Outcomes of Outpatient Parenteral Antimicrobial Therapy in Patients With Injection Drug Use.

BACKGROUND: Historically, there has been a restrictive approach toward outpatient parenteral antimicrobial therapy (OPAT) in patients with injection drug use (IDU) due to the fear that they might utilize the intravenous catheter to inject illicit substances. OBJECTIVE: We tested the hypothesis that patients with current IDU on OPAT would have less favorable treatment outcomes compared to those without current IDU. METHODS: In this retrospective cohort chart review study of Cleveland Clinic OPAT registry, we identified patients with current IDU by both electronic and manual review. For each patient with current IDU, we identified 3 matched controls among those on OPAT and without current IDU, by propensity score matching on age, sex, OPAT year, and OPAT diagnosis. We compared treatment failure, infection relapse, line infection, hospital readmission, number of emergency room visits, and 90-day mortality, for patients with current IDU and their matched controls. RESULTS: We identified 39 patients with current IDU and 117 matched controls. Most patients with current IDU (82%) were discharged to skilled nursing facilities, whereas the majority of the control group (74%) was treated at home (p < 0.01). There was no significant difference in the examined treatment outcomes between the 2 groups. CONCLUSIONS: Patients with current IDU on OPAT did not have less favorable treatment outcomes compared to those without current IDU. Although the reason for this finding could potentially be related to difference in disposition, more studies need to be done to assess safety of home disposition among these patients.

Treatment of Kratom Withdrawal and Addiction With Buprenorphine.

: In this article, we describe a middle-aged woman with a history of addiction to opioid medications who eventually became dependent on kratom. Her kratom-related withdrawal symptoms responded to a trial of buprenorphine-naloxone. Subsequently, she was maintained on this medication.

Correction: Quitting smoking: still a challenge, but newer tools show promise.

In the article "Quitting smoking: Still a challenge, but newer tools show promise," (Collins GB, Jerry JM, Bales R. Cleve Clin J Med 2015; 82:39-48), the reference sequencing has been corrected.

E-cigarettes: Safe to recommend to patients?

Electronic cigarettes (e-cigarettes)--devices that generate a nicotine vapor that can be inhaled by the user in a fashion that mimics the experience of smoking--are increasing in popularity, and many people seem to view them as reasonable alternatives to nicotine replacement therapy to help them refrain from smoking. Physicians should not encourage such a view. E-cigarettes are unregulated nicotine delivery systems that have never been subjected to any kind of testing of safety or of efficacy as nicotine replacement therapy. Moreover, for young people who have never smoked, these devices could potentially serve as a gateway drug.

Quitting smoking: still a challenge, but newer tools show promise.

Smoking continues to be a major public health problem with devastating consequences in terms of morbidity and mortality. Physicians are strongly encouraged to engage patients in a serious, concerted, and consistent effort to overcome nicotine addiction. Brief counseling in combination with medications has been shown to be effective. This article provides physicians guidelines for helping patients to quit this addictive disorder.

Bath salts in the emergency department: a survey of emergency clinicians' experience with bath salts-intoxicated patients.

OBJECTIVES: Several novel synthetic amphetamines have been marketed worldwide as "bath salts." The use of bath salts is associated with severe medical consequences resulting in a US federal ban over the last 3 years on the more common substances found in this group. Bath salts intoxication has a relatively nonspecific presentation, and urine toxicology confirmation in emergency departments (EDs) is impractical because the turnaround time is several days. Emergency clinicians must therefore rely heavily on patients' self-reports to verify the diagnosis. We performed an online survey of emergency clinicians to determine their degree of exposure to bath salts-intoxicated patients, the clinically relevant features of such patients, and the typical emergency management. METHODS: We invited 124 physicians and physician assistants in 7 Cleveland Clinic EDs to participate in an online survey. RESULTS: From a total of 43 of the 124 respondents, 77% did not specifically ask patients about bath salts use. Sixty percent had encountered a bath salts-intoxicated individual. Most respondents reported that the majority of patients were male, were between 19 and 29 years old, and used other drugs in addition to bath salts. Agitation, aggression/violence, and hallucinations were reported to be the most common presentations, and intravenous/intramuscular tranquilization was reported as the most often used management. Most patients were discharged home from the ED. CONCLUSIONS: Despite the lack of toxicology screening in EDs, about two thirds of the surveyed emergency clinicians encountered bath salts-intoxicated individuals. Our study demonstrates the need for increased screening of bath salts intoxication in EDs, especially in agitated patients.

Injection Drug Use and Outcomes After Surgical Intervention for Infective Endocarditis.

BACKGROUND: Infective endocarditis (IE) requiring surgical intervention in patients who actively inject drugs poses treatment challenges. Decisions regarding the need for operation are affected by concern for relapse of IE from ongoing injection drug use (IDU). The purpose of this study was to evaluate the effect of active IDU on outcomes after operation for IE. METHODS: All patients with IE surgically treated at Cleveland Clinic from July 1, 2007 to July 1, 2012 were identified from the Cleveland Clinic Infective Endocarditis Registry and the Cardiovascular Information Registry. Of 536 patients operated on for IE during the study period, 41 (8%) actively injected drugs. The primary outcome of the study was death or reoperation for IE. RESULTS: Patients who injected drugs had poorer survival free of reoperation, and the risk of events varied with time. In a multivariable Cox proportional hazards model, using time-dependent covariates, IDU was associated with a higher hazard of death or reoperation between 90 and 180 days (hazard ratio [HR], 9.8; 95% confidence interval [CI], 2.7-35.3) but not before 90 days (HR, 0.38; 95% CI, 0.05-3.1) or after 180 days (HR, 1.8; 95% CI, 0.8-3.8). Among patients who injected drugs, reoperation and death contributed equally to the outcome, whereas among patients who did not inject drugs, reoperation for IE was far less common. CONCLUSIONS: Between 3 and 6 months after operation for IE, patients who inject drugs have a hazard of death or reoperation that is about 10 times that of patients who do not inject drugs. Before and after, the HRs are much smaller and not statistically significant.

Aripiprazole: profile on efficacy and safety.

Aripiprazole (Abilitat, Bristol-Myers Squibb) is the most recent addition to the new class of atypical antipsychotic medications, following the release of clozapine, risperidone, olanzapine, quetiapine and ziprasidone. Aripiprazole exhibits typical antagonism at dopamine (D2) receptors in the mesolimbic pathway, as well as having unique partial agonist activity at D2 receptors in the mesocortical pathway. As exemplified by other atypical antipsychotics, it displays strong 5-HT(2a) receptor antagonism and is similar to ziprasidone in also having agonistic activity at the 5-HT(1a) receptor. Among the atypical antipsychotics, aripiprazole displays the lowest affinity for alpha(1)adrenergic (alpha(1)), histamine (H1) and muscarinic (M1) receptors. This combination of effects may be responsible for its efficacy in positive and negative symptoms of schizophrenia and in bipolar disorder. Similarly, this profile may be the reason for the low rates of reported side effects observed. This includes general adverse events, a low incidence of reported weight gain and a low liability for inducing movement disorders. Other early data suggest that aripiprazole may induce reductions in plasma prolactin, as well as in plasma glucose and lipid profiles. Finally, results also support the proposition that aripiprazole may lead to reductions in corrected QT interval and have minimal drug interactions.

Medication-assisted treatment of opiate dependence is gaining favor.

People addicted to opiates are more likely to avoid returning to these drugs if they participate in a program that includes taking maintenance doses of methadone or buprenorphine than with an abstinence program. Although medical opinion has long been divided on the issue of abstinence vs medication-assisted treatment, the latter seems to be gaining respect as an evidence-based approach.