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OBJECTIVES: Nonmedical use (NMU) of stimulants is an increasingly common phenomenon worldwide. Motivated by enhancing academic performance, peer pressure, and seeking pleasure, students in the Middle East are thought to be a high-risk population. This is especially important in times when the political instability in the region facilitates the production and trafficking of such substances. This study aimed to unveil the burden of NMU of stimulants and examine associated correlates among senior high school and university students in Jordan. METHODS: We describe a cross-sectional study of senior high school and university students in Jordan assessing NMU of stimulants. Data were collected between January and April of 2022 through a survey, which was distributed online leading to a google forms page. The survey queried sociodemographic characteristics, history of NMU of stimulants, use of other illicit substances, attitudes toward NMU of stimulants, as well as a mental health assessment. RESULTS: A total of 8739 students completed the survey (mean age of 20.40 ± 2.45 years), of which 5.1% reported a lifetime NMU of stimulants. Fenethylline (Captagon) was the most widely reported stimulant (2.6%). Living in the southern region, being diagnosed with a personality disorder, and using concomitant illicit substances were associated with the NMU of stimulants. CONCLUSIONS: The NMU of CNS stimulants, especially fenethylline, is prevalent in Jordan. More surveillance ought to be heeded toward the southern borders of Jordan. Students who use stimulants for academic reasons must be made aware of the potential consequences of the NMU of stimulants.
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Estimulantes do Sistema Nervoso Central , Estudantes , Humanos , Jordânia/epidemiologia , Masculino , Feminino , Estudos Transversais , Estudantes/estatística & dados numéricos , Adulto Jovem , Adolescente , Universidades , Adulto , Inquéritos e Questionários , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Uso Recreativo de Drogas/estatística & dados numéricosRESUMO
BACKGROUND: Shared medical appointments (SMAs) are a novel modality for treating patients with similar conditions, together, by a team of interdisciplinary providers. SMAs benefit patients with substance use disorder (SUD), but no research has focused on the feasibility of implementation of SMAs in a teaching clinic. METHODS: Primary care residents rotated in a half-day ambulatory addiction clinic for 4 weeks where a third-year resident co-facilitated 4 SMAs. Confidence, knowledge, and attitudes about SUD care were assessed using web-based surveys at weeks 0, 4, and 8. Pre- and post-intervention scores were compared using a t test for paired samples. RESULTS: Ten residents were included in the analyses. Using a 10-point Likert scale, confidence in SUD knowledge (7.0-8.3, P = .003), confidence in counseling patients with SUD (7.1-8.2, P = .023), and confidence in facilitating an SMA (5.7-8.3, P = .007) showed statistically significant increases from baseline following exposure to the SMAs. Confidence that counseling and other treatments will make a difference for patients with illicit drug use increased (7.1-8.0, P = .142), but did not differ statistically. Furthermore, on a 4-point Likert scale, understanding of behavioral therapies for treating and preventing the relapse of SUD (2.9-3.2, P = .180) showed a similar increase. Attitudes toward patients with SUD (42.4-42.1, P = .303) and physician empathy (119.3-119.2, P = .963) did not change from pre- to post-intervention. CONCLUSIONS: SMAs are a feasible training tool in the education of primary care residents on an addiction medicine rotation. Residents develop confidence co-facilitating SMAs after 4 weeks. Overall, exposure to SMAs during residency can provide an opportunity to increase confidence in treating patients with SUD, as well as provide a training modality that may shift the way residents interact with patients receiving SUD treatment.
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Internato e Residência , Consultas Médicas Compartilhadas , Transtornos Relacionados ao Uso de Substâncias , Humanos , Transtornos Relacionados ao Uso de Substâncias/terapia , Transtornos Relacionados ao Uso de Substâncias/psicologia , Masculino , Feminino , Atenção Primária à Saúde , Adulto , Conhecimentos, Atitudes e Prática em SaúdeRESUMO
BACKGROUND: Physicians in internal medicine lack comfort and skills required to diagnose and treat substance use disorder (SUD). Formal training in substance use treatment within primary care training has traditionally been inconsistent and sparse. The purpose of this study is to assess the impact of a longitudinal experiential addiction curriculum on the attitudes and experiences of graduates from a primary care/internal medicine residency program that included formal addiction didactics, rotations in an outpatient addiction clinic embedded within the resident primary care clinic, and exposure to addiction medicine faculty across treatment settings. METHODS: A survey was emailed to all graduates from a single academic primary care residency program who graduated between 2016 and 2018 (n = 53). The survey assessed pharmacotherapy for SUD prescribing patterns, comfort with SUD pharmacotherapy, overall comfort treating SUD, experience correcting stigmatizing language, and providing guidance to colleagues on the care of patients with SUD. A subset of respondents (n = 14) were interviewed regarding their experience with the residency program's addiction medicine curriculum and its impact on their current clinical practice. RESULTS: Sixty percent (n = 28) of graduates responded to the survey. All respondents felt comfortable using medications to treat SUD. Eighty-four percent perceived themselves as more comfortable using pharmacotherapy to treat SUD than their colleagues. Qualitative interviews revealed that this addiction medicine training shaped participants' attitudes toward patients with SUD and imparted them with the skills to address stigmatizing language. Participants described how they have become ambassadors of addiction medicine in their workplace and a resource to colleagues with less comfort in the management of SUD. CONCLUSION: Graduates of a primary care/internal medicine residency with a dedicated addiction medicine curriculum are comfortable prescribing pharmacotherapy for SUD, taking an active role in reducing SUD-related stigma, and serving as a resource for colleagues.
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Medicina do Vício , Currículo , Medicina Interna , Internato e Residência , Transtornos Relacionados ao Uso de Substâncias , Humanos , Medicina Interna/educação , Transtornos Relacionados ao Uso de Substâncias/terapia , Medicina do Vício/educação , Inquéritos e Questionários , Atitude do Pessoal de Saúde , Competência Clínica , Feminino , Masculino , Educação de Pós-Graduação em MedicinaRESUMO
BACKGROUND: Understanding the epidemiology of substance use disorders (SUDs) and mental health disorders (MHDs) among forced migrants from the Middle East and North Africa and Türkiye (MENAT) region is of utmost importance given their distinct challenges and vulnerabilities. Existing research on the topic is substantial; however, comprehensive systematic reviews are limited. We aim to conduct a systematic literature review to bridge this gap, providing a thorough understanding of SUDs and MHDs epidemiology among this population. METHODS: The systematic review will include original, peer-reviewed research articles published in English or Arabic between 2013 and 2023. It will encompass qualitative, quantitative, and mixed-methods studies focusing on SUDs and/or MHDs among forced migrants from the MENAT region. A Medline (via Ovid) search strategy was developed and will be translated into databases of EMBASE (via Ovid), Web of Science Core Collection (as licensed at Yale), and CINAHL. Risk of Bias in the included studies will be assessed using the Joanna Briggs Institute (JBI) checklist for observational studies and the Cochrane Risk of Bias (ROB) 2 tool for intervention studies. Meta-analysis using random-effects models will be conducted and subgroup analyses based on studies' data will be performed. The systematic review will be conducted based on the framework introduced by the Joanna Briggs Institute. Additionally, the PRISMA-P extension for systematic reviews was used to report the present protocol. The present systematic review protocol has been registered with PROSPERO, an international prospective register of systematic reviews. The review's registration ID is CRD42021286882. DISCUSSION: The systematic review aims to explore, identify and synthesize the evidence to reveal the epidemiology of SU and/or MH of forced migrants of the MENAT region as described in this protocol. In sum, the review will provide evidence to fill the gap in the literature and help the stakeholders, policymakers, and health providers to expand current knowledge of the prevalence and risk factors of SU and/or MH in humanitarian settings.
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Transtornos Relacionados ao Uso de Substâncias , Migrantes , Humanos , Saúde Mental , Revisões Sistemáticas como Assunto , Metanálise como Assunto , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , África do Norte , Oriente Médio/epidemiologiaRESUMO
BACKGROUND: In 2020 COVID-19 was the third leading cause of death in the United States. Increases in suicides, overdoses, and alcohol related deaths were seen-which make up deaths of despair. How deaths of despair compare to COVID-19 across racial, ethnic, and gender subpopulations is relatively unknown. Preliminary studies showed inequalities in COVID-19 mortality for Black and Hispanic Americans in the pandemic's onset. This study analyzes the racial, ethnic and gender disparities in years of life lost due to COVID-19 and deaths of despair (suicide, overdose, and alcohol deaths) in 2020. METHODS: This cross-sectional study calculated and compared years of life lost (YLL) due to Deaths of Despair and COVID-19 by gender, race, and ethnicity. YLL was calculated using the CDC WONDER database to pull death records based on ICD-10 codes and the Social Security Administration Period Life Table was used to get estimated life expectancy for each subpopulation. RESULTS: In 2020, COVID-19 caused 350,831 deaths and 4,405,699 YLL. By contrast, deaths of despair contributed to 178,598 deaths and 6,045,819 YLL. Men had more deaths and YLL than women due to COVID-19 and deaths of despair. Among White Americans and more than one race identification both had greater burden of deaths of despair YLL than COVID-19 YLL. However, for all other racial categories (Native American/Alaskan Native, Asian, Black/African American, Native Hawaiian/Pacific Islander) COVID-19 caused more YLL than deaths of despair. Also, Hispanic or Latino persons had disproportionately higher mortality across all causes: COVID-19 and all deaths of despair causes. CONCLUSIONS: This study found greater deaths of despair mortality burden and differences in burden across gender, race, and ethnicity in 2020. The results indicate the need to bolster behavioral health research, support mental health workforce development and education, increase access to evidence-based substance use treatment, and address systemic inequities and social determinants of deaths of despair and COVID-19.
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COVID-19 , Desigualdades de Saúde , Mortalidade Prematura , Determinantes Sociais da Saúde , Feminino , Humanos , Masculino , COVID-19/epidemiologia , COVID-19/etnologia , COVID-19/psicologia , Estudos Transversais , Etanol , Etnicidade/psicologia , Etnicidade/estatística & dados numéricos , Hispânico ou Latino/psicologia , Hispânico ou Latino/estatística & dados numéricos , Suicídio/etnologia , Suicídio/psicologia , Suicídio/estatística & dados numéricos , Estados Unidos/epidemiologia , Causas de Morte , Fatores Raciais , Fatores Sexuais , Overdose de Drogas/epidemiologia , Overdose de Drogas/etnologia , Overdose de Drogas/mortalidade , Overdose de Drogas/psicologia , Transtornos Relacionados ao Uso de Álcool/epidemiologia , Transtornos Relacionados ao Uso de Álcool/etnologia , Transtornos Relacionados ao Uso de Álcool/mortalidade , Transtornos Relacionados ao Uso de Álcool/psicologia , Negro ou Afro-Americano/psicologia , Negro ou Afro-Americano/estatística & dados numéricos , Determinantes Sociais da Saúde/etnologia , Determinantes Sociais da Saúde/estatística & dados numéricos , Brancos/psicologia , Brancos/estatística & dados numéricos , Indígena Americano ou Nativo do Alasca/psicologia , Indígena Americano ou Nativo do Alasca/estatística & dados numéricos , Asiático/psicologia , Asiático/estatística & dados numéricos , Havaiano Nativo ou Outro Ilhéu do Pacífico/psicologia , Havaiano Nativo ou Outro Ilhéu do Pacífico/estatística & dados numéricos , Efeitos Psicossociais da Doença , Mortalidade Prematura/etnologia , Expectativa de Vida/etnologiaRESUMO
Introduction. National strategies to end the HIV epidemic and eliminate hepatitis c (HCV) through a syndemic approach require improvements in testing for HIV and HCV. Given the intersection of the opioid crisis with HIV and HCV acquisition, substance use disorder (SUD) treatment centers providing medications for opiate use disorder (MOUD) provide a critical opportunity to expand testing. Rates of testing in MOUD clinics have been suboptimal. Method. We employed the Nominal Group Technique (NGT), Ishikawa cause and effect diagrams, and individualized Quality Improvement (QI) efforts at two SUD clinics (SUD A and B) in Connecticut (CT) as part of an HRSA-funded grant focused on improving HCV cure in persons with HIV/HCV coinfection. Baseline and longitudinal data were collected on rates of HIV and HCV testing and positivity as well as linkage to treatment. Results. Between April 1, 2019, and May 31, 2021, for SUD A and B respectively, HIV testing increased from 13% to 90% and 33% to 83%; HCV testing increased from 4% to 90% and 30% to 82%, with few reported cases of HIV/HCV coinfection. HCV testing revealed new and prior diagnoses at both sites, with subsequent referrals for treatment. Qualitative assessments identified best practices which included the institution of formal policies and procedures, streamlining of testing logistics, designation of a site champion, and broadening relevant education to staff and clients. Conclusion. Strategic assessment of barriers and facilitators to HIV and HCV testing at MOUD clinics can lead to improved testing and referral rates that are key to improving the cascade of care for both diseases.
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Coinfecção , Infecções por HIV , Hepatite C , Alcaloides Opiáceos , Transtornos Relacionados ao Uso de Substâncias , Humanos , Alcaloides Opiáceos/uso terapêutico , Hepatite C/diagnóstico , Hepatite C/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/terapia , Hepacivirus , Infecções por HIV/diagnóstico , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologiaRESUMO
People may use nonprescribed substances during an acute hospitalization. Hospital policies and responses can be stigmatizing, involve law enforcement, and lead to worse patient outcomes, including patient-directed discharge. In the United States, there is currently little data on hospital policies that address the use of substances during hospitalization. In this cross-sectional study, we surveyed clinicians at US hospitals with Accreditation Council of Graduate Medical Education (ACGME)-accredited addiction medicine fellowships about their current practices and policies and what they would include in an ideal policy. We had 77 responses from 55 out of 86 ACGME-addiction medicine fellowships (63.9%). Respondents identified policies at 21.8% of the institutions surveyed. Current responses to inpatient substance use vary, though most do not match what clinicians identify as an ideal response. Our results suggest that the use of nonprescribed substances during a hospitalization may be common, but a majority of hospitals likely do not have patient-centered policies to address this.
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Importance: Direct-acting antiviral (DAA) treatment for hepatitis C virus (HCV) infection is associated with lower mortality and is effective in individuals with alcohol use disorder (AUD). However, despite recommendations, patients with AUD may be less likely to receive DAAs. Objective: To assess the association between alcohol use and receipt of DAA treatment among patients with HCV within the Veterans Health Administration (VHA). Design, Setting, and Participants: This cohort study included 133â¯753 patients with HCV born from 1945 to 1965 who had completed the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questionnaire and had at least 1 outpatient visit in the VHA from January 1, 2014, through May 31, 2017, with maximal follow-up of 3 years until May 31, 2020; DAA receipt; or death, whichever occurred first. Exposures: Alcohol use categories generated using responses to the AUDIT-C questionnaire and International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnoses: current AUD, abstinent with AUD history, at-risk drinking, lower-risk drinking, and abstinent without AUD history. Demographic, other clinical, and pharmacy data were also collected. Main Outcomes and Measures: Associations between alcohol use categories and DAA receipt within 1 and 3 years estimated using Cox proportional hazards regression stratified by calendar year. Results: Of 133â¯753 patients (130â¯103 men [97%]; mean [SD] age, 60.6 [4.5] years; and 73â¯493 White patients [55%]), 38% had current AUD, 12% were abstinent with a history of AUD, 6% reported at-risk drinking, 14% reported lower-risk drinking, and 30% were abstinent without a history of AUD. Receipt of DAA treatment within 1 year was 7%, 33%, 53%, and 56% for patients entering the cohort in 2014, 2015, 2016, and 2017, respectively. For patients entering in 2014, those with current AUD (hazard ratio [HR], 0.72 [95%, CI, 0.66-0.77]) or who were abstinent with an AUD history (HR, 0.91 [95% CI, 0.84-1.00]) were less likely to receive DAA treatment within 1 year compared with patients with lower-risk drinking. For those entering in 2015-2017, patients with current AUD (HR, 0.75 [95% CI, 0.70-0.81]) and those who were abstinent with an AUD history (HR, 0.76 [95% CI, 0.68-0.86]) were less likely to receive DAA treatment within 1 year compared with patients with lower-risk drinking. Conclusions and Relevance: This cohort study suggests that individuals with AUD, regardless of abstinence, were less likely to receive DAA treatment. Improved access to DAA treatment for persons with AUD is needed.
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Alcoolismo , Hepatite C Crônica , Hepatite C , Masculino , Humanos , Pessoa de Meia-Idade , Hepacivirus , Antivirais/uso terapêutico , Alcoolismo/tratamento farmacológico , Alcoolismo/epidemiologia , Alcoolismo/complicações , Estudos de Coortes , Hepatite C Crônica/tratamento farmacológico , Hepatite C Crônica/epidemiologia , Hepatite C Crônica/complicações , Hepatite C/tratamento farmacológico , Hepatite C/epidemiologia , Hepatite C/complicaçõesRESUMO
BACKGROUND: Open-access opioid treatment programs (OTP) offer same-day access to methadone without an appointment and aim to minimize treatment barriers that often reduce admission and/or retention. We explored whether patients with benzodiazepine exposure at treatment entry would have similar 12-month retention compared to those without benzodiazepine exposure. METHODS: We conducted a retrospective cohort study of 2968 patients consecutively initiated on methadone between January 2015 and February 2017 at an open-access OTP. The sample was stratified into benzodiazepine-exposed and nonexposed groups based on intake urine toxicology. Group comparison of 12-month retention was conducted. Kaplan Meier analysis compared time to methadone treatment discontinuation between groups with a log-rank test. Multivariable Cox regression was performed to compare retention by baseline benzodiazepine exposure with adjustment for confounders. RESULTS: Overall, 31% of patients with benzodiazepine exposure (n = 171) and 31% without exposure (n = 2423) were retained at 12 months (p = 0.95). Median treatment duration was 182 days (95% CI, 152-239) and 175 days (95% CI, 156-196) for patients with and without benzodiazepine exposure, respectively. Kaplan-Meier analysis showed no significant difference in treatment duration between groups (log-rank test p = 0.73). Cox regression found no difference in treatment retention between groups (adjusted Hazard Ratio= 1.03, 95% CI, 0.91-1.16). CONCLUSIONS: In this cohort of patients receiving methadone at an open-access OTP, benzodiazepine exposure at intake was not observed to impact 12-month treatment retention or duration. These findings support U.S. Food and Drug Administration (FDA) recommendations to not withhold medications for opioid use disorder from patients taking benzodiazepines.
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Metadona , Transtornos Relacionados ao Uso de Opioides , Humanos , Benzodiazepinas/efeitos adversos , Estudos Retrospectivos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/reabilitação , Tratamento de Substituição de Opiáceos , Analgésicos Opioides/uso terapêuticoRESUMO
Background Addiction programs at academic medical centers must navigate complex, multidisciplinary environments as they work to advance the field and improve substance use treatment access and outcomes. Programs can employ strategic planning processes to identify goals and strategies for success. Methods: The Yale Program in Addiction Medicine began a series of strategic planning activities in February 2020 with the primary aims of (1) conducting a point-in-time needs assessment for the Program and (2) identifying goals for Program improvement and expansion. Drawing upon a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis framework and the Delphi method for group decision-making, these strategic planning activities were implemented in four steps involving multimodal engagement and iterative feedback amongst Program faculty and selected stakeholders. Results: Primary deliverables included four overarching programmatic goals, associated action items, strategies for success, a proposed implementation timeline, and a revised Mission, Vision, and Values statement for the Program. Conclusion: Methodologic considerations and environmental factors offer insight into the strengths, limitations, and adaptive potential of this approach as well as others described in the literature. Key outputs highlight the benefits and timeliness of strategic planning for addiction programs, as heightened interest and investment in substance use treatment, prevention, and harm reduction paves the way for opportunity and innovation.
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Medicina do Vício , Transtornos Relacionados ao Uso de Substâncias , Centros Médicos Acadêmicos , Docentes , Humanos , Planejamento Estratégico , Transtornos Relacionados ao Uso de Substâncias/terapiaRESUMO
The COVID-19 pandemic has further limited access to treatment for opioid use disorder (OUD). Advanced practice registered nurses can reduce opioid related complications and overdose by obtaining a Drug Enforcement Administration (DEA) regulated X-waiver that allows for prescription of medications for OUD (MOUD) in general medical settings. Graduate nursing education, where advanced practice nurse practitioner (NP) students are educated, has not incorporated this content into standard curricula. We describe an innovative approach to incorporate DEA X-waiver training in a required community health NP in partnership with addiction medicine clinicians. Advanced practice NP students (N = 114) either completed fully online or hybrid (virtual didactic and online) X-waiver training on MOUD. We describe how an interprofessional partnership to incorporate MOUD education into graduate nursing curricula is a feasible method for training students to treat OUD in the context of the pandemic. This approach is responsive to the crucial need for more health care providers to address the opioid overdose crisis.
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COVID-19 , Educação de Pós-Graduação em Enfermagem , Transtornos Relacionados ao Uso de Opioides , Analgésicos Opioides/efeitos adversos , Humanos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , PandemiasRESUMO
Among the many people experiencing grief in response to opioid overdose deaths, individuals with opioid use disorder (OUD) bear one of the largest emotional burdens. Grief and loss of social support networks have the potential to destabilize OUD and result in overdose, suicide, and other harmful consequences. However, few clinicians discuss how overdose losses impact their patients with OUD, let alone consider the role of grief in treatment outcomes. Lessons from the acquired immunodeficiency syndrome (AIDS) epidemic and crack cocaine crisis can inform our understanding of grief in the context of stigma and societal injustices. In this commentary, we describe how these historical lessons can be adapted to the opioid overdose crisis to improve the care of people with OUD.
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Overdose de Drogas , Overdose de Opiáceos , Transtornos Relacionados ao Uso de Opioides , Humanos , Overdose de Drogas/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Estigma Social , Pesar , Analgésicos Opioides/uso terapêuticoRESUMO
The 21st Century Cures Act of 2016 mandates that patients have access to their clinical notes, labs, and imaging through electronic portals and requires information sharing among healthcare entities. We provide practical tips to healthcare professionals on best practices in documenting substance use in the era of transparent electronic medical records, as well as provide guidance on the application of the Cures Act information blocking exceptions for their patients who use substances.
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Sabões , Transtornos Relacionados ao Uso de Substâncias , Atenção à Saúde , Registros Eletrônicos de Saúde , Humanos , Transtornos Relacionados ao Uso de Substâncias/terapiaRESUMO
BACKGROUND: Office-based opioid treatment (OBOT) is an evidence-based treatment model for opioid use disorder (OUD) offered by both addiction and general primary care providers (PCPs). Calls exist for more PCPs to offer OBOT. Few studies have been conducted on the primary care characteristics of OBOT patients. OBJECTIVE: To characterize medical conditions, medications, and treatment outcomes among patients receiving OBOT with buprenorphine for OUD, and to describe differences among patients by age and by time in care. METHODS: This study is a retrospective review of medical records on or before 4/29/2019 at an outpatient primary care clinic within a nonprofit addiction treatment setting. Inclusion criterion was all clinic patients actively enrolled in the OBOT program. Patients not prescribed buprenorphine or with no OBOT visits were excluded. RESULTS: Of 355 patients, 42.0% had another PCP. Common comorbid conditions included chronic pain and psychiatric diagnosis. Few patients had chronic viral hepatitis or HIV. Patients reported a median of 4 medications. Common medications were cardiovascular, antidepressant, and nonopioid pain agents. Older patients had a higher median number of medications. There was no significant difference in positive opioid urine toxicology (UT) based on age, chronic pain status, or psychoactive medications. Patients retained >1 year were less likely to have positive opioid UT. CONCLUSION: Clinical needs of many patients receiving OBOT are similar to those of the general population, supporting calls for PCPs to provide OBOT.
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Buprenorfina , Dor Crônica , Transtornos Relacionados ao Uso de Opioides , Analgésicos Opioides/uso terapêutico , Buprenorfina/uso terapêutico , Dor Crônica/tratamento farmacológico , Humanos , Conduta do Tratamento Medicamentoso , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Atenção Primária à SaúdeRESUMO
â¢We developed a two-session behavioral intervention to prevent HCV reinfection.â¢The intervention was piloted at an OTP and integrated into HCV treatment.â¢Baseline data showed limited knowledge & application of safer injection practices.â¢Implementation barriers included logistics and the lack of financial incentive.â¢Adaptations addressed barriers, yielding a more feasible and acceptable intervention.
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ABSTRACT: Low dose buprenorphine initiation, is an alternative method of initiating buprenorphine in which the starting dose is very low and gradually increased to therapeutic levels over a period of days. This method takes advantage of slow displacement of the full opioid agonist from mu-opioid receptors, avoiding the need for a person with opioid use disorder to experience opioid withdrawal symptoms before initiating buprenorphine, while also minimizing the risk of precipitated opioid withdrawal. With this initiation method, full opioid agonists can be continued as buprenorphine is initiated, expanding the population to which buprenorphine can be offered. To date, the literature on low dose initiation is primarily case-based but rapidly growing. While evidence emerges, guidance for the use of low dose initiation is clearly desired and urgently needed in the context of an increasingly risky and contaminated opioid drug supply, particularly with high potency synthetic opioids, driving overdose deaths. Despite limited evidence, several principles to guide low dose initiation have been identified including: (1) choosing the appropriate clinical situation, (2) initiating at a low buprenorphine dose, (3) titrating the buprenorphine dose gradually, (4) continuing the full opioid agonist even if it is nonmedical, (5) communicating clearly with frequent monitoring, (6) pausing or delaying buprenorphine dose changes if opioid withdrawal symptoms occur, and (7) prioritizing care coordination. We review a practical approach to low dose initiation in hospital-based and outpatient settings guided by the current evidence.
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Buprenorfina , Transtornos Relacionados ao Uso de Opioides , Síndrome de Abstinência a Substâncias , Analgésicos Opioides/efeitos adversos , Buprenorfina/uso terapêutico , Humanos , Entorpecentes/uso terapêutico , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Síndrome de Abstinência a Substâncias/tratamento farmacológicoRESUMO
OBJECTIVES: Treatment of hepatitis C virus infection (HCV) with direct acting antiviral therapy is encouraged regardless of substance use status. Patients with substance use disorder are at risk of HCV reinfection after cure. Follow up viral load testing (FUVL) with HCV RNA is recommended. We investigated factors associated with adoption of FUVL in real-world clinical settings. METHODS: Medical records of all patients with SUD who achieved HCV cure with direct acting antivirals at a multidisciplinary addiction treatment program between 2014 and 2019 were reviewed as part of a quality improvement initiative. Demographic and clinical characteristics including SUD treatment, urine toxicology results, and medical service use were collected. Factors associated with FUVL were analyzed and the rate of HCV reinfection was determined. RESULTS: Among 149 patients, 58.4% received FUVL. Receipt of FUVL was associated with engagement in ongoing primary medical care after cure (AOR 4.39, 95% CI [1.67, 11.49]). The HCV reinfection rate among those who received FUVL was 1.95 per 100 person-years of follow up (95% CI [0.64, 5.98]). There was no significant difference in the percentage of negative urine toxicology results before and after cure. CONCLUSIONS: Over half of a cohort of patients with substance use disorder cured of HCV received FUVL. The relationship between FUVL and engagement in primary medical and substance use treatment highlights the importance of integrated systems in providing longitudinal care for patients cured of HCV. Standardized interventions that facilitate FUVL testing and management of infectious complications of SUD in addiction treatment settings are needed.
Assuntos
Hepatite C Crônica , Hepatite C , Transtornos Relacionados ao Uso de Substâncias , Antivirais/efeitos adversos , Seguimentos , Hepacivirus , Hepatite C/tratamento farmacológico , Hepatite C/epidemiologia , Hepatite C Crônica/tratamento farmacológico , Humanos , Atenção Primária à Saúde , Reinfecção , Transtornos Relacionados ao Uso de Substâncias/tratamento farmacológico , Transtornos Relacionados ao Uso de Substâncias/terapia , Carga ViralRESUMO
More effective treatments to reduce pathological alcohol drinking are needed. The glutamatergic system and the NMDA receptor (NMDAR), in particular, are implicated in behavioral and molecular consequences of chronic alcohol use, making the NMDAR a promising target for novel pharmacotherapeutics. Ethanol exposure upregulates Fyn, a protein tyrosine kinase that indirectly modulates NMDAR signaling by phosphorylating the NR2B subunit. The Src/Fyn kinase inhibitor saracatinib (AZD0530) reduces ethanol self-administration and enhances extinction of goal-directed ethanol-seeking in mice. However, less is known regarding how saracatinib affects habitual ethanol-seeking. Moreover, no prior studies have assessed the effects of Src/Fyn kinase inhibitors on alcohol-seeking or consumption in human participants. Here, we tested the effects of saracatinib on alcohol consumption and craving/seeking in two species, including the first trial of an Src/Fyn kinase inhibitor to reduce drinking in humans. Eighteen male C57BL/6NCrl mice underwent operant conditioning on a variable interval schedule to induce habitual responding for 10% ethanol/0.1% saccharin. Next, mice received 5 mg/kg saracatinib or vehicle 2 h or 30 min prior to contingency degradation to measure habitual responding. In the human study, 50 non-treatment seeking human participants who drank heavily and met DSM-IV criteria for alcohol abuse or dependence were randomized to receive 125 mg/day saracatinib (n = 33) or placebo (n = 17). Alcohol Drinking Paradigms (ADP) were completed in a controlled research setting: before and after 7-8 days of treatment. Each ADP involved consumption of a priming drink of alcohol (0.03 mg%) followed by ad libitum access (3 h) to 12 additional drinks (0.015 g%); the number of drinks consumed and craving (Alcohol Urge Questionnaire) were recorded. In mice, saracatinib did not affect habitual ethanol seeking or consumption at either time point. In human participants, no significant effects of saracatinib on alcohol craving or consumption were identified. These results in mice and humans suggest that Fyn kinase inhibition using saracatinib, at the doses tested here, may not reduce alcohol consumption or craving/seeking among those habitually consuming alcohol, in contrast to reports of positive effects of saracatinib in individuals that seek ethanol in a goal-directed manner. Nevertheless, future studies should confirm these negative findings using additional doses and schedules of saracatinib administration.