Journal Article Annotations
2017, 2nd Quarter

Substance Use & Addictive Disorders

Annotations by S. Alex Sidelnik, MD, Diana Robinson, MD, and Thomas Penders, MD
July 2017

Inpatient addiction consultation for hospitalized patients increases post-discharge abstinence and reduces addiction severity
Intentional misuse and abuse of loperamide: a new look at a drug with “low abuse potential”

Also of interest:

Cheng C, Huang CL, Tsai CJ, Chou PH, Lin CC, Chang CK: Alcohol-related dementia: a systematic review of epidemiological studies
Psychosomatics 2017; 58(4):331-342

This systematic review of studies published within the past 25 years revealed that the prevalence of alcohol-related dementia (ARD) was wide-ranged, from 8.27 per 100,000 to 25.6% in various study populations, with the condition detected more often in males. The proportion of ARD in dementia was more consistent in early-onset dementia (approximately 10%); however, data remained scarce on those in late-onset dementia. People with ARD are more often unmarried.

Consultation-liaison psychiatrists are often called to assist with the diagnosis and management of patients with cognitive decline. This review offers some guidance based on evidence from extant literature to determining the extent to which a history of heavy alcohol use might contribute to a dementing disorder.

There is a need for standardization of diagnosis for alcohol-related cognitive disorder. Further study is also needed to define the extent to which ARD is potentially reversible and its relationship to Korsakoff’s syndrome. —Thomas Penders

PUBLICATION #1 — Substance Use & Addictive Disorders

Inpatient addiction consultation for hospitalized patients increases post-discharge abstinence and reduces addiction severity

Wakeman SE, Metlay JP, Chang Y, Herman GE, Rigotti NA

J Gen Intern Med 2017; 32(8):909-916

BACKGROUND: Alcohol and drug use results in substantial morbidity, mortality, and cost. Individuals with alcohol and drug use disorders are overrepresented in general medical settings. Hospital-based interventions offer an opportunity to engage with a vulnerable population that may not otherwise seek treatment.

OBJECTIVE: To determine whether inpatient addiction consultation improves substance use outcomes 1 month after discharge.

DESIGN: Prospective quasi-experimental evaluation comparing 30-day post-discharge outcomes between participants who were and were not seen by an addiction consult team during hospitalization at an urban academic hospital.

PARTICIPANTS: Three hundred ninety-nine hospitalized adults who screened as high risk for having an alcohol or drug use disorder or who were clinically identified by the primary nurse as having a substance use disorder.

INTERVENTION: Addiction consultation from a multidisciplinary specialty team offering pharmacotherapy initiation, motivational counseling, treatment planning, and direct linkage to ongoing addiction treatment.

MAIN MEASURES: Addiction Severity Index (ASI) composite score for alcohol and drug use and self-reported abstinence at 30 days post-discharge. Secondary outcomes included 90-day substance use measures and self-reported hospital and ED utilization.

KEY RESULTS: Among 265 participants with 30-day follow-up, a greater reduction in the ASI composite score for drug or alcohol use was seen in the intervention group than in the control group (mean ASI-alcohol decreased by 0.24 vs. 0.08, p < 0.001; mean ASI-drug decreased by 0.05 vs. 0.02, p = 0.003.) There was also a greater increase in the number of days of abstinence in the intervention group versus the control group (+12.7 days vs. +5.6, p < 0.001). The differences in ASI-alcohol, ASI-drug, and days abstinent all remained statistically significant after controlling for age, gender, employment status, smoking status, and baseline addiction severity (p = 0.018, 0.018, and 0.02, respectively). In a sensitivity analysis, assuming that patients who were lost to follow-up had no change from baseline severity, the differences remained statistically significant.

CONCLUSIONS: In a non-randomized cohort of medical inpatients, addiction consultation reduced addiction severity for alcohol and drug use and increased the number of days of abstinence in the first month after hospital discharge.

On PubMed: J Gen Intern Med 2017; 32(8):909-916

Annotation (S. Alex Sidelnik)

The finding: A comprehensive addiction consultation service for hospitalized patients leads to a number of positive outcomes including decreased alcohol and drug use severity after discharge, increased number of days abstinent, reduced substance-related rehospitalizations, and increased engagement in substance use treatment.

Strength and weaknesses: This a prospective, quasi-experimental study evaluating the effectiveness of an addiction consultation service on multiple primary and secondary outcomes at 30 days and 60 days after discharge from a general hospital. Patients were identified through the use of two addiction-screening measures and treatment teams requested subsequent consultations. The consultation service provided a multidisciplinary approach with an assessment for pharmacotherapy, psychiatric evaluation, motivational enhancement therapy, support by recovery coaches, along with evaluation and referral to higher levels of care. The study had a number of strengths including a multifaceted intervention with a robust effort to measure clinically significant measures at 30 and 90 days after discharge. While loss to follow-up was similar to other studies, the authors’ results remained statistically significant with an intention-to-treat analysis assuming patients lost to follow-up had no improvement in addiction severity measures. Furthermore, results continued to be statistically significant after adjusting for differences between control and intervention groups including differences in disease severity. The authors also relied on a number of self-reported outcomes that may limit accuracy of results. However, other studies have shown general agreement between self-reported measures and biologic measures in substance use assessment.

Relevance: Given the emergence of addiction as a major public health issue in the United States, improvements in addiction diagnosis, treatment, and linkage to treatment are needed. The study provides a unique and comprehensive model for establishing addiction care in the hospital setting through the use of a comprehensive addiction consultation service. The findings add to the growing body of literature that the hospital setting can be utilized for engaging patients in substance use treatment.

PUBLICATION #2 — Substance Use & Addictive Disorders

Intentional misuse and abuse of loperamide: a new look at a drug with “low abuse potential”

Borron SW, Watts SH, Tull J, Baeza S, Diebold S, Barrow A

J Emerg Med 2017 May 10 (Epub ahead of print)

BACKGROUND: Despite its opioid properties, loperamide has long been thought to have low abuse potential due to its poor absorption from the gastrointestinal tract and limited potential to cross the blood-brain barrier. A recent patient reportedly taking loperamide to avoid heroin withdrawal symptoms, at doses approximately 100 times those recommended, directed our attention to this issue.

OBJECTIVES: 1) Investigate number of cases of intentional loperamide abuse and misuse reported to poison centers between 2009 and 2015; 2) Compile reports of clinical effects of loperamide abuse; and 3) Search for evidence of increasing Internet interest in the central opioid effects of loperamide.

METHODS: For the years 2009 thru 2015, we reviewed exposure calls related to misuse/abuse of loperamide in the Texas Poison Center Network’s database and the National Poison Data System. We used Google trend analysis to detect evidence of increased Internet interest in the illicit use of loperamide.

RESULTS: Between 2009 and 2015, the number of misuse/abuse calls related to loperamide alone nearly doubled, with about one-third of cases occurring in teens and young adults in their 20s. Of particular concern are reports of significant cardiotoxic effects (∼18% of cases), including conduction defects and various dysrhythmias, sometimes leading to death. Google Trends analysis demonstrates an increasing number of searches for “loperamide high” and “loperamide withdrawal” beginning in 2011.

CONCLUSIONS: Loperamide misuse/abuse seems to be on the rise. Given its propensity to induce conduction disturbances and dysrhythmias at very high doses, emergency physicians should be vigilant for this form of drug abuse.

On PubMed: J Emerg Med 2017 May 10 (Epub ahead of print)

Annotation (Diana Robinson)

The finding: As prescription opioids become more difficult to obtain, it is likely that patients with opioid dependence will look to other illicit and over-the-counter alternatives for relief from withdrawal and for euphoria. Although loperamide or “lope” has long been viewed as an opioid agonist with low abuse potential due to minimal CNS effects, there is a trend toward increasing loperamide misuse and abuse. This retrospective database review of the Texas Poison Center Network’s database and the National Poison Data System showed 39 cases of loperamide ingestion alone and 44 cases of mixed ingestions in the state, and 947 loperamide-alone and 1925 mixed ingestions nationally. Thus, there is an increased number of cases of loperamide misuse/abuse, some with significant morbidity (cardiotoxic and neurotoxic effects) and even mortality in rare cases. 66% of the cases were less than 60 years old with 33% in their teens and 20s. Doses ingested ranged from 32mg to 576mg, yet some patients were combining loperamide with P-glycoprotein inhibitors such as quinidine, guanidine and piperidine, and/or cytochrome P450 inhibitors such as cimetidine to enhance CNS penetration and prolong effects.

Strength and weaknesses: This is a retrospective analysis of large state and nationwide poison databases from 2009-2015. Limitations included data from poison centers being reliant on the quality of the history and veracity of information provided by the callers, an underrepresentation of cases as many patients do not call when there are not significant symptoms, and many experienced physicians do not call when they are comfortable with the clinical management of a toxic ingestion. Additionally, without sales data for loperamide, it is difficult to establish a denominator.

Relevance: Given that C-L psychiatrists are frequently involved in assessing patient medical clearance for psychiatric admission from the emergency department and inpatient medicine, it is important to educate ourselves about the morbidity and mortality of emerging drugs of abuse, such as loperamide. This is particularly relevant given that ~18% of cases reported significant cardiotoxic effects, including conduction defects and various dysrhythmias resulting in death in rare instances.