OPIOID USE DISORDER
Is kratom an acceptable alternative therapy?
Some of my patients who are struggling to overcome opioid use disorder (OUD) self-medicate with kratom as an alternative to prescribed therapy. They believe it helps them to safely manage the signs and symptoms of opioid withdrawal. What does the evidence show?—L.V., TEX.
Evidence is mounting that kratom, which is available in the US as an unregulated herbal supplement, is a potentially toxic substance that by itself may lead to opioid dependence and addiction. Many patients are unaware that its active ingredient, mitragynine, has agonist activity at mu-opioid receptors and may lead to dependence and addiction. Hydroxymitragynine, a minor ingredient, also has opioid activity that may be more potent than morphine.1
In a recent retrospective review of kratom exposures reported to the National Poison Data System, researchers identified 2,312 kratom exposures; in 935 cases kratom was the only substance.1 Kratom most commonly caused agitation (19%), tachycardia (17%), drowsiness (14%), vomiting (11%), and confusion (8%). Less commonly, they found reports of seizures, withdrawal, hallucinations, respiratory depression, coma, and cardiac or respiratory arrest. The county medical examiner listed kratom as the cause or a contributing factor in the deaths of four individuals.
Based on the evidence, the researchers concluded that kratom's opioid effects “put patients at risk for withdrawal, respiratory depression, and death.” Warn patients about the dangers of kratom use and urge them to discuss evidence-based treatment options with a healthcare provider who has expertise in OUD.
1. Eggleston W, Stoppacher R, Suen K, Marraffa JM, Nelson LS. Kratom use and toxicities in the United States. Pharmacotherapy. 2019;39(7):775–777.
How to encourage flu vaccinations for kids
As part of my work in a pediatric provider's office, I encourage seasonal influenza vaccinations according to CDC recommendations.1 I am concerned about a few patients who decline to have their children vaccinated for various reasons. What is the best way to overcome parental resistance to vaccination?—V.R., N.C.
Recent research suggests that an educational intervention provided in the waiting room before a visit with the provider may be helpful in overcoming parents' vaccination reluctance.2 The study involved a convenience sample of parents of children age 6 months or older at two pediatric clinics between August 2016 and March 2017. Participants were randomly assigned to one of three groups. Those in the control group received usual care. Those in the intervention groups received either an educational handout about influenza disease based on local data or an educational handout about influenza disease based on national data. The handouts were provided to parents in the waiting room before the provider visit. Primary outcomes were child influenza vaccine receipt on the day of the clinic visit and by the end of the flu season. The results:
- Parents who received either educational intervention (versus usual care) had greater odds of child influenza vaccine receipt by the end of the season (74.9% versus 65.4%) but not on the day of the clinic visit.
- Parents who received the national data handout (versus usual care) had greater odds of child influenza vaccine receipt on the day of the clinic visit (59.0% versus 52.6%) but not by the end of the season.
The authors concluded that “providing an educational intervention in the waiting room before a pediatric provider visit may help increase child influenza vaccine receipt.” Sounds like it is worth a try.
Centers for Disease Control and Prevention. Who should and who should not get a flu vaccine? http://www.cdc.gov/flu/prevent/whoshouldvax.htm.
Scott VP, Opel DJ, Reifler J, et al Office-based educational handout for influenza vaccination: a randomized controlled trial. Pediatrics. 2019;144(2).
My patient, who recently completed a course of chemotherapy, wants to take a trip to Costa Rica this winter with her family. Does her immune status affect the vaccines she needs?—M.P., CALIF.
First, advise the patient to discuss her travel plans with her oncologist or other healthcare provider who is familiar with her current health status. In addition, patients and providers can turn to the CDC for detailed travel recommendations for people traveling out of the country based on destination. The recommendations include special considerations for immunocompromised travelers.
For travelers to Costa Rica, the CDC recommends routine vaccinations for all travelers plus certain additional vaccinations based on vaccine-preventable diseases endemic to the country.1 Most travelers to Costa Rica should be vaccinated for typhoid, for example, but immunocompromised patients should receive the injectable typhoid vaccine because it is theoretically safer for them than the oral formulation. In addition, severely immunocompromised travelers should not receive the yellow fever vaccine.
To make sure the patient gets all vaccines appropriate for her condition and destination, tell her to ask her provider for guidance well in advance of her departure date.
Centers for Disease Control and Prevention. Health information for travelers to Costa Rica: clinician view. 2019. wwwnc.cdc.gov/travel/destinations/clinician/none/costa-rica.