Will this patient go into severe alcohol withdrawal?

bottle in bag

New research from the BC Centre on Substance Use (BCCSU) suggests applying easy and effective tool to identify patients at high risk of going into withdrawal, in efforts to modernize alcohol detox. In a study published in the August issue of the peer-reviewed Journal of American Medical Association, BCCSU researchers used data from approximately 71,295 persons taking part in 14 scientific studies to predict which patient will develop serious complications, including seizures and delirium.

Which patient will go into severe alcohol withdrawal?

From the press release by British Columbia Centre on Substance Use (Aug 28, 2018):

Research sheds light on how to improve diagnosis and treatment of severe alcohol withdrawal syndrome
The treatment of alcohol withdrawal urgently needs to be modernized in order to improve patient outcomes and safety and reduce health care cost, according to new research from the BC Centre on Substance Use (BCCSU).
The study, published today in the Journal of the American Medical Association, involved a multi-year systematic review involving more than 71,000 patients and sought to determine how best to identify the risks of developing severe, complicated alcohol withdrawal – a potentially life-threatening emergency. Those who consume alcohol in quantities above low-risk recommendations may develop this syndrome when they abruptly stop or substantially reduce their alcohol consumption.
Researchers found that patients are commonly over-admitted into inpatient alcohol withdrawal management care, resulting in a poor patient experience and unnecessary health care resource consumption. The review identified highly valid and easily administered screening tools to properly assess symptoms and risks before recommending acute treatment such as withdrawal management, and to look at outpatient care to improve patient outcomes and reduce the burden on the health system.
“Alcohol addiction is not only the most common substance use disorder, it’s among the most devastating in terms of both health impacts and the costs to our health system,” said Dr. Evan Wood, executive director of the BCCSU and lead author of the study. “This study demonstrates that there are more sophisticated tools that the health system should be employing to provide more appropriate care for patients, which will result not only in better outcomes but also free-up resources for high-priority needs.”
According to a study released by the University of Victoria’s Canadian Institute for Substance Use Research (CISUR) and the Canadian Centre on Substance Use and Addiction (CCSA), alcohol use costs Canadians $14.6 billion per year in health care, lost production, criminal justice, and other direct costs – higher than all other substances combined.
B.C. has the highest rate in the country of hospitalizations entirely caused by alcohol, and consumption is rising faster in the province than elsewhere in Canada. Research from the Canadian Institute for Health Information published last year found that British Columbians who use alcohol consume, on average, 9.4 litres of pure alcohol each year —  the equivalent of roughly 14 bottles of beer or two-and-half bottles of wine each week.
“Hospital wards are often filled with individuals suffering the consequences alcohol addiction,” said Dr. Keith Ahamad, a co-author on the study and Medical Director at Vancouver Coastal Health’s Regional Addiction Program. “This study helps identify those who truly need admission and demonstrates that many patients can be better treated as outpatients, even in primary care.”
The BCCSU is funded by the provincial government and is currently developing provincial guidelines for treating alcohol use disorder, expected to be released later this. They will be the first evidence-based guidelines of their kind for the province.

(Text taken from http://www.bccsu.ca/news-releases/)

From: Will This Hospitalized Patient develop Severe Alcohol Withdrawal Syndrome?: The Rational Clinical Examination Systematic Review. JAMA (In Press) JAMA Network: jama.jamanetwork.com

If you’re interested in alcohol, read more about my alcohol research here.

For more information about the study or to schedule an interview, please contact:
Kevin Hollett, BC Centre on Substance Use
778-918-1537
khollett[at]cfenet.ubc.ca

Addiction social work fellowship launched

man and boy

Addiction social work fellowship launched!

Substance use disorders disproportionately contribute to the global social and economic burden of disease.

Sadly, their treatment has been inadequate in large part due to an enduring research to practice gap. Here, the competencies for treating and preventing substance use disorders are often lacking from social work education curricula.

Addiction social work fellowship launched in Canada

Recently, the British Columbia Centre on Substance Use started a new interdisciplinary fellowship in addiction social work, nursing and medicine in Vancouver, Canada. We describe the new fellowship program and outline initial impact of the training on knowledge and skills in addiction social work from our qualitative evaluation of the fellowship.

“The Addiction Social Work Fellowship program accepts two positions in Social Work annually. The program strives for excellence in clinical training, scholarship, research, and advocacy and includes specialty training in inpatient and outpatient addiction services, as well as related concurrent disorders training. The program prepares Fellows to work clinically in the field of addictions and take leadership roles in academic and/or research settings.” (www.bccsu.ca)

 

To read the whole story, please visit the journal website https://www.tandfonline.com/loi/wswp20 or lookup the paper using the following citation:

Callon, C., Reel, B., Bosma, H., Durante, E., Johnson, C., Wood, E., Klimas, J.  (In Press) Addiction Social Work Fellowship in Addiction Medicine: A Novel Programme in a Canadian setting. (Early Online July 30th) Journal of Social Work Practice in the Addictions 

If you enjoyed reading this post, you may also enjoy reading about the fellowship here.

Systematic reviews enhance drugs conference

conference meeting

Systematic reviews are the cream of the research crop. Those who understand their value thrive at an opportunity to meet the review authors at scientific conferences. This year, the annual meeting of the College on Problems of Drug Dependence (CPDD) in San Diego featured several important reviews. Here’s a listing of all the posters presenting reviews from the session on Wednesday, June 13th, 2018.

Overdose

Non-fatal overdose prevalence among people who inject drugs Samantha Colledge (June 11, 2018);

Prescription drug monitoring programs on nonfatal and fatal drug overdoses David Fink;

Gender

Limited inclusion of women in functional neuroimaging studies of opioid-use disorder Hestia Moningka;

Women’s prescription drug misuse Bridgette Peteet;

Gender differences in HIV, anti-HCV and HBsAg prevalence among people who inject Janni Leung;

Services

Case for hospital teams in treatment of opioid use disorders Kelsey Priest;

Addiction-related characteristics of substances users in harm reduction settings Charlotte Kervran;

STDs and injecting

Extremely low HIV incidence among PWID: Terminology, high/middle income settings, methodology, and addressing new outbreaks Don Des Jarlais;

Use of opioids and stimulants by people who inject drugs Amy Peacock;

Factors associated with uptake or willingness to use pre-exposure prophylaxis (PrEP) among people who inject drugs Yohansa Fernández;

Pre-exposure prophylaxis (PrEP) for people who inject drugs? Angela Bazzi;

Cannabis

Cannabis and cannabinoids for the treatment of people with chronic non-cancer pain conditions Emily Stockings;

Medical marijuana laws and adolescent marijuana use in the US Aaron Sarvet;

Does liberalization of cannabis policy influence adolescents’ levels of use? Maria Melchior;

Other topics

Clinical and toxicological profile of NBOMESs Nino Marchi;

Sensation-seeking personality trait and its association to drug seeking behavior in adolescents Thiago Fidalgo.

Systematic reviews cream of the crop from Brazil through Egypt

NIDA International poster session on Monday, June 11, 2018

Three Australians, two North Americans; an Egyptian, African and Brazilian had one poster on systematic review each. Five were meta-analyses.

The Australian reviews dealt with overdose, STDs and injecting:

Nonfatal overdose prevalence among people who inject drugs S. Colledge, (UK, Australia);

Gender differences in HIV, anti-hepatitis C virus, and hepatitis B virus surface antigen prevalence among people who inject drugs J. Leung, (Australia, UK, Portugal);

Use of opioids and stimulants by people who inject drugs: A. Peacock, (Australia);

 

The North-Americans reviewed drug monitoring programmes:

Global review of drug-checking services 2017 L.J. Maier, (California);

Urinalysis frequency and health outcomes for persons on opioid agonist therapy: J. McEachern, (Canada);

 

Anger, brain stimulation and antipsychotics were reviewed too:

Anger in users of psychoactive substances H.V. Laitano, (Brazil);

Noninvasive brain stimulation in addiction medicine A. Elaghoury.(Egypt);

Atypical versus typical antipsychotics for the treatment of addiction: S. Hanu. (Ghana).

With the increasing demands on scientists’ workloads, systematic reviews are an effective way of staying up to date with the most recent developments in the field. See also my previous blog posts about CPDD from the previous years:

 

2017: Dr Wood tells the forum recipe for research-centre success

2016: Changing the ways of CPDD – College on Problems of Drug Dependence – June 12-16, #CPDD2016

2015: Getting the most out of the Conference of the College on Problems of Drugs Dependence #CPDD2015

2014: 76th Annual Conference of College on Problems of Drug Dependence: Decide to be fearless& fabulous 

2013: My itinerary for the Conference – College on Problems of Drug Dependence, San Diego, June 15-20 

Frequent urine testing lacks evidence

testing flasks

Clinicians commonly use urine drug tests to detect or validate self-reported drug use, particularly when beginning and maintaining opioid agonist therapy (for example buprenorphine or methadone). Until now, there has been no clinical consensus on urine drug testing frequency in Canada.

National guidelines for opioid use disorder released: Canadian consensus on urine drug testing frequency

Vancouver, B.C. [March 5, 2018] — “A first of its kind Canadian guideline setting out best practices for treating people with opioid addiction has been released today. The national guideline was based on provincial guidelines developed by the BC Centre on Substance Use (BCCSU) and implemented in British Columbia last year.” This guideline has been federalized and published in the Canadian Medical Association Journal. Health care professionals should follow the new guidelines.

Large Variation in Provincial Guidelines for Urine Drug Tests during Opioid Agonist Treatment

Before the new guidelines, each province had their own guidelines for treating opioid addiction. At that time, there was no summary of the published clinical practice guidelines for urine drug tests in Canada. Also, no one measured the consistency with which different provinces suggested administering drug screening. In June 2017, the American Society of Addiction Medicine released the national consensus document for appropriate use of drug testing.

Therefore, we looked at all policies and guidelines for Urine drug screening in Canada, examining the published clinical practice guidelines for each Canadian province and extracting all relevant data in March 2017. Our recent provincial guideline and policy scan found that urine drug screening frequency recommendations vary greatly among Provinces for persons receiving opioid agonist therapy for opioid addiction.

To read the whole story, please visit the journal website www.canadianjournalofaddiction.org or lookup the paper using the following citation:

Moss, E., McEachern, J., Adye-White, L., Priest, K., Gorfinkel, L., Wood, E., Cullen, W., Klimas, J. (2018) Large Variation in Provincial Guidelines for Urine Drug Screening during Opioid Agonist Treatment in Canada.  Canadian Journal of Addiction, 9(2):6-9

If you enjoyed reading this post, you may also enjoy reading similar posts about methadone treatment.

The opioids and addiction mismatch

hammer and spanner mismatch

Will an increasing pressure on prescribers curb the rising opioid overdose rates?

With only 0.5% of patients prescribed opioids reportedly developing addictions, there must be something else going on that’s making people overdose. A mismatch. Research on this topic is messy and patchy–– simply put, the large correlational research and incidence studies of addiction do not match up. In a recent commentary, we outline how prescription opioids might indirectly influence the rising overdose and addiction rates.

Mismatch: Why Correlation and Incidence Might Not Match Up

First, diversion gets medically prescribed opioids (MPOs) to those who are not prescribed the medication. Diverted MPOs can be sold, gifted (mostly to family members or friends), stolen, or sometimes obtained through “doctor shopping”, where patients get the same prescription from multiple physicians. But we don’t know how much diversion is due to sold, gifted or stolen medicines. How much do the different diversion types contribute to addiction and overdose? And for that matter, how much is diversion occurring, and to what extent is it contributing to national opioid crises?

We need to start accepting that biological factors are a part of this picture

Second, because overdose is often preceded by addiction, many researchers have focused on the persons who develop an addiction when prescribed opioids. However, if addiction doesn’t come before overdose, some high-risk patients go unstudied, and thus unreported. This has been shown in some states, such as West Virginia, where prescription opioids contributed to 93% of overdose deaths and very few of the deceased had iatrogenic addiction. So, some people might be at risk of sudden overdose but are missed in research studies that focus on medical diagnoses of addiction. This gap in the research is likely due the difficulty of studying overdose risk without the presence of addiction.

Polydrug use and overdose

Third, polydrug use may lead to overdose in people who use prescription opioids but do not specifically have addiction to their MPO. Here benzodiazepines are a big issue. It is important to note that many studies of addiction to MPOs do account for polydrug use by incorporating urine drug screens; however, positive results are often lumped together with other “aberrant” behaviours such as failed pill counts or requesting opioids from multiple doctors. Ultimately,  we can’t tell how much polydrug use is really leading to addiction or overdose in this context.

Finally, it is possible that incidence studies to date could be misrepresenting the true risk of addiction to MPOs. Studies of OUD incidence in pain care use definitions of addiction that range from very broad to highly specific, mixing up terms like “dependence”, “abuse”, “misuse”, or “problematic use”. This could make it so our guesses about the risk of addiction to MPOs are muddled, leading to skewed results.

We need to understand better if reduced opioid prescriptions can reduce the opioid crisis. Then we can make the change happen.

To read the whole commentary, please visit the journal website www.canadianjournalofaddiction.org or lookup the paper using the following citation:

Gorfinkel, L., Wood, E., Klimas, J. (In Press) Prescription opioids, opioid use disorder, and Overdose Crisis: Current Dilemmas and Remaining Questions. (Published ahead of Print, June 4th) Canadian Journal on Addiction

I thank Lauren Gorfinkel for feedback on this post.

If you enjoyed reading this post, you may also like my poem about pain. See link below: