Journal of Addiction Medicine最新文献

Objectives: To evaluate infection management in people who inject drugs (PWID) who elect for self-directed discharge (SDD) and to identify characteristics associated with an oral antimicrobial therapy offer (OATO).

Methods: This was a retrospective cohort of hospitalized adult PWID with an injection drug use (IDU)-related infection who elected for SDD between January 1, 2014, to January 31, 2024, at a five-hospital health system in southeast Michigan. Patients were excluded if they were hospitalized for <24 hours or if antimicrobial treatment was completed before SDD. The primary outcome was the proportion of patients with an OATO at or before SDD. Secondary outcomes at 30 days included retreatment, infection-related readmission, and all-cause mortality.

Results: One hundred fifty patients were included; 55 (37%) received an OATO, 95 (63%) did not receive an offer. Patient outcomes were not different between the OATO and no offer groups: infection retreatment 19 (34%) versus 32 (34%); infection-related readmission 14 (25%) versus 31 (33%); and all-cause mortality 1 (2%) versus 3 (3%). In multivariable logistic regression, variables independently associated with OATO included prescribing/continuing medications for opioid use disorder (MOUD) (adjusted odds ratio [aOR], 2.8; 95% CI: 1.36-5.92), infection source control (aOR, 2.3; 95% CI: 1.10-4.84), and early-career clinician care (aOR, 2.8; 95% CI: 1.01-7.89).

Conclusions: Most hospitalized PWID with IDU-related infections with SDD did not receive an OATO. Early career clinicians more commonly offered oral antimicrobials in PWID with less complicated infection types. Standardizing OATO in PWID at risk for SDD should be considered as a future direction to improve health outcomes.

Postpartum depression is a serious, but treatable condition experienced after childbirth. While most cases do not involve excess substance use, alcohol and other substance use have been strongly associated with this condition. While serotonergic antidepressants have been a mainstay of pharmacologic therapy for postpartum depression, studies of antidepressant use in postpartum depression have largely excluded those with substance use disorder, and meta-analyses suggest antidepressants offer limited benefit in those with depression and co-occurring substance use disorder. There is also under-appreciated literature demonstrating the potential for a medication-mediated increase in substance use in some individuals taking serotonergic antidepressants. These facts and an examination of guideline recommendations on the treatment for postpartum depression highlight the need for new research and practice improvements for patients with comorbid substance use disorder and postpartum depression.

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.

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.

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.

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.

With the expansion of the "medical cannabis" or "medical marijuana" market, there is significant confusion surrounding cannabinoid terminology. This commentary provides definitions for cannabinoid terminology, examines US Food and Drug Administration (FDA)-approved and non-FDA-approved medications with cannabinoids as the main ingredient, and discusses how vague terminology may lead to a public misperception regarding the lack of evidence-based medical indications for cannabis.

Objectives: The objective of the study was to conduct a systematic review of the available literature on non-medical use of mephentermine, including its pattern of use, associated complications, and treatment approaches.

Methods: We conducted a systematic search across PubMed, Scopus, EMBASE, Web of Science, and EBSCO, to identify studies reporting non-medical mephentermine use. Two independent reviewers screened the studies, and methodological quality was assessed using the Joanna Briggs Institute tools. Extracted data included demographics, use patterns, psychiatric and physical complications, cooccurring substance use, and treatment approaches.

Results: Of 695 retrieved studies, 23 full-text studies met inclusion criteria (4 case series, 19 case reports, 30 cases). The majority (n = 28, 93.3%) were from India, all male (age: 19-39 y, mean = 27.9). Most used mephentermine for performance enhancement (63%), primarily through intravenous injection (77.8%). Psychiatric comorbidities were reported in 60%, with psychosis (43.3%) being the most common. Cooccurring substance use (40%) included alcohol, tobacco, and anabolic steroids. Treatment was largely symptomatic, with antipsychotics and benzodiazepines being most frequently prescribed.

Conclusions: Non-medical mephentermine use appears to be rising, particularly among athletes and bodybuilders, with notable psychiatric complications. Targeted education and clinical awareness are needed. Further research should explore addiction potential, long-term effects, and treatment strategies.

Objectives: People with childbearing potential and opioid use disorder (OUD) have high rates of unintended pregnancies. Addiction medicine providers occupy an important role in diagnosing and counseling those who become pregnant; however, no guidelines exist to facilitate these conversations. We sought to explore participant experiences with pregnancy options counseling while in opioid use disorder treatment clinics.

Methods: We conducted semistructured interviews with people who became pregnant while in OUD treatment, regardless of pregnancy outcome. The interview domains included (1) interactions with health care upon pregnancy discovery, (2) pregnancy options counseling provision, and (3) factors affecting pregnancy decision. A codebook was formulated through an iterative process using a P3 framework (practice, provider, patient). All interviews were double-coded and analyzed for content and themes.

Results: Eighteen participants completed interviews between December 2022 and April 2023. Participants reported valuing nonjudgmental communication when providers disclose unexpected pregnancy results, as well as the need for unbiased and trustworthy information regarding the impact of OUD and OUD treatment on their options. They also identified the unique stigma and bias experienced by pregnant people with OUD.

Conclusions: Although no guidelines exist to guide pregnancy options counseling in addiction medicine settings, efforts should be made to integrate all pregnancy options counseling-parenting, adoption, and abortion-and/or referrals into the care of pregnant patients at OUD treatment centers. Effective discussions should be conducted in a nonbiased and nonjudgmental fashion. Our findings can be used to develop patient-centered counseling aimed at improving pregnancy decision-making while in treatment for OUD.

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.