Background In 2020, New Mexico had the highest alcohol related death and the 11th highest drug overdose rate in the U.S. Towards the long-term goal of addressing this public health problem, we are ...implementing and evaluating an multi-level intervention designed to identify adults at risk of substance use disorder (SUD) and encourage linkage to and retention in treatment. The first level includes equipping the ED and medical inpatient units of a safety-net hospital with a method to screen individuals at risk of a SUD. The second level includes Seeking Safety (SS), a trauma-specific treatment for PTSD and SUD; and pharmacotherapy for SUD. Motivational Interviewing (MI) is used throughout both levels. Using the SPIRIT guidelines and checklist, this study protocol describes the multi-level intervention and the methodology we are using to assess feasibility and effectiveness. Methods We are using a Type 1 hybrid implementation design with a non-randomized approach (ISRCTN registration # ISRCTN33100750). We aim to enroll 110 adults ( ≧ 18 ) who screen positive for unhealthy use of alcohol, prescription medications (used nonmedically) and/or illicit drugs. Peer support workers are responsible for screening, using MI to increase engagement in screening and treatment and delivery of SS. Pharmacotherapy is provided by addiction clinical specialists. Treatment is provided post hospital discharge via telehealth to increase access to care. Participants are identified through (1) review of electronic health records for individuals with a chief or secondary complaint or mental health condition relating to alcohol and/or other drug use, (2) referrals from clinical staff and (3) screening in the ED and medical inpatient units. Feasibility is being measured through process data. Effectiveness will be determined by changes in two primary outcomes: (i) PTSD symptom severity; and (ii) substance use. Discussion Our study will expand on research related to the implementation of treatment strategies for patients presenting at EDs and admitted to medical inpatients units wherein there is a significant window of opportunity to link patients with follow-up behavioral and clinical services for alcohol and/or drug misuse. The challenges associated with implementation and strategies that have been helpful to address these challenges will further inform the field.
Background and Aims
Expanding access to medication‐assisted treatment with buprenorphine is a cornerstone of the opioid crisis response, yet buprenorphine remains underutilized. Research has ...identified multiple barriers to prescribing buprenorphine. This study aimed to examine clinician characteristics, prescribing practices and barriers and incentives to prescribing buprenorphine among clinicians with a federal Drug Addiction Treatment Act of 2000 (DATA) waiver to prescribe buprenorphine for opioid use disorder treatment.
Design
Electronic survey of 4225 clinicians conducted between March and April 2018.
Setting
United States.
Participants
Clinicians obtaining an initial federal DATA waiver or an increase in authorized patient limit to prescribe buprenorphine for opioid use disorder treatment in 2017.
Measurements
Descriptive statistics and multivariable logistic regression examined clinician characteristics, prescribing practices and primary barriers and incentives to prescribing buprenorphine or prescribing at or near the authorized patient limit.
Findings
Among respondents, 75.5% had prescribed buprenorphine since obtaining a DATA waiver; the mean (standard deviation) number of patients treated in the past month was 26.6 (40.3), and 13.1% of providers were prescribing at or near their patient limit in the past month. Lack of patient demand, cited by 19.4% of clinicians, was the most common primary barrier to prescribing buprenorphine or prescribing to the authorized patient limit, followed by time constraints in practice (14.6%) and insurance reimbursement, prior authorization or other insurance requirements (13.2%). Increased patient demand (22.2%), institutional support for buprenorphine treatment (12.5%) and increased reimbursement (12.2%) were the most endorsed primary incentives for buprenorphine prescribing. Multivariable logistic regression models identified multiple clinician characteristics associated with buprenorphine prescribing and prescribing at or near the authorized patient limit.
Conclusions
US clinicians recently waivered to prescribe buprenorphine for opioid use disorder treatment appear to prescribe well below their patient limit, and many do not prescribe at all.
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BFBNIB, DOBA, FSPLJ, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Ketamine is a dissociative anaesthetic drug which acts on the central nervous system chiefly through antagonism of the n-methyl-d-aspartate (NMDA) receptor. Recently, ketamine has attracted attention ...as a rapid-acting anti-depressant but other studies have also reported its efficacy in reducing problematic alcohol and drug use. This review explores the preclinical and clinical research into ketamine's ability to treat addiction. Despite methodological limitations and the relative infancy of the field, results thus far are promising. Ketamine has been shown to effectively prolong abstinence from alcohol and heroin in detoxified alcoholics and heroin dependent individuals, respectively. Moreover, ketamine reduced craving for and self-administration of cocaine in non-treatment seeking cocaine users. However, further randomised controlled trials are urgently needed to confirm ketamine's efficacy. Possible mechanisms by which ketamine may work within addiction include: enhancement of neuroplasticity and neurogenesis, disruption of relevant functional neural networks, treating depressive symptoms, blocking reconsolidation of drug-related memories, provoking mystical experiences and enhancing psychological therapy efficacy. Identifying the mechanisms by which ketamine exerts its therapeutic effects in addiction, from the many possible candidates, is crucial for advancing this treatment and may have broader implications understanding other psychedelic therapies. In conclusion, ketamine shows great promise as a treatment for various addictions, but well-controlled research is urgently needed.
This article is part of the Special Issue entitled ‘Psychedelics: New Doors, Altered Perceptions’.
•Preliminary evidence suggests that ketamine may be effective in addiction.•Potential interacting mechanisms are enhancing neurogenesis and psychological therapies.•Ketamine may reduce depressive symptoms in a risky window for addiction relapse.
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GEOZS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPUK, ZRSKP
Introduction
Currently, few hospitals provide medications for opioid use disorder (MOUD) to admitted patients with opioid use disorder (OUD). Data are needed to inform whether the choice of ...medication during hospitalization influences probability of retention in outpatient OUD treatment.
Methods
This was a retrospective cohort analysis of patients who received a medical toxicology consult for OUD. Medical records were reviewed to determine if patients received MOUD and were referred to Engaging Patients in Care Coordination (EPICC), a service that connects hospitalized patients with OUD to outpatient care. Patients were stratified by the last form of MOUD they received in the hospital (methadone verses buprenorphine); retention in outpatient treatment was measured at 2 weeks, 30 days, and 12 weeks. The log-rank test was used to determine the difference in probabilities of retention in the methadone and buprenorphine groups. An event was defined as drop-out from outpatient treatment.
Results
Of 267 total patients with medical toxicology consults for OUD, 155 received MOUD and referral to EPICC. One hundred six patients received buprenorphine and 46 received methadone. Three additional patients were excluded. The rate of retention in outpatient treatment for patients who received buprenorphine was 37%, 26%, and 13% and for patients who received methadone was 43%, 39%, and 35% at 2 weeks, 30 days, and 12 weeks, respectively. Methadone was associated with a statistically significant increased probability of retention in outpatient treatment as compared to buprenorphine (
P
< 0.01).
Conclusion
Despite the limitations of this retrospective study, in hospitalized patients who received MOUD, the probability of retention in outpatient treatment was higher in patients receiving methadone compared to buprenorphine.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
A considerable portion of the opioid epidemic has been driven by physician-prescribed opioids for pain management. Thus, policies to address the epidemic must consider not only the resources ...available to manage addiction but those to manage acute and chronic pain as well. For the period 2017 to 2019, the authors sought to describe the distribution, by state, of indicators of the supply of resources to address pain and addiction (graduate medical education subspecialty training in pain and addiction, number of board-certified pain and addiction specialists, number of opioid treatment centers), as well as indicators of the demands for those services (opioid prescriptions, opioid overdose deaths), to identify states that seem to suffer from a mismatch between supply and demand. It was also sought to examine the relationships between these treatment resources and indicators of the magnitude of the opioid epidemic, through an exploratory correlational analysis. The resulting model may inform public policy by suggesting areas in need of greater graduate medical education training and more pain and addiction specialists and by suggesting hypotheses about the impact of these specialists on outcome that are worthy of further study.
•Psychedelics may be a promising alternative in the treatment of SUD.•The set and setting are critical for the success of the treatments with psychedelics.•Psychedelics seem more effective when used ...as an adjunct therapy with psychotherapy.•The beneficial effects observed in some studies were partial and temporary.
Substance use disorder (SUD) is a global public health concern that affects millions of people worldwide. Considering current research, addiction has been noted as the last stage of a chronic disease that may impair brain reward circuit responses and affects personal and social life. Treatments for SUD face challenges including availability and limited pharmacological response, often resulting in low retention of patients. A growing number of studies from the ‘psychedelic renaissance’ have highlighted the therapeutic potential of psychedelics for several psychiatric disorders, including SUD. In this non-systematic review we discuss past and current clinical and observational studies with classic (LSD, DMT, psilocybin and mescaline) and non-classic (ibogaine, ketamine, MDMA, salvinorin A and THC) psychedelics for the treatment of SUD published until December 2021. Although results are still inconclusive for LSD, DMT, mescaline, MDMA and Salvinorin A, in general, the literature presents moderate evidence on the controlled use of psilocybin and ketamine for Alcohol Use Disorder, ketamine for management of opiate and alcohol withdrawal, and THC preparations for reducing withdrawal symptoms in Cannabis and possibly in Opioid Use Disorder. Importantly, studies suggest that psychedelics should be more effective when employed as an adjunct therapy. Extensive research is warranted to further elucidate the role of psychedelics in the treatment of SUD.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
For Chinese policymakers, shouldering responsibility is often associated with high liability risk, thus resulting in low-level care for risky and stigmatized populations such as drug users. ...Therefore, it is crucial to explore ways to improve care access in such an uneasy policy environment. Based on long-term ethnographic fieldwork conducted in Yunnan province in southwestern China from 2013 to 2021, this paper traces the policy-making process of the Yunnan Province Methadone Oral Solution Take-Home Treatment Work Proposal. All stakeholders involved considered this policy attempt “impossible” at first, as the highly addictive methadone becomes an illegal drug once it is taken outside a clinical setting. By analyzing how a group of local government officials, together with medical practitioners and drug users, strive to legitimize and ultimately implement the policy, I argue that people's concern over liability risks strengthens the boundary between methadone as a “drug” and methadone as a “medicine,” between methadone solution drinkers as “drug users” and as “patients,” and between “inside the clinic” and “outside the clinic.” By utilizing a culturalist approach to explore the possibility of care in such a context, this paper reveals that a “heqing heli hefa worthy-of-being-cared-for” discourse is crucial in that it acts as symbolic capital to dissolve the above boundaries embedded in the dominant political culture. Moreover, it is the key cultural logic of the “building” of care. The findings also illustrate how local policymakers negotiate and balance responsibility and liability to create a potential policy space for enabling care practices. Additionally, this study sheds light on the inclusion of care for the most stigmatized and marginalized populations, and has broad implications for policy-making in other contexts.
•In the field of drug control, policies often delay and even exclude care for drug users.•Concerns over liability risks hamper users' access to take-home methadone service.•Liability risks affect people's categorizing of methadone as a medicine or a drug.•Privatization of compassion helps to mitigate liability risks.•Policymaking could also be a process of accumulating and building care.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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