Journal of Addiction Medicine最新文献

Objectives: Buprenorphine may be offered less frequently than indicated for treatment of opioid withdrawal in the emergency department (ED) due to patient and clinician concerns regarding precipitated withdrawal (PW). Our objective is to determine an accurate estimate of the incidence of PW following buprenorphine initiation in the ED.

Methods: We performed a retrospective study of adults seen in one of the 15 EDs within the University of Maryland Medical System who received ED-initiated buprenorphine between January 1, 2019 and December 31, 2023. Patients were excluded if they were given buprenorphine to continue an established treatment regimen, had buprenorphine ordered by an inpatient clinician, or did not have a Clinical Opiate Withdrawal Scale (COWS) score recorded before treatment. PW was defined as either a ≥5-point increase in COWS score within 4 hours of buprenorphine administration or any increase in the COWS score associated with additional opioid administration within 4 hours of the first buprenorphine dose.

Results: A total of 1229 patients received buprenorphine in the ED during the study period; 990 were excluded. We identified 16 cases of PW [6.7% (95% CI: 3.5%-9.9%)]. No association was found between the development of PW and initial COWS, buprenorphine formulation, fentanyl use, or buprenorphine dose.

Conclusions: PW was uncommon following ED-initiated buprenorphine in this cohort. However, the rate of PW was higher than reported in some prior studies. Patients should be counseled regarding the possibility of PW before treatment, and clinicians should be prepared to address symptoms of PW when they occur.

Objectives: Pregnant and postpartum individuals' opioid overdose rates in the United States continue to rise, despite having safe and effective treatments in pregnancy and postpartum. This study examines the role of inpatient admissions to labor and delivery units for initiating or titrating medication for opioid use disorders (MOUD).

Methods: We conducted a retrospective review of all pregnant and postpartum (up to 1 y) patients admitted to a public safety-net hospital in San Francisco, for MOUD initiation or titration from 2019 to 2023. We excluded patients stable on MOUD.

Results: Among 124 individuals, 130 pregnancies met inclusion criteria. Ninety percent of individuals were unstably housed or homeless, and 78% had mental illness. The majority of patients (82%) initiated methadone and 18% initiated buprenorphine. The median admission length was 6 days. Patients were initiated or titrated on MOUD a median of 2 times during pregnancy/postpartum. Those with fentanyl OUD (defined as fentanyl being the primary opioid used) required longer admissions and higher MOUD doses compared with non-fentanyl OUD, and were more likely to initiate methadone over buprenorphine. The majority of patients experienced child protective services (CPS) involvement (79%), remained united as a parent-infant dyad at discharge (57%), and transitioned directly to residential treatment (63%).

Conclusions: In this study, admissions for opioid use complicating pregnancy increased among a diverse population with high rates of homelessness and mental illness. Inpatient labor and delivery units serve as critical access points for OUD treatment in the perinatal period, particularly for individuals facing structural barriers to care.

Objectives: Opioid use, both prescribed and illicit, has caused considerable harm and fatalities. This study aims at characterising patterns of emergency department (ED) presentations related to opioid abuse across Europe.

Methods: Data on demographics, clinical features, and epidemiology were extracted from the Euro-DEN Plus data set for presentations involving acute opioid toxicity between October 2013 and December 2021.

Results: Of 62,545 presentations, 3888 (6.2%) involved prescription opioids, 11,252 (18.0%) illicit opioids, and 587 (0.9%) both. Heroin accounted for 99.8% of illicit opioid cases. The most commonly reported prescription opioids were methadone (51.3%), buprenorphine (13.9%), morphine (9.3%), fentanyl (6.8%), and tramadol (6.7%). Co-use of benzodiazepines and Z-drugs (35.6%) and pregabalin (6.6%) was significantly higher in prescription opioid cases compared with illicit (20.6% and 1.5%, respectively; P < 0.001). Mortality was greater with prescription opioids (1.2%) than illicit opioids (0.4%, P < 0.001).

Conclusions: Heroin remains the predominant opioid; though the relative contribution of prescription opioids varies significantly across centres and countries. Methadone and buprenorphine predominate among prescribed opioids, while fentanyl and oxycodone account for a small proportion, contrasting with North American patterns.

Objectives: Xylazine is a public health threat for individuals who use drugs. Data informing xylazine concentrations are hampered by a lack of point-of-care urinalysis testing. This study evaluated the performance of qualitative immunoassay strips designed for drug checking in identifying xylazine in urine samples.

Methods: The ability of 2 noncleared xylazine qualitative immunoassay test strips (W.H.P.M. Inc, 500 ng/mL and Rapid Response [BTNX Inc., 1000 ng/mL]), developed for use in drug-checking paradigms, to detect xylazine in urine samples of persons presenting for opioid use disorder treatment was evaluated. Samples were tested using each test strip twice, and consensus results were compared with results from quantitative LC-MS/MS analyses (5 ng/mL).

Results: Quantitative testing revealed 67% (71/106) samples tested positive for xylazine >5 ng/mL. Concentrations ranged between 5.3 and 30,900.50 ng/mL, 12 of which exceeded >500 ng/mL and 6 of which exceeded >1000 ng/mL. W.H.P.M. Inc. showed excellent sensitivity and specificity (92% and 94%, respectively) at the 500 ng/mL threshold but did not detect 63% of true positive samples (ie, those that tested positive in the quantitative testing >5 ng/mL). Rapid Response also had excellent sensitivity and specificity (100%, 100%, respectively) at the 1000 ng/mL threshold, but did not detect 74% of true positive samples.

Conclusions: Two immunoassay strips designed for drug checking showed strong sensitivity and specificity at their detection thresholds; however, most samples testing positive for xylazine were below those thresholds, resulting in most participants with true xylazine exposure not being accurately identified. Prospectively designed urine point-of-care strips are necessary to help inform the relationship between xylazine exposure and its related consequences.

Objectives: With emerging novel adulterants in the unregulated US drug supply, people who use drugs (PWUD) bear the downstream consequences of unpredictable effects and increased health risks. Xylazine, a veterinary sedative, is associated with severe sedation and chronic ulcerations. To better understand PWUD perspectives on xylazine adulteration, we interviewed individuals with xylazine-associated wounds in Pittsburgh, Pennsylvania.

Methods: From March to April 2024, we conducted semi-structured interviews with adult PWUD with at least 1 current or prior xylazine-associated wound and past-90-day xylazine exposure confirmed by urine toxicology or xylazine test strip. We thematically analyzed a subset of the data focused on xylazine experiences.

Results: Five major themes emerged from 20 interviews. First, PWUD recognition of xylazine developed only after experiencing its negative effects, including wounds. Second, xylazine was an unwanted adulterant with PWUD, citing its sedating effects and associated wounds as barriers to daily functioning. Third, xylazine wounds imposed significant physical, emotional, and social challenges. Fourth, PWUD found it challenging to avoid xylazine given the saturated supply and employ traditional harm reduction strategies such as transitioning routes of use. Lastly, PWUD felt unable to stop using the xylazine-adulterated opioid supply due to worsening withdrawal symptoms, uncontrolled pain from xylazine wounds, and difficulty with initiating and continuing medications for opioid use disorder.

Conclusions: Overall, PWUD with xylazine-associated wounds perceived xylazine as harmful and undesired, yet difficult to avoid, highlighting the urgent need for adaptive harm reduction strategies, accessible drug checking services, tailored clinical interventions, and supportive policies to promote a safer drug supply.

Objectives: To evaluate types of substance use disorder (SUD), recommended medications, and implementation of a new SUD eConsult offering asynchronous chart review and recommendations for primary care clinicians at an academic medical center. In addition, to understand contextual factors that affected program implementation, as identified by the Practical, Robust Implementation and Sustainability (PRISM) model.

Methods: A retrospective analysis of SUD eConsults between December 1, 2020 and September 30, 2024 was performed, using SUD eConsult orders and electronic medical record chart review. The PRISM model was applied to understand contextual factors affecting the implementation of the eConsult program.

Results: There were 103 completed SUD eConsults. The most common reasons for eConsult were alcohol use disorder (46.6%), followed by opioid use disorder (37.9%), tobacco use disorder (4.9%), stimulant use disorder (3.9%), cannabis use disorder (1.9%), and benzodiazepine use disorder (1.0%). In total, 65.1% of eConsults recommended new prescriptions. Recommended medications were prescribed for 58.2% of patients, and 82.1% of these patients continued the medications for the study period. Utilizing the PRISM model, key factors that facilitated the SUD eConsult program include an existing eConsult infrastructure, a team of specialists available to review eConsults, a low threshold substance use disorder treatment clinic, and incentive pay for completed eConsults. Factors that hindered program implementation include competing demands within primary care, clinician hesitancy to use eConsults for SUD, stigma related to SUD, difficulty advertising, and reliance upon internal incentive pay.

Conclusions: The SUD eConsult program extends addiction medicine expertise to and supports pharmacotherapy initiation by primary care providers.

Background: The rise of high-potency synthetic opioids such as fentanyl in the illicit opioid supply has contributed to increased overdose deaths and complicated methadone initiation for opioid use disorder (OUD). Traditional methadone initiation protocols may be insufficient in the context of fentanyl's high potency and pharmacokinetics. This systematic review evaluates current evidence on accelerated (≥60 mg within the first 7 d of treatment) methadone initiation strategies.

Methods: Following PRISMA guidelines, we conducted a comprehensive search of databases for studies from 2013 to June 16, 2025, reporting on methadone initiation in fentanyl-exposed patients. Key outcomes included patient selection, dosing, retention, and adverse events.

Results: Ten observational studies met the inclusion criteria, with 8 inpatient, 2 outpatient, and 2 studies focused on pregnant individuals. Studies selected for 18- to 65-year-olds without end-organ failure, QTc prolongation, or medications affecting methadone metabolism. The mean and median dose on day 1 ranged from 30 to 53.4 mg (pooled weighted mean=40.7 mg). By day 5, doses increased to 59.2-90 mg (pooled weighted mean=70.2 mg), and by day 7 to 65-100 mg (pooled weighted mean=81.9 mg). Patient-directed discharge occurred in 0%-31% of patients. Sedation occurred in 0%-28.6% of patients, while severe adverse events (requiring naloxone, ICU admission, intubation, or death) occurred in 1.08% of treatment episodes. The certainty of evidence was very low using a GRADE framework.

Conclusions: The current observational literature is limited, with some support for accelerated methadone initiation in inpatient and outpatient settings for appropriately selected patients exposed to fentanyl.

Objectives: This study examined changes in social media use among adults with past-year treatment for substance use disorder (SUD) in New England, focusing on the prevalence of such changes, reasons for modifying social media habits, perceived success, and factors associated with attempts to change social media use.

Methods: Participants [N = 255; 45% female, 85% white, mean age = 41.4 (9.6)] recently treated for SUD completed an online survey. The survey gathered demographics, SUD histories, and social media use data. We report descriptive statistics and logistic regression models testing relationships between attempts to change social media use while in treatment and individual factors.

Results: Overall, 62% of respondents reduced or stopped social media use during SUD treatment. A substantial minority (34%) viewed their attempts as unsuccessful or neutral. Logistic regressions indicated that having alcohol as one's drug of choice and having previously sought drugs on social media were both positively associated with attempting to reduce or quit social media. People who reported being motivated to avoid social media to reduce drug/alcohol triggers also reported being more successful in changing their social media use.

Conclusions: Many individuals in SUD treatment actively limit social media to reduce exposure to substance-related triggers, yet success varies. Future research should explore how digital environments might be reshaped to support treatment goals, balancing the risk of exposure to substance use content with the potential benefits of online resources.

Objective: We examined the association between alcohol consumption and mortality among people living with HIV (PWH).

Methods: We included individuals aged ≥18 years, enrolled between 2004 and 2022 in CoRIS, a Spanish multicenter cohort study of ART-naive PWH at enrolment. We calculated mortality rates per 100 persons-year (p-y) of follow-up, and used multivariable Cox models to estimate hazard ratio (HR) (95% confidence interval [CI]) for the association between alcohol consumption at enrolment and mortality after controlling for confounders (sex at birth, age, mode of HIV infection, education level, region of origin, HCV infection [EIA+], CD4 cell count and HIV-RNA load at enrolment).

Findings: We included 6087 participants (14% women); median age 36 years (interquartile range [IQR]: 29-45). Men who had sex with men were 63.2% of the participants, 27.9% were heterosexuals, and 4.9% were persons who inject drugs. Prevalence of HCV was 7.5%, median RNA-HIV load was 70,431 copies/mL (IQR: 16,982-261,000), and median CD4 count was 363 cells/mm3 (IQR: 196-547). Two hundred seventy participants (4.4%) reported alcohol consumption of ≥40 g/d. Over 31,171 p-y of follow-up, 240 participants (3.9%) died. The mortality rate among individuals who drank ≥40 g/d was 2.13 (95% CI: 1.56-2.93) per 100 p-y compared with 0.68 (95% CI: 0.60-0.79) per 100 p-y among those who drank <40 g/d. After adjustment, alcohol consumption of ≥40 g/d was associated with increased mortality (adjusted HR: 1.54 [95% CI: 1.06-3.42], P =0.02).

Conclusion: In this cohort of PWH, excessive alcohol use was associated with a higher risk of death.