Journal of Addiction Medicine最新文献

Low-threshold buprenorphine treatment has been described as a general approach to office-based buprenorphine treatment that prioritizes access to care, flexibility, and patient-centeredness. Proposed principles have included same-day treatment entry, flexible policies and procedures, a harm reduction orientation, and availability in unconventional settings. This commentary, which summarizes critical insights from practitioners of low-threshold buprenorphine treatment, expands on these principles by describing clinical and social services that have been included in successful programs. Potential critiques of low-threshold buprenorphine treatment are also addressed. The main goal of the commentary is to describe the ideal components of low-threshold buprenorphine treatment that could inform the development, evaluation, and dissemination of these innovative programs.

Objectives: Posttraumatic stress disorder (PTSD) during pregnancy is associated with adverse consequences and has an estimated prevalence of 3% in community samples. The prevalence of current PTSD among pregnant women with opioid use disorder (OUD), a population at increased risk of adverse birth outcomes and other mental disorders, has been estimated at 16%-37% based on 3 small studies. We used the Centers for Disease Control and Prevention's MATernaL and Infant clinical NetworK (MAT-LINK) surveillance network to (1) further examine current PTSD prevalence among pregnant women with OUD and (2) compare characteristics of those with and without PTSD.

Methods: PTSD prevalence estimates during the current pregnancy were based on (1) presence of an ICD-9/10-CM code indicating PTSD (ie, extracted); (2) documentation of a PTSD diagnosis in abstracted data (ie, abstracted); and (3) PTSD identified by either source.

Results: Of 3315 pregnancies among women with OUD, estimated current PTSD prevalence was 14.7% (95% CI: 13.5-15.8) based on extracted data alone, 23.3% (95% CI: 22.0-24.6) based on abstracted data alone, and 25.9% (95% CI: 24.1-27.7) when based on either data source. Those with PTSD had a higher prevalence of most substance use and mental health disorders examined compared with those without.

Conclusions: These estimates underscore the substantial prevalence of PTSD among pregnant women with OUD and emphasize the need to screen for and treat PTSD and other mental health disorders in this population. Given that evidence-based treatments for PTSD have not been systematically evaluated in pregnant women, more research is sorely needed.

Objectives: Employment can provide structure and economic opportunity. We examined whether changes in employment status from treatment admission to discharge co-occurred with changes in methamphetamine use frequency over the same period.

Methods: The Substance Abuse and Mental Health Services Administration Treatment Episode Dataset-Discharges (2017-2022) provided the data. Methamphetamine use frequency (daily use, some use, and no use in the past month) and employment status (full-time, part-time, unemployed, and not in the labor force) were reported at treatment admission and discharge. Changes in methamphetamine use frequency were recorded as a reduction or no reduction. Logistic regression modeled reduced methamphetamine use frequency as the dependent variable. Analyses included employment status at admission, discharge, and their interaction. An adjusted model estimated marginal probabilities of reduced methamphetamine use at discharge.

Results: There were 89,015 first treatment admissions. Individuals who gained full-time employment showed the greatest reductions in methamphetamine use frequency (75.7% [95% CI: 72.9-78.4] and 73.9% [95% CI: 72.2-75.6]), compared with 25.5% (95% CI: 25.1-26.0) among those who remained unemployed. More people completed treatment in the reduction group (45.2% vs 22.6%).

Conclusions: Results indicate that gains in employment status during treatment co-occurred with reduced methamphetamine use frequency. This is consistent with prior research linking stable employment to improved health and recovery outcomes. Integrating employment‑support services into outpatient treatment may complement existing interventions and support patient-centered goals. Future prospective studies are needed to establish temporal ordering between employment transitions and methamphetamine use changes and to evaluate employment-support strategies as an adjunct to treatment.

Background: Urine toxicology is a cornerstone of monitoring abstinence in substance use disorder treatment, yet commonly cited detection windows are based on studies in healthy volunteers and do not account for metabolic variability. Prolonged metabolite positivity is typically interpreted as continued use, which can jeopardize treatment engagement and erode the therapeutic alliance.

Case summary: We describe a 42-year-old man with severe stimulant use disorder whose urine toxicology remained positive for cocaine metabolites for 18 days, including 12 days after verified abstinence in a residential program. Laboratory evaluation revealed hepatic steatosis, and pharmacogenomic testing demonstrated a poor metabolizer phenotype at CYP2D6 and CYP3A5. Creatinine-corrected benzoylecgonine levels showed steady monotonic decline without fluctuation, consistent with delayed elimination rather than recurrent use. No cross-reactive medications or confounding substances were present.

Discussion: Cocaine metabolism depends on cytochrome P450 enzymes-particularly CYP2D6 and CYP3A isoforms-and nonspecific esterases. Impaired activity of these pathways, combined with hepatic steatosis and chronic stimulant exposure, can significantly prolong metabolite clearance. This case highlights the importance of distinguishing biological variability from behavioral relapse, especially in settings where misinterpretation may undermine therapeutic rapport.

Clinical implications: Unexpectedly persistent cocaine positivity should prompt consideration of pharmacogenomic variation, hepatic function, and confirmatory testing rather than immediate assumptions of relapse. Integrating biological, behavioral, and contextual data supports accurate interpretation and protects the therapeutic alliance.

Conclusions: Prolonged cocaine metabolite detection can reflect delayed metabolic clearance rather than continued use. Awareness of pharmacokinetic and pharmacogenomic factors is essential for accurate urine toxicology interpretation and patient-centered addiction care.

Objectives: Gabapentin is frequently used as a benzodiazepine-sparing agent for the management of mild to moderate alcohol withdrawal and is generally considered well-tolerated. Although neurological adverse effects have been reported, objective ocular motor abnormalities associated with gabapentin use during alcohol withdrawal are rarely described. Recognition of such effects is important to guide evaluation and management.

Methods: We report a 60-year-old man admitted to a residential treatment program for alcohol use disorder who developed acute diplopia and transient ophthalmoplegia shortly after initiation of gabapentin for mild alcohol withdrawal. The patient had no history of withdrawal seizures or delirium tremens and presented with a low CIWA-Ar score. Gabapentin was initiated at a total daily dose of 1800 mg using a fixed-dose taper. Within 24 hours, he developed diplopia, gaze-evoked nystagmus, and mild gait ataxia. Neurological examination revealed unilateral ophthalmoplegia, while neuroimaging and laboratory evaluation were unremarkable. Gabapentin was discontinued, and symptoms resolved completely within 24 hours without recurrence.

Results: The temporal relationship between gabapentin initiation and symptom onset, along with rapid resolution after discontinuation, supports a medication-induced neurological effect rather than alcohol withdrawal-related encephalopathy or structural neurological disease. The findings localize to cerebellar-brainstem pathways and are consistent with gabapentin's known effects on voltage-gated calcium channels.

Conclusions: Gabapentin remains a useful option for mild to moderate alcohol withdrawal; however, rapid dose escalation may increase the risk of reversible neurological adverse effects. New-onset diplopia or ocular motor abnormalities should prompt medication review and appropriate neurological evaluation to ensure patient safety.

Background: Kratom (Mitragyna speciosa) and its active alkaloids, mitragynine and 7-hydroxymitragynine, can produce opioid-like dependence and withdrawal meeting DSM-5 criteria for opioid use disorder (OUD). While buprenorphine has been described for kratom use disorder (KUD), published experience with methadone is limited.

Methods: We identified 14 patients across multiple Opioid Treatment Programs (OTPs) with KUD who were treated with methadone between January 2024 and October 2025. Demographic, dosing, and urine toxicology data were reviewed.

Results: The mean age was 36.8 years; 71% were male. Sixty-four percent reported using both kratom and 7-OH. The mean first-day methadone dose was 27.5 mg (range 15-30), and the mean maximum dose was 98.6 mg (range 35-190). Thirteen patients (93%) remained in treatment at the last follow-up. No adverse events were reported.

Conclusions: Methadone was well tolerated and effective in stabilizing patients with KUD, supporting its use as a viable alternative when buprenorphine is not suitable.

Objectives: The prevalence of xylazine, an agonist at the alpha-2 adrenergic receptor often used in veterinary medicine, has increased in the illicit opioid drug supply. Case series and survey data suggest that xylazine may increase the nature and severity of opioid withdrawal. We sought to evaluate the association between quantified levels of xylazine exposure and withdrawal symptoms in people undergoing opioid withdrawal.

Methods: People (n=36; 11 female) with opioid use disorder and physical dependence were enrolled in two harmonized clinical trials. Urine specimens were collected at admission to a residential unit and were analyzed for xylazine, fentanyl, and its inactive metabolite norfentanyl. Opioid withdrawal and physiological effects were collected during stabilization on oral hydromorphone without illicit opioid access.

Results: Urinary xylazine was detected in 69% of samples with concentrations ranging from 5.7 to 15481.1 ng/mL. Among participants with detectable urinary xylazine, higher xylazine concentrations were significantly associated with higher systolic blood pressure (b=7.68 [2.03, 13.33], P=0.011) and COWS total scores (b=1.53 [0.17, 2.88], P=0.029). No significant differences in blood pressure or COWS were observed between participants with and without xylazine detected.

Conclusions: Potential rebound hypertensive effects following xylazine exposure were observed, consistent with alpha-2 adrenergic mechanisms, which may be accompanied by an exacerbated withdrawal syndrome. Continued preclinical and clinical evaluation of strategies are needed to understand how co-exposure to drug adulterants like xylazine influences withdrawal expression and the utility of existing pharmacological approaches for withdrawal management in clinical settings.

Objective: Determine whether employer-mandated transitions from low- to high-deductible health plans (HDHPs) are associated with delays in opioid use disorder (OUD)-related care presentations. Cost-sharing may negatively impact timely diagnosis and treatment of OUD.

Methods: Using 2003-2017 national commercial insurance claims data, we used a matched time-to-event and difference-in-differences design to examine the association between employer-mandated transitions from low to HDHPs on OUD-related care presentations. Study group included 574,058 adults aged 18-64 years continuously enrolled in low-deductible (<$500) health plans during a baseline year followed by up to 4 years in HDHPs (≥$1000) after an employer-mandated transition (exposure). Control group included 4,386,636 adults contemporaneously enrolled in low-deductible plans matched on employee and employer characteristics. Outcomes included first OUD-related office visit, buprenorphine pharmacy fill, and OUD-related high-acuity visit. The secondary outcome was the yearly number of high-acuity care days.

Results: After an employer-mandated HDHP transition, there were no differences in time-to-first OUD-related office visit (HR, 1.02, 95% CI: 0.94, 1.11) or buprenorphine fill (HR, 1.05, 95% CI: 0.97-1.13) in the HDHP versus control cohort. In contrast, the HDHP transition was associated with delays in time-to-first OUD-related high-acuity visits compared with control members (HR 0.86, 95% CI: 0.79-0.93). HDHP members experienced a 37.4% (95% CI: -57.8, -17.0) relative reduction in high-acuity care days relative to the control group from baseline to follow-up.

Conclusions: Employer-mandated transitions to HDHPs were associated with delays and reductions in OUD-related high-acuity presentations. Such delays and reductions in timely OUD care could lead to adverse health outcomes.

Objectives: Medetomidine is an alpha-2 adrenoreceptor agonist approved only for veterinary sedation and was reported in the US illicit drug supply starting in 2022. Our aim was to determine the prevalence of medetomidine exposure and associated clinical characteristics among emergency department patients presenting with opioid and/or stimulant overdoses.

Methods: The Toxicology Investigators Consortium (ToxIC) Drug Overdose Toxico-Surveillance (DOTS) Reporting Program included 17 US medical centers. Emergency department (ED) patients with acute opioid and/or stimulant overdose were enrolled between April 2023 and September 2024. Blood was obtained for toxicological analysis, and chart reviews and structured patient interviews were conducted.

Results: Among 964 cases, medetomidine was detected in 2.8% (n = 27). After adjusting for confounders, medetomidine exposure was associated with an increased odds (odds ratio: 4.03; 95% CI: 1.35, 10.58) of bradycardia (<50 beats per minute) within 24 hours of presentation. Patients with medetomidine exposure had significantly higher rates of BVM (20.5%) than those without medetomidine exposure (3.7%; P=0.03) but did not require more intubation, BiPAP/CPAP, or naloxone than medetomidine-unexposed patients. No differences between medetomidine-exposed and unexposed groups were found for length of stay, critical care unit disposition, hypotension (<50 mmHg), or sedation. No patients completing an interview (n = 24) reported medetomidine use.

Conclusions: Medetomidine exposure among ED patients with overdose was associated with increased bradycardia but not greater sedation, respiratory support, or need for higher level of care. Sentinel toxico-surveillance can identify emerging drug trends not captured through routine clinical data.

Objectives: Deaths attributed to stimulants in the United States are largely driven by fentanyl coinvolvement. We sought to compare antecedents of acute stimulant deaths involving fentanyl to those that do not involve opioids.

Methods: We analyzed data from 31 fentanyl-stimulant and 70 stimulant-no-opioid decedents in a psychological autopsy study in San Francisco, CA. We used Least Absolute Shrinkage and Selection Operator (LASSO) regression to identify variables potentially associated with coinvolvement of fentanyl in death. We included 36 variables (sociodemographic characteristics, substance use, medical history, and circumstances surrounding death) from medical examiner reports, informant interviews, and medical records. We conducted multivariable logistic regression using variables selected by the LASSO model to assess associations with coinvolvement of fentanyl in death.

Results: Past-year fentanyl use and opioid-related emergency department visits in the 3 years before death were associated with higher odds of fentanyl involvement in death [adjusted odds ratio (aOR) = 3.10, 95% CI: 1.16-8.29, P = 0.02 and aOR = 4.62, 95% CI: 1.03-20.66, P = 0.045, respectively]. Having a cardiac condition (from medical history, autopsy, or informant report) was associated with lower odds of fentanyl involvement in death (aOR = 0.13, 95% CI: 0.03-0.46, P < 0.002).

Conclusions: Our findings add to existing evidence that fentanyl-stimulant deaths are markedly different than stimulant-no-opioid deaths. The association of opioid-related emergency department history with fentanyl involvement in death reinforces a potential touch point for overdose prevention efforts (eg, naloxone, medications for opioid use disorder). Our finding of cardiac conditions being associated with lower odds of fentanyl involvement in death supports the hypothesis that stimulant-no-opioid deaths may be driven by cardiovascular conditions.