Medications for management of opioid use disorder.

PURPOSE: The use of buprenorphine, methadone, and long-acting naltrexone for treatment of opioid use disorder (OUD) is discussed, including a review of current literature detailing treatment approaches and action steps to optimize treatment in acute care and office-based settings. SUMMARY: The U.S. epidemic of opioid-related deaths has been driven by misuse of prescription opioids and, increasingly, illicit drugs such as heroin, fentanyl, and fentanyl analogs, necessitating a refocusing of treatment efforts on expanding access to life-saving, evidence-based OUD pharmacotherapy. Inpatient treatment of opioid withdrawal includes acute symptom control through a combination of nonopioid medications and long-term pharmacotherapy to lessen opioid craving and facilitate stabilization and recovery. Methadone and buprenorphine reduce opioid craving, increase treatment retention, reduce illicit opioid use, and increase overall survival. Buprenorphine has logistical advantages over methadone, such as greater flexibility of treatment setting and less risk of adverse effects. Studies have shown the efficacy of long-acting injectable naltrexone to be comparable to that of buprenorphine if patients are detoxified prior to initiation of therapy; however, patients with active OUD are often not able to complete the week-long period of opioid abstinence needed prior to initiation of naltrexone injections. Although buprenorphine is preferred by many patients and can be prescribed in office-based settings, there remains a paucity of physicians certified to prescribe it. CONCLUSION: Buprenorphine has become the medication of choice for many patients with OUD, but its use is limited by the low number of physicians certified to prescribe the agent. Other agents studied for treatment of OUD include methadone and naltrexone.

Descriptive study of drug-drug interactions attributed to prescriptions written upon discharge from the emergency department.

OBJECTIVE: The primary purpose of this study was to identify the most common drug-drug interactions (DDI'S) in patients prescribed medications upon discharge from the emergency department. METHODS: We conducted a respective chart review of patients discharged home with a prescription from an academic emergency department. The study period was from August 1, 2015 to August 31, 2015. Patients will be excluded if they meet the following criteria: age under 20 years; discharge home without a prescription; inpatient hospital admission; transfer to another inpatient facility; or sign out against medical advice. The primary endpoint is the identification and characterization of drug-drug interactions caused by discharge prescriptions written by the treating physician. RESULTS: A total of 500 patient charts were included, with 38% having at least one DDI. Overall, there were 429 DDIs among 858 prescriptions written. 15.6% (n = 67) of the DDI's were classified as B, no modification of therapy needed. 60% (n = 260) of the DDIs were risk-rating category C, requiring monitoring of therapy. 22% (n = 95) of the DDI's identified were category D, which are consider modification of therapy. Lastly, we identified 1.6% (n = 7) category X DDI's. The top 3 most commonly associated drugs were oxycodone/acetaminophen, ibuprofen, and ciprofloxacin. CONCLUSION: DDIs are occurring upon discharge from a large, urban, tertiary care, academic medical center. Many of the DDI's identified do not require any modification to therapy. However, 23.6% of identified DDI's required modification or were contraindicated. A majority of the category X drug interactions involved QT prolongation.

Effectiveness of empiric aztreonam compared to other beta-lactams for treatment of Pseudomonas aeruginosa infections.

PURPOSE: To evaluate the use of aztreonam as an active empiric therapy against subsequent culture of Pseudomonas aeruginosa (P. aeruginosa). METHODS: This was a retrospective cohort study conducted among patients who received either aztreonam or an antipseudomonal beta-lactam (BL) as an empiric therapy with subsequent culture with P. aeruginosa. All patients with at least one positive culture for P. aeruginosa between January 2014 and August 2016 were included in this analysis. The primary composite outcome was empiric therapy failure, defined as inappropriate empiric therapy, alteration of empiric antibiotic following culture results, or 30-day in-hospital mortality. Secondary outcomes included appropriate empiric therapy, alteration of empiric therapy, 30-day-in-hospital mortality, and post-culture hospital length of stay. RESULTS: The primary outcome of empiric therapy failure was significantly higher in the aztreonam group than in the BL group (77.8% vs 41.9%; P=0.004). The aztreonam group had a lower rate of appropriate empiric therapy compared with the BL group (44.4% vs 66.1%; P=0.074) and higher alteration of empiric therapy once susceptibilities were known than when compared with the BL group (61.1%vs 28.2%; P=0.005). Although numerically higher, 30-day-in-hospital mortality and median hospital length of stay were not significantly different between the two groups. CONCLUSION: Empiric therapy failure occurred more often when initially using aztreonam vs a BL in a patient who subsequently had a P. aeruginosa infection. Only a third of patients within the aztreonam group had a documented BL allergy, demonstrating an inclination for clinicians to utilize this drug as an empiric therapy when there were more appropriate therapies available.

Glucagon for refractory asthma exacerbation.

Glucagon, a hormone secreted by pancreatic alpha cells, causes bronchial smooth muscle relaxation by activating the synthesis of cyclic adenosine monophosphate. It was studied in the 1980s and 1990s as a treatment option for the management of asthma but has since not been evaluated. Data to support its use are limited, but it may serve as a last-line agent for refractory asthma exacerbation. Here we describe 4 cases in which intravenous glucagon was used to manage severe, refractory asthma exacerbation in the emergency department.

Use of an Intravascular Heat Exchange Catheter and Intravenous Lipid Emulsion for Hypothermic Cardiac Arrest After Cyclobenzaprine Overdose.

In this case report, a 22-year-old male developed severe hypothermia after an accidental overdose of cyclobenzaprine. During transport, the patient developed cardiac arrest. He received active rewarming measures, including pleural lavage, gastric lavage, an intravascular heat exchange catheter, and cardiopulmonary bypass. Intravenous lipid emulsion (ILE) was also administered. A discussion of cyclobenzaprine toxicity, hypothermia, ILE, and accidental hypothermic cardiac arrest follows.