Journal of Addiction Medicine最新文献

Background: Nonprescribed use of ketamine has increased worldwide due to its hallucinogenic and psychedelic effects. Ketamine use disorders (KUDs) are marked by intense cravings and tolerance, which often trigger relapses and worsen recovery outcomes, defined as sustained ketamine abstinence with reduced cravings, resolved withdrawal symptoms, and improved psychosocial functioning. Currently, there are no approved pharmacological treatments for KUDs. This report examines the off-label use of naltrexone in a patient with KUDs.

Case presentation: The case was a 25-year-old woman diagnosed with KUDs enrolled in an outpatient, specialist addiction service. The patient presented with ketamine daily use and intense cravings when trying to stop. The patient was prescribed oral naltrexone at the initial dose of 25 mg/day, which was increased to 50 mg/day after 7 days. After the initiation of treatment, the patient experienced a marked reduction in ketamine cravings. She was able to maintain abstinence and to progress in her recovery. The positive response to naltrexone suggests its potential as an effective intervention for managing KUDs.

Conclusions: Our findings are consistent with 2 prior reports that have highlighted the use of naltrexone in KUDs. The 2 previous case reports indicated that naltrexone at the dosage of 50 mg/day successfully helped the patients to achieve abstinence. Studies have shown that naltrexone reduces the antidepressant effects of ketamine in treatment-resistant depression, indicating an overlap between the opioid system and ketamine's NMDA receptor activity. Larger, double-blind studies are needed to evaluate naltrexone's efficacy, safety, and optimal dosing for KUDs.

Objectives: The Asian American Pacific Islander (AAPI) community accesses substance use disorder (SUD) services less frequently and at more advanced stages compared with the general population. Understanding experiences of AAPI patients with SUDs is important to identify opportunities to engage patients into treatment earlier and address community needs. This study explored the experiences of diverse AAPI patients with SUD and treatment services in a large urban setting, specifically examining influences of social norms within the AAPI community.

Methods: We conducted semi-structured qualitative interviews with AAPI participants who received SUD treatment in Los Angeles. Participants discussed their experiences with SUD and treatment services. We used the Rigorous and Accelerated Data Reduction (RADaR) data analysis approach to identify key themes related to SUD treatment experiences, specifically highlighting facilitators or barriers to accessing care.

Results: Among 20 interviews analyzed, the following themes were identified: the model minority myth, family dynamics, and AAPI community connection. Sub-themes are presented as facilitators or barriers to SUD treatment services.

Conclusions: We found that social norms within the AAPI community can be both facilitators and barriers to treatment. We explored the role of the model minority myth and saving face as barriers to care, and family dynamics rooted in cultural beliefs and AAPI community values as facilitators during recovery. These findings reveal opportunities for cultural nuances to be incorporated into SUD care, inform more inclusive clinical practices, and potentially improve AAPI patient outcomes. Such insights may help reduce stigma and enhance SUD treatment engagement in the AAPI community.

Objectives: US regulatory changes now allow practitioners to dispense up to a 3-day supply of methadone from the inpatient pharmacy at hospital dishcarge at one time. We characterized outcomes related to hospital-dispensed discharge methadone, including saved hospital days and reductions in hospital costs.

Methods: We included all hospitalizations involving hospital-dispensed discharge methadone for opioid use disorder. We identified the mean number of discharge methadone doses ordered per hospitalization to determine a reduction in length of hospital stay, where 1 discharge methadone dose equals 1 hospital day saved. We used 2 approaches: a health care cost accounting approach that uses patient-level health care cost data and an adjusted inpatient day metric that uses data from the hospital's aggregated operating costs to estimate hospital cost reductions related to discharge methadone.

Results: Between April 2023 and July 2025, 175 hospitalizations involving 374 orders for discharge methadone reduced length of stay by 357 days after accounting for split doses, that is, twice daily doses for pain, pregnancy, or rapid methadone metabolism. The mean number of discharge methadone doses per hospitalization was 2.1. Using a health care cost accounting approach, the median cost reduction was $850/d with a total cost reduction of $304,450 over the study period. Using an adjusted inpatient day estimate, the total cost reduction was $3953/d with a total cost reduction of $1,411,221 over the study period.

Conclusions: Hospital-dispensed discharge methadone reduced costs by facilitating hospital discharges. Cost savings related to reduced emergency department overcrowding or avoidance of nosocomial infections were not captured and should be considered when implementing discharge methadone processes.

Medetomidine has been increasingly found in the illegal opioid supply across the country over the last few years. In 2024, it replaced xylazine as the most common adulterant of the illegal opioid supply in the Philadelphia area. Medetomidine is estimated to be over 100 times as potent and selective for the alpha-2 receptor than xylazine. This leads to increased sedative effects compared with other alpha-2 agonists and in some patients, a severe autonomic withdrawal syndrome when medetomidine is abruptly stopped. Severe hypertension, tachycardia, vomiting, and tremors have been seen, often requiring hospital admission and critical care. As a result, the capacity of local health systems and ability to accurately triage patients to the proper level of care have been stretched. Drug checking and testing of biospecimens for medetomidine remains limited. Clinician and public health awareness of this new entity will be foundational to robust responses to this next adulterant threat.

Objectives: Little is known about the demographic and clinical features of patients with xylazine-related wounds. We sought to characterize hospitalized patients with substance use disorder (SUD) and xylazine-related wounds seen for infectious diseases consultation.

Methods: We retrospectively reviewed the medical records of 193 patients diagnosed with SUD at 3 Philadelphia hospitals between October 2023 and January 2024. Patients were identified as either being diagnosed with (n=73) or without (n=120) xylazine-related wounds. We compared the demographic and clinical features between the 2 groups.

Results: Patients diagnosed with wounds were younger ( P <0.001), more likely to be White or Hispanic and less likely to be Black/AA ( P <0.001), more likely to have tested positive for fentanyl ( P <0.001), amphetamines ( P <0.001), and cocaine ( P 0.001), more likely to acknowledge injection ( P <0.001), and more likely to leave the hospital by patient-directed discharge (PDD) ( P <0.001). Most patients had multiple wounds (75%), and more than half (53%) had at least one wound greater than 10 cm at its widest dimension. Although most patients diagnosed with wounds received antibiotics, many did not have symptoms or signs of infection.

Conclusions: Xylazine-related wounds are highly associated with illicitly manufactured fentanyl (IMF) use and with drug injection in the city of Philadelphia. Many patients with xylazine-associated wounds do not have signs of infection and may not benefit from antibiotics. Understanding precisely how xylazine is responsible for wound development and how to best manage the wounds, including wound care and the role of antibiotics, is urgent.

Objectives: Private methadone treatment paid for by the Department of Veterans Affairs (VA), called community care (CC), and mobile opioid treatment programs (OTPs) are strategies to expand Veteran access to methadone treatment for opioid use disorder. The purpose of this evaluation was to investigate leader and clinician perspectives on these modalities compared with treatment provided directly by VA OTPs.

Methods: Semi-structured interviews were conducted with VA OTP leaders and clinicians from 12 of the 33 VA OTP sites nationwide. Participants (N=24) were asked to compare access, quality, and cost of methadone treatment between VA OTPs and CC and asked about the feasibility of deploying mobile OTP services. Two analysts independently coded the transcribed data and used thematic analysis to identify salient themes and representative quotes.

Results: VA leaders and clinicians perceived CC to have longer wait times and lower quality care, but expected these services to be less expensive than VA OTPs. Mobile OTP services were viewed as a potential solution to improve access, though concerns were raised about staffing and the reduced availability of wrap-around services. Key considerations for successful mobile OTP implementation included identifying high-need localities, addressing patient needs, and ensuring financial viability.

Conclusions: Within and outside VA, there is growing interest in expanding access to medications for OUD, such as methadone. Leaders and clinicians highlighted important access, quality, and cost considerations when exploring innovative treatment modalities for methadone, such as mobile OTP services and CC. Findings from this VA evaluation may guide methadone treatment improvement in other health systems.

Objectives: Opioid use during pregnancy is a critical public health concern that has given rise to significant treatment needs throughout the perinatal period. The purpose of this study was to gather perspectives of pregnant and parenting individuals in recovery from opioid use disorder (OUD) to better understand their needs and identify ways to improve care and support parenting.

Methods: We conducted semi-structured interviews with 18 pregnant and postpartum people receiving medication for opioid use disorder (MOUD) at an outpatient buprenorphine clinic. The coding team developed a codebook using both inductive and deductive methods that was applied to all interviews. Key topics and trends were identified using thematic analysis.

Results: Four themes emerged from participants' reflections on their experiences with health care as pregnant and parenting people in recovery: (1) need for support with parenting, (2) concerns about MOUD, (3) difficulty accessing resources, and (4) value of peer support and options for receiving information.

Conclusions: There is a need to prioritize support with parenting, understanding MOUD, and accessing basic needs to better prepare pregnant and early postpartum individuals for parenting in recovery from OUD. It is also important to incorporate peer support into services to better support pregnant and parenting people in recovery.

Objectives: To describe the validity of alcohol use disorder (AUD), the International Classification of Diseases (ICD) codes for alcohol use and repeated or harm-associated use in pregnancy.

Methods: We conducted a retrospective study of pregnancies in individuals who sought care at a medical center from May 2014 to August 2023. We selected all pregnancies with an ICD 9th (ICD-9) or 10th (ICD-10) revision AUD code (ICD-9: 303.9x and 305.x; ICD-10: F10.x and O99.31x) and calculated their positive predictive value (PPV) for capturing alcohol use and repeated or harm-associated use in pregnancy using review of health record as the reference standard. We defined alcohol use as any alcohol consumption during pregnancy and repeated or harm-associated alcohol use as a repeated pattern associated with adverse consequences.

Results: AUD ICD codes were associated with 305 unique pregnancies. The most common AUD ICD code group was 305.x (n=177, 56.4%), followed by F10.x (n=105, 33.4%), O99.31x (n=25, 8.0%), and 303.9x (n=7, 2.2%). The PPV of AUD codes for capturing alcohol use in pregnancy ranged from 10.0% (95% confidence interval [CI], 8.9%-11.2%) for 305.x to 100% (95% CI, 80.9%-99.5%) for O99.31x. The PPV of AUD codes for capturing repeated or harm-associated use in pregnancy ranged from 1.7% (95% CI, 1.6%-1.8%) for 305.x to 28.0% (95% CI, 21.3%-35.9%) for O99.31x.

Conclusions: The PPV of AUD codes for identifying alcohol use and repeated or harm-associated use in pregnancy varies widely across ICD-9 and ICD-10 code groups. These results should be considered when estimating alcohol exposure in pregnancy from administrative data.

Sex differences in the prevalence of substance use disorders (SUD) are well recognized. While a greater proportion of males endorse consuming substances and SUDs, the gap between the sexes has been narrowing over time, due to an increased rate of substance use among females. Yet, the mechanisms underlying sex differences in SUD are unclear, and evidence is lacking to inform the development of personalised preventions and treatment for males and females. The neuroscientific evidence to date is inadequate to explain sex differences in SUD, due to a range of methodological issues (eg, study design, recruitment, and statistical modelling). A harmonised multidisciplinary approach that considers sex at each stage of the research cycle is required to create new mechanistic knowledge and to inform the identification of prevention and treatment targets for males and females with an SUD.

Objectives: The Mainstreaming Addiction Treatment Act removed the separate registration requirement to prescribe scheduled medications for maintenance or detoxification treatment, creating an opportunity to utilize community pharmacists' expertise and accessibility to expand access to medications for opioid use disorder (MOUD). This study aimed to develop pharmacist prescribing models of care within community pharmacies.

Methods: Data were collected via interviews with community pharmacists and pharmacy technicians, treatment providers, and people with lived experience in Washington State from January to May 2024. Interviews were analyzed using a rapid content analysis approach guided by the Practice, Robust Implementation and Sustainability Model and existing evidence-based models of care for MOUD in primary care settings. The research team utilized the themes to develop models of care with input from an interdisciplinary advisory panel.

Results: Thirty-one interviews were conducted with 9 community pharmacy staff, 11 treatment providers, and 11 people with lived experience. In total, 21 themes were identified, including 8 themes regarding intervention characteristics, 5 regarding recipients, 5 regarding implementation and sustainability infrastructure, and 3 regarding external environment. Within intervention characteristics, 3 themes were identified regarding medication therapy, 3 regarding education, 1 regarding coordination of care, and 1 regarding psychosocial services. Two models of care were developed: one for MOUD initiation and another for maintenance or ongoing treatment.

Conclusions: This study resulted in the development of models of care for MOUD initiation and maintenance at community pharmacies. Future research is needed to evaluate the effectiveness of these models of care.