Pub Date : 2024-09-02DOI: 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。
{"title":"Expert Panel Consensus on the Effectiveness and Implementation of Models to Support Posthospitalization Care Transitions for People With Substance Use Disorders.","authors":"Michael A Incze, Sophia Huebler, Kathryn Szczotka, Sean Grant, Stefan G Kertesz, Adam J Gordon","doi":"10.1097/ADM.0000000000001369","DOIUrl":"https://doi.org/10.1097/ADM.0000000000001369","url":null,"abstract":"<p><strong>Objectives: </strong>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.</p><p><strong>Methods: </strong>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.</p><p><strong>Results: </strong>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.</p><p><strong>Conclusions: </strong>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.</p>","PeriodicalId":14744,"journal":{"name":"Journal of Addiction Medicine","volume":null,"pages":null},"PeriodicalIF":4.2,"publicationDate":"2024-09-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142107595","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}
Pub Date : 2024-09-01Epub Date: 2024-06-05DOI: 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.
{"title":"Drug Testing Interpretation in the Peripartum Setting: Results of Clinician Survey.","authors":"Theresa Kurtz, Elizabeth Charron, Julie Shakib, Marcela C Smid","doi":"10.1097/ADM.0000000000001322","DOIUrl":"10.1097/ADM.0000000000001322","url":null,"abstract":"<p><strong>Objectives: </strong>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.</p><p><strong>Methods: </strong>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).</p><p><strong>Results: </strong>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.</p><p><strong>Conclusions: </strong>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.</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":"141262160","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}
Pub Date : 2024-09-01Epub Date: 2024-05-22DOI: 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.
{"title":"Machine Learning-Driven Analysis of Individualized Treatment Effects Comparing Buprenorphine and Naltrexone in Opioid Use Disorder Relapse Prevention.","authors":"Majid Afshar, Emma J Graham Linck, Alexandra B Spicer, John Rotrosen, Elizabeth M Salisbury-Afshar, Pratik Sinha, Matthew W Semler, Matthew M Churpek","doi":"10.1097/ADM.0000000000001313","DOIUrl":"10.1097/ADM.0000000000001313","url":null,"abstract":"<p><strong>Objective: </strong>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.</p><p><strong>Methods: </strong>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.</p><p><strong>Results: </strong>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).</p><p><strong>Conclusions: </strong>Causal machine learning identified differing individualized treatment effects between medications based on characteristics associated with preventing relapse.</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":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11446670/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141081337","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01Epub Date: 2024-08-10DOI: 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."
{"title":"Treatment Failure Versus Failed Treatments: The Risks of Embracing Treatment Refractory Addiction.","authors":"David A Fiellin","doi":"10.1097/ADM.0000000000001351","DOIUrl":"https://doi.org/10.1097/ADM.0000000000001351","url":null,"abstract":"<p><strong>Abstract: </strong>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.\"</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":"142365280","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}
Pub Date : 2024-09-01Epub Date: 2024-07-15DOI: 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。
{"title":"A Source Control Model for Treatment-Resistant Substance Use Disorder.","authors":"Matthew Robert Dernbach, Karen Drexler, Elizabeth McCord, Joseph E Carpenter","doi":"10.1097/ADM.0000000000001344","DOIUrl":"10.1097/ADM.0000000000001344","url":null,"abstract":"<p><strong>Abstract: </strong>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.</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":"141619918","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}
Pub Date : 2024-09-01Epub Date: 2024-06-11DOI: 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.
{"title":"Early Surgical Excision of Necrotic Tissue Following Unintentional Dermal Injection of Extended-Release Buprenorphine.","authors":"Carly Taylor, Vanessa Loukas, Jasmine Muwonge, Jessica L Taylor, Joseph Boyle","doi":"10.1097/ADM.0000000000001327","DOIUrl":"10.1097/ADM.0000000000001327","url":null,"abstract":"<p><strong>Introduction: </strong>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.</p><p><strong>Case report: </strong>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.</p><p><strong>Discussion: </strong>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.</p><p><strong>Conclusions: </strong>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.</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":"141310653","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}
Pub Date : 2024-09-01Epub Date: 2024-08-10DOI: 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.
{"title":"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.","authors":"Lucas X Marinacci, Audrey Li, Annie Tsay, Yoel Benarroch, Kevin P Hill, Adolf W Karchmer, Rishi K Wadhera, Katherine Kentoffio","doi":"10.1097/ADM.0000000000001368","DOIUrl":"10.1097/ADM.0000000000001368","url":null,"abstract":"<p><strong>Background: </strong>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.</p><p><strong>Methods: </strong>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.</p><p><strong>Results: </strong>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.</p><p><strong>Discussion and conclusion: </strong>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.</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":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11449258/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142365275","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01Epub Date: 2024-05-31DOI: 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.
{"title":"\"Coke in the Dope\": The Underrecognized Complications of a Cocaine-Adulterated Fentanyl Supply.","authors":"Vincent Mariano, Justin Berk","doi":"10.1097/ADM.0000000000001319","DOIUrl":"10.1097/ADM.0000000000001319","url":null,"abstract":"<p><strong>Abstract: </strong>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.</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":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11446664/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141199888","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01Epub Date: 2024-06-05DOI: 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.
{"title":"Low Risk of Cardiac Complications During Long-Term Follow-Up of Opioid Dependence.","authors":"Chris Tremonti, David S Celemajer, Christina Marel, Katherine Mills, Shawn Foo, Jack Wilson, Tim Slade, Maree Teesson, Paul Haber","doi":"10.1097/ADM.0000000000001317","DOIUrl":"10.1097/ADM.0000000000001317","url":null,"abstract":"<p><strong>Objectives: </strong>To prospectively assess rates of QT prolongation, arrhythmia, syncope, and sudden cardiac death (SCD) in a cohort of people with heroin dependence.</p><p><strong>Methods: </strong>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.</p><p><strong>Results: </strong>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).</p><p><strong>Conclusions: </strong>Low rates of QT prolongation, arrhythmia, syncope, and SCD in the cohort despite high rates of heroin use and methadone treatment.</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":"141468063","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}
Pub Date : 2024-09-01Epub Date: 2024-08-10DOI: 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.
{"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}