Inpatient management of gamma-hydroxybutyrate withdrawal.

OBJECTIVES: To describe the baseline characteristics, treatment and retention in patients electively admitted for gamma-hydroxybutyrate (GHB) withdrawal management. METHODS: All patients admitted between July 2010 to June 2016 who used GHB two or more times per week with a minimum duration of 3 months were identified and data extracted by file review. RESULTS: Twelve cases satisfied the inclusion criteria, of whom 50% were female; 75% were using GHB daily, with an average daily amount of 16 ml. Average duration of use was 60 months. All subjects were using amphetamine type stimulants and nicotine. Psychiatric comorbidity and unintentional overdose were common; 50% completed treatment. Medications used included diazepam and neuroleptic. Two patients completed withdrawal with no medications. No subject using greater than 90 ml GHB in the preceding week completed treatment. Pattern of GHB use did not predict medication requirements during withdrawal management. CONCLUSIONS: There were low numbers attending for elective treatment for GHB use. Heavier GHB use predicted poor treatment retention. Polysubstance use and psychiatric co-morbidities need consideration in treatment planning.

Opioid use disorder in anaesthesia and intensive care: Prevention, diagnosis and management.

Opioid misuse is common, as is opioid agonist treatment of opioid dependence. Almost 3% of Australians and over 3.5% of those living in New Zealand report misuse of analgesics. Over 50,000 Australians receive opioid agonist treatment with methadone or buprenorphine for management of severe opioid use disorder.The perioperative period is an opportunity to identify pre-existing opioid misuse, and to introduce interventions to reduce the risk of development of opioid use disorder. Challenges of acute perioperative pain management or intensive care management of patients receiving opioid agonist treatment include opioid tolerance and ongoing prescribing of methadone or buprenorphine. There has been some ambiguity about the optimal perioperative management of buprenorphine, a partial agonist at the mu receptor.In this article, a framework to identify emerging opioid misuse problems, identify risk of overdose and to manage the opioid-dependent patient on opioid agonist treatment perioperatively or in the intensive care unit is provided. Diagnostic criteria and risk stratification criteria are presented. Management strategies include trauma-informed care, care planning and care coordination with community practitioners and opioid agonist treatment providers. Continuing methadone or buprenorphine perioperatively with additional opioid and non-opioid analgesia is generally recommended. Increased opioid agonist treatment doses may be required on discharge. An algorithm for decisions about opioid agonist treatment management in the intensive care unit based on the risks of opioid withdrawal and toxicity is considered. Strategies for managing the opioid-dependent patient who is not in treatment are also discussed.

Training in addiction medicine in Australia.

Barriers to entering addiction medicine (AM) have led to a persisting workforce shortage. To address this problem, the Chapter of Addiction Medicine (AChAM) was formed in 2001 as a subdivision of the Royal Australasian College of Physicians (RACP). Through consultation, AChAM has identified the scope of practice and offered fellowship to suitable established practitioners. The Chapter successfully applied to the Australian Government for recognition of AM as a medical specialty, which was finalized in November 2009. Specialist reimbursement item numbers were incorporated into that decision process and commence operating in November 2010. AChAM has designed and implemented a training scheme using a model similar to that of the RACP internal medicine training program. This comprises 3 years of basic general medical training post internship followed by 3 years of discipline-specific supervised training. The training is broadly based, with experience in both ambulatory care and inpatient care, and including physical health as well as mental health. Assessment is continuous and competency based. There is no exit examination. The overriding clinical approach rests upon the harm minimization framework consistent with long-established national drug policy in Australia and favors evidence-based treatment.

Prescription and administration of opioids to hospital in-patients, and barriers to effective use.

OBJECTIVE: This study aimed to describe prescribing and administration of opioids in a tertiary referral teaching hospital. Secondary aims were assessment of staff knowledge of opioid pharmacology and available preparations, and of perceived barriers limiting opioid use. DESIGN: A cross-sectional survey of in-patients requiring opioid analgesia was performed. An anonymous semi-structured questionnaire was administered to medical and nursing staff. SETTING: Australian tertiary referral teaching hospital. PATIENTS: All patients prescribed opioids on study wards over 3 months (N = 190). RESULTS: Oxycodone was the most frequently prescribed opioid (51.4%). The majority (64.7%) of participants had incomplete pain relief, which was significantly associated with having opioid related side effects. There was no association between pain relief and prescribed daily dose or received daily dose of opioids. Limited understanding of opioid preparations, tolerance, and dependence was demonstrated by staff. The most common perceived barriers to opioid use included difficulties in identifying the right dose, staff time required to prescribe and monitor, and large numbers of preparations. While prescription of inadequate doses was perceived as a barrier, this study identified that submaximal doses were administered. An opioid educational session improved knowledge of opioid formulations. CONCLUSION: The majority of participants had incomplete pain relief and the maximum prescribed doses of opioids were not administered. Reported barriers included staff knowledge of opioid dose titration and opioid preparations, and time constraints. Identified barriers included poor knowledge of opioid preparations.

Utility of urine drug screening: a clinical audit.

OBJECTIVE: To assess requesting patterns and clinical utility of urine drug screens (UDS). METHODS: All UDS requests received between March 2002 and October 2002 were identified. Two trained assessors reviewed case histories and categorized the utility of the UDS and gave a utility score using a Visual Analogue Scale. RESULTS: Of 171 UDS requested, 67.3% were men. Age range was 15-92 (mean 36) years. In total, 70.8% were received from accident and emergency centre (AEC). Clinical utility was identified in only 85 of 171 UDS. Sixty-one per cent of requests from AEC were defined as having no clinical utility. Twenty-four per cent of requests originating from other specialities were identified as having no clinical utility. Overall, a test was more likely to be of utility if it was requested from non-AEC than from AEC (Pearson's chi(2) two-sided t-test, P < 0.0001). Indications for UDS were toxic ingestion (33.3%), psychosis (15.2%), impaired consciousness (13.5%), behavioural disturbance (4.1%), confusion with HIV infection (3.5%), alleged adulteration (3.5%), seizure (9.4%), cardiac arrest (1.8%) and miscellaneous (15.8%). CONCLUSIONS: Our data show excessive requesting for UDS in routine overdose, contrary to international guidelines. Requests for UDS originating from AEC are more likely to have no utility than those from other specialities. Availability of point of care UDS might increase use of UDS, but cost-effectiveness and utility must be assessed.

The assessment of frailty in older people in acute care.

AIM: Develop a measure of frailty for older acute inpatients to be performed by non-geriatricians. METHOD: The Reported Edmonton Frail Scale (REFS) was adapted from the Edmonton Frail Scale for use with Australian acute inpatients. With acute patients aged over 70 years admitted to an Australian teaching hospital, we validated REFS against the Geriatrician's Clinical Impression of Frailty (GCIF), measures of cognition, comorbidity and function, and assessed inter-rater reliability. RESULTS: REFS was moderately correlated with GCIF (n = 105, R = 0.61, P < 0.01), Mini-Mental State Examination impairment (n = 61, R = 0.49, P < 0.001), Charlson Comorbidity Index (n = 59, R = 0.51, P < 0.001) and Katz Daily Living Scale (n = 59, R = 0.51, P < 0.001). Inter-rater reliability of REFS administered by two researchers without medical training was excellent (kappa = 0.84, n = 31). CONCLUSION: In this cohort of older acute inpatients, REFS is a valid, reliable test of frailty, and may be a valuable research tool to assess the impact of frailty on prognosis and response to therapy.