Journal of Addiction Medicine最新文献

Objectives: Matching individuals to the appropriate substance use treatment level is related to treatment and other health outcomes. However, only 1 study has explored whether ASAM Criteria for placement ratings differ based on demographic or contextual factors. This study aims to determine if factors commonly related to treatment outcomes correlate with ASAM placement ratings.

Methods: This repeated cross-sectional study examined 1955 assessments of individuals served by Kentucky's Sobriety Treatment and Recovery Teams (START) program from 2013 to 2022. START serves parents referred to child welfare services because of substance use. Ordinal logistic regression was used to analyze the relationship between demographic factors and ASAM level of care recommendations.

Results: Over the study period, recommendations for intensive outpatient decreased, while recommendations for outpatient and inpatient/residential increased. The ordinal logistic regression model identifying correlates of ASAM level of care ratings found that age and being a woman were positively associated with the odds of being assessed as needing a higher level of care, whereas compared with White people, Black people and people of other races had lower odds of being recommended higher levels of care. The year of assessment and the county were also associated with ASAM recommendations.

Conclusions: Future studies should explore whether differences in ASAM ratings among racial groups are consistent across samples. If so, it will be critical for the field to understand whether these differences are driven predominantly by variations in substance use severity among racial groups or whether they represent underassessment among members of minoritized groups.

Objectives: Our group has previously established how remote on-body electrocardiogram (ECG) sensors may discriminate cocaine use from other sympathomimetic conditions. The current analyses assess whether discriminatory power is mainly driven by differences in heart rate between conditions.

Methods: Individuals who use cocaine (N = 11) wore ECG sensors during (1) cocaine self-administration, (2) methylphenidate administration, (3) aerobic exercise, and (4) tobacco use (N = 9). Primary outcomes included: (1) time elapsed between 2 successive R waves (ie, RR interval), (2) ECG interval proxies, and (3) waveforms. ECG traces were matched for heart rate between conditions for all discriminations.

Results: ECG interval proxies and waveforms exhibited high discriminatory power in distinguishing cocaine use from methylphenidate, exercise, and tobacco use, with mean areas under the receiver operating characteristics ranging from 0.87 to 0.99, while RR-related measures ranged from 0.49 to 0.5, reflecting low discriminatory power.

Conclusion: Our results suggest that the ECG sensors' discriminatory power is based on nuances in ECG data beyond mere changes in heart rate.

Objectives: Despite rising adolescent opioid overdose deaths, adolescents under the age of 18 years are frequently excluded from the provision of medication for opioid use disorder (MOUD/OUD). As part of preimplementation work to inform the expansion of evidence-based practices to close this service gap, we designed this qualitative study to examine the perspectives of MOUD-providing clinicians on barriers and facilitators to providing MOUD for adolescents younger than 18.

Methods: We recruited clinicians who reported prescribing MOUD at least once per month, purposively sampling to include individuals who varied on training and practice backgrounds, experience prescribing to adolescents younger than 18, and practice settings (urban, suburban, and rural). We performed semistructured interviews and subsequent qualitative thematic analysis of transcripts.

Results: Three major barriers emerged: (1) the overcomplicated, intimidating nature of MOUD training and regulations, (2) poor understanding of MOUD treatment recommendations and consent/confidentiality laws for adolescents younger than 18, and (3) negative, stigmatizing views of adolescents with substance use disorders and the perceived difficulty of treating them. Facilitators identified included: (1) treatment demystification with adolescent-specific OUD implementation protocols/training, (2) clinician-to-clinician peer messaging and encouragement, and (3) formal family and community-level education medicalizing addiction.

Conclusions: Significant barriers to prescribing MOUD to adolescents younger than 18 persist despite the removal of federal training requirements. Comprehensive, multilevel adolescent-specific MOUD education paired with may expand the MOUD-prescribing workforce and improve treatment access. Further research should continue to explore these themes to inform policy and practice reforms aimed at improving outcomes for adolescents affected by OUD.

Fentanyl, a potent synthetic opioid, has been linked to an increasing number of overdose deaths in the United States. It began replacing heroin in the illicit drug supply in 2013, and now contributes to both drug-related criminal offenses and the need for treatment. Its unique pharmacokinetics complicate the role of drug testing, which is a ubiquitous practice in both criminal justice and treatment settings. Still, there exists no clear consensus on the role of drug testing in clinical practice for patients involved in the criminal justice system. In this case report, we describe an adult female patient in outpatient addiction treatment for opioid use disorder who self-reported fentanyl abstinence while receiving medication for addiction treatment. The patient's drug test results remained positive for fentanyl and its metabolite, norfentanyl, for 95 days and 245 days. This case illustrates the challenges of relying on drug testing in the treatment of substance use disorders due to the lack of definitive interpretation guidelines for drug levels. In addition, it highlights the importance of advocacy and collaboration between treatment providers and third-party legal entities. It may provide guidance on the role of urine drug testing in substance use treatment, particularly for emerging substances with largely unknown metabolic properties.

Objectives: To evaluate infection management in people who inject drugs (PWID) who elect for self-directed discharge (SDD) and to identify characteristics associated with an oral antimicrobial therapy offer (OATO).

Methods: This was a retrospective cohort of hospitalized adult PWID with an injection drug use (IDU)-related infection who elected for SDD between January 1, 2014, to January 31, 2024, at a five-hospital health system in southeast Michigan. Patients were excluded if they were hospitalized for <24 hours or if antimicrobial treatment was completed before SDD. The primary outcome was the proportion of patients with an OATO at or before SDD. Secondary outcomes at 30 days included retreatment, infection-related readmission, and all-cause mortality.

Results: One hundred fifty patients were included; 55 (37%) received an OATO, 95 (63%) did not receive an offer. Patient outcomes were not different between the OATO and no offer groups: infection retreatment 19 (34%) versus 32 (34%); infection-related readmission 14 (25%) versus 31 (33%); and all-cause mortality 1 (2%) versus 3 (3%). In multivariable logistic regression, variables independently associated with OATO included prescribing/continuing medications for opioid use disorder (MOUD) (adjusted odds ratio [aOR], 2.8; 95% CI: 1.36-5.92), infection source control (aOR, 2.3; 95% CI: 1.10-4.84), and early-career clinician care (aOR, 2.8; 95% CI: 1.01-7.89).

Conclusions: Most hospitalized PWID with IDU-related infections with SDD did not receive an OATO. Early career clinicians more commonly offered oral antimicrobials in PWID with less complicated infection types. Standardizing OATO in PWID at risk for SDD should be considered as a future direction to improve health outcomes.

Postpartum depression is a serious, but treatable condition experienced after childbirth. While most cases do not involve excess substance use, alcohol and other substance use have been strongly associated with this condition. While serotonergic antidepressants have been a mainstay of pharmacologic therapy for postpartum depression, studies of antidepressant use in postpartum depression have largely excluded those with substance use disorder, and meta-analyses suggest antidepressants offer limited benefit in those with depression and co-occurring substance use disorder. There is also under-appreciated literature demonstrating the potential for a medication-mediated increase in substance use in some individuals taking serotonergic antidepressants. These facts and an examination of guideline recommendations on the treatment for postpartum depression highlight the need for new research and practice improvements for patients with comorbid substance use disorder and postpartum depression.

Buprenorphine is a partial opioid agonist effective for the treatment of opioid use disorder. However, precipitated opioid withdrawal remains a barrier to its initiation. As opioid use disorder and related complications continue at alarming rates, it is crucial to evaluate alternative means of initiating this lifesaving medication whenever patients interact with the health care system. In this case report, we discuss a patient who completed low-dose buprenorphine initiation while intubated and sedated in an intensive care setting, in the setting of recent chart documentation of a desire to initiate buprenorphine. Upon extubation, the patient elected to continue buprenorphine. We discuss potential advantages, ethical considerations, and patient perspectives related to initiating buprenorphine in this manner.

Background: Methadone, a mu-opioid receptor agonist, is one of 3 FDA-approved medications for opioid use disorder (OUD). Acute liver dysfunction can impair hepatic metabolism and increase sedation risk. Methadone can induce QT prolongation, which increases the risk of Torsades de Pointes, more commonly in patients on doses higher than 100 mg. Options for managing methadone-related QT prolongation include lowering the methadone dose or switching to buprenorphine, a partial mu-opioid agonist also FDA-approved for OUD. Precipitated withdrawal poses a challenge when transitioning from methadone to buprenorphine, and acute impaired hepatic metabolism of methadone contributes to uncertainty about how long clinicians must wait before initiating full-dose buprenorphine. Limited guidance exists on this transition.

Case summary: We report the case of a 37-year-old man with hepatitis C, alcohol use disorder, and OUD in long-term remission on methadone 210 mg daily who was transferred to a quaternary care center for liver transplant evaluation due to acute liver failure. On presentation, an EKG showed a QTc of 785 milliseconds prompting discontinuation of methadone. Oxycodone 10 mg every 6 hours as needed was started, with nearly full amelioration of withdrawal symptoms. Eleven days after the last methadone dose, and 12 hours after the last oxycodone dose, buprenorphine 8 mg SL was administered, and the patient experienced severe precipitated withdrawal.

Discussion: This case report highlights the challenge of estimating methadone half-life in a patient with severe acute liver dysfunction who needs to switch from methadone to buprenorphine. A buprenorphine low-dose induction strategy may reduce the risk and severity of precipitated withdrawal.

Objectives: To characterize patterns of outpatient buprenorphine induction and examine factors associated with the use of low-dose initiation (LDI).

Methods: A retrospective cohort study of 4510 adults initiating buprenorphine between January 1, 2016 and December 31, 2019 in British Columbia (BC), Canada, was undertaken using linked administrative data in the Provincial Overdose Cohort, which contains a 20% random sample of BC residents. Using multivariable modelling, we examined the association between sociodemographic, co-morbidity, treatment, and health service utilization variables, and the outcome of LDI. Joinpoint analysis was also conducted to assess inflection points in the prevalence of this practice.

Results: Overall, 7.2% of included buprenorphine inductions during the study period were classified as LDI. Joinpoint analysis revealed that the percentage of buprenorphine inductions classified as LDI increased significantly beginning in the fourth quarter of 2017. In multivariable analyses, factors positively associated with LDI included: older age (adjusted odds ratio [aOR]: 1.01, 95% CI: 1.00-1.02), living in Vancouver Coastal (aOR: 1.53, 95% CI: 1.13-2.06) and Fraser Health Authority regions (aOR: 2.56, 95% CI: 1.89-3.48) (vs interior region); having been prescribed slow-release oral morphine for opioid use disorder in the last 3 years (aOR: 4.03, 95% CI: 2.51-6.49), and having 1 (aOR: 2.40, 95% CI: 1.80-3.20) or ≥2 (vs 0) opioid agonist treatment episodes in the last 5 years (aOR: 2.56, 95% CI: 1.89-3.48). Factors negatively associated with microinduction included: male sex (aOR: 0.50, 95% CI:0.41-0.61), alcohol use disorder (aOR: 0.62, 95% CI: 0.40-0.96), injection drug use (aOR: 0.75, 95% CI: 0.61-0.94) and past-year incarceration (aOR: 0.19, 95% CI: 0.10-0.33).

Conclusions: The use of LDI has increased in BC in recent years. Markers of treatment experience were positively associated with receipt of LDI. A ssessment of outcomes associated with LDI is needed.