Over the past two decades, the National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) has made major contributions to progress in substance use treatment research. However, contributions to research addressing the considerable medical and mental health comorbidities of substance use, which can impede treatment efficacy and compromise health, have been emphasized less. In this Commentary, we review the contributions of CTN studies focused on medical comorbidities, initially centered on the HIV epidemic in people who use drugs, and subsequently broadened to address hepatitis C and life-threatening bacterial infections; as well as mental health comorbidities, especially post-traumatic stress disorder, attention-deficit/hyperactivity disorder, and suicidality. These studies demonstrate that comorbidities assessments and treatment can be feasibly implemented in substance use treatment programs and, conversely, that substance use assessments and treatments can be feasibly implemented in clinical care sites. We highlight the NIDA CTN Data Share as an invaluable resource for secondary analyses of comorbidities using data from CTN substance use treatment protocols and provide examples of its use. We describe the work of the CTN Comorbidities of Substance Use Special Interest Group (SIG), formerly known as the HIV SIG, as an example of the role that SIGs can play in facilitating CTN research in areas of emerging significance. We emphasize the importance of implementing a "whole person" approach-one that integrates both substance use and comorbidities outcomes. We identify promising opportunities for conducting this research by studying strategies for integrating prevention, screening, linkage, treatment, adherence, and retention support for comorbidities into substance use disorder (SUD) treatment venues; as well as strategies for integrating SUD treatment into primary care venues, hospitals, and other non-SUD clinical settings.
Studies have identified differences by patient characteristics in addiction treatment utilization in the early COVID-19 pandemic period, yet an understanding of longitudinal changes in utilization patterns remains unclear. We examined treatment utilization trends over three years post-pandemic, with a particular focus on differences by age and race and ethnicity. Using electronic health record data, this retrospective cohort study examined overall and telehealth addiction treatment initiation and engagement 3 years pre- and 3 years post-pandemic (3/16/2020) following identification of 170,618 episodes involving problematic substance use among 124,413 adults in a large, integrated Northern California health system. Interrupted time series models were fit to examine annual utilization rates during pre- and post-pandemic periods (3/1/2017-1/15/2020 and 5/17/2020-2/28/2023, respectively), and level- and trend-changes in utilization from pre- to post-pandemic, overall and by age group and race and ethnicity. Overall treatment initiation decreased from 27.0% to 24.2% during the pre-pandemic period by approximately 2% annually (RR [95% CI] = 0.98 [0.96, 0.99]), increased by 6% after the onset of the pandemic (1.06 [1.03, 1.10]), and then decreased by 2% annually in the post-pandemic period to 23.0% (0.98 [0.79, 0.99]). Telehealth initiation increased from 1.9% to 2.6% during the pre-pandemic period by 12% annually (RR [95% CI] = 1.12 [1.06, 1.19]), increased five-fold immediately after pandemic onset (RR [95% CI] = 5.14 [4.62, 5.72]), and then decreased by 10% annually (RR [95% CI] = 0.90 [0.88, 0.92]). Overall and telehealth engagement followed similar patterns. Pre- to post-pandemic trends in utilization varied by age group and slightly by race and ethnicity, which may have been primarily driven by initial increases in utilization at the onset of the pandemic. Following immediate increases in treatment initiation and engagement during the pandemic, utilization via telehealth decreased slightly over time. Availability of telehealth was not associated with increased or sustained utilization over time. Despite some variation in trends over time by age group and race and ethnicity, we did not find strong evidence of differences across groups.
Highly accessible and scalable, digital mental health interventions can reduce barriers associated with traditional treatment. Woebot for Substance Use Disorders (W-SUD) is a smartphone application in development that uses Woebot, a guided self-help relational agent intended to offer support to track and reduce problematic substance use. Two formative studies supported W-SUD's feasibility, acceptability, and efficacy to reduce substance use at end-of-treatment (EOT). In a randomized trial with a 1-month post-treatment follow-up, we aimed to evaluate W-SUD's efficacy in reducing substance use occasions relative to a psychoeducational control. U.S. adults (N = 258) with problematic substance use (CAGE-AID≥2) were recruited online and randomized to W-SUD or an email-delivered psychoeducational control. Primary and secondary outcomes were change in past-month substance use occasions from baseline to 8-weeks EOT and baseline to 1-month follow-up, respectively. The analytic sample (N = 202; 107 = W-SUD; 95 = psychoeducation) averaged 38.3 years of age (SD = 10.4) and was 53.5% (108/202) female and 71.3% (144/202) White. At baseline, participants averaged 33.1 (SD = 18.3) past-month substance use occasions with problematic substance use reported as alcohol (73.3%, 148/202), cannabis (30.7%, 62/202), stimulants (17.3%, 35/202), and cocaine (12.4%, 25/202). Anxiety (32.7%, 66/202) or depression (23.3%, 47/202) co-occurred. W-SUD participants sent a median of 322.5 (interquartile range: 59.8, 924.0) in-app messages during the intervention. There was no significant treatment effect on the primary (beta = -0.675, p = 0.741; 95%CI = -4.96-3.49) or secondary outcomes. Baseline to EOT within-group change in past-month substance use occasions were - 13.6 (SD = 15.4, d = -0.879) and - 12.9 (SD = 15.3, d = -0.847) for the W-SUD and psychoeducation conditions, respectively, indicating moderate to large changes in both, which was sustained at 1-month follow-up. Decreases in substance use occasions significantly correlated with decreases in anxiety and depression and with greater treatment satisfaction in both groups. There were no serious adverse events. Participants in both conditions reported significant improvements in primary and secondary outcomes at EOT and 1-month post-treatment, with no statistically significant difference in improvement between conditions. GOV (POSTED 2021-06-14): NCT04925570, https://clinicaltrials.gov/study/NCT04925570.
To maximize, and possibly prioritize, opportunities for using patient experience surveys for quality improvement and evaluation purposes we assessed the association between specific domains of patient experience in an inpatient substance use treatment program and post-discharge wellness-oriented and clinical outcomes. Upon entry to an inpatient substance use treatment program, 297 participants completed a self-administered battery of measures that assessed a variety of clinical as well as wellness-oriented outcomes. During the final week of the program participants completed an abbreviated form of the assessment battery as well as the Ontario Perception of Care- Mental Health and Addictions (OPOC-MHA) tool to assess patients' perceptions of the care they had just received. The battery of tests was repeated at 1-, 3-, 6- and 12-months post-discharge. Using mixed-effects models we analysed the association between patients' perceptions of care (POC) as they relate to each of the eight OPOC-MHA domains and each of the wellness-oriented - life satisfaction, quality of life and hopefulness - and the clinical outcomes, craving and frequency of substance use. Overall, we found strong associations between the various dimensions of participants' POC and the three wellness-oriented outcomes. Importantly, dimensions that most closely reflected therapeutic interactions during treatment - services provided, participation and rights, and the therapist-patient relationship - were significantly associated with each of these outcomes. Notably, none of the eight dimensions of POC demonstrated a significant association with either of the two clinical outcomes. The results contribute important information on the relation between patient satisfaction or POC and outcomes given the paucity of research with a focus on post-discharge outcomes in the substance use treatment sector. Consistent with advocating for person-centred care, our results also point to potentially important aspects of the patient experience for targeted quality improvement and evaluation as well as application in measurement-based care.
Racial and ethnic inequities persist in medication treatment initiation and adherence for pregnant and postpartum people with opioid use disorder (OUD). Our objective was to understand the experiences of "positive outliers," specifically pregnant and postpartum people of color with OUD who utilized medication treatment and engaged in a randomized clinical trial for buprenorphine despite historical, cultural, and structural barriers. We conducted two sets of semi-structured qualitative interviews. First, trained peers with lived expertise as mothers in recovery interviewed individuals who identified with a non-white race and/or ethnicity and enrolled in the Medication Treatment for OUD in Expectant Mothers (MOMs) trial (NCT03918850). Second, we interviewed principal investigators, clinicians, and research coordinators from the 13 MOMs trial sites. We used an inductive thematic approach informed by the Social Ecological Model of Racism and Anti-Racism. Transcripts were double-coded and reviewed until consensus was reached. Preliminary findings from participant and staff interviews were merged and triangulated with peers to inform theme development. We completed 17 interviews with MOMs trial participants from 7 sites. Participants identified as Hispanic (29%), Black non-Hispanic (24%), multi-racial Hispanic (18%), multi-racial non-Hispanic (18%), and American Indian, Native Hawaiian, or Pacific Islander (12%). Thirty-two interviews with trial staff were also completed. Three themes emerged: (1) Although some participants expected racist treatment and research exploitation, all participants interviewed reported non-discriminatory, non-judgmental care within the MOMs trial; (2) Compassionate care, frequent, personalized, and integrated encounters, and emotional support helped counteract prior stigmatizing and discriminatory health care interactions, enabling participants of color to feel particularly supported, trusted, and empowered during the MOMs trial; and (3) Despite pervasive cultural stigma around addiction and concerns about taking an investigational drug while pregnant, participants expressed that pregnancy status, care team trust, and transparent communication with MOMs trial staff encouraged medication utilization and adherence. Facilitators of successful engagement in the MOMs trial and retention in medication treatment among pregnant and postpartum people of color with OUD included non-judgmental care, sustained trust, and frequent contact. Key perinatal OUD clinical interventions and trial improvements include personalized communication and scheduling flexibility to promote engagement of marginalized populations.
Among individuals with opioid use disorder (OUD) and co-occurring mental illness, stimulant co-use may be associated with more severe symptoms and less treatment utilization. We sought to understand the association of stimulant use with social needs and OUD and mental illness severity and treatment. This cross-sectional study used baseline data from a randomized controlled trial of collaborative care for primary care patients with OUD and co-occurring depression and/or posttraumatic stress disorder (PTSD). We categorized stimulant use (cocaine/methamphetamine) into daily use (20 or more days), non-daily use (1-19 days), and no use (0 days). We conducted comparisons across measures of social needs and OUD and mental illness severity and treatment through one-way analysis of variance for continuous variables and chi-square tests for categorical/binary variables. 123 (15.4%) participants used stimulants daily, 164 (20.6%) reported non-daily use, and 510 (64%) used no stimulants. When comparing participants by stimulant use, we found differences in education (p = 0.020), housing status (p < 0.001), legal problems (p < 0.001), recent overdose (p < 0.001), overdose risk (p < 0.001), MOUD use (p < 0.001), depression/PTSD symptoms (p < 0.001), and receipt of therapy (p = 0.004) or medication (p < 0.001) for depression/PTSD with all differences demonstrating more unmet social needs, greater OUD and mental illness severity, and lower treatment utilization for participants using stimulants. Among primary care patients with OUD and co-occurring depression/PTSD, individuals using stimulants experienced a higher disease burden and decreased utilization of care across multiple measures. These associations suggest that clinicians should specifically address stimulant use in the context of co-occurring OUD and mental illness.
People who inject drugs (PWID) experience high rates of serious injection-related bacterial and fungal infections (SIRI), including cellulitis, osteomyelitis, and endocarditis. These infections often require prolonged antibiotic treatment and result in frequent rehospitalizations, with over 50% of patients readmitted within 1 year. Few evidence-based interventions exist to optimize continuity of care for addiction, management, and prevention of SIRI following hospitalization. CHOICE-STAR is a hybrid type 1 randomized effectiveness-implementation trial, guided by the Exploration, Preparation, Implementation, and Sustainment Framework (EPIS), conducted at five hospitals across the USA. The study aims to assess the effectiveness of the integrated infectious diseases (ID) and substance use disorder (SUD) outpatient clinic on 6-month infection-related rehospitalization among people hospitalized with an infection related to injecting opioids or stimulants. The study also includes implementation outcomes guided by Proctor's Implementation Outcomes taxonomy, as well as cost-effectiveness outcomes. The integrated clinic (IC) will offer facilitated linkage to a clinic providing medical care aimed at treating SUD and ID by completing treatment for the index infection, treating existing ID complications of SUD, and preventing subsequent infections by providing low barrier care for SUD including medication for OUD (MOUD) and harm reduction integrated into a single appointment and co-located at a single site for a minimum of monthly appointments over a 6 month time period. An additional 6 months' follow-up will be included to assess outcomes following the completion of the intervention. The IC includes a weekly care coordination meeting between the ID and SUD providers. The study will enroll approximately 304 participants. This trial addresses a critical gap in post-hospitalization care for PWID with SIRI. If effective, the integrated care model could significantly reduce rehospitalizations, improve treatment completion, and provide a replicable framework for healthcare systems. The study's implementation science components will inform the scalability and sustainability of this intervention. Results will inform evidence-based policy and practice recommendations for managing this high-risk population, potentially leading to improved patient health outcomes. ClinicalTrials.gov NCT06513156 . Registered on August 09, 2024.
Sex trafficking affects millions globally, leading to severe psychological and physical trauma among survivors. Peer support services, which utilize individuals with lived experiences to provide care, have shown promise in substance use disorder (SUD) and mental health treatment settings. This study explored the perspectives of service providers on the role and impact of peer support in the aftercare and recovery of sex trafficking survivors who use substances. Using purposive and snowball sampling, 21 service providers were recruited from agencies in the southwestern United States. The semi-structured interviews were approximately one hour long and were audio recorded and transcribed verbatim. The research team conducted member checking with participants, and data analysis was guided by Braun and Clarke's six-stage thematic analysis process. The study identified several key factors contributing to the effectiveness of peer support for survivors of sex trafficking who use substances. Trust and empathy emerged as foundational elements, with peer mentors providing emotional support and practical guidance based on shared lived experiences. Participants highlighted the benefits of peer support in building trust, fostering empathy, and aiding recovery. However, challenges such as potential re-traumatization of mentors and maintaining boundaries were noted. Best practices included comprehensive training for peer mentors and collaboration with mental health professionals. Peer support services offer unique advantages in the recovery and reintegration of sex trafficking survivors, leveraging trust, empathy, and shared lived experiences. Integrating peer support into existing human trafficking and SUD treatment frameworks can enhance service engagement and recovery. Addressing complex needs through peer support is crucial for survivors of sex trafficking.
American Indian and Alaska Native (AIAN) populations experience disproportionately high rates of substance use disorders (SUD), yet limited research has examined their engagement with and outcomes from specialty SUD treatment. This cross-sectional study used data from the 2021 Treatment Episode Dataset - Discharges (TEDS-D) to examine differences in clinical characteristics, treatment utilization, and outcomes between AIAN and non-Hispanic White adults (N = 423,990). Logistic and multinomial logistic regression models estimated unadjusted and adjusted odds ratios comparing American Indian and Alaska Native and non-Hispanic White individuals across multiple treatment domains. Covariates included age, gender, education, and housing status. AIAN individuals were more likely to initiate substance use in early adolescence (adjusted OR = 1.69, 95% CI: 1.57-1.81), be referred to treatment through the criminal justice system (OR = 2.12, 95% CI: 2.04-2.21), and receive detoxification services (OR = 3.21, 95% CI: 3.08-3.35). They were significantly less likely to receive medications for opioid use disorder (OR = 0.76, 95% CI: 0.71-0.82) despite clinical need, and had higher odds of reporting substance use at discharge. Rates of treatment completion did not differ significantly by race. AIAN individuals were also less likely to receive diagnoses of co-occurring psychiatric disorders, highlighting potential gaps in screening and linkage to mental health services. Disparities in referral source, service utilization, and clinical management suggest that AIAN individuals may not be receiving fully equitable or culturally responsive care. Efforts to improve treatment outcomes should prioritize early intervention, expanded access to pharmacotherapy, and the integration of trauma-informed, community-based models of care.
This study aimed to evaluate the relationship between self-control, psychological resilience, and level of addiction severity in individuals with substance use disorder (SUD). This cross-sectional study was carried out with 129 participants at the Alcohol and Drug Addicts Treatment and Research Center. The data were collected using the Brief Self-Control Scale (BSCS), Brief Resilience Scale (BRS), and Addiction Profile Index (API). All the participants were male and polysubstance users. Although no statistically significant relationship was found between BRS and API, there was a low negative relationship between BSCS and API levels (r: -250, p < 0.01). Simple regression analysis was performed to determine the effect of individuals' self-control on addiction severity and the established model was found to be significant (F: 8.466, p: 0.000). The R2 value, stated as the explanatory power of the model, was calculated to be 0.062. Accordingly, it is seen that the self-control predictor variable explains 6.2 % of the variance in the addiction severity predicted variable (R2: 0.062). It was determined that individuals with SUDs had low self-control and moderate psychological resilience, and most of them had low addiction severity. It has been found that as the level of self-control increases, the severity of addiction decreases. This study suggests that self-control enhancing interventions for individuals with SUD will positively contribute to the treatment process.
Polysubstance use, particularly co-occurring opioid and stimulant use, disproportionately impacts rural communities. Our team has worked to address the inaccessibility of treatment in rural settings by expanding access to medication for opioid use disorder (MOUD) via telemedicine aboard a mobile treatment unit. Long-term retention in MOUD care remains a challenge, particularly for individuals with polysubstance use. Peer recovery specialists (PRSs) may be uniquely suited to support individuals with polysubstance use in MOUD care through their shared experience and ability to deliver brief behavioral interventions, such as behavioral activation (BA). The current qualitative study assessed patient and stakeholder-identified adaptations to PRS-delivered BA to address polysubstance use and support MOUD retention aboard a mobile treatment unit in rural Maryland. Semi-structured interviews were conducted with 30 participants, including patients with polysubstance use and staff members at the mobile treatment unit to assess feasibility, accessibility, and appropriateness of PRS-delivered BA in this context, and transcripts were analyzed using thematic analysis. PRS-delivered BA was viewed as highly appropriate for addressing polysubstance use in this rural community. Despite potential barriers to effective implementation, such as lack of transportation and activity availability, key adaptations were identified by patients and staff ensure intervention feasibility and acceptability. Findings also highlighted the importance of PRS familiarity with the rural environment, alongside unique training and supervision needs for PRSs working in these contexts. Findings support the acceptability, feasibility, and appropriateness of the PRS-delivered intervention in a rural context, addressing key gaps in care for polysubstance use in this community.
The illegal use of opioids has emerged as a major global public health concern, contributing to widespread addiction and a growing number of overdose-related deaths. In response, the US federal government has invested billions of dollars in combating the opioid epidemic through treatment, prevention, and law enforcement initiatives. Despite these efforts, there remains an urgent need for automated tools capable of detecting overdose cases and assessing the risk levels of substances-tools that can enable faster, more effective responses with less reliance on human intervention. Social media, particularly Reddit, has become a valuable source of self-reported data on opioid misuse, offering rich insights into user experiences and symptoms. This research aimed to develop an advanced automated tool for detecting opioid overdose risks and classifying substances into high-risk and low-risk categories by analyzing social media posts. A multistage methodology was used to achieve the objectives of this work. First, a new dataset was constructed from Reddit posts and manually annotated. Each post was labeled according to the risk level of the mentioned substance, using contextual indicators and user-reported experiences as the basis for classification. To ensure reliability and annotator consistency, detailed annotation guidelines were developed and applied throughout the labeling process. Second, a bidirectional encoder representation from transformers for biomedical text mining (BioBERT)-based classification framework was implemented and enhanced with a custom attention mechanism to capture relevant semantic information for more accurate predictions. Third, the model's performance was evaluated using 5-fold cross-validation and compared against several baseline approaches, including traditional supervised learning, deep learning, and transfer learning methods. In total, 14 experiments were conducted to evaluate comparative effectiveness. To further assess the contribution of the attention layer, the best-performing model was also evaluated against a version incorporating the standard self-attention mechanism, using a train-test split. Finally, a paired t test was conducted to statistically assess the performance difference between the BioBERT-based model and the strongest baseline, extreme gradient boosting (XGBoost), providing validation of the observed improvements. The proposed BioBERT model with custom attention achieved an F1-score of 0.99 in cross-validation, outperforming the best baseline, XGBoost (F1-score=0.97), with a relative improvement of 2.06%. A paired t test conducted across the 5 folds (n=5) confirmed that the performance gain was statistically significant (P=.003), providing strong evidence that the improvement reflects genuine advances in overdose risk detection. This paper demonstrates the potential of leveraging social media data and advanced natural language processing models to build reliable systems for opioid overdose risk detection. The BioBERT model with custom attention shows state-of-the-art performance and robustness, offering a powerful tool to support timely intervention and harm reduction strategies in the ongoing opioid crisis.
To develop and validate knowledge scales that span the continuum of substance use disorder (SUD) prevention, treatment, and recovery. Study 1 focused on ensuring the content validity of scale items, and study 2 focused on evaluating the structural, convergent, and known groups validity as well as reliability of the scales. Study 1 included n = 15 experts in the SUD field. Study 2 included n = 5355 community members from throughout the U.S. Both studies were conducted online. The SUD Prevention Knowledge Scale includes 16 items measuring age-related risk factors, other risk factors, and protective factors for SUD. The SUD Knowledge Scale includes 16 items measuring SUD-related characteristics, treatment and recovery, and medications. Supporting content validity, results of study 1 demonstrated that the scales include items with high item-level content validity indexes. Results of study 2 suggested that three-factor models are appropriate for both scales, supporting structural validity, and that the overall scales and subscales have acceptable reliability scores. Both scales and subscales were correlated with indicators of stigma, supporting convergent validity. Participants who were professionals working in the SUD field had the highest scores on the scales, supporting known groups validity. Results support the validity and reliability of two new measures of SUD-related knowledge. These scales may be appropriate for basic research to characterize levels of SUD knowledge within community settings as well as explore associations between knowledge and SUD-related health behaviors. They may also be useful for evaluating interventions that aim to promote SUD-related knowledge.
Alcohol use disorder (AUD) is the most common substance use disorder globally and is associated with increased healthcare costs and utilization. Our study aimed to compare healthcare costs and resource utilization associated with a recent diagnosis of AUD to non-AUD controls using a national database of commercially insured individuals in the United States. This cohort study used Merative™️ MarketScan® Commercial Claims data from 2016 to 2020. We identified individuals with an AUD diagnosis in each year of the study period (2017, 2018, 2019) based on at least 1 primary/secondary AUD diagnosis in inpatient and outpatient claims using ICD-9/ICD-10 codes. Individuals were included if they were 18+ years old; had no missing values for key variables; and had at least 6 months of continuous health insurance coverage before and after the earliest date of their AUD diagnosis. We identified and measured patient-level sociodemographic and clinical characteristics. The outcomes estimated included healthcare utilization (i.e., inpatient visits and length of stay [LOS], emergency department [ED] visits, and total and AUD-indicated prescriptions) and costs (i.e., inpatient, outpatient, ED, total and AUD-indicated prescriptions). A random control group with no prior or current AUD diagnosis was identified and were matched to the AUD cohort using propensity score matching. After matching, generalized linear models were used to estimate the differences in healthcare costs and utilization between the AUD and control groups for the 6-month follow-up period. We identified 72,410, 76,075, and 73,485 individuals with AUD in 2017, 2018, and 2019, respectively. The study cohort for each year had a mean age of 41 (SD 14) and were predominantly male (63%). In the 6-month follow-up period, individuals with AUD had significantly higher total healthcare costs compared to controls (p-value<0.0001), with an average marginal effect of $1231, $1973, and $1009, for 2017, 2018, and 2019, respectively. Individuals with AUD in each year had significantly higher healthcare utilization compared to controls for LOS, ED visits, and prescriptions (p-value<0.0001). This study demonstrates the continuing significant disease and economic burden of individuals with AUD. Healthcare cost and resource utilization associated with AUD may be reduced through appropriate treatment.
The use of public health vending machines (PHVMs) is an emerging strategy implemented to mitigate drug-related harms via the dispensation of supplies like naloxone and sterile syringes from vending machines that have been documented to reduce transmission of blood borne viruses, support hygiene and basic personal health needs, and prevent overdose. To inform future applications of this technology and performed initially as part of a technical assistance request, we sought to examine PHVM adoption and implementation by conducting semi-structured interviews with 26 individuals from diverse roles and organizations/agencies across the United States in March 2023 about their experiences launching and optimizing PHVMs. We engaged in a secondary thematic analysis of the interview data using both deduction and induction. Using the interview guide as the frame, we broadly organized our findings into themes that are pertinent to consider prior to PHVM implementation ("Pre-implementation") and those that are relevant during implementation ("Implementation and maintenance"). Pre-implementation themes included (1) Motivating factors influencing implementation, (2) Intended PHVM uptake population, (3) Partnership cultivation, (4) Responsiveness to community needs and concerns, and (5) Factors influencing placement of PHVMs. Implementation and maintenance themes included: (1) Operational components of implementation and (2) Tracking consumer use of machines and supply flow. We found that PHVMs have emerged as versatile and central tools to expand and extend critical, life-saving supplies and services to PWUD and other groups within communities throughout the United States, especially to underserved and high-risk populations, such as people of color, young people, rural residents, individuals leaving incarceration, and veterans. We also found that the planning phases of implementation were shaped by local needs, funding opportunities, collaboration, and community engagement, with PHVM placement most often determined by feasibility and willingness of host sites, as well as the perceptions and needs of the community. Operational challenges included unanticipated costs related to maintenance and supply stocking of the PHVMs. Our findings elucidate the local, ground-up, and bold approaches and innovations undertaken by many organizations, agencies, and programs throughout the country in PHVM implementation. Policymakers and government officials should consider passing local ordinances or granting permissions in support of placing PHVMs and securing access to life saving materials.
Substance use disorders often affect not only individuals but entire family systems, creating patterns that can persist across generations. This lived experience essay explores the emotional, relational, and developmental impact of growing up in a family affected by addiction, with particular attention to stigma, intergenerational trauma, and identity formation. The narrative aims to contribute to a more humanized understanding of addiction and recovery within counseling and treatment contexts. This article uses a first-person lived experience narrative approach, drawing on reflective analysis of personal and family experiences with substance use disorder. The narrative is integrated with professional insight gained through counseling training, allowing for examination of how lived experience informs perspective, values, and clinical orientation. Key themes include the cyclical nature of addiction within families (conceptualized as the "circle"), the pervasive impact of stigma, and the role of shame in limiting help-seeking and connection. The narrative illustrates how repeated exposure to addiction shapes emotional development, relational patterns, and a heightened awareness of instability. A central turning point-"This ends with me"-represents a shift toward intentional change and meaning-making. These experiences inform the development of the "Coleman Compass," a framework grounded in safety, dignity, choice, stability, and meaning, which guides counseling practice and supports recovery-oriented care. Lived experience can deepen clinical understanding and support more compassionate, dignity-centered approaches to addiction treatment. Reducing stigma and prioritizing human connection are essential for effective care. This narrative highlights the importance of integrating personal insight with professional training to promote recovery, preserve dignity, and interrupt intergenerational cycles of addiction.
Alcohol-associated hepatitis (AH) carries high short-term mortality and long-term morbidity. Current guidelines recommend that patients hospitalized with AH receive treatment for alcohol use disorder (AUD), including behavioral counseling and pharmacotherapy. However, integration of addiction treatment into routine inpatient care remains low. We evaluated whether inpatient hepatology consultation is associated with increased provision of AUD counseling and pharmacotherapy. We conducted a retrospective cohort study of adults hospitalized with AH between January 2020 and July 2024 at a single academic center. AH was defined by ICD-10 code and NIAAA criteria. The primary exposure was liver service consultation. Primary outcomes were AUD counseling (dichotomized as referral provided vs. not) and pharmacotherapy (prescription vs. none). Multivariable logistic and mixed effects regression modeling was used to assess associations. There were 134 unique patients with 213 hospitalizations for AH. Median age was 47 years, 67% were male, and 73% were English-speaking. While nearly all patients (96%) received some form of counseling, only 17% were referred to structured rehabilitation programs and 30% received pharmacotherapy such as naltrexone, acamprosate, gabapentin and baclofen. In adjusted analyses, hepatology consultation (with or without GI involvement) was independently associated with higher odds of both referral to AUD treatment services (aOR 3.99, 95% CI 1.23-13.73 in a per-patient analysis and aOR 3.10, 95% CI 1.21-7.93 in a per-hospitalization analysis) and prescription of AUD pharmacotherapy (aOR 2.44, 95% CI 0.59-10.4 per-patient and aOR 3.74, 95% CI 1.16-12.06 per hospitalization). Despite hospitalization being a critical opportunity to initiate evidence-based AUD care, most patients with AH did not receive guideline-concordant treatment. Liver consultation services were associated with improved pharmacotherapy delivery and AUD referrals. Embedding addiction treatment protocols within hepatology pathways may improve delivery of AUD care and reduce disparities in this high-risk population.
Substance use disorders (SUDs) among healthcare workers, legal professionals, and pilots pose risks to public safety and professional performance. Physician health programs (PHPs), lawyer assistance programs (LAPs), and the Human Intervention Motivational Study (HIMS) program for pilots aim to address these challenges through structured referral, treatment, and monitoring. PHPs and LAPs operate through state-based programs with guidance from national organizations such as the Federation of State Physician Health Programs (FSPHP) and the Commission on Lawyer Assistance Programs (CoLAP). In contrast, HIMS follows a standardized federally regulated model. Despite shared goals, no prior study has systematically compared these distinct frameworks. Using the READ (Ready, Extract, Analyze, Distill) framework for document analysis, this study reviewed best practice guidelines from FSPHP and CoLAP alongside publicly available HIMS materials to compare treatment referral, monitoring/aftercare expectations, and return-to-work policies. All three programs emphasize rehabilitation and confidentiality but differ in structure. FSPHP guidelines provide detailed recommendations for evaluation, monitoring, and reintegration; HIMS materials outline evaluation and recertification requirements and associated monitoring expectations; and CoLAP offers flexible guidance that emphasizes support and early intervention. Adherence to the guidelines is not well documented at the state or organizational levels, underscoring variability within professions. This study compares the FSPHP, CoLAP, and HIMS guidelines, offering insights into standardizing aftercare, monitoring, and return-to-work policies for safety-sensitive professionals. Aligning state and organizational level programs more closely with national guidance may enhance accountability, improve equity, and reinforce public safety.
To estimate all-cause and cause-specific mortality burden in patients who received medication treatment for opioid use disorder (OUD). We conducted a cohort study of 27,230 patients who received medications for opioid use disorder (MOUD), buprenorphine or naltrexone, matched 1:1 to individuals without MOUD from 4 US health systems in California, Colorado, and Michigan between 2012 and 2021. We calculated standardized mortality ratios (SMRs) with bootstrapped 95% CI to assess mortality burden. Patients who received treatment for OUD were 4 times more likely to die from any cause (SMR 4.37, 95% CI 3.80-4.64) and 37 times more likely to die from drug overdose (SMR 37.58, 95% CI 29.33-55.09; 41.6% of all deaths) compared to demographically similar individuals. Deaths from non-overdose causes showed modest but significant burden (SMR 2.68, 95% CI 2.31-2.86; 58.4% of deaths). The top contributors to non-overdose deaths were circulatory system diseases (SMR 3.06, 95% CI 1.73-3.63; 13.9% of deaths), other external causes (SMR 4.50, 95% CI 3.64-5.62; 11.3% of deaths), and cancers (SMR 1.59, 95% CI 1.30-1.86; 9.4% of deaths), which all showed elevated mortality. Continued efforts are needed to prevent high burden of mortality from both overdose and non-overdose causes among patients with MOUD treatment.
Accurate detection and management of intoxication is critical in healthcare, particularly in alcohol and other drug (AOD) settings. While alcohol intoxication is often reliably assessed, drug intoxication is harder to detect. For clients receiving opioid agonist treatment (OAT), intoxication status can impact safety, treatment planning and driving eligibility. This study explores AOD healthcare staff confidence, training and concerns in managing intoxication and driving safety amongst OAT clients. A cross-sectional survey was conducted with staff across 12 public AOD clinics in New South Wales, Australia. Data were collected on self-reported confidence and training regarding client intoxication and driving safety, concerns and experiences managing intoxicated OAT clients, and substances of concern for intoxication and driving safety. Seventy-nine staff (58% nursing, 19% allied health, 17% medical, 6% other) completed the survey, with a median of 7 years' AOD experience. Two-thirds reported confidence managing intoxicated OAT clients, and 87% felt adequately trained. Key barriers to managing suspected intoxication included risk of aggression (72%), concern about upsetting clients (44%), and risk of incorrect assessment (38%). Half of staff (55%) reported encountering an intoxicated client in the past year. Substances of greatest concern for client intoxication and driving safety were benzodiazepines (95%), heroin (94%), alcohol (92%) and amphetamines (87%). While many AOD staff feel relatively confident identifying and managing client intoxication, they reported concerns around managing such scenarios. Ongoing training, alongside tools or structured frameworks, may support healthcare staff to better detect and manage intoxication and driving safety of clients.