Focus (American Psychiatric Publishing)最新文献

[This corrects the article DOI: 10.1176/appi.focus.20220088.].

The United States is in the midst of an evolving overdose crisis, driven by the proliferation of potent synthetic opioids (e.g., illicitly made fentanyl), the resurgence of stimulants (e.g., methamphetamine), and the introduction of adulterants (e.g., xylazine) into the illicit drug supply. These substance use challenges are happening against the backdrop of rising mental health challenges that are closely linked to substance use and overdose. As overdose deaths have increased, the demographic profile of those dying has shifted and now disproportionately affects certain racial and ethnic minority populations. Social determinants of health (SDOH) are an underexplored component of the prevention response but are particularly salient in addressing substance use and overdose. Many SDOH have been linked to an increased risk for substance use and overdose, either directly or indirectly. The author examines the connection between SDOH and substance use and overdose, with a particular focus on young adults.

Prevention of substance misuse and substance use disorders is a national public health priority. The home environment can represent risk or protective factors for development of substance misuse. Children in homes with caregiver substance use are biologically, developmentally, interpersonally, and environmentally vulnerable to substance misuse and associated consequences, making it necessary for substance use prevention to focus on families early. Children and families who are minoritized, marginalized, and disenfranchised experience disproportionate consequences of substance use, through experiences of poverty, racism, trauma, and the built environment. Strengthening protective factors in early childhood by improving the health of caregivers and supporting the caregiver-child relationship can have enduring benefits over the life course. Pediatric primary care practices are an important setting for adopting a family-focused approach to prevention and early intervention of substance use. By engaging families early, identifying substance use in the family and household, recognizing the intersection of social needs and substance use, providing culturally tailored, trauma-informed, evidence-based care, and advising and supporting families on ways to minimize substance-related harm, pediatric care providers can play an important role in preventing substance use and substance-related consequences to children and families. Pediatric care providers are ideally suited to deliver prevention messages in a nonstigmatizing manner and serve as a conduit to evidence-based, family-focused intervention programs.

Renal impairment is defined as an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m² with or without kidney damage. Creatinine, which is found in serum and urine, is a common biomarker to estimate renal function and is used in most eGFR equations. Renal impairment can decrease or increase drug effects, necessitating therapeutic adjustments. Increased effect is related to drug accumulation that leads to increased elimination time and potential toxicity. eGFR plays a crucial role in drug dosing, particularly for renally excreted medications. However, the lack of recognition of pre-existing renal impairment and the incorrect interpretation of eGFR equations remain challenges. This case report explores the significance of eGFR in patients with psychiatric conditions, especially in the context of long-acting antipsychotic drug dosing.

The recently released National Drug Control Strategy (2022) from the White House Office of National Drug Control Policy (ONDCP) lays out a comprehensive plan to, not only enhance access to treatment and increase harm reduction strategies, but also increase implementation of evidence-based prevention programming at the community level. Furthermore, the Strategy provides a framework for enhancing our national data systems to inform policy and to evaluate all components of the plan. However, not only are there several missing components to the Strategy that would assure its success, but there is a lack of structure to support a national comprehensive service delivery system that is informed by epidemiological data, and trains and credentials those delivering evidence-based prevention, treatment, and harm reduction/public health interventions within community settings. This paper provides recommendations for the establishment of such a structure with an emphasis on prevention. Systematically addressing conditions known to increase liability for behavioral problems among vulnerable populations and building supportive environments are strategies consistently found to avert trajectories away from substance use in general and substance use disorders (SUD) in particular. Investments in this approach are expected to result in significantly lower rates of SUD in current and subsequent generations of youth and, therefore, will reduce the burden on our communities in terms of lowered social and health systems involvement, treatment needs, and productivity. A national strategy, based on strong scientific evidence, is presented to implement public health policies and prevention services. These strategies work by improving child development, supporting families, enhancing school experiences, and cultivating positive environmental conditions. Appeared originally in Clin Child Fam Psychol Rev 2023; 26:1-16.

There is a growing recognition in the fields of public health and medicine that social determinants of health (SDOH) play a key role in driving health inequities and disparities among various groups, such that a focus upon individual-level medical interventions will have limited effects without the consideration of the macro-level factors that dictate how effectively individuals can manage their health. While the health impacts of mass incarceration have been explored, less attention has been paid to how the "war on drugs" in the United States exacerbates many of the factors that negatively impact health and wellbeing, disproportionately impacting low-income communities and people of colour who already experience structural challenges including discrimination, disinvestment, and racism. The U.S. war on drugs has subjected millions to criminalisation, incarceration, and lifelong criminal records, disrupting or altogether eliminating their access to adequate resources and supports to live healthy lives. This paper examines the ways that "drug war logic" has become embedded in key SDOH and systems, such as employment, education, housing, public benefits, family regulation (commonly referred to as the child welfare system), the drug treatment system, and the healthcare system. Rather than supporting the health and wellbeing of individuals, families, and communities, the U.S. drug war has exacerbated harm in these systems through practices such as drug testing, mandatory reporting, zero-tolerance policies, and coerced treatment. We argue that, because the drug war has become embedded in these systems, medical practitioners can play a significant role in promoting individual and community health by reducing the impact of criminalisation upon healthcare service provision and by becoming engaged in policy reform efforts.

Key messages: • A drug war logic that prioritises and justifies drug prohibition, criminalisation, and punishment has fuelled the expansion of drug surveillance and control mechanisms in numerous facets of everyday life in the United States negatively impacting key social determinants of health, including housing, education, income, and employment.• The U.S. drug war's frontline enforcers are no longer police alone but now include physicians, nurses, teachers, neighbours, social workers, employers, landlords, and others.• Physicians and healthcare providers can play a significant role in promoting individual and community health by reducing the impact of criminalisation upon healthcare service provision and engaging in policy reform.Appeared originally in Ann Med 2022; 54:2024-2038.

The authors discuss the multidimensionality of risk factors for substance use and substance use disorder across the lifespan and the interplay between biological and environmental factors that may lead to substance use. When these underlying factors are not addressed, and usage continues, altered networks in the brain may lead to substance use disorders. Progress in prevention science, and in approaches to delay or prevent substance use initiation and progression to substance use disorder, is reviewed. Four barriers to delivering prevention approaches-unstable funding with a lack of coordination across systems, insufficient workforce capacity, states not knowing where to find evidence-based programs, and a lack of knowledge in how to adapt programs for specific settings-are identified, highlighting the need for a national prevention infrastructure. The authors conclude by providing examples and resources for mental health professionals in promoting prevention of substance use initiation and disorders.