Changing cannabis legislation in Canada and a longitudinal look at "regular" cannabis use in patients with eating disorders.

Regular cannabis use (CU), defined as "weekly or more often", is associated with a number of negative mental health outcomes. In the last decade, Canada legalized first medical and then recreational CU. Despite higher prevalence in mental health populations, little research has documented changes in frequency of CU with progressive legalization of cannabis. This study examined rates of CU in a sample of 843 treatment-seeking patients with eating disorders (ED) in an outpatient setting between 2004 and 2020. Across ED diagnoses, segmented regression indicated a significant break-point in regular CU in 2014, commensurate with the relaxation of medical cannabis laws. Regular CU increased from 4.9 % to 23.7 % from 2014 to 2020; well above the stable 6 % found in the general population. No significant break-point was observed in either alcohol or illicit substance use over the same time period. Significant increases in regular CU were found in patients with anorexia nervosa and binge eating disorder, while regular use remained stable in patients with bulimia nervosa. Comorbid psychiatric diagnoses did not increase odds of regular CU. Findings suggest certain patient groups with mental illness may be at risk of engaging in high frequency use in the context of legislation implying medical benefits of cannabis.

Measuring and understanding "quality of life" among emerging adults in a substance use program.

OBJECTIVE: This work focuses on understanding quality of life and evaluating a brief quality of life measure in an outpatient emerging adult (17-25 years of age) substance use program. METHOD: Mixed methods were used including: (a) psychometric evaluation of the adapted MyLifeTracker (MLT) based on assessments completed four times throughout treatment (n = 100) and (b) qualitative interviews with 12 emerging adults in the program. The study was codesigned, cofacilitated, and cointerpreted with emerging adults with lived experience. RESULTS: At intake, emerging adults reported quality of life scores of 3.7/10 on average and significantly improved (change M = 2.1 points, d = 0.86, p < .001) at the ∼12-week follow-up demonstrating program effects and sensitivity to change. Factor analysis suggested unidimensionality of the measure and internal consistency was high (ω = 0.81). MLT scores correlated in expected directions with other measures of quality of life, functioning, and mental health symptoms and demonstrated incremental validity in explaining variability in these measures over and above World Health Organization quality of life items. Emerging adults thought the five items (i.e., general well-being, day-to-day activities, relationships with friends, relationships with family, coping) generally captured the most important aspects of quality of life to them and had positive impressions regarding the use of this measure for measurement-based care. Other important aspects of quality of life included feeling a sense of meaning, purpose, motivation, and independence. CONCLUSION: Overall, the MLT demonstrated evidence of psychometric and content validity among emerging adults in substance use treatment. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Reward learning capacity in a community sample of individuals who use cannabis.

Cannabis use has been linked to deficient reward processing; however, little is known about its relation to the specific construct of reward learning, in which behavior is modified through associating novel stimuli with a positive outcome. The probabilistic reward task was used to objectively evaluate reward learning in 38 individuals who use recreational cannabis and 34 control comparison participants from the community. Reward learning was evidenced by the development of a response bias, which indicates the propensity to modulate behavior as a function of prior reinforcement. Both cannabis and control groups demonstrated reward learning, with no group differences in response bias development. Among cannabis participants, trending significant relationships between greater chronicity, r(36) = -.30, p = .077, self-reported potency, r(19) = -.33, p = .052, and poorer reward learning were found. Nonsignificant relationships were found between reward learning and frequency, age of initiation, weekly quantity or Cannabis Use Disorder Identification Test-Revised (CUDIT-R) scores (all p > .05). The ability to form noncannabis reward associations is promising for the success of therapeutic interventions for problematic cannabis use; however, indications of severity of use in relation to poorer reward learning suggests a need for a better pharmacological and pharmacokinetic understanding of cannabis. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Anti-craving medications for alcohol use disorder treatment in the emergency department: A systematic review of direct evidence for SAEM GRACE.

OBJECTIVES: Alcohol-related concerns commonly present to the emergency department (ED), with a subset of individuals experiencing the symptoms of an alcohol use disorder (AUD). As such, examining the efficacy of pharmacological anti-craving treatment for AUD in the ED is of increasing interest. The objective of this systematic review was to evaluate the direct evidence assessing the efficacy of providing anti-craving medications for AUD treatment in the ED. METHODS: A systematic search was conducted according to the patient-intervention-control-outcome question: (P) adults (≥18 years old) presenting to the ED with an AUD (including suspected AUD); (I) anti-craving medications (i.e., naltrexone, acamprosate, gabapentin); (C) no prescription or placebo; (O) reduction of repeat ED visits, engagement in addiction services, reductions in heavy drinking days, reductions in any drinking and amount consumed (or abstinence), and in relapse. Two reviewers independently assessed articles for inclusion and conducted risk of bias assessments for included studies. RESULTS: From 143 potentially relevant articles, 6 met inclusion criteria: 3 clinical trials, and 3 case studies. The clinical trials identified evaluated oral versus extended-release naltrexone, monthly extended-release naltrexone injections, and disulfiram. Both oral and extended-release naltrexone resulted in decreased alcohol consumption. Monthly extended-release naltrexone injections resulted in significant improvements in drinking and quality of life. Although out of scope, the disulfiram studies identified did not result in an improvement in drinking in comparison to no medication. CONCLUSIONS: Overall, there are few studies directly examining the efficacy of anti-craving medications for AUD in the ED, although the limited evidence that exists is supportive of naltrexone pharmacotherapy, particularly extended-release injection formulation. Additional randomized controlled trials are necessary for substantive direct evidence on anti-craving medication initiation in the ED.

Phenobarbital for alcohol withdrawal management in the emergency department: A systematic review of direct evidence for the SAEM GRACE initiative.

OBJECTIVES: Alcohol withdrawal syndrome (AWS) is a commonly presenting condition in the emergency department (ED) and can have severe complications, including mortality. Benzodiazepines are first-line medications for treating AWS but may be unavailable or insufficient. This systematic review evaluates the direct evidence assessing the utility of phenobarbital for treating AWS in the ED. METHODS: A systematic search was conducted and designed according to the patient-intervention-comparator-outcome (PICO) question: (P) adults (≥18 years old) presenting to the ED with alcohol withdrawal; (I) phenobarbital (including adjunctive); (C) benzodiazepines or no intervention; and (O) AWS complications, admission to a monitored setting, control of symptoms, adverse effects, and adjunctive medications. Two reviewers independently assessed articles for inclusion and conducted risk of bias assessments for included studies. RESULTS: From 70 potentially relevant articles, seven studies met inclusion criteria: three retrospective cohort studies, two retrospective chart reviews, and two randomized controlled trials (RCTs), one examining phenobarbital monotherapy and one examining adjunctive phenobarbital. Across the retrospective cohort studies, treatment of AWS with phenobarbital resulted in lower odds of a subsequent ED visit. The retrospective chart reviews indicated that phenobarbital was associated with higher discharge rate compared to benzodiazepine-only treatments. For the two RCTs, phenobarbital did not differ significantly from benzodiazepine for most outcomes, although concomitant treatment with phenobarbital was associated with lower benzodiazepine use and intensive care unit admission. The heterogeneous designs and small number of studies prevented quantitative synthesis. CONCLUSIONS: Relatively few studies provide direct evidence on the utility of phenobarbital for AWS in the ED, but the evidence that exists generally suggests that it is a reasonable and appropriate approach. Additional RCTs and other methodologically rigorous investigations are needed for more definitive direct evidence.

Initial insights from a quality improvement initiative to develop an evidence-informed young adult substance use program.

High rates of substance misuse during emerging adulthood (~17-25 years of age, also referred to as young adulthood) require developmentally appropriate clinical programs. This article outlines: 1) the development of an evidence-informed young adult outpatient substance use program that takes a biopsychosocial patient-centred approach to care; 2) a quality improvement process and protocol; and 3) the patient characteristics of an initial cohort. Literature reviews, program reviews, environmental scans, and consultations with interested parties (including individuals with lived expertise) were used to develop the program. A 12-week measurement-based care program was developed comprising: 1) individual measurement-based care and motivational enhancement therapy sessions; 2) group programming focused on cognitive behavioural therapy, mindfulness, distress tolerance, and emotional regulation; 3) clinical consultations for diagnostic clarification and/or medication review; and 4) an independent Community Reinforcement Approach Family Training (CRAFT) group for loved ones. A measurement system was concurrently created to collect clinical and program evaluation data at six time points. In the first 21 months of the program, 152 young adults enrolled in the program (mean age = 21 years old, 47% female gender) primarily reporting treatment targets of cannabis (68%) and alcohol (63%) and almost all presenting with co-occurring mental health concerns (95%). The initial cohort who completed the program showed symptom improvements. Collectively, the program demonstrates the feasibility of developing an evidence-informed young adult substance use program using measurement-based care, but also the need for flexibility and ongoing monitoring to meet local needs.

Des taux élevés d'abus de substances durant la vie d'adulte émergente (~17­25 ans d'âge, aussi nommé jeune âge adulte) nécessitent des programmes cliniques appropriés au développement. Cet article présente: 1) le développement d'un programme fondé sur des données probantes sur l'utilisation de substances des jeunes patients ambulatoires qui adopte une approche biopsychosociale axée sur les patients; 2) un processus et un protocole d'amélioration de la qualité; et 3) les caractéristiques du patient d'une cohorte initiale. Les revues de la littérature, les examens de programme, les analyses de l'environnement, et les consultations avec les parties intéressées (notamment les personnes ayant une expertise vécue) ont servi à élaborer le programme. Un programme de soins de 12 semaines basés sur la mesure a été élaboré qui comprend: 1) ides soins individuels basés sur la mesure et des séances de thérapie d'amélioration de la motivation; 2) une programmation de groupe axée sur la thérapie cognitivo-comportementale, la pleine conscience, la tolérance à la détresse, et la régulation émotionnelle; 3) les consultations cliniques pour la clarification du diagnostic et/ou la revue des médicaments; et (4) un groupe indépendant d'Approche de renforcement communautaire Formation familiale (ARCFF) pour les êtres chers. Un système de mesure a été créé simultanément pour recueillir les données cliniques et d'évaluation du programme à six points dans le temps. Dans les 21 premiers mois du programme, 152 jeunes adultes s'y sont inscrits (âge moyen = 21 ans, 47 % de sexe féminin) et déclaraient principalement que les cibles du traitement étaient le cannabis (68 %) et l'alcool (63 %) et presque tous présentaient des problèmes de santé mentale co-occurrents (95 %). La cohorte initiale qui a terminé le programme présentait des améliorations des symptômes. Collectivement, le programme démontre la faisabilité de développer un programme d'utilisation de substances pour jeunes adultes fondé sur des données probantes et utilisant des soins basés sur la mesure, mais également le besoin de flexibilité et de surveillance constante pour répondre aux besoins locaux.

SAEM GRACE: Dopamine antagonists and topical capsaicin for cannabis hyperemesis syndrome in the emergency department: A systematic review of direct evidence.

BACKGROUND: Adults with cannabis hyperemesis syndrome (CHS) are increasingly presenting to the emergency department (ED), and this systematic review will evaluate the direct evidence on the effectiveness of capsaicin and dopamine antagonists in its clinical management. METHODS: A bibliographic search was conducted to address the following population-intervention-control-outcome (PICO) question: (P) adults >18 years old with a diagnosis of acute CHS presenting to the ED; (I) dopamine antagonists (e.g., haloperidol, droperidol) and topical capsaicin; (C) usual care or no active comparator; and (O) symptoms improvement/resolution in ED, ED length of stay, admission rate, ED recidivism, need for rescue medication, and adverse events. This systematic review was conducted in accordance with PRISMA reporting recommendations. RESULTS: From 53 potentially relevant articles, seven articles were included: five observational studies and two randomized controlled trials, including a total of 492 patients. Five of these studies evaluated the efficacy of capsaicin cream (n = 386), and two examined dopamine antagonists (haloperidol, droperidol; n = 106). There was mixed evidence for the efficacy of capsaicin for reducing nausea and emesis. Both studies evaluating dopamine antagonists detected clinical benefit to usual care or no active comparator. CONCLUSIONS: There is limited direct evidence on the efficacy of dopamine antagonists or capsaicin for treating CHS in the ED. Current evidence is mixed for capsaicin and potentially beneficial for dopamine antagonists. Because of the small number of studies, small number of participants, lack of standardization of treatment administration, and risk of bias of the included studies, methodologically rigorous trials on both types of intervention are needed to directly inform ED management of CHS.