Precipitated Withdrawal, Delirium, and Cerebellar Stroke: The Pharmacology of Buprenorphine Induction in Non-pharmaceutical Fentanyl and the Neuropsychiatric Manifestations of Cerebellar Stroke.
Precipitated Withdrawal, Delirium, and Cerebellar Stroke: The Pharmacology of Buprenorphine Induction in Non-pharmaceutical Fentanyl and the Neuropsychiatric Manifestations of Cerebellar Stroke.
复制标题
突然戒断、谵妄和小脑中风：非药物芬太尼中丁丙诺啡诱导的药理学和小脑中风的神经精神表现。
DOI：
10.1097/hrp.0000000000000305
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发表时间：
2021
影响因子：
3.8
通讯作者：
Suzuki,Joji
中科院分区：
文献类型：
--
作者：
Montalvo,Cristina;vonHorn,Amanda;Lane,ChadrickE;Weinstein,ZoeM;Sharma,Malveeka;Suzuki,Joji
KI是一名61岁的间歇性无家可归的白人男性，有酒精使用障碍、阿片类药物使用障碍（OUD）、股动脉旁路移植术后外周动脉疾病状态并发持续性疝、高血压、和丙型肝炎状态后治疗ledipasvir/sofosbuvir谁最初自我-在住院第1天（HD），被送至住院精神科自愿入院，接受医学监督戒断阿片类药物和酒精。KI称，他在入院前48小时最后一次饮酒，并在入院前静脉注射（IV）海洛因和芬太尼。尿液毒理学筛查对阿片类药物和芬太尼均呈阳性，芬太尼确认试验阳性，尽管尿液酒精水平为阴性，但他的乙基葡萄糖醛酸苷试验阳性。在住院进行戒断管理时，使用临床阿片类戒断量表（COWS）和临床研究所酒精戒断评估量表（CIWA）监测KI。HD 1-4时，其CIWA评分范围为0 - 3，患者仅接受一剂奥沙西泮15 mg作为机构方案的一部分，但不需要任何额外的苯二氮卓类药物用于疑似GABA能戒断。他在HD 1-4时的COWS评分范围为0 - 6，为此，他接受了布洛芬600 mg和可乐定0.1 mg的剂量，随后他的COWS评分降低。治疗团队制定了HD 4时丁丙诺啡/纳洛酮（以下简称丁丙诺啡）诱导治疗计划。KI表示，他在几个月前接受了丁丙诺啡治疗，但已经退出治疗，并有兴趣重新开始，因为他在使用丁丙诺啡期间能够保持清醒数年。在诱导当天，HD 4，KI在午夜的COWS评分为5分，在6：40 am的评分为6分，在8：37 am的评分为4分，主要评分为出汗、震颤和焦虑。他最后一次使用芬太尼和海洛因是在HD 1午夜出现之前，他的诱导是HD 4上午10：53（大约59小时后）。在他入院期间，没有明显的阿片类药物滥用的证据，而在设施（他是在一个锁定的单位），没有担心他从其他患者获得外部阿片类药物，也没有被醉酒的外观，以解释为什么他的COWS分数仍然很低。在HD 4上午10：53给予KI丁丙诺啡2 mg/0.5 mg。大约1小时后，KI出现急性阿片类戒断症状，COWS评分为16分，恶心、呕吐、出汗、坐立不安、流鼻涕和肌肉疼痛评分。给予患者奥沙西泮30 mg剂量，CIWA为15;然而，考虑到距离其末次饮酒已有6天，认为该评分升高是由于其急性阿片类戒断而非复杂的GABA能戒断所致。CIWA监测随后停止。当时，他没有得到充分的阿片类激动剂，以协助他的阿片类戒断症状。尽管
KI is a 61-year-old, intermittently homeless Caucasian male with a history of alcohol use disorder, opioid use disorder (OUD), peripheral arterial disease status post aortofemoral bypass graft complicated by persistent hernia, hypertension, and hepatitis C status post treatment with ledipasvir/sofosbuvir who initially self-presented to an inpatient psychiatric unit for voluntary admission for a medically supervised withdrawal from both opioids and alcohol on hospital day (HD) 1. KI stated he had last used alcohol 48 hours prior to admission and noted using intravenous (IV) heroin and fentanyl right before presenting to the facility. A urine toxicology screen was positive for both opioids and fentanyl with a positive fentanyl confirmation test, and although urine alcohol level was negative, he had a positive ethyl glucuronide test. While admitted for withdrawal management, KI was monitored with clinical opioid withdrawal scale (COWS) and clinical institute withdrawal assessment of alcohol scale (CIWA). On HDs 1–4, his CIWA scores ranged from 0 to 3, and the patient received only one dose of oxazepam 15 mg as part of the facilities’ protocol but did not require any additional benzodiazepines for suspected GABAergic withdrawal. His COWS scores on HDs 1–4 ranged from 0 to 6, for which he received doses of ibuprofen 600 mg and clonidine 0.1 mg, with subsequent reduction in his COWS. The treatment team had made a plan for induction of buprenorphine/naloxone (hereinafter buprenorphine) on HD 4. KI stated he had been on buprenorphine a few months prior but had fallen out of treatment and was interested in restarting as he had been able to maintain sobriety for several years while on it. On the day of induction, HD 4, KI scored on COWS 5 at midnight, 6 at 6: 40 am, and 4 at 8: 37 am, primarily scoring for sweating, tremor, and anxiety. His last use of fentanyl and heroin were right before presenting at midnight on HD 1, and his induction was HD 4 at 10: 53 am (approximately 59 hours later). During his admission, there was no overt evidence of opioid misuse while at the facility (he was on a locked unit), no concern for his obtaining outside opioid medications from other patients, and no appearance of being intoxicated—to explain why his COWS scores remained low. KI was administered buprenorphine 2 mg/0.5 mg at 10: 53 am on HD 4. Approximately one hour later KI developed acute opioid withdrawal symptoms with a COWS of 16, scoring for nausea, vomiting, sweating, restlessness, runny nose, and muscle aches. He was given a dose of oxazepam 30 mg for a CIWA of 15; this elevated score was thought to be confounded, however, by his acute opioid withdrawal rather than a complicated GABAergic withdrawal, given it was now six days since his last alcohol use. CIWA monitoring was subsequently discontinued. At that time, he was not given full opioid agonists to assist with his opioid withdrawal symptoms. Despite