[Benzodiazepine withdrawal syndrome in the elderly patient]

Withdrawal syndrome is a well known diagnostic entity. As the symptomatology related to this syndrome is extremely unspecific, care must be taken not to ignore withdrawal syndrome, the consequences of which, while rare, can lead to often long and complicated hospitalisations.

Adolescents at risk: pain pills to heroin: part II

Casually exposing adolescents to prescription opioid agents may escalate to daily use. A trend exists for adolescents using prescription opioid agents to substitute heroin because it is significantly cheaper than pills (approximately half of the cost) and is often more readily available. Additionally, it is more potent than most prescription opioid agents and carries increased risks of overdose and death. Although treatment for substance use disorders has traditionally centered on total abstinence, opioid replacement therapy (ORT) is an option that saves lives and prevents overdose deaths. In the United States, ORT is based on two medicines: methadone and buprenorphine. These drugs can be substituted for other opiate agents and have much lower overdose risks. Nursing implications and web-based resources for teaching are presented.

[Outpatient cannabis withdrawal programme]

Cannabis is the most consumed illicit substance in France, and its use can lead to dependency. Lille university hospital, le Pari association, offers patients wanting to stop using cannabis a support therapy based on positive feedback led by nurses, as well as symptomatic treatment of anxiety and sleep disorders.

Satisfaction of nurses with the Withdrawal Assessment Tool-1 (WAT-1)

BACKGROUND

Use of opioids and benzodiazepines in critically ill children results in an increased risk of withdrawal syndrome requiring the pediatric nurse to accurately assess the patient's clinical state. A valid and reliable pediatric withdrawal assessment tool could be of considerable value to improve nursing care.

OBJECTIVE

To evaluate nurses' satisfaction with a new pediatric assessment tool, the Withdrawal Assessment Tool-1 (WAT-1).

METHODS

Forty-one Pediatric Intensive Care Unit (PICU) and 27 Pediatric Intermediate Care Unit (PIMC) staff participated in a pre- and post-implementation survey. The survey looked at confidence in assessment skills, perception of communication about withdrawal, and satisfaction with nursing care of the child undergoing withdrawal syndrome. Staff were surveyed, completed online education about the WAT-1, and then repeated the survey after six months of clinical use.

RESULTS

Overall confidence in assessment changed very little. There was improvement in the perception of communication (p = 0.005) as well as satisfaction with care provided (p = 0.00002) after implementation of the WAT-1. In particular, satisfaction with nursing documentation of withdrawal syndrome improved significantly (p = 0.00002).

CONCLUSIONS

The WAT-1 improves nurses' satisfaction with their care of children undergoing withdrawal syndrome, in particular, their documentation of the level of withdrawal symptoms.

Unplanned alcohol withdrawal: a survey of consecutive admissions to an acute medical unit in 2010 and 2011

BACKGROUND

Alcohol-related presentations to hospital have been increasing in the UK in recent years, including the occurrence of acute withdrawal. This study sought to better characterize the clinical features, patterns of treatment and outcomes in this patient group.

METHODS

Patients admitted to the Acute Medical Unit of York Hospital due to acute alcohol withdrawal are normally treated according to a protocol that involves both fixed-dose and symptom-triggered drug administration. Admissions between 2010 and 2011 inclusive were studied.

RESULTS

There were 211 admission episodes solely due to acute alcohol withdrawal, involving 127 patients (97 men, 76.4%) with median age of 45 years (interquartile range: 39-52 years). There was a high prevalence of depression (34%), alcoholic liver disease (22%) and drug misuse (12%). Total dose of chlordiazepoxide varied between 0 and 610 mg and tapered rapidly after the first day of admission. Vitamin supplements were administered to >90% of patients, including parenteral and oral in 74%, parenteral alone in 9% and oral alone in 9%. A specialist alcohol nurse reviewed patients while in hospital in 40% of cases. Approximately one-third of patients had multiple admissions for alcohol withdrawal during the study period.

CONCLUSION

A high prevalence of physical and mental health disorders was observed. The local policy permitted high initial chlordiazepoxide doses and prompt downward titration, with a broad range of doses between individuals. Approximately 10% required no specific therapy, and there may be opportunities for developing alternative pathways for delivery of care in an ambulatory setting for these patients.

[A metaphor of the nurse's work in addictology]

The mechanism of addiction can be compared to a rut in a road, towards which patients are attracted and into which they inevitably fall. The role of the nurse in addictology is to lead the patient to consider other roads, to tread a new path taking them in a more positive direction. It is on this condition that programmes based on substitution can prove effective.

Managing depressive symptoms in the context of abstinence: findings from a qualitative study of women

PROBLEM

In both community and clinical studies, higher rates of co-occurring depression and substance use disorder have been found in women. Within the past decade, there has been a plethora of research addressing co-occurring depression and substance abuse. However, comparatively few studies include individuals who suffer with depressive symptoms, which may not meet specific diagnostic criteria despite the significant impairment they may experience.

METHOD

An ethnographic method was used to elicit the experiences of women dependent on alcohol and/or other substances and who have stopped drinking and/or using.

FINDINGS

Findings corroborated those from previous studies in which depressive symptoms preceded substance abuse and continued during sustained abstinence. Separation in services between mental health and substance abuse resulted in fragmented care.

CONCLUSION

Based on these findings, recommendations for screening, assessment, and treatment implications are forwarded.

Adverse responses: sedation, analgesia and neuromuscular blocking agents in critically ill children

Advanced practice nurses (APNs) prescribe sedation, analgesia, and neuromuscular blocking agents in the management of critically ill children. Although most children are unscathed from the use of the medications, some suffer adverse responses. This article elucidates adverse responses to these medications for the APN, including withdrawal syndrome, muscle weakness, decreased gastric motility, corneal abrasions, and costs associated with these morbidities.

How to manage opiate dependence and withdrawal

Problematic drug use has received considerable media attention over the past decade. This has raised awareness of the escalation of drug use as well as the complex issues that accompany it. According to the Audit Commission (2002), there were 250,000 known drug users in the UK in 2002 and only half were in treatment. This was considered to be a conservative estimate as not all drug users were willing or able to access treatment.

Dexamethasone Therapy in Patients with Brain Tumors—A Focus on Tapering

Administration of corticosteriods in brain tumor patients requires an understanding of the physiology of the adrenal system and desired patient response. Close attention to other concomitant medications will ensure adequate amounts of all drugs, including dexamethasone. Nurses need to assess patients' tolerance of dexamethasone, discuss these findings with physicians and pharmacists, and educate both patients and family members on doses and tapering schedules tailored to individual patient needs.

The search for insight: Clients' psychological experiences of alcohol withdrawal in a voluntary, residential, health care setting

This study utilized a life history approach to describe clients' psychological experiences of the alcohol withdrawal process while voluntarily residing in a specialist alcohol withdrawal facility. Reflection on the past and anticipation of the future frequently occupied the thoughts of participants as they sought insight in to their lives. These insights were associated with a range of emotions that included embarrassment, shame, optimism, feelings of support and a sense of loss of control. The findings provide additional information on the human experience of alcohol withdrawal and, thus, increase empathy, understanding and knowledge. This increased understanding can be utilized to improve the quality of nursing care provided to this complex client group.

Introducing an in-patient treatment for alcohol detoxification into a community setting

Alcohol detoxification in the UK is not standardized and treatment is usually determined by local policies. Drug regimens are often predetermined and unrelated to the extent and duration of dependence, recent consumption, or previous withdrawal symptoms. Diazepam loading shortens the detoxification period and avoids the indiscriminate use of medication. It has been shown to be effective as an in-patient treatment. This paper examines the feasibility of introducing diazepam loading in a community setting, and discusses the implications that this would have for clinical practice.

Assessing the impact of a nurse-led health education intervention for people with peripheral vascular disease who smoke: the use of physiological markers, nicotine dependence and withdrawal

This study evaluated the impact of a nurse-led health education programme on the behaviour, nicotine dependence and nicotine withdrawal in patients who smoke and suffer from peripheral vascular disease, based in a large teaching hospital in the north of England. Smoking behaviour was measured by self report, end-expired carbon monoxide and urinary cotinine. Nicotine dependence and withdrawal were measured using a nicotine dependence scale and a nicotine withdrawal scale. The findings demonstrated that the programme did have some impact on behaviour. The study raised issues concerning the measurement of physiological markers for smoking as nursing outcomes. Issues about the measurement of nicotine dependence and withdrawal are highlighted.

Opioid tapering in hematopoietic progenitor cell transplant recipients

PURPOSE/OBJECTIVES

To describe current opioid-tapering practice, patient pain levels and withdrawal symptoms, and nurse documentation during opioid tapers.

DESIGN

Descriptive, exploratory, prospective, quantitative, and qualitative.

SETTING

A 32-bed blood and marrow transplant unit in a large, tertiary U.S. care center.

SAMPLE

45 blood and marrow transplant recipients between the ages of 7-64. Types of transplant were autologous, allogeneic, and unrelated donor marrow; peripheral blood stem cell; and umbilical cord blood.

METHODS

In daily interviews, patients reported pain levels and withdrawal symptoms during opioid tapers. Demographic, medication, and nurse documentation data were obtained from patient hospital records.

MAIN RESEARCH VARIABLES

Taper length, daily opioid dosage, pain, withdrawal symptoms, and nurse documentation.

FINDINGS

Length of taper ranged from 1-17 days (X = 6.53, SD = 4.26). Analysis of variance indicated no difference by disease or transplant type in length of taper, cumulative opioids given pretaper or during taper, or number of self-reports of withdrawal symptoms. Daily changes in nurse-administered opioid dosage during tapers ranged from a decrease of 67% to an increase of 14%. Children received significantly more opioids/kg during taper than adults. Means of adults' and children's self-reports of pain were low. The means of patient-reported withdrawal symptoms were highest on taper days two through six. Nurse documentation was sparse.

CONCLUSIONS

Daily taper rates vary widely, pain is well managed, and most patients experience several withdrawal symptoms.

IMPLICATIONS FOR NURSING PRACTICE

Use of an opioid-taper guideline may promote consistency of tapering while not increasing levels of pain or withdrawal symptoms.

Rapid detox: understanding new treatment approaches for the addicted patient

TOPIC

Despite substantive advances in understanding of genetic and biochemical basis of substance abuse and addiction in the last decade, little information has been translated into alternative treatment models for the addicted patient. Rapid detox, an alternative form of detox treatment, is gaining in both acceptance and popularity.

PURPOSE

To increase readers' understanding of the neurobiology of addiction and the mode of action of new detox approaches for patients addicted to opiate drugs.

SOURCES

A review of the current literature pertaining to rapid detox.

CONCLUSIONS

Rapid detox is a viable alternative for selected patients attempting to detox from opiate agents of abuse. Increasing knowledge of new treatment approaches allows nurses working to assist addicted patients in planning and receiving treatment based on new awareness of the neurobiology of addiction.

The physical and psychosocial consequences of opioid addiction: an overview of changes in opioid treatment

This paper examines a selection of the current literature to gain information concerning opioids, addiction profiles, public opinion, legal issues and withdrawal protocols. Hundreds of Australians have died at a young age due to the complications of their own opioid misuse. This paper outlines what has been achieved in recent times in the management of people withdrawing from opioid misuse, as well as reviewing the new evidence that offers hope for faster opioid withdrawal and rehabilitation.

Alcohol withdrawal in critical care

Alcohol withdrawal syndrome can be fatal if not recognized and treated immediately. An estimated 10% to 50% of hospitalized patients abuse alcohol, and they may develop withdrawal syndrome during hospitalization. However, nurses can successfully treat alcohol withdrawal syndrome, even in critically ill patients, with benzodiazepines, the treatment of choice.

Managing alcohol withdrawal in the acutely ill hospitalized adult

Managing individuals with acute illness who are at high risk for alcohol withdrawal presents multiple challenges to the treatment teams caring for them. Following realization that management of this group was often characterized by severe withdrawal symptoms (delirium tremens, seizures and the need for leather restraints), a Task Force developed protocols to guide care. Its principal goal was to avoid cardiorespiratory and neurologic morbidities associated with severe withdrawal. The first 441 episodes of care treated after protocol implementation are described in this report. There were no instances of oversedation requiring pharmacological reversal or intubation, few individuals suffered seizures outside of the emergency department and the use of leather restraints declined dramatically. Outstanding issues arising from analysis include the necessity of subjecting the symptom severity instrument to rigorous psychometric study and reconsideration of the appropriateness of a symptom-triggered approach in treating this population. Our experience suggests that use of a nonprescriptive approach by educated and motivated nursing and medical staffs can reduce serious morbidity in this at-risk population.

A procedure for withdrawal of sleep medication in elderly women who have been long-term users

A program for withdrawal of sedative/hypnotic medication was investigated in elderly women, ages 64 to 91. The sleep cycles of 10 drug withdrawal (DW) and 10 non-drug withdrawal (N-DW) subjects were monitored for a 24-hour period for 5 successive weeks, using a nonintrusive recording procedure. The first 2 baseline weeks were followed by 1 week of half-dose, then 2 weeks of full withdrawal for the DW group. The results indicated no demonstrable effect on sleep, sleep complaints, levels of depression, or daytime sleepiness on the DW group. The conclusion is that the procedure of withdrawal from sleep medication over a 2-week period, combined with the use of a substitute pill to maintain the ritual of nightly pill-taking, is appropriate and effective for long-term elderly users.

Opioid withdrawal in neonates after continuous infusions of morphine or fentanyl during extracorporeal membrane oxygenation

BACKGROUND

Complications of opioid analgesia include tolerance and withdrawal.

OBJECTIVES

To determine the effects of morphine and fentanyl on the prevalence of withdrawal after extracorporeal membrane oxygenation.

METHODS

Two groups of neonates were compared during and after extracorporeal membrane oxygenation: a prospective group receiving a continuous infusion of morphine for analgesia and sedation and a retrospective group who had received a continuous infusion of fentanyl.

RESULTS

Neonates receiving morphine required significantly less supplemental analgesia (P < .001) than did neonates who had received fentanyl and had a significantly lower prevalence of withdrawal after the therapy (P = .01). Neonates receiving morphine were discharged from the hospital a mean of 9.6 days sooner (P = .01) than neonates who had received fentanyl.

CONCLUSIONS

Morphine may offer marked advantages over fentanyl for providing continuous analgesia and sedation in neonates.

[A new candidate for intensive care: patients undergoing rapid opiate withdrawal, and their care]

Withdrawal from drugs currently is and interesting topic because of the repercussions it has on different aspects of life, particularly: health, work, family and social relationships, etc. In this article we report a new system for minimizing the adverse effects of withdrawal from opiates (which usually are prolonged), and for carrying out withdrawal as quickly and effectively as possible. A protocol is described in detail, as well as special nursing care. This protocol is called ultrashort withdrawal (24 hours) and it has been developed and used in the intensive care department of the General University Hospital of Murcia (Spain), in collaboration with the center's hospital detoxification unit.

Treating acute withdrawal from alcohol and other drugs

The withdrawal syndrome is the predictable constellation of signs and symptoms that follow abrupt discontinuation of, or rapid decrease in, the use of a substance that has been used consistently over a period of time. To manage the withdrawal syndrome in a way that is safe and humane for the patient, the nurse must understand the pharmacological principles underlying the drug use. Whereas supportive nursing care is often effective, many patients require some pharmacotherapy. Rating scales for assessing signs and symptoms of withdrawal and for placing patients in the most appropriate setting can be used to guide the clinical decision making process. The treatment of withdrawal should provide a link to other services that promote the recovery process.

Development of an alcohol withdrawal clinical pathway: an interdisciplinary process

Studies show that as many as 40 percent of all patients in general hospitals are admitted because of complications related to alcoholism. However, the literature has little in specific clinical pathways, treatment protocols, or guidelines for the interdisciplinary care of these patients in the acute care setting. Furthermore, the little information that is published shows a lack of consistency in recommended treatment regimes. This article reviews a coordinated, interdisciplinary effort in developing and implementing a clinical pathway for alcohol withdrawal.