Addiction最新文献

{"title":"Not all kratom is equal: The important distinction between native leaf and extract products","authors":"Oliver Grundmann, Albert Garcia-Romeu, Christopher R. McCurdy, Abhisheak Sharma, Kirsten E. Smith, Marc T. Swogger, Stephanie T. Weiss","doi":"10.1111/add.16366","DOIUrl":"10.1111/add.16366","url":null,"abstract":"<p>The Southeast Asian plant kratom (<i>Mitragyna speciosa</i> Korth.) has garnered growing popularity among North American consumers as a herbal product used for recreational, performance enhancement and self-treatment purposes. Scientifically, there has also been substantial interest in studying kratom and its constituents as a possible therapy for several conditions, including pain, mood, fatigue and substance use disorders (SUDs) [<span>1</span>]. Pre-clinical animal studies, human surveys and clinical case reports indicate that kratom has potential therapeutic effects as well as possible abuse and dependence potential, consistent with its complex opioidergic, adrenergic and serotonergic pharmacology [<span>2</span>].</p><p>Kratom is not federally recognized as a dietary supplement, and is therefore largely unregulated. Native kratom leaf material contains up to 2% of the major indole alkaloid mitragynine by weight. In addition, more than 50 other indole and oxindole alkaloids, some with known pharmacological effects, are present in lesser, but potentially significant, amounts [<span>3</span>].</p><p>Recently, there is a growing and concerning commercial trend in Western countries towards the production and marketing of kratom extract products created via extraction of kratom leaves using organic solvents. This enrichment process can increase the mitragynine concentration to 40% or higher in such products. Of great concern from a public health perspective, commercial kratom extract products lack data regarding their safety, efficacy and abuse potential. In addition, the formulation of concentrated kratom extracts as capsules, tablets, liquid shots or gummies circumvents kratom’s natural self-limiting qualities (e.g. unpleasant taste) and reduces the volume of product needed to achieve an effect, thereby raising the risk of users ingesting larger amounts of alkaloids with potentially toxic effects.</p><p>History has shown us that developing enriched natural-product elixirs or purified active agents, as with cocaine from the coca shrub and morphine from the opium poppy, can be both a blessing and a curse: a blessing in that some of these concentrates can be medically useful to improve quality of life for patients suffering from a variety of disorders and a curse of increased risk. Concentrated kratom extracts are analogous to these previous historical examples. They may provide benefit to some, but they may result in unpredictable adverse effects and other potential harms resulting from dependence and drug–drug interactions.</p><p>As researchers studying the therapeutic potential of kratom, while also desiring to reduce possible associated harms, we strongly recommend that kratom in its native form as the unadulterated fresh or dried leaf material remains available to consumers with proper oversight and regulation, including clear labeling describing the amount of mitragynine per dose, recommended maximum daily doses, potential for drug interac","PeriodicalId":109,"journal":{"name":"Addiction","volume":"119 1","pages":"202-203"},"PeriodicalIF":6.0,"publicationDate":"2023-10-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/add.16366","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41181437","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Alcohol-related morbidity and mortality by fathers' parental leave: A quasi-experimental study in Sweden","authors":"Helena Honkaniemi, Sol Pía Juárez","doi":"10.1111/add.16354","DOIUrl":"10.1111/add.16354","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background and Aims</h3>\u0000 \u0000 <p>Fathers' parental leave has been associated with decreased risks of alcohol-related hospitalizations and mortality. Whether this is attributable to the health protections of parental leave itself (through stress reduction or behavioral changes) or to selection into leave uptake remains unclear, given that fathers are more likely to use leave if they are in better health. Using the quasi-experimental variation of a reform incentivizing fathers' leave uptake (the 1995 <i>Father's quota</i> reform), this study aimed to assess whether fathers' parental leave influences alcohol-related morbidity and mortality.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Design</h3>\u0000 \u0000 <p>Quasi-experimental interrupted time series and instrumental variable analyses.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Setting</h3>\u0000 \u0000 <p>Sweden.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Participants</h3>\u0000 \u0000 <p>Fathers of singleton children born from January 1992 to December 1997 (<i>n</i> = 220 412).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Measurements</h3>\u0000 \u0000 <p>Exposure was indicated by the child's birthdate before or after the reform and used to instrument fathers' 2- and 8-year parental leave uptake. Outcomes included fathers' hospitalization rates for acute alcohol-related (intoxication; mental and behavioral disorders) and chronic alcohol-related diagnoses (cardiovascular, stomach and other diseases; liver diseases), as well as alcohol-related mortality, up to 2, 8 and 18 years after the first child's birthdate.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Findings</h3>\u0000 \u0000 <p>In interrupted time series analyses, fathers of children born after the reform exhibited immediate decreases in alcohol-related hospitalization rates up to 2 (incidence rate ratio [IRR] = 0.66, 95% confidence interval [CI] = 0.51–0.87), 8 (IRR = 0.74, 95% CI = 0.57–0.96) and 18 years after birth (IRR = 0.72, 95% CI = 0.54–0.96), particularly in acute alcohol-related hospitalization rates, compared with those with children born before. No changes were found for alcohol-related mortality. Instrumental variable results suggest that alcohol-related hospitalization decreases were driven by fathers' parental leave uptake (e.g. 2-year hospitalizations: IRR = 0.16, 95% CI = 0.03–0.84).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>In Swe","PeriodicalId":109,"journal":{"name":"Addiction","volume":"119 2","pages":"301-310"},"PeriodicalIF":6.0,"publicationDate":"2023-10-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/add.16354","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41093032","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Improving the epidemiology of low-risk drinking guidelines is not enough","authors":"Michael Livingston","doi":"10.1111/add.16358","DOIUrl":"10.1111/add.16358","url":null,"abstract":"<p>Shield <i>et al</i>. [<span>1</span>] draw upon the recent redevelopment of the Canadian Low Risk Drinking Guidelines to formulate some key principles that, they argue, should underpin future guidelines work internationally. This is an admirable attempt to further earlier work by Holmes <i>et al</i>. [<span>2</span>] arguing for increasing rigour and transparency in the guidelines setting process and offers much food for thought.</p><p>Fundamentally, the setting of guidelines is concerned with risk, with (i) accurately estimating via sophisticated epidemiology and modelling the risks of various outcomes (often mortality) associated with drinking, (ii) determining some level of population risk considered acceptable and (iii) communicating these risks to the population. Much of the energy in the various guidelines committees in recent decades has been focused upon (i), which has led to substantial improvements in our understanding of the population impacts of alcohol e.g. [<span>3, 4</span>], although there remains ongoing debate and uncertainty in key areas [<span>5</span>].</p><p>Strikingly little research has been conducted on either (ii) or (iii). It is remarkable that guidelines committees have, from at least the 2009 Australian guidelines [<span>6</span>], relied upon a 1969 analysis of risk acceptability by Starr [<span>7</span>], which has since been critiqued and expanded upon in a large body of work examining risk perception and acceptability [<span>8, 9</span>]. Research has demonstrated clearly that risk perceptions and acceptability vary markedly among different risks, depending upon factors including familiarity, immediacy, personal experience and perceived benefits (among many others) [<span>10</span>]. Further, there are clear and predictable variations in risk acceptability between subpopulations, based on gender, age, living situation and more [<span>11-13</span>]. Surprisingly little work has followed to situate alcohol epidemiology within these broader literatures on risk. Thus, our reliance upon relatively simplistic risk thresholds (1/100 in the recent Australian and UK guidelines) seems arbitrary.</p><p>This supports the argument put forward by Shield <i>et al</i>. that providing a continuum of risk is a more appropriate approach to guideline development, letting individuals make their own, informed decisions about risk acceptability by providing a range of risk thresholds or a continuous risk function. This is, however, obviously contingent upon (iii), the communication and understanding of risk by the general public. The Canadian guidelines provide a good example of the challenges here, with the relatively sophisticated risk continuum simplified throughout hundreds of media articles into a single guideline of two drinks per week [<span>14, 15</span>]. Our understanding of how best to communicate the risks that underpin drinking guidelines remains poor, despite potential lessons from a substantial broader research field [","PeriodicalId":109,"journal":{"name":"Addiction","volume":"119 1","pages":"20-21"},"PeriodicalIF":6.0,"publicationDate":"2023-10-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/add.16358","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41090439","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Is sexual craving a sign of sex addiction?","authors":"Ingmar H. A. Franken","doi":"10.1111/add.16362","DOIUrl":"10.1111/add.16362","url":null,"abstract":"<p>Craving has a very long history in the addiction field. In the early days, many authors questioned the relevance of the craving concept for addictive behaviours [<span>1, 2</span>]. After decades of research into craving, however, studies have increasingly demonstrated the relevance of this concept for addictive behaviour. It is, for example, currently part of the DSM criteria [<span>3, 4</span>], and many studies have shown that craving is an important predictor of relapse [<span>5, 6</span>]. However, there are still many issues that are not fully understood or addressed. One such issue is whether craving for substances is similar in nature to craving associated with behavioural addictions. Miele and colleagues [<span>7</span>] ask an important but scarcely addressed question: what about behavioural cravings such as sexual cravings?</p><p>Although, as Miele <i>et al</i>. show, there are many similarities between substance craving and sexual craving, there are also differences. Unlike alcohol and drug addiction, sexual addiction has different characteristics because sexual desire is also, at least for most people, a normal and healthy behaviour. The authors aptly introduce the term ‘egodystonic’ to address this issue. I assume they are referring to desires that conflict with an individual’s ideal self-concept. I would argue that future research should explore possible ways of further quantifying this construct. Is there really a difference between egodystonic or problematic cravings and egosyntonic or non-conflicting cravings? Are there mere quantitative differences in terms of frequency and intensity or are there also qualitative differences? I predict that it will be difficult to differentiate between egodystonic and egosyntonic sexual craving, especially in the field of sexual violence, where it is likely that craving will be presented as egodystonic. As sexual craving is still taboo and there are possible legal consequences, it will be unlikely that self-reports alone could reveal meaningful insights into this particular topic. For example, a sexual offender is likely to explain the offence by pointing towards an egodystonic (‘I was not myself’) rather than an egosyntonic mechanism.</p><p>Psychophysiological measures, such as electroencephalography (EEG) and functional magnetic resonance imaging (fMRI), could be employed to gain a richer understanding of the nature of behavioural cravings, including sexual craving. Although it is tempting to look for similarities, there is work showing remarkable differences between the psychophysiology associated with sexual craving and that associated with alcohol and drug craving. One notable difference was found in a study by Prause and colleagues [<span>8</span>], who found opposite results to the addiction models. That is, participants with problematic and ‘excessive’ viewing of visual sexual stimuli, who were reported to have higher sexual desire, had lower EGG responses to sexual images compared t","PeriodicalId":109,"journal":{"name":"Addiction","volume":"118 12","pages":"2315-2316"},"PeriodicalIF":6.0,"publicationDate":"2023-10-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41099004","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Understanding people's experiences of the formal health and social care system for co-occurring heavy alcohol use and depression through the lens of relational autonomy: A qualitative study","authors":"Katherine Jackson, Eileen Kaner, Barbara Hanratty, Eilish Gilvarry, Lucy Yardley, Amy O'Donnell","doi":"10.1111/add.16350","DOIUrl":"10.1111/add.16350","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background and Aims</h3>\u0000 \u0000 <p>Heavy alcohol use and depression commonly co-occur. However, health and social care services rarely provide coordinated support for these conditions. Using relational autonomy, which recognizes how social and economic contexts and relational support alter people's capacity for agency, this study aimed to (1) explore how people experience formal care provision for co-occurring alcohol use and depression, (2) consider how this context could lead to adverse outcomes for individuals and (3) understand the implications of these experiences for future policy and practice.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Design</h3>\u0000 \u0000 <p>Semi-structured qualitative interviews underpinned by the methodology of interpretive description.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Setting</h3>\u0000 \u0000 <p>North East and North Cumbria, UK.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Participants</h3>\u0000 \u0000 <p>Thirty-nine people (21 men and 18 women) with current or recent experience of co-occurring heavy alcohol use ([Alcohol Use Disorders Identification Test [AUDIT] score ≥ 8]) and depression ([Patient Health Questionnaire test ≥ 5] screening tools to give an indication of their current levels of alcohol use and mental score).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Measurements</h3>\u0000 \u0000 <p>Semi-structured interview guide supported in-depth exploration of the treatment and care people had sought and received for heavy alcohol use and depression.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Findings</h3>\u0000 \u0000 <p>Most participants perceived depression as a key factor contributing to their heavy alcohol use. Three key themes were identified: (1) ‘lack of recognition’ of a relationship between alcohol use and depression and/or contexts that limit people's capacity to access help, (2) having ‘nowhere to go’ to access relevant treatment and care and (3) ‘supporting relational autonomy’ as opposed to assuming that individuals can organize their own care and recovery. Lack of access to appropriate treatment and provision that disregards individuals’ differential capacity for agency may contribute to delays in help-seeking, increased distress and suicidal ideation.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Among people with co-occurring heavy alcohol use and depression, lack of recognition of a relationship","PeriodicalId":109,"journal":{"name":"Addiction","volume":"119 2","pages":"268-280"},"PeriodicalIF":6.0,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/add.16350","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41090295","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Commentary on the current state of perioperative and critical care buprenorphine management","authors":"Aurora Quaye, Charlotte Crist, Simba Matoi, Yi Zhang","doi":"10.1111/add.16346","DOIUrl":"10.1111/add.16346","url":null,"abstract":"<p>For over two decades, the United States has grappled with our current opioid use disorder (OUD) epidemic [<span>1</span>]. In response, there has been a significant increase in the utilization of buprenorphine for OUD treatment, in part because of its distinctive pharmacologic properties [<span>2, 3</span>]. Compared to other opioids, buprenorphine has a long half-life, high binding affinity and slow dissociation from opioid receptors. Therefore, it resists displacement from these receptors when other opioids are used in conjunction [<span>4</span>]. The therapeutic doses of buprenorphine used for chronic pain treatment are significantly lower than those required for OUD treatment; therefore, opioid receptors are available when additional opioids are used concomitantly to enhance analgesia [<span>5</span>]. Conversely, when buprenorphine is used for OUD treatment, the diminished availability of opioid receptors resulting from the higher buprenorphine doses required can pose challenges for analgesic management [<span>6</span>]. Although routine practice involves continuing chronic pain buprenorphine formulations when acute pain is anticipated, the prevailing practice until recently has been withholding OUD dosed buprenorphine [<span>4, 7</span>]. Emerging evidence challenges these notions and supports opioid based analgesia can be achieved in parallel with OUD buprenorphine continuation [<span>5, 8, 9</span>].</p><p>In our previous retrospective study of surgical patients with OUD comparing patients where buprenorphine was continued or discontinued, we identified significantly higher outpatient opioid dispensing with buprenorphine discontinuation [<span>5</span>]. Similar findings were reported by Li <i>et al</i>., [<span>8</span>] where patients who continued buprenorphine perioperatively at various tapered doses received significantly fewer opioid prescriptions compared to those where buprenorphine was discontinued.</p><p>Despite these studies, our recent national survey revealed significant variation in perioperative buprenorphine management practices [<span>10</span>]. Among surveyed anesthesiologists, only 36% of institutions had a protocol for buprenorphine management, and over a third endorsed either discontinuing buprenorphine in situations where moderate to severe pain was anticipated or adopting inconsistent management practices because of the lack of an institutional protocol. Premature discontinuation of buprenorphine is associated with an increased risk of opioid-induced relapse, making such practices concerning [<span>11, 12</span>].</p><p>The lack of clear guidance for buprenorphine management also extends to the critical care community. The 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility and Sleep Disruption in Adult Patients in the Intensive Care Unit did not provide recommendations for managing buprenorphine in patients maintained on this medication [<span>1","PeriodicalId":109,"journal":{"name":"Addiction","volume":"119 1","pages":"200-201"},"PeriodicalIF":6.0,"publicationDate":"2023-09-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/add.16346","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41091576","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Community exposure to armed conflict and subsequent onset of alcohol use disorder","authors":"Ronny Bruffaerts, William G. Axinn, Dirgha J. Ghimire, Corina Benjet, Stephanie Chardoul, Kate M. Scott, Ronald C. Kessler, Paul Schulz, Jordan W. Smoller","doi":"10.1111/add.16343","DOIUrl":"10.1111/add.16343","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Aims</h3>\u0000 \u0000 <p>To measure the independent consequences of community-level armed conflict beatings on alcohol use disorders (AUD) among males in Nepal during and after the 2000–2006 conflict.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Design</h3>\u0000 \u0000 <p>A population-representative panel study from Nepal, with precise measures of community-level violent events and subsequent individual-level AUD in males. Females were not included because of low AUD prevalence.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Setting</h3>\u0000 \u0000 <p>Chitwan, Nepal.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Participants</h3>\u0000 \u0000 <p>Four thousand eight hundred seventy-six males from 151 neighborhoods, systematically selected and representative of Western Chitwan. All residents aged 15–59 were eligible (response rate 93%).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Measurements</h3>\u0000 \u0000 <p>Measures of beatings in the community during the conflict (2000–2006), including the date and distance away, were gathered through neighborhood reports, geo-location and official resources, then linked to respondents' life histories of AUD (collected in 2016–2018) using the Nepal-specific Composite International Diagnostic Interview with life history calendar. Beatings nearby predict the subsequent onset of AUD during and after the armed conflict. Data were analyzed in 2021–2022.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Findings</h3>\u0000 \u0000 <p>Cohort-specific, discrete-time models revealed that within the youngest cohort (born 1992–2001), those living in neighborhoods where armed conflict beatings occurred were more likely to develop AUD compared with those in other neighborhoods (odds ratio = 1.66; 95% confidence interval = 1.02–2.71). In this cohort, a multilevel matching analysis designed to simulate a randomized trial showed the post-conflict incidence of AUD for those living in neighborhoods with any armed conflict beatings was 9.5% compared with 5.3% in the matched sample with no beatings.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Among male children living in Chitwan, Nepal during the 2000–2006 armed conflict, living in a neighborhood where armed conflict beatings occurred is associated with increased odds of developing subsequent alcohol use disorder. This association was independent of personal exposure to beatings and other mental disorders.","PeriodicalId":109,"journal":{"name":"Addiction","volume":"119 2","pages":"248-258"},"PeriodicalIF":6.0,"publicationDate":"2023-09-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/add.16343","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41090273","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"In the balance: No new diagnosis needed in addition to opioid use disorder to study harms associated with long-term opioid therapy","authors":"Karen Drexler, Ellen L. Edens, Jodie A. Trafton, Wilson M. Compton","doi":"10.1111/add.16349","DOIUrl":"10.1111/add.16349","url":null,"abstract":"<p>The inability to reduce or discontinue opioids when benefits do not outweigh harms is concerning and needs to be assessed in patients on long-term opioid therapy for pain (LTOT). Overwhelming evidence finds that increased opioid prescribing fueled by assurances that addiction is rare during LTOT has led to opioid-related harms including falls, overdoses, suicides and opioid use disorder (OUD) [<span>1</span>]. Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria for OUD better describe opioid-related risks than a new diagnosis exclusively for patients prescribed LTOT.</p><p>Decades of research on current and previous DSM criteria support the validity of the OUD diagnosis. Previous editions of the DSM contained two forms of substance use disorders (SUD)—‘substance abuse’ (diagnosed by meeting one of four criteria) and ‘substance dependence’ (diagnosed by meeting three of seven additional criteria including ‘tolerance’ and ‘withdrawal’). The DSM-5 workgroup found no clustering of specific criteria such as ‘loss of control’ with the more severe end of the SUD spectrum [<span>2</span>]. Rather, increasing numbers of criteria met indicated increasing severity of SUD. In DSM-5, an exception was made to exclude ‘tolerance’ and ‘withdrawal’ when diagnosing OUD if opioids are taken ‘under appropriate medical supervision’ [<span>3</span>]. This exclusion was created to avoid an OUD diagnosis in patients prescribed LTOT because these signs are routinely expected. The exclusion was not because these signs did not predict harm or correlate with other OUD criteria.</p><p>Both elements of the proposed new LTOT diagnosis are already described by DSM-5 OUD criteria 2 and 9 (see Table 1). ‘Difficulty tapering LTOT’ is indistinguishable from DSM-5 OUD criterion 2 ‘unsuccessful efforts to cut down or control opioid use’. In those with OUD, difficulty cutting down or discontinuing opioid use is driven both by a desire for the positive effects of intoxication and by an imperative to avoid withdrawal and other aversive symptoms such as pain. As tolerance increases, these aversive symptoms are exacerbated during withdrawal. Gradually, avoidance of withdrawal-associated discomfort becomes the major driver for continued substance use [<span>4</span>].</p><p>Criterion 9 states that one continues opioid use ‘despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance’; that is, patients continue opioid use although ‘benefits do not outweigh harms’. Clinically, this occurs when patients, after being informed of LTOT harms and risks and evidence of low benefit, nonetheless decline a change in opioid prescribing. If OUD criteria 2 and 9 are present, then a diagnosis of mild OUD is indicated and sufficient for medication treatment (e.g. buprenorphine). The proposal to create a new diagnosis that includes two of the 11 DSM-5 SUD criteria may have unint","PeriodicalId":109,"journal":{"name":"Addiction","volume":"119 1","pages":"6-8"},"PeriodicalIF":6.0,"publicationDate":"2023-09-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/add.16349","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41090247","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Cannabis use disorder and adverse cardiovascular outcomes: A population-based retrospective cohort analysis of adults from Alberta, Canada","authors":"Anees Bahji,&nbsp;Josh Hathaway,&nbsp;Denise Adams,&nbsp;David Crockford,&nbsp;E. Jennifer Edelman,&nbsp;Michael D. Stein,&nbsp;Scott B. Patten","doi":"10.1111/add.16337","DOIUrl":"10.1111/add.16337","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Aim</h3>\u0000 \u0000 <p>To measure the association between cannabis use disorder (CUD) and adverse cardiovascular disease (CVD) outcomes.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Design and Setting</h3>\u0000 \u0000 <p>We conducted a matched, population-based retrospective cohort study involving five linked administrative health databases from Alberta, Canada.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Participants</h3>\u0000 \u0000 <p>We identified participants with CUD diagnosis codes and matched them to participants without CUD codes by gender, year of birth and time of presentation to the health system. We included 29 764 pairs (<i>n</i> = 59 528 individuals in total).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Measurements</h3>\u0000 \u0000 <p>CVD events were defined by at least one incident diagnostic code within the study period (1 January 2012–31 December 2019). Covariates included comorbidity, socio-economic status, prescription medication use and health service use. Using mortality-censored Poisson regression models, we computed survival analyses for time to incident CVD stratified by CUD status. In addition, we calculated crude and stratified risk ratios (RRs) across various covariates using the Mantel–Haenszel technique.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Findings</h3>\u0000 \u0000 <p>The overall prevalence of documented CUD was 0.8%. Approximately 2.4% and 1.5% of participants in the CUD and unexposed groups experienced an incident adverse CVD event (RR = 1.57; 95% confidence interval = 1.40–1.77). CUD was significantly associated with reduced time to incident CVD event. Individuals who appeared to have greater RRs for incident CVD were those without mental health comorbidity, who had not used health-care services in the previous 6 months, who were not on prescription medications and who did not have comorbid conditions.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Canadian adults with cannabis use disorder appear to have an approximately 60% higher risk of experiencing incident adverse cardiovascular disease events than those without cannabis use disorder.</p>\u0000 </section>\u0000 </div>","PeriodicalId":109,"journal":{"name":"Addiction","volume":"119 1","pages":"137-148"},"PeriodicalIF":6.0,"publicationDate":"2023-09-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/add.16337","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41091778","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"When harms outweigh benefits of long-term opioid therapy for pain: Need for a new diagnostic entity, research and improved treatments","authors":"William C. Becker,&nbsp;Joseph W. Frank,&nbsp;Sara N. Edmond,&nbsp;Joanna L. Starrels","doi":"10.1111/add.16348","DOIUrl":"10.1111/add.16348","url":null,"abstract":"&lt;p&gt;Given myriad harms and modest or absent benefit of long-term opioid therapy (LTOT) for chronic pain [&lt;span&gt;1&lt;/span&gt;], guidelines recommend prescribers frequently reassess LTOT and, in a patient-centered fashion using shared-decision making, taper when harms outweigh benefit [&lt;span&gt;2, 3&lt;/span&gt;]. When tapering is indicated, a subset of patients are unsuccessful; some experts suggest that struggling to taper represents impaired control over opioid use, a hallmark of opioid use disorder (OUD), described by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) as a problematic pattern of opioid use leading to problems or distress. Specifically at issue is the DSM-5 criterion of ‘persistent desire or unsuccessful efforts’ to reduce use. We posit that interpretation of this criterion is unclear and leads to confusion about when to diagnose OUD in the context of LTOT, causing negative consequences for patients and stymying treatment and research. We believe the best path forward is to revise DSM-5 to define a condition specific to LTOT with difficulty tapering (without otherwise meeting criteria for OUD).&lt;/p&gt;&lt;p&gt;Regarding unsuccessful efforts to cut down and its corollary ‘use for longer than intended’ in the context of LTOT, several points must be considered. First, ‘efforts’ may be driven by the prescriber, conducted at their pace, with prescribers having control rather than patients. Patients may lack desire to cut down, a wholly different scenario than that intended to be captured by the DSM-5, wherein individuals want to curtail substance use, but are unable to. Second, although tolerance and withdrawal were excluded from the DSM-5 definition in the context of LTOT because they are ‘normal, expected’ symptoms, this is also true of difficulty tapering. Prolonged exposure to opioids downregulates μ-opioid receptors, upregulates sympathomimetic hormones and alters in the hypogonadal-pituitary-adrenal axis. Disturbing homeostasis through tapering elicits predictable responses including fear, anxiety and other withdrawal symptoms. Therefore, as DSM-5 asserts tolerance and withdrawal symptoms during LTOT should not be counted when diagnosing OUD, we propose that neither should difficulty tapering.&lt;/p&gt;&lt;p&gt;A new diagnosis is needed that better aligns with patients' experience on LTOT; by defining and naming it, the field could more effectively conduct research to measure, prognosticate and treat it. To begin the process of consensus-generation on the diagnostic criteria for a new diagnosis, we engaged 38 multi-disciplinary experts in a Delphi study [&lt;span&gt;4, 5&lt;/span&gt;]. Although this project will soon expand—because of a recent United States (US) National Institutes of Health award—to include persons with lived experience and a broader array of researchers, policymakers and clinicians, preliminary criteria include (1) benefits not outweighing harms of LTOT; (2) difficulty tapering; and (3) absence of loss of control, marked by overu","PeriodicalId":109,"journal":{"name":"Addiction","volume":"119 1","pages":"4-5"},"PeriodicalIF":6.0,"publicationDate":"2023-09-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/add.16348","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41096119","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}