Pharmacist-led sedative-hypnotic deprescribing in team-based primary care practice

Background: Sedative-hypnotic (SH) medications are often used to treat chronic insomnia, with potentially serious long-term side effects. The objective of this study is to evaluate an interprofessional SH deprescribing program within a community team-based, primary care practice, with or without cognitive behavioural therapy for insomnia (CBT-I). Methods: Retrospective chart review for patients referred to the team pharmacist for SH deprescribing from February 2016 to June 2019. Results: A total of 121 patients were referred for SH deprescribing, with 111 (92%) patients who attempted deprescribing (average age 69, range 29-97 years) and 22 patients who also received CBT-I. Overall, 36 patients (32%) achieved complete abstinence, and another 36 patients (32%) reduced their dosage by ≥50%. For the 36 patients who achieved complete abstinence, 26 (72%) patients remained abstinent at 6 months (9 patients resumed using SH and 1 patient was lost to follow-up). The proportion of patients achieving complete abstinence or reduced dosage of ≥50% (successful tapering) was higher with CBT-I than without CBT-I but did not reach statistical significance (77% vs 62%, p = 0.22). There were also no statistically significant differences detected in the success between those who took a benzodiazepine and those who took a Z-drug (67% vs 61%, p = 0.55) or for those who took SH daily and those who took them intermittently (67% vs 44%, p = 0.09). Conclusion: Almost two-thirds of patients participating in our pharmacist-led program were able to stop or taper their SH medications by ≥50%. The role of CBT-I in SH deprescribing remains to be further elucidated. Can Pharm J (Ott) 2021;154:xx-xx.

Determining Optimal Cutoffs for Exhaled Carbon Monoxide and Salivary Cotinine to Identify Smokers among Korean Americans in a Smoking Cessation Clinical Trial

Introduction. It is critical to accurately identify individuals who continue to smoke even after treatment, as this may prompt the use of more intensive and effective treatment strategies to help them attain complete abstinence. Aims. This study examined optimal cutoffs for exhaled carbon monoxide (CO) and salivary cotinine to identify smokers among Korean Americans in a smoking cessation clinical trial. Methods. CO and cotinine were measured three to four times over 12 months from the quit day. Statistical analysis was conducted using Receiver Operating Characteristic (ROC) curves. Results. A CO cutoff of 5 parts per million provided robust sensitivity (80.8-98.3%) and perfect specificity (100%), and a salivary cotinine cutoff of level 2 (30-100 ng/ml) provided the best sensitivity (91.2-95.6%) and perfect specificity (100%). Using these cutoffs, the agreement between self-reports and the two biomarkers ranged from 88.6% to 97.7%. The areas under ROC curves (AUCs) of exhaled CO ranged from 0.90 to 0.99, all of which were significant (all p values < 0.001), and the AUCs of salivary cotinine ranged from 0.96 to 0.98 (all p values < 0.001). Conclusion. Exhaled CO and salivary cotinine are complementary, and they should be used together to verify smoking abstinence for smokers in a clinical trial.

Effect of a Six-Week Intermittent Fasting Intervention Program on the Composition of the Human Body in Women over 60 Years of Age

The objective of this research was to determine the effectiveness of intermittent fasting (IF) in reducing body fat and lowering body mass index. An additional objective was to determine the feasibility of applying IF in overweight women over 60 years of age, which was assessed by the ratio of subjects who resigned from the diet plan. This study included a group of 45 women over 60 years of age. The intervention in the experimental group involved complete abstinence from food intake for 16 h per day, from 20:00 p.m. to 12:00 a.m. (the next day). The results demonstrated that the body weight in the subjects in the experimental group (EXP) group decreased by almost 2 kg and this decrease was visible in the remaining parameters related to body fat mass. The skeletal muscle mass did not change significantly, which indicates an actual decrease in the fat mass. The proportion of subjects who did not succeed in following the prescribed diet plan was 12%. The application of intermittent fasting in female subjects over 60 years of age resulted in positive changes in body composition. Time-restricted feeding (TRF) was characterized by a lower resignation rate compared to other diets involving intermittent fasting.

Kappa antagonist to prevent drug relapse: Does stage in addiction cycle matter?

Introduction: An upregulation of the kappa opioid receptor (KOR) system during drug preoccupation stage in addiction cycle will cause dysphoria among addicts which can lead to relapse. Therefore, KOR antagonism treatment might hold the key to prevent relapse. In this study, we aim to identify the exact addiction’s stage in which KOR antagonist can be given. Methods: Using a conditioned place preference (CPP) model, adult male Swiss albino mice were divided into two major groups. The first group received treatment at the initial stage of morphine withdrawal (7.5 mg/kg, i.p) while the second group received treatment after complete abstinence was achieved. Each major groups were further divided into two treatment groups (n=8-12), either received a functional KOR antagonist (0.3 mg/kg buprenorphine/ 1 mg/kg naltrexone combination, i.p) or a selective KOR antagonist (10 mg/kg nor-BNI, i.p) prior to morphine priming (2.5 mg/kg, i.p). All data were analyzed using paired sample t-test. Results: The results showed that relapse was successfully attenuated in the groups that received KOR antagonists only after complete abstinence was successfully achieved (not significantly different from their baseline). However, the mice developed unusual sign of behavior sensitization (intermittent freezing, licking) when buprenorphine/naltrexone combination was given at initial stage of withdrawal. Conclusions: Our initial findings suggest that KOR antagonism might be beneficial only after the addicts achieved complete abstinence to prevent future druginduced relapse. Brain study should be conducted to explain the unusual behavior seen when the drug intervention is given at an earlier stage of withdrawal.

The Value of Providing Smokers with Free E-Cigarettes: Smoking Reduction and Cessation Associated with the Three-Month Provision to Smokers of a Refillable Tank-Style E-Cigarette

Despite the uptake of tobacco smoking declining in the UK, smoking is still the leading cause of preventable poor health and premature death. While improved approaches to smoking cessation are necessary, encouraging and assisting smokers to switch by using substantially less toxic non-tobacco nicotine products may be a possible option. To date few studies have investigated the rates of smoking cessation and smoking reduction associated with the free provision of electronic-cigarettes (e-cigarette) to smokers. In this study the Blu Pro e-cigarette was given to smokers for use in place of tobacco for 90 days. The rates of smoking abstinence and daily smoking patterns were assessed at baseline 30 days, 60 days and 90 days. The response rate was 87%. After 90 days, the complete abstinence rate was 36.5% from 0% at baseline. Frequency of daily smoking reduced from 88.7% to 17.5% (P&lt;0.001) and median consumption of cigarettes/day from 15 to 5 (P&lt;0.001). Median days per month participants smoked also dropped from 30 to 13 after 90-days (P&lt;0.001). On the basis of these results there may be value in smoking cessation services and other services ensuring that smokers are provided with e-cigarettes at zero or minimal costs for at least a short period of time.

Maintainence Treatment of Opioid Dependence with Tramadol

ABSTRACT Background: Although tramadol has been used in the management of acute withdrawal in patients with opioid dependence, its use for maintenance treatment as a harm reduction approach has not been assessed systematically. This case series describes patients with opioid dependence who were treated with tramadol for long-term maintenance. Methods: Patients with opioid dependence who received treatment at the National Drug Dependence Treatment Centre of All India Institute of Medical Sciences, New Delhi, were included in the study. Patients who received at least 6 months of tramadol and had follow-up adherence of more than 80% were included in the case series. Results: A total of 25 cases were included, all of whom were males. The types of opioids being taken at the time of initiation of tramadol were natural opiates (poppy husk and raw opium), followed by heroin. The median dose of tramadol at initiation and maintenance was 300 mg/day. Nineteen patients were able to achieve complete abstinence to other opiates on tramadol. Conclusion: Tramadol may be an effective option in the long-term management of patients with opioid dependence. Further studies are required for establishing the efficacy of tramadol for agonist management of patients with opioid dependence.

Psychosis, cause or consequence of substance use disorder

IntroductionThe use of psychostimulants, such as amphetamines and cocaine in psychotic patients is 4 times more frequent than non-psychotic ones. It is believed that people with psychosis may use substances as a self-treatment for negative symptoms. However, early onset of substance use disorder can develop psychotic and/or negative symptoms, leading to confusion between primary or secondary psychosis.MethodSystematic review of the literature in English (PubMed) and patient's clinical record. Keywords: “Substance use disorder”; “psychosis”.Objectivesto highlight the importance of an adequate characterization of psychotic symptoms in patients with substance use disorder.CaseA 29-year-old man, with psychostimulants and cannabis abuse since adolescence and very short abstinence episodes. Later on, he developed paranoia symptoms that slightly improved once he decreased drugs dosage, but they were still present even on complete abstinence. Over the last year he has showed negative and psychotic symptoms that have been worsening with aggressive behavior during the last months, so he had to be hospitalized. During this period, he has been treated successfully with aripiprazol depot once monthly. His evolution has been positive, it has disappeared psychotic symptoms and paranoia, and after discharge he has managed to remain abstinent to psychostimulants.ConclusionsAdequate characterization of patients with psychotic symptoms and substance abuse is essential to determine whether the psychotic disorder is associated with primary or induced TUS. Therefore, it is essential a thorough clinical evaluation to make an accurate diagnosis and to draw an individualized treatment plan.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Overcoming Your Pathological Gambling: Workbook

Though gambling has become increasingly prevalent in society, pathological gambling is a serious condition. Through this treatment program, patients will learn not only how to avoid problem situations, but also the truth about gambling. Written by researchers who have spent over two decades studying the psychology of gambling, this guide represents the treatment they have found to be most effective at controlling the urge to gamble, understanding the true nature of gambling games, and preventing future gambling problems. Intended for use in conjunction with supervised therapy, this online workbook includes various self-assessments and exercises designed to help patients reach the ultimate goal of complete abstinence from gambling.