Nicotine addiction among youth is a continuing public health concern, and vaping serves as a major pathway to nicotine use. Conventional assessments of craving and addiction risk rely on self-reports, which are prone to bias and lack sensitivity to real-time processes. Virtual reality (VR) enables controlled cue exposure while capturing real-time multimodal data, including subjective experiences, behavioral patterns, and physiological responses, which offer a more implicit and dynamic approach to identifying addiction risk. This pilot study examines whether subjective craving and psychophysiological responses (eg, eye gaze, heart rate, and electrodermal activity) to vaping-related cues in VR can distinguish young adults who vape from those who do not. Our secondary objective is to explore associations between these multimodal biomarkers and self-reported measures of craving, dependence, motivation to quit, and susceptibility to initiate vaping. Bespoke VR scenes were developed with input from a youth advisory board to ensure ecological validity. Forty young adults aged 18 to 21 years (20 vapers and 20 nonvapers) will complete a single laboratory session. Participants will experience 3 VR scenes (neutral baseline, vaping cues without social pressure, and vaping cues with social pressure in counterbalanced order). Eye gaze, heart rate, and electrodermal activity will be recorded continuously. Participants will complete standardized assessments of craving, sense of presence, and social presence in VR after each cue scene, followed by a short interview at the end. Quantitative data will be analyzed using mixed-model ANOVAs, correlation metrics, and exploratory regularized regression analyses to examine relationships between physiological responses, behavioral measures, and vaping status. The project received institutional review board approval in August 2025 and was registered publicly in the Open Science Framework in November 2025. Development of the VR stimuli was completed in December 2025. Participant recruitment and data collection began in February 2026, and 7 participants have been enrolled as of March 2026. This protocol outlines a pilot study integrating immersive VR and multimodal biometrics to examine vaping cue reactivity in young adults. The findings will guide the development and evaluation of VR-based psychophysiological tools for identifying early markers of nicotine use risk. This work will also lay the foundation for adapting the approach to younger adolescents to support scalable early detection and prevention of nicotine addiction and initiation.
Neuroscientific models of addiction have evolved over the past four decades from single-circuit dopamine frameworks to dual-process, tripartite, and multidimensional accounts. Despite these advances, existing models incompletely account for the lived experience of addiction and for developmental, social, and mental-health factors that contribute to heterogeneity in risk and outcome. This review synthesizes this progression and evaluates the need for more integrative frameworks. Recent work highlights addiction-related alterations in large-scale brain networks and demonstrates that psychosocial and contextual factors play a more central mechanistic role than previously acknowledged. Emerging interventions, including psychedelic-assisted therapies, further underscore the relevance of multilevel change across neurobiological, cognitive, and affective domains. Framing addiction as a multilevel, interactive process within a biopsychosocial framework provides a unifying perspective that accommodates heterogeneity in pathways and outcomes. Integrative models may better inform mechanistic research and guide the development of more precise, clinically meaningful interventions.
The evolving landscape of illicit drug markets necessitates effective approaches to harm reduction and addiction prevention for people who use drugs (PWUD). In response, integrated drug checking services (DCS), which combine chemical analyses and psychosocial interventions, have been shown to contribute to safer drug use behaviour, particularly in festival settings. However, little is known about how people who predominantly use drugs occasionally engage with and perceive fixed-site DCS and how specific service characteristics contribute to its overall impact. In this study, we qualitatively assess the impact of a well-established multimodal DCS in Vienna, Austria, from the viewpoint of actual and prospective users. From June 2024 through January 2025, semi-structured interviews were conducted with 23 PWUD (7 self-identified as female; 16 as male), of whom 12 were current users of at least one drug checking modality (mobile or fixed-site), and 11 had no prior experience with DCS. Including both groups provided a broader perspective, acknowledging the limited reach of the DCS and the access barriers faced by some individuals. Participants reported diverse drug use patterns, with many reporting occasional use. Interviews were analysed using reflexive thematic analysis. During analysis, three central themes were developed: (1) "Knowledge creates safety and agency" illustrates how knowledge of the exact composition of a substance fosters a sense of safety and empowers individuals to make informed decisions about their drug use; (2) "Personal circumstances as key to engagement and impact" captures the effect of situational context and current needs in shaping the depth and engagement with DCS; and (3) "Social effects beyond the individual" reflects the broader impact of drug checking, on the level of peers, people who sell drugs, and the drug market. Our findings suggest that DCS can considerably promote safer use behaviour, as well as risk awareness and management among PWUD. To be effective as a tool for early intervention and addiction prevention, services must remain low threshold to address the diverse needs of PWUD, allowing for varying degrees of engagement, such as keeping psychosocial counselling optional. Acknowledging the critical role of peers in building trust, facilitating access, and sharing safer use information underscores the importance of social relations in extending the harm reduction impacts of DCS.
Addiction has traditionally been framed as a disorder of negative affect and impaired downregulation of distress, yet disturbances in positive emotional experience and regulation are equally fundamental to the development and persistence of substance use disorders (SUDs). This review synthesizes clinical and psychophysiological evidence documenting the impact of addictive substances on positive emotion dysregulation, and highlights the role of positive emotion regulation on craving and drug relapse. Individuals who engage in addictive use of opioids, nicotine, cannabis, and stimulants exhibit blunted positive affect, diminished responsiveness to natural rewards, and deficits in the volitional upregulation of positive emotion. These impairments reflect neuroplastic alterations in corticostriatal and corticolimbic circuits that weaken endogenous reward generation, and erode the capacity to derive pleasure from, and savor, everyday experiences. Addiction is underpinned by positive emotion dysregulation. Restoring positive affective functioning through positive emotion regulation interventions may revolutionize addiction recovery.
Cannabis legalization has expanded rapidly across high-income jurisdictions, altering patterns of cannabis use, product potency, and commercial markets. Although surveillance systems increasingly quantify cannabis exposure, clinically meaningful harm is more difficult to detect. Cannabis use disorder (CUD) represents a key construct linking exposure to sustained impairment, yet its epidemiologic visibility depends heavily on diagnostic frameworks and measurement design. This review examines how contemporary surveillance systems detect cannabis-related harm and evaluates the implications of diagnostic classification, epidemiologic measurement, and treatment capacity for understanding and responding to CUD in the post-legalization era. We conducted a narrative review synthesizing literature on cannabis legalization, psychiatric epidemiology, and treatment of CUD. Evidence was identified from biomedical databases, epidemiologic surveys, systematic reviews, randomized trials, and policy analyses. Sources were examined across three domains: (1) post-legalization surveillance of cannabis exposure and harm, (2) diagnostic evolution and measurement of CUD in population surveys, and (3) current evidence for treatment interventions and treatment system responses. Population surveillance systems measure cannabis exposure with increasing precision but show limited sensitivity for persistent or clinically meaningful harm. Transitions from DSM-IV's hierarchical abuse-dependence framework to the dimensional DSM-5 model expanded detection of mild and moderate disorder and altered prevalence estimates across epidemiologic surveys. International studies using DSM-5-aligned instruments generally report past-year CUD prevalence of approximately 2-3% in the general population, with substantially higher conditional risk among frequent users. However, surveillance systems relying on legacy diagnostic modules or restrictive assessment logic may underestimate disorder prevalence despite rising cannabis exposure and increasing acute health-care encounters. Evidence for CUD treatment indicates modest but consistent benefits from psychosocial interventions-including motivational, cognitive-behavioral, and contingency-based approaches-while no pharmacotherapies are currently approved, and treatment engagement remains low relative to estimated prevalence. Apparent uncertainty in post-legalization health outcomes often reflects limitations in measurement rather than absence of harm. Aligning surveillance systems with contemporary diagnostic frameworks and strengthening treatment pathways are essential for translating exposure monitoring into effective public health response. As legalization continues to expand, CUD provides an important test of whether addiction treatment systems can adapt to legalized substances whose harms are diffuse, chronic, and frequently under-recognized.
Objective: To summarize current evidence on the use of buprenorphine for chronic pain management in individuals with sickle cell disease (SCD) and identify gaps for future research. Data Sources: PubMed, Embase, and Cochrane CENTRAL were systematically searched from database inception through August 2025 using keywords related to buprenorphine, SCD, chronic pain, and analgesia. Searches were limited to human studies published in English. Study Selection: Seven studies were included involving pediatric or adult patients with SCD treated with buprenorphine for chronic pain. Eligible studies reported at least 1 patient-centered outcome, including pain severity, opioid utilization, health care use, or quality of life. Included study designs were case reports, case series, observational studies, and qualitative studies. Abstract-only publications and studies not specific to SCD were excluded. Data Extraction: Two reviewers independently extracted data using the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews guidelines, with discrepancies resolved by consensus. Data Synthesis: A descriptive synthesis was performed. Most studies evaluated buprenorphine initiation using microinduction strategies. Buprenorphine was generally well tolerated and associated with reduced full opioid agonist use, fewer emergency department visits and hospitalizations, and improvements in functional outcomes and patient-reported autonomy. Study heterogeneity and small sample sizes limited comparative analysis. Conclusions: Available evidence suggests that buprenorphine may be a safe and effective option for chronic pain management in SCD. Larger prospective studies with standardized induction protocols and validated outcome measures are needed to guide clinical practice. Prim Care Companion CNS Disord 2026;28(3):25r04126. Author affiliations are listed at the end of this article.
'Habit theory' is a pervasive framework that describes addiction as a transition from goal-directed use (e.g. of drugs) to habitual response, accompanied by a neurobiological shift in fronto-striatal brain circuitry. As a theory that has been explored in the context of substance addictions, this article evaluates the conceptual fit of habit theory to gambling behavior and gambling disorder, and summarizes recent empirical evidence. Relevant research falls into two main themes. First, studies have compared behavioral markers of habit (e.g. the two-step task, Pavlovian-to-Instrumental Transfer effects) in groups with and without gambling problems. These studies find limited direct support for the hypothesis. Second, psychological research has begun to examine habit-like behaviors in naturalistic gambling. These studies find behavioral expressions consistent with habit formation, primarily during engagement with slot machines, but are yet to test key tenets of habit theory such as insensitivity to outcome devaluation. Modern gambling products (e.g. slot machines, in-play sports betting) create rich learning environments that may be highly amenable to habit formation. Further research is needed to develop and validate new tools for testing habit formation and habit strength / persistence in the context of gambling.
Obsessive-compulsive and related disorders (OCRDs) are characterized by obsessions, compulsive or repetitive behaviors, hoarding and saving, or recurrent body-focused repetitive behaviors. Although pharmacological, cognitive-behavioral, or behavioral therapies provide relief for many for these conditions, a substantial proportion respond insufficiently or experience relapses. Neurofeedback (NF) enables individuals to self-modulate neural activity in real time and has been explored as a non-invasive neuromodulation strategy in obsessive-compulsive disorder (OCD), the only OCRD in which NF has been empirically tested to date. Conventional electroencephalogram-based (EEG-NF) and functional magnetic resonance imaging-based (fMRI-NF) protocols have demonstrated that patients can learn to regulate oscillatory activity or region-specific blood-oxygen-level-dependent signals, with some studies reporting symptom improvements. However, heterogeneity in targets, limited personalization, and modest clinical effects constrain conclusions regarding efficacy and scalability. This narrative review synthesizes the existing empirical evidence of NF studies to-date. In addition, it highlights the potential for decoded neurofeedback (DecNef) as a next-generation NF method. Unlike conventional NF, DecNef leverages multivoxel pattern analysis to reinforce distributed neural representations, in some cases without explicit awareness or symptom exposure, and may allow greater precision and personalization of circuit-level interventions. We discuss how DecNef can address limitations of traditional NF and outline its potential translational applications across the OCRD spectrum. By integrating current empirical findings with a forward-looking precision psychiatry framework, this review offers ideas for conceptual and methodological advances for targeting dysfunctional neural systems underlying OCRDs.
Psychedelic and psychedelic-adjacent substances, including 3,4-methylenedioxymethamphetamine (MDMA) and classic serotonergic hallucinogens, are undergoing renewed therapeutic investigation and remain in non-medical use. Inadvertent exposure during early, unrecognized pregnancy is clinically plausible, yet pregnancy-specific safety evidence is limited. To map and synthesize the extent, characteristics, and limitations of primary human evidence on prenatal exposure to MDMA, psilocybin, and classic hallucinogens (lysergic acid diethylamide (LSD), mescaline/peyote, and N,N-dimethyltryptamine (DMT)/ayahuasca), and to identify clinically relevant evidence gaps for perinatal counseling and pharmacovigilance. Peer-reviewed primary human studies (cohort, case-control, cross-sectional, case series, case reports, and brief reports) describing prenatal exposure with reported maternal, obstetric, neonatal, congenital anomaly, or child neurodevelopmental outcomes were included. Animal and preconception-only studies were excluded. MEDLINE, Embase, PsycINFO, CINAHL, and the Cochrane Library were searched from inception to March 2025. Supplementary methods included Google Scholar screening and citation tracking. Data were charted in duplicate using a standardized form and synthesized descriptively by substance and outcome domain. Consistent with scoping methodology, no formal risk-of-bias assessment or meta-analysis was undertaken. Twenty-three primary human sources (1968-2020) met inclusion criteria: MDMA (n = 11), LSD (n = 11), and mescaline/peyote (n = 1). No eligible primary human pregnancy outcome studies were identified for psilocybin or DMT/ayahuasca. The evidence base was heterogeneous and predominantly comprised small cohorts, teratology service follow-up reports, and case-based publications, frequently limited by self-reported exposure, polysubstance confounding, and inconsistent outcome definitions. Human evidence on prenatal psychedelic exposure remains sparse and methodologically constrained. Absence of data for several substances should not be interpreted as evidence of safety. Clinicians should counsel with explicit acknowledgment of uncertainty while supporting harm reduction and appropriate follow-up. Structured perinatal pharmacovigilance and ethically designed evidence-generation strategies are needed as therapeutic psychedelic research expands. What we know about psychedelic drug exposure during pregnancy Some people may be exposed to psychedelic drugs such as MDMA (“ecstasy”), LSD, or psilocybin during pregnancy, often before they realize they are pregnant. As interest in psychedelic therapies grows, clinicians are increasingly asked about possible risks to pregnancy and child development. In this review, we examined all available human studies that reported pregnancy or child outcomes following exposure to psychedelic or psychedelic-related substances. We found that the human evidence base is very limited and mostly consists of small observational studies, case reports, and follow-up data from teratology information services. Most available studies focus on MDMA or LSD, while there is little to no direct human pregnancy outcome data for substances such as psilocybin or ayahuasca. Because the available evidence is sparse and highly variable, it is not possible to reliably estimate the risks of miscarriage, birth defects, or long-term child development following psychedelic exposure during pregnancy. This review highlights important gaps in current knowledge and explains why careful, individualized clinical counselling is needed when such exposures occur. The findings are relevant for clinicians, patients, and researchers involved in drug safety and pregnancy care.
Cocaine use disorder (CUD) is a significant global health concern, characterized by persistent craving despite severe consequences. Recent theories highlight maladaptive memory processes - such as intrusive, vivid recollections of past substance use that arise spontaneously in daily life - as key contributors to craving and relapse; however, empirical studies examining such substance-related intrusions in naturalistic contexts remain scarce. This study therefore used ecological momentary assessment (EMA) to investigate the frequency, phenomenology and emotional and behavioural correlates of substance-related memory intrusions in individuals with CUD, and how these relate to craving, cocaine use severity (CUS) and psychotherapy experience. A 14-day EMA study captured event-based reports of intrusions, craving and related experiences in participants diagnosed with CUD. The study was conducted in Switzerland in a naturalistic setting, with data collected via individuals' smartphones. N = 43 participants (recruited in Switzerland, 16% female; 18-59 years old, median compliance rate 82.8%) with a current DSM-5 diagnosis of CUD made a total of n = 360 event-based reports that were analysed. EMA reports included intrusion episode types (pure intrusions, intrusions with subsequent or simultaneous craving or pure craving), intrusion characteristics (vividness, intrusiveness, modalities), craving intensity, episode triggers and cognitive-behavioural, emotional and physiological responses. CUS was assessed based on use quantity, duration and obsessive-compulsive use symptoms. Participants recorded an average of 8.4 episodes (standard deviation = 5.8) across 14 days. Intrusions frequently occurred independently of craving (42.4%) but were statistically significantly associated with greater craving intensity when more vivid (unstandardized regression coefficient b = 0.53, P = 0.002) and intrusive (b = 0.48, P < 0.001). Episodes involving craving were characterized by greater distress (b = 1.52-2.17, all P < 0.001) and greater loss of control (b = 2.41-3.22, all P < 0.001) and were associated with higher odds of reporting obtaining cocaine (odds ratio = 19.90, P < 0.001). Higher CUS predicted more frequent intrusion episodes (unstandardized regression coefficient β = 0.52, P < 0.001), while psychotherapy experience was associated with lower vividness (b = -1.45, P = 0.008), intrusiveness (b = -1.33, P = 0.004) and craving intensity (b = -1.56, P = 0.010). Substance-related memory intrusions in people with cocaine use disorder are distinct cognitive-affective events that often occur independently of craving but are closely linked to its intensity, particularly when experienced as vivid and emotionally charged. Targeting these features through behavioural or pharmacological interventions may help mitigate craving-driven distress and impulsive use-related behaviour.
Ibogaine has garnered interest for its potential therapeutic properties in substance use and psychiatric disorders. Unlike classic psychedelics such as psilocybin or LSD, ibogaine remains underexplored in clinical research. This review aimed to synthesize the clinical literature on ibogaine use in humans over the past 3 decades, focusing on outcomes and safety. We conducted a narrative review of studies on ibogaine's clinical use published from 1990 to February 2025, including randomized controlled trials (RCTs), open-label, retrospective, and observational studies. Databases were searched for reports on efficacy and safety across various indications. Twenty-four studies and 38 case reports/series were included. Most of the positive efficacy data come from uncontrolled, open-label, or retrospective studies, many conducted in nonclinical settings, with a high risk of bias. No double-blind RCT to date has demonstrated that ibogaine or noribogaine can effectively treat opioid use disorder (OUD). Only 1 small RCT reported significant effects for cocaine use disorder. Although observational data suggest that ibogaine may alleviate symptoms of OUD, PTSD, or polysubstance dependence, these findings remain exploratory. Moreover, serious ibogaine-related adverse events have been reported, especially cardiotoxicity due to QT prolongation, which represents a considerable risk given the currently unproven efficacy. While ibogaine remains a compound of interest for neuropsychiatric research, current evidence is insufficient to support its clinical use. Further studies are needed to better demonstrate ibogaine's efficacy, optimize its safety profile, and determine how it could be integrated into psychiatric care, especially in relation to the emerging therapeutic use of classic psychedelics.
The opioid epidemic remains a critical public health issue, with orthopedic surgeons being among the highest prescribers of opioids for post-operative pain management. To elucidate the provisions of the Non-Opioid Prevent Addiction in the Nation (NOPAIN) Act and its implications for reducing opioid use in orthopedic surgery. A comprehensive review of the NOPAIN Act's legislative framework, historical opioid use in orthopedic practices, current nonopioid pain management strategies, and insights from relevant reports was conducted. The NOPAIN Act, effective January 1, 2025, mandates Medicare reimbursement for Food and Drug Administration-approved nonopioid pain treatments at 106 percent of the average sales price (+6 percent) in hospital outpatient departments and ambulatory surgery centers. This legislation incentivizes the adoption of nonopioid alternatives, promoting multimodal analgesia and regional anesthesia techniques. The Act may improve patient outcomes, reduce opioid-related adverse events, and help offset institutional costs. Implementation of the NOPAIN Act may influence orthopedic surgeons in adopting evidence-based, nonopioid pain management protocols, enhancing patient outcomes and contributing to national efforts against the opioid crisis. The Act's financial incentives and structured reimbursement framework may contribute to the transition toward safer practices.
Overdose Response Hotlines and Apps (ORHAs) are novel technologies designed to avert fatal overdose associated with solitary use of illicit substances. While they can be a useful tool for those who cannot reach in-person harm reduction support, previous literature has cited potential barriers to their access. The aim of this study was to quantitatively evaluate the types of barriers that may hinder the uptake and utilization of ORHAs from the perspective of key stakeholders. The current study reports on the data obtained from Canadian National Questionnaire on Overdose Monitoring (CNQOM) focusing on people who currently use substances (PWUS-C), have used substances in the past (PWUS-P), and addiction service providers (ASP). A combination of purposive and representative sampling was used for recruitment. A list of potential partner organizations across Canada was contacted between July 2022 and May 2023. We explored logistical, technological, and social barriers to assess the acceptability of ORHAs. A total of 971 participants were included in this study, consisting of 268 PWUS-C, 525 PWUS-P, and 178 ASP. Barriers to ORHA were categorized into: service delivery and quality barriers, technological barriers, and stigma/social barriers. More than half of the respondents across all groups rated the barriers as 4 (significant) or higher on the Likert scale. Ordinal logistic regression revealed that being an ASP was associated with higher likelihood of rating certain barriers as more significant compared to PWUS-C and PWUS-P. This study is the first to quantify concerns about potential barriers to the use of ORHAs from the perspectives of key Canadian interest groups and provide valuable information on how to improve accessibility and utility of overdose prevention technologies to a wider range of demographics.
Irritability is a prevalent and impairing feature associated with autism, yet remains poorly understood, particularly in adults. Drawing heavily on insights translated from pediatric and transdiagnostic literatures, we propose that irritability in autistic individuals often reflects a psychophysiological stress or threat response, rooted in a vulnerable neurobiology (e.g., sensory sensitivities, intolerance of uncertainty), but may also stem from intrinsic neurobiological dysregulation independent of environmental triggers. The current treatment paradigm for autistic adults, largely extrapolated from pediatric antipsychotic trials, leaves these adults critically underserved due to a lack of evidence-based treatments, clinical trials, or validated tools to measure their internal experience. This viewpoint deconstructs irritability, differentiating its affective nature from aggression, and highlights heterogeneity across the lifespan and support needs. We critique the limitations of current assessment methods and recommend a shift toward a multi-modal strategy integrating self-report (when feasible) with objective, physiologically-informed tools (e.g., wearable biosensors) and nuanced observer reports. We argue that the field is poised for neuroscience-informed treatment innovation-including novel pharmacological agents and adapted psychosocial interventions-but is hampered by a lack of rigorous clinical trials in adults. Finally, we call for mechanistically driven trials to address the large unmet burden of inadequately treated irritability, ultimately improving the quality of life for autistic adults and their families/caregivers. Irritability in autistic adults is a major crisis, but most treatments are decades old and were only tested on children. Drawing on evidence primarily from youth and related conditions, our review explains that irritability is often a physical and emotional stress response to things like sensory overload or trauma, not just a “behavior problem.” We call for urgent research into new, adult‐focused treatments and tools, like wearable sensors, to directly address the root causes of this distress.
Post-diagnostic support is a critical yet underdeveloped aspect of dementia care, especially for autistic adults who present with distinct cognitive, sensory, and communication needs. Although interventions such as medication management, psychosocial support, environmental modifications, and carer training are known to improve outcomes, their relevance and accessibility for autistic individuals remain poorly understood. As part of the Second International Summit on Intellectual Disability and Dementia, an international working group examined the intersection of autism and dementia with a focus on post-diagnostic care. Drawing on interdisciplinary expertise, the group identified key barriers and opportunities in clinical practice, caregiving, and service delivery. Recommendations are organized across seven areas, including models of post-diagnostic support, caregiving contexts, pharmacological and non-pharmacological interventions, environmental adaptations, and care planning. The discussion emphasizes the complex needs of autistic adults-many of whom have co-occurring intellectual disabilities, psychiatric conditions, or chronic health issues-and the need for individualized approaches that account for sensory sensitivities and communication differences. Existing dementia care frameworks often fail to address these complexities, resulting in significant service gaps. The report calls for urgent investment in research, workforce training, and policy reform to promote equitable, autism-informed post-diagnostic support and improve quality of life for this underserved population.Lay AbstractAutistic adults who develop dementia often experience challenges that are not well addressed by current dementia care systems. After a dementia diagnosis, people may need help with memory, communication, behavior changes, and daily living. For autistic adults, these supports must be adapted to their individual sensory sensitivities, communication styles, and social differences. This article reports on the work of an international group of researchers, clinicians, and advocates who met during the Second International Summit on Intellectual Disability and Dementia. The group examined how post-diagnostic support for autistic adults with dementia could be improved. They reviewed existing evidence, identified key barriers to care, and proposed strategies to strengthen services in areas such as medication use, environmental design, caregiver training, and personalized care planning. The report emphasizes that many autistic adults also have intellectual disabilities, mental health conditions, or long-term physical health issues, which can make care more complex. Current dementia care frameworks often overlook these overlapping needs, resulting in limited or unsuitable supports. The authors call for more research, workforce training, and autism-informed policy changes to ensure that post-diagnostic care is equitable, individualized, and responsive. Enhancing understanding and adapting support can help autistic adults with dementia maintain dignity, comfort, and quality of life.
Buprenorphine is a semi-synthetic opioid approved for pain and opioid use disorder (OUD). A challenge in its initiation is the risk of precipitated withdrawal if a large sublingual buprenorphine dose is administered too soon after a full mu opioid receptor (MOR) agonist. This experience can be so discomforting that it might prevent further efforts to transition patients to an otherwise safe and effective treatment for OUD and/or chronic pain. Recent evidence supports a newer initiation method that may not carry as great of a risk, known as low-dose buprenorphine initiations (LDBI). While current literature demonstrates LDBIs in addiction medicine extensively, there is limited evidence detailing its use in pain, and even less detailing LDBIs led by clinical pharmacy practitioners. This case series describes five successful pharmacist-led LDBIs at a Veterans Affairs Medical Center (VAMC) among patients with chronic pain and/or OUD who required urgent transitions from their full MOR agonist to sublingual buprenorphine where a standard induction strategy would have been highly challenging and unrealistic. These cases demonstrate the versatility and clinical utility of LDBI across a variety of urgent clinical settings with unique baseline opioid regimens and continue to reinforce its possible role as a first-line induction strategy for buprenorphine.
Alcohol misuse is responsible for a significant public health burden in the United States and remains undertreated despite approved treatments for alcohol misuse such as naltrexone. The current study characterizes the views of stakeholders in an Alaska Native healthcare system regarding pharmacotherapy for alcohol misuse. A secondary, mixed-methods analysis was conducted using qualitative data from 70 interview participants (patients, providers, and health system leaders) and survey data completed by 944 stakeholders (patients, providers, leadership, and administrative staff). Five major themes were identified from the qualitative data: gaps in medication awareness and knowledge, perceived benefits of naltrexone, medication as a component of comprehensive treatment, concerns about pharmacotherapy for alcohol misuse, and the importance of shared decision-making. Survey results found that providers were significantly more likely than other stakeholders to favor the use of medications like naltrexone. Compared to non-AN/AI respondents, AN/AI individuals were less likely to believe that medication can help people achieve sobriety and were more likely to endorse survey statements that (1) strong people don't need medication and (2) people who use medication to support sobriety might be trading one addiction for another. Most respondents did not find medication assisted treatment to be against AN/AI cultural values, with no statistical difference between AN/AI and non-AN/AI survey respondents. Identifying mismatches in stakeholders' attitudes and beliefs can highlight opportunities to increase uptake of effective therapies for alcohol misuse. Concerns about pharmacotherapy among patients as compared to providers and AN/AI individuals as compared to non-AN/AI suggests that under-prescribing may not be the main issue in lack of uptake of naltrexone. These findings suggest the importance of identifying patient beliefs about medication use as well as the need for wraparound services and supports for patients prescribed naltrexone.
Romantic relationships are important contexts for substance use and emotional well-being. We tested the hypotheses that (i) genetic predispositions for alcohol consumption would be positively associated with partner substance use, (ii) partner substance use would moderate genetic influences on one's own alcohol outcomes, and (iii) partner discordance in substance use would be associated with lower emotional well-being and relationship quality. Analyses included 2,357 participants (Mage = 51.4, 58.2% female) from the Collaborative Studies on the Genetics of Alcoholism. Focal measures included participants' reports of their own and their current partner's past-year substance use (frequencies of alcohol use, heavy drinking, drunkenness, cannabis use, and nicotine use), emotional well-being, and relationship quality. Participants' genetic predispositions were indexed with genome-wide polygenic scores for alcohol consumption (PGSAlc). Participant-partner substance use discordance was calculated as the difference between the participant's and their partner's use for each substance use measure, separately. Participant PGSAlc was not significantly associated with partners' perceived substance use. Frequent perceived partner alcohol use and heavy drinking significantly amplified the association between PGSAlc and alcohol use or drunkenness. Frequent perceived partner drunkenness and cannabis use significantly attenuated the association between PGSAlc and heavy drinking or frequency of alcohol use. Participant-partner discordance for several substance use measures was significantly associated with lower emotional well-being and relationship quality, controlling for participant and partner substance use main effects. The results highlight the importance of partner substance use in etiological models of alcohol use, emotional health outcomes, and relationship quality.
The stigma attached to substance use disorder (SUD) can prevent entry into, and engagement with, treatment services. This paper provides an initial exploration into what could be an emerging trend using a case study approach. Semi-structured interviews were conducted with 15 women who have used, or were currently using, residential or community-based addiction services in Cork (Ireland). Some participants reported the well documented stigma attached to SUD as a barrier for entry into, and engaging with, the recovery process. Two participants reported feeling ashamed of being unable to identify specific traumas that could account for their substance use. They felt the stereotype of 'the addict' having had a traumatic life did not map onto their experiences, and felt stigmatised by others within recovery for this. Consequently, they questioned whether they had a SUD and should access treatment, and this initially prevented them from engaging in therapy. This paper does not refute the association between trauma and SUD. Rather it argues that common misunderstandings of trauma and substance use, and increased use of trauma talk, may have contributed to a new form of stereotype that some with SUDs must navigate.
Reward learning can contribute to addictive behaviors by shaping attention and action selection. While reward-associated stimuli are known to capture attention, it remains unclear whether such learning can also guide behavior without stimulus-outcome contingency awareness. This study examined whether implicitly learned reward associations influence both attention and action selection, and how these effects relate to risky alcohol use. Eighty university students (40 low-risk and 40 high-risk drinkers) completed a Pavlovian-to-instrumental transfer task combined with an emotional attentional blink paradigm. During learning, conditioned stimuli and responses were probabilistically paired with monetary rewards. Awareness of stimulus-outcome contingencies was assessed at the individual level, using the Bayesian Awareness Categorization Technique. Reward-related influences on attention and response selection were then tested in a transfer phase. We observe no evidence of Pavlovian-to-instrumental transfer in either participants aware or unaware of reward contingencies. Similarly, reward associations did not modulate attention. The absence of effects in both aware and unaware participants makes it difficult to determine whether Pavlovian influences on attention and behavior are truly absent or simply not detectable under the current task conditions. However, exploratory analyses show that high-risk drinkers present greater preference for high-probability, low-value responses in the transfer phase. The observed preference for high-probability rewards in high-risk drinkers may reflect altered reward sensitivity. Together, these findings underscore the importance of evaluating reward-driven attentional and behavioral biases under well-controlled conditions and highlight the value of publishing null results to refine theoretical models of Pavlovian influences in addiction.