Addiction Medicine

Consensus and Controversies Between Pain and Addiction Experts on the Prevention, Diagnosis, and Management of Prescription Opioid Use Disorder Objectives: Prescription opioid use disorder (POUD) is an established public health crisis in many countries, and current evidence indicates it is a growing problem in Europe. Many specialists play a role, including pain and addiction medicine specialists, in the diagnosis and management of POUD, but neither group can fully address these patients’ needs alone. The purpose of this consensus process was to bring together experts from pain and addiction medicine to examine the positions of both specialties. Methods: In all, 13 international pain medicine, addiction medicine, and addiction psychiatry experts convened a meeting to formulate a set of consensus statements on the diagnosis and management of POUD. The statements were further refined by a wider group of 22 European expert clinicians. At a second meeting of all 35 participants, a set of controversy statements was also developed to recognize some of the key areas of divergent opinion. Results/conclusions: There was a high level of agreement between pain and addiction specialists. Key themes that emerged were the need to strengthen interdisciplinary communication, a desire for greater education and training for clinicians in both specialties, and mutual acknowledgment of the importance of multidisciplinary management of POUD. The blurred line between poorly managed pain and POUD was also a subject of much discussion, reflecting the difficulties in defining and diagnosing this complex condition.

Job Satisfaction Among Methadone Maintenance Treatment Clinic Service Providers in Jiangsu, China: A Cross-sectional Survey Objective: Service providers’ job satisfaction is critical to the stability of the work force and thereby the effectiveness of methadone maintenance treatment (MMT) programs. This study aimed to explore MMT clinic service providers’ job satisfaction and associated factors in Jiangsu, China. Methods: This secondary study used baseline data of a randomized interventional trial implemented in Jiangsu, China. A survey was conducted among 76 MMT service providers using the computer-assisted self-interview (CASI) method. Job satisfaction responses were assessed via a 30-item scale, with a higher score indicating a higher level of job satisfaction. Perceived institutional support and perceived stigma due to working with drug users were measured using a 9-item scale. Correlation and multiple linear regression analyses were performed to identify factors associated with job satisfaction. Results: Correlation analyses found a significant association between job satisfaction and having professional experience in the prevention and control of HIV, other sexually transmitted infections, or other infectious diseases (P = 0.046). Multiple regression analyses revealed that working at MMT clinics affiliated with Center for Disease Control and Prevention sites was associated with a lower level of job satisfaction (P = 0.014), and perception of greater institutional support (P = 0.001) was associated with a higher level of job satisfaction. Conclusion: Job satisfaction among MMT clinic service providers was moderate in our study. Our findings suggest that institutional support for providers should be improved, and that acquisition of additional expertise should be encouraged.

Exploring the Effects of Vitamin D Supplementation on Cognitive Functions and Mental Health Status in Subjects Under Methadone Maintenance Treatment Objectives: Vitamin D deficiency may be linked to several mental complications including cognitive deficits, depression, and anxiety in patients under methadone maintenance treatment (MMT). This study was designed to explore the effect of vitamin D supplementation on cognitive functions and mental health parameters in subjects under MMT. Methods: This randomized, double-blinded, placebo-controlled clinical trial was carried out among 64 patients under MMT. Participants were randomly allocated to receive either 50,000 IU vitamin D supplements (n = 32) or placebo (n = 32) every 2 weeks for 24 weeks. Cognitive functions and mental health parameters were taken at baseline and posttreatment to evaluate relevant variables. Results: After the 24-week intervention, compared with the placebo, serum 25(OH) vitamin D levels significantly increased in participants who received vitamin D supplements (β 14.50; 95% confidence interval [CI], 13.17–15.83; P < 0.001). In addition, compared with the placebo, subjects who received vitamin D had a significant reduction in Iowa Gambling Task (β −6.25; 95% CI, −8.60 to −3.90; P < 0.001), and significant increases in Verbal Fluency Test (β 2.82; 95% CI, 0.78–4.86; P = 0.007), Immediate Logic Memory (β 1. 32; 95% CI, 0.27–2.37; P = 0.01), Reverse Digit Span (β 2.06; 95% CI, 1.18–2.94; P < 0.001) and visual working memory (β 0.75; 95% CI, 0.33–1.16; P = 0.001). Also, vitamin D supplementation significantly improved BDI (β −2.76; 95% CI, −3.97 to −1.55; P < 0.001) compared with the placebo. When we applied Bonferroni correction, LM-Immediate (P = 0.07) became nonsignificant, and other mental health parameters did not alter. Conclusions: Overall, taking 50,000 IU vitamin D supplements every 2 weeks for 24 weeks by patients under MMT had beneficial effects on cognitive functions and some mental health parameters. Further studies are needed to confirm our findings.

Pain Anxiety as a Mechanism Linking Pain Severity and Opioid Misuse and Disability Among Individuals With Chronic Pain Objective: Chronic pain affects a significant number of individuals in the United States and is associated with several negative health-related outcomes, including possibility of opioid misuse and disability. The identification of factors associated with both opioid misuse and disability is of critical public health importance, and significant research suggests that pain severity has been shown to be associated with both. Pain-related anxiety has been uniquely associated with both opioid misuse and disability, yet little research has examined pain-related anxiety as a potential mechanism linking pain severity with opioid misuse and disability. Method: Therefore, the current study examined whether pain-related anxiety explains, in part, the relationship between pain severity, opioid misuse, and disability among 396 adults with chronic pain (55.8% female, Mage 36.61, SD 11.40). Results: Cross-sectional analyses indicated that pain-related anxiety significantly mediated the relationship between pain severity, opioid misuse outcomes, and psychosocial disability, but not physical disability. Conclusions: These results build upon the literature indicating the importance of pain-related anxiety in those with chronic pain by suggesting this construct may account, in part, for the relation of pain intensity to opioid misuse and psychosocial disability. Future research should longitudinally examine these associations.

Further Utilization of Emergency Department and Inpatient Psychiatric Services Among Young Adults Admitted at the Emergency Department With Clinical Alcohol Intoxication Objectives: To assess in a cohort of young adults admitted with alcohol intoxication (AI) to the Emergency Department (ED): how many patients are readmitted to the ED or to a Psychiatric Department (PD) inpatient unit; and which characteristics are associated with further ED and PD inpatient admissions. Methods: In 630 patients aged 18 to 30 years admitted for AI in 2006 to 2007 to the ED of a Swiss tertiary hospital, further ED and PD inpatient admissions through 2013 were assessed. Patient characteristics at the index (initial) ED visit were assessed using administrative and medical records. Measurements: Proportion of subjects with at least 1 further ED admission, 1 further ED admission with AI, and any PD admission over the study period. Associations between patients’ characteristics at index visit and readmissions were assessed using backward selection multivariate regression analyses. Results: Mean age was 24, 66% were male, 60% had any ED/PD admissions during the study period, 17.9% a PD admission, and 13.8% were re-admitted to ED with AI. Disruptive behavior at the index visit was associated with further ED (odds ratio [OR] 1.69 [1.13; 2.54]) and PD admissions (OR 2.41 [1.44; 4.05]). Psychiatric diagnosis was associated with any further ED admission (OR 2.07 [1.41; 3.05]), with further ED admission with AI (OR 4.56 [2.36; 8.81]) and with PD admission (OR 3.92 [2.40; 6.41]). Female sex predicted any further ED admission (OR 1.65 [1.14; 2.39]). Conclusions: Young adults presenting with alcohol intoxication have high rates of subsequent inpatient emergency and psychiatric admissions. Being female, presenting with disruptive behavior, and having a psychiatric diagnosis at the ED visit were predictors of further admissions.

Opioid Overdose in the Hospital Setting: A Systematic Review Objective: Our objective was to determine the percentage of opioid overdose events among medical and surgical inpatient admissions, and to identify risk factors associated with these events. Methods: We searched PubMed and CINAHL databases from inception through July 30, 2017 and identified additional studies from reference lists and other reviews. Articles were included if they reported original research on the rate of opioid overdoses or opioid-related adverse events, and the adverse events occurred in a general medical hospital during an inpatient stay. We extracted information on study population, design, results, and risk for bias using the Newcastle-Ottawa Quality Assessment Scale. We performed this review in accordance with recently suggested standards and report our findings as per the Meta-Analyses and Systematic Reviews of Observational Studies guidelines. Results: Thirteen studies met our eligibility criteria. The percentage of opioid overdoses ranged from 0.06% to 2.50% of hospitalizations. The majority of studies used only 1 method of event detection. Risk factors for overdose included older age, infancy, medical comorbidity, substance use disorder diagnosis, combining opioids with other sedatives, and admission to hospitals with higher opioid-prescribing rates. Conclusions: Opioid overdose in the inpatient setting is a serious preventable harm and is likely underestimated in much of the current literature. Improved detection methods are needed to more accurately measure the rate of inpatient opioid overdose. Refined estimates of opioid overdose should be used to drive safety and quality improvement initiatives in hospitals.

Association of Marijuana, Mental Health, and Tobacco in Colorado Objectives: Marijuana's evolving legality may change marijuana use patterns in adults. Co-use of marijuana and tobacco are strongly associated, and populations with mental health disorders are disproportionately likely to use either substance, but neither association has been assessed in the context of legal recreational marijuana. We assessed the associations of tobacco smoking with marijuana use and with mental health disorders in Colorado in 2015. Methods: Data came from a population-based survey of adults (n = 8023). Multiple logistic regressions were used with current tobacco smoking as the primary outcome. Past 30-day marijuana use and mental health status were the independent variables of interest. Covariates included age, sex, ethnicity, poverty level, and education. Results: Adults who used marijuana in the past 30 days had 3.4 (95% confidence interval [CI] 2.7, 4.2) greater odds of currently smoking tobacco compared to adults who had not recently used marijuana, after adjusting for sociodemographic and economic factors. A mental health disorder was independently associated with tobacco smoking (adjusted odds ratio [OR] 1.7, 95% CI 1.4, 2.1). Prevalence of co-use among adults self-reporting a mental health disorder was significantly higher compared those without a mental health disorder (11.1% vs 4.3%; P < 0.0001). Conclusions: This study examined the associations between mental health, marijuana use, and tobacco smoking after the legalization of recreational marijuana in Colorado. Adults using marijuana and/or self-reporting a mental health disorder were more likely to smoke tobacco and should be targeted for cessation interventions.

Drug Legalization and Decriminalization Beliefs Among Substance-using and Nonusing Individuals Objectives: There has been advocacy for legalization of abusable substances, but systematic data on societal beliefs regarding such legalization are limited. People who use substances may have unique beliefs about legalization, and this study assessed whether they would be in favor of drug legalization/decriminalization. It was hypothesized that those who use particular drugs (especially marijuana) would support its legalization/decriminalization, but that this would not be the case across all classes (especially opioids and stimulants). Methods: A nationwide sample of 506 adults were surveyed online to assess demographic characteristics, substance misuse, and beliefs regarding drug legalization/decriminalization. Legalization/decriminalization beliefs for specific drugs were assessed on an 11-point scale (0, strongly disagree; 10, strongly agree). Results: For persons with opioid misuse (15.4%), when asked about their agreement with: “heroin should be legalized,” the mean score was 4.6 (SEE = 0.4; neutral). For persons with stimulant misuse (12.1%), when asked about their agreement with: “cocaine should be legalized,” the score was 4.2 (0.5). However, for persons with marijuana misuse (34.0%), when asked about their agreement with: “medical marijuana should be legalized” the score was 8.2 (0.3; indicating agreement), and for “recreational marijuana” the score was also 8.2 (0.3). Conclusions: These results suggest that persons who used marijuana strongly support the legalization of both recreational and medical marijuana, whereas persons who primarily have opioid or stimulant misuse have less strongly held beliefs about legalization of substances within those respective categories. By including those who misuse drugs, these data assist in framing discussions of drug legalization and have the potential to inform drug policy considerations.

Rates of and Factors Associated With Patient-reported Illicit Drug Use Screening by Health Care Professionals in the United States From 2013 to 2015 Objectives: To examine rates of and factors associated with patient-reported illicit drug use screening by health care professionals. Methods: The National Survey on Drug Use and Health (NSDUH), limited to individuals who reported prior year healthcare service utilization, was used to capture the odds of patient-reported illicit drug use screening for survey years 2013 to 2015. Screened patients were contrasted with those not screened by demographic and behavioral characteristics. Adjusted models were produced by year and adjusted odds ratios were compared for changes across years. A separate adjusted model including year as a fixed effect was produced to estimate changes in overall adjusted screening odds. Results: The percentage of individuals reporting screening by a health care provider increased from 48.5% in 2013 to 50.9% (2014), and 54.3% (2015) (P < 0.0001). The adjusted model, including year as a fixed effect, indicated that the odds of screening significantly increased from 2013 to 2015. In multivariable regression, individuals reporting screening were more likely to be female, of higher income and educational strata, and received drug or alcohol treatment in the past year and were less likely to be non-Hispanic Asian. Conclusions: Only roughly half of individuals seen by a healthcare provider report illicit drug use screening. Racial disparities in screening persist although they are overall decreasing. Coupling screening with treatment initiation, rather than brief intervention, may increase screening rates.

A Multicenter, Randomized, Double-blind, Parallel, Placebo-controlled Clinical Study to Evaluate the Efficacy and Safety of a Nicotine Mint Lozenge (2 and 4 mg) in Smoking Cessation Objective: To evaluate the efficacy in smoking cessation and safety of 2 and 4 mg nicotine mint lozenges in Chinese adult smokers. Methods: This was a multicenter, randomized, stratified, double-blind, placebo-controlled, parallel-group study. The low-dependence stratum included 483 smokers (241 randomized to active 2 mg nicotine lozenge and 242 to placebo lozenge). The high-dependence stratum included 240 smokers (120 randomized to active 4 mg nicotine lozenge and 120 to placebo lozenge). The primary endpoint was successful smoking cessation at 6 weeks postquit, defined as continuous abstinence from smoking for the 28-day period up to and including the 6-week visit (verified by CO measurement). Cochran–Mantel–Haenszel tests were performed to compare quit rates between active nicotine and placebo separately for the high-dependence and low-dependence strata. Results: The primary analysis showed that in the low-dependence (2 mg) stratum, 59 subjects (24.5%) of 241 in the active nicotine group and 52 subjects (21.5%) of 242 in the placebo group were successful quitters (P = .3851). In the high-dependence (4 mg) stratum, 37 subjects (30.8%) of 120 in the active nicotine group and 24 subjects (20.2%) of 119 in the placebo group were successful quitters (P = .0565). Conclusions: The 4 mg nicotine lozenge provided a directionally significant improvement in smoking cessation rates compared with placebo in Chinese adult smokers with high nicotine dependence for the primary endpoint. The 2 mg nicotine lozenge provided higher, but nonsignificant, smoking cessation rates than placebo. Both nicotine lozenges were generally well tolerated in Chinese adult smokers.