Journal of Addiction Medicine最新文献

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.

Objectives: To compare the effects of different interventions for maintaining smoking abstinence in postpartum individuals.

Methods: We searched PubMed, EMBASE, CENTRAL, CINAHL, PsycINFO, and ProQuest up to February 2024. Randomized controlled trials (RCTs) that studied the effects of any interventions on maintaining smoking abstinence in postpartum individuals who quit smoking before delivery were included. A frequentist network meta-analysis using a random-effect model was performed to compare the efficacy of interventions cognitive behavioral therapy (CBT) and motivational interviewing (MI). The surface under the cumulative ranking curve was used to rank the intervention effects. The GRADE approach assessed evidence certainty.

Results: We included 11 studies from 10 RCTs (3365 participants). Comparisons with standard care revealed that CBT [relative risk (RR) = 1.03; 95% CI: 0.86, 1.19], CBT-MI (RR = 1.41; 95% CI: 0.87, 2.27), and MI (RR = 1.06; 95% CI: 0.90, 1.24) failed to maintain smoking abstinence at 12 months postpartum. The absolute differences were imprecise, with wide CIs encompassing both potential increases and decreases in smoking abstinence: 7 more per 1000 (95% CI: -31, 43) for CBT, 92 more per 1000 (95% CI: -29, 284) for CBT-MI, and 13 more per 1000 (95% CI: -22, 54) for MI, all with moderate certainty evidence. Subgroup analyses for follow-up periods of <12 months indicated that CBT-MI (RR = 1.67; 95% CI: 1.08, 2.60) and MI (RR = 1.16; 95% CI: 1.01, 1.33) may improve the maintenance of smoking abstinence over the short term.

Conclusions: CBT-MI and MI appear promising in improving the maintenance of smoking abstinence within 12 months postpartum, though further research is needed to enhance long-term abstinence.

Background: Drug use-related stigma amplifies the harms faced by people who use drugs (PWUD). Media often dehumanizes PWUD, particularly those using xylazine, a veterinary sedative and opioid adulterant, by labeling them with terms like "zombie." This perpetuates discrimination and stigma, distracting from the public health crisis. To assess this, we conducted a content analysis to quantify the prevalence of stigmatizing terms like "zombie" and related imagery in xylazine-related web-based media.

Methods: We analyzed web-based news media reporting on xylazine from October 1, 2022, to September 30, 2023, using Google News. "Stigmatizing term" was defined as the use of the word "zombie," and "stigmatizing imagery" was defined as an embedded image of nonsterile or discarded drug use supplies, visibly intoxicated individuals, unhoused persons, or necrotic wounds. Two trained reviewers followed a standardized protocol to examine article titles, text, and images. Articles using stigmatizing term and/or imagery were coded as stigmatizing; and data were aggregated by month to assess any temporal changes in relation to federal xylazine alerts.

Results: In a 12-month period, 910 news articles mentioned xylazine, 23.9% featured stigmatizing content, of which 57% (124/217) used "zombie" only, 26.3% (57/217) had stigmatizing imagery only, and 16.6% (36/217) had both. Stigmatizing articles peaked in March and July 2023, coinciding with federal alerts about xylazine in the opioid supply. Of the 601 articles with embedded images, 15% had stigmatizing imagery.

Conclusions: Stigmatizing content in web-based news media about xylazine continues to proliferate, highlighting the need for more efforts to challenge these narratives.

Objectives: Prior studies have documented rising rates of referrals to skilled nursing facilities (SNFs) for hospitalized patients with opioid use disorder (OUD). However, the care transitions and survival of people with OUD who enter SNFs have not been evaluated. We examined differences in hospital readmissions and mortality between individuals with and without OUD discharged to SNFs.

Methods: Using 2016-2020 100% Medicare inpatient claims, we identified acute hospitalizations with discharge to SNFs. We matched each beneficiary with OUD with up to 5 without OUD based on age, sex, low-income subsidy status, and residential county. Outcomes were hospital readmissions and all-cause mortality within 180 days following hospital discharge. Inverse-probability weighting (IPW) covariates included demographics, state of residence, year of SNF admission, intensive care use, Gagne comorbidity score, and conditions associated with SNF admission or that disproportionately affect people with OUD. Unadjusted and IPW-adjusted risk differences were calculated.

Results: There were 30,922 fee-for-service beneficiaries with OUD and 137,454 matched beneficiaries without OUD, with a mean age of ~71 years. Of those with OUD, 5.3% had evidence of receiving medications for OUD. In unadjusted analyses, beneficiaries with OUD had higher readmission risk (44.5% vs 27.9%) and comparable mortality risk (17.8% vs 16.5%) relative to beneficiaries without OUD. After adjustment through IPW, there were minimal differences in mortality; however, beneficiaries with OUD remained at a greater risk for readmissions than those without OUD.

Conclusions: Hospital readmissions were dramatically higher among Medicare beneficiaries with OUD than those without OUD, suggesting that important gaps in OUD care exist in SNFs.

Introduction: Xylazine is a veterinary anesthetic increasingly present alongside illicit fentanyl in the United States and Canada, presenting novel health risks. Although xylazine remains less common in the Western US, Mexican border cities serve as key trafficking hubs and may have a higher prevalence of novel substances, but surveillance there has been limited.

Methods: We examined deidentified records from the Prevencasa free clinic in Tijuana, describing urine and paraphernalia testing from patients reporting using illicit opioids within the past 24 hours. Xylazine (Wisebatch and Safelife brands), fentanyl, opiate, methamphetamine, amphetamine, benzodiazepine, and nitazene test strips were used to test urine and paraphernalia samples. Paraphernalia samples were also analyzed with mass spectrometry.

Results: Of n=23 participants providing urine and paraphernalia samples concurrently, 100%, 91.3%, and 69.6% reported using China White/fentanyl, methamphetamine, and tar heroin, respectively. The mean age was 41.7 years, 95.7% were male, 65.2% were unhoused, and 30.4% had skin wounds currently. Xylazine positivity in urine for the 2 strip types used was 82.6% and 65.2%. For paraphernalia testing, the xylazine positivity was 65.2% and 47.8%. Confirmatory testing of paraphernalia samples by mass spectrometry indicated a 52.2% xylazine positivity, as well as fentanyl (73.9%), fluorofentanyl (30.4%), tramadol (30.4%), and lidocaine (30.4%). Mass spectrometry suggested lidocaine triggered n=3 and n=0 false positives among the xylazine test strip types.

Discussion: Xylazine is present on the US-Mexico border, requiring public health intervention. High lidocaine positivity complicates the clinical detection of xylazine via testing strips. Routine urine testing for xylazine in clinical scenarios is likely feasible, yet confirmatory urine studies are needed.

Objective: This study investigated community bystander presence and naloxone administrations by location type during accidental fatal opioid-involved overdoses in Rhode Island.

Methods: We analyzed accidental opioid-involved overdose fatalities among adults in Rhode Island between 2020 and 2022, obtained from the State's Unintentional Drug Overdose Reporting System (SUDORS). Variables of interest included location of death, community bystander presence, and naloxone administration. We calculated the proportion of overdose deaths where community bystanders were present and naloxone was administered. Using multivariable Poisson regression with robust standard errors, we identified statistically significant ( P <0.05) correlates of naloxone administration by any responder during fatal overdose events.

Results: Of 1084 opioid-involved overdose fatalities analyzed, bystanders were present in 44.7% of cases. Most fatal overdoses occurred in housing environments (84.5%), where the widest disparity between bystander presence (61.1%) and naloxone administration (29.0%) was observed. In multivariable analysis, naloxone was more likely to be administered in overdoses occurring in outdoor spaces (adjusted prevalence ratio [adjPR] = 1.50, 95% CI: 1.07-2.02), hotels/motels (adjPR=1.57, CI: 1.12-2.21), businesses (adjPR=1.89, CI: 1.14-3.12), and motor vehicles (adjPR=2.00, CI: 1.18-3.38), relative to overdoses in housing environments. Naloxone administration clustered in younger decedents (10-year decrements: adjPR=1.10, CI: 1.01-1.20) and persons experiencing homelessness (adjPR=1.67, CI: 1.23-2.26).

Conclusion: Fatal opioid-involved overdoses in housing environments were more likely to have community bystanders present but less likely to have responders intervene with naloxone. Equipping families and cohabitants with the tools, resources, and self-efficacy for earlier, timelier naloxone intervention may address overdose fatalities in Rhode Island.