Journal of Addiction Medicine最新文献

Xylazine, an alpha-2 adrenergic agonist veterinary sedative, has emerged as a frequent adulterant in illicit opioids, contributing to the ongoing "tranq dope" crisis. Its effects on human pregnancy are largely unknown, posing new challenges in obstetric addiction medicine. We present the case of a 25-year-old woman (G4P2113) with opioid use disorder who unknowingly used fentanyl adulterated with xylazine throughout pregnancy. She developed preeclampsia with HELLP syndrome, requiring urgent preterm cesarean delivery at 34 weeks. The neonate was treated for neonatal abstinence syndrome. Four days postpartum, the patient-discharged without medication for opioid use disorder-suffered intractable vomiting from withdrawal, leading to a Mallory-Weiss tear with massive hemorrhage and cardiac arrest. She required intensive care with transfusions, endoscopic hemostasis, and mechanical ventilation. Upon extubation, she disclosed fentanyl-xylazine ("tranq") use. She was transitioned to buprenorphine maintenance with supportive care for xylazine withdrawal and discharged in improved condition. We review the sparse human literature on xylazine exposure in pregnancy and relevant animal studies. Human data confirm placental transfer of xylazine, with umbilical cord assays detecting exposure, and suggest that xylazine may contribute to maternal CNS depression and neonatal sedation. Animal models demonstrate dose-dependent uterine vasoconstriction, reduced uteroplacental blood flow, fetal growth restriction, and pregnancy loss. We discuss management considerations for pregnant patients using xylazine-adulterated opioids, including challenges in diagnosis, withdrawal management, and the need for expanded harm-reduction strategies. This case and review highlight the urgent need for surveillance and evidence-based protocols to address xylazine in the perinatal setting.

Objectives: In contrast to methadone, buprenorphine is susceptible to precipitated withdrawal complicated by fentanyl in the unregulated opioid supply. The objective of this study was to examine associations between drug supply characteristics and the prevalence of precipitated withdrawal.

Methods: We conducted a cross-sectional analysis of a cohort study during 2023-2025 among people with a lifetime history of buprenorphine or methadone treatment currently using a drug checking program. Explanatory variables included drug supply, health care, and treatment characteristics. The primary outcome was a self-reported lifetime history of precipitated withdrawal during a buprenorphine induction. Binomial linear regression models were used to calculate prevalence ratios with 95% CIs.

Results: Among 234 people, 64% were men, 67% were non-Hispanic white, 41 was the median age, 94% reported a history of fentanyl use, 92% had a history of methadone treatment, and 68% had a history of buprenorphine treatment. Among those with a history of buprenorphine treatment, 29% reported precipitated withdrawal during buprenorphine inductions, of which 67% occurred when starting via outpatient pathways. Buprenorphine-associated precipitated withdrawal was slightly higher among those with recent xylazine use compared with those without (32% vs 22%, prevalence ratio: 2.10, 95% CI: 0.94, 4.67). People with recent buprenorphine inductions commonly started without clinical or social support (63%) or used standard dosing (53%).

Conclusions: Buprenorphine-associated precipitated withdrawal was commonly reported. Improved guidance and treatment approaches should be prioritized to minimize these complications, particularly in outpatient settings.

Objectives: Substance use disorder (SUD) affects critically ill patients before, during, and after their intensive care unit (ICU) stay. Medicaid is the primary payor for patients with SUD and an increasing number of ICU stays; however, little is known about the prevalence of SUD among Medicaid-covered ICU beneficiaries.

Methods: Using Medicaid claims from Virginia in 2023-2024, we examined the prevalence of SUD, demographic characteristics, specific types of SUD, and SUD-related characteristics among Medicaid beneficiaries ages 18-64 with an ICU and compared these ICU beneficiaries to 2 groups: beneficiaries with a non-ICU hospitalization and beneficiaries with no acute hospitalizations.

Results: Nearly half of Medicaid ICU beneficiaries have a SUD [49.2% (95% CI: 48.3-50.1)], over 8 times higher than general Medicaid and >20% higher than beneficiaries with non-ICU hospitalizations. Almost one in 5 ICU beneficiaries [19.2% (95% CI: 18.3%-19.8%)] had a stay for overdose or withdrawal, twice the rate of Medicaid beneficiaries with a non-ICU hospitalization. SUD was more prevalent among beneficiaries with an ICU hospitalization across most beneficiary demographic characteristics and types of SUD with alcohol and "other" (polysubstance/unknown) SUD relatively greater among beneficiaries with an ICU hospitalization compared with beneficiaries with non-ICU hospitalizations and all beneficiaries.

Conclusions: SUD is highly prevalent among Medicaid beneficiaries with an ICU hospitalization. Further studies are required to understand the needs of critically ill patients with SUD. Efforts by Medicaid and managed care organizations to promote SUD treatment during hospitalization may improve the long-term recovery of critically ill patients.

Objectives: Opioid use disorder (OUD) and overdose among pregnant and postpartum women pose severe risks to maternal and infant health. Naloxone, a life-saving opioid antagonist, effectively reverses opioid overdoses but remains underutilized in this population. We examined naloxone prescription or receipt and administration during overdose events among perinatal women with OUD from the MATernaL and Infant Clinical NetworK (MAT-LINK).

Methods: We analyzed data collected through 7 MAT-LINK clinical sites from pregnant women with OUD and known pregnancy outcomes between January 1, 2014 and August 31, 2021. Outcomes included naloxone prescriptions and naloxone administration during overdose events during pregnancy or within 12 months postpartum (perinatal period). Weighted prevalence estimates and confidence intervals were calculated by demographic characteristics, substances involved in overdoses, and receipt of medications for opioid use disorder (MOUD).

Results: Only 3.1% of women received a naloxone prescription during the perinatal period; the percentage of women receiving naloxone from the clinic without a prescription was unknown and not systematically captured in the data. Women experiencing overdose events most commonly were non-Hispanic, white, had public health insurance, and lived in urban areas, reflecting the demographic composition of the MAT-LINK cohort, with high co-occurrence of tobacco/nicotine (80.5%) and stimulant use disorders (59.2%). Among women who experienced an opioid-involved overdose event, 23.4% were not administered naloxone. No significant demographic differences were observed by naloxone administration.

Conclusions: These findings highlight the need for further investigation into barriers and facilitators to naloxone clinical documentation, access, and use during the perinatal period.

Objectives: iSTEP-N is a novel, bioresorbable, subcutaneous implant designed to release naltrexone for 6-12 months after a single procedure and improve adherence. This first-in-human study evaluated the safety and pharmacokinetics of iSTEP-N.

Methods: This was a single-center, randomized, double-blind, placebo-controlled, single-ascending-dose trial. Sixteen healthy adults (6 females and 10 males) were assigned to receive either 1 implant (4.8 g naltrexone), 2 implants (9.6 g naltrexone), or placebo implants. Participants were followed for 12 weeks, after which implants were removed per regulatory requirement. Plasma naltrexone concentrations and safety outcomes were assessed throughout.

Results: All participants completed the study. The 9.6 g cohort maintained mean plasma naltrexone concentrations above the 2.0 ng/mL opioid blockade threshold from Tmax at 10 hours through the end of the study at 12 weeks; no mean value fell below 2.8 ng/mL during this time. The 4.8 g cohort maintained therapeutic levels of naltrexone through week 6 but dropped below threshold thereafter. In both cohorts, ∼22% of implant drug content was released over 12 weeks, based on plasma exposure and estimated clearance, indicating potential for extended coverage. In the 9.6 g group, seroma formation was observed in 3 of 6 participants (50%) and resolved without intervention. No serious adverse events occurred.

Conclusions: At the 9.6 g dose, iSTEP-N provided sustained therapeutic naltrexone exposure for 12 weeks with a favorable safety profile, while releasing less than one-fourth of its drug content. Further studies will evaluate longer-term exposure, safety, and clinical feasibility in individuals with opioid use disorder.

Objectives: Kratom is now widely available in the United States, yet epidemiological data remain sparse. This study examined the prevalence and correlates of kratom use among adults in the civilian noninstitutionalized US population using the most recent National Survey on Drug Use and Health (NSDUH) data.

Methods: Data from the 2021-2023 NSDUH were limited to adults aged 18+ years (n = 139,524). Weighted prevalence estimates were calculated overall, by year, and by demographic and clinical characteristics. Logistic regression models were used to examine correlates of past-year kratom use.

Results: The combined (2021-2023) weighted prevalence of past-year kratom use among US adults was 0.68% (95% CI, 0.60%-0.77%), remaining stable across survey years. Kratom use was more common among males, adults aged 26-49, and non-Hispanic white or multiracial adults. Prevalence exceeded 2% among adults reporting serious psychological distress or a major depressive episode, and exceeded 5% among those reporting certain types of substance use or prescription medication misuse. In covariate-adjusted analyses, higher odds of kratom use were observed among men, adults aged 35-49 years, and those reporting prescription pain reliever use or misuse, as well as cigarette, cannabis, and ketamine use, whereas lower odds were observed among black and Hispanic adults compared with white adults.

Conclusions: Kratom use among adults in the United States was relatively stable between years 2021 and 2023 and concentrated among individuals with reported psychological distress and substance use. Future studies should include more comprehensive assessments of kratom use, and screening for kratom use in high-risk clinical populations may be warranted.

Objectives: Fentanyl test strips (FTS) have the potential to moderate drug use behavior amidst an unregulated drug supply, yet are underutilized in medical settings. We aimed to describe emergency department (ED) FTS distribution across a large NYC health system and examine characteristics associated with clinicians' ordering FTS compared with the current standard-of-care, take-home naloxone (THN), to identify opportunities to optimize FTS distribution.

Methods: We conducted a retrospective review of THN and FTS provision across a large urban health system in its first year of FTS distribution. We evaluated the demographic and clinical characteristics of visits in which clinicians ordered FTS, compared with THN only.

Results: From July 20, 2022 to July 20, 2023, 237 (of 423) clinicians ordered THN for 1279 unique individuals in 1376 eligible visits (436 with FTS, 940 without). In pairwise analysis, FTS receipt was associated with being male, younger, non-White, lacking commercial insurance; substance-related or overdose-related visit chief complaint or diagnosis, attending physician, and patient-directed discharge ( P <0.05 for each). In multivariable regression, higher odds of FTS receipt were associated with male gender (OR=2.4; 95% CI=1.8-3.5), a substance-related chief complaint (OR=2.0; 95% CI=1.2-3.2) or visit diagnosis (OR=5.5; 95% CI=3.8-8.0), and overdose visit diagnosis (OR=1.7; 95% CI=1.1-2.8). Lower odds of FTS receipt were associated with older age (OR=0.98; 95% CI=0.97-0.99), noncommunity hospital sites (OR=0.71; 95% CI=0.60-0.83), and non-attending clinicians (OR=0.83; 95% CI=0.69-0.98).

Conclusions: Integrating FTS into an existing ED THN program was feasible without disrupting clinical workflow. ED encounters where FTS were dispensed differed significantly from THN-only, revealing opportunities to optimize FTS ordering.

Clinicians have prescribed benzodiazepines for a range of symptoms and conditions since the Food and Drug Administration approved chlordiazepoxide in 1960. Between 1969 and 1982, the benzodiazepine diazepam was the most prescribed medication in the United States. Since then, recognition of benzodiazepine's risks-such as falls, psychomotor and cognitive impairment, withdrawal, benzodiazepine use disorder (BzUD), and suicidality-and limited data on long-term safety and efficacy have created challenges for clinicians and patients, including when and how to safely taper these medications. In 2025, 10 professional societies, including the American Society of Addiction Medicine (ASAM), released the Joint Clinical Practice Guideline on Benzodiazepine Tapering. This commentary explores implications for addiction treatment.