Journal of Addiction Medicine最新文献

Background: The dosing regimen in the package insert for sublingual buprenorphine is similar for pregnant and nonpregnant people despite the physiologic changes seen during pregnancy.

Aims: To compare plasma buprenorphine pharmacokinetics during and after pregnancy and relate buprenorphine concentration to the pharmacodynamic endpoints of pupil diameter, Clinical Opioid Withdrawal Scale (COWS), and craving scores.

Study design: Prospective cohort of 22 pregnant people undergoing 33 pharmacologic studies (6-8 hours each) during pregnancy or postpartum. Participants were on a stable daily dose of 2-8 mg sublingual buprenorphine every 6 or 8 hours. The dosing frequency was selected by the participant. On study day, baseline measurements of plasma buprenorphine, pupil diameter, COWS, and craving scores were obtained, then the usual morning dose was taken, and measurements were repeated several times over 1 dosing interval.

Findings: The dose-normalized area under the plasma buprenorphine concentration time curve was significantly (P = 0.036) lower during pregnancy (155 ± 52 ng × min/mL) than postpartum (218 ± 113 ng × min/mL). Buprenorphine trough concentrations were similar at the start (1.1 ± 0.7 ng/mL) and end of a dosing cycle (1.2 ± 0.8 ng/mL) regardless of dosing frequency. Pupillary diameter, COWS, and craving scores returned to baseline as buprenorphine concentrations approached ~1 ng/mL.

Conclusions: Pregnant people require a higher dose of buprenorphine to achieve concentrations comparable to nonpregnant people. There is a temporal relationship between the plasma buprenorphine concentration and the pharmacodynamic markers of pupillary diameter, COWS, and craving scores. An average plasma concentration of ~1 ng/mL was associated with the lowest level of COWS and craving scores.

Objectives: The aim of this study was to identify distinct trajectories of prescription opioid exposure in pregnancy-encompassing both medication for opioid use disorder (MOUD) and opioid analgesics-and explore their associations with birth outcomes.

Methods: Trajectories were identified using latent class analysis among Wisconsin Medicaid-insured live births 2011-2019. Logistic regression estimated associations between these trajectories and neonatal opioid withdrawal syndrome (NOWS), small for gestational age, preterm birth, birth weight, and gestational age.

Results: Of 138,123 births, 27,293 (19.8%) had prenatal opioid exposure. Five trajectory classes were identified: (1) stable MOUD treatment (5.8%), (2) inconsistent MOUD treatment (3.9%), (3) chronic analgesic use (4.2%), (4) intermittent analgesic use (7.8%), and (5) low-level use of MOUD and analgesics (78.3%). NOWS incidence per 1000 infants was 667 for class 1 (adjusted odds ratio [aOR]: 21.74, 95% confidence interval [CI]: 17.89, 26.41), 570 for class 2 (aOR: 15.35, 95% CI: 12.49, 18.87), 235 for class 3 (aOR: 19.42, 95% CI: 15.93, 23.68), 67 for class 4 (aOR: 6.23, 95% CI: 4.99, 7.76), and 12 for class 5 (aOR: 1.73, 95% CI: 1.47, 2.02). Classes 1-4 had elevated risk of small for gestational age, preterm birth, lower birth weight, and shorter gestational age, with no significant differences among these classes. Among individuals with opioid use disorder, stable MOUD treatment was associated with higher birth weights and longer gestational ages compared to inconsistent treatment, despite higher odds of NOWS.

Conclusions: Early initiation and consistent MOUD treatment may improve birth weight and gestational age. For pregnant individuals with opioid use disorder using chronic analgesics, transition to MOUD may promote birth outcomes.

Introduction: Cannabinoid hyperemesis syndrome is characterized by recurrent episodes of severe nausea and vomiting, often associated with prolonged and excessive cannabis use. With the recent legalization and rising consumption of cannabidiol (CBD) in Europe and the United States, concerns have emerged about its potential role in triggering similar symptoms.

Case report: A 32-year-old male with a history of cannabis, tobacco and alcohol use disorder experienced multiple cyclic vomiting episodes after switching from cannabis to CBD. Initially, the patient presented with abdominal pain and vomiting after ceasing cannabis use, with symptoms alleviated by hot showers. Three months later, similar symptoms reappeared despite abstinence from cannabis but regular CBD consumption. Over the next 6 months, recurrent episodes of abdominal pain and vomiting persisted with daily CBD use but no cannabis consumption. Clinical data, laboratory results, and treatment responses were analyzed to investigate the connection between CBD consumption and symptom onset.

Discussion: The pathophysiology of cannabis-induced cyclic vomiting is poorly understood. Hypotheses include tetrahydrocannabinol accumulation in adipose tissue, pyrolytic conversion of CBD into tetrahydrocannabinol, and CBD's intrinsic effects, particularly its interaction with transient receptor potential vanilloid 1 receptors. Our analysis suggests that high doses of CBD may activate transient receptor potential vanilloid 1 receptors, inducing proemetic effects.

Conclusions: Although the connection between CBD and cyclic vomiting remains uncertain, it warrants further investigation. The increasing use of CBD, perceived as a safe dietary supplement, underscores the need to understand its potential health impacts better.

Objective: Little is known about naloxone care practices for peripartum persons from the patient or provider perspectives. The objective of this study was to survey peripartum persons and providers about naloxone-related practices.

Methods: Individuals who had an OUD diagnosis during a pregnancy and Ohio healthcare professionals who provide care for peripartum patients with OUD and/or infants with prenatal exposure to opioids were eligible for this study. Patient experiences were assessed through a survey codeveloped with members with lived experience of opioid use disorder. Provider perspectives were examined through a survey codeveloped by the Ohio Perinatal Quality Collaborative. Descriptive statistics and logistic regression were used to examine the proportion of participants who received or provided naloxone care practices and the effect on having a naloxone kit during the perinatal period.

Results: Of the 100 peripartum participants with opioid use disorder, 24% reported receiving naloxone from their prenatal care provider and 48% reported ever having a naloxone kit during the perinatal period. Of the 63 maternal care provider participants, 32 (49%) reported discussing or prescribing naloxone to pregnant patients. Of the 62 pediatric provider participants, 10 (16%) reported that they provide naloxone information to parenting individuals of their patients.

Conclusion: Study results demonstrate critical gaps in naloxone care practices for peripartum persons, emphasizing the need for targeted interventions at the patient, clinician, practice, and system levels.

Objectives: The objectives of this study were to (1) survey obstetrical and pediatric clinicians' experience, confidence, and training in maternal and neonatal drug testing interpretation; (2) determine their proficiency in drug test interpretation; and (3) assess predictors of correct interpretation.

Methods: We conducted a cross-sectional survey of clinicians caring for pregnant people or newborns at an urban academic center. We assessed clinicians' demographic characteristics, experience, confidence, and prior training in interpretation of maternal and newborn drug tests. We assessed proficiency in interpreting drug tests using 11 clinical vignettes and categorized scores as poor (0-2), fair (3-5), and good (≥6) performance to facilitate data interpretation. We used descriptive statistics to summarize responses. Multinomial logistic regression was used to determine associations of clinician characteristics and score category (reference category: poor performance).

Results: In total, 103 respondents completed the survey including 60 obstetrical clinicians (58.3%), 19 family medicine physicians (18.5%), 21 pediatric clinicians (20.4%), and 3 social workers (2.9%) (response rate, ~40%). The mean correct response was 4.1 (SD, 2.17; range, 0-11). Most respondent scores were fair (n = 47.6%), followed by good (n = 28.2%) and poor (n = 24.3%). Increased frequency, confidence, and training in interpreting maternal screening and confirmatory tests were associated with higher proficiency. Increased confidence and training in interpreting neonatal screening and confirmatory tests, but not frequency, were associated with higher proficiency.

Conclusions: Most clinicians demonstrated fair proficiency in interpreting drug tests. Predictors of proficiency were confidence and prior training for drug test interpretation, suggesting that educational interventions could improve proficiency.

Objective: A trial comparing extended-release naltrexone and sublingual buprenorphine-naloxone demonstrated higher relapse rates in individuals randomized to extended-release naltrexone. The effectiveness of treatment might vary based on patient characteristics. We hypothesized that causal machine learning would identify individualized treatment effects for each medication.

Methods: This is a secondary analysis of a multicenter randomized trial that compared the effectiveness of extended-release naltrexone versus buprenorphine-naloxone for preventing relapse of opioid misuse. Three machine learning models were derived using all trial participants with 50% randomly selected for training (n = 285) and the remaining 50% for validation. Individualized treatment effect was measured by the Qini value and c-for-benefit, with the absence of relapse denoting treatment success. Patients were grouped into quartiles by predicted individualized treatment effect to examine differences in characteristics and the observed treatment effects.

Results: The best-performing model had a Qini value of 4.45 (95% confidence interval, 1.02-7.83) and a c-for-benefit of 0.63 (95% confidence interval, 0.53-0.68). The quartile most likely to benefit from buprenorphine-naloxone had a 35% absolute benefit from this treatment, and at study entry, they had a high median opioid withdrawal score ( P < 0.001), used cocaine on more days over the prior 30 days than other quartiles ( P < 0.001), and had highest proportions with alcohol and cocaine use disorder ( P ≤ 0.02). Quartile 4 individuals were predicted to be most likely to benefit from extended-release naltrexone, with the greatest proportion having heroin drug preference ( P = 0.02) and all experiencing homelessness ( P < 0.001).

Conclusions: Causal machine learning identified differing individualized treatment effects between medications based on characteristics associated with preventing relapse.

Introduction: Extended-release subcutaneous buprenorphine is an increasingly common treatment for opioid use disorder. Serious adverse events are rare and may be poorly understood. This report describes an early surgical intervention to address tissue necrosis resulting from misplaced subcutaneous buprenorphine injection. We review identifying characteristics that distinguish the necrotic reaction from other adverse effects of subcutaneous buprenorphine and offer guidance to continue treatment with subcutaneous buprenorphine.

Case report: A 33-year-old patient returned to clinic within an hour of his buprenorphine injection, reporting pain and skin changes unlike his previous injections. Non blanching erythema consistent with early necrosis was evident, and the patient was referred for surgical removal of his buprenorphine depot. The patient had uncomplicated healing of the surgical site and was provided sublingual buprenorphine before returning to continue treatment with subcutaneous buprenorphine.

Discussion: Although skin necrosis is known to be a rare complication of subcutaneous buprenorphine injection, early surgical excision to limit injury has not been described. Signs and symptoms of skin necrosis must be better understood to facilitate early intervention and continued treatment.

Conclusions: This case affirms that a patient may continue treatment with subcutaneous buprenorphine despite suffering skin necrosis and demonstrates the value of early surgical intervention after superficial placement of extended-release buprenorphine.

Abstract: We propose applying the "source control" model of infectious disease treatment to the management of treatment-resistant substance use disorder (SUD). We believe that this conceptual framework complements other models for understanding SUD, fills a gap in our current understanding of treatment-resistant SUD, and advances the destigmatization of SUD by reinforcing SUD as a disease similar to other medical conditions. The model also harmonizes the need for multimodal treatment and novel interventions for both acute supportive care and long-term treatment of SUD. In this manuscript, we discuss the justification for, as well as the strengths and limitations of, the "source control" model for the management of treatment-resistant SUD. We also discuss the model's potential to direct innovative research questions and therapeutic interventions.

Abstract: In this issue, Strain advocates for the field of addiction medicine to consider a new diagnostic signal-treatment-refractory addiction. Also in this issue, Nunes and McLellan support the concepts advanced by Strain. I provide an alternate view and propose that it is premature to create such a signal and that doing so could lead to unintended adverse consequences. My argument is based on 4 concerns: (1) the lack of neuroscientific correlates, (2) the profound impact that context has on what patients receive as "treatment," (3) the rare provision of sequentially stepped treatment, and (4) the potential for misuse of the signal. Addiction medicine should be cautious in introducing concepts such as treatment-refractory addiction to ensure that patients are not seen as "treatment failures." Our efforts should rather focus on the development of additional effective treatments, improving access to existing effective treatments and a creating a system that does not provide "failed treatments."

Background: Patients who undergo cardiac surgery for drug use-associated infective endocarditis (DUA-IE) have high rates of readmissions for recurrent endocarditis, substance use disorder (SUD), and septicemia. Our primary objective was to assess whether exposure to an addiction consult team (ACT) was associated with reduced readmissions in this population.

Methods: This single-center retrospective analysis identified patients who underwent cardiac surgery for DUA-IE between 1/2012-9/2022 using the Society for Thoracic Surgeons database, and compared the cumulative incidence of readmissions at 1, 3, 6, and 12 months among those cared for before and after the implementation of an ACT in 9/2017, accounting for competing risk of mortality and adjusted for measured confounders using inverse probability of treatment weighting.

Results: The 58 patients (35 pre-ACT and 23 post-ACT) were young (36.4 +/- 7.7 years) and predominantly White (53.4%) and male (70.7%). The post-ACT cohort had a significantly lower risk of readmission at 1 month (adjusted risk difference [RD] -23.8% [95% CI -94.4%, -8.3%], P = 0.005) and 3 months (RD -34.1% [-55.1%, -13.1%], P = 0.005), but not at 6 or 12 months. In a sensitivity analysis, the post-ACT cohort also had significantly lower risk of readmissions for SUD complications at 3 months.

Discussion and conclusion: ACT exposure was associated with a lower risk of short-term readmission among patients with surgically managed DUA-IE, possibly due to a reduction in SUD-related complications. Additional studies are needed to replicate these findings and to identify ways to sustain the potential benefits of ACTs over the longer term.