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Gary Evans: Addicted Patients Inject, Infect Their Own Lines

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CareFusion: Clamping: Required Sequence or Patient Safety?

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University of Pittsburgh, PA: Risk Factors Associated With Outpatient Parenteral Antibiotic Therapy Program Failure Among IVDUs

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National University Hospital Singapore: Safe Treatment of IVDUs with a PICC in Outpatient Parenteral Antibiotic Treatment Service

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AMA: Buprenorphine Treatment for Hospitalized, Opioid-Dependent Patients, A Randomized Clinical Trial

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NEJM: Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis

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JAMA: The Burden of Opioid-Related Mortality in the United States

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EXTERNAL REFERENCES
Want to read more? Most of these articles can be accessed through PubMed. Go to www.pubmed.gov and enter the PMID number at the end of the reference into the search line.

Section 1. Opioid Use, Public Policy, Prescribing, Abuse & Mortality
1. New Data on Opioid Use and Prescribing in the United States JAMA. 2017 Aug 1;318(5):425-426. doi: 10.1001/jama.2017.8913. PMID 28687823

Too many individuals in the United States are adversely affected by the opioid crisis, either from misuse of prescription opioids or use of illicit opioids. Physicians and other health professionals can help prevent many individuals from becoming addicted to opioids or overdosing by improving opioid prescribing practices as part of a coordinated public health approach.

2. Modeling Health Benefits and Harms of Public Policy Responses to the US Opioid Epidemic. Am J Public Health. 2018 Aug 23:e1-e7. doi: 10.2105/AJPH.2018.304590. [Epub ahead of print] . Am J Public Health. Published online ahead of print August 23, 2018: e1-e7. doi:10.2105/AJPH.2018.304590). PMID30138057

We used dynamic compartmental modeling of US adults, in various pain, opioid use, and opioid addiction health states, to project addiction-related deaths, life years, and quality-adjusted life years from 2016 to 2025 for 11 policy responses to the opioid epidemic.
Over 5 years, increasing naloxone availability, promoting needle exchange, expanding medication-assisted addiction treatment, and increasing psychosocial treatment increased life years and quality-adjusted life years and reduced deaths. Other policies reduced opioid prescription supply and related deaths but led some addicted prescription users to switch to heroin use, which increased heroin-related deaths. Over a longer horizon, some such policies may avert enough new addiction to outweigh the harms. No single policy is likely to substantially reduce deaths over 5 to 10 years. Policies focused on services for addicted people improve population health without harming any groups. Policies that reduce the prescription opioid supply may increase heroin use and reduce quality of life in the short term, but in the long term could generate positive health benefits. A portfolio of interventions will be needed for eventual mitigation. Policies focused on services for addicted people (naloxone, needle exchange, medication assisted addiction treatment) improve population health without haring any groups. Policies that reduce prescription opioid supply may increase heroin use and reduce quality of life in the short term, but in the long term could generate positive health benefits. A portfolio of interventions will be needed for eventual mitigation.

3. Worldwide Prevalence and Trends in Unintentional Drug Overdose: A Systematic Review of the Literature. Am J Public Health. 2015 Nov;105(11):e29-49. doi: 0.2105/AJPH.2015.302843. PMID: 26451760

There is a need to invest in research to understand the distinct determinants of prescription drug overdose worldwide. Several other countries need to collect in a systematic and continuous fashion such data on sales of prescription opioids and other prescription drugs, nonmedical use of prescription drugs, and hospitalization secondary to overdoses on prescription drugs. The sparse evidence on the environmental determinants of overdose suggests a need for research that will inform the types of environmental interventions we can use to prevent drug overdose. Methodological issues for future studies include enhancing data collection methods on unintentional fatal and nonfatal overdoses, and collecting more detailed information on drug use history, source of drug use (for prescription drugs), and demographic and psychiatric history characteristics of the individual who overdosed

4. The Burden of Opioid-Related Mortality in the United States. JAMA Network Open. 2018:1(2):e180217.doi:10.1001.jamaworkopen.2018.0217.

Increased rates of opioid prescribing and the associated negative health consequences have emerged as leading public health problems in North America,1 particularly among young and middle-aged adults.2 By 2014, Canada and the United States had the highest per capita opioid consumption in the world,3 and deaths related to opioid use have increased dramatically in both countries.2,4,5 Importantly, opioid-related death rates are increasing most quickly among adults aged 25 to 44 years in the United States.2 Consequently, the public health burden resulting from early loss of life is substantial. Premature death from opioid-related causes imposes an enormous public health burden across the United States. The recent increase in deaths attributable to opioids among those aged 15 t0 34 years highlights a need for targeted programs and policies that focus on improved addiction care and harm reduction measures in this high-risk population.

5. Open

6. Suggested Paths to Fixing the Opioid Crisis: Directions and Misdirections. JAMA Network Open. 2018;1(2):e180218. doi:10.1001/jamanetworkopen.2018.0218

It will be challenging to reverse the trend of opioid overdose deaths given the extent of the epidemic as described by many, including Gomes et al.1 Training health professionals how to clinically respond to the addiction epidemic and building systems that enable effective care will be much easier in a health system that adopts payment processes that do not construct barriers to patients who need help. Medical efforts to address substance use disorders, and in particular opioid use disorders, should grow within primary care and be allied with the addiction subspecialty care system. Accessible, effective medical care that routinely includes medications should be the standard to which clinical practice is held.

7. Drug Overdose Deaths in the United States 199902016 https://www.cdc.gov/nchs/products/databriefs/db294.htm

Key Findings
•In 2016, there were more than 63,600 drug overdose deaths in the United States.
•The age-adjusted rate of drug overdose deaths in 2016 (19.8 per 100,000) was 21% higher than the rate in 2015 (16.3).
•Among persons aged 15 and over, adults aged 25–34, 35–44, and 45–54 had the highest rates of drug overdose deaths in 2016 at around 35 per 100,000.
•West Virginia (52.0 per 100,000), Ohio (39.1), New Hampshire (39.0), the District of Columbia (38.8), and Pennsylvania (37.9) had the highest observed age-adjusted drug overdose death rates in 2016.
•The age-adjusted rate of drug overdose deaths involving synthetic opioids other than methadone (drugs such as fentanyl, fentanyl analogs, and tramadol) doubled between 2015 and 2016, from 3.1 to 6.2 per 100,000.

Section 2. General Risks & Management of Hospitalized IVDU Inpatients with PICC or Central Lines
(See also sections 4, 5 & 6 for Clamp, MAT, & ID consultation recommendations)
1. Addicted Patients Inject, Infect Their Own IV Lines. AHC Media. At risk of bloodstream infections, overdose. www.ahcmedia.com/138503-addicted-patients-inject-infect-their-own-iv-lines . August 15, 2016

Baptist Medical Center Jacksonville, Florida reported that 8 of the 16 bloodstream infections recorded between October 2014 and September 2015 were related to patient line injection and access to illicit drugs. Retrospective chart review showed that warning signs of line abuse and illicit drug injection were behavioral changes, increased anxiety, depression and aggression, over-sedation, insistence on closed doors and privacy, and prolonged bathroom stays. Recommended adjustments included using screening tools for addiction risk, placing the PICC in the dominant arm, limiting visitors, and moving patients near with nursing station with good views of the patient and open doors.

2. In-hospital Illicit Drug Use, Substance Use Disorders, and Acceptance of Residential Treatment in a Prospective Pilot Needs Assessment of Hospitalized Adults with Severe Infections from Injecting Drugs. J of Substance Abuse Treatment 94, 2018: pages 64-69. PMID: 30032946.

This pilot data gathering study gathered data on substance use disorder patients who required extended IV antibiotics through PICC lines. The most interesting findings were 1) Most patients said the presence of a PICC line did not make the more likely to use IV drugs 2) At least 40% of patients used illicit drugs while in the acute hospital 3) most patients were not willing to accept treatment in a residential treatment center, probably because the center would not provide maintenance substance abuse pharmacologic treatment and because the center was far from home and support.

3. Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis. NEJM 2018, epublication ahead of print. DOI: 10.1056/NEJMoa1808312 . PMID 30152252.
In this Danish study, 400 adults with left-sided endocarditis were initially treated with culture-guided IV antibiotics. After stabilization at an average of 10 days, the patients were randomly assigned to either continued IV antibiotics or oral antibiotics. Outcomes for the oral group were just as good as for the IV group.

4. Harm Reduction in Hospitals. Harm Reduct J. 2017; 14: 32. Published online 2017 Jun 5. doi: 10.1186/s12954-017-0163-0. PMID: 28583121

Despite the high rates of hospitalization among people who use drugs (PWUD), harm reduction interventions have not been widely adopted in inpatient settings. We list several harm reduction practices that we believe should be considered in hospitals. Interventions to decrease stigma, including guidance regarding language and partnering with people with lived experience of drug use, can be implemented expeditiously. Hospitals with a high prevalence of drug use can establish addiction consultation services to address issues including initiation of medication-assisted therapy. We believe that new evidence generation is required to address the optimal use of peripherally inserted central venous catheters, to determine the relative benefits and harms of treatment contracts for inpatients, and to assess the efficacy of supervised injection services for inpatients. The need for harm reduction programs in hospitals emphasizes the need for a pragmatic, patient-centered, non-judgmental approach to the care of PWUD.

5. Responsible Compassionate Care: Meeting the Needs of Patients with a History of Intravenous Drug Abuse. JAVA (Journal of the Association for Vascular Access); http:dx.doi.org/10.1016/j.java.2016.08.004

This thoughtful piece on the use of Tamper-Evident Technology provides perspective and the rationale, realistic and compassionate management of patients with PICC lines and a history of intravenous drug use. The paper advocate for the role of tamper-evident technology in the management of this patients.

Section 3. Safety of Hospital Discharge & Outpatient Home or OPAT Treatment for IVDU Patients with a PICC or Central Line
1. Safe and Successful Treatment of Intravenous Drug Users with a Peripherally Inserted Central Catheter in an Outpatient Parenteral Antibiotic Treatment Service. J Antimicrob Chemother 2010; 65: 2641–2644. doi:10.1093/jac/dkq355. PMID: 20864497

Twenty-nine IVDU patients received treatment in our OPAT service (total 675 patient-days). The median duration of therapy was 18 days (range 1–85). Infective endocarditis was the primary diagnosis in 42% of cases. Two patients (7%) had recrudescent infection after absconding during their inpatient stay. These two patients subsequently completed treatment in OPAT. There were no deaths or cases of PICC abuse. Five patients (17%) during OPAT and one patient (3%) during the 30-day follow-up period required readmission for infective or treatment-related complications. Appropriately selected, counseled and monitored patients with a history of being an IVDU can be treated safely and successfully via OPAT centers. It is likely that some will respond better to treatment in an outpatient setting.

2. Risk Factors Associated with Outpatient Parenteral Antibiotic Therapy Program Failure Among Intravenous Drug Users. Open Forum Infectious Diseases, Brief Report. 2017 May 23;4(3):ofx102. doi: 10.1093/ofid/ofx102. eCollection 2017 Summer
61% of IVDU patients enrolled in OPAT (Outpatient Antibiotic Therapy) were either readmitted, required a change in their antibiotic regiment, or had adverse drug reactions and were therefore considered OPAT failures. There was no control group. Only 2% of patients were found to have abused their PICC lines.

3. Small-Town America’s Despair: Infected Substance Users Needing Outpatient Parenteral Therapy and Risk Stratification. Cureus 9(8); e1579 DOI10.7759/cureus 1579 PMID: 29057191 .

This retrospective review discusses a risk stratification strategy to aid healthcare providers in determining which patients with addictive disorders can be safely discharged for outpatient antimicrobial therapy with a PICC in place. A psychosocial analysis was used to evaluate the patients. In this analysis of only 20 cases, 5 patients were low risk and all completed treatment without incident.

4. Perceptions and Practices of Physicians Regarding Outpatient Parenteral Antibiotic Therapy in Persons Who Inject Drugs. J. Hosp. Med. 2016 August;11(8):581-582 PMID: 27043146
This survey illustrates the extremely complex barriers present when treating hospitalized persons who inject drugs requiring long courses of IV antibiotics and supports the anecdotal evidence that physicians often keep these patients in the hospital for weeks to administer IV antibiotics. The majority of our sample of physicians believes that the largest barriers to OPAT are socioeconomic factors and the potential risk of the patient misusing the PICC line. This survey suggests that while there is variability, OPAT may be an option if outpatient follow up and ancillary services were put in place (i.e., home health and possibly intensive case management.)

5. Bundle in the Bronx: Impact of a Transition-0f-Care Outpatient Parenteral Antibiotic Therapy Bundle on All-Case 30-Day Hospital Readmission. Open Forum Infectious Diseases. Epub DOI:10.1093/ofidofx097. PMID 28852672

Implementation of a multidisciplinary team approach to post-acute hospital discharge to SNF or home lead to a decrease in readmission rates from 26% to 13% at 30 days. An effective transitions of care program can reduce readmissions in an economically disadvantaged area.

6. Outpatient Parenteral Antimicrobial Therapy (OPAT): Is It Safe for Selected Patients to Self-Administer at Home? A Retrospective Analysis of a Large Cohort over 13 years. J Antimicrob Chemother. 2007 Aug;60(2):356-62. Epub 2007 Jun 11. PMID: 17566002

Provision of outpatient parenteral antimicrobial therapy (OPAT) is an evolving field, facilitating discharge from hospital for selected patients with serious infections. We report on a large OPAT cohort focusing on the practice of supervised parenteral antibiotic administration in the community by patients and relatives, which we collectively term 'self-administration'. To distinguish between healthcare professional OPAT and self-administered OPAT, we have coined the terms H-OPAT and S-OPAT, respectively. We analyzed data on 2059 OPAT episodes collected prospectively over a 13-year time period from 1993 to 2005. Clinical diagnosis, microbiology and antibiotics in this OPAT series are comparable to those previously reported. We identified no excess complications or hospital re-admissions in the S-OPAT group compared with the H-OPAT group. Self-administration of intravenous antimicrobial therapy, in selected patients under the supervision of a specialist team, is a safe and feasible strategy.

7. Outcomes According to Discharge Location for Persons Who Inject Drugs Receiving Outpatient Parenteral Antimicrobial Therapy Open Forum Infect Dis. 2018 Apr 18;5(5):ofy056. doi: 10.1093/ofid/ofy056. eCollection 2018 May. PMID: 29766017

Fifty-two patients met inclusion criteria, 21 of whom were discharged to home and 31 were discharged to a SNF/rehab. Of the patients discharged to home, 17 (81%) completed their planned antibiotic courses without complication. Twenty (64%) patients discharged to a SNF/rehab completed the antibiotic courses without complication. Six (11%) patients had line infections, 6 (11%) had injection drug use relapse, and 12 (23%) required readmission. Persons who inject drugs discharged home were not more likely to have complications than those discharged to a SNF/rehab. Home OPAT may be a safe discharge option in carefully selected patients.

8. Risk Factors Associated with Outpatient Parenteral Antibiotic Therapy Program Failure Among Intravenous Drug Users. Open Forum Infect Dis. 2017 Summer; 4(3): ofx102. Published online 2017 May 23. doi: 10.1093/ofid/ofx102. PMID: 28680904

OPAT costs just 41% of what comparable inpatient antibiotic administration would cost [7], and it is estimated to save ~$4 million/year [8]. In light of the limited data and the growing need to provide OPAT to IVDUs, our goal was to report our initial experience providing OPAT to this population. Our objectives were to define the prevalence of OPAT among IVDUs eligible for hospital discharge and to identify factors associated with OPAT failures. Sixty-one percent of intravenous drug users (IVDUs) who received outpatient parenteral antibiotic therapy (OPAT) failed treatment. On balance, however, we found that patients with remote histories of IVDU (>5 years) had much lower rates of failure (21%). These data suggest that a detailed patient history may identify IVDU patients who are suitable for OPAT; however, further studies are needed to confirm these findings. Hospital readmission and adverse drug reactions occurred in 25%. By multivariate analysis, time since last IVDU was associated with failure (P = .04). Intravenous drug users requiring OPAT are at high risk for failure; additional studies are needed to explore alternatives.

9. Clinical and Cost-Effectiveness, Safety and Acceptability of Community Intravenous Antibiotic Service Models: CIVAS Systematic Review. BMJ Open. 2017 Apr 20;7(4):e013560. doi: 10.1136/bmjopen-2016-013560. PMID: 28428184

128 studies involving >60 000 OPAT episodes were included. 22 studies (17%) did not indicate the OPAT model used; only 29 involved a comparator (23%). There was little difference in duration of OPAT treatment compared with inpatient therapy, and overall OPAT appeared to produce superior cure/improvement rates. However, when models were considered individually, outpatient delivery appeared to be less effective, and self-administration and specialist nurse delivery more effective. Drug side effects, deaths and hospital readmissions were similar to those for inpatient treatment, but there were more line-related complications. Patient satisfaction was high, with advantages seen in being able to resume daily activities and having greater freedom and control. However, most professionals perceived challenges in providing OPAT. There were no systematic differences related to the impact of OPAT on treatment duration or adverse events. However, evidence of its clinical benefit compared with traditional inpatient treatment is lacking, primarily due to the dearth of good quality comparative studies. There was high patient satisfaction with OPAT use but the few studies considering practitioner acceptability highlighted organizational and logistic barriers to its delivery.

10. Self-Administration of Outpatient Parenteral Antibiotic Therapy and risk of Catheter-Related Adverse Events: A Retrospective Cohort Study. Eur J Clin Microbiol Infect Dis. 2012 Oct;31(10):2611-9. Epub 2012 Apr 12. PMID: 22526869

Despite increasing use, limited data has been published comparing safety of different outpatient parenteral antimicrobial therapy (OPAT) models. Potential risks of self-administration at home include venous access device infection and other line complications. This study aims to investigate rates and predictors of intravenous access device complications in a large OPAT cohort. This is a retrospective cohort study of all uses of midlines, peripherally inserted central catheters (PICCs) and tunneled central venous catheters (TCVCs) with univariate and multivariate (logistic regression) analysis of factors associated with line infections (LIs) and with other line events (OLEs). On univariate analysis, line infections were associated with length of line use, female sex and TCVC lines (compared to midlines). Patients self-administering OPAT in the home had a non-significantly lower rate of LIs. On multivariate analysis, only duration of line use was a significant predictor of LIs-OR 1.012 (95%CI 1.001-1.023). For OLEs, multivariate analysis suggested that only line type and use of flucloxacillin were significant explanatory variables. In this cohort, there is no evidence that self-administration of OPAT is associated with higher rates of venous access device complications after controlling for confounding variables.

11. Outpatient Parenteral Antibiotic Therapy for Infective Endocarditis: A Review of 4 Years' Experience at a UK Centre. Postgrad Med J. 2012 Jul;88(1041):377-81. doi: 10.1136/postgradmedj-2011-130355. Epub 2012 Feb 25. PMID: 22366395

A total of 36 episodes of IE were treated in 34 patients. All patients received initial treatment as inpatients. Treatment was successful in 34/36 episodes (94.4%) with no evidence of recurrence at a median of 30 months follow-up. One patient had a relapse 2 months after completion of OPAT for enterococcal endocarditis and was found to have concurrent chronic prostatitis. One patient died of a ruptured pulmonary root abscess while receiving OPAT. Adverse events occurred in 12 episodes (33.3%), of which seven were line associated. In four cases adverse events resulted in re-hospitalization. A successful outcome was achieved in 22/24 episodes (91.7%) deemed to be less suitable for OPAT due to higher risk of complications by Infectious Diseases Society of America guidelines. OPAT is a safe and effective means of completing therapy for IE, including prosthetic valve endocarditis and other cases at a higher risk of complicated disease. However, the relatively high rate of adverse events highlights the need for well-developed protocols and policies for patient selection and follow-up within the context of a formal OPAT service.

12. Self-Administered Antimicrobial Infusion by Uninsured Patients Discharged from a Safety-Net Hospital. A Propensity-Score-Balanced Retrospective Cohort Study. PLoS Med 12(12):e PMID: 26671467

Uninsured patients were trained while in hospital to give themselves IV antibiotics after they were stabilized for discharge. Compared to patients with insurance who were provided outpatient services at home, the self-care patients (S-OPAT) had a 47% lower readmission rate and successful treatment and mortality were the same in the self- care group as in the health care supervised insured group. Uninsured medically stable patients can administer their own antibiotics at home with equal or even better outcomes than insured patients supervised in their homes for antibiotic administration.

13. Optimising Health and Safety of People Who Inject Drugs during Transition from Acute to Outpatient Care. Postgrad Med J. 2016 June; 92 (1088) 356 -63. HHS Public Access PMC available 2017 June 1. PMID 27004476

The opioid epidemic in the USA continues to worsen. Medical providers are faced with the challenge of addressing complications from opioid use disorders and associated drug use. The narrative review cites approaches to comprehensive care that include readiness for change assessment followed by medication interventions to treat addiction, safe injection, naloxone rescue kits, and screening for STDs and hepatitis C and HIV.

14. Supervised Self-administration of Outpatient Parenteral Antibiotic Therapy: A Report from a Large Tertiary Hospital in Australia. Int. J Infect Dis. 30 (2015) 161-165, PMID 25603999

OPAT using a patient or caregiver administration model is an effective and safe option for the management of selected patients with infection requiring intravenous antibiotics.

Section 4. Opioid-Use Disorder Treatment to Prevent Relapse and Complications During Treatment
1. Buprenorphine Treatment for Hospitalized Opioid-Dependent Patients: A Randomized Clinical Trial. JAMA Internal Med 2014;174(8):1369-1376 PMID: 25090173

139 hospitalized, opioid-addicted patients were randomly assigned to either an opioid detoxification process or initiation of buprenorphine/naloxone and referring to the outpatient addiction treatment clinic after discharge. Compared with inpatient detoxification alone, the patients placed on chronic treatment and referred to the clinic were more likely to enter into treatment (72% versus 12%) and more likely to be in treatment at 6 months (17% versus 3%). The inpatient linkage to outpatient treatment was successful for most patients, but maintenance in the outpatient treatment deteriorated over 6 months.

2. Putting Parity into Practice — Integrating Opioid-Use Disorder Treatment into the Hospital Setting. N Engl J Med 2016; 375:811-813. DOI: 10.1056/NEJMp1606157. PMID: 27579631

Implementing evidence-based care for hospitalized patients with OUD may substantially improve outcomes and reduce costs. A reasonable first step is to ensure that all patients admitted to the hospital with an opioid overdose, or a medical illness with concomitant opioid use, receive a comprehensive assessment for substance-use disorder. If there is a current diagnosis of OUD, we believe that informed consent and initiation of MAT for OUD should be a priority. Though OUD is a complex medical illness amenable to treatment, stigma and conflict unfortunately continue to influence care, frustrate providers, and marginalize patients.
The Affordable Care Act mandates parity between treatment of substance-use disorders and that of other medical illnesses, and the American Board of Medical Specialties now recognizes addiction medicine as a medical subspecialty. Since there are not enough trained addiction medicine physicians to curb the opioid epidemic, we believe education about evidence-based OUD treatment should be expanded to all members of the care team and integrated into standard hospital care. Education coupled with expanded treatment resources can improve patients’ experience, increase adherence to treatment recommendations, and improve health outcomes. It is time to put parity into practice.

3. Medication for Opioid Use Disorder after Nonfatal Opioid Overdose and Association with Mortality. Annals of Internal Medicine, 2018; 169(3). Pages 137-145. Editorial comment on page 190. PMID: 29913516

This was a retrospective data analysis from 7 linked data sets from Massachusetts government agencies. Although only a minority of patients received medications for opioid use disorder after their overdose episode, those who did had a more than 50% reduction in mortality compared to those who did not receive buprenorphine or methadone.

4. Improving Outcomes for Persons with Opioid Use Disorders: Buprenorphine Implants to Improve Adherence and Access to Care. JAMA. 2016 Jul 19;316(3):277-9. doi: 10.1001/jama.2016.8897. PMID: 27434440

A key approach is to treat the underlying opioid use disorder, which contributes to morbidity and mortality for many patients. Treatment for opioid use disorders should include medication-assisted treatment of an adequate duration. Current medical interventions for treating opioid use disorders and preventing relapse include full agonists (oral methadone), nonselective partial agonists (oral or trans-mucosal buprenorphine), and antagonists (oral and long-acting injectable naltrexone) of the µ-opioid receptor. When used correctly, the interaction between these medications and the µ-opioid receptor minimizes (to various degrees that depend on the pharmacology of the specific agent) the intoxicating effects of abused opioids, including heroin. These medications also prevent the emergence of withdrawal symptoms, which are frequently associated with relapse into heroin taking. The rationale behind these medications is that by stabilizing opioid signaling, they minimize relapse, allowing for recovery from the drug-induced changes in brain function that result in emotional distress and loss of self-regulation. These medications also allow for the relearning processes that are essential for recovery.

5. Treatment of Opioid-Use Disorders. N Engl J Med. 2016 Jul 28;375(4):357-68. doi: 10.1056/NEJMra1604339. PMID: 27464203

This article provides an overview of the current treatment of opioid-related conditions, including treatments provided by general practitioners and by specialists in substance-use disorders. The recent dramatic increase in misuse of prescription analgesics, the easy accessibility of opioids such as heroin on the streets, and the epidemic of opioid overdoses underscore how important it is for physicians to understand more about these drugs and to be able to tell patients about available treatments for substance-use disorders.

6. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ. 2017 Apr 26;357:j1550. doi: 10.1136/bmj.j1550. PMID: 28446428

Retention in methadone and buprenorphine treatment is associated with substantial reductions in the risk for all cause and overdose mortality in people dependent on opioids. The induction phase onto methadone treatment and the time immediately after leaving treatment with both drugs are periods of particularly increased mortality risk, which should be dealt with by both public health and clinical strategies to mitigate such risk. These findings are potentially important, but further research must be conducted to properly account for potential confounding and selection bias in comparisons of mortality risk between opioid substitution treatments, as well as throughout periods in and out of each treatment.

7. Hospitalist Involvement Needed to Treat Opioid Epidemic. ACP Hospitalist. October 2017.

A call for hospitalists to become involved with and knowledgeable about the treatment of opioid use disorder.

8. Primary Care and the Opioid-Overdose Crisis – Buprenorphine Myths and Realities. NEJM 2018. 379;1:1-6. PMID 29972748.

Medical treatment of opioid use disorder is effective but not widely available because of legal restrictions on prescribing. There are more than 320,000 primary care doctors in the US and only 3000 diplomats of the American Board of Addiction Medicine. “In part, the opioid crisis is an epidemic of poor access to care.” Life expectancy among certain groups in the US is actually decreasing as a result of this crisis. “Mobilizing the PCP workforce to offer office-based buprenorphine treatment is a plausible, practical, and scalable intervention that could be implemented immediately.”

9. Opioid agonist treatment for pharmaceutical opioid dependent people. A Cochrane Library Review. Cochrane Database Syst Rev. 2016 May 9;(5):CD011117. doi:10.1002/14651858.CD011117.pub2. PMID 27157143
There was low to moderate quality evidence supporting the use of maintenance agonist pharmacotherapy for pharmaceutical opioid dependence. The main weaknesses in the quality of the data were the use of open-label designs. Maintenance treatment with buprenorphine appeared more effective than detoxification or psychological treatments.

Section 5. PICC & Central Line Clamping
1. Clamping: Required sequence or patient safety? CareFusion Corporation. www.carefusion.com .
Clamps are provided for patient safety.

2. ECRI Hazard Report, Health Devices. December 1995;24(12)515.
Manual clamping of the set between the injection site and the catheter itself will prevent both gas embolism and blood loss.

3. Central Venous Access Devices. Radiologic Technology. March 2006.
Open-ended PICCs must be clamped when not is use.

4. Infusion Nursing Society. http://ins1.org/files/public/QA_session_1_webinar.pdf
Many institutions and agencies believe that clamping the catheter provides protection from venous air emboli if the needleless connector were to become loosened or completely removed. Positive and neutral displacement connectors can be clamped after syringe disconnection to enhance patient safety.

5. Chernecky, Macklin et al. Oncology Nursing 101. Caring for Patients with Cancer. Nursing-Knowledge of IV Connectors. December 2009.
Care of a neutral connector does not require a clamping sequence, so the nurse should simply clamp when not is use for patient safety.

6. Intensive Care Collaborative. Nursing Care of Central Venous Catheters in Adult Intensive Care. 2008
The use of CVCs is common in intensive care; however, there are occasions where a CVC lumen or section of a multiflow adapter may not be in use. This can create opportunities for problems to develop such as: 1) air embolism if disconnection occurs; 2) reflux of blood that can contribute to blockage of the lumen and 3) admixture or reflux of intravenous fluids. For these reasons, it is important that the clamps on the not-in-use CVC lumens and multiflow adaptors are used.

7. Textbook: IV Therapy Made Incredibly Easy. Lippincott Williams & Williams. 2016.
After flushing, engage the clamping mechanism on the central line.

8. Hadaway L. Post from February 16, 2010. http://-therapy.net.
Catheter clamping is a critical component of patient safety. Vascular air emboli happen far too easily, and one of the frequent times is when the tubing or needleless connector becomes loosened from the catheter hub. A clamped catheter will protect against air getting into the line. Remember air emboli can cause devastating effect on your patient and the treatment, which could mean a nursing home for the rest of their life, which is not reimbursed to the hospital. Needleless connectors (NC) can be clamped, but it depends upon the function of the NC as to when it is clamped. Negative displacement NC should be clamped before syringe disconnection. Positive displacement NC should be clamped after syringe disconnection.

Section 6. Infectious Disease Consultation
1. Impact of Infectious Disease Consultation on Quality of Care, Mortality, and Length of Stay in Staphylococcus aureus Bacteremia: Results from a Large Multicenter Cohort Study. CID 2015;60 (15 May); 1451. PMID 25701854
Inpatient ID consultation lead to an absolute mortality risk reduction of 8% with better adherence to quality measures and earlier discharge in patients with Staph aureus bacteremia.

2. Impact of Routine Infectious Diseases Service Consultation on Evaluation, Management, and Outcomes of Staphylococcus aureus Bacteremia. CID.2008:46 (1 April) 1000. PMID 18444816
A policy of routine consultation with an infectious diseases consultant lead to improved core quality measures and also to less frequent microbiological failure, recurrent bacteremia, late metastatic infection and death.

3. Mandatory Infectious Diseases Approval of Outpatient Parenteral Antimicrobial Therapy (OPAT): Clinical and Economic Outcomes of Averted Cases. J Antimicrobial Chemotherapy 2014; 69:1695-1700. PMID 24532684
There is concern about the overuse of OPAT. ID consultants can provide alternative approaches to completion of antibiotic therapy. 56 patients were denied OPAT during the study and were discharged with either oral or no additional antibiotics. Overall cost saving was $3847 per patient.

Section 7. Controlled-Substance Agreements with IVDU Patients
1. Breaking the Pain Contract: A Better Controlled-Substance Agree for Patient on Chronic Opioid Therapy. Cleve Clin J Med. 2016 Nov;83(11):827-835. doi: 10.3949/ccjm.83a.15172. PMID 27824537
Pain contracts remain controversial and can stigmatize patients or create barriers between patients and providers. Controlled-substance agreements should be used only in the context of personalized patient counseling, compassionate care and shard decision-making. This same approach should be taken to the management of IVDU patients who require PICC or central lines. The implementation of a Controlled-Substance PICC Line Agreement can be an opportunity for discussion with the patient about realistic treatment parameters, the risk of illicit use of the central line, and the potential consequences when illicit use of the line is identified.