Treating Benzodiazepine Withdrawal in a Bridge Clinic.

IF 4.2 3区 医学 Q1 SUBSTANCE ABUSE Journal of Addiction Medicine Pub Date : 2024-11-01 Epub Date: 2024-06-26 DOI:10.1097/ADM.0000000000001334
Jordana Laks, Theresa W Kim, Paul J Christine, James Evans, Natalija M Farrell, Jessica Kehoe, Morgan Younkin, Jessica L Taylor
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Abstract

Background: Benzodiazepine-involved overdose deaths are rising, driven by increasing use of nonprescribed benzodiazepine pills. For patients who wish to stop nonprescribed benzodiazepine use, rapid inpatient tapers are typically the only option to treat benzodiazepine withdrawal. Substance use disorder bridge clinics can provide the high-touch care needed to manage outpatient benzodiazepine tapers in patients at high risk due to other substance use disorders.

Objective: Describe the implementation and short-term outcomes of an outpatient benzodiazepine taper protocol to treat benzodiazepine withdrawal in a substance use disorder bridge clinic.

Methods: The clinical team developed a 4- to 6-week intensive outpatient taper protocol using diazepam. Patients with benzodiazepine use disorder were eligible if they had benzodiazepine withdrawal, lacked a prescriber, wanted to stop benzodiazepines completely, and agreed to daily visits. For patients who initiated a taper between April 2021 and December 2022, we evaluated the proportion of patients who completed a taper (i.e., tapered to a last prescribed dose of diazepam 10 mg/d or less); likelihood of remaining on the taper over time; and seizure, overdose, or death documented at the study institution during or within 1 month of taper completion or discontinuation. Other secondary outcomes included HIV testing and prevention, hepatitis C testing, and referrals to recovery coaching or psychiatry.

Results: Fifty-four patients initiated a total of 60 benzodiazepine tapers. The population was mostly male (61%) and non-Hispanic White (85%). Nearly all patients had opioid use disorder (96%), and most (80%) were taking methadone or buprenorphine for opioid use disorder before starting the taper. Patients reported using multiple substances in addition to benzodiazepines, most commonly fentanyl (75%), followed by cocaine (41%) and methamphetamine (21%). Fourteen patients (23%) completed a taper with a median duration of 34 days (IQR 27.8-43.5). Most tapers were stopped when the patient was lost to follow-up (57%), or the team recommended inpatient care (18%). Two patients had a seizure, and 4 had a presumed opioid-involved overdose during or within 1 month after the last taper visit, all individuals who did not complete a taper. No deaths occurred during or within 1 month of taper completion or discontinuation. Challenges included frequent loss to follow-up in the setting of other unstable substance use. Patients received other high-priority care during the taper including HIV testing (32%), PrEP initiation (6.7%), hepatitis C testing (30%), and referrals to recovery coaches (18%) and psychiatry (6.7%).

Conclusions: Managing benzodiazepine withdrawal with a 4- to 6-week intensive outpatient taper in patients with benzodiazepine and opioid use disorders is challenging. More work is needed to refine patient selection, balance safety risks with feasibility, and study long-term, patient-centered outcomes.

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在桥梁诊所治疗苯二氮卓类药物戒断。
背景:由于越来越多地使用非处方苯并二氮杂卓药片,苯并二氮杂卓导致的过量用药死亡人数正在上升。对于希望停止使用非处方苯二氮卓的患者来说,快速住院减量通常是治疗苯二氮卓戒断的唯一选择。药物使用障碍桥接诊所可以为因其他药物使用障碍而面临高风险的患者提供所需的高接触护理,以管理苯二氮卓类药物的门诊减量:描述在药物使用障碍桥梁诊所治疗苯二氮卓戒断的苯二氮卓门诊减量方案的实施情况和短期疗效:方法:临床团队使用地西泮制定了一个为期 4 到 6 周的门诊强化减量方案。苯并二氮杂卓使用障碍患者只要有苯并二氮杂卓戒断症状、没有处方医生、希望完全停用苯并二氮杂卓并同意每天出诊,就符合条件。对于在 2021 年 4 月至 2022 年 12 月期间开始减量的患者,我们评估了完成减量(即减量至最后处方剂量为地西泮 10 毫克/天或更少)的患者比例;随着时间推移继续减量的可能性;以及在减量完成或停药期间或 1 个月内研究机构记录的癫痫发作、用药过量或死亡情况。其他次要结果包括艾滋病检测和预防、丙型肝炎检测以及转诊至康复指导或精神科:54名患者共开始了60次苯二氮卓类药物减量治疗。患者大多为男性(61%)和非西班牙裔白人(85%)。几乎所有患者都患有阿片类药物使用障碍(96%),大多数患者(80%)在开始减量治疗前正在服用美沙酮或丁丙诺啡治疗阿片类药物使用障碍。除苯二氮卓类药物外,患者还报告使用了多种药物,其中最常见的是芬太尼(75%),其次是可卡因(41%)和甲基苯丙胺(21%)。14 名患者(23%)完成了减药,中位持续时间为 34 天(IQR 27.8-43.5)。大多数减量治疗在患者失去随访(57%)或治疗小组建议住院治疗(18%)时停止。在最后一次减量就诊期间或之后的 1 个月内,有 2 名患者出现癫痫发作,4 名患者出现推测的阿片类药物过量,所有这些患者都没有完成减量。在完成或停止减量治疗期间或 1 个月内没有发生死亡病例。面临的挑战包括在使用其他不稳定药物的情况下经常失去随访。患者在减量期间还接受了其他优先护理,包括 HIV 检测(32%)、PrEP 启动(6.7%)、丙型肝炎检测(30%)、转诊至康复指导员(18%)和精神病科(6.7%):对于苯并二氮杂卓和阿片类药物使用失调的患者来说,通过 4 到 6 周的门诊强化减量来管理苯并二氮杂卓戒断是一项挑战。还需要做更多的工作来完善患者选择、平衡安全风险与可行性,并研究以患者为中心的长期疗效。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
Journal of Addiction Medicine
Journal of Addiction Medicine 医学-药物滥用
CiteScore
6.10
自引率
9.10%
发文量
260
审稿时长
>12 weeks
期刊介绍: The mission of Journal of Addiction Medicine, the official peer-reviewed journal of the American Society of Addiction Medicine, is to promote excellence in the practice of addiction medicine and in clinical research as well as to support Addiction Medicine as a mainstream medical sub-specialty. Under the guidance of an esteemed Editorial Board, peer-reviewed articles published in the Journal focus on developments in addiction medicine as well as on treatment innovations and ethical, economic, forensic, and social topics including: •addiction and substance use in pregnancy •adolescent addiction and at-risk use •the drug-exposed neonate •pharmacology •all psychoactive substances relevant to addiction, including alcohol, nicotine, caffeine, marijuana, opioids, stimulants and other prescription and illicit substances •diagnosis •neuroimaging techniques •treatment of special populations •treatment, early intervention and prevention of alcohol and drug use disorders •methodological issues in addiction research •pain and addiction, prescription drug use disorder •co-occurring addiction, medical and psychiatric disorders •pathological gambling disorder, sexual and other behavioral addictions •pathophysiology of addiction •behavioral and pharmacological treatments •issues in graduate medical education •recovery •health services delivery •ethical, legal and liability issues in addiction medicine practice •drug testing •self- and mutual-help.
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