Addiction Medicine Research Articles

Clinicians' Perspectives and an Ethical Analysis of Safer Supply Opioid Prescribing.

In British Columbia, Canada, many physicians providing care to individuals with high-risk opioid use disorder adopted safer supply (SS) opioid prescribing in the spring of 2020 with the goal of facilitating public health measures for COVID-19. This prescribing practice continued after measures were lifted. This study aimed to explore prescribers' perspectives following several years of local experience in prescribing SS opioids, primarily in the form of hydromorphone tablets, and to apply ethical concepts to explore current challenges and ongoing sources of provider distress. Addiction medicine SS prescribers participated in individual or small group semi-structured interviews. Each interview was transcribed and analysed for recurrent themes. Themes were then integrated into a narrative ethics discussion. Eleven addiction medicine physicians practicing in various settings within Vancouver participated in this study. Six themes were identified: clinical assessment, clinician distress, gaps in care, models of safer supply, research, and special populations. Ethical dilemmas in prescribing SS are identified and explored through a discussion of biomedical ethics principles and the physician role.

Prevalence and severity of insomnia in adult outpatients attending Kasralainy Psychiatry and Addiction Treatment Hospital

BackgroundInsomnia is common among patients with psychiatric disorders and affects the clinical presentation and outcomes of the psychiatric disorder. The presentation of insomnia varies according to the type and severity of the psychiatric disorder.ObjectivesThis cross-sectional study aimed to assess the prevalence and severity of insomnia in adult psychiatric outpatients attending Psychiatry and Addiction Medicine Hospital, Faculty of Medicine, Cairo University. The study included 390 patients diagnosed with the following disorders: depressive disorders (n = 126 (32.2%)), anxiety disorders (n = 69 (17.6%)), psychotic spectrum disorders (n = 67 (17.1%)), bipolar and related disorders (n = 50 (12.8%)), trauma and stress-related disorders (n = 46 (11.8%)), obsessive–compulsive disorder (n = 30 (7.7%)), and somatic symptoms disorders (n = 2 (0.5%)). Patients were assessed using the Sleep Disorder Interview, Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), and Global Assessment of Functioning Scale (GAF).ResultsAmong the assessed patients, 314 (80.5%) had insomnia, with a higher prevalence in females (91.5%) compared to males (67.2%). The prevalence of insomnia was 96% in depressive disorders, 97.1% in anxiety disorders, 49.3% in psychotic disorders, and 32% in bipolar and related disorders; while all patients with trauma and stress-related disorders, obsessive–compulsive disorders, and somatic symptoms disorders had insomnia.The severity of insomnia as measured by ISI was positively correlated with the global functioning score (r = 0.341, p = < 0.001) and negatively correlated with the duration of the psychiatric illness (r = − 0.285, p = < 0.001).ConclusionsInsomnia is highly prevalent in outpatients with psychiatric disorders.

8798 How Low Can You Go: Suspected Methadone-Induced Hyperinsulinemia

Abstract Disclosure: L. Ravindra: None. M.G. Fernandez: None. V. Cheng: None. Background: Studies have shown that methadone use can result in severe hypoglycemia. This is thought to be related to methadone having antagonistic activity at NMDA receptors, resulting in increased pancreatic insulin release, suppressed glucagon and epinephrine, and inhibition of hepatic glycogenolysis. These mechanisms affect the normal physiologic response to hypoglycemia and can result in hyperinsulinemic-induced hypoglycemia. Clinical case: We present a case of a 56-year-old male with complex regional pain syndrome managed with a high daily dose of methadone (345 mg) who presented to the hospital for evaluation of failure to thrive and hypoglycemia. During the hospital admission, evaluation of hypoglycemia included a serum blood glucose level of 41 mg/dL (normal &amp;gt;60 mg/dL), with an inappropriately normal level of insulin 10 (Reference Range (RR) 3-25 mU/L), C-peptide 2.9 (RR 0.5-3.3 ng/ml), Pro-insulin 2.9 (RR 3-20 pmol/L), an undetectable level of Beta-hydroxybutyrate &amp;lt;0.10 (RR 0.02-0.27 mMol/L) negative insulin antibodies &amp;lt;0.4 (RR 0.0 - 0.4 U/mL), and negative sulfonylurea screen. Additional labs included a normal TSH of 2.8 (RR 0.3-5.5 mIU/ml) and appropriate morning cortisol of 23 (RR &amp;gt;14-15 μg/dL). The abdominal CT and follow-up MRI did not reveal any definite abnormalities in the pancreas. Given persistent evidence of hyperinsulinemic-induced hypoglycemia, a PET Dotatate scan was performed, confirming the absence of a neuroendocrine tumor. While admitted, management included nutritional optimization, close glucose monitoring, and an intravenous dextrose infusion. Diazoxide was also initiated and gradually increased to 150 mg three times a day. Addiction Medicine assisted in tapering down the methadone dose from 115 mg to 105 mg three times a day. With these interventions, the patient had no further episodes of hypoglycemia. On discharge, the patient was provided with a continuous glucose monitor. On follow-up, the patient has continued to show improvement and the diazoxide dose has been decreased without recurrent hypoglycemia. Given this, a selective arterial calcium stimulation test was not pursued. Conclusion: Methadone is an uncommon cause of hyperinsulinemic-induced hypoglycemia. Suspicion should arise, particularly in patients on high doses. Current evidence suggests tapering methadone dosage as the primary intervention, as insulin levels can decrease drastically and improve hypoglycemia. This therapeutic approach should be considered before pursuing invasive and costly diagnostic testing. Presentation: 6/3/2024

B-262 Validation of a point-of-care lateral flow immunoassay for urine drug testing prior to application in an outpatient rapid access addiction medicine clinic

Abstract Background Point-of-care (POC) urine drug testing is a useful adjunct to self-reporting in rapid access addiction medicine settings to immediately guide patient management. However, available POC immunoassays have limitations including cross-reactivity with unrelated compounds or low sensitivity that may cause false results. Here, we assessed the performance of a multi-drug test panel by comparing against gold-standard liquid chromatography tandem mass spectrometry (LC-MS/MS) testing. Methods 102 residual urine specimens were assayed using a competitive lateral flow immunoassay (LFA) for 10 drugs: 2-ethylene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP, methadone metabolite), buprenorphine, morphine, hydromorphone, oxycodone, fentanyl, cocaine, methamphetamine, amphetamine, and benzodiazepines (BTNX Rapid ResponseTM Multi-Drug Panel). Results were compared to those obtained by LC-MS/MS (n=67, 66%) or kinetic interaction of microparticles in solution automated immunoassay (KIMS) (Roche Diagnostics, n=35, 33%). Broad spectrum LC-MS/MS results were reviewed in entirety for discordant cases, particularly in false positives to identify the presence of any known cross-reacting compounds. Results Of 10 drugs evaluated, four demonstrated ≥95% agreement with LC-MS/MS or KIMS immunoassay (EDDP, buprenorphine, oxycodone, methamphetamine). Fentanyl demonstrated the highest false negative rate of 44% (LFA cut-off: 10 ng/mL) followed by amphetamines (22%, cut-off: 1000 ng/mL). Morphine and hydromorphone demonstrated false positive rates of 14% and 18%, respectively, with most cases likely due to cross-reacting opiate or opioid metabolites. Benzodiazepines (target: Oxazepam) demonstrated false positive and negative rates of 13% and 24%, respectively. Conclusions To our knowledge, this is the first study to evaluate the performance of the BTNX multi-drug test panel against definitive testing in urine samples. While good concordance was observed for most drugs, high rates of discordant results for fentanyl and others emphasize the need for confirmatory testing by methods with higher sensitivity and specificity. Careful consideration prior to implementation would be essential, including physician education, interpretative comments, and training resources.

A non randomised pilot study to investigate the acceptability and feasibility of LivR Well: a multifaceted 28-day home based liver optimisation program for acute-on-chronic liver failure.

Background and AimsAcute-on-chronic liver failure (ACLF) has a 22-74% 28-day mortality rate and 30-40% 30-day re-admission rate. We investigated the acceptability and feasibility of a multimodal community intervention for ACLF. MethodsA single-arm, non-randomized pilot study of consecutive participants with ACLF was conducted in a tertiary health service. Participants received weekly medical and nursing reviews, dietetics, physiotherapy, pharmacy, social work, addiction medicine, and/or neuropsychiatry. A digital platform included remote weight monitoring, and online surveys. The primary outcome was acceptability/feasibility. Secondary outcomes included safety, mortality, re-admission, liver disease severity, and costs. ResultsFifty-nine patients were enrolled with median age 51 years (IQR: 45-59); majority alcohol etiology (74%),and median Model for End-Stage Liver Disease Sodium (MELD-Na) score 16 (IQR: 12-21). LivR Well was acceptable with low attrition (8/59), adherence to the program including home visits (mean 8.4±4.2) and consultations (mean 2.4±1.5) per patient. This was supported by positive feedback and themes identified through a qualitative sub-analysis. Feasibility was demonstrated by recruitment rate of 4.94 patients/month and 86% completion. Mortality was lower than expected at 3%, 30-day readmission rate was 15%, and median MELD-Na score reduced to 15 (p = 0.01). Median 6-month costs reduced from $30,454 (IQR: 21953-$65657) to $17, 657 ($4249-42876) (p=0.009). The total 6-month healthcare cost was $1,868,859 (95% CI 1,081,821-2,655,897) compared to $2,518,227 (95% CI 1,959,610-3,076,844). ConclusionLivR Well was acceptable, feasible and safe with low short-term mortality and readmission rates. Healthcare costs were reduced by 26% driven by a 40% reduction in 30-day re-admission. Further evaluation includes a randomized, controlled trial of LivR Well compared to standard care.

Xylazine-induced Skin Necrosis, Emerging Public Health Crisis and the Ethical Considerations in Surgical Reconstruction: A Case Report

Xylazine, a non-opioid veterinary sedative, is increasingly being used to adulterate illicit fentanyl. Injection into the extremities causes progressive necrotic wounds, resulting in a compromised limb and life. Managing xylazine-induced skin necrosis may require extensive surgical intervention, including serial debridements and soft tissue reconstruction. Moreover, managing these complex wounds requires a multi-disciplinary approach, including hospital medicine, infectious disease, psychiatry, addiction medicine, pain/palliative care, ethics, wound care, orthopedic surgery, and plastic surgery. A 38-year-old female with a history of intravenous drug use presented with severe bilateral dorsal forearm wounds, and despite initial non-compliance with surgical debridement, she eventually underwent successful skin grafting after extensive treatment, including antibiotics and negative pressure therapy, but was later lost to follow-up. She relapsed into fentanyl use, leading to severe bilateral lower extremity wounds requiring further debridement and skin grafting, and later returned with new forearm wounds, at which point further reconstruction was deemed inappropriate without addressing her addiction; she refused inpatient rehabilitation and ultimately being lost to follow-up again.

Racism, not race: Quantitative analysis of the use of race and racism in the addiction literature

RationalePrior research has demonstrated that medical journals rarely mention racism, potentially contributing to an incorrect understanding of and inappropriate interventions for health inequities affecting Black and Brown communities in the US. While this infrequency of mentions of racism has been documented in the general medical literature, it is unknown if this pattern extends to the addiction literature, where some have argued that structural racism has played a specific role in shaping policy and treatment. ObjectiveTo assess how frequently the addiction literature for the last 30 years has mentioned race and racism and if these rates vary with social movements. MethodsWe created an algorithm to download and process over 30,000 published articles published from 1990 to 2022 in five major addiction journals: Addiction, Addictive Behaviors, Drug and Alcohol Dependence, Journal of Substance Abuse and Treatment, and International Journal of Drug Policy. Using this data, we reported temporal patterns of mentioning both race and racism across journals and article types. Further, we utilized interrupted time series analysis to identify if the social movements against police violence and the murder of George Floyd in 2020 were associated with significant changes in rates of mentioning racism. ResultsWhile over 30% of the articles in addiction medicine journals included the word race, only 1.5% of articles mentioned racism. Based on an interrupted time series model, after the racial reckoning following the murder of George Floyd in 2020, mentions of racism increased in the addiction literature (OR = 3.21, 95% CI: [2.39, 4.32], P<.001). ConclusionsA large chasm remains between how often authors mention race versus racism in addiction medicine, a field with a unique history intertwined with structural racism. Addressing inequities in addiction outcomes, including burgeoning inequities in overdose deaths, will require acknowledging racism in the scientific literature.

Sexual Dysfunction, Marital Adjustment, and Quality of Life Among Male Persons with Alcohol Dependence Syndrome Attending Tertiary Healthcare Institution in Northeast India: A Cross-Sectional Study

Background: Sexual dysfunction is one of the major problems associated with the chronic use of alcohol. Sexual dysfunction is also significantly associated with marital adjustment and quality of life. Aim and objectives: To determine the prevalence of sexual dysfunction and its association with marital adjustment and quality of life among persons with alcohol dependence syndrome (ADS) and to compare with the healthy control group. Materials and methods: The present study used a cross-sectional, comparative, and descriptive research design. A purposive sampling technique was used to select the sample of 128 (64 patients with ADS and 64 healthy control persons) between the ages of 21 and 50, from the Department of Addiction Medicine, LGB Regional Institute of Mental Health (LGBRIMH), Tezpur, Assam. Sociodemographic and clinical data sheet, the Arizona Sexual Experience Scale (ASEX), the Severity of Alcohol Dependence Questionnaire (SDAQ), the Alcohol Use Disorders Identification Test (AUDIT), the International Index of Erectile Dysfunction (IIED), and The Drug Abuse Screening Test scales (DAST) were used. Results: The study revealed a higher prevalence of sexual dysfunction in the ADS group (64%) compared to the healthy control group (35.9%) (Chi-square = 46.916; p &lt; .001). Marital satisfaction was significantly lower in the ADS group than in the healthy control group (Fisher’s exact test = 76.932; p &lt; .001). Quality of life was also diminished in the ADS group, particularly in the physical ( t = −5.310; p &lt;.001), social ( t = −4.481; p &lt; .001), and environmental domains ( t = −4.250; p &lt; .001). Furthermore, sexual dysfunction exhibited a significant negative correlation with marital adjustment ( r = −0.676; p &lt; .01) and all domains of quality of life [physical domain ( r = −0.235; p &lt; .001), social domain ( r = −0.383; p &lt; .001), and environmental domain ( r = −0.383; p &lt; .001)]. Conclusion: The prevalence of sexual dysfunction and erectile dysfunction was high in persons with alcohol dependence syndrome as compared to the healthy control group and it has a relationship with marital adjustment and quality of life. The findings highlight the importance of screening and evaluating sexual dysfunction in individuals with alcohol dependence. Comprehensive pharmacological and nonpharmacological services are warranted to address the unique needs of this population, promoting both recovery from alcohol dependence and improvement in overall quality of life.

Prevalence of a dual diagnosis of mental illness and substance use disorder in Ontario, Canada: a retrospective cohort study using linked administrative data

ObjectivePopulation-based prevalence estimates of co-occurring mental illness and substance use disorder (herein dual diagnosis) are scarce and derived from a single source (e.g., survey data) which may lead to underestimation of prevalence. We linked administrative data to a representative mental health survey in Ontario, Canada to estimate dual diagnosis prevalence using a data triangulation method. Approach We retrospectively linked the 2002 and 2012 Canadian Community Health Survey on Mental Health (CCHS-MH) to emergency department, inpatient hospital, and outpatient physician records in Ontario, Canada. Mental illness and substance use disorder were ascertained though self-report, Composite International Diagnostic Interview screening, and linked administrative health records. We estimated 1-year, 5-year, and lifetime prevalence of dual diagnosis. ResultsOf the CCHS-MH survey participants, 14,790 (99.8%) were included in the study. The 1-year, 5-year, and lifetime prevalence of dual diagnosis was 2.3%, 4.8%, and 9.8%, respectively, which attenuated to 2.1%, 4.1%, and 8.4%, respectively, when tobacco use disorder was removed from substance use disorder ascertainment. ConclusionDual diagnosis is more common in the general population than previously estimated. Considering barriers to accessing care for both mental illness and substance use disorders among people with dual diagnosis annually, our 5-year prevalence estimate is likely most informative for health system planning. ImplicationsIn the context of increased health burden, barriers to care access, and challenges to effective treatment associated with dual diagnosis, our findings present a case for increased investment in integrated models of mental healthcare and addiction medicine.

Evaluation of DSM-5 Diagnostic Criteria for Betel-Quid Use Disorder Using the Addiction Characteristics Defined by American Society of Addiction Medicine

Background The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), categorizes betel-quid use disorder (BUD) under Other (Or Unknown) Substance Use Disorder, and the diagnostic criteria used are adapted from those of Substance Use Disorder. Because different substances have different characteristics, an improved set of diagnostic criteria is required to better detect BUD. Objective The objective of this study was to examine the different measures of accuracy for DSM-5 BUD by using the addiction characteristics defined by the American Society of Addiction Medicine (ASAM). Methods A certified psychiatrist conducted face-to-face diagnostic interviews. Questionnaires were administered to assess betel-quid use history, patterns of use, and dependence features. All betel-quid users were evaluated for BUD by using the DSM-5 criteria and addiction characteristics defined by the ASAM. Results One of the DSM-5 diagnostic criteria for BUD, namely large amount of time spent on obtaining and using betel quid and recovering from betel-quid use, showed the lowest sensitivity of 0.14, lowest diagnostic accuracy of 0.63, and lowest diagnostic odds ratio of 2.61. Another DSM-5 diagnostic criterion, namely continued betel-quid use despite knowledge of physical or psychological problems, had the lowest specificity of 0.49. The diagnostic threshold of five or more DSM-5 BUD criteria showed a sensitivity of 0.86 and a specificity of 0.97. Conclusions This study is the first to evaluate the different measures of accuracy for DSM-5 BUD. Given that each addictive substance has unique addictive characteristics, the composition and number of criteria for diagnosing DSM-5 BUD must be reconsidered.

Implementation of a rural emergency department-initiated buprenorphine program in the mountain west: a study protocol

BackgroundOpioid related overdose morbidity and mortality continue to significantly impact rural communities. Nationwide, emergency departments (EDs) have seen an increase in opioid use disorder (OUD)-related visits compared to other substance use disorders (SUD). ED-initiated buprenorphine is associated with increased treatment engagement at 30 days. However, few studies assess rural ED-initiated buprenorphine implementation, which has unique implementation barriers. This protocol outlines the rationale and methods of a rural ED-initiated buprenorphine program implementation study.MethodsThis is a two-year longitudinal implementation design with repeated qualitative and quantitative measures of an ED-initiated buprenorphine program in the rural Mountain West. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework outlines intervention assessments. The primary outcome is implementation measured by ED-initiated buprenorphine protocol core components. Reach, adoption, and maintenance are secondary outcomes. External facilitators from an academic institution with addiction medicine and prior program implementation expertise partnered with community hospital internal facilitators to form an implementation team. External facilitators provide ongoing support, recommendations, education, and academic detailing. The implementation team designed and implemented the rural ED-initiated buprenorphine program. The program includes OUD screening, low-threshold buprenorphine initiation, naloxone distribution and administration training, and patient navigator incorporation to provide warm hand off referrals for outpatient OUD management. To address rural based implementation barriers, we organized implementation strategies based on Expert Recommendations for Implementing Change (ERIC). Implementation strategies include ED workflow redesign, local needs assessments, ED staff education, hospital leadership and clinical champion involvement, as well as patient and community resources engagement.DiscussionMost ED-initiated buprenorphine implementation studies have been conducted in urban settings, with few involving rural areas and none have been done in the rural Mountain West. Rural EDs face unique barriers, but tailored implementation strategies with external facilitation support may help address these. This protocol could help identify effective rural ED-initiated buprenorphine implementation strategies to integrate more accessible OUD treatment within rural communities to prevent further morbidity and mortality.Trial RegistrationClinicalTrials.gov National Clinical Trials, NCT06087991. Registered 11 October 2023 – Retrospectively registered, https://clinicaltrials.gov/study/NCT06087991.

Outcome Evaluation of an Integrated, Combined-care Perinatal Addiction Medicine- Primary Care Obstetrics Model for Urban, Inner-city Pregnant Patients With Severe Substance Use Disorders

ABSTRACT Objective: Programs for pregnant individuals with severe substance use disorders that combine addiction, obstetrical, and psychosocial care contribute to better neonatal and maternal outcomes. This research aims to describe patient demographics, retention in care, and maternal and neonatal outcomes associated with an integrated perinatal addiction program. Methods: Retrospective chart review of patients who received care in the Substance Use in Pregnancy (SUP) program at St Michael’s Hospital, Toronto, ON, Canada, between July 1, 2013, and December 31, 2019. Demographic information, as well as outcome measures, were collected for each mother-infant dyad. Descriptive statistics were used to describe study participants and maternal and neonatal outcomes. Results: A total of 121 pregnancies were included in the study. Most of the cohort was unemployed, single, and with unstable housing. Pregnant patients attended, on average, 10 prenatal visits (SD=7.8), and 77% of the cohort had a visit after delivery. Ninety-seven percent of the pregnant individuals completed prenatal screening. Sixty-one percent of infants required admission to the neonatal intensive care unit with an average length of stay of 14 days (SD=14.9). Nicotine (71%) and cannabis (50%) were the most used drugs at program enrolment, followed by opioids (41%), cocaine (34%) and alcohol (32%). The proportion of pregnant patients using substances was lower at delivery, compared with the first visit, except for fentanyl users. Conclusions: The SUP program yields positive maternal and neonatal outcomes associated with high rates of prenatal appointment attendance. Participation in this integrated, combined care program is associated with sustained retention in care for a highly marginalized patient population. Objectif: Les programmes destinés aux personnes enceintes souffrant de troubles sévères liés à l’utilisation de substances psychoactives qui combinent les soins en toxicomanie, obstétricaux et psychosociaux contribuent à de meilleurs résultats néonataux et maternels. Cette recherche vise à décrire les caractéristiques démographiques des patients la rétention dans les soins et les résultats maternels et néonataux associés à un programme intégré en toxicomanie périnatale. Méthodes: Examen rétrospectif des dossiers des patientes ayant reçu des soins dans le cadre du programme Substance Use in Pregnancy (SUP) à l’hôpital St Michael, Toronto, ON, Canada entre le 1er juillet 2013 et le 31 décembre 2019. Des données démographiques ainsi que des mesures de résultats ont été collectées pour chaque dyade mère-enfant. Des statistiques descriptives ont été utilisées pour décrire les participants à l'étude et les résultats maternels et néonataux. Résultats: Au total, 121 grossesses ont été incluses dans l'étude. La plupart des membres de la cohorte étaient sans emploi, célibataires et avaient un logement instable. Les patientes enceintes ont assisté en moyenne à 10 visites prénatales (écart-type=7,8) et 77% de la cohorte ont eu une visite après l’accouchement. 97% des femmes enceintes ont effectué un dépistage prénatal. 61% des nourrissons ont dû être admis dans une unité de soins intensifs néonataux, avec une durée moyenne de séjour de 14 jours (écart-type=14,9). La nicotine (71%) et le cannabis (50%) étaient les drogues les plus consommées au moment de l’inscription au programme, suivies des opioïdes (41%), de la cocaïne (34%) et de l’alcool (32%). La proportion de patientes enceintes consommant des substances était plus faible à l’accouchement qu'à la première visite, sauf pour les consommatrices de fentanyl. Conclusions: Le programme SUP produit des résultats maternels et néonataux positifs associés à des taux élevés d’assiduité aux rendez-vous prénataux. La participation à ce programme de soins intégrés et combinés est associée à une rétention durable des soins pour une population de patients très marginalisés.

Buprenorphine Induction in Trauma Patients With Opioid Use Disorder — A Single Center Experience?

IntroductionBuprenorphine is a Food and Drug Administration-approved therapy for opioid use disorder, with proven efficacy in treatment retention and reduction in opioid use and mortality. Low-dose buprenorphine initiation or microinduction is a novel means of initiation that may allow for an easier transition in patients. Trauma patients have high rates of opioid use disorder and patient directed discharges (PDD). We hypothesized that patients initiated on a buprenorphine microinduction program would have increased protocol completion and fewer PDD compared with patients initiated historically on a traditional induction. MethodsOur retrospective cohort study compared buprenorphine microinduction and traditional induction in trauma patients at an urban level one trauma center between December 2020 and June 2022. Patients aged 18-89 y with traumatic injuries who received buprenorphine were included. Our primary outcome was in-hospital protocol completion, defined as reaching 16 mg of buprenorphine within 24 h or a documented stable dose. Statistical analysis was performed using chi-square for categorical variables and two sample t-tests for continuous variables. ResultsNinety-eight patients were included, with 46 initiating with microinduction and 52 initiating with traditional induction. There was no difference in protocol completion, (P = 0.29) and 83% of subjects who started an induction protocol completed it. Those who completed a protocol were more likely to be discharged home (P = 0.0002), had less PDD (P = 0.001), and had an increased likelihood of attending outpatient addiction clinic follow-up (P = 0.038). ConclusionsRegardless of the protocol type, buprenorphine induction can be implemented in trauma patients with high protocol completion rates. In our population, those who complete a protocol had a higher likelihood of discharge home and postdischarge follow-up in addiction medicine clinic.

Supervised Disulfiram Should Be Considered First-Line Treatment for Alcohol Use Disorder.

Despite the prevalence of alcohol use disorder (AUD) in the United States, the armamentarium of FDA-approved medications available for AUD treatment is remarkably small. Disulfiram, 1 of only 3 approved medications, is consistently designated as a second-line option in national treatment guidelines, citing inconsistent evidence, lack of patient preference, and safety concerns. These concerns, however, stem from a misguided interpretation of the evidence that exclusively relies upon double-blind randomized controlled trials (RCT). When viewed instead as both a medication and a behavioral intervention, open-label RCTs become a more appropriate research method, yielding overwhelmingly favorable efficacy data for disulfiram, and supervised disulfiram, in particular. With these data in mind, supervised disulfiram should be redesignated as a first-line intervention in both treatment guideline creation and clinical pathway tools. The addiction medicine community can no longer afford to neglect this critical therapeutic resource.

Revisiting Preaddiction

Abstract The directors of the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism have proposed new efforts to enable earlier identification and intervention for harmful substance use and its consequences. As editors of The ASAM Principles of Addiction Medicine, we fully support this goal. The word “preaddiction” has been suggested as a diagnostic label to describe individuals who would be targeted for early intervention. In this commentary, we offer that “unhealthy substance use” would be a better descriptor than “preaddiction” and review several potential barriers to be addressed in order to maximize the impact of introducing this new paradigm.

Treatment Failure Versus Failed Treatments: The Risks of Embracing Treatment Refractory Addiction.

In this issue, Strain advocates for the field of addiction medicine to consider a new diagnostic signal-treatment-refractory addiction. Also in this issue, Nunes and McLellan support the concepts advanced by Strain. I provide an alternate view and propose that it is premature to create such a signal and that doing so could lead to unintended adverse consequences. My argument is based on 4 concerns: (1) the lack of neuroscientific correlates, (2) the profound impact that context has on what patients receive as "treatment," (3) the rare provision of sequentially stepped treatment, and (4) the potential for misuse of the signal. Addiction medicine should be cautious in introducing concepts such as treatment-refractory addiction to ensure that patients are not seen as "treatment failures." Our efforts should rather focus on the development of additional effective treatments, improving access to existing effective treatments and a creating a system that does not provide "failed treatments."

Inpatient initiation of long-acting injectable buprenorphine at a community hospital: A retrospective case series

Objectives Determine if long-acting injectable buprenorphine (LAIB) can be successfully and safely administered in the hospital with minimal sublingual buprenorphine lead-in and potentially improve follow-up engagement in care. Methods We performed a retrospective case series of 46 patients who received LAIB while hospitalized at a safety-net community hospital. We abstracted demographic information, details about substance use disorder treatment history, in-hospital buprenorphine initiation methods and follow-up data from inpatient and outpatient electronic medical records. Results In total, 46 hospitalized patients received LAIB during the study period. The majority of our patients were older Black adults with Medicaid who self-reported intranasal heroin use. A low-dose buprenorphine initiation protocol was used most commonly, either in sublingual or intravenous form, with only two cases of precipitated withdrawal occurring during the buprenorphine initiation process and no cases of precipitated withdrawal after the administration of LAIB. 87% (40) of the patients received LAIB after receiving either sublingual or IV buprenorphine for fewer than the recommended seven days. Of the 46 hospitalized patients who received LAIB, 23 (50%) attended a follow-up addiction medicine appointment within 30 days of discharge. Conclusions Hospital administration of LAIB could play an important role in retention in care after hospital discharge.

A detox dilemma beyond benzodiazepines; clonidine's quandary in alcohol withdrawal management.

Benzodiazepines are the primary method of treatment of alcohol withdrawal, though the American Society of Addiction Medicine guidelines also include alternative agents for consideration. Observations in a Department of Veterans Affairs (VA) psychiatric emergency room noted consistent benzodiazepine use with an overall lack of use of alternative agents, even with low Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scores and in the absence of other concerning symptoms. Due to concerns of potential more-than-necessary benzodiazepine use, we analyzed adjunctive clonidine use for elevated blood pressure/pulse in alcohol withdrawal among this Veteran population. This is a single-site VA retrospective chart review of the psychiatric emergency room from July 1, 2022, to June 30, 2023, focused on patients with alcohol withdrawal managed on a CIWA protocol. Excluding concurrent opioid withdrawal and clonidine as home medication, 167 patient charts were analyzed for this study. Among 167 patients, 99 (59.3%) had comorbid hypertension. A total of 614 medication doses were given for elevated CIWA (373, 60.8%) and elevated blood pressure/pulse (241, 39.2%). Of the 241 doses for elevated blood pressure/pulse, only 2.5% were clonidine. Among all benzodiazepine doses, 75.3% were given to patients with comorbid hypertension. Clonidine was administered to 3.0% of patients, making up 2.5% of total dosing. Alcohol withdrawal management lacks optimization. Integrating adjunctive medications could reduce potential benzodiazepine overuse effectively addressing elevated blood pressure/pulse. This study sheds light on the potential underutilization of clonidine and its potential role in improving alcohol withdrawal syndrome management. By addressing elevated blood pressure/pulse and curbing potential overuse of benzodiazepines, it may contribute to further optimizing patient care.

Alcohol does not impact chronic hepatitis C treatment outcomes but increases risk for progressive liver disease: Findings from a prospective multicentre Australian study (OPERA-C).

Alcohol use is common in patients with chronic hepatitis C virus (HCV) infection. We examined the impact of alcohol use on direct-acting antiviral (DAA) therapy outcome and the clinical course of liver disease and 2-year survival for patients receiving HCV DAA therapy. Adults (n = 2624) recruited from 26 Australian hospital liver clinics during 2016-2021 were followed up for 2 years. Risky alcohol use was defined by a combination of self-report (≥40 g/day of ethanol), physician-reported history of problematic alcohol use, and anti-craving medication prescription via population-based database linkage. We examined factors associated with advanced liver fibrosis and survival using multivariable logistic and Cox regression. Among 1634 patients (62.3%) with risky alcohol use, 24.6% reported consuming ≥40 g/day of alcohol, 98.3% physician-reported problematic alcohol use; only 4.1% were dispensed naltrexone/acamprosate. One hundred and forty-three patients with cirrhosis reported ≥40 g/day of alcohol, 6 (4.3%) were prescribed naltrexone/acamprosate. Risky alcohol use was associated with advanced fibrosis (adjusted-odds ratio 1.69, 95% confidence interval 1.32-2.17) and patients were over-represented for cirrhosis (45.1% vs. 25.6% in no-risky alcohol use [p < 0.001]) and hepatocellular carcinoma (5.7% vs. 2.5% [p < 0.001]). Sustained viral response (p = 0.319) and 2-year survival (adjusted-hazard ratio 1.98, 95% confidence interval 0.84-4.63) after DAA therapy were not associated with risky alcohol use. Risky alcohol use in HCV patients was prevalent, but did not reduce HCV cure. Treatment for alcohol dependence was low. Risky alcohol use may be under-recognised in liver clinics. Better integration of addiction medicine into liver services and increased resourcing and addiction medicine training opportunities for hepatologists may help address this.

Experience Starting an Addiction Medicine Practice-Based Research Network.

This paper outlines the experience developing Addiction Medicine Practice-Based Research Network (AMNet), which promotes the adoption of patient-reported outcome measures (PROMs) and measurement-based care in outpatient addiction treatment practices and creates a platform for quality improvement and research. From August 2019 to July 2023, the AMNet team selected patient-reported outcome measures for implementation in the American Psychiatric Association's clinical data registry (PsychPRO), recruited addiction medicine providers, and collected PROMs data. AMNet selected 12 PROMs for implementation in PsychPRO. Through July 2023, 1565 providers expressed interest, of whom 216 of the 929 eligible providers (23%) attended an onboarding call/webinar. Two hundred six providers (95%) from 54 practices returned Participation Agreements. Subsequently, 65 providers (32%) from 39 practices withdrew, resulting in 141 (68%) providers from 15 practices. From November 2020 to July 2023, 38 providers submitted PROMs data using 1 of 3 PsychPRO patient portals. Sixteen of the 53 providers (30%) who signed up for the initial portal collected data from 468 patients. As of July 2023, 83 of the 141 providers (59%) opted to submit PROMs data from their own portal or electronic health record. Next steps will include continued recruitment of providers, addressing barriers to data transfer and integrating data from providers' portals into the registry to create a platform for future research.