Journal of Addiction Medicine最新文献

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.

Objectives: Treatment for opioid use disorder (OUD) is constrained by financial and geographic barriers. Community-based approaches may help address these challenges, yet evidence regarding their sustained impact on treatment retention and quality of life (QOL) remains limited. This study evaluated treatment retention and QOL outcomes in a community-based care coordination program for OUD.

Methods: We conducted a retrospective cohort study of participants enrolled in the Houston Emergency Opioid Engagement System (HEROES), a community-based treatment program in the Texas Medical Center. From January 1, 2020, through December 31, 2024, 1124 participants received individualized treatment plans, including medical visits, counseling, peer support, and group services. The primary outcome was treatment retention at 90 days. As a secondary descriptive measure, mean days retained within a 180-day observation window were compared across service utilization categories using analysis of variance. Additional secondary outcomes included substance use reoccurrence, overdose, and mortality.

Results: Participants were 57.7% male with a mean age of 34.9 years (SD, 9.76); 62.8% were uninsured, and 63.6% had a prior overdose. At 90 days, 74.1% of participants remained in treatment. Mean days retained differed significantly across service utilization categories, with greater engagement associated with longer retention. Nearly 71% of participants reported improvements in QOL, with a mean increase of 13.2 points.

Conclusions: In this 5-year retrospective cohort study, greater participation in a community-based care coordination program for OUD was associated with improved treatment retention and quality of life. Strategies that increase patient engagement through counseling and peer support may improve outcomes.

Objectives: Kratom ( Mitragyna speciosa ) is a psychoactive herbal product increasingly used for pain, anxiety, and opioid withdrawal. Although marketed as a natural dietary product, concerns have emerged regarding adverse effects like cardiotoxicity, seizures, opioid-like physical dependence, and, particularly, liver toxicity.

Methods: We conducted a systematic review following PRISMA 2020 guidelines of all studies on kratom use and liver toxicity.

Results: Thirty-one studies were included, comprising 32 cases of kratom-associated liver injury. Most reports originated from the United States and were single-patient case reports. Most patients were adult males, with frequent co-occurrence of polysubstance use and comorbid conditions. Concomitant exposures were commonly reported but variably characterized across studies. Baseline liver disease was present in 3 patients (9%). Kratom dose, form, frequency, and duration were inconsistently reported. Only 7 cases (22%) provided complete exposure details, whereas the remainder lacked one or more elements. Kratom use was temporally associated with the onset of liver injury, commonly presenting with jaundice and elevations in liver enzymes. The patterns of injury were predominantly cholestatic. In most cases, liver enzymes and function improved after cessation of kratom use. In 4 cases, the patient's liver function did not improve and progressed to liver transplantation. Although formal causality assessments were inconsistently reported, many reports supported an association based on exclusion of alternative etiologies and, in some cases, rechallenge episodes.

Conclusions: Further research is needed to better characterize kratom's mechanisms of liver injury and to inform clinical decision-making and public health policy.

Objectives: Peripartum opioid use disorder (OUD) is a significant public health concern. Although hospital admission for labor and delivery is common, little is known about hospitalized peripartum individuals with OUD or their inpatient management. The purpose of this study was to characterize hospitalized peripartum individuals with OUD who were seen by an OUD consult service and to examine their inpatient OUD treatment.

Methods: This was a retrospective cohort study of peripartum individuals who received an OUD consult from May 2020 to April 2022. All individuals were pregnant or up to 3 months postpartum at admission. Substance use and psychosocial history were collected, along with timing and acceptance of medication for opioid use disorder (MOUD) and details of discharge transitions.

Results: Of the 23 peripartum individuals with OUD who received a consult during admission, 61% were white, 30% were black, and all were non-Hispanic. Most individuals (78%) had Medicaid. Only 30% were using MOUD at hospital admission. Two-thirds (63%) of those not using MOUD were started on treatment during hospitalization, most commonly with buprenorphine-naloxone. At discharge, most (74%) individuals were connected to outpatient OUD treatment. Of the total, 35% self-directed their discharge, and there was a higher proportion of self-directed discharges among those who did not receive inpatient MOUD compared with those who did ( P < 0.01).

Conclusions: Hospitalization during the peripartum period is an important opportunity for initiation of MOUD and linkage to longitudinal, community OUD services. Further understanding of factors contributing to high rates of self-directed discharge in the peripartum period is needed.

Objectives: Social support is associated with myriad health benefits, including recovery from alcohol use disorder (AUD). Understanding its neural features may aid in intervention development. However, most neuroimaging studies investigating social support do not consider potential neuroanatomical differences related to sex and AUD, even though both factors have been related to social support. This study investigated neuroanatomical correlates of perceived emotional and instrumental support as a function of sex and lifetime AUD using Human Connectome Project data.

Methods: T1-weighted magnetic resonance imaging data were collected. Gray-matter volume in brain regions associated with social support was quantified in a large sample of young adults (522 women and 432 men) who did and did not have a lifetime AUD status. Perceived emotional and instrumental support were determined via self-report scales. Relationships between gray-matter volumes and perceived emotional/instrumental support were determined for each demographic category (women/men, lifetime AUD/no-AUD) via interaction analyses.

Results: Gray-matter volumes in 2 brain regions (left rostral anterior cingulate cortex and left lateral orbitofrontal cortex) were inversely associated with perceived emotional support in women with lifetime AUD, such that larger gray-matter volume was associated with lower perceived emotional support. This relationship was not observed in women without lifetime AUD or men with or without lifetime AUD. No associations were observed with instrumental support.

Conclusions: Women differ from men in brain-behavior relationships involving perceived emotional support in a manner linked to AUD status. Sex differences warrant further investigation as social support in AUD may operate differently in women and men.