Trends in hallucinogen-associated emergency department visits and hospitalizations in California, USA, from 2016 to 2022.

BACKGROUND AND AIMS: Hallucinogens encompass a diverse range of compounds of increasing scientific and public interest. Risks associated with hallucinogen use are under-researched and poorly understood. We aimed to compare the trends in hallucinogen-associated health-care use with alcohol- and cannabis-associated health-care use. DESIGN, SETTING AND CASES: We conducted an ecological study with publicly available data on International Classification of Diseases, 10th Revision (ICD-10) diagnosis codes associated with emergency department (ED) visits and hospitalizations from the California Department of Healthcare Access and Information (HCAI). HCAI includes primary and secondary ICD-10 codes reported with ED or hospital discharge from every non-federal health-care facility licensed in California, United States, from 2016 to 2022. MEASUREMENTS: ICD-10 codes were classified as hallucinogen-, cannabis- or alcohol-associated if they were from the corresponding category in the ICD-10 block 'mental and behavioral disorders due to psychoactive substance use'. FINDINGS: Observed hallucinogen-associated ED visits increased by 54% between 2016 and 2022, from 2260 visits to 3476 visits, compared with a 20% decrease in alcohol-associated ED visits and a 15% increase in cannabis-associated ED visits. The observed hallucinogen-associated hospitalizations increased by 55% during the same period, from 2556 to 3965 hospitalizations, compared with a 1% increase in alcohol-associated hospitalizations and a 1% increase in cannabis-associated hospitalizations. This rise in hallucinogenic ED visits was significantly different from the trend in cannabis-associated (P < 0.001) and alcohol-associated (P = 0.005) ED visits. The hallucinogen-associated hospitalizations trend also significantly differed when compared with cannabis- (P < 0.001) and alcohol-associated (P < 0.001) hospitalizations. CONCLUSIONS: Hallucinogen-associated emergency department visits and hospitalizations in California, USA, showed a large relative but small absolute increase between 2016 and 2022.

A telehealth inpatient addiction consult service is both feasible and effective in reducing readmission rates.

The COVID-19 pandemic compelled fast adaptation of telehealth to addiction treatment services. This study aims to examine the feasibility and effectiveness of transitioning an in-person hospital addiction consult service (ACS) to telehealth. The Stanford Hospital ACS adapted to the pandemic by transforming an in-person ACS to a telehealth ACS. We compared 30-day readmission rates in patients with and without an addiction medicine consult pre-pandemic (in-person ACS) and during the pandemic (telehealth ACS). The ACS completed 370 and 473 unique patient consults in the year preceding (in-person consults) and during the pandemic (telehealth consults) respectively. Patients seen by telehealth ACS had decreased 30-day readmission rates consistent with those seen before COVID-19. A telehealth ACS is feasible and effective in the in-patient setting. Telehealth ACS holds promise to extend the reach of substance use disorder evaluation and treatment in underserved areas.

Predicting premature discontinuation of medication for opioid use disorder from electronic medical records.

Medications such as buprenorphine-naloxone are among the most effective treatments for opioid use disorder, but limited retention in treatment limits long-term outcomes. In this study, we assess the feasibility of a machine learning model to predict retention vs. attrition in medication for opioid use disorder (MOUD) treatment using electronic medical record data including concepts extracted from clinical notes. A logistic regression classifier was trained on 374 MOUD treatments with 68% resulting in potential attrition. On a held-out test set of 157 events, the full model achieved an area under the receiver operating characteristic curve (AUROC) of 0.77 (95% CI: 0.64-0.90) and AUROC of 0.74 (95% CI: 0.62-0.87) with a limited model using only structured EMR data. Risk prediction for opioid MOUD retention vs. attrition is feasible given electronic medical record data, even without necessarily incorporating concepts extracted from clinical notes.

Buprenorphine Microdosing Cross Tapers: A Time for Change.

Buprenorphine is a partial opioid agonist that is Food and Drug Administration (FDA) approved to treat chronic pain and opioid use disorder (OUD). The national prescribing guidelines in the United States (US) recommend that patients transitioning from full opioid agonists to buprenorphine first undergo 12 or more hours of active opioid withdrawal, in order to avoid buprenorphine-precipitated opioid withdrawal. This opioid-free period imposes a significant barrier for many patients. Evidence is accumulating that using microdoses of buprenorphine to cross taper from full-agonist opioids to buprenorphine is a safe and effective way to avoid opioid withdrawal and uncontrolled pain. This microdose cross-tapering strategy is already being used across the US. The US prescribing guidelines and buprenorphine training would benefit from acknowledging this new approach. Additionally, to facilitate this strategy, the FDA should approve transdermal buprenorphine formulations for OUD and manufacturers could produce lower dose formulations of sublingual buprenorphine. The time has come for us to embrace buprenorphine microdosing cross tapers as a new standard of care.

Qualitative exploration of the psychological dimensions of telehealth shared medical appointments (SMAs) for buprenorphine prescribing.

Background: Shared medical appointments (SMAs) for buprenorphine prescribing are clinical encounters in which multiple patients with opioid problems receive treatment from providers in a group setting. Telehealth, the provision of clinical services remotely using telecommunications technology, is an essential modality for improving access to healthcare when combined with SMAs, especially since the COVID pandemic. Objectives: The current study specifically examined psychological components of telehealth SMAs for buprenorphine prescribing to learn about the benefits and drawbacks of this treatment model. Methods: Data was collected through qualitative interviews with patients (N=10) in a psychiatry addiction medicine clinic. Narrative synthesis using grounded theory was conducted to identify salient themes from the interviews. Results: Findings highlighted the advantages and downsides of telehealth SMA to treat addictive disorders in a digital age: (1) Shared group identity; (2) Decreased stigma around buprenorphine; (3) Benefits of telehealth; (4) Discomfort with group SMA format; (5) Strategies for managing medication side effects; and (6) Enhanced empathy for providers. Several themes corresponded to therapeutic factors identified in group therapy (i.e., installation of hope, universality, imparting information, altruism) and mechanisms theorized in previous SMA research (e.g., combating isolation, disease self-management, feeling inspired by others). Conclusion: Telehealth SMAs for buprenorphine prescribing may be a unique opportunity for patients to receive both ongoing medication management and psychosocial benefits that promote recovery and reduce stigma. The SMA group had shortcomings for some patients, including privacy concerns, fear of judgment from other patients and limited time to discuss individual concerns with providers.

A systematic review of stigma interventions for providers who treat patients with substance use disorders.

BACKGROUND: Stigma surrounding substance use disorders (SUDs) is a frequently cited barrier to treatment engagement. Research consistently demonstrates that healthcare professionals' attitudes towards patients with addiction problems are often negative and may adversely impact service delivery. The current study presents a systematic review of stigma interventions for providers who treat patients with SUDs, in order to evaluate the quality of existing studies and potential for implementation in clinical settings. METHODS: This systematic literature review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Databases included PubMed, APA PsycInfo and the Cochrane Database of Systematic Reviews. Of the 1462 records identified between 2011 and 2019, 15 studies were eligible for inclusion. A narrative synthesis of stigma interventions summarized the change in stigmatizing attitudes held by providers. RESULTS: Studies included heterogeneous and culturally diverse samples of providers (N = 1324), who varied by age, location, discipline, and experience, with the exception of primarily female providers (75%). Results delineated six types of provider stigma interventions with components including online education, in-person education, in-person contact with consumers in recovery, or some combination of these elements. The highest quality studies incorporated motivational interviewing or communication training interventions, and many interventions combined either in-person mentorship or contact with individuals in recovery. Positive effects on provider attitudes occurred at several levels of educational and consumer contact interventions. Interventions with consumer contact demonstrated long-term maintenance of attitudinal shifts. Despite significant methodological limitations and low-quality assessment ratings, several studies utilized real-world providers and patients, as well as practical, innovative, brief, and potentially cost-effective interventions, particularly in locations with limited technological resources. CONCLUSIONS: Research on provider stigma interventions increased in recent years, indicating greater worldwide attention to the negative impact of stigma. While educational interventions alone can be helpful in attitudinal change, contact with individuals in recovery from SUDs is a vital component of provider stigma interventions, particularly for lasting effects. This review highlights the importance of including implementation outcomes, such as sustainability and cost-effectiveness, in the study of stigma interventions for providers of addiction treatment.

Gabapentin dependence and withdrawal requiring an 18-month taper in a patient with alcohol use disorder: a case report.

Gabapentin has been widely used to manage post-herpetic neuralgia, peripheral neuropathy, seizure disorders, alcohol use disorder (AUD), alcohol withdrawal, and insomnia. Although usually well tolerated, gabapentin has been reported to cause severe physiologic dependence and withdrawal. Tapering gabapentin in this context poses a significant clinical challenge, with little published information to date on meeting this challenge. This case highlights the need for patient-centered slow tapers in patients with severe gabapentin dependence and withdrawal. We present a 32-year-old female effectively treated for AUD with 1,200 mg daily dose of gabapentin, who developed gabapentin dependence and severe withdrawal. Recognizing her intolerance to gabapentin withdrawal after a brief accidental pause of medication, a taper plan was initiated using the framework of the BRAVO Protocol. On average, she reduced daily gabapentin dose by 100 mg per month until she reached 300 mg. The taper then slowed to 20-30 mg dose decrements per month. For the last 100 mg, she tapered down at 5 mg decrements every one to two weeks to 60 mg, at which point she discontinued gabapentin. The entire taper process took eighteen months. The BRAVO protocol outlines a safe and compassionate strategy. Originally developed for opioids and adapted to benzodiazepines, the use of the Bravo Protocol provides a framework for a gabapentin taper. For patients in whom gabapentin treatment leads to severe dependence and withdrawal, the BRAVO Protocol provides a practical, patient-centered framework for tapering.

Online mutual-help intervention for reducing heavy alcohol use.

Online interventions have potential to reach a wide range of people, including heavy drinkers unable or unwilling to seek formal treatment or support groups. This study examined a self-guided alcohol Internet intervention that provides access to several different online social networks and is based on principles of harm reduction, cognitive-behavioral therapy (CBT), and relapse prevention. Active participants in the online program (N = 57) completed a survey that retrospectively assessed prior alcohol use, current alcohol use patterns, drinking goals, involvement in online activities, and use of CBT self-help tools. Findings indicated significant reductions in drinks per week (DPW), drinks per day (DPD), and drinking days per week (DDW) from baseline to post-intervention. Longer time in the online program was associated with greater reduction in DDW, rs(57) = .31, p = .02; while use of CBT self-help tools was positively correlated with reduction in DPW, rs(57) = .37, p = .005. Engagement in multiple online activities (i.e., social networking, e-mail groups, chat room, forum discussion) was associated with greater drinking reductions in DPW, (F[1,55]) = 8.55, p < .005; and DDW, (F[1,55]) = 7.12, p < .01). Results suggest that an online program may assist heavy drinkers in decreasing alcohol use through utilization of a cyber community, social networking, and self-help tools. Conversely, 74% of participants were still engaging in high-risk drinking, raising the possibility that an online mutual-help group with personalized goals intended to reduce harm, may inadvertently normalize heavy alcohol use.

Patterns of Opioid and Benzodiazepine Use in Opioid-Naïve Patients with Newly Diagnosed Low Back and Lower Extremity Pain.

BACKGROUND: The morbidity and mortality associated with opioid and benzodiazepine co-prescription is a pressing national concern. Little is known about patterns of opioid and benzodiazepine use in patients with acute low back pain or lower extremity pain. OBJECTIVE: To characterize patterns of opioid and benzodiazepine prescribing among opioid-naïve, newly diagnosed low back pain (LBP) or lower extremity pain (LEP) patients and to investigate the relationship between benzodiazepine prescribing and long-term opioid use. DESIGN/SETTING: We performed a retrospective analysis of a commercial database containing claims for more than 75 million enrollees in the USA. PARTICIPANTS: Participants were adult patients newly diagnosed with LBP or LEP between 2008 and 2015 who did not have a red flag diagnosis, had not received an opioid prescription in the 6 months prior to diagnosis, and had 12 months of continuous enrollment after diagnosis. MAIN OUTCOMES AND MEASURES: Among patients receiving at least one opioid prescription within 12 months of diagnosis, we defined discrete patterns of benzodiazepine prescribing-continued use, new use, stopped use, and never use. We tested the association of these prescription patterns with long-term opioid use, defined as six or more fills within 12 months. RESULTS: We identified 2,497,653 opioid-naïve patients with newly diagnosed LBP or LEP. Between 2008 and 2015, 31.9% and 11.5% of these patients received opioid and benzodiazepine prescriptions, respectively, within 12 months of diagnosis. Rates of opioid prescription decreased from 34.8% in 2008 to 27.0% in 2015 (P < 0.001); however, prescribing of benzodiazepines only decreased from 11.6% in 2008 to 10.8% in 2015. Patients with continued or new benzodiazepine use consistently used more opioids than patients who never used or stopped using benzodiazepines during the study period (one-way ANOVA, P < 0.001). For patients with continued and new benzodiazepine use, the odds ratio of long-term opioid use compared with those never prescribed a benzodiazepine was 2.99 (95% CI, 2.89-3.08) and 2.68 (95% CI, 2.62-2.75), respectively. LIMITATIONS: This study used administrative claims analyses, which rely on accuracy and completeness of diagnostic, procedural, and prescription codes. CONCLUSION: Overall opioid prescribing for low back pain or lower extremity pain decreased substantially during the study period, indicating a shift in management within the medical community. Rates of benzodiazepine prescribing, however, remained at approximately 11%. Concurrent prescriptions of benzodiazepines and opioids after LBP or LEP diagnosis were associated with increased risk of long-term opioid use.

Perioperative Considerations for the Patient with Opioid Use Disorder on Buprenorphine, Methadone, or Naltrexone Maintenance Therapy.

As part of a national effort to combat the current US opioid epidemic, use of currently Food and Drug Administration-approved drugs for the treatment of opioid use disorder/opioid addiction (buprenorphine, methadone, and naltrexone) is on the rise. To provide optimal pain control and minimize the risk of relapse and overdose, providers need to have an in-depth understanding of how to manage these medications in the perioperative setting. This article reviews key principles and discusses perioperative considerations for patients with opioid use disorder on buprenorphine, methadone, or naltrexone.

Qualitative Assessment of Clerkship Students' Perspectives of the Topics of Pain and Addiction in their Preclinical Curriculum.

OBJECTIVE: A majority of physicians feel poorly trained in the treatment of chronic pain and addiction. As such, it is critical that medical students receive appropriate education in both pain management and addiction. The purpose of this study was to assess the pre-clinical curriculum in pain medicine and addiction from the perspective of students after they had completed their pre-clinical training and to assess what they perceived as the strengths and weaknesses of their training. METHODS: The authors conducted focused interviews among clinical medical students who had completed at least 6 months of clerkships. The interviews targeted the students' retrospective opinions about the pre-clinical curriculum and their preparedness for clinical encounters with either pain or addiction-related issues during their rotations. Coders thematically analyzed the de-identified interview transcripts, with consensus reached through discussion and code modification. RESULTS: Themes that emerged through the focused interviews included: fragmented curricular structure (and insufficient time) for pain and addiction medicine, not enough specific treatment strategies for pain or addiction, especially for complex clinical scenarios, and lack of a trained work-force to provide guidance in the management of pain and addiction. CONCLUSION: This study demonstrated the feasibility of gathering student perspectives to inform changes to improve the pre-clinical curriculum in pain and addiction medicine. Students identified multiple areas for improvement at the pre-clerkship level, which have informed updates to the curriculum. More research is needed to determine if curricular changes based on student feedback lead to improved learning outcomes.