Rethinking Substance Use as Social History: Charting a Way Forward.

Physicians have traditionally asked about substance use within the Social History section of the consultation note. Drawing on social science theory and using the authors' own experiences as generalists and addiction scholars, we consider the possible unintended harms associated with this approach. The inclusion of the substance use history within the Social History reproduces the discourse of substance use disorders as "life-style choices" rather than medical conditions, and reinforces stigma among healthcare workers through the attribution of personal responsibility for complications associated with problematic substance use. The ongoing placement of the substance use history within the Social History may lead to a failure to diagnose and make appropriate management plans for clients with substance use disorders. These missed opportunities may include inadequate withdrawal management leading to discharge before medically advised, insufficient use of evidence-based pharmacotherapy and psychotherapy, polypharmacy, medical complications, and repeated admissions to hospital. We argue instead that the Substance Use History should be a stand-alone section within the consultation note. This new section would reduce the invisibility of substance use disorders within our medical systems and model that these chronic medical conditions are amenable to prevention, treatment and harm reduction through the application of evidence-based practices.

Benzodiazepine-Involved Overdose Deaths in the USA: 2000-2019.

BACKGROUND: Despite the focus on overdose deaths co-involving opioids and benzodiazepines, little is known about the epidemiologic characteristics of benzodiazepine-involved overdose deaths in the USA. OBJECTIVE: To characterize co-involved substances, intentionality, and demographics of benzodiazepine-involved overdose deaths in the USA from 2000 to 2019. DESIGN: Cross-sectional study using national mortality records from the National Vital Statistics System. SUBJECTS: US residents in the 50 states and District of Columbia who died from a benzodiazepine-involved overdose from 2000 to 2019. MAIN MEASURES: Demographic characteristics, intention of overdose, and co-involved substances KEY RESULTS: A total of 118,208 benzodiazepine-involved overdose deaths occurred between 2000 and 2019 (median age, 43 [IQR, 32-52]; male, 58.6%; White, 93.3%; Black, 4.9%; American Indian and Alaska Native, 0.9%; Asian American and Pacific Islander, 0.9%; Hispanic origin, 6.4%). Opioids were co-involved in 83.5% of the deaths. Nine percent of benzodiazepine-involved overdose deaths did not involve opioids, cocaine, other psychostimulants, barbiturates, or alcohol. Overdose deaths were classified as suicides in 8.5% of cases with benzodiazepine and opioid co-involvement and 36.2% of cases with benzodiazepine but not opioid involvement. Rates of benzodiazepine-involved overdose deaths increased from 0.46 per 100,000 individuals in 2000 to 3.55 per 100,000 individuals in 2017 before decreasing to 2.96 per 100,000 individuals in 2019. Benzodiazepine-involved overdose mortality rates increased from 2000 to 2019 among all racial groups, both sexes, and individuals of Hispanic and non-Hispanic origin. Rates of benzodiazepine-involved overdose deaths decreased among White individuals, but not Black individuals, from 2017 to 2019. CONCLUSIONS: Interventions to reduce benzodiazepine-involved overdose mortality should consider the demographics of, co-involved substances in, and presence of suicides among benzodiazepine-involved overdose deaths.

Excessive Spending in a "Free-to-Play" Smartphone Game.

BACKGROUND AND OBJECTIVES: Although gaming disorder is increasingly recognized, there has been limited consideration of the impact of free-to-play games with in-game purchases, also called microtransactions. METHODS: Case report (n = 1). RESULTS: A patient with posttraumatic stress disorder, major depressive disorder in remission, polysubstance use disorders in remission, and opioid use disorder on buprenorphine/naloxone developed gaming disorder (based on International Classification of Diseases, 11th revision) and spent up to 40% of his monthly income on microtransactions within a smartphone game. Treatment consisted of relinquishing access to electronic payment mechanisms, motivational interviewing, and couples therapy. DISCUSSION AND CONCLUSIONS: The case highlights how in-game purchases may cause patients with gaming disorder to experience financial consequences, and the need for further characterization of the clinical ramifications of microtransactions. SCIENTIFIC SIGNIFICANCE: To the best of our knowledge, this is the first report in the medical literature of a patient with gaming disorder developing excessive in-game spending from expenditures on microtransactions. (Am J Addict 2020;29:528-530).