SA国际传媒

This Week in the SA国际传媒Weekly

New Guideline on Benzodiazepine Tapering

Emily Brunner, MD, DFASAM
Chwen-Yuen A. Chen, MD, FACP, FASAM
Chinyere Ogbonna, MD, MPH
Tricia Wright, MD, MS, FACOG, DFASAM

This week SA国际传媒released the new  Joint Clinical Practice Guideline on Benzodiazepine Tapering. This guideline was developed to help clinicians determine when the risks of continued BZD prescribing outweigh the benefits for a given patient and how to safely taper the medication when indicated.

Existing guidelines generally recommend limiting duration of BZD use to 2-4 weeks (except for limited conditions such as severe treatment-resistant generalized anxiety disorder, complex seizure disorders, spasticity, and sleep disorders involving abnormal movements). However, long-term BZD prescribing remains prevalent.

The challenges of BZD tapering are not specific to addiction medicine. Nearly all patients who take BZD regularly for more than a month will develop physical dependence, while only 1.5% will develop a BZD use disorder. As such, the Guideline is applicable to diverse clinical specialties and was developed by a coalition of medical and professional societies representing psychiatrists, neurologists, family practice providers, addiction medicine specialists, geriatricians, obstetricians, medical toxicologists, psychiatric pharmacists, and advanced practice providers, with funding provided by the US Food and Drug Administration (FDA). In performing a rigorous, systematic review of the evidence around tapering BZD, the guideline development committee was surprised by the paucity of research given that the need for BZD tapering is a relatively common clinical situation.

Read the full editorial . 

New Clinical Practice Guideline - Benzodiazepine Tapering

ASAM, in partnership with nine other medical societies and professional associations, has just released new clinical practice guideline: Joint Clinical Practice Guideline on Benzodiazepine Tapering: Considerations When Benzodiazepine Risks Outweigh Benefits. Funded by the US Food and Drug Administration (FDA), this document offers information on evidence-informed and consensus-based strategies to help clinicians determine whether tapering benzodiazepine medications may be appropriate for a given patient, and, if so, how to taper them.

To support implementation, SA国际传媒is also offering a webinar series to explore guideline concepts in depth (), a provider pocket guide summarizing key recommendations, a patient pocket guide and infographics for patients and families, microlearning videos highlighting key takeaways from the guideline, and additional resources. To access the full document and associated materials, . 

Lead Story 

Journal of the American Medical Association

Utilizing a multistaged probability-based survey, this study assessed the prevalence of illicit substance use, treatment, nonfatal overdose, and naloxone possession among 3,200 adults experiencing homelessness in California from October 2021 to November 2022. An estimated 37% of respondents reported using any illicit substance regularly (≥ 3 times per week) in the last 6 months; methamphetamine use (33%) was the most common. Of those who reported regular use, an estimated 21% wanted but were unable to receive treatment. Approximately 20% of participants reported a nonfatal overdose, and 25% reported being in possession of naloxone. Substance use and nonfatal overdose were common among people experiencing homelessness in California. There was a high unmet need for substance use treatment and naloxone.

Research and Science 

Journal of Addiction Medicine

Persons with substance use disorders (SUD), including persons with stimulant use disorders (StUD), are at higher risk of cardiovascular complications, compared with the population at large. In this retrospective cohort study, researchers used electronic health record data from 2015-2023 to assess if persons with StUD were at higher risk for major adverse cardiac events (MACE) than persons with non-stimulant SUD (including alcohol and tobacco). Findings showed that persons with StUD were at higher risk of both MACE (HR=1.37, P<0.001) and death (HR=1.23, P=0.026) than those with other SUD. The authors support screening for StUD in persons with cardiovascular disease and developing treatment guidelines for this population. 

Journal of the American Medical Association

This retrospective observational study explored how California emergency clinician buprenorphine initiation and subsequent prescriptions changed from 2017 to 2022. Researchers used data from 345,024 patients who filled 3.8 million buprenorphine prescriptions in California. Emergency clinicians increased from 2% to 16% of buprenorphine prescribers, and their buprenorphine initiation increased from 0.1% to 5% of initiations. The ratio of initiation prescriptions to second prescriptions within 40 days was 2.8. The ratio of initiation prescriptions to 180 days or more of continuous prescriptions within 1 year was 9.1. From 2017 to 2022, California emergency clinicians increasingly adopted buprenorphine prescribing for opioid use disorder, with approximately 1 in 3 patients going on to receive a second prescription and approximately 1 in 9 patients going on to receive continuous prescriptions.

American Journal of Preventive Medicine

Receipt of medications for opioid use disorder (MOUD) is low in general and particularly low in patients > 65 years old. In this study, researchers examined trends in MOUD receipt and factors associated with a likelihood of receiving MOUD in this population. MOUD rates increased from 4.8% in 2017 to 7.5% in 2019, and increased further to 15% in 2022, after Medicare started providing coverage for methadone. Male, Black, Hispanic, rural, and older patients were less likely to receive MOUD, while those with Medicare and Medicaid dual coverage were more likely to receive MOUD. Patients having anxiety, depression, liver disease, or alcohol or tobacco use disorders were more likely to receive MOUD, and those with dementia, cancer, kidney disease, chronic pain, or stroke were less likely to receive MOUD. The authors suggest policies and interventions are needed to address barriers to MOUD in those over age 65. 

Learn More 

The New England Journal of Medicine

The authors of this Perspective cite studies showing it takes an average of 8 years and several treatment episodes for people with substance use disorder (SUD) to achieve sustained remission. They describe community-based recovery-support services – including mutual-aid organizations, peer recovery coaching, recovery residences, recovery-support centers, and recovery-friendly schools and workplaces – and note evidence that mutual-aid organizations and recovery residences produce improved rates of remission, increased employment, and less legal involvement. The authors also point to evidence that community recovery-support services can restore quality of life and functioning in 5 years, compared to 15 years in previous studies, and call for greater integration of SUD clinics with community recovery support and improved funding for these services.

 馃敁&苍产蝉辫;

Annals of Internal Medicine: Clinical Cases

This is a case report of a 27-year-old woman who developed substernal chest pain 8 hours after her first use of cocaine (by nasal insufflation). EKG and troponin showed no evidence of myocardial ischemia or injury. A chest CT angiogram was negative for pulmonary embolus but showed air in the mediastinum, as well as perihilar and peribronchial air. Cocaine-induced pneumomediastinum has been reported. Over 90% of cocaine users seen in the ER have chest pain and 64% of these have subcutaneous emphysema. It is thought the negative airway pressure generated by sniffing, followed by positive airway pressure from breath holding, causes alveolar rupture. Direct alveolar toxicity from inhaled cocaine may also play a role. The authors suggest that pneumomediastinum be considered in cocaine-related chest pain once cardiac ischemia and injury have been ruled out.

In The News 

 馃敁

Reuters

 馃敁

Fortune

 馃敁

Oregon Capital Chronicle

 馃敁

KFF Health News

 馃敁

Health Affairs

 馃敁

Bloomberg News/The Spokesman-Review