Journal of Addiction Medicine最新文献

Objectives: Despite rising adolescent opioid overdose deaths, adolescents under the age of 18 years are frequently excluded from the provision of medication for opioid use disorder (MOUD/OUD). As part of preimplementation work to inform the expansion of evidence-based practices to close this service gap, we designed this qualitative study to examine the perspectives of MOUD-providing clinicians on barriers and facilitators to providing MOUD for adolescents younger than 18.

Methods: We recruited clinicians who reported prescribing MOUD at least once per month, purposively sampling to include individuals who varied on training and practice backgrounds, experience prescribing to adolescents younger than 18, and practice settings (urban, suburban, and rural). We performed semistructured interviews and subsequent qualitative thematic analysis of transcripts.

Results: Three major barriers emerged: (1) the overcomplicated, intimidating nature of MOUD training and regulations, (2) poor understanding of MOUD treatment recommendations and consent/confidentiality laws for adolescents younger than 18, and (3) negative, stigmatizing views of adolescents with substance use disorders and the perceived difficulty of treating them. Facilitators identified included: (1) treatment demystification with adolescent-specific OUD implementation protocols/training, (2) clinician-to-clinician peer messaging and encouragement, and (3) formal family and community-level education medicalizing addiction.

Conclusions: Significant barriers to prescribing MOUD to adolescents younger than 18 persist despite the removal of federal training requirements. Comprehensive, multilevel adolescent-specific MOUD education paired with may expand the MOUD-prescribing workforce and improve treatment access. Further research should continue to explore these themes to inform policy and practice reforms aimed at improving outcomes for adolescents affected by OUD.

Objectives: To assess patients' demographic factors associated with declination of recommended American Society of Addiction Medicine (ASAM) Continuum levels of care and analyze patients' self-reported reasons for declination.

Methods: This cross-sectional observational study examined data collected during clinical care delivery in a safety net health system's primary care setting for patients receiving medication treatment and recovery support services for opioid and/or alcohol use disorder (OUD, AUD). We evaluated intake assessments to identify recommended levels of care, acceptance or declination of the recommendation, and self-reported reasons for declination. We stratified the acceptance data by demographic factors and analyzed reasons for declination to identify themes.

Results: Of 1399 completed intakes, 42% declined all ASAM levels of care as a complement to medication and within-clinic recovery support services. Patients who identified as non-White, male, and/or 60 years or older were significantly more likely to decline all levels of care. Among the 125 patients who provided a documented reason for declining, 26% endorsed work, financial, or family obligations; 26% indicated a preference for alternative forms of psychosocial support; and 14% indicated possible interest in the future.

Conclusions: It is important for substance use disorder treatment providers and policymakers to understand the barriers patients face regarding engagement in treatment and reasons for the declination of services. Recognizing variations in care acceptance by demographic factors can help us understand common barriers and guide future directions to address health inequities.

Objectives: CAM2038 weekly and monthly extended-release buprenorphine (BPN) formulations are effective for treating opioid use disorder (OUD). Little is known about the effect of dose on patient outcomes, particularly under blinded and flexible dosing conditions. We evaluated the number of dose changes and the impact of (1) dose on treatment outcomes and (2) baseline primary opioid use (heroin vs prescription opioids) and route of use (injection or not) on the dose.

Methods: This was a post hoc analysis of an outpatient randomized double-blind, double-dummy trial comparing weekly (first 12 wk) and monthly (second 12 wk) CAM2038 to SL-BPN (24 wk) for OUD treatment. Dosing was flexible and guided by clinical response. Maximum doses were 32 mg weekly/160 mg monthly CAM2038 and 24 mg/32 mg SL-BPN in the first and second 12 weeks, respectively. Effect of each dose was evaluated using four outcomes: urine drug test (UDT) opioid results, Clinical Opiate Withdrawal Scale scores, Subjective Opiate Withdrawal Scale scores, and need- and desire-to-use opioid visual analogue scales. Associations between baseline route of use and primary opioid used and study dose were investigated.

Results: After titration to 16 mg SL-BPN/24 mg weekly CAM2038, most participants had 0-1 dose adjustments in both first and second 12 weeks. All doses were utilized. Number of adjustments was not associated with retention. Withdrawal, craving, and opioid-positive UDTs decreased for all CAM2038 and SL-BPN doses. There were few clinically significant associations between dose and primary opioid used/route of use.

Conclusions: Results support current practice guidelines, emphasizing the importance of individualized dosing based on patient response.

This narrative review examines the evolving landscape of online drug markets, focusing on darknet markets for illegal drugs and their implications for addiction medicine. We provide an overview of the development and current state of these markets, highlighting key features of their operation and the demographics of users. Finally, we address the implications for addiction medicine clinicians, including the need for adapted prevention efforts, new approaches to intervention and relapse prevention, and the potential for leveraging digital platforms in treatment. This review aims to equip addiction medicine professionals with the knowledge needed to navigate the challenges posed by online drug markets and to enhance their ability to provide effective care in this changing environment.

Objectives: We explored sustainability of confidence in key skills related to opioid use disorder (OUD) care and barriers and facilitators of prescribing buprenorphine among residents who had completed buprenorphine training during medical school.

Methods: Medical students who took an elective buprenorphine training course before graduation were surveyed immediately following the training ("baseline") and again 1 year later. Baseline surveys included demographics and confidence with key skills in OUD care. Follow-up surveys re-assessed confidence with key skills and additionally included waiver status, history of prescribing buprenorphine, and residency climate toward buprenorphine. Focus group interviews explored barriers and facilitators of prescribing buprenorphine.

Results: Sixty-one students participated in the training and completed the baseline survey. Seventy-two percent of trainees completed the follow-up survey; of these, 36% had obtained a waiver and just over half of those had used it to prescribe buprenorphine. In unadjusted analyses comparing 1-year follow-up results to the baseline survey, smaller percentages of learners reported strong confidence in screening for and diagnosing OUD (23% vs 46%, P=0.004), counseling patients with OUD regarding treatment options (11% vs 44%, P<0.001), and prescribing buprenorphine to treat a patient with OUD (11% vs 33%, P<0.001). Qualitative results suggested that learners experienced both bureaucratic and environmental barriers to prescribing buprenorphine.

Conclusions: Removal of the waiver requirement addresses only some barriers to buprenorphine prescribing among medical trainees. Residency climate and clinical systems conducive to prescribing buprenorphine will be necessary to sustain confidence managing OUD and increase buprenorphine prescribing during residency.

Buprenorphine is a partial opioid agonist effective for the treatment of opioid use disorder. However, precipitated opioid withdrawal remains a barrier to its initiation. As opioid use disorder and related complications continue at alarming rates, it is crucial to evaluate alternative means of initiating this lifesaving medication whenever patients interact with the health care system. In this case report, we discuss a patient who completed low-dose buprenorphine initiation while intubated and sedated in an intensive care setting, in the setting of recent chart documentation of a desire to initiate buprenorphine. Upon extubation, the patient elected to continue buprenorphine. We discuss potential advantages, ethical considerations, and patient perspectives related to initiating buprenorphine in this manner.

Objectives: To characterize patterns of outpatient buprenorphine induction and examine factors associated with the use of low-dose initiation (LDI).

Methods: A retrospective cohort study of 4510 adults initiating buprenorphine between January 1, 2016 and December 31, 2019 in British Columbia (BC), Canada, was undertaken using linked administrative data in the Provincial Overdose Cohort, which contains a 20% random sample of BC residents. Using multivariable modelling, we examined the association between sociodemographic, co-morbidity, treatment, and health service utilization variables, and the outcome of LDI. Joinpoint analysis was also conducted to assess inflection points in the prevalence of this practice.

Results: Overall, 7.2% of included buprenorphine inductions during the study period were classified as LDI. Joinpoint analysis revealed that the percentage of buprenorphine inductions classified as LDI increased significantly beginning in the fourth quarter of 2017. In multivariable analyses, factors positively associated with LDI included: older age (adjusted odds ratio [aOR]: 1.01, 95% CI: 1.00-1.02), living in Vancouver Coastal (aOR: 1.53, 95% CI: 1.13-2.06) and Fraser Health Authority regions (aOR: 2.56, 95% CI: 1.89-3.48) (vs interior region); having been prescribed slow-release oral morphine for opioid use disorder in the last 3 years (aOR: 4.03, 95% CI: 2.51-6.49), and having 1 (aOR: 2.40, 95% CI: 1.80-3.20) or ≥2 (vs 0) opioid agonist treatment episodes in the last 5 years (aOR: 2.56, 95% CI: 1.89-3.48). Factors negatively associated with microinduction included: male sex (aOR: 0.50, 95% CI:0.41-0.61), alcohol use disorder (aOR: 0.62, 95% CI: 0.40-0.96), injection drug use (aOR: 0.75, 95% CI: 0.61-0.94) and past-year incarceration (aOR: 0.19, 95% CI: 0.10-0.33).

Conclusions: The use of LDI has increased in BC in recent years. Markers of treatment experience were positively associated with receipt of LDI. A ssessment of outcomes associated with LDI is needed.

Background: Methadone, a mu-opioid receptor agonist, is one of 3 FDA-approved medications for opioid use disorder (OUD). Acute liver dysfunction can impair hepatic metabolism and increase sedation risk. Methadone can induce QT prolongation, which increases the risk of Torsades de Pointes, more commonly in patients on doses higher than 100 mg. Options for managing methadone-related QT prolongation include lowering the methadone dose or switching to buprenorphine, a partial mu-opioid agonist also FDA-approved for OUD. Precipitated withdrawal poses a challenge when transitioning from methadone to buprenorphine, and acute impaired hepatic metabolism of methadone contributes to uncertainty about how long clinicians must wait before initiating full-dose buprenorphine. Limited guidance exists on this transition.

Case summary: We report the case of a 37-year-old man with hepatitis C, alcohol use disorder, and OUD in long-term remission on methadone 210 mg daily who was transferred to a quaternary care center for liver transplant evaluation due to acute liver failure. On presentation, an EKG showed a QTc of 785 milliseconds prompting discontinuation of methadone. Oxycodone 10 mg every 6 hours as needed was started, with nearly full amelioration of withdrawal symptoms. Eleven days after the last methadone dose, and 12 hours after the last oxycodone dose, buprenorphine 8 mg SL was administered, and the patient experienced severe precipitated withdrawal.

Discussion: This case report highlights the challenge of estimating methadone half-life in a patient with severe acute liver dysfunction who needs to switch from methadone to buprenorphine. A buprenorphine low-dose induction strategy may reduce the risk and severity of precipitated withdrawal.

Emergency clinicians frequently care for patients with complications from underlying opioid use disorder. While many clinicians are comfortable addressing the immediate medical complications of opioid use disorder, too many do not offer evidence-based medications that stabilize the patient by alleviating withdrawal and cravings, and that also treat opioid use disorder, the underlying cause of the presentation. Because medication for opioid use disorder, namely methadone and buprenorphine, reduces the risk of death by up to 50%, this omission at a critical touchpoint in the health care system misses an opportunity to engage people in care and reduce fatal overdose. It also exposes the emergency department and health care facility to potential legal liability. Under federal civil rights laws, it is illegal to discriminate against people with opioid use disorder; discrimination may include failure to screen for and diagnose opioid use disorder and offer medications for opioid use disorder alongside a facilitated referral for outpatient treatment. Advocates for a more effective emergency department response to opioid use disorder can use these civil rights laws to press for the adoption of evidence-based practices for people with opioid use disorder. Legal advocacy is an important tool to utilize during this unrelenting overdose crisis.