Although severe alcohol withdrawal syndrome (SAWS) is associated with substantial morbidity and mortality, most at-risk patients will not develop this syndrome. Predicting its occurrence is important because the mortality rate is high when untreated.
Objective
To assess the accuracy and predictive value of symptoms and signs for identifying hospitalized patients at risk of SAWS, defined as delirium tremens, withdrawal seizure, or clinically diagnosed severe withdrawal.
Data Sources
MEDLINE and EMBASE (1946-January 2018) were searched for articles investigating symptoms and signs predictive of SAWS in adults. Reference lists of retrieved articles were also searched.
Study Selection
Original studies that were included compared symptoms, signs, and risk assessment tools among patients who developed SAWS and patients who did not.
Data Extraction and Synthesis
Data were extracted and used to calculate likelihood ratios (LRs), sensitivity, and specificity. A meta-analysis was performed to calculate summary LR.
Results
Of 530 identified studies, 14 high-quality studies that included 71 295 patients and 1355 relevant cases of SAWS (1051 cases), seizure (53 cases), or delirium tremens (251 cases) were analyzed. A history of delirium tremens (LR, 2.9 [95% CI 1.7-5.2]) and baseline systolic blood pressure 140 mm Hg or higher (LR, 1.7 [95% CI, 1.3-2.3) were associated with an increased likelihood of SAWS. No single symptom or sign was associated with exclusion of SAWS. Six high-quality studies evaluated combinations of clinical findings and were useful for identifying patients in acute care facilities at high risk of developing SAWS. Of these combinations, the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) was most useful, with an LR of 174 (95% CI, 43-696; specificity, 0.93) when patients had 4 or more individual findings and an LR of 0.07 (95% CI, 0.02-0.26; sensitivity, 0.99) when there were 3 or fewer findings.
Conclusions and Relevance
Assessment tools that use a combination of symptoms and signs are useful for identifying patients at risk of developing severe alcohol withdrawal syndrome. Most studies of these tools were not fully validated, limiting their generalizability.
The United States and Canada are experiencing an opioid overdose crisis driven largely by exposure to fentanyl (a potent synthetic opioid), with little known about fentanyl exposure among HIV-positive people who use unregulated drugs (PWUD). We sought to estimate the prevalence and correlates of fentanyl exposure among a community-recruited sample derived from a prospective cohort study of HIV-positive PWUD in Vancouver, Canada. Generalized linear mixed-effects analyses were used to identify longitudinal factors associated with a fentanyl-positive urine drug screen test. Between June 2016-November 2017, 456 participants were recruited and contributed 1007 observations. At baseline, 96% of participants were ART-exposed, 72% had an HIV viral load (VL) <50 copies/mL and 21% had a fentanyl-positive test. Longitudinally, fentanyl-positive tests were characterized by: younger participant age (Adjusted Odds Ratio [AOR] = 0.45), recent non-fatal overdose (AOR = 2.30), engagement in opioid agonist therapy (AOR = 1.91), and at least daily heroin injection (AOR = 11.27). CD4+ cell count was negatively associated with fentanyl urine positivity (AOR = 0.92) (all p < 0.05). We identified several risk factors for overdose linked to fentanyl exposure among this sample, although no link with HIV treatment engagement or detectable HIV VL. Innovative strategies are needed to reduce the harmful effects of the contaminated unregulated drug supply experienced by PWUD.
Active illicit drug use can present a barrier to the medical management of HIV infection by complicating adherence to antiretroviral therapy (ART). Plasma HIV-1 RNA viral load (VL) rebound, defined as a period of detectable HIV VL following ART and VL suppression, can lead to the generation of viral resistance and potential treatment failure. We sought to investigate the contribution of substance use patterns on rates of VL rebound.We used data from the ACCESS study, a long-running community-recruited prospective cohort of HIV-positive people who use illicit drugs in Vancouver, Canada, a setting of universal no-cost HIV treatment. We analysed time to VL rebound (that is, two consecutive observations ≥1,000 copies/ml) after ART initiation and sustained viral suppression (that is, two consecutive observations <50 copies/ml) using extended Cox regression models with a recurrent events framework.Between May 1996 and November 2013, 564 ART-exposed participants achieved at least one instance of VL suppression and contributed 1,893.8 person-years of observation. Over follow-up, 198 (35.1%) participants experienced ≥ one instance of VL rebound. In adjusted analyses, VL rebound was associated with younger age (adjusted hazard ratio [AHR] =0.97, 95% CI: 0.95, 0.98), heroin injection (≥ daily versus < daily, AHR =1.52, 95% CI: 1.01, 2.30), crack use (≥ daily versus < daily, AHR = 1.73, 95% CI: 1.08, 1.92) and heavy alcohol use (≥ four versus < four drinks/day, AHR =1.97, 95% CI: 1.17, 3.31).The present study suggests that in addition to heavy alcohol use, high-intensity illicit drug use, particularly ≥ daily heroin injection and ≥ daily crack smoking are risk factors for VL rebound. In addition to the impact of high-intensity drug use on health-care engagement and ART adherence, some evidence exists on the direct impact of psychoactive substances on ART metabolism and the natural progression of HIV disease. At-risk individuals should be provided additional supports to preserve virological control and maintain the benefits of ART.
Opioid overdose is a major public health burden worldwide. While the development of community based opioid overdose prevention programs have expanded in recent years, the implementation of such programs for patients in a hospital setting is not well described. This case report describes the implementation of British Columbia's Provincial Take Home Naloxone Program to patients evaluated by the Addiction Medicine Consult Team at St. Paul's Hospital in Vancouver, Canada between August 2014 and August 2015. During this period, 61 individuals were educated on the use of naloxone and were trained on how to administer it intramuscularly in the suspected case of an opioid overdose. In total, 23 naloxone kits were dispensed for future use in the community upon discharge. Overall, the Take Home Naloxone program has been recognized as a worthwhile initiative by patients, physicians of the addiction medicine consult team and other interdisciplinary hospital staff. Given the ongoing burden of disease attributable to opioid overdose and the feasibility of providing naloxone education and take-home kits to high-risk hospitalized patients with an opioid use disorder and their family and friends, these findings underscore the unique opportunity that exists for overdose prevention interventions in an acute care setting. Keywords: naloxone, overdose, implementation, harm reduction, Vancouver Les surdoses d'opioïdes sont un fardeau mondial de santé publique. Bien que le développement de programmes communautaires de prévention en surdose d'opioïdes ait crû considérablement au cours des dernières années, l'implantation de tels programmes en milieu hospitalier est peu décrit. Cette étude de cas décrit l'implantation en Colombie-Britannique du programme provincial Take Home Naloxone pour des patients évalués par l’équipe de consultation en toxicomanie à l'hôpital St. Paul's de Vancouver, Canada entre le mois d'août 2014 et le mois d'août 2015. Pendant cette période, 61 individus ont été informés sur l'utilisation du naloxone et formés sur son administration intramusculaire en situation de surdose d'opioïdes suspectée. Au total, 23 ensembles de naloxone ont été distribués pour une utilisation future dans la communauté. Dans l'ensemble, les patients, les médecins de l’équipe de consultation en toxicomanie et le personnel interdisciplinaire de l'hôpital ont reconnu le programme Take Home Naloxone comme une initiative valable. Étant donné le fardeau actuel attribué aux surdoses d'opioïdes et la faisabilité d'offrir de l'information sur la naloxone et des ensembles à emporter aux patients hospitalisés les plus à risque, à leur famille et à leurs amis, ces données soulignent l'opportunité unique qui existent d'intervenir en prévention des surdoses en établissements de soins aigus. Mots clés: naloxone, surdose, implantation, réduction des méfaits, Vancouver
Background The overdose crisis in North America has prompted system-level efforts to restrict opioid prescribing for chronic pain. However, little is known about how discontinuing or tapering prescribed opioids for chronic pain shapes overdose risk, including possible differential effects among people with and without concurrent opioid use disorder (OUD). We examined associations between discontinuation and tapering of prescribed opioids and risk of overdose among people on long-term opioid therapy for pain, stratified by diagnosed OUD and prescribed opioid agonist therapy (OAT) status. Methods and findings For this retrospective cohort study, we used a 20% random sample of residents in the provincial health insurance client roster in British Columbia (BC), Canada, contained in the BC Provincial Overdose Cohort. The study sample included persons aged 14 to 74 years on long-term opioid therapy for pain (≥90 days with ≥90% of days on therapy) between October 2014 and June 2018 ( n = 14,037). At baseline, 7,256 (51.7%) persons were female, the median age was 55 years (quartile 1–3: 47–63), 227 (1.6%) persons had been diagnosed with OUD (in the past 3 years) and recently (i.e., in the past 90 days) been prescribed OAT, and 483 (3.4%) had been diagnosed with OUD but not recently prescribed OAT. The median follow-up duration per person was 3.7 years (quartile 1–3: 2.6–4.0). Marginal structural Cox regression with inverse probability of treatment weighting (IPTW) was used to estimate the effect of prescribed opioid treatment for pain status (discontinuation versus tapered therapy versus continued therapy [reference]) on risk of overdose (fatal or nonfatal), stratified by the following groups: people without diagnosed OUD, people with diagnosed OUD receiving OAT, and people with diagnosed OUD not receiving OAT. In marginal structural models with IPTW adjusted for a range of demographic, prescription, comorbidity, and social-structural exposures, discontinuing opioids (i.e., ≥7-day gap[s] in therapy) was associated with increased overdose risk among people without OUD (adjusted hazard ratio [AHR] = 1.44; 95% confidence interval [CI] 1.12, 1.83; p = 0.004), people with OUD not receiving OAT (AHR = 3.18; 95% CI 1.87, 5.40; p < 0.001), and people with OUD receiving OAT (AHR = 2.52; 95% CI 1.68, 3.78; p < 0.001). Opioid tapering (i.e., ≥2 sequential decreases of ≥5% in average daily morphine milligram equivalents) was associated with decreased overdose risk among people with OUD not receiving OAT (AHR = 0.31; 95% CI 0.14, 0.67; p = 0.003). The main study limitations are that the outcome measure did not capture overdose events that did not result in a healthcare encounter or death, medication dispensation may not reflect medication adherence, residual confounding may have influenced findings, and findings may not be generalizable to persons on opioid therapy in other settings. Conclusions Discontinuing prescribed opioids was associated with increased overdose risk, particularly among people with OUD. Prescribed opioid tapering was associated with reduced overdose risk among people with OUD not receiving OAT. These findings highlight the need to avoid abrupt discontinuation of opioids for pain. Enhanced guidance is needed to support prescribers in implementing opioid therapy tapering strategies with consideration of OUD and OAT status.
We thank Drs. Palis and MacDonald for their commentary on incorporating prescription psychostimulants into the continuum of care for people with stimulant use disorder.[1][1] Although the evidence is still evolving, psychostimulants remain promising agents for the pharmacologic treatment of
