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Ratner JA, Blaney H, Rastegar DA. Management of alcohol withdrawal syndrome in patients with alcohol-associated liver disease. Hepatol Commun 2024; 8:e0372. [PMID: 38251886 PMCID: PMC10805424 DOI: 10.1097/hc9.0000000000000372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 12/13/2023] [Indexed: 01/23/2024] Open
Abstract
Alcohol-associated liver disease is a common and severe sequela of excessive alcohol use; effective treatment requires attention to both liver disease and underlying alcohol use disorder (AUD). Alcohol withdrawal syndrome (AWS) can be dangerous, is a common barrier to AUD recovery, and may complicate inpatient admissions for liver-related complications. Hepatologists can address these comorbid conditions by learning to accurately stage alcohol-associated liver disease, identify AUD using standardized screening tools (eg, Alcohol Use Disorder Identification Test), and assess risk for and symptoms of AWS. Depending on the severity, alcohol withdrawal often merits admission to a monitored setting, where symptom-triggered administration of benzodiazepines based on standardized scoring protocols is often the most effective approach to management. For patients with severe liver disease, selection of benzodiazepines with less dependence on hepatic metabolism (eg, lorazepam) is advisable. Severe alcohol withdrawal often requires a "front-loaded" approach with higher dosing, as well as intensive monitoring. Distinguishing between alcohol withdrawal delirium and HE is important, though it can be difficult, and can be guided by differentiating clinical characteristics, including time to onset and activity level. There is little data on the use of adjuvant medications, including anticonvulsants, dexmedetomidine, or propofol, in this patient population. Beyond the treatment of AWS, inpatient admission and outpatient hepatology visits offer opportunities to engage in planning for ongoing management of AUD, including initiation of medications for AUD and referral to additional recovery supports. Hepatologists trained to identify AUD, alcohol-associated liver disease, and risk for AWS can proactively address these issues, ensuring that patients' AWS is managed safely and effectively and supporting planning for long-term recovery.
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Affiliation(s)
- Jessica A. Ratner
- Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Hanna Blaney
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Darius A. Rastegar
- Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Liang Y, Roberts J, Conigrave K, Kim S, Doyle MF. Alcohol relapse prevention health care after alcohol withdrawal in New South Wales prisons, Australia: A patient file review. Drug Alcohol Rev 2023; 42:1733-1743. [PMID: 37608431 DOI: 10.1111/dar.13741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 08/24/2023]
Abstract
INTRODUCTION People who enter custody have complex health issues and comorbidities may include alcohol use disorders. We investigated clinical service provision and comorbidities recorded among individuals with a likely alcohol withdrawal syndrome within prison in New South Wales, Australia. METHODS For this clinical case series review, electronic medical data were used to identify 50 people entering custody between August and November 2018 who likely had a treated alcohol withdrawal syndrome. We aimed for a 3:2 ratio of men and women, and a 1:1 ratio of Aboriginal and non-Aboriginal individuals. Data were extracted using a purposefully designed tool which included current alcohol withdrawal management, comorbidities and alcohol relapse prevention approaches used or recommended. RESULTS Thirty-eight men and 12 women, of whom 22 were Aboriginal, were included. Twenty-nine individuals (58%) reported a history of medical comorbidities. Thirty-five (70%) reported using other substances and over half (60%) had a diagnosis of mental health disorders. Fourteen (28%) individuals had a record of receiving brief intervention and five (10%) of motivational interviewing. Twenty-three individuals (46%) were referred to and seen by drug and alcohol clinicians. Only seven (14%) of the sample had pre-release community care plans. DISCUSSION AND CONCLUSIONS Individuals treated for an alcohol withdrawal syndrome in New South Wales prisons have a high prevalence of medical comorbidities and other substance use. Clinical interventions focused on alcohol withdrawal management, and relapse prevention interventions were not recorded for most individuals. Service innovation and expansion are needed to increase the provision of post-withdrawal management.
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Affiliation(s)
- Yichao Liang
- Justice Health and Forensic Mental Health Network, Sydney, Australia
| | - Jillian Roberts
- Justice Health and Forensic Mental Health Network, Sydney, Australia
| | - Katherine Conigrave
- Centre of Research Excellence in Indigenous Health and Alcohol, Sydney Medical School, The University of Sydney, Sydney, Australia
- Edith Collins Centre (Translational Research in Alcohol Drugs and Toxicology), Drug Health Services, Sydney Local Health District, Sydney, Australia
- Royal Prince Alfred Hospital, Sydney, Australia
| | - Sobi Kim
- Justice Health and Forensic Mental Health Network, Sydney, Australia
- Edith Collins Centre (Translational Research in Alcohol Drugs and Toxicology), Drug Health Services, Sydney Local Health District, Sydney, Australia
| | - Michael F Doyle
- Centre of Research Excellence in Indigenous Health and Alcohol, Sydney Medical School, The University of Sydney, Sydney, Australia
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Running Bear U, Hanson JD, Noonan C, Muller C, Trojan J, Manson SM. Factors associated with readmission to alcohol and opioid detoxification in the Alaska Interior. Am J Addict 2022; 31:406-414. [PMID: 35434885 PMCID: PMC9463080 DOI: 10.1111/ajad.13288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 02/16/2022] [Accepted: 03/28/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND OBJECTIVES A "revolving door" of repeated admissions to detoxification treatment facilities has long plagued alcohol and drug use patients, yet few studies examine factors associated with readmission. This study examined risk factors for readmission to alcohol and opioid detoxification in a sample from the Alaska Interior. METHODS Data were extracted from electronic medical records for admissions between 2012 and 2016 at an inpatient detoxification facility in Fairbanks, Alaska. Data from 1014 patients admitted for alcohol detoxification and 267 patients admitted for opioid detoxification were analyzed. The analysis employed descriptive statistics for risk factors (substance use history, adverse life experiences, and psychosocial functioning) and prevalence of readmission to either alcohol or opioid detoxification. Inferential analyses used marginal standardization to calculate differences in readmission risk by patient characteristics. RESULTS Male, Alaska Native/American Indian, single-never married patients, and those seeking work were at higher risk for readmission to alcohol detoxification, while those with stable housing were at reduced risk. Being single-never married and completing detoxification treatment reduced readmission to opioid detoxification. Family involvement in detoxification reduced readmission risk for both alcohol and opioid patients. DISCUSSION AND CONCLUSIONS Further research that investigates the mechanism(s) by which family may act as a protective factor may be efficacious in eliminating the "revolving door" of detoxification. SCIENTIFIC SIGNIFICANCE This study is the first to examine both alcohol and opioid use risk and protective factors in the Alaska Interior. The results can be used in the development of interventions for subpopulations with high detoxification readmission rates.
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Affiliation(s)
- Ursula Running Bear
- Department of Population HealthUniversity of North DakotaGrand ForksNorth DakotaUSA
| | - Jessica D. Hanson
- Department of Applied Human SciencesUniversity of Minnesota DuluthDuluthMinnesotaUSA
| | - Carolyn Noonan
- Institute for Research and Education to Address Community HealthWashington State UniversitySeattleWashingtonUSA
| | - Clemma Muller
- Department of Medical Education and Clinical Science, Elson S. Floyd College of Medicine, Institute for Research and Education to Address Community HealthWashington State UniversitySeattleWashingtonUSA
| | | | - Spero M. Manson
- Centers for American Indian and Alaska Native Health, Colorado School of Public HealthUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
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Day E, Daly C. Clinical management of the alcohol withdrawal syndrome. Addiction 2022; 117:804-814. [PMID: 34288186 DOI: 10.1111/add.15647] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 07/06/2021] [Indexed: 02/06/2023]
Abstract
Up to half of individuals with a history of long-term, heavy alcohol consumption will experience the alcohol withdrawal syndrome (AWS) when consumption is significantly decreased or stopped. In its most severe form, AWS can be life-threatening. Medically assisted withdrawal (MAW) often forms the first part of a treatment pathway. This clinical review discusses key elements of the clinical management of MAW, necessary adjustments for pregnancy and older adults, likely outcome of an episode of MAW, factors that might prevent completion of the MAW process and ways of overcoming barriers to ongoing treatment of alcohol use disorder. The review also discusses the use of benzodiazepines in MAW. Although there is clear evidence for their use, benzodiazepines have been associated with abuse liability, blunting of cognition, interactions with depressant drugs, craving, delirium, dementia and disrupted sleep patterns. Because glutamatergic activation and glutamate receptor upregulation contribute to alcohol withdrawal, anti-glutamatergic strategies for MAW and other potential treatment innovations are also considered.
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Affiliation(s)
- Ed Day
- Addiction Psychiatry, Institute for Mental Health, School of Psychology, University of Birmingham, Edgbaston, Birmingham, UK
| | - Chris Daly
- Addiction Psychiatry, Greater Manchester Mental Health FT, Chapman Barker Unit, Prestwich Hospital, Manchester, UK
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Cohen SM, Alexander RS, Holt SR. The Spectrum of Alcohol Use: Epidemiology, Diagnosis, and Treatment. Med Clin North Am 2022; 106:43-60. [PMID: 34823734 DOI: 10.1016/j.mcna.2021.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In the United States, alcohol is the most common substance used and the spectrum of unhealthy alcohol use is highly prevalent. Complications of unhealthy alcohol use affect nearly every organ system. One of the most frequent and potentially life-threatening of these complications is alcohol withdrawal syndrome for which benzodiazepines remain first-line therapy. Pharmacologic treatment of alcohol use disorder, the most severe form of unhealthy alcohol use, is underutilized despite the availability of multiple effective medications. Although behavioral therapies are an important component of treatment, they are overemphasized at the expense of pharmacotherapy.
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Affiliation(s)
- Shawn M Cohen
- Program in Addiction Medicine, Section of General Internal Medicine, Yale School of Medicine, 367 Cedar Street, Harkness Hal A, Suite 417A, New Haven, CT 06510, USA.
| | - Ryan S Alexander
- Program in Addiction Medicine, Section of General Internal Medicine, Yale School of Medicine, 367 Cedar Street, Harkness Hal A, Suite 417A, New Haven, CT 06510, USA; Department of Preventive Medicine, Griffin Hospital, Derby, CT 06418, USA; Department of Internal Medicine, Griffin Hospital, Derby, CT 06418, USA
| | - Stephen R Holt
- Program in Addiction Medicine, Section of General Internal Medicine, Yale School of Medicine, 367 Cedar Street, Harkness Hal A, Suite 417A, New Haven, CT 06510, USA
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Moore TA. Ambulatory detoxification in alcohol use disorder and opioid use disorder. Ment Health Clin 2020; 10:307-316. [PMID: 33224688 PMCID: PMC7653729 DOI: 10.9740/mhc.2020.11.307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Ambulatory detoxification in alcohol use disorder and opioid use disorder is an important component in the management of patients experiencing withdrawal symptoms from alcohol or opioids. The goal of withdrawal management is ultimately to provide each patient with comfort and safety. Having the knowledge of the possible signs and symptoms of intoxication and withdrawal assists providers to institute the most appropriate treatment protocol and setting for the patient. Pharmacists play a vital role in choosing appropriate therapeutic management options for common or complex clinical situations involving ambulatory detoxification from alcohol and opioids. Ambulatory detoxification serves as an appealing option to many patients and helps save the limited inpatient resources that many institutions have for those patients with more severe withdrawal presentations.
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Abstract
Treatment of alcohol use disorders typically involves a combination of pharmacotherapy and psychosocial interventions. About one-quarter of people with alcohol dependence (‘alcoholics’) who seek treatment remain abstinent over 1 year. Research has consistently shown that less intensive, community treatment (particularly brief interventions) is just as effective as intense, residential treatment. Many psychosocial treatments are probably equally effective. Techniques for medically assisted detoxification are widespread and effective. More recent evidence provides some support for the use of drugs such as acamprosate to prevent relapse in the medium to long term.
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Nalpas B, Boulze-Launay I. Maintenance of Abstinence in Self-Help Groups. Alcohol Alcohol 2017; 53:89-94. [DOI: 10.1093/alcalc/agx085] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 10/07/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Bertrand Nalpas
- Inserm Scientific Information and Communication Department, Inserm, Paris, France
- Department of Addictology, CHRU Caremeau, Nîmes, France
| | - Isabelle Boulze-Launay
- Department of Addictology, CHRU Caremeau, Nîmes, France
- Epsylon Laboratory, Dynamics of Human Abilities and Health Behaviours, Montpellier University III, Montpellier, France
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Donroe JH, Tetrault JM. Recognizing and Caring for the Intoxicated Patient in an Outpatient Clinic. Med Clin North Am 2017; 101:573-586. [PMID: 28372714 DOI: 10.1016/j.mcna.2016.12.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Recognizing an intoxication syndrome in patients presenting to an outpatient clinical practice with behavior or mental status change requires initial consideration of a broad differential diagnosis. After a thorough evaluation, management may include treatment of the presenting concern, triage to a higher level of care, and management substance withdrawal. Providers should be aware of the medico-legal aspects of caring for intoxicated patients related to privacy, informed consent, and risk of harm to self and others upon leaving clinic. An essential aspect of care for patients presenting to clinic intoxicated is the follow up assessment and management of substance use disorders.
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Affiliation(s)
- Joseph H Donroe
- Department of Internal Medicine, Yale New Haven Hospital, St. Raphael Campus, Yale University School of Medicine, Office M330, 1450 Chapel Street, New Haven, CT 06511, USA.
| | - Jeanette M Tetrault
- Department of Internal Medicine, Yale University School of Medicine, 367 Cedar Street, Suite 305, New Haven, CT 06510, USA
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Sheikh WA, Paul R, Banda H, Agath K, Luty J. Impact of brief relapse prevention intervention in patients with alcohol dependence in Zambia. JOURNAL OF SUBSTANCE USE 2016. [DOI: 10.3109/14659891.2015.1090494] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Waqas Ahmed Sheikh
- Department of Psychiatry, School of Medicine, University of Zambia/Chainama Hills Hospital, Lusaka, Zambia
| | - Ravi Paul
- Lecturer &Head Department of Psychiatry, School of Medicine, University of Zambia, Lusaka, Zambia
| | | | - Kostas Agath
- Consultant Psychiatrist & Medical Governor CNWL NHS Foundation Trust, Westminster, UK
| | - Jason Luty
- Consultant in Addictions Psychiatry, Wiselawmill Farmhouse, Lauder, Oxton TD2 6PF, Scotland
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Rolland B, Paille F, Gillet C, Rigaud A, Moirand R, Dano C, Dematteis M, Mann K, Aubin H. Pharmacotherapy for Alcohol Dependence: The 2015 Recommendations of the French Alcohol Society, Issued in Partnership with the European Federation of Addiction Societies. CNS Neurosci Ther 2016; 22:25-37. [PMID: 26768685 PMCID: PMC6492872 DOI: 10.1111/cns.12489] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Revised: 10/30/2015] [Accepted: 11/03/2015] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The latest French good practice recommendations (GPRs) for the screening, prevention, and treatment of alcohol misuse were recently published in partnership with the European Federation of Addiction Societies (EUFAS). This article aims to synthesize the GPRs focused on the pharmacotherapy of alcohol dependence. METHODS A four-member European steering committee defined the questions that were addressed to an 18-member multiprofessional working group (WG). The WG developed the GPRs based on a systematic, hierarchical, and structured literature search and submitted the document to two review processes involving 37 French members from multiple disciplines and 5 non-French EUFAS members. The final GPRs were graded A, B, or C, or expert consensus (EC) using a reference recommendation grading system. RESULTS The treatment of alcohol dependence consists of either alcohol detoxification or abstinence maintenance programs or drinking reduction programs. The therapeutic objective is the result of a decision made jointly by the physician and the patient. For alcohol detoxification, benzodiazepines (BZDs) are recommended in first-line (grade A). BZD dosing should be guided by regular clinical monitoring (grade B). Residential detoxification is more appropriate for patients with a history of seizures, delirium tremens, unstable psychiatric comorbidity, or another associated substance use disorder (grade B). BZDs are only justified beyond a 1-week period in the case of persistent withdrawal symptoms, withdrawal events or associated BZD dependence (grade B). BZDs should not be continued for more than 4 weeks (grade C). The dosing and duration of thiamine (vitamin B1) during detoxification should be adapted to nutritional status (EC). For relapse prevention, acamprosate and naltrexone are recommended as first-line medications (grade A). Disulfiram can be proposed as second-line option in patients with sufficient information and supervision (EC). For reducing alcohol consumption, nalmefene is indicated in first line (grade A). The second-line prescription of baclofen, up to 300 mg/day, to prevent relapse or reduce drinking should be carried out according to the "temporary recommendation for use" measure issued by the French Health Agency (EC). During pregnancy, abstinence is recommended (EC). If alcohol detoxification is conducted during pregnancy, BZD use is recommended (grade B). No medication other than those for alcohol detoxification should be initiated in pregnant or breastfeeding women (EC). In a stabilized pregnant patient taking medication to support abstinence, the continuation of the drug should be considered on a case-by-case basis, weighing the benefit/risk ratio. Only disulfiram should be always stopped, given the unknown risks of the antabuse effect on the fetus (EC). First-line treatments to help maintain abstinence or reduce drinking are off-label for people under 18 years of age and should thus be considered on a case-by-case basis after the repeated failure of psychosocial measures alone (EC). Short half-life BZDs should be preferred for the detoxification of elderly patients (grade B). The initial doses of BZDs should be reduced by 30 to 50% in elderly patients (EC). In patients with chronic alcohol-related physical disorders, abstinence is recommended (EC). Any antidepressant or anxiolytic medication should be introduced after a psychiatric reassessment after 2-4 weeks of alcohol abstinence or low-risk use (grade B). A smoking cessation program should be offered to any smokers involved in an alcohol treatment program (grade B).
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Affiliation(s)
- Benjamin Rolland
- Société Française d'AlcoologieIssy‐les‐MoulineauxFrance
- Service d'AddictologieCHRU de LilleINSERM U1171Univ LilleLilleFrance
| | - François Paille
- Société Française d'AlcoologieIssy‐les‐MoulineauxFrance
- Service d'AddictologieCHU de NancyVandœuvre‐lès‐NancyNancyFrance
| | - Claudine Gillet
- Société Française d'AlcoologieIssy‐les‐MoulineauxFrance
- Centre d'AddictologieHôpital VilleminNancyFrance
| | - Alain Rigaud
- Société Française d'AlcoologieIssy‐les‐MoulineauxFrance
- Pôle d'addictologieEPSM MarneChâlons‐en‐Champagne et ReimsReimsFrance
- Association Nationale de Prévention en Alcoologie et Addictologue (ANPAA)ParisFrance
| | - Romain Moirand
- Société Française d'AlcoologieIssy‐les‐MoulineauxFrance
- CHU de RennesUnité d'AddictologieRennesFrance
- INSERMUMR 991RennesFrance
| | - Corine Dano
- Société Française d'AlcoologieIssy‐les‐MoulineauxFrance
- Service d'AddictologieCHU d'AngersAngersFrance
| | - Maurice Dematteis
- Société Française d'AlcoologieIssy‐les‐MoulineauxFrance
- Clinique d'AddictologieCHU de GrenobleUniversité Grenoble AlpesGrenobleFrance
| | - Karl Mann
- Central Institute of Mental HealthMedical Faculty MannheimUniversity of HeidelbergMannheimGermany
- EUFAS Scientific Secretariat Professor Antoni Gual (MD; PhD)Clinic Hospital of BarcelonaAddictive Behaviors UnitBarcelonaSpain
| | - Henri‐Jean Aubin
- Société Française d'AlcoologieIssy‐les‐MoulineauxFrance
- EUFAS Scientific Secretariat Professor Antoni Gual (MD; PhD)Clinic Hospital of BarcelonaAddictive Behaviors UnitBarcelonaSpain
- Département de Psychiatrie et d'AddictologieINSERM U1178Hôpital Paul BrousseAPHP VillejuifVillejuifFrance
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Sachdeva A, Choudhary M, Chandra M. Alcohol Withdrawal Syndrome: Benzodiazepines and Beyond. J Clin Diagn Res 2015; 9:VE01-VE07. [PMID: 26500991 DOI: 10.7860/jcdr/2015/13407.6538] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 07/03/2015] [Indexed: 11/24/2022]
Abstract
Alcohol dependence is an increasing and pervasive problem. Alcohol withdrawal symptoms are a part of alcohol dependence syndrome and are commonly encountered in general hospital settings, in most of the departments. Alcohol withdrawal syndrome ranges from mild to severe. The severe complicated alcohol withdrawal may present with hallucinations, seizures or delirium tremens. Benzodiazepines have the largest and the best evidence base in the treatment of alcohol withdrawal, and are considered the gold standard. Others, such as anticonvulsants, barbiturates, adrenergic drugs, and GABA agonists have been tried and have evidence. Supportive care and use of vitamins is essential in the management. Symptom triggered regime is favoured over fixed tapering dose regime, although monitoring through scales is cumbersome. This article aims to review the evidence base for appropriate clinical management of the alcohol withdrawal syndrome. We searched Pubmed for articles published in English on 'Alcohol withdrawal syndrome' in humans during the last 10 years. A total of 1182 articles came up. Articles not relevant to clinical utility and management were excluded based on the titles and abstract available. Full text articles, meta-analyses, systematic reviews and randomized controlled trials were obtained from this list and were considered for review.
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Affiliation(s)
- Ankur Sachdeva
- Assistant Professor, Department of Psychiatry, ESIC Medical College and Hospital , Faridabad, Haryana, India
| | - Mona Choudhary
- Senior Resident, Department of Psychiatry and Drug De-addiction, Post Graduate Institute of Medical Education and Research, Dr Ram Manohar Lohia Hospital , New Delhi, India
| | - Mina Chandra
- Chief Medical Officer (NFSG), Department of Psychiatry and Drug De-addiction, Post Graduate Institute of Medical Education and Research, Dr Ram Manohar Lohia Hospital , New Delhi, India
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Salman M, Subbe C. Alcohol detoxification in Ysbyty Gwynedd: Two small sips or one big gulp? Two-step screening more reliable for identification of alcohol dependency syndrome at risk of delirium tremens for routine care. BMJ QUALITY IMPROVEMENT REPORTS 2015; 4:bmjquality_uu206149.w2528. [PMID: 26734413 PMCID: PMC4693067 DOI: 10.1136/bmjquality.u206149.w2528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 06/18/2015] [Indexed: 11/03/2022]
Abstract
Compliance with pathways for hospitalised patients with alcohol dependency syndrome is often poor. A pathway for recognition and treatment of alcohol dependency was redesigned as part of a 12 month service improvement project in the acute medical unit using plan, do, study, act (PDSA) cycles. A needs assessment was undertaken: Audit data from 2013 showed over-prescription of chlordiazepoxide for detoxification treatment (DT) leading to prolonged hospital admissions with an average length of stay of 5.5 days in 2012/2013. Acceptability of screening tools was tested: Common screening tools (CEWA, AUDIT) were rejected by junior doctors due to the high number of questions as too cumbersome for routine practice. Compliance with usage in random samples over a three month period was persistently (n=10%. Testing of an abbreviated AUDIT questionnaire with only two questions and a specified threshold showed a AUROC of 1 (p<0.001 for correct identification). The screening tool was implemented in several PDSAs cycles. After the final cycle a random sample of 100 patients was reviewed for pathway compliance over a three months period. Eighty-six patients were screened with the two-question tool of these 18 were identified as possible risk. Of these 16 patients had the full AUDIT questionnaire, only eight with elevated values were started on DT. Overall compliance with the pathway increased to 84%.
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Timko C, Below M, Schultz NR, Brief D, Cucciare MA. Patient and Program Factors that Bridge the Detoxification-Treatment Gap: A Structured Evidence Review. J Subst Abuse Treat 2015; 52:31-9. [DOI: 10.1016/j.jsat.2014.11.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 10/30/2014] [Accepted: 11/19/2014] [Indexed: 10/24/2022]
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Lee D, Schroeder JR, Karschner EL, Goodwin RS, Hirvonen J, Gorelick DA, Huestis MA. Cannabis withdrawal in chronic, frequent cannabis smokers during sustained abstinence within a closed residential environment. Am J Addict 2014; 23:234-42. [PMID: 24724880 DOI: 10.1111/j.1521-0391.2014.12088.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 05/15/2013] [Accepted: 06/01/2013] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Chronic, frequent cannabis smokers may experience residual and offset effects, withdrawal, and craving when abstaining from the drug. We characterized the prevalence, duration, and intensity of these effects in chronic frequent cannabis smokers during abstinence on a closed research unit. METHODS Non-treatment-seeking participants (N = 29 on admission, 66% and 34% remaining after 2 and 4 weeks) provided subjective effects data. A battery of five instruments was computer-administered daily to measure psychological, sensory, and physical symptoms associated with cannabinoid intoxication and withdrawal. Plasma and oral fluid specimens were concurrently collected and analyzed for cannabinoids. Outcome variables were evaluated as change from admission (Day 0) with regression models. RESULTS Most abstinence effects, including irritability and anxiety were greatest on Days 0-3 and decreased thereafter. Cannabis craving significantly decreased over time, whereas decreased appetite began to normalize on Day 4. Strange dreams and difficulty getting to sleep increased over time, suggesting intrinsic sleep problems in chronic cannabis smokers. Symptoms likely induced by residual drug effects were at maximum intensity on admission and positively correlated with plasma and oral fluid cannabinoid concentrations on admission but not afterward; these symptoms showed overall prevalence higher than cannabis withdrawal symptoms. CONCLUSIONS The combined influence of residual/offset drug effects, withdrawal, and craving was observed in chronic cannabis smokers during monitored abstinence. Abstinence symptoms were generally more intense in the initial phase, implying importance of early intervention in cannabis quit attempts. Sleep disturbance persisting for an extended period suggests that hypnotic medications could be beneficial in treating cannabis dependence.
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Affiliation(s)
- Dayong Lee
- Chemistry and Drug Metabolism, National Institute on Drug Abuse, National Institute of Health, Baltimore, Maryland
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Stallvik M, Gastfriend DR, Nordahl HM. Matching patients with substance use disorder to optimal level of care with the ASAM Criteria software. JOURNAL OF SUBSTANCE USE 2014. [DOI: 10.3109/14659891.2014.934305] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Capsule commentary on Stephens et al., Who needs inpatient detox? Development and implementation of a hospitalist protocol for the evaluation of patients for alcohol detoxification. J Gen Intern Med 2014; 29:647. [PMID: 24449035 PMCID: PMC3965761 DOI: 10.1007/s11606-014-2772-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Stephens JR, Liles EA, Dancel R, Gilchrist M, Kirsch J, DeWalt DA. Who needs inpatient detox? Development and implementation of a hospitalist protocol for the evaluation of patients for alcohol detoxification. J Gen Intern Med 2014; 29:587-93. [PMID: 24395104 PMCID: PMC3965748 DOI: 10.1007/s11606-013-2751-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 09/04/2013] [Accepted: 12/09/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Clinicians caring for patients seeking alcohol detoxification face many challenges, including lack of evidence-based guidelines for treatment and high recidivism rates. OBJECTIVES To develop a standardized protocol for determining which alcohol dependent patients seeking detoxification need inpatient versus outpatient treatment, and to study the protocol's implementation. DESIGN Review of best evidence by ad hoc task force and subsequent creation of standardized protocol. Prospective observational evaluation of initial protocol implementation. PARTICIPANTS Patients presenting for alcohol detoxification. INTERVENTION Development and implementation of a protocol for evaluation and treatment of patients requesting alcohol detoxification. MAIN MEASURES Number of admissions per month with primary alcohol related diagnosis (DRG), 30-day readmission rate, and length of stay, all measured before and after protocol implementation. RESULTS We identified one randomized clinical trial and three cohort studies to inform the choice of inpatient versus outpatient detoxification, along with one prior protocol in this population, and combined that data with clinical experience to create an institutional protocol. After implementation, the average number of alcohol related admissions was 15.9 per month, compared with 18.9 per month before implementation (p = 0.037). There was no difference in readmission rate or length of stay. CONCLUSIONS Creation and utilization of a protocol led to standardization of care for patients requesting detoxification from alcohol. Initial evaluation of protocol implementation showed a decrease in number of admissions.
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Affiliation(s)
- John R Stephens
- Division of General Medicine and Clinical Epidemiology, University of North Carolina School of Medicine, 5034 Old Clinic Building, CB#7110, Chapel Hill, NC, 27599-7110, USA,
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Deacon RM, Hines S, Curry K, Tynan M, Day CA. Feasibility of ambulatory withdrawal management delivered in a NSW drug health service and correlates of completion. AUST HEALTH REV 2014; 38:186-9. [PMID: 24589255 DOI: 10.1071/ah13014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Accepted: 12/12/2013] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The aim of the present study was to assess short-term ambulatory withdrawal management (AWM) outcomes at a drug health service (DHS) in Sydney, Australia, in the absence of specific funding. METHODS A clinic file audit review was conducted of patients who commenced AWM at the service during January 2009-June 2011. Successful completion was defined as daily attendance with ≤1 missed day, or transfer onto opioid substitution treatment. RESULTS Of 110 episodes, 69 (63%) were completed. Median patient age was 35 years (range 18-71 years), and most patients (68%) were male. Patients presented primarily for cannabis (33%) or alcohol (30%) withdrawal, followed by heroin (19%) or other opioids (6%), and benzodiazepines (12%). Completion rates varied from 86% for non-heroin opioids to 31% for benzodiazepines. Older age was associated with increased completion: 76% of those aged >35 years completed compared with 50% of those ≤35 years of age. Only 46% of women who commenced withdrawal management completed compared with 71% of men. CONCLUSIONS Most people commencing AWM at the DHS completed the program, indicating AWM can be performed at public drug and alcohol clinics. Service improvements may help increase completion rates among women and patients withdrawing from benzodiazepines. What is known about the topic? WM is not a standalone treatment for substance dependence, but is commonly a first attempt at treatment. AWM is often more acceptable to patients, and cheaper, than in-patient services. What does this paper add? About two-thirds of patients entering an AWM program operating since 2001 continue to complete the program. What are the implications for practitioners? AWM can be carried out successfully through public drug and alcohol services, although clinic staff support is important.
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Affiliation(s)
- Rachel M Deacon
- Discipline of Addiction Medicine, Central Clinical School, Sydney Medical School, The University of Sydney, Drug Health Services, Level 6 KGV Building, Missenden Road, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia.
| | - Susan Hines
- Canterbury Drug Health Services, Sydney Local Health District, Corner Tudor Street and Canterbury Road, Campsie, NSW 2209, Australia. ;
| | - Kenneth Curry
- Canterbury Drug Health Services, Sydney Local Health District, Corner Tudor Street and Canterbury Road, Campsie, NSW 2209, Australia. ;
| | - Maggie Tynan
- Canterbury Drug Health Services, Sydney Local Health District, Corner Tudor Street and Canterbury Road, Campsie, NSW 2209, Australia. ;
| | - Carolyn A Day
- Discipline of Addiction Medicine, Central Clinical School, Sydney Medical School, The University of Sydney, Drug Health Services, Level 6 KGV Building, Missenden Road, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia.
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Cooper E, Vernon J. The effectiveness of pharmacological approaches in the treatment of alcohol withdrawal syndrome (AWS): a literature review. J Psychiatr Ment Health Nurs 2013; 20:601-12. [PMID: 22989012 DOI: 10.1111/j.1365-2850.2012.01958.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Mortality statistics for excessive alcohol consumption show no signs of abatement, with a report published in 2011 from the World Health Organization (WHO) estimating that 2.5 million people worldwide died because of their alcohol consumption. Serious physiological, psychological, social and legal problems are thought to affect many more. Alcohol withdrawal syndrome (AWS) is a potentially life-threatening condition that often occurs in those individuals who significantly reduce or stop their intake after a prolonged and excessive period of drinking. Pharmacological treatment of the AWS has traditionally been undertaken by the use of the benzodiazepines, but recent years have witnessed the emergence of several alternatives. The aim of this paper was (1) to review the evidence base supporting the use of various pharmacological agents currently employed to treat AWS, and (2) to consider the efficacy and safety of the emerging alternatives to the benzodiazepines. The Cochrane Database of Systematic Reviews, CINAHL, Embase, PsycINFO, MEDLINE and BNI databases were extensively searched in order to retrieve the maximum number of relevant articles. Reference lists from relevant literature were also used to identify other potential studies for inclusion. All studies concerned with measuring the efficacy and safety of the various pharmacological treatment options for AWS were considered and a total of 63 trials were included in this review. Findings support the use of benzodiazepines as the recommended drug of choice for the treatment of AWS in the absence of adequate evidence to support the use of alternative agents. There is a lack of evidence of a superior pharmacological agent to the benzodiazepines for the treatment of AWS. There are several studies that have shown that there are pharmacological alternatives that could compete or act as an adjunct with the benzodiazepines in terms of high efficacy and safety in the treatment of AWS, but there is a need for further quality research to be carried out before definitive conclusions can be drawn.
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Affiliation(s)
- E Cooper
- Community Mental Health Team, Pennine Care NHS foundation Trust, Stockport , UK
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Fiellin DA, Butler R, D'Onofrio G, Brown RL, O'Connor PG. The physician's role in caring for patients with substance use disorders: implications for medical education and training. Subst Abus 2013; 23:207-22. [PMID: 23580996 DOI: 10.1080/08897070209511516] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- David A Fiellin
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
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Husain OM, Lynas PS, Totty JP, Williams K, Waring WS. Unplanned alcohol withdrawal: a survey of consecutive admissions to an acute medical unit in 2010 and 2011. QJM 2013; 106:43-9. [PMID: 23019589 DOI: 10.1093/qjmed/hcs175] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- O M Husain
- Acute Medical Unit, York Hospital, York, UK
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de la Espriella Guerrero R, de la Hoz Bradford AM, Zárate AUH, Lee PR, Menéndez MC, Rentería AMC, Hernández DC, Cardeño C, Barré MC, Kunzel GH, Gómez-Restrepo C. [Clinical Practice Guide for Early Detection, Diagnosis and Treatment of the Acute Intoxication Phase in Patients with Alcohol Abuse or Dependence: Part II: Evaluation and Management of Patients with Acute Alcohol Intoxication]. REVISTA COLOMBIANA DE PSIQUIATRIA 2012; 41:805-25. [PMID: 26572267 DOI: 10.1016/s0034-7450(14)60048-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Accepted: 11/06/2012] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Worldwide, alcohol is the second most-used psychotropic substance and the third risk factor for early death and disability. Its noxious use is a world public health problem given its personal, labor, family, economic and social impact. The identification of acute alcohol intoxication is extremely important, as well as the alcohol withdrawal syndrome and its complications, such as delirium tremens and Wernicke's encephalopathy in order to grant a timely treatment for those patients. This article introduces the evidence found so as to face and treat these clinic manifestations. METHODOLOGY Systematic revision of the evidence available together with an evaluation of pertinent guidelines found in literature so as to decide whether to adopt or adapt the existing recommendation for each question or to develop de novo recommendations. For de novo recommendations as well as those adapted, it was carried out an evidence synthesis, together with evidence tables and formulation of recommendations based on the evidence. RESULTS Evidence was found and recommendations were made for the diagnosis and treatment of acute alcohol intoxication, withdrawal syndrome, delirium tremens and Wernicke's encephalopathy.
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Affiliation(s)
- Ricardo de la Espriella Guerrero
- Médico psiquiatra, terapeuta sistémico, magíster Epidemiología Clínica, Pontificia Universidad Javeriana, director, Bogotá, Colombia.
| | - Ana María de la Hoz Bradford
- Médica cirujana, magíster en Epidemiología Clínica, Pontificia Universidad Javeriana, coordinadora GAI, Bogotá, Colombia
| | - Alina Uribe-Holguín Zárate
- Médica cirujana, residente de Psiquiatría, Pontificia Universidad Javeriana, asistente de investigación, Bogotá, Colombia
| | - Patricia Rodríguez Lee
- Médica cirujana, residente de Psiquiatría, Pontificia Universidad Javeriana, asistente de investigación, Bogotá, Colombia
| | - Miguel Cote Menéndez
- Médico psiquiatra, fellow en abuso de sustancias, Magíster en psicología y terapia sistémica, psiquiatra de CAD Fundar Bogotá, profesor de psiquiatría de la Facultad de Medicina de la Universidad Nacional de Colombia, experto temático, Bogotá, Colombia
| | - Ana María Cano Rentería
- Médica psiquiatra, miembro activo del subcomité de adicciones de la ACP, coordinadora del área científica de la ESE Hospital Mental de Filandia, Quindío, docente de clínica psiquiátrica, programa de Medicina de la Facultad de Ciencias de la Salud, Universidad del Quindío, entrenadora del Programa Treatnet II Colombia de ONU-DC. Asociación Colombiana de Psiquiatría, experta temática, Filandia, Quindío, Colombia
| | - Delia Cristina Hernández
- Médico psiquiatra, Universidad del Valle; máster en Conductas Adictivas, Universidad de Valencia; docente de Farmacodependencia, Universidad Libre; Asociación Colombiana de Psiquiatría; directora general de Fundar Colombia (Cali). Asociación Colombiana de Psiquiatría; Coordinadora del subcomité de adicciones de la ACP. Experta temática. Cali, Colombia
| | - Carlos Cardeño
- Médico Psiquiatra, psiquiatría de enlace. Magíster en Farmacología. Coordinador de Psiquiatría del Hospital Universitario Fundación Hospitalaria San Vicente de Paúl; Docente. Universidad de Antioquia. Experto temático, Bogotá, Colombia
| | - Michelle Cortés Barré
- Médica y cirujana, magíster en Educación, candidata a Maestría en Epidemiología Clínica. Pontificia Universidad Javeriana. Asistente de investigación. Bogotá, Colombia
| | - Gabriel Hernández Kunzel
- Médico psiquiatra, Hospital Militar Central y Clínica del Country; docente de Farmacodependencia de la Universidad Militar, Pontificia Universidad Javeriana y Universidad Sanitas. Miembro del Comité de Adicciones de la Asociación Colombiana de Psiquiatría. Asociación Colombiana de Psiquiatría. Experto temático, Bogotá, Colombia
| | - Carlos Gómez-Restrepo
- Médico psiquiatra, MSc Epidemiología Clínica, Psiquiatra de Enlace, Psicoanalista, profesor titular Departamento de Psiquiatría y Salud Mental, director Departamento de Psiquiatría y Salud Mental, director Departamento de Epidemiología Clínica y Bioestadística, Pontificia Universidad Javeriana, Director GAI Depresión, codirector CINETS, Bogotá, Colombia
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Abstract
OBJECTIVE : The objective of this study was to determine whether additional "take-home" medication after inpatient opioid detoxification would lead to improved rates of subsequent treatment initiation and abstinence. METHODS : We randomly assigned 60 inpatients to a 7-day or 37-day extension of sublingual buprenorphine/naloxone after hospitalization. Follow-up telephone interviews were conducted approximately 5 weeks after discharge. The primary outcomes were abstinence, initiation of aftercare outpatient counseling, and initiation of self-help meeting attendance. RESULTS : Of the 30 participants in each group, outcome data were obtained for 25 (83%) in the 7-day extension group and 27 (90%) in the 37-day extension group. There was not a significant difference in the rates of abstinence (53% versus 41%) or initiation of self-help (57% versus 54%) between the 7-day and 37-day groups, respectively. Of those in the 7-day group, 15 (65%) initiated outpatient treatment compared with 21 (88%) of those assigned to the 37-day group. Although not significant in unadjusted analysis (P = 0.093), this difference was significant in regression analysis when controlling for a history of intravenous drug use (P = 0.034). Among all participants, individual characteristics at the time of hospital admission (eg, age of first drug use, previous history of intravenous drug, type of health insurance) were predictive of outcomes. CONCLUSIONS : In this preliminary study, additional medication beyond a week after inpatient detoxification was not associated with clinically important improvements in rates of abstinence or treatment initiation. Baseline patient characteristics seem to affect these clinical outcomes after hospitalization.
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Rana A, Luthra V, Noman Khan Wazir M, Yadav R, Raistrick D. Audit of alcohol detoxification at Leeds Addiction Unit. DRUGS AND ALCOHOL TODAY 2012. [DOI: 10.1108/17459261211211700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeAt any one time, 76 million people have an alcohol use disorder. Detoxification is a common intervention for alcohol dependence. There is a need regularly to assess and evaluate detoxification practice. The aim and objective of this paper is to describe the findings of audits which assessed the quality and safety of the detoxification experience and to implement changes to improve practice.Design/methodology/approachAll community detoxifications in March 2009 and 2010 were included for the successive audits. Notes were inspected retrospectively three months post completion of detoxification using the audit standard.FindingsA total of 50 and 59 people were eligible in respective audits. At 3 months post‐detoxification 23 per cent of patients had dropped out of treatment compared to 15 per cent in the re‐audit. In 2009, 31 per cent of patients remained completely abstinent and 10 per cent were drinking within safe limits but in 2010 figures improved to 36 per cent and 22 per cent, respectively. Disulfiram was continued by 66 per cent of abstinent patients in the initial audit and 89 per cent in the reaudit. Improved follow‐up protocol, regular advice and monitoring of disulfiram resulted in better abstinence and reduced drop out rates over successive years. Social and Behavioral Network Therapy and disulfiram taken under medical supervision after detoxification play a pivotal role in relapse prevention.Originality/valueThe study considers the importance of the post‐detoxification period, in terms of maintaining a patient's abstinence from alcohol.
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FOOS JAMESA, OTTENS ALLENJ, HILL LARRYK. Managed Mental Health: A Primer for Counselors. JOURNAL OF COUNSELING AND DEVELOPMENT 2011. [DOI: 10.1002/j.1556-6676.1991.tb01516.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Blondell RD, Frydrych LM, Jaanimagi U, Ashrafioun L, Homish GG, Foschio EM, Bashaw HL. A randomized trial of two behavioral interventions to improve outcomes following inpatient detoxification for alcohol dependence. J Addict Dis 2011; 30:136-48. [PMID: 21491295 DOI: 10.1080/10550887.2011.554777] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Participants (n=150), undergoing inpatient alcohol detoxification, were randomized into 3 groups: treatment as usual (TAU), motivation enhancement therapy (MET), or peer-delivered 12-step facilitation (P-TSF). The main outcome was the initiation of any type of subsequent rehabilitation service (i.e., professional treatment or self-help) within 30 and 90 days of discharge. At the 30-day follow-up interview, there was no significant difference among the groups in the rate of initiation of any type of subsequent care (82%, 74%, and 82%, respectively, p=0.617); however, the MET group had significantly more patients initiate subsequent inpatient treatment by the 90-day follow-up interview compared to the P-TSF group (31% and 61%, respectively, p=0.007) and a greater proportion of MET participants completed subsequent inpatient treatment compared to both the TAU and P-TSF groups. There were no differences in drinking-related outcomes. MET during inpatient detoxification may help patients initiate subsequent inpatient rehabilitation treatment.
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Carrier E, McNeely J, Lobach I, Tay S, Gourevitch MN, Raven MC. Factors associated with frequent utilization of crisis substance use detoxification services. J Addict Dis 2011; 30:116-22. [PMID: 21491293 DOI: 10.1080/10550887.2011.554776] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Previous research suggests that some substance users have multiple crisis detoxification visits and never access rehabilitation care. This care-seeking pattern leads to poorer outcomes and higher costs. The authors aimed to identify predictors of repeat detoxification visits by analyzing state-level data routinely collected at the time of substances use services admission. Repeat detoxification clients were more likely to be homeless, city-dwelling fee-for-service Medicaid recipients. Repeat detoxification clients were less likely than those with one admission to enter rehabilitation within 3 days. Treatment providers should aim for rapid transfer to rehabilitation and consider expanding detoxification intake data to improve risk stratification.
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Affiliation(s)
- Emily Carrier
- New York University, School of Medicine, Bellevue Hospital Center, New York University, New York, NY, USA.
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PENNAY AMYE, LEE NICOLEK. Putting the call out for more research: The poor evidence base for treating methamphetamine withdrawal. Drug Alcohol Rev 2010; 30:216-22. [DOI: 10.1111/j.1465-3362.2010.00240.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Welcome to the third module in our Continuing Professional Development Section (CPD). CPD is now a key element in the clinical activity of all health professionals and a cornerstone of good clinical governance throughout mental health services. This section of the Irish Journal of Psychological Medicine will provide CPD modules dedicated to key topics in mental health care. In order to assist learning and self-assessment, multiple choice questions will be provided at the end of each module.This module and its multiple choice questions are available online on the website of the Irish Journal of Psychological Medicine (www.ijpm.org). The CPD policy of the College of Psychiatry of Ireland indicates that psychiatrists who participate in suitable online learning which fits the criteria for CPD may claim CPD points under the Personal CPD category (up to a maximum of 5 points per year).We are confident that this CPD Section of the Irish Journal of Psychological Medicine will prove to be a valuable resource for consultant psychiatrists, psychiatric trainees and all journal readers. We welcome feedback from readers and, especially, any suggestions for topics to be covered in future CPD modules. Suggestions should be emailed to: psychological@medmedia.ie
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Abstract
In the fourth in a series of six articles on packages of care for mental disorders in low- and middle-income countries, Vivek Benegal and colleagues discuss the treatment of alcohol use disorders.
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Affiliation(s)
- Vivek Benegal
- Deaddiction Centre, National Institute of Mental Health and Neurosciences, Bangalore, India.
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Luce A, Heather N, McCarthy S. National census of UK alcohol treatment agencies: I. Characteristics of clients, treatment and treatment providers. JOURNAL OF SUBSTANCE USE 2009. [DOI: 10.3109/14659890009053075] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Sannibale C, Fucito L, O'Connor D, Curry K. Process evaluation of an out-patient detoxification service. Drug Alcohol Rev 2009; 24:475-81. [PMID: 16361203 DOI: 10.1080/09595230500292912] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This paper describes the process evaluation of an out-patient detoxification service (ODS) established by Drug Health Services (DHS) to increase the supervised withdrawal options for substance users in a Sydney metropolitan Area Health Service. The ODS aimed to provide a safe and effective supervised withdrawal to substance users who were at low risk of severe withdrawal, engage those with severe dependence in further treatment and increase the involvement of general practitioners (GPs) in the medical care of ODS clients. During its first 10 months of operation, the ODS received 199 inquiries, assessed 82 individuals and admitted 76 clients for detoxification. Withdrawal treatment proceeded without complications and within the expected time frames. Fifty-four clients completed withdrawal, 10 ceased treatment, 10 remained in treatment without completing withdrawal and two were transferred elsewhere. Clients who injected substances (mainly heroin) daily at admission, compared to others, were less likely to complete withdrawal and more likely to use a range of non-prescribed substances during withdrawal. One-fifth of clients went on to further treatment with DHS, attending at least once. Overall, the ODS met its goals, providing a safe and effective supervised withdrawal to local residents, especially women, young people and those withdrawing from benzodiazepines who had significant substance dependence, impairment and previous alcohol and other drug (AOD) treatment. Non-injecting substance users benefited most from the ODS in terms of withdrawal completion and ongoing treatment. The level of GP involvement in the conjoint care of ODS clients remained constant over time. The development and expansion of the ODS are discussed.
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Affiliation(s)
- Claudia Sannibale
- Drug Health Services, Central Sydney Area Health Service, Sydney, New South Wales, Australia
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Abstract
Three lines of argument support the use of in-patient treatment for alcohol dependence. The first of these is that of natural justice. People ailing from their dependence on alcohol have a right to as full a range of treatment options as other people have for other disorders. Alcohol dependence is a disorder with a substantial morbidity and mortality. We should not forget that. Secondly, a variety of in-patient treatments have been shown to have a place in the treatment armamentarium. Some in-patient treatment is better than others, and treatment matching produces better results. Thirdly, the cost of in-patient treatment for alcohol dependence has repeatedly been shown to produce a worthwhile economic benefit.
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Affiliation(s)
- S Jurd
- Drug and Alcohol Services, Herbert Street Clinic, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
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SILINS EDMUND, SANNIBALE CLAUDIA, LARNEY SARAH, WODAK ALEX, MATTICK RICHARD. Residential detoxification: essential for marginalised, severely alcohol- and drug-dependent individuals. Drug Alcohol Rev 2009; 27:414-9. [DOI: 10.1080/09595230701750650] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Frydrych LM, Greene BJ, Blondell RD, Purdy CH. Self-help program components and linkage to aftercare following inpatient detoxification. J Addict Dis 2009; 28:21-7. [PMID: 19197592 DOI: 10.1080/10550880802544799] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Many patients fail to initiate aftercare for addictive disease rehabilitation following detoxification. This study of 136 inpatients compared characteristics of those who initiated aftercare (behavior therapy or self-help programs) during the week following discharge with those who did not. Among this group of patients, 77% (91/119) linked to aftercare. Self-help treatment related components were associated with increased aftercare treatment attendance rates and included: having a copy of the "12 Steps" (81% vs. 46%, P = .002), having read self-help literature (73% vs. 42%, P = .007), and having telephone numbers of self-help program members (50% vs. 18%, P = .008). Those who initiated aftercare treatment were also more likely to have remained abstinent from drugs and alcohol (81% vs. 39%, P < .001). Having self-help treatment related components was associated with increased rates of aftercare attendance following hospital inpatient detoxification.
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Affiliation(s)
- Lynne M Frydrych
- Department of Family Medicine, Family Medicine Research Institute, Buffalo, New York, USA.
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Babor TF, Stenius K, Romelsjo A. Alcohol and drug treatment systems in public health perspective: mediators and moderators of population effects. Int J Methods Psychiatr Res 2008; 17 Suppl 1:S50-9. [PMID: 18543363 PMCID: PMC6879072 DOI: 10.1002/mpr.249] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
This article describes a public health approach to the study of service systems for people with substance use disorders. Such an approach is broadly conceived to include the consideration not only of specialized services for alcohol and drug dependence, but also of medical care and social welfare services that interact with and complement specialized drug and alcohol services. After describing a conceptual model of the substance abuse service system, we discuss how systems of care may contribute to population health and social welfare by reducing the societal burden of substance use disorders. The article then summarizes key systems issues pertaining to mediators and moderators of effective treatment systems. The potential benefits of systems thinking in relation to the management of substance use disorders are described. It is suggested that systems concepts and research may help to improve access, efficiency, economy, continuity of care, and effectiveness, thereby improving the population impact of treatment services.
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Affiliation(s)
- Thomas F Babor
- Department of Community Medicine, University of Connecticut School of Medicine, Farmington, CT 06030-6325, USA.
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The cost-effectiveness and cost-benefit of screening and brief intervention for unhealthy alcohol use in medical settings. Subst Abus 2008; 28:67-77. [PMID: 18077304 DOI: 10.1300/j465v28n03_07] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Economic evaluation can be a valuable tool for assessing the efficiency and value of health care programs. To examine the literature on the economic evaluation of alcohol screening and brief intervention in medical settings, relevant studies were identified in the MEDLINE database (1966 through November 2006) and by hand-searching the references of identified articles and relevant journals. The 15 identified studies used a range of economic evaluation methods, including cost analysis, cost-benefit, cost-effectiveness, and cost-utility. Nearly all of the studies supported the use of alcohol screening and brief intervention. The studies that prospectively collected cost and effect data and/or conformed closely to methodological guidelines demonstrated a strong economic benefit of alcohol screening and brief intervention when compared to usual care. Overall, the reviewed studies support alcohol SBI in medical settings as a wise use of health care resources and illustrate the usefulness of economic evaluation for assessing alcohol prevention and treatment programs.
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Affiliation(s)
- Zachary Hartsell
- Department of Hospital Internal Medicine, Mayo Clinic Hospital, Phoenix, Arizona, USA
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Effectiveness of daily outpatient alcohol detoxification by an Irish public psychiatric hospital - A pilot study. Ir J Psychol Med 2007; 24:23-26. [PMID: 30290500 DOI: 10.1017/s0790966700010119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To assess the effectiveness of daily outpatient alcohol detoxification in an Irish public psychiatric hospital. METHOD The outpatient records of patients presenting to the Assessment Unit of St Brendan's Hospital in one year (August 2004-July 2005) with symptoms of Alcohol Dependence Syndrome (ADS) and commencing daily outpatient detoxification were examined retrospectively for parameters relevant to the objectives of the study. The results were compiled and analysed using descriptive statistics. RESULTS Forty patients underwent outpatient alcohol detoxification in one year and complete records were available for 32 patients (80%). Twenty patients had fixed addresses in the hospital catchment areas, eight patients had no fixed addresses and the remaining four patients had addresses outside the catchment areas. Seven patients (22%) presented with a co-morbid psychiatric condition including depression (four patients), anxiety disorder (two patients) and personality disorder (one patient). All seven patients were known to psychiatric sector services. Of the 32 patients commencing detoxification, 28 patients (87.5%) attended on the second day whilst 22 patients (69%) attended their third day's appointment. Only 17 patients (53%) completed the outpatient detoxification. Thirteen patients (40.6%) received at least two outpatient detoxifications during the year; of whom seven patients (58%) received their second detoxification within two months of the first one. The record of 20 patients (62.5%) showed that they had received advice regarding selfreferral to counselling services. CONCLUSION A high proportion of patients (47%) presenting with symptoms of ADS did not complete daily outpatient detoxifications. A high proportion of all patients (40.6%) also underwent multiple outpatient detoxifications during the year. It is possible that the separation between alcohol detoxification and alcohol counselling services in Ireland contributed to these disappointing results.
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Blondell RD, Amadasu A, Servoss TJ, Smith SJ. Differences Among Those who Complete and Fail to Complete Inpatient Detoxification. J Addict Dis 2006; 25:95-104. [PMID: 16597577 DOI: 10.1300/j069v25n01_12] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Some individuals hospitalized for alcohol or drug detoxification leave against medical advice (AMA). We hypothesized that certain characteristics would be associated with AMA discharges. A case-control study of 1,426 hospital admissions for detoxification (representing 1,080 individuals) was conducted to compare patients leaving the hospital AMA (n=231) with a random sample of those completing detoxification (n=286). Latino ethnicity, detoxification from drugs, Friday or Saturday discharge, Medicaid or no health insurance, and not being treated by one specific attending physician were characteristics associated with an AMA discharge in a backward logistic regression model. Although 85% of the patients with all these characteristics left AMA, only one patient, without any of these five characteristics, did so. We conclude that clinicians can use certain clinical features to predict AMA discharge. Additional research could evaluate if treatment strategies that consider these ethnic and socioeconomic disparities may reduce rates of AMA discharge.
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Affiliation(s)
- Richard D Blondell
- Department of Family Medicine, Family Medicine Research Institute, The State University of New York, University at Buffalo, 462 Grider St, CC-175, Buffalo, NY 14215, USA.
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Blondell RD, Smith SJ, Canfield MC, Servoss TJ. Abstinence and Initiation of Treatment Following Inpatient Detoxification. Am J Addict 2006; 15:462-7. [PMID: 17182449 DOI: 10.1080/10550490600998815] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
This prospective cohort study compared in-patients who remained abstinent and initiated aftercare treatment following detoxification with those who did not. Of 110 patients enrolled, 58% (46/79) were totally abstinent and 72% (67/93) initiated treatment during the first 30 days following hospital discharge. Patients who relapsed after hospital discharge were more likely than those who remained abstinent to have a primary drug-use disorder (p = 0.05), prior mental health treatment (p = .007), or previous incarceration (p = 0.035). Those who initiated aftercare treatment were less likely to have had prior mental health treatment than those who did not (p = .046).
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Affiliation(s)
- Richard D Blondell
- Department of Family Medicine, Family Medicine Research Institute, The State University of New York at Buffalo, Buffalo, New York, USA.
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Volpicelli JR. New Options for the Treatment of Alcohol Dependence. Psychiatr Ann 2005. [DOI: 10.3928/00485713-20050601-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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