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Deptola S, Hemmann B, Hemmelgarn T, DiPaola K, Cortezzo DE. Propofol Sedation Washouts in Critically Ill Infants: A Case Series. J Pediatr Pharmacol Ther 2023; 28:354-364. [PMID: 37795284 PMCID: PMC10547045 DOI: 10.5863/1551-6776-28.4.354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/29/2022] [Indexed: 10/06/2023]
Abstract
Medically complex infants are experiencing longer hospital stays, more invasive procedures, and increasingly involved therapeutic interventions that often require long-term analgesia and sedation. This is most commonly achieved with continuous intravenous infusions of opioids and benzodiazepines. There are times when patients develop a tolerance for these medications or the clinical scenario necessitates a rapid wean of them. A rapid wean of either class of medication can lead to increased signs of pain and agitation or withdrawal symptoms. As a result, when a rapid wean is needed or there has been a failure to control symptoms with conventional measures, alternative therapies are considered. Propofol, a sedative hypnotic typically used for general anesthesia and procedural sedation, is one such medication. It has effectively been used for short-term sedation in adults and children to facilitate weaning benzodiazepines and opioids. There is a paucity of data on the use of propofol in infants for this purpose. Here we describe the use of propofol to rapidly wean high-dose sedation and analgesia medications, a propofol sedation washout, in 3 infants. The washouts proved to be safe and efficacious. Based on institutional experience and a literature review, considerations and recommendations are made for propofol sedation washouts in infants.
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Affiliation(s)
- Stephen Deptola
- Division of Pharmacy (SD, BH, TH, KD), Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Brianna Hemmann
- Division of Pharmacy (SD, BH, TH, KD), Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Trina Hemmelgarn
- Division of Pharmacy (SD, BH, TH, KD), Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Kyle DiPaola
- Division of Pharmacy (SD, BH, TH, KD), Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - DonnaMaria E. Cortezzo
- Division of Neonatology and Pulmonary Biology (DEC), Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Division of Pain and Palliative Medicine (DEC), Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics (DEC), University of Cincinnati College of Medicine, Cincinnati, Ohio
- Department of Anesthesiology (DEC), University of Cincinnati College of Medicine, Cincinnati, Ohio
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2
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Stuart Bradley E, Liss D, Pepper Carreiro S, Brush DE, Babu K. Potential uses of naltrexone in emergency department patients with opioid use disorder. Clin Toxicol (Phila) 2019; 57:753-759. [PMID: 30831039 PMCID: PMC6908461 DOI: 10.1080/15563650.2019.1583342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 01/21/2019] [Accepted: 01/25/2019] [Indexed: 10/27/2022]
Abstract
Introduction: Despite widespread recognition of the opioid crisis, opioid overdose remains a common reason for Emergency Department (ED) utilization. Treatment for these patients after stabilization often involves the provision of information for outpatient treatment options. Ideally, an ED visit for overdose would present an opportunity to start treatment for opioid use disorder (OUD) immediately. Although widely recognized as effective, opioid agonist therapy with methadone and buprenorphine commonly referred to as "medication-assisted therapy" but more correctly as "medication for addiction treatment" (MAT), can be difficult to access even for motivated individuals due to shortages of prescribers and treatment programs. Moreover, opioid agonist therapy may not be appropriate for all patients, as many patients who present after overdose are not opioid dependent. More treatment options are required to successfully match patients with diverse needs to an optimal treatment plan in order to avoid relapse. Naltrexone, a long-acting opioid antagonist, available orally and as a monthly extended-release intramuscular injection, may represent another treatment option. Methods: We conducted a literature search of MEDLINE and PubMed. We aimed to capture references related to naltrexone and is use as MAT for OUD, as well as manuscripts that discussed naltrexone in comparison toother agents used for MAT, opioid detoxification, and naltrexone metabolism. Our initial search logic returned a total of 618 articles. Following individual evaluation for relevance, we selected 65 for in-depthreview. Manuscripts meeting criteria were examined for citations meriting further review, leading to the addition of 30 manuscripts Conclusions: Here, we review the pharmacology of naltrexone as it relates to OUD, its history of use, and highlight recent studies and new approaches for use of the drug as MAT including its potential initiation after ED visit for opioid overdose.
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Affiliation(s)
- Evan Stuart Bradley
- Department of Emergency Medicine, Division of Medical Toxicology, University of Massachusetts Medical School and Umass Memorial Medical Center, Worcester, MA, USA
| | - David Liss
- Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Stephanie Pepper Carreiro
- Department of Emergency Medicine, Division of Medical Toxicology, University of Massachusetts Medical School and Umass Memorial Medical Center, Worcester, MA, USA
| | - David Eric Brush
- Department of Emergency Medicine, Division of Medical Toxicology, University of Massachusetts Medical School and Umass Memorial Medical Center, Worcester, MA, USA
| | - Kavita Babu
- Department of Emergency Medicine, Division of Medical Toxicology, University of Massachusetts Medical School and Umass Memorial Medical Center, Worcester, MA, USA
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Franchitto N, Jullian B, Salles J, Pelissier F, Rolland B. Management of precipitated opiate withdrawal syndrome induced by nalmefene mistakenly prescribed in opiate-dependent patients: a review for clinicians. Expert Opin Drug Metab Toxicol 2017; 13:669-677. [DOI: 10.1080/17425255.2017.1312340] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Nicolas Franchitto
- Service d’Addictologie, Centre Hospitalo-Universitaire Toulouse-Purpan, Toulouse, France
- Centre Antipoison et de Toxicovigilance, Centre Hospitalo-Universitaire Toulouse-Purpan, Toulouse, France
- Institut National de la Santé et de la Recherche Médicale (INSERM) UMR 1027, Université Paul Sabatier, Toulouse, France
| | - Benedicte Jullian
- Service d’Addictologie, Centre Hospitalo-Universitaire Toulouse-Purpan, Toulouse, France
| | - Juliette Salles
- Service d’Addictologie, Centre Hospitalo-Universitaire Toulouse-Purpan, Toulouse, France
| | - Fanny Pelissier
- Centre Antipoison et de Toxicovigilance, Centre Hospitalo-Universitaire Toulouse-Purpan, Toulouse, France
| | - Benjamin Rolland
- Département de Psychiatrie et d'Addictologie, Centre Hospitalo-Universitaire Lille, Lille, France
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Mai J, Franklin G, Tauben D. Guideline for Prescribing Opioids to Treat Pain in Injured Workers. Phys Med Rehabil Clin N Am 2016; 26:453-65. [PMID: 26231959 DOI: 10.1016/j.pmr.2015.04.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Recently, there has been a dramatic increase in the use of opioids to treat chronic noncancer pain. Opioids are also being prescribed in stronger potencies and larger doses for musculoskeletal injuries. In some cases, the use of opioids for work-related injuries may actually increase the likelihood of disability. Chronic opioid use is associated with increased risk for overdose morbidity and mortality and other nonfatal adverse outcomes. The risk of dependence and addiction is much more common than previously thought. This guideline provides recommendations for prudent opioid prescribing and addresses issues critical to the care and rehabilitation of injured workers.
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Affiliation(s)
- Jaymie Mai
- Washington State Department of Labor and Industries, Olympia, WA, USA
| | - Gary Franklin
- Washington State Department of Labor and Industries, Olympia, WA, USA; Department of Environmental Health, Neurology and Health Services, University of Washington, Seattle, WA, USA.
| | - David Tauben
- Division of Pain Medicine, Anesthesia and Pain Medicine, University of Washington Medical Center, University of Washington, Seattle, WA, USA
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5
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Forozeshfard M, Hosseinzadeh Zoroufchi B, Saberi Zafarghandi MB, Bandari R, Foroutan B. Six-month follow-up study of ultrarapid opiate detoxification with naltrexone. INTERNATIONAL JOURNAL OF HIGH RISK BEHAVIORS & ADDICTION 2014; 3:e20944. [PMID: 25741479 PMCID: PMC4331657 DOI: 10.5812/ijhrba.20944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 07/20/2014] [Accepted: 08/03/2014] [Indexed: 11/16/2022]
Abstract
Background: Illicit opiate use has an increasing incidence and prevalence, which increases mortality and morbidity, marginalization, and criminal behaviors, and causes major adverse effects on society. Objectives: This study aimed to investigate and follow the outcome of patients who underwent ultrarapid opiate detoxification (UROD) prospectively. Patients and Methods: In this randomized clinical trial, 64 patients who underwent UROD were evaluated. The opiate antagonist regimen of naloxone was administered intravenously under general anesthesia, and detoxification was confirmed by naloxone challenge test. All patients were cared in intensive care unit (ICU) for 24 hours, and oral naltrexone was prescribed the next day, after recovery and discharge. Patients were followed up for one month after the procedure. Relapse was considered if routine use of opiates (daily use for at least two weeks) was reported by the patient after detoxification. The data was analyzed by SPSS 16.5 and the study was performed using descriptive analysis and Chi square test. Results: All 64 participants were opiate-dependent males (ASA physical status of I or II) who aged over 18 years with a mean age of 31.11 ± 8.93 years at the time of UROD. One month after UROD, 48 patients (75%) reported relapse and 16 (25%) reported abstinence; however, four patients of the non-relapsed group reported one episode of opiate use. There was no significant difference between relapsed and non-relapsed patients regarding their marital status, level of education, and family history of opiate dependency (P > 0.05). Conclusions: Although UROD by naloxone is a safe and effective method of detoxification, if used alone, it has a very high relapse rate in long term.
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Affiliation(s)
- Mohammad Forozeshfard
- Department of Anesthesia and Critical Care, Semnan University of Medical Sciences, Semnan, IR Iran
| | - Babak Hosseinzadeh Zoroufchi
- Department of Anesthesia and Critical Care, Semnan University of Medical Sciences, Semnan, IR Iran
- Corresponding author: Babak Hosseinzadeh Zoroufchi, Department of Anesthesia and Critical Care, Amir Hospital, Semnan University of Medical Sciences, Semnan, IR Iran. Tell: +98-9121481098, Fax: +98-2333437849, E-mail:
| | | | - Razieh Bandari
- Research Center for Social Determinants of Health, Semnan University of Medical Sciences, Semnan, IR Iran
| | - Behzad Foroutan
- Department of Pharmacology, School of Medicine, Shahroud University of Medical Sciences, Shahroud, IR Iran
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6
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Salimi A, Safari F, Mohajerani SA, Hashemian M, Kolahi AA, Mottaghi K. Long-Term Relapse of Ultra-Rapid Opioid Detoxification. J Addict Dis 2014; 33:33-40. [DOI: 10.1080/10550887.2014.882727] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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7
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Yassini Ardekani SM, Yassini Ardekani S. Ultrarapid Opioid Detoxification: Current Status in Iran and Controversies. INTERNATIONAL JOURNAL OF HIGH RISK BEHAVIORS AND ADDICTION 2013; 2:96-9. [PMID: 24971284 PMCID: PMC4070154 DOI: 10.5812/ijhrba.13140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Revised: 09/10/2013] [Accepted: 09/23/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Seyyed Mojtaba Yassini Ardekani
- Department of Psychiatry, Yazd Shahid Sadoughi University of Medical Sciences, Yazd, IR Iran
- Corresponding author: Seyyed Mojtaba Yassini Ardekani, Department of Psychiatry, Yazd Shahid Sadoughi University of Medical Sciences, Yazd, IR Iran. Tel: +98-3516292300, Fax: +98-3516238080, E-mail:
| | - Sara Yassini Ardekani
- Department of Medicine, Yazd Shahid Sadoughi University of Medical Sciences, Yazd, IR Iran
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8
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Use of Ultra Rapid Opioid Detoxification in the Treatment of US Military Burn Casualties. ACTA ACUST UNITED AC 2011; 71:S114-9. [DOI: 10.1097/ta.0b013e3182219209] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Gowing L, Ali R, White JM. Opioid antagonists under heavy sedation or anaesthesia for opioid withdrawal. Cochrane Database Syst Rev 2010; 2010:CD002022. [PMID: 20091529 PMCID: PMC7065589 DOI: 10.1002/14651858.cd002022.pub3] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Withdrawal (detoxification) is necessary prior to drug-free treatment or as the end point of long-term substitution treatment. OBJECTIVES To assess the effectiveness of opioid antagonists to induce opioid withdrawal with concomitant heavy sedation or anaesthesia, in terms of withdrawal signs and symptoms, completion of treatment and adverse effects. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2009), Medline (January 1966 to 11 August 2009), Embase (January 1985 to 2009 Week 32), PsycINFO (1967 to July 2009), and reference lists of articles. SELECTION CRITERIA Controlled studies of antagonist-induced withdrawal under heavy sedation or anaesthesia in opioid-dependent participants compared with other approaches, or a different regime of anaesthesia-based antagonist-induced withdrawal. DATA COLLECTION AND ANALYSIS One reviewer assessed studies for inclusion, undertook data extraction and assessed quality. Inclusion decisions and the overall process were confirmed by consultation between all authors. MAIN RESULTS Nine studies (eight randomised controlled trials) involving 1109 participants met the inclusion criteria for the review.Antagonist-induced withdrawal is more intense but less prolonged than withdrawal managed with reducing doses of methadone, and doses of naltrexone sufficient for blockade of opioid effects can be established significantly more quickly with antagonist-induced withdrawal than withdrawal managed with clonidine and symptomatic medications. The level of sedation does not affect the intensity and duration of withdrawal, although the duration of anaesthesia may influence withdrawal severity. There is a significantly greater risk of adverse events with heavy, compared to light, sedation (RR 3.21, 95% CI 1.13 to 9.12, P = 0.03) and probably with this approach compared to other forms of detoxification. AUTHORS' CONCLUSIONS Heavy sedation compared to light sedation does not confer additional benefits in terms of less severe withdrawal or increased rates of commencement on naltrexone maintenance treatment. Given that the adverse events are potentially life-threatening, the value of antagonist-induced withdrawal under heavy sedation or anaesthesia is not supported. The high cost of anaesthesia-based approaches, both in monetary terms and use of scarce intensive care resources, suggest that this form of treatment should not be pursued.
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Affiliation(s)
- Linda Gowing
- University of AdelaideDiscipline of PharmacologyFrome RoadAdelaideSouth AustraliaAustralia5005
| | - Robert Ali
- University of AdelaideDiscipline of PharmacologyFrome RoadAdelaideSouth AustraliaAustralia5005
| | - Jason M White
- University of AdelaideDiscipline of PharmacologyFrome RoadAdelaideSouth AustraliaAustralia5005
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10
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Abstract
The development of effective treatments for opioid dependence is of great importance given the devastating consequences of the disease. Pharmacotherapies for opioid addiction include opioid agonists, partial agonists, opioid antagonists, and alpha-2-adrenergic agonists, which are targeted toward either detoxification or long-term agonist maintenance. Agonist maintenance therapy is currently the recommended treatment for opioid dependence due to its superior outcomes relative to detoxification. Detoxification protocols have limited long-term efficacy, and patient discomfort remains a significant therapy challenge. Buprenorphine's effectiveness relative to methadone remains a controversy and may be most appropriate for patients in need of low doses of agonist treatment. Buprenorphine appears superior to alpha-2 agonists, however, and office-based treatment with buprenorphine in the USA is gaining support. Studies of sustained-release formulations of naltrexone suggest improved effectiveness for retention and sustained abstinence; however, randomized clinical trials are needed.
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Affiliation(s)
- Angela L Stotts
- University of Texas Medical School at Houston, Department of Family and Community Medicine, 6431 Fannin, JJL 324, Houston, TX 77030, USA.
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11
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Ludlow J, Christmas T, Paech MJ, Orr B. Drug abuse and dependency during pregnancy: anaesthetic issues. Anaesth Intensive Care 2008; 35:881-93. [PMID: 18084978 DOI: 10.1177/0310057x0703500605] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Drug abuse is a significant social problem that can lead to serious obstetric complications, some of which may be confused with pregnancy-related disease states. Substance abuse poses a number of challenges with respect to the management of pain and the conduct of anaesthesia in the peripartum period. This review was based on information from a literature search of epidemiological, research and review papers on substance abuse during pregnancy, obtained for the purpose of preparing a background paper for the Ministerial Council on Drug Strategy, Commonwealth Government of Australia. Given that almost 80% of substance-abusing parturients require anaesthetic services in the perinatal period, early antenatal referral for anaesthetic review is recommended. To optimise the care of these vulnerable patients, obstetricians, general practitioners and midwives should attempt to identify substance-abusing parturients and refer them to an anaesthetist. A careful anaesthetic evaluation with non-judgemental questioning is essential, with management tailored to individual patient needs and the urgency of obstetric intervention for vaginal delivery or caesarean section. Opioid-dependent women, in particular, benefit from antenatal pain management planning. Patients recovering from drug addiction should also have a well-documented analgesic strategy. A multidisciplinary approach will involve obstetricians, anaesthetists and staff of the Drug and Alcohol Service. In acute admissions of women by whom antenatal care was not accessed, a high index of suspicion for illicit drug use should arise. Because illicit substance use is so prevalent, if untoward reactions occur during an otherwise uneventful anaesthetic, the possibility of drug abuse should be considered.
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Affiliation(s)
- J Ludlow
- Department of Women and Babies, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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12
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Abstract
BACKGROUND Withdrawal (detoxification) is necessary prior to drug-free treatment. It may also represent the end point of long-term opioid replacement treatment such as methadone maintenance. The availability of managed withdrawal is essential to an effective treatment system. OBJECTIVES To assess the effectiveness of interventions involving the administration of opioid antagonists to induce opioid withdrawal with concomitant heavy sedation or anaesthesia, in terms of withdrawal signs and symptoms, completion of treatment and adverse effects. SEARCH STRATEGY We searched the Drugs and Alcohol Group register (October 2003), Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2004), Medline (January 1966 to January 2005), Embase (January 1985 to January 2005), PsycINFO (1967 to January 2005), and Cinahl (1982 to December 2004) and reference lists of studies. SELECTION CRITERIA Controlled trials comparing antagonist-induced withdrawal under heavy sedation or anaesthesia with another form of treatment, or a different regime of anaesthesia-based antagonist-induced withdrawal. DATA COLLECTION AND ANALYSIS One reviewer assessed studies for inclusion and undertook data extraction and assessed quality. Inclusion decisions and the overall process were confirmed by consultation between all three reviewers. MAIN RESULTS Six studies (five randomised controlled trials) involving 834 participants met the inclusion criteria for the review.Antagonist-induced withdrawal is more intense but less prolonged than withdrawal managed with reducing doses of methadone, and doses of naltrexone sufficient for blockade of opioid effects can be established significantly more quickly with antagonist-induced withdrawal than withdrawal managed with clonidine and symptomatic medications. The level of sedation does not affect the intensity and duration of withdrawal, although the duration of anaesthesia may influence withdrawal severity. There is a significantly greater risk of adverse events with heavy, compared to light, sedation (RR 3.21, 95% CI 1.13 to 9.12, P = 0.03) and probably also other forms of detoxification. AUTHORS' CONCLUSIONS Heavy sedation compared to light sedation does not confer additional benefits in terms of less severe withdrawal or increased rates of commencement on naltrexone maintenance treatment. Given that the adverse events are potentially life-threatening, the value of antagonist-induced withdrawal under heavy sedation or anaesthesia is not supported. The high cost of anaesthesia-based approaches, both in monetary terms and use of scarce intensive care resources, suggest that this form of treatment should not be pursued.
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Affiliation(s)
- L Gowing
- University of Adelaide, Department of Clinical and Experimental Pharmacology, DASC Evidence-Bsed Practice Unit, Adelaide, Australia, 5005.
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13
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Gonzalez G, Oliveto A, Kosten TR. Combating opiate dependence: a comparison among the available pharmacological options. Expert Opin Pharmacother 2005; 5:713-25. [PMID: 15102558 DOI: 10.1517/14656566.5.4.713] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Pharmacotherapies for heroin addiction may target opiate withdrawal symptoms, facilitate initiation of abstinence and/or reduce relapse to heroin use either by maintenance on an agonist or antagonist agent. Available agents include opioid agonists, partial opioid agonists, opioid antagonists and alpha 2 -agonists for use during managed withdrawal and long-term maintenance. Experimental approaches combine alpha 2 -agonists with naltrexone to reduce the time of opiate withdrawal and to accelerate the transition to abstinence. Recently, buprenorphine has been introduced in the US for office-based maintenance, with the hope of replicating the success of this treatment in Europe and Australia. Naloxone has been added to buprenorphine in order to reduce its potential diversion to intravenous use, whilst facilitating the expansion of treatment. Although comprehensive substance abuse treatment is not limited to pharmacotherapy, this review will focus on the rationale, indications and limitations of the range of existing medications for detoxification and relapse prevention treatments. The two major goals of pharmacotherapy are to relieve the severity of opiate withdrawal symptoms during the managed withdrawal of the opioid and to prevent relapse to heroin use either after abstinence initiation or after being stabilised on a long-acting opiate agonist, such as methadone.
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Affiliation(s)
- Gerardo Gonzalez
- Department of Psychiatry,Yale University School of Medicine, West Haven, CT 06516, USA.
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15
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Abstract
PURPOSE OF REVIEW Drug abuse, especially with designer drugs, continues to grow, involving a wide demographic range. Consequently, anesthesiologists may be involved in the care of patients under the acute and chronic influence of a myriad of substances. In addition to the usual physiological damage to vital organs (heart, lungs, kidneys, and immune system) new evidence of permanent damage in regions of the brain responsible for memory and pain mediation is emerging. As drug use continues to increase, anesthesiologists must learn to detect drug abusing patients and avoid known interactions. This article will attempt to review the recent literature on this subject. RECENT FINDINGS Cocaine, marijuana, ethanol, and heroin top the list of abused drugs, alone and in combination. The combined effects of these drugs can be synergistic in creating cardiovascular instability and toxicity. Because combinations create synergy in dopamine and serotonin transmission, addiction is possibly faster, more entrenched, and more difficult to treat. Anesthesiologists are now becoming involved in many of the rapid detoxification procedures to combat/treat addiction. Only limited research has addressed the newer designer drugs, but case reports regarding hyperthermia, cerebral edema, cerebral vasospasm, and lethal interactions with commonly used medications such as beta-blockers implicate the need for awareness in anesthesia personnel. SUMMARY Drug abuse continues to be a major problem facing our society. Anesthesiologists encounter emergency cases in which 'party drugs' have clearly been used, and may also be anesthetizing patients in whom abuse is present but unrecognized. Understanding how illicit drugs interact with anesthetic agents is of paramount importance.
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Affiliation(s)
- Joy L Steadman
- University of Miami School of Medicine, Miami, Florida, USA
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Prieto IJ, Poyo-Guerrero R, Fernández R, Ochoa E. Ultrarapid high-dose methadone detoxification. Psychopharmacology (Berl) 2003; 165:430. [PMID: 12491030 DOI: 10.1007/s00213-002-1345-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2002] [Accepted: 11/08/2002] [Indexed: 11/28/2022]
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Gonzalez G, Oliveto A, Kosten TR. Treatment of heroin (diamorphine) addiction: current approaches and future prospects. Drugs 2002; 62:1331-43. [PMID: 12076182 DOI: 10.2165/00003495-200262090-00004] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
New pharmacological treatments for heroin (diamorphine) addiction include drugs that reduce opiate withdrawal symptoms and agents that are given during the maintenance phase of treatment. A variety of different types of pharmacological agents (opioid agonists, partial opioid agonists, opioid antagonists and alpha(2)-adrenoreceptor agonists) are reviewed and the evidence of their use during managed withdrawal and maintenance are presented. Experimental approaches attempting to reduce the time of opiate withdrawal and to accelerate the transition to abstinence are being developed. The combination tablet of buprenorphine and naloxone that is to be introduced for office-based maintenance is currently undergoing intense evaluation in the US. This new approach may facilitate the expansion of treatment while reducing the potential for medication diversion and intravenous use.
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Affiliation(s)
- Gerardo Gonzalez
- Department of Psychiatry, Division of Substance Abuse, Yale University School of Medicine, VA Connecticut Healthcare System, West Haven, Connecticut 06516, USA.
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18
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Gowing L, Ali R, White J. Opioid antagonists under heavy sedation or anaesthesia for opioid withdrawal. Cochrane Database Syst Rev 2002:CD002022. [PMID: 12076432 DOI: 10.1002/14651858.cd002022] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Withdrawal (detoxification) is necessary prior to drug-free treatment. It may also represent the end point of long-term opioid replacement treatment such as methadone maintenance. The availability of managed withdrawal is essential to an effective treatment system. OBJECTIVES To assess the effectiveness of interventions involving the administration of opioid antagonists to induce opioid withdrawal with concomitant heavy sedation or anaesthesia. SEARCH STRATEGY Multiple electronic databases (including MEDLINE, EMBASE, PsycLIT, Australian Medical Index, Cochrane Controlled Trials Register, and CINAHL) were systematically searched. Reference lists of retrieved studies, reviews and conference abstracts were handsearched. SELECTION CRITERIA Randomised or quasi-randomised controlled trials that compared the administration of opioid antagonists under heavy sedation or anaesthesia with another form of treatment. DATA COLLECTION AND ANALYSIS One reviewer assessed studies for inclusion and undertook data extraction. Inclusion decisions and the overall process were confirmed by consultation between all three reviewers. MAIN RESULTS As yet, no studies have been published comparing treatment regimes involving the administration of opioid antagonists under heavy sedation or anaesthesia with other approaches to detoxification. Treatment regimes for the studies considered for this review varied in the opioid antagonist used, the dose and mode of administration, the anaesthetic agent, duration of anaesthesia and adjunct medications employed. More detailed monitoring of withdrawal is required before any conclusions can be drawn as to what comprises a typical pattern of withdrawal and what factors might influence the pattern. There is only very limited information on referral to ongoing treatment, and relapse to opioid use. Together with the lack of adequate comparisons, this makes it impossible to draw any conclusions about the long-term effectiveness, or the cost-effectiveness, of withdrawal induced by opioid antagonists under heavy sedation or anaesthesia. REVIEWER'S CONCLUSIONS Considerably more research evidence will be needed before any conclusions can be drawn regarding the effectiveness of managing withdrawal by administration of opioid antagonists under heavy sedation or anaesthesia. The risk of vomiting during sedation, respiratory depression and cardiac irregularities point to the approach being limited to facilities equipped for intubation, assisted ventilation and a high level of monitoring, and with the capacity to respond to adverse events that might occur. The approach must be regarded as experimental with both risks and benefits remaining uncertain.
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Affiliation(s)
- L Gowing
- Evidence-Based Practice Unit, Drug and Alcohol Services Council, 161 Greenhill Road, Parkside, SA, Australia, 5063.
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Abstract
This paper is the twenty-third installment of the annual review of research concerning the opiate system. It summarizes papers published during 2000 that studied the behavioral effects of the opiate peptides and antagonists, excluding the purely analgesic effects, although stress-induced analgesia is included. The specific topics covered this year include stress; tolerance and dependence; learning, memory, and reward; eating and drinking; alcohol and other drugs of abuse; sexual activity, pregnancy, and development; mental illness and mood; seizures and other neurological disorders; electrical-related activity; general activity and locomotion; gastrointestinal, renal, and hepatic function; cardiovascular responses; respiration and thermoregulation; and immunological responses.
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Affiliation(s)
- A L Vaccarino
- Department of Psychology, University of New Orleans, New Orleans, LA 70148, USA.
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Bristow K, Meek R, Clark N. Acute opioid withdrawal in the emergency department: inadvertent naltrexone abuse? EMERGENCY MEDICINE (FREMANTLE, W.A.) 2001; 13:359-63. [PMID: 11554869 DOI: 10.1046/j.1035-6851.2001.00240.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
From July 1999 it became evident that a rising number of heroin users were presenting to the Dandenong Hospital Emergency Department with a rapid onset, florid opioid withdrawal syndrome following the intravenous injection of what they had believed to be heroin. We suspect that the injected substance was in fact naltrexone. This paper describes two such cases and reviews the literature on naltrexone. Recommendations regarding the management of the acute opioid withdrawal syndrome are made.
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Affiliation(s)
- K Bristow
- Emergency Department, Dandenong Hospital, Victoria, Australia
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Sneyd JR. Conflicts of interest: are they a problem for anaesthesia journals? What should we do about them? Br J Anaesth 2000; 85:811-4. [PMID: 11732510 DOI: 10.1093/bja/85.6.811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
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.
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Affiliation(s)
- S McCabe
- East Tennessee State University, Johnson City, TN, USA.
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