Showing papers in "Journal of Addiction Medicine in 2016"
TL;DR: The results generally support the efficacy of providing psychosocial interventions in combination with medications to treat opioid addictions, although the incremental utility varied across studies, outcomes, medications, and interventions.
Abstract: Opioid use and overdose rates have risen to epidemic levels in the United States during the past decade. Fortunately, there are effective medications (ie, methadone, buprenorphine, and oral and injectable naltrexone) available for the treatment of opioid addiction. Each of these medications is approved for use in conjunction with psychosocial treatment; however, there is a dearth of empirical research on the optimal psychosocial interventions to use with these medications. In this systematic review, we outline and discuss the findings of 3 prominent prior reviews and 27 recent publications of empirical studies on this topic. The most widely studied psychosocial interventions examined in conjunction with medications for opioid addiction were contingency management and cognitive behavioral therapy, with the majority focusing on methadone treatment. The results generally support the efficacy of providing psychosocial interventions in combination with medications to treat opioid addictions, although the incremental utility varied across studies, outcomes, medications, and interventions. The review highlights significant gaps in the literature and provides areas for future research. Given the enormity of the current opioid problem in the United States, it is critical to gain a better understanding of the most effective ways to deliver psychosocial treatments in conjunction with these medications to improve the health and well-being of individuals suffering from opioid addiction.
235 citations
TL;DR: This narrative review of overdose prevention and the role of prescribers and pharmacists in distributing naloxone addresses these priority areas and presents a clinical scenario within the review involving a pharmacist, a patient with chronic pain and anxiety, and a primary care physician.
Abstract: In March of 2015, the United States Department of Health and Human Services identified 3 priority areas to reduce opioid use disorders and overdose, which are as follows: opioid-prescribing practices; expanded use and distribution of naloxone; and expansion of medication-assisted treatment. In this narrative review of overdose prevention and the role of prescribers and pharmacists in distributing naloxone, we address these priority areas and present a clinical scenario within the review involving a pharmacist, a patient with chronic pain and anxiety, and a primary care physician. We also discuss current laws related to naloxone prescribing and dispensing. This review was adapted from the Prescribe to Prevent online continuing medical education module created for prescribers and pharmacists (http://www.opioidprescribing.com/naloxone_module_1-landing).
76 citations
TL;DR: A notable increase in the ED visit numbers and rates for both the use of cannabis-only and cannabis-polydrug during the studied period is suggested, particularly among young people and non-Hispanic blacks.
Abstract: OBJECTIVES To examine trends and correlates of cannabis-involved emergency department (ED) visits in the United States from 2004 to 2011. METHODS Data were obtained from the 2004 to 2011 Drug Abuse Warning Network. We analyzed trend in cannabis-involved ED visits for persons aged ≥12 years and stratified by type of cannabis involvement (cannabis-only, cannabis-polydrug). We used logistic regressions to determine correlates of cannabis-involved hospitalization versus cannabis-involved ED visits only. RESULTS Between 2004 and 2011, the ED visit rate increased from 51 to 73 visits per 100,000 population aged ≥12 years for cannabis-only use (P value for trend = 0.004) and from 63 to 100 for cannabis-polydrug use (P value for trend < 0.001). Adolescents aged 12-17 years showed the largest increase in the cannabis-only-involved ED visit rate (rate difference = 80 per 100,000 adolescents). Across racial/ethnic groups, the most prevalent ED visits were noted among non-Hispanic blacks. Among cannabis-involved visits, the odds of hospitalization (vs ED visits only) increased with age strata compared with age 12 to 17 years. CONCLUSIONS These findings suggest a notable increase in the ED visit numbers and rates for both the use of cannabis-only and cannabis-polydrug during the studied period, particularly among young people and non-Hispanic blacks.
72 citations
TL;DR: Attorneys experience problematic drinking that is hazardous, harmful, or otherwise consistent with alcohol use disorders at a higher rate than other professional populations, and mental health distress is also significant.
Abstract: Objectives:
Rates of substance use and other mental health concerns among attorneys are relatively unknown, despite the potential for harm that attorney impairment poses to the struggling individuals themselves, and to our communities, government, economy, and society. This study measured the prevalence of these concerns among licensed attorneys, their utilization of treatment services, and what barriers existed between them and the services they may need.
71 citations
TL;DR: Current data suggest that increases in marijuana use preceded legalization in 2012, with modest increases in poison center calls in both states and increases in acute medical visits in Denver.
Abstract: OBJECTIVES: This study presents information on the status and impact of medical and legalized marijuana, and the latest data on attitudes and prevalence of use since implementation of these laws. Recent reports from epidemiologists in Denver and Seattle are summarized to give the readers a sense of the changes as these laws have taken effect in their communities. METHODS: The status of these laws is reviewed and the results of surveys taken before and after the laws were enacted are presented, along with data on changing potency and driving under the influence of marijuana. SUMMARY: Prevalence of use by youths has not increased, but their negative attitudes towards the risk of using marijuana have decreased, and use by adults has increased. Potency continues to increase, as has the proportion of drivers testing positive for use of the drug. Data from Denver show increases in hospital admissions, emergency department visits, and calls to poison centers, with decreasing arrests and admissions to substance abuse treatment programs. Data from the Seattle area show similar decreases in treatment admissions and police involvement, but also increased prevalence of more frequent use. CONCLUSIONS: Current data suggest that increases in marijuana use preceded legalization in 2012. Treatment admissions were declining before these laws, but some indicators of morbidity seem to be increasing subsequent to legalization, with modest increases in poison center calls in both states and increases in acute medical visits in Denver. Data are needed to understand the relationship between the patterns and amounts of use in terms of consequences, and data on the health conditions of those receiving medical marijuana and the impact of higher potency. Language: en
66 citations
TL;DR: Intranasal oxytocin has potential to improve social perception, reduce cue-induced alcohol cravings, and reduce appetitive approach bias in subjects with alcohol abuse, and can be safely tolerated in this population.
Abstract: Objectives A pharmacotherapy that both improves social abilities and promotes abstinence may be particularly helpful for the treatment of alcohol use disorder. Recent clinical and preclinical evidence suggests that oxytocin has prosocial and antiaddiction effects. We performed a pilot, laboratory-based, preclinical trial of oxytocin in subjects with alcohol abuse (as per Diagnostic and Statistical Manual of Mental Disorders, 4 Edition criteria) to evaluate therapeutic potential and assess tolerability. Methods Social perceptual ability, cue-induced craving, and approach bias for alcohol and appetitive imagery were quantified after intranasal oxytocin and placebo administration to 32 nontreatment-seeking individuals with alcohol abuse in a double-blind, crossover study. Because attachment style can moderate the effects of oxytocin, we also explored whether attachment style moderated oxytocin's effects on our behavioral measures. Results Oxytocin significantly improved recognition of easier items on a social perception task, but had no significant group-level effect on cue-induced craving. However, oxytocin effects on craving were moderated by attachment anxiety, with oxytocin reducing craving in more anxiously attached individuals and increasing craving in less anxiously attached individuals. Subjects did not display an approach bias to alcohol images on the placebo day, preventing meaningful analysis of this measure. Subjects did display an approach bias to appetitive images on the placebo day, which was significantly reduced by oxytocin administration. No adverse reactions were observed. Conclusions Intranasal oxytocin has potential to improve social perception, reduce cue-induced alcohol cravings, and reduce appetitive approach bias in subjects with alcohol abuse, and can be safely tolerated in this population. The effects of oxytocin are complex, however, and require further investigation.
66 citations
TL;DR: Opioid dosage was the factor most consistently analyzed and also associated with increased risk of overdose and other risk factors include concurrent use of sedative-hypnotics, use of extended-release/long-acting opioids, and the presence of substance use and other mental health disorder comorbidities.
Abstract: Overdoses involving opioid analgesics represent a significant public health problem in the United States. We reviewed the literature on risk factors for overdose, with a focus on studies that examine clinical populations of patients receiving opioids for pain and potential risk factors for overdose in these populations. A structured review resulted in 15 articles published between 2007 and 2015 that examined risk factors for fatal and nonfatal overdose in patients receiving opioid analgesics. Opioid dosage was the factor most consistently analyzed and also associated with increased risk of overdose. Other risk factors include concurrent use of sedative-hypnotics, use of extended-release/long-acting opioids, and the presence of substance use and other mental health disorder comorbidities. Future research is needed to better characterize populations taking opioids for pain to help clarify discrepancies between existing studies and identify previously unexplored risk factors for overdose. Given that policy and clinical practice have shifted as a result of prior studies reviewed here, further efforts in understanding patient groups and opioid-related prescribing practices associated with overdose risk have great potential to impact policy and practice in the treatment of pain while improving the safety around opioid prescribing.
53 citations
TL;DR: In the midst of a vast epidemic of opioid use, medication treatment, for which medication-assisted treatment stands as the best antidote, the guideline serves an important purpose by bringing together in 1 document both scientific knowledge and expert wisdom concerning the use of the 3 medications currently approved to treat opioid use disorder.
Abstract: A recent summary guideline in the Journal of Addiction Medicine summarized the newly released ‘‘American Society of Addiction Medicine National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use’’ (Kampman and Jarvis, 2015). In the midst of a vast epidemic of opioid use, for which medication treatment (commonly known as medication-assisted treatment or MAT) stands as the best antidote, the guideline serves an important purpose by bringing together in 1 document both scientific knowledge and expert wisdom concerning the use of the 3 medications currently approved to treat opioid use disorder. It logically organizes the relevant topics and highlights key concepts of using these medications. Creating a treatment guideline presents challenges. It often comes as a surprise how little rigorous and replicated evidence exists to inform the clinical interventions necessary to treat a complex disease like opioid use disorder. Guideline developers then face the choice of recommending only the interventions supported by very high levels of evidence or of melding high levels of scientific evidence with expert opinion to craft recommendations. The former approach can leave the guideline user uncertain how to proceed in managing various
44 citations
TL;DR: The Brief Opioid Overdose Knowledge questionnaire was developed to provide an efficient metric for assessing and comparing educational interventions, facilitate conversations between physicians and patients about overdose risks, and help formally identify knowledge deficits in other patient populations.
Abstract: Background Opioid overdose is a public health crisis. This study describes efforts to develop and validate the Brief Opioid Overdose Knowledge (BOOK) questionnaire to assess patient knowledge gaps related to opioid overdose risks. Methods Two samples of illicit opioid users and a third sample of patients receiving an opioid for the treatment of chronic pain (total N = 848) completed self-report items pertaining to opioid overdose risks. Results A 3-factor scale was established, representing Opioid Knowledge (4 items), Opioid Overdose Knowledge (4 items), and Opioid Overdose Response Knowledge (4 items). The scale had strong internal and face validity. Patients with chronic pain performed worse than illicit drug users in almost all items assessed, highlighting the need to increase knowledge of opioid overdose risk to this population. Conclusions This study sought to develop a brief, internally valid method for quickly assessing deficits in opioid overdose risk areas within users of illicit and prescribed opioids, to provide an efficient metric for assessing and comparing educational interventions, facilitate conversations between physicians and patients about overdose risks, and help formally identify knowledge deficits in other patient populations.
41 citations
TL;DR: Men and women in SUD treatment have unmet reproductive health needs and as Sud treatment moves toward greater integration, the programmatic inclusion of family planning services should be considered.
Abstract: OBJECTIVES Individuals with substance use disorders (SUDs) have unique reproductive health needs. The aim of this study was to evaluate these needs and assess the acceptability of family planning service delivery of SUD treatment clients. METHODS Reproductive health needs of drug treatment clients were assessed using a cross-sectional anonymous survey in 4 treatment sites in Baltimore City, MD. Surveys were distributed by staff. Contraceptives assessed included sterilization, intrauterine devices, implants, injections, pills, patches, rings, condoms, spermicide, withdrawal, and the rhythm method. Results are stratified by sex and between those using and not using highly effective contraceptive methods. RESULTS A total of 115 women and 95 men completed the survey (80% younger than 50 years), with 39% of women and 54% of men reporting using condoms, but only 24% of women and 26% of men reporting consistent use. All other methods were used by less than 12% of the sample. Only 20% of sexually active women reported using a highly reliable form of contraception and only 53% were using any form of contraception at all. Contraceptive use correlated inversely with age, but did not correlate with having had sexually transmitted infection testing or other preventive health services. Although more than 90% of participants had access to health care services in the past 3 years, 25% of women and 33% of men reported difficulty accessing health care providers. The majority of respondents said they would likely use family planning services if available at their SUD treatment (83% of women and 58% of men). CONCLUSIONS Men and women in SUD treatment have unmet reproductive health needs. As SUD treatment moves toward greater integration, the programmatic inclusion of family planning services should be considered.
36 citations
TL;DR: Although length of sedation/analgesia for at least5 days has been widely proposed for monitoring IWS, the data suggest that initiating monitoring after 3 sedation days is highly recommended and patients requiring infusion rates of midazolam above 0.35 mg/kg/h should be considered at high risk for IWS.
Abstract: Background and aims Although iatrogenic withdrawal syndrome (IWS) has been recognized in patients exposed to opioids and benzodiazepines, very few studies have used a validated tool for diagnosis and assessment of IWS in critically ill children. We sought to determine IWS rate, risk factors, and outcomes of IWS patients. Methods Prospective observational study conducted in a pediatric intensive care unit. A total of 137 patients (31 with IWS and 106 with no IWS) received a continuous infusion of fentanyl and midazolam for 3 or more days. The Sophia Observation withdrawal Symptoms scale was repeatedly applied when children were weaned off sedation/analgesia. Results The overall incidence of IWS was 22.6%. Of the 31 IWS patients, 6 showed IWS with less than 5 days sedation or analgesia. Logistic regression showed that the median peak dose of midazolam was associated with IWS development (odds ratio 1.4). Receiver-operating curve showed a cut-off value of 0.35 mg/kg/h for midazolam peak dose (sensitivity 96.7%, specificity 51%, positive predictive value 36.6%, and negative predictive value 98.2%), with area under the curve of 0.80. IWS patients had a longer time on mechanical ventilation, prolonged pediatric intensive care unit, and hospital stays, and required prolonged period to have drugs discontinued. Conclusions Although length of sedation/analgesia for at least5 days has been widely proposed for monitoring IWS, our data suggest that initiating monitoring after 3 sedation days is highly recommended. In addition, patients requiring infusion rates of midazolam above 0.35 mg/kg/h should be considered at high risk for IWS.
TL;DR: Results support the effectiveness of a learning collaborative approach to engage physicians, modestly improve patient access, and significantly reduce practice variation and are potentially generalizable to other systems and regions struggling with this important public health problem.
Abstract: OBJECTIVES Rapidly escalating rates of heroin and prescription opioid use have been widely observed in rural areas across the United States. Although US Food and Drug Administration-approved medications for opioid use disorders exist, they are not routinely accessible to patients. One medication, buprenorphine, can be prescribed by waivered physicians in office-based practice settings, but practice patterns vary widely. This study explored the use of a learning collaborative method to improve the provision of buprenorphine in the state of Vermont. METHODS We initiated a learning collaborative with 4 cohorts of physician practices (28 total practices). The learning collaborative consisted of a series of 4 face-to-face and 5 teleconference sessions over 9 months. Practices collected and reported on 8 quality-improvement data measures, which included the number of patients prescribed buprenorphine, and the percent of unstable patients seen weekly. Changes from baseline to 8 months were examined using a p-chart and logistic regression methodology. RESULTS Physician engagement in the learning collaborative was favorable across all 4 cohorts (85.7%). On 6 of the 7 quality-improvement measures, there were improvements from baseline to 8 months. On 4 measures, these improvements were statistically significant (P < 0.001). Importantly, practice variation decreased over time on all measures. The number of patients receiving medication increased only slightly (3.4%). CONCLUSIONS Results support the effectiveness of a learning collaborative approach to engage physicians, modestly improve patient access, and significantly reduce practice variation. The strategy is potentially generalizable to other systems and regions struggling with this important public health problem.
TL;DR: HIV-infected smokers are less likely to have undetectable viral loads and frequently have psychosocial comorbidities including depression and substance abuse that impact antiretroviral therapy adherence and viral load suppression.
Abstract: BACKGROUND The prevalence of smoking among HIV-infected individuals is 2-3 times that of the general population, increasing the risk of smoking-related morbidity and mortality. We examined characteristics associated with smoking behavior among a large cohort of HIV-infected individuals in care in the United States. METHODS A convenience sample of 2952 HIV-infected patients in the Centers for AIDS Research (CFAR) Network of Integrated Clinical Systems (CNICS) was assessed during routine clinic visits and was included. Multinomial logistic regression was used to examine the relationship between smoking status, depression/panic symptoms, alcohol/substance use, and demographic and clinical characteristics. RESULTS Compared with never-smokers, current smokers were more likely to have moderate to severe depression (odds ratio [OR] 1.37), endorse current substance use (OR 14.09), and less likely to report low-risk alcohol use on the Alcohol Use Disorders Identification Test (AUDIT-C) (OR 0.73). Current smokers were less likely to have an undetectable viral load (OR 0.75), and more likely to have current substance abuse (OR 2.81) and moderate to severe depression (OR 1.50), relative to smokers who had quit smoking. CONCLUSIONS HIV-infected smokers are less likely to have undetectable viral loads and frequently have psychosocial comorbidities including depression and substance abuse that impact antiretroviral therapy adherence and viral load suppression. To be effective, smoking-cessation interventions need to address the complex underlying concurrent risks in this population.
TL;DR: This clinical case conference discusses the treatment of a pregnant woman with opioid use disorder in a comprehensive care program that includes buprenorphine pharmacotherapy and describes the elements of a successful comprehensive care model and corollary neonatal abstinence syndrome treatment regimen.
Abstract: The increase in opioid use among the general population is reflected in pregnant women and neonatal abstinence syndrome (NAS) statistics. This increase has produced an unprecedented focus on NAS from both the political-judicial sphere and the medical community. Under the banner of fetal protection, judges and prosecutors have implemented punitive approaches against women who use prescribed and nonprescribed opioids during pregnancy, including arrest, civil commitment, detention, prosecution, and loss of custody or termination of parental rights. Within the medical community, questions have been raised regarding protocols to detect prenatal drug exposure at delivery, NAS treatment protocols, the need for quality-improvement strategies to standardize care and reduce length of stay for mother and infant, and the benefits of engaging the mother in the care of her infant. It is not uncommon for the expression of strong discordant views on these issues both between and among these political-judicial and medical constituencies. Closely examining the issues often reveal a lack of understanding of substance use disorders, their treatment, and the occurrence and treatment of NAS. This study provides an in-depth examination of NAS, including variations in presentation and factors that impact the efficacy of treatment, and also identifying questions that remain unanswered. Finally, 4 key areas on which future research should focus to guide both medical care and public policy are discussed.
TL;DR: Most bupropion abuse occurs in adolescents and young adults, andTachycardia and seizures are common indicating the potential for serious effects, and providers should be aware of risk of buPropion abuse.
Abstract: OBJECTIVES: Bupropion use to obtain nonmedical psychoactive effects has been reported. The objective was to determine the prevalence, characteristics, clinical effects, and outcomes of bupropion "abuse." METHODS: A 14-year retrospective review was conducted of single substance bupropion cases with "intentional abuse" as the coded reason for exposure in individuals 13 and older reported to the National Poison Data System. Data were evaluated for prevalence, demographics, clinical effect, route, final management site, and coded outcome. RESULTS: There were 975 bupropion abuse cases, which accounted for 3.3% of single substance bupropion cases reported to US poison centers. The prevalence of abuse increased by 75%, from 2000 to 2012, declining slightly in 2013. The majority of cases were 13 to 29 years old (67.4%). The most frequent clinical effects were tachycardia (57.0%), seizures (33.5%), agitation/irritable (20.2%), hallucinations/delusions (14.0%), and tremor (13.1%). Most exposures were ingestions (745) followed by insufflation (166), parenteral (17), and other/unknown (17); 30 cases involved 2 routes. Seizure frequency was not significantly different between routes (P = 0.783) or exposure chronicity (P = 0.264). Final management sites were predominantly emergency department (36.9%) and admission to critical care unit (27.3%) or noncritical care unit (20.1%). Outcomes were major (11.4%), moderate (48.2%), minor (24.5%), and no effect (15.5%). There were 4 deaths. CONCLUSIONS: Most bupropion abuse occurs in adolescents and young adults. Tachycardia and seizures are common indicating the potential for serious effects. Seizures occur regardless of route. Providers should be aware of risk of bupropion abuse. Language: en
TL;DR: Almost half of the patients with opioid use disorders attributed to tramadol had psychiatric comorbidity, and approximately 3 out of 4 had cluster B personality disorders.
Abstract: Objective Opioid use disorders attributed to tramadol (OUD-T) is a public health problem in Egypt. The objective of this study was to assess the psychiatric comorbidity among patients with opioid use disorder attributed to tramadol. Methods This study included 100 patients with opioid use disorders attributed to tramadol (according to DSM-IV-TR) and 100 control persons (matched for age, sex, and education), who were recruited from Zagazig University Hospital, Egypt. The participants were interviewed using Structured Clinical Interview for DSM disorders (SCID-I and SCID-II), Addiction Severity Index scale (patients), and urine screening for drugs. Results Twenty-four percent of the patients used tramadol only (pure tramadol group), whereas 76% of the patients used other substances in addition to tramadol (polysubstance group). Most (91%) of the patients had tramadol dependence. Forty-nine percent of the patients had psychiatric comorbidity, especially mood disorders (59.2%), whereas only 24% of the control persons had psychiatric comorbidity, especially anxiety disorders (83.3%). The most common personality disorders among patients were borderline (24%) and antisocial (22%), whereas in control persons, the most common personality disorders were obsessive compulsive personality disorder (8%) and the avoidant personality disorder (7%). Cluster B (76.6%) was the most common category among patients (compared with 25.8% in control persons), whereas cluster C (51.6%) was the most common category among control persons (compared with 15.6% in patients). Conclusions Most of the patients were dependent on tramadol, and approximately 3 out of 4 used many substances. Almost half of the patients had psychiatric comorbidity, and approximately 3 out of 4 had cluster B personality disorders.
TL;DR: This pilot study found that with Sativex in combination with MET/CBT reduced cannabis use while preventing increases in craving and withdrawal in the 4 participants completing the study.
Abstract: Objectives Cannabis is the most commonly used illicit drug; a substantial minority of users develop dependence. The current lack of pharmacological treatments for cannabis dependence warrants the use of novel approaches and further investigation of promising pharmacotherapy. In this case series, we assessed the use of self-titrated dosages of Sativex (1:1, Δ-tetrahydrocannabinol [THC]/cannabidiol [CBD] combination) and motivational enhancement therapy and cognitive behavioral therapy (MET/CBT) for the treatment of cannabis dependence among 5 treatment-seeking community-recruited cannabis-dependent subjects. Methods Participants underwent a 3-month open-label self-titration phase with Sativex (up to 113.4 of THC/105 mg of CBD) and weekly MET/CBT, with a 3-month follow-up. Results Sativex was well-tolerated by all participants (average dosage 77.5 THC/71.7 mg CBD). The combination of Sativex and MET/CBT reduced the amount of cannabis use and progressively reduced craving and withdrawal scores. THC/CBD metabolite concentration indicated reduced cannabis use and compliance with medication. Conclusions In summary, this pilot study found that with Sativex in combination with MET/CBT reduced cannabis use while preventing increases in craving and withdrawal in the 4 participants completing the study. Further systematic exploration of Sativex as a pharmacological treatment option for cannabis dependence should be performed.
TL;DR: The process of operationalizing 3 standards of care for the Addiction Specialist Physician into quality measures is described, and the initial measure specifications and results of pilot testing these measures in a large health care system are presented.
Abstract: Author(s): Harris, Alex HS; Weisner, Constance M; Chalk, Mady; Capoccia, Victor; Chen, Cheng; Thomas, Cindy Parks | Abstract: ObjectivesIn 2013, the American Society of Addiction Medicine (ASAM) approved its Standards of Care for the Addiction Specialist Physician. Subsequently, an ASAM Performance Measures Panel identified and prioritized the standards to be operationalized into performance measures. The goal of this study is to describe the process of operationalizing 3 of these standards into quality measures, and to present the initial measure specifications and results of pilot testing these measures in a large health care system. By presenting the process rather than just the end results, we hope to shed light on the measure development process to educate, and also to stimulate debate about the decisions that were made.MethodsEach measure was decomposed into major concepts. Then each concept was operationalized using commonly available administrative data sources. Alternative specifications examined and sensitivity analyses were conducted to inform decisions that balanced accuracy, clinical nuance, and simplicity. Using data from the US Veterans Health Administration (VHA), overall performance and variation in performance across 119 VHA facilities were calculated.ResultsThree measures were operationalized and pilot tested: pharmacotherapy for alcohol use disorder, pharmacotherapy for opioid use disorder, and timely follow-up after medically managed withdrawal (aka detoxification). Each measure was calculable with available data, and showed ample room for improvement (no ceiling effects) and wide facility-level variability.ConclusionsNext steps include conducting feasibility and pilot testing in other health care systems and other contexts such as standalone addiction treatment programs, and also to study the specification and predictive validity of these measures.
TL;DR: The commonly held belief that opioid agonist treatment alone is inferior treatment to such treatment combined with 'psychosocial' treatment is not supported by the research evidence and it results in limitations on the use of these effective medications.
Abstract: This commentary reviews the limitations of the recent literature review by that examined the role of psychosocial interventions with medication for opioid addiction treatment. The commonly held belief that opioid agonist treatment alone is inferior treatment to such treatment combined with 'psychosocial' treatment (which many will understand to mean counseling) is not supported by the research evidence and it results in limitations on the use of these effective medications.
TL;DR: Results suggest that higher plasma levels of varenicline may be needed to maximize the effect of v Karenicline on alcohol consumption and should be investigated in drinkers meeting criteria for alcohol use disorders.
Abstract: OBJECTIVES Varenicline (2 mg/d) has been shown to be efficacious in reducing alcohol consumption. A lower dose of varenicline may be effective in reducing alcohol use while minimizing the potential for side effects. METHODS This double-blind, placebo-controlled investigation examined the effect of varenicline (0, 1, 2 mg/d) on alcohol consumption in nontreatment-seeking adults meeting the Diagnostic and Statistical Manual of Mental Disorders 4th Edition (DSM-IV) criteria for alcohol use disorders (N = 60). Following 7 days of medication pretreatment, participants were administered a low fixed dose of alcohol (0.3 g/dL), and subjective and physiologic responses were assessed. A 2-hour ad libitum alcohol self-administration period followed. We also explored relationships between plasma varenicline levels and consumption. RESULTS Overall, frequency and severity of adverse events were minimal. The 1 mg/d dose reduced the frequency of insomnia compared with the 2 mg/d dose. The 2 mg/d varenicline dose versus placebo reduced alcohol craving and showed limited effect on reduced alcohol consumption. Alcohol craving and consumption did not differ between the 1 mg/d varenicline dose versus placebo. Trough varenicline plasma levels greater than or equal to 3 ng/mL were associated with reduced drinking and levels greater than or equal to 5 ng/mL were associated with reduced heavy drinking. CONCLUSIONS Overall, we found no evidence supporting an effect of 1 mg/d varenicline on craving or consumption, suggesting that doses of varenicline less than 2 mg/d may not be effective in reducing alcohol-related outcomes. Importantly, results suggest that higher plasma levels of varenicline may be needed to maximize the effect of varenicline on alcohol consumption and should be investigated in drinkers meeting criteria for alcohol use disorders.
TL;DR: The International Society of Addiction Journal Editors recommends against the use of terminology that can stigmatize people who use alcohol, drugs, other addictive substances or who have addictive behavior, unless there is particular scientific justification.
Abstract: J ournal of Addiction Medicine has been encouraging the use of precise and nonstigmatizing terminology (Saitz, 2015 and http://journals.lww.com/journaladdictionmedicine/Pages/informationforauthors.aspx#languageandterminologyguidance). As a member journal of the International Society of Addiction Journal Editors (ISAJE), we endorse the statement made by ISAJE regarding the use of terminology that stigmatizes that appears below, here http://www.parint.org/isajewebsite/ (the ISAJE website), and may be published simultaneously in a number of member journals. The statement, verbatim, is as follows: ‘‘The International Society of Addiction Journal Editors recommends against the use of terminology that can stigmatize people who use alcohol, drugs, other addictive substances or who have addictive behavior. Rationale: Terms that stigmatize can affect the perception and behavior of patients/ clients, their loved ones, the general public, scientists, and clinicians (Kelly et al., 2010; Broyles et al., 2014; Kelly et al., 2015). For example, Kelly and Westerhoff (2010) found that the terms used to refer to individuals with substance-related conditions affected clinician perceptions. Clinicians who read a clinical vignette about ‘‘abuse’’ and an ‘‘abuser’’ agreed more with notions of personal culpability and an approach that involved punishment than did those who read an identical vignette that replaced ‘‘abuse’’ and ‘‘abuser’’ with ‘‘substance use disorder’’ and ‘‘person with a substance use disorder.’’ The International Society of Addiction Journal Editors is aware that terminology in the addiction field varies across cultures and countries and over time. It is thus not possible to give globally relevant recommendations about the use or nonuse of specific terms. ‘‘Abuse’’ and ‘‘abuser’’ or equivalent words in other languages should, however, in general, be avoided, unless there is particular scientific justification (an example of scientific justification of the use of ‘‘abuse’’ is when referring to a person who meets criteria for a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000), alcohol abuse; that person would be said to have ‘‘alcohol abuse’’. Another example of stigmatizing language is describing people as ‘‘dirty’’ (or ‘‘clean’’) because of a urinalysis that finds the presence (or absence) of a drug (Kelly et al., 2015). Instead, the test results and clinical condition should be described.’’ The above was approved by the International Society of Addiction Journal Editors at its 2015 annual meeting (Budapest, Hungary, August 31–September 2, 2015).
TL;DR: These results offer the first assessment of online drug forums as a valid source for estimating demographic and temporal trends in drug use, and suggest that online forums are a reliable source for estimation of demographic associations and early identification of emerging drugs, but a less reliable sources for measurement of long-term temporal trends.
Abstract: OBJECTIVES: Addiction researchers have begun monitoring online forums to uncover self-reported details about use and effects of emerging drugs. The use of such online data sources has not been validated against data from large epidemiological surveys. This study aimed to characterize and compare the demographic and temporal trends associated with drug use as reported in online forums and in a large epidemiological survey. METHODS: Data were collected from the Web site, drugs-forum.com, from January 2007 through August 2012 (143,416 messages posted by 8087 members) and from the US National Survey on Drug Use and Health (NSDUH) from 2007 to 2012. Measures of forum participation levels were compared with and validated against 2 measures from the NSDUH survey data: percentage of people using the drug in past 30 days and percentage using the drug more than 100 times in the past year. RESULTS: For established drugs (eg, cannabis), significant correlations were found across demographic groups between drugs-forum.com and the NSDUH survey data, whereas weaker, nonsignificant correlations were found with temporal trends. Emerging drugs (eg, Salvia divinorum) were strongly associated with male users in the forum, in agreement with survey-derived data, and had temporal patterns that increased in synchrony with poison control reports. CONCLUSIONS: These results offer the first assessment of online drug forums as a valid source for estimating demographic and temporal trends in drug use. The analyses suggest that online forums are a reliable source for estimation of demographic associations and early identification of emerging drugs, but a less reliable source for measurement of long-term temporal trends. Language: en
TL;DR: Findings suggest that the experience of childhood physical abuse may be an important mechanism through which family history of substance use is associated with an earlier age of first drug use.
Abstract: OBJECTIVES: The current study examined the association among family history of substance use problems, childhood maltreatment, and age of first drug use in a sample of men and women seeking treatment for methamphetamine dependence. Various forms of childhood maltreatment were considered as mediators of the association between family history of substance use problems and age of first drug use. METHODS: Participants (N = 99, 40% women, mean age 33) who were under treatment for methamphetamine dependence completed a baseline interview that obtained demographic information, past substance use by participants, history of drug/alcohol problems in their family of origin, and age at first use of any drug (excluding alcohol and tobacco). The Early Trauma Inventory Self-Report-Short Form was used to assess child maltreatment experiences before the age of 18. RESULTS: Family history of substance use problems and childhood physical (but not emotional or sexual) trauma significantly predicted age of first drug use. Further, childhood physical trauma mediated the association between family history of substance use problems and age of first drug use. CONCLUSIONS: These findings suggest that the experience of childhood physical abuse may be an important mechanism through which family history of substance use is associated with an earlier age of first drug use. Language: en
TL;DR: Under-reporting of drug use is prevalent even among self-reported drug users in primary care patients of FQHCs (22%), but varied considerably based on the substance used.
Abstract: OBJECTIVE: The Affordable Care Act encourages integration of behavioral health into primary care. We aim to estimate the level of under-reporting of drug use in federally qualified health centers (FQHCs) among self-reported risky drug users. METHODS: Adult patients in the waiting rooms of 4 FQHCs who self-reported risky drug use on the screening instrument World Health Organization's Alcohol, Smoking and Substance Involvement Screening Test (score 4-26), who participated in the "Quit Using Drugs Intervention Trial," submitted urine samples for drug testing. Under-reporters were defined as patients who denied use of a specific drug via questionnaire, but whose urine drug test was positive for that drug. Descriptive statistics, Pearson chi-square test, and logistic regression were used for analysis. RESULTS: Of the 192 eligible participants, 189 (96%) provided urine samples. Fifty-four samples were negative or indeterminate, yielding 135 participants with positive urine drug tests for this analysis: 6 tested positive for amphetamines, 18 opiates, 21 cocaine, 97 marijuana. Thirty patients (22%) under-reported drug use and 105 (78%) reported drug use accurately. Under-reporting by specific substances was: amphetamines 66%, opiates 45%, cocaine 14%, and marijuana 7%. Logistic regression revealed that under-reporting of any drug was associated with history of incarceration and older age (odds ratios 2.6 and 3.3, respectively; P CONCLUSIONS: Under-reporting of drug use is prevalent even among self-reported drug users in primary care patients of FQHCs (22%), but varied considerably based on the substance used. Further research is indicated to assess the extent of under-reporting among all primary care patients, regardless of their self-reported drug use status. Language: en
TL;DR: With the exception of cannabis, UDTs are important assessment tools when treating drug use disorders in primary care and might be particularly helpful when treating patients who are older, female, disabled, have legal and social problems, and have more severe drug problems.
Abstract: Objectives To determine if urine drug tests (UDTs) can detect under-reporting of drug use (ie, negative self-report, but positive UDT) and identify patient characteristics associated with underreporting when treating substance use disorders in primary care Methods Self-reported use (last 30 d) and UDTs were gathered at baseline, 3, 6, 9, and 12 months from 829 primary care patients participating in a drug use intervention study Rates of under-reporting were calculated for all drugs, cannabis, stimulants, opioids, and sedatives Logistic regressions were used to identify characteristics associated with under-reporting Results Among the participants, 40% (n = 331) denied drug use in the prior 30 days despite a corresponding positive UDT during at least 1 assessment Levels of under-reporting during 1 or more assessments were 3% (n = 22) for cannabis, 20% (n = 167) for stimulants, 27% (n = 226) for opioids, and 13% (n = 106) for sedatives Older (odds ratio [OR] 104), female (OR 166), or disabled (OR 142) individuals were more likely to under-report any drug use Under-reporting of stimulant use was also more likely in individuals with lower levels of educational attainment, previous arrests, and family and social problems Under-reporting of opioid use was more likely in those with other drug problems, but less likely in those with better physical health, more severe alcohol and psychiatric comorbidities, and African-Americans Conclusions With the exception of cannabis, UDTs are important assessment tools when treating drug use disorders in primary care UDTs might be particularly helpful when treating patients who are older, female, disabled, have legal and social problems, and have more severe drug problems
TL;DR: These exploratory findings indicate that ED-based screening and brief intervention approaches addressing substance use and/or dating victimization may need to account for previously undiagnosed sleep problems.
Abstract: Objectives: To determine correlates of sleep problems among adolescents. Specifically, to assess the relative strength of associations between sleep problems and dating victimization, reasons for emergency department (ED) visit, depression, unhealthy alcohol use, and other drug use (marijuana, nonmedical use of prescription opioids, stimulants, and tranquilizers). Methods: A total of 1852 adolescents aged 14 to 20 years presenting for care to the University of Michigan Emergency Department, Ann Arbor, Michigan, during 2011–2012, self-administered a computerized health survey. Sleep problems were identified if any of the 4 items on the Sleep Problems Questionnaire were rated by a patient as greater than 3 on a 0 to 5 scale. Adolescents who were too sick to be screened in the ED were eligible to participate in the study during their inpatient stay. Exclusion criteria for baseline included insufficient cognitive orientation precluding informed consent, not having parent/guardian present if younger than 18 years, medical severity precluding participation, active suicidal/homicidal ideation, non-English-speaking, deaf/visually impaired, or already participated in this study on a prior visit. Results: 23.5% of adolescents reported clinically significant sleep problems. Female gender, depression, dating victimization, tobacco use, nonmedical use of prescription medication, and an ED visit for medical reasons were each associated with sleep problems among adolescents, even while controlling for age, other types of drug use, receiving public assistance, and dropping out of school. Conclusions: These exploratory findings indicate that ED-based screening and brief intervention approaches addressing substance use and/or dating victimization may need to account for previously undiagnosed sleep problems.
TL;DR: Key aspects of the ASAM dimensions of care and placement levels are reviewed, with emphasis on how they apply to tobacco use and case examples of typical smokers who would benefit from a higher intensity of tobacco dependence treatment.
Abstract: Tobacco use is a major threat to public health in the United States, and the number one cause of preventable death. Although most smokers try to quit unaided, robust data indicate that pairing behavioral support to US Food Drug Administration-approved cessation medications significantly increase cessation rates. Those who do receive assistance in quitting usually receive very low intensity treatment, regardless of the severity of their dependence or their medical and environmental circumstances. This is in stark contrast to how other substance use disorders are treated, where there are varying levels of care depending on addiction severity and biopsychosocial circumstances. The American Society of Addiction Medicine (ASAM) developed a formal algorithm for assessing substance use disorders and determining the optimal level of care. The ASAM Patient Placement Criteria are regularly used to determine the appropriate level of care for all substance use disorders except tobacco. This paper will review key aspects of the ASAM dimensions of care and placement levels, with emphasis on how they apply to tobacco use and present case examples of typical smokers who would benefit from a higher intensity of tobacco dependence treatment. We also present current barriers to reimbursing healthcare providers for these services. We conclude with a commentary and discussion regarding recommendations for improvements in tobacco dependence treatment care.
TL;DR: Patients’ knowledge about hepatitis C was found to be significantly improved after the educational intervention, suggesting HCV-related education could be the first step toward effective enrollment of patients on opioid agonist therapy into hepatitis C care.
Abstract: OBJECTIVES Lack of knowledge about hepatitis C virus (HCV) is a principal barrier to substance users' engagement into care for the infection. As a step toward their increased engagement into HCV care, the objective of this study was to deliver an HCV-related educational intervention to substance users on opioid agonist therapy and to assess the change in HCV-related knowledge after the intervention. METHODS We designed a comprehensive and interactive hepatitis C-related educational intervention, composed of two 30 to 60-minute sessions conducted during 2 consecutive weeks. Patients' knowledge about hepatitis C was assessed immediately before and after the intervention using a 7-item questionnaire. RESULTS A total of 110 patients completed both educational sessions. Patients' mean age was 54.7 ± 7.8 years, 58.7% were men, 70.4% African American, and 30% were Hispanic. We observed a significant increase in HCV-related knowledge after completion of the educational intervention. Whereas 65.45% of patients answered 5 or more questions correctly before the intervention, 83.64% had 5 or more questions answered correctly on the posteducational quiz (P < 0.001). Male sex, ever receiving an HCV diagnostic test before the educational intervention, and a higher level of HCV knowledge on the preeducational quiz were found to be significantly associated with HCV-related knowledge after the educational intervention. CONCLUSIONS Patients' knowledge about hepatitis C was found to be significantly improved after the educational intervention. Therefore, HCV-related education could be the first step toward effective enrollment of patients on opioid agonist therapy into hepatitis C care.
TL;DR: These findings highlight the importance of examining unprescribed medication use even with patients at moderate levels of psychiatric symptoms and pain, and highlight the need to proactively address this problem in outpatient encounters.
Abstract: BACKGROUND The nonmedical use of prescription medication among US adults is a growing public health problem. Healthcare providers should proactively address this problem in outpatient encounters. OBJECTIVE We sought to understand the interactive effects among prescription drugs, pain, and psychiatric symptoms among adult outpatients to build an empirical foundation for comprehensive screening. METHODS We screened 625 adult neurosurgery and orthopedic patients at a suburban satellite clinic of an urban academic medical center. A convenience sample was screened for psychiatric and substance use disorder symptoms using the American Psychiatric Association's recommended screening protocol. We tested whether psychiatric symptoms moderated the relationship between pain level and nonmedical use of prescription medicine. RESULTS Patients reported average levels of depression, anxiety, and pain symptoms, within 1 standard deviation of the screeners' normative data. However, patients reported highly elevated levels of nonmedical use of opioids and benzodiazapines compared with national data. Controlling for age, sex, and race, pain level predicted nonprescription use of opioid and benzodiazapine medications. Patients with high levels of depression and pain were more likely to engage in the unprescribed use of opioids. Likewise, patients with reduced levels of depression and pain were protected against the unprescribed use of opioids. CONCLUSIONS These findings highlight the importance of examining unprescribed medication use even with patients at moderate levels of psychiatric symptoms and pain.
TL;DR: Higher dosage of methadone is recommended as a way to improve treatment adherence in patients newly enrolled or re-enrolled on MMT programs in Yunnan Province, China.
Abstract: BACKGROUND China initiated the methadone maintenance treatment (MMT) program since 2004. The main challenge has been poor clinic adherence, which has a serious impact on treatment efficacy. OBJECTIVES The aim of the study was to identify predictors of poor adherence to MMT in Yunnan Province, China. METHODS We performed a case-control study of 764 patients, newly enrolled or re-enrolled on MMT programs, between January 1, 2007 and December 31, 2011. Information was obtained from clinic databases. RESULTS The frequency of poor adherence was 561 (73.43%). Lower daily methadone dosage (<60 mg) was significantly associated with poor adherence (odds ratio 4.07; 95% confidence interval, 2.88-5.74; P value < 0.001). Younger age was also a significant predictor of poor adherence (odds ratio 1.04; 95% confidence interval, 1.01-1.05; P value < 0.01). CONCLUSIONS Higher dosage of methadone is recommended as a way to improve treatment adherence.