Journal of Addiction Medicine最新文献

Background: Xylazine is not approved for human use, yet it has emerged as a common adulterant of illicit fentanyl. It is currently unclear whether there is a withdrawal syndrome associated with xylazine and the potential impact of fentanyl coexposure.

Methods: A retrospective cohort study of patients with opioid use disorder admitted to an inpatient medically monitored withdrawal facility was performed. Patients positive for fentanyl were compared to patients copositive for fentanyl and xylazine. Outcomes were self-directed discharge and completion of treatment. Independent variables included Clinical Opioid Withdrawal Scale (COWS) scores, heart rate, and blood pressure. Associations between individuals with or without xylazine were measured.

Results: Among 71 patients admitted for opioid withdrawal management positive for fentanyl, 51.4% were copositive with xylazine. There was no difference detected in average COWS scores (P = 0.12-0.78) or average heart rate (P = 0.33-0.80) between groups. Xylazine copositive patients had higher average systolic blood pressure on days 1 (129.0 vs 123.0, P = 0.01) and 2 (127.9 vs 116.3, P = 0.04) although unclear if clinically meaningful. Individuals copositive for xylazine were less likely to complete treatment (43.2% vs 55.9%, P = 0.23) and more likely to have self-directed discharge (67.6% vs 44.1%; OR, 2.64; 95% CI, 1.0-6.9) although not statistically significant.

Conclusions: Among 71 patients admitted for medically monitored withdrawal, individuals who were copositive for xylazine at the time of admission had higher average blood pressure and were more likely to have a self-directed discharge. Additional research is needed to determine the impact of xylazine on withdrawal.

Objectives: The objectives of this study were to i) provide population-level prevalence rates of pregnancy, birth, elective termination, and miscarriage among females treated for SUDs and their demographic counterparts and ii) examine associations between SUD treatment and pregnancy and elective terminations.

Methods: Data were analyzed from a prospective registry-linkage study of all females (15-45 years) recorded as treated for SUDs in the Norwegian Patient Registry over a 2-year period (n = 6470) and a non-treated frequency-matched cohort of females from the general population (n = 6286). Pregnancy and pregnancy outcomes over a 4-year follow-up were retrieved from the Norwegian Patient Registry. Multivariable logistic regression models tested for associations of SUD treatment with pregnancy and with elective termination among pregnant females.

Results: Annual pregnancy and elective termination rates per 1000 females were significantly higher for the SUD cohort than the non-treated cohort (94.2 vs 71.3 for pregnancy, P < 0.001; 54.7 vs 17.8 for elective termination, P < 0.001), the annual birth rate was lower for the SUD cohort (25.3 vs 41.8, P < 0.001), and the rate of miscarriage did not differ across cohorts. Multivariable analysis showed that SUD treatment was associated with a significant increase in the odds of pregnancy (adjusted Odds Ratio 1.34, Confidence Interval [1.18-1.54]) and the odds of an elective termination, conditional on pregnancy (aOR 2.55, Confidence Interval [1.97-3.29]).

Conclusions: Females treated for SUDs had substantially higher odds of pregnancy and elective terminations than the non-treated cohort. To improve their reproductive health, targeted interventions such as free long-acting contraception and integration of family planning guidance into substance use treatment should be considered.

Objectives: The aim of this study is to determine the difference, if any, in prevalence of wounds in individuals who were exposed to xylazine and fentanyl compared to individuals who were exposed to fentanyl and not xylazine.

Methods: A large inpatient substance use disorder specialty hospital provided medical records over an 8-month period from July 2023 to February 2024. Individuals were admitted to an American Society of Addiction Medicine 3.7 level of care where a urine drug screen and skin assessment was conducted on admission. If the urine screen noted a presence of fentanyl, the sample was then tested for xylazine exposure. Patients were considered positive for wounds on admission to treatment if any wound was noted during the skin assessment during the admission process.

Results: A total of 282 medical records were identified. A chi square test of association was completed and revealed a statistically significant association between xylazine exposure and wounds (P = 0.002, odds ratio = 2.420, 95% confidence interval = 1.376-4.254).

Conclusions: This study provides early support for the previously theorized connection between xylazine exposure and wounds.

Objectives: The US Food and Drug Administration (FDA) issued a warning about buprenorphine-induced dental caries of unknown mechanism in 2022. To investigate the potential mechanism, the association between local buprenorphine exposure and dental biofilm formation will be explored in this study.

Methods: Female F344 rats were dosed with sublingual buprenorphine film or intravenous injection to explore the oral cavity exposure of the buprenorphine. The buprenorphine distribution in salivary glands after the sublingual and intravenous administration was also evaluated. To investigate the effects of buprenorphine exposure on dental caries formation, buprenorphine's impact on the biofilm formation of S. mutans in vitro was measured.

Results: The absolute sublingual bioavailability of buprenorphine in rats was 17.8% with a high ratio of oral fluid exposure to blood concentration in the pharmacokinetic study. Salivary gland concentrations of buprenorphine and its active metabolite norbuprenorphine were significantly higher than their blood concentrations after both sublingual (s.l.) and intravenous (i.v.) administration. Correlation analysis showed that the oral fluid concentration of buprenorphine and norbuprenorphine was highly correlated to salivary gland concentration rather than blood concentration. These data indicate that the salivary gland serves as an accumulation organ for buprenorphine, allowing prolonged oral fluid exposure to buprenorphine. Lastly, buprenorphine and its metabolites contributed to the biofilm formation of S. mutans in high concentration.

Conclusions: Sublingual administration substantially increased the salivary gland distribution of buprenorphine and norbuprenorphine. Depot effects following sublingual dosing and salivary gland accumulation likely sustained high oral fluid exposure to buprenorphine and stimulated the biofilm formation of S. mutans.

Abstract: Phosphatidylethanol (PEth) testing is becoming increasingly common as a tool to assess for alcohol consumption in the practice of addiction medicine. Its potential to be an objective measure of ethanol exposure is appealing; however, the field has yet to develop a complete understanding of the factors that can influence a PEth level. Here we describe 3 patient cases in which blood transfusion within the preceding 28 days was the reason that PEth studies were positive in patients undergoing liver transplant evaluation. These patients all had in-depth evaluations by physicians on an addiction medicine consult service and were believed abstinent from alcohol. In the field of liver transplant, even a mildly elevated PEth level can result in listing delay or even liver transplant candidacy denial. Further study is needed to understand how PEth is impacted by medical procedures and events such as blood transfusion if we are to maintain a just and ethical practice in the setting of addiction and transplant medicine.

Objectives: This article describes the development and evaluation of the Global Appraisal of Individual Needs Quick Version 4 (GAIN-Q4) for the American Society of Addiction Medicine (ASAM) 4th edition patient placement dimension ratings and level of care placement recommendations. The research questions are as follows: (1) Can the GAIN-Q4 replicate recommendations from the prior longer instrument within adolescents and adults? (2) What are the substantive differences in the results by age?

Methods: The 35- to 45-minute GAIN-Q4 was developed through modification of the GAIN-Q3 and evaluated in terms of its ability to predict ASAM dimensional ratings and level of care placement recommendations from the 60- to 120-minute GAIN-I instrument. Data were obtained from participants who are adolescents aged 12 to 17 years (n = 101,897) and adults 18 years and older (n = 204,711) interviewed between 2002 and 2018 across 530 US sites. Reliability between measures was assessed with Cohen's κ statistic within age group; substantive differences by age were evaluated with logistic regression and χ2.

Results: The ability of the 35- to 45-minute GAIN-Q4 measure to predict ASAM 6 dimensional ratings from the 60- to 120-minute GAIN-I was excellent (κ > 0.8) for 4 dimensions, good (0.6-0.79) for 1, and fair for 1 (0.4-0.59) - both for adolescents and young adults. κ for general level of care placement to ASAM levels of care was excellent for both adolescents and young adults.

Conclusions: The GAIN-Q4 demonstrates the ability to predict ASAM dimensional ratings and general level of care placement reliably when compared to the lengthier GAIN-I measure. These results highlight that clinicians using the GAIN-Q4 measure will be equipped to evaluate patients from a wide variety of sources with an accurate and reliable screening tool.

Abstract: Alcohol withdrawal syndrome is most frequently treated with benzodiazepines, but due to their short half-life, tapering prescriptions are frequently required for outpatients, which presents challenges to both clinicians and patients. Our local health system has had significant success treating alcohol withdrawal in the emergency department with phenobarbital loading doses. As patients also present in alcohol withdrawal to our outpatient addictions clinic, we have adapted our emergency department intravenous protocol to a staggered, oral loading protocol for the treatment of mild and moderate alcohol withdrawal syndrome in the community setting. In this case report, we successfully treat a 36-year-old man with mild alcohol withdrawal symptoms using this approach and without requiring a tapering sedative prescription.