Tratamiento de abstinencia alcohólica moderada/ grave con dexmedetomidina: serie de 11 pacientes y revisión de literatura / Treatment of moderate/severe alcohol withdrawal with dexmedetomidine: series of 11 patients and literature review

Describir las características clínicas de un grupo de pacientes con abstinencia moderada/grave tratados con dexmedetomidina de forma adyuvante al tratamiento con benzodiacepinas. Métodos. Se realizó un estudio descriptivo y retrospectivo a partir de los registros de historia clínica donde se seleccionó 11 casos que cursaron con diagnóstico de abstinencia alcohólica y que requirieron tratamiento con dexmedetomidina como adyuvante a benzodiacepinas entre el año 2018 y 2022. Las variables de resultado principal dosis máxima diaria alcanzada de dexmedetomidina, dosis total recibida de dexmedetomidina, días de tratamiento con dexmedetomina y días de internación en Unidad de Terapia Intensiva /Unidad de emergencias. Resultados. Once pacientes cumplieron con los criterios de este estudio los cuales recibieron dexmedetomidina en infusión continua durante un promedio de 4,8 días. La dosis máxima que recibieron de forma diaria presentó una media de 1526.18 microgramos. El 27% necesitaron más 7500 microgramos en total durante la internación. Durante la internación, 7 pacientes (63%) intercurrieron con complicaciones. Conclusiones. Puede considerarse a la dexmedetomidina como una opción eficaz en el tratamiento de abstinencia alcohólica

To describe the clinical characteristics of a group of patients with moderate/severe withdrawal treated with dexmedetomidine as an adjunct to treatment with benzodiazepines. Methods. A descriptive and retrospective study was carried out from the clinical history record where 11 cases were selected that were diagnosed with alcohol withdrawal and that required treatment with dexmedetomidine as an adjuvant to benzodiazepines between 2018 and 2022. The main outcome variables were maximum dose. daily dose of dexmedetomidine reached, total dose of dexmedetomidine received, days of treatment with dexmedetomidine and days of hospitalization in the Intensive Care Unit /Emergency Unit. Results. Eleven patients met the criteria for this study who received continuous infusion of dexmedetomidine for an average of 4.8 days. The maximum dose they received on a daily basis presented an average of 1526.18 micrograms. 27% needed more than 7500 micrograms in total during hospitalization. During hospitalization, 7 patients (63%) had complications. Conclusions. Dexmedetomidine can be considered as an effective option in the treatment of alcohol withdrawal

Opioid tapering and weaning protocols in pediatric critical care units: a systematic review.

OBJECTIVE: Opioid abstinence syndrome is common in the pediatric intensive care environment because sedation is often needed during the children's treatment. There is no specific guideline regarding the management of these patients; and lately, methadone is an important drug for the prevention of abstinence symptoms during the weaning of opioids. This study gathers the available research to establish the initial dose of methadone, the rate of taper and tools to recognize this syndrome and act promptly. METHODS: A systematic review was made from data of four different databases. Forty-nine articles of observational and experimental studies were selected based on the inclusion criteria (critical pediatric patients in acute use of opioids) and exclusion criteria (previous chronic use of opioids, other medications). The data regarding specific themes were separated in sections: initial dose of methadone, use of protocols in clinical practice, abstinence scales and adjuvant drugs. RESULTS: The articles showed a great heterogeneity of ways to calculate the initial dose of methadone. The pediatric intensive care units of the study had different weaning protocols, with a lower incidence of abstinence when a pre-defined sequence of tapering was used. The Withdrawal Assessment Tool - 1 was the most used scale for tapering the opioids, with good sensitivity and specificity for signs and symptoms. CONCLUSION: There is still little evidence of other medications that can help prevent the abstinence syndrome of opioids. This study tries to promote a better practice during opioid weaning.

Opioid tapering and weaning protocols in pediatric critical care units: a systematic review

SUMMARY OBJECTIVE: Opioid abstinence syndrome is common in the pediatric intensive care environment because sedation is often needed during the children's treatment. There is no specific guideline regarding the management of these patients; and lately, methadone is an important drug for the prevention of abstinence symptoms during the weaning of opioids. This study gathers the available research to establish the initial dose of methadone, the rate of taper and tools to recognize this syndrome and act promptly. METHODS: A systematic review was made from data of four different databases. Forty-nine articles of observational and experimental studies were selected based on the inclusion criteria (critical pediatric patients in acute use of opioids) and exclusion criteria (previous chronic use of opioids, other medications). The data regarding specific themes were separated in sections: initial dose of methadone, use of protocols in clinical practice, abstinence scales and adjuvant drugs. RESULTS: The articles showed a great heterogeneity of ways to calculate the initial dose of methadone. The pediatric intensive care units of the study had different weaning protocols, with a lower incidence of abstinence when a pre-defined sequence of tapering was used. The Withdrawal Assessment Tool - 1 was the most used scale for tapering the opioids, with good sensitivity and specificity for signs and symptoms. CONCLUSION: There is still little evidence of other medications that can help prevent the abstinence syndrome of opioids. This study tries to promote a better practice during opioid weaning.

RESUMO OBJETIVO: A síndrome de abstinência de opioides é comum no ambiente de terapia intensiva pediátrica porque a sedação é frequentemente necessária durante o tratamento das crianças. Não existe uma diretriz específica sobre o manejo desse paciente e, ultimamente, a metadona tem sido uma droga importante para a prevenção dos sintomas de abstinência durante o desmame dos opioides. Este estudo reúne as pesquisas disponíveis para estabelecer a dose inicial de metadona, taxa de redução e ferramentas para reconhecer essa síndrome e agir prontamente. MÉTODOS: Uma revisão sistemática foi feita a partir de dados de quatro diferentes bases de dados. Quarenta e nove artigos, de estudos observacionais e experimentais, foram selecionados com base nos critérios de inclusão (pacientes críticos pediátricos em uso de opioides agudamente) e critérios de exclusão (uso crônico prévio de opioides, outros medicamentos). Os dados referentes a temas específicos foram separados em seções: dose inicial de metadona, uso de protocolos na prática clínica, escalas de abstinência e drogas adjuvantes. RESULTADOS: Os artigos mostraram uma grande heterogeneidade de formas de calcular a dose inicial de metadona. As unidades de terapia intensiva pediátrica do estudo apresentaram diferentes protocolos de desmame, com menor incidência de abstinência quando foi utilizada uma sequência predefinida de redução gradual. A Ferramenta de Avaliação de Retirada - 1 foi a escala mais utilizada durante a redução dos opioides, com boa sensibilidade e especificidade para sinais e sintomas. CONCLUSÃO: Ainda há poucas evidências de outros medicamentos que possam ajudar a prevenir a síndrome de abstinência dos opioides. Este estudo tenta promover uma prática melhor durante o desmame dos opioides.

How to face a patient with benzodiazepine dependence in primary health care? Strategies for withdrawal. / ¿Cómo afrontar un paciente con dependencia a benzodiacepinas en atención primaria? Estrategias para la deshabituación.

Benzodiazepines are widely used in primary health care, and their prolonged use is an important problem given the medical consequences particularly in older adults, such as dependence, cognitive impairment, and risk of falls, among others. Primary care doctors generally have few tools to help with managing withdrawal from benzodiazepines. We conducted a review of the best available evidence on practical strategies to avoid dependence at the time of the initial prescription, and to help the patient with prolonged and probably dependent use. We found ten relevant systematic reviews showing evidence in favor of the use of multifaceted prescription strategies, gradual dose reduction, standardized letters, standardized counseling, pharmacotherapy and cognitive behavioral psychotherapy. For benzodiazepine withdrawal, a simple strategy that can be effective and long-lasting is to inform patients of the need to reduce consumption, giving them in writing the withdrawal guideline, indicating the possible effects of withdrawal and its solution. Given the available evidence, an integrated and step-by-step model is proposed for the management of the benzodiazepine user, from prescription to withdrawal.

Las benzodiacepinas son fármacos ampliamente utilizados en atención primaria de salud. Su uso prolongado se ha convertido en un problema relevante dadas las consecuencias médicas que ocasionan, especialmente en adultos mayores. Entre otras, estas son: dependencia, deterioro cognitivo y riesgo de caídas. Además, los médicos que trabajan en atención primaria cuentan con pocas herramientas para ayudar al paciente en su deshabituación. Se realizó una búsqueda y revisión de la mejor evidencia disponible sobre estrategias prácticas para el médico no especialista en adicciones, para evitar la dependencia al momento de la prescripción inicial y en el paciente con uso prolongado y probablemente dependiente. Se encontraron 10 revisiones sistemáticas relevantes que mostraron evidencia a favor del uso de estrategias multifacéticas en la prescripción, disminución progresiva, cartas y consejería estandarizadas, farmacoterapia y psicoterapia cognitiva conductual. Una estrategia sencilla, eficaz y duradera para prescribir benzodiacepinas es informar al paciente de la necesidad de reducir su consumo, dándole por escrito la pauta de retirada, señalando sus posibles efectos y su solución. Debido a la evidencia disponible, se propone un modelo integrado y escalonado para el manejo del paciente usuario de benzodiacepinas, desde su prescripción hasta su descontinuación.

¿Cómo afrontar un paciente con dependencia a benzodiacepinas en atención primaria? Estrategias para la deshabituación / How to face a patient with benzodiazepine dependence in primary health care? Strategies for withdrawal

Las benzodiacepinas son fármacos ampliamente utilizados en atención primaria de salud. Su uso prolongado se ha convertido en un problema relevante dadas las consecuencias médicas que ocasionan, especialmente en adultos mayores. Entre otras, estas son: dependencia, deterioro cognitivo y riesgo de caídas. Además, los médicos que trabajan en atención primaria cuentan con pocas herramientas para ayudar al paciente en su deshabituación. Se realizó una búsqueda y revisión de la mejor evidencia disponible sobre estrategias prácticas para el médico no especialista en adicciones, para evitar la dependencia al momento de la prescripción inicial y en el paciente con uso prolongado y probablemente dependiente. Se encontraron 10 revisiones sistemáticas relevantes que mostraron evidencia a favor del uso de estrategias multifacéticas en la prescripción, disminución progresiva, cartas y consejería estandarizadas, farmacoterapia y psicoterapia cognitiva conductual. Una estrategia sencilla, eficaz y duradera para prescribir benzodiacepinas es informar al paciente de la necesidad de reducir su consumo, dándole por escrito la pauta de retirada, señalando sus posibles efectos y su solución. Debido a la evidencia disponible, se propone un modelo integrado y escalonado para el manejo del paciente usuario de benzodiacepinas, desde su prescripción hasta su descontinuación.

Benzodiazepines are widely used in primary health care, and their prolonged use is an important problem given the medical consequences particularly in older adults, such as dependence, cognitive impairment, and risk of falls, among others. Primary care doctors generally have few tools to help with managing withdrawal from benzodiazepines. We conducted a review of the best available evidence on practical strategies to avoid dependence at the time of the initial prescription, and to help the patient with prolonged and probably dependent use. We found ten relevant systematic reviews showing evidence in favor of the use of multifaceted prescription strategies, gradual dose reduction, standardized letters, standardized counseling, pharmacotherapy and cognitive behavioral psychotherapy. For benzodiazepine withdrawal, a simple strategy that can be effective and long-lasting is to inform patients of the need to reduce consumption, giving them in writing the withdrawal guideline, indicating the possible effects of withdrawal and its solution. Given the available evidence, an integrated and step-by-step model is proposed for the management of the benzodiazepine user, from prescription to withdrawal.

Alcohol Withdrawal Syndrome: Improving Outcomes Through Early Identification And Aggressive Treatment Strategies.

Alcoholism is a prevalent medical and psychiatric disease, and, consequently, alcohol withdrawal is encountered frequently in the emergency department. This issue reviews the pathophysiology of the alcohol withdrawal syndrome, describes the 4 manifestations of alcohol withdrawal, and looks at the available evidence for optimal treatment of alcohol withdrawal in its diverse presentations. Patients commonly manifest hyperadrenergic signs and symptoms, necessitating admission to the intensive care unit, intravenous benzodiazepines, and, frequently, adjunctive pharmacotherapy. An aggressive front-loading approach with benzodiazepines is proposed and the management of benzodiazepine-resistant disease is addressed.

Early abstinence of crack-cocaine is effective to attenuate oxidative stress and to improve antioxidant defences.

RATIONALE: Preclinical studies have shown that cocaine exposure and withdrawal are associated with cellular oxidative stress damage. However, the impact of crack-cocaine dependence on oxidative stress biomarkers remains unclear. Here, we assessed peripheral oxidative stress and antioxidant defences during two periods of crack-cocaine detoxification treatment and associated these changes with psychological morbidity. METHODS: Thirty female inpatients were recruited, and plasma samples were collected at the 4th and 18th days of abstinence; 30 healthy controls were also recruited. Plasma levels of protein carbonyl, protein thiol content, superoxide dismutase (SOD), glutathione peroxidase (GPx), reduced reduced (GSH) and total reactive antioxidant potential (TRAP) were measured by standard methods; the questionnaires Cocaine Selective Severity Assessment, Beck Depressive Inventory and the Addiction Severity Index were applied. RESULTS: We report higher oxidative stress damage after 4 days of detoxification, as shown by increased total thiol content and protein carbonylation when compared with control group and after 18 days of detoxification. After 18 days of treatment, we observed a recovery of the oxidative stress damage and increase of the antioxidant defences, as shown by higher levels of SOD, GPx, GSH and TRAP. There was a positive correlation between protein carbonylation and psychological variables; in contrast, there was a negative correlation between TRAP levels and clinical assessments. CONCLUSIONS: Taken together, these results suggest that drug rehabilitation treatment was effective in decreasing oxidative damage represented by the reduction in biological markers, which are closely related to the severity of withdrawal symptoms.

Long-term cannabis abuse and early-onset cannabis use increase the severity of cocaine withdrawal during detoxification and rehospitalization rates due to cocaine dependence.

BACKGROUND: Long-term and early-onset cannabis consumption are implicated in subsequent substance- related problems. The aim of this follow-up study was to investigate whether these patterns of cannabis use could impact cocaine withdrawal severity and cocaine craving intensity during detoxification. In addition, we investigated their impact in the rehospitalization rates due to cocaine dependence 2.5 years after detoxification assessment. METHODS: The sample was composed of 93 female cocaine-dependent inpatients who were enrolled in an inpatient detoxification unit. Cocaine withdrawal symptoms were measured at the 4th, 9th and 14th days of detoxification using the cocaine selective severity assessment (CSSA). Data on the age of first years of drug use - alcohol, cannabis and cocaine - and the years of substance abuse were obtained using the Addiction Severity Index (ASI-6). Other relevant clinical variables were also investigated, including a 2.5 years follow-up assessment of number of rehospitalization due to cocaine dependence. RESULTS: Early-onset cannabis use and long-term cannabis abuse were associated with an increase instead of a reduction in the severity of cocaine withdrawal symptoms and craving intensity during detoxification. In addition, long-term cannabis abuse predicted higher number of rehospitalization due to cocaine dependence after 2.5 years of the first detoxification assessment. CONCLUSIONS: Early-onset cannabis use and long-term cannabis abuse are associated with a worse detoxification treatment response. Our findings may help to identify patients who will struggle more severely to control cocaine withdrawal syndrome during early drug abstinence, and indicate that cannabis use prior to cocaine withdrawal should be considered an adverse factor.

Avances en la comprensión de las adicciones: niveles, modelos, farmacoterapia / Progress in the understanding of addictins: Levels, models, pharmacotherapy

La comprensión de los mecanismos subyacentes en las diversas adicciones avanza continuamente. Las diferentes líneas de investigación, ya sea tanto en el plano molecular, o de los circuitos y áreas involucradas, como así también de los abordajes psicosociales, profundizan su búsqueda con el objetivo de mejorar la eficacia de los tratamientos. Un interesante artículo de Koob y colaboradores (2009), que lleva por subtítulo El abordaje de la piedra de Rosetta, revisa detalladamente los distintos niveles en juego en esta compleja problemática. El objetivo del mencionado artículo es aportar elementos en el sentido de favorecer el desarrollo de fármacos adecuados para el tratamiento de estas condiciones patológicas, que incluyen tanto el uso de drogas ilícitas, como del alcohol y el tabaco. Las actuales farmacoterapias utilizadas para el tratamiento de la adicción pueden ser empleadas para validar y mejorar los modelos de laboratorios en animales y humanos, para así identificar nuevos candidatos viables para tratamientos. Esta aproximación tiene la capacidad de promover la investigación traslacional y puede proveer un marco heurístico para desarrollar farmacoterapias eficientes y efectivas para la adicción

The comprehension of the mechanisms underlying the different addictions is in constant progess. The different lines of research, both in the molecular field or the circuits and areas involved, as well as in psychosocial approaches emphasize their investigations with the purpose of enhancing the efficacy of the treatments. An interesting article by Koob et al (2009), which is subtitled "The Rosetta Stone Approach", provides a detailed review of the different levels involved in this complex issue. The purpose of the mentioned article is to provide elements that promote the development of pharmacological drugs suitable for the treatment of these pathological conditions, which include both the use of illegal drugs, as well as acohol and tobacco. The current pharmacological therapies used for the treatment of addiction can be used to validate and improve labortory models in animals and humans, in order to identify new potential candidates for treatments. This approach is able to promote a translational research and can offer a heuristic framework to develop efficient and effective pharmacotherapies for addiction

[Management of patients with substance use illnesses in psychiatric emergency department]. / Manejo do paciente com transtornos relacionados ao uso de substância psicoativa na emergência psiquiátrica.

OBJECTIVE: Substance use disorders are prevalent in emergency departments in medical and psychiatric services, reaching rates of 28% of cases in medical emergency departments. However, professionals in the emergency department identify less than 50% of cases of alcohol-related problems. This article aims to provide evidence-based interventions for the specific treatment to patients who meet diagnostic criteria for substance use disorders and who present to emergency rooms during intoxication or abstinence. METHOD: A literature review was performed on Medline database, using the descriptors "acute intoxication", "withdrawal", "alcohol", "cocaine", "cannabis", "opioid", "inhalant", "management", using English as the language. RESULTS: AND CONCLUSION: The care of persons with substance use disorders should include: comprehensive assessment (medical and psychiatric), treatment of diagnosed disorders (withdrawal, intoxication and clinical features that characterize an emergency), awareness of the patient to carry out treatment if necessary and referral.

Manejo do paciente com transtornos relacionados ao uso de substância psicoativa na emergência psiquiátrica / Management of patients with substance use illnesses in psychiatric emergency department

OBJETIVO: Transtornos por uso de substâncias são prevalentes em setores de emergência gerais e psiquiátricos, atingindo taxas de 28 por cento das ocorrências em prontos-socorros gerais. Todavia, profissionais dos setores de emergência identificam menos que 50 por cento dos casos de problemas relacionados ao álcool. Este artigo visa fornecer base fundamentada em evidências para o tratamento específico a pacientes que preencham os critérios diagnósticos de transtornos por uso de substâncias e que se apresentam ao pronto-socorro em quadros de intoxicação ou abstinência. MÉTODO: Uma revisão sobre o tema foi realizada na base de dados Medline, usando-se os descritores "intoxicação aguda", "abstinência", "álcool", "cocaína", "cannabis", "opioides", "inalantes" e "manejo", tendo o inglês como idioma. RESULTADOS E CONCLUSÃO: O cuidado de pessoas com transtornos por uso de substâncias deve conter: avaliação completa (médica geral e psiquiátrica), tratamento dos quadros diagnosticados (abstinência, intoxicação e quadros clínicos que caracterizem uma emergência), sensibilização do paciente para realizar tratamento, se for necessário, e elaboração de encaminhamento.

OBJECTIVE: Substance use disorders are prevalent in emergency departments in medical and psychiatric services, reaching rates of 28 percent of cases in medical emergency departments. However, professionals in the emergency department identify less than 50 percent of cases of alcohol-related problems. This article aims to provide evidence-based interventions for the specific treatment to patients who meet diagnostic criteria for substance use disorders and who present to emergency rooms during intoxication or abstinence. METHOD: A literature review was performed on Medline database, using the descriptors "acute intoxication", "withdrawal", "alcohol", "cocaine", "cannabis", "opioid", "inhalant", "management", using English as the language. RESULTS: AND CONCLUSION: The care of persons with substance use disorders should include: comprehensive assessment (medical and psychiatric), treatment of diagnosed disorders (withdrawal, intoxication and clinical features that characterize an emergency), awareness of the patient to carry out treatment if necessary and referral.

Getting clean and harm reduction: adversarial or complementary issues for injection drug users

Muitas intervencões para prevenir a infeccão pelo HIV entre usuários de drogas injetáveis adotam a técnica de reducão de danos como referencial teórico. Entretanto, os próprios usuários tendem a preferir modelos baseados na abstinência, defendidos pelos Narcóticos Anônimos, além de outras abordagens adotadas amplamente para o tratamento da dependência química. O artigo descreve uma avaliacão etnográfica da dicotomia ideológica entre reducão de danos e o modelo terapêutico baseado na abstinência (getting clean) durante a fase piloto de uma intervencão para a prevencão de HIV na Cidade de Baltimore, Maryland, Estados Unidos. O artigo descreve como o conflito foi identificado e que mudancas foram introduzidas na intervencão para ajudar a resolver as idéias dicotômicas dos participantes em relacão às questões de dependência química.

Tratamento farmacológico da síndrome de dependencia ao álcool / Pharmacological treatment of alcohol dependence syndrome

O autor realiza revisäo bibliográfica sobre vários aspectos do tratamento farmacológico da síndrome de dependencia ao álcool, discorrendo também sobre alguns aspectos de saúde pública e diagnóstico. Enfatiza a utilizaçäo de psicofarmacoterapia específica, como o acamprosato, uma droga recente ainda näo utilizada no Brasil, mas com importante experiência na Europa e Estados Unidos.(au)

Tabaquismo: repercusión y métodos de control / Smoking: repercution and control method

El tabaquismo es un hábito muy arraigado en nuestra sociedad, un trascendente problema de salud pública al constituirse en la principal causa prevenible de muerte prematura, morbilidad y gastos innecesarios en salud. El tabaco es responsable del 20 por ciento de la mortalidad general y se encuentra directamente involucrado en numerosas entidades, tales como cáncer pulmonar y laríngeo entre otros, patología vascular periférica, coronaria y cerebral; es el principal factor etiológico de la enfermedad pulmonar obstructiva crónica y se asocia a morbilidad perinatal entre otras. Su control es difícil y de todas las personas que anualmente intentan abandonar, sólo unos pocos lo logran debido al poder adictivo de la nicotina y los intensos síntomas sufridos en el período de abstinencia a causa del síndrome de privación. En el control del hábito tabáquico es crucial el consejo médico, asociado al apoyo psicológico y técnicas conductuales y en situaciones específicas, un apoyo especializado ya sea con psicofármacos del tipo Bupropión o con terapia de sustitución nicotínica tipo parche

Sindrome de abstinencia alcohólica / Alcoholic withdrawal syndrome

El Sindrome de abstinencia alcohólica es una de las mayores complicaciones vinculadas al alcoholismo. En esta revisión hacemos referencia a su fisiopatología, las diferentes presentaciones clínicas, desde las más leves en las que predominan las manifestaciones de hiperactividad adrenérgica a las formas más severas: la convulsión y el delirium tremens. Se describen los trastornos electrolíticos más frecuentemente encontrados. Hacemos hincapié en el manejo de estos pacientes, las medidas no farmacológicas y las farmacológicas, basándonos en el uso de la escala de CIWA-Ar para cuantificar la severidad del cuadro clínico y la oportunidad de tratamiento farmacológico(AU)

Sindrome de abstinencia alcohólica / Alcoholic withdrawal syndrome

El Sindrome de abstinencia alcohólica es una de las mayores complicaciones vinculadas al alcoholismo. En esta revisión hacemos referencia a su fisiopatología, las diferentes presentaciones clínicas, desde las más leves en las que predominan las manifestaciones de hiperactividad adrenérgica a las formas más severas: la convulsión y el delirium tremens. Se describen los trastornos electrolíticos más frecuentemente encontrados. Hacemos hincapié en el manejo de estos pacientes, las medidas no farmacológicas y las farmacológicas, basándonos en el uso de la escala de CIWA-Ar para cuantificar la severidad del cuadro clínico y la oportunidad de tratamiento farmacológico