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Expert Panel Consensus on the Effectiveness and Implementation of Models to Support Posthospitalization Care Transitions for People With Substance Use Disorders. 专家小组就支持药物使用失调患者住院后护理过渡模式的有效性和实施达成共识。
IF 4.2 3区 医学 Q1 SUBSTANCE ABUSE Pub Date : 2024-09-02 DOI: 10.1097/ADM.0000000000001369
Michael A Incze, Sophia Huebler, Kathryn Szczotka, Sean Grant, Stefan G Kertesz, Adam J Gordon

Objectives: Hospitals are increasingly offering treatment for substance use disorders (SUDs) during medical admissions. However, there is a lack of consensus on the best approach to facilitating a successful transition to long-term medical and SUD care after hospitalization. We aimed to establish a hierarchy of existing SUD care transition models in 2 categories-effectiveness and implementation-using an expert consensus approach.

Methods: We conducted a modified online Delphi study that convened 25 interdisciplinary clinicians with experience facilitating posthospitalization care transitions for patients with SUD. Panelists rated 10 prespecified posthospitalization care transition models according to 6 criteria concerning each model's anticipated effectiveness (eg, linkage to care, treatment retention) and implementation (eg, feasibility, acceptability). Ratings were made on a 9-point bidirectional scale. Group consensus was determined using the interpercentile range adjusted for symmetry.

Results: After 3 rounds of the Delphi process (96% retention across all 3 rounds), consensus was reached on all 60 rating criteria. Interdisciplinary addiction consult teams (ACTs) and in-reach from partnering outpatient clinics were rated highest for effectiveness. Interdisciplinary ACTs and bridge clinics were rated highest for implementation. Screening, brief intervention, and referral to treatment; protocol implementation; and postdischarge outreach received the lowest ratings overall. Feasibility of implementation was perceived as the largest challenge for all highly rated models.

Conclusions: An expert consensus approach including diverse clinician stakeholders found that interdisciplinary ACT, in-reach from partnering outpatient clinics, and bridge clinics had the greatest potential to enhance posthospitalization care transitions for patients with SUD when considering both perceived effectiveness and implementation.

目的:越来越多的医院在病人住院期间提供药物使用障碍 (SUD) 治疗。然而,对于促进住院后成功过渡到长期医疗和药物滥用治疗的最佳方法,目前还缺乏共识。我们的目标是采用专家共识法,将现有的 SUD 护理过渡模式分为有效性和实施性两个类别,并建立一个层次结构:我们开展了一项经过修改的在线德尔菲研究,召集了 25 名具有促进 SUD 患者住院后护理过渡经验的跨学科临床医生。专家组成员根据每种模式的预期效果(如与护理的联系、治疗的保持)和实施情况(如可行性、可接受性)等 6 项标准,对 10 种预先指定的入院后护理过渡模式进行评分。评分采用 9 分双向量表。根据对称性调整后的百分位间范围确定小组共识:经过三轮德尔菲程序(三轮程序的保留率均为 96%),就所有 60 项评分标准达成了共识。跨学科戒毒咨询小组(ACTs)和合作门诊诊所的内联有效性被评为最高。跨学科戒毒咨询小组和桥接诊所的实施率最高。筛查、简单干预和转诊治疗、协议实施和出院后外联的总体评分最低。在所有评分较高的模式中,实施的可行性被认为是最大的挑战:通过专家共识法(包括不同的临床医生利益相关者)发现,跨学科 ACT、合作门诊诊所的内联和桥梁诊所在加强 SUD 患者出院后的护理过渡方面具有最大的潜力,这要同时考虑到感知效果和实施情况。
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引用次数: 0
Drug Testing Interpretation in the Peripartum Setting: Results of Clinician Survey. 围产期药物检测的解释:临床医生调查结果。
IF 4.2 3区 医学 Q1 SUBSTANCE ABUSE Pub Date : 2024-09-01 Epub Date: 2024-06-05 DOI: 10.1097/ADM.0000000000001322
Theresa Kurtz, Elizabeth Charron, Julie Shakib, Marcela C Smid

Objectives: The objectives of this study were to (1) survey obstetrical and pediatric clinicians' experience, confidence, and training in maternal and neonatal drug testing interpretation; (2) determine their proficiency in drug test interpretation; and (3) assess predictors of correct interpretation.

Methods: We conducted a cross-sectional survey of clinicians caring for pregnant people or newborns at an urban academic center. We assessed clinicians' demographic characteristics, experience, confidence, and prior training in interpretation of maternal and newborn drug tests. We assessed proficiency in interpreting drug tests using 11 clinical vignettes and categorized scores as poor (0-2), fair (3-5), and good (≥6) performance to facilitate data interpretation. We used descriptive statistics to summarize responses. Multinomial logistic regression was used to determine associations of clinician characteristics and score category (reference category: poor performance).

Results: In total, 103 respondents completed the survey including 60 obstetrical clinicians (58.3%), 19 family medicine physicians (18.5%), 21 pediatric clinicians (20.4%), and 3 social workers (2.9%) (response rate, ~40%). The mean correct response was 4.1 (SD, 2.17; range, 0-11). Most respondent scores were fair (n = 47.6%), followed by good (n = 28.2%) and poor (n = 24.3%). Increased frequency, confidence, and training in interpreting maternal screening and confirmatory tests were associated with higher proficiency. Increased confidence and training in interpreting neonatal screening and confirmatory tests, but not frequency, were associated with higher proficiency.

Conclusions: Most clinicians demonstrated fair proficiency in interpreting drug tests. Predictors of proficiency were confidence and prior training for drug test interpretation, suggesting that educational interventions could improve proficiency.

目标:本研究的目的是:(1) 调查产科和儿科临床医生在解释孕产妇和新生儿药物检测方面的经验、信心和培训情况;(2) 确定他们解释药物检测的熟练程度;(3) 评估正确解释的预测因素:我们对一家城市学术中心负责孕妇或新生儿护理的临床医生进行了横断面调查。我们评估了临床医生的人口统计学特征、经验、信心以及在解释孕产妇和新生儿药物测试方面接受过的培训。我们使用 11 个临床小故事来评估解读药物测试的熟练程度,并将得分分为差(0-2 分)、一般(3-5 分)和好(≥6 分),以方便数据解读。我们使用描述性统计来总结回答。多项式逻辑回归用于确定临床医生特征与评分类别(参考类别:表现差)之间的关联:共有 103 名受访者完成了调查,其中包括 60 名产科临床医生(58.3%)、19 名家庭医生(18.5%)、21 名儿科临床医生(20.4%)和 3 名社会工作者(2.9%)(回复率约为 40%)。平均正确率为 4.1(标准差,2.17;范围,0-11)。大多数受访者的回答为 "一般"(47.6%),其次是 "好"(28.2%)和 "差"(24.3%)。解释孕产妇筛查和确诊试验的频率、信心和培训的增加与熟练程度的提高有关。在解释新生儿筛查和确证试验方面,信心和培训的增加与熟练程度的提高有关,但与频率无关:结论:大多数临床医生对药物检测的解释能力尚可。熟练程度的预测因素是信心和之前接受过的药物检测解读培训,这表明教育干预可以提高熟练程度。
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引用次数: 0
Machine Learning-Driven Analysis of Individualized Treatment Effects Comparing Buprenorphine and Naltrexone in Opioid Use Disorder Relapse Prevention. 机器学习驱动的个性化治疗效果分析,比较丁丙诺啡和纳曲酮在阿片类药物使用障碍复发预防中的作用。
IF 4.2 3区 医学 Q1 SUBSTANCE ABUSE Pub Date : 2024-09-01 Epub Date: 2024-05-22 DOI: 10.1097/ADM.0000000000001313
Majid Afshar, Emma J Graham Linck, Alexandra B Spicer, John Rotrosen, Elizabeth M Salisbury-Afshar, Pratik Sinha, Matthew W Semler, Matthew M Churpek

Objective: A trial comparing extended-release naltrexone and sublingual buprenorphine-naloxone demonstrated higher relapse rates in individuals randomized to extended-release naltrexone. The effectiveness of treatment might vary based on patient characteristics. We hypothesized that causal machine learning would identify individualized treatment effects for each medication.

Methods: This is a secondary analysis of a multicenter randomized trial that compared the effectiveness of extended-release naltrexone versus buprenorphine-naloxone for preventing relapse of opioid misuse. Three machine learning models were derived using all trial participants with 50% randomly selected for training (n = 285) and the remaining 50% for validation. Individualized treatment effect was measured by the Qini value and c-for-benefit, with the absence of relapse denoting treatment success. Patients were grouped into quartiles by predicted individualized treatment effect to examine differences in characteristics and the observed treatment effects.

Results: The best-performing model had a Qini value of 4.45 (95% confidence interval, 1.02-7.83) and a c-for-benefit of 0.63 (95% confidence interval, 0.53-0.68). The quartile most likely to benefit from buprenorphine-naloxone had a 35% absolute benefit from this treatment, and at study entry, they had a high median opioid withdrawal score ( P < 0.001), used cocaine on more days over the prior 30 days than other quartiles ( P < 0.001), and had highest proportions with alcohol and cocaine use disorder ( P ≤ 0.02). Quartile 4 individuals were predicted to be most likely to benefit from extended-release naltrexone, with the greatest proportion having heroin drug preference ( P = 0.02) and all experiencing homelessness ( P < 0.001).

Conclusions: Causal machine learning identified differing individualized treatment effects between medications based on characteristics associated with preventing relapse.

目的:一项比较缓释纳曲酮和舌下含服丁丙诺啡-纳洛酮的试验显示,随机接受缓释纳曲酮治疗的患者复发率更高。治疗效果可能因患者特征而异。我们假设因果机器学习可以识别每种药物的个性化治疗效果:这是一项多中心随机试验的二次分析,该试验比较了缓释纳曲酮与丁丙诺啡-纳洛酮在预防阿片类药物滥用复发方面的效果。利用所有试验参与者得出了三个机器学习模型,其中随机抽取 50%用于训练(n = 285),其余 50%用于验证。个体化治疗效果通过Qini值和c-for-benefit来衡量,无复发表示治疗成功。根据预测的个体化治疗效果将患者分为四等分,以检查特征和观察到的治疗效果之间的差异:表现最好的模型的 Qini 值为 4.45(95% 置信区间为 1.02-7.83),c-效益为 0.63(95% 置信区间为 0.53-0.68)。最有可能从丁丙诺啡-纳洛酮治疗中获益的四分位组的绝对获益率为 35%,在研究开始时,他们的阿片戒断评分中位数较高(P < 0.001),在过去 30 天内使用可卡因的天数多于其他四分位组(P < 0.001),酒精和可卡因使用障碍的比例最高(P ≤ 0.02)。预测第4四分位数的人最有可能从缓释纳曲酮中获益,其中有海洛因毒品偏好(P = 0.02)和无家可归经历(P < 0.001)的比例最高:因果机器学习根据与预防复发相关的特征确定了不同药物的个体化治疗效果。
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引用次数: 0
Treatment Failure Versus Failed Treatments: The Risks of Embracing Treatment Refractory Addiction. 治疗失败与治疗失败:接受难治性成瘾治疗的风险。
IF 4.2 3区 医学 Q1 SUBSTANCE ABUSE Pub Date : 2024-09-01 Epub Date: 2024-08-10 DOI: 10.1097/ADM.0000000000001351
David A Fiellin

Abstract: In this issue, Strain advocates for the field of addiction medicine to consider a new diagnostic signal-treatment-refractory addiction. Also in this issue, Nunes and McLellan support the concepts advanced by Strain. I provide an alternate view and propose that it is premature to create such a signal and that doing so could lead to unintended adverse consequences. My argument is based on 4 concerns: (1) the lack of neuroscientific correlates, (2) the profound impact that context has on what patients receive as "treatment," (3) the rare provision of sequentially stepped treatment, and (4) the potential for misuse of the signal. Addiction medicine should be cautious in introducing concepts such as treatment-refractory addiction to ensure that patients are not seen as "treatment failures." Our efforts should rather focus on the development of additional effective treatments, improving access to existing effective treatments and a creating a system that does not provide "failed treatments."

摘要:在本期杂志中,Strain 主张成瘾医学领域考虑一种新的诊断信号--治疗难治性成瘾。同样在本期中,Nunes 和 McLellan 支持 Strain 提出的概念。我提出了另一种观点,并认为现在设立这样一个信号还为时过早,而且这样做可能会导致意想不到的不良后果。我的论点基于以下四点:(1)缺乏神经科学相关性;(2)环境对患者所接受的 "治疗 "有着深远的影响;(3)很少提供有顺序的阶梯式治疗;(4)信号可能被滥用。成瘾医学在引入治疗难治性成瘾等概念时应谨慎从事,以确保患者不会被视为 "治疗失败者"。我们的工作重点应该是开发更多有效的治疗方法,改善现有有效治疗方法的可及性,并建立一个不提供 "失败治疗 "的系统。
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引用次数: 0
A Source Control Model for Treatment-Resistant Substance Use Disorder. 治疗耐药性药物使用障碍的源头控制模型。
IF 4.2 3区 医学 Q1 SUBSTANCE ABUSE Pub Date : 2024-09-01 Epub Date: 2024-07-15 DOI: 10.1097/ADM.0000000000001344
Matthew Robert Dernbach, Karen Drexler, Elizabeth McCord, Joseph E Carpenter

Abstract: We propose applying the "source control" model of infectious disease treatment to the management of treatment-resistant substance use disorder (SUD). We believe that this conceptual framework complements other models for understanding SUD, fills a gap in our current understanding of treatment-resistant SUD, and advances the destigmatization of SUD by reinforcing SUD as a disease similar to other medical conditions. The model also harmonizes the need for multimodal treatment and novel interventions for both acute supportive care and long-term treatment of SUD. In this manuscript, we discuss the justification for, as well as the strengths and limitations of, the "source control" model for the management of treatment-resistant SUD. We also discuss the model's potential to direct innovative research questions and therapeutic interventions.

摘要:我们建议将传染病治疗的 "源头控制 "模式应用于耐药性药物使用障碍(SUD)的管理。我们认为,这一概念框架补充了其他理解药物滥用障碍的模式,填补了我们目前对耐药药物滥用障碍理解的空白,并通过强化药物滥用障碍是一种与其他病症类似的疾病,推进了药物滥用障碍的去污名化。该模型还协调了急性支持性护理和长期治疗 SUD 对多模式治疗和新型干预措施的需求。在本手稿中,我们讨论了采用 "源头控制 "模式来管理耐药性药物依赖性障碍的理由、优势和局限性。我们还讨论了该模式在指导创新性研究问题和治疗干预措施方面的潜力。
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引用次数: 0
Early Surgical Excision of Necrotic Tissue Following Unintentional Dermal Injection of Extended-Release Buprenorphine. 皮肤意外注射缓释丁丙诺啡后坏死组织的早期手术切除。
IF 4.2 3区 医学 Q1 SUBSTANCE ABUSE Pub Date : 2024-09-01 Epub Date: 2024-06-11 DOI: 10.1097/ADM.0000000000001327
Carly Taylor, Vanessa Loukas, Jasmine Muwonge, Jessica L Taylor, Joseph Boyle

Introduction: Extended-release subcutaneous buprenorphine is an increasingly common treatment for opioid use disorder. Serious adverse events are rare and may be poorly understood. This report describes an early surgical intervention to address tissue necrosis resulting from misplaced subcutaneous buprenorphine injection. We review identifying characteristics that distinguish the necrotic reaction from other adverse effects of subcutaneous buprenorphine and offer guidance to continue treatment with subcutaneous buprenorphine.

Case report: A 33-year-old patient returned to clinic within an hour of his buprenorphine injection, reporting pain and skin changes unlike his previous injections. Non blanching erythema consistent with early necrosis was evident, and the patient was referred for surgical removal of his buprenorphine depot. The patient had uncomplicated healing of the surgical site and was provided sublingual buprenorphine before returning to continue treatment with subcutaneous buprenorphine.

Discussion: Although skin necrosis is known to be a rare complication of subcutaneous buprenorphine injection, early surgical excision to limit injury has not been described. Signs and symptoms of skin necrosis must be better understood to facilitate early intervention and continued treatment.

Conclusions: This case affirms that a patient may continue treatment with subcutaneous buprenorphine despite suffering skin necrosis and demonstrates the value of early surgical intervention after superficial placement of extended-release buprenorphine.

导言:皮下注射丁丙诺啡缓释剂是一种越来越常见的治疗阿片类药物使用障碍的方法。严重的不良事件非常罕见,而且可能很少为人所知。本报告介绍了一种早期外科干预方法,以解决因皮下注射丁丙诺啡位置错误而导致的组织坏死。我们回顾了将坏死反应与皮下注射丁丙诺啡的其他不良反应区分开来的识别特征,并为继续使用皮下注射丁丙诺啡治疗提供指导:一名 33 岁的患者在注射丁丙诺啡后一小时内返回诊所,报告说疼痛和皮肤变化与之前的注射不同。患者皮肤上出现了与早期坏死一致的不褪色红斑,医生建议其手术切除丁丙诺啡注射部位。患者手术部位的愈合并不复杂,在返回继续接受皮下注射丁丙诺啡治疗之前,患者接受了舌下注射丁丙诺啡治疗:讨论:虽然皮肤坏死是皮下注射丁丙诺啡的罕见并发症,但早期手术切除以限制损伤的情况尚未见报道。必须更好地了解皮肤坏死的体征和症状,以便及早干预和继续治疗:本病例证实了患者在皮肤坏死的情况下仍可继续使用皮下注射丁丙诺啡进行治疗,并证明了浅表注射缓释丁丙诺啡后早期手术干预的价值。
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引用次数: 0
Readmissions Among Patients With Surgically Managed Drug Use Associated-Infective Endocarditis Before and After the Implementation of an Addiction Consult Team: A Retrospective, Observational Analysis. 瘾癖咨询小组成立前后手术治疗的药物使用相关感染性心内膜炎患者的再住院情况:一项回顾性观察分析。
IF 4.2 3区 医学 Q1 SUBSTANCE ABUSE Pub Date : 2024-09-01 Epub Date: 2024-08-10 DOI: 10.1097/ADM.0000000000001368
Lucas X Marinacci, Audrey Li, Annie Tsay, Yoel Benarroch, Kevin P Hill, Adolf W Karchmer, Rishi K Wadhera, Katherine Kentoffio

Background: Patients who undergo cardiac surgery for drug use-associated infective endocarditis (DUA-IE) have high rates of readmissions for recurrent endocarditis, substance use disorder (SUD), and septicemia. Our primary objective was to assess whether exposure to an addiction consult team (ACT) was associated with reduced readmissions in this population.

Methods: This single-center retrospective analysis identified patients who underwent cardiac surgery for DUA-IE between 1/2012-9/2022 using the Society for Thoracic Surgeons database, and compared the cumulative incidence of readmissions at 1, 3, 6, and 12 months among those cared for before and after the implementation of an ACT in 9/2017, accounting for competing risk of mortality and adjusted for measured confounders using inverse probability of treatment weighting.

Results: The 58 patients (35 pre-ACT and 23 post-ACT) were young (36.4 +/- 7.7 years) and predominantly White (53.4%) and male (70.7%). The post-ACT cohort had a significantly lower risk of readmission at 1 month (adjusted risk difference [RD] -23.8% [95% CI -94.4%, -8.3%], P = 0.005) and 3 months (RD -34.1% [-55.1%, -13.1%], P = 0.005), but not at 6 or 12 months. In a sensitivity analysis, the post-ACT cohort also had significantly lower risk of readmissions for SUD complications at 3 months.

Discussion and conclusion: ACT exposure was associated with a lower risk of short-term readmission among patients with surgically managed DUA-IE, possibly due to a reduction in SUD-related complications. Additional studies are needed to replicate these findings and to identify ways to sustain the potential benefits of ACTs over the longer term.

背景:因药物使用相关感染性心内膜炎(DUA-IE)而接受心脏手术的患者因复发性心内膜炎、药物使用障碍(SUD)和败血症而再次入院的比例很高。我们的主要目的是评估在这一人群中,接受成瘾咨询团队(ACT)的治疗是否与再入院率的降低有关:这项单中心回顾性分析利用胸外科医师协会数据库确定了2012年1月至2022年9月期间因DUA-IE接受心脏手术的患者,并比较了2017年9月实施ACT前后1、3、6和12个月再入院的累积发生率,考虑了死亡率竞争风险,并利用反治疗概率加权法调整了测量的混杂因素:58名患者(35名实施ACT前患者和23名实施ACT后患者)都很年轻(36.4 +/- 7.7岁),主要为白人(53.4%)和男性(70.7%)。ACT后组群的再入院风险在1个月(调整后风险差异[RD] -23.8% [95% CI -94.4%, -8.3%],P = 0.005)和3个月(RD -34.1% [-55.1%, -13.1%],P = 0.005)时明显降低,但在6个月或12个月时则没有降低。在一项敏感性分析中,ACT后队列在3个月时因SUD并发症再入院的风险也显著降低:ACT暴露与手术治疗的DUA-IE患者短期再入院风险降低有关,这可能是由于SUD相关并发症的减少。需要进行更多的研究来复制这些发现,并找出长期维持ACT潜在益处的方法。
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引用次数: 0
"Coke in the Dope": The Underrecognized Complications of a Cocaine-Adulterated Fentanyl Supply. "毒品中的可卡因":可卡因掺假芬太尼供应的并发症未被充分认识。
IF 4.2 3区 医学 Q1 SUBSTANCE ABUSE Pub Date : 2024-09-01 Epub Date: 2024-05-31 DOI: 10.1097/ADM.0000000000001319
Vincent Mariano, Justin Berk

Abstract: The opioid crisis, particularly the "fourth wave" involving fentanyl and stimulants, has been responsible for an alarming increase in overdose deaths in the United States. Although fentanyl contamination in cocaine has gained significant attention, the converse-cocaine-adulterated fentanyl-has been largely overlooked despite its health implications. The rise in concurrent cocaine and fentanyl overdose deaths could be attributed to various factors, from intentional polysubstance use to unintentional adulterations. Cocaine-related health issues may amplify the problem. Four potential pathways for the increased risk of overdose with cocaine-adulterated opioids include enhanced drug reinforcement, potential overdose risk with switching drug samples, altered metabolism of medications used for opioid use disorder, and increased myocardial demand juxtaposed with opioid-induced respiratory depression. With these risks, the importance of drug testing becomes paramount in the unregulated drug market. As polysubstance use overdoses surge, there is an urgent need to understand how drug supplies are changing in order to effectively identify appropriate harm reduction strategies. Specifically, further research is needed evaluating complications of low-level cocaine exposure with chronic/persistent opioid use. The hazards associated with cocaine-adulterated fentanyl emphasize the significance of understanding not only fentanyl's presence in cocaine but also cocaine's role in the fentanyl supply.

摘要:阿片类药物危机,特别是涉及芬太尼和兴奋剂的 "第四次浪潮",导致美国因吸毒过量而死亡的人数急剧增加。尽管可卡因中的芬太尼污染已引起人们的极大关注,但可卡因中掺杂芬太尼的反面却在很大程度上被忽视,尽管它对健康有影响。可卡因和芬太尼同时过量致死人数的增加可归因于各种因素,从有意使用多种物质到无意掺杂。与可卡因相关的健康问题可能会加剧这一问题。掺入可卡因的阿片类药物会增加用药过量的风险,这可能有四种途径,包括药物强化作用增强、更换药物样本可能带来用药过量风险、治疗阿片类药物使用障碍的药物代谢发生改变,以及心肌需求增加与阿片类药物引起的呼吸抑制并存。有了这些风险,在无管制的毒品市场中,药物检测就变得至关重要。随着多种物质使用过量的激增,迫切需要了解毒品供应是如何变化的,以便有效地确定适当的减低伤害策略。具体而言,需要进一步研究评估低水平可卡因暴露与长期/持久使用阿片类药物的并发症。与掺杂可卡因的芬太尼相关的危害强调了了解芬太尼在可卡因中的存在以及可卡因在芬太尼供应中的作用的重要性。
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引用次数: 0
Low Risk of Cardiac Complications During Long-Term Follow-Up of Opioid Dependence. 阿片类药物依赖长期随访期间心脏并发症风险较低
IF 4.2 3区 医学 Q1 SUBSTANCE ABUSE Pub Date : 2024-09-01 Epub Date: 2024-06-05 DOI: 10.1097/ADM.0000000000001317
Chris Tremonti, David S Celemajer, Christina Marel, Katherine Mills, Shawn Foo, Jack Wilson, Tim Slade, Maree Teesson, Paul Haber

Objectives: To prospectively assess rates of QT prolongation, arrhythmia, syncope, and sudden cardiac death (SCD) in a cohort of people with heroin dependence.

Methods: To estimate rates of QT prolongation, arrhythmia, and syncope, a subcohort (n = 130) from the Australian Treatment Outcomes Study, a prospective longitudinal cohort study of 615 people with heroin dependence, underwent medical history, venepuncture, and ECG at the 18- to 20-year follow-up.To estimate rates of SCD, probabilistic matching for the entire cohort was undertaken with the Australian Institute of Health and Welfare National Death Index. Deaths were classified into suicide, accidental overdose, trauma, unknown, and disease, which were then further subclassified by probability of SCD. SCD rate was the number of possible or probable SCDs divided by total patient years from the cohort.

Results: From the subcohort, 4 participants (3%) met the criteria for QT prolongation; 3 were prescribed methadone. Seven participants (5%) reported history of arrhythmia, including 2 transferred from methadone to buprenorphine. Thirty participants (23%) reported a previous syncopal event-14 diagnosed as nonarrhythmic syncope and 13 not investigated. In the previous 12 months, 66 participants (51%) reported heroin use; 55 participants (42%) were prescribed methadone. No participant had QTc greater than 500 milliseconds.There were 3 possible SCDs, translating to an estimated SCD rate of 0.29 (CI: 0.05, 0.8) events per 1000 patient years. More cohort members died of overdose (n = 50), suicide (n = 11), and hepatitis C (n = 4).

Conclusions: Low rates of QT prolongation, arrhythmia, syncope, and SCD in the cohort despite high rates of heroin use and methadone treatment.

目的前瞻性评估海洛因依赖者队列中QT延长、心律失常、晕厥和心脏性猝死(SCD)的发生率:澳大利亚治疗结果研究是一项对 615 名海洛因依赖者进行的前瞻性纵向队列研究,为了估算 QT 间期延长、心律失常和晕厥的发生率,对该研究的一个子队列(n = 130)进行了病史、静脉穿刺和 18-20 年随访时的心电图检查。死亡分为自杀、意外用药过量、外伤、未知和疾病,然后根据 SCD 的概率进一步细分。SCD率是可能或疑似SCD的数量除以队列中患者的总年数:子队列中有 4 名参与者(3%)符合 QT 间期延长的标准;其中 3 人服用了美沙酮。7名参与者(5%)报告有心律失常病史,其中包括2名从美沙酮转用丁丙诺啡的患者。30 名参与者(23%)报告曾发生过晕厥事件,其中 14 人被诊断为非心律失常性晕厥,13 人未接受调查。在过去 12 个月中,66 名参与者(51%)报告使用过海洛因;55 名参与者(42%)被处方美沙酮。没有人的 QTc 超过 500 毫秒。有 3 例可能的 SCD,估计每 1000 患者年的 SCD 发生率为 0.29(CI:0.05,0.8)次。更多队列成员死于用药过量(50 人)、自杀(11 人)和丙型肝炎(4 人):尽管使用海洛因和接受美沙酮治疗的比例较高,但队列中QT延长、心律失常、晕厥和SCD的发生率较低。
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引用次数: 0
The Concept of Treatment-Refractory Addiction: Implications for Addiction Treatment Systems and Research. 难治性成瘾的概念:对成瘾治疗系统和研究的影响。
IF 4.2 3区 医学 Q1 SUBSTANCE ABUSE Pub Date : 2024-09-01 Epub Date: 2024-08-10 DOI: 10.1097/ADM.0000000000001350
Edward V Nunes, A Thomas McLellan

Abstract: The concept of treatment-refractory addiction, proposed by Eric Strain in this edition of the Journal, has the potential to invigorate the field of addiction treatment and research by focusing on a phenomenon that is familiar to any clinician treating patients with substance use disorders, namely, the patient who does not experience sufficient improvement from standard treatments. An analogy is drawn to the concept of treatment-resistant depression and the STAR*D study, which demonstrated an algorithmic approach to treatment, where if the first antidepressant medication tried did not result in remission from depression, subsequent trials of medications or cognitive behavioral therapy doubled the proportion of patients achieving remission. Recognizing treatment-refractory addiction challenges our field to develop analogous, stepwise, algorithmic approaches to treatment of substance use disorders, moving away from siloed treatment programs toward integrated treatment systems where alternative treatments are available, offering the kind of personalized, tailored forms of care used in the treatment of most other chronic illnesses. Like in STAR*D, research could focus on samples of patients who have not benefitted from initial trials of standard addiction treatments, addressing the key clinical question of what to do next when previous treatments fail.

摘要:埃里克-斯特恩(Eric Strain)在本期期刊中提出的 "难治性成瘾"(treatment-refractory addiction)概念,通过关注治疗药物使用障碍患者的临床医生所熟悉的一种现象,即患者在接受标准治疗后病情未得到充分改善,有可能为成瘾治疗和研究领域注入新的活力。该研究展示了一种算法治疗方法,即如果首次尝试的抗抑郁药物治疗未能使抑郁症得到缓解,那么后续的药物治疗或认知行为疗法试验可使获得缓解的患者比例增加一倍。认识到难治性成瘾对我们的领域提出了挑战,我们需要开发类似的、循序渐进的、算法化的方法来治疗药物使用障碍,从孤立的治疗方案转向综合治疗系统,在综合治疗系统中提供可供选择的治疗方法,提供用于治疗大多数其他慢性疾病的个性化、量身定制的护理形式。与 STAR*D 项目一样,研究也可以侧重于那些在标准成瘾治疗的初步试验中未能获益的患者样本,以解决临床上的一个关键问题,即当之前的治疗失败时,下一步该怎么做。
{"title":"The Concept of Treatment-Refractory Addiction: Implications for Addiction Treatment Systems and Research.","authors":"Edward V Nunes, A Thomas McLellan","doi":"10.1097/ADM.0000000000001350","DOIUrl":"https://doi.org/10.1097/ADM.0000000000001350","url":null,"abstract":"<p><strong>Abstract: </strong>The concept of treatment-refractory addiction, proposed by Eric Strain in this edition of the Journal, has the potential to invigorate the field of addiction treatment and research by focusing on a phenomenon that is familiar to any clinician treating patients with substance use disorders, namely, the patient who does not experience sufficient improvement from standard treatments. An analogy is drawn to the concept of treatment-resistant depression and the STAR*D study, which demonstrated an algorithmic approach to treatment, where if the first antidepressant medication tried did not result in remission from depression, subsequent trials of medications or cognitive behavioral therapy doubled the proportion of patients achieving remission. Recognizing treatment-refractory addiction challenges our field to develop analogous, stepwise, algorithmic approaches to treatment of substance use disorders, moving away from siloed treatment programs toward integrated treatment systems where alternative treatments are available, offering the kind of personalized, tailored forms of care used in the treatment of most other chronic illnesses. Like in STAR*D, research could focus on samples of patients who have not benefitted from initial trials of standard addiction treatments, addressing the key clinical question of what to do next when previous treatments fail.</p>","PeriodicalId":14744,"journal":{"name":"Journal of Addiction Medicine","volume":null,"pages":null},"PeriodicalIF":4.2,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142365278","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
期刊
Journal of Addiction Medicine
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