Substance Use & Addictive Disorders

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

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

Also of interest:

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

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

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.