Evaluation of an emergency safe supply drugs and managed alcohol program in COVID-19 isolation hotel shelters for people experiencing homelessness

BACKGROUND

During a COVID-19 outbreak in the congregate shelter system in Halifax, Nova Scotia, Canada, a healthcare team provided an emergency "safe supply" of medications and alcohol to facilitate isolation in COVID-19 hotel shelters for residents who use drugs and/or alcohol. We aimed to evaluate (a) substances and dosages provided, and (b) outcomes of the program.

METHODS

We reviewed medical records of all COVID-19 isolation hotel shelter residents during May 2021. The primary outcome was successful completion of 14 days isolation, as directed by public health orders. Adverse events included (a) overdose; (b) intoxication; and (c) diversion, selling, or sharing of medications or alcohol.

RESULTS

Seventy-seven isolation hotel residents were assessed (mean age 42 ± 14 years; 24% women). Sixty-two (81%) residents were provided medications, alcohol, or cigarettes. Seventeen residents (22%) received opioid agonist treatment (methadone, buprenorphine, or slow-release oral morphine) and 27 (35%) received hydromorphone. Thirty-one (40%) residents received prescriptions stimulants. Six (8%) residents received benzodiazepines and forty-two (55%) received alcohol. Over 14 days, mean daily dosages increased of hydromorphone (45 ± 32 - 57 ± 42 mg), methylphenidate (51 ± 28 - 77 ± 37 mg), and alcohol (12.3 ± 7.6 - 13.0 ± 6.9 standard drinks). Six residents (8%) left isolation prematurely, but four returned. During 1059 person-days, there were zero overdoses. Documented concerns regarding intoxication occurred six times (0.005 events/person-day) and medication diversion/sharing three times (0.003 events/person-day).

CONCLUSIONS

COVID-19 isolation hotel residents participating in an emergency safe supply and managed alcohol program experienced high rates of successful completion of 14 days isolation and low rates of adverse events.

Perioperative Pain and Addiction Interdisciplinary Network (PAIN) clinical practice advisory for perioperative management of buprenorphine: results of a modified Delphi process

Until recently, the belief that adequate pain management was not achievable while patients remained on buprenorphine was the impetus for the perioperative discontinuation of buprenorphine. We aimed to use an expert consensus Delphi-based survey technique to 1) specify the need for perioperative guidelines in this context and 2) offer a set of recommendations for the perioperative management of these patients. The major recommendation of this practice advisory is to continue buprenorphine therapy in the perioperative period. It is rarely appropriate to reduce the buprenorphine dose irrespective of indication or formulation. If analgesia is inadequate after optimisation of adjunct analgesic therapies, we recommend initiating a full mu agonist while continuing buprenorphine at some dose. The panel believes that before operation, physicians must distinguish between buprenorphine use for chronic pain (weaning/conversion from long-term high-dose opioids) and opioid use disorder (OUD) as the primary indication for buprenorphine therapy. Patients should ideally be discharged on buprenorphine, although not necessarily at their preoperative dose. Depending on analgesic requirements, they may be discharged on a full mu agonist. Overall, long-term buprenorphine treatment retention and harm reduction must be considered during the perioperative period when OUD is a primary diagnosis. The authors recognise that inter-patient variability will require some individualisation of clinical practice advisories. Clinical practice advisories are largely based on lower classes of evidence (level 4, level 5). Further research is required in order to implement meaningful changes in practitioner behaviour for this patient group.

Homelessness and the mentally ill offender

This paper presents the results of a retrospective analysis of the discharge summaries of 69 mentally ill offenders. The subjects were patients in a New York State Psychiatric Hospital for a two-year period between January 1988 and December 1989 who were referred by the courts under New York State Criminal Procedure Law (CPL). The subjects were further compared as to homelessness at the time of the instant offense to study the association of this variable and criminal behavior among the mentally ill. Statistical analyses demonstrated significant relationships between variables of homelessness, prior offense history, and substance abuse.

Psychobiology of the violent offender

The antecedents of violent crime may include childhood victimization, head injuries, and alcohol and drug abuse. Neuropsychological and neuropsychiatric findings suggest temporal and frontal lobe dysfunctions in violent offenders; these dysfunctions appear to be more pronounced in the dominant hemisphere. Recent studies implicate disturbances of central serotonergic functions in impulsive homicide and arson. These results provide an adequate rationale for larger interdisciplinary studies using neurochemical, neuropsychiatric/neuropsychological, and psychosocial methods on the same subjects.

Beta-blockers in the severely and profoundly mentally retarded

The authors present data from four different institutions from open clinical trials of propranolol in 19 mentally retarded patients with IQs less than 50. When customary forms of treatment had failed, propranolol was initiated. A table showing changes in the patients' behavior is included. Twelve patients demonstrated a pronounced improvement in self-abusive and aggressive behavior, four made moderate gains, and three were considered unchanged. The authors postulate that at least some aspects of the behavioral improvement were due to the peripheral anxiolytic action of the beta-blockers. Contrary to other reports of using higher doses (greater than 520 mg/day range), the authors used a mean dose of 120 mg/day and consider the duration of time spent on the medication as a crucial factor in its effectiveness.