Journal of Addiction Medicine最新文献

Background: Ketamine is a dissociative anesthetic increasingly utilized in United States medical settings for the treatment of mental health conditions. Additionally, it is increasingly used in nonmedical settings for its dissociative properties. While nonmedical ketamine use and ketamine use disorder (KUD) have been observed internationally, KUD, and approaches to its treatment, have not been previously described in the US.

Case presentation: We present the case of a 32-year-old man with KUD who experienced severe cravings despite receipt of residential and intensive outpatient substance use disorder treatment. He resumed use after an initial period of abstinence and was subsequently started on lamotrigine and naltrexone for treatment of depressive symptoms and cravings. This combination altered his experience while on ketamine, resulting in nausea and decreased hallucinogenic effects. In addition, it substantially decreased his cravings, aiding him in achieving longer-term abstinence in combination with receipt of dialectical behavioral therapy, familial support, and involvement in 12-step programming.

Discussion: KUD is a poorly described condition that may become more prevalent as US ketamine use increases. Combining treatment of depressive symptoms and cravings, in this case with lamotrigine and naltrexone, may be a promising pharmacotherapeutic strategy. Lamotrigine, an antiepileptic with glutamate modulating effects, has been utilized to decrease cravings in a variety of substance use disorders. Naltrexone is an opioid antagonist approved for alcohol use disorder and opioid use disorder and is used off-label for stimulant use disorder. This combination offers a possible pharmacotherapeutic option for KUD with more research needed to further evaluate.

Abstract: In recent years, there has been a marked surge in opioid overdose deaths among Black, Latino, and Native American populations. The emergency department (ED) represents a crucial opportunity to address these racial and ethnic inequities by initiating buprenorphine and providing referral for ongoing addiction treatment. Yet Black, Latino, and Native American populations encounter substantial inequities in ED-based addiction treatment access. Within this context, Koeber et al conducted their cross-sectional study of ED patients who screened positive for opioid misuse to evaluate inequities in buprenorphine administration. The authors found that Black ED patients were less likely (odds ratio, 0.56; 95% confidence interval, 0.35-0.88) to receive buprenorphine. There is an urgent need for mixed methods research to understand the drivers of these inequities and interventions to address the multilevel factors across the opioid use disorder care continuum to promote equitable, accessible, person-centered opioid use disorder treatment.

Objectives: The aim of this study was to identify distinct trajectories of prescription opioid exposure in pregnancy-encompassing both medication for opioid use disorder (MOUD) and opioid analgesics-and explore their associations with birth outcomes.

Methods: Trajectories were identified using latent class analysis among Wisconsin Medicaid-insured live births 2011-2019. Logistic regression estimated associations between these trajectories and neonatal opioid withdrawal syndrome (NOWS), small for gestational age, preterm birth, birth weight, and gestational age.

Results: Of 138,123 births, 27,293 (19.8%) had prenatal opioid exposure. Five trajectory classes were identified: (1) stable MOUD treatment (5.8%), (2) inconsistent MOUD treatment (3.9%), (3) chronic analgesic use (4.2%), (4) intermittent analgesic use (7.8%), and (5) low-level use of MOUD and analgesics (78.3%). NOWS incidence per 1000 infants was 667 for class 1 (adjusted odds ratio [aOR]: 21.74, 95% confidence interval [CI]: 17.89, 26.41), 570 for class 2 (aOR: 15.35, 95% CI: 12.49, 18.87), 235 for class 3 (aOR: 19.42, 95% CI: 15.93, 23.68), 67 for class 4 (aOR: 6.23, 95% CI: 4.99, 7.76), and 12 for class 5 (aOR: 1.73, 95% CI: 1.47, 2.02). Classes 1-4 had elevated risk of small for gestational age, preterm birth, lower birth weight, and shorter gestational age, with no significant differences among these classes. Among individuals with opioid use disorder, stable MOUD treatment was associated with higher birth weights and longer gestational ages compared to inconsistent treatment, despite higher odds of NOWS.

Conclusions: Early initiation and consistent MOUD treatment may improve birth weight and gestational age. For pregnant individuals with opioid use disorder using chronic analgesics, transition to MOUD may promote birth outcomes.

Objective: This analysis evaluated the validation results of the Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS) tool for older adults.

Methods: We performed a subgroup analysis of older adults aged ≥65 (n = 184) from the TAPS tool validation study conducted in 5 primary care clinics. We compared the interviewer and self-administered versions of the TAPS tool at a cutoff of ≥1 for identifying problem use with a reference standard measure, the modified World Mental Health Composite International Diagnostic Interview.

Results: The mean age was 70.6 ± 5.9 years, 52.7% were female, and 49.5% were non-Hispanic Black. For identifying problem use, the self-administered TAPS tool had sensitivity of 0.91 (95% CI: 0.75-0.98) and specificity of 0.91 (95% CI: 0.85-0.95) for tobacco; sensitivity of 0.68 (95% CI: 0.45-0.86) and specificity of 0.88 (95% CI: 0.82-0.93) for alcohol; and sensitivity 0.86 (95% CI: 0.42-1.00) and specificity 0.94 (95% CI: 0.90-0.97) for cannabis. The interviewer-administered TAPS tool had similar results. We were unable to evaluate its performance for identifying problem use of individual classes of drugs other than cannabis in this population due to small sample sizes.

Conclusions: While the TAPS had excellent sensitivity and specificity for identifying tobacco use among older adults, the results for other substances lack precision, and we were unable to evaluate its performance for prescription medications and individual illicit drugs in this sample. This analysis underlines the critical need to adapt and validate screening tools for unhealthy substance use, specifically for older populations who have unique risks.

Background: Alcohol-associated liver disease (ALD) is the most common indication for liver transplantation in the United States. Alcohol use disorder (AUD) treatment is recommended in all patients with ALD and AUD, but it remains underutilized.

Aims: To identify predictors of AUD treatment and to assess 30-day readmission, return to drinking, and 1-year transplant-free survival.

Methods: Retrospective single-center cohort study of consecutive patients hospitalized with ALD and AUD between 2018 and 2020. Patients who died or were lost to follow-up at 90 days after hospitalization were excluded. AUD treatment was defined as receiving medication or participating in residential, outpatient, or support groups within 90 days of discharge.

Results: One hundred nine patients were included. Mean age was 51.7 years, and 63% were male. Fifty-six (51%) patients received AUD treatment, and 23 (21%) patients received more than one treatment. Predictors of AUD treatment were younger age (OR, 1.07 [95% CI, 1.04-1.12]; P < 0.001), gastroenterology/hepatology consult (AOR, 8.54 [95% CI, 2.55-39.50]; P = 0.0002), addiction psychiatry consult (AOR, 2.77 [95% CI, 1.16-6.84]; P = 0.02), and a brief AUD intervention (AOR, 18.19 [95% CI, 3.36-339.07]; P = 0.0001). Cirrhosis decompensation, MELD-Na score, and insurance status were not associated with treatment. Thirty-one patients (28.4%) were readmitted, and 29 (26.6%) remained abstinent 30 days from discharge. Patients who received treatment had improved transplant-free survival (HR, 0.44, P = 0.04).

Conclusion: A brief intervention on AUD had the strongest association with receiving AUD treatment in our cohort. Further efforts to incorporate brief interventions when offering AUD treatment to patients with ALD may be beneficial.

Objectives: As carceral settings increasingly offer medications for opioid use disorders (MOUD), community-based providers will need to navigate relationships with correctional agencies to ensure continuity of MOUD upon release. Although collaboration has been identified as critical between agencies, limited research is available that details how providers can work with jails. We describe the perspectives of MOUD providers about their experiences collaborating with jails that had recently begun to offer MOUD.

Methods: We conducted hour-long interviews with 36 MOUD providers from 18 community-based agencies. Exploration, Preparation, Implementation, and Sustainment (EPIS) concepts informed data collection and analysis.

Results: MOUD providers described agency-specific (inner context) factors that facilitated collaboration, including staffing (employing staff with knowledge of co-occurring conditions) and agency culture (adaptability to change, recognition of gaps in services, being judgment-free). Providers also reported external factors as facilitators, such as broad community support of MOUD services and provision of training about MOUD to jail staff. Holding regular meetings, with a dedicated contact person, helped to overcome communication problems. However, the fragmentation of in-jail treatment services, exacerbated by jails' contracting with different healthcare providers, made it difficult to coordinate re-entry and establish agency relationships. Actively and intentionally building interagency partnerships and collaborating across interagency cultural and structural differences were bridging factors that developed and sustained collaborations.

Conclusions: Our findings offer promising suggestions for establishing collaborations with carceral partners, including assessing internal agency conditions, seeking external community supports, committing to actively engaging and sustaining collaborations, and using interagency differences to develop mutually beneficial relationships.

Introduction: Cannabinoid hyperemesis syndrome is characterized by recurrent episodes of severe nausea and vomiting, often associated with prolonged and excessive cannabis use. With the recent legalization and rising consumption of cannabidiol (CBD) in Europe and the United States, concerns have emerged about its potential role in triggering similar symptoms.

Case report: A 32-year-old male with a history of cannabis, tobacco and alcohol use disorder experienced multiple cyclic vomiting episodes after switching from cannabis to CBD. Initially, the patient presented with abdominal pain and vomiting after ceasing cannabis use, with symptoms alleviated by hot showers. Three months later, similar symptoms reappeared despite abstinence from cannabis but regular CBD consumption. Over the next 6 months, recurrent episodes of abdominal pain and vomiting persisted with daily CBD use but no cannabis consumption. Clinical data, laboratory results, and treatment responses were analyzed to investigate the connection between CBD consumption and symptom onset.

Discussion: The pathophysiology of cannabis-induced cyclic vomiting is poorly understood. Hypotheses include tetrahydrocannabinol accumulation in adipose tissue, pyrolytic conversion of CBD into tetrahydrocannabinol, and CBD's intrinsic effects, particularly its interaction with transient receptor potential vanilloid 1 receptors. Our analysis suggests that high doses of CBD may activate transient receptor potential vanilloid 1 receptors, inducing proemetic effects.

Conclusions: Although the connection between CBD and cyclic vomiting remains uncertain, it warrants further investigation. The increasing use of CBD, perceived as a safe dietary supplement, underscores the need to understand its potential health impacts better.

Aims: To compare a low-dosing protocol to standard practice for methadone-buprenorphine transfers.

Methods: We undertook a nonrandomized open-label clinical trial across 8 sites from NSW, Australia. Participants prescribed methadone wishing to transfer to buprenorphine could either choose or be randomized to a low-dose transfer or standard care transfer as per NSW health guidelines. The low-dose protocol started at 0.2 mg BD and increased to 16 mg on day 6, with flexible dosing thereafter. The primary outcome was continuation of buprenorphine 1 week post-transfer. Binary logistic regression was used to access the primary outcome with demographic differences between the groups included as covariates.

Results: There were 117 participants who commenced the study, 101 in the low-dose arm and 16 in standard care. Mean methadone dose was 82 mg in the low-dose arm and 46 mg in standard care. The primary outcome was met by 81 participants in the low-dose arm (80%) and 13 participants in standard care (81%). There was no significant between-arm difference in the odds of the primary outcome (OR = 2.22; 95% CI: 0.45-10.91; P = 0.327). Four participants (4%) in the low-dose arm experienced precipitated withdrawal against 1 (6%) in standard care. Higher methadone dose decreased the odds of successful transfer by 20% (OR = 0.8 per 10 mg methadone; 95% CI: 0.7-0.99; P = 0.04). Withdrawal scores between the 2 arms were similar.

Conclusions: We were unable to detect a difference between low dosing and standard care for methadone to buprenorphine transfers. Increasing methadone dose was a predictor of success; setting (ambulatory or inpatient) was not.

Objectives: Trauma screening is recommended for pregnant persons with opioid use disorder (OUD), but there is limited literature on screening results from buprenorphine treatment. This study's objectives were to 1) describe the types, and severity, of traumatic events reported and 2) evaluate the associations between trauma and health-related quality of life (HRQoL).

Methods: Baseline data from an ongoing trial were analyzed. Participants were 155 pregnant persons with OUD receiving, or enrolling in, buprenorphine treatment at one of 13 sites. The experience, and relative severity, of 14 high magnitude stressors were assessed with the trauma history screen. The Patient-Reported Outcomes Measurement Information System-29+2 was used to assess 8 HRQoL domains.

Results: Traumatic stressors were reported by 91% of the sample (n = 155), with 54.8% reporting a lifetime persisting posttraumatic distress (PPD) event and 29.7% reporting a childhood PPD event. The most prevalent lifetime PPD event was sudden death of a close family/friend (25.8%); physical abuse was the most prevalent childhood PPD event (10.3%). Participants with lifetime PPD, relative to no PPD, reported significantly greater pain interference ( P = 0.02). Participants with childhood PPD, relative to no PPD, had significantly worse HRQoL overall ( P = 0.01), and worse pain intensity ( P = 0.002), anxiety ( P = 0.003), depression ( P = 0.007), fatigue ( P = 0.002), and pain interference ( P < 0.001).

Conclusions: A majority of pregnant persons enrolled/enrolling in buprenorphine treatment reported persisting posttraumatic distress with sudden death of close family/friend being the most prevalent originating event; clinicians should consider the impact that the opioid-overdose epidemic may be having in increasing trauma exposure in patients with OUD.

Objectives: The COVID-19 pandemic led to increased substance-related morbidity and mortality and transformed care for opioid use disorder (OUD). We assessed the perceived impacts of the pandemic on substance use and related consequences among patients in office-based addiction treatment (OBAT).

Methods: We recruited patients with OUD on buprenorphine from July 2021 to July 2022, with data collection at baseline and 6 months. Exposures of interest were the following 6 domains potentially impacted by COVID-19: personal or family infection, difficulty accessing healthcare/medication, economic stressors, worsening physical or mental health, social isolation, and conflicts/disruptions in the home. Outcomes were past 30-day alcohol and other substance use, increased use, and substance-related consequences at baseline and 6 months. Generalized estimating equations Poisson regression models quantified associations between increasing impact domain scores and relative risks of each outcome.

Results: All participants (N = 150) reported at least one domain negatively impacted by COVID-19 at both time points. Higher "worsening physical or mental health" domain scores were associated with increased relative risk of recent alcohol or drug use (adjusted risk ratio [aRR] 1.04, 95% confidence interval [CI]: 1.01-1.07). Relative risks of experiencing substance-related consequences increased with higher scores in the domains of economic stressors (aRR 1.07, 95% CI: 1.02-1.13), difficulty accessing healthcare/medication (aRR 1.11, 95% CI: 1.04-1.19), and worsening physical or mental health (aRR 1.08, 95% CI: 1.04-1.12).

Conclusions: Among patients with OUD, stressors from COVID-19 were common. Three life domains impacted by COVID-19 appeared to be associated with consequential substance use, highlighting opportunities to address barriers to healthcare access and economic stressors.