Journal of Addiction Medicine最新文献

Objectives: Pre-exposure prophylaxis (PrEP) is a critical strategy for HIV prevention in women who inject drugs (WWID); however, only 1%-2% of WWID use PrEP. We aim to characterize factors associated with longitudinal PrEP eligibility in women with a history of injection drug use to inform optimization of PrEP implementation strategies.

Methods: Women who did not have HIV and were participating in the AIDS Linked to the Intravenous Experience (ALIVE) Cohort between 2014 and 2020 were included. Data on sociodemographic characteristics, substance use, depressive symptoms, and HIV risk behaviors were collected at semiannual visits. PrEP-eligibility was defined as sex-related (>1 partner with condomless sex, partner with HIV or who injects drugs, transactional sex or sexually transmitted infection) or injection-related (sharing drug use equipment) in the past 6 months. Associations between individual factors and PrEP eligibility were estimated using unadjusted and adjusted logistic regression with generalized estimating equations.

Results: Among 382 women, the average follow-up was 3.2 years, and 41% were PrEP-eligible. At baseline, among PrEP-eligible women, 89% met sex-related, 41% met injection-related, and 30% met both sex-related and injection-related criteria; women were eligible for PrEP during 58% of follow-up. Periods of PrEP-eligibility were longitudinally associated with younger age [adjusted odds ratio (95% CI): 0.92 (0.90-0.94)], recent incarceration [aOR=2.29 (1.17-4.50)], severe depression [aOR=1.31 (1.06-1.62)], and recent overdose [aOR=1.56 (1.07-2.28)].

Conclusions: PrEP implementation efforts that incorporate strategies to support the needs of women with recent incarceration, severe depression, and recent overdose have the potential to maximize outcomes for WWID.

Objectives: People who inject drugs (PWID) have higher mortality risks and excessive alcohol use compared with the general population. However, long-term alcohol usage trajectories' impacts on mortality outcomes among PWID are not well-established. We aim to characterize different longitudinal alcohol use patterns and evaluate their mortality outcomes among lifetime PWID.

Methods: Data are from our community-based, prospective cohort study of PWID in Baltimore, Maryland, United States. The analysis included participants from January 1, 2005, through February 29, 2020, who answered alcohol use screening questions at least once. We first performed group-based trajectory modeling to identify longitudinal patterns of alcohol use. Next, we applied time-to-event methods to assess the mortality risks associated with these patterns.

Results: The analysis included 1935 participants. Five alcohol use patterns emerged: consistent high-risk use (7.1%), gradual decline from moderate-risk to lower-risk use (25.8%), faster decline from moderate-risk to minimal use (10.4%), consistent lower-risk use (28.6%), and minimal use (28.1%). Compared with high-risk use, faster decline [adjusted hazard ratio (aHR): 0.44 (95% CI: 0.30, 0.65)], lower-risk [aHR: 0.54 (95% CI: 0.39, 0.74)], and minimal [aHR: 0.58 (95% CI: 0.42, 0.80)] use each had a lower all-cause mortality risk. Furthermore, these 3 comparison groups also showed reduced noncommunicable disease-related mortality risks.

Conclusions: Relative to consistent high-risk alcohol use, alcohol reduction/cessation and long-term lower-risk or minimal alcohol use have lower all-cause and noncommunicable disease-related mortality risks. Our findings highlight the importance of alcohol use treatment services as a preventive health care strategy among lifetime PWID and other high-risk populations.

Objectives: Preclinical studies indicate that neuroactive steroids mediate some effects of alcohol. Dutasteride is an inhibitor of 5-alpha reductase enzymes, which play a central role in the production of 5α-reduced neuroactive steroids. A prior randomized clinical trial in men found that dutasteride reduced drinking compared with placebo. The purpose of this study was to examine dutasteride's tolerability and efficacy for reducing drinking in a sample of men and women.

Methods: A total of 167 participants who were current heavy drinkers and had a goal to stop or reduce drinking to nonhazardous levels were randomized to placebo or 1 mg dutasteride daily for 12 weeks. We hypothesized that both dutasteride-treated men and women would be more successful in reducing drinking compared with placebo.

Results: Dutasteride was well tolerated. Generalized linear mixed models identified significant effects of medication such that dutasteride-treated participants reduced drinking and heavy drinking more than placebo-treatment. During the last month of treatment, dutasteride-treated participants had reduced heavy drinking days by 40% versus 23% for placebo-treated participants (P=0.041, Cohen's d=0.48) and the number of drinks per week by 32% versus 16% for placebo participants (P=0.016, Cohen's d=0.42). When the sample was stratified by sex, a significant effect of medication compared with placebo was evident for men (n=88) but not for women (n=67) due to a large placebo response rate in women.

Conclusion: Dutasteride 1 mg daily was efficacious in reducing the number of heavy drinking days and drinks per week in treatment-seeking men, confirming findings from a prior RCT involving 142 men.

Objectives: Functional magnetic resonance imaging studies have shown that smoking cues activate reward-related brain regions, with activation intensity increasing with smoking addiction severity. A recent study on cocaine addiction reported increased striatal glutamatergic tone in response to cocaine-associated cues; however, the role of glutamate in smoking cue-induced brain activation and its relationship with addiction severity remain unclear.

Methods: This study investigated glutamate modulation in the anterior striatum and dorsal anterior cingulate cortex (ACC) of male participants, comprising smokers (n = 38) and healthy controls (n = 48), exposed to smoking cues. Magnetic resonance spectroscopy (MRS) was used to measure glutamate levels at baseline (neutral images) and during smoking cue (smoking images) presentation.

Results: A mixed-model ANOVA followed by post hoc paired t tests revealed a significant increase in striatal glutamate levels in smokers exposed to smoking cues, whereas no changes were observed in controls. This effect on striatal glutamate in smokers remained significant after controlling for age. No significant changes were observed in the ACC in either smokers or controls. Although a positive association trend was found between smoking severity, as measured by the Fagerström Test for Nicotine Dependence (FTND) scores, and striatal cue-induced glutamate changes, it was not statistically significant.

Conclusions: These findings suggested that smoking cue-induced increases in striatal glutamate tone may reflect the neurochemical mechanisms underlying cue-induced phenomena in humans.

Background: Products containing semi-synthetic 7-hydroxymitragynine (7-OH), a potent mu-opioid receptor (MOR) agonist, have proliferated in the United States. In kratom leaf, trace amounts of 7-OH are formed by spontaneous oxidization of kratom's primary alkaloid, mitragynine. Hepatic and intestinal microsomes also convert mitragynine to 7-OH. Some products have sublingual and nasal administration routes that circumvent hepatic first-pass metabolism, increasing bioavailability and accelerating effect onset, features that increase risk. We report a patient who developed substance use disorder (SUD) related to a 7-OH sublingual film.

Case presentation: A 35-year-old man with supraventricular tachycardia and profound urinary retention described using "Hydroxie," a novel, semi-synthetic 7-OH product. He currently vaped cannabis and nicotine, and reported injection heroin addiction a decade prior. He used kratom 6 months before trying Hydroxie, which began 10 weeks before hospitalization. Within days of initiating use, he noticed tolerance; within 2 weeks, he was using one film every 1-2 hours. The patient met criteria for severe SUD related to Hydroxie and was inducted onto buprenorphine. Analysis confirmed 7-OH in the product and blood.

Discussion: The MOR selectivity and brief duration of action of some 7-OH formulations support our observation that repeated use may lead to physical dependence. Standard laboratory testing can detect mitragynine but not 7-OH due to its relatively shorter half-life, an issue that may confuse semi-synthetic 7-OH use with kratom. Novel 7-OH products are not kratom. The potency of 7-OH places unwitting consumers who may believe they are using kratom, not a partial MOR agonist, at risk.

Objectives: Following ST-elevation myocardial infarction (STEMI), there are standard guideline-indicated therapies including revascularization (percutaneous coronary intervention or coronary artery bypass surgery), medications (aspirin, angiotensin converting enzyme [ACE] inhibitors and angiotensin receptor blockers [ARBs], beta-blockers, high-intensity statins, P2Y12 inhibitors], and outpatient rehabilitation (cardiac rehabilitation [CR]). Those with substance use disorder (SUD), including cocaine use disorder (CUD), have been shown to be less likely to receive certain medical treatments, but the effect of SUD history on receipt of post-STEMI therapies is not well known.

Methods: The TriNetX Research database was used to identify adults aged 18 years or older hospitalized with STEMI between 2014 and 2024. Patients were divided into two groups: those with and without a history of CUD. After 1:1 propensity score matching for demographic, psychosocial, and medical characteristics, differences in receipt of guideline-indicated therapies by CUD history were examined.

Results: After propensity matching, 1366 patients were identified in each group. Those with a history of CUD were more likely to be prescribed ACE/ARBs [OR: 1.22, 95% CI: 1.05-1.41] or statins [OR: 1.19, 95% CI: 1.03-1.39], less likely to receive revascularization [OR: 0.69, 95% CI: 0.51-0.94] and much less likely to attend CR [OR: 0.41, 95% CI: 0.28-0.61] as compared with those without. No differences were seen by group in prescription of other medications.

Conclusions: History of CUD was associated with modest effects on receipt of prescriptions post-STEMI. However, revascularization and attendance at CR were much lower in those with CUD. There is a need for more targeted, individualized, and supportive treatment plans in patients with CUD who present with STEMI.

Objectives: To assess documented substance use indicators and the probable role of substance use disorders (SUDs) in deaths occurring in US Immigration and Customs Enforcement (ICE) custody between April 2018 and May 2025.

Methods: A retrospective cross-sectional review was conducted using all 69 publicly available ICE Detainee Death Reviews (DDRs) during the study period. Medically licensed reviewers analyzed each DDR for documented substance use indicators, clinical screening or diagnosis, referral, treatment, and emergency response. Additional variables included demographic information, psychiatric symptoms, and access to medical or mental health care.

Results: Among 27 deaths involving a probable substance use history or related medical/psychiatric conditions, none showed documentation of SUD diagnosis, referral, or evidence-based treatment. Nine individuals (33.3%) died from complications potentially related to untreated substance use, including opioid and alcohol withdrawal. Over half of these cases showed documented signs of delayed emergency response. Although DDRs frequently noted patient "refusal" of care (n=11), none documented formal assessments of decision-making capacity. Most individuals in the sample had resided in the United States for over 2 decades before ICE detention.

Conclusions: Our findings reveal probable gaps in the documented identification and treatment of SUD among individuals who died in ICE custody. Standardized behavioral health protocols, timely emergency response, and greater transparency are needed to address substance-related risks in immigration detention settings.

Emergency clinicians frequently care for patients with complications from underlying opioid use disorder. While many clinicians are comfortable addressing the immediate medical complications of opioid use disorder, too many do not offer evidence-based medications that stabilize the patient by alleviating withdrawal and cravings, and that also treat opioid use disorder, the underlying cause of the presentation. Because medication for opioid use disorder, namely methadone and buprenorphine, reduces the risk of death by up to 50%, this omission at a critical touchpoint in the health care system misses an opportunity to engage people in care and reduce fatal overdose. It also exposes the emergency department and health care facility to potential legal liability. Under federal civil rights laws, it is illegal to discriminate against people with opioid use disorder; discrimination may include failure to screen for and diagnose opioid use disorder and offer medications for opioid use disorder alongside a facilitated referral for outpatient treatment. Advocates for a more effective emergency department response to opioid use disorder can use these civil rights laws to press for the adoption of evidence-based practices for people with opioid use disorder. Legal advocacy is an important tool to utilize during this unrelenting overdose crisis.

Objectives: Stigmatizing experiences for mothers with opioid use disorder (OUD) may impede health care engagement. We sought to characterize attitudes and terminology use among pediatric primary care clinicians as a potential target for improvement.

Methods: We conducted a cross-sectional survey of 1004 clinicians at 28 clinics affiliated with 7 US residency programs (April to June 2022). Survey questions focused on trust, blame, and support for mothers with OUD were adapted from prior studies of self-reported attitudes, and terminology was categorized as preferred versus nonpreferred based on national recommendations. Frequencies were tabulated, and a 2-stage process of factor analysis and k-means clustering was used to group respondents by attitudinal responses. Multivariable logistic regression evaluated the association between participant characteristics and attitudinal groups.

Results: Of 272 respondents (response rate 27.1%), most were female, non-Hispanic White residents; the distribution of clinical roles was similar among nonrespondents. Use of nonpreferred terminology was infrequent, although over 69% reported usual or occasional use of "substance abuse." Analyses supported clustering respondents across 3 main constructs of trust, blame, and support. About 27% were categorized as having a low level of blame, and about 38% had a high level of trust. Adjusting for covariates, high trust was associated with confidence in training to provide care for opioid-exposed children (adjusted odds ratio [AOR] 1.84, P =0.04), and low blame was associated with education on OUD stigma (AOR 3.43, P =0.001).

Conclusions: Pediatrician attitudes reflecting mistrust and blame toward mothers with OUD are not uncommon but may be addressed through training and education.