Journal of Addiction Medicine最新文献

Objectives: The rising global prevalence of electronic cigarette (e-cigarette) use poses significant public health concerns, including nicotine dependence. This systematic review and meta-analysis evaluated the efficacy and safety of pharmacological interventions for e-cigarette cessation.

Methods: We systematically searched 5 databases, including Cochrane Library, PubMed, Ovid Embase, Sinomed, and Web of Science Core Collection, up to May 1, 2024, that evaluated the efficacy and safety of pharmacological intervention compared with placebo for e-cigarette cessation. Two investigators independently screened studies, extracted data, and assessed the risk of bias. The outcomes of interest were (1) continuous abstinence rate (CAR); (2) 7-day point prevalence of e-cigarette abstinence at different weeks; and (3) adverse effects. This study was registered with PROSPERO (CRD42024577356).

Results: Of 1567 initially identified records, 7 studies involving 1161 participants were included. Most studies had a low risk of bias. The results indicated that varenicline (4 studies, n=463; OR=2.52, 95% CI: 1.14-5.58) was effective, while the effect of nicotine replacement therapy (NRT; 2 studies, n=538; OR=1.38, 95% CI: 0.61-3.14) was not statistically significant. One study on cytisine also suggested potential benefit.

Conclusions: Varenicline has demonstrated efficacy in supporting e-cigarette cessation, whereas the current evidence for NRT and cytisine remains insufficient to draw firm conclusions. Further well-designed studies are needed to clarify the effectiveness of these 2 interventions. Although pharmacotherapies used for cigarette smoking show potential for repurposing, their utility in e-cigarette cessation should be interpreted cautiously until stronger evidence becomes available.

Objectives: In the United States, adults aged 65 and older are the fastest-growing age group using cannabis. People living with HIV (PLWH) are an aging population with prevalent cannabis use exceeding the general population. We examined cannabis use disorder (CUD) diagnoses from 2000 to 2022, by age, race/ethnicity, sex, comorbidity, and HIV status.

Methods: This analysis (2000-2022) includes electronic health records from 185,372 individuals in the Veterans Aging Cohort Study-HIV, a national US cohort of PLWH matched 1:2 to people without HIV (PLWoH). Annual CUD diagnosis was determined by dividing the number with CUD International Classification of Diseases-Clinical Modification codes by total observations. We examined trends by age, race/ethnicity, sex, comorbidity, and HIV status graphically and with multivariable logistic models.

Results: Demographic characteristics were comparable for PLWH (n=58,959) versus PLWoH (n=126,413): 45% Black non-Hispanic (NH); 35% White NH; 7% Hispanic; 3% women, mean age 48 years. Twenty percent of PLWH had a CUD from 2000 to 2022. CUD increased in all subgroups and was consistently higher among PLWH (odds ratio=1.14 [95% CI=1.11-1.18]). Individuals 65 and older experienced the greatest relative increase: PLWH (0.9% vs. 4.0%) and PLWoH (0.03% vs. 3.15%).

Conclusions: CUD increased dramatically among all subgroups over time and was higher among PLWH. CUD increase among older PLWH and those with multimorbidity is especially concerning as cannabis interacts with many prescription medications. Universal screening and treatment advances are needed, as is research characterizing patterns and modalities of cannabis use, CUD, and potential harms and benefits in PLWH and PLWoH.

Objectives: We explored sustainability of confidence in key skills related to opioid use disorder (OUD) care and barriers and facilitators of prescribing buprenorphine among residents who had completed buprenorphine training during medical school.

Methods: Medical students who took an elective buprenorphine training course before graduation were surveyed immediately following the training ("baseline") and again 1 year later. Baseline surveys included demographics and confidence with key skills in OUD care. Follow-up surveys re-assessed confidence with key skills and additionally included waiver status, history of prescribing buprenorphine, and residency climate toward buprenorphine. Focus group interviews explored barriers and facilitators of prescribing buprenorphine.

Results: Sixty-one students participated in the training and completed the baseline survey. Seventy-two percent of trainees completed the follow-up survey; of these, 36% had obtained a waiver and just over half of those had used it to prescribe buprenorphine. In unadjusted analyses comparing 1-year follow-up results to the baseline survey, smaller percentages of learners reported strong confidence in screening for and diagnosing OUD (23% vs 46%, P =0.004), counseling patients with OUD regarding treatment options (11% vs 44%, P <0.001), and prescribing buprenorphine to treat a patient with OUD (11% vs 33%, P <0.001). Qualitative results suggested that learners experienced both bureaucratic and environmental barriers to prescribing buprenorphine.

Conclusions: Removal of the waiver requirement addresses only some barriers to buprenorphine prescribing among medical trainees. Residency climate and clinical systems conducive to prescribing buprenorphine will be necessary to sustain confidence managing OUD and increase buprenorphine prescribing during residency.

Using serum methadone levels to calculate methadone clearance can help providers individualize dosing, particularly in patients displaying clinical symptoms of rapid clearance, such as peak sedation with concomitant trough withdrawal. Multiple factors may impact methadone dose requirements and serum levels, necessitating deviation from standard methadone titration protocols. The physiologic changes of pregnancy generally shorten methadone's half-life due to CYP450 enzyme induction and increased volume of distribution. Additionally, the emergence of fentanyl-a far more potent opioid than its predecessors-has led to increased opioid tolerance among individuals who use it. As a result, these individuals may require higher methadone doses to effectively manage their opioid dependence. We present a case of a pregnant patient with opioid use disorder, primarily using fentanyl, who presented to labor and delivery at 36 weeks 6 days of gestation. She delivered at 37 weeks 1 day and remained admitted for 4 weeks while undergoing methadone induction. At the time of discharge, she endorsed ongoing opioid withdrawal and required ongoing methadone dose escalation at her outpatient methadone clinic after discharge. Laboratory testing one month postpartum indicated a methadone half-life of 9.22, and she was determined to need thrice daily dosing to maintain therapeutic serum levels, with her total daily dose ultimately reaching 300 mg 3 times daily. In patients who do not respond to standard methadone titration protocols, laboratory testing can support individualized dosing strategies to achieve therapeutic levels while maintaining patient safety.

Objectives: The COVID-19 pandemic has had widespread effects on the global economy. The present study seeks to examine the enduring impact of the COVID-19 pandemic on the relationship between financial well-being, alcohol use, and mental health outcomes in individuals with and without an alcohol use disorder (AUD).

Methods: Participants who were enrolled in the NIAAA COVID-19 Pandemic Impact on Alcohol Study (C19-PIA) were invited to complete questionnaires on financial well-being, alcohol use, and mental health symptoms as part of an online anniversary survey collected between April 6, 2022, and July 2, 2022. The analytic sample included 250 participants who had valid data on key study variables, including past year AUD previously assessed in the NIAAA Natural History Protocol using structured clinical interviews.

Results: Individuals with AUD were less likely to apply for financial assistance and reported greater worries about their financial well-being. Lower financial well-being during the pandemic was associated with higher problematic drinking and worse mental health outcomes. Significant covariates included age, sex, and race.

Conclusions: The findings suggest an association between financial stress and problematic alcohol use during financial instability that appeared to persist 2 years into the COVID-19 pandemic. This highlights the potential impact of outreach efforts to improve accessibility of financial assistance, particularly for vulnerable individuals with AUD with financial worries and uncertainties during the pandemic.

Objectives: Medication for opioid use disorder (MOUD) is a standard of care for mortality-reducing treatment for people with opioid use disorder (OUD). Some health care settings have blanket policies forbidding MOUD treatment, which can increase mortality risk and violate the Americans with Disabilities Act (ADA). Clinicians are not routinely educated on the ADA as it applies to OUD.

Methods: This prospective survey study conducted in 2023 evaluates clinicians' knowledge, attitudes and current clinical practice before and after a 1-hour educational intervention (interactive didactic session) focused on patients with OUD who are experiencing discrimination under the ADA for being in MOUD treatment.

Results: Seventy-nine participants were invited to participate in the study; 84.8% completed the baseline survey and 60.8% completed both surveys. Before the intervention, participants identified understanding the protections for people with OUD under the ADA as important (38.3%) or extremely important (57.5%). Yet, the minority (17.4%) felt they were able to identify a potential ADA violation or knew how to report one (13.1%). After the intervention, the majority of participants (99.6%) were confident in identifying potential ADA violations, knew how to report them (97.9%), and reported intent to report potential violations (89.3%).

Conclusions: Education on the ADA as it applies to people with OUD significantly increased participants' self-reported ability to identify and willingness to report ADA violations ( P < 0.001). More research is needed to assess whether education translates into increased reporting and sustained clinical practice change.

Background: Adolescents and young adults (AYA) face distinct barriers when accessing care for opioid use disorder (OUD). Our objective was to compare characteristics of young adults to older adults seeking buprenorphine via telehealth and examines retention in care.

Methods: This retrospective cohort study compares young adults (ages 18-29) to older callers (age 30 and above) prescribed buprenorphine via a health system-based telehealth bridge clinic, CareConnect, in Philadelphia, Pennsylvania from 2021 to 2023. We compared patient and treatment characteristics using χ2 tests. Interactions between the age groups and independent variables were analyzed. Significant interactions were retained. Multivariable logistic regression evaluated factors associated with buprenorphine retention.

Results: Of the 1023 telehealth callers, 152 (15%) were young adults. The majority identified as male (60%) and were enrolled in Medicaid (74%). Of the sample, 45% identified as White, 36% identified as Black, and 12% identified as Hispanic. Young adult callers were more likely to identify as Hispanic than older callers (19% vs. 11%, P<0.03) and more likely to report incarceration in the last 1 month (17% vs. 9%, P<0.03). There were no significant differences in buprenorphine retention between younger and older adults. Lack of insurance among all adults was associated with lower odds of retention in buprenorphine treatment than insured patients (aOR=0.4, 95% CI=0.2-0.6). Young adults who identified as Black had lower odds of buprenorphine retention(aOR=0.3, 95% CI=0.1-0.8).

Conclusions: Our study highlights the importance of insurance coverage to support continued buprenorphine treatment engagement. This analysis also underscores the need for interventions to mitigate OUD treatment disparities among minoritized young.

Objectives: Programs to increase linkage to medications for opioid use disorder (MOUD) through peer recovery coaches may hold promise in increasing MOUD initiation. However, the impact of linkage programs may vary based on contextual factors, such as the implementation setting. This study examines whether implementation setting is associated with MOUD initiation following participation in peer-based linkage programs.

Methods: The University of Kentucky and Voices of Hope Lexington, a recovery community organization, trained recovery coaches to implement a MOUD linkage program. Coaches were deployed in 9 criminal-legal organizations (ie, jails, specialty court, and pretrial services) and 20 community organizations in 4 rural and 4 urban counties. Coaches worked with participants (n = 754) to set person-centered goals, provided MOUD education, addressed MOUD initiation barriers, and assisted with scheduling appointments. A typology of implementation setting categorized participants by where they enrolled in the linkage program: (1) urban community organizations (reference group), (2) urban criminal-legal organizations, (3) rural community organizations, or (4) rural criminal-legal organizations. The odds of MOUD initiation were estimated using multivariate logistic regression.

Results: Of 754 participants, 23.1% (n = 174) reported initiating MOUD. Relative to urban community organizations, individuals enrolled in rural community organizations were more likely to initiate MOUD (odds ratio = 1.85, P = 0.04), whereas individuals enrolled in rural criminal-legal organizations were less likely to initiate MOUD (odds ratio = 0.34, P = 0.005).

Conclusions: Implementation setting may impact the likelihood of MOUD initiation through peer-based linkage programs. Future research should examine how implementation strategies might overcome setting-specific barriers to MOUD initiation, particularly in rural criminal-legal settings.

Objectives: Individuals with co-occurring opioid use disorder (OUD) and mental health disorders experience complex treatment trajectories. The collaborative care model (CoCM) is an effective approach for improving behavioral health outcomes in primary care, but has not been tested for patients with co-occurring disorders. We sought to understand patients' experiences receiving CoCM for co-occurring OUD and depression and/or PTSD.

Methods: We conducted interviews with patients (N=24) who received CoCM for co-occurring disorders as part of a randomized trial. CoCM was delivered across 18 clinics by 10 care managers who were community health workers embedded into primary care teams. Themes were identified by 2 coders using rapid content analyses.

Results: We identified 4 major themes. First, patients hoped CoCM would provide an opportunity to make OUD treatment possible by helping them navigate barriers. Second, patients thought that OUD and mental health disorders were connected and that treatment should be integrated. Third, patients felt that care managers improved their treatment, emphasizing how their compassionate style and commitment facilitated access to and retention in medications for OUD and mental health disorders. Finally, patients reported experiencing barriers to accessing mental health therapy, although support from care managers sometimes helped address those barriers.

Conclusions: Patients expressed how care managers facilitated their positive experience with treatment and decreased access barriers common for individuals with co-occurring conditions. Our findings inform how community health workers in the role of care managers can facilitate access to and retention in care for people with co-occurring disorders.

Objectives: Naltrexone may be utilized for the treatment of opioid and/or alcohol use disorder during pregnancy. However, limited information is available on the pharmacokinetics of naltrexone during pregnancy and lactation. The objective of this study was to evaluate maternal and infant concentrations of naltrexone and its major metabolite 6β-naltrexol in relevant matrices across pregnancy and the immediate postpartum period.

Methods: Pregnant individuals receiving naltrexone were enrolled in this prospective cohort study. Maternal plasma and urine samples were collected serially during pregnancy at up to 6 time points. At delivery, cord blood, maternal plasma, infant plasma, and infant urine were collected. Four weeks after delivery, breastmilk, maternal plasma, and infant plasma samples were collected. All samples were analyzed for naltrexone and 6β-naltrexol using a validated liquid chromatography tandem mass spectrometry assay.

Results: A total of 7 pregnant individuals were enrolled: 4 receiving extended-release and 3 receiving oral naltrexone. Concentrations of naltrexone in maternal plasma in pregnancy remained detectable across the dosing interval for both formulations. The ratio of median cord blood to maternal plasma concentration was 1.11 in the extended-release and 0.74 in the oral group. Of the 7 infants, 1 remained breastfed at 4 weeks. The relative infant naltrexone dose via breastmilk at 31 days after delivery from the 1 infant was 0.83%.

Conclusions: While limited due to sample size, these data provide valuable information about the pharmacokinetics of prenatal use of naltrexone and perinatal transfer, guiding counseling and clinical management of the parent-infant dyad.