Journal of Addiction Medicine最新文献

Objective: Illicitly manufactured fentanyl has largely replaced heroin throughout the United States. Characteristics of fentanyl-specific withdrawal are not well understood compared to traditional opioid withdrawal. This study examines opioid withdrawal severity among 2 cohorts of study participants who underwent identical morphine stabilization procedures before and after fentanyl was introduced to the local drug market.

Methods: The Non-Fentanyl study (n = 103) included participants testing positive for non-fentanyl opioids, and the Fentanyl study (n = 30) included participants testing positive for fentanyl. Both studies completed a 7-day morphine stabilization protocol (30 mg subcutaneous, 4 times daily) and multiple daily self-report and observer-rated assessments of opioid withdrawal and vital signs. Two-way repeated-measures analyses of variance (ANOVAs) examined the effects of study, time, and study × time on daily peak ratings for each outcome.

Results: There were significant elevations in self-report and observer-rated withdrawal scores among the Fentanyl versus Non-Fentanyl study (study × time, P < 0.05) during stabilization days 2-5 and days 2-6, respectively. There was a higher rate of tachycardia among the Fentanyl group compared to the Non-Fentanyl study, and peak diastolic blood pressure was greater among the Fentanyl study compared to the Non-Fentanyl study.

Conclusions: Individuals with fentanyl exposure were less stabilized by morphine and experienced more severe opioid withdrawal via several metrics compared to persons with non-fentanyl opioid exposure. Withdrawal also remained elevated for several days despite morphine initiation. Adjustments to existing treatment induction protocols may be needed given the permeation of fentanyl into the heroin supply.

Objectives: We conducted a systematic review and meta-analysis (PROSPERO ID: CRD42023401796) of randomized placebo-controlled trials evaluating the effectiveness and safety of naltrexone as a standalone pharmacotherapy for amphetamine-type stimulant use disorder (ATSUD).

Methods: We searched EMBASE, MEDLINE, EBM Reviews, PsycINFO, CINAHL, Google Scholar, and trial registries on April 11, 2023, and updated on September 24, 2024, to identify randomized placebo-controlled trials evaluating the effectiveness of naltrexone for the treatment of ATSUD. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines were followed for reporting the study. Risk of bias and quality of evidence were assessed with the Cochrane Risk-of-bias Assessment tool and the Grading of Recommendations, Assessment, Development, and Evaluation. Risk ratios (RRs) or Peto odds ratio were estimated for binary outcomes as appropriate. Standardized mean differences were calculated for continuous outcomes.

Results: Five studies (n = 419 participants) were eligible. We found no significant difference between naltrexone and placebo for amphetamine-type stimulant use (RR = 0.903, 95% confidence interval [CI] = 0.698 to 1.167, P = 0.44, I2 = 96.1%; 4 studies), study retention (RR = 1.055, 95% CI = 0.942 to 1.182, P = 0.35, I2 = 45.0%; 4 studies), end-of-treatment craving (standardized mean difference = 0.069, 95% CI = -0.272 to 0.410, P = 0.69, I2 = 0.0%; 2 studies), and serious adverse events (odds ratio = 1.086, 95% CI = 0.414 to 2.849, P = 0.87, I2 = 0.0%; 3 studies). The quality of evidence was low to very low.

Conclusions: The available evidence does not support the use of standalone naltrexone to treat ATSUD. Significant research efforts must be put toward to identify effective pharmacotherapies to complement psychosocial interventions for ATSUD.

Background: Buprenorphine and methadone are US Food and Drug Administration-approved medications for opioid use disorder (MOUD). Although utilization of MOUD was increasing pre-COVID-19, it is not well understood how this trend shifted during and "after" the COVID-19 pandemic in Rhode Island. This analysis will consider the differential utilization of MOUD over time and by key demographic factors.

Methods: We utilized two of Rhode Island's statewide databases to examine aggregate counts of dispensed buprenorphine and methadone from January 1, 2017, to December 31, 2023. Data were stratified by age group, sex assigned at birth, and race/ethnicity (where available). Counts were stratified into pre-COVID-19 (Q1 2017-Q1 2020), COVID-19 (Q2 2020-Q4 2022), and endemic COVID-19 (2023) eras. Averages and annualized percent change for each period were calculated to understand how utilization changed over time.

Results: Before COVID-19, buprenorphine and methadone utilization were increasing annually. During COVID-19, utilization declined annually by 0.40% and 0.43%, respectively. In the endemic COVID-19 time period, buprenorphine and methadone utilization declined more rapidly at 2.59% and 1.77%, respectively. Declines were more dramatic for adults aged 18-34.

Conclusions: We observed a decline in MOUD utilization during and after COVID-19 in Rhode Island, primarily driven by substantial decreases in MOUD use among the youngest group of adult residents. Interventions specifically tailored to youth, such as school-based or primary healthcare-based programs, may be particularly effective in engaging with youth in substance use disorder treatment.

Objectives: The study sought to describe the association between alcohol-related conditions (ARCs) and long-term opioid therapy (LTOT) dose trajectories among patients with chronic pain. We explored if ARCs moderated the association between LTOT tapers and mortality.

Methods: We conducted a retrospective cohort study of 3912 patients receiving LTOT. The association of ARCs before initiating LTOT with subsequent LTOT dose trajectories (increasing, decreasing, stable) was assessed using multinomial regression models. The association of LTOT trajectories with subsequently diagnosed new (incident) ARC was assessed using competing risks regression models. Lastly, we explored whether ARCs moderated the association between LTOT trajectories and all-cause mortality using Cox-proportional hazards models.

Results: Overall, 6.2% (n = 244) of patients receiving LTOT were diagnosed with an ARC prior to initiating LTOT. There was no association between an ARC prior to LTOT initiation with subsequent LTOT trajectory. Among patients without an ARC diagnosis before initiating LTOT, newly diagnosed ARCs were made in 1.3% (n = 50) of patients. Patients in the decreasing LTOT trajectory were twice as likely to be diagnosed with new ARCs compared to those in the stable LTOT trajectory (adjusted hazard ratio, 2.23 [95% CI, 1.15-4.29]). The presence of ARCs did not significantly moderate the relationship between LTOT trajectories and mortality risk.

Conclusions: Patients in the decreasing LTOT trajectory are at a higher risk of developing a new ARC. Implementing routine alcohol use screening among patients with LTOT taper would enable early identification for alcohol use. Interventions to reduce alcohol use may mitigate harms associated with LTOT taper.

Abstract: Climate change and the opioid epidemic in combination may pose significant challenges for individuals with opioid use disorder due to potential disruptions in access to essential addiction treatment services caused by extreme weather events. Despite concerns over the escalating health impacts of climate change, limited research has documented and explored the vulnerability of patients enrolled in opioid treatment programs to disruptions caused by climate change and particularly extreme cold events. In this commentary, we describe the impact of a catastrophic flooding event during record-setting cold temperatures at an opioid treatment program in Seattle, WA. By examining this event, we highlight the potential vulnerabilities the methadone treatment infrastructure faces regarding climate change and future extreme weather events. In doing so, we hope to draw attention to a critical need for research that describes, plans for, and addresses disruptions to opioid use disorder treatment resulting from climate change-related weather events.

Introduction: The US age-adjusted drug overdose rate increased by 298%, with fentanyl being the main contributor to drug overdose deaths. The contribution of kratom to drug overdoses or intoxication is seldom reported despite its increasing use and detection among overdose decedents.

Methods: Our cross-sectional study utilized deidentified data from the Florida Department of Law Enforcement, 2020-2021 (N = 30,845). The medical examiners ascertained the exposures of interest (kratom, opioids, and other substances) and the outcome variable of drug intoxication-related mortality (DIRM) through autopsies and toxicology results. DIRM refers to any death from a substance identified as drug toxicity or intoxication. We used regression modeling to examine the association of exposure with DIRM.

Results: Five hundred fifty-one cases were confirmed kratom (mitragynine) exposures. More males died of DIRM (81.5%), primarily White (95.1%) and 35-44 years old (40.5%). Among mitragynine exposures, 484 (87.8%) died of DIRM; 36 decedents (6.5%) used kratom as the sole substance, and 515 (93%) used multiple substances; 437 (79.3%) used at least 1 opioid. The odds of dying of DIRM were 7.6 times higher among those mitragynine exposed compared with non-mitragynine exposed (univariate model) and 5.6 times higher after adjusting for confounders (multivariate model) (adjusted odds ratio = 5.6; 95% confidence interval, 4.1-7; P < 0.001). Opioid use increased the odds of dying of DIRM (adjusted odds ratio = 11.7; 95% confidence interval, 10.9-12.7; P < 0.001).

Conclusion: Our results indicate that dozens of decedents died of kratom (mitragynine) exposures alone, which has safety implications. Co-using opioids with kratom further increased the odds of dying of DIRM, indicating that kratom may not always work as a harm-reduction agent.

Objectives: This study aims to explore the impact of telehealth on buprenorphine prescribing and retention in care for patients with opioid use disorder (OUD) seen at a large federally qualified health center (FQHC) the year prior to and following the start of the COVID-19 pandemic.

Methods: We conducted a retrospective study of patients with OUD and at least one medical visit to the FQHC between March 1, 2019, and February 28, 2021. This study utilized March 1, 2020, to delineate the beginning of COVID as the FQHC widely instituted telehealth during the month in response to the pandemic. We examined buprenorphine prescribing before and during year 1 of the pandemic; we applied logistic regression to estimate the association between telehealth and buprenorphine prescribing and we assessed buprenorphine retention through survival analysis.

Results: In the year before COVID, 24% of patients (502/2090) received buprenorphine compared with 31% (656/2110) during the first year of COVID ( P < 0.01). Patients with at least one telehealth visit were three times more likely to receive buprenorphine compared to those without telehealth (odds ratio: 3.2, confidence interval: 2.1-5.0). Among those who received buprenorphine, those with at least one telehealth visit were retained in buprenorphine care longer (hazard ratio: 2.7, confidence interval: 1.8-3.9).

Conclusions: During the first year of COVID, telehealth was associated with increased likelihood that patients received buprenorphine; those who had telehealth remained in buprenorphine care longer compared to those who only had office-based visits. Increasing buprenorphine access through telehealth can play a significant role in retention in care for OUD.

Objectives: Naltrexone for alcohol reduction has been poorly studied in women with HIV (WWH), for whom heavy alcohol use is associated with negative HIV outcomes. This study offers recommendations for researchers conducting alcohol pharmacotherapy trials among PWH as suggested by WWH who participated in an alcohol pharmacotherapy trial in Florida.

Methods: The WHAT-IF? Study enrolled WWH with a history of heavy alcohol use in Miami, Florida, into a clinical trial where participants were randomized to receive naltrexone or placebo to assess effectiveness among WWH. Twenty participants (mean age, 49 years; 85% Black/African American) completed interviews that included questions about barriers to participation and recommendations for future researchers and WWH. Interviews were analyzed using a reflexive thematic approach.

Results: We identified six recommendations: 1) increasing opportunities for study engagement, 2) fostering positive relationships to support change, 3) addressing medication concerns, 4) considering structural barriers to participation, 5) improving alcohol-related education, and 6) preventing fraudulent participation. Positive relationships included both study staff and external support. Medication concerns included cost, accessibility, and adherence. Structural barriers included transportation, substance use, and mental health conditions. Better education included information on the risks of alcohol use and encouraging women to quit. Overall, women reported having positive experiences in the WHAT-IF? trial, and many recommended that the study continue.

Conclusion: Future alcohol pharmacotherapy studies could consider these recommendations when working with women from underserved communities, including WWH. Additionally, these recommendations could be applied to increase alcohol pharmacotherapy uptake and adherence in clinical practice.

Introduction: There is an urgent need to improve the identification of psychosocial vulnerabilities in clinical practice (eg, stress, unstable living conditions) and examine their contribution to prenatal substance use, especially for legal substances such as alcohol, tobacco, and recently, cannabis.

Methods: We conducted a retrospective chart review of 1842 patients who completed the PROMOTE screening instrument during their first prenatal visit to outpatient clinics of a New York State health system in 6/2019-11/2020. The PROMOTE includes 18 core items to assess psychosocial vulnerabilities including the NIDA Quick Screen assessing past year substance use. Outcomes were tobacco, cannabis, and alcohol use during pregnancy based on electronic medical record abstraction including clinical notes, self-report, or urine toxicology.

Results: A total of 188 (10.2%) patients used at least 1 substance prenatally, including 132 (7.2%) tobacco, 50 (2.7%) cannabis, and 45 (2.4%) alcohol. Two of the NIDA Quick Screen items (past year tobacco use and past year illegal drug use) were associated in the bivariate analysis with greater use risk of all 3 substances. Additional risk factors uniquely associated with specific prenatal substance use variables include low education predicting tobacco use (adjusted odds ratio [AOR] = 2.74, 95% confidence interval [CI] = 1.43-5.23), being unpartnered predicting cannabis use (AOR = 3.37, 95% CI = 1.21-9.39), and major life events predicting alcohol use (AOR = 3.25, 95% CI = 1.439-7.38).

Conclusions: Utilizing brief psychosocial self-screening instruments such as the PROMOTE can help identify and refer at-risk patients to appropriate care. Particular attention should be paid to life context including partner support, emotional health, stress, and past year substance use.

Objectives: Most US treatment and recovery services are abstinence-based. However, many people in recovery from an alcohol or other drug (AOD) use problem do not abstain completely. This study estimated the prevalence of and characteristics associated with nonabstinence among US adults in recovery.

Methods: Nonabstinence-operationalized as past-month use of alcohol, illicit drugs, or nonmedical use of prescription drugs-was estimated among a sample of 3763 US adults in self-identified recovery from the 2022 National Survey on Drug Use and Health, weighted to be nationally representative. Multivariable logistic regression identified factors associated with nonabstinence.

Results: An estimated 65.2% (95% confidence interval [CI] = 62.6-67.8) of adults in self-identified recovery reported past-month AOD use. Half (50.8%) reported alcohol use, and one-third (33.2%) reported cannabis use. Females had lower odds of use than males (adjusted odds ratio [AOR] = 0.73, 95% CI = 0.54-0.99), and lesbian/gay-identified individuals had greater odds of use than heterosexual/straight-identified individuals (AOR = 2.39, 95% CI = 1.13-5.07). Greater religiosity (AOR = 0.90, 0.84-0.96) and mutual aid attendance (AOR = 0.16, 95% CI = 0.06-0.27) were associated with lower odds of use. Significant differences were not detected for self-reported health, psychological distress, and other measures of functioning. However, relative to those without a past-year substance use disorder (SUD), odds of nonabstinence were greater among those with one mild (AOR = 14.60, 9.05-23.55), one moderate or severe (AOR = 13.05, 7.06-24.14), and multiple (AOR = 23.33, 10.59-51.37) past-year SUDs.

Conclusions: Most US adults who self-identified as in recovery from an AOD use problem were nonabstinent. Treatment and recovery services may improve engagement and outcomes by supporting nonabstinent goals.