Journal of Addiction Medicine最新文献

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.

Objectives: Unhealthy alcohol use, which includes alcohol use disorder (AUD), is common among cancer survivors and can lead to negative health outcomes. Prior research found that an AUD diagnosis is associated with hospital readmission up to 180 days after discharge among alcohol-related cancer survivors. This study investigates whether AUD diagnosis is associated with hospital readmission 30 and 90 days after discharge and in-hospital mortality.

Methods: We conducted a retrospective cohort study using the all-payer Nationwide Readmissions Database (NRD) from 2017 to 2020. We identified hospitalized adults with a history of alcohol-related cancer and stratified them by AUD diagnosis status. We applied 1:1 propensity score matching to balance measured demographic and clinical characteristics. We used logistic regression models to assess the association between AUD diagnosis and 30-day and 90-day readmission and mortality and Cox proportional hazards models to estimate time to readmission and mortality.

Results: Among 70,731 alcohol-related cancer survivors, 3067 (4.34%) had an AUD diagnosis. In the matched cohort (n=2916), AUD diagnosis was significantly associated with increased odds of 90-day readmission (odds ratio [OR], 1.150; 95% CI, 1.021-1.295) but was not significantly associated with 30-day readmission (OR, 1.102; 95% CI, 0.888-1.368) or mortality (OR, 1.102; 95% CI, 0.888-1.368).

Conclusions: Hospitalized cancer survivors with AUD are at a higher risk for 90-day readmission. Findings from this and prior studies underscore the need for targeted postdischarge interventions to reduce the risk of long-term readmission in this population.

Objectives: The accelerated development of additive pharmacotherapy treatment (ADAPT-2) for methamphetamine use disorder (MUD) trial demonstrated the efficacy of extended-release injectable naltrexone (NTX) and oral bupropion (BUP). In this secondary analysis, we determined whether craving and impulsivity levels could predict subsequent use of methamphetamine.

Methods: Participants (N = 357) of the ADAPT-2 trial with at least one transition point [transition from positive-to-negative urine drug screen (UDS) or vice versa] during stage 1 (baseline through week-6) were included in this secondary analysis. Craving was assessed using the Visual Analog Scale (VAS). Impulsivity was assessed using the 2-item impulsivity factor of the Concise Health Risk Tracking (CHRT) Scale.

Results: A significant treatment by craving by time interaction was noted ( P = 0.018), where higher craving levels were consistently associated with a lower likelihood positive-to-negative UDS transition at the next visit in both NTX-BUP and placebo groups. However, no such effect was present by week 6 of treatment in the placebo group. CHRT Impulsivity also had a significant effect on the probability of a positive-to-negative UDS transition ( P = 0.019) in addition to the 3-way interaction of VAS, week, and treatment group. Individuals with lower craving levels but higher impulsivity exhibited a lower probability of transitioning to negative UDS at the next visit. Higher craving, but not impulsivity, was associated with a higher likelihood of negative-to-positive UDS transition at the next visit in both treatment groups.

Conclusions: Further investigations are necessary to optimize NTX-BUP treatment, focusing on the impact of craving and impulsivity on outcomes.

Objectives: The addiction field lacks consensus terminology for individuals who utilize multiple treatments but do not enter remission. This scoping review evaluates how this concept is defined across the literature.

Methods: A comprehensive search was conducted on September 16, 2024, by a medical librarian. Included articles presented new data in adult substance-using populations described as treatment-resistant or treatment-refractory. Articles were excluded if they lacked a clear definition, if the population assessed was dual diagnosis-focused, or if individuals did not want to engage in care (ie, resisting).

Results: In total, 1834 and 379 articles were reviewed at the abstract and full-text levels, respectively, with 39 meeting inclusion criteria. Treatment-resistant (n=23) and treatment-refractory (n=11) were the most used terms. Alcohol (n=10) and opioid (n=27) use cohorts were most commonly assessed. Six studies occurred in deep brain stimulation cohorts. Themes of severity of use, treatment history with ongoing use, and psychosocial or functional impairments overlapped definitions; however, they varied widely in specificity. The most comprehensive definitions incorporated thresholds for amount/frequency consumed, duration of addiction or age of onset, number of treatment encounters, treatment duration, and a pharmacological treatment trial.

Conclusions: The lack of a consistent definition for continued treatment nonresponse poses challenges for research and clinical care. The use of "treatment-refractory" over "treatment-resistant" may better align with person-first language, emphasizing the multifaceted nature of addiction rather than implying something about the individual. An agreed-upon definition may improve the identification of this resource-intensive and at-risk population, guiding the development of tailored interventions that better address their treatment needs.

Objectives: The United States is in an overdose crisis, with many Americans seeking emergency medical services for drug overdose. Patients who leave against medical advice (AMA) have higher risk of subsequent health complications and hospital readmission. This cross-sectional study uses electronic health records (EHRs) to identify insurance-related risk factors for leaving AMA among patients hospitalized for opioid overdose.

Methods: Documented opioid overdose hospitalizations between June 2019 and November 2021 were identified using ICD-10 codes from EHR at a large Midwest academic hospital. Multivariate logistic regression was used to identify risk factors associated with leaving AMA. Opioid overdose hospitalizations were aggregated by patient, and bivariate analyses (χ 2 ​​​​​, ANOVA) and logistic regression were used to test for associations between demographics and repeat hospitalization.

Results: Among 3608 hospitalizations, 2985 unique patients were admitted. Compared with Medicare, patients with all other specified insurance types were more likely to leave AMA: self-pay 294% more (aOR = 3.94; 95% CI = 1.83-10.34), Medicaid 299% more (aOR = 3.99; 95% CI = 1.78-10.72), and commercial 402% more (aOR = 5.02; 95% CI = 1.88-14.94). Risk factors for repeat hospitalization included black race (aOR = 1.61, 95% CI = 1.26,2.07), and young age (aOR = 0.99, 95% CI = 0.98, 0.99), while female sex was associated with decreased odds (aOR = 0.73, 95% CI = 0.57, 0.92).

Conclusions: Insurance may be associated with AMA discharge after opioid overdose. Tailored interventions addressing patients' financial concerns after hospitalization may increase access to care and reduce inequities.

Introduction: Samidorphan is an opioid receptor antagonist and naltrexone analogue that has been harnessed in unique ways. Samidorphan has been paired with olanzapine in the new oral agent Lybalvi, approved by the FDA in 2021 for the treatment of schizophrenia and bipolar I disorder. The addition of samidorphan to olanzapine has the intention of reducing olanzapine's metabolic side effects (ie, weight gain), however, samidorphan's antagonism of the mu opioid receptor can lead to complications in patients with opioid use disorder on agonist therapy. These complications include not just precipitated withdrawal, as explored in prior case studies, but also the risk of reduced opioid tolerance and overdose in the event of olanzapine/samidorphan (Lybalvi) discontinuation and concurrent opioid use.

Case report: A 42-year-old female with a history of opioid use disorder, posttraumatic stress disorder (PTSD), and bipolar disorder presented to an opioid treatment program for buprenorphine/naloxone (BUP/NX) continuation. On presentation, she was being treated with a combination of olanzapine/samidorphan (Lybalvi) for bipolar disorder and 18 mg/d of transmucosal BUP/NX for opioid use disorder. Due to concern for interaction between buprenorphine and samidorphan, she was gradually tapered to a lower dose of buprenorphine to allow for discontinuation of olanzapine/samidorphan then titrated to an effective buprenorphine dose for long-term treatment.

Discussion: This case report outlines the safety concerns of utilizing an opioid antagonist (samidorphan) in conjunction with an opioid partial agonist (buprenorphine) and demonstrates the process for safe transition to an alternative regimen.

Care models for professionals with substance use disorder (SUD), such as those for physicians, attorneys, military personnel and commercial pilots, currently do not have a standard method to determine whether to allow medication for addiction treatment (MAT) in profession-specific treatment plans. The decision to endorse the use of MAT involves a tradeoff between maximizing SUD relapse prevention and minimizing MAT-related adverse effects that might impact safety. We propose a decision analysis process to facilitate an objective and evidence-based use of MAT in these circumstances. Already implemented in high-reliability sectors such as aviation, decision tree analysis of quantifiable hazards and mitigating variables can be used to calculate an evidence-based risk for the number of bad outcomes with one alternative versus another. Greater data transparency from and increased resource availability to professional care models are necessary to conduct and disseminate these analyses.