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Rates of cannabis use have been rising in the US due to the increasing legalization/decriminalization of cannabis products for medical and recreational use. Individuals with attention-deficit hyperactivity disorder (ADHD) may be at an increased risk of experiencing cannabis use problems due to deficits in self-regulation. This article explores motivations for cannabis use in ADHD populations. Research on the neural correlates and therapeutic potential of cannabis use are reviewed.

Cognitive behavioral therapy (CBT) is an effective treatment for alcohol use disorder (AUD). We hypothesized that the dorsolateral prefrontal cortex (DLPFC), a brain region implicated in cognitive control and goal-directed behavior, plays a role behavior change during CBT by facilitating regulation of craving. To examine this, treatment-seeking participants with AUD (N=22) underwent functional MRI scanning both before and after a 12-week single-arm trial of CBT, using a regulation of craving (ROC) fMRI task designed to measure an individual’s ability to control alcohol craving and previously shown to engage the DLPFC. We found that both the number of heavy drinking days (NHDD, the primary clinical outcome) and the self-reported alcohol craving measured during the ROC paradigm were significantly reduced from pre- to post-CBT [NHDD: t=15.69, p

Objective:The COVID-19 pandemic has dramatically affected health care delivery, effects that are juxtaposed with health care professional (HCP) burnout and mental distress. The Opioid Use Disorder ...

This study aims to describe which substance use service (SUS) organizations and who within these organizations support the maintenance of policies targeted at improving substance use treatment services. An online survey assessing respondent, organizational and program demographics, and knowledge and support regarding policy changes was distributed to all certified SUS and harm reduction programs in NYS. Bivariate and latent class analyses were used to identify patterns and associations to policy choices. Across the 227 respondents, there was a support for maintaining expansion of insurance coverage, virtual behavioral health/counseling and medication initiation/maintenance visits, reductions in prior authorizations, and access to prevention/harm reduction services. Three classes of support for policies were derived: (1) high-supporters (n = 49; 21%), (2) low-supporters (n = 66; 29%), and (3) selective-supporters. Having knowledge of policy changes was associated with membership in the high-supporters class. Implications regarding the role of knowledge in behavioral health policies dissemination structures, decision-making, and long-term expansion of SUS are discussed.

Zusammenfassung. Hintergrund: Eine Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung (ADHS) im Kindesalter stellt einen Risikofaktor für Substanzmissbrauch und Störungen durch Substanzgebrauch (Substance Use Disorder, SUD) in der Pubertät und dem (frühen) Erwachsenenalter dar. ADHS und SUD treten auch häufig bei therapiesuchenden Jugendlichen auf, was die Diagnosestellung und Therapie erschwert sowie mit schlechten Behandlungsergebnissen verbunden ist. Forschungsergebnisse über die Wirkung der Behandlung von ADHS im Kindesalter auf die Prävention von SUD im Jugendalter sind nicht eindeutig und Studien über die Diagnose und Behandlung von Jugendlichen mit ADHS und SUD sind selten. Daher reicht die verfügbare Evidenz allgemein nicht aus, um starke Behandlungsempfehlungen zu rechtfertigen. Fragestellung: Ziel dieser Arbeit war es, eine Konsenserklärung auf der Grundlage von wissenschaftlichen Daten und klinischen Erfahrungen zu erhalten. Methodik: Es wurde eine modifizierte Delphi-Studie durchgeführt, um basierend auf der Kombination von wissenschaftlichen Daten und klinischer Erfahrung mit einer multidisziplinären Gruppe von 55 Expert_innen aus 17 Ländern einen Konsens zu erzielen. Die Expert_innen wurden gebeten, eine Reihe von Aussagen über die Wirkung der Behandlung von ADHS im Kindesalter auf die SUD bei Jugendlichen sowie über das Screening, die Diagnostik und die Behandlung von Jugendlichen mit komorbidem ADHS und SUD zu bewerten. Ergebnisse: Nach drei iterativen Bewertungsrunden und der Anpassung von 37 Aussagen wurde ein Konsens über 36 dieser Aussagen erzielt, die sechs Bereiche repräsentieren: allgemein ( n = 4), Risiko der Entwicklung einer SUD ( n = 3), Screening und Diagnostik ( n = 7), psychosoziale Behandlung ( n = 5), pharmakologische Behandlung ( n = 11) und komplementäre Behandlungen ( n = 7). Der Einsatz von Routinescreenings auf ADHS wird bei adoleszenten Patient_innen in einer Suchtbehandlung ebenso wie Routinescreenings auf SUD bei jugendlichen Patient_innen mit ADHS in allgemeinpsychiatrischen Therapiesettings empfohlen. Langwirksame Stimulanzien werden als Behandlung der ersten Wahl von ADHS bei Jugendlichen mit gleichzeitiger ADHS und SUD empfohlen. Die Pharmakotherapie sollte vorzugsweise in psychosoziale Behandlung eingebettet werden. Die einzige nichtkonsentierte Aussage betraf die Notwendigkeit von Abstinenz vor Beginn einer pharmakologischen Behandlung bei Jugendlichen mit ADHS und gleichzeitigem SUD. Im Gegensatz zur Mehrheit verlangten einige Expert_innen eine vollständige Abstinenz vor Beginn einer pharmakologischen Behandlung, einige waren gegen die Verwendung von Stimulanzien bei der Behandlung dieser Patient_innen (unabhängig von Abstinenz), während einige sich gegen die alternative Anwendung von Bupropion aussprachen. Schlussfolgerungen: Diese internationale Konsenserklärung kann von Kliniker_innen und Patient_innen zusammen in einem gemeinsamen Entscheidungsprozess genutzt werden, um die besten Interventionen auszuwählen und die bestmöglichen Ergebnisse bei adoleszenten Patient_innen mit gleichzeitiger ADHS und SUD zu erzielen.

Chronic pain, pain catastrophizing, and mental health disorders such as anxiety or depression frequently occur together and are challenging to treat. To help understand the relationship between these conditions, we sought to identify distinct phenotypes associated with worse pain and function. In a cohort of people with chronic pain on opioids seeking medical cannabis in New York, we conducted latent class analysis to identify clusters of participants based on pain catastrophizing and mental health symptoms of depression, anxiety, post-traumatic stress disorder (PTSD) and attention deficit/hyperactivity disorder (ADHD). We then compared clusters with respect to sociodemographic and clinical characteristics using descriptive statistics. Among 185 participants, we identified four discrete groups: low pain catastrophizing and low mental health symptoms (49% of participants), low pain catastrophizing and ADHD-predominant mental health symptoms (11%), high pain catastrophizing and anxiety-predominant mental health symptoms (11%), and high pain catastrophizing and high mental health symptoms (30%). The group with high pain catastrophizing and high mental health symptoms had the worst pain intensity and interference, disability, insomnia, and quality of life, compared to the two groups with lower pain catastrophizing, though not all differences were statistically significant. Our findings highlight the importance of identifying and addressing pain catastrophizing in patients with comorbid chronic pain and mental health symptoms.

ImportanceNovel treatments for opioid use disorder (OUD) are needed to address both the ongoing opioid epidemic and long-standing barriers to existing OUD treatments that target the endogenous μ-opioid receptor (MOR) system. The goal of this review is to highlight unique clinical trial design considerations for the study of emerging treatments for OUD that address targets beyond the MOR system. In November 2019, the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership with the US Food and Drug Administration sponsored a meeting to discuss the current evidence regarding potential treatments for OUD, including cannabinoids, psychedelics, sedative-hypnotics, and immunotherapeutics, such as vaccines.ObservationsConsensus recommendations are presented regarding the most critical elements of trial design for the evaluation of novel OUD treatments, such as: (1) stage of treatment that will be targeted (eg, seeking treatment, early abstinence/detoxification, long-term recovery); (2) role of treatment (adjunctive with or independent of existing OUD treatments); (3) primary outcomes informed by patient preferences that assess opioid use (including changes in patterns of use), treatment retention, and/or global functioning and quality of life; and (4) adverse events, including the potential for opioid-related relapse or overdose, especially if the patient is not simultaneously taking maintenance MOR agonist or antagonist medications.Conclusions and RelevanceApplying the recommendations provided here as well as considering input from people with lived experience in the design phase will accelerate the development, translation, and uptake of effective and safe therapeutics for individuals struggling with OUD.

Objective To describe first-year trajectories of medical cannabis use and identify characteristics associated with patterns of use in a cohort of adults using opioids for chronic pain. Design Latent class trajectory analysis of a prospective cohort study using data on the 14-day frequency of medical cannabis use. Setting A large academic medical center and four medical cannabis dispensaries in the New York City metropolitan area. Subjects Adults with chronic pain using opioids and newly certified for medical cannabis in New York between 2018 and 2020. Methods Using latent class trajectory analysis, we identified clusters of participants based on the 14-day frequency of medical cannabis use. We used logistic regression to determine factors associated with cluster membership, including sociodemographic characteristics, pain, substance use, and mental health symptoms. Results Among 99 participants, the mean age was 53 years; 62% were women, and 52% were White. We identified three clusters of medical cannabis use: infrequent use (n = 30, mean use = 1.5 days/14-day period), occasional use (n = 28, mean = 5.7 days/14-day period), and frequent use (n = 41, mean = 12.1 days/14-day period). Within clusters, use patterns did not vary significantly over 52 weeks. Differences were observed in two sociodemographic variables: Frequent (vs infrequent) use was associated with non-Hispanic White race/ethnicity (adjusted odds ratio 4.54, 95% confidence interval 1.49–14.29), while occasional (vs infrequent) use was associated with employment (adjusted odds ratio 13.84, 95% confidence interval 1.21–158.74). Conclusions Three clusters of medical cannabis use patterns emerged and were stable over time. Results suggest that structural factors related to race/ethnicity and employment may be major drivers of medical cannabis use, even among adults certified for its use.

ImportanceCannabis use is increasingly viewed by adolescents as not harmful. Youths with cannabis use disorder (CUD) are recognized by clinicians as being at risk for adverse outcomes, yet little is known about the associations between subclinical cannabis use (ie, nondisordered cannabis use [NDCU]) and adverse psychosocial events.ObjectiveTo describe the prevalence and demographics of NDCU and to compare associations of cannabis use with adverse psychosocial events among adolescents with no cannabis use, NDCU, and CUD.Design, Setting, and ParticipantsThis cross-sectional study used a nationally representative sample derived from the 2015 to 2019 National Survey on Drug Use and Health. Participants were adolescents aged 12 to 17 years, separated into 3 distinct groups: nonuse (no recent cannabis use), NDCU (recent cannabis use below diagnostic threshold), and CUD. Analysis was conducted from January to May 2022.ExposuresCUD, NDCU, or cannabis nonuse. NDCU was defined as endorsing recent cannabis use but not meeting the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) CUD criteria. CUD was defined using DSM-5 criteria.Main Outcomes and MeasuresThe main outcomes were prevalence of adolescents meeting criteria for NDCU and associations between adverse psychosocial events and NDCU, adjusted for sociodemographic characteristics.ResultsThe 68 263 respondents (mean [SD] age, 14.5 [1.7] years; 34 773 [50.9%] males) included in the analysis represented an estimated yearly mean of 25 million US adolescents during 2015 to 2019. Among respondents, 1675 adolescents (2.5%) had CUD, 6971 adolescents (10.2%) had NDCU, and 59 617 adolescents (87.3%) reported nonuse. Compared with nonusers, individuals with NDCU had approximately 2 to 4 times greater odds of all adverse psychosocial events examined, including major depression (adjusted odds ratio [aOR], 1.86; 95% CI, 1.67-2.08), suicidal ideation (aOR, 2.08; 95% CI, 1.88-2.29), slower thoughts (aOR, 1.76; 95% CI, 1.58-1.96), difficulty concentrating (aOR, 1.81; 95% CI, 1.65-2.00), truancy (aOR, 1.90; 95% CI, 1.67-2.16), low grade point average (aOR, 1.80; 95% CI, 1.62-2.00), arrest (aOR, 4.15; 95% CI, 3.17-5.43), fighting (aOR, 2.04; 95% CI, 1.80-2.31), and aggression (aOR, 2.16; 95% CI, 1.79-2.62). Prevalence of adverse psychosocial events was greatest for adolescents with CUD (range, 12.6% to 41.9%), followed by NDCU (range, 5.2% to 30.4%), then nonuse (range, 0.8% to 17.3%).Conclusions and RelevanceIn this cross-sectional study of US adolescents, past-year NDCU was approximately 4 times as prevalent as past-year CUD. A stepwise gradient association was observed for odds of adverse psychosocial events between adolescent NDCU and CUD. In the context of US normalization of cannabis use, prospective research into NDCU is necessary.

The size of the physician-scientist workforce has declined for the past 3 decades, which raises significant concerns for the future of biomedical research. There is also a considerable gender disparity among physician-scientists. This disparity is exacerbated by race, resulting in a compounding effect for women of color. Proposed reasons for this disparity include the time and expense physicians must devote to obtaining specialized research training after residency while at the same time burdened with mounting medical school debt and domestic and caretaking responsibilities, which are disproportionately shouldered by women. These circumstances may contribute to the overall gender disparity in research funded by the National Institutes of Health (NIH). Women apply for NIH grants less often than men and are therefore less likely to receive an NIH grant. However, when women do apply for NIH grants, their funding success is comparable to that of men. Increasing representation of women and groups underrepresented in medicine (UIM) requires not only improving the pipeline (e.g., through training) but also assisting early and midcareer women-and especially women who are UIM-to advance. In this article, the authors propose the following solutions to address the challenges women and other UIM individuals face at each of these career stages: developing specific NIH research training programs targeted to women and UIM individuals in medical school and residency; creating institutional and individual grant initiatives; increasing student loan forgiveness; setting up robust institutional mentorship programs for individuals seeking to obtain independent funding; providing childcare stipends as part of NIH grants; and instituting an NIH requirement that funded investigators participate in efforts to increase diversity in the physician-scientist workforce. Enabling more women and UIM individuals to enter and thrive in the physician-scientist workforce will increase the size and diversity of this critical component of biomedical research.

BACKGROUND Despite advances in the development of pharmacotherapy for alcohol use disorder (AUD), there remains a need for medications that can be administered to actively drinking outpatients to promote a reduction in harmful alcohol consumption. The primary aim of this pilot study was to determine whether high-dose gabapentin (3600 mg/daily) is more effective than placebo in reducing harmful alcohol consumption in outpatients with AUD. METHODS Forty patients (27 men) who met DSM-IV-TR criteria for alcohol dependence and reporting at least 4 heavy drinking days (HDD) per week were recruited at a single site. Participants were actively drinking at study entry and received double-blind gabapentin (3600 mg/day; n = 19) or placebo (n = 20) for 8 weeks. Study medication was titrated over 5 days and administered in three divided doses (1200 mg three times per day). The proportion of HDD (primary outcome) and percent days abstinent (PDA; secondary outcome) were analyzed using generalized longitudinal mixed models with the predictors being study arm, week, study arm by week interaction, and corresponding baseline drinking measure. RESULTS There was a significant interaction between study arm and week for the proportion of HDD per week, F (7, 215) = 3.33, p = 0.002 . There was also a significant interaction between study arm and week for PDA per week, F (7, 215) = 3.11, p = 0.004. The overall retention rate was 67.5% with no significant difference in time-to-dropout between treatment groups. There were no serious adverse events. No participants were removed from the trial due to the development of moderate-to-severe alcohol withdrawal (CIWA-Ar ≥ 13). CONCLUSIONS Gabapentin treatment rapidly titrated to a dosage of 3600 mg/day is associated with a reduction in the proportion of HDD per week and an increase in PDA per week in actively drinking outpatients with AUD. High-dose gabapentin is potentially a feasible approach to treating AUD and deserving of further study.

Objective Attention-deficit/hyperactivity disorder (ADHD) is an established risk factor for developing alcohol use disorder (AUD), and AUD-ADHD comorbidity is associated with additional psychiatric diagnoses. Several lines of evidence support the role of impulsivity as a pathway of these relationships; however, impulsivity is not a unitary construct. Thus, we sought to explore whether separate aspects of impulsivity may explain the relationship between ADHD symptoms and psychiatric comorbidity among inpatients (N = 136) with AUD. Methods: We assessed ADHD symptoms (childhood ADHD [Wender Utah Rating Scale], adult ADHD [Adult ADHD self-report scale]), health-related quality of life (HRQL; EQ-5D-5L), psychiatric comorbidity (Mini International Neuropsychiatric Interview), and impulsive personality traits (Urgency, Premeditation, Perseverance, Sensation seeking [UPPS] scale). Results: 19% of patients screened positive in the retrospective assessment of childhood ADHD, and 17% for adult ADHD. Participants reported moderate levels of problem severity in the HRQL dimensions, and 65% had ≥1 current psychiatric disorders other than AUD and ADHD. Multiple mediation indicated that there was a significant direct effect of childhood ADHD symptoms on psychiatric comorbidity (β = 0.224, 95% CI [0.080, 1.114]), and indirect effects of both reacting impetuously when experiencing negative emotions (negative urgency; β = 0.999, 95% CI [0.043, 0.461]) and the tendency to not finish tasks (lack of perseverance; β = 0.075, 95% CI [0.002, 0.297]). Conclusions: The subcomponents of impulsivity to react rashly when experiencing negative emotions and the tendency to not persist in activities seem to contribute to the relationship between ADHD symptoms (particularly those in childhood) and psychiatric comorbidity among patients with severe AUD.

Stimulant medication use is common among individuals receiving buprenorphine for opioid use disorder (OUD). Associations between prescription stimulant use and treatment outcomes in this population have been understudied.To investigate whether use of prescription stimulants was associated with (1) drug-related poisoning and (2) buprenorphine treatment retention.This retrospective, recurrent-event cohort study with a case-crossover design used a secondary analysis of administrative claims data from IBM MarketScan Commercial and Multi-State Medicaid databases from January 1, 2006, to December 31, 2016. Primary analyses were conducted from March 1 through August 31, 2021. Individuals aged 12 to 64 years with an OUD diagnosis and prescribed buprenorphine who experienced at least 1 drug-related poisoning were included in the analysis. Unit of observation was the person-day.Days of active stimulant prescriptions.Primary outcomes were drug-related poisoning and buprenorphine treatment retention. Drug-related poisonings were defined using International Classification of Diseases, Ninth Revision, and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, codes; treatment retention was defined by continuous treatment claims until a 45-day gap was observed.There were 13 778 567 person-days of observation time among 22 946 individuals (mean [SD] age, 32.8 [11.8] years; 50.3% men) who experienced a drug-related poisoning. Stimulant treatment days were associated with 19% increased odds of drug-related poisoning (odds ratio [OR], 1.19 [95% CI, 1.06-1.34]) compared with nontreatment days; buprenorphine treatment days were associated with 38% decreased odds of poisoning (OR, 0.62 [95% CI, 0.59-0.65]). There were no significant interaction effects between use of stimulants and buprenorphine. Stimulant treatment days were associated with decreased odds of attrition from buprenorphine treatment (OR, 0.64 [95% CI, 0.59-0.70]), indicating that stimulants were associated with 36% longer mean exposure to buprenorphine and its concomitant protection.Among persons with OUD, use of prescription stimulants was associated with a modest increase in per-day risk of drug-related poisoning, but this risk was offset by the association between stimulant use and improved retention to buprenorphine treatment, which is associated with protection against overdose.

Individuals with opioid use disorder (OUD) suffer disproportionately from COVID-19. To inform clinical management of OUD patients, research is needed to identify characteristics associated with COVID-19 progression and death among this population. We aimed to investigate the role of OUD and specific comorbidities on COVID-19 progression among hospitalized OUD patients.Retrospective cohort study of merged electronic health records (EHR) from five large private health systems SETTING: New York City, New York, USA, 2011-2021 PARTICIPANTS: Adults with a COVID-19 encounter and OUD or opioid overdose diagnosis between March 2020-February 2021 MEASUREMENTS: Primary exposure included diagnosis of OUD/opioid overdose. Risk factors included age, sex, race/ethnicity and common medical, substance use and psychiatric co-morbidities known to be associated with COVID-19 severity. Outcomes included COVID-19 hospitalization and subsequent intubation, acute kidney failure, severe sepsis and death.Of 110,917 COVID-19+ adults, 1.17% were ever diagnosed with OUD/opioid overdose. OUD patients had higher risk of COVID-19 hospitalization (adjusted risk ratio [aRR]: 1.40 [95% confidence interval (CI) 1.33, 1.47]), intubation (adjusted aood ratio [aOR]: 2.05 [95% CI 1.74, 2.42]), kidney failure (aRR: 1.51 [95% CI 1.34, 1.70)), sepsis (aRR: 2.30 [95% CI 1.88, 2.81]), and death (aRR: 2.10 [95% CI 1.84, 2.40)]. Among hospitalized OUD patients, risks for COVID-19 outcomes included being male; older; of a race/ethnicity other than white, Black or Hispanic; and having co-morbid chronic kidney disease, diabetes, obesity or cancer. Protective factors included having asthma, hepatitis-C, and chronic pain.Opioid use disorder patients appears to have a substantial risk for COVID-19-associated morbidity and mortality, with particular comorbidities and treatments potentially moderating this risk.

BACKGROUND: Cocaine use disorder (CUD) is a substantial public health problem with no FDA-approved medication treatments. Psychostimulants have shown promise as pharmacotherapy for CUD. Lisdexamfetamine, a novel prodrug psychostimulant, is roughly 40–50% as potent as dextroamphetamine. OBJECTIVES: To evaluate the safety, tolerability, and optimal dosing of lisdexamfetamine for treating CUD. METHODS: Open-label, 8-week trial of 17 CUD adults. Participants were titrated to the maximum tolerated dose of 140 mg over 2-week period and maintained for 4 weeks, followed by a two-week taper period. The primary outcome measures were the maximum daily dose achieved during the study period and tolerability as measured by medication-related study drop-out. RESULTS: Among the 16 participants with post-enrollment data, the mean dose of lisdexamfetamine achieved was 118.1 mg (standard deviation (SD) = 40.4), mean retention was 6.5 weeks (SD = 2.0), and no participants discontinued study medication due to adverse effects. Four participants had dose reductions due to adverse effects and continued in the trial. Six participants (37.5%) were abstinent for the last 3 weeks of their study participation. Mean dollars of cocaine spent per day significantly decreased from $19.72 at baseline to $7.57 during the last 3 weeks of study participation (t(15) = 3.60, p = .003). The mean percent of using days significantly decreased from 25% at baseline to 12% during the last 3 weeks of study participation (t(15) = 3.33, p = .005). CONCLUSION: The use of lisdexamfetamine for CUD in doses ranging to 140 mg daily was safe and generally well tolerated.

Substance use disorders (SUD) are chronic relapsing medical conditions characterised by compulsive substance seeking and use. They constitute a substantial disease burden globally. Labelling of persons with SUD has created barriers to treatment but there are effective management strategies. The dental profession has embraced reforms designed to address the SUD epidemic by promoting continuing education for practitioners and initiating curriculum changes in dental schools. Screening, Brief Intervention and Referral to Treatment (SBIRT) is an evidence-based model for managing patients with SUD. The use of a formative 1-station Objective Structured Clinical Examination (OSCE) for learning and assessment in SBIRT, operationalised with the MD3 rating scale is presented in this study. In 3 years of implementation, the SBIRT OSCE successfully integrated into the curriculum of the College of Dental Medicine, Columbia University. Mean score of total adherent behaviours was 11.80 (SD =4.23) (range: 2 – 24) and Cronbach’s coefficient alpha for across-items reliability in adherent behaviours was 0.66. Adherent behaviours correlated with the global ratings (r = 0.66). Mean of global rating scores were 2.90 (SD =1.01) for collaboration and 2.97 (SD =1.00) for empathy and the global rating scores correlated with each other (r = 0.85). Histograms of global rating scores resembled normal distribution. The 1-station OSCE is a good model for learning about SBIRT. Psychometric analysis was useful in understanding the underlying construct of the MD3 rating scale and supported its reliability, validity and utility in dental education.

Sub-anesthetic ketamine infusions may benefit a range of psychiatric conditions, including alcohol and cocaine use disorders. Currently, there are no effective pharmacological treatments for cannabis use disorder.The objective of this uncontrolled proof of concept trial was to test the feasibility, tolerability, and potential therapeutic effects of integrating ketamine infusions with a behavioral platform of motivational enhancement therapy and mindfulness-based relapse prevention in treating cannabis use disorder (CUD).Eight cannabis-dependent individuals (four female, four male) receiving motivational enhancement therapy and mindfulness-based relapse prevention behavioral treatments completed this single-blind outpatient 6-week study. Participants received either one or two infusions of ketamine (0.71 mg/kg [infusion 1]; 1.41 mg/kg [infusion 2] for non-responders) during the study. Participants self-reported cannabis use (Timeline Follow-Back) and underwent an assessment of confidence in abstaining from using cannabis (Drug-Taking Confidence Questionnaire) at predetermined time points throughout the study.Ketamine infusions were well-tolerated and there were no adverse events. Frequency of cannabis use decreased significantly from baseline (B = 5.1, s.e = 0.7) to the week following the first infusion (B = 0.8, s.e = 0.412), and remained reduced at the end of the study (B = 0.5, s.e = 0.3). Participants' confidence in their ability to abstain from cannabis in potentially triggering situations increased significantly from baseline to the end of study.These findings suggest that combining ketamine with behavioral therapy is feasible,tolerable, and potentially helpful, in treating cannabis-dependent individuals.

As a result of the coronavirus 2019 (Covid-19) pandemic, clinical research for substance use disorders (SUDs) has been impeded due to widespread stay-at-home mandates limiting the operations of "non-essential" work. Although appropriate to proceed with an abundance of caution to prevent viral spread, there will be detrimental consequences for patients with SUDs if clinical trials research cannot adapt and continue uninterrupted. The field of digital health has strong evidence for its feasibility and effectiveness and offers tools that can facilitate the continuation of SUD clinical trials research remotely in accordance with Covid-19 precautions. Some digital tools have been used as components of SUD research in the past; however, no published clinical trial in SUDs to-date has been entirely virtual. This has important implications for disrupted clinical care, as providers seek guidelines for best digital practices. This paper provides a roadmap for integrating the fields of digital health and SUD clinical trials by proposing methods to complete recruitment, screening, informed consent, other study procedures, and internal lab operations digitally. The immediate future of SUD research depends on the ability to comply with social distancing. Investment in research of digital clinical trials for SUDs provides an opportunity to cultivate benefits for research and clinical care long-term as we can (1) define regulatory requirements for the implementation of digital systems, (2) develop consensus on system-wide standards and protocols in the appropriate use of technology, and (3) gain experience that can translate to the treatment of patients with SUDs through telehealth in the community.

The treatment of opioid withdrawal is an important area of clinical concern when treating patients with chronic, non-cancer pain, patients with active opioid use disorder, and patients receiving medication for opioid use disorder. Current standards of care for medically supervised withdrawal include treatment with μ-opioid receptor agonists, (eg, methadone), partial agonists (eg, buprenorphine), and α2-adrenergic receptor agonists (eg, clonidine and lofexidine). Newer agents likewise exploit these pharmacological mechanisms, including tramadol (μ-opioid receptor agonism) and tizanidine (α2 agonism). Areas for future research include managing withdrawal in the context of stabilising patients with opioid use disorder to extended-release naltrexone, transitioning patients with opioid use disorder from methadone to buprenorphine, and tapering opioids in patients with chronic, non-cancer pain.

Background and objectives Highly potent synthetic opioids (HPSO) are increasingly responsible for opioid overdose deaths in the United States. Methods In an open-label, uncontrolled trial to test the feasibility of extended-release buprenorphine (BXR) injection treatment of heroin-using individuals with opioid use disorder testing positive for HPSO, participants were enrolled and began an induction with sublingual BXR (n = 5). During the induction, ancillary medications (clonidine, clonazepam, zolpidem, and prochlorperazine) were provided for breakthrough opioid withdrawal symptoms. Results Two participants received the BXR injection on the second day of the induction and three participants on the third day. Discussion and conclusion All five participants were retained at least 1-month postinduction. Scientific significance It may be feasible to provide BXR treatment to HPSO-positive heroin users rapidly to achieve clinical stabilization. (Am J Addict 2020;00:00-00).

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based model for managing patients with substance use disorders (SUD). Historically, SUD were seen as a criminal issue and access to treatment was limited, but that paradigm is shifting and substance abuse is now being recognized as a disease state and the management of patients with SUD is increasingly within the healthcare system starting with primary healthcare settings including dental facilities. In a new training initiative, first-year dental students (DDS1) attended a 90-minute SBIRT training. An Attitudes and Opinion Survey (AOS) consisting of 8 questions that separately assesses DDS1 attitudes toward alcohol and drug use disorders was utilized to evaluate the training. Assenting DDS1 anonymously completed the AOS before and following the training. Over 3 years, we analyzed changes in the AOS of 230 DDS1 using Chi-squared test for bivariate comparison. We then applied a Bonferroni correction to the P-values. Response rate was 95.5%. The SBIRT training improved DDS1 attitudes and opinions toward patients with SUD with respect to all AOS questions. There was a statistically significant improvement (P < 0.003) in DDS1 attitudes and opinions with respect to whether other patients care suffers because of time and resources spent on patients with SUD and whether the SBIRT training provided adequate education to prepare DDS1 to manage patients with SUD. SBIRT training is relevant to dental education. It fills an important educational gap and is a suitable model for other dental schools.

Among opioid use disorder (OUD)-treating providers, to characterize adaptations used to provide medications for OUD (MOUD) and factors associated with desire to continue virtual visits post-COVID-19 pandemic.In a national electronic survey of OUD-treating prescribers (July-August 2020), analyses restricted to X-waivered buprenorphine prescribers providing outpatient, longitudinal care for adults with OUD, quantitative and qualitative analyses of survey items and free text responses were conducted.Among 797 respondents, 49% were men, 57% ≥50 years, 76% White, 68% physicians. Respondents widely used virtual visits to continue prescribing existing MOUD regimens (79%), provide behavioral healthcare (71%), and initiate new MOUD prescriptions (49%). Most prescribers preferred to continue/expand use of virtual visits after COVID-19. In multivariable models, factors associated with preference to continue/expand virtual visits to initiate MOUD postpandemic were treating a moderate number of patients prepandemic (aOR = 1.67; 95%[CI] = 1.06,2.62) and practicing in an urban setting (aOR = 2.17; 95%[CI] = 1.48,3.18). Prescribing buprenorphine prepandemic (aOR = 2.06; 95%[CI] = 1.11,3.82) and working in an academic medical center (aOR = 2.47; 95%[CI] = 1.30,4.68) were associated with preference to continue/expand use of virtual visits to continue MOUD postpandemic. Prescribing naltrexone extended-release injection prepandemic was associated with preference to continue/expand virtual visits to initiate and continue MOUD (aOR = 1.51; 95%[CI] = 1.10,2.07; aOR = 1.74; 95%[CI] = 1.19,2.54). Qualitative findings suggest that providers appreciated virtual visits due to convenience and patient accessibility, but were concerned about liability and technological barriers.Surveyed prescribers widely used virtual visits to provide MOUD with overall positive experiences. Future studies should evaluate the impact of virtual visits on MOUD access and retention and clinical outcomes.

Introduction Le trouble du déficit de l’attention/hyperactivité chez l’enfant (TDAH) est un facteur de risque de mésusage et de troubles de l’usage de substances (TUS) chez l’adolescent et le jeune adulte. Le TDAH et le TUS coexistent également fréquemment chez les adolescents en demande de soins, compliquant le diagnostic et le traitement et étant associé à de mauvais résultats thérapeutiques. Les recherches concernant l’effet du traitement du TDAH chez l’enfant sur la prévention du TUS à l’adolescence sont peu concluantes et les études sur le diagnostic et le traitement des adolescents atteints de TDAH et de TUS comorbides sont rares. Ainsi, les preuves disponibles ne sont pas suffisantes pour justifier des recommandations de traitement solides. Objectif Le but de cette étude était d’aboutir à une déclaration de consensus basée sur une combinaison de données scientifiques et d’expérience clinique. Méthode La méthode Delphi modifiée a été utilisée pour parvenir à un consensus basé sur la combinaison de données scientifiques et d’expérience clinique, avec un groupe multidisciplinaire de 55 experts provenant de 17 pays. Les experts ont été invités à évaluer un ensemble d’énoncés portant sur l’effet du traitement du TDAH de l’enfant sur le TUS à l’adolescence ainsi que sur le dépistage, le diagnostic et le traitement des adolescents souffrant de TDAH et de TUS comorbides. Résultats Après trois tours de cotation et d’adaptation de 37 énoncés, un consensus a été atteint sur 36 d’entre eux, représentant six domaines : généralités (n = 4), risque de développer un TUS (n = 3), dépistage et diagnostic (n = 7), prise en charges psychosociales (n = 5), traitement pharmacologique (n = 11) et traitements complémentaires (n = 7). Le dépistage systématique du TDAH est recommandé auprès des patients adolescents vus en addictologie et du TUS auprès des patients adolescents souffrant de TDAH vus en santé mentale. Les stimulants à action prolongée sont recommandés comme traitement de première intention du TDAH chez les adolescents souffrant de la comorbidité TDAH-TUS et la pharmacothérapie doit de préférence être incluse dans une prise en charge psychosociale (psychoéducation, entretien motivationnel, thérapies comportementales et cognitives, prise en charge familiale). L’unique déclaration non consensuelle restante concerne l’exigence d’abstinence avant l’initiation d’un traitement pharmacologique chez les adolescents atteints de TDAH et de TUS concomitants. Contrairement à la majorité des experts, certains exigent une abstinence complète avant de débuter tout traitement pharmacologique, certains se positionnent contre l’utilisation de stimulants dans le traitement de ces patients (indépendamment de l’abstinence), tandis que d’autres n’approuvent pas l’utilisation alternative du bupropion. Conclusion Cette déclaration de consensus internationale peut être utilisée par les cliniciens et les patients dans un processus collaboratif de prise de décision partagée pour sélectionner les meilleures interventions et obtenir des résultats optimaux chez les patients adolescents souffrant de TDAH et de TUS comorbides.

Background Connectivity between the anterior insula (AI) and the bed nucleus of the stria terminalis (BNST) may play a role in negative emotions that drive compulsive drinking in patients with alcohol use disorder (AUD). We hypothesized that reductions in drinking during cognitive behavioral therapy (CBT), an effective treatment that teaches regulation (coping) skills for managing negative emotions during abstinence, would be associated with reductions in resting-state functional connectivity (RSFC) between the AI and the BNST. Methods We included 18 patients with a Diagnostic and Statistical Manual of Mental Disorders, fifth edition diagnosis of AUD who were (1) seeking treatment and (2) drinking heavily at baseline. We measured RSFC as Pearson's correlation between the BNST and multiple regions of interest in the insula at baseline and after completion of 12 weeks of a single-arm clinical trial of outpatient CBT. We also assessed the number of heavy drinking days over the previous 28 days (NHDD) at both time points. We used 1-sample t-tests to evaluate AI-BNST RSFC at baseline, paired t-tests to evaluate changes in AI-BNST RSFC from pre-CBT to post-CBT, and linear regression to evaluate the relationship between changes in AI-BNST RSFC and NHDD. Results We found a significant positive RSFC between the AI and the BNST at baseline (p = 0.0015). While there were no significant changes in AI-BNST RSFC from pre- to post-CBT at the group level (p = 0.42), we found that individual differences in reductions in AI-BNST RSFC from pre- to post-CBT were directly related to reductions in NHDD from pre- to post-CBT (r = 0.73, p = 0.0008). Conclusions These findings provide preliminary evidence that reduced AI-BNST RSFC may be a mechanism of drinking reduction in AUD and that AI-BNST RSFC may be a target for CBT and possibly other treatments.

Background and objectives Fentanyl and other highly potent synthetic opioids are the leading cause of opioid overdose deaths in the United States. Methods This study was an open-label, uncontrolled 12-week outpatient clinical trial to test the feasibility of a single-day induction onto extended-release buprenorphine (BXR) injection treatment for five adults (N = 5) with opioid use disorder using heroin-containing fentanyl. Participants were planned to receive three monthly BXR injections (300, 300, and 100 mg). Results After receiving 24 mg sublingual buprenorphine (SL-BUP), all five participants received the BXR 300 mg injection on the first day of induction. All five participants were retained for the full 3-month study period postinduction and received all three scheduled BXR injections. Discussion and conclusion This study provides preliminary evidence supporting the feasibility of inducting users of heroin-containing fentanyl onto BXR 300 mg in a single day. Scientific significance The ability to administer a long-acting injection of BXR that assures therapeutic serum levels for a month on the first day of treatment contact is a promising development for the treatment of OUD.

Background: There is a need for alcohol use disorder (AUD) pharmacotherapy that can be administered to actively drinking outpatients. Pregabalin, a gabapentoid anticonvulsant, has preliminary evide...

Substance Use Disorders (SUD) are chronic health conditions with heritability characteristics, environmental influences, long-term management considerations and they cooccur. The US opioid epidemic is a crisis of both prescription and nonprescription opioid use. Clinicians now have access to evidence-based practices but the evolving trends require continuous attention including curriculum initiatives for dental schools. The purpose of this study was to obtain information about the content and educational strategies of current SUD curricula, beneficial educational products for a standardized curriculum and perceived barriers toward standardization. Invitations were sent to 64 US dental schools describing the purpose of this study and a link to complete the survey was provided. Fully completed responses were received from 32 (50.0%) of the schools. Descriptive statistics was used to analyze the data. Most dental schools surveyed (81.3%) have a curriculum for SUD with classroom lectures being the most commonly used teaching method (96.2%), followed by online modules (42.3%). About 30% of the responding schools provided additional educational experiences. Instruction occurred mostly in second (73.1%) and third (77.0%) academic years. Opioids, alcohol, nicotine, and marijuana were the most frequently taught substance classes. Curriculum standardization with online modules (81.3%), case-based exercises (59.4%), and simulation with standardized patients (43.8%) was considered desirable to improve student competency in the management of patients with SUD. Lack of time (62.5%), space (56.3%), and faculty (50.0%) were cited as the most common barriers to curriculum initiatives. Experiential and achievable options for improving SUD curriculum were highlighted.

Objective While transgender people report higher rates of risky drinking than the general population, no studies have examined transgender alcohol use longitudinally. This study investigated minority stress and identity development predictors of improvement in risky drinking among transgender individuals. Methods Data come from a multi-site, longitudinal cohort study of U.S. transgender individuals (N = 330) and include measures of enacted stigma, felt stigma, identity development, and risky alcohol use. Theory-driven, hierarchical multivariable logistic regression was used to investigate the hypothesis that minority stress and identity development factors are related to improvement in risky drinking between baseline and 1-year follow-up. Results Baseline risky drinkers (n = 106; 37.1%) were younger and more likely to have female sex assigned at birth. At 1-year follow-up, 68 baseline risky drinkers (64.2%) reported persistent risky drinking, while 38 (35.8%) reported improved drinking. Controlling for demographics and study site, female sex assigned at birth and enacted stigma were associated with lower odds of improved drinking. Non-white/Hispanic race/ethnicity, felt stigma, change in gender role/expression for 1–5 years, and diffuse-avoidant identity style were associated with higher odds of improvement. Conclusions/importance This is the first study to identity predictors of improvement in risky drinking among transgender individuals. Compared to trans-feminine individuals (assigned male at birth), trans-masculine individuals (assigned female at birth) were more likely to report risky drinking at baseline and had lower odds of improvement at 1-year follow-up. Improved drinking may be facilitated by preventing anti-transgender discrimination. Felt stigma and diffuse-avoidant identity style may lower alcohol risk via avoidance of drinking venues. Further research is needed to explicate these relationships and to inform culturally-tailored alcohol interventions for this at-risk population.

BACKGROUND: Currently, there are no established pharmacotherapies for cannabis use disorders (CUDs). As a long-acting alpha-2-adrenergic receptor agonist, guanfacine extended-release (G-XR) could be useful in the treatment of CUDs by mitigating withdrawal and improving behavioral control. OBJECTIVES: To evaluate the feasibility and tolerability of G-XR as a treatment for CUDs. METHODS: In an eight-week open-label outpatient pilot trial, we evaluated the safety and tolerability of G-XR in 22 cannabis dependent individuals. Using 2 different titration schedules, G-XR was gradually titrated to a dose of 4 mg or the highest dose tolerated. All participants received standard medication management. RESULTS: Retention at week eight was 41%. Average daily amount of cannabis use (in grams: F(1,86) = 8.74, p = .004; in dollars: F(1,86) = 16.67, p < .0001) and cannabis using days (F(1,86) = 7.67, p = .007) significantly reduced over the course of study participation. There were no significant differences between the titration schedules on emergence of side effects (Fisher exact test, p = .378) or retention (Log-Rank Test X(2)(1) = 0.021, p = .886). A total of 3 participants achieved 3 weeks or greater of total abstinence. CONCLUSIONS: G-XR is a feasible treatment for CUDs, and should be evaluated further in an efficacy trial.