1. A NOVEL BUPRENORPHINE/NALOXONE TABLET FORMULATION FOR THE TREATMENT OF OPIOID DEPENDENCE
Orexo AB, Novum Pharmaceutical Research Services
Martin Jönsson1, Andreas Fischer1, Cornelia Tiberg1, Christopher H. Hendy2, Darin B. Brimhall2, Peter Hjelmström1
Summary: A novel sublingual tablet formulation of buprenorphine/naloxone, OX219 (Zubsolv™), was developed using interactive mixing techniques, with the aim of improving buprenorphine bioavailability and tablet characteristics compared to the currently marketed buprenorphine/naloxone tablet formulation (Suboxone®). A new drug application (NDA) was submitted for OX219 to the US FDA on September 6, 2012. In this comparative bioavailability study, pharmacokinetic properties and acceptability of the OX219 formulation were compared to Suboxone® 8/2 mg.
Methods: An open label, 2-period cross-over study was performed in 60 healthy volunteers under naltrexone block. Plasma concentrations of buprenorphine and naloxone were determined over 72 hours after dosing. Taste and overall acceptability was assessed on a 10-graded rating scale (1 = “extremely unpleasant”; 10 = “extremely pleasant”). After the last treatment, subjects chose which formulation they preferred.
Results: Buprenorphine exposure from the OX219 formulation met standard pharmacokinetic criteria for bioequivalence to Suboxone® 8/2 mg (90% CIs of geometric mean ratios for AUC(0-t), AUC(0-inf) and Cmax were within 0.8000 and 1.2500). Naloxone exposure was not higher with OX219 compared to Suboxone® (90%CIs of geometric mean ratios < 1.2500). Subjects rated taste and overall acceptability higher for OX219 compared to Suboxone® (median ratings of 7 vs 4 and 7 vs 5 respectively). 77% of subjects preferred the OX219 formulation.
Conclusion: The OX219 formulation displayed equivalent buprenorphine exposure to 8/2 mg Suboxone®. The interactive mixing technology yielded small, fast dissolving tablets, contributing to higher acceptability and preference scores for OX219.
2. ABUSE OF REFORMULATED OPANA ER: EARLY FINDINGS FROM NAVIPPRO DATA STREAMS
Reformulated extended release (ER) oxymorphone, surveillance, abuse
Mirella Zulueta, MD; Theresa Cassidy, MD
Summary: Reformulated extended release (ER) oxymorphone (OPANA ER; Endo Pharmaceuticals Inc., Chadds Ford, PA) was approved in December 2011 and released in February 2012. The reformulation has physicochemical resistance to crushing and dissolution intended to present obstacles to abuse by non-oral routes of administration (ROA, e.g., injecting, snorting). Initial observations regarding abuse of oxymorphone ER after its reformulation were gathered using two NAVIPPRO data sources.
Methods: The ASI-MV (Addiction Severity Index-Multimedia Version), a computer-administered interview, collects self-report of past 30 day substance abuse, including prescription opioids, among adults assessed for substance abuse and treatment planning. WIS (Web-Informed Services) collects discussion among individuals on eight drug-related websites. Ongoing surveillance data collected on reformulated oxymorphone ER will be reviewed and compared to abuse of other prescription opioid analgesics.
Results: Observations from 12,099 assessments during the second quarter of 2012 indicate lower abuse of reformulated oxymorphone ER (0.31 cases per 100 assessments) versus comparator opioid compounds (hydromorphone and morphine ER; 1.29 and 0.98 cases per 100 assessments, respectively). Of those who abused reformulated oxymorphone ER (n = 38), most administered the product orally (71.1%, n = 27), followed by injection (21.1%, n = 8) and snorting (15.8%, n = 6). Data from Internet discussions suggests dislike and frustration with the reformulation among recreational drug users including conversation indicating difficulty tampering with and use of the product via alternate ROAs. Posts regarding reformulated oxymorphone ER will be further examined to understand recreational drug users reactions to the new tablet.
Conclusion: These observations provide a preliminary impression of reformulated oxymorphone ER abuse from two large national data sources.
3. ACUTE PAIN EPISODE OUTCOMES IN PATIENTS TREATED WITH INJECTABLE EXTENDED-RELEASE NALTREXONE (XR-NTX)
pain management, XR-NTX
Paul Earley, MD, FASAM; David Gastfriend, MD; Amy Turncliff, PhD; Scott Erickson, MD; Robert Woolhandler, MD
Summary: To analyze whether acute pain can be managed during opioid receptor blockade with once-monthly XR-NTX 380 mg IM.
Methods: We analyzed: 1) Clinical trial pain-related events for XR-NTX discontinuations; 2) Post-marketing reports; and 3) health economic data on emergency room and hospitalization utilization.
Results: In seven studies, 1,169 patients reported 6,795 adverse events (AEs) or serious AEs (SAEs; e.g., involving ER or hospital admission) for which they received 12,285 medications. Pain medication was received for pain-related AEs or SAEs by 28% (325/1,169) of subjects; both non-opioid and/or opioid analgesics were utilized. Following pain-related AEs associated with pain medication, 92% (278/303) of subjects accepted subsequent XR-NTX injection. Following pain-related SAEs associated with pain medication, 73% (16/22) accepted subsequent XR-NTX dosing. Pain-related AE discontinuations did not occur more frequently during weeks 1-2 after XR-NTX administration (Range: 3-4% discontinuation rate per week; p = 0.988). Pain-related AEs or SAEs coded as severe were not associated with greater potential for study discontinuation. There were no pain-related SAE discontinuations during the first two weeks after XR-NTX. In post-marketing reports, (4/200611/2011) the proportion related to inadequate pain relief was <1%. In four national commercial insurance database analyses (aggregate XR-NTX-treated patient N = 1,323), XR-NTX patients had no greater emergency room use and significantly fewer hospital admissions than patients treated with approved oral agents for alcohol or opioid dependence. Clinical case vignettes describing the management of acute pain during XR-NTX treatment will be presented.
Conclusion: Once-monthly treatment with XR-NTX appears to be compatible with effective acute pain management.
Disclosures: Once-monthly treatment with XR-NTX appears to be compatible with effective acute pain management. Funded by Alkermes, Inc., Waltham, MA. Dr. Turncliff is a paid consultant for Alkermes. XR-NTX (VIVITROL) was developed with support from NIDA Grant R43DA013531 & NIAAA Grant N43AA001002.
4. ASSOCIATIONS BETWEEN ANXIETY DISORDERS AND SUBSTANCE USE DISORDERS IN SUBSTANCE-DEPENDENT ADOLESCENTS
Adolescents, Anxiety Disorders, Substance Use Disorders, Order of Onset
Alexandra R. Wang, B.A.; Michael D. Scur, B.A.; Christina M. Delos Reyes, M.D.; Maria E. Pagano, PhD.
Background: Comorbid anxiety disorders and substance use disorders (SUDs) are common in adolescents. The purpose of this study is to examine the following in substance dependent adolescents: the association between anxiety disorders (social phobia, panic disorder, and agoraphobia) and SUDs; the order of onset between anxiety disorders and SUDs; and changes in the mean age of secondary disorder onset in the presence or absence of a primary disorder.
Methods: One-hundred ninety-five substance-dependent adolescents (50% female, aged 14-18) who were referred to a residential treatment program were assessed at intake. Age of first symptom onset for anxiety disorders and SUDs were measured using the Mini International Neuropsychiatric Interview Plus (MINI-Plus).
Results: Social phobia and panic disorder preceded and increased the likelihood of marijuana dependency in adolescents. First use of marijuana occurred at earlier ages among adolescents with social phobia.
Conclusions: These results are consistent with the theory that onset ordering between anxiety disorder and SUD varies by disorder type.
5. BILATERAL BLINDNESS AND PARAPLEGIA ASSOCIATED WITH CRACK COCAINE ABUSE. A CASE OF LEVAMISOLE ASSOCIATED TOXICITY?
Cocaine, levamisole, crack
Timothy Wiegand MD, FACMT
University of Rochester Medical Center
Joseph Bettendorf, MD
University of Rochester Medical Center
Summary: Crack cocaine is a highly addictive freebase form of cocaine. Abuse has been associated with multiple adverse sequallae. Complete blindness after cocaine abuse has been very rarely reported. We present the case of a patient who experienced bilateral blindness and paraplegia that developed during a crack cocaine binge.
Methods: Case Report
Results: A 50 year-old male presented complaining of bilateral blindness that developed after a heavy “binge” with crack cocaine. About four days prior the patient had purchased a “quarter ounce” of crack. After he had smoked about half of the cocaine he noted that the vision in his right eye had begun to diminish, “like a curtain being pulled across the eye.” Despite developing complete blindness in the eye the patient finished the rest of the cocaine over a two day period and developed the same type of vision loss in his other eye while he was smoking the rest of the cocaine. He described not being able to stop using the cocaine despite the blindness, now in both eyes, during his binge. In addition to the vision loss the patient developed numbness and weakness in his lower back and legs as well as urinary retention shortly after arrival to the ED. This progressed to complete paraplegia shortly after admission. Laboratory results included leukopenia, a mild elevation of ESR and CRP, positive rheumatoid factor, positive anti-dsDNA, p-ANCA-titer, and HLA-B27 genotype. Exam showed normal corneas, non-hyperemic disc edema without hemorrhage on the right and trace disc edema on the left with attenuated arteries in both fundi. CT angiography revealed asymmetry in the ophthalmic arteries (R>L) without significant stenosis of major vessels. MRI showed no signs of ischemia and ophthalmic arteries were symmetric without abnormal contrast enhancement. Both optic nerves, however, had increases signal intensity and there was a high T2 signal lesion in the posterior spinal cord at T9 and 10. The patient did not regain vision and remained paraplegic despite treatment with steroids and plasmapharesis.
Conclusion: The features of this case as well as specific laboratory markers suggest that levamisole, as an adulterant of the cocaine, may have been the cause of this presentation. We were not able to confirm levamisole, however, due to a several day delay in presentation. This case illustrates the extremely reinforcing potential of crack cocaine and potentially devastating sequellae of addiction to this substance in susceptible individuals.
6. BUPRENORPHINE/NALOXONE FILM DIVERSION AND ABUSE RATES ARE LESS THAN TABLET FORMULATIONS
Buprenorphine, diversion, abuse
Lavonas EJ, Severtson SG, Bucher-Bartelson B, Green JL, Cicero T, Kurtz SP, Rosenblum A, Surratt HL, Dart RC.
Summary: Background: Buprenorphine and buprenorphine/naloxone sublingual formulations are sometimes abused. Little is known about how formulation affects diversion and abuse.
Methods: Data from the Researched Abuse, Diversion, and Addiction-Related Surveillance (RADARS) System Drug Diversion, Opioid Treatment Program (OTP), and Survey of Key Informants Patients (SKIP) programs from October 2010 June 2012, were analyzed. A Drug Diversion case was a law enforcement investigation involving a buprenorphine product. A treatment program event was a new patient who reported using buprenorphine to get high in the previous 30 days. Data were collected for buprenorphine tablets and buprenorphine/naloxone tablets and sublingual film. To adjust for drug availability, rates were calculated based on the number of persons filling prescriptions. Rates in year-quarters where all drug products were surveyed were averaged and compared across the 3 categories using negative binomial regression. Data from OTP and SKIP were combined for analysis.
Results: The combination film had the lowest average rate in all programs. In the Drug Diversion program, cases involving combination tablets (Rate Ratio (RR): 12.3, 95% CI: 7.8 19.5, p < 0.0001) and single ingredient tablets (RR: 7.4, 95% CI: 4.6 12.0, p < 0.0001) were more common than cases involving combination film. Treatment program reports of buprenorphine abuse were more common for the single ingredient tablets (RR 6.2, 95% CI: 5.1 7.6, p < 0.001) and for combination tablets (RR 2.0, 95% CI: 1.6 2.4, p < 0.001) than for the combination film.
Conclusion: Diversion and abuse rates of buprenorphine and buprenorphine/naloxone tablets exceed those of buprenorphine/naloxone combination film.
7. CANNABIS HYPEREMESIS SYNDROME
Cannabis Hyperemesis Syndrome
Muhammad Sadiq MBBS, MD, St Mary Mercy Hospital
Summary: Cannabis is the commonly used drug in United States for pain control, appetite stimulation and suppression of nausea and vomiting. In recent studies paradoxical emetic effects have been recognized in patients with chronic cannabis use.
Results: Our patient is an 18-year-old female who presented to the hospital with complaints of nausea and vomiting for 2 days. She had similar episodes in the past. Social history was significant for smoking marijuana. Exam was normal. Urine was positive for cannabinoids. Imaging studies were unremarkable. Patient continued to be symptomatic despite giving antiemetics and keeps asking for hot showers. Repeated hot showers helped her symptoms.
Conclusion: Cannabinoids exert their effects via two primary receptors, CB1 and CB2. CB1 receptor is found mainly in the CNS and enteric nervous system. Over stimulation of CB1 causes an increase in release of corticotrophin releasing factor (CRF) that may be contributory for cyclical vomiting. CB1 receptors also cause an increase in GABA release that in turn leads to hypothermia. As a compensatory mechanism, patients tend to take long, hot showers. The diagnosis of CHS should be a diagnosis of exclusion. Management requires adequate hydration. Patients tend to respond well to hot showers. On average, patients require supportive care for 24-72 hours. Finally, patients should be advised to avoid using cannabis.
8. CASE-BASED ONLINE TRAINING TO IMPROVE KNOWLEDGE AND ATTITUDES ABOUT SAFE OPIOID PRESCRIBING
opioid prescribing, online training, primary care
Brad Tanner MD
Clinical Tools, Inc.
Summary: Improving knowledge about opioid medications and attitudes towards patients with addiction is essential to ensuring proper prescribing of prescription opioids. With funding from NIDA we created and evaluated a web-based training program for primary care providers on the proper way to safely and appropriately prescribe opioid medications for pain. The interactive case-based learning experience alters practice behavior and improves clinical decision making via patient case scenarios.
Methods: Learners complete a pre/post test of clinical skill measures, as well as attitude and intended behavior surveys. The experience meets the requirement of AMA PRA Category 1 Credit (tm). Data from 47 professionals has been analyzed. For professionals, there was significant improvement in the knowledge from pre- to post-core training program (p < 0.01). Positive behavior changes indicated a willingness to use urine drug screens and treatment agreements, although only 80% of participants report intent to use. After the program, 98% of providers recognized that addiction is not inevitable if appropriate safeguards are taken, a 30% increase.
Results: We are now evaluating a sister program targeted towards medical students. Preliminary results suggest that training may be able to similarly influence attitude and improve knowledge for providers in training as well. Data collection from residents and students will conclude in Spring 2013 and results will be presented.
Conclusion: A web-based skills training curriculum can improve necessary knowledge and skills related to safe prescribing of opioids for chronic pain. Our ongoing studies will compare the impact of a prescription opioid curriculum at different points in physician training.
9. CHILDHOOD SEXUAL TRAUMA RELATED TO CONCURRENT OPIATE AND AMPHETAMINE USE DISORDERS IN ADOLESCENTS
adolescence, sexual abuse, emotional abuse, neglect, methamphetamine, opiates
Susan Wiet, MD; Lisa Ord, LCSW, PhD
Summary: A subset of adolescents develops substance abuse disorders (SUD), compared to normative experimentation. Life-long SUD (and somatic diagnoses) and mental health disorders (MHD) have been linked to adverse childhood events (ACEs). Effects of specific childhood traumas (CT) are likely implicated in severe SUDs and life-long dysfunction.
Methods: A blinded, retrospective chart review of 126 adolescents (ages 12.5-18 y/o) in a long-term SUD residential; average age = 11.9 y/o for SUD onset; male:female ratio = 2:1; relationships established between self-reported CTs, mental health diagnoses (MHD) and specific SUDs. CTs analyzed: sexual abuse (SA), physical abuse (PA), neglect (N), and community violence (CV: domestic and/or gang violence). Age at onset of trauma was documented for SA, PA and N; type of perpetrator was identified for SA.
Results: A two-way contingency table analysis evaluated statistical relationships between Axis 1 MHDs/SUD, CT/SUD and CT/MHD. Results of CT/MHD were consistent with epidemiological studies. The strongest MHD/SUD relationships were PTSD/methamphetamine (p = 0.003), MDD/Cocaine (p = 0.003), RAD/methamphetamine (p = 0.031). The strongest CT/SUD relationships were: PA/methamphetamine (p = 0.010), SA/methamphetamine or opiate (p = 0.000 and p = 0.041, respectively), SA/methamphetamine AND opiate (p = 0.000).
Conclusion: Childhood PA and SA demonstrated a relationship with opiate and/or stimulant SUDs. The combination of SA and PA demonstrated more potent risk for opiate and/or stimulant SUDs. Opiate and stimulant SUDs should promote investigation of CT. Neuroendocrine alterations due to ACEs likely affect reward pathways via chronic release of pro-opiomelanocortin (POMC) and downstream hormonal cascades of the endogenous opioid and HPA; pre-adolescent priming of the reward pathways for later opiate and/or stimulant abuse may be induced by POMC. Screening for Adverse Childhood Events (ACEs) may lead to earlier identification of those at-risk for or having active SUDs, leading to earlier intervention and/or prevention. Early identification and therapeutic resolution of ACEs would likely reduce the long-term dysfunction and result in vast medical cost-savings.
10. CONTINUITY OF CLINICAL EFFICACY WITH INJECTABLE EXTENDED-RELEASE NALTREXONE (XR-NTX)
XR-NTX, cravings, placebo-controlled
David Gastfriend, MD; Bernard Silverman, MD; Asli Memisoglu, ScD; Evgeny Krupitsky, MD, PhD; Walter Ling, MD
Summary: To determine whether clinical outcomes vary over the four-week injection cycle with XR-NTX.
Methods: In opioid-dependent patients who received XR-NTX (N = 126) or placebo (N = 124) during a 24-week (i.e., 6 injection cycles), double-blind, placebo-controlled clinical trial, repeated measures regression was used to analyze craving scores, opioid use and discontinuation with predictor terms for treatment cohort, total number of injections, time from previous injection, and treatment by time from previous injection interaction terms. Craving over time was explored with quadratic and logarithmic trend mixed models, and opioid use and discontinuation with generalized estimating equation models.
Results: Craving: Both linear and quadratic parameters for time from previous injection were significant (both p = 0.001) indicating that the relationship is not simply linear. This association, however, did not differ for XR-NTX vs. PBO (interaction term p = 0.251). Opioid Use and Discontinuation: Time from previous injection was significant (all p ≤ 0.001), indicating that the longer the time from injection the greater the likelihood of a patient using opioids and discontinuing. These associations were not different, however, for XR-NTX vs. PBO (p = 0.872 and p = 0.478, respectively).
Conclusion: Within the 4-week injection cycle, the observed time course of change in craving, opioid use and discontinuation was not different between XR-NTX vs. PBO. This nonsignificant interaction means the XR-NTX benefit vs. PBO is consistent over wks 1-4. Although this analysis is post hoc, the double-blind, placebo-controlled RCT design indicates that the effect of time is not pharmacologic in nature. These findings underscore the clinical role for psychosocial management with XR-NTX treatment.
Disclosures: Funded by Alkermes, Inc., Waltham, MA. Drs. Silverman, Gastfriend, and Memisoglu are employees of Alkermes. Dr. Krupitsky is a consultant for Alkermes and received research funding for this study from Alkermes. XR-NTX (VIVITROL®) was developed with support from NIDA Grant R43DA013531 & NIAAA Grant N43AA001002.
11. CORRELATING DEPRESSION TO PROGRESS THROUGH DRUG TREATMENT COURT
Depression, substance abuse treatment, drug treatment court, alternative diversion program, mental health
Sara Mamman, BS, BA; Randall Brown, MD, PhD, FASAM; Michele Gassman, MA
Summary: Mental health disorders, particularly depression, frequently co-occur with substance dependence. Criminal behaviors also frequently co-occurs with substance dependence. Systems addressing crime will also deal with addiction and mental illness. The impact of depression uponoutcomes for addicted offenders in jail diversion programs, such as drug court, is poorly understood. The Dane County Drug Treatment Court (DTC) is a program for non-violent substance dependent offenders. DTC participants agree to participate in substance abuse treatment, case-management, court appearances, and random drug testing, in order to have their sentence reduced or dismissed. This study examined depression in a DTC sample and assessed correlations with progress through DTC.
Methods: A 31-item, survey was administered to 44 DTC participants. The questionnaire included measures for depression (Patient Health Questionnaire-9), substance use (Timeline Follow Back), and well-being (Short Warwick Edinburgh Mental Well Being Scale-7).
Results: PHQ-9 scores decreased and SWEMWBS-7 scores increased as time spent in the DTC program increased. Secondary findings included associations between (1) employment and shorter time in Phase 1 of DTC, (2) opiate use and higher PHQ-9 scores, and (3) more frequent substance use and higher PHQ-9 scores.
Conclusion: DTC programs may increase the well-being of participants over time by decreasing depression severity, independent of other forms of depression treatment. Next steps would include examining depression severity at multiple time points over the full length of the program and also measuring depression after participants graduate to see if well-being is sustained after they reintegrate into society.
12. DEVELOPING A RELAPSE PREVENTION TOOL: ASSESSING MOTIVATIONS FOR USE IN ADDICTED PROFESSIONALS
motivations for use; relapse prevention
Ashley Bassett MD; Evan Goulding MD; Stephanie Ryan, MPH; Daniel Angres, MD; Stephanie Bologeorges, MD
Northwestern Memorial Hospital
Summary: Helping individuals with substance dependence gain insight into their reasons for initiating and maintaining substance use may assist them in changing their patterns of behavior and allow providers to better tailor treatment. With this in mind, this study aims to ascertain individuals' self-identified motivations for substance use initiation and maintenance in a population of professionals (e.g. physicians, nurses, pharmacists, lawyers).
Methods: An initial series of 96 questions aimed at examining reasons and motivations for use was distributed to addiction treatment professionals to obtain feedback on the utility of the questions. A reduced question set (49) was then provided to patients at a boarded partial hospital program for professionals. Participant (N = 249) responses were examined to identify if motivations for substance use fall into clusters of distinct motivations for initiating and maintaining use.
Results: We found that the questions about motivations for use separated into three different groups: coping, social, and work enhancement motivations. Motivations for work enhancement were more prominent in our study than in many prior studies of motivations for substance use which have often been carried out in adolescent populations and address only motivations for alcohol use.
Conclusion: The prominence of work motivations in this study may due to the professional nature of our population. Interestingly, individuals who endorsed opioids as their primary substance of abuse endorsed work motives more strongly than individuals whose primary substance of abuse was alcohol.
13. DO REDUCTIONS IN DRINKING WEAR OFF? EXAMINING ALCOHOL USE PATTERNS IN AN SBIRT CONTROL GROUP OVER 30 MONTHS
SBIRT, emergency department, reducing drinking
Aaron Johnson, PhD; Jason Dhabliwala, BS; Paul Seale, MD
Medical Center of Central Georgia
Summary: Screening, brief intervention and referral to treatment (SBIRT) for risky drinking has been shown to be effective in reducing patients alcohol use. SBIRT studies often report significant alcohol use reductions in control groups that may result from the assessment, the event that led to the healthcare visit, a Hawthorne effect/social desirability, or regression to the mean. This study examines whether decreases in alcohol use found in control groups represent short-term changes in drinking or are sustained over an extended period of time.
Methods: Patients presenting to an emergency department in Georgia between February and April 2009 were enrolled as control group participants (n = 893). Participants received a 15 minute assessment by a health education specialist, and a list of local addiction treatment resources. Telephone follow-up interviews were completed with participants at 6, 18, and 30 months to identify changes in substance use. Data were analyzed using Linear Mixed Models.
Results: Results show the expected decrease between baseline and 6 months on both major alcohol use measures, past 30 day drinking days (8.69 days to 5.75 days) and past 30 day binge drinking days (6.03 days to 3.91 days). Past 30 day drinking days declined further at 18 and 30 months (5.12 days and 5.12 days), while past 30 day binge drinking days showed ongoing decline across this period (2.93 days at 18 months, 2.17 days at 30 months).
Conclusion: These findings suggest that the reductions in alcohol use patterns commonly seen among control group participants in SBIRT studies may represent long-term changes.
14. ENGAGING RESIDENTS IN ONLINE LEARNING
Education, training, web-based curriculum
Bruce Horwitz, PhD
Summary: We are now in Year 4 of our 5-year SAMHSA-funded SBIRT residency training project. We are working with residents in 6 academic departments and students in medicine, nursing, and social work. Initially, we delivered our online training with Blackboard, provided by the University. In 2011 we developed a web site for learners to access and track training. That has worked well, and students, residents, and faculty have given the site positive reviews. But we decided it could be made even better: more engaging, more enjoyable, and more memorable.
Methods: Creative staff in the University's video production services have recreated our didactic content using kinetic typography in which text is animated in ways that illustrate key concepts. A local web-design company, MayeCreate, has made the website more user friendly with intuitive navigation and more appealing illustrations and color.
Results: We are also adding new videos to the website to demonstrate how a nurse can comfortably screen patients for tobacco, alcohol, and drug use, and how a clinician can engage a patient in thinking about possibilities for changing substance use behavior, tapping into the patient's internal motivation using motivational interviewing skills.
Conclusion: All these parts are in production as of October 2012, to be finished before April 2013. At the poster presentation, we will have the videos available on a laptop. All will be at our website https://adept.missouri.edu, freely accessible to everyone. We will also have flash drives with copies for anyone who would like to have them.
15. EVALUATE THE EFFECTIVENESS OF COGNITIVE BEHAVIORAL THERAPY AND RELAXATION TRAINING ON REDUCING ATTITUDE TOWARD TOBACCO SMOKING
Cognitive Behavioral Therapy, Relaxation Training, Attitude toward Tobacco Smoking
Hamideh Jahangiri, MS; Alireza Norouzi, BS
Payame Noor University
Summary: Evidences show the connection between personal and educational factors on students addicted to smoking tobacco (positive correlation) seriously are increasing. The prevalence of smoking tobacco worldwide before 18. Personal and Educational factors are considered as important factors in Smoking Tobacco. Most Tobacco Addicts take up the addiction with smoking tobacco.
Methods: To evaluate attitude and orientation toward tobacco smoking among 700 smoker and non-smoker university students' of the three alternative universities were randomly selected in the province of Tehran was conducted. This study as a descriptive, analytical, and cross sectional study. The objective data 1) Demographic questionnaires 2) WHO questionnaires and 3) Attitude and orientation to smoking questionnaires (Nicotine dependence or Fagstrvm Test) and 4) had withdrawal symptoms questionnaires were collected, then the information analyzed by spss-19. Results show 700 smoker and non-smoker university students' of the three alternative universities were randomly selected: 1) Non-smoker group 2) groups of smokers, as control group, without any independent variable, 3) Group smokers.
Results: Test group, received cognitivebehavioral therapy and educate and training coping skills. Tobacco smoking prevalence among university students in the province of Tehran was found to be 39.8%. Reliability coefficient (Cronbach's alpha) in the attitudes and withdrawal symptoms were respectively 76% and 81% and 74% respectively. Analysis of variance of attitude scores at pre-test results showed that attitudes toward tobacco smokers and non-smokers, the difference is significant. (P = 0). The smokers compared with non-smokers had more positive attitude towards smoking. This difference was 71%. The results of covariance showed that the difference between the test scores of interest groups with a control test is significant (P = 0). After the test group received less training than the control group tended to have smoking. Its the effect of education on 52% interest. The results also showed that the difference between the test scores after withdrawal of the test is significant with the control group (P = 0). The group tested after training, fewer withdrawal symptoms were observed. The effect of education on the health care and withdrawal of 93%. 86% of smoker students' believed that smoking have affected the relatives health. 95% of smoker students' believed that the lungs have been affected more than the other organs such as heart and brain.
Conclusion: Finally, according to community of health education and research on substance abuse treatment, Cognitive Behavioral Strategies effective in the treatment of addiction. Acknowledge and training the benefit of non_text book, magazine, Internet by students and change and correct orientation about their self experimentation were the major factors found to be associated with the withdrawal symptoms among university students' and becoming non-smokers.
16. PILOT INVESTIGATE OF THE LIKELY LINKAGE (P.I.L.L.) BETWEEN GENETIC VARIATIONS IN THE MESOLIMBIC DOPAMINE SYSTEM AND ELEVATED RISK OF OPIOID ABUSE IN CHOICE PAIN PATIENTS
Mesolimbic dopamine system, chronic pain genetic variation neurochemical deficiencies narcotics addiction
Timothy Deer, MD1; Gregory A. Smith, MD3; Brian J. Meshkin2; John Hubbard, RPT2; Michael S. Sinel, MD4; Benjamin Arthur, PhD., MS, EMTM2
1-Center for Pain Relief, Charleston, West Virginia; 2-Proove Biosciences Inc., Irvine, California; 3-Comprehensive Pain Relief Group, Fresno, California; 4-UCLA School of Medicine, Los Angeles, California
Background: Many chronic pain patients fail to control their pain with current treatment. Addiction and death from medically prescribed opioids are major public health problems and are more prevalent than drugs obtained illicitly. Approximately 60% of the factors known to contribute to addictions have genetic basis. Currently, evaluations of these genetic factors are generally not included in Standard of Care in Clinical Practices. Prolonged pain leads to neurochemical changes that tend to be exacerbated in subjects predisposed to neurochemical deficiency.
Objective: To evaluate the prevalence of genotypes linked with neurochemical deficiency among chronic pain patients taking narcotic pain medications.
Methods: 100 subjects diagnosed with chronic pain taking prescription narcotics were genotyped using the proprietary Narcotic Risk Panel (Proove Biosciences) by RealTime PCR TaqMan Assay (Applied Biosystems). The following SNPs based on the mesolimbic reward system were evaluated: DRD1 -48A>G, DRD2 A1 allele, DRD4 -521C/T, DAT1 Ddel, COMT Val158Met, OPRK1 36G>T, OPRM1 A118G, DBH -1021C/T, 5-HT2A -1438G/A, 5-HTTLPR, GABA 1519T>C and MTHFR C677T.
Results: The percentages were compared between the variants in the study and Literature controls. Statistical significance was found in the prevalence of DRD4-521C/T (79% v. 29%; p<0.001), DAT1 Ddel (68% v. 55%; p<0.5), COMT Val158Met (74% v. 47%; p<0.001), OPRK1 36G>T (16% v. 3%; p<0.05) and OPRM1 A118G (17% v. 47%; p<0.01).
Conclusion: The prevalence of a genetic predisposition to substance abuse among chronic pain patients taking prescription narcotic pain medications provides information to prescribers that may improve therapeutic decisions to avoid tolerance, dependence, or misuse of narcotics.
17. INJECTABLE EXTENDED-RELEASE NALTREXONE IN OPIOID DEPENDENCE: PATIENTS CHARACTERISTICS, COVERAGE AND HOSPITAL COURSE
XR-NTX, opioid dependence, Medicaid reimbursement
Roger Meyer, MD; David Gastfriend, MD; William Milchak, LCSW, CAC, CCDP; Edward Bixler, PhD; David Gastfriend, MD; Doug Leslie, PhD; Jeb Bird, MD; Philip Herschman, PhD
Summary: A naturalistic study of characteristics, hospital course & health coverage of opioid dependent patients treated with (or without) extended release naltrexone (XR-NTX).
Methods: We analyzed retrospective electronic records of 7,687 detoxification/rehabilitation inpatients in Pennsylvania with a diagnosis of opioid dependence in terms of demography, diagnosis, primary payer, and hospital course.
Results: XR-NTX was recommended for 598/7,687 patients (7.8%) by the clinical staff (R+). Injections were administered to 168/598 (28.1%; R++) but not to 430 (72%; R+ −). R++ and R+ - patients did not differ demographically or diagnostically from patients not recommended for XR-NTX (R− −; n = 7089), except that 64% of R− − patients were male vs. 50% of R++ and R+ − individuals. Of the R++ group, 142/168 (84.5%) vs. 71% of R+ − and 73.2% of R− − patients were on Medicaid. Commercial insurance covered 13% of R++ patients (vs. 26.5% of R+ − and 22.4% of R− −). R+ + patients were much more likely to complete inpatient treatment (93.5%) vs. 60% of other patients. Only 4.8% of R+ + patients were discharged against medical advice (AMA) vs. 30% of other patients (R+ − and R − −).
Conclusion: In these Pennsylvania based residential programs, Medicaid was a feasible reimbursement source for XR-NTX treatment. Women were as likely as men to accept XR-NTX for treatment. Limitations include retrospective design and possible group differences. Nevertheless, XR NTX patients had an 84% Relative Risk Reduction for AMA departure in early recovery, which suggests implications for opioid residential treatment.
Disclosures: In these Pennsylvaniabased residential programs, Medicaid was a feasible reimbursement source for XR-NTX treatment. Women were as likely as men to accept XR-NTX for treatment. Limitations include retrospective design and possible group differences. Nevertheless, XR NTX patients had a 84% Relative Risk Reduction for AMA departure in early recovery, which suggests implications for opioid residential treatment. Disclosures: This analysis was conducted under a research services agreement with Penn State University from Alkermes, Inc. XR-NTX (VIVITROL) was developed with support from NIDA Grant R43DA013531 & NIAAA Grant N43AA001002. Dr. Herschman and Mr. Bird are employees of CRC Health Group, Inc. Dr. Gastfriend is a full-time employee of Alkermes.
18. MEDICAL STUDENT PERCEPTIONS OF ALCOHOL USE AMONG THEIR PEERS
Alcohol; Medical students; Coping; Stress
Lisa Merlo PhD, MPE
University of Florida
Summary: Medical school matriculation is associated with increased stress, and research has demonstrated relatively high rates of depression, anxiety, and other psychiatric conditions. Yet, students report being discouraged from seeking treatment, and anecdotally describe coping through alcohol consumption. The present study examined medical students perceptions of alcohol use among their peers.
Methods: Following IRB approval, current 2nd-4th year medical students were invited to complete an anonymous online survey regarding alcohol use. A total of 131 students (33% of those eligible) participated. The final sample included only students who reported being completely honest in their responses (n = 112).
Results: The plurality of students (47.3%) endorsed that the general attitude of their peers is getting drunk is a good release for the pressures of medical school; and 41.1% endorsed medical students should be able to drink in moderation. Over 60% reported believing that they drink less than their peers, 23.2% reported consuming an average amount, 11.6% reported drinking slightly more, and 4.5% acknowledged drinking significantly more than their peers. Students estimated that 8.8% of medical student peers suffer from alcohol abuse or dependence (SD = 8.0%, range = 0-40%). This was similar to the percentage of students (10.7%) who strongly disagreed with the statement, I feel in control of my alcohol consumption. Primary reasons endorsed for alcohol consumption by medical students were to celebrate/party/have fun, to relieve anxiety/stress from school, and to get drunk, buzzed, or feel high. Over half of students agreed with the statement, The stresses of medical training encourage medical students to use alcohol more than other students.
Conclusion: Many medical students use alcohol as a means of coping with school-related pressures, and a significant minority endorse having difficulty controlling their alcohol consumption. Improved prevention programs and access to treatment may be needed for this high-risk population.
19. METHADONE MAINENANCE TREATMENT FOR OPIOID DEPENDENCE AND QTC INTERVAL
Shannon Robinson, MD; Cassidy Zanko, MD; Abigail Goldsmith, PhD
Summary: Studies show methadone prolongs the QTc interval, which can lead to the life-threatening arrhythmia, Torsade de Pointes. A panel of experts proposed recommendations in 2009 for surveillance of methadone patients. This project reviewed the pretreatment ECG, post treatment ECG and intermittent ECGs of opioid dependent methadone participants and then met with participants individually to discuss their risk profile and establish an individual treatment plan.
Methods: Fifty-one consented participants were included (49 males, 2 females). Participants underwent ECGs, medical chart review and individual appointments to discuss results and receive recommendations.
Results: Thirty (59%) of patients had at least one QTc on methadone 450 ms, five (10%) had at least one QTc 500 ms. At the time of the study, 24 (47%) of the 51 participants had QTc 450 ms and one had QTc 500 ms. 8.5% (3/35) had a change in QTc 100 ms. The mean of the highest QTc for participants on 80 mg methadone was greater than participants on <80 mg, t(49) = −2.103, p = 0.041. The mean of the highest QTc of particpants on 80 mg was greater than general population (mean = 440 ms), t(23) = 4.168, p = 0.000.
Conclusion: Results demonstrate that methadone patients have significantly higher mean QTc compared to general population when on 80 mg of methadone. The findings support routine ECG monitoring of patients on methadone, particularly at or above this dose.
20. PERSISTENCE AND HEALTHCARE CHARGES AMONG OPIOID-DEPENDENT PATIENTS TREATED WITH BUPRENORPHINE/NALOXONE FILM AND TABLET FORMULATION: RETROSPECTIVE STUDY OF A PRIVATELY INSURED DATABASE
Opioid Addiction, Buprenorphine Naloxone
Vladimir Zah, PhD; Jane Ruby, PhD; Samuel Aballea, MS; Elizaveta Kharitonova, MS; Emilie Clay, MS
ZRx Outcomes Research Inc.
Summary: The buprenorphine/naloxone combination (BUP/NAL) has been available in a film formulation since 2010 for the treatment of opioid dependence. Insurance claims data were analyzed to compare patient persistence and healthcare charges between film and tablet formulations.
Methods: A retrospective cohort analysis was performed using medical claim records extracted from the Invision DataMart database. Patients initiating treatment with BUP/NAL after the launch of film (September 2010) were classified in two groups according to formulation of initial prescription: film or tablet. Time to treatment discontinuation and monthly healthcare charges by treatment phase (before treatment, initiation period, during treatment, discontinuation period, after discontinuation and reinitiation period) were compared between the two groups, adjusting on baseline characteristics (demographics, comorbidities, treatment, and resource utilization before treatment).
Results: Analysis included 1,847 patients initially treated with film and 1,318 with tablet, followed over 8.0 and 10.9 months on average respectively. Of those treated with tablet, 13.20% of patients switched to film. Patients treated with film were on average 1.2 year younger at treatment initiation (p = 0.01), were less likely to be diagnosed with a mental disorder (p = 0.004). The average dose at initiation was higher in the film group. The proportion of patients persistent at 6 months was higher in the film group than in the tablet group (58.46% vs. 63.26; p = 0.03). The hazard ratio for treatment discontinuation with film vs. tablet, adjusted on baseline characteristics, was 0.83 (p = 0.02). Monthly charges were highest around the time of treatment initiation and discontinuation. Monthly charges during treatment were $2,445 for patients treated with film and $3,265 with tablet (p = 0.005). Monthly costs during treatment discontinuation were 42% lower among patients treated with film (p = 0.006).
Conclusion: Patients treated with BUP/NAL film appear to have a lower probability of early treatment discontinuation. Treatment with the film formulation may generate charge savings since charges around discontinuation are relatively high, and charges after treatment discontinuation were found to be lower among patient previously treated with film.
21. PREDICTORS OF RESPONSE TO NALTREXONE IN ALCOHOL DEPENDENCE: A SYSTEMATIC REVIEW AND INTEGRATION OF THE WORLD LITERATURE
alcohol dependence, naltrexone, predictors, craving, genetics, family history
James Garbutt M.D.
University of North Carolina at Chapel Hill
Summary: Identifying predictors of response to naltrexone in alcohol dependence is an important goal to advancing clinical care. Currently, naltrexone shows only modest effectiveness for alcohol dependence though some individuals demonstrate robust response. A systematic review of the world literature on predictors of naltrexone response in alcohol dependence was completed of publications through mid 2012. The literature indicated that there is evidence in support of certain predictors, e.g. craving, family history of alcoholism, and u-opioid receptor Asp40 polymorphism, being associated with response to naltrexone. However, overall, that evidence is generally weak and insufficient to recommend any predictor as a practical tool in real-world clinical care.
Methods: A systematic search of Pubmed, CINHAL, Embase, Psycinfo and the Cochrane Library from 1/1/1990 through 2/28/2011 yielded 753 citations, with an updated PubMed search conducted on 4/26/2012. Each title and abstract was dually reviewed for inclusion with disagreements adjudicated by discussion. We reviewed the full text of papers meeting the inclusion criteria to determine if they contained analyses of factors influencing naltrexone response. Publications with predictor information were abstracted into standardized evidence tables that also captured risk of bias.
Results: We abstracted information from 76 articles that contained information on one or more of these 10 potential predictors: age, sex, craving, family history of alcoholism, genetics, alcohol subtypes, smoking status, comorbid psychopathology, adjunct psychosocial treatment, and pretreatment level of drinking. Of these, the evidence suggested that that the following are predictors of a good response to naltrexone: male gender, higher craving for alcohol, the Asp40 polymorphism of the u-opioid receptor, positive family history of alcoholism, and receiving cognitive behavioral therapy. It is important to note that the risk of bias for this literature was relatively high as there were very few a priori studies examining predictors, many studies were secondary analyses on subsets of subjects, sample sizes were generally small, and there were significant methodological weaknesses including differences in how predictors and treatment outcomes were defined.
Conclusion: The field is evolving towards a better understanding of factors influencing naltrexone effectiveness so as to allow tailoring of treatment for individual patients. While weak associations have been noted for a number of clinical and biological factors, the overall strength of evidence is not sufficient to support their use for clinical recommendations. Future studies must be designed to identify best treatments for important patient subgroups before clinical practice can advance. Such trials of the Asp40 polymorphism are underway.
22. QUALITATIVE EVALUATION OF THE EXPERIENCE OF PARTICIPANTS IN THE DANE COUNTY OPERATING WHILE INTOXICATED TREATMENT COURT
drunk driving, treatment court, alcohol dependence
Randall Brown, MD, PhD, FASAM; Michele Gassman, MA
University of Wisconsin School of Medicine & Public Health
Summary: Repeat drunk driving (OWI, in Wisconsin) offenders are highly likely to meet diagnostic criteria for alcohol abuse or dependence. For these offenders, when adjudication is not accompanied by treatment, previous patterns of use, including drunken driving, frequently resume. Public safety is likely enhanced, if formal treatment is offered to repeat offenders. OWI Treatment Courts provide treatment and supervision to repeat offenders in an effort to facilitate reintegration while still administering justice. The goal of this project was to collect qualitative pilot data via confidential surveys on participants opinions and experiences as they relate to OWI Treatment Court services and support in the Dane County OWI Treatment Court.
Methods: A one-time survey was administered to 42 OWI Court participants. Participants were surveyed regarding their opinions regarding OWI Treatment Court components. Survey items were framed such that answers were given on a 10-point Likert scale Higher numbers indicated that the item/individuals was viewed as more helpful or positive.
Results: The primary motivation for OWI Court participation was avoidance of jail (58%) followed by getting sober (23%), and getting drivers license back (15%). Similarly, the most helpful component of OWI Court was reduction of jail sentence (58%). Other components frequently cited as most important included attending treatment sessions (40%), and attending support groups (33%).
Conclusion: These OWI Treatment Court participants were most motivated by reductions in sentences, but were appreciative of treatment contacts and group support. These findings provide some evidence supportive of the role of criminal justice programs in leveraging treatment participation for dependent offenders.
23. RECURRENT VASCULITIS DUE TO LEVAMISOLE-ADULTERATED COCAINE CONFIRMED BY LABORATORY TESTING
levamisole; cocaine; vasculitis
Timothy Wiegand MD, FACMT
University of Rochester Medical Center
Rachel Gorodetsky, PharmD
D'Youville College School of Pharmacy
Summary: Levamisole is an antihelminthic and immunomodulatory drug that has become a very common cocaine adulterant. Potentiation of cocaine effects, interference with screening methods for cocaine, and use as a chemical signature are three of the most common hypotheses expressed as to why levamisole is used as an adulterant. DEA figures show a dramatic increase in levamisole as an adulterant with less than 1% of US cocaine found to contain levamisole in 2001 compared to over 80% in 2011. Complications related to levamisole such as agranulocytosis and cutaneous lesions are an increasing problem among cocaine users. We present a case of a 25-year-old woman with a history of cocaine abuse who presented to our Emergency Department eight times over a one-year period with exacerbations of cutaneous lesions, severe pain at the lesion sites and diffuse arthralgias with the use of cocaine. Her reactions manifested as discrete, purpuric, painful lesions with necrosis in the most severely affected areas. We were able to confirm, via quantitative analysis, the presence of levamisole and cocaine metabolites.
Results: LCMS quantitative results for levamisole and metabolites as well as cocaine metabolites in patients urine revealed: Levamisole - 11,244 ng/ml, 4-OH Levamisole - 118 ng/ml, Cocaethylene - 1714 ng/mL, Benzoylecognine - 72,739 ng/ml, Ecognine methyl ester - 21,017 ng/ml, Aminorex - <10 ng/mL
Conclusion: This case highlights the addictive nature of cocaine and complications related to not only the cocaine but adulterant exposure in a highly addicted individual. Clinicians need to appreciate the potential complications of cocaine adulterants, especially levamisole. This case presentation also contains images of the clinical manifestations including vasculitic changes of the ears, nose and legs.
24. REFERRALS TO AND PARTICIPATION IN AN AMBULATORY DETOXIFICATION PROGRAM FROM 2007 TO 2011
Detoxification, Opioids, Alcohol
Julie Kmiec DO
University of Pittsburgh
Summary: Ambulatory detoxification is a safe and accepted means of detoxification from alcohol, benzodiazepines, and opioids. Detoxification is thought to be successful if patients complete the program and continue in aftercare. The present study focuses on the success of Western Psychiatric Institute and Clinic's ambulatory detoxification program from 2007 to 2011.
Methods: A retrospective chart review was conducted. The number of patients who 1) were referred for ambulatory detoxification, 2) presented for their first medication check, 3) completed detoxification, and 4) went to aftercare, were tallied annually from 2007 to 2011. The number of patients presenting for alcohol and opioid withdrawal each of these years was noted as well.
Results: From 2007 to 2011, the number of referrals for ambulatory detoxification increased from 638 to 1118. The percentage of patients who presented for their first medication check or completed detox ranged from 60 to 69% over the years. The percentage of patients who participated in aftercare decreased from 72.4% in 2007 to 58.8% in 2011. Over the 5 year period, 38 to 45% of the patients were withdrawing from opioids while 26 to 37% were withdrawing from alcohol.
Conclusion: The number of patients presenting for detoxification grew from 2007 to 2011. Over that time period, the percentage of patients who presented for their first medication check and completed detox remained steady. The percentage of patients participating in aftercare, however, decreased slightly. The percentage of patients presenting for opioid and alcohol detoxification remained constant.
25. UNUSUAL CASE OF STREPTOCOCCUS MITIS ENDOCARDITIS IN IV METHAMPHETAMINE USER
Iv Methamphetamine, Streptococcus mitis, Infective endocarditis.
Ashwin George M.D, Hopsitalist and Peri-op Consultant, Regions Hospital, St Paul, MN
Svetlana Zaydman D.O, Medical Director, Britton Pain Center, St Paul, MN
Introduction: Infective endocarditis (IE) is the most common cardiac complication of injection drug use but streptococcus mitis is not a common pathogen seen in this patient cohorts. Here we are presenting a patient whose needle licking habit before injecting iv meth amphetamine is identified as a risk factor for oral pathogens causing IE.
Case Report: Patient is a 37 year old male with past medical history significant for hypertension, bicuspid aortic valve and intravenous (IV) drug use, came to the emergency room with complaints of progressively worsening dyspnea and fatigue over 2 month period. His social history was significant for IV methamphetamine use. He used to lick his needles before each use. He has stopped drug use for the last 3 – 4 months. On exam patient had a fever of 101 degree Fahrenheit, loud systolic and diastolic murmur, bilateral lung congestion and pedal edema. His labs showed an elevated WBC count. Chest Xray showed pulmonary congestion and chest CT was negative for infiltrate or pulmonary embolism. Blood cultures where drawn and he was admitted to the hospital. Within 8 hours blood cultures came back positive for gram-positive cocci. Patient was started on IV Vancomycin, Ceftriaxone and Gentamycin. Blood cultures grew Streptococcus mitis sensitive to Penicillin G. TEE revealed large mitral vegetation with perforation and a small mobile mass on bicuspid aortic valve. Diagnosis of IE was confirmed. Antibacterial coverage was changed to PCN and preparations were made for valve replacement. A dental exam did not reveal any dental cavity, abscess or gingivitis.
Results: Gram stain
Discussion: Streptococcus mitis is not a common pathogen causing IE in IV drug users. It is a oral pathogen which can cause endocarditis in patients with poor oral hygiene. Our patient was a productive, well functioning male going to work every day. He had good personal and oral hygiene. Three months before admission he was using IV methamphetamine recreationally. Two weeks after he discontinued using IVD he developed mild fatigue and myalgia. He attributed these symptoms to withdrawal. In the next 8 weeks he visited his PMD twice with similar vague complaints but was again thought to be due to withdrawal. Finally, he came to ER with rapidly worsening shortness of breath, which required admission and aggressive work up leading to the diagnosis of IE. This case illustrates the challenges in early clinical identification of subacute IE which presents with generalized symptoms that are easily confused with withdrawal. Also details of drug administration history is important to identify the etiology. Possibly because of delay in the diagnosis and treatment this patient ended up with a perforated mitral valve requiring surgery.
Mathew J, Addai T, Anand A, Morrobel A, Maheshwari P, Freels S. Clinical features, site of involvement, bacteriologic findings, and outcome of infective endocarditis in intravenous drug users. Arch Intern Med. 1995;155(15):1641.
Dressler FA, Roberts WC. Infective endocarditis in opiate addicts: analysis of 80 cases studied at necropsy. Am J Cardiol. 1989;63(17):1240.
Newton TF, Kalechstein AD, Duran S, Vansluis N, Ling W. Methamphetamine abstinence syndrome: preliminary findings. Am J Addict. 2004 May;13(3):248–55.
26. USE OF FLUMAZENIL IN DRUG OVERDOSE
JoAn Laes MD
Summary: Flumazenil is a benzodiazepine antagonist that is not often used the setting of unknown overdose due to concerns regarding seizures in those physically dependent on benzodiazepines or in patients who have overdosed on pharmaceuticals that lower the seizure threshold, such as tricyclic antidepressants (TCA). In review of the literature, there is limited and conflicting data regarding the adverse effects (e.g. seizures) of flumazenil used in patients chronically dependent on benzodiazepines or in mixed drug overdoses. We describe a case in which low dose flumazenil was safely used to reverse cns depression in a patient chronically on benzodiazepines who acutely overdosed on clonazepam and amitryptiline.
Methods: Case Report
Results: A 49 year old female presented with altered mental status. She reportedly ingested 100mg of clonazepam and 700mg of amitryptiline. She had been regularly using both of these medications for at least a month. Vital signs: blood pressure 153/94, pulse 81, afebrile, respiratory rate 13. EKG showed a qrs of 102ms and qtc 479ms. Urine drug screen was positive for tricyclic antidepressants and benzodiazepines. She was given 0.2 mg of flumazenil twice, with improvement in her mental status. No adverse effects were reported.
Conclusion: While data is sparse regarding the safety of flumazenil use in unknown overdoses (especially TCA) or in chronic benzodiazepine users, case reports and retrospective studies have reported safe use of low dose flumazenil. Reversal of CNS depression can theoretically decrease length of hospital stay as well as decrease number of adverse procedures such as intubation. Additional data would be useful to assist in determining criteria for “safe” use of flumazenil to assist the physician in weighing the risk and benefits of using this medication in an overdose patient.
27. UTILIZATION OF BUPRENORPHINE ASSISTED OPIOID DEPENDENCE TREATMENT IN A COUNTY DRUG COURT PROGRAM
buprenorphine, drug court, criminal justice, medically assisted treatment
Michael Frost, MD; Brynn Iacobacci, MA, LMFT
Summary: The efficacy of buprenorphine for the treatment of opioid dependence has been well established however its implementation as part of a treatment paradigm by criminal justice programs has been limited. The following poster will explore the authors experiences over a two year period, in utilizing buprenorphine for the treatment of opioid dependent individuals in a county drug court program. Participants who were treated with buprenorphine remained on the medication for an average of 13 months. Based on urine drug testing, 39% of participants remained abstinent from all addictive substances during treatment, with 95% remaining abstinent from opioids during that time. Program structure, selection of patients for treatment, use of urine drug testing, and challenges faced by the treatment team are all discussed.
Methods: Participants in the drug court program and evaluated for the appropriateness of medication assisted treatment by members of the treatment team. All participants must attend weekly individual and group counseling and must submit to random urine drug testing while in the program. Burpenorphine is managed by an addiction medicine physician. Noncompliance with treatment, including illicit drug use, noncompliance with prescribed medication or failure to attend counseling sessions results in 24-48 hr incarceration.
Results: Individuals in the program who received treatment with buprenorphine remained on the medication for an average of 13 months. When compared to the period before receiving buprenorphine, participants showed increases in advancement through the program and higher rates of program completion. 39% of participants remained abstinent from all substances while receiving treatment and 95% remained abstinent from opioids during that period.
Conclusion: Buprenorphine can effectively be utilized in a drug court program and results in less opioid use and overall improvement in program participation and completion.
28. VIDEO GAMES AMONG CHILDREN AND TEENAGERS: MOROCCAN AVATARS
Teenager, video games, Internet consumption, addiction
Soumia Berrada Professor of psychiatry; Imane Kendili, MD
Summary: Morocco is experiencing nowadays an unparalleled Internet boom that places it among the first consumers in Africa and as the first in the Maghreb. Moroccan teenage population seems increasingly greedy video game while the demand for addiction care is very limited. This survey is the first study ever conducted in the Arab world and North Africa. It provides a description of a population of two hundred Moroccan players of video games with the filling of the CUNG/RETZ questionnaire of dependency in order to assess the present situation.
Methods: Criteria for inclusion were held as follows with a sample of subjects aged from 7 to 16 years, addicted to video games: score ≥ 2 according to Cunji scale (1). Persons with a previous episode of (hypo-) mania, which could be directly related to the chronological gambling or cognitive functions disorder, were excluded from the study. The evaluation results from a self-administered questionnaire including demographics and information about the game (types of games, motivation of players, family issues ...) followed by the CUNG/RETZ dependency questionnaire, which is a general dependence test, evaluating the degree of consumption of the product or the importance of behavior. Statistical analysis was performed by SPSS software in its 11th version, and uses the techniques of descriptive statistics (frequency (%), average, standard deviation, range) and analysis of contingency tables with two variables. The chi-2 test for homogeneity and linear trend was used to analyze qualitative variables. The t Student test and the analysis of variance were used to analyze quantitative variables.
Results: The sample consisted of 40 subjects. Male sex is predominant with a percentage of 52.5%. 27.5% of subjects in this sample had divorced parents. The majority of subjects are issued from urban areas (92.5%). Family income was over 5 000 MAD (450 Euros) in 85% of cases. The mean age was 12.9 y.o. 3,3 with a range of [7-16 y.o], the most represented group was that of 15 to 16 y.o. Moreover, half the subjects had toxic habits, essentially tobacco followed by alcohol and cannabis as well. The mean score of Cunji and Hertz was 4.20 1.28. A score of 3 was found in 40% of subjects. The game characteristics highlighted mainly consoles and laptops which are used by 32.5% of subjects. According to this survey, initiation to games was due to the father in 30% of cases, and to friends in 42.5% of cases with an early starting age ≤ 8 y.o. in 77.5% of cases. Money used for gaming was provided by parents in 90% of cases. The approximate row play time is between 1 and 4 hours in 80% of subjects and more than 4 hours in 22.5%. 42.5% confess they play daily while 40% play 3 to 4 times per week. The socialization exploring found out that 55% of addicts were playing alone, while friends and video playmates were present in only a quarter of the sample. Most of the teenagers 72.5% play at home. Furthermore, only half of the sample participate in family activities such as traveling during holidays. The reported motivations for video games playing were the need of escape and reality life break for 32.5% of subjects, the necessity to fill the time for 20%, whereas 32.5% consider games a means of manipulation, and 7.5% play games as it represents a means of communication.
Conclusion: To our knowledge, no epidemiological study on video games has been published by an Arab country. The only study on the game has been in the gambling and found that the prevalence of pathological gamblers in a population of players is 53%. (2) This survey of a population of children and adolescents has found that about 200 people assessed by the scale of Cunji 20% had an addiction. The same concept has been reported by Griffiths et al. who found that a teenager was dependent on 5 video games, while a recent study by Grsse SM et al. concerned with 7069 players, found that 11.9% of participants met diagnostic criteriaaddiction. It should be emphasized that many factors combined environment are likely to push the youth to high intakes: the incentives of commercial society, the abundance of advertising and the emptiness of attractiveness of certain areas of life than s of interest and seek to understand the world, they taught the people to “fill” brief and strong feelings, emotions, flash, shocking images: he is an increased stimulation and high speed According to this study, the school is one of the initiators video games anything in 2.5% cases only. According Hayez, the school thinks it can not be a good school without computers: the battery of these is a good selling point, she introduces him to the computer, she is doing school work via software Internal and often and more or less subtly discourages the submission of papers Manuscripts. Another initiator is represented by a family member. The father represents 30% of cases. Parents control many less games than television. The family would encourage consumption by distinct components: “Filling of life” by absorbing products; There are tensions and dysfunctions are not specific, that the young can fly, in isolation in his cyberworlds, not to mention that some parents are very ignorant, naive and/or resigned and do not perceive the risks associated with qualitative or quantitative cyberconduct their child. The player plays alone in 55% of cases. It should be noted that females accounted for 47.5 of the sample. According to the literature, boys play more often than girls and are more often dependent than girls However, the study has certain limitations, the most important being the fact that it is a purely descriptive study enumerating the various characteristics of a young person playing video games in the city of Casablanca. It concerned a population at risk with a reduced sample does not allow to establish significant correlations. Risk factors such as the use and abuse of substances should be better explored by assessing the amount consumed and on a larger sample. It would be interesting to explore a population of players who are not addicted to highlight the risk factors that may be associated with video games. At the end of this present study, a descriptive profile first stands with a proportion of 20% of addicts that despite the sampling bias and a population known to Casablanca take risk to develop this specification to support the risk factors and establish preventive action despite limited literature. More specifically, studies that focus on addiction to video games may be limited because the subject is vast and soliciting interest for a short time but also by the fact that dependence on a psychoactive effect is evaluated experimentally quite easily. However, progress will probably by a model animal, so a phenomenological and neuropsychological analysis even more precise behavioral and personality disorder subjects with addictive behavior.