirical research on factors inducing turnover intention among microfinance employees. Hence, this study aims to explore employee turnover intention in MFIs and identify its critical determinants from the Indian perspective. A self-report questionnaire administered to employees working in five MFIs in Ranga Reddy district, Telangana, India, yielded 159 responses. The results showed that 46.5 per cent of the respondents often thought about quitting their job, indicating severe job dissatisfaction and withdrawal predisposition. The logistic regression established that a mix of individual (psychological capital), job-related (person-job fit, work pressure, emotional labour), and organisation-related factors (pay, rewards and promotion, supervisor support, organisational support) influenced respondents’ turnover intention in MFIs. Based on the results, this study made suggestions for how MFIs could improve their HR management practices and cut down on employee turnover.