The opioid crisis is still a big issue with no end in sight.
Kory London, associate professor of emergency medicine at Thomas Jefferson University in Philadelphia, explores a new method for treating those afflicted.
Dr. London is an emergency and addiction physician who practices in Center City and South Philadelphia. He is the co-director of the Jefferson Addiction Multidisciplinary Service, part of the philanthropic effort of the Stephen and Sandra Sheller Consult and Bridge Program, and has spent nearly ten years designing and implementing hospital-based interventions to help people who use drugs. His work includes efforts to find novel withdrawal treatments for patients who are suffering from non-medical opioid withdrawal, dispensing harm reduction materials such as reversal kits, drug checking equipment and syringe service from the hospitals and increasing access to hospital-based peer, or certified recovery specialists. These are trained counsellors themselves in long term recovery, who act as experiential interpreters helping patients cope with the stresses of being hospitalized while engaging them on the process of recovery. His work has been the subject of multi-million dollar grants from the City of Philadelphia, NIH and other funding sources. He strongly believes that everyone deserves a healing environment when they need to be in the hospital and that reducing the stigma of substance use, while confirming it’s place as a medical disorder, are vital pieces to solving the opioid crisis.
Opioid Withdrawal in the Era of Fentanyl
Heroin is no longer heroin. As incoherent as this sounds, in many communities, heroin has been replaced by synthetic opioids, such as fentanyl, which do not require poppy plants or opium to produce, and other contaminants, such as the veterinary sedative xylazine. The latter was added to increase the duration of the fentanyl’s effects, but the totality of the change has waylaid our ability to care for patients with opioid use disorder.
The combination of the two, colloquially known as ‘tranq dope’, has wrought a series of obstacles that makes it significantly harder for patients to stop using. Fentanyl is being used in amounts that are unfathomably large. Xylazine adds the twin challenges of skin ulceration and sedative withdrawal. Well studied, bedrock interventions we used for years to manage opioid withdrawal, like starting life-saving buprenorphine, became ineffective, or worse. Precipitated withdrawal, where providing Buprenorphine paradoxically worsens withdrawal symptoms, poisoned the reputation of a medication that has been repeatedly shown to save lives.
Our team tried a different approach. In our research, we paired short acting opioids — pain medications — with a low dose of buprenorphine; this combination effectively prevented precipitated withdrawal. Our doses come nowhere close to meeting the amount of opioids some are using, nor address the xylazine they are also exposed to, so we use a host of adjunctive medications to take advantage of the concepts of synergism and potentiation to provide a healing care environment. Our treatment pathways were associated with improved withdrawal severity scores, and also may reduce the risk of patient directed discharge, or leaving prematurely against the advice of their doctors, which is universally associated with worse outcomes. While this is only one small piece of the puzzle, reducing the suffering and fear patients face coming to the hospital is something everyone can get behind.
Read More:
[WHYY PBS] – New research from Philly ER doctors shows the ‘excruciating’ effect of xylazine withdrawal, and how to manage it
[The Conversation] – Philly hospitals test new strategy for ‘tranq dope’ withdrawal – and it keeps patients from walking out before their treatment is done
[ALiEM] – Tranq dope (fentanyl-xylazine combination): A new horizon in opioid withdrawal treatment
[ScienceDirect] – Tranq Dope: Characterization of an ED cohort treated with a novel opioid withdrawal protocol in the era of fentanyl/xylazine
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