Wellness Check: Addictions

2 Minute Medicine is pleased to announce that we are launching Wellness Check, a new series dedicated to exploring new research evidence focused on wellness. Each week, we will report on articles examining different aspects of wellness, including (but not limited to) nutrition, sleep, reproductive health, substance use and mental health. This week, we explore the latest evidence-based updates in addictions.

Altering electronic medical records may increase naloxone prescriptions

1. This quantitative study found that adding an easy way to prescribe opioids within the hospital electronical medical record system increased hospital naloxone prescription rates.

2. Visual reminders and a more intuitive ordering experience may increase naloxone prescription rates.

Evidence Rating Level: 2 (Good)

A staggering number of Americans use opiates for nonmedical reasons. Intranasal naloxone is a commonly used rescue medication for opioid overdoses. In order to combat this epidemic, New York state implemented the Internet System for Tracking Over-Prescribing (I-STOP), which requires physicians to review a patient’s medication history before prescribing any new medications. However, it is not known whether logistical hurdles integrated within programs like I-STOP, such as the complex ordering process, hinder naloxone prescriptions to treat opioid overdose.

This quantitative study implemented a clinical decision support system within the I-STOP note to streamline naloxone prescription and compared amounts of naloxone prescribed prior to, and post intervention at the James J. Peters VA Medical Center (Bronx, New York). The new system was launched July 1, 2019; pre-intervention data was collected from May 1-June 30, 2019, and post-intervention data was collected from July 1-August 31, 2019. The intervention involved researchers adding another section within the I-STOP that added an option to prescribe intranasal naloxone as well as several other follow-up questions. The primary outcomes of the study were the number of naloxone orders and the number of providers who prescribed naloxone with the system, which were compared pre-intervention to post-intervention.

After these modifications, intranasal naloxone prescriptions increased by more than three-fold (from 65 to 203 orders) across the hospital with this more intuitive platform. However, there were limitations to this study: Electronic medical record setups differ widely at institutions, so this implementation may not be easily reproducible at other locations. Despite these limitations, this study was significant as it provided one avenue to increase the availability of life-saving naloxone through electronic medical record automation.

Combination of buprenorphine and naloxone may be safe for those hospitalized with acute hepatitis A

1. This quantitative study found that buprenorphine/naloxone can be safely administered to patients with acute hepatitis A without increased risk of liver problems such as hepatic encephalopathy.

2. Buprenorphine/naloxone should not be withheld from hospitalized patients with acute hepatitis A.

Evidence Rating Level: 2 (Good)

The combination of buprenorphine and naloxone (bup/nx) is a highly effective rescue medication for opioid overdoses; however, it is not known whether those with acute hepatitis A (HAV) can tolerate the medication well. HAV infections have risen dramatically since 2017, especially among the homeless and those who use opioid drugs. Currently, it is unknown whether liver function will be affected by bup/nx administration and how best to care for those with both acute HAV and opioid use disorder.

This retrospective quantitative study analyzed data from 31 patients hospitalized for acute HAV from the University of Kentucky (October 2018-July 2019) who also had an addiction problem. Inclusion criteria included age > 18 and acute HAV, which was defined by symptoms and a positive anti-HAV IgM titer. Measured outcomes assessed liver function tests (aspartate aminotransferase, alanine aminotransferase, total bilirubin, and INR) as well as patient tolerability of bup/nx induction in patients.

No significant differences were found in any liver function test between those who received bup/nx and those who did not, indicating that bup/nx may be safe for these patients. However, those who received bup/nx were more likely to report nausea. This study did have several limitations including its reliance on physician documentation, which might not have included mild or moderate symptoms. Additionally, this was an observational study, so other differences between the two groups may exist. Finally, there was limited follow-up data, so long-term liver function could not be determined. Despite these limitations, this study expands our understanding of bup/nx and shows that bup/nx may be used for patients with HAV.

Prescription tranquilizer and sedative misuse motives vary widely amongst United States of America population

1. This quantitative study found that motives for prescription tranquilizer/sedative misuse differ widely by age group in the United States of America.

2. Recreational use of tranquilizers/sedatives is most strongly associated with other substance use, physical health, and mental health problems.

Evidence Rating Level: 2 (Good)

Misuse of prescription tranquilizers and/or sedatives is common in the United States of America (US), especially among adults aged 18-25. Prior research shows that such misuse can lead to overdoses and is correlated with other substance use disorders and psychiatric comorbidities. However, motives for tranquilizer/sedative misuse are not well understood. Other researchers have postulated potential motives including desire for better sleep, reduction of anxiety, or recreational motives.

This retrospective quantitative study collected data on substance use behaviour via the US National Survey on Drug Use and Health (NSDUH) from 2015-2018. Participants were included if they answered yes to any prescription tranquilizer/sedative misuse in the past year (N=6892). Participants were excluded if they did not respond to the motive question. Measured outcomes included other substance use behaviors (ex. binge alcohol use, marijuana use, and various others), mental health correlates (ex. depression, suicidal ideation), and physical health correlates (ex. emergency department use, inpatient hospitalization).

Prescription tranquilizer/sedative motives differed widely by age based on data from 223,520 respondents. For adolescents, desire to experiment or recreational motives were notable motives (26.9% and 39.2%, respectively). Recreational motives decreased almost linearly as age increased. In contrast, for adults aged 65 and older, desire to sleep better was a major motive (63.9%). Across all age groups, any tranquilizer/sedative misuse was associated with worse mental health, including rates of depression and suicidality. Misuse was associated with worse physical health correlates across all age groups. However, this study had several limitations including its reliance on self-reported data. The dataset also did not include homeless or incarcerated individuals and under-sampled older adults. Nonetheless, this study expands our understanding of tranquilizer/sedative misuse amongst different age groups, which may allow for targeted interventions.

Image: PD

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