Questioning methadone split-dosing for analgesia among hospitalized patients with opioid use disorder.

Methadone is hypothesized to provide greater analgesic coverage when split into two or more divided doses. However, empirical data are lacking, and our anecdotal experience at a safety-net hospital among patients with opioid use disorder suggests that it may not be straightforward. Guidelines and clinicians should exercise appropriate caution when recommending this strategy.

Quadruple pharmacotherapy for alcohol use disorder tolerable yet insufficient: a case report.

BACKGROUND: Combinations of alcohol use disorder (AUD) medications have been investigated, but few if any reports describe patients maintained on more than two options at the same time. CASE PRESENTATION: We report a case of a middle-aged man hospitalized with gastrointestinal bleeding and acute kidney injury who had been maintained on four AUD medications (naltrexone, acamprosate, disulfiram, and gabapentin) and multiple psychiatric medications simultaneously as an outpatient. Direct quotations of his experiences with each AUD medication are included, revealing some deviations from what was prescribed as well as nuanced perceptions of effects. Overall, he tolerated the regimen well, but its AUD effects were insufficient to prevent several episodes of returning to alcohol use. He had very high hospital utilization. This prompted the initiation of an involuntary commitment, which began a period of at least six months of sobriety. CONCLUSIONS: Quadruple pharmacotherapy for AUD may be well tolerated and supportive of recovery for an extended period of time. However, for our patient the regimen ultimately failed to prevent multiple episodes of returning to alcohol use and serious medical complications. In refractory cases like this, more intensive interventions such as involuntary commitment can be considered.

Characterizing safer drinking strategies among hospitalized adults with severe alcohol use disorder; a cross-sectional secondary analysis.

BACKGROUND: Safer drinking strategies (SDS) reduce alcohol-related harms in outpatient settings. Little is known about SDS among hospitalized patients. OBJECTIVE: Evaluate SDS among hospitalized patients with alcohol use disorder (AUD) and assess for association with past-year acute-care utilization. METHODS: We conducted a cross-sectional, secondary analysis of hospitalized adults with AUD at a safety-net hospital in Colorado from January-December 2021. Participants completed a questionnaire on SDS and were categorized as low (≤2 reported) or high SDS (≥3 reported). Past-year emergency department visits and hospital admissions were identified using the electronic health record. A Mann-Whitney test compared encounters between low and high SDS groups. RESULTS: Among 43 hospitalized adults with AUD, 38 (88.4%) reported ≥1 SDS and 21 (48.8%) reported ≥3 SDS. The low SDS group had fewer past-year admissions than the high SDS group (U = 145.0, p = 0.015). CONCLUSION: SDS are frequently identified by patients and may be an acceptable form of inpatient AUD management.

Intramuscular, extended-release naltrexone inadvertently administered in the deltoid muscle: A case report.

BACKGROUND: Extended-release, intramuscular (IM) naltrexone can be an effective and convenient medication option for alcohol use disorder. We sought to assess the clinical impact of an alternate, if inadvertent, administration of IM naltrexone in the deltoid muscle instead of the recommended gluteal muscle. CASE SUMMARY: IM naltrexone was prescribed to a hospitalized 28-year-old man with severe alcohol use disorder as part of an inpatient clinical trial. A nurse unfamiliar with naltrexone administration mistakenly administered the drug to the deltoid instead of the gluteal muscle recommended by the manufacturer. Despite concerns that injection of the large-volume suspension to the smaller muscle would potentially contribute to increased pain and higher chance of adverse events owing to faster medication absorption, the patient experienced only mild discomfort to the deltoid region, without other adverse events on immediate physical and laboratory examinations. The patient later denied additional adverse events in the period after hospitalization, but he did not endorse any anti-craving effect of the medication, resuming drinking alcohol quickly following initial discharge. PRACTICE IMPLICATIONS: This case represents a unique procedural challenge of administering a medication in the inpatient setting that is typically given in the outpatient setting. Inpatient staff members frequently rotate and may be relatively unfamiliar with IM naltrexone, so handling should be limited to personnel who have received focused training on its administration. Fortunately, in this case deltoid administration of naltrexone was well-tolerated and even deemed quite "acceptable" to the patient. Clinically, the medication was insufficiently effective, but biopsychosocial context may have made his AUD especially refractory. More research is needed to fully establish whether naltrexone given via deltoid muscle injection has comparable safety and efficacy to gluteal muscle administration.

Severe, Nondelirium Agitation as an Underreported Characteristic of Precipitated Fentanyl Withdrawal: A Case Report.

Opioid overdose deaths continue to rise in conjunction with a surge in fentanyl use. Treating withdrawal and initiating recovery may involve rapid initiations of medications for opioid use disorder, such as buprenorphine, but there is a high risk of precipitated withdrawal. We report a case of a 30-year-old man in police custody who experienced precipitated fentanyl withdrawal, and it was refractory to continued buprenorphine escalation. After buprenorphine, he exhibited a particularly dramatic, nondelirium agitation, which we suspect is a common yet underreported characteristic of precipitated withdrawal. Although there was initial concern for delirium secondary to benzodiazepine withdrawal, this was ruled out by mental status examination and verified later by the patient himself. Nondelirium agitation, clarified by mental status testing, ought to be further reported and characterized in future studies of precipitated withdrawal as clinicians and researchers tackle the new challenges of widespread fentanyl use in the United States.

Single-dose intravenous ketamine or intramuscular naltrexone for high-utilization inpatients with alcohol use disorder: pilot trial feasibility and readmission rates.

BACKGROUND: Alcohol use disorder (AUD) accounts for millions of acute care encounters annually in the United States. Hospitalization represents a vital opportunity to intervene pharmacologically, but low medication adherence is a significant barrier. Two single-dose, adherence-independent interventions are well suited for pre-discharge administration: intravenous (IV) ketamine and intramuscular (IM) naltrexone. Their feasibility and readmission-reducing efficacy in hospital settings are not well-established. METHODS: A 3-arm, open-label randomized trial was conducted at our safety-net medical hospital among high-utilization inpatients with severe AUD. Consented adults (age 18-65) were randomized to (1) IV ketamine (KET) 0.5 mg/kg over 40 min, (2) IM naltrexone (NTX) 380 mg once, or (3) linkage alone (LA). The primary clinical outcome was 30-day all-cause hospital readmission rate. All were provided enhanced linkage to outpatient addiction clinic. RESULTS: We consented and randomized 44 participants (n = 13, 14, 17 for KET, NTX, LA, respectively), with a mean of 3.2 past-year hospitalizations. Compared to the LA arm, both the KET arm (RR 0.37, p = 0.17) and NTX arm (RR 0.52, p = 0.27) had a lower 30-day readmission rate, though the differences were nonsignificant. Immediate acceptability ratings of KET and NTX were 9.50 and 9.17 out of 10, respectively. No serious adverse events or illicit ketamine use was reported. CONCLUSIONS: Both interventions are feasible and showed promise in reducing readmissions for high-utilization AUD inpatients. Despite randomization, baseline characteristics may have differed in ways that biased against the control arm. Additional pragmatic studies-with larger sample size, blinding, and robust follow-up data collection-are needed to verify findings and better understand mediating factors. CLINICALTRIALS: gov Identifier NCT04562779. Registered 24 September 2020. https://clinicaltrials.gov/ct2/show/NCT04562779.

Advanced Inpatient Management of Opioid Use Disorder in a Patient Requiring Serial Surgeries.

Opioid use disorder has affected many lives across the US. Medications for opioid use disorder (MOUD), including buprenorphine, have been shown to decrease mortality in this patient population. Here we present a case of a 32-year-old woman on buprenorphine/naloxone undergoing multiple surgical operations, whose course included buprenorphine discontinuation, methadone initiation, and buprenorphine re-induction using a novel "microdosing" approach. This report includes a presentation of the case and a discussion of the clinical decision making and relevant literature to give hospitalbased providers a perspective on management of peri-operative patients on MOUD.

Tramadol Withdrawal in the Setting of Buprenorphine Induction: A Case Report.

: Initiating opioid use disorder treatment with buprenorphine conventionally requires the cessation of other opioid medications, including tramadol. Tramadol's spectrum of activity differs from most opioids, acting through serotonin and norepinephrine reuptake inhibition. Here, we report a case of 45-year-old man who experienced a complicated transition from tramadol to buprenorphine. We believe there were similarities to antidepressant discontinuation syndrome, which could be explained by tramadol's serotoninergic activity. Clinicians should be aware of these effects when discontinuing tramadol, even if replacing with another opioid.

Transitioning Hospitalized Patients with Opioid Use Disorder from Methadone to Buprenorphine without a Period of Opioid Abstinence Using a Microdosing Protocol.

STUDY OBJECTIVE: Buprenorphine, a partial µ-opioid agonist, is an effective treatment for opioid use disorder that conventionally requires symptoms of withdrawal before initiation to avoid precipitating withdrawal. Our institution implemented a microdosing approach to transition patients from full µ-opioid agonists to buprenorphine without requiring patients to undergo a period of opioid abstinence. Little has been published about this strategy in the inpatient setting in the United States, and even less has been published dealing with the transition from methadone to buprenorphine. Our objective was to demonstrate that a microdosing protocol to transition patients from methadone to buprenorphine can be feasibly implemented in a U.S. hospital setting. DESIGN: Case series. PATIENTS: Three hospitalized adults with opioid use disorder who received a 1-week buprenorphine microdosing protocol. MEASUREMENTS AND MAIN RESULTS: In January 2019, we implemented a 1-week buprenorphine microdosing protocol for hospitalized adult patients with opioid use disorder who were initially stabilized on methadone and wished to start buprenorphine. We gave low-dose buprenorphine concurrently with each patient's full dose of methadone, and the buprenorphine dose was gradually titrated up over 7 days. On day 8, methadone was abruptly discontinued. The buprenorphine dose was further increased based on clinical judgment. All three patients were successfully transitioned from methadone 40-100 mg/day to buprenorphine 12-16 mg/day with minimal symptoms of opioid withdrawal. One patient relapsed and was lost to follow-up; two remained in treatment. CONCLUSION: A protocol using microdosing of buprenorphine can successfully transition patients receiving full µ-opioid agonist therapy, including methadone, to buprenorphine without the need for a period of opioid abstinence.

Length of Residence and Vehicle Ownership in Relation to Physical Activity Among U.S. Immigrants.

Physical activity among U.S. immigrants over time is not well understood. Transportation may affect this trajectory. Using a survey of documented immigrants (N = 7240), we performed simple, then multivariable logistic regression to calculate ORs and 95 % CIs between length of residence (LOR) and both light-to-moderate (LPA) and vigorous (VPA) activity. We adjusted for demographic variables, then vehicle ownership to assess changes in ORs. Compared to new arrivals, all four LOR time-intervals were associated with lower odds of LPA and higher odds of VPA in simple analysis. All ORs for LPA remained significant after including demographics, but only one remained significant after adding vehicle ownership. Two ORs for VPA remained significant after including demographics and after adding vehicle ownership. Immigrants lower their light-to-moderate activity the longer they reside in the U.S., partly from substituting driving for walking. Efforts to maintain walking for transportation among immigrants are warranted.

Anger expression, violent behavior, and symptoms of depression among male college students in Ethiopia.

BACKGROUND: Depression is an important global public health problem. Given the scarcity of studies involving African youths, this study was conducted to evaluate the associations of anger expression and violent behavior with symptoms of depression among male college students. METHODS: A self-administered questionnaire was used to collect information on socio-demographic and lifestyle characteristics and violent behavior among 1,176 college students in Awassa, Ethiopia in June, 2006. The questionnaire incorporated the Spielberger Anger-Out Expression (SAOE) scale and symptoms of depression were evaluated using the Patient Health Questionnaire (PHQ-9). Multivariable logistic regression procedures were used to calculate adjusted odds ratios (OR) and 95% confidence intervals (95%CI). RESULTS: Symptoms of depression were evident in 23.6% of participants. Some 54.3% of students reported committing at least one act of violence in the current academic year; and 29.3% of students reported high (SAOE score > or = 15) levels of anger-expression. In multivariate analysis, moderate (OR = 1.97; 95%CI 1.33-2.93) and high (OR = 3.23; 95%CI 2.14-4.88) outward anger were statistically significantly associated with increased risks of depressive symptoms. Violent behavior was noted to be associated with depressive symptoms (OR = 1.82; 95%CI 1.37-2.40). CONCLUSION: Further research should be conducted to better characterize community and individual level determinants of anger-expression, violent behavior and depression among youths.