Journal of Addiction Medicine最新文献

Background: The contamination of non-opioid drugs with fentanyl presents a risk at US music festivals, where environmental factors exacerbate overdose-related risks. Naloxone is an opioid antagonist medication that can be used by festival attendees to reverse opioid overdose.

Methods: We conducted a field survey at a 4-day Colorado music festival (N=227) to characterize attendees' prior experience with naloxone and to investigate whether attendees carry naloxone with them in both festival and non-festival settings. We also assessed attendees' level of confidence in responding to an overdose with naloxone and asked attendees to report any barriers they experienced to carrying naloxone at festivals.

Results: Prevalence of carrying naloxone in any context was 55.5% (N=126). Festival carriage was more common than carriage in non-festival settings, with 55.1% reporting at least "sometimes" carrying at festivals compared with 32.7% outside festival settings. In addition, 8.4% had used naloxone to respond to an overdose, and 4.4% had personally been administered naloxone. Among participants who reported carrying naloxone, 65.3% had never received training. Regarding confidence in overdose response, 29.9% of naloxone carriers reported being only "slightly confident" or "not at all confident." Barriers included access, festival restrictions and legal concerns, lack of education, training, and awareness, convenience factors, and perceived responsibility of carrying naloxone.

Conclusions: Findings highlight the need for increased naloxone access, training, and awareness among festival attendees. Actionable recommendations include free or low-cost naloxone distribution, on-site training, and transparent entry policies to reduce barriers and promote overdose response as a community responsibility.

Buprenorphine is a prescribed controlled substance that effectively treats opioid use disorder. Fear of federal prosecution contributes to buprenorphine's under-prescribing. Such fears may be heightened in jurisdictions that follow a "disjunctive standard" of prosecution under the federal Controlled Substances Act (CSA). In jurisdictions with a "disjunctive standard," clinicians can be prosecuted for either (a) lack of a legitimate medical practice (eg, to improve the health of the patient) or (b) deviating from the "usual" course of professional practice. Problematically, the disjunctive standard could allow for the prosecution of clinicians even when no harm results and the clinician's deviation from usual practice was intended to improve the patient's health. This Commentary argues that the "conjunctive standard" is more approrpiate than the "disjunctive standard" for prosecution under the CSA. The conjunctive standard would require prosecutors to additionally prove the clinician lacked a legitimate medical purpose when prescribing. Therefore, federal prosecutors could focus on truly bad actors-those who clearly lack a legitimate medical purpose, such as those prescribing merely for profit to patients without health conditions that would benefit from the prescription. Ultimately, by decreasing fears of prosecution, a conjunctive standard might contribute to an increased buprenorphine treatment supply during the ongoing overdose crisis.

Methamphetamine has potent stimulant effects on the central nervous system, resulting in significant behavioral and autonomic changes. There is substantial literature on the behavioral and cardiovascular complications of methamphetamine use, but literature on the gastrointestinal complications of methamphetamine use is very sparse. Search of the published literature in English-language journals has not revealed any case of colonic perforation attributable to methamphetamine use. Here, we report a case of perforation of the sigmoid colon in the setting of chronic rectal administration of methamphetamine. A written informed consent to publish this case report was obtained from the patient.

Methadone is a highly effective medication for opioid use disorder (OUD) but has a risk of QT prolongation and life-threatening arrhythmias. This case report presents a patient with OUD on methadone treatment who experienced syncopal episodes due to recurrent episodes of polymorphic ventricular tachycardia (PMVT). Due to the effectiveness of methadone and prior lack of response to alternative treatments, including buprenorphine, rather than methadone dose-reduction, the patient ultimately received an extravascular implantable cardioverter defibrillator (ICD) for prevention of out-of-hospital arrest. This case highlights an important clinical dilemma in balancing the risks of procedures and arrhythmias with improved OUD-related outcomes with methadone. In this report, we review the literature and advocate for consideration of ICD placement in select, high-risk patients with methadone-related QT prolongation or arrhythmias.

Objectives: Disparities in urine toxicology screening (UTS) during labor and delivery may perpetuate healthcare inequities with significant social and legal consequences for minoritized populations. This study examines whether UTS rates during labor and delivery differ by race or ethnicity.

Methods: A retrospective cross-sectional study was conducted using electronic health record data of labor and delivery admissions between July 1, 2018 and June 30, 2022 from 3 health systems in Minnesota and Wisconsin. Eligible records included labor and delivery admissions for patients aged 12 years and older, resulting in live birth or fetal demise. Patients who opted out of research at the health system level were excluded.

Results: Among 71,341 patients (81,999 admissions), most identified as White (66.2%), followed by Black/African American (14.8%), Asian (9.5%), multiracial (2.5%), American Indian or Alaskan Native (0.7%), and other races (1.4%). Hispanic/Latinx patients comprised 6.1%. UTS was ordered in 14.2% of admissions (n=10,176). Compared with White patients, UTS was more likely for Black (aOR=2.09, 95% CI=1.93-2.25), American Indian (aOR=2.50, 95% CI=2.00-3.13), and multiracial patients (aOR=2.04, 95% CI=1.77-2.36), despite similar positive test rates across groups when excluding cannabis/THC.

Conclusions: Racial disparities in UTS persist, driven by nonclinical factors and biases, despite similar rates of substance use across groups. Standardized, equitable testing protocols are needed to mitigate harm and improve outcomes for minoritized birthing populations.

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.