The possible clinical utility of the alcohol biomarker phosphatidylethanol for managing suspected alcohol withdrawal in hospitalized patients: A case report

BACKGROUND AND OBJECTIVES

The decision to initiate pharmacotherapy for alcohol withdrawal is typically based on examining self-reported use of alcohol and symptoms of withdrawal. Phosphatidylethanol (PEth) is a biomarker that could aim in clinical decision-making in withdrawal management.

METHODS

This report describes three cases highlighting the potential clinical utility of PEth in caring for individuals at risk for alcohol withdrawal.

RESULTS

Two of the cases received phenobarbital when their PEth showed that the risk of withdrawal was low and one case where PEth could have shown this was needed. The results were only available in a delayed fashion, however, could have been useful in informing clinical care.

DISCUSSION AND CONCLUSION

PEth can be a useful tool if available without delay. PEth can be used to quickly rule out alcohol withdrawal and avoid misdiagnoses and prolonged hospital stays.

SCIENTIFIC SIGNIFICANCE

This is a clinical case study available looking at PEth and withdrawal in hospitalized patients. It proposes that PEth can be used as a way to quickly rule out alcohol withdrawal to avoid misdiagnoses and the possibility of a prolonged hospital stay.

A Comparison of Injectable Diazepam and Lorazepam in the Goal-Directed Management of Severe Alcohol Withdrawal

BACKGROUND

Benzodiazepines are the gold standard for treatment of alcohol withdrawal, yet the selection of a preferred benzodiazepine is limited due to a lack of comparative studies.

OBJECTIVES

The primary objective of this study was to compare the efficacy and safety of injectable lorazepam (LZP) and diazepam (DZP) in the treatment of severe alcohol withdrawal syndrome (AWS).

METHODS

Retrospective cohort study of adult patients admitted to an intensive care unit with a primary diagnosis of AWS. Subjects who received at least 12 LZP equivalent units (LEU) of injectable DZP or LZP within 24 hours of initiation of the severe AWS protocol were included. The primary outcome was time with Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) scores at goal over the first 24 hours of treatment.

RESULTS

A total of 191 patients were included (DZP n = 89, LZP n = 102). Time with CIWA-Ar scores at goal during the first 24 hours was similar between groups (DZP 12 hours [interquartile range, IQR, = 9-15] vs LZP 14 hours [IQR = 10-17]), P = 0.06). At 24 hours, LEU requirement was similar (DZP 40 [IQR = 22-78] vs LZP 32 [IQR = 18-56], P = 0.05). Drug cost at 24 hours was higher in the DZP group ($204.6 [IQR = 112.53-398.97] vs $8 [IQR = 4.5-14], P < 0.01).

CONCLUSION AND RELEVANCE

DZP or LZP are equally efficacious for the treatment of severe AWS. LZP may be preferred due to cost but both medications can be used interchangeably based on availability.

Suicide attempt in a dopamine agonist withdrawal syndrome in Parkinson's disease

Dopamine agonist withdrawal syndrome (DAWS) results from the reduction or suspension of dopamine agonist medications; it encompasses mainly psychiatric symptoms, including suicidal behaviors. In patients with Parkinson's disease (PD), the impact of DAWS can be significant in terms of distress and disability; however, we must take this syndrome into account as a threatening condition because suicidal behaviors could be developing in the context of DAWS. Here we present a brief case of DAWS affecting a young man with PD, whom abruptly discontinued DA treatment and developed psychiatric symptoms within two weeks which led to a suicidal attempt.

Measuring Objective and Subjective Sleep during Lisdexamfetamine Treatment of Acute Methamphetamine Withdrawal: A Feasibility Study

INTRODUCTION

Sleep disturbance is common during methamphetamine (MA) use and withdrawal; however, the feasibility of combined subjective-objective measurement of sleep-wake has not been shown in this population. Actigraphy is a well-established, non-invasive measure of sleep-wake cycles with good concordance with polysomnography. This study aimed to investigate the feasibility and utility of using actigraphy and sleep diaries to investigate sleep during MA withdrawal.

METHODS

We conducted a feasibility and utility study of actigraphy and sleep diaries during a clinical trial of lisdexamfetamine for MA withdrawal. Participants were inpatients for 7 days, wore an actigraph (Philips Actiwatch 2) and completed a modified Consensus Sleep Diary each morning. Participants were interviewed between days 3-5.

RESULTS

Ten participants (mean age 37 years, 90% male) were enrolled. No participant removed the device prematurely. Participants interviewed (n = 8) reported that the actigraph was not difficult or distracting to wear or completion of daily sleep diary onerous. Actigraphic average daily sleep duration over 7 days was 568 min, sleep onset latency 22.4 min, wake after sleep onset (WASO) 75.2 min, and sleep efficiency 83.6%. Sleep diaries underreported daily sleep compared with actigraphy (sleep duration was 56 min (p = 0.008) and WASO 47 min (p < 0.001) less). Overall sleep quality was 4.4 on a nine-point Likert scale within the diary.

CONCLUSIONS

Continuous actigraphy is feasible to measure sleep-wake in people withdrawing from MA, with low participant burden. We found important differences in self-reported and actigraphic sleep, which need to be explored in more detail.

Acute REM sleep behaviour disorder associated with alcohol withdrawal: A case report and literature review

INTRODUCTION

Rapid eye movement (REM) sleep behaviour disorder (RBD) is a parasomnia characterised by the loss of REM sleep muscle atonia and the enactment of dreams. Acute RBD associated with alcohol withdrawal syndrome is known, but the studies are limited, particularly on its neurobiological underpinnings and management alongside the withdrawal state. This work attempts to address this using a case study and relevant literature review.

CASE PRESENTATION

A 40-year-old male with alcohol dependence (for 20 years) reported new-onset terrifying nightmares and violent behaviours in his sleep precipitated by alcohol withdrawal states for the last 18 months. The polysomnographic finding of REM-without-atonia supported the diagnosis of RBD. He was treated with chlordiazepoxide 100 mg/day (gradually tapered and stopped) and thiamine supplements. Post-discharge, he remained abstinent and symptom-free during the three months of follow-up.

DISCUSSION

RBD related to alcohol withdrawal syndrome has been previously described in a few anecdotal reports. Sudden withdrawal from central nervous system suppressants like alcohol is hypothesised to cause a homeostatic imbalance in gamma-aminobutyric acid (GABA) pathways and 'REM rebound', resulting in the clinical and polysomnographic picture of RBD. Benzodiazepines have been found to be useful in both RBD and alcohol withdrawal.

CONCLUSIONS

Alcohol withdrawal syndrome may present with acute RBD, which can be treated with a short course of benzodiazepine. However, further studies are needed to explore the long-term course of RBD in these patients.

Examining Adult Patients' Success with Discontinuing Long-term Benzodiazepine Use: a Qualitative Study

BACKGROUND

Little is known about patients' experiences with benzodiazepine (BZD) discontinuation, which is thought to be challenging given the physiological and psychological dependence and accompanying potential for significant withdrawal symptoms. The marked decline in BZD prescribing over the past decade in the US Department of Veterans Affairs healthcare system presents an important opportunity to examine the experience of BZD discontinuation among long-term users.

OBJECTIVE

Examine the experience of BZD discontinuation among individuals prescribed long-term BZD treatment to identify factors that contributed to successful discontinuation.

DESIGN

Descriptive qualitative analysis of semi-structured interviews conducted between April and December of 2020.

PARTICIPANTS

A total of 21 Veterans who had been prescribed long-term BZD pharmacotherapy (i.e., > 120 days of exposure in a 12-month period) and had their BZD discontinued.

APPROACH

We conducted semi-structured interviews with Veteran participants to learn about their BZD use and the process of discontinuation, with interviews recorded and transcribed verbatim. Data were deductively and inductively coded and coded text entered into a matrix to identify factors that contributed to successful BZD discontinuation.

KEY RESULTS

The mean age of interview participants was 63.0 years (standard deviation 3.9); 94.2% were male and 76.2% were white. Of 21 participants, only 1 had resumed BZD treatment (prescribed by a non-VA clinician). Three main factors influenced success with discontinuation: (1) participants' attitudes toward BZDs (e.g., risks of long-term use, perceived lack of efficacy, potential for dependence); (2) limited withdrawal symptoms; and (3) effective alternatives, either from their clinician (e.g., medication, psychotherapy) or identified by participants.

CONCLUSIONS

BZD discontinuation after long-term use is relatively well tolerated, and participants appreciated reducing their medication exposure, particularly to one associated with physical dependence. These findings may help reduce both patient and clinician anxiety related to BZD discontinuation.

Screening for Alcohol Use Disorder and Management of Alcohol Withdrawal Syndrome in Critical Care Patients

BACKGROUND

Evidence-based research indicates that subjective questionnaires should be eliminated in screening for alcohol use disorder and management of alcohol withdrawal syndrome in critical care patients. However, transitioning clinicians away from these screening tools remains challenging.

OBJECTIVE

To improve screening for alcohol use disorder and management of alcohol withdrawal syndrome in the critical care setting by implementing an evidence-based alcohol use disorder screening tool and alcohol withdrawal syndrome protocol for critical care patients.

METHODS

The project site was a 17-bed adult medical intensive care unit in a large, southeastern US teaching hospital. Interventions consisted of the elimination of previously used tools such as the Clinical Institute Withdrawal Assessment for Alcohol-Revised and implementation of the Prediction of Alcohol Withdrawal Severity Scale for alcohol use disorder screening and the Richmond Agitation-Sedation Scale and symptom-triggered benzodiazepine administration for alcohol withdrawal syndrome management.

RESULTS

Alcohol use disorder screening among the critical care patient population increased by 49% from before to after the intervention. Of the patients at risk for withdrawal, 79% had an order for monitoring with the new intensive care unit alcohol withdrawal protocol in the postintervention group, compared with 35% who had an order for monitoring with the Clinical Institute Withdrawal Assessment for Alcohol-Revised in the preintervention group.

CONCLUSION

The elimination of previously used tools and the implementation of the Prediction of Alcohol Withdrawal Severity Scale and the new intensive care unit alcohol withdrawal protocol improved alcohol use disorder screening and alcohol withdrawal syndrome management among critical care patients.

Management of alcohol withdrawal syndrome in patients with alcohol-associated liver disease

Alcohol-associated liver disease is a common and severe sequela of excessive alcohol use; effective treatment requires attention to both liver disease and underlying alcohol use disorder (AUD). Alcohol withdrawal syndrome (AWS) can be dangerous, is a common barrier to AUD recovery, and may complicate inpatient admissions for liver-related complications. Hepatologists can address these comorbid conditions by learning to accurately stage alcohol-associated liver disease, identify AUD using standardized screening tools (eg, Alcohol Use Disorder Identification Test), and assess risk for and symptoms of AWS. Depending on the severity, alcohol withdrawal often merits admission to a monitored setting, where symptom-triggered administration of benzodiazepines based on standardized scoring protocols is often the most effective approach to management. For patients with severe liver disease, selection of benzodiazepines with less dependence on hepatic metabolism (eg, lorazepam) is advisable. Severe alcohol withdrawal often requires a "front-loaded" approach with higher dosing, as well as intensive monitoring. Distinguishing between alcohol withdrawal delirium and HE is important, though it can be difficult, and can be guided by differentiating clinical characteristics, including time to onset and activity level. There is little data on the use of adjuvant medications, including anticonvulsants, dexmedetomidine, or propofol, in this patient population. Beyond the treatment of AWS, inpatient admission and outpatient hepatology visits offer opportunities to engage in planning for ongoing management of AUD, including initiation of medications for AUD and referral to additional recovery supports. Hepatologists trained to identify AUD, alcohol-associated liver disease, and risk for AWS can proactively address these issues, ensuring that patients' AWS is managed safely and effectively and supporting planning for long-term recovery.

Dexmedetomidine Withdrawal Syndrome in Children in the PICU: Systematic Review and Meta-Analysis

OBJECTIVES

To systematically review literature describing the clinical presentation, risk factors, and treatment for dexmedetomidine withdrawal in the PICU (PROSPERO: CRD42022307178).

DATA SOURCES

MEDLINE/PubMed, Cochrane, Web of Science, and Scopus databases were searched.

STUDY SELECTION

Eligible studies were published from January 2000 to January 2022 and reported clinical data for patients younger than 21 years old following discontinuation of dexmedetomidine after greater than or equal to 24 hours of infusion.

DATA EXTRACTION

Abstracts identified during an initial search were screened and data were manually abstracted after full-text review of eligible articles. The Newcastle-Ottawa Scale was used to assess study quality. Summary statistics were provided and Spearman rank correlation coefficient was used to identify relationships between covariates and withdrawal signs. A weighted prevalence for each withdrawal sign was generated using a random-effects model.

DATA SYNTHESIS

Twenty-three studies (22 of which were retrospective cohort studies) containing 28 distinct cohorts were included. Median cumulative dexmedetomidine exposure by dose was 105.95 μg/kg (range, 30-232.7 μg/kg), median dexmedetomidine infusion duration was 131.75 hours (range, 20.5-525.6 hr). Weighted estimates for proportion (95% CI) of subjects experiencing withdrawal signs across all cohorts were: hypertension 0.34 (range, 0.0-0.92), tachycardia 0.26 (range, 0.0-0.87), and agitation 0.26 (range, 0.09-0.77). Meta-analysis revealed no correlation between dexmedetomidine exposure variables and withdrawal signs. A moderate negative monotonic relationship existed between the proportion of patients who had undergone cardiac surgery and the proportion experiencing hypertension (correlation coefficient, -0.47; p = 0.048) and tachycardia (correlation coefficient, -0.57; p = 0.008), indicating that in cohorts with a higher proportion of patients who were postcardiac surgery, there were fewer occurrences of hypertension and or tachycardia.

CONCLUSIONS

On review of the 2000-2022 literature, dexmedetomidine withdrawal may be characterized by tachycardia, hypertension, or agitation, particularly with higher cumulative doses or prolonged durations. Since most studies included in the review were retrospective, prospective studies are needed to further clarify risk factors, establish diagnostic criteria, and identify optimal management strategies.

Atypical Withdrawal Symptoms after Abrupt Tramadol Discontinuation: A Case Report

Tramadol is a commonly utilized analgesic in the United States. One common misconception is that tramadol is safer than other opioid medications, or less likely to cause physical dependence. Given these misconceptions, the likelihood of patients experiencing withdrawal after discontinuation may be commonly overlooked as well. A 68-year old female patient with fibromyalgia was referred to a clinical pharmacy pain clinic for medication management. The patient was evaluated one month after abrupt discontinuation of tramadol 50 mg every 6 h for at least 10 years of use. She reports concerning symptoms of significant mucus production, fullness in chest and soreness in neck. Although tramadol is a Schedule IV Controlled Substance the risk of physical dependence and likelihood of patients experiencing withdrawal symptoms after abrupt cessation should not be diminished. Tramadol should not be considered a "safer" opioid therapy without potential of classic or atypical withdrawal symptoms, as well as risk of abuse, misuse or addiction.

Assessment of a modified MINDS-based protocol for management of alcohol withdrawal syndrome on an inpatient medical service

OBJECTIVE

To determine if a novel symptom-based alcohol withdrawal syndrome (AWS) protocol in a US Veterans cohort leads to significant clinical improvements in patient outcomes and safety.

BACKGROUND

Prior studies of AWS management, oftentimes using the revised version of the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) index, have demonstrated the effectiveness of symptom-triggered therapy for AWS. The Minnesota Detoxification Scale (MINDS) is an alternative to the CIWA-Ar index but remains unevaluated outside of the intensive care unit (ICU) setting. This study assesses outcomes in AWS management prior to and after the implementation of a novel MINDS-based AWS protocol (SDAWP) utilizing a revised MINDS index (MINDS-rev) in an inpatient medical ward setting.

METHODS

Retrospective cohort study including encounters prior to (n = 342) and after (n = 338) the implementation of the protocol. Pre- and post-protocol encounters were selected by combinations of diagnostic codes and charting elements. Outcome measures of AWS management were obtained in both groups. The primary endpoint was median total benzodiazepine exposure. Secondary outcomes included median length of hospitalization, median duration of benzodiazepine administration, and the incidence of complications.

RESULTS

The median total benzodiazepine exposure in the post-SDAWP group was significantly lower than the pre-SDAWP group (21.2 vs. 12.0 mg, p < 0.0001) and for a significantly shorter median duration of time (4.0 vs. 3.0 days, p < 0.0001). There was no significant difference in the median length of stay (4.0 vs. 4.0 days, p = 0.50). The incidence of delirium tremens (21 vs. 7, p = 0.01) and need for transfer to a higher level of care (33 vs. 12, p = 0.002) was significantly lower in the post-SDAWP group.

CONCLUSION

The SDAWP has provided significant improvements in AWS management in our institution and may potentially serve as a template for wider use in other inpatient settings.

Factorial, Construct, and Predictive Validity of the Motivation for Treatment Scale in Alcohol-Use Disorder Withdrawal Treatment

INTRODUCTION

The aim of the present study was to examine for the first time the factorial, construct, and predictive validity of the motivation for treatment (MfT) scale in a cohort of patients undergoing inpatient-qualified alcohol withdrawal treatment with the goal of referring patients to further treatment. The MfT scale has previously been evaluated in different settings of substance abuse treatment, revealing factorial ambiguity. To the best of our knowledge, the present study is the first study that conducted comprehensive factor analyses versus separate analyses of the factors conducted in prior studies in order to clarify the aforementioned factorial ambiguity.

METHODS

A total of 249 patients (mean age 45.2 years (SD = 10.3); 34.4% females) with alcohol dependence were assessed. Data were obtained from four inpatient clinics specialized in qualified alcohol withdrawal treatment in Germany. First, confirmatory factor analyses were carried out to examine the fit of the four models discussed in the literature. Second, an exploratory factor analysis was conducted. Correlations of the new factors with other motivational constructs and referral to a subsequent treatment were investigated as measures of construct and predictive validity.

RESULTS

None of the four models showed an acceptable fit to the data in confirmatory analyses. The exploratory analysis suggested to eliminate seven items because of inappropriate factor loadings and resulted in a shortened MfT scale, which consists of three factors based on 17 items. For the latent variables "problem recognition," "desire for help," and "treatment readiness," satisfactory composite reliability was found with 0.82, 0.80, and 0.78, respectively. Evidence for predictive validity was found in the correlation between "treatment readiness" and referral to a subsequent treatment.

DISCUSSION/CONCLUSION

The new shortened MfT scale exhibited remarkable parsimony, which is desirable in settings such as withdrawal treatment, where patients frequently are cognitively or physically impaired. Despite its briefness, construct and predictive validity were better than in the original version of the MfT scale. The factorial validity of the suggested scale needs to be corroborated in further research.

Decreasing Length of Stay in Opioid Withdrawal

INTRODUCTION

In 2017, more than 1,200 opioid-related deaths were reported in Virginia, with slightly fewer in 2018, at 1,193 deaths. The current opioid crisis has placed a strain on an already limited number of mental health (MH) inpatient beds. The industry standard for assessment and treatment of opioid withdrawal symptoms, in the inpatient setting, is the Clinical Opiate Withdrawal Scale (COWS), and yet some units continue to utilize the Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) for this population.

AIM

The purpose of this nurse-led performance improvement project was to implement COWS in the inpatient MH setting and improve length of stay (LOS) by 1 day.

METHOD

In 2018, in a large federal teaching facility in the mid-Atlantic region, the COWS was implemented to replace the CIWA-Ar for opioid withdrawal, with the focus on decreasing LOS. Prior to implementation of COWS, LOS on the inpatient MH unit for opioid withdrawal was 8.6 days, which was higher than the ~6- to 7-day LOS for surrounding private sector hospitals. Individual electronic medical records were reviewed for LOS and completion of COWS and pertinent details were discussed daily with nursing staff and monthly with the interdisciplinary team. Baseline data were collected from April 2017 to March 2018, with data collection continuing through the project implementation, April to September 2018.

RESULTS

Completion of COWS on 100% of patients admitted with opioid withdrawal and a decrease in LOS from 8.6 to 4.7 days was found, a 45% reduction.

CONCLUSION

The nurse-driven performance improvement project affected business acumen, through decreased LOS, as well as quality of care, through better symptom management.

Implementation of an algorithm for tapering analgosedation reduces iatrogenic withdrawal syndrome in pediatric intensive care

BACKGROUND

Proper analgosedation is a cornerstone in the treatment of critically ill patients in Pediatric Intensive Care Units (PICUs). Medications, such as fentanyl, morphine, and midazolam, are essential to safe and respectful care. The use of these medications over time may lead to side effects such as iatrogenic withdrawal syndrome (IWS) in the tapering phase. The aim of the study was to test an algorithm for tapering analgosedation to reduce the prevalence of IWS in two Norwegian PICUs at Oslo University Hospital.

METHODS

A cohort of mechanically ventilated patients from newborn to 18 years with continuous infusions of opioids and benzodiazepines for 5 days or more were included consecutively from May 2016 to December 2021. A pre- and posttest design, with an intervention phase using an algorithm for tapering analgosedation after the pretest, was used. The ICU staffs were trained in using the algorithm after the pretest. The primary outcome was a reduction in IWS. The Withdrawal Assessment Tool-1 (WAT-1) was used to identify IWS. A WAT-1 score ≥3 indicates IWS.

RESULTS

We included 80 children, 40 in the baseline group, and 40 in the intervention group. Age and diagnosis did not differ between the groups. The prevalence of IWS was 95% versus 52.5% in the baseline group versus the intervention group, and the peak WAT-1 median was 5.0 (IQR 4-6.8) versus 3.0 (IQR 2.0-6.0) (p = .012). Based on SUM WAT-1 ≥ 3, which describes the burden over time better, we demonstrated a reduction of IWS, from a median of 15.5 (IQR 8.25-39) to a median of 3 (IQR 0-20) (p = <.001).

CONCLUSION

We suggest using an algorithm for tapering analgosedation in PICUs since the prevalence of IWS was significantly lower in the intervention group in our study.

[Assessment of alcohol withdrawal syndrome: new perspectives]

Alcohol withdrawal syndrome is one of the most important consequences of alcohol use disorder, a complex neuropsychiatric disorder, which is firstly treated in non-specific and secondly in psychiatric/addictive in- or outpatient units. On the other hand, alcohol withdrawal syndrome is one of the most important outcomes of the severity of alcohol use disorder, further, it can lead to the development of alcohol-related seizure and delirium tremens. Hence, early recognition and optimal treatment of alcohol withdrawal syndrome have a critical importance. Therefore, the main goal of the present review was - by systematically summarizing the scientific data published during the past two decades - to form a unique diagnostic and therapeutic algorithm. During the recognition and the course of alcohol withdrawal syndrome, the Clinical Institute Withdrawal Assessment for Alcohol, Revised scale, while in the risk assessment the Prediction of Alcohol Withdrawal Severity Scale are the recommended psychometric tools. Benzodiazepines are the key elements of the pharmacotherapy of alcohol withdrawal syndrome. Many studies have evaluated that diazepam, chlordiazepoxide, lorazepam and oxazepam with distinct indications have sufficient evidence in the treatment of alcohol withdrawal syndrome. However, in the past few years some authors have recommended the importance of non-benzodiazepine medications. The efficacy of propofol, phenobarbital, carbamazepin, oxcarbamazepin and alpha-2 receptor agonists in the treatment of alcohol withdrawal syndrome have been revealed. Furthermore, it has been evaluated that benzodiazepines are recommended in the treatment of alcohol-related seizure and delirium tremens. In the present review, our aim was to construct a unique, up-to-date diagnostic and therapeutic algorithm by summarizing the related papers published during the past two decades. Hence this scheme may be useful in the optimal treatment of patients diagnosed with alcohol use disorder and it could help to conduct further clinical researches. Orv Hetil. 2023; 164(38): 1487-1496.

Risk factors for alcohol withdrawal-related hospital transfer in a correctional setting

INTRODUCTION

A major health concern among individuals with alcohol use disorder is alcohol withdrawal syndrome (AWS), where individuals with physical dependence on alcohol may experience withdrawal signs and symptoms upon stopping or reducing alcohol use. AWS has a range of severity, with the most severe cases referred to as complicated AWS, presenting as seizure or signs and symptoms indicative of delirium or new onset of hallucinations. In the general community, risk factors or predictors of complicated AWS among hospitalized patients have been described, but there is no literature that examines such risk factors in a correctional population. The Los Angeles County Jail (LACJ) is the nation's largest jail system and manages 10-15 new patients per day for AWS. Here we aim to identify the risk factors associated with alcohol withdrawal-related hospital transfers among incarcerated patients being managed for AWS in the LACJ.

METHODS

From January 1, 2019, to December 31, 2020, data were gathered about LACJ patients who required transfer to an acute care facility for alcohol withdrawal-related concerns while on the Clinical Institute Withdrawal Assessment for Alcohol revised (CIWA-Ar) protocol. Log regression analysis was performed to generate an odds ratio for acute care facility transfer for the following variables: race, sex assigned at birth, age, CIWA-Ar scores, highest systolic blood pressure (SBP), and highest heart rate (HR).

RESULTS

Out of 15,658 patients on CIWA-Ar protocol during this 2-year time frame, a total of 269 (1.7%) were transferred to an acute care facility for alcohol withdrawal-related concerns. Of those 269 patients, significant risk factors associated with withdrawal-related hospital transfer included: Other race (OR 2.9, 95% CI 1.5-5.5), male sex assigned at birth (OR 1.6, 95% CI 1.0-2.5), age ≥55 years (OR 2.3, 95% 1.1-4.9), CIWA-Ar score 9-14 (OR 4.1, 95% CI 3.1-5.3), CIWA-Ar score ≥15 (OR 21.0, 95% CI 12.0-36.6), highest SBP ≥150 mmHg (OR 2.3, 95% CI 1.8-3.0), highest HR ≥ 110 bpm (OR 2.8, 95% CI 2.2-3.8).

CONCLUSION

Among patients studied, the higher CIWA-Ar score was the most significant risk factor associated with alcohol withdrawal-related hospital transfer. Other significant risk factors identified are race other than Hispanic, white, and African American; male sex assigned at birth; age ≥55 years; highest SBP ≥150 mmHg; and highest HR ≥ 110 bpm.

Assessment and management of iatrogenic withdrawal syndrome and delirium in pediatric intensive care units across Europe: An ESPNIC survey

INTRODUCTION

Analgesia and sedation are essential for the care of children in the pediatric intensive care unit (PICU); however, when prolonged, they may be associated with iatrogenic withdrawal syndrome (IWS) and delirium. We sought to evaluate current practices on IWS and delirium assessment and management (including non-pharmacologic strategies as early mobilization) and to investigate associations between the presence of an analgosedation protocol and IWS and delirium monitoring, analgosedation weaning, and early mobilization.

METHODS

We conducted a multicenter cross-sectional survey-based study collecting data from one experienced physician or nurse per PICU in Europe from January to April 2021. We then investigated differences among PICUs that did or did not follow an analgosedation protocol.

RESULTS

Among 357 PICUs, 215 (60%) responded across 27 countries. IWS was systematically monitored with a validated scale in 62% of PICUs, mostly using the Withdrawal Assessment Tool-1 (53%). The main first-line treatment for IWS was a rescue bolus with interruption of weaning (41%). Delirium was systematically monitored in 58% of PICUs, mostly with the Cornell Assessment of Pediatric Delirium scale (48%) and the Sophia Observation Scale for Pediatric Delirium (34%). The main reported first-line treatment for delirium was dexmedetomidine (45%) or antipsychotic drugs (40%). Seventy-one percent of PICUs reported to follow an analgosedation protocol. Multivariate analyses adjusted for PICU characteristics showed that PICUs using a protocol were significantly more likely to systematically monitor IWS (odds ratio [OR] 1.92, 95% confidence interval [CI] 1.01-3.67) and delirium (OR 2.00, 95% CI 1.07-3.72), use a protocol for analgosedation weaning (OR 6.38, 95% CI 3.20-12.71) and promote mobilization (OR 3.38, 95% CI 1.63-7.03).

CONCLUSIONS

Monitoring and management of IWS and delirium are highly variable among European PICUs. The use of an analgosedation protocol was associated with an increased likelihood of monitoring IWS and delirium, performing a structured analgosedation weaning and promoting mobilization. Education on this topic and interprofessional collaborations are highly needed to help reduce the burden of analgosedation-associated adverse outcomes.

Use of Gabapentin for Alcohol Withdrawal Syndrome in the Hospital Setting: A Randomized Open-Label Controlled Trial

Background/objectives: Patients hospitalized with alcohol withdrawal syndrome (AWS) are typically treated with CIWA-directed benzodiazepines to prevent complications, such as seizures and delirium tremens. Gabapentin is an evidence-based alternative to benzodiazepines in the outpatient setting, but there is limited data for hospitalized patients with AWS. This study compared fixed-dose gabapentin to CIWA-directed benzodiazepines for AWS in the hospital setting. Methods: This open-label, randomized controlled trial enrolled 88 adults from February 1, 2017 to August 16, 2020 with a risk of complicated alcohol withdrawal as defined by the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) ≥4. Patients were randomized within 16 h of admission to either fixed-dose gabapentin taper or continued CIWA-directed benzodiazepine administration. The primary outcome was the length of stay (LOS). Secondary outcomes included seizure, delirium tremens, ICU transfer, and patient-reported symptoms (alcohol cravings, anxiety, sleepiness). Results: LOS was shorter, but not statistically different in the gabapentin group compared to the benzodiazepine group. Because benzodiazepines were received in both gabapentin and benzodiazepine groups before randomization, the mean amount of benzodiazepines received in each group was also not statistically different, although the amount received by the gabapentin group was less than half of that received by the benzodiazepine group (4.3 vs. 10.6 mg, p = 0.146 by per protocol analysis). There were no statistical differences in secondary measures. Conclusions: Fixed-dose gabapentin taper showed similar outcomes compared to CIWA-directed benzodiazepines for the treatment of hospitalized patients with mild/moderate AWS, but the interpretation of the results is limited due to under-enrollment and the use of benzodiazepines in both groups pre-enrollment.Clinical trial registration: NCT03012815.

[Withdrawal syndrome following chronic use of gamma-hydroxybutyric acid (GHB)]

Chronic use of gamma-hydroxybutyric acid (GHB) and its precursors can rapidly lead to physical dependence with the emergence of a withdrawal syndrome. This complication is similar to the one linked to alcohol or benzodiazepines. The onset of symptoms and specially neuro-psychiatric symptoms is, however, more rapid in the case of the GHB and precursors. There is currently no consensus on the therapeutic management of GHB withdrawal syndrome. High-dose benzodiazepines are the most commonly used treatment. The use of GHB by titration and tapering could show fewer side effects and withdrawal symptoms. It appears necessary to reflect on and pursue research on the use of GHB and its precursors, which remains poorly understood, on the management of withdrawal syndrome due to the lack of protocol and on its probably underestimated impact on public health.

Sedation Weaning Initiative Targeting Methadone Exposure: Single Center Improvements in Withdrawal Symptoms and Hospital Length of Stay for Pediatric Cardiac Critical Care

OBJECTIVES

Sedation and pain medications are necessary in the management of postoperative pediatric cardiac patients. Prolonged exposure to these medications can lead to negative side effects including withdrawal. We hypothesized that standardized weaning guidelines would decrease exposure to sedation medications and decrease withdrawal symptoms. The primary aim was to decrease average days of methadone exposure to within goal for moderate- and high-risk patients within 6 months.

DESIGN

Quality improvement methods were used to standardize sedation medication weaning in a pediatric cardiac ICU.

SETTING

This study took place at Duke Children's Hospital Pediatric Cardiac ICU in Durham, North Carolina from January 1, 2020, to December 31, 2021.

PATIENTS

Children less than 12 months old admitted to the pediatric cardiac ICU who underwent cardiac surgery.

INTERVENTIONS

Sedation weaning guidelines were implemented over the course of 12 months. Data were tracked every 6 months and compared with the 12 months pre-intervention. Patients were stratified into low, moderate, and high risk withdrawal categories based on duration of opioid infusion exposure.

MEASUREMENTS AND MAIN RESULTS

Total sample size was 94 patients in the moderate and high risk categories. Process measures included documentation of Withdrawal Assessment Tool scores and appropriate methadone prescription in patients which increased to 100% post-intervention. For outcome measures, we observed decreased dexmedetomidine infusion duration, decreased methadone wean duration, decreased frequency of elevated Withdrawal Assessment Tool scores, and decreased hospital length of stay post-intervention. For the primary aim, methadone wean duration consistently decreased after each study period. Our intervention did not adversely impact balancing measures.

CONCLUSIONS

A quality improvement initiative to standardize sedation weaning in a Pediatric Cardiac ICU was successfully implemented and was correlated with decreased duration of sedation medications, decreased withdrawal scores, and decreased length of stay.

Eat, Sleep, Console Approach or Usual Care for Neonatal Opioid Withdrawal

BACKGROUND

Although clinicians have traditionally used the Finnegan Neonatal Abstinence Scoring Tool to assess the severity of neonatal opioid withdrawal, a newer function-based approach - the Eat, Sleep, Console care approach - is increasing in use. Whether the new approach can safely reduce the time until infants are medically ready for discharge when it is applied broadly across diverse sites is unknown.

METHODS

In this cluster-randomized, controlled trial at 26 U.S. hospitals, we enrolled infants with neonatal opioid withdrawal syndrome who had been born at 36 weeks' gestation or more. At a randomly assigned time, hospitals transitioned from usual care that used the Finnegan tool to the Eat, Sleep, Console approach. During a 3-month transition period, staff members at each hospital were trained to use the new approach. The primary outcome was the time from birth until medical readiness for discharge as defined by the trial. Composite safety outcomes that were assessed during the first 3 months of postnatal age included in-hospital safety, unscheduled health care visits, and nonaccidental trauma or death.

RESULTS

A total of 1305 infants were enrolled. In an intention-to-treat analysis that included 837 infants who met the trial definition for medical readiness for discharge, the number of days from birth until readiness for hospital discharge was 8.2 in the Eat, Sleep, Console group and 14.9 in the usual-care group (adjusted mean difference, 6.7 days; 95% confidence interval [CI], 4.7 to 8.8), for a rate ratio of 0.55 (95% CI, 0.46 to 0.65; P<0.001). The incidence of adverse outcomes was similar in the two groups.

CONCLUSIONS

As compared with usual care, use of the Eat, Sleep, Console care approach significantly decreased the number of days until infants with neonatal opioid withdrawal syndrome were medically ready for discharge, without increasing specified adverse outcomes. (Funded by the Helping End Addiction Long-term (HEAL) Initiative of the National Institutes of Health; ESC-NOW ClinicalTrials.gov number, NCT04057820.).

Working Toward a Gold Standard: The Severity of Ethanol Withdrawal Scale (SEWS) Versus the Clinical Institute Withdrawal Assessment Alcohol Scale (CIWA-Ar)

AIM

Proving the Severity of Ethanol Withdrawal Scale (SEWS) significantly reduces Alcohol Withdrawal Syndrome (AWS) treatment Time on Medication Protocol (TOMP).

METHOD

Head-to-head Quality Assurance outcome compared separate cohorts of SEWS or Clinical Institute Withdrawal Assessment Alcohol Scale, Revised (CIWA-Ar) data using Student's t and Wilcoxon tests.

RESULTS

SEWS-driven treatment (n = 244) reduced TOMP to 2.2 days versus 3.4 days for CIWA-Ar (n = 137); P < 0.0001.

CONCLUSION

The SEWS is the superior measure of AWS symptoms.

[Anxiolytics: Appropriate Use of Benzodiazepine Receptor Agonists]

Anxiolytics are a class of drugs that include benzodiazepine receptor agonists and serotonin 1A receptor partial agonists. Although benzodiazepine receptor agonists have anxiolytic, sedative-hypnotic, muscle relaxant, and anticonvulsant effects, their use should be carefully monitored due to their potential for paradoxical reactions, withdrawal symptoms, and dependence. On the other hand, serotonin 1A receptor partial agonists have a slower onset, and their use also presents challenges. In clinical practice, having a thorough understanding of the various types of anxiolytics and their unique features is crucial.

The impact of depression on opioid withdrawal symptoms among smokers with opioid use disorder receiving medication-assisted opioid detoxification

Individuals with opioid use disorder (OUD) endorse high rates of combustible smoking (Zale et al., 2015) which is associated with poorer outcomes (e.g., opioid craving and lower detoxification completion rates) among individuals receiving medications for opioid use disorder (MOUD; Mannelli et al., 2013) and lower smoking cessation rates (Okoli et al., 2010). The complex pharmacological relationship between opioids and nicotine may help explain these findings (Kohut, 2017); however, little is known about psychosocial variables that influence MOUD processes among combustible smokers with OUD. The present study sought to expand upon prior work (Mannelli et al., 2013) by examining the impact of psychological factors and smoking-related variables on opioid withdrawal symptoms among smokers with OUD receiving Suboxone at an inpatient substance use treatment facility. Current smokers with OUD (N = 64) completed a battery of psychological measures examining depression, anxiety, and smoking constructs. The present study tested the influence of daily smoking rate, nicotine dependence, smoking urges, anxiety, and depression on opioid withdrawal symptoms through a hierarchical multiple regression. Findings revealed that smoking urges (p = .003) predicted severity of opioid withdrawal symptoms while controlling for race, daily smoking rate, and nicotine dependence. Depression (p = .000), however, explained variance in severity of opioid withdrawal symptoms above and beyond all smoking-related variables and anxiety. Results highlight the importance of considering psychological factors, specifically depression, which impact treatment processes among smokers with OUD to help inform the development of effective treatment interventions for both OUD and smoking cessation among individuals with OUD. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Psychosis Related to Baclofen Withdrawal or Overdose: A Systematic Review

OBJECTIVE

To systematically review case reports of psychosis related to withdrawal or overdose of baclofen, which is a gamma-aminobutyric acid (GABA) _B agonist.

METHODS

PubMed, MEDLINE, CINAHL, and PsychINFO were searched to identify articles related to psychosis secondary to withdrawal or overdose of baclofen using the terms 'baclofen' and ' psychosis'. Comparisons were made between cases in terms of concomitant antipsychotic use, diagnosis of delirium, and evidence of association. Quality of case reports was assessed using the CARE Case Report Guidelines checklist.

RESULTS

In total, 34 patients from 28 case reports were reviewed. Twenty-three patients experienced psychosis upon baclofen withdrawal; among them, 18 had resolution of psychosis upon reinitiation of baclofen, whereas antipsychotic monotherapy was less successful (only four of eight patients responded). An additional baclofen withdrawal period led to recurrence of psychotic symptoms in four of seven patients. Eleven patients had psychosis on induction or after overdose of baclofen; among them, four patients had resolution of psychosis upon cessation of baclofen. The mean quality of the case reports was 6.4 of 13.

CONCLUSION

Considering its GABAergic agonism, along with evidence of psychosis on induction or withdrawal, baclofen may have some antipsychotic and pro-psychotic properties.

Piloting Smart Home Sensors to Detect Overnight Respiratory and Withdrawal Symptoms in Adults Prescribed Opioids

BACKGROUND

Novel strategies are needed to curb the opioid overdose epidemic. Smart home sensors have been successfully deployed as digital biomarkers to monitor health conditions, yet they have not been used to assess symptoms important to opioid use and overdose risks.

AIM

This study piloted smart home sensors and investigated their ability to accurately detect clinically pertinent symptoms indicative of opioid withdrawal or respiratory depression in adults prescribed methadone.

METHODS

Participants (n = 4; 3 completed) were adults with opioid use disorder exhibiting moderate levels of pain intensity, withdrawal symptoms, and sleep disturbance. Participants were invited to two 8-hour nighttime sleep opportunities to be recorded in a sleep research laboratory, using observed polysomnography and ambient smart home sensors attached to lab bedroom walls. Measures of feasibility included completeness of data captured. Accuracy was determined by comparing polysomnographic data of sleep/wake and respiratory status assessments with time and event sensor data.

RESULTS

Smart home sensors captured overnight data on 48 out of 64 hours (75% completeness). Sensors detected sleep/wake patterns in alignment with observed sleep episodes captured by polysomnography 89.4% of the time. Apnea events (n = 118) were only detected with smart home sensors in two episodes where oxygen desaturations were less severe (>80%).

CONCLUSIONS

Smart home technology could serve as a less invasive substitute for biologic monitoring for adults with pain, sleep disturbances, and opioid withdrawal symptoms. Supplemental sensors should be added to detect apnea events. Such innovations could provide a step forward in assessing overnight symptoms important to populations taking opioids.

Trauma center admission risk conditions and the probability for developing alcohol withdrawal syndrome: A retrospective study

BACKGROUND

Because the proportion of trauma patients developing alcohol withdrawal syndrome (AWS) is low, AWS risk conditions have not been precisely delineated. We aimed to create multifactor screening strategies to assess probabilities for the likelihood of developing AWS.

METHODS

We performed a retrospective chart review of 1,011 trauma patients admitted to a Level I trauma center to investigate the associations between AWS and probable AWS risk conditions. Included patients were adults who met trauma registry inclusion criteria and had blood alcohol concentration (BAC) testing performed. Patients were excluded if they had a traumatic brain injury with a Glasgow Coma Score (GCS) ≤ 8, or no BAC testing performed. We defined heavy drinking as daily drinking or >7 per week.

RESULTS

AWS had univariate associations with heavy drinking history, Injury Severity Score (ISS) ≥15, psychiatric disorders, liver disease, smoking history, in-hospital bronchodilator administration, age ≥45, male sex, Intensive Care Unit (ICU) admission, serum aspartate aminotransferase (AST) ≥40 U/L, and cognitive preservation (GCS ≥13 with BAC ≥100 mg/dL) (all, p < 0.05). ICU admission, AST ≥40 U/L, cognitive preservation, male sex, and age ≥45 had associations with ISS ≥15 or alcohol misuse (all, p < 0.0001). For patients with age ≥45 and heavy drinking history or age <45 and heavy drinking history with ISS ≥15 and ICU admission, the AWS proportion (15.3%) was greater in comparison to other patients (0.3%). The AWS risk score was the sum of the following nine conditions, assigned a zero when the condition was absent and one when present (range 0-9): ISS ≥15, psychiatric disorders, liver disease, smoking history, in-hospital bronchodilator administration, age ≥45, male sex, AST ≥40 U/L, and cognitive preservation. The AWS proportion was greater with a risk score of 5-9 (16.8%) than of 0-4 (1.2%; p < 0.0001).

CONCLUSIONS

AWS in the setting of traumatic injury is associated with multiple risk conditions. The presence of multiple risk conditions might have additive effects that could contribute toward a clinical manifestation of AWS. The identified risk conditions may be associated with a hyperadrenergic state.

Diagnostic Overlap of Brain Abscess Symptoms with Methamphetamine Withdrawal Symptoms

From the perspective of forensic medicine, substance abuse is an important topic due to its nature and consequences. The usage of methamphetamine is a significant public health problem with deleterious side effects, one of the most serious of which is mimicking central nervous system infection. A 40-year man was brought to the emergency department with complaints of headache, vomiting, fever, and loss of consciousness. According to his relative, he had abstained from methamphetamine abuse for two weeks. The initial diagnosis was made of methamphetamine withdrawal symptoms. However, computed tomography of the head revealed sinusitis and a hypodense lesion with dimensions of 35 x 35 mm. Moreover, Streptococcus agalactiae (group B streptococcus) was grown in the blood culture. A diagnosis of brain abscess and ventriculitis was made. The aim of this report is to draw physicians attention to substance abstinence symptoms that may mask more serious diseases. Key Words: Brain abscess, Methamphetamine withdrawal, Sinusitis.

Description of antidepressant withdrawal symptoms in clinical practice guidelines on depression: A systematic review

BACKGROUND

Antidepressant withdrawal symptoms may mimic symptoms of depression relapse and can be challenging for patients when tapering or discontinuing antidepressants. We aimed to assess how withdrawal symptoms are described in major clinical practice guidelines on depression.

METHODS

Systematic review of major clinical practice guidelines on depression from the United Kingdom, the United States, Canada, Australia, Singapore, Ireland, and New Zealand. We searched PubMed, 14 guideline registries, and the websites of relevant organisations (last search 10 July 2022). The guidelines were assessed for information and descriptions of antidepressant withdrawal symptoms regarding their type, incidence, duration, severity, onset, and presumed mechanism.

RESULTS

We included 21 guidelines, 15 (71 %) of which stated that withdrawal or discontinuation symptoms can occur. None of the guidelines provided an exhaustive list of potential withdrawal symptoms; ten (48 %) guidelines mentioned at least one specific symptom, ranging between four and 39 symptoms. The symptomatic overlap between withdrawal and relapse was mentioned in four (19 %) guidelines. Withdrawal symptoms were generally described as mild, brief, and self-limiting; and severe in a minority of cases. Estimates of the duration, incidence, or expected onset were reported in five (24 %) guidelines, and were in all cases lower than those reported in systematic reviews.

LIMITATIONS

We included clinical practice guidelines from English-speaking countries only; our findings may not be generalizable to non-English-speaking countries.

CONCLUSIONS

Clinical practice guidelines provide scarce and inadequate information on antidepressant withdrawal symptoms and limited guidance for distinguishing withdrawal symptoms from symptoms of relapse.

Leveraging Accelerometry as a Prognostic Indicator for Increase in Opioid Withdrawal Symptoms

Treating opioid use disorder (OUD) is a significant healthcare challenge in the United States. Remaining abstinent from opioids is challenging for individuals with OUD due to withdrawal symptoms that include restlessness. However, to our knowledge, studies of acute withdrawal have not quantified restlessness using involuntary movements. We hypothesized that wearable accelerometry placed mid-sternum could be used to detect withdrawal-related restlessness in patients with OUD. To study this, 23 patients with OUD undergoing active withdrawal participated in a protocol involving wearable accelerometry, opioid cues to elicit craving, and non-invasive Vagal Nerve Stimulation (nVNS) to dampen withdrawal symptoms. Using accelerometry signals, we analyzed how movements correlated with changes in acute withdrawal severity, measured by the Clinical Opioid Withdrawal Scale (COWS). Our results revealed that patients demonstrating sinusoidal-i.e., predominantly single-frequency oscillation patterns in their motion almost exclusively demonstrated an increase in the COWS, and a strong relationship between the maximum power spectral density and increased withdrawal over time, measured by the COWS (R = 0.92, p = 0.029). Accelerometry may be used in an ambulatory setting to indicate the increased intensity of a patient's withdrawal symptoms, providing an objective, readily-measurable marker that may be captured ubiquitously.

Strategies for the management and prevention of withdrawal syndrome in critically ill pediatric patients: a systematic review

OBJECTIVE

To verify strategies for the prevention and treatment of abstinence syndrome in a pediatric intensive care unit.

METHODS

This is a systematic review in the PubMed database®, Lilacs, Embase, Web of Science, Cochrane, Cinahl, Cochrane Database Systematic Review and CENTRAL. A three-step search strategy was used for this review, and the protocol was approved in PROSPERO (CRD42021274670).

RESULTS

Twelve articles were included in the analysis. There was great heterogeneity among the studies included, especially regarding the therapeutic regimens used for sedation and analgesia. Midazolam doses ranged from 0.05mg/kg/hour to 0.3mg/kg/hour. Morphine also varied considerably, from 10mcg/kg/hour to 30mcg/kg/hour, between studies. Among the 12 selected studies, the most commonly used scale for the identification of withdrawal symptoms was the Sophia Observational Withdrawal Symptoms Scale. In three studies, there was a statistically significant difference in the prevention and management of the withdrawal syndrome due to the implementation of different protocols (p < 0.01 and p < 0.001).

CONCLUSION

There was great variation in the sedoanalgesia regimen used by the studies and the method of weaning and evaluation of withdrawal syndrome. More studies are needed to provide more robust evidence about the most appropriate treatment for the prevention and reduction of withdrawal signs and symptoms in critically ill children.

PROSPERO REGISTER

CRD 42021274670.

Strategies for the management and prevention of withdrawal syndrome in critically ill pediatric patients: a systematic review

OBJECTIVE

To verify strategies for the prevention and treatment of abstinence syndrome in a pediatric intensive care unit.

METHODS

This is a systematic review in the PubMed database®, Lilacs, Embase, Web of Science, Cochrane, Cinahl, Cochrane Database Systematic Review and CENTRAL. A three-step search strategy was used for this review, and the protocol was approved in PROSPERO (CRD42021274670).

RESULTS

Twelve articles were included in the analysis. There was great heterogeneity among the studies included, especially regarding the therapeutic regimens used for sedation and analgesia. Midazolam doses ranged from 0.05mg/kg/hour to 0.3mg/kg/hour. Morphine also varied considerably, from 10mcg/kg/hour to 30mcg/kg/hour, between studies. Among the 12 selected studies, the most commonly used scale for the identification of withdrawal symptoms was the Sophia Observational Withdrawal Symptoms Scale. In three studies, there was a statistically significant difference in the prevention and management of the withdrawal syndrome due to the implementation of different protocols (p < 0.01 and p < 0.001).

CONCLUSION

There was great variation in the sedoanalgesia regimen used by the studies and the method of weaning and evaluation of withdrawal syndrome. More studies are needed to provide more robust evidence about the most appropriate treatment for the prevention and reduction of withdrawal signs and symptoms in critically ill children.

PROSPERO REGISTER

CRD 42021274670.

Managing acute opioid withdrawal with tramadol during COVID-19 lockdown in a peri-urban setting

Background

The coronavirus disease 2019 (COVID-19) has highlighted the scope of heroin dependence and need for evidence-based treatment amongst marginalised people in South Africa. Acute opioid withdrawal management without maintenance therapy carries risks of increased morbidity and mortality. Due to the high costs of methadone, Tshwane’s Community Oriented Substance Use Programme (COSUP) used tramadol for opioid withdrawal management during the initial COVID-19 response.

Aim

To describe demographics, route of heroin administration and medication-related experiences amongst people accessing tramadol for treatment of opioid withdrawal.

Setting

Three community-based COSUP sites in Mamelodi (Tshwane, South Africa).

Methods

A retrospective cross-sectional study was conducted. Data were collected using an interviewer-administered paper-based tool between April and August 2020. Descriptive statistics were used to analyse data.

Results

Of the 220 service users initiated onto tramadol, almost half (n = 104, 47%) were not contactable. Fifty-eight (26%) people participated, amongst whom most were male (n = 55, 95%). Participants’ median age was 32 years. Most participants injected heroin (n = 36, 62.1%). Most participants experienced at least one side effect (n = 47, 81%) with 37 (64%) experiencing two or more side effects from tramadol. Insomnia occurred most frequently (n = 26, 45%). One person without a history of seizures experienced a seizure. Opioid withdrawal symptoms were experienced by 54 participants (93%) whilst taking tramadol. Over half (n = 38, 66%) reported using less heroin whilst on tramadol.

Conclusion

Tramadol reduced heroin use but was associated with withdrawal symptoms and unfavourable side effects. Findings point to the limitations of tramadol as opioid withdrawal management to retain people in care and the importance of access to first-line opioid agonists.

Contribution

This research contributes to the limited data around short-acting tramadol for opioid withdrawal management in the African context, with specific focus on the need for increased access to opioid agonists for those who need them, in primary care settings.

Abstinence phobia among adult African American/Black cannabis users

OBJECTIVE

African American/Black individuals experience significant health disparities, particularly as it relates to cannabis use. As such, there is a need to identify intrapersonal factors related to more severe patterns of use among this subpopulation. Worry about quitting or reducing cannabis as a result of the anticipated anxiety-related states during deprivation (i.e., abstinence phobia) is one factor that is theoretically important in the context of cannabis-related disparities.

METHOD

The current study sought to examine the cross-sectional association between abstinence phobia and cannabis use problems, perceived barriers for cannabis cessation, and cannabis withdrawal symptoms. Participants included 83 African American/Black cannabis users (31.3% female, M_age = 38.12, SD = 10.42).

RESULTS

Cannabis abstinence phobia was associated with greater severity of cannabis use problems, more perceived barriers for quitting cannabis use, and more severe cannabis withdrawal symptoms.

CONCLUSIONS

Abstinence phobia may represent an underrecognized intervention target for addressing cannabis use problems and quit success.

Diagnostic Performance of AST Scale in Mexican Male Population for Alcohol Withdrawal Syndrome

Alcohol withdrawal syndrome (AWS) represents an adverse consequence of chronic alcohol use that may lead to serious complications. Therefore, AWS requires timely attention based on its early recognition, where easy-to-apply diagnostic tools are desirable. Our aim was to characterize the performance of a short-scale AST (Anxiety, Sweats, Tremors) in patients from public general hospitals. We conducted a cross-sectional study of patients attended at the Emergency Department diagnosed with AWS. Three scales were applied: CIWA-Ar (Clinical Institute Retirement Assessment Scale-Revised), GMAWS (Glasgow Modified Alcohol Withdrawal Syndrome) and AST. Cronbach’s alpha and Cohen’s kappa tests were used for reliability and concordance. Factorial analysis and diagnostic performance including ROC curve were carried out. Sixty-eight males with a mean age of 41.2 years old, with high school education and robust alcohol consumption, were included. Mean scores for CIWA-Ar, GMWAS and AST were 17.4 ± 11.2, 3.9 ± 2.3 and 3.8 ± 2.6, respectively, without significant differences. The AST scale showed an acceptable reliability and concordance (0.852 and 0.439; p < 0.0001) compared with CIWA-Ar and GMAWS. AST component analysis evidenced tremor (77.5% variance), sweat (12.1% variance) and anxiety (10.4% variance). Diagnostic performance of the AST scale was similar to the GMAWS scale, evidencing a sensitivity of 84%, specificity of 83.3% and Area Under the Curve (AUC) of 0.837 to discriminate severe AWS, according to CIWA-Ar. The performance of the AST scale to evaluate AWS is comparable with the commonly used CIWA-Ar and GMAWS scales. AST further represents an easy-to-apply instrument.

Tobacco cigarette smokers who endorse greater intolerance for nicotine withdrawal also report more severe insomnia symptoms

It has been suggested that nighttime nicotine withdrawal may help to explain why tobacco cigarette smokers are more likely than nonsmokers to experience clinically significant insomnia. There is also reason to believe that intolerance for withdrawal symptoms could play a role in withdrawal-related sleep disturbance. However, we are not aware of any previous research that examined whether smokers who endorse greater intolerance for smoking abstinence also report greater difficulty initiating and/or maintaining sleep. To address this question, 224 adult cigarette smokers (42.9% female, Mcigarettes per day = 21.3) completed the baseline portion of an experimental study that included assessment of current/historical smoking behavior, perceived intolerance for smoking abstinence, and insomnia severity and impact on functioning. The results indicated that, after accounting for general distress intolerance and sociodemographic factors, smokers who endorsed greater intolerance for nicotine withdrawal also reported greater insomnia severity and impact. Logistic regression further revealed that, for every 1-point increase in nicotine withdrawal intolerance scores, smokers were nearly twice as likely to score above threshold for clinically significant insomnia (p = .001). Collectively, these initial findings suggest that intolerance for nicotine withdrawal may warrant consideration as a potentially modifiable mechanistic factor in comorbid insomnia and nicotine/tobacco dependence. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Specificity and sensibility of the Spanish version of the COMFORT Behaviour Scale for assessing pain, grade of sedation and withdrawal syndrome in the critically ill paediatric patient. Multicentre COSAIP study (Phase 1)

AIM

The main aim of this investigation was to analyse the specificity and sensibility of the COMFORT Behaviour Scale (CBS-S) in assessing grade of pain, sedation, and withdrawal syndrome in paediatric critical care patients.

METHOD

An observational, analytical, cross-sectional and multicentre study conducted in Level III Intensive Care Areas of 5 children's university hospitals. Grade of sedation was assessed using the Spanish version of the CBS-S and the Bispectral Index on sedation, once per shift over one day. Grade of withdrawal was determined using the CBS-S and the Withdrawal Assessment Tool-1, once per shift over three days.

RESULTS

A total of 261 critically ill paediatric patients with a median age of 5.07 years (P25:0.9-P75:11.7) were included in this study. In terms of the predictive capacity of the CBS-S, it obtained a Receiver Operation Curve of .84 (sensitivity of 81% and specificity of 76%) in relation to pain; .62 (sensitivity of 21% and specificity of 78%) in relation to sedation grade, and .73% (sensitivity of 40% and specificity of 74%) in determining withdrawal syndrome.

CONCLUSIONS

The Spanish version of the COMFORT Behaviour Scale could be a useful, sensible and easy scale to assess the degree of pain, sedation and pharmacological withdrawal of critically ill paediatric patients.

Challenges of Diagnosing and Managing Designer Benzodiazepine Dependence and Withdrawal: A Case Report

BACKGROUND

Over the last 10 years, an increasing number of unregulated novel psychoactive substances, including "designer benzodiazepines" (DBZDs), have emerged on the recreational drug market. Despite the rapidly increasing usage of DBZDs, there is a significant lack of information regarding clinical management. Here we present a case illustrating the difficulties of diagnosing and managing DBZD related sedative-hypnotic use disorder.

CASE PRESENTATION

Our patient is a 30-year-old man with severe opioid and sedative-hypnotic use disorders. He had a 10-year history of using heroin, clonazolam, and alprazolam. He stopped using heroin when on methadone maintenance therapy but continued using clonazolam and nonprescribed alprazolam. His opioid treatment program discontinued methadone due to benzodiazepine intoxication, and he returned to heroin use. He then presented for residential withdrawal management where he underwent successful buprenorphine induction and benzodiazepine withdrawal management. During a 3-month period of benzodiazepine abstinence, he struggled with ongoing cravings and post-acute withdrawal syndrome, ultimately leading to return to DBZD use.

DISCUSSION

Despite the increasing prevalence of DBZD use, the usage of DBZDs is likely under-recognized because these compounds are generally not included on standard in-office urine drug immunoassay tests. Initial studies suggest that DBZDs have high potencies, shorter half-lives, are more addictive, and can result in more severe withdrawal symptoms compared to known benzodiazepines. However, there remains a lack of information about the pharmacokinetics and pharmacodynamics of DBZDs, making clinical management for DBZD related sedative-hypnotic use disorders challenging to treat.

[Stopping antidepressants: withdrawal symptoms and rebound effects : Review and practical recommendations]

Stopping antidepressants can cause withdrawal (discontinuation) symptoms, the return of the original illness, and rebound. The latter means that the disease will return stronger, faster, or with greater likelihood than if it had not been treated with medication. The Psychiatry Working Group of the Drug Commission of the German Medical Association (AkdÄ) presents the scientific findings and provides practical recommendations for action. Withdrawal symptoms are multiform; unspecific physical symptoms are predominant. Distinguishing them from the recurrence of depressive symptoms can be difficult. Most of them are mild and self-limiting. There is insufficient evidence on the extent and frequency of rebound depression. The rebound risk implies that when establishing the medication, the short-term benefit must be weighed against the possible long-term risk of chronic depression or the possible need for long-term medication. Patients should be informed about the risk of withdrawal both as early as the joint decision-making process about treatment initiation and regularly during the course of treatment. Withdrawal should take place gradually, except in emergency situations, whereby small steps should be taken, especially in the low-dose range.

Factors associated with methamphetamine withdrawal symptoms among people who inject drugs

BACKGROUND

Regular methamphetamine (MA) use can result in withdrawal syndrome characterized by fatigue, agitation, depression, and anxiety. No studies that we are aware of have examined the prevalence and predictors of MA withdrawal symptoms among people who inject drugs (PWID).

METHODS

PWID were recruited using targeted sampling methods in Los Angeles and San Francisco, California from 2016 to 2017. Survey questions included demographics, drug use, and MA withdrawal symptoms, frequency, and symptom severity. Participants who reported regular MA use (> 12 times in the last 30 days) were included in this analysis (N = 595). Multivariable regression models were developed to examine factors associated with any MA withdrawal, withdrawal frequency, symptom severity, and receptive syringe sharing.

RESULTS

MA withdrawal symptoms in the past 6 months were reported by 53 % of PWID, with 25 % reporting weekly withdrawal symptoms, and 20 % reporting very or extremely painful symptoms. In multivariable logistic regression, presence of any MA withdrawal symptoms was positively associated with more frequent MA use and non-injection tranquilizer use and inversely associated with crack cocaine use. Among those reporting any withdrawal, female sex was associated with more frequent withdrawal symptoms. Very or extremely painful withdrawal symptoms were associated with being in residential treatment. Receptive syringe sharing was associated with any MA withdrawal symptoms and weekly frequency of symptoms.

CONCLUSION

MA withdrawal symptoms are common among PWID and are associated with receptive syringe sharing. Strategies for implementing MA use treatment, safe supply programs, and syringe services programs targeting people who inject MA are indicated.

Alcohol Abuse and Alcohol Withdrawal Are Associated with Adverse Perioperative Outcomes Following Elective Spine Fusion Surgery

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

Alcohol abuse (AA) and alcohol withdrawal (AW), both belonging to alcohol use disorders, bring about vast health consequences, social issues, and financial burden in United States. This study aims to explore the relationship of AA and AW with perioperative outcomes following elective spine fusion surgery.

SUMMARY OF BACKGROUND DATA

Large studies evaluating the outcomes of spine surgery in patients with AA or AW are lacking.

METHODS

We used the National Inpatient Sample (NIS) from 2006 to 2014 to extract records with a primary procedure of spinal fusion surgery. Multivariable regression analysis was used to assess the association of AA and AW with in-hospital mortality, perioperative complications, cost and length of stay (LOS).

RESULTS

Among 3,132,192 patients undergoing elective spinal fusion surgery, the prevalence of AA and AW was 1.14% (35,833) and 0.15% (4623), respectively. Among the AA admissions, 12.90% of patients developed AW. The incidence of overall complications was 6.14%, 10.15%, and 33.73% in patients without AA, with AA and with AW, respectively. After multivariable adjustment, AW was associated with elevated risk of overall complications (odds ratio [OR]: 4.51; 95% confidence interval [CI]: 3.86-5.27), neurologic (OR: 2.58; 95% CI: 1.62-4.12), respiratory (OR: 8.04; 95% CI: 6.62-9.77), cardiac (OR: 3.58; 95% CI: 2.60-4.93), gastrointestinal (OR: 2.31; 95%CI: 1.68-3.17), urinary and renal (OR: 2.68; 95% CI: 2.11-3.39), venous thromboembolism (OR: 3.06; 95% CI: 1.94-4.82), wound-related complications (OR: 3.84; 95% CI: 2.96-4.98) and in-hospital mortality (OR: 5.95; 95% CI: 3.25-10.90). AW was also linked to 40% higher cost and 85% longer LOS.

CONCLUSION

Both AA and AW are associated with adverse outcomes in patients undergoing spinal fusion surgery with more pronounced risks for AW. Aggressive management in perioperative period is required to improve outcomes in these patients.Level of Evidence: 3.

Should the CIWA-Ar be the standard monitoring strategy for alcohol withdrawal syndrome in the intensive care unit?

BACKGROUND

The Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) is commonly used in hospitals to titrate medications for alcohol withdrawal syndrome (AWS), but may be difficult to apply to intensive care unit (ICU) patients who are too sick or otherwise unable to communicate.

OBJECTIVES

To evaluate the frequency of CIWA-Ar monitoring among ICU patients with AWS and variation in CIWA-Ar monitoring across patient demographic and clinical characteristics.

METHODS

The study included all adults admitted to an ICU in 2017 after treatment for AWS in the Emergency Department of an academic hospital that standardly uses the CIWA-Ar to assess AWS severity and response to treatment. Demographic and clinical data, including Richmond Agitation-Sedation Scale (RASS) assessments (an alternative measure of agitation/sedation), were obtained via chart review. Associations between patient characteristics and CIWA-Ar monitoring were tested using logistic regression.

RESULTS

After treatment for AWS, only 56% (n = 54/97) of ICU patients were evaluated using the CIWA-Ar; 94% of patients had a documented RASS assessment (n = 91/97). Patients were significantly less likely to receive CIWA-Ar monitoring if they were intubated or identified as Black.

CONCLUSIONS

CIWA-Ar monitoring was used inconsistently in ICU patients with AWS and completed less often in those who were intubated or identified as Black. These hypothesis-generating findings raise questions about the utility of the CIWA-Ar in ICU settings. Future studies should assess alternative measures for titrating AWS medications in the ICU that do not require verbal responses from patients and further explore the association of race with AWS monitoring.