Tranq Dope: Characterization of an ED cohort treated with a novel opioid withdrawal protocol in the era of fentanyl/xylazine
Treating opioid use disorder has reached a new level of challenge. Synthetic opioids and xylazine have joined the non-medical opioid supply, multiplying the complexities of caring for individuals in emergency departments (ED). This combination, known as ‘tranq dope,’ is poorly described in literatur...
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| Veröffentlicht in: | The American journal of emergency medicine 2024-11, Vol.85, p.130-139 |
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| container_title | The American journal of emergency medicine |
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| creator | London, Kory Li, Yutong Kahoud, Jennifer L. Cho, Davis Mulholland, Jamus Roque, Sebastian Stugart, Logan Gillingham, Jeffrey Borne, Elias Slovis, Benjamin |
| description | Treating opioid use disorder has reached a new level of challenge. Synthetic opioids and xylazine have joined the non-medical opioid supply, multiplying the complexities of caring for individuals in emergency departments (ED). This combination, known as ‘tranq dope,’ is poorly described in literature. Inadequate withdrawal treatment results in a disproportionately high rate of patient-directed discharges (also known as against medical advice dispositions, or AMA). This study aimed to describe a cohort of individuals who received a novel order set for suspected fentanyl and xylazine withdrawal in the ED.
This is a descriptive study evaluating a cohort of ED patients who received withdrawal medications from a novel protocol and electronic health record order set. Individuals being assessed in the ED while suffering from withdrawal were eligible. Individuals under age 18, on stable outpatient MOUD or who were pregnant were excluded. Treatment strategies included micro-induction buprenorphine, short acting opioids, non-opioid analgesics, and other adjunctive medications. Data collected included: demographics including zip code, urine toxicology screening, order set utilization and disposition data. Clinical Opiate Withdrawal Scale (COWS) scores were recorded, where available, before and following exposure to the medications.
There were 270 patient encounters that occurred between September 14, 2022, and March 9, 2023 included in the total study cohort. Of those, 66 % were male, mean age 37 with 71 % residing within Philadelphia zip codes. 100 % of urine toxicology screenings were positive for fentanyl. Of the 177 patients with both pre- and post-exposure COWS scores documented, constituting the final cohort, patients receiving medications had their COWS score decrease from a median of 12 to a median of 4 (p |
| doi_str_mv | 10.1016/j.ajem.2024.08.036 |
| format | Article |
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This is a descriptive study evaluating a cohort of ED patients who received withdrawal medications from a novel protocol and electronic health record order set. Individuals being assessed in the ED while suffering from withdrawal were eligible. Individuals under age 18, on stable outpatient MOUD or who were pregnant were excluded. Treatment strategies included micro-induction buprenorphine, short acting opioids, non-opioid analgesics, and other adjunctive medications. Data collected included: demographics including zip code, urine toxicology screening, order set utilization and disposition data. Clinical Opiate Withdrawal Scale (COWS) scores were recorded, where available, before and following exposure to the medications.
There were 270 patient encounters that occurred between September 14, 2022, and March 9, 2023 included in the total study cohort. Of those, 66 % were male, mean age 37 with 71 % residing within Philadelphia zip codes. 100 % of urine toxicology screenings were positive for fentanyl. Of the 177 patients with both pre- and post-exposure COWS scores documented, constituting the final cohort, patients receiving medications had their COWS score decrease from a median of 12 to a median of 4 (p < 0.001). The AMA rate for this cohort was 3.9 %, whereas the baseline for the population with OUD was 10.7 %. Recorded adverse effects were few and resolved without complication.
Fentanyl and xylazine withdrawal are challenging for patients and providers. A novel tranq dope withdrawal order set may reduce both COWS scores and rate of patient-directed discharge in this cohort of patients, though further investigation is needed to confirm findings.
•Fentanyl and Xylazine are contaminating an ever-growing portion of non-medical opioid supply in the United States•The withdrawal syndromes faced by those using fentanyl and xylazine are unprecedented in their severity and complexity•Use of a multi-modal strategy to address pain, sympathetic activation and other features of the withdrawal may be important.•Potential options include micro-induction dosed buprenorphine, short acting conventional opioids and adjunctive medications.•Use of treatments may reduce withdrawal severity and risk of patient-directed discharge (against medical advice disposition).</description><identifier>ISSN: 0735-6757</identifier><identifier>ISSN: 1532-8171</identifier><identifier>EISSN: 1532-8171</identifier><identifier>DOI: 10.1016/j.ajem.2024.08.036</identifier><identifier>PMID: 39260041</identifier><language>eng</language><publisher>United States: Elsevier Inc</publisher><subject>Adult ; Analgesics ; Analgesics, Opioid - therapeutic use ; Buprenorphine ; Cattle ; Cohort Studies ; Drug abuse ; Drug addiction ; Drug administration ; Drug Combinations ; Drug dosages ; Drug overdose ; Drug stores ; Drug withdrawal ; Electronic medical records ; Emergency medical care ; Emergency Service, Hospital ; FDA approval ; Female ; Fentanyl ; Fentanyl - therapeutic use ; Firing rate ; Heroin ; Hospitals ; Humans ; Immunoassay ; Male ; Methadone ; Middle Aged ; MOUD ; Narcotics ; Opioid withdrawal ; Opioid-Related Disorders - drug therapy ; Opioids ; Patients ; Public health ; Substance use disorder ; Substance Withdrawal Syndrome - drug therapy ; Toxicology ; Tranq dope ; Trauma ; Trauma centers ; Urine ; Vital signs ; Xylazine</subject><ispartof>The American journal of emergency medicine, 2024-11, Vol.85, p.130-139</ispartof><rights>2024 The Author(s)</rights><rights>Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.</rights><rights>2024. The Author(s)</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><cites>FETCH-LOGICAL-c309t-d3791833f649a5f65ab2c34546e7681b31fbfef4d585cae3959ebde2e1d192fb3</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktohtml>$$Uhttps://dx.doi.org/10.1016/j.ajem.2024.08.036$$EHTML$$P50$$Gelsevier$$Hfree_for_read</linktohtml><link.rule.ids>314,780,784,3550,27924,27925,45995</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/39260041$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>London, Kory</creatorcontrib><creatorcontrib>Li, Yutong</creatorcontrib><creatorcontrib>Kahoud, Jennifer L.</creatorcontrib><creatorcontrib>Cho, Davis</creatorcontrib><creatorcontrib>Mulholland, Jamus</creatorcontrib><creatorcontrib>Roque, Sebastian</creatorcontrib><creatorcontrib>Stugart, Logan</creatorcontrib><creatorcontrib>Gillingham, Jeffrey</creatorcontrib><creatorcontrib>Borne, Elias</creatorcontrib><creatorcontrib>Slovis, Benjamin</creatorcontrib><title>Tranq Dope: Characterization of an ED cohort treated with a novel opioid withdrawal protocol in the era of fentanyl/xylazine</title><title>The American journal of emergency medicine</title><addtitle>Am J Emerg Med</addtitle><description>Treating opioid use disorder has reached a new level of challenge. Synthetic opioids and xylazine have joined the non-medical opioid supply, multiplying the complexities of caring for individuals in emergency departments (ED). This combination, known as ‘tranq dope,’ is poorly described in literature. Inadequate withdrawal treatment results in a disproportionately high rate of patient-directed discharges (also known as against medical advice dispositions, or AMA). This study aimed to describe a cohort of individuals who received a novel order set for suspected fentanyl and xylazine withdrawal in the ED.
This is a descriptive study evaluating a cohort of ED patients who received withdrawal medications from a novel protocol and electronic health record order set. Individuals being assessed in the ED while suffering from withdrawal were eligible. Individuals under age 18, on stable outpatient MOUD or who were pregnant were excluded. Treatment strategies included micro-induction buprenorphine, short acting opioids, non-opioid analgesics, and other adjunctive medications. Data collected included: demographics including zip code, urine toxicology screening, order set utilization and disposition data. Clinical Opiate Withdrawal Scale (COWS) scores were recorded, where available, before and following exposure to the medications.
There were 270 patient encounters that occurred between September 14, 2022, and March 9, 2023 included in the total study cohort. Of those, 66 % were male, mean age 37 with 71 % residing within Philadelphia zip codes. 100 % of urine toxicology screenings were positive for fentanyl. Of the 177 patients with both pre- and post-exposure COWS scores documented, constituting the final cohort, patients receiving medications had their COWS score decrease from a median of 12 to a median of 4 (p < 0.001). The AMA rate for this cohort was 3.9 %, whereas the baseline for the population with OUD was 10.7 %. Recorded adverse effects were few and resolved without complication.
Fentanyl and xylazine withdrawal are challenging for patients and providers. A novel tranq dope withdrawal order set may reduce both COWS scores and rate of patient-directed discharge in this cohort of patients, though further investigation is needed to confirm findings.
•Fentanyl and Xylazine are contaminating an ever-growing portion of non-medical opioid supply in the United States•The withdrawal syndromes faced by those using fentanyl and xylazine are unprecedented in their severity and complexity•Use of a multi-modal strategy to address pain, sympathetic activation and other features of the withdrawal may be important.•Potential options include micro-induction dosed buprenorphine, short acting conventional opioids and adjunctive medications.•Use of treatments may reduce withdrawal severity and risk of patient-directed discharge (against medical advice disposition).</description><subject>Adult</subject><subject>Analgesics</subject><subject>Analgesics, Opioid - therapeutic use</subject><subject>Buprenorphine</subject><subject>Cattle</subject><subject>Cohort Studies</subject><subject>Drug abuse</subject><subject>Drug addiction</subject><subject>Drug administration</subject><subject>Drug Combinations</subject><subject>Drug dosages</subject><subject>Drug overdose</subject><subject>Drug stores</subject><subject>Drug withdrawal</subject><subject>Electronic medical records</subject><subject>Emergency medical care</subject><subject>Emergency Service, Hospital</subject><subject>FDA approval</subject><subject>Female</subject><subject>Fentanyl</subject><subject>Fentanyl - 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therapeutic use</topic><topic>Buprenorphine</topic><topic>Cattle</topic><topic>Cohort Studies</topic><topic>Drug abuse</topic><topic>Drug addiction</topic><topic>Drug administration</topic><topic>Drug Combinations</topic><topic>Drug dosages</topic><topic>Drug overdose</topic><topic>Drug stores</topic><topic>Drug withdrawal</topic><topic>Electronic medical records</topic><topic>Emergency medical care</topic><topic>Emergency Service, Hospital</topic><topic>FDA approval</topic><topic>Female</topic><topic>Fentanyl</topic><topic>Fentanyl - therapeutic use</topic><topic>Firing rate</topic><topic>Heroin</topic><topic>Hospitals</topic><topic>Humans</topic><topic>Immunoassay</topic><topic>Male</topic><topic>Methadone</topic><topic>Middle Aged</topic><topic>MOUD</topic><topic>Narcotics</topic><topic>Opioid withdrawal</topic><topic>Opioid-Related Disorders - drug therapy</topic><topic>Opioids</topic><topic>Patients</topic><topic>Public health</topic><topic>Substance use disorder</topic><topic>Substance Withdrawal Syndrome - drug therapy</topic><topic>Toxicology</topic><topic>Tranq dope</topic><topic>Trauma</topic><topic>Trauma centers</topic><topic>Urine</topic><topic>Vital signs</topic><topic>Xylazine</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>London, Kory</creatorcontrib><creatorcontrib>Li, Yutong</creatorcontrib><creatorcontrib>Kahoud, Jennifer L.</creatorcontrib><creatorcontrib>Cho, Davis</creatorcontrib><creatorcontrib>Mulholland, Jamus</creatorcontrib><creatorcontrib>Roque, Sebastian</creatorcontrib><creatorcontrib>Stugart, Logan</creatorcontrib><creatorcontrib>Gillingham, Jeffrey</creatorcontrib><creatorcontrib>Borne, Elias</creatorcontrib><creatorcontrib>Slovis, Benjamin</creatorcontrib><collection>ScienceDirect Open Access Titles</collection><collection>Elsevier:ScienceDirect:Open Access</collection><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>ProQuest Central (Corporate)</collection><collection>Nursing & Allied Health Database</collection><collection>Immunology Abstracts</collection><collection>Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Medical Database (Alumni Edition)</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>Research Library (Alumni Edition)</collection><collection>ProQuest Central (Alumni Edition)</collection><collection>ProQuest One Sustainability</collection><collection>ProQuest Central UK/Ireland</collection><collection>ProQuest Central Essentials</collection><collection>ProQuest Central</collection><collection>ProQuest One Community College</collection><collection>ProQuest Central Korea</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>ProQuest Central Student</collection><collection>Research Library Prep</collection><collection>AIDS and Cancer Research Abstracts</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Nursing & Allied Health Database (Alumni Edition)</collection><collection>Health & Medical Collection (Alumni Edition)</collection><collection>Medical Database</collection><collection>Research Library</collection><collection>Research Library (Corporate)</collection><collection>Nursing & Allied Health Premium</collection><collection>ProQuest One Academic Eastern Edition (DO NOT USE)</collection><collection>ProQuest One Academic</collection><collection>ProQuest One Academic UKI Edition</collection><collection>ProQuest Central Basic</collection><collection>MEDLINE - Academic</collection><jtitle>The American journal of emergency medicine</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>London, Kory</au><au>Li, Yutong</au><au>Kahoud, Jennifer L.</au><au>Cho, Davis</au><au>Mulholland, Jamus</au><au>Roque, Sebastian</au><au>Stugart, Logan</au><au>Gillingham, Jeffrey</au><au>Borne, Elias</au><au>Slovis, Benjamin</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Tranq Dope: Characterization of an ED cohort treated with a novel opioid withdrawal protocol in the era of fentanyl/xylazine</atitle><jtitle>The American journal of emergency medicine</jtitle><addtitle>Am J Emerg Med</addtitle><date>2024-11</date><risdate>2024</risdate><volume>85</volume><spage>130</spage><epage>139</epage><pages>130-139</pages><issn>0735-6757</issn><issn>1532-8171</issn><eissn>1532-8171</eissn><abstract>Treating opioid use disorder has reached a new level of challenge. Synthetic opioids and xylazine have joined the non-medical opioid supply, multiplying the complexities of caring for individuals in emergency departments (ED). This combination, known as ‘tranq dope,’ is poorly described in literature. Inadequate withdrawal treatment results in a disproportionately high rate of patient-directed discharges (also known as against medical advice dispositions, or AMA). This study aimed to describe a cohort of individuals who received a novel order set for suspected fentanyl and xylazine withdrawal in the ED.
This is a descriptive study evaluating a cohort of ED patients who received withdrawal medications from a novel protocol and electronic health record order set. Individuals being assessed in the ED while suffering from withdrawal were eligible. Individuals under age 18, on stable outpatient MOUD or who were pregnant were excluded. Treatment strategies included micro-induction buprenorphine, short acting opioids, non-opioid analgesics, and other adjunctive medications. Data collected included: demographics including zip code, urine toxicology screening, order set utilization and disposition data. Clinical Opiate Withdrawal Scale (COWS) scores were recorded, where available, before and following exposure to the medications.
There were 270 patient encounters that occurred between September 14, 2022, and March 9, 2023 included in the total study cohort. Of those, 66 % were male, mean age 37 with 71 % residing within Philadelphia zip codes. 100 % of urine toxicology screenings were positive for fentanyl. Of the 177 patients with both pre- and post-exposure COWS scores documented, constituting the final cohort, patients receiving medications had their COWS score decrease from a median of 12 to a median of 4 (p < 0.001). The AMA rate for this cohort was 3.9 %, whereas the baseline for the population with OUD was 10.7 %. Recorded adverse effects were few and resolved without complication.
Fentanyl and xylazine withdrawal are challenging for patients and providers. A novel tranq dope withdrawal order set may reduce both COWS scores and rate of patient-directed discharge in this cohort of patients, though further investigation is needed to confirm findings.
•Fentanyl and Xylazine are contaminating an ever-growing portion of non-medical opioid supply in the United States•The withdrawal syndromes faced by those using fentanyl and xylazine are unprecedented in their severity and complexity•Use of a multi-modal strategy to address pain, sympathetic activation and other features of the withdrawal may be important.•Potential options include micro-induction dosed buprenorphine, short acting conventional opioids and adjunctive medications.•Use of treatments may reduce withdrawal severity and risk of patient-directed discharge (against medical advice disposition).</abstract><cop>United States</cop><pub>Elsevier Inc</pub><pmid>39260041</pmid><doi>10.1016/j.ajem.2024.08.036</doi><tpages>10</tpages><oa>free_for_read</oa></addata></record> |
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| subjects | Adult Analgesics Analgesics, Opioid - therapeutic use Buprenorphine Cattle Cohort Studies Drug abuse Drug addiction Drug administration Drug Combinations Drug dosages Drug overdose Drug stores Drug withdrawal Electronic medical records Emergency medical care Emergency Service, Hospital FDA approval Female Fentanyl Fentanyl - therapeutic use Firing rate Heroin Hospitals Humans Immunoassay Male Methadone Middle Aged MOUD Narcotics Opioid withdrawal Opioid-Related Disorders - drug therapy Opioids Patients Public health Substance use disorder Substance Withdrawal Syndrome - drug therapy Toxicology Tranq dope Trauma Trauma centers Urine Vital signs Xylazine |
| title | Tranq Dope: Characterization of an ED cohort treated with a novel opioid withdrawal protocol in the era of fentanyl/xylazine |
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