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Ebeling‐Koning NE, Goodman D, Amaducci AM, Smith ES, Surmaitis RM, Katz KD, Koons AL, Fikse DJ, Ferdock M, Greenberg MR, Cook MD. Load and go: Assessing safety outcomes of patients discharged from the emergency department after receiving phenobarbital for alcohol withdrawal. J Am Coll Emerg Physicians Open 2024; 5:e13178. [PMID: 38707981 PMCID: PMC11066564 DOI: 10.1002/emp2.13178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/16/2024] [Accepted: 04/01/2024] [Indexed: 05/07/2024] Open
Abstract
Objectives Phenobarbital (PB) is a long-acting GABA A-agonist with favorable pharmacokinetics (long half-life and duration of effect) that allows effective treatment of alcohol withdrawal (AW) after administration of a single loading dose. Current evidence suggests that in the setting of AW, PB administration may be associated with decreased hospital admissions and hospital length of stay. The aim of this study was to evaluate the safety outcomes of AW patients who were treated and discharged from the emergency department (ED) after receiving PB for AW. Methods This retrospective chart review included a convenience sample of 33 AW patients who presented to four EDs within an 18-month span. Descriptive statistics (frequencies and percentages) were used to describe demographics, distribution of resources and referrals, and the safety outcomes of PB administration for low-risk AW patients. Patients were selected for inclusion in consultation with a medical toxicologist, treated with PB, and discharged from the ED. Electronic medical records were utilized to gather information on the patient cohort. Results All patients were treated with at least a single loading dose of 5‒10 mg/kg (ideal body weight) of intravenous or per os PB during their ED stay. Only one patient had an unanticipated event after discharge, which was related to driving against advice. Two additional patients had ED revisits for recurrent alcohol use within 72 h, and 16 patients had recurrent alcohol use within 30 days. All 33 patients were provided with resources for linkage to treatment. None required hospital admission. Conclusion ED PB "load and go" may be a safe, effective AW treatment that could help treat AW, facilitate linkage to specific rehabilitation treatments, and decrease hospital admissions.
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Affiliation(s)
- Natalie E. Ebeling‐Koning
- Department of Emergency and Hospital MedicineLehigh Valley Health Network/USF Morsani College of Medicine, Lehigh Valley CampusAllentownPennsylvaniaUSA
| | - David Goodman
- Department of Emergency and Hospital MedicineLehigh Valley Health Network/USF Morsani College of Medicine, Lehigh Valley CampusAllentownPennsylvaniaUSA
| | - Alexandra M. Amaducci
- Department of Emergency and Hospital MedicineLehigh Valley Health Network/USF Morsani College of Medicine, Lehigh Valley CampusAllentownPennsylvaniaUSA
| | - Erin S. Smith
- Department of Family MedicineLehigh Valley Health Network/USF Morsani College of MedicineLehigh Valley CampusAllentownPennsylvaniaUSA
| | - Ryan M. Surmaitis
- Department of Emergency and Hospital MedicineLehigh Valley Health Network/USF Morsani College of Medicine, Lehigh Valley CampusAllentownPennsylvaniaUSA
| | - Kenneth D. Katz
- Department of Emergency and Hospital MedicineLehigh Valley Health Network/USF Morsani College of Medicine, Lehigh Valley CampusAllentownPennsylvaniaUSA
| | - Andrew L. Koons
- Department of Emergency and Hospital MedicineLehigh Valley Health Network/USF Morsani College of Medicine, Lehigh Valley CampusAllentownPennsylvaniaUSA
| | - Derek J. Fikse
- Department of Emergency and Hospital MedicineLehigh Valley Health Network/USF Morsani College of Medicine, Lehigh Valley CampusAllentownPennsylvaniaUSA
| | - Matthew Ferdock
- Department of Emergency and Hospital MedicineLehigh Valley Health Network/USF Morsani College of Medicine, Lehigh Valley CampusAllentownPennsylvaniaUSA
| | - Marna Rayl Greenberg
- Department of Emergency and Hospital MedicineLehigh Valley Health Network/USF Morsani College of Medicine, Lehigh Valley CampusAllentownPennsylvaniaUSA
| | - Matthew D. Cook
- Department of Emergency and Hospital MedicineLehigh Valley Health Network/USF Morsani College of Medicine, Lehigh Valley CampusAllentownPennsylvaniaUSA
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Qu L, Ma XP, Simayi A, Wang XL, Xu GP. Comparative efficacy of various pharmacologic treatments for alcohol withdrawal syndrome: a systematic review and network meta-analysis. Int Clin Psychopharmacol 2024; 39:148-162. [PMID: 38170803 DOI: 10.1097/yic.0000000000000526] [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] [Indexed: 01/05/2024]
Abstract
This study was to compare multiple classes of medications and medication combinations to find alternatives or additives for patients not applicable to benzodiazepines (BZDs). We performed a network meta-analysis to assess the comparative effect of 11 pharmacologic treatments in patients with alcohol withdrawal syndrome. Forty-one studies were included, comprising a total sample size of 4187 participants. The pooled results from the randomized controlled trials showed that there was no significant difference in the Clinical Institute Withdrawal Assessment-Alcohol, revised (CIWA-Ar) reduction with other medications or medication combinations compared to BZDs. Compared to BZDs, the mean difference in ICU length of stay of anticonvulsants + BZDs was -1.71 days (95% CI = -2.82, -0.59). Efficacy rankings from cohort studies showed that anticonvulsant + BZDs were superior to other treatments in reducing CIWA-Ar scores and reducing the length of stay in the ICU. Synthesis results from randomized controlled trials indicate that there are currently no data suggesting that other medications or medication combinations can fully replace BZDs. However, synthetic results from observational studies have shown that BZDs are effective in the context of adjuvant anticonvulsant therapy, particularly with early use of gabapentin in combination with BZDs in the treatment of alcohol withdrawal syndrome, which represents a promising treatment option.
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Affiliation(s)
- Li Qu
- Department of Anesthesia, People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang, China
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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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Unlu H, Macaron MM, Ayraler Taner H, Kaba D, Akin Sari B, Schneekloth TD, Leggio L, Abulseoud OA. Sex difference in alcohol withdrawal syndrome: a scoping review of clinical studies. Front Psychiatry 2023; 14:1266424. [PMID: 37810604 PMCID: PMC10556532 DOI: 10.3389/fpsyt.2023.1266424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/04/2023] [Indexed: 10/10/2023] Open
Abstract
Background We conducted a review of all studies comparing clinical aspects of alcohol withdrawal syndrome (AWS) between men and women. Methods Five databases (PubMed, Cochrane, EMBASE, Scopus and Clinical Trials) were searched for clinical studies using the keywords "alcohol withdrawal syndrome" or "delirium tremens" limited to "sex" or "gender" or "sex difference" or "gender difference." The search was conducted on May 19, 2023. Two reviewers selected studies including both male and female patients with AWS, and they compared males and females in type of AWS symptoms, clinical course, complications, and treatment outcome. Results Thirty-five observational studies were included with a total of 318,730 participants of which 75,346 had AWS. In twenty of the studies, the number of patients presenting with or developing AWS was separated by sex, resulting in a total of 8,159 (12.5%) female patients and a total of 56,928 (87.5%) male patients. Despite inconsistent results, males were more likely than females to develop complicated AWS [delirium tremens (DT) and AW seizures, collective DT in Males vs. females: 1,792 (85.4%) vs. 307 (14.6%), and collective seizures in males vs. females: 294 (78%) vs. 82 (22%)]. The rates of ICU admissions and hospital length of stay did not show sex differences. Although variable across studies, compared to females, males received benzodiazepine treatment at higher frequency and dose. One study reported that the time from first hospitalization for AWS to death was approximately 1.5 years shorter for males and males had higher mortality rate [19.5% (197/1,016)] compared to females [16% (26/163)]. Conclusion Despite the significant heterogeneity of the studies selected and the lack of a focus on investigating potential sex differences, this review of clinical studies on AWS suggests that men and women exhibit different AWS manifestations. Large-scale studies focusing specifically on investigating sex difference in AWS are needed.
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Affiliation(s)
- Hayrunnisa Unlu
- Department of Psychiatry and Psychology, Mayo Clinic Arizona, Phoenix, AZ, United States
- Department of Child and Adolescent Psychiatry, Baskent University School of Medicine Hospital, Ankara, Turkey
| | | | - Hande Ayraler Taner
- Department of Child and Adolescent Psychiatry, Baskent University School of Medicine Hospital, Ankara, Turkey
| | - Duygu Kaba
- Department of Child and Adolescent Psychiatry, Baskent University School of Medicine Hospital, Ankara, Turkey
| | - Burcu Akin Sari
- Department of Child and Adolescent Psychiatry, Baskent University School of Medicine Hospital, Ankara, Turkey
| | - Terry D. Schneekloth
- Department of Psychiatry and Psychology, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Lorenzo Leggio
- Section on Clinical Psychoneuroendocrinology and Neuropsychopharmacology, Translational Addiction Medicine Branch, National Institute on Drug Abuse, and National Institute on Alcohol Abuse and Alcoholism, Baltimore, MD, United States
| | - Osama A. Abulseoud
- Department of Psychiatry and Psychology, Mayo Clinic Arizona, Phoenix, AZ, United States
- Department of Neuroscience, Graduate School of Biomedical Sciences, Mayo Clinic College of Medicine, Phoenix, AZ, United States
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5
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Nishimura Y, Choi H, Colgan B, Kistler H, Mercado F. Current evidence and clinical utility of phenobarbital for alcohol withdrawal syndrome. Eur J Intern Med 2023; 112:52-61. [PMID: 36935249 DOI: 10.1016/j.ejim.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/28/2023] [Accepted: 03/06/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND Phenobarbital (PB) has been acknowledged among clinicians as a potential alternative to benzodiazepines (BZD) to decrease the need for hospital length of stay and complications associated with alcohol withdrawal syndrome (AWS). However, the level of evidence, including appropriate dosing, is unclear. We aim to summarize the evidence regarding PB used in AWS and provide future agendas for research. METHODS Following the PRISMA guidelines, we searched MEDLINE, EMBASE, ClinicalTrials.gov, and WHO ICTRP for all peer-reviewed articles and clinical trials using keywords including"alcohol withdrawal", "delirium tremens", "phenobarbital," and "barbiturate" from their inception to September 18, 2022. RESULTS We included 20 articles, nine in the emergency department (ED) and 11 in the general floors or intensive care units (ICUs). Studies performed in the ED included two RCTs, although both suffered from a considerably small sample size. Six studies done in the general floors or ICUs compared PB and BZD monotherapy, while four compared the utility of adjunct PB in addition to BZD compared with BZD monotherapy and one was a database study without specific dosing information. Overall, there was considerable heterogeneity in PB dosing, measured outcomes, and AWS severity measurement scales. CONCLUSION This systematic review summarizes the current evidence related to PB use in AWS. While considerable heterogeneity exists among studies available, PB as monotherapy without BZD may be a safe and effective alternative in AWS treatment. Future prospective studies or trials should focus on the standardization of PB dosing and outcomes.
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Affiliation(s)
- Yoshito Nishimura
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, 96813, United States of America.
| | - Horyun Choi
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, 96813, United States of America
| | - Bridget Colgan
- Department of Medicine, Tripler Army Medical Center, Honolulu, HI 96859, United States of America
| | - Harrison Kistler
- Department of Medicine, Tripler Army Medical Center, Honolulu, HI 96859, United States of America
| | - Francisco Mercado
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, 96813, United States of America; Department of Medicine, Tripler Army Medical Center, Honolulu, HI 96859, United States of America
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Seshadri A, Appelbaum R, Carmichael SP, Farrell MS, Filiberto DM, Jawa R, Kodadek L, Mandell S, Miles MVP, Paul J, Robinson B, Michetti CP. Prevention of alcohol withdrawal syndrome in the surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document. Trauma Surg Acute Care Open 2022; 7:e001010. [PMCID: PMC9680182 DOI: 10.1136/tsaco-2022-001010] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/02/2022] [Indexed: 11/23/2022] Open
Abstract
Alcohol withdrawal syndrome is a common and challenging clinical entity present in trauma and surgical intensive care unit (ICU) patients. The screening tools, assessment strategies, and pharmacological methods for preventing alcohol withdrawal have significantly changed during the past 20 years. This Clinical Consensus Document created by the American Association for the Surgery of Trauma Critical Care Committee reviews the best practices for screening, monitoring, and prophylactic treatment of alcohol withdrawal in the surgical ICU.
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Affiliation(s)
- Anupamaa Seshadri
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Rachel Appelbaum
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Samuel P Carmichael
- Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | | | - Dina M Filiberto
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Randeep Jawa
- Department of Surgery, Stony Brook University, Stony Brook, New York, USA
| | - Lisa Kodadek
- Surgery, Yale University School of Medicine, New Haven, Connecticut, USA,Department of Surgery, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Samuel Mandell
- Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - M Victoria P Miles
- College of Medicine Chattanooga, The University of Tennessee Health Science Center, Chattanooga, Tennessee, USA
| | - Jasmeet Paul
- Department of Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Bryce Robinson
- Department of Surgery, Harborview Medical Center, Seattle, Washington, USA
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7
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Toews JR, Leonard JC, Shi J, Lloyd JK. Implementation of an Automated Sepsis Screening Tool in a Children's Hospital Emergency Department: A Cost Analysis. J Pediatr 2022; 250:38-44.e1. [PMID: 35772510 DOI: 10.1016/j.jpeds.2022.06.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 06/09/2022] [Accepted: 06/22/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To determine the effect of implementation of an automated sepsis screening tool on the median cost of affected patient encounters. STUDY DESIGN This retrospective cohort study used propensity score-matched comparison groups to assess the difference in median cost for comparable affected patient encounters before and after the implementation of an automated sepsis screening tool in a large US children's hospital emergency department (ED) with >90 000 annual visits. All patient encounters in 2018 impacted by the automated sepsis screening tool were included and compared with a propensity score-matched comparison group drawn from patient encounters in 2012 that might have been affected by the screening tool had it been active at that time. The main outcome was the change in the median cost for comparable affected patient encounters. RESULTS The overall median cost for those affected by an automated sepsis screening tool decreased by 21.2%, from $6454 (IQR, $968-$21 697) to $5084 (IQR, $802-$16 618). The median cost for encounters with an associated International Classification of Diseases sepsis code decreased by 51.1%, from $58 685 (IQR, $32 224-$134 895) to $28 672 (IQR, $16 796-$60 657). CONCLUSIONS The median cost for comparable patient encounters decreased with implementation of an automated sepsis screening tool in the pediatric ED. Costs were decreased even more substantially for patients with sepsis. In addition to improving outcomes, an automated sepsis screening tool appears to be at least cost-effective and may be cost-saving, an incentive for more widespread use of this technology.
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Affiliation(s)
- Jason R Toews
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, OH; Division of Emergency Medicine, Dayton Children's Hospital, Dayton, OH
| | - Julie C Leonard
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Junxin Shi
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Julia K Lloyd
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, OH.
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Franco JG, Molano JC, Rincón H, Tirado JDV, Cardeño C, Rodriguez LP, Lugo GFO, Miranda JB, Moreno MR. Consensus of the Liaison-Psychiatry Committee of the Colombian Psychiatric Association on the diagnosis and treatment of delirium in the context of the COVID-19 pandemic. REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2022; 51:245-255. [PMID: 36085127 PMCID: PMC9433347 DOI: 10.1016/j.rcpeng.2020.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 11/02/2020] [Indexed: 11/18/2022]
Abstract
The pandemic caused by the new coronavirus named SARS-CoV-2 poses unprecedented challenges in the health care. Among them is the increase in cases of delirium. The severe SARS-CoV-2 disease, COVID-19, has common vulnerabilities with delirium and produces alterations in organs such as the lungs or the brain, among others, which have the potential to trigger the mental disorder. In fact, delirium may be the first manifestation of the infection, before fever, general malaise, cough or respiratory disturbances. It is widely supported that delirium increases the morbidity and mortality in those who suffer from it during hospitalization, so it should be actively sought to carry out the relevant interventions. In the absence of evidence on the approach to delirium in the context of COVID-19, this consensus was developed on three fundamental aspects: diagnosis, non-pharmacological treatment and pharmacological treatment, in patients admitted to the general hospital. The document contains recommendations on the systematic use of diagnostic tools, when to hospitalize the patient with delirium, the application of non-pharmacological actions within the restrictions imposed by COVID-19, and the use of antipsychotics, taking into account the most relevant side effects and pharmacological interactions.
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Affiliation(s)
- José G Franco
- Escuela de Ciencias de la Salud, Facultad de Medicina, Grupo de Investigación en Psiquiatría de Enlace (GIPE), Universidad Pontificia Bolivariana, Medellín, Colombia.
| | - Juan Carlos Molano
- Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia; Facultad de Medicina, Departamento de Salud Mental, Grupo de Investigación Fundamental: Psiquiatría de Enlace Salud Poblacional, Uniandes, Bogotá, Colombia
| | - Hernán Rincón
- Hospital Universitario Fundación Valle del Lili, Cali, Colombia; Escuela de Medicina, Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
| | - Juan David Velasquez Tirado
- Escuela de Ciencias de la Salud, Facultad de Medicina, Grupo de Investigación en Psiquiatría de Enlace (GIPE), Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Carlos Cardeño
- Hospital Universitario San Vicente Fundación, Medellín, Colombia; Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia; Facultad de Medicina, Departamento de Psiquiatría, Grupo de Investigación Clínica Aplicada, Universidad de Antioquia, Medellín, Colombia
| | - Liliana Patarroyo Rodriguez
- Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia; Facultad de Medicina, Departamento de Salud Mental, Grupo de Investigación Fundamental: Psiquiatría de Enlace Salud Poblacional, Uniandes, Bogotá, Colombia
| | - Gabriel Fernando Oviedo Lugo
- Hospital Universitario San Ignacio, Centro de Memoria y Cognición Intellectus, Bogotá, Colombia; Facultad de Medicina, Departamento de Psiquiatría y Salud Mental, Grupo de Investigación: Perspectivas en ciclo vital, salud mental y psiquiatría, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Jaime Bernal Miranda
- Remeo Medical Center, Cali, Colombia; IBIS Biomedical Research Group, Cali, Colombia
| | - Monica Rojas Moreno
- Clínica Reina Sofía, Bogotá, Colombia; Psiquiatría de Enlace e Interconsulta, Grupo de Investigación: Salud Mental, Neurodesarrollo y Calidad de Vida, Universidad El Bosque, Bogotá, Colombia
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Staidle A, Geier C. Phenobarbital and/or benzodiazepines for recurrent alcohol withdrawal: A self-controlled, retrospective cohort study. Am J Emerg Med 2022; 54:263-266. [DOI: 10.1016/j.ajem.2022.02.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 02/13/2022] [Accepted: 02/16/2022] [Indexed: 11/28/2022] Open
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Franco JG, Oviedo Lugo GF, Patarroyo Rodriguez L, Bernal Miranda J, Carlos Molano J, Rojas Moreno M, Cardeño C, Velasquez Tirado JD. Survey of psychiatrists and psychiatry residents in Colombia about their preventive and therapeutic practices in delirium. REVISTA COLOMBIANA DE PSIQUIATRÍA (ENGLISH ED.) 2021; 50:260-272. [PMID: 34728177 DOI: 10.1016/j.rcpeng.2020.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 02/20/2020] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To describe pharmacological and non-pharmacological practices for delirium, carried out by psychiatry residents and psychiatrists in Colombia. METHODS An anonymous survey was conducted based on the consensus of experts of the Liaison Psychiatry Committee of the Asociación Colombiana de Psiquiatría [Colombian Psychiatric Association] and on the literature review. It was sent by email to the association members. RESULTS 101 clinicians participated. Non-pharmacological preventive measures such as psychoeducation, correction of sensory problems or sleep hygiene are performed by 70% or more. Only about 1 in 10 participants are part of an institutional multi-component prevention programme. The preventive prescription of drugs was less than 20%. Regarding non-pharmacological treatment, more than 75% recommend correction of sensory difficulties, control of stimuli and reorientation. None of the participants indicated that the care at their centres is organised to enhance non-pharmacological treatment. 17.8% do not use medication in the treatment of delirium. Those who use it prefer haloperidol or quetiapine, particularly in hyperactive or mixed motor subtypes. CONCLUSIONS The practices of the respondents coincide with those of other experts around the world. In general, non-pharmacological actions are individual initiatives, which demonstrates the need in Colombian health institutions to commit to addressing delirium, in particular when its prevalence and consequences are indicators of quality of care.
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Affiliation(s)
- José G Franco
- Escuela de Ciencias de la Salud, Facultad de Medicina, Grupo de Investigación en Psiquiatría de Enlace (GIPE), Universidad Pontificia Bolivariana, Medellín, Colombia.
| | - Gabriel Fernando Oviedo Lugo
- Hospital Universitario San Ignacio, Centro de Memoria y Cognición Intellectus, Bogotá, Colombia; Facultad de Medicina, Departamento de Psiquiatría y Salud Mental, Grupo de Investigación: Perspectivas en ciclo vital, salud mental y psiquiatría, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Liliana Patarroyo Rodriguez
- Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia; Facultad de Medicina, Departamento de Salud Mental, Grupo de Investigación Fundamental: Psiquiatría de Enlace Salud Poblacional, Uniandes, Bogotá, Colombia
| | - Jaime Bernal Miranda
- Remeo Medical Center, Cali, Colombia; IBIS Biomedical Research Group, Cali, Colombia
| | - Juan Carlos Molano
- Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia; Facultad de Medicina, Departamento de Salud Mental, Grupo de Investigación Fundamental: Psiquiatría de Enlace Salud Poblacional, Uniandes, Bogotá, Colombia
| | - Monica Rojas Moreno
- Clínica Reina Sofía, Bogotá, Colombia; Psiquiatría de Enlace e Interconsulta, Grupo de Investigación: Salud Mental, Neurodesarrollo y Calidad de Vida, Universidad El Bosque, Bogotá, Colombia
| | - Carlos Cardeño
- Hospital Universitario San Vicente Fundación, Medellín, Colombia; Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia; Facultad de Medicina, Departamento de Psiquiatría, Grupo de Investigación Clínica Aplicada, Universidad de Antioquia, Medellín, Colombia
| | - Juan David Velasquez Tirado
- Escuela de Ciencias de la Salud, Facultad de Medicina, Grupo de Investigación en Psiquiatría de Enlace (GIPE), Universidad Pontificia Bolivariana, Medellín, Colombia
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Steel TL, Afshar M, Edwards S, Jolley SE, Timko C, Clark BJ, Douglas IS, Dzierba AL, Gershengorn HB, Gilpin NW, Godwin DW, Hough CL, Maldonado JR, Mehta AB, Nelson LS, Patel MB, Rastegar DA, Stollings JL, Tabakoff B, Tate JA, Wong A, Burnham EL. Research Needs for Inpatient Management of Severe Alcohol Withdrawal Syndrome: An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2021; 204:e61-e87. [PMID: 34609257 PMCID: PMC8528516 DOI: 10.1164/rccm.202108-1845st] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: Severe alcohol withdrawal syndrome (SAWS) is highly morbid, costly, and common among hospitalized patients, yet minimal evidence exists to guide inpatient management. Research needs in this field are broad, spanning the translational science spectrum. Goals: This research statement aims to describe what is known about SAWS, identify knowledge gaps, and offer recommendations for research in each domain of the Institute of Medicine T0-T4 continuum to advance the care of hospitalized patients who experience SAWS. Methods: Clinicians and researchers with unique and complementary expertise in basic, clinical, and implementation research related to unhealthy alcohol consumption and alcohol withdrawal were invited to participate in a workshop at the American Thoracic Society 2019 International Conference. The committee was subdivided into four groups on the basis of interest and expertise: T0-T1 (basic science research with translation to humans), T2 (research translating to patients), T3 (research translating to clinical practice), and T4 (research translating to communities). A medical librarian conducted a pragmatic literature search to facilitate this work, and committee members reviewed and supplemented the resulting evidence, identifying key knowledge gaps. Results: The committee identified several investigative opportunities to advance the care of patients with SAWS in each domain of the translational science spectrum. Major themes included 1) the need to investigate non-γ-aminobutyric acid pathways for alcohol withdrawal syndrome treatment; 2) harnessing retrospective and electronic health record data to identify risk factors and create objective severity scoring systems, particularly for acutely ill patients with SAWS; 3) the need for more robust comparative-effectiveness data to identify optimal SAWS treatment strategies; and 4) recommendations to accelerate implementation of effective treatments into practice. Conclusions: The dearth of evidence supporting management decisions for hospitalized patients with SAWS, many of whom require critical care, represents both a call to action and an opportunity for the American Thoracic Society and larger scientific communities to improve care for a vulnerable patient population. This report highlights basic, clinical, and implementation research that diverse experts agree will have the greatest impact on improving care for hospitalized patients with SAWS.
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Franco JG, Molano JC, Rincón H, Velasquez Tirado JD, Cardeño C, Patarroyo Rodriguez L, Oviedo Lugo GF, Bernal Miranda J, Rojas Moreno M. Consensus of the Liaison-Psychiatry Committee of the Colombian Psychiatric Association on the Diagnosis and Treatment of Delirium in the Context of the COVID-19 Pandemic. REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2020; 51:S0034-7450(20)30118-9. [PMID: 33735042 PMCID: PMC7709601 DOI: 10.1016/j.rcp.2020.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 09/14/2020] [Accepted: 11/02/2020] [Indexed: 12/15/2022]
Abstract
The pandemic caused by the new coronavirus named SARS-CoV-2 poses unprecedented challenges in the health care. Among them is the increase in cases of delirium. The severe SARS-CoV-2 disease, COVID-19, has common vulnerabilities with delirium and produces alterations in organs such as the lungs or the brain, among others, which have the potential to trigger the mental disorder. In fact, delirium may be the first manifestation of the infection, before fever, general malaise, cough or respiratory disturbances. It is widely supported that delirium increases the morbidity and mortality in those who suffer from it during hospitalization, so it should be actively sought to carry out the relevant interventions. In the absence of evidence on the approach to delirium in the context of COVID-19, this consensus was developed on three fundamental aspects: diagnosis, non-pharmacological treatment and pharmacological treatment, in patients admitted to the general hospital. The document contains recommendations on the systematic use of diagnostic tools, when to hospitalize the patient with delirium, the application of non-pharmacological actions within the restrictions imposed by COVID-19, and the use of antipsychotics, taking into account the most relevant side effects and pharmacological interactions.
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Affiliation(s)
- José G Franco
- Escuela de Ciencias de la Salud, Facultad de Medicina, Grupo de Investigación en Psiquiatría de Enlace (GIPE), Universidad Pontificia Bolivariana, Medellín, Colombia.
| | - Juan Carlos Molano
- Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia; Facultad de Medicina, Departamento de Salud Mental, Grupo de Investigación Fundamental: Psiquiatría de Enlace Salud Poblacional, Uniandes, Bogotá, Colombia
| | - Hernán Rincón
- Hospital Universitario Fundación Valle del Lili, Cali, Colombia; Escuela de Medicina, Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
| | - Juan David Velasquez Tirado
- Escuela de Ciencias de la Salud, Facultad de Medicina, Grupo de Investigación en Psiquiatría de Enlace (GIPE), Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Carlos Cardeño
- Hospital Universitario San Vicente Fundación, Medellín, Colombia; Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia; Facultad de Medicina, Departamento de Psiquiatría, Grupo de Investigación Clínica Aplicada, Universidad de Antioquia, Medellín, Colombia
| | - Liliana Patarroyo Rodriguez
- Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia; Facultad de Medicina, Departamento de Salud Mental, Grupo de Investigación Fundamental: Psiquiatría de Enlace Salud Poblacional, Uniandes, Bogotá, Colombia
| | - Gabriel Fernando Oviedo Lugo
- Hospital Universitario San Ignacio, Centro de Memoria y Cognición Intellectus, Bogotá, Colombia; Facultad de Medicina, Departamento de Psiquiatría y Salud Mental, Grupo de Investigación: Perspectivas en ciclo vital, salud mental y psiquiatría, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Jaime Bernal Miranda
- Remeo Medical Center, Cali, Colombia; IBIS Biomedical Research Group, Cali, Colombia
| | - Monica Rojas Moreno
- Clínica Reina Sofía, Bogotá, Colombia; Psiquiatría de Enlace e Interconsulta, Grupo de Investigación: Salud Mental, Neurodesarrollo y Calidad de Vida, Universidad El Bosque, Bogotá, Colombia
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Rastegar DA, Jarrell AS, Chen ES. Implementation of a Protocol Using the 5-Item Brief Alcohol Withdrawal Scale for Treatment of Severe Alcohol Withdrawal in Intensive Care Units. J Intensive Care Med 2020; 36:1361-1365. [PMID: 32851920 DOI: 10.1177/0885066620952762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is variation in the treatment of patients with severe alcohol withdrawal and a need for effective protocols. The purpose of this study was to evaluate the implementation of a symptom-triggered benzodiazepine protocol using the 5-item Brief Alcohol Withdrawal Scale (BAWS) for treatment of alcohol withdrawal in intensive care units (ICUs). METHODS This retrospective study included admissions to ICUs of 2 hospitals over 6 months who had an alcohol withdrawal protocol ordered and experienced severe withdrawal. Records were reviewed to collect demographic data, benzodiazepine exposure, duration of treatment, and withdrawal severity. RESULTS The protocol was ordered and implemented in 279 admissions; 48 (17.9%) had severe withdrawal defined as a BAWS of 6 or more. The majority of the 48 patients were from the emergency department (79.2%); mean hospital length of stay was 11.2 days and mean ICU stay 6.6 days; 31.3% required mechanical ventilation. A little more than half were treated only with the protocol (53.2%); 25.0% received additional benzodiazepines, 20.8% dexmedetomidine, 10.4% propofol, 25.0% antipsychotics and 2.0% phenobarbital. CONCLUSION Among ICU patients treated for alcohol withdrawal with a symptom-triggered benzodiazepine protocol using a novel 5-item scale, most did not develop severe withdrawal, and of those who did, approximately half were treated with the protocol alone.
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Affiliation(s)
- Darius A Rastegar
- Division of Addiction Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Andrew S Jarrell
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Edward S Chen
- Division of Pulmonary and Critical Care Medicine, 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Franco JG, Oviedo Lugo GF, Patarroyo Rodriguez L, Bernal Miranda J, Molano JC, Rojas Moreno M, Cardeño C, Velasquez Tirado JD. Survey of psychiatrists and psychiatry residents in Colombia about their preventive and therapeutic practices in delirium. REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2020; 50:S0034-7450(20)30031-7. [PMID: 33735057 DOI: 10.1016/j.rcp.2020.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 01/02/2020] [Accepted: 02/20/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe pharmacological and non-pharmacological practices for delirium, carried out by psychiatry residents and psychiatrists in Colombia. METHODS An anonymous survey was conducted based on the consensus of experts of the Liaison Psychiatry Committee of the Asociación Colombiana de Psiquiatría [Colombian Psychiatric Association] and on the literature review. It was sent by email to the association members. RESULTS 101 clinicians participated. Non-pharmacological preventive measures such as psychoeducation, correction of sensory problems or sleep hygiene are performed by 70% or more. Only about 1 in 10 participants are part of an institutional multi-component prevention programme. The preventive prescription of drugs was less than 20%. Regarding non-pharmacological treatment, more than 75% recommend correction of sensory difficulties, control of stimuli and reorientation. None of the participants indicated that the care at their centres is organised to enhance non-pharmacological treatment. 17.8% do not use medication in the treatment of delirium. Those who use it prefer haloperidol or quetiapine, particularly in hyperactive or mixed motor subtypes. CONCLUSIONS The practices of the respondents coincide with those of other experts around the world. In general, non-pharmacological actions are individual initiatives, which demonstrates the need in Colombian health institutions to commit to addressing delirium, in particular when its prevalence and consequences are indicators of quality of care.
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Affiliation(s)
- José G Franco
- Escuela de Ciencias de la Salud, Facultad de Medicina, Grupo de Investigación en Psiquiatría de Enlace (GIPE), Universidad Pontificia Bolivariana, Medellín, Colombia.
| | - Gabriel Fernando Oviedo Lugo
- Hospital Universitario San Ignacio, Centro de Memoria y Cognición Intellectus, Bogotá, Colombia; Facultad de Medicina, Departamento de Psiquiatría y Salud Mental, Grupo de Investigación: Perspectivas en ciclo vital, salud mental y psiquiatría, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Liliana Patarroyo Rodriguez
- Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia; Facultad de Medicina, Departamento de Salud Mental, Grupo de Investigación Fundamental: Psiquiatría de Enlace Salud Poblacional, Uniandes, Bogotá, Colombia
| | - Jaime Bernal Miranda
- Remeo Medical Center, Cali, Colombia; IBIS Biomedical Research Group, Cali, Colombia
| | - Juan Carlos Molano
- Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia; Facultad de Medicina, Departamento de Salud Mental, Grupo de Investigación Fundamental: Psiquiatría de Enlace Salud Poblacional, Uniandes, Bogotá, Colombia
| | - Monica Rojas Moreno
- Clínica Reina Sofía, Bogotá, Colombia; Psiquiatría de Enlace e Interconsulta, Grupo de Investigación: Salud Mental, Neurodesarrollo y Calidad de Vida, Universidad El Bosque, Bogotá, Colombia
| | - Carlos Cardeño
- Hospital Universitario San Vicente Fundación, Medellín, Colombia; Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia; Facultad de Medicina, Departamento de Psiquiatría, Grupo de Investigación Clínica Aplicada, Universidad de Antioquia, Medellín, Colombia
| | - Juan David Velasquez Tirado
- Escuela de Ciencias de la Salud, Facultad de Medicina, Grupo de Investigación en Psiquiatría de Enlace (GIPE), Universidad Pontificia Bolivariana, Medellín, Colombia
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Glahn A, Proskynitopoulos PJ, Bleich S, Hillemacher T. Pharmacotherapeutic management of acute alcohol withdrawal syndrome in critically Ill patients. Expert Opin Pharmacother 2020; 21:1083-1092. [PMID: 32281894 DOI: 10.1080/14656566.2020.1746271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Alcohol withdrawal syndrome is a common and life-threatening condition in patients suffering from alcohol use disorder. Treatment of this syndrome is challenging, especially in patients that are critically ill, either because of withdrawal symptoms or underlying conditions. For the treatment, several pharmacological agents exist, such as benzodiazepines, barbiturates, or dexmedetomidine. Nonetheless, as alcohol withdrawal syndromes can occur in every clinical setting, it is necessary to provide a guideline for clinicians confronted with this syndrome in varying clinical contexts. AREAS COVERED The authors provide a systematic review of the literature found in PubMed and Embase following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. EXPERT OPINION For the treatment of alcohol withdrawal syndrome, medications targeting the GABA system are preferred. Benzodiazepines are regarded as the gold standard. However, as many adjunct therapeutic options exist, it is essential to find symptom-triggered approaches and treatment protocols for the variety of clinical contexts. Apart from that, it is necessary to compare protocols toward clinical variables rather than investigating medications that are in use for the treatment of alcohol withdrawal syndrome.
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Affiliation(s)
- A Glahn
- Department of Psychiatry, Psychotherapy and Social Psychiatry, Hannover Medical School , Hannover, Germany
| | - P J Proskynitopoulos
- Department of Psychiatry, Psychotherapy and Social Psychiatry, Hannover Medical School , Hannover, Germany
| | - S Bleich
- Department of Psychiatry, Psychotherapy and Social Psychiatry, Hannover Medical School , Hannover, Germany
| | - T Hillemacher
- Department of Psychiatry, Psychotherapy and Social Psychiatry, Hannover Medical School , Hannover, Germany.,Department of Psychiatry and Psychotherapy, Paracelcus Medical University , Nuremberg, Germany
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Skryabin VY, Zastrozhin MS, Torrado MV, Grishina EA, Ryzhikova KA, Shipitsyn VV, Galaktionova TE, Sorokin AS, Bryun EA, Sychev DA. How do CYP2C19*2 and CYP2C19*17 genetic polymorphisms affect the efficacy and safety of diazepam in patients with alcohol withdrawal syndrome? Drug Metab Pers Ther 2020; 35:/j/dmdi.ahead-of-print/dmpt-2019-0026/dmpt-2019-0026.xml. [PMID: 32134726 DOI: 10.1515/dmpt-2019-0026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/17/2020] [Indexed: 11/15/2022]
Abstract
Background Diazepam is one of the most commonly prescribed tranquilizers for therapy of alcohol withdrawal syndrome (AWS). Despite its popularity, there is currently no precise information on the effect of genetic polymorphisms on its efficacy and safety. The objective of our study was to investigate the effect of CYP2C19*2 and CYP2C19*17 genetic polymorphisms on the efficacy and safety of diazepam in patients with AWS. Methods The study was conducted on 30 Russian male patients suffering from the AWS who received diazepam in injections at a dosage of 30.0 mg/day for 5 days. The efficacy and safety assessment was performed using psychometric scales and scales for assessing the severity of adverse drug reactions. Results Based on the results of the study, we revealed the differences in the efficacy of therapy in patients with different CYP2C19 681G>A (CYP2C19*2, rs4244285) genotypes: (CYP2C19*1/*1) -8.5 [-15.0; -5.0], (CYP2C19*1/*2 and CYP2C19*2/*2) -12.0 [-13.0; -9.0], p = 0.021. The UKU scale scores, which were used to evaluate the safety of therapy, were also different: (CYP2C19*1/*1) 7.0 [6.0; 12.0], (CYP2C19*1/*2 and CYP2C19*2/*2) 9.5 [8.0; 11.0], p = 0.009. Patients carrying different CYP2C19 -806C>T (CYP2C19*17, rs12248560) genotypes also demonstrated differences in therapy efficacy and safety rates. Conclusions Thus, the effects of CYP2C19*2 and CYP2C19*17 genetic polymorphisms on the efficacy of diazepam were demonstrated.
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Affiliation(s)
- Valentin Yu Skryabin
- Moscow Research and Practical Centre on Addictions of the Moscow Department of Healthcare, 37/1 Lyublinskaya Street, Moscow109390,Russia, Phone: +7-925-367-64-13, Fax: +7499-709-64-03
| | - Mikhail S Zastrozhin
- Moscow Research and Practical Centre on Addictions of the Moscow Department of Healthcare, Moscow, Russia.,Russian Medical Academy of Continuous Professional Education of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Marco V Torrado
- University of Lisbon, Faculty of Medicine, ISAMB (Instituto de Saúde Ambiental), Avenida Professor Egas Moniz MB, Lisboa, Portugal
| | - Elena A Grishina
- Russian Medical Academy of Continuous Professional Education of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Kristina A Ryzhikova
- Russian Medical Academy of Continuous Professional Education of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Valery V Shipitsyn
- Moscow Research and Practical Centre on Addictions of the Moscow Department of Healthcare, Moscow, Russia
| | - Tatiana E Galaktionova
- Moscow Research and Practical Centre on Addictions of the Moscow Department of Healthcare, Moscow, Russia
| | - Alexander S Sorokin
- Moscow Research and Practical Centre on Addictions of the Moscow Department of Healthcare, Moscow, Russia
| | - Evgeny A Bryun
- Moscow Research and Practical Centre on Addictions of the Moscow Department of Healthcare, Moscow, Russia.,Russian Medical Academy of Continuous Professional Education of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Dmitry A Sychev
- Russian Medical Academy of Continuous Professional Education of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
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