Journal of Addiction Medicine最新文献

The increased availability of fentanyl in the United States over the past decade extends to women of reproductive age, raising concern about maternal and fetal risks when used in pregnancy. A 2023 case series of 10 infants exposed to fentanyl in utero proposed a "fetal fentanyl syndrome" (FFS), characterized by distinctive craniofacial features, limb anomalies, and genitourinary defects. However, as with any case series, concerns about selective case ascertainment, uncontrolled confounding, imprecise timing of exposure, phenotype heterogeneity, and lack of a denominator preclude causal inference or risk quantification. Two new studies in this issue-Mirsky et al and Dorsey et al-had the opportunity to quantify the risk in prospective cohorts of patients with substance use disorder. However, they leave key questions unresolved. Mirsky et al identify 4 additional infants with craniofacial anomalies and prenatal fentanyl exposure, but their analysis remains effectively a case series. Dorsey et al use a case-control analysis and report a modestly elevated odds of FFS-compatible anomalies with fentanyl exposure, but broad exposure windows, limited phenotype specificity, and lack of adjustment for confounding limit interpretability. Further studies are needed to clarify to what extent prenatal fentanyl exposure contributes to specific patterns of congenital structural anomalies.

Objectives: To investigate if previously described anomalies associated with fentanyl could be identified in our cohort of individuals with active fentanyl use in pregnancy.

Methods: Potential cases of a novel syndrome were identified from a prospectively collected database of obstetric patients with substance use disorder enrolled in a multispecialty treatment program from 2014 to 2024 in this case series study. Suspected Fetal Fentanyl Syndrome (FFS) was defined as small head circumference (<10%ile) and at least one other sign: cleft palate, clubfoot, rocker bottom feet, toe syndactyly, single palmar crease, hypoplastic corpus callosum, and hypospadias. The database was screened for findings consistent with this syndrome resembling Smith-Lemli-Opitz Syndrome.

Results: From 2014 to 2024, 639 patients were enrolled in the cohort. Of the 103 patients found to have neonates with a small head circumference, 51 individuals self-reported fentanyl use within the last year. Six of these individuals had confirmatory toxicology testing for fentanyl upon program enrollment. Of these individuals' neonates, 4 displayed characteristic anomalies consistent with FFS. All cases shared lagging head growth, while additional anomalies identified included cleft palate (n=3), short nasal tip (n=1), thin upper lip (n=1), micrognathia (n=1), and hypospadias (n=1). Genetic screening/diagnostic testing varied but an assessment of cholesterol metabolism was not performed.

Conclusions: In this cohort, 7.8% of individuals with self-reported fentanyl use had neonates with signs of the previously described FFS. FFS is a proposed syndrome and results should be interpreted with caution. Similar data is needed to confirm and delineate this association and determine long-term developmental effects.

Objectives: Illness severity may influence the relationship between opioid use disorder (OUD) and adverse outcomes, yet factors affecting severity are not fully understood. The objective of this study is to examine sociodemographic and hospital-related factors associated with severity among OUD-related hospitalizations.

Methods: We used data from the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) from 2015 to 2022. The HCUP NIS includes severity measures that assign patients overall severity of illness (SOI) and risk of mortality (ROM) subclasses (ie, minor, moderate, major, and extreme) based on their secondary diagnoses and other clinical characteristics (eg, age, procedures). Partial proportional odds models were used to measure the association between sociodemographic/clinical factors and SOI/ROM subclass severity among OUD-related hospitalizations.

Results: SOI shifted toward more severe subclasses in 2019-2022 and ROM in 2015-2022 (higher share major/extreme). Medicare and self-pay, compared with private insurance, were associated with higher odds (adjusted odds ratio [aOR] [95% CI]) of extreme SOI (vs. minor, moderate, or major) (Medicare: 1.07 [1.05, 1.09]; self-pay: 1.08 [1.05, 1.11]). Rural hospitals, compared with urban ones, had lower odds of higher SOI severity (aOR 0.80 [0.77, 0.82]). Results were similar for ROM. Age, sex, race, income, region, hospital size, admission timing, and admission type were also significantly associated with SOI/ROM.

Conclusions: Structural/systematic factors play a role in shaping the course of inpatient OUD. These findings highlight the need to strengthen hospital addiction care capacity, address insurance and income-related inequities, and develop targeted inpatient risk stratification strategies to improve outcomes for patients with OUD.

Objectives: People who inject drugs (PWID) face elevated risks of hospitalizations and readmissions due to serious injection-related infections, yet few evidence-based interventions exist to prevent readmissions. This study aimed to explore factors contributing to rehospitalization among PWID, potential strategies, and assess the acceptability of 2 proposed interventions and implementation considerations.

Methods: We conducted 22 semistructured interviews with 36 health care providers and staff across 4 study sites in Georgia, Maryland, the District of Columbia, and West Virginia from June 2023 to September 2023. Participants were purposively sampled to represent diverse roles in providing or overseeing care to PWID. Interviews explored barriers to care, challenges contributing to rehospitalization, and perceptions of 2 proposed interventions: (1) integrated care for addiction and infectious diseases, and (2) patient navigation to support linkage to care postdischarge. Data were analyzed using rapid qualitative analysis informed by framework and thematic approaches.

Results: Three main themes emerged regarding rehospitalization factors (unaddressed structural, health system, and social determinants; gaps in addiction care training; and continuity of care). Participants expressed high acceptability toward the proposed interventions. Three main themes emerged as recommendations for the implementation of the proposed interventions (organizational needs and capacity; leveraging existing resources; patient engagement and retention).

Conclusions: Reducing readmissions among PWID requires addressing provider training gaps, care fragmentation, and structural barriers. Both proposed interventions were deemed acceptable by health care team members. Key implementation factors include strengthening organizational capacity, leveraging existing resources effectively, and using person-centered approaches to build trust and maintain patient engagement and retention.

Since 2000, the suicide rate from opioid overdoses has more than doubled, and the number of self-reported intentional opioid overdoses is likely undercounted. This commentary discusses how a sensitive and validated assessment is crucially needed to identify those at risk for intentional opioid overdose. Developing this, however, requires an understanding of the affective, cognitive, and behavioral factors that uniquely contribute to this phenomenon. These include higher prevalences of psychiatric diagnoses and pain in the opioid use disorder (OUD) population; a deleterious negative emotional state that occurs with chronic opioid use; and risky opioid-use patterns worsened by the introduction of fentanyl into the illicit opioid supply that give individuals with OUD easy access to lethal means for dying by suicide. Although there is an urgent need to identify intentional opioid overdose risk, previous research has shown that validated screening tools for suicide risk, which ask about previous suicide attempts, may not detect all those at risk for intentional opioid overdose. This may be because the intent preceding opioid overdoses is ambiguous, making it challenging for individuals with OUD to identify these as suicide attempts. Because validated screening tools for suicide risk are insufficient for detecting intentional opioid overdose risk, a screening tool developed specifically for this purpose using validated psychometric methods is necessary to identify and intervene in the morbidity and mortality associated with intentional opioid overdose.

Objectives: Buprenorphine is a partial opioid agonist used in the treatment of opioid use disorder. Dosing of buprenorphine is determined clinically, with peripartum adjustments often indicated due to physiological and psychosocial changes in pregnancy and the postpartum period. We sought to describe these postpartum dose changes, how adjustments varied across demographics, and their association with treatment retention.

Methods: This is a retrospective, descriptive analysis of antenatal buprenorphine initiations at one academic institution over 2 years. The primary outcome of interest was the difference in buprenorphine dose at 3 months postpartum compared with the delivery dose.

Results: Sixty-six individuals were included in this study. The majority (36/66; 55%) had no change in buprenorphine dose between delivery and 3 months postpartum. One-third of patients had their dose increased postpartum, with a minority of individuals (8/66; 12%) reducing their dose postpartum. Individuals who were incarcerated at the time of delivery were more likely to experience a dose reduction (P = 0.045). There was no significant difference in treatment retention at 1 year postpartum between the groups.

Conclusions: Our data suggest heterogeneity in the management of buprenorphine dosing in the postpartum period. The vast majority (58/66; 88%) of patients either increased or maintained their total daily dose between delivery and 3 months postpartum. These results underscore the importance of an individualized approach to postpartum buprenorphine, factoring in delivery dose, biopsychosocial factors, and risk of return to use and overdose. Future qualitative work is needed to explore the dynamic patient and provider priorities at play in this decision-making.

Despite a recent decline in overdose deaths, the United States continues to have the highest global overdose mortality rate. Polysubstance use-taking opioids along with other drugs-has been increasingly recognized as a key contributor to preventable overdose cases. We propose that psychotropic polypharmacy, or the co-use of multiple psychiatric medications, is emerging as a related but distinct and underappreciated issue that is crucial for continued progress in slowing the pace of the overdose epidemic. This commentary aims to center psychotropic polypharmacy in the overdose prevention conversation, given its high rates in the United States and an increasing prevalence of psychiatric prescription medications implicated in overdose deaths. We present evidence for multiple mechanisms through which psychotropic polypharmacy increases overdose risk, including drug-drug interactions, lethal means access in cases of suicidality, and desensitization to overdose-related behaviors. We also propose several potential solutions to address this public health crisis, including discontinuing inappropriate and unnecessary medications, broadening access to evidence-based nonpharmacological prevention strategies for persons at risk for overdose, and improving overdose monitoring and surveillance.

Objectives: This study assesses treatment initiation and retention among South Carolina Medicaid enrollees newly diagnosed with opioid use disorder in 2021, situating these outcomes within the broader opioid treatment cascade of care. We examine how patient characteristics and community context shape progression through the stages of the cascade.

Methods: Using South Carolina Medicaid claims data for 464,493 enrollees aged 18-64 in 2021, we identify 2930 individuals newly diagnosed with OUD and examine initiation and 90-day retention in psychosocial and medication treatment. Generalized estimating equation models were used to estimate associations between treatment outcomes and sociodemographic and area-of-residence characteristics.

Results: Among newly diagnosed individuals, 34.6% initiated psychosocial treatment and 49.6% initiated medication treatment; 27.0% and 55.0%, respectively, were retained for at least 90 days. Non-Hispanic black enrollees had lower odds of initiating psychosocial (AOR = 0.72; 95% CI = 0.54-0.96) and medication treatment (AOR = 0.51; 95% CI = 0.44-0.58) compared with non-Hispanic white enrollees. Age differences were pronounced: enrollees aged 25-34 were more likely to initiate psychosocial treatment (AOR = 1.16; 95% CI = 1.00-1.35), while those aged 35-44 were more likely to initiate and retain medication treatment. Associations between treatment outcomes and county-level factors were not significant.

Conclusions: Rates of OUD treatment initiation and retention among South Carolina Medicaid enrollees remain low, with pronounced demographic variations. Findings highlight the need for targeted interventions to improve access and engagement in treatment.

Objectives: This study evaluated ReSET-O, a mobile app derived from the previously studied, computer-based therapeutic education system (TES), delivering cognitive behavioral therapy (CBT) lessons plus contingency management, rewarding CBT lesson completion and drug-negative urines, as an intervention to improve medication retention for opioid use disorder (MOUD).

Methods: A 24-week randomized controlled trial was conducted in an outpatient opioid treatment program where patients starting methadone or buprenorphine treatment were randomized to treatment as usual (TAU) or TAU plus the app. The primary outcome, medication retention, was defined as at most a 28-day gap in the first 24 weeks of medication dispensation or prescription. Secondary outcomes examined urine drug tests, mood assessments, app engagement, and app feedback. Fifty-two participants were randomized to TAU (29 on buprenorphine, 23 on methadone) and 48 (28 on buprenorphine, 20 on methadone) to TAU+ the app.

Results: 51.9% (n=27) on TAU met 24-week MOUD medication retention, compared with 70.8% (n=34) on TAU + the app (OR: 2.28; 95% CI: [0.99, 5.24]); P=0.053; Rate difference: 18.9% (95% CI: [0.2, 37.6]). No significant differences resulted between groups in urine toxicology or mood outcomes. Adherence to the app varied, with over half of participants (53%, 25/48) completing <10 out of 48 CBT therapy lessons.

Conclusions: ReSET-O had no significant impact on MOUD retention. The study did not meet its recruitment target, was underpowered, and adherence to the app was poor. Further research is indicated on apps delivering CBT plus contingency management for improving MOUD outcomes, including improving adherence to app use.

Objectives: In 2022, the FDA issued a drug safety communication based on case studies that transmucosal buprenorphine, a medication for opioid use disorder (MOUD), may contribute to dental disease. We sought to assess longitudinal dental care utilization patterns among patients with opioid use disorder (OUD) in the 18 months before and 36 months after MOUD initiation.

Methods: Using data from the Veterans Affairs Corporate Data Warehouse (2003-2020), we created a cohort of patients coded for OUD and prescribed MOUD. Outcomes included preventive and therapeutic dental visits and oral infections within 18 months before and up to 36 months after index MOUD. We used unadjusted Poisson models to estimate incidence per 1000 patients by MOUD. We performed analyses with and without interval censoring for edentulism, death, or a 60-day gap in MOUD.

Results: Among 49,675 eligible patients, 21,551 received methadone, 17,759 transmucosal buprenorphine, 8993 oral naltrexone, and 1372 injectable naltrexone. Median (IQR) days on treatment varied by drug: methadone 95 (52, 257), buprenorphine 309 (102, 968), oral naltrexone 49 (30, 101), injectable naltrexone 28 (28, 85). We observed an immediate increase in dental visits from a baseline range of 135-144 visits/1000/6-month period to 223-686 visits/1000/6-month period after initiating any MOUD. Patterns were similar by MOUD agent and formulation. Results were similar in analyses with and without interval censoring.

Conclusions: Both preventive and therapeutic dental utilization increased immediately following initiation with MOUD. Future observational studies of the effects of MOUD on adverse dental outcomes should account for confounding due to health-seeking behavior.