Predictors of dropout from inpatient opioid detoxification with buprenorphine: a chart review

What is the ideal time to begin tapering opioid agonist treatment? A protocol for a retrospective population-based comparative effectiveness study in British Columbia, Canada

INTRODUCTION

Opioid agonist treatment (OAT) tapering involves a gradual reduction in daily medication dose to ultimately reach a state of opioid abstinence. Due to the high risk of relapse and overdose after tapering, this practice is not recommended by clinical guidelines, however, clients may still request to taper off medication. The ideal time to initiate an OAT taper is not known. However, ethically, taper plans should acknowledge clients' preferences and autonomy but apply principles of shared informed decision-making regarding safety and efficacy. Linked population-level data capturing real-world tapering practices provide a valuable opportunity to improve existing evidence on when to contemplate starting an OAT taper. Our objective is to determine the comparative effectiveness of alternative times from OAT initiation at which a taper can be initiated, with a primary outcome of taper completion, as observed in clinical practice in British Columbia (BC), Canada.

METHODS AND ANALYSIS

We propose a population-level retrospective observational study with a linkage of eight provincial health administrative databases in BC, Canada (01 January 2010 to 17 March 2020). Our primary outcomes include taper completion and all-cause mortality during treatment. We propose a 'per-protocol' target trial to compare different durations to taper initiation on the likelihood of taper completion. A range of sensitivity analyses will be used to assess the heterogeneity and robustness of the results including assessment of effectiveness and safety.

ETHICS AND DISSEMINATION

The protocol, cohort creation and analysis plan have been classified and approved as a quality improvement initiative by Providence Health Care Research Ethics Board and the Simon Fraser University Office of Research Ethics. Results will be disseminated to local advocacy groups and decision-makers, national and international clinical guideline developers, presented at international conferences and published in peer-reviewed journals electronically and in print.

A narrative review of outcome measures used in drug and alcohol inpatient withdrawal treatment research

ISSUES

Assessing drug and alcohol inpatient withdrawal treatment programs is important, as these represent a first step of treatment among people with alcohol and drug problems. However, there are many ways of measuring outcomes making it difficult for service providers to decide which domains and methods to use. This narrative review aims to clarify frequencies of the domains and methods used to assess withdrawal treatment outcomes.

APPROACH

We reviewed published studies that examined outcomes of inpatient drug and alcohol withdrawal treatment. The types of outcome measures used and the frequency of use were summarised.

KEY FINDINGS

The review showed that assessment of withdrawal treatment outcomes goes beyond traditional abstinence measures. Outcomes mainly focus on biological and psychological outcomes, with social outcomes rarely measured. Even within outcome domains (e.g., cravings), there were many assessment methods.

IMPLICATIONS

The review provides service providers with an outline of common outcome domains and measures. Given the importance of social functioning to recovery from alcohol and drug problems, greater emphasis on such measures is desirable. Future research could develop greater consensus on outcome measures for use in withdrawal management services to facilitate clarity around factors associated with treatment success.

CONCLUSION

Outcome assessment in withdrawal treatment goes beyond abstinence to include holistic measurement of biological, psychological and some social outcomes; but more work needs to be done to cohere the different assessment methods and broaden the scope to include social functioning.

Treatment retention and abstinence of patients with substance use disorders according to addiction severity and psychiatry comorbidity: A six-month follow-up study in an outpatient unit

INTRODUCTION

The impact of psychiatric comorbidity and addiction features throughout the course of addiction has been widely studied. This is a naturalistic study conducted in an outpatient unit, where treatment follow-up studies are scarce compared to studies including inpatients or those under experimental conditions. Therefore, this follow-up study aims to analyze the treatment adherence and abstinence of outpatients with SUD (Substance Use Disorders) according to addiction severity and psychiatric comorbidity.

METHODS

The current six-month follow-up study examined 404 SUD outpatients. Psychiatric comorbidity, addiction severity, substance consumption and treatment adherence were systematically evaluated using semistructured interviews. Survival analyses were conducted to compare the time of treatment adherence and abstinence in a bivariate and multivariate level.

RESULTS

A progressive dropout was observed, reaching 32.2% of dropouts at the six-month follow-up. More than 50% achieved abstinence during the first month and similar percentages were found until the six-month follow-up. At the multivariate level, treatment adherence, cannabis use disorder and polyconsumption were independently associated with earlier dropout. ADHD was the only mental disorder significantly related with dropout. Regarding substance consumption, the time of abstinence was independently associated with months of treatment adherence and the achievement of abstinence before starting treatment. In general, dual diagnosis was associated with less time of abstinence, but only depressive disorder across the lifespan was related to less time of abstinence in the multivariate model.

CONCLUSION

These findings highlight the importance of an accurate diagnosis at the beginning of treatment, especially in an outpatient setting, addressing the treatment needs and promoting strategies that improve treatment adherence and reduce the risk of relapses.

Predictors of and reasons for early discharge from inpatient withdrawal management settings: A scoping review

ISSUES

Early discharges, also known as 'against medical advice' discharges, frequently occur in inpatient withdrawal management settings and can result in negative outcomes for patients. The purpose of this scoping review is to identify what is known about predictors of and reasons for the early discharge among adults accessing inpatient withdrawal management settings.

APPROACH

MEDLINE, CINAHL, PsycINFO, ASSIA and EMBASE were searched, resulting in 2587 articles for screening. Title and abstract screening and full-text review were completed by two independent reviewers. Results were synthesised in quantitative and qualitative formats.

KEY FINDINGS

Sixty-two studies were included in this scoping review. All studies focused on predictors of early discharge, except one which only described reasons for the early discharge. Forty-eight percent of studies involved retrospective review of health records data. The most frequently examined variables were demographics. Variables related to the treatment setting, such as referral source and treatment received, were examined less frequently but were more consistently associated with early discharge compared to demographics. Only six studies described patient reasons for the early discharge, which were retrieved via clinical documentation. The most common reasons for early discharge were dissatisfaction with treatment and family issues.

IMPLICATIONS AND CONCLUSIONS

Most demographic variables do not consistently predict early discharge, and reasons for early discharge are not well understood. Future studies should focus on the predictive value of non-patient-level variables, or conduct analyses to account for predictors of early discharge among different subgroups of people (e.g. by gender or ethnicity). Qualitative research exploring patient perspectives is needed.

Predictors of Leaving an Inpatient Medical Withdrawal Service Against Medical Advice: A Retrospective Analysis

OBJECTIVES

The purpose of this study was to determine the frequency and predictors of patients leaving an inpatient medical withdrawal unit against medical advice (AMA).

METHODS

This study used a case-control design to compare patients who were discharged AMA (n = 164) with those who completed treatment (n = 678). Logistic regression analysis was used to determine which variables were independent predictors of patients leaving AMA.

RESULTS

We found that being admitted through the emergency department (odds ratio [OR] 3.17, confidence interval [CI] 1.66-6.08), having gamma-hydroxybutyrate (OR 7.61, CI 1.81-32.09) as a primary substance of concern compared to alcohol, and having multiple axis I psychiatric diagnoses (OR 2.20, CI 1.16-4.18) or depression (OR 2.86, CI 1.32-6.17) compared with no psychiatric diagnosis increased the odds of leaving inpatient medical withdrawal AMA. By contrast, not being dependent on nicotine (OR 0.45, CI 0.23-0.88) and increasing time since admission (OR 0.42, CI 0.36-0.48) reduced the odds of leaving AMA.

CONCLUSIONS

The findings of this study reveal novel information about patients who leave inpatient medical withdrawal AMA and can inform targeted interventions to prevent vulnerable patients from terminating treatment early and improve healthcare service utilization.

Expectations about alcohol, cocaine, and benzodiazepine abstinence following inpatient heroin withdrawal management

BACKGROUND AND OBJECTIVES

Polysubstance use is associated with relapse and poor treatment outcomes among people dependent on heroin. Despite the high prevalence of polysubstance use among patients detoxifying from heroin, little is known about patients' expectations to abstain or use non-opiate substances. The current study examined factors associated with expectations about abstaining from alcohol, cocaine, and benzodiazepines (BZDs) following heroin withdrawal management.

METHODS

Between May and December of 2015, we surveyed 417 patients (71.9% male, 31.7 [±8.39] mean years old) initiating short-term inpatient heroin withdrawal management who reported alcohol, cocaine, or BZD use in the past 30 days. We used logistic regression to evaluate the adjusted associations of background characteristics with expectations about using each substance following discharge.

RESULTS

Approximately half of respondents reported past month alcohol (52%), cocaine (47.0%), or BZD (47.0%) use, and 25.9% reported using all three substances. Approximately half of those reporting drinking, 6.6% reporting cocaine use, and 27% of reporting BZD use expected to abstain from using that substance following heroin withdrawal. Prior opioid withdrawal was associated with a lower likelihood of expecting to stop using alcohol and BZDs, and more days of BZD use was associated with a greater likelihood of expecting to abstain from BZDs following discharge.

CONCLUSION

Persons with opioid use disorder often do not expect to stop using other substances following withdrawal management, with very few planning cocaine cessation.

SCIENTIFIC SIGNIFICANCE

Inpatient heroin withdrawal programs need to address and educate patients about how polysubstance use complicates recovery from heroin use. (Am J Addict 2019;28:36-42).

Severity of Withdrawal Symptoms, Plasma Oxytocin Levels, and Treatment Outcome in Heroin Users Undergoing Acute Withdrawal

Pre-clinical studies show that, following chronic opioid exposure, oxytocin neurons exhibit over-excitation upon withdrawal, causing an increase in oxytocin brain and plasma levels. Relevant clinical data on humans are scarce. This study investigates the opioid withdrawal stress effect on oxytocin plasma levels in humans. We evaluated 57 male chronic heroin users in a residential detoxification program. We determined plasma oxytocin levels by ELISA and measured the stress effects of withdrawal using the COWS scale for opioid withdrawal, the VAS scale for craving, and the Hamilton scales for anxiety and depression on the second day of admission. Out of the 57 patients enrolled in the study, 27 completed the 21-day program, while the remaining 30 dropped out prior to completion. Plasma oxytocin levels were significantly higher in those individuals who dropped out than in those who completed the program. Participants who dropped out at some stage scored higher in the COWS, VAS-Craving, and Hamilton-anxiety scales, indicating a higher stress and explaining the higher oxytocin levels. In addition, plasma oxytocin levels correlated positively with the scores achieved in the COWS and Hamilton-anxiety scales. Higher withdrawal stress levels are associated with higher plasma oxytocin levels and early treatment discharge.

Predictors of Relapse after Inpatient Opioid Detoxification during 1-Year Follow-Up

Introduction. Relapse rate after opioid detoxification is very high. We studied the possibility that predetoxification patient characteristics might predict relapse at follow-up and thus conducted this 1-year follow-up study to assess the predictors of relapse after inpatient opioid detoxification. Materials and Methods. We conducted this study in our tertiary care institute in India over two-year time period (1 Jan 2014 to 31 Dec 2015). Out of 581 patients admitted, 466 patients were considered for study. Results and Discussion. No significant difference was found between relapsed and nonrelapsed patients regarding sociodemographic profile; however substance abuse pattern and forensic history showed significant differences. Relapsed patients abused greater amount and used injections more commonly, as compared to nonrelapsed group. Longer duration of abuse was also a significant risk factor. Patients with past attempt of opioid detoxification and family history (parental or first degree) of alcohol abuse had decreased possibility of maintaining remission during 1-year follow-up. Relapsed patients were found to abuse their spouse or parents. Conclusion. Our study compared profiles of relapsed and nonrelapsed patients after inpatient detoxification and concluded predictors of relapse during 1-year follow-up period. Early identification of predictors of relapse and hence high risk patients might be helpful in designing more effective and focused treatment plan.