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Rhode Island Medical Journal (2013) Jul 2024This study examined if emergency department (ED) operational metrics, such as wait time or length of stay, are associated with interest in substance use disorder (SUD)... (Observational Study)
Observational Study
OBJECTIVE
This study examined if emergency department (ED) operational metrics, such as wait time or length of stay, are associated with interest in substance use disorder (SUD) treatment referral among patients at high risk of opioid overdose.
METHODS
In this observational study, 648 ED patients at high risk of opioid overdose completed a baseline questionnaire. Operational metrics were summarized using electronic health record data. The association between operational metrics and treatment interest was estimated with multivariable logistic regression.
RESULTS
Longer time to room (adjusted odds ratio [AOR]=1.12, 95% confidence interval [CI]=1.01-1.25) and length of stay (AOR=1.02, 95% CI=1.00-1.05) were associated with treatment referral interest. Time to provider and number of treating providers showed no significant association.
CONCLUSION
Longer rooming wait times and longer ED visits were associated with increased SUD treatment referral interest. This suggests patients who wait for longer periods may be motivated for treatment and warrant further resource investment.
Topics: Humans; Emergency Service, Hospital; Rhode Island; Female; Male; Adult; Middle Aged; Referral and Consultation; Length of Stay; Substance-Related Disorders; Surveys and Questionnaires; Opioid-Related Disorders; Drug Overdose; Young Adult; Time Factors; Logistic Models
PubMed: 38917311
DOI: No ID Found -
JAMA Network Open Jun 2024Fentanyl has exacerbated the opioid use disorder (OUD) and opioid overdose epidemic. Data on the effectiveness of medications for OUD among patients using fentanyl are... (Randomized Controlled Trial)
Randomized Controlled Trial
IMPORTANCE
Fentanyl has exacerbated the opioid use disorder (OUD) and opioid overdose epidemic. Data on the effectiveness of medications for OUD among patients using fentanyl are limited.
OBJECTIVE
To assess the effectiveness of sublingual or extended-release injection formulations of buprenorphine for the treatment of OUD among patients with and without fentanyl use.
DESIGN, SETTING, AND PARTICIPANTS
Post hoc analysis of a 24-week, randomized, double-blind clinical trial conducted at 35 outpatient sites in the US from December 2015 to November 2016 of sublingual buprenorphine-naloxone vs extended-release subcutaneous injection buprenorphine (CAM2038) for patients with OUD subgrouped by presence vs absence of fentanyl or norfentanyl in urine at baseline. Study visits with urine testing occurred weekly for 12 weeks, then 6 times between weeks 13 and 24. Data were analyzed on an intention-to-treat basis from March 2022 to August 2023.
INTERVENTION
Weekly and monthly subcutaneous buprenorphine vs daily sublingual buprenorphine-naloxone.
MAIN OUTCOMES AND MEASURES
Retention in treatment, percentage of urine samples negative for any opioids (missing values imputed as positive), percentage of urine samples negative for fentanyl or norfentanyl (missing values not imputed), and scores on opiate withdrawal scales and visual analog craving scales.
RESULTS
Of 428 participants, 123 (subcutaneous buprenorphine, n = 64; sublingual buprenorphine-naloxone, n = 59; mean [SD] age, 39.1 [10.8] years; 75 men [61.0%]) had evidence of baseline fentanyl use and 305 (subcutaneous buprenorphine, n = 149; buprenorphine-naloxone, n = 156; mean [SD] age, 38.1 [11.1] years; 188 men [61.6%]) did not have evidence of baseline fentanyl use. Study completion was similar between the fentanyl-positive (60.2% [74 of 123]) and fentanyl-negative (56.7% [173 of 305]) subgroups. The mean percentage of urine samples negative for any opioid were 28.5% among those receiving subcutaneous buprenorphine and 18.8% among those receiving buprenorphine-naloxone in the fentanyl-positive subgroup (difference, 9.6%; 95% CI, -3.0% to 22.3%) and 36.7% among those receiving subcutaneous buprenorphine and 30.6% among those receiving buprenorphine-naloxone in the fentanyl-negative subgroup (difference, 6.1%; 95% CI, -1.9% to 14.1%), with significant main associations of baseline fentanyl status and treatment group. In the fentanyl-positive subgroup, the mean percentage of urine samples negative for fentanyl during the study was 74.6% among those receiving subcutaneous buprenorphine vs 61.9% among those receiving sublingual buprenorphine-naloxone (difference, 12.7%; 95% CI, 9.6%-15.9%). Opioid withdrawal and craving scores decreased rapidly after treatment initiation across all groups.
CONCLUSIONS AND RELEVANCE
In this post hoc analysis of a randomized clinical trial of sublingual vs extended-release injection buprenorphine for OUD, buprenorphine appeared to be effective among patients with baseline fentanyl use. Patients with fentanyl use had fewer opioid-negative urine samples during the trial compared with the fentanyl-negative subgroup. These findings suggest that the subcutaneous buprenorphine formulation may be more effective at reducing fentanyl use.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT02651584.
Topics: Humans; Opioid-Related Disorders; Fentanyl; Male; Female; Administration, Sublingual; Adult; Double-Blind Method; Buprenorphine; Middle Aged; Delayed-Action Preparations; Injections, Subcutaneous; Narcotic Antagonists; Analgesics, Opioid; Opiate Substitution Treatment; Buprenorphine, Naloxone Drug Combination; Treatment Outcome
PubMed: 38916892
DOI: 10.1001/jamanetworkopen.2024.17377 -
Medizinische Klinik, Intensivmedizin... Jun 2024Direct oral anticoagulants (DOAC) are increasingly used for prophylaxis and treatment of thromboembolic events. Incorrectly dosed DOAC treatment is associated with... (Review)
Review
BACKGROUND
Direct oral anticoagulants (DOAC) are increasingly used for prophylaxis and treatment of thromboembolic events. Incorrectly dosed DOAC treatment is associated with excess mortality.
PURPOSE
This article aims at raising awareness of DOAC overdosing and its causes as well as presenting a diagnostic and therapeutic work-up.
MATERIAL AND METHODS
Based on a case presentation, a structured review of the current literature on DOAC overdosing was performed and treatment recommendations were extracted.
RESULTS
In addition to wittingly or unwittingly increased DOAC intake, common causes of overdose are inadequate dose adjustment for concomitant medication or comorbidities. Global coagulation testing should be supplemented with DOAC-specific testing. Severe bleeding and the need for invasive diagnostics or urgent surgery represent indications for treating DOAC overdoses. Based on the cause of an DOAC overdose, active charcoal, endoscopic pill rescue, antagonization with idarucizumab or andexanet alfa and the targeted substitution of coagulation factors represent treatment options.
CONCLUSION
The sensitization of clinicians is important to ensure a timely diagnosis and adequate treatment of DOAC overdosing. This report provides an overview of current knowledge on diagnostics and treatment; however, further studies are necessary to improve the existing algorithms.
PubMed: 38916655
DOI: 10.1007/s00063-024-01154-8 -
Cureus Jun 2024Bupropion is an antidepressant used in the treatment of major depressive disorder, seasonal affective disorder, nicotine addiction, and weight loss. It primarily...
Bupropion is an antidepressant used in the treatment of major depressive disorder, seasonal affective disorder, nicotine addiction, and weight loss. It primarily functions via norepinephrine and dopamine reuptake inhibition. At toxic doses, bupropion can elicit seizures, as well as precipitate corrected QT interval (QTc) and QRS prolongation. We describe a case of an 18-year-old female who reportedly ingested 28 grams of extended-release bupropion, a dose much higher than in previously reported cases. Toxic ingestion precipitated status epilepticus, prolonged QTc, widened QRS, pulseless ventricular tachycardia (pVT), and subsequent cardiovascular collapse necessitating veno-arterial extracorporeal membrane oxygenation (ECMO) and Impella support. Historically, the cardiotoxic effects of bupropion toxicity have largely been treated with supportive care, sometimes requiring ECMO. This patient's course was complicated by a widening QRS despite aggressive bicarbonate therapy and recurrent pVT, which was ultimately aborted with lidocaine. Neurological prognostication was further complicated by a lack of brainstem reflexes on the exam. With maximal supportive care, the patient was liberated from Impella, ECMO, and the ventilator by hospital day seven. At discharge, she was neurologically intact with full recovery of cardiac function. This case emphasizes the need for early consideration of transfer to an ECMO center in the setting of a bupropion overdose and offers a potentially effective treatment option for bupropion-induced ventricular arrhythmia.
PubMed: 38915842
DOI: 10.7759/cureus.62873 -
Journal of the American Pharmacists... Jun 2024Fentanyl test strips (FTS) are used to detect the presence of fentanyl in other substances, but Alabama pharmacists' opinions regarding FTS provision are unknown.
BACKGROUND
Fentanyl test strips (FTS) are used to detect the presence of fentanyl in other substances, but Alabama pharmacists' opinions regarding FTS provision are unknown.
OBJECTIVE
The purpose of this study was to assess the knowledge and perceptions of Alabama pharmacists regarding FTS and factors influencing pharmacists' FTS provision intentions across community pharmacy locations and types.
METHODS
An anonymous cross-sectional survey was distributed via email to Alabama pharmacists employed in community (retail) pharmacies. The survey consisted of multiple-choice questions and 5-point Likert-type scales (1=strongly disagree, 5=strongly agree) informed by the Theory of Planned Behavior. Primary outcome measures included: knowledge; general attitudes; perceived benefits; perceived barriers; self-efficacy; subjective norms; perceived behavioral control (PBC); and intention regarding FTS provision. Outcomes were characterized using descriptive statistics and differences in scales scores across pharmacy locations (rural versus urban) and types (corporately- versus independently-owned) were assessed using Mann-Whitney U tests. Predictors of FTS provision intentions were evaluated using multiple linear regression (alpha=0.05).
RESULTS
Respondents (N=131; 3.82% response rate) were mostly female (64%) and Caucasian (92%). No respondents stocked FTS at their pharmacy and knowledge about FTS was low (mean[SD] knowledge score: 58.7%[15.1]). Despite the existence of perceived barriers (mean[SD] scale score: 3.2[0.6]), pharmacists' general attitudes (3.4[0.5]), perceived benefits (3.7[0.6]), self-efficacy (3.1[0.8]), and intentions (3.2[0.7]) were positive. While subjective norms were positive (3.5[0.6]), PBC over FTS decision-making was negative (2.7[0.8]). Subjective norms were higher (p=0.040) and PBC was lower (p<0.001) amongst corporately- versus independently-owned pharmacies, but no differences existed between rural and urban locations for any measures. Additionally, perceived benefits (β=0.342, p=0.002), PBC (β=0.133, p=0.045), and self-efficacy (β=0.142, p=0.034) were positive predictors and perceived barriers (β=-0.211, p=0.029) was a negative predictor of intention.
CONCLUSION
Alabama community pharmacists have positive attitudes regarding FTS, but future research should focus on strategies to increase PBC and overcome perceived barriers.
PubMed: 38914293
DOI: 10.1016/j.japh.2024.102148 -
Journal of Addiction Medicine Jun 2024We aimed to determine the prevalence of self-reported naloxone use during pregnancy among people in the United States with a recent live birth. A secondary objective was...
OBJECTIVES
We aimed to determine the prevalence of self-reported naloxone use during pregnancy among people in the United States with a recent live birth. A secondary objective was to characterize people at increased risk of overdose who did and did not use naloxone.
METHODS
We analyzed data from the Pregnancy Risk Assessment Monitoring System from 26 US jurisdictions that conducted an opioid supplement survey from 2019 to 2020. Respondents with increased risk of experiencing an opioid overdose were identified based on self-reported use of illicit amphetamines, heroin, cocaine, or receiving medication for opioid use disorder (MOUD) during pregnancy. Weighted prevalence estimates and 95% confidence intervals were calculated for reported naloxone use at any point during pregnancy among people with an increased risk of overdose.
RESULTS
Naloxone use during pregnancy was reported by <1% of the overall study population (unweighted N = 88/34,528). Prevalence of naloxone use was 5.0% (95% CI: 0.0-10.6) among respondents who reported illicit amphetamine use, 15.2% (1.8-28.6) among those who reported heroin use, and 17.6% (0.0-38.1) among those who reported cocaine use. Naloxone use was 14.5% (8.4-20.6) among those who reported taking MOUD. Among people with increased risk of overdose, no significant differences in naloxone use were observed by age, race/ethnicity, education level, residential metropolitan status, or insurance status.
CONCLUSIONS
Prevalence of naloxone use among people with an increased risk of overdose during pregnancy ranged from 5.0% to 17.6%. Access to naloxone, overdose prevention education, and treatment for substance use disorders may help reduce morbidity and mortality.
PubMed: 38912696
DOI: 10.1097/ADM.0000000000001337 -
Journal of Addiction Medicine Jun 2024Our study evaluated if rapid inpatient titration of methadone for pregnant patients with opioid use disorder (OUD) improved outcomes without increasing the risk for...
OBJECTIVES
Our study evaluated if rapid inpatient titration of methadone for pregnant patients with opioid use disorder (OUD) improved outcomes without increasing the risk for overdose.
METHODS
This is a retrospective cohort study of pregnant patients admitted for inpatient methadone titration from January 2020 to June 2022. Outcomes were compared between standard versus rapid titration protocols. Standard titration involved an initial methadone dose with additional doses every 6 hours if clinical opiate withdrawal score (COWS) is >9. Rapid titration involved an initial methadone dose with additional doses every 4 hours if COWS is >9. The primary outcome was time required to achieve stable dose. Secondary outcomes included elopement prior to achieving stable dose, methadone-related readmission, opioid overdose, and final dose.
RESULTS
There were 97 patients in the standard titration (STP) and 97 patients in the rapid titration (RTP) groups. Demographic characteristics and substance use history did not differ between the 2 groups. Time to stable dose did not differ between the 2 groups (RTP, 5.0 days ±4.0; STP, 4.0 days ±3.0; P = 0.08). Patients in the rapid titration group were less likely to elope from the hospital prior to stabilization (RTP 23.0% vs STP 37.9%, P = 0.03) and had fewer methadone-related readmissions (P < 0.001). One patient (1.0%) in the RTP group required naloxone treatment while inpatient for concern for overdose, while none did in the STP group (P = 0.32). There was no difference in median final stable dose between the 2 groups (P = 0.07).
CONCLUSIONS
Rapid titration of methadone for pregnant patients with OUD was associated with decreased medical elopement and methadone-related readmission, without increasing the risk for overdose.
PubMed: 38912695
DOI: 10.1097/ADM.0000000000001339 -
Substance Use & Addiction Journal Jun 2024Treatment for substance use disorders (SUD) remains low in the United States. To better meet needs of people who use alcohol and other drugs, low threshold bridge...
BACKGROUND
Treatment for substance use disorders (SUD) remains low in the United States. To better meet needs of people who use alcohol and other drugs, low threshold bridge clinics which offer treatment without barrier and harm reduction services have gained prevalence. Bridge clinics work to surmount barriers to care by providing same day medication and treatment for SUD and eventually transitioning patients to community-based treatment providers. In this study, we examine SUD treatment outcomes among patients who transitioned out of a bridge clinic.
METHODS
This is a retrospective cohort study of posttreatment outcomes of patients seen at an urban medical center's bridge clinic between 2017 and 2022. The primary outcome was being in care anywhere at time of follow-up. We also examined the proportion of patients who completed each step of the cascade of care following transfer: connection to transfer clinic, completion of a clinic visit, retention in care, and medication use among those remaining in care at the transfer clinic. We examined the association of different bridge clinic services with still being in care anywhere and the association between successful transfer with being in care and taking medication at follow-up.
RESULTS
Of 209 eligible participants, 63 were surveyed. Sixty-five percent of participants identified as male, 74% as white, 12% as Hispanic, 6% as Black, and 16% were unhoused. Most participants (78%) reported being connected to SUD treatment from the Bridge Clinic, and 37% remained in care at the same facility at the time of survey. Eighty-four percent reported being in treatment anywhere and 68% reported taking medication for SUD at follow-up, with most participants reporting taking buprenorphine (46%).
CONCLUSION
Of those participants who transitioned out of a bridge clinic into community-based SUD care, 78% were successfully connected to ongoing care and 84% were still in care at follow-up.
PubMed: 38912689
DOI: 10.1177/29767342241261609 -
Journal of Addiction Medicine Jun 2024The opioid intervention court (OIC) is an innovative, pre-plea treatment court to facilitate rapid linkage to medications for opioid use disorder (MOUD) for people at...
OBJECTIVE
The opioid intervention court (OIC) is an innovative, pre-plea treatment court to facilitate rapid linkage to medications for opioid use disorder (MOUD) for people at risk of overdose. This study compares participants in OIC and participants with opioid use problems in a traditional drug treatment court model on (i) initiation for any substance use (SU) treatment, (ii) initiation of MOUD, (iii) number of days to MOUD initiation, and (iv) retention in the OIC program/retention on MOUD.
METHODS
We used administrative court records from n = 389 OIC and n = 229 drug court participants in 2 counties in New York State. Differences in outcomes by court were assessed using logistic, multinomial, or linear regressions.
RESULTS
After adjusting for current charge severity, gender, race/ethnicity, age, and county, OIC participants were no more likely to initiate any SU treatment but were significantly more likely to initiate MOUD (81.2% OIC vs 45.9% drug court, P < 0.001) and were more quickly linked to any SU treatment (hazard ratio = 1.68, 95% confidence interval = 1.35-2.08) and MOUD (hazard ratio = 4.25, 95% confidence interval = 3.23-5.58) after starting the court. Retention in court/MOUD was higher among drug court participants and may speak to the immediate sanctions (eg, jail) for noncompliance with drug court directives as compared with opioid court, which does not carry such immediate sanctions for noncompliance.
CONCLUSIONS
These analyses suggest that the new OIC model can more rapidly link participants to treatment, including MOUD, as compared with traditional drug court model, and may demonstrate improved ability to immediately stabilize and reduce overdose risk in court participants.
PubMed: 38912685
DOI: 10.1097/ADM.0000000000001330 -
Cureus May 2024Sertraline hydrochloride belongs to the selective serotonin reuptake inhibitor class of antidepressants, which can cause respiratory depression, hypotension, malignant...
Sertraline hydrochloride belongs to the selective serotonin reuptake inhibitor class of antidepressants, which can cause respiratory depression, hypotension, malignant vomiting, liver function impairment, and other symptoms when taken in excess. To our knowledge, reports of sertraline hydrochloride overdose causing diabetes insipidus in patients are rare. This report describes a unique case of a 17-year-old female patient who developed diabetes insipidus after a one-time oral intake of 20 sertraline hydrochloride tablets (50 mg/tablet) during the later course of treatment. Her symptoms were effectively relieved after treatment with pituitrin.
PubMed: 38910706
DOI: 10.7759/cureus.60952