Tramadol Withdrawal in the Setting of Buprenorphine Induction: A Case Report Initiating opioid use disorder treatment with buprenorphine conventionally requires the cessation of other opioid medications, including tramadol. Tramadol's spectrum of activity differs from most opioids, acting through serotonin and norepinephrine reuptake inhibition. Here, we report a case of 45-year-old man who experienced a complicated transition from tramadol to buprenorphine. We believe there were similarities to antidepressant discontinuation syndrome, which could be explained by tramadol's serotoninergic activity. Clinicians should be aware of these effects when discontinuing tramadol, even if replacing with another opioid. Send correspondence to Dale Terasaki, MD, MPH, 1693 N Quentin St. Aurora, CO 80045. E-mail: djterasaki@gmail.com Received 30 May, 2019 Accepted 25 July, 2019 The authors report no conflicts of interest. © 2019 American Society of Addiction Medicine

Self-reported Health Diagnoses and Demographic Correlates With Kratom Use: Results from an Online Survey Objectives: To determine whether diagnosed pre-existing health conditions correlate with Kratom demographics and use patterns. Methods: A cross-sectional, anonymous US national online survey was conducted among 8049 Kratom users in October, 2016 to obtain demographic, health, and Kratom use pattern information. Results: People who use Kratom to mitigate illicit drug dependence self-reported less pain and better overall health than individuals who used Kratom for acute/chronic pain. Self-reported improvements in pre-existing mental health symptoms (attention deficit and hyperactivity disorder/attention deficit disorder, anxiety, bipolar disorder, post-traumatic stress disorder, and depression) attributed to Kratom use were greater than those related to somatic symptoms (back pain, rheumatoid arthritis, acute pain, chronic pain, fibromyalgia). Demographic variables, including female sex, older age, employment status, and insurance coverage correlated with increased likelihood of Kratom use. Conclusions: Kratom use may serve as a self-treatment strategy for a diverse population of patients with pre-existing health diagnoses. Healthcare providers need to be engaging with patients to address safety concerns and potential limitations of its use in clinical practice for specific health conditions. Send correspondence to Oliver Grundmann, PhD, Department of Medicinal Chemistry, College of Pharmacy, University of Florida, 1345 Center Drive, Room P6-20, Gainesville, FL 32611. E-mail: grundman@ufl.edu Received 16 March, 2019 Accepted 9 August, 2019 Financial disclosure: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors state no conflict of interest. © 2019 American Society of Addiction Medicine

Defining Low-threshold Buprenorphine Treatment Buprenorphine treatment for opioid use disorder is safe and effective, but only a fraction of Americans who need treatment receive it. One reason for this is that many buprenorphine treatment programs have rigid requirements for entry and continuation, limiting the number of people who receive treatment. “Low-threshold treatment” is a term used to describe an alternative approach that attempts to remove as many barriers to treatment as possible. However, few studies have described its essential features. In this article, we define low-threshold treatment and propose the approach be guided by the following principles: same-day treatment entry; harm-reduction approach; flexibility; and wide availability in places where people with opioid use disorder go. We discuss the evidence and rationale for these principles and directions for future research. Send correspondence to Andrea Jakubowski, MD, Division of General Internal Medicine, 3300 Kossuth Avenue, Bronx, New York, NY 10467. E-mail: ajakubow@montefiore.org Received 25 March, 2019 Accepted 16 June, 2019 Funding: The work was supported by NIH/National Center for Advancing Translational Science (NCATS) Einstein-Montefiore CTSA Grant Number UL1TR001073. Financial disclosure: Dr Fox is supported by R01 DA044878. The authors report no conflicts of interest. © 2019 American Society of Addiction Medicine

Pilot Study of an Integrated Smartphone and Breathalyzer Contingency Management Intervention for Alcohol Use Introduction: Monitoring devices provide a platform for assessing alcohol use and implementing alcohol interventions. This pilot study focused on assessing the early-stage feasibility and usability of a smartphone-based application and breathalyzer used in a contingency management intervention for alcohol use. Methods: Six nontreatment-seeking participants completed a 9-week ABA within-subjects designed intervention targeting alcohol use. Participants submitted 2 to 8 alcohol breathalyzer samples per day and completed self-report drinking measures and usability assessments. During the A phases (weeks 1–3 and 8–9), participants received reinforces for submitting breathalyzer samples, regardless of their results. During the contingency management, B phase (weeks 4–7), and received reinforcers only when negative breathalyzer samples were submitted. Usability assessment of the application was also conducted during weeks 2 and 9. Results: Participants in the contingent B phase (49%) were more likely to submit alcohol-negative breathalyzer samples compared with the noncontingent A phases (27%; P < 0.001). Usability assessment of the application varied, and participants noted several technical concerns. Conclusion: The use of smartphones and breathalyzers may be a practical solution to extend the reach of contingency management during and after treatment. Send correspondence to Oladunni Oluwoye, PhD, CHES, Elson S. Floyd College of Medicine, PO Box 1495, Washington State University, Spokane, WA 99210-1495. E-mail: oladunni.oluwoye@wsu.edu. Received 1 February, 2019 Accepted 28 April, 2019 Funding: This work was supported by the National Institute on Alcohol Abuse and Alcoholism R01AA020248 and R01AA020248-05S1. Conflicts of interests: Dr McPherson has received research funding from the Bristol-Myers Squibb Foundation, Orthopedic Specialty Institute, Ringful Health, and has consulted for Consistent Care company. This funding is in no way related to the investigation reported here. No disclosures from any other authors. © 2019 American Society of Addiction Medicine

Attitudes and Approaches Towards Repeat Valve Surgery in Recurrent Injection Drug Use-associated Infective Endocarditis: A Qualitative Study Objective: The aim of this study was to explore the diversity of attitudes and approaches towards treating patients with recurrent injection drug use-associated infective endocarditis (IDU-IE) with a focus on surgical decision-making. Methods: Nineteeen qualitative, semistructured interviews were performed with healthcare providers at a single academic medical center. Purposive sampling was used to recruit participants with the goal of sampling a diversity of providers involved in the care of patients with IDU-IE. An inductive, grounded theory approach was used to analyze data. Results: Nineteen healthcare providers (12 physicians, 3 social workers, 2 registered nurses, 2 advanced practice providers) with experience caring for patients with IDU-IE across a variety of disciplines and departments participated in the study. Three themes emerged from the interviews: providers feel underprepared to care for patients with IDU-IE; implicit and explicit bias remain pervasive; and criteria for surgical decision-making are not transparent. When discussing surgical decision-making, participants relied on 2 predominant bioethical concepts: futility and rationing. Conclusions: There was a wide divergence of opinions on how to approach repeat valve surgeries, ranging from those who endorsed strict single surgery policies to those who felt patients should be offered as many surgeries as needed. Therefore, there is a need to further develop general principles for the care of recurrent IDU-IE to provide more reliable and equitable care to these patients. This will require input from an interdisciplinary group and should address empirical data, and also the appropriateness of futility and rationing of care questions. Send correspondence to Margaret Hayden, MD, MPhil, Brigham and Women's Hospital, Internal Medicine Residency Office, 75 Francis Street, Boston, MA 02115. E-mail: Mhayden3@bwh.harvard.edu Received 28 March, 2019 Accepted 8 July, 2019 Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors have no conflicts of interest to report. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (www.journaladdictionmedicine.com). © 2019 American Society of Addiction Medicine

Buprenorphine and Naloxone Versus Buprenorphine for Opioid Use Disorder in Pregnancy: A Cohort Study Objective: To compare maternal and fetal outcomes among dyads prescribed buprenorphine and naloxone or buprenorphine during pregnancy. Methods: Retrospective cohort study of patients with opioid use disorder obtaining care in a comprehensive, perinatal program. Patients utilized medication for opioid use disorder: a buprenorphine and naloxone combination product or buprenorphine monotherapy. The primary outcome was neonatal abstinence syndrome requiring treatment. Maternal secondary outcomes included: negative urine drug screen at delivery, obstetrical care attendance, primary cesarean delivery, and preterm delivery. Neonatal secondary outcomes included neonatal biometry, admission to neonatal intensive care, appropriate findings on cord toxicology, and length of stay. Univariate analyses included Chi square, Fisher exact, t-, or Mann-Whitney tests, as appropriate. Multivariate binary logistic regressions examined the association of type of buprenorphine product with diagnosis of neonatal abstinence syndrome requiring treatment and adjusted for variables significantly different in between-group comparisons and correlates of treatments and the primary outcome. Results: The rate of neonatal abstinence syndrome was significantly higher (P = 0.007) among infants exposed in utero to buprenorphine versus buprenorphine and naloxone: 59/108 (54.6%) versus 30/85 (35.3%), respectively. The combined product, relative to the monoproduct, was associated with lower odds of neonatal abstinence syndrome: odds ratio (OR) = 0.453 (95% confidence interval [CI] 0.253–0.813; P = 0.008). Adjusting for dose of buprenorphine product at delivery, year of expected delivery, type of prescriber, diagnosis of hepatitis C, and preterm delivery negated these results: adjusted OR = 0.627 (95% CI 0.309–1.275). Secondary outcomes were similar. Conclusion: Compared with buprenorphine monotherapy, the combined buprenorphine and naloxone product was an acceptable alternative pharmacologic treatment for opioid use disorder during pregnancy. Send correspondence to Shelley L. Galvin, MA, Department of Obstetrics and Gynecology, Mountain Area Health Education Center, 119 Hendersonville Road, Asheville, NC 28803. E-mail: Shelley.Galvin@mahec.net Received 3 April, 2019 Accepted 11 July, 2019 Sager B, Mullins N, Galvin SL, Ramage M, Coulson CC. Buprenorphine versus buprenorphine and naloxone for the treatment of opioid use disorder in pregnancy. Presented at the Annual Meeting of the North Carolina Obstetrical and Gynecological Society, April 20–22, 2018; Asheville, NC. The authors report no conflicts of interest. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (www.journaladdictionmedicine.com). © 2019 American Society of Addiction Medicine

Referral to Treatment After Positive Screens for Unhealthy Drug Use in an Outpatient Veterans Administration Setting Objectives: To measure the rates and predictors of clinician recommendation for follow-up after a positive screen for unhealthy drug use, in a context of mandatory routine screening. To measure response to clinician recommendations and identification of new drug use diagnoses. Methods: Data are from a Veterans Health Administration (VHA) medical center that introduced mandatory routine screening for unhealthy drug use in outpatient primary care and mental health settings, using a validated single question. This study analyzed VHA electronic health records data for patients who screened positive for unhealthy drug use (n = 570) and estimated logistic regression models to identify the predictors of receiving a recommendation for any follow-up and for specialty substance use disorder (SUD) treatment. Bivariate tests were used for other analyses. Results: Among patients who screened positive for unhealthy drug use, 66% received no recommendation to return to primary care or another setting from the screening clinician. Further, among the 23% of patients who received a recommendation to visit specialty SUD treatment, only 25% completed the visit within 60 days. Six percent of all positive screens both received a referral to specialty SUD treatment and acted upon it. Conclusions: In the context of mandatory drug use screening using a single item, rates of clinician action and patient receipt of care appeared low. Improved follow-up will require health systems to provide more supports for clinicians and patients at each of the stages from positive screen to attending the follow-up appointment. Send correspondence to Dominic Hodgkin, PhD, Heller School for Social Policy and Management, Brandeis University, 415 South St, Waltham, MA 02453-2728. E-mail: hodgkin@brandeis.edu Received 23 January, 2019 Accepted 4 August, 2019 Funding: NIDA grant R01 DA033402 (PI: Hodgkin); Brandeis-Harvard NIDA Center to Improve System Performance of Substance Use Disorder Treatment (P30 DA035772); and the VA RR&D REAP D1873-F (PI: Drebing; Social and Community Reintegration Research (SoCRR) Program). The authors have no conflicts of interest to disclose. © 2019 American Society of Addiction Medicine

Long-term Dextromethorphan Use and Acute Intoxication Results in an Episode of Mania and Autoenucleation The pharmacologic and neuropsychiatric sequelae of long-term dextromethorphan use and acute dextromethorphan intoxication are reviewed in this case report. Dextromethorphan ingestion at the high end of toxicity, although rare, can cause violence to oneself and others, even in those previously without any history of such behaviors. In this article, the neuropsychiatric consequences of dextromethorphan toxicity are highlighted in a case report of a 37-year-old woman who had been using dextromethorphan for 5 years. She presented to a large urban emergency department in a psychotic and manic state after attempting autoenucleation. She reported to consult liaison psychiatry staff that she had taken a total of 1400 mg of dextromethorphan over the course of 3 days with intent to experience altered state of consciousness. Toxicology screens on admission did not reveal any other substances in her system. She had no formal psychiatric history and no history of mania, psychosis, or self-harm. To our knowledge, this is the first case of autoenucleation resulting from dextromethorphan-induced mania with psychotic features. Send correspondence to Laura B. Bernstein, PsyD, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY. E-mail: Dr.laurabernstein@gmail.com Received 22 March, 2019 Accepted 25 July, 2019 Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article. © 2019 American Society of Addiction Medicine

Alcohol Medical Intervention Clinic: A Rapid Access Addiction Medicine Model Reduces Emergency Department Visits Objectives: Problematic alcohol use accounts for a large proportion of Emergency Department (ED) visits and revisits. We developed the Alcohol Medical Intervention Clinic (AMIC), a Rapid Access Addiction Medicine (RAAM) service, to reduce alcohol-related ED re-utilization and improve care for individuals with alcohol problems. This article describes the AMIC model and reports on an evaluation of its impact on patients and the ED system. Methods: Individuals presenting to The Ottawa Hospital Emergency Departments (TOH-ED) for an alcohol-related issue were referred to AMIC. Using data collected via medical chart review, and also self-report questionnaires, we assessed ED visits, revisits, and changes in alcohol use and mental health symptoms in patients before and after receiving services in AMIC. The incidence of alcohol-related ED visits and re-visits from 12-month periods before and after the introduction of AMIC were compared using data from TOH Data Warehouse. Connections made to additional services and patient satisfaction was also assessed. Results: For patients served by AMIC, from May 26, 2016 to June 30, 2017 (n = 194), there was an 82% reduction in 30-day visits and re-visits (P < 0.001). An 8.1% reduction in total alcohol-related 30-day TOH-ED revisit rates and a 10% reduction in total alcohol-related TOH-ED visits were found. After receiving AMIC services, clients reported reductions in alcohol use, depression, and anxiety (P < 0.001). Conclusions: AMIC demonstrated positive impacts on patients and the healthcare system. AMIC reduced ED utilization, connected people with community services, and built system capacity to serve people with alcohol problems. Send correspondence to Kimberly Corace, PhD, The Royal Ottawa Mental Health Centre, 1145 Carling Avenue, Ottawa, Ontario K1Z 7K4, Canada. E-mail: kim.corace@theroyal.ca Received 24 December, 2018 Accepted 19 April, 2019 The authors report no conflicts of interest © 2019 American Society of Addiction Medicine

Do Patients Require Emergency Department Interventions After Prehospital Naloxone? Objective: Patients receiving naloxone for suspected opioid overdose in the prehospital setting are typically transported to the emergency department (ED) for further evaluation, regardless of Glasgow Coma Scale (GCS). The objective of our study is to determine whether patients with GCS ≥14 after receiving prehospital naloxone received additional doses of naloxone and medical interventions in the ED compared with those with GCS <14 after prehospital naloxone. Methods: Our retrospective observational study included patients ≥18 years old treated with naloxone and transported by an inner-city hospital-based Emergency Medical Services (EMS) to its affiliated ED from January 2, 2016 to December 31, 2016. Investigators collected demographic data, prehospital interventions, GCS, ED interventions, and dispositions. Institutional Review Board approval was obtained. The main outcome measures were repeat doses of naloxone and ED interventions. Results: In all, 473 patient encounters were reviewed. Most common route of prehospital naloxone administration was intranasal (68%). Nearly two-thirds (n = 473) of patients had GCS ≥14 upon ED arrival. Repeat naloxone was administered to 3.5% (n = 314) of patients with GCS ≥14 versus 14.6% (n = 159) of patients with GCS <14. ED interventions, such as airway maneuvers, laboratory and radiology testing, and cardiac monitoring, were less common among patients who had improved GCS of 14 or higher (n = 314). There were 8 deaths among patients with GCS <14 (n = 159) and no deaths among patients with GCS ≥14 (n = 314). Conclusion: Patients with GCS score ≥14 after administration of prehospital naloxone are less likely to receive additional naloxone doses and medical interventions in the ED compared with those with a GCS score <14 after prehospital naloxone and may present an invaluable opportunity for the ED to initiate an addiction treatment program for patients with nonfatal overdose. Send correspondence to Rick Hong, MD, Cooper University Hospital, Department of Emergency Medicine, One Cooper Plaza, Camden, NJ 08103. E-mail: hong-rick@cooperhealth.edu Received 8 January, 2019 Accepted 10 July, 2019 The authors declare that they have no conflicts of interest. © 2019 American Society of Addiction Medicine