Journal of Addiction Medicine最新文献

Objective: Fentanyl is a major driver of the overdose crisis in the United States, yet little is known about the intentionality of fentanyl use and its correlates among people who use drugs (PWUD). We examined the intentionality of fentanyl use and associated factors among PWUD.

Methods: We recruited 246 PWUD in New York City in 2023. Participants completed structured interviews and provided urine samples for toxicology screening. Fentanyl use was classified as no use (negative in both self-report and urine toxicology), unintentional use (self-report negative but toxicology positive), and intentional use (positive in self-report with or without positive toxicology). We used multinomial logistic regression to identify factors associated with fentanyl use intentionality.

Results: Fentanyl was detected in 40.7%, while 26.0% self-reported intentional fentanyl use. Intentional fentanyl use was significantly associated with chronic pain (RRR: 2.21; 95% CI: 1.02-4.80) and higher Risk Assessment Battery (RAB) scores (RRR: 1.09; 95% CI: 1.01-1.18), and inversely associated with high cannabis use severity (RRR: 0.16; 95% CI: 0.05-0.61). Unintentional fentanyl use was positively associated with older age (RRR: 1.08; 95% CI: 1.02-1.13) and negatively with moderate alcohol use severity (RRR: 0.25; 95% CI: 0.09-0.69).

Conclusions: Unintentional fentanyl use was more common among older PWUD, highlighting the need for targeted outreach and fentanyl education. Intentional fentanyl use, while reflecting awareness of the drug supply, was associated with chronic pain and elevated HIV risk behaviors, indicating a subgroup with greater health and prevention needs. Tailored interventions integrating harm reduction, pain management, and HIV prevention are needed.

Objectives: A recent case series suggested a possible syndrome associated with prenatal fentanyl exposure. We described, among a cohort of maternal-infant dyads affected by opioid use disorder (OUD), the prevalence of these observed infant features.

Methods: We used data from MAT-LINK, a surveillance system compiling electronic health record (EHR) information from 7 US clinical sites on pregnancies affected by OUD between 2014 and 2021. We described the prevalence of EHR-documented prenatal fentanyl exposure and infant features of interest (cleft palate, corpus callosum abnormality, foot positioning deformities, genital anomalies, microcephaly, micrognathia, toe syndactyly).

Results: Among 5053 maternal-infant dyads affected by OUD, 667 (13.5%; 95% CI: 13.0%-14.0%) had documented prenatal fentanyl exposure, including an over 20-fold increase from 2014 to 2021. Health insurance, prenatal care timing, and nonopioid substance exposures differed between dyads with and without documented prenatal fentanyl exposure. At least one feature of interest was documented for 406 (8.0%) infants, and at least 2 were documented for 0.7%. Among infants with at least one of these features, 18.9% (95% CI: 17.1%-20.8%) had documented prenatal fentanyl exposure, compared with 13.0% (95% CI: 12.5%-13.6%) of infants without any of these features.

Conclusions: In this perinatal OUD cohort, prenatal fentanyl exposure was more commonly documented among infants with at least one compared with none of these infant features. However, features were rare and contextual factors differed among dyads by prenatal fentanyl exposure status. Further analyses examining these infant features, while considering multiple exposures, are needed before substantiating a fetal fentanyl syndrome.

Background: Opioid overdose (OD) remains a pressing public health crisis in the United States, with substantial gaps in postoverdose care, particularly among veterans. Understanding the demographic and clinical factors associated with appropriate postoverdose care is essential to addressing these gaps.

Methods: A retrospective cohort study of 1032 veterans who experienced a nonfatal opioid overdose and received care through the veterans Health Administration system was conducted. Data were extracted from electronic health records, including demographic, pharmacy, and clinical variables. The primary outcome was receipt of appropriate clinical response within 90 days postoverdose, defined as initiation of medication for opioid use disorder (MOUD), counseling for opioid use disorder (OUD), or a ≥25% reduction in morphine equivalent daily dose. A binary logistic regression model was used to examine factors associated with receiving appropriate overdose care.

Results: Of the total sample, 57.46% received an appropriate clinical response postoverdose, the majority of which reflected opioid dose reductions rather than initiation of MOUD or counseling for OUD. There were statistically significant differences between those who received appropriate clinical response versus not by rurality, marital status, substance use disorder and treatment, care access, bipolar disorder, and schizophrenia. In adjusted models, those with a documented substance use disorder had significantly higher adjusted odds of receiving appropriate clinical response (aOR=1.91; 95% CI: 1.38-2.63; P<0.0001). Black veterans had significantly lower odds of receiving appropriate clinical response compared with White veterans (aOR=0.71; 95% CI: 0.51-0.98; P=0.04). Other variables were not statistically significantly associated with appropriate clinical response in the adjusted model.

Conclusions: The primary response to OD was dose reduction and MOUD was profoundly underutilized. Future research should incorporate social determinants of health to better understand contextual influences on overdose risk and care access.

Objectives: Addictive behaviors are frequently associated with anxiety and depressive disorders. Adolescence represents a critical period of heightened vulnerability to both types of disorders. In recent years, a significant global decline in adolescent mental health-especially among girls-has raised concerns about the short-term evolution of addictive behaviors. Despite available data, this relationship remains poorly understood, warranting further research to improve prevention and care strategies.

Methods: This study analyzed data from a French cross-sectional observational study (DOPADO), which aimed to assess addictive behaviors among adolescents aged 13 to 18 years attending middle and high schools. Data were collected between 2018 and 2020 using electronic surveys, enabling the evaluation of past-12-month psychoactive substance use, associated risky behaviors, sociodemographic characteristics, anxiety and depressive symptoms, psychological distress, and quality of life.

Results: Among 4844 adolescents, half exhibited anxiety and/or depressive symptoms. These were associated with higher levels of substance use, increased risky behaviors, and impaired quality of life. A Principal Component Analysis revealed 3 distinct profiles: one with preserved well-being, and 2 with significant impairment. These were characterized by higher anxiety-depressive symptoms (especially in the second cluster) and more pronounced addictive behaviors and risky use (notably in the third cluster).

Conclusions: Our study highlights robust associations between anxiety/depressive symptoms, addictive behaviors, and quality of life. Several distinct adolescent profiles emerged with respect to mental health and addictive behaviors, each characterized by specific patterns of quality of life and functioning, underscoring the importance of integrated assessment, prevention, and treatment strategies in adolescents.

Objectives: Clinical guidelines recommend providing adjunctive psychosocial interventions with medications for opioid use disorder (MOUD); however, limited evidence exists regarding when and how to provide them. This 2-group unblinded randomized controlled trial evaluated the efficacy of an adaptive approach to providing cognitive behavioral therapy and peer support for individuals receiving office-based buprenorphine treatment.

Methods: Between September 2020 and May 2023, 125 patients who recently initiated office-based buprenorphine treatment at 2 federally qualified health centers in the Mid-Atlantic region and provided informed consent were randomly assigned (1:1) to treatment as usual (TAU; n = 63) or TAU plus adjunctive psychosocial treatment delivered using an adaptive algorithm informed by baseline characteristics, engagement, and responsiveness (TAU+Adaptive; n = 62). Assessments occurred at baseline and 3- and 6-month follow-ups. Primary outcomes were treatment retention and opioid use.

Results: No significant between-group differences were observed. Across conditions, about 30% tested positive for opioids at follow-up, and 40% remained in MOUD treatment at 6 months. Exploratory post hoc analyses indicated greater retention among participants prescribed a 24 mg baseline buprenorphine dose (46%) compared with those on 16 (24%) or 8 mg (26%). No serious study-related adverse events were reported.

Conclusions: Although the efficacy of the adaptive approach was not supported, high rates of treatment discontinuation and polysubstance use highlight the need for additional support for some patients. Findings also suggest that dosing strategies may need to be tailored to the increasing potency of the illicit opioid supply.

Objectives: The rising global prevalence of electronic cigarette (e-cigarette) use poses significant public health concerns, including nicotine dependence. This systematic review and meta-analysis evaluated the efficacy and safety of pharmacological interventions for e-cigarette cessation.

Methods: We systematically searched 5 databases, including Cochrane Library, PubMed, Ovid Embase, Sinomed, and Web of Science Core Collection, up to May 1, 2024, that evaluated the efficacy and safety of pharmacological intervention compared with placebo for e-cigarette cessation. Two investigators independently screened studies, extracted data, and assessed the risk of bias. The outcomes of interest were (1) continuous abstinence rate (CAR); (2) 7-day point prevalence of e-cigarette abstinence at different weeks; and (3) adverse effects. This study was registered with PROSPERO (CRD42024577356).

Results: Of 1567 initially identified records, 7 studies involving 1161 participants were included. Most studies had a low risk of bias. The results indicated that varenicline (4 studies, n=463; OR=2.52, 95% CI: 1.14-5.58) was effective, while the effect of nicotine replacement therapy (NRT; 2 studies, n=538; OR=1.38, 95% CI: 0.61-3.14) was not statistically significant. One study on cytisine also suggested potential benefit.

Conclusions: Varenicline has demonstrated efficacy in supporting e-cigarette cessation, whereas the current evidence for NRT and cytisine remains insufficient to draw firm conclusions. Further well-designed studies are needed to clarify the effectiveness of these 2 interventions. Although pharmacotherapies used for cigarette smoking show potential for repurposing, their utility in e-cigarette cessation should be interpreted cautiously until stronger evidence becomes available.

Objectives: In the United States, adults aged 65 and older are the fastest-growing age group using cannabis. People living with HIV (PLWH) are an aging population with prevalent cannabis use exceeding the general population. We examined cannabis use disorder (CUD) diagnoses from 2000 to 2022, by age, race/ethnicity, sex, comorbidity, and HIV status.

Methods: This analysis (2000-2022) includes electronic health records from 185,372 individuals in the Veterans Aging Cohort Study-HIV, a national US cohort of PLWH matched 1:2 to people without HIV (PLWoH). Annual CUD diagnosis was determined by dividing the number with CUD International Classification of Diseases-Clinical Modification codes by total observations. We examined trends by age, race/ethnicity, sex, comorbidity, and HIV status graphically and with multivariable logistic models.

Results: Demographic characteristics were comparable for PLWH (n=58,959) versus PLWoH (n=126,413): 45% Black non-Hispanic (NH); 35% White NH; 7% Hispanic; 3% women, mean age 48 years. Twenty percent of PLWH had a CUD from 2000 to 2022. CUD increased in all subgroups and was consistently higher among PLWH (odds ratio=1.14 [95% CI=1.11-1.18]). Individuals 65 and older experienced the greatest relative increase: PLWH (0.9% vs. 4.0%) and PLWoH (0.03% vs. 3.15%).

Conclusions: CUD increased dramatically among all subgroups over time and was higher among PLWH. CUD increase among older PLWH and those with multimorbidity is especially concerning as cannabis interacts with many prescription medications. Universal screening and treatment advances are needed, as is research characterizing patterns and modalities of cannabis use, CUD, and potential harms and benefits in PLWH and PLWoH.

Objectives: We explored sustainability of confidence in key skills related to opioid use disorder (OUD) care and barriers and facilitators of prescribing buprenorphine among residents who had completed buprenorphine training during medical school.

Methods: Medical students who took an elective buprenorphine training course before graduation were surveyed immediately following the training ("baseline") and again 1 year later. Baseline surveys included demographics and confidence with key skills in OUD care. Follow-up surveys re-assessed confidence with key skills and additionally included waiver status, history of prescribing buprenorphine, and residency climate toward buprenorphine. Focus group interviews explored barriers and facilitators of prescribing buprenorphine.

Results: Sixty-one students participated in the training and completed the baseline survey. Seventy-two percent of trainees completed the follow-up survey; of these, 36% had obtained a waiver and just over half of those had used it to prescribe buprenorphine. In unadjusted analyses comparing 1-year follow-up results to the baseline survey, smaller percentages of learners reported strong confidence in screening for and diagnosing OUD (23% vs 46%, P =0.004), counseling patients with OUD regarding treatment options (11% vs 44%, P <0.001), and prescribing buprenorphine to treat a patient with OUD (11% vs 33%, P <0.001). Qualitative results suggested that learners experienced both bureaucratic and environmental barriers to prescribing buprenorphine.

Conclusions: Removal of the waiver requirement addresses only some barriers to buprenorphine prescribing among medical trainees. Residency climate and clinical systems conducive to prescribing buprenorphine will be necessary to sustain confidence managing OUD and increase buprenorphine prescribing during residency.

Using serum methadone levels to calculate methadone clearance can help providers individualize dosing, particularly in patients displaying clinical symptoms of rapid clearance, such as peak sedation with concomitant trough withdrawal. Multiple factors may impact methadone dose requirements and serum levels, necessitating deviation from standard methadone titration protocols. The physiologic changes of pregnancy generally shorten methadone's half-life due to CYP450 enzyme induction and increased volume of distribution. Additionally, the emergence of fentanyl-a far more potent opioid than its predecessors-has led to increased opioid tolerance among individuals who use it. As a result, these individuals may require higher methadone doses to effectively manage their opioid dependence. We present a case of a pregnant patient with opioid use disorder, primarily using fentanyl, who presented to labor and delivery at 36 weeks 6 days of gestation. She delivered at 37 weeks 1 day and remained admitted for 4 weeks while undergoing methadone induction. At the time of discharge, she endorsed ongoing opioid withdrawal and required ongoing methadone dose escalation at her outpatient methadone clinic after discharge. Laboratory testing one month postpartum indicated a methadone half-life of 9.22, and she was determined to need thrice daily dosing to maintain therapeutic serum levels, with her total daily dose ultimately reaching 300 mg 3 times daily. In patients who do not respond to standard methadone titration protocols, laboratory testing can support individualized dosing strategies to achieve therapeutic levels while maintaining patient safety.

Objectives: The COVID-19 pandemic has had widespread effects on the global economy. The present study seeks to examine the enduring impact of the COVID-19 pandemic on the relationship between financial well-being, alcohol use, and mental health outcomes in individuals with and without an alcohol use disorder (AUD).

Methods: Participants who were enrolled in the NIAAA COVID-19 Pandemic Impact on Alcohol Study (C19-PIA) were invited to complete questionnaires on financial well-being, alcohol use, and mental health symptoms as part of an online anniversary survey collected between April 6, 2022, and July 2, 2022. The analytic sample included 250 participants who had valid data on key study variables, including past year AUD previously assessed in the NIAAA Natural History Protocol using structured clinical interviews.

Results: Individuals with AUD were less likely to apply for financial assistance and reported greater worries about their financial well-being. Lower financial well-being during the pandemic was associated with higher problematic drinking and worse mental health outcomes. Significant covariates included age, sex, and race.

Conclusions: The findings suggest an association between financial stress and problematic alcohol use during financial instability that appeared to persist 2 years into the COVID-19 pandemic. This highlights the potential impact of outreach efforts to improve accessibility of financial assistance, particularly for vulnerable individuals with AUD with financial worries and uncertainties during the pandemic.