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A growing number of individuals are employed as peer recovery coaches to mentor, support, and educate those in recovery. Despite the robust evidence base for the benefits of medications for treating opioid use disorder (OUD), prior research has identified peers in recovery to hold both positive and negative attitudes toward medications for OUD (MOUDs). We aimed to survey peer recovery coaches in Massachusetts about their attitudes toward working with individuals utilizing MOUDs.All 202 individuals certified as peer recovery coaches in Massachusetts were invited to participate in a brief, anonymous online survey between August and October 2020. The survey collected the respondents' age, sex, certification year, duration of employment as a coach, personal history of substance use disorders, and MOUD treatment.A total of 129 responses were received, representing a 63.9% response rate. Eighty-six (64.3%) reported a personal history of OUD, of whom 64 (74.4%) reported prior MOUD treatment. The majority held positive views about MOUDs, endorsing them as appropriate treatments to achieve sobriety. Coaches with personal history of MOUDs were more likely to report enjoying working with patients on methadone. Coaches without any personal history of OUD or MOUDs were older, more likely to have an alcohol use disorder, and more likely to encourage drug-free treatments before MOUDs and shorter duration of MOUD treatment.Results indicate that peer recovery coaches in Massachusetts hold generally positive attitudes toward MOUDs, but those without any personal history of OUD or MOUDs may be less likely to encourage MOUD treatment.

BACKGROUND AND OBJECTIVES Despite the high incidence of alcohol withdrawal syndrome (AWS) in psychiatric inpatients, standardized methods for assessing and treating AWS have been studied only once before in this population. We evaluated a novel AWS assessment and treatment protocol designed for psychiatric inpatients. METHODS This retrospective cohort study evaluated outcomes before and after implementation of the protocol. We collected consecutive data on patients (N = 138) admitted to inpatient psychiatric units at a single center. Participants were patients admitted for nonsubstance-related psychiatric reasons, who were also at risk for developing AWS. Those who developed AWS were treated with either (a) treatment as usual (TAU) or (b) a novel standardized protocol. The primary outcome was duration of benzodiazepine treatment for symptoms of alcohol withdrawal. Secondary outcomes included cumulative benzodiazepine dose administered, treatment duration, and incidence of complications. RESULTS Of 138 participants, 83 received TAU and 55 were assessed and treated with the novel protocol. Median duration of benzodiazepine treatment following protocol implementation was 19.7 hours (interquartile range [IQR], 0-46) prior to implementation (TAU) and 0 hours (IQR, 0-15) following protocol implementation (protocol group) (P

Psychogenic nonepileptic seizures (PNES) are a highly disabling disorder frequently encountered by neurologists, psychiatrists, and emergency medicine physicians. There is accumulating evidence for the efficacy of psychological therapies, yet the majority of patients do not complete treatment. A range of health care system-based, clinician-based, and patient-based barriers to treatment exists, including stigma, poor clinician-patient communication, and patient ambivalence about the diagnosis and treatment of PNES. These barriers frequently lead to treatment nonadherence. Motivational interviewing (MI) is a patient-centered counseling style targeting ambivalence about behavior change, which has been shown to be effective in improving psychotherapy adherence and outcomes among patients with PNES. The authors review MI processes and techniques that may be useful to health care providers helping patients with PNES and other functional neurological disorders to engage in psychotherapy. The authors examine common challenges arising during MI for patients with PNES, including somatic symptoms distracting from clinician-patient communication, ambivalence about making concrete plans for treatment, and psychiatric comorbidities. Strategies for overcoming these obstacles are reviewed, including the use of complex reflections to enhance patient engagement; the use of an ask-tell-ask format and specific, measurable, achievable, relevant, and time-limited (SMART) goals to facilitate treatment planning; and close collaboration between the neurology and psychotherapy teams.

Background There is a great public health need to identify novel treatment strategies for opioid use disorder (OUD) in order to reduce relapse and overdose. Noninvasive brain stimulation (NIBS) has demonstrated preliminary effectiveness for substance use, but little is known about its use in OUD. Neuromodulation may represent a potential adjunctive treatment modality for OUD, so we conducted a systematic review to understand the state of the current research in this field. Methods We conducted a systematic review of studies using noninvasive brain stimulation to affect clinical outcomes related to substance use for adults with opioid use disorder. We searched the following online databases: PubMed, The Cochrane Library, PsycINFO (EBSCOhost, 1872-present), and Science Citation Index Expanded (ISI Web of Science, 1945-present). All studies that measured clinical outcomes related to substance use, including cue-induced craving, were included. We assessed risk of bias using the Cochrane Handbook. Results The initial search yielded 5590 studies after duplicates were removed. After screening titles and abstracts, 14 full-text studies were assessed for eligibility. Five studies were determined to meet inclusion criteria with a combined total subjects of N = 150. Given the paucity of studies and small number of total subjects, no quantitative analysis was performed. These studies used TMS (n = 3), tDCS (n = 1), and the BRIDGE device (n = 1), a noninvasive percutaneous electrical nerve field stimulator, to reduce cue-induced craving (n = 3), reduce clinical withdrawal symptoms (n = 1), or measure substance-use-related cortical plasticity (n = 1). Conclusions There is a dearth of research in the area of noninvasive brain stimulation for OUD. NIBS represents a novel treatment modality that should be further investigated for OUD.

BACKGROUND In recent years, there has been increasing interest in implementing digital technologies to diagnose, monitor, and intervene in substance use disorders. Smartphones are now a vehicle for facilitating telepsychiatry visits, measuring health metrics, and communicating with health care professionals. In light of the COVID-19 pandemic and the movement toward web-based and hybrid clinic visits and meetings, it has become especially salient to assess phone ownership among individuals with substance use disorders and their comfort in navigating phone functionality and using phones for mental health purposes. OBJECTIVE The aims of this study were to summarize the current literature around smartphone ownership, smartphone utilization, and the acceptability of using smartphones for mental health purposes and assess these variables across two disparate substance use treatment sites. METHODS We performed a focused literature review via a search of two academic databases (PubMed and Google Scholar) for publications since 2007 on the topics of smartphone ownership, smartphone utilization, and the acceptability of using mobile apps for mental health purposes among the substance use population. Additionally, we conducted a cross-sectional survey study that included 51 participants across two sites in New England—an inpatient detoxification unit that predominantly treats patients with alcohol use disorder and an outpatient methadone maintenance treatment clinic. RESULTS Prior studies indicated that mobile phone ownership among the substance use population between 2013 and 2019 ranged from 83% to 94%, while smartphone ownership ranged from 57% to 94%. The results from our study across the two sites indicated 96% (49/51) mobile phone ownership and 92% (47/51) smartphone ownership among the substance use population. Although most (43/49, 88%) patients across both sites reported currently using apps on their phone, a minority (19/48, 40%) reported previously using any apps for mental health purposes. More than half of the participants reported feeling at least neutrally comfortable with a mental health app gathering information regarding appointment reminders (32/48, 67%), medication reminders (33/48, 69%), and symptom surveys (26/45, 58%). Most patients were concerned about privacy (34/51, 67%) and felt uncomfortable with an app gathering location (29/47, 62%) and social (27/47, 57%) information for health care purposes. CONCLUSIONS The majority of respondents reported owning a mobile phone (49/51, 96%) and smartphone (47/51, 92%), consistent with prior studies. Many respondents felt comfortable with mental health apps gathering most forms of personal information and with communicating with their clinician about their mental health. The differential results from the two sites, namely greater concerns about the cost of mental health apps among the methadone maintenance treatment cohort and less experience with downloading apps among the older inpatient detoxification cohort, may indicate that clinicians should tailor technological interventions based on local demographics and practice sites and that there is likely not a one-size-fits-all digital psychiatry solution.

Amidst the ongoing opioid crisis, the number of individuals with substance use disorders being hospitalized for acute medical illnesses has increased. There is now a growing recognition that these events may be psychologically traumatic, leading to the development of acute stress reactions, and post-traumatic stress disorder. Patients who use drugs may be particularly susceptible to being traumatized due to their underlying psychiatric comorbidities, prior trauma histories, inadequate treatment of the underlying substance use disorders, and stigmatization. Interventions such as early identification and screening, trauma-informed care, and specialized addiction services may help to mitigate the risks of trauma amongst this population. More research is needed to better guide hospitals to ensure people who use drugs receive optimal care.

Objectives Infective endocarditis (IE) among people who inject drugs is associated with high rates of mortality and repeat episodes of endocarditis. We sought to report on longer-term clinical outcomes of patients with IE who were offered buprenorphine or methadone treatment for opioid use disorder (OUD) at their initial hospital admission. Methods Individuals with OUD hospitalized between 2013 and 2015 with IE were included for the retrospective study. The following data were extracted from the medical record: sociodemographic data, mortality, repeat episodes of endocarditis, and evidence of ongoing buprenorphine and methadone treatment. The impact of medication use on mortality and repeat episode of endocarditis was examined using survival analysis. Results Overall, 26 individuals were included in the study. The mean duration of follow-up was 45.0 months (SD 7.2, range 34.0-56.0). During the index admission, 8 received buprenorphine, 8 received methadone, and 10 declined medications. During the follow-up period, 4 (15.4%) individuals died and 10 (38.5%) individuals experienced a repeat episode of endocarditis. Survival analysis of mortality (log-rank P = 0.066) and repeat episode of endocarditis (log-rank P = 0.86) comparing those who received buprenorphine, received methadone, and declined medication did not differ significantly. Conclusions Initiation of medication treatment alone may not be sufficient to impact long-term mortality and rates of repeat episode of endocarditis. More research is needed to identify optimal treatment strategies for people who inject drugs with IE.

Background: Patients taking methadone for opioid use disorder may desire transition to buprenorphine for a number of reasons. However, the current recommended approach for this transition generally takes weeks to months as an outpatient, causing considerable discomfort to the patient and a heightened risk of relapse during the transition period. Case: We describe the case of a patient on methadone maintenance who was rapidly transitioned to buprenorphine because of her desire to not return to her methadone clinic. In order to rapidly transition the patient from methadone to buprenorphine, naltrexone was administered to precipitate acute opioid withdrawal, which was followed soon after by buprenorphine induction. Discussion: Rapid transition from methadone maintenance to buprenorphine can be accomplished in inpatients by precipitating acute withdrawal with naltrexone, providing an effective alternative for patients who cannot tolerate the typical protracted methadone taper required prior to buprenorphine induction as an outpatient.

Hospitalizations related to infectious complications from injection drug use are increasing in the context of the opioid crisis. Unfortunately, these hospital encounters are infrequently used to initiate treatment for the underlying opioid use disorder, even though many patients are amenable to treatment initiation. Both buprenorphine and methadone can be utilized with good effect to manage not only opioid use disorder but also acute pain. Controversies exist over the ethics of surgical management for patients who relapse and require reoperation. The appropriate approach may be to ensure that all patients with endocarditis are offered evidence-based treatment for the underlying substance use disorder as soon as possible. In addition, the initiation of medication treatment should be paired with ongoing outpatient treatment, given the high rates of mortality and reinfection due to endocarditis among this population. There is growing evidence that outpatient parenteral antimicrobial therapy may be appropriate even among people who inject drugs.

Opioid use disorder (OUD) represents a global public health crisis that challenges classic clinical decision making. As existing hospital screening methods are resource-intensive, patients with OUD are significantly under-detected. An automated and accurate approach is needed to improve OUD identification so that appropriate care can be provided to these patients in a timely fashion. In this study, we used a large-scale clinical database from Mass General Brigham (MGB; formerly Partners HealthCare) to develop an OUD patient identification algorithm, using multiple machine learning methods. Working closely with an addiction psychiatrist, we developed a set of hand-crafted rules for identifying information suggestive of OUD from free-text clinical notes. We implemented a natural language processing (NLP)-based classification algorithm within the Medical Text Extraction, Reasoning and Mapping System (MTERMS) tool suite to automatically label patients as positive or negative for OUD based on these rules. We further used the NLP output as features to build multiple machine learning and a neural classifier. Our methods yielded robust performance for classifying hospitalized patients as positive or negative for OUD, with the best performing feature set and model combination achieving an F1 score of 0.97. These results show promise for the future development of a real-time tool for quickly and accurately identifying patients with OUD in the hospital setting.

Background and objectives Buprenorphine's high-binding affinity as a partial µ-opioid agonist displaces preexisting full agonists causing precipitated withdrawal, which requires most individuals starting buprenorphine to endure moderate withdrawal prior to induction to avoid precipitated withdrawal. A novel approach called microinduction has emerged to remove this prerequisite. Our aim is to review the literature on these alternative approaches. Methods Using keywords including buprenorphine, buprenorphine/naloxone, transdermal buprenorphine, suboxone, microinduction, microdosing, rapid induction, buprenorphine-dosing protocol, the authors searched PubMed/Medline, EMBASE, PsycINFO, PsychARTICLES, and Scopus databases from the date of inception through April 30, 2020, which yielded 1726 results, which, in turn, after manual exclusion for irrelevant content and publication in languages other than English, generated a total of 18 papers. Results On the basis of 18 papers included in this review, 63 patients were successfully transitioned to buprenorphine using different microdosing techniques, primarily in the inpatient setting. From the available data, patients were transitioned from a variety of opioids over a range of dosing without significant withdrawal, and initial doses ranged most frequently from 0.2 to 0.5 mg. While the timeframe for the various schedules ranged from 3 to 112 days, most transitioned over a period of 4 to 8 days, and most participants completed the cross titration at 8 to 16 mg. Discussion and conclusions The growing literature demonstrates some initial promise for alternative induction models, specifically targeting patients averse to withdrawal, patients prescribed opioids for chronic pain, patients on high-dose methadone, and patients using illicit or pharmaceutical fentanyl. Scientific significance This manuscript provides a review of the existing literature to help clinicians better understand the approaches to microdosing of buprenorphine in various clinical settings and populations. (Am J Addict 2020;00:00-00).

With the growing public interest in the potential therapeutic benefits of cannabis and cannabinoids in the treatment of opioid use disorder (OUD), some states have now either added or proposed to add OUD as an indication for their state's medical marijuana program. However, these initiatives are based on weak evidence which at present do not support the listing of cannabis or cannabinoids as a treatment for OUD. Nevertheless, studying the potential therapeutic applications of carefully chosen components of cannabis or cannabinoids to treat specific aspects of OUD is not without scientific merit. Given the high rates of treatment discontinuation among those taking medications for OUD, interventions that further improve clinical outcomes are especially needed. The potential therapeutic applications of cannabis and cannabinoids in the treatment of OUD are worthy of further study, but it should be conducted with the same rigor that we expect of all pharmaceutical products. Until we have more research to show their efficacy, policy makers and clinicians should refrain from portraying cannabis and cannabinoids as evidence-based treatments for OUD.

Background Research is limited on combining outpatient parenteral antimicrobial therapy (OPAT) with addiction treatment for people who inject drugs (PWID) with serious infections. Methods This is a retrospective study of PWID (n = 68) requiring intravenous antibiotics evaluated for suitability for our OPAT program with concurrent addiction treatment. Results Most common infections were bacteremia and/or endocarditis (73.5%), bone and/or joint infections (32.4%), and epidural abscess (22.1%). Of the 20 patients (29.4%) who qualified, 100.0% completed the course of antibiotics, 30.0% experienced a 30-day readmission, and 15.0% relapsed. No overdoses, deaths, or peripherally inserted central catheter-line complications were reported. Conclusions Outpatient parenteral antimicrobial therapy with addiction treatment may be feasible and safe for PWID with serious infections.

Background Patients with opioid use disorder (OUD) who are hospitalized for serious infections requiring prolonged intravenous antibiotics may face barriers to discharge, which could prolong hospital length of stay (LOS) and increase financial burden. We investigated differences in LOS, discharge disposition, and charges between hospitalizations for serious infections in patients with and without OUD. Methods and findings We utilized the 2016 National Inpatient Sample—a nationally representative database of all discharges from US acute care hospitals. The population of interest was all hospitalizations for infective endocarditis, epidural abscess, septic arthritis, or osteomyelitis. The exposure was OUD, and the primary outcome was LOS until discharge, assessed by using a competing risks analysis to estimate adjusted hazard ratios (aHRs). Adjusted odds ratio (aOR) of discharge disposition and adjusted differences in hospital charges were also reported. Of 95,470 estimated hospitalizations for serious infections (infective endocarditis, epidural abscess, septic arthritis, and osteomyelitis), the mean age was 49 years and 35% were female. 46% had Medicare (government-based insurance coverage for people age 65+ years), and 70% were non-Hispanic white. After adjustment for potential confounders, OUD was associated with a lower probability of discharge at any given LOS (aHR 0.61; 95% CI 0.59–0.63; p < 0.001). OUD was also associated with lower odds of discharge to home (aOR 0.38; 95% CI 0.33–0.43; p < 0.001) and higher odds of discharge to a post-acute care facility (aOR 1.85; 95% CI 1.57–2.17; p < 0.001) or patient-directed discharge (also referred to as “discharge against medical advice”) (aOR 3.47; 95% CI 2.80–4.29; p < 0.001). There was no significant difference in average total hospital charges, though daily hospital charges were significantly lower for patients with OUD. Limitations include the potential for unmeasured confounders and the use of billing codes to identify cohorts. Conclusions Our findings suggest that among hospitalizations for some serious infections, those involving patients with OUD were associated with longer LOS, higher odds of discharge to post-acute care facilities or patient-directed discharge, and similar total hospital charges, despite lower daily charges. These findings highlight opportunities to improve care for patients with OUD hospitalized with serious infections, and to reduce the growing associated costs., In a study of nationally representative hospital discharges in the US included in the 2016 National Inpatient Sample database, June-Ho Kim and colleagues identify associations between opioid use disorder and factors related to hospitalization for the treatment of serious bacterial infections., Author summary Why was this study done? There has been an increase in hospitalizations in the United States for serious infections among patients with opioid use disorder. These infections typically require several weeks of intravenous antibiotics, which can eventually be administered at home or at facilities outside of the hospital if the patient has no other inpatient needs. However, patients with opioid use disorder are often kept in the hospital to finish their treatment, which could have significant financial costs, use hospital resources, and cause patient harm. We conducted this study in order to understand differences in length of hospital stay, type of hospital discharge, and related financial charges between patients with and without opioid use disorder in the US. What did the researchers do and find? We analyzed a cross-sectional dataset representative of all hospitalizations for serious infections in the US during 2016 and compared length of hospital stay, type of hospital discharge, and financial charges. From 95,470 estimated hospitalizations, patients with opioid use disorder stayed an average of 4 days longer in the hospital compared to those without the disorder, with a 39% lower likelihood of discharge from the hospital at any given length of stay. Patients with opioid use disorder were less likely to be discharged home and more likely to be sent to a post-acute care facility or to self-discharge. Although daily hospital charges were lower for patients with opioid use, charges for the total hospitalization were similar given the longer stays. What do these findings mean? These disparities in hospital stays and destinations after discharge suggest that people with opioid use disorder may lack post-discharge options such as skilled nursing facilities or home care for antibiotic infusions and thus remain in the hospital longer than their counterparts without opioid use disorder. Consideration should be given to expanding discharge options for people with opioid use disorder to reduce costly hospital stays and provide equitable care for serious infections.

UNSTRUCTURED Due to the COVID-19 pandemic, many clinical addiction treatment programs have been required to transition to telephonic or virtual visits. Novel solutions are needed to enhance substance use treatment during a time when many patients are disconnected from clinical care and social support. Digital phenotyping, which leverages the unique functionality of smartphone sensors (GPS, social behavior, and typing patterns), can buttress clinical treatment in a remote, scalable fashion. Specifically, digital phenotyping has the potential to improve relapse prediction and intervention, relapse detection, and overdose intervention. Digital phenotyping may enhance relapse prediction through coupling machine learning algorithms with the enormous amount of collected behavioral data. Activity-based analysis in real time can potentially be used to prevent relapse by warning substance users when they approach locational triggers such as bars or liquor stores. Wearable devices detect when a person has relapsed to substances through measuring physiological changes such as electrodermal activity and locomotion. Despite the initial promise of this approach, privacy, security, and barriers to access are important issues to address.

There is a growing recognition for the need to improve the treatment of individuals with opioid use disorder who are hospitalized for serious infections such as infective endocarditis. Unfortunately, patients face enormous hurdles not only in coping with the life-threatening medical illness, but also in maintaining their recovery and engagement with treatment due in part to the difficulties navigating the fragmented addiction treatment system. The journey mapping research presented by Bearnot and Mitton is a novel approach that has the potential to improve our understanding of the challenges faced by patients. Given the severe health consequences that can result from these infections, more research is clearly needed to improve the treatment we currently provide. The journey mapping approach appears to be a useful method of incorporating the patient voice in order to improve our understanding of their experience, but also help identify how we can provide treatments that are acceptable and preferred by patients.

Background and objectives The impact of medications for opioid use disorder (MOUD) on against medical advice (AMA) discharges among people who inject drugs (PWID) hospitalized for endocarditis is unknown. Methods A retrospective review of all PWID hospitalized for endocarditis at our institution between 2016 and 2018 (n = 84). Results PWID engaged with MOUD at admission, compared with those who were not, were less likely to be discharged AMA but this did not reach statistical significance in adjusted analysis (odds ratio [OR], 0.22; 95% confidence interval [CI], 0.033-1.41; P = .11). Among out-of-treatment individuals, newly initiating MOUD did not lead to significantly fewer AMA discharges (OR, 0.98; 95% CI, 0.26-3.7; P = .98). Conclusion and scientific significance PWID hospitalized for endocarditis are at high risk for discharge AMA but more research is needed to understand the impact of MOUD. (Am J Addict 2020;29:155-159).

Understand the key components of the spirit of Motivational Interviewing (MI) and how it differs from more directive communication approaches. MI is a strengths-based approach that holds that clients have within themselves the capabilities to make lifestyle changes successfully. MI was birthed in the addictions field and is a therapeutic approach that pays specific attention to the language of change. MI first garnered attention as an effective technique for use in alcohol use disorder in the early 1980s. Since then, research has continued to suggest that it is an effective intervention for individuals with alcohol use disorder. The effects of MI extend to many other health behavior changes. In the current iteration of MI, there are four processes of MI to which clinicians need to be mindful: Engaging, Focusing, Evoking, and Planning. The use of a metaphor may be helpful in understanding the four processes of MI.