Predictors of and reasons for early discharge from an inpatient withdrawal management service

Early discharges, also known as against medical advice discharges, are a significant concern in inpatient withdrawal management settings. Early discharges are associated with negative outcomes for patients and are costly for the healthcare system. A recent scoping review found gaps in the literature regarding patient perspectives, and a lack of research exploring predictors of early discharge according to demographic factors such as sex or gender which are known to influence healthcare experiences. It is vital to advance our understanding of patient perceptions of early discharges and what may predict them in order to prevent early discharges from occurring.The aim of this research was to investigate possible predictors of early discharge and patient experiences of early discharge from an inpatient withdrawal management service in Toronto, Ontario, Canada. This aim was accomplished using 2 studies. A retrospective cohort study using administrative health data was conducted to examine independent predictors of early discharge among patients admitted to an inpatient withdrawal management service between 2016 and 2020. Sex-stratified analyses using logistic regression and generalized estimating equations revealed that weekends and younger age were the strongest predictors of early discharge for both males and females. Among females only, being part of an ethnic minority group predicted early discharge.A qualitative descriptive study was conducted to explore patient perceptions of precipitants and processes related to early discharge. Thirteen people who had recently experienced an early discharge participated in the study and reported that precipitants to early discharge included external pressures, concerns about COVID-19, and dissatisfaction. Participants also described hitting a wall or reaching a breaking point prior to early discharge. Further, they often described difficult conversations about their desire to leave early and had mixed perceptions of their early discharge experience. This research demonstrates that there may be opportunities to prevent early discharges by responding to sources of dissatisfaction and exploring contributing factors during high-risk times such as weekends. Further, this research indicates that patient experiences could be improved by modifying processes associated with early discharge when they cannot be prevented. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Managing acute opioid withdrawal with tramadol during COVID-19 lockdown in a peri-urban setting.

BACKGROUND: The coronavirus disease 2019 (COVID-19) has highlighted the scope of heroin dependence and need for evidence-based treatment amongst marginalised people in South Africa. Acute opioid withdrawal management without maintenance therapy carries risks of increased morbidity and mortality. Due to the high costs of methadone, Tshwane's Community Oriented Substance Use Programme (COSUP) used tramadol for opioid withdrawal management during the initial COVID-19 response. AIM: To describe demographics, route of heroin administration and medication-related experiences amongst people accessing tramadol for treatment of opioid withdrawal. SETTING: Three community-based COSUP sites in Mamelodi (Tshwane, South Africa). METHODS: A retrospective cross-sectional study was conducted. Data were collected using an interviewer-administered paper-based tool between April and August 2020. Descriptive statistics were used to analyse data. RESULTS: Of the 220 service users initiated onto tramadol, almost half (n = 104, 47%) were not contactable. Fifty-eight (26%) people participated, amongst whom most were male (n = 55, 95%). Participants' median age was 32 years. Most participants injected heroin (n = 36, 62.1%). Most participants experienced at least one side effect (n = 47, 81%) with 37 (64%) experiencing two or more side effects from tramadol. Insomnia occurred most frequently (n = 26, 45%). One person without a history of seizures experienced a seizure. Opioid withdrawal symptoms were experienced by 54 participants (93%) whilst taking tramadol. Over half (n = 38, 66%) reported using less heroin whilst on tramadol. CONCLUSION: Tramadol reduced heroin use but was associated with withdrawal symptoms and unfavourable side effects. Findings point to the limitations of tramadol as opioid withdrawal management to retain people in care and the importance of access to first-line opioid agonists.Contribution: This research contributes to the limited data around short-acting tramadol for opioid withdrawal management in the African context, with specific focus on the need for increased access to opioid agonists for those who need them, in primary care settings.

COVID-19 and overdose prevention: Challenges and opportunities for clinical practice in housing settings.

The global coronavirus disease 2019 (COVID-19) will exacerbate the negative health outcomes associated with the concurrent opioid overdose crisis in North America. COVID-19 brings unique challenges for practitioners who provide opioid use disorder (OUD) care. The majority of overdose deaths in the Canadian province of British Columbia occur in housing environments. Some supportive housing environments in Vancouver, British Columbia, have on-site primary care and substance use disorder treatment clinics. Some of these housing environments also include supervised consumption services. These housing environments needed to make adjustments to their care to adhere to COVID-19 physical distancing measures. Such adjustments included a pandemic withdrawal management program to provide patients with a pharmaceutical grade alternative to the toxic illicit drug supply, which allow patients to avoid the heightened overdose risk while using illicit drugs alone or potentially exposing themselves to COVID-19 while using drugs in a group setting. Other modifications to the OUD care continuum included modified supervised injection spaces to adhere to physical distancing, the use of personal protective equipment for overdose response, virtual platforms for clinical encounters, writing longer prescriptions, and providing take-home doses to promote opioid agonist treatment retention. These strategies aim to mitigate indoor overdose risk while also addressing COVID-19 risks.