Specialist alcohol inpatient treatment admissions and non-specialist hospital admissions for alcohol withdrawal in England: an inverse relationship.

AIMS: We assessed the relationship between specialist and non-specialist admissions for alcohol withdrawal since the introduction of the UK government Health and Social Care Act in 2012. METHODS: Using publicly available national data sets from 2009 to 2019, we compared the number of alcohol withdrawal admissions and estimated costs in specialist and non-specialist treatment settings. RESULTS: A significant negative correlation providing strong evidence of an association was observed between the fall in specialist and rise in non-specialist admissions. Significant cost reductions within specialist services were displaced to non-specialist settings. CONCLUSIONS: The shift in demand from specialist to non-specialist alcohol admissions due to policy changes in England should be reversed by specialist workforce investment to improve outcomes. In the meantime, non-specialist services and staff must be resourced and equipped to meet the complex needs of these service users.

Alcohol withdrawal is associated with poorer outcome in acute ischemic stroke.

OBJECTIVE: To determine the association between alcohol abuse (AA) and alcohol withdrawal (AW) with acute ischemic stroke (AIS) outcomes. METHODS: All adult AIS admissions in the United States from 2004 to 2014 were identified from the National Inpatient Sample (weighted n = 4,438,968). Multivariable-adjusted models were used to evaluate the association of AW with in-hospital medical complications, mortality, cost, and length of stay in patients with AIS. RESULTS: Of the AA admissions, 10.6% of patients, representing 0.4% of all AIS, developed AW. The prevalence of AA and AW in AIS increased by 45.2% and 40.0%, respectively, over time (p for trend <0.001). Patients with AA were predominantly men (80.2%), white (65.9%), and in the 40- to 59-year (44.6%) and 60- to 79-year (45.6%) age groups. After multivariable adjustment, AIS admissions with AW had >50% increased odds of urinary tract infection, pneumonia, sepsis, gastrointestinal bleeding, deep venous thrombosis, and acute renal failure compared to those without AW. Patients with AW were also 32% more likely to die during their AIS hospitalization compared to those without AW (odds ratio 1.32, 95% confidence interval 1.11-1.58). AW was associated with ≈15-day increase in length of stay and ≈$5,000 increase in hospitalization cost (p < 0.001). CONCLUSION: AW is associated with increased cost, longer hospitalizations, and higher odds of medical complications and in-hospital mortality after AIS. Proactive surveillance and management of AW may be important in improving outcomes in these patients.

Recurrent use of inpatient withdrawal management services: Characteristics, service use, and cost among Medicaid clients.

Reducing repeat use of costly inpatient services, such as inpatient withdrawal management, among Medicaid members is a target of healthcare reform. However, characteristics of frequent users of inpatient withdrawal management are understudied. We described the characteristics, service utilization, and costs of New York Medicaid clients who use withdrawal management services by analyzing data from Medicaid records from 2008. We examined follow-up care for individuals with different levels of repeat withdrawal management. We found 32,196 Medicaid withdrawal management patients with a total of 67,073 episodes and we divided patients into low (1 episode, n = 19,602), medium (2-3 episodes, n = 8619) and high (≥4 episodes, n = 3978) use categories. High users had almost 8 times the withdrawal management cost of low users. Similarly, they had 5 times more emergency department visits than low users. High users had high levels of homelessness (75%), 20% had HIV/AIDS, and 40% had Hepatitis. High withdrawal management users were less likely than low users to receive any follow-up treatment services. Medicaid clients with high utilization of inpatient withdrawal management are a small but costly population with poor follow-up rates to subsequent treatment services. They are a socially disenfranchised group that may benefit from targeted services to address their complex clinical needs.

[Evaluation of selected socioeconomic factors in patients with acute ethanol intoxication and alcohol withdrawal syndrome]. / Ocena wybranych czynników socjoekonomicznych u chorych z ostrym zatruciem etanolem i alkoholowym zespolem abstynencyjnym.

INTRODUCTION: Ethanol is commonly overused psychoactive substance in Poland and all around the world. It causes addiction, which occurs as a result of its chronic administration. One of the main symptoms of addiction is hunger due to psychoactive substance that prevents interruption of its adoption and contributes to relapse drinking. Acute poisoning with ethyl alcohol and alcohol withdrawal syndrome are diseases causing a potential danger to life. The prevalence of use and abuse of alcoholic beverages is a potential risk, causing health problems, including permanent damage of the central and peripheral nervous system and socio-economic problems. OBJECTIVE: The aim of this study is to analyze certain aspects of the socio-economic situation of the patients hospitalized in the Department of Toxicology in Raszeja City Hospital in Poznan due to acute ethanol intoxication or alcohol withdrawal syndrome in 2010. MATERIAL AND METHODS: 299 patients history was evaluated, among which 161 were treated for acute intoxication with ethanol and 138 due to alcohol withdrawal syndrome. Objects of interest were elements of subjective tests including: marital status of patients, their education and professional activity and the problem of homelessness. RESULTS: The study group consisted of 299 patients in age from 16 to 77 years, hospitalized in the Department of Toxicology in Raszeja City Hospital in Poznan due to acute ethanol intoxication or alcohol withdrawal syndrome. It was found that the largest group consisted of patients remaining married (42.81%) and unmarried (30.43%). Alcohol abuse affects people of all levels of education. In the present study, most patients had a vocational education (37.79%) and medium (23.08%). Patients were analyzed in terms of economic activity, among which about 40% were unemployed. In the whole group more than 10% of those were homeless. CONCLUSIONS: Ethyl alcohol intoxication and alcohol withdrawal represents a significant hazard. As a result of reliance, patients lose control of alcohol consumption and they cannot reduce the amount and the time of its adoption. Reducing the dose of alcohol can lead to unpleasant withdrawal symptoms that the patient eliminate by adopting another dose. Typical is to continue the alcohol consumption despite knowledge of its harmful health and difficulties such as professional (problems at work or loss), financial (lack of livelihood, poverty) and interpersonal (loss of friends, marriage breakdown, loss of relationships with relatives).

"I just wanted to tell you that loperamide WILL WORK": a web-based study of extra-medical use of loperamide.

AIMS: Many websites provide a means for individuals to share their experiences and knowledge about different drugs. Such User-Generated Content (UGC) can be a rich data source to study emerging drug use practices and trends. This study examined UGC on extra-medical use of loperamide among illicit opioid users. METHODS: A website that allows for the free discussion of illicit drugs and is accessible for public viewing was selected for analysis. Web-forum posts were retrieved using web crawlers and retained in a local text database. The database was queried to extract posts with a mention of loperamide and relevant brand/slang terms. Over 1290 posts were identified. A random sample of 258 posts was coded using NVivo to identify intent, dosage, and side-effects of loperamide use. RESULTS: There has been an increase in discussions related to loperamide's use by non-medical opioid users, especially in 2010-2011 Loperamide was primarily discussed as a remedy to alleviate a broad range of opioid withdrawal symptoms, and was sometimes referred to as "poor man's" methadone. Typical doses ranged 70-100mg per day, much higher than an indicated daily dose of 16mg. CONCLUSIONS: This study suggests that loperamide is being used extra-medically to self-treat opioid withdrawal symptoms. There is a growing demand among people who are opioid dependent for drugs to control withdrawal symptoms, and loperamide appears to fit that role. The study also highlights the potential of the Web as a "leading edge" data source in identifying emerging drug use practices.

Socioeconomic status and smoking: a review.

Smoking prevalence is higher among disadvantaged groups, and disadvantaged smokers may face higher exposure to tobacco's harms. Uptake may also be higher among those with low socioeconomic status (SES), and quit attempts are less likely to be successful. Studies have suggested that this may be the result of reduced social support for quitting, low motivation to quit, stronger addiction to tobacco, increased likelihood of not completing courses of pharmacotherapy or behavioral support sessions, psychological differences such as lack of self-efficacy, and tobacco industry marketing. Evidence of interventions that work among lower socioeconomic groups is sparse. Raising the price of tobacco products appears to be the tobacco control intervention with the most potential to reduce health inequalities from tobacco. Targeted cessation programs and mass media interventions can also contribute to reducing inequalities. To tackle the high prevalence of smoking among disadvantaged groups, a combination of tobacco control measures is required, and these should be delivered in conjunction with wider attempts to address inequalities in health.

Clinical experience with fortnightly buprenorphine/naloxone versus buprenorphine in Italy: preliminary observational data in an office-based setting.

Buprenorphine/naloxone is a new option for the management of opioid dependence. It has a reduced potential for abuse or misuse compared with methadone and buprenorphine alone, and has a long half-life allowing less frequent dosing. Buprenorphine/naloxone appears to be well suited for the management of opioid dependence in an office-based setting. The aim of this study was to evaluate the efficacy and safety of a buprenorphine/naloxone combination treatment in an office-based setting. Therefore, we evaluated the effect on misuse/diversion, quality of care, quality of life and service delivery. Seventy-eight patients were switched to buprenorphine/naloxone from either methadone or buprenorphine alone; the median duration of previous buprenorphine or methadone treatment was 10 years. Patients received buprenorphine/naloxone and were evaluated throughout a 1-year follow-up period. Treatment was self-administered by the patients every 2 weeks and the mean buprenorphine dosage at 1 year was 8 mg/day. Comparisons were made before and after the switch for patients who switched from buprenorphine alone to buprenorphine/naloxone. Switching to buprenorphine/naloxone was not associated with clinically relevant problems in 50% of patients studied. Buprenorphine/naloxone provided satisfactory coverage of withdrawal symptoms in 78.1% of patients, and 50% of patients were satisfied with buprenorphine/naloxone therapy. Seventy-eight per cent of patients reported improved psychosocial functioning. The majority of patients (approximately 85%) were negative for opioids during toxicological testing. A significantly higher proportion of treatment recipients were highly satisfied during buprenorphine/naloxone administration (p < 0.001 compared with buprenorphine given before the switch). Other outcomes were similar during buprenorphine and buprenorphine/naloxone administration. Fortnightly self-administration of buprenorphine/naloxone appeared to be cost saving for the clinic. Buprenorphine/naloxone is an effective and safe treatment option for the outpatient management of opioid dependence.

Subjective social status affects smoking abstinence during acute withdrawal through affective mediators.

OBJECTIVES: Direct and mediated associations between subjective social status (SSS), a subjective measure of socio-economic status, and smoking abstinence were examined during the period of acute withdrawal among a diverse sample of 421 smokers (33% Caucasian, 34% African American, 33% Latino) undergoing a quit attempt. METHODS: Logistic regressions examined relations between SSS and abstinence, controlling for socio-demographic variables. Depression, stress, positive affect and negative affect on the quit day were examined as potential affective mediators of the SSS-abstinence association, with and without adjusting for pre-quit mediator scores. RESULTS: SSS predicted abstinence to 2 weeks post-quit. Abstinence rates were 2.6 (postquit week 1) and 2.4 (postquit week 2) times higher in the highest versus the lowest SSS quartile. Depression and positive affect mediated the SSS-abstinence relationships, but only depression maintained significance when adjusting for the baseline mediator score. CONCLUSIONS: Among a diverse sample of quitting smokers, low SSS predicted relapse during acute withdrawal after controlling for numerous covariates, an effect accounted for partially by quit day affective symptomatology. Smokers endorsing lower SSS face significant hurdles in achieving cessation, highlighting the need for targeted interventions encompassing attention to quit day mood reactivity.

Alcohol withdrawal syndrome: Turning minor injuries into a major problem.

BACKGROUND: Abrupt cessation of chronic drinking patterns places hospitalized patients at risk for alcohol withdrawal syndrome (AWS). The purpose of this study was to investigate the effect of AWS on length of stay, morbidity, mortality, and cost in low injury acuity trauma patients. METHODS: A retrospective review of the National Trauma Registry of the American College of Surgeons database from July 1999 to February 2004 was performed. All patients 15 years or older admitted to our Level I trauma center with an Injury Severity Score (ISS) <16 were included. AWS patients were compared with those without AWS. Demographics, mechanism of injury (MOI), ISS, revised trauma score, Glasgow Coma score, hospital course, morbidity, requirement of additional procedures, mortality, and cost were compared. Analysis was done with chi2 test and Student's t test. A p value of < or =0.05 determined significance. RESULTS: Of 6,431 patients, 55 (0.9%) developed AWS. AWS patients were likely men (p < 0.001); had a higher ISS (p = 0.001) and lower Glasgow Coma score (p = 0.01); had more ventilator days (p = 0.008), intensive care unit days (p < 0.0001), and hospital days (p < 0.0001); suffered more complications, including respiratory failure (p < 0.0001), pneumonia (p < 0.0001), urinary tract infection (p = 0.0005), sepsis (p < 0.0001), tracheostomy (p < 0.0001), and percutaneous endoscopic gastrostomy (p < 0.0001); and had higher cost (p < 0.0001). Mortality was similar (p = 0.38) among groups. CONCLUSIONS: Low injury acuity patients with AWS have increased morbidity, leading to increased hospital stay and cost. To allow minor injuries to remain minor problems, the best modality to identify patients at risk and to achieve AWS prophylaxis require further investigation.

Delay discounting and the behavioural economics of cigarette purchases in smokers: the effects of nicotine deprivation.

RATIONALE: In smokers, nicotine deprivation may increase impulsive decision-making and the demand for cigarettes. OBJECTIVES: To investigate the effects of acute nicotine deprivation on (a) the delay discounting of monetary and cigarette rewards, and (b) the behavioural economics of hypothetical cigarette purchases. MATERIALS AND METHODS: A repeated measures design was employed, with participants (daily cigarette smokers, N=30) repeating experimental tasks in two different sessions, once after at least 13 h of abstinence from smoking and once after ad lib smoking. Participants completed measures of cigarette craving, impulsivity, delay discounting and a behavioural economic simulation in which participants made hypothetical purchases of cigarettes and other commodities as the price of cigarettes was systematically varied. RESULTS: Participants showed more pronounced delay discounting of both cigarette and monetary rewards after abstinence compared to after ad lib smoking. In the behavioural economic simulation, nicotine deprivation had no influence on hypothetical cigarette purchases. However, spending on some commodities (alcohol, clothing, household goods, leisure activities and long-distance travel) was reduced as the price of cigarettes increased in order to fund increased spending on cigarettes, although the number of packs of cigarettes purchased actually decreased. CONCLUSIONS: Nicotine deprivation increases impulsive choices for both cigarette and monetary rewards in a delay-discounting task. Results from a behavioural economic simulation suggest that increases in the price of cigarettes may increase smokers' spending on cigarettes, while also reducing the number of cigarettes purchased.

Ergot and triptan overuse in Austria--an evaluation of clinical data and cost.

Austria is one of the countries, in which ergots are still the most commonly used acute anti-migraine drugs. Overuse and chronification is a clinical problem for ergots, but also for the recently developed triptans. In a retrospective study for the year 1999 we evaluated clinical data from all Austrian neurological hospitals including cost of withdrawal as well as the estimated cost for ergots and triptans on the pharmaceutical retail market. We identified a total of 96 patients that underwent withdrawal, all of whom because of ergot overuse, and some with considerable long-term side-effects. The cost of withdrawal (more than 1300 000) together with direct cost of medication amounted to more than 11 million. In contrast, cost of medication for triptans was 12.8 million for the same year, without any cost for withdrawal. If only cost aspects were to be considered in the prescription of acute anti-migraine drugs, our data would suggest to choose ergots rather than triptans. However, as scientific evidence is clearly in favour of triptans, decision making for the prescribing clinicians is more complex and will primarily focus on optimizing patient care, but also depend on the respective socio-economic situation.

Withdrawal of peripheral vasodilators in primary care.

AIMS: To investigate the use of peripheral vasodilators in selected practices in primary care and to observe the effect of withdrawing therapy in a sample of patients. METHODS: Patients receiving repeat prescriptions for peripheral vasodilators, identified from two practices in Grampian, were interviewed prior to and following withdrawal of therapy. RESULTS: Of the 35 patients, review of the continued need for therapy was documented in the medical notes of only one patient. Treatment was successfully withdrawn from 17 patients, generating considerable savings. CONCLUSIONS: Review of peripheral vasodilators merits further attention in larger numbers of patients.

Clinical issues related to the costs of alcoholism.

Alcohol (ethanol) use disorders are prevalent in many countries and are associated with significant social and health costs. Little is known, however, about the comparative cost effectiveness of treatments for alcoholism. Pharmacoeconomic evaluations are largely (if not wholly) absent from the alcoholism treatment outcome database. We discuss pharmacological approaches to the treatment of alcohol withdrawal and dependence, describing agents that ameliorate withdrawal symptoms, deter alcohol consumption, reduce alcohol craving and produce conditioned alcohol aversion. Cost-relevant clinical considerations are elucidated and recommendations for cost-conscious pharmacological treatment of alcohol dependence are proffered.

A prospective evaluation of benzodiazepine guidelines in the management of patients hospitalized for alcohol withdrawal.

Our institution adopted guidelines for the selection of benzodiazepines to be administered to patients hospitalized for alcohol withdrawal. We assessed the guidelines' impact on prescribing habits, benzodiazepine dosage requirements and costs, and length of intensive care unit (ICU) stay. A 6-month prospective, observational study was performed in 50 patients who exhibited signs of alcohol withdrawal and received benzodiazepine therapy. Appropriate therapy was defined as lorazepam for patients 60 years and older or those with hepatic dysfunction, and chlordiazepoxide for all other patients. Benzodiazepine costs were calculated based on acquisition cost. Based on our guidelines, 76% of patients were appropriate candidates for a long-acting agent such as chlordiazepoxide; 61% of these candidates actually received such a drug. Using a benzodiazepine conversion to compare doses in chlordiazepoxide equivalents, there was a significant difference in the total mean dose of chlordiazepoxide (1295.5 mg, SD +/- 1571) compared with lorazepam (365.5 mg; SD +/- 446) (p < 0.01). The mean total chlordiazepoxide acquisition cost was $61.74 (range $0.03-585.98) per patient (28 patients); prior to adoption of the guidelines, the mean cost of benzodiazepine therapy was $1008.72 (+/- $1554.45). For patients receiving chlordiazepoxide, the mean days of ICU and hospital stay were 1.1 days (range 0-9 days) and 5.6 days (range 1-17 days), respectively; before adoption of the guidelines, the mean number of days of ICU stay was significantly greater (4.1 days, p < 0.0001). The guidelines resulted in a substantial change in benzodiazepine prescribing patterns.(ABSTRACT TRUNCATED AT 250 WORDS)

A retrospective review and assessment of benzodiazepines in the treatment of alcohol withdrawal in hospitalized patients.

Little information has been published concerning differences among the benzodiazepines in treating hospitalized patients with severe symptoms of alcohol withdrawal. We attempted to determine the length and type of hospital stay, and the pattern and appropriateness of administration, dosage requirements, and costs associated with benzodiazepines in patients undergoing alcohol withdrawal. A 1-year retrospective analysis was performed for 57 hospitalized patients. Appropriate therapy was defined as lorazepam for patients 60 years and older or those with hepatic dysfunction, and chlordiazepoxide or diazepam for all other patients. Drug costs were calculated based on acquisition costs. The mean number of days of benzodiazepine treatment and length of stay in the intensive care unit (ICU) were 6.2 days (range 1-30 days) and 3.9 days (range 0-12 day), respectively. Fifty-six patients were admitted to the ICU for management or for monitoring continuous-infusion lorazepam; one patient received chlordiazepoxide on a general ward. Total mean lorazepam infusion required per patient was 324 mg (range 2-5956 mg). The total benzodiazepine acquisition cost was $56,489 (mean $1009, range $0.06-7157/patient). The total costs of benzodiazepine acquisition and ICU charge were $404,346 (mean $7462/patient). Based on our criteria, 41 of 57 patients could have been treated appropriately with chlordiazepoxide, which would have resulted in an estimated drug-acquisition cost savings of at least $37,000. Mean benzodiazepine dosage requirements in patients hospitalized for alcohol withdrawal appear higher than previously reported. Approximately 70% of our patients were not of advanced age and had no evidence of organ dysfunction, and therefore, could have been treated with an oxidized benzodiazepine (i.e., chlordiazepoxide).(ABSTRACT TRUNCATED AT 250 WORDS)

Alcohol withdrawal: what is the benzodiazepine of choice?

OBJECTIVE: To review the literature concerning the use of benzodiazepines for treatment of alcohol withdrawal and to determine if the current literature assessment justifies the use of lorazepam as first-line therapy. DATA SOURCES: A thorough review of the literature was performed with an online database (BRS Colleague). Articles directed at the targeted issue were chosen and additional references were obtained from the bibliographies of these articles. STUDY SELECTION: Clinical trials and case reports concerning the use of chlordiazepoxide, diazepam, and lorazepam in alcohol withdrawal treatment were reviewed. DATA SYNTHESIS: Lorazepam is considered by many to be the drug of choice for alcohol withdrawal because it undergoes glucuronidation and has an intermediate half-life. These characteristics have suggested its superiority when treating elderly patients or patients with liver disease. However, some studies suggest that a drug with a longer half-life would provide smoother withdrawal. In addition, the number of patients with liver disease treated for alcohol withdrawal is unknown. These and other factors question the recommendation of lorazepam as the drug of choice. CONCLUSIONS: Well-controlled comparison studies should be performed before recommending the routine use of lorazepam for treating alcohol withdrawal syndrome.