Stimulants for preschool ADHD down,A2As up

The diagnosis of attention deficit hyperactivity disorder (ADHD) is decreasing among children ages 2 to 5 in Kentucky, but the use of alpha‐2 agonists (A2As, such as clonidine and guanfacine) is increasing, and the use of stimulants is decreasing. The researchers urge long‐term follow‐up of these children, as well as vigilance in checking diagnosis and treatment. For the study, published in the Journal of Child and Adolescent Psychopharmacology and based on Medicaid claims, the researchers were not able to ascertain whether the diagnoses or the treatments were appropriate.     

Alcohol store closure in Pennsylvania: Withdrawals in future?

Last week, the Pennsylvania Liquor Control Board, which runs all liquor stores in the state (and employs all the workers), announced that the stores would be closed 24/7 to mitigate against the spread of COVID‐19. The announcement came on March 16, with stores to close at 9:00 p.m. the next day (St. Patrick's Day, a notorious drinking day).     

Kolodny counters Wakeman,but both agree on many points

It wasn't a live debate as had been planned, with most presenters, including Sarah Wakeman, M.D., and Andrew Kolodny, M.D., presenting remotely like almost all of the speakers, with their slides and microphones, at the American College of Medical Toxicology (ACMT) opioids symposium March 12 in New York City.     

NASADAD releases updated timeline of STR and SOR funding

Last month, the National Association of State Alcohol and Drug Abuse Directors (NASADAD) released an updated timeline of the State Targeted Response to the Opioid Crisis (STR) and State Opioid Response (SOR) grant programs. The key dates, including when the grants were authorized, when Congress appropriated funds and when funding opportunity announcements were released by the Substance Abuse and Mental Health Services Administration, and funding award period for states are listed, as well as more information. The updated version reflects two recent developments.     

ONDCP issues first ‘treatment plan’: Not part of Strategy

Last week, in a surprise move, the Office of National Drug Control Policy (ONDCP) issued its first National Treatment Plan for Substance Use Disorder, along with its National Drug Control Strategy. If anyone was expecting an additional windfall like the $1 billion annual State Opioid Response grant program, it's not there.     

Collocating FQHC and addiction treatment at Damian

If leaders of substance use treatment programs that work with at‐risk children and families have often seen themselves at cross‐purposes with child welfare and criminal justice agencies, there is growing evidence of greater cooperation. The director of an innovative women and children's treatment program at the University of North Carolina at Chapel Hill made a pitch for coordinated and family‐centered care in a webinar presentation last week, using her agency's experience as an example.     

Philadelphia says smoking ban has not led to treatment impact

Despite charges by Brooke Feldman and others (see “Advocate: Philadelphia smoking ban shuts some patients out of treatment,” https://onlinelibrary.wiley.com/doi/10.1002/adaw.32388 , ADAW, June 10), the number of people leaving addiction treatment in Philadelphia is up, not down, after the smoking ban, the Department of Behavioral Health and Intellectual disAbility services (DBHIDS) stated last week in a press release. The statement came out June 24, the day before a planned protest spearheaded by Feldman.     

Sublocade: Why a placebo arm?

In a time when people are dying from illicit fentanyl overdoses, why would a trial for a new medication to treat opioid use disorder — a formulation of buprenorphine, already proven to be safe and effective in oral form — include a placebo arm? This was the question asked by many when the results of Indivior's trial for Sublocade, a buprenorphine injection that lasts a month, were published last month in The Lancet (see ADAW, Feb. 25). The trial results were what led to Sublocade's approval by the Food and Drug Administration (FDA) for the treatment of opioid use disorder more than a year ago (see ADAW, Dec. 11, 2017).     

Study: Don't implement CIWA protocol (benzodiazepines) unnecessarily

In an article published April 27 in JAMA Internal Medicine, “Challenges in Prediction, Diagnosis, and Treatment of Alcohol Withdrawal in Medically Ill Hospitalized Patients: A Teachable Moment,” Thomas D. Brothers, M.D., and Paxton Bach, M.D., write about the case of a man admitted to the hospital for planned bowel resection. The patient said he drank 8 to 10 ounces of whiskey a day but that his last drink was three days prior to admission. There were no symptoms of alcohol withdrawal during the first week. But he required an urgent reoperation on day 6, and on day 9, he became disoriented and inattentive, with large intra‐abdominal abscesses. On day 13, he became more agitated and confused, and clinicians implemented withdrawal treatment protocol using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale. He scored high — anxiety, agitation, hallucinations and disorientation — and was given 10 mg of diazepam, with improvement in his symptoms requiring no further medication. However, the next day he was even more confused and agitated, again scoring high. After another 10‐mg dose of diazepam, he became sedated and had to be transferred to a monitored unit. “In this case, poor understanding of the natural history of alcohol withdrawal led the inpatient team to misdiagnose alcohol withdrawal and inappropriately implement a CIWA protocol,” the researchers wrote. “Alcohol withdrawal symptoms generally begin 6 to 12 hours after the last drink and peak at 24 to 72 hours. Although withdrawal‐related seizures can occur at any time during this course, delirium tremens tends to occur three to seven days after the last drink, and only after progressing through more mild symptoms. For this patient, acute onset of severe alcohol withdrawal more than 1 week after the last drink would be highly unusual, especially without first demonstrating mild withdrawal.” Patients do become agitated under certain medical conditions, including pain and intubation. In this case, the patient was unnecessarily given high doses of benzodiazepines. He was not in alcohol withdrawal.