1
|
Lindberg HB, Steindal SA, Kvande ME. Critical care nurses' experiences of caring for patients with iatrogenic opioid withdrawal in the intensive care unit: A qualitative study. Intensive Crit Care Nurs 2023; 78:103452. [PMID: 37178587 DOI: 10.1016/j.iccn.2023.103452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 04/20/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVES To explore critical care nurses' experiences of caring for adult patients experiencing iatrogenic opioid withdrawal in the intensive care unit. RESEARCH METHODOLOGY/DESIGN A qualitative study with an explorative and descriptive design was conducted. Data were collected through semi-structured interviews and systematic text condensation was used to analyse the data. The study was reported according to the consolidated criteria for reporting qualitative research checklist. SETTING AND PARTICIPANTS Ten critical care nurses, working at three different intensive care units in two university hospitals in Norway. FINDINGS Three categories were identified in the data analysis. "Subtle signs and symptoms of opioid withdrawal", lack of a systematic approach to opioid withdrawal, and the prerequisites for appropriate management of opioid withdrawal. Critical care nurses experienced challenges in identifying opioid withdrawal due to subtle and vague signs and symptoms, especially when not knowing their patient or when difficulties were encountered with patient communication. A systematic approach to opioid withdrawal and increased knowledge, definitive plans for weaning, as well as interdisciplinary unity and collaboration, could improve the management of opioid withdrawal. CONCLUSION Validated assessment tools, systematic strategies, and guidelines are essential for the management of opioid withdrawal in opioid naïve patients in intensive care units. The prerequisites for an appropriate management of opioid withdrawal are an accurate and effective communication among critical care nurses and other healthcare professionals involved in patient care. IMPLICATIONS FOR CLINICAL PRACTICE There is a need for a validated assessment tool, systematic strategies, and guidelines for the management of opioid withdrawal in opioid naïve patients in intensive care units. Increased emphasis needs to be placed on the process of identifying iatrogenic opioid withdrawal and improving opioid withdrawal management in the education system and clinical practice.
Collapse
Affiliation(s)
- Hedda Bekken Lindberg
- Lovisenberg Diaconal University College, Lovisenberggata 15B, 0456 Oslo, Norway; Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway.
| | - Simen A Steindal
- Lovisenberg Diaconal University College, Lovisenberggata 15B, 0456 Oslo, Norway; Faculty of Health Studies, VID Specialized University, Oslo, Norway.
| | - Monica Evelyn Kvande
- Lovisenberg Diaconal University College, Lovisenberggata 15B, 0456 Oslo, Norway; Department of Anaesthesiology and Surgery, University Hospital of North Norway, Tromsø, Norway.
| |
Collapse
|
2
|
Genaro K, Yoshimura RF, Doan BP, Johnstone TB, Hogenkamp DJ, Gee KW. Allosteric modulators of the δ GABA A receptor subtype demonstrate a therapeutic effect in morphine-antinociceptive tolerance and withdrawal in mice. Neuropharmacology 2022; 219:109221. [PMID: 36084794 PMCID: PMC11012237 DOI: 10.1016/j.neuropharm.2022.109221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 07/29/2022] [Accepted: 08/09/2022] [Indexed: 11/26/2022]
Abstract
The present study evaluated the effects of compounds targeting extrasynaptic δ subunit-containing γ-aminobutyric acid type A receptors (δ*-GABAARs) to interrogate the role of tonic inhibition in the development of antinociceptive tolerance caused by repeated morphine administration. We investigated the effect of subchronic or acute treatment with non-steroidal positive allosteric modulators (PAMs) of δ*-GABAARs, such as 2-261, on the morphine-antinociceptive tolerance. Mice were treated twice daily with morphine for 9 days and antinociception was measured using the hot water tail immersion test. Co-treatment with 2-261 and morphine prevented morphine-antinociceptive tolerance and acute administration of 2-261 on day 9 was sufficient to reverse the tolerance. Other compounds with activity at δ*-GABAARs also reversed morphine tolerance, whereas an enaminone that lacked activity at δ*-GABAARs did not. Acute administration of 2-261 did not cause an additive or synergistic antinociceptive effect when combined with an acute submaximal dose of morphine. We then used Cre/LoxP recombination to generate GABAA δ-subunit knockout mice to corroborate the pharmacological results. Observations of male δ-knockout mice demonstrated that the δ*-GABAARs was necessary for 2-261 modulation of both analgesic tolerance and somatic withdrawal symptoms produced by subchronic morphine. While female mice still benefited from the positive effects of 2-261, the δ-subunit was not necessary for these effects, highlighting a distinction of the different pathways that could have implications for some of the sex-related differences seen in human opioid-induced outcomes. Consequently, subtype-specific allosteric modulators of GABAARs may warrant further investigation as pharmacological targets to manage tolerance and withdrawal from opioids.
Collapse
Affiliation(s)
- K Genaro
- Department of Pharmaceutical Sciences, University of California Irvine, Irvine, CA, 92697-4625, USA; Department of Anesthesiology, School of Medicine, University of California, Irvine, CA, 92697, USA.
| | - R F Yoshimura
- Department of Pharmaceutical Sciences, University of California Irvine, Irvine, CA, 92697-4625, USA.
| | - B P Doan
- Department of Pharmaceutical Sciences, University of California Irvine, Irvine, CA, 92697-4625, USA; Department of Anesthesiology, School of Medicine, University of California, Irvine, CA, 92697, USA
| | - T B Johnstone
- Department of Pharmaceutical Sciences, University of California Irvine, Irvine, CA, 92697-4625, USA
| | - D J Hogenkamp
- Department of Pharmaceutical Sciences, University of California Irvine, Irvine, CA, 92697-4625, USA
| | - K W Gee
- Department of Pharmaceutical Sciences, University of California Irvine, Irvine, CA, 92697-4625, USA
| |
Collapse
|
3
|
Tirado CF, Washburn SN, Covalin A, Hedenberg C, Vanderpool H, Benner C, Powell DP, McWade MA, Khodaparast N. Delivering transcutaneous auricular neurostimulation (tAN) to improve symptoms associated with opioid withdrawal: results from a prospective clinical trial. Bioelectron Med 2022; 8:12. [PMID: 35978394 PMCID: PMC9385243 DOI: 10.1186/s42234-022-00095-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 07/29/2022] [Indexed: 11/23/2022] Open
Abstract
Background As pharmacological treatments are the primary option for opioid use disorder, neuromodulation has recently demonstrated efficacy in managing opioid withdrawal syndrome (OWS). This study investigated the safety and effectiveness of transcutaneous auricular neurostimulation (tAN) for managing OWS. Methods This prospective inpatient trial included a 30-minute randomized, sham-controlled, double-blind period followed by a 5-day open-label period. Adults with physical dependence on opioids were randomized to receive active or sham tAN following abrupt opioid discontinuation. The Clinical Opiate Withdrawal Scale (COWS) was used to determine withdrawal level, and participants were required to have a baseline COWS score ≥ 13 before enrollment. The double-blind period of the study occurred during the first 30-minutes to assess the acute effects of tAN therapy compared to a sham control. Group 1 received active tAN during both the 30-minute double-blind period and the 5-day open-label period. Group 2 received passive sham tAN (no stimulation) during the double-blind period, followed by active tAN during the 5-day open-label period. The primary outcome was change in COWS from baseline to 60-minutes of active tAN (pooled across groups, accounting for 30-minute delay). Secondary outcomes included difference in change in COWS scores between groups after 30-minutes of active or sham tAN, change in COWS scores after 120-minutes of active tAN, and change in COWS scores on Days 2–5. Non-opioid comfort medications were administered during the trial. Results Across all thirty-one participants, the mean (SD) COWS scores relative to baseline were reduced by 7.0 (4.7) points after 60-minutes of active tAN across both groups (p < 0.0001; Cohen’s d = 2.0), demonstrating a significant and clinically meaningful reduction of 45.9%. After 30-minutes of active tAN (Group 1) or sham tAN (Group 2), the active tAN group demonstrated a significantly greater COWS score reduction than the sham tAN group (41.7% vs. 24.1%; p = 0.036). Participants across both groups achieved an average COWS reduction up to 74.7% on Days 2–5. Conclusion Results demonstrate tAN is a safe and effective non-opioid approach for reducing symptoms of OWS. This study supported an FDA clearance. Clinical trial registration clinicaltrials.gov/ct2/show/NCT04075214, Identifier: NCT04075214, Release Date: August 28, 2019.
Collapse
Affiliation(s)
- Carlos F Tirado
- CARMAhealth Management, Inc., 630 W 34th St #301, Austin, TX, 78705, USA
| | | | - Alejandro Covalin
- Spark Biomedical, Inc., 18208 Preston Road, Ste D9-531, Dallas, TX, 75252, USA
| | - Caroline Hedenberg
- CARMAhealth Management, Inc., 630 W 34th St #301, Austin, TX, 78705, USA
| | - Heather Vanderpool
- Spark Biomedical, Inc., 18208 Preston Road, Ste D9-531, Dallas, TX, 75252, USA
| | - Caroline Benner
- Spark Biomedical, Inc., 18208 Preston Road, Ste D9-531, Dallas, TX, 75252, USA
| | - Daniel P Powell
- Spark Biomedical, Inc., 18208 Preston Road, Ste D9-531, Dallas, TX, 75252, USA
| | - Melanie A McWade
- Spark Biomedical, Inc., 18208 Preston Road, Ste D9-531, Dallas, TX, 75252, USA
| | - Navid Khodaparast
- Spark Biomedical, Inc., 18208 Preston Road, Ste D9-531, Dallas, TX, 75252, USA.
| |
Collapse
|
4
|
Bruneau A, Frimerman L, Verner M, Sirois A, Fournier C, Scott K, Perez J, Shir Y, Martel MO. Day-to-day opioid withdrawal symptoms, psychological distress, and opioid craving in patients with chronic pain prescribed opioid therapy. Drug Alcohol Depend 2021; 225:108787. [PMID: 34091157 DOI: 10.1016/j.drugalcdep.2021.108787] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/27/2021] [Accepted: 03/25/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Research has shown that opioid craving is one of the strongest determinants of opioid misuse in patients with chronic pain. To date, however, little is known on the factors that contribute to opioid craving in these patients. It is possible that patients' physical dependence to opioids, manifested by opioid withdrawal symptoms in between daily opioid doses, contribute to opioid craving. Physical dependence symptoms might also lead to psychological distress, which in turn might contribute to opioid craving. The first objective of this study was to examine the day-to-day association between opioid withdrawal symptoms and opioid craving among patients with chronic pain. We also examined whether negative affect and catastrophic thinking mediated this association. METHODS In this longitudinal study, chronic pain patients (n = 79) prescribed short-acting opioids completed daily diaries for 14 consecutive days. Diaries assessed a host of pain, psychological, and opioid-related variables. RESULTS Day-to-day elevations in opioid withdrawal symptoms were associated with heightened opioid craving (p < .001). Results of a multilevel mediation analysis revealed that this association was mediated by patients' daily levels of negative affect and catastrophizing (p < .001). CONCLUSIONS Our study provides valuable new insights into our understanding of factors that may contribute to prescription opioid craving among patients with chronic pain.
Collapse
|
5
|
Parkin S, Neale J, Brown C, Campbell ANC, Castillo F, Jones JD, Strang J, Comer SD. Opioid overdose reversals using naloxone in New York City by people who use opioids: Implications for public health and overdose harm reduction approaches from a qualitative study. Int J Drug Policy 2020; 79:102751. [PMID: 32304981 PMCID: PMC7572435 DOI: 10.1016/j.drugpo.2020.102751] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/30/2020] [Accepted: 04/01/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Adverse reactions to naloxone, such as withdrawal symptoms and aggression, are widely recognised in the literature by pharmaceutical manufacturers and clinical practitioners as standard reactions of individuals who are physically dependent upon opioid drugs following the reversal of potentially fatal opioid overdose. This paper seeks to provide a differentiated view on reactions to naloxone that may have important implications for public health and harm reduction approaches. METHODS Analyses from a qualitative investigation embedded within a 5-year Randomised Controlled Trial (RCT) examined the risks and benefits of Overdose Education and Naloxone Distribution (OEND) training models (brief or extended training) in various populations of people who use opioids in New York City. The qualitative experiences (obtained through semi-structured interviews) of 46 people who use opioids and who were each involved in the delivery of naloxone, during 56 separate overdose events that occurred throughout 2016-2018, were studied. Situational analysis and inductive content analysis of interview data focused upon overdose reversals in an attempt to provide understandings of the various adverse effects associated with naloxone from their perspective. These analyses were supplemented by data sessions within the research team during which the findings obtained from situational analysis and inductive content analysis were reviewed and complemented by deductive (clinical) appraisals of the various physical and psychological effects associated with the overdose reversals. RESULTS People who use opioids recognise three distinct and interconnected outcomes that may follow a successful opioid overdose reversal after intramuscular or intranasal administration of naloxone. These outcomes are here termed, (i) 'rage' (describing a wide range of angry, hostile and/or aggressive outbursts), (ii) 'withdrawal symptoms,' and (iii) 'not rage, not withdrawal' (i.e., a wide range of short-lived, 'harmless' conditions (such as temporary amnesia, mild emotional outbursts, or physical discomfort) that do not include rage or withdrawal symptoms). CONCLUSION Physical and psychological reactions to naloxone should not be understood exclusively as a consequence of acute, opioid-related, withdrawal symptoms. The three distinct and interconnected reversal outcomes identified in this study are considered from a harm reduction policy perspective and are further framed by concepts associated with 'mediated toxicity' (i.e., harm triggered by medicine). The overall conclusion is that harm reduction training programmes that are aligned to the policy and practice of take home naloxone may be strengthened by including awareness and training in how to best respond to 'rage' associated with overdose reversal following naloxone administration by people who use opioids and other laypersons.
Collapse
Affiliation(s)
- Stephen Parkin
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill SE5 8BB, United Kingdom.
| | - Joanne Neale
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill SE5 8BB, United Kingdom; Centre for Social Research in Health, University of New South Wales, Sydney, NSW 2052, Australia
| | - Caral Brown
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill SE5 8BB, United Kingdom
| | - Aimee N C Campbell
- Division on Substance Use Disorders, Columbia University Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 20, New York, NY 10032, United States
| | - Felipe Castillo
- Division on Substance Use Disorders, Columbia University Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 20, New York, NY 10032, United States
| | - Jermaine D Jones
- Division on Substance Use Disorders, Columbia University Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 20, New York, NY 10032, United States
| | - John Strang
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill SE5 8BB, United Kingdom; South London and Maudsley NHS Foundation Trust, Maudsley Hospital, London SE5 8AZ, United Kingdom
| | - Sandra D Comer
- Division on Substance Use Disorders, Columbia University Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 20, New York, NY 10032, United States
| |
Collapse
|
6
|
Pergolizzi JV, Varrassi G, Paladini A, LeQuang J. Stopping or Decreasing Opioid Therapy in Patients on Chronic Opioid Therapy. Pain Ther 2019; 8:163-76. [PMID: 31378000 DOI: 10.1007/s40122-019-00135-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Indexed: 12/19/2022] Open
Abstract
With the rising concerns about long-term opioid use, particularly in patients with chronic noncancer pain, more and more patients are being considered for decreased doses or discontinuation of opioid therapy. This is a challenging clinical situation for both patient and clinician and should be presented in a shared decision-making model so that the patient understands the risks of opioid therapy and how the therapy will be discontinued. The patient should be aware of the long-range plan and its milestones. It is imperative that alternate pain control treatments be made available to the patient early, and that the patient never feels abandoned by the healthcare team. There can be many barriers in shared decision-making and multiple discussions between patient and provider may be required. Opioid use should not be decreased sharply or discontinued abruptly, but should be gradually decremented in a process known as tapering. Tapering should be systematic and planned in advance with the patient knowing the steps. Slow tapers (over months) are more comfortable for the patients but may not always be appropriate. There is guidance for planning the taper and the patient should be closely monitored throughout this process. If withdrawal symptoms occur, they can be managed, for example, with lofexidine. Patients should get full support as they explore new pain control options. For patients who have opioid use disorder, addiction counseling may be appropriate. Navigating opioid discontinuation can be slow work, but optimal results occur when the healthcare team works together and respectfully with the patient.
Collapse
|