Effectiveness of buprenorphine (naloxone) for opioid dependence does not differ across opioid categories: a retrospective cohort study from India

We aimed to examine whether treatment retention, abstinence, and adherence to buprenorphine-naloxone (BNX) differ among individuals with opioid dependence (OD) across three common categories of opioids- heroin, opium, and low-potency pharmaceutical. In a retrospective cohort study, we analyzed outpatient treatment records from March 2020 through February 2022. Opioid category was determined by lifetime and current opioid use. We defined treatment retention as weeks of uninterrupted clinic attendance. Abstinence and BNX adherence were calculated by weeks of extra-medical opioid-negative and buprenorphine-positive urine screening from treatment initiation. Four-hundred-thirteen patients were eligible; 406 (98.3%) were included in the final analysis. Two-hundred-ninety (71.4%) patients were dependent on heroin; 66 (16.3%) were natural opioid dependent, and 50 (12.3%) were dependent on low-potency pharmaceutical opioids. BNX effectiveness in treatment retention, abstinence, and adherence did not differ in patients dependent on heroin, natural, and low-potency pharmaceutical opioids. Patients on ≥8 mg daily BNX had better retention and adherence than those on <8 mg daily. Patients from lower socioeconomic status (SES) had higher odds of retention, abstinence, and adherence than those from upper/middle SES. Treatment outcomes on BNX did not differ across opioid categories. However, BNX should be dosed adequately.

How did the COVID-19 lockdown impact patients with dual diagnoses?

Purpose

Individuals with dual diagnoses might experience significant clinical and social vulnerabilities during the pandemic and lockdown. This study aims to compare medication adherence, substance use, clinical stability and overall functioning before and during lockdown periods.

Design/methodology/approach

This was a cross-sectional survey among patients registered in dual diagnosis clinic of an addiction psychiatry center in Northern India between March 2019 and February 2020. This study approached 250 patients for telephonic interviews. This study assessed adherence to medications with the brief adherence rating scale (BARS). Global functioning was measured by global assessment of functioning. Clinical interviews assessed substance use and the clinical status of psychiatric disorders.

Findings

One hundred fifty patients were recruited. The mean age of the sample was 35.8 years. The sample had a slight preponderance of alcohol dependence. Depressive disorder was the largest category of psychiatric diagnosis. Compared to prelockdown period, during the lockdown, there were an increased number of days of nonadherence (X2 17.61, p <  0.05), proportion of patients underdosing (X2 8.96, p = 0.003) and lower BARS scores (t = 10.52, df = 144, p < 0.0001). More patients were abstinent from substances during the lockdown (X2 49.02, p < 0.0001). Clinical stability of psychiatric disorders did not differ during the two-time points, but overall functioning decreased during the lockdown (t = 2.118, p = 0.036). This study observed a small positive correlation (r = 0.2, p = 0.02) between functioning and adherence levels.

Originality/value

Lockdown was associated with poor medication adherence, change in substance use patterns and functional impairment. In the future, treatment programs and policies must take preemptive steps to minimize the effects of restrictions.

Predictors of Five-Year Readmission to an Inpatient Service among Patients with Alcohol Use Disorders: Report from a Low-Middle Income Country

BACKGROUND

Alcohol use disorder (AUD) is a relapsing-remitting disease that accounted for a sizable proportion of all-cause adult inpatient stays.

OBJECTIVES

To determine the predictors of any and multiple readmissions to inpatient care for AUD within 5 years of the index admission.

METHODS

This retrospective, register-based cohort study assessed consecutive patients with AUD admitted to a publicly-funded inpatient service between January 2007 and December 2014. Binary logistic regression was used to determine independent predictors for readmissions based on relevant demographic, clinical, and treatment variables that showed significant differences (p < 0.05) on univariate analysis.

RESULTS

Among 938 patients (age 35.9 ± 10.3 years; duration of alcohol use 159.6 ± 104.5 months; dual diagnosis 19%; comorbidity of substance use disorder 49.3%; medical disorder 34.8%, 299 (31.9%) and 115 (12.3%) had any and multiple readmissions, respectively. Comorbid "severe mental illness" (Odds ratio [OR] 1.99, 95% confidence interval [CI] 1.11-3.57) and urban residence (OR 1.58, 95% CI 1.13-2.18) increased the odds of any readmission; "Improved" status at discharge (OR 0.51, 95% CI 0.35-0.72) during index hospitalization reduced odds of readmission. Additionally, any medical or psychiatric comorbidities increased (OR 2.23, 95% CI 1.26-3.97), and comorbid substance use disorder decreased (OR 0.41, 95% CI 0.19-0.89) risk of multiple readmissions.

CONCLUSIONS

Clinicians could identify patients at-risk for any and multiple readmissions during the index hospitalization. A policy aimed at reducing the risk of rehospitalization, healthcare cost, and stigma should pay attention to the predictors of readmission. Such policy should further benefit resource-limited settings.

Management of a Psychiatry Inpatient Unit During the COVID-19 Pandemic: An Audit of Services

Objective: To evaluate the demographic and clinical profiles of patients admitted to the psychiatry ward during the coronavirus disease 2019 (COVID-19) pandemic and compare with profiles of patients admitted 1 year before the onset of the pandemic (ie, before the lockdown announcement in India). An additional objective was to evaluate the incidence of COVID-19 infection in the psychiatry inpatient unit and discuss the measures taken to run the unit during the pandemic, including the measures taken if any patient or staff member was detected to have COVID-19 infection.

Methods: This retrospective study was conducted in a tertiary care hospital in North India. Data of patients admitted to the inpatient unit from March 24, 2019, to March 23, 2020, were compared with data from March 24, 2020, to March 23, 2021. The data were extracted from the inpatient registry.

Results: Compared to the pre-pandemic period, fewer patients were admitted during the pandemic, and the patients admitted had more severe illness. During the ongoing pandemic, the incidence of COVID-19 infection among the residents was 5%, nursing staff was 4.7%, and support staff was 6.66%. The incidence rate of COVID-19 among the patients was 3.2%. Patients were not found to be the primary source of infection; on the other hand, COVID-positive status among the health care professionals was responsible for patients becoming infected.

Conclusions: During the ongoing COVID-19 pandemic, psychiatry inpatient facility can be managed with reduced capacity and by following COVD-19 protocol.

Disulfiram Ethanol Reaction with Alcohol-Based Hand Sanitizer: An Exploratory Study

Aims

We conducted a cross-sectional survey to estimate the prevalence and clinical manifestation of disulfiram ethanol reaction (DER) and isopropanol toxicity (IT) in patients with alcohol use disorders, on disulfiram. Alcohol-based hand rub contains either ethanol or isopropanol or both. COVID-19 pandemic has led to wide scale usage of sanitizers. Patients with alcohol use disorders, on disulfiram, might experience disulfiram ethanol like reactions with alcohol-based sanitizers.

Methods

We telephonically contacted 339 patients, prescribed disulfiram between January 2014 and March 2020. The assessment pertained to the last 3 months (i.e. third week of March to third week of June 2020).

Result

The sample consisted of middle-aged men with a mean 16 years of alcohol dependence. Among the 82 (24%) patients adherent to disulfiram, 42 (12.3%) were using alcohol-based hand rubs. Out of these, a total of eight patients (19%; 95% CI 9–33) had features suggestive of DER; four of whom also had features indicative of IT. Five patients (62.5%) had mild and self-limiting symptoms. Severe systemic reactions were experienced by three (37.5%). Severe reactions were observed with exposure to sanitizers in greater amounts, on moist skin or through inhalation.

Conclusion

Patients on disulfiram should be advised to use alternate methods of hand hygiene.

Attitude and perceptions of patients towards long acting depot injections (LAIs)

BACKGROUND

Despite the well-established efficacy of the long acting depot injectable (LAIs) antipsychotics, these are significantly underused and underutilized by the mental health professionals, with a belief that patients will not accept the same.

AIMS & OBJECTIVES

To explore the acceptability and perception of patients towards various psychiatric treatments, with specific focus on LAIs. Additionally the study aimed to compare the acceptability of various types of treatments including LAIs between patients with severe mental disorders (Psychotic disorders and Bipolar disorder) and those with Common mental disorders (Anxiety, neurotic and depressive disorders).

METHODOLOGY

A self-designed semi-structured questionnaire was used to evaluate the preferred treatment options of all the new patients attending the psychiatry outpatient clinic of a tertiary care hospital. Depending on the response, they were further probed for the reasons for accepting or rejecting the LAIs.

RESULTS

2659 patients were interviewed who were divided into two groups (Group I - 321 subjects with psychotic disorders and 120 subjects with bipolar affective disorder (BPAD) and Group II - 2218 subjects with neurotic, stress-related and unipolar depressive disorders). More than three-fourth (78.8%) of the participants in the whole study sample opted for tablets only as their first preferred choice and injectables were opted by about 5% of the participants only, with no significant difference between the 2 groups. After being explained about LAIs, one fourth of the participants (24.9%) reported that they may consider LAIs, without any significant difference between the 2 groups. Among those who refused to take LAIs even after explanation, the commonly reported reasons were difficulty in visiting hospital frequently for the injectables (41.69%), injectables being painful (19.41%), fear of injections (13.96%), no need to take LAIs (12.45%) and preference to take some other types of medicines (8.52%).

CONCLUSIONS

Considering the fact that LAIs are highly underused in patients with severe mental disorders and there is lack of awareness about LAIs among patients with severe mental disorders, the present study findings suggest that there is reasonable level of acceptance of LAIs among patients with severe mental disorders when explained about the same.

Risk, reversibility and resilience of brain circuitries linked to opioid dependence: A diffusion tensor imaging study of actively opioid-using subjects and three comparison groups

BACKGROUND

Drug addiction is linked with micro-structural changes in the fronto-striatal white matter (WM) tracts. However, little is known regarding causality (risk factor for subsequent drug use vs. effect of chronic drug use) and reversibility of such changes.

METHODS

In this study, 30-direction diffusion tensor imaging (DTI) was used to examine WM integrity of selected fronto-striatal circuitries: the orbito-frontal circuit (OFC), anterior cingulate (AC), inferior frontal circuit (IFC), and genu of corpus callosum (CC-G). Fractional anisotropy (FA) as a measure of WM integrity was compared between actively opioid dependent subjects [OD, N = 30], their non-substance-dependent siblings [SG, N = 30], opioid dependent subjects currently abstinent [AG, N = 15] and non-substance-dependent controls [CG, N = 15] who were gender and handedness-matched. Trait impulsivity and executive functions were also compared.

RESULTS

Compared to CG, OD group had significantly lower FA in the bilateral IFC and right OFC. Reduced FA in left IFC was also present in SG, when compared to CG, whereas SG had higher FA in the left anterior cingulum than OD. AG had significantly low FA in left IFC and CCG than CG. Trait impulsivity was highest in OD, followed by SG and CG. Non-planning impulsiveness score was significantly correlated with FA of left IFC. OD had impairment in executive functions compared to CG. WM changes in opioid dependence involve fronto-striatal circuits implicated in poor decisional balance and impulsivity.

CONCLUSION

Changes in Left IFC appear to predate the onset of addiction, conferring vulnerability, and persist during abstinence. Behavioral and neuro-psychological assessments concur with the imaging results.

Modafinil Dependence and Hypersexuality: A Case Report and Review of the Evidence

Apart from sleep wake disorders, nowadays, modafinil is being prescribed for several psychiatric disorders including depression. Despite being reported as to be having very low abuse potential, cases of modafinil dependence had come to the limelight. In this case report, we describe a 35 year old man with bipolar affective disorder while in remission who developed modafinil dependence and later on, had hypersexuality when he increased the dose of modafinil from 400 to 1,000 mg/day. Existing literature suggests that modafinil when taken above prescribed doses can cause many side effects ranging from nausea, vomiting to psychotic exacerbation and mania. However, hypersexuality as a side effect of modafinil overuse is not commonly seen. The exact pathophysiological mechanism of modafinil induced hypersexuality is not clear. Clinicians should be aware of possibility of modafinil leading to dependence and this rare significant side effect of modafinil.

Delirium in children and adolescents

OBJECTIVE

To study the clinical profile of children and adolescents (< or = 14 years) referred to the Consultation-Liaison (CL) psychiatry services of a Tertiary Care Centre.

DESIGN

Retrospective chart review.

SETTING

Patients seen by the CL psychiatry services of Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh.

PARTICIPANTS

Subjects diagnosed as delirium (as per ICD-10) during their inpatient stay was done.

MAIN OUTCOME MEASURES

phenomenology of delirium and response to treatment.

RESULT

Forty-six children and adolescents were diagnosed as delirium by the psychiatry consultation-liaison team. The most common underlying pathology was infection of various types, followed by neoplasms. All subjects exhibited sleep-wake cycle disturbance and impaired orientation. Other common symptoms were impaired attention (89.5%), impaired short-term memory (84.2%), agitation (68.4%), and lability of affect (60.5%). Delusions and hallucinations were reported by only a few patients. Most of the patients were treated with low dose haloperidol and they responded well.

CONCLUSION

Sleep wake cycle disturbances and cognitive dysfunction are common in children and adolescents with delirium.