Phenibut: Review and Pharmacologic Approaches to Treating Withdrawal

β-Phenyl-γ-aminobutyric acid (phenibut) is an analog of the inhibitory neurotransmitter γ-aminobutyric acid (GABA) that was first synthesized in Russia in the early 1960s. It is marketed as a nootropic (smart drug) to improve cognitive performance, and to treat generalized and social anxiety, insomnia, and alcohol withdrawal. The use of phenibut is legal in the USA and it is widely available online without a prescription. Increased public awareness of phenibut has led to a growing number of reports of acute intoxication and withdrawal. In this review, we describe the pharmacology of phenibut, the presentation and management of acute intoxication, and regulatory issues, placing particular emphasis on the treatment of acute withdrawal, for which there are no comparative studies. Among 29 cases of phenibut withdrawal, patients were successfully treated with baclofen, benzodiazepines, and phenobarbital, as individual agents or in various combinations. Ancillary medications included antipsychotics, dexmedetomidine, gabapentin, and pregabalin. After stabilization, a number of patients did well on baclofen tapers, whereas others were weaned off benzodiazepines or phenobarbital. Phenobarbital may be preferred over baclofen, or used as an added agent, in patients at risk for seizures. As long as phenibut remains legal, cases of phenibut intoxication and withdrawal are likely to increase. As urine or plasma drug screening for phenibut is not widely available, it is vital that clinicians obtain a detailed medication history in patients presenting to the emergency department with nonspecific symptoms that may represent phenibut intoxication or withdrawal. Further, clinicians may wish to consult an addiction specialist or toxicologist in these situations.

Perspectives and Recommendations from Hospitalized Patients with Substance Use Disorders: A Qualitative Study

BACKGROUND

Individuals with substance use disorders (SUDs) are hospitalized in growing numbers. Stigma is pervasive among their hospital providers, and SUD management during medical admissions is often inadequate. However, little is known about how these patients perceive their care quality. In particular, few studies have explored their positive care perceptions or recommendations for improvement.

OBJECTIVE

To explore perspectives on positive aspects, negative aspects, and consequences of care, as well as recommendations for improvement among hospitalized patients with SUDs.

DESIGN AND PARTICIPANTS

We conducted semi-structured, in-depth bedside interviews (n = 15) with patients who have been diagnosed with a SUD and were admitted to medical or surgical floors of an urban academic medical center.

APPROACH

Interviews explored patients' hospital experiences and recommendations for improvement. The interviews were audio-recorded, transcribed verbatim, and imported into NVivo software. Two reviewers independently coded the transcripts using interpretative phenomenological analysis and inductive thematic analysis according to grounded theory, and recurring themes were identified from the data. Patients' demographic and clinical data were analyzed with descriptive statistics.

KEY RESULTS

Perceived clinical and emotional proficiency were the most important components of positive experiences, whereas perceived bias and stigmatized attitudes, clinical improficiency, and inhumane treatment were characteristic of negative experiences. Such care components were most consequential for patients' emotional well-being, trust, and care quality. Recommendations for improving care included specific suggestions for initiating and promoting continued recovery, educating, and partnering in compassionate care.

CONCLUSIONS

Hospitalized patients with SUDs often experience lower quality and less compassionate care linked to pervasive stigma and poor outcomes. Our study highlights under-recognized perspectives from this patient population, including socioemotional consequences of care and recommendations grounded in lived experiences. By striving to advance our care in accordance with patients' viewpoints, we can turn hospitalizations into opportunities for engagement and promoting recovery.

Examining disparities in regional anaesthesia and pain medicine

In high-resource countries, health disparities exist in both treatment approaches and health outcomes. Race and ethnicity can serve as proxies for other socioeconomic factors and social determinants of health such as income, education, social support, and residential neighbourhood, which strongly influence health outcomes and disparities. In regional anaesthesia and pain medicine, disparities exist across several surgical specialties including obstetrics, paediatrics, and orthopaedic surgery. Understanding these disparities will facilitate development of solutions aimed at eliminating disparities at the patient, physician/provider, and healthcare system levels.

Managing Opioid Withdrawal Symptoms During the Fentanyl Crisis: A Review

Illicitly manufactured fentanyl (IMF) is a significant contributor to the increasing rates of overdose-related deaths. Its high potency and lipophilicity can complicate opioid withdrawal syndromes (OWS) and the subsequent management of opioid use disorder (OUD). This scoping review aimed to collate the current OWS management of study populations seeking treatment for OWS and/or OUD directly from an unregulated opioid supply, such as IMF. Therefore, the focus was on therapeutic interventions published between January 2010 and November 2023, overlapping with the period of increasing IMF exposure. A health science librarian conducted a systematic search on November 13, 2023. A total of 426 studies were screened, and 173 studies were reviewed at the full-text level. Forty-nine studies met the inclusion criteria. Buprenorphine and naltrexone were included in most studies with the goal of transitioning to a long-acting injectable version. Various augmenting agents were tested (buspirone, memantine, suvorexant, gabapentin, and pregabalin); however, the liberal use of adjunctive medication and shortened timelines to initiation had the most consistently positive results. Outside of FDA-approved medications for OUD, lofexidine, gabapentin, and suvorexant have limited evidence for augmenting opioid agonist initiation. Trials often have low retention rates, particularly when opioid agonist washout is required. Neurostimulation strategies were promising; however, they were developed and studied early. Precipitated withdrawal is a concern; however, the rates were low and adequately mitigated or managed with low- or high-dose buprenorphine induction. Maintenance treatment continues to be superior to detoxification without continued management. Shorter induction protocols allow patients to initiate evidence-based treatment more quickly, reducing the use of illicit or non-prescribed substances.

Prevalence, Characteristics, and Reasons for Kratom Use among Psychiatrically Ill Inpatients Who Use Substances

OBJECTIVE

Despite kratom impacting neurobiological systems involved in psychiatric disorders, little is known about the prevalence of use among patients with severe psychopathologies. Here, we investigated the prevalence of kratom use, motives for use, and the clinical associations among inpatients with severe psychiatric disorders.

METHODS

A total of 578 patients, aged 18 to 65, were evaluated by New Hampshire Hospital's Addiction Services from January 1, 2020, to February 28, 2022. The study collected demographic information and used chi-square tests, multivariable logistic regression, and subgroup analyses with 95% confidence intervals to examine trends among kratom users. A receiver operating characteristic curve analysis was also conducted. All statistical tests were performed using IBM SPSS Version 28.0.1.

RESULTS

Of the patients assessed, 2.2% (n = 13) reported using kratom. The reasons for kratom use were managing withdrawal symptoms (15.4%), maintaining sobriety and reducing cravings for opioids (53.8%), improving focus and concentration (30.8%), alleviating low moods (38.5%), and managing pain (15.4%). Compared to non-kratom users, the only factor with a fair to good association with kratom use is postsecondary education (Area Under Curve, AUC = 0.77).

CONCLUSIONS

Prevalence of kratom use among patients with serious mental illness at our site aligns with that reported in the general population. Users often cite self-management of cravings and sobriety from opioids, as well as treatment of low mood states, as motivations for consumption. While observations suggest a possible association between kratom use and individuals with post-secondary education, multiple substance use, and experience of substance-induced psychosis or mood disorders, it is essential to interpret these links cautiously until further rigorous studies are carried out to substantiate these findings.

Analysis of the Relationship between Psychiatric and Addiction-Related Disorders in Patients of an Outpatient Addiction Treatment Clinic for Children and Adolescents

INTRODUCTION

Dual diagnosis is used in addiction medicine to refer to the co-occurrence of an addiction-related disorder and another psychiatric disorder in the same individual. Adolescence is a key period for the development of both mental disorders and addictions.

OBJECTIVE

The aim of this study is to describe the relationships between psychiatric and addiction-related disorders in patients of the Outpatient Addiction Treatment Clinic for Children and Adolescents at the 1st Faculty of Medicine, Charles University in Prague in 2015-2022.

METHODS

Data were retrospectively analyzed from the hospital's medical system, which collects basic diagnostic data on patients. Descriptive statistics and cluster analysis were performed to identify relationships between psychiatric and addiction-related disorders.

RESULTS

Of the 450 patients, 153 patients (34%) met the criteria for dual diagnosis. The most common addiction-related disorders were mental and behavioural disorders due to the use of cannabinoids (35%) and internet gaming disorder (35%). The most common psychiatric diagnoses were behavioural and emotional disorders with usual onset in childhood and adolescence (64%), with a lower prevalence in girls than in boys.

CONCLUSIONS

These findings may be important for the diagnosis and treatment of risky behaviours and addictions in children and adolescents.

World addiction medicine reports: formation of the International Society of Addiction Medicine Global Expert Network (ISAM-GEN) and its global surveys

Addiction medicine is a dynamic field that encompasses clinical practice and research in the context of societal, economic, and cultural factors at the local, national, regional, and global levels. This field has evolved profoundly during the past decades in terms of scopes and activities with the contribution of addiction medicine scientists and professionals globally. The dynamic nature of drug addiction at the global level has resulted in a crucial need for developing an international collaborative network of addiction societies, treatment programs and experts to monitor emerging national, regional, and global concerns. This protocol paper presents methodological details of running longitudinal surveys at national, regional, and global levels through the Global Expert Network of the International Society of Addiction Medicine (ISAM-GEN). The initial formation of the network with a recruitment phase and a round of snowball sampling provided 354 experts from 78 countries across the globe. In addition, 43 national/regional addiction societies/associations are also included in the database. The surveys will be developed by global experts in addiction medicine on treatment services, service coverage, co-occurring disorders, treatment standards and barriers, emerging addictions and/or dynamic changes in treatment needs worldwide. Survey participants in categories of (1) addiction societies/associations, (2) addiction treatment programs, (3) addiction experts/clinicians and (4) related stakeholders will respond to these global longitudinal surveys. The results will be analyzed and cross-examined with available data and peer-reviewed for publication.

Substance use during hospitalisation requiring an urgent clinical response: an opportunity for intervention

BACKGROUND

There are few reports on drug use in patients while hospitalised and none regarding management or clinical outcomes.

AIMS

To describe cases of drug use by inpatients requiring an urgent clinical response.

METHODS

We retrospectively reviewed cases at a teaching hospital in Sydney, Australia, from February 2019 to March 2021.

RESULTS

Thirty cases were identified, with no deaths. Two patient groups were identified: (i) substance use disorders, using illicit drugs and (ii) self-harm history, using prescribed or over-the-counter drugs. Management involved cardiac monitoring (40%), intensive care (30%), charcoal (20%), antidotes (20%) and intubation (13%). Discharge was planned in 22 of 30 patients, against medical advice in four and directed by medical staff in four.

CONCLUSIONS

Inpatient drug use requiring an urgent clinical response was infrequently recognised but presents a risk of harm to patients and staff and increases service utilisation and costs. Both harm reduction and systematic approaches guided by institutional policy are recommended. Using these events as reachable moments to address driving factors may modify patients' risk from future events.

Cerebellar Leukoencephalopathy following Fentanyl Intoxication. A case report and review of the literature

The opioid crisis has become a significant public health concern in recent years. Although respiratory depression and overdose are the most reported side effects of fentanyl, there have been rare cases of cerebellar leukoencephalopathy (CLE) following fentanyl intoxication. A 29-year-old man with a history of opioid use disorder and intravenous drug use presented to the emergency room with significant ataxia and dysarthria following fentanyl intoxication. According to the patient, the symptoms began four days prior after "chasing the dragon" with "pure fentanyl", and he reported experiencing nausea and dizziness, particularly during ambulation. Neurological examination revealed a positive Romberg test, ataxia, and delayed speech. Brain magnetic resonance imaging (MRI) indicated there was toxic degeneration of the cerebellar white matter that extended into the posterior limbs of the internal capsule. Urine drug screening was positive for opioids, making fentanyl-induced cerebellar leukoencephalopathy the most likely diagnosis in this case. This case of opioid-induced CLE underscores the critical significance of early recognition, which is vital for enhancing a patient's recovery and averting the development of severe neurological complications.

Service-level barriers to and facilitators of accessibility to treatment for problematic alcohol use: a scoping review

Introduction

Services to treat problematic alcohol use (PAU) should be highly accessible to optimize treatment engagement. We conducted a scoping review to map characteristics of services for the treatment of PAU that have been reported in the literature to be barriers to or facilitators of access to treatment from the perspective of individuals with PAU.

Methods

A protocol was developed a priori, registered, and published. We searched MEDLINE®, Embase, the Cochrane Library, and additional grey literature sources from 2010 to April 2022 to identify primary qualitative research and surveys of adults with current or past PAU requiring treatment that were designed to identify modifiable characteristics of PAU treatment services (including psychosocial and pharmacologic interventions) that were perceived to be barriers to or facilitators of access to treatment. Studies of concurrent PAU and other substance use disorders were excluded. Study selection was performed by multiple review team members. Emergent barriers were coded and mapped to the accessibility dimensions of the Levesque framework of healthcare access, then descriptively summarized.

Results

One-hundred-and-nine included studies reported an extensive array of unique service-level barriers that could act alone or together to prevent treatment accessibility. These included but were not limited to lack of an obvious entry point, complexity of the care pathway, high financial cost, unacceptably long wait times, lack of geographically accessible treatment, inconvenient appointment hours, poor cultural/demographic sensitivity, lack of anonymity/privacy, lack of services to treat concurrent PAU and mental health problems.

Discussion

Barriers generally aligned with recent reviews of the substance use disorder literature. Ranking of barriers may be explored in a future discrete choice experiment of PAU service users. The rich qualitative findings of this review may support the design of new or modification of existing services for people with PAU to improve accessibility.

Systematic Review Registration

Open Science Framework doi: 10.17605/OSF.IO/S849R.

Preparing fourth year medical students to care for patients with opioid use disorder: how this training affects their intention to seek addiction care opportunities during residency

BACKGROUND & OBJECTIVES

In 2021, the USA recorded 100,000 annual deaths from drug overdose, representing the most frequent cause of death in adults under age 55. The integration of care for substance use disorders (SUDs) into undergraduate medical education is not well established. It is unclear whether a short course on management of opioid use disorder (OUD) offered to fourth year medical students could increase graduating students' knowledge and preparedness to treat these disorders.

METHODS

We designed a 2-hour interactive case-based session on patient care for OUD and delivered it virtually as part of a Transition to Residency course. A retrospective pre-/post-test assessment instrument determined the impact of this session on students' perceived knowledge, confidence, and intention to seek further educational opportunities for OUD.

RESULTS

Of 144 participants, 58 students (40.3%) completed the retrospective pre-/post- survey. There were statistically significant improvements in perceived knowledge and attitudes on the 12-item survey. The largest gains in perceived knowledge on a 5-point scale occurred in the categories regarding buprenorphine induction (pre 2.9; post 4.22; p < 0.001), managing inpatient opioid withdrawal (pre 2.84; post 4.27; p < 0.001), and the role of methadone in treating withdrawal (pre 3.16; post 4.29; p < 0.001). All (n = 58) survey respondents would recommend the training to a colleague and felt that the session would benefit their professional practice. Over 90% (93.1%) of respondents planned on seeking additional SUD learning opportunities during residency.

CONCLUSIONS

A 2-hour interactive case-based teaching session delivered to medical students improved perceived knowledge, attitudes, and future interest in obtaining education around OUD. As the opioid epidemic shows no sign of abating, we would advocate for the inclusion SUD education as part of Transition to Residency courses.

Racial and Ethnic Inequities in Buprenorphine and Methadone Utilization Among Reproductive-Age Women with Opioid Use Disorder: an Analysis of Multi-state Medicaid Claims in the USA

BACKGROUND

Associations between race/ethnicity and medications to treat OUD (MOUD), buprenorphine and methadone, in reproductive-age women have not been thoroughly studied in multi-state samples.

OBJECTIVE

To evaluate racial/ethnic variation in buprenorphine and methadone receipt and retention in a multi-state U.S. sample of Medicaid-enrolled, reproductive-age women with opioid use disorder (OUD) at the beginning of OUD treatment.

DESIGN

Retrospective cohort study.

SUBJECTS

Reproductive-age (18-45 years) women with OUD, in the Merative™ MarketScan® Multi-State Medicaid Database (2011-2016).

MAIN MEASURES

Differences by race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, "other" race/ethnicity) in the likelihood of receiving buprenorphine and methadone during the start of OUD treatment (yes/no) were estimated using multivariable logistic regression. Differences in time to medication discontinuation (days) by race/ethnicity were evaluated using multivariable Cox regression.

RESULTS

Of 66,550 reproductive-age Medicaid enrollees with OUD (84.1% non-Hispanic White, 5.9% non-Hispanic Black, 1.0% Hispanic, 5.3% "other"), 15,313 (23.0%) received buprenorphine and 6290 (9.5%) methadone. Non-Hispanic Black enrollees were less likely to receive buprenorphine (adjusted odds ratio, aOR = 0.76 [0.68-0.84]) and more likely to be referred to methadone clinics (aOR = 1.78 [1.60-2.00]) compared to non-Hispanic White participants. Across both buprenorphine and methadone in unadjusted analyses, the median discontinuation time for non-Hispanic Black enrollees was 123 days compared to 132 days and 141 days for non-Hispanic White and Hispanic enrollees respectively (χ2 = 10.6; P = .01). In adjusted analyses, non-Hispanic Black enrollees experienced greater discontinuation for buprenorphine and methadone (adjusted hazard ratio, aHR = 1.16 [1.08-1.24] and aHR = 1.16 [1.07-1.30] respectively) compared to non-Hispanic White peers. We did not observe differences in buprenorphine or methadone receipt or retention for Hispanic enrollees compared to the non-Hispanic White enrollees.

CONCLUSIONS

Our data illustrate inequities between non-Hispanic Black and non-Hispanic White Medicaid enrollees with regard to buprenorphine and methadone utilization in the USA, consistent with literature on the racialized origins of methadone and buprenorphine treatment.

Kratom use disorder: case reports on successful treatment with home induction of buprenorphine-naloxone

BACKGROUND

Kratom has been used for different reasons such as pain, opioid withdrawal, and relaxation. Kratom can cause dependence and overdose, and it's classified under 'drugs of concern' by the US Drug Enforcement Administration. Despite these concerns, kratom is legal in most of the United States and many countries around the world with easy accessibility. Literature searches reveal recommendations to use buprenorphine (or buprenorphine-naloxone), which are medications to treat opioid use disorder, in order to treat patients with kratom use disorder; however, there are no formal guidelines available. Buprenorphine (or buprenorphine-naloxone) induction is recommended to be conducted under observation (i.e. in the clinic) in the United States, but COVID-19 has resulted in shifts toward telehealth.

OBJECTIVES

Describe case series of successful management of kratom use disorder using telehealth followed by unobserved buprenorphine-naloxone home induction and highlight implications for future management, including maintenance dosage and induction method.

METHODS

We present 2 very similar kratom use disorder patients who reported taking 35 g of kratom per day who underwent unobserved buprenorphine-naloxone home induction.

RESULTS

Both were seen via telehealth initially. They reported no adverse effects before, during, or after the unobserved home induction on buprenorphine-naloxone but stabilized on significantly different dosages.

CONCLUSION

Telehealth followed by unobserved buprenorphine-naloxone induction at home may be an alternative to traditional buprenorphine-naloxone induction where treatment accessibility is limited. In addition to daily doses of kratom use, other factors, such as duration of kratom use and individual psychological factors may determine the most comfortable dose of buprenorphine-naloxone.

Evaluation of the New England Office Based Addiction Treatment ECHO: A Tool for Strengthening the Addiction Workforce

INTRODUCTION

Reducing substance-related morbidity requires an educated and well-supported workforce. The New England Office Based Addiction Treatment Extension for Community Healthcare Outcomes (NE OBAT ECHO) began in 2019 to support community-based addiction care teams through virtual mentoring and case-based learning. We sought to characterize the program's impact on the knowledge and attitudes of NE OBAT ECHO participants.

METHODS

We conducted an 18-month prospective evaluation of the NE OBAT ECHO. Participants registered for 1 of 2 successive ECHO clinics. Each 5-month clinic included ten 1.5-hour sessions involving brief didactic lectures and de-identified patient case presentations. Participants completed surveys at Month-0, -6, -12, and -18 to assess attitudes about working with patients who use drugs and evidence based practices (EBPs), stigma toward people who use drugs, and addiction treatment knowledge. We compared outcomes using 2 approaches: (i) between-groups, which involved comparing the first intervention group to the delayed intervention (comparison) group, and (ii) within-groups, which involved comparing outcomes at different time points for all participants. In the within-group approach, each participant acted as their own control.

RESULTS

Seventy-six health professionals participated in the NE OBAT ECHO, representing various roles in addiction care teams. Approximately half (47% [36/76]) practiced primary care, internal, or family medicine. The first intervention group reported improved job satisfaction and openness toward EBPs compared to the delayed intervention group. Within-group analyses revealed that ECHO participation was associated with increased positive perceptions of role adequacy, support, legitimacy, and satisfaction 6 months following program completion. No changes were identified in willingness to adopt EBPs or treatment knowledge. Stigma toward people who use drugs was persistent in both groups across time points.

CONCLUSIONS

NE OBAT ECHO may have improved participants' confidence and satisfaction providing addiction care. ECHO is likely an effective educational tool for expanding the capacity of the addiction workforce.

Primary Care at the Intersection of Lifestyle Interventions and Unhealthy Substance Use

Primary care physicians are well-positioned to integrate lifestyle interventions into the management of patients with unhealthy substance use, who may also have mental and physical chronic health comorbidities. However, the COVID-19 pandemic exacerbated the U.S.'s poor state of health, revealing that its current approach to chronic disease management is neither effective nor sustainable. Today's full spectrum comprehensive care model requires an expanded toolkit. Lifestyle interventions broaden current treatment approaches and may enhance Addiction Medicine care. Primary care providers have the potential to have the greatest impact on unhealthy substance use care because they are experts in chronic disease management and their frontline accessibility minimizes healthcare barriers. Individuals with unhealthy substance use are at an increased risk of chronic physical conditions. Incorporating lifestyle interventions with unhealthy substance use care at every level of medicine, from medical school through practice, normalizes both as part of the standard care of medicine and will drive evidence-based best practices to support patients through prevention, treatment, and reversal of chronic diseases.

Acupuncture in Addiction Medicine: Its History, Evidence, and Possibilities

Substance-use disorders (SUDs) and drug addiction are not only national, but also global health concerns that have worsened during and after the COVID-19 pandemic. Acupuncture augments the endogenous opioid system and, therefore, has a theoretical basis as a treatment for opioid use disorders (OUDs). The basic science of acupuncture, its clinical research in addiction medicine, and decades of success of the National Acupuncture Detoxification Association protocol offer positive findings supporting this protocol's utility for treating SUDs. Considering the mounting opioid/substance-use concerns and deficiencies in SUD treatment availability in the United States, acupuncture can be a safe, feasible treatment option and adjunct in addiction medicine. Furthermore, large governmental agencies are lending support to acupuncture for treating acute and chronic pain, which, in turn, could translate to prevention of SUDs and addictions. This article is a narrative review of the background, the basic science and clinical research, and future direction of acupuncture in addiction medicine.

AuTomaTed Alcohol Misuse INterventions in a Bariatric Surgery Population: The ATTAIN Bariatric Pilot

Introduction Alcohol screening and brief intervention has been shown to reduce unhealthy alcohol use, although widespread adoption into primary care practice has been slow. Patients undergoing bariatric surgery are at an increased risk of unhealthy alcohol use. The authors compared a novel, web-based screening tool called ATTAIN to usual care for real-world effectiveness and accuracy among bariatric surgery registry patients. Methods The authors analyzed the results of a quality improvement project that tested ATTAIN among bariatric surgery registry patients. Participants were stratified into 3 groups by surgery status (preoperative vs postoperative) and prior screening for unhealthy alcohol use (screened vs not screened in the past year). Participants in these 3 groups were divided into intervention plus usual care (n = 2249) and control (n = 2130) groups, with intervention being an email to complete ATTAIN, and control being usual care (eg, office-based screening). Primary outcomes included screening and positivity rates for unhealthy drinking behavior between groups. Secondary outcomes included positivity rates via ATTAIN vs usual care for individuals who were screened by both modalities. Chi-square test was used for statistical analysis. Results The overall screening rates were 67.4% (intervention arm) and 38.6% (control). The ATTAIN response rate was 47% of those invited. The overall positive screen rate was 7.7% (intervention) and 2.6% (control); p < .001 for both. For dual screened intervention participants, the positive screen rate was 10% (ATTAIN) vs 2% (usual care) with p < .001. Conclusion ATTAIN is a promising method of increasing screening and detection rates for unhealthy drinking behavior.

An unexpected path to addiction medicine

The field of Addiction Medicine needs dedicated reproductive healthcare specialists who are motivated to move the field forward to provide optimal patient care.

Implementation of Telemedicine Delivery of Medications for Opioid Use Disorder in Pennsylvania Treatment Programs During COVID-19

INTRODUCTION

Temporary policy changes during the coronavirus disease 2019 pandemic facilitated rapid expansion of medication for opioid use disorder via telemedicine (tele-MOUD). Evidence for tele-MOUD best practices and its impact on treatment engagement and retention remains limited. This quality improvement initiative compared tele-MOUD implementation among Pennsylvania medication for opioid use disorder (MOUD) programs, evaluated sociodemographic characteristics of patients using tele-MOUD, and described trends in tele-MOUD use and patient engagement and retention.

METHODS

Five health systems with MOUD programs completed questionnaires regarding their tele-MOUD models and provided aggregated sociodemographic data for MOUD patients with in-person and telemedicine visits in 2020. Three programs provided aggregated monthly appointment data (scheduled, completed, no-show, tele-MOUD visits) over the period in which tele-MOUD scaled up.

RESULTS

Differences in tele-MOUD protocols related to provision of tele-MOUD inductions, patient eligibility for tele-MOUD, and operationalization of remote drug testing. Across programs, 88% of prescribers conducted tele-MOUD appointments, and 50% of patients used tele-MOUD in 2020. We observed sociodemographic differences, with a greater proportion of female, White, and non-Hispanic patients using tele-MOUD. Across programs with appointment data, overall patient enrollment increased, and new patient enrollment remained relatively constant. Engagement trends suggested a temporary decline in no-show appointments that aligned with the escalation of tele-MOUD in one program.

CONCLUSIONS

Tele-MOUD protocol differences indicate a need for research to inform evidence-based guidance. Findings suggest that patients largely remained engaged and retained in MOUD as tele-MOUD was implemented but reveal inequities in tele-MOUD use, highlighting the need for efforts to overcome technology access barriers and avoid exacerbating disparities in MOUD access.

Methadone Maintenance Treatment Discontinuation Among Young People who use Opioids in Vancouver, Canada

OBJECTIVE

Retaining adolescents and young adults (AYA) in medications for opioid use disorder (MOUD), like methadone maintenance treatment (MMT), is critical to reducing toxic drug fatalities. This analysis sought to identify factors associated with MMT discontinuation among AYA.

METHOD

Data were derived from the At-Risk Youth Study, a prospective cohort study of street-involved AYA in Vancouver, Canada, between December 2005 and June 2018. Multivariable extended Cox regression identified factors associated with time to MMT discontinuation among AYA who recently initiated MMT. In subanalysis, multivariable extended Cox regression analysis identified factors associated with time to "actionable" MMT discontinuation, which could be addressed through policy changes.

RESULTS

A total of 308 participants reported recent MMT during the study period. Participants were excluded if they reported MMT in the past 6 months at baseline and were retained in MMT (n = 94, 30.5%); were missing MMT status data (n = 43, 14.0%); or completed an MMT taper (n = 11, 3.6%). Of the remaining 160 participants who initiated MMT over the study period, 102 (63.8%) discontinued MMT accounting for 119 unique discontinuation events. In multivariable extended Cox regression, MMT discontinuation was positively associated with recent weekly crystal methamphetamine use (adjusted hazard ratio [AHR] = 1.67, 95% confidence interval [CI]: 1.19 to 2.35), but negatively associated with age of first "hard" drug use (per year older) (AHR = 0.95, 95% CI: 0.90 to 1.00) and female sex (AHR = 0.66, 95% CI: 0.44 to 0.99). In subanalysis, recent weekly crystal methamphetamine use (AHR = 4.61, 95% CI: 1.78 to 11.9) and weekly heroin or fentanyl use (AHR = 3.37, 95% CI: 1.21 to 9.38) were positively associated with "actionable" MMT discontinuation, while older age (AHR = 0.87, 95% CI: 0.76 to 0.99) was negatively associated.

CONCLUSIONS

Efforts to revise MMT programming; provide access to a range of MOUD, harm reduction, and treatments; and explore coprescribing stimulants to AYA with concurrent stimulant use may improve treatment retention and reduce toxic drug fatalities.

Reporting of patient-reported outcomes in trials on alcohol use disorder: a meta-epidemiological study

OBJECTIVES

Currently, limited research exists to assess the extent of patient-reported outcome (PRO) reporting among randomised controlled trials (RCTs) evaluating alcohol use disorder (AUD). We sought to investigate the completeness of reporting of PROs using the Consolidated Standards of Reporting Trials-PRO (CONSORT-PRO) extension in AUD RCTs.

DESIGN SETTING

Meta-epidemiological study.

METHODS

We searched MEDLINE, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) on 29 June 2021 for published RCTs focused on AUD. Following these searches, title and abstract screening, and full-text screening were performed by two investigators. To be included, a study must have employed a randomised trial design, published in English, focused on treatment of AUD and included at least one PRO. Trials meeting inclusion criteria were evaluated for completeness of reporting using the CONSORT-PRO extension adaptation. These trials were also evaluated for risk of bias (RoB) using the Cochrane RoB V.2.0 tool. Additionally, an exploratory analysis of each RCT's therapeutic area was extracted using the Mapi Research Trust's ePROVIDE platform. Screening and data collection were all performed in masked, duplicate fashion.

MAIN OUTCOME MEASURES

PRO completeness of reporting, identification of factors associated with completeness of reporting and PRO measures used in RCTs to evaluate patients with AUD.

RESULTS

Nineteen RCTs were evaluated in our analysis. Our primary outcome, the mean completion score for CONSORT-PRO, was 40.8%. Our secondary outcome-the identification of factors associated with completeness of reporting-found that trials published after 2014 (ie, 1 year after the publication of the CONSORT-PRO extension) were 15.0% more complete than trials published before 2014. We found no additional associations with better reporting.

CONCLUSIONS

We found that the completeness of PRO reporting in RCTs involving AUD was deficient. Complete reporting of PROs is instrumental in understanding the effects of interventions, encourages patient participation in their treatment and may increase clinician confidence in the value of PROs. High quality treatment strategies for AUD require properly reported PROs.

Impact of Stigma on Clinician Training for Opioid Use Disorder Care: A Qualitative Study in a Primary Care Learning Collaborative

PURPOSE

We undertook a study to examine how stigma influences the uptake of training on medication for opioid use disorder (MOUD) in primary care academic programs.

METHODS

We conducted a qualitative study of 23 key stakeholders responsible for implementing MOUD training in their academic primary care training programs that were participants in a learning collaborative in 2018. We assessed barriers to and facilitators of successful program implementation and used an integrated approach to develop a codebook and analyze the data.

RESULTS

Participants represented the family medicine, internal medicine, and physician assistant fields, and they included trainees. Most participants described clinician and institutional attitudes, misperceptions, and biases that enabled or hindered MOUD training. Perceptions included concerns that patients with OUD are "manipulative" or "drug seeking." Elements of stigma in the origin domain (ie, beliefs by primary care clinicians or the community that OUD is a choice and not a disease), the enacted domain (eg, hospital bylaws banning MOUD and clinicians declining to obtain an X-Waiver to prescribe MOUD), and the intersectional domain (eg, inadequate attention to patient needs) were perceived as major barriers to MOUD training by most respondents. Participants described strategies that improved the uptake of training, including giving attention to clinician concerns, clarifying the biology of OUD, and ameliorating clinician fears of being ill equipped to provide care for patients.

CONCLUSIONS

OUD-related stigma was commonly reported in training programs and impeded the uptake of MOUD training. Potential strategies to address stigma in the training context, beyond providing content on effective evidence-based treatments, include addressing the concerns of primary care clinicians and incorporating the chronic care framework into OUD treatment.

Methamphetamine-associated cardiomyopathy: an addiction medicine perspective

Methamphetamine-associated cardiomyopathy (MaCM) is an increasingly recognised serious complication from methamphetamine (MA) use. It is characterised as the development of otherwise unexplained heart failure in the context of MA use. MaCM predominantly affects a young and vulnerable population with high morbidity and mortality. It is the second leading cause of mortality in patients with MA use disorder (MUD). Our understanding of MaCM pathogenesis is based on observational cohorts and autopsy studies. Currently, the treatment of MaCM is predicated on abstinence. Medical therapies offer some benefit to a minority of patients; however, without abstinence, medical therapies are often ineffective. Abstinence is difficult for most patients to achieve; all clinicians require an understanding of MaCM and how to educate patients on the risks of ongoing use. Where available, referral to addiction medicine specialists to assist with treatment of MUD is recommended. This review aims to: (i) explain the proposed pathologic mechanisms of MaCM; (ii) summarise recent recommendations of the screening and treatment of MaCM; and (iii) highlight the role of addiction medicine in the management of patient with MaCM.

Description and Evaluation of a Pilot Advanced Pharmacy Practice Experience in Addiction Medicine

Objective. To assess the impact of a pilot advanced pharmacy practice experience (APPE) on fourth-year (P4) Doctor of Pharmacy (PharmD) students' knowledge and confidence related to substance use disorder, harm reduction, and co-occurring psychiatric conditions.Methods. Beginning in 2020, a 62-item assessment was developed and administered to P4 students at the beginning and end of the six-week APPE. The assessment tested knowledge in 10 content areas related to substance use disorder, harm reduction, and co-occurring disorders. Students also ranked their confidence in providing care related to each content area. The post-assessment included a free-text (open-ended) item to provide feedback on the APPE experience. Descriptive statistics and paired t tests were used to analyze the data.Results. Complete pre- and post-assessments were obtained from all participating students (N=7). The mean cumulative knowledge score increased from 55.2% to 81.5%, and the mean cumulative confidence score improved from 34.2% to 81.8%. Free-text responses garnered positive feedback from students, who indicated that the APPE allowed them to immerse themselves in all stages of the recovery process, gain confidence in presentation skills with patients, and solidify their passion for addiction medicine.Conclusion. A novel APPE in addiction medicine addressed a current gap in pharmacy education, earned positive evaluations from student pharmacists, increased student knowledge and confidence related to substance use disorder, harm reduction, and co-occurring disorders, and supported the development of new interprofessional collaborations. United States colleges of pharmacy that do not yet offer APPEs in this clinical domain should consider this model.

Management of Infective Endocarditis in People Who Inject Drugs: A Scientific Statement From the American Heart Association

BACKGROUND

The American Heart Association has sponsored both guidelines and scientific statements that address the diagnosis, management, and prevention of infective endocarditis. As a result of the unprecedented and increasing incidence of infective endocarditis cases among people who inject drugs, the American Heart Association sponsored this original scientific statement. It provides a more in-depth focus on the management of infective endocarditis among this unique population than what has been provided in prior American Heart Association infective endocarditis-related documents.

METHODS

A writing group was named and consisted of recognized experts in the fields of infectious diseases, cardiology, addiction medicine, and cardiovascular surgery in October 2021. A literature search was conducted in Embase on November 19, 2021, and multiple terms were used, with 1345 English-language articles identified after removal of duplicates.

CONCLUSIONS

Management of infective endocarditis in people who inject drugs is complex and requires a unique approach in all aspects of care. Clinicians must appreciate that it requires involvement of a variety of specialists and that consultation by addiction-trained clinicians is as important as that of more traditional members of the endocarditis team to improve infective endocarditis outcomes. Preventive measures are critical in people who inject drugs and are cured of an initial bout of infective endocarditis because they remain at extremely high risk for subsequent bouts of infective endocarditis, regardless of whether injection drug use is continued.

Final-year medical student Psychiatry and Addiction Medicine synchronous summative tele-assessments during a COVID-19 Delta-variant stay-at-home lockdown

OBJECTIVE

We describe the planning, process and evaluation of final-year Psychiatry and Addiction Medicine summative assessments in a four-year graduate medical degree program, during a COVID-19 Delta-variant public health stay-at-home lockdown.

CONCLUSIONS

We conducted separate written and clinical synchronous (real-time simultaneous) tele-assessments. We used online assessment technology with students, examiners and simulated patients, all in different physical locations. Medical students' examination performance showed a good range. This was comparable to other discipline stations, and performance in previous years. There was no differential performance of students through the day of the assessments.

Informed consent is poorly documented when obtaining toxicology testing at delivery in a Massachusetts cohort

BACKGROUND

Positive toxicology testing at delivery can have enormous consequences for birthing persons and their families, including charges of child abuse or neglect and potential loss of custody for the birthing parent. Therefore state and national guidelines stipulate that, clinicians must obtain consent before toxicology testing at delivery.

OBJECTIVE

This study aimed (1) to determine clinician documentation of patient consent for peripartum toxicology testing and (2) to characterize the extent to which patient and hospital characteristics were associated with documented consent.

STUDY DESIGN

This was a retrospective cohort of individuals who underwent toxicology testing within 96 hours of delivery between April 2016 and April 2020 at 5 affiliated hospitals across Massachusetts. Medical records were reviewed for documentation of clinician intent to obtain maternal toxicology, testing indication, verbal consent to testing, and child protective services involvement. Hierarchical multivariable logistic regression was used to examine the association between patient and hospital characteristics and documentation of verbal consent.

RESULTS

Among 60,718 deliveries, 1562 maternal toxicology tests were obtained. Verbal consent for testing was documented in 466 cases (29.8%). Documented consent was lacking across most demographic groups. Consent was no more likely to be documented when a report was filed with child protective services and less likely in cases where the birthing parent lost custody before discharge (P=.003). In our multivariable model, consent was least likely to be documented when a maternal complication (abruption, hypertension, preterm labor, preterm premature rupture of membranes, or intrauterine fetal demise) was the indication for testing (adjusted odds ratio, 0.46; 95% confidence interval, 0.28-0.76). Verbal consent was twice as likely to be documented in delivery hospitals with established consent policies (adjusted odds ratio, 2.10; 95% confidence interval, 1.01-4.37).

CONCLUSION

Consent for toxicology testing at delivery seemed to be infrequently obtained on the basis of clinician documentation. Provider education and hospital policies for obtaining informed consent are needed to protect the rights of birthing individuals.

Medication prescribing for alcohol use disorders during alcohol-related encounters in a Colorado regional healthcare system

RATIONALE

Investigations show that medications for alcohol use disorders (MAUD) reduce heavy drinking and relapses. However, only 1.6% of individuals with alcohol use disorders (AUD) receive MAUD across care settings. The epidemiology of MAUD prescribing in the acute care setting is incompletely described. We hypothesized that MAUD would be under prescribed in inpatient acute care hospital settings compared to the outpatient, emergency department (ED), and inpatient substance use treatment settings.

METHODS

We evaluated electronic health record (EHR) data from adult patients with an International Classification of Diseases, 10th revision (ICD-10) alcohol-related diagnosis in the University of Colorado Health (UCHealth) system between January 1, 2016 and 31 December, 2019. Data from patients with an ICD-10 diagnosis code for opioid use disorder and those receiving MAUD prior to their first alcohol-related episode were excluded. The primary outcome was prescribing of MAUD, defined by prescription of naltrexone, acamprosate, and/or disulfiram. We performed bivariate and multivariate analyses to identify independent predictors of MAUD prescribing at UCHealth.

RESULTS

We identified 48,421 unique patients with 136,205 alcohol-related encounters at UCHealth. Encounters occurred in the ED (42%), inpatient acute care (17%), inpatient substance use treatment (18%), or outpatient primary care (12%) settings. Only 2270 (5%) patients received MAUD across all settings. Female sex and addiction medicine consults positively predicted MAUD prescribing. In contrast, encounters outside inpatient substance use treatment, Hispanic ethnicity, and black or non-white race were negative predictors of MAUD prescribing. Compared to inpatient substance use treatment, inpatient acute care hospitalizations for AUD was associated with a 93% reduced odds of receiving MAUD.

CONCLUSIONS

AUD-related ED and inpatient acute care hospital encounters in our healthcare system were common. Nevertheless, prescriptions for MAUD were infrequent in this population, particularly in inpatient settings. Our findings suggest that the initiation of MAUD for patients with alcohol-related diagnoses in acute care settings deserves additional evaluation.

Barriers to care for perinatal patients with opioid use disorder: family physician perspectives

BACKGROUND

While barriers to care for pregnant patients with opioid use disorder (OUD) have been described, the experiences and challenges of the physicians providing care to these patients are poorly understood.

OBJECTIVES

To describe the experiences of family physicians providing comprehensive care to pregnant people with OUD and the challenges they face in providing such care.

METHODS

Qualitative thematic analysis of 17 semistructured interviews conducted from July 2019 to September 2020 with family physicians who possess a Drug Enforcement Administration "X" waiver and provide care to pregnant patients.

RESULTS

Seventeen family physicians practicing in the United States who care for pregnant people with OUD were interviewed. They described physician-, patient-, and systems-level barriers to providing and accessing care for this patient population. Of the 12 interrelated themes regarding challenges to delivering and accessing this care, 3 were particularly salient: the pervasive effects of social determinants of health, a lack of adequately trained providers, and social stigma associated with pregnant people with OUD.

CONCLUSION

A comprehensive, multilevel, and multidisciplinary approach is necessary to address these barriers and move towards health equity for this vulnerable patient population.

Substance use disorder approaches in US primary care clinics with national reputations as workforce innovators

BACKGROUND

Over the last decade, primary care clinics in the United States have responded both to national policies encouraging clinics to support substance use disorders (SUD) service expansion and to regulations aiming to curb the opioid epidemic.

OBJECTIVE

To characterize approaches to SUD service expansion in primary care clinics with national reputations as workforce innovators.

METHODS

Comparative case studies were conducted to characterize different approaches among 12 primary care clinics purposively and iteratively recruited from a national registry of workforce innovators. Observational field notes and qualitative interviews from site visits were coded and analysed to identify and characterize clinic attributes.

RESULTS

Codes describing clinic SUD expansion approaches emerged from our analysis. Clinics were characterized as: avoidant (n = 3), contemplative (n = 5) and responsive (n = 4). Avoidant clinics were resistant to planning SUD service expansion; had no or few on-site behavioural health staff; and lacked on-site medication treatment (previously termed medication-assisted therapy) waivered providers. Contemplative clinics were planning or had partially implemented SUD services; members expressed uncertainties about expansion; had co-located behavioural healthcare providers, but no on-site medication treatment waivered and prescribing providers. Responsive clinics had fully implemented SUD; members used non-judgmental language about SUD services; had both co-located SUD behavioural health staff trained in SUD service provision and waivered medication treatment physicians and/or a coordinated referral pathway.

CONCLUSIONS

Efforts to support SUD service expansion should tailor implementation supports based on specific clinic training and capacity building needs. Future work should inform the adaption of evidence-based practices that are responsive to resource constraints to optimize SUD treatment access.

A retrospective, observational study on medication for opioid use disorder during pregnancy and risk for neonatal abstinence syndrome

OBJECTIVES

The prevalence of opioid use disorder (OUD) among pregnant women is increasing. Research consistently demonstrates the efficacy of medications for OUD (MOUD); however, researchers have called for additional studies evaluating the safety of MOUD during pregnancy, particularly the relative safety of two commonly used MOUD medications-methadone and buprenorphine. This study aimed to evaluate the consequences of MOUD exposure during pregnancy on risk for neonatal abstinence syndrome (NAS).

METHODS

In a clinical sample of infants born to women with OUD, we evaluated the risk of NAS among those exposed to (i) methadone and (ii) buprenorphine compared with those unexposed to MOUD, as well as the risk of NAS among those exposed to (i) methadone compared with those exposed to (ii) buprenorphine.

RESULTS

Compared with buprenorphine-exposed infants (n = 37), methadone-exposed infants (n = 27) were at increased risk for NAS (odds ratio [OR] = 4.67, 95% confidence interval [CI]: 1.03, 21.17). Compared with unexposed infants (n = 43), buprenorphine-exposed infants were at decreased risk for NAS (OR = 0.45, 95% CI: 0.14, 1.39) and methadone-exposed infants were at increased risk for NAS (OR = 2.64, 95% CI: 0.79, 8.76), though these associations were not statistically significant.

CONCLUSIONS

Our study suggests that when methadone and buprenorphine are equally appropriate options for the treatment of OUD in pregnant women, buprenorphine may add the additional benefit of reduced risk of newborn NAS.

Expert advice for prescribing cannabis medicines for patients with epilepsy-drawn from the Australian clinical experience

There is international interest for consensus advice for prescribers working in the field of drug resistant epilepsy intending to trial potential therapies that are nonregistered or off‐label. Cannabinoids are one such therapy. In 2017, the New South Wales State Government (Australia) set up a cannabinoid prescribing guidance service for a wide variety of indications, based on known pharmacology together with the relevant new literature as it became available. Increasing interest in cannabis medicines use outside this State over the following 5 years together with a paucity of registration‐standard clinical trials, lack of information around dosing issues, drug interactions and biological plausibility meant there remained a large unmet need for such advice. To address the unmet need in epilepsy, and until medicines were registered or regulator quality data were available, it was agreed to bring together a working group comprising paediatric and adult epilepsy specialists, clinical pharmacists., clinical pharmacologists and cannabis researchers from across Australia to develop interim consensus advice for prescribers. Although interim, this consensus advice addresses much of the current practice gap by providing an informed overview of the different cannabis medicines currently available for use in the treatment of epilepsy in paediatric and adult settings, with information on dose, drug interactions, toxicity, type of seizure and frequency of symptom relief. As such it supplements the limited evidence currently available from clinical trials with experience from front‐line practice. It is expected that this consensus advice will be updated as new evidence emerges and will provide guidance for a subsequent Guideline.

Perceptions on navigating ACGME-accredited addiction psychiatry fellowship program websites: A thematic analysis across a race- and gender-diverse pool of potential applicants

Background: There is an alarming shortage of addiction psychiatrists in the United States. To promote interest in addiction psychiatry (ADP), it is essential to maximize resources available through ADP fellowship websites. The aim of this study was to investigate the perceived adequacy and accessibility of content on ADP fellowship websites and discover what further information is considered important among trainees interested in becoming addiction specialists. Methods: Three virtual focus groups were conducted between January and February 2021 among medical students and residents in diverse geographic regions. Participants were asked about the availability of information on ADP fellowship program websites and other material they would like to see available. Focus groups were recorded, with data transcribed and coded using NVivo 11 and Dedoose. A coding scheme was deductively developed based on the core research questions. Results: The majority of participants (N = 27) identified areas of dissatisfaction with the content currently available on ADP websites. The sample was highly representative of racial and ethnic minoritized trainees (n = 12) and genderqueer/non-binary participants (n = 3). Three major themes were identified and durable across all focus groups: lack of emphasis on diversity/health equity, lack of portrayal of everyday life and activities of fellows, and inadequate representation of curricula. Overwhelmingly, participants identified a dedication to health equity (for example, working with minoritized populations) as a key deciding factor in whether to apply to a particular ADP fellowship. Conclusions: ADP fellowship websites are perceived to have considerable variability in the amount and quality of information. Many do not appear to provide the full spectrum of content desired by diverse potential applicants, such as information regarding current fellows and community-centered initiatives. This is concerning, as it suggests ADP fellowships may be interfacing poorly with burgeoning leaders, especially those from race and gender minoritized backgrounds, neglecting potential opportunities to develop future addiction specialists.

Uptake of slow-release oral morphine as opioid agonist treatment among hospitalised patients with opioid use disorder

INTRODUCTION

Buprenorphine and methadone are highly effective first-line medications for opioid agonist treatment (OAT) but are not acceptable to all patients. We aimed to assess the uptake of slow-release oral morphine (SROM) as second-line OAT among medically ill, hospitalised patients with opioid use disorder who declined buprenorphine and methadone.

METHODS

This study included consecutive hospitalised patients with untreated moderate-to-severe opioid use disorder referred to an inpatient addiction medicine consultation service, between June 2018 and September 2019, in Nova Scotia, Canada. We assessed the proportion of patients initiating first-line OAT (buprenorphine or methadone) in-hospital, and the proportion initiating SROM after declining first-line OAT. We compared rates of outpatient OAT continuation (i.e., filling outpatient OAT prescription or attending first outpatient OAT clinic visit) by medication type, and compared OAT selection between patients with and without chronic pain, using χ² tests.

RESULTS

Thirty-four patients were offered OAT initiation in-hospital; six patients (18%) also had chronic pain. Twenty-one patients (62%) initiated first-line OAT with buprenorphine or methadone. Of the 13 patients who declined first-line OAT, seven (54%) initiated second-line OAT with SROM in-hospital. Rates of outpatient OAT continuation after hospital discharge were high (>80%) and did not differ between medications (P = 0.4). Patients with co-existing chronic pain were more likely to choose SROM over buprenorphine or methadone (P = 0.005).

DISCUSSION AND CONCLUSIONS

The ability to offer SROM (in addition to buprenorphine or methadone) increased rates of OAT initiation among hospitalised patients. Increasing access to SROM would help narrow the opioid use disorder treatment gap of unmet need.

Challenges with buprenorphine inductions in the context of the fentanyl overdose crisis: A case series

INTRODUCTION AND AIMS

North America is currently experiencing an epidemic of opioid overdose deaths, driven by the proliferation of fentanyl in the street drug market. Although buprenorphine/naloxone (BUP/NX) is an evidence-based, first-line opioid agonist for the management of opioid use disorder, a key challenge in its prescribing lies in the fact that it can precipitate opioid withdrawal during its initial induction process. At this time, there is minimal literature on the BUP/NX induction process in individuals who use illicit fentanyl regularly.

DESIGN, METHODS AND RESULTS

A case series from a Vancouver, Canada addiction medicine clinic of three fentanyl-exposed patients who experienced unexpected, precipitated withdrawal when initiating BUP/NX.

DISCUSSION AND CONCLUSION

These cases describe incidents of precipitated opioid withdrawal occurring after unusually long periods of fentanyl abstention. Although fentanyl is experienced as a short-acting opioid, the drug persists much longer in the body's peripheral tissues. Here, we highlight the new challenges fentanyl may pose to current BUP/NX induction strategies, and explore the possibility of a long-acting pharmacokinetic effect of fentanyl in the setting of repeated illicit use.

Transdermal buprenorphine for in-hospital transition from full agonist opioids to sublingual buprenorphine: a retrospective observational cohort study

INTRODUCTION

Patients with opioid use disorder may have difficulty transitioning from full-agonist opioids to sublingual buprenorphine due to the risk of precipitated opioid withdrawal. Novel strategies have been developed to facilitate this transition, including the use of micro-dosing with transdermal buprenorphine. We began using a transdermal buprenorphine transition strategy at our hospital in 2019.

METHODS

We performed a retrospective observational cohort study of patients treated with transdermal buprenorphine to facilitate transition from full-agonist opioids (prescribed or recreational) while hospitalized between January 2019 and December 2020. Patients were excluded if transdermal buprenorphine was given for pain, if they did not receive at least one dose of sublingual buprenorphine while hospitalized, or if their clinical course precluded analysis of their tolerance of the transition protocol. Data on the doses and timing of medications, symptoms during transition, and hospital outcomes were abstracted from the electronic medical record.

RESULTS

We identified 41 cases that satisfied inclusion and exclusion criteria. Thirty-five cases involved a transition from medically indicated opioids; of these, 8 cases involved a transition from methadone. Six cases involved a transition from illicit opioids used prior to hospital presentation. For patient transitioning from medically indicated opioids, the median milligram morphine equivalent (MME) on the day prior to transdermal buprenorphine application was 63.8 (range 0-900, IQR 153.8) and the median MME on the day of transdermal buprenorphine application was 34.5 (range 0-600, IQR 65.3). The median initial dose of sublingual buprenorphine administered was 8 mg (range 2-8mg, IQR 6mg), the median total first-day dose was 16mg (range 2-24mg, IQR 16mg), and the median total daily dose on the last day of follow-up was 16mg (range 2-24mg, IQR 16mg). In 38 cases, patients completed the transition to sublingual buprenorphine and were still taking buprenorphine at the time they left the hospital. The transition protocol was fairly well-tolerated, with 59% of cases tolerating it well and 32% tolerating it fairly.

DISCUSSION

Our findings suggest that the use of transdermal buprenorphine to facilitate transition to sublingual buprenorphine is generally well-tolerated, and may be helpful in hospitalized patients. We identified several areas for improvement in future practice by reviewing the clinical courses of patients who tolerated transition poorly. Limitations of the study include its retrospective chart review design, the lack of a standardized transition protocol during the study period, and the lack of standardized data in the medical record regarding patients' tolerance of the transition protocol. Future research should include prospective studies using a standardized protocol and structured, pre-planned assessments of opioid withdrawal during the transition period.

CONCLUSION

The use of transdermal buprenorphine to facilitate induction of sublingual buprenorphine therapy in hospitalized patients with OUD was generally well-tolerated in this single-center retrospective observational study. Further prospective research is needed to demonstrate efficacy and optimize treatment protocols.

Primary care physicians' attitudes and knowledge regarding medical cannabis and willingness to prescribe it: the Israeli experience

BACKGROUND

Use of medical cannabis (MC) in Israel has increased since its regulatory approval in 2016. Currently, more than 1% of Israeli adults are treated with MC; this requires primary care physicians (PCPs) to be familiar with this treatment option.

OBJECTIVES

We assessed the attitudes and knowledge of Israeli PCPs toward MC and evaluated their willingness to prescribe it for different medical conditions.

METHODS

A cross-sectional survey which was distributed to PCPs in Israel. Physicians were asked about their opinions, knowledge, and willingness to prescribe MC.

RESULTS

Two hundred and one PCPs answered the questionnaire. Their average age was 47 years (±11.2), 71% were specialists. 51% of the respondents thought that MC is an effective treatment. 63% replied that they had little knowledge and 75% indicated that they would like to deepen it. 61% of the respondents were willing to initiate an MC treatment for a dying patient, while less than 50% were willing to initiate MC treatment for various other conditions. Most respondents indicated that they were willing to renew a prescription for any approved medical condition. Willingness to prescribe MC increased for physicians who agreed that MC was effective (odds ratio [OR] 21.9, 95% confidence interval [CI] 2.40-200.85), for physicians who strongly agreed with the statement that they had sufficient knowledge (OR 5.0, 95% CI 1.58-15.83) and for residents compared with specialists (OR 4.0, 95% CI 1.52-10.73).

CONCLUSIONS

Our survey revealed PCPs' differing opinions and insufficient knowledge regarding treatment with MC. These findings suggest that continuing medical education regarding MC is needed.

Integrated hepatitis C treatment is associated with improved retention and success in outpatient treatment for opioid use disorder at a private clinic

BACKGROUND

Direct acting antiretrovirals (DAA) are effective for individuals who are infected with chronic hepatitis C virus (HCV), yet many people go without access to these lifesaving treatments.

MATERIALS AND METHODS

We conducted a non-randomized study evaluating treatment data for patients in outpatient treatment for opioid use disorder (OUD) at a private clinic. Patients who were HCV-positive, had been in OUD treatment for at least 4 weeks, and engaged in integrated HCV treatment with DAA (co-located within their treatment for OUD) were compared to patients with HCV who only received OUD treatment. We evaluated HCV cure; OUD medication adherence, treatment utilization and retention; and illicit substance use for those engaged in treatment between 9/2016 and 1/2018.

RESULTS

Seventy-four patients completed integrated HCV-OUD treatment with DAA, with 87.8% achieving cure. Of the 66 who completed treatment and were subsequently evaluated for sustained viral response 98.5% were cured. Patients who received integrated HCV and OUD treatment in our clinic, stayed in OUD treatment longer, demonstrated higher OUD medication adherence, and used less opioids or cocaine compared to HCV-infected patients (n = 572) being treated only for OUD.

DISCUSSION

We have reported on a reproducible intervention that lends itself to outpatient OUD treatment. Analyses demonstrate the potential positive impact HCV treatment has on OUD recovery, including reduction in opioid and cocaine use and increased retention in care.

CONCLUSION

Co-locating HCV treatment with existing OUD treatment is feasible, effective, and demonstrates positive outcomes for the treatment of both conditions.

Educational Studies Examining Knowledge of Substance Use Disorders and Career Aspirations Among Medical Trainees in an Inner-City Hospital

OBJECTIVES

Gaps in addiction medicine training are a reason for poor substance use care in North America. Hospital addiction medicine consult services (AMCS) provide critical medical services, including screening and treatment of substance use disorders. Although these programs often feature an educational component for medical learners, the impact of AMCS teaching on objective knowledge and career aspirations in addiction medicine has not been well described.

METHODS

The authors report findings from two sequential studies conducted at a large academic hospital in Vancouver, Canada. The first study assessed the impact of an AMCS clinical rotation on medical trainee addiction medicine objective knowledge using an online survey of 6 true/false questions before and after the rotation. The second study examined the impact of an AMCS rotation on career aspirations using 4 seven-point Likert-type questions. One-sample t tests on mean differences (MD) with Benjamini-Hochberg adjustment for multiple comparisons were employed for statistical analyses.

RESULTS

Between May 2017 and June 2018, knowledge scores were significantly higher postrotation (MD = 4.78, standard deviation [SD] = 19.5, P = 0.034) among 115 medical trainees. Between July 2018 and July 2019, aspirations to practice addiction medicine were significantly more favorable postrotation (MD = 3.48, SD = 3.15, P < 0.001) among 101 medical trainees.

CONCLUSIONS

AMCS rotations appear to improve addiction medicine knowledge and aspirations to practice addiction medicine among medical trainees. Larger-scale evaluations and outcomes research on integrating substance use disorders teaching in these settings will help move the discipline forward.

Nonstigmatizing and Precise Terminology to Describe Processes and Outcomes in Addiction Medicine

ABSTRACT

Scholarly journals and professional organizations in addiction medicine have recently discussed the importance of adopting nonstigmatizing and precise terminology. The present commentary expands that ongoing discussion to terms related to treatment processes and outcomes. Four implicit assumptions of stigmatizing and imprecise terms related to treatment processes and outcomes are overviewed, and research evidence against these assumptions is presented. The commentary ends with recommendations for the use of positive behavioral indicators of processes and outcomes and, more importantly, accompanying them with nonevaluative, objective descriptors of patients' behaviors.

Exploring how hospitalization can alter hepatitis c virus treatment prioritization and trajectories in people who use drugs: A qualitative analysis

Background: People who use drugs (PWUD) have high rates of hepatitis C virus (HCV) infection. Hospitalization can be a time for PWUD to engage in addiction treatment, but little is known about how hospitalization shapes HCV treatment readiness. We aimed to describe how hospitalization and addiction medicine consult service (AMCS) can alter HCV prioritization of inpatient PWUD with HCV. Methods: We conducted a qualitative study consisting of semi-structured interviews (n = 27) of hospitalized adults with addiction and HCV infection seen by an AMCS at a single, urban, academic center. Interviews were audio-recorded, transcribed, and coded iteratively at the semantic level, and analyzed for themes. Results: Of the 27 participants, most identified as Caucasian (85%), male gender (67%), and they primarily used opioids (78%); approximately half (48%) reported HCV diagnosis over 5 years ago. We identified three main themes around hospitalization altering the prioritizations and HCV treatment preferences for PWUD: (1) HCV treatment non-engaged (2) HCV treatment urgency, and (3) HCV treatment in the future. Those wanting to treat HCV-whether urgently or in the future-shared the overlapping theme of hospitalization as a reachable moment for their addiction and HCV. These participants recognized the long-term benefits of addressing HCV and connected their hospitalization to substance use. Conclusion: In our study, PWUD with HCV expressed varying and competing priorities and life circumstances contributing to three main HCV treatment trajectories. Our results suggest ways hospitalization can serve as an HCV touchpoint for PWUD, especially in the context of addressing substance use, and could be used when designing and implementing targeted interventions to improve the HCV care continuum for PWUD.

Conduct and evaluation of final-year medical student summative assessments in Psychiatry and Addiction Medicine during COVID-19: an Australian University Medical School experience

OBJECTIVE

To describe and share with the medical education community, the conduct and evaluation of summative graduate medical student assessments in Psychiatry and Addiction Medicine during COVID-19 at an Australian university.

METHODS

Summative assessments were redesigned as follows: written assessments were administered via an online platform (WATTLE), while the Objective Structured Clinical Examinations (OSCE) were conducted via a secure video-conferencing software (Zoom).

RESULTS

Our preliminary analysis of the summative assessments indicated that both examiners and students adapted to the format, with overall performance of the students showing no variation due to timing of the assessment (earlier versus later in the day) and performances similar to face-to-face assessments in previous years. Examiners also expressed positive feedback on the assessment process.

CONCLUSIONS

Our graduate fourth-year medical student summative assessments were effectively conducted using online and video-conferencing software in accordance with existing COVID-19 pandemic public health measures for physical distancing and hygiene.

Clinical Pharmacology of the Dietary Supplement, Kratom (Mitragyna speciosa)

Kratom (Mitragyna speciosa) consists of over 40 alkaloids with two of them, mitragynine (MG) and 7-OH-mitragynine (7-OH-MG) being the main psychoactive compounds. MG and 7-OH-MG each target opioid receptors and have been referred to as atypical opioids. They exert their pharmacologic effects on the μ, δ, and κ opioid receptors. In addition, they affect adrenergic, serotonergic, and dopaminergic pathways. Kratom has been touted as an inexpensive, legal alternative to standard opioid replacement therapy such as methadone and buprenorphine. Other uses for kratom include chronic pain, attaining a "legal high," and numerous CNS disorders including anxiety depression and post-traumatic stress disorder (PTSD). Kratom induces analgesia and mild euphoria with a lower risk of respiratory depression or adverse central nervous system effects compared to traditional opioid medications. Nonetheless, kratom has been associated with both physical and psychological dependence with some individuals experiencing classic opioid withdrawal symptoms upon abrupt cessation. Kratom use has been linked to serious adverse effects including liver toxicity, seizures, and death. These risks are often compounded by poly-substance abuse. Further, kratom may potentiate the toxicity of coadministered medications through modulation of cytochrome P450, P-glycoprotein, and uridine diphosphate glucuronosyltransferase enzymes (UGDT). In 2016 the U.S. Drug Enforcement Administration (DEA) took steps to classify kratom as a federal schedule 1 medication; however, due to public resistance, this plan was set aside. Until studies are conducted that define kratom's role in treating opioid withdrawal and/or other CNS conditions, kratom will likely remain available as a dietary supplement for the foreseeable future. This article is protected by copyright. All rights reserved.

Psoriasis and addiction: assessing mental health based on a cross-sectional study in Germany

Psoriasis is a chronic skin disease with a high mental burden. Well-known comorbidities include depression, anxiety, as well as alcohol and tobacco addiction, however, there is barely any evidence on other addictions. The aim of this study was to estimate the prevalence of the six most common addictions among psoriasis patients in Germany and to determine associated clinical factors. Dermatologists working in four dermatological clinics and 32 practices across Germany recruited patients between September 2018 and November 2019. This cross-sectional study contained questionnaires on six addictions, depression, anxiety, and the Dermatology Life Quality Index (DLQI). In addition, scores for the Psoriasis Area and Severity Index (PASI) were obtained by physicians. Overall, 502 patients (43.4% women; mean age: 49.7 ± 14.6 years) were included. Positive addictions were found in 30.3% for daily smoking, 8.6% for alcohol, 1.2% for gambling, 3.8% for internet use, 3.6% for food, and 6.0% for drugs. Younger age was associated with a higher probability of addiction except for alcohol dependency. The PASI was only significantly associated with smoking. Addictions seem to be common among psoriasis patients. Further research should include comprehensive data and control groups, furthermore, standardised screenings and early referrals could represent first steps to improve people-centred healthcare for patients with psoriasis.

Repetitive transcranial magnetic stimulation for smoking cessation: a pivotal multicenter double-blind randomized controlled trial

Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive brain stimulation method increasingly used to treat psychiatric disorders, primarily depression. Initial studies suggest that rTMS may help to treat addictions, but evaluation in multicenter randomized controlled trials (RCTs) is needed. We conducted a multicenter double-blind RCT in 262 chronic smokers meeting DSM-5 criteria for tobacco use disorder, who had made at least one prior failed attempt to quit, with 68% having made at least three failed attempts. They received three weeks of daily bilat-eral active or sham rTMS to the lateral prefrontal and insular cortices, followed by once weekly rTMS for three weeks. Each rTMS session was administered following a cue-induced craving procedure, and participants were monitored for a total of six weeks. Those in abstinence were monitored for additional 12 weeks. The primary outcome measure was the four-week continuous quit rate (CQR) until Week 18 in the intent-to-treat efficacy set, as determined by daily smoking diaries and verified by urine cotinine measures. The trial was registered at ClinicalTrials.gov (NCT02126124). In the intent-to-treat analysis set (N=234), the CQR until Week 18 was 19.4% following active and 8.7% following sham rTMS (X² =5.655, p=0.017). Among completers (N=169), the CQR until Week 18 was 28.0% and 11.7%, respectively (X² =7.219, p=0.007). The reduction in cigarette consumption and craving was significantly greater in the active than the sham group as early as two weeks into treatment. This study establishes a safe treatment protocol that promotes smoking cessation by stimulating relevant brain circuits. It represents the first large multicenter RCT of brain stimulation in addiction medicine, and has led to the first clearance by the US Food and Drug Administration for rTMS as an aid in smok-ing cessation for adults.

Addiction Medicine Practice-Based Research Network (AMNet): Assessment Tools and Quality Measures

INTRODUCTION

The need for innovative approaches to address the opioid epidemic in the United States is widely recognized. Many challenges exist to addressing this epidemic, including the obstacles outpatient substance use treatment practices face in implementing measurement-based care (MBC), quality measurement systems, and evidence-based treatments. Also, there are insufficient opportunities for clinicians in these settings to participate in research, resulting in diminished translation of research findings into community-based practice. To address these challenges, the Addiction Medicine Practice-Based Research Network (AMNet) was developed to facilitate the uptake of MBC in outpatient practices via implementation of patient-reported assessments and quality of care performance measures to improve patient outcomes. This network will offer clinicians in outpatient settings (not incuding opioid treatment programs [OTPs]) the opportunity to participate in future substance use disorder treatment research studies.

METHODS

A key step in the development of AMNet was the selection of substance use-specific assessment tools and quality of care performance measures for incorporation into the American Psychiatric Association's mental health patient registry, PsychPRO. A scoping review and multi-step consensus-based process were used to identify, review and select candidate assessment tools and quality of care performance measures for opioid use disorders (OUD) and substance use disorders (SUD).

RESULTS

Following a consensus-based methodology, 12 standardized assessment tools and 3 quality of care performance measures for OUD and SUD were selected to help facilitate the implementation of MBC and quality improvement for AMNet participants. These tools were further categorized as core and optional.

CONCLUSION

By offering a collection of carefully vetted assessment tools and quality measures through PsychPRO, AMNet will help participating clinicians with the systematic uptake of MBC and delivery of evidence-based treatment for patients with SUD. Also, AMNet will act as a centralized repository of data collected from patients and clinicians in non-OTP outpatient addiction medicine practices and serve as a platform for opioid treatment research.

A 5-Factor Framework for Assessing Tobacco Use Disorder

Cigarette use is the leading cause of preventable death in the United States. Despite the well documented dangers of smoking, nearly 20% of adults report regular use of tobacco. A majority desire to discontinue but the long-term cessation success rate remains near 4%. One challenge to reducing the prevalence of tobacco use is an incomplete understanding of the individual correlates that reinforce continued use. Evidence from research on nicotine and tobacco suggests that Tobacco Use Disorder is a complex, and multifactorial condition. Personality traits, comorbidities, habits and lifestyle, genetics, socioeconomic status, and mental and physical health all contribute to the risk for dependence and to the likelihood of quitting. This perspective review provides an overview of some common factors that contribute to liability risk for Tobacco Use Disorder and a framework for assessing individual tobacco users. The framework includes 5 areas that research suggests contribute to continued tobacco use: nicotine addiction, psychological influences, behavioral dependencies, neurobiological factors, and social reinforcement. Nicotine addiction includes drug-seeking behavior and the role of withdrawal avoidance. Psychological and emotional states contribute to a perceived reliance on tobacco. Behavioral dependence is reinforced by associative and non-associative learning mechanisms. Neurobiological factors include genetic variables, variations in neurotransmitters and receptors, pharmacogenetics, and interaction between psychiatric illnesses and nicotine use and dependence. Finally, social reinforcement of smoking behavior is explained by a network phenomenon and consistent visual cues to smoke. A comprehensive assessment of individual tobacco users will help better determine appropriate treatment options to achieve improved efficacy and outcomes.