Addiction Science & Clinical Practice最新文献

Background: Cocaine and methamphetamine use disorders (CcUD/MtUD) have serious public health, medical, and psychiatric consequences. Yet, there are no U.S. Food and Drug Administration (FDA) approved treatments available. The STIMULUS study is a multi-site trial, sponsored by the National Drug Abuse Treatment Clinical Trials Network (CTN), that aims to investigate the feasibility and preliminary efficacy of repetitive transcranial magnetic stimulation (rTMS) as a potential treatment for moderate to severe CcUD/MtUD.

Methods: The study is a double-blind, sham-controlled trial seeking to recruit 160 participants with a current moderate to severe CcUD or MtUD diagnosis, randomized to receive active rTMS (10-Hz stimulation at 120% motor threshold over the left dorsolateral prefrontal cortex) or sham. Feasibility is assessed by a target of at least 20 treatment sessions administered within an 8-week period. Additionally, the study aims to evaluate the efficacy of rTMS in reducing stimulant use and craving, the impact of rTMS on mood, anxiety, sleep, and other measures, and the utility of electroencephalography as a treatment response biomarker.

Discussion: Studies exploring rTMS for stimulant use disorders remain limited by small sample sizes, as well as great heterogeneity in defined study population, treatment parameters, retention in treatment, and number of sessions. In this paper, we highlight key study design decisions, such as safety, sham procedure, and schedule flexibility.

Conclusion: We hope that the data collected will lay the groundwork for a robust randomized controlled trial of rTMS as a therapeutic intervention for individuals with CcUD/MtUD.

Trial registration: http://www.

Clinicaltrials: gov . Identifier: NCT04907357. TRIAL DATA SET: https://clinicaltrials.gov/study/NCT04907357?tab=table .

Protocol: Version 7.0, 11/10/2023.

Background: Opioid use disorder often co-occurs with other mental health and substance use disorders. Identifying clusters of individuals receiving treatment for opioid use disorder based on co-diagnosed conditions, healthcare plans, and service utilization over a seven-year treatment period provides insight into service needs. Objectives included [1] characterizing the sample [2], examining subtypes of the sample using cluster analysis, and [3] identifying differences in Current Procedural Terminology by subtype to examine service utilization among identified clusters.

Methods: This study uses secondary data from the electronic medical records of a community health center in a large urban area in the Northeastern United States from 2015 to 2021. The study sample included N = 705 adults who had an opioid use disorder diagnosis as indicated by the community health center's electronic medical records. Measures include [1] age [2], race and ethnicity [3], sex [4], healthcare plan(s) [5], co-occurring mental health disorder [6], co-occurring substance use disorder [7], co-occurring mental health disorder or substance use disorder, and [8] Current Procedural Terminology codes for behavioral health service utilization. Cluster analysis was used to examine the sample. These clusters were then analyzed for service utilization with a one-way analysis of variance.

Results: The cluster analysis identified six clusters with an average silhouette of 0.5, indicating good clustering. These six clusters were operationalized as [1] Medicare/Medicaid healthcare plan with substance use disorder needs [2], Private pay and charity care healthcare plan with cocaine use disorder needs [3], Medicare/Medicaid and other publicly-funded healthcare plans with mood disorder needs [4], Private healthcare plan with low co-occurring disorder needs [5], Other publicly-funded healthcare plan with cannabis use disorder needs [6], Medicare/Medicaid healthcare plan with mental health disorder needs. Service utilization differed between these clusters with cluster mean differences for psychotherapy sessions (F = 8.55, p < 0.001), psychiatric sessions (F = 22.72, p < 0.001), and group therapy sessions (F = 10.76, p < 0.001).

Conclusions: This study highlights the importance of comprehensive and integrated treatment for substance use disorders and mental health disorders, particularly for those in underserved communities. Healthcare coverage, a socioeconomic factor that impacts access to care, is critical in distinguishing treatment needs and utilization.

Background: Medications for opioid use disorder are evidence-based, guideline-recommended treatments. While buprenorphine can be prescribed in nonspecialized office-based settings, it is underutilized. Using a multifaceted implementation initiative, the Veterans Health Administration (VHA) sought to expand access to buprenorphine in nonspecialized office-based settings, including primary care clinics. The purpose of this qualitative evaluation was to assess and describe primary care clinicians' perspectives on delivering buprenorphine care during the first year of the initiative.

Methods: Using a snowball sampling approach, individualized emails were sent to primary care clinicians participating in a VHA initiative (n = 43) inviting them to be interviewed. Individual semi-structured interviews were conducted September 2019 through January 2020, and were audio-recorded, transcribed, and analyzed using thematic analysis. The Consolidated Framework for Implementation Research (CFIR), a meta-theoretical framework of five domains associated with successful adoption of interventions, was used to organize findings.

Results: Of 43 clinicians invited, 19 responded and were interviewed (44.2%). Findings represented two CFIR domains: Inner Setting and Characteristics of Individuals. For Inner Setting, three themes were identified as influencing implementation during the first year of the initiative. Clinicians reported a shared receptivity to implement buprenorphine, organizational support from pharmacy services and leadership, as well as cohesive relationships among implementation team members and collaboration with outside clinics. Noted barriers included fit within primary care workflows and lack of staff, time and access to onsite laboratory services and buprenorphine. For Characteristics of Individuals, two themes were identified that may facilitate clinicians' willingness to provide buprenorphine care. Namely, clinicians reported positive attitudes about and experiences delivering opioid use disorder care and a willingness to learn/do something new.

Conclusions: While implementation strategies should be tailored to individual clinic needs, prioritizing factors identified in this evaluation may support successful implementation of buprenorphine delivery in primary care.

Background: Programs that aim to increase access to substance use disorder (SUD) treatment in hospital-based settings have proliferated in recent years. These efforts include transitional opioid programs (TOPs), which navigate patients to community-based SUD treatment programs post-discharge. Successful navigation from TOPs to outpatient treatment hinges on effective coordination between hospitals and post-discharge endpoints, yet it is unclear how hospitals can best develop effective partnerships with outpatient treatment organizations. The objective of this study is to synthesize the common themes underpinning the development of partnerships to facilitate care transitions between TOPs and ongoing SUD treatment.

Methods: Qualitative study with staff and providers from hospitals affiliated with four safety-net health systems (n = 21) and leaders from community-based organizations (CBOs) and treatment facilities that had established referral partnerships with one of the four health systems in our study (n = 4).

Results: Analysis of interview transcripts revealed seven common themes that underpinned the development of care transitions partnerships: (1) Active, intentional outreach; (2) Responding to a community need; (3) External Enabling Factors; (4) Leveraging reputations and community connections; (5) Focusing on operations; (6) Reciprocal relationships; and (7) Building Infrastructure and Processes to Ensure Collaboration. The seven identified themes were categorized into three groups corresponding to different partnership development stages. The first group revolves around the initial stage of meeting and developing a relationship (themes #1-4). The second set focuses on navigating and resolving challenges that arise in the partnership (themes #5-6). Lastly, the third group pertains to sustaining a partnership long-term (theme #7).

Conclusions: This study identifies seven core themes underlying the development of care transition partnerships for SUD patients within four safety net health systems and their CBO partners. These themes demonstrate how partner organizations can establish the trust, reciprocity, and commitment necessary to support patients through the critical transition period.

Background: E-cigarette use (i.e., vaping) is prevalent among young adults in the U.S. Studies show that young adults who vape are more likely to initiate cigarette smoking than young adults who do not vape. Despite this, little research on vaping interventions and prevention of smoking for young adults who vape exist.

Methods: A 2-arm pilot randomized controlled trial (RCT) will be conducted by recruiting young adults ages 18-24 who reported vaping at least once per week in the past 30 days and having never smoked cigarettes at baseline. Participants will be recruited via social media ads and be randomly assigned to an intervention arm, which will be the Live Free From E-cigarettes (LIFFE) mobile-based program (n = 50), or a waitlist control arm (n = 50). The primary outcomes are biochemically verified 7-day point prevalence abstinence for nicotine vaping, vaping reduction, and smoking susceptibility. Outcomes are measured at 2-, 4-, and 8-weeks after randomization.

Discussion: This is the first RCT to evaluate the effectiveness of a mobile-based intervention that targets smoking susceptibility while also supporting vaping cessation or vaping reduction in young adults. Findings may inform future efforts to prevent transition to cigarette smoking and vaping cessation and reduction in young adults.

Trial registration: ClinicalTrials.gov: NCT06129123; Date of registration: 11/10/2023.

Background: Longer duration of treatment with medication for opioid use disorder (MOUD) is associated with improved outcomes, but long-term retention remains a challenge. Research is needed to identify psychosocial interventions that support MOUD retention. To address this gap, we examined associations between a wide range of psychosocial services and buprenorphine treatment discontinuation across 18 months among a large cohort of Veterans initiating buprenorphine nationwide.

Methods: We identified a cohort of patients with new buprenorphine initiation in 2017-2018 in Veterans Health Administration electronic health record data (N = 11,704). We examined prescription fills for up to 18 months after initiation. The primary outcome was first discontinuation of buprenorphine. We examined a variety of services, including psychotherapy in specialty substance use disorder (SUD) and mental health clinics, other healthcare services, and residential programs. To examine time-varying associations between psychosocial services and risk of discontinuation, we fit extended Cox regression models for each service separately and simultaneously.

Results: Overall, 80.5% of patients discontinued buprenorphine at least once within 18 months. Risk of discontinuation was 18% (HR: 0.82, 95% CI: 0.77, 0.87) relatively lower following SUD psychotherapy and 26% (HR: 1.26, 95% CI: 1.15,1.39) higher following residential treatment.

Conclusions: Several services, including residential treatment, were associated with greater risk of subsequent buprenorphine discontinuation, whereas only SUD psychotherapy was consistently associated with lower risk of later discontinuation. These findings emphasize the need for future studies to increase understandings of beneficial and disruptive components of psychosocial services to improve treatment retention among patients receiving MOUD.

Background: Cue exposure (CE) is used for relapse prevention as part of smoking cessation therapy to reduce the automatized response to smoking-related cues. Using CET in virtual reality (VR) is an approach to increase its efficacy by creating cost-efficient high-risk situations. The efficacy of VR-based CETs was compared to that of an unspecific relaxation intervention as an add-on to an established cognitive-behaviorally oriented smoking cessation group therapy (G-CBT).

Methods: N = 246 abstinence-motivated smokers were included in a two-armed randomized controlled trial (G-CBT with VR-CET vs. G-CBT with progressive muscle relaxation/PMR) with 1-, 3-, and 6-month follow-ups (measurements in 2018-2020). All smokers joined a well-established G-CBT smoking cessation program with six sessions with four additional sessions of either VR-based smoking cue exposure therapy (VR-CET) or four sessions of group-based PMR. The primary outcome was abstinence after 6 months according to the Russell Standard; secondary outcomes included changes in the number of smoked cigarettes, craving (assessed by the Questionnaire of Smoking Urges/QSU), and self-efficacy (assessed by the Smoking Abstinence Self-Efficacy Scale/SES) over time.

Results: Primary outcome: Six months after G-CBT, 24% of the participants were abstinent, and there was no significant difference between the PMR (n = 34/124) and VR-CET (n = 24/122) groups (odds ratio PMR/VR = 0.64). Secondary measures: SES increased, and QSU and the number of smoked cigarettes decreased over time. Baseline craving ratings predicted abstinence only in the VR-CET group.

Conclusion: This randomized controlled trial did not show increased abstinence rates related to smoking cue exposure in virtual reality. Secondary measures demonstrated significant reductions in craving and cigarette consumption as well as increases in self-efficacy over time, regardless of the intervention. However, high baseline craving was negatively related to abstinence in the VR-CET group, suggesting that intense craving was insufficiently addressed. This may indicate that the amount of training was insufficient and should be intensified. Individualization, e.g., adaptive, individualized approaches, is required to improve the effects of the VR-CET on smoking cessation in future studies.

Trial registration: ClinicalTrials.gov Identifier NCT03707106.

Background: In response to greater illicit fentanyl use, buprenorphine daily doses exceeding the FDA's recommended target daily dose (16 mg) and maximum suggested daily dose (24 mg) may provide better outcomes, but little is known about higher dosage prescribing patterns. To better understand buprenorphine prescribing patterns, this manuscript examines the frequency and characteristics of dispensed buprenorphine of ≤ 16mg, > 16-24 mg, and > 24 mg daily dose.

Methods: We used IQVIA data to conduct a cross-sectional study of opioid use disorder-indicated buprenorphine prescriptions dispensed at retail pharmacies January 2019 - December 2020; categorized prescriptions as ≤ 16mg, > 16 to 24 mg, and > 24 mg daily dose; and examined overall rates and rates by patient, insurer and county characteristics, and prescriber specialty. We categorized buprenorphine prescriptions by patient sex, age cohort, primary payment source, and prescriber specialty and state and conducted univariate and bivariate analyses of buprenorphine daily dose categories overall and among clinicians frequently prescribing buprenorphine at the highest doses, > 24 mg.

Results: Approximately 19.5% (n = 5,568,964) of the 28 million buprenorphine prescriptions from 68,898 clinicians were > 16-24 mg; 2% (n = 641,390) were > 24 mg. Approximately 26% (n = 17,939) of clinicians wrote at least one prescription > 24 mg; 2,780 clinicians (4% of buprenorphine prescribers) were responsible for 82.2% (n = 527,597) of dispensed prescriptions > 24 mg. 28% of prescriptions > 24 mg written by these prescribers were cash-pay, 12.5% covered by Medicaid, and 6.7% covered by Medicare. There was no correlation between state fentanyl overdose rate and buprenorphine prescriptions > 24 mg per 1,000,000 residents.

Conclusions: In 2019-2020, fewer than 3% of dispensed buprenorphine prescriptions exceeded the FDA suggested maximum of 24 mg daily dose; 80% of the prescriptions for a > 24 mg daily dose were written by 4% of buprenorphine prescribers. As clinicians and policymakers pay greater attention to ensuring individuals are receiving buprenorphine dosages adequate to effectively treat their opioid use disorder, the recently revised FDA recommendations may encourage such behavior. Additionally, disproportionate reliance on cash payment for higher daily doses suggests public and private insurers could facilitate access to such treatment when appropriate.

Background: Palliative care focuses on controlling symptoms and improving the patient's quality of life. To achieve this, medications with addictive potential are often used. There have been various case reports of substance misuse in palliative care. This study aims to explore how practitioners perceive the issue and management of substance misuse in palliative care patients.

Materials and methods: Following an extensive literature review, a 23-question questionnaire was developed to assess attitudes and practices related to substance misuse in palliative care and distributed to all German palliative care units (PCUs) listed on the website of the German Society for Palliative Medicine (n = 334).

Results: A total of 116 responses from PCUs (34.7%) were included in the analysis. Of these, 49.1% estimated that approximately 1-5% of their patients suffer from medication-related substance misuse. Most respondents (72.4%) assumed that 1-5% of their patients use illicit substances. In addition, 62.9% of the PCUs do not screen their patients for substance use disorders, while only 0.9% report doing so regularly. In the case of addiction problems, 55.2% of the PCUs do not implement any specific measures. Most respondents described their approach to prescribing medications with potential for substance misuse as liberal (71.6%) or very liberal (12.9%). Furthermore, 78.4% reported that the addictive potential of a medication has little or no influence on their prescribing decisions. Finally, 67.2% of participants expressed a desire for more education about addiction in palliative care.

Discussion: The data collected in our study indicate that, from the perspective of palliative care professionals, substance use disorders are not perceived as a significant problem for patients receiving inpatient palliative care. However, we found that most PCUs do not screen their patients for substance misuse, suggesting that most practitioners may not have a comprehensive view of the actual number of dependent patients. Further research is therefore needed to obtain reliable data on the number of patients with substance use disorders in palliative care and to determine the point at which substance misuse is caused by medical prescription.

Background: Detrimental smoking-related health outcomes warrant the investigation of novel smoking cessation interventions; the cessation program nuumi integrates digital behavioral therapy and an electronic cigarette (EC).

Objective: The relationship between program participation and smoking cessation among adults who smoke and are motivated to quit was investigated, as well as program acceptability, changes in smoking-related outcomes, including cigarettes per day (CPD), urges to smoke and psychophysiological health variables (perceived stress, mindfulness, cessation-related self-efficacy, life satisfaction, subjective psychophysiological health) and their associations with smoking cessation.

Methods: A prospective 6-month single-arm pilot study was conducted; 71 adults who smoked and were motivated to quit received a cognitive behavioral therapy (CBT) app, a closed-system EC, and pods containing decreasing nicotine concentrations. Online surveys were issued at baseline, and at 4, 8, 12, and 24 weeks post-baseline. Intention-to-treat (ITT) and complete-case analyses were conducted to assess self-reported 7-day point prevalence of smoking abstinence (PPA; primary outcome), 30-day PPA, and repeated PPA. T-tests and logistic regressions were used to assess changes in secondary outcomes CPD, urges to smoke, and psychophysiological health variables by smoking status at 12 and 24 weeks, and their relationship with cessation.

Results: Per ITT, self-reported abstinence rates were high at 12 weeks (39.4%), and 24 weeks (32.4%), as was 30-day PPA of 32.4% at both 12 and 24 weeks. Repeated PPA per ITT was 22.5% at both 12 and 24 weeks. Non-abstinent participants significantly reduced their CPD at 12 weeks (t(34) = 6.12, p < 0.001), and at 24 weeks (t(30) = 6.38, p < 0.001). Urges to smoke and perceived stress decreased, and mindfulness, cessation-related self-efficacy, life satisfaction and subjective psychophysiological health increased significantly (all ps < 0.05), predominantly in individuals who reported abstinence. Lower urges to smoke, lower perceived stress, and higher self-efficacy and subjective mental health were related to greater odds of cessation at 24 weeks (all ps < 0.05). Most participants rated the program as highly (43%) or moderately (54%) acceptable.

Discussion: Program participation seems to support cessation and improvements in smoking-related outcomes, but adjustments to the program may be needed to improve engagement and acceptability. Findings may inform the development of future trials and cessation programs.

Trial registration: German Clinical Trials Register DRKS00032652, registered prospectively 09/15/2023, https://drks.de/search/de/trial/DRKS00032652.