Combined Pharmacotherapy and Cognitive Behavioral Therapy for Adults With Alcohol or Substance Use Disorders: A Systematic Review and Meta-analysis

Associations between employees' alcohol consumption, insomnia and HR management strength

BACKGROUND

Understanding of hazardous alcohol drinking and insomnia among Australian ambulance personnel is limited. Australian ambulance organizations have strengthened their organizational human resource management (HRM) to promote their employees' healthy lifestyles, health and well-being.

AIMS

To describe the prevalence of hazardous alcohol consumption and insomnia among Australian ambulance personnel and to explore their associations with the organizational HRM strength.

METHODS

This cross-sectional study was conducted on 492 ambulance personnel randomly selected from three Australian states. The Alcohol Use Disorders tool, The Insomnia Severity Index and the Perceived HRM System Strength instrument measured alcohol consumption, insomnia and HRM strength. Descriptive analyses, bivariate association analyses and general linear models were used for data analysis.

RESULTS

Twenty per cent of Australian ambulance personnel consumed alcohol at a hazardous level and 68% experienced clinically significant insomnia. There was no significant association between organizational HRM strength and ambulance personnel's hazardous alcohol consumption. There was a significant association between organizational HRM strength (consensus) and ambulance personnel's insomnia experience.

CONCLUSIONS

Hazardous alcohol consumption and insomnia were concerns among Australian ambulance personnel. Even though strengthening the HRM system might reduce their experience of insomnia, simply strengthening the HRM system could not reduce their hazardous alcohol consumption.

Medicaid expansion and medications to treat opioid use disorder in outpatient specialty care from 2010 to 2020

INTRODUCTION

Medications for opioid use disorder (MOUD) are considered the first line treatment for opioid use disorder. As states expanded Medicaid beginning in 2014 under the Affordable Care Act, policymakers and public health officials were interested in the potential for expansion to increase access to MOUD. This study examined whether there were changes in MOUD use within outpatient admissions to specialty treatment facilities in Medicaid expansion states beyond the initial expansion period.

METHODS

Analyses were conducted using 2010-2020 data from the Treatment Episode Data Set - Admissions. For states that expanded Medicaid prior to 2015, a difference-in-differences analysis was conducted to evaluate whether expansion was associated with an increased proportion of MOUD treatment comparing the initial 2014-2017 period and the 2018-2020 period to 2010-2013. We then conducted a difference-in-differences analysis to examine the overall effect of Medicaid expansion on outpatient MOUD using all states that passed expansion at any point during the study period.

RESULTS

Among outpatient treatment episodes for OUD in states that expanded Medicaid in 2014, there was a 9.5 percentage point (95 % CI: 0.7-18.2) increase in the probability of receiving MOUD during the initial expansion period from 2014 to 2017 compared to 2010-2013 period, and a 7.5 percentage point (95 % CI: -8.1 -23.1) increase in 2018-2020 (compared to the 2010-2013 period) after adjusting for individual-level covariates. After incorporating states that expanded Medicaid between 2015 and 2020, there was a 6.4 percentage point (95 % CI: -0.01-13.0) increase in the probability of receiving MOUD among individuals receiving care after expansion (compared to the pre-expansion period). During the study period, there was variability among states in the change in probability of receiving MOUD from prior to after Medicaid expansion from an almost 30 percentage point increase in New York to an almost 20 percentage point decrease in Washington, DC.

CONCLUSIONS

Medicaid expansion increased the probability of receiving MOUD in outpatient settings across states from initial expansion through 2020. However, these results were not statistically significant. Additionally, significant variability between states warrants further study and suggests that improving access to MOUD will require additional state and local strategies.

Disparities in Treatment for Alcohol Use Disorder Among All of Us Participants

OBJECTIVE

The authors examined racial/ethnic and socioeconomic disparities in receiving treatment for alcohol use disorder (AUD).

METHODS

A retrospective cohort study was conducted that included adults (≥18 years) with AUD from the All of Us Controlled Tier database v7. Outcomes were lifetime receipt of FDA-approved medications (disulfiram, acamprosate, and naltrexone), psychotherapy (individual, family, and group-based session), and combination treatment (medication and psychotherapy). The study examined treatment receipt by race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, other), insurance (private, Medicare, Medicare and Medicaid, Medicaid, Veteran Affairs [VA], none), income (<$10K, $10-<$50K, $50-$100K, >$100K), and area deprivation index (ADI) quintiles. Multivariable logistic and multinomial logistic regressions were used to assess the association between patient characteristics and treatment receipt.

RESULTS

The cohort consisted of 18,692 patients (mean age=57.1 years; 60.7% were male; 47.1% were non-Hispanic White). Almost 70% received no treatment, 11.4% received medication, 24.0% received psychotherapy, and 4.9% received combination treatment. In adjusted analysis, non-Hispanic Black (aOR=0.78, 95% CI=0.69-0.89) and Hispanic (aOR=0.75, 95% CI=0.64-0.88) individuals were less likely to receive medication than non-Hispanic White counterparts. There was no association between race/ethnicity and receipt of psychotherapy or combination treatment. Compared with private insurance, dual eligibility was associated with less use of medication, Medicare and Medicaid with less use of medication and combination treatment, and VA and no insurance with more use of psychotherapy and combination treatment. Higher income and lower ADI were positively associated with all treatment types.

CONCLUSIONS

There are disparities in AUD treatment by race/ethnicity, socioeconomic status, and insurance. Systematic approaches are required to improve equitable access to effective treatment.

Do treatments for mental disorders affect relationship satisfaction? A systematic review and meta-analysis

Objective: Psychiatric disorders have been linked to poor social functioning, including deficits in relationship satisfaction. Treatments have shown strong effectiveness in reducing clinical symptoms for a range of disorders, though less is known of the effects disorder-focused treatments have on relationship satisfaction.

Methods: The present study describes a systematic review that was conducted to determine the efficacy of treatments for specific psychiatric disorders in improving relationship satisfaction. Surprisingly, only seventeen studies were identified and included in the review.

Results: We found that a majority of these studies reported modest improvement in relationship satisfaction among people who completed treatment. However, studies were severely hampered by methodological limitations, and all therapy-related improvements could be attributable to placebo effects or the passage of time.

Conclusion: Important gaps in the literature were found that future research should seek to address to maximize treatment outcomes and psychosocial functioning.

EASL Clinical Practice Guidelines on liver transplantation

Liver transplantation (LT) is an established life-saving procedure. The field of LT has changed in the past 10 years from several perspectives, with the expansion of indications, transplantation of patients with acute-on-chronic liver failure, evolution of transplant oncology, the use of donations after cardiac death, new surgical techniques, and prioritisation of recipients on the waiting list. In addition, the advent of organ perfusion machines, the recognition of new forms of rejection, and the attention paid to the transition from paediatric to adult patients, have all improved the management of LT recipients. The purpose of the EASL guidelines presented here is not to cover all aspects of LT but to focus on developments since the previous EASL guidelines published in 2016.

Factors affecting problem-solving court team decisions about medications for opioid use disorder

BACKGROUND

Problem-solving courts (PSCs) provide alternatives to prosecution and incarceration for drug-related crimes and offer integrated support for people who have lost custody of children due to drug use. Methadone and buprenorphine are lifesaving medications for opioid use disorder (MOUD) but are underused by PSC clients. Even when PSCs lack a court-level prohibition against MOUD, court staff still make individualized decisions about whether a court client can use MOUD. Therefore, we sought to identify factors involved in such individualized PSC court decisions about clients' use of MOUD.

METHODS

We conducted semi-structured interviews and focus groups between Summer and Fall 2022 with a convenience sample of 54 PSC staff members from 33 courts across four states. Data were analyzed using iterative categorization.

RESULTS

Interviewees indicated that their courts had eliminated blanket prohibitions against MOUD due to federal and state policy funding requirements, widespread dissemination of voluntary best practice standards, fear of lawsuits, and MOUD education targeting courts. Courts allowed MOUD if the court client accessed it through a treatment provider with whom the court collaborates. Some courts only allowed court clients to access MOUD from non-partnering treatment providers after a court-led "vetting" process of the proposed MOUD provider. MOUD provider characteristics considered during the vetting process included the provider's willingness to communicate with the court, frequent drug testing, adjustments of medication or dosage in response to aberrant results, offering of counseling, and acceptance of Medicaid or sliding scale payments. PSC staff were least comfortable with court clients using methadone treatment.

CONCLUSIONS

The presence (or lack of) a PSC-MOUD partnership is a key factor involved in court staff decisions when a court client desires MOUD. Therefore, increasing the number of partnerships between PSCs and MOUD providers could lead to higher rates of MOUD utilization. It is unclear whether court-led vetting processes for non-partnering MOUD treatment providers are necessary or appropriate, and such vetting processes could reduce treatment choice or access in communities with few MOUD providers.

Improvement in coping skills from culturally-adapted digital CBT for Spanish-speaking Hispanics with substance use disorder: Secondary analysis of a randomized clinical trial

INTRODUCTION

Developing adaptive coping skills for avoiding substance use is a proposed treatment mechanism of cognitive behavioral therapy (CBT) for substance use disorder (SUD). However, the generalizability of research on treatment mechanisms of CBT for SUD is limited by the underrepresentation of racial/ethnic minorities in clinical trials. In a secondary analysis of clinical trial data, we tested whether a culturally-adapted digital CBT program for Hispanics ("Spanish CBT4CBT") improved the quality of coping skills for avoiding substance use. We also tested whether coping skills' quality was associated with reductions in primary substance use.

METHODS

Participants were Spanish-speaking Hispanic adults seeking outpatient treatment for SUD (n = 85; 68 % male; primary substance type: 36 % cannabis, 33 % alcohol, 26 % cocaine, 5 % other). They were randomized to 8 weeks of outpatient treatment as usual (TAU) or TAU + Spanish CBT4CBT and assessed for 6 months after treatment. The study conducted separate analyses for the full sample (n = 85) and for those who engaged in at least 5 treatment sessions ("treatment exposed"; n = 64). Daily substance use and coping skills' quality were assessed repeatedly during the treatment and follow-up periods. Bayesian mixed models for repeated measures tested hypotheses.

RESULTS

Among treatment-exposed participants, those receiving TAU + Spanish CBT4CBT improved the quality of coping skills more than TAU alone during the treatment period (b = 0.77; 95 % CI[0.08, 1.47]), but this difference was not detected during the follow-up period. In the full sample and treatment exposed subsample, participants with higher quality coping skills during the study reported less primary substance use (b = -0.67; 95 % CI[-1.08, -0.26]). Among treatment-exposed participants only, within-person increases in the quality of coping skills were associated with reductions in future primary substance use (b = -0.18; 95 % CI[-0.36, -0.01]).

CONCLUSIONS

Spanish-speaking Hispanics with SUD may improve the quality of their coping skills more when they are sufficiently exposed to a culturally-adapted digital CBT program during outpatient treatment. Coping skills' quality may be a mechanism of CBT for SUD among Hispanic populations. Spanish-speaking Hispanics' access to treatments that target mechanisms of behavior change may be expanded by digital therapeutics.

Treatment of insomnia associated with alcohol and opioid use: a narrative review

Substance use disorders (SUDs) are associated with profound sleep disturbances, including insomnia, sleep fragmentation, and circadian rhythm dysfunction resulting in serious mental and physical consequences. This minireview presents an overview of the neurocircuitry underlying sleep disturbances in SUDs and elaborates on treatment options with emphasis on alcohol use disorder (AUD) and opioid use disorder (OUD). A PubMed, Embase, CINAHL Plus, Cochrane, and Scopus search were conducted using sleep- and AUD/OUD related keywords from January 1st, 2000, to January 31st, 2023, with preferences for recent publications and randomized-controlled trials. A bidirectional relationship exists between insomnia and addiction with the status of each condition impacting the other in dictating clinical outcome. Existing evidence points to a resurgence of insomnia during detoxification, and unless treated satisfactorily, insomnia may lead to relapse. The discussion summarizes the strengths and limitations of cognitive behavioral therapy and pharmacological treatment for insomnia in SUDs covering evidence from both animal and clinical studies. The assumption of reestablishing normal sleep patterns by attaining and maintaining sobriety is misguided. Comorbid insomnia in patients with SUDs should be approached as an independent condition that requires its own treatment. Future clinical trials are needed with the aim of providing a resource for guiding clinical management of the many patients with insomnia and SUD.

Integrated behavioral interventions for adults with alcohol use disorder: A systematic review

BACKGROUND

This systematic review synthesized evidence from randomized controlled trials (RCTs) on the effects of integrated behavioral interventions for adults with alcohol use disorder (AUD).

METHODS

A comprehensive search of three databases was conducted in 2022, utilizing terms related to alcohol/substance use disorders and integrated interventions. The sample included adults aged ≥18 years at low, moderate, or high risk for AUD, and had at least two other mental health conditions. Only RCTs were included and screened using Covidence. The quality of the study was evaluated using Cochrane risk of bias tool.

RESULTS

Across all 11 studies, the total AUD participants were 1543 aged 18 or older. Integrated intervention led to significant reductions in heavy drinking compared to usual care or other interventions. Measures included percent days of alcohol use, grams of alcohol consumed, and increased days of abstinence. Three studies compared integrated treatments with Twelve-Step Facilitation, indicating a better abstinence rate among participants in the integrated group at the end of treatment. Comparisons between delivery modes demonstrated more significant reductions in alcohol consumption with interventionists. Integrated interventions were also compared with various other treatments, including brief intervention, telephone and individual counseling, and psychological education. Participants in the integrated group showed greater improvement in alcohol consumption and depression compared to those in the standalone intervention group.

CONCLUSIONS

Integrated behavioral interventions effectively reduce alcohol consumption, decrease heavy drinking and promote alcohol abstinence. However, there is limited evidence to determine whether these interventions are more effective than usual care for individuals with AUD.

Predictors of alcohol and other drug treatment completion among young people accessing residential and community-based treatment: A retrospective analysis of routinely collected service data

BACKGROUND AND AIMS

Young people accessing alcohol and other drug (AOD) treatment experience high rates of treatment disengagement, contributing to poorer outcomes. To improve outcomes, it is important to identify factors associated with treatment retention. This study measured the relationships between client characteristics, treatment characteristics, clinical severity measures and completion of treatment among young people.

DESIGN, SETTING AND PARTICIPANTS

This study was a retrospective analysis of routinely collected data set in residential- and community-based AOD services in New South Wales, Australia. Routinely collected data from the Network of Alcohol and Other Drug Agencies' (NADA) database were used. Included individuals were aged 10-24 years and accessed treatment between 2012 and 2023 (n = 17 474).

MEASUREMENTS

Variables included client-related characteristics, service characteristics and baseline measures of clinical severity [Kessler-10 (K10), EUROHIS-QoL, severity of dependence scale (SDS)]. Multivariable binary logistic regression models assessed the relationships between these characteristics and treatment completion.

FINDINGS

Rates of treatment completion were highest among adolescents in community-based treatment (57%) and lowest among young adults in residential treatment (35%). Polysubstance use was negatively associated with treatment completion among adolescents [adjusted odds ratio (adjOR) = 0.71, P < 0.001] and adults (adjOR = 0.70, P < 0.001) in community-based treatment, and adolescents in residential treatment (adjOR = 0.62, P = 0.006), as was housing insecurity (adolescents in community treatment, adjOR = 0.61, P = 0.001; adults in community treatment, adjOR = 0.77, P = 0.002; adolescents in residential treatment, adjOR = 0.42, P = 0.005). Attending youth-specific services was associated with higher treatment completion rates among adults in community-based (adjOR = 1.81, P < 0.001) and residential treatment (adjOR = 1.72, P < 0.001). Varying correlates of treatment completion were identified throughout treatment groups, reflecting the differences in population and/or needs across contexts.

CONCLUSIONS

In New South Wales, Australia, fewer than half of young people accessing alcohol and other drug treatment between 2012 and 2023 completed treatment, and completion rates were lower among those facing barriers such as polysubstance use and housing insecurity.

Effective but Undertaught: Training Psychiatrists in Psychotherapy for Substance Use Disorders

Considering the escalating gap between the population-level need for substance use services and the availability of board-certified addiction specialty physicians, all psychiatrists must be equipped to treat substance use disorders. Residency training programs must therefore ensure that graduates are equipped with a sufficient knowledge base and skill set to treat substance use disorders, including an understanding of medications for addiction treatment and appropriate selection and utilization of psychotherapy for substance use disorders. Resources for teaching psychiatric residents about psychotherapeutic approaches to substance use disorders are often limited, and many programs may struggle to include this content in their curricula. The authors highlight the core evidence-based psychotherapeutic approaches relevant to the care of patients with substance use disorders and identify supervised experiential learning opportunities for psychiatric residents to practice psychotherapy for substance use disorders during existing clinical rotations within their general psychiatry residency programs.

Designing clinical trials to address alcohol use and alcohol-associated liver disease: an expert panel Consensus Statement

Most patients with alcohol-associated liver disease (ALD) engage in heavy drinking defined as 4 or more drinks per day (56 g) or 8 (112 g) or more drinks per week for women and 5 or more drinks per day (70 g) or 15 (210 g) or more drinks per week for men. Although abstinence from alcohol after diagnosis of ALD improves life expectancy and reduces the risk of decompensation of liver disease, few studies have evaluated whether treatment of alcohol use disorders will reduce progression of liver disease and improve liver-related outcomes. In November 2021, the National Institute of Alcohol Abuse and Alcoholism commissioned a task force that included hepatologists, addiction medicine specialists, statisticians, clinical trialists and members of regulatory agencies to develop recommendations for the design and conduct of clinical trials to evaluate the effect of alcohol use, particularly treatment to reduce or eliminate alcohol use in patients with ALD. The task force conducted extensive reviews of relevant literature on alcohol use disorders and ALD. Findings were presented at one in-person meeting and discussed over the next 16 months to develop the final recommendations. As few clinical trials directly address this topic, the 28 recommendations approved by all members of the task force represent a consensus of expert opinions.

A machine learning model to predict liver-related outcomes after the functional cure of chronic hepatitis B

BACKGROUND & AIMS

The risk of hepatocellular carcinoma (HCC) and hepatic decompensation persists after hepatitis B surface antigen (HBsAg) seroclearance. This study aimed to develop and validate a machine learning model to predict the risk of liver-related outcomes (LROs) following HBsAg seroclearance.

METHODS

A total of 4,787 consecutive patients who achieved HBsAg seroclearance between 2000 and 2022 were enrolled from six centers in South Korea and a territory-wide database in Hong Kong, comprising the training (n = 944), internal validation (n = 1,102), and external validation (n = 2,741) cohorts. Three machine learning-based models were developed and compared in each cohort. The primary outcome was the development of any LRO, including HCC, decompensation, and liver-related death.

RESULTS

During a median follow-up of 55.2 (IQR 30.1-92.3) months, 123 LROs were confirmed (1.1%/person-year) in the Korean cohort. The model with the best predictive performance in the training cohort was selected as the final model (designated as PLAN-B-CURE), which was constructed using a gradient boosting algorithm and seven variables (age, sex, diabetes, alcohol consumption, cirrhosis, albumin, and platelet count). Compared to previous HCC prediction models, PLAN-B-CURE showed significantly superior accuracy in the training cohort (c-index: 0.82 vs. 0.63-0.70, all p <0.001; area under the receiver-operating characteristic curve: 0.86 vs. 0.62-0.72, all p <0.01; area under the precision-recall curve: 0.53 vs. 0.13-0.29, all p <0.01). PLAN-B-CURE showed a reliable calibration function (Hosmer-Lemeshow test p >0.05) and these results were reproduced in the internal and external validation cohorts.

CONCLUSION

This novel machine learning model consisting of seven variables provides reliable risk prediction of LROs after HBsAg seroclearance that can be used for personalized surveillance.

IMPACT AND IMPLICATIONS

Using large-scale multinational data, we developed a machine learning model to predict the risk of liver-related outcomes (i.e., hepatocellular carcinoma, decompensation, and liver-related death) after the functional cure of chronic hepatitis B (CHB). The new model named PLAN-B-CURE was constructed using seven variables (age, sex, alcohol consumption, diabetes, cirrhosis, serum albumin, and platelet count) and a gradient boosting machine algorithm, and it demonstrated significantly better predictive accuracy than previous models in both the training and validation cohorts. The inclusion of diabetes and significant alcohol intake as model inputs suggests the importance of metabolic risk factor management after the functional cure of CHB. Using seven readily available clinical factors, PLAN-B-CURE, the first machine learning-based model for risk prediction after the functional cure of CHB, may serve as a basis for individualized risk stratification.

Advancements in addressing drug dependence: A review of promising therapeutic strategies and interventions

Substance dependence represents a pervasive global concern within the realm of public health. Presently, it is delineated as a persistent and recurrent neurological disorder stemming from drug-triggered neuroadaptations in the brain's reward circuitry. Despite the availability of various therapeutic modalities, there has been a steady escalation in the mortality rate attributed to drug overdoses. Substantial endeavors have been directed towards the exploration of innovative interventions aimed at mitigating cravings and drug-induced repetitive behaviors. Within this review, we encapsulate the most auspicious contemporary treatment methodologies, accentuating meta-analyses of efficacious pharmacological and non-pharmacological approaches: including gabapentin, topiramate, prazosin, physical exercise regimens, and cerebral stimulation techniques.

Evolution of the substance use landscape: Implications for contingency management

Contingency management (CM), which involves the delivery of incentives upon meeting behavioral goals, has the potential to improve substance use treatment outcomes. The intervention allows for flexibility through numerous modifiable components including changes to incentive magnitude and schedule, target behavior, and intervention structure. Unfortunately, numerous changes in the substance use landscape have occurred in the past 10 to 15 years: Substances are more potent, overdose risk has increased, new substances and methods of use have been introduced, and substance classes are increasingly being intentionally and unintentionally mixed. These developments potentially undermine CM outcomes. We explored recent substance use changes due to legislative, regulatory, social, and economic factors for four substance classes: stimulants, opioids, tobacco, and cannabis. We discuss potential adjustments to the modifiable components of CM for future research in response to these changes. By continually adapting to the shifting substance use landscape, CM can maintain optimal efficacy.

A mixed method study exploring similarities and differences in general and social services-specific barriers to treatment-seeking among individuals with a problematic use of alcohol, cannabis, or gambling

INTRODUCTION

The treatment gap for addictive disorders is one of the largest in health care. Several studies have investigated barriers to treatment for different addictive disorders, but very few studies conducted have explored whether the barriers differ depending on substance or behavior or if they are common among all addictive disorders. In Sweden, addiction care is provided both by the healthcare and social services, where the latter is common, but also less popular. To our knowledge, there are no studies exploring whether the barriers are different depending on where the treatment is given.

AIM

The aim was to thoroughly explore both which general and social services-specific barriers to treatment that are common, which barriers that differs, and how the barriers are described among individuals with a problematic use of alcohol, cannabis and/or gambling.

METHOD

A mixed method convergent parallel design was conducted. For the quantitative measures, surveys including the validated Barriers to Treatment Inventory as well as questions regarding barriers in the Swedish multi-provider landscape, were collected from individuals with a problematic use of alcohol (n = 207), cannabis (n = 51), and gambling (n = 37). In parallel, 17 semi-structured interviews from the same population were conducted and analyzed with thematic analysis. Thereafter, the quantitative and qualitative data was compared, contrasted, and at last, interpreted.

RESULTS

The quantitative data showed that the largest general barriers in all groups were privacy concern and poor availability, and the largest barriers for seeking help from the social services was stigma, unawareness of what is offered, and fear of consequences for all groups. The qualitative data resulted in five general barriers: stigma, ambivalence, accessibility, fear of consequences, and lack of knowledge about addiction and its' treatments, and three barriers specifically towards social services: social services reputation, fear of meeting acquaintances, and lack of knowledge. The themes were developed from data from all groups, but different aspects of the themes were mentioned by different groups.

CONCLUSION

There are details and aspects that differentiates both the general and social service-specific barriers to treatment between individuals with a problematic use of alcohol, cannabis, and gambling, but in large they perceive similar barriers.

Predictors of urine toxicology and other biologic specimen missingness in randomized trials of substance use disorders

BACKGROUND

High levels of missing outcome data for biologically confirmed substance use (BCSU) threaten the validity of substance use disorder (SUD) clinical trials. Underlying attributes of clinical trials could explain BCSU missingness and identify targets for improved trial design.

METHODS

We reviewed 21 clinical trials funded by the NIDA National Drug Abuse Treatment Clinical Trials Network (CTN) and published from 2005 to 2018 that examined pharmacologic and psychosocial interventions for SUD. We used configurational analysis-a Boolean algebra approach that identifies an attribute or combination of attributes predictive of an outcome-to identify trial design features and participant characteristics associated with high levels of BCSU missingness. Associations were identified by configuration complexity, consistency, coverage, and robustness. We limited results using a consistency threshold of 0.75 and summarized model fit using the product of consistency and coverage.

RESULTS

For trial design features, the final solution consisted of two pathways: psychosocial treatment as a trial intervention OR larger trial arm size (complexity=2, consistency=0.79, coverage=0.93, robustness score=0.71). For participant characteristics, the final solution consisted of two pathways: interventions targeting individuals with poly- or nonspecific substance use OR younger age (complexity=2, consistency=0.75, coverage=0.86, robustness score=1.00).

CONCLUSIONS

Psychosocial treatments, larger trial arm size, interventions targeting individuals with poly- or nonspecific substance use, and younger age among trial participants were predictive of missing BCSU data in SUD clinical trials. Interventions to mitigate missing data that focus on these attributes may reduce threats to validity and improve utility of SUD clinical trials.

Management of alcohol-associated liver disease and alcohol use disorder in liver transplant candidates and recipients: Challenges and opportunities

Alcohol-associated liver disease poses a significant global health burden, with rising alcohol consumption and prevalence of alcohol use disorder (AUD) contributing to increased morbidity and mortality. This review examines the challenges and opportunities in the care of candidates and recipients of liver transplant (LT) with AUD. Despite advancements in posttransplant patient survival, the risk of disease recurrence and alcohol relapse remains substantial. Several challenges have been identified, including (1) rising disease burden of alcohol-associated liver disease, variable transplant practices, and systemic barriers; (2) disparities in mental health therapy access and the impact on transplant; (3) variable definitions, underdiagnosis, and stigma affecting access to care; and (4) post-LT relapse, its risk factors, and consequential harm. The review focuses on the opportunities to improve AUD care for candidates and recipients of LT through effective biochemical monitoring, behavioral and pharmacologic approaches, creating Centers of Excellence for post-LT AUD care, advocating for policy reforms, and ensuring insurance coverage for necessary services as essential steps toward improving patient outcomes. The review also highlights unmet needs, such as the scarcity of addiction specialists, and calls for further research on personalized behavioral treatments, digital health, and value-based care models to optimize AUD care in the LT setting.

Novel therapeutics in development for the treatment of stimulant-use disorder

Misuse and accidental overdoses attributed to stimulants are escalating rapidly. These stimulants include methamphetamine, cocaine, amphetamine, ecstasy-type drugs, and prescription stimulants such as methylphenidate. Unlike opioids and alcohol, there are no therapies approved by the US Food and Drug Administration (FDA) to treat stimulant-use disorder. The high rate of relapse among this population highlights the insufficiency of current treatment options, which are limited to abstinence support programs and behavioral modification therapies. Here, we briefly outline recent regulatory actions taken by FDA to help support the development of new stimulant use disorder treatments and highlight several new therapeutics in the clinical development pipeline.

The Brain Salience Network at the Intersection of Pain and Substance use Disorders: Insights from Functional Neuroimaging Research

Purpose of Review

The brain's salience network (SN), primarily comprising the anterior insula and anterior cingulate cortex, plays a key role in detecting salient stimuli and processing physical and socioemotional pain (e.g., social rejection). Mounting evidence underscores an altered SN in the etiology and maintenance of substance use disorders (SUDs). This paper aims to synthesize recent functional neuroimaging research emphasizing the SN's involvement in SUDs and physical/socioemotional pain and explore the therapeutic prospects of targeting the SN for SUD treatment.

Recent Findings

The SN is repeatedly activated during the experience of both physical and socioemotional pain. Altered activation within the SN is associated with both SUDs and chronic pain conditions, characterized by aberrant activity and connectivity patterns as well as structural changes. Among individuals with SUDs, functional and structural alterations in the SN have been linked to abnormal salience attribution (e.g., heightened responsiveness to drug-related cues), impaired cognitive control (e.g., impulsivity), and compromised decision-making processes. The high prevalence of physical and socioemotional pain in the SUD population may further exacerbate SN alterations, thus contributing to hindered recovery progress and treatment failure. Interventions targeting the restoration of SN functioning, such as real-time functional MRI feedback, neuromodulation, and psychotherapeutic approaches, hold promise as innovative SUD treatments.

Summary

The review highlights the significance of alterations in the structure and function of the SN as potential mechanisms underlying the co-occurrence of SUDs and physical/socioemotional pain. Future work that integrates neuroimaging with other research methodologies will provide novel insights into the mechanistic role of the SN in SUDs and inform the development of next-generation treatment modalities.

Prevalence and correlates of common mental disorders among participants of the Uganda Genome Resource: Opportunities for psychiatric genetics research

Genetics research has potential to alleviate the burden of mental disorders in low- and middle-income-countries through identification of new mechanistic pathways which can lead to efficacious drugs or new drug targets. However, there is currently limited genetics data from Africa. The Uganda Genome Resource provides opportunity for psychiatric genetics research among underrepresented people from Africa. We aimed at determining the prevalence and correlates of major depressive disorder (MDD), suicidality, post-traumatic stress disorder (PTSD), alcohol abuse, generalised anxiety disorder (GAD) and probable attention-deficit hyperactivity disorder (ADHD) among participants of the Uganda Genome Resource. Standardised tools assessed for each mental disorder. Prevalence of each disorder was calculated with 95% confidence intervals. Multivariate logistic regression models evaluated the association between each mental disorder and associated demographic and clinical factors. Among 985 participants, prevalence of the disorders were: current MDD 19.3%, life-time MDD 23.3%, suicidality 10.6%, PTSD 3.1%, alcohol abuse 5.7%, GAD 12.9% and probable ADHD 9.2%. This is the first study to determine the prevalence of probable ADHD among adult Ugandans from a general population. We found significant association between sex and alcohol abuse (adjusted odds ratio [AOR] = 0.26 [0.14,0.45], p < 0.001) and GAD (AOR = 1.78 [1.09,2.49], p = 0.019) respectively. We also found significant association between body mass index and suicidality (AOR = 0.85 [0.73,0.99], p = 0.041), alcohol abuse (AOR = 0.86 [0.78,0.94], p = 0.003) and GAD (AOR = 0.93 [0.87,0.98], p = 0.008) respectively. We also found a significant association between high blood pressure and life-time MDD (AOR = 2.87 [1.08,7.66], p = 0.035) and probable ADHD (AOR = 1.99 [1.00,3.97], p = 0.050) respectively. We also found a statistically significant association between tobacco smoking and alcohol abuse (AOR = 3.2 [1.56,6.67], p = 0.002). We also found ever been married to be a risk factor for probable ADHD (AOR = 2.12 [0.88,5.14], p = 0.049). The Uganda Genome Resource presents opportunity for psychiatric genetics research among underrepresented people from Africa.

A Descriptive Review and Meta-Regression Study of Demographic and Study Context Factors in US Clinical Trials of Cognitive Behavioral Interventions for Alcohol or Other Drug Use

Objectives. Cognitive-Behaviorally Based Interventions (CBIs) are evidence-based treatments for alcohol and other drug (AOD) use with potential variable effectiveness by population sub-groups. This study used evidence synthesis to examine treatment effect by demographic and study context factors in clinical trials of CBI for AOD. Methods. Studies were systematically identified, and their characteristics and outcome data were extracted and summarized. Standardized mean differences were calculated for within- and between-condition effects on substance use outcomes. Demographic and study context moderators were identified during data acquisition and several sensitivity analyses were conducted. Results. The sample included K = 29 trials and a total of 15 study-level moderators were examined. Information on participants' age, biological sex, and race were reported in at least 26 trials, but information on gender identity, sexual orientation, and ethnicity were reported infrequently or in non-inclusive ways. The mean between-condition effect size was small and moderately heterogenous (d = 0.158, 95% CI = 0.079, 0.238, I2 = 46%) and the mean within-condition effect size was large and showed high heterogeneity (dz = 1.147, 95% CI = 0.811, 1.482, - I2 = 96%). The specific drug targeted in the study and whether biological assay-based outcomes were used moderated between-condition CBI efficacy and the inclusion of co-occurring mental health conditions and study publication date moderated within-condition CBI effects. Conclusions. Results provide preliminary data on study context factors associated with effect estimates in United States based clinical trials of CBI for AOD.

The methods and baseline characteristics of a multi-site randomized controlled trial evaluating mindfulness-based relapse prevention in conjunction with peer support to improve adherence to medications for opioid use disorders

Introduction

Medications for opioid use disorders (MOUD) remain the gold standard for treating OUD, but treatment initiation and adherence remain challenging. Exclusive utilization of pharmacotherapy as a treatment modality for OUD is sub-optimal, and a combination of psychotherapies and pharmacotherapies is recommended. General trends indicate the benefits of peer mentoring and MBRP separately. Therefore, we hypothesize that the combined effect of MBRP and Peer mentoring will produce synergistic improvements in MOUD adherence compared to an enhanced twelve-step facilitation (TSF).

Methods

This paper describes the methods and baseline characteristics of a multi-site randomized controlled trial evaluating the effectiveness of a combination of MBRP and peer support (MiMP) compared to an enhanced TSF in improving adherence to MOUD. Both MiMP and TSF are 12-week manualized protocols that utilize licensed therapists. The interventions are delivered in weekly group sessions that last about 75-90 minutes per session. The primary outcome is MOUD adherence. Secondary and exploratory outcomes include relapse, cravings, depression, anxiety, stress, quality of life, and pain catastrophizing.

Results

The participants' ages ranged from 21 years to 77 years, with a mean age of 44.5 (SD ± 11.5 years). There was an almost equal distribution of gender and place of residence. Overall, 51.9% (n=54) of participants identified as female and 48.1% (n=50) were male. Similarly, 51.9% (n=54) of participants resided in urban areas, while 48.1% (n=50) resided in rural areas. Participants identified as either black or white, with over three-quarters identifying as white (77.9%, n= 81) and 22.1% (n= 23) as black. Most participants randomized to the 12-step facilitation group were white (93.1%). Relationships and employment status were well distributed between categories. Over half of the participants reported some college or higher education. Over 90% of the participants made less than $75,000 per year. Some participants indicated that they had both public and private health insurance.

Discussion and conclusion

This study is innovative in several ways including combining MBRP and peer support, addressing comorbid mental health issues among individuals with OUD, utilizing manualized protocols, and evaluating of both physiological and self-reported measures in assessing cortisol reactivity as a predictor of relapse and treatment outcomes.

Novel medications for problematic alcohol use

Alcohol-related harm, a major cause of disease burden globally, affects people along a spectrum of use. When a harmful pattern of drinking is present in the absence of significant behavioral pathology, low-intensity brief interventions that provide information about health consequences of continued use provide large health benefits. At the other end of the spectrum, profound behavioral pathology, including continued use despite knowledge of potentially fatal consequences, warrants a medical diagnosis, and treatment is strongly indicated. Available behavioral and pharmacological treatments are supported by scientific evidence but are vastly underutilized. Discovery of additional medications, with a favorable balance of efficacy versus safety and tolerability can improve clinical uptake of treatment, allow personalized treatment, and improve outcomes. Here, we delineate the clinical conditions when pharmacotherapy should be considered in relation to the main diagnostic systems in use and discuss clinical endpoints that represent meaningful clinical benefits. We then review specific developments in three categories of targets that show promise for expanding the treatment toolkit. GPCRs remain the largest category of successful drug targets across contemporary medicine, and several GPCR targets are currently pursued for alcohol-related indications. Endocrine systems are another established category, and several promising targets have emerged for alcohol indications. Finally, immune modulators have revolutionized treatment of multiple medical conditions, and they may also hold potential to produce benefits in patients with alcohol problems.

Support after return to alcohol use: a mixed-methods study on how abstinence motivation and app use change after return to alcohol use in an app-based aftercare intervention for individuals with alcohol use disorder

BACKGROUND

As the return to alcohol use in individuals with alcohol use disorder (AUD) is common during treatment and recovery, it is important that abstinence motivation is maintained after such critical incidences. Our study aims to explore how individuals with AUD participating in an app-based intervention with telephone coaching after inpatient treatment perceived their abstinence motivation after the return to alcohol use, whether their app use behavior was affected and to identify helpful factors to maintain abstinence motivation.

METHODS

Using a mixed-methods approach, ten participants from the intervention group of the randomized controlled trial SmartAssistEntz who returned to alcohol use and recorded this in the app Appstinence, a smartphone application with telephone coaching designed for individuals with AUD, were interviewed about their experiences. The interviews were recorded, transcribed and coded using qualitative content analysis. App use behavior was additionally examined by using log data.

RESULTS

Of the ten interviewees, seven reported their abstinence motivation increased after the return to alcohol use. Reasons included the reminder of negative consequences of drinking, the desire to regain control of their situation as well as the perceived support provided by the app. App data showed that app use remained stable after the return to alcohol use with an average of 58.70 days of active app use (SD = 25.96, Mdn = 58.50, range = 24-96, IQR = 44.25) after the return to alcohol use which was also indicated by the participants' reported use behavior.

CONCLUSIONS

The findings of the study tentatively suggest that the app can provide support to individuals after the return to alcohol use to maintain and increase motivation after the incidence. Future research should (1) focus on specifically enhancing identification of high risk situations and reach during such critical incidences, (2) actively integrate the experience of the return to alcohol use into app-based interventions to better support individuals in achieving their personal AUD behavior change goals, and (3) investigate what type of support individuals might need who drop out of the study and intervention and discontinue app use altogether.

TRIAL REGISTRATION

The primary evaluation study is registered in the German Clinical Trials Register (DRKS, registration number DRKS00017700) and received approval of the ethical committee of the Friedrich-Alexander University Erlangen-Nuremberg (193_19 B).

Psychotherapies in opioid use disorder: toward a step-care model

Opioid use disorder (OUD) is characterized by a lack of control in opioid use, resulting in psychological distress and deficits in interpersonal and social functioning. OUD is often associated with psychiatric comorbidities that increase the severity of the disorder. The consequences of OUD are dramatic in terms of increased morbi-mortality. Specific medications and psychotherapies are essential tools not only in the treatment of OUD but also in the prevention of suicide and overdoses. In our review, we assess the different types of psychotherapies (counseling, motivational interviewing, contingency management, cognitive-behavioral therapy, and dialectical-behavior therapy) that are delivered to opioid users, either associated or un-associated with OUD medications and/or medications for psychiatric disabilities. We describe the application of these therapies first to adult opioid users and then to adolescents. This work led us to propose a stepped-care model of psychotherapies for OUD which provided information to assist clinicians in decision-making regarding the selection of psychotherapeutic strategies according to patients' OUD severity.

Current treatments of alcohol use disorder

Emerging treatments for alcohol dependence reveal an intricate interplay of neurobiological, psychological, and circumstantial factors that contribute to Alcohol Use Disorder (AUD). The approved strategies balancing these factors involve extensive manipulations of neurotransmitter systems such as GABA, Glutamate, Dopamine, Serotonin, and Acetylcholine. Innovative developments are engaging mechanisms such as GABA reuptake inhibition and allosteric modulation. Closer scrutiny is placed on the role of Glutamate in chronic alcohol consumption, with treatments like NMDA receptor antagonists and antiglutamatergic medications showing significant promise. Complementing these neurobiological approaches is the progressive shift towards Personalized Medicine. This strategy emphasizes unique genetic, epigenetic and physiological factors, employing pharmacogenomic principles to optimize treatment response. Concurrently, psychological therapies have become an integral part of the treatment landscape, tackling the cognitive-behavioral dimension of addiction. In instances of AUD comorbidity with other psychiatric disorders, Personalized Medicine becomes pivotal, ensuring treatment and prognosis are closely defined by individual characteristics, as exemplified by Lesch Typology models. Given the high global prevalence and wide distribution of AUD, a persistent necessity exists for development and improvement of treatments. Current research efforts are steadily paving paths towards more sophisticated, effective typology-based treatments: a testament to the recognized imperative for enhanced treatment strategies. The potential encapsulated within the ongoing research suggests a promising future where the clinical relevance of current strategies is not just maintained but significantly improved to effectively counter alcohol dependence.

A phase III multisite randomised controlled trial to compare the efficacy of cannabidiol to placebo in the treatment of cannabis use disorder: the CBD-CUD study protocol

BACKGROUND

Cannabis use disorder (CUD) is increasingly common and contributes to a range of health and social problems. Cannabidiol (CBD) is a non-intoxicating cannabinoid recognised for its anticonvulsant, anxiolytic and antipsychotic effects with no habit-forming qualities. Results from a Phase IIa randomised clinical trial suggest that treatment with CBD for four weeks reduced non-prescribed cannabis use in people with CUD. This study examines the efficacy, safety and quality of life of longer-term CBD treatment for patients with moderate-to-severe CUD.

METHODS/DESIGN

A phase III multi-site, randomised, double-blinded, placebo controlled parallel design of a 12-week course of CBD to placebo, with follow-up at 24 weeks after enrolment. Two hundred and fifty adults with moderate-to-severe CUD (target 20% Aboriginal), with no significant medical, psychiatric or other substance use disorders from seven drug and alcohol clinics across NSW and VIC, Australia will be enrolled. Participants will be administered a daily dose of either 4 mL (100 mg/mL) of CBD or a placebo dispensed every 3-weeks. All participants will receive four-sessions of Cognitive Behavioural Therapy (CBT) based counselling. Primary endpoints are self-reported cannabis use days and analysis of cannabis metabolites in urine. Secondary endpoints include severity of CUD, withdrawal severity, cravings, quantity of use, motivation to stop and abstinence, medication safety, quality of life, physical/mental health, cognitive functioning, and patient treatment satisfaction. Qualitative research interviews will be conducted with Aboriginal participants to explore their perspectives on treatment.

DISCUSSION

Current psychosocial and behavioural treatments for CUD indicate that over 80% of patients relapse within 1-6 months of treatment. Pharmacological treatments are highly effective with other substance use disorders but there are no approved pharmacological treatments for CUD. CBD is a promising candidate for CUD treatment due to its potential efficacy for this indication and excellent safety profile. The anxiolytic, antipsychotic and neuroprotective effects of CBD may have added benefits by reducing many of the mental health and cognitive impairments reported in people with regular cannabis use.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trial Registry: ACTRN12623000526673 (Registered 19 May 2023).

Neuroimmune modulators as novel pharmacotherapies for substance use disorders

One promising avenue of research is the use of neuroimmune modulators to treat substance use disorders (SUDs). Neuroimmune modulators target the interactions between the nervous system and immune system, which have been found to play a crucial role in the development and maintenance of SUDs. Multiple classes of substances produce alterations to neuroimmune signaling and peripheral immune function, including alcohol, opioids, and psychostimulants Preclinical studies have shown that neuroimmune modulators can reduce drug-seeking behavior and prevent relapse in animal models of SUDs. Additionally, early-phase clinical trials have demonstrated the safety and feasibility of using neuroimmune modulators as a treatment for SUDs in humans. These therapeutics can be used as stand-alone treatments or as adjunctive. This review summarizes the current state of the field and provides future directions with a specific focus on personalized medicine.

The Modulatory Effects of Atomoxetine on Aberrant Connectivity During Attentional Processing in Cocaine Use Disorder

BACKGROUND

Cocaine use disorder is associated with cognitive deficits that reflect dysfunctional processing across neural systems. Because there are currently no approved medications, treatment centers provide behavioral interventions that have only short-term efficacy. This suggests that behavioral interventions are not sufficient by themselves to lead to the maintenance of abstinence in patients with cocaine use disorder. Self-control, which includes the regulation of attention, is critical for dealing with many daily challenges that would benefit from medication interventions that can ameliorate cognitive neural disturbances.

METHODS

To address this important clinical gap, we conducted a randomized, double-blind, placebo-controlled, crossover design study in patients with cocaine use disorder (n = 23) and healthy control participants (n = 28). We assessed the modulatory effects of acute atomoxetine (40 mg) on attention and conflict monitoring and their associated neural activation and connectivity correlates during performance on the Eriksen flanker task. The Eriksen flanker task examines basic attentional processing using congruent stimuli and the effects of conflict monitoring and response inhibition using incongruent stimuli, the latter of which necessitates the executive control of attention.

RESULTS

We found that atomoxetine improved task accuracy only in the cocaine group but modulated connectivity within distinct brain networks in both groups during congruent trials. During incongruent trials, the cocaine group showed increased task-related activation in the right inferior frontal and anterior cingulate gyri, as well as greater network connectivity than the control group across treatments.

CONCLUSIONS

The findings of the current study support a modulatory effect of acute atomoxetine on attention and associated connectivity in cocaine use disorder.

Virtual reality-assisted cognitive behavioral therapy for patients with alcohol use disorder: a randomized feasibility study

Introduction

Cognitive behavioral therapy (CBT) is an evidence-based treatment for alcohol use disorder (AUD). Exposure to high-risk situations in virtual reality (VR) has been suggested to have a potential therapeutical benefit, but no previous study has combined VR and CBT for AUD. We aimed to investigate the feasibility of using VR-simulated high-risk environments in CBT-based treatment of AUD.

Methods

We randomized ten treatment-seeking AUD-diagnosed individuals to three sessions of conventional CBT or VR-assisted CBT performed at two outpatient clinics in Denmark. In each session, patients randomized to VR-CBT were exposed to VR-simulations from a restaurant to induce authentic thoughts, emotions, physiological reactions, and craving for CBT purposes. The primary outcome measure was feasibility: Drop-out rate, psychological reactions, and simulator sickness. Secondary outcomes were assessment of preliminary short-term changes in alcohol consumption and craving from baseline to one-week and one-month follow-up. In addition, the study was conducted for training in operationalization of VR equipment, treatment manuals, and research questionnaires.

Results

The majority of patients completed all study visits (90%). VR induced authentic high-risk related thoughts, emotions, and physiological reactions that were considered relevant for CBT by patients and therapists. Four of five patients randomized to VR-CBT experienced cravings during VR simulations, and most of these patients (3/5) experienced mild simulator sickness during VR exposure. The preliminary data showed that patients receiving VR-CBT had more reduction in alcohol consumption than patients receiving conventional CBT at one week- (median 94% vs. 72%) and one-month follow-up (median 98% vs. 55%). Similar results were found regarding changes in cravings.

Conclusion

We demonstrated VR-CBT to be a feasible intervention for patients with AUD which supports continued investigations in a larger randomized clinical trial evaluating the efficacy of VR-CBT.

Clinical trial registration

https://www.clinicaltrials.gov/study/NCT04990765?cond=addiction%20CRAVR&rank=2, identifier NCT05042180.

Navigating the Complex Intersection of Substance Use and Psychiatric Disorders: A Comprehensive Review

The co-occurrence of substance use disorders (SUDs) and psychiatric conditions, often referred to as comorbidity or concurrent disorders, presents intricate challenges in both diagnosis and treatment. This comprehensive narrative review aims to synthesize and critically evaluate the existing evidence surrounding the management of individuals with comorbid SUDs and psychiatric disorders. Comorbidity in these domains carries profound implications for clinical practice, research, and policymaking, emphasizing the need for a holistic understanding of the intricate dynamics that arise when these conditions coexist. This review explores recent research findings, evidence-based guidelines, and emerging trends within the field, offering valuable insights for clinicians, researchers, and policymakers seeking to navigate the complex terrain of comorbidity in substance use and psychiatric disorders.

Alcohol use disorder in alcohol-associated liver disease: Two sides of the same coin

Alcohol-associated liver disease (ALD) has emerged as the leading indication for liver transplantation (LT) worldwide, with 40% of LTs in the United States performed for ALD in 2019. The ALD-related health care burden accelerated during the COVID-19 pandemic, especially in young individuals. Alcohol use disorder (AUD), which focuses on the negative effects of alcohol on psychosocial, physical, and mental health, is present in the majority of patients with ALD, with moderate to severe AUD in 75%-80%. During the last decade, early liver transplantation (eLT) has emerged as a lifesaving treatment for selected patients with alcohol-associated hepatitis; these patients may have a higher risk of using alcohol after LT. The risk of alcohol use recurrence may be reduced during the pretransplant or post-transplant period with AUD treatment using behavioral and/or pharmacological therapies and with regular monitoring for alcohol use (self-reported and complemented with biomarkers like phosphatidylethanol). However, AUD treatment in patients with ALD is challenging due to patient, clinician, and system barriers. An integrated model to provide AUD and ALD care by hepatologists and addiction experts in a colocated clinic starting from LT evaluation and selection to monitoring listed candidates and then to following up on recipients of LT should be promoted. However, the integration of addiction and hepatology teams in an LT program in the real world is often present only during evaluation and candidate selection for LT. Data are emerging to show that a multidisciplinary integrated AUD treatment within an LT program reduces recurrent alcohol use after LT. If we want to continue using early liver transplantation for patients with severe alcohol-associated hepatitis, LT programs should focus on building integrated multidisciplinary care teams for the integrated treatment of both AUD and ALD.

Effects of fisetin on ethanol-induced rewarding properties in mice

Background: Alcohol use disorder (AUD) is a chronic relapsing disorder associated with compulsive drinking of alcohol. Natural flavonoid fisetin affects a variety of transmitter systems relevant to AUD, such as aminobutyric acid, N-methyl-D-aspartate, and dopamine, as well as peroxisome proliferator-activated receptors.Objectives: This study investigated fisetin's impact on the motivational properties of ethanol using conditioned place preference (CPP) in mice (n = 50).Methods: Mice were conditioned with ethanol (2 g/kg, i.p.) or saline on alternating days for 8 consecutive days and were given intragastric (i.g.) fisetin (10, 20, or 30 mg/kg, i.g.), 45 min before ethanol conditioning. During extinction, physiological saline was injected to the control and ethanol groups, and fisetin was administered to the fisetin groups. To evaluate the effect of fisetin on the reinstatement of ethanol-induced CPP, fisetin was given 45 min before a priming dose of ethanol (0.4 g/kg, i.p.; reinstatement test day).Results: Fisetin decreased the acquisition of ethanol-induced CPP (30 mg/kg, p < .05) and accelerated extinction (20 and 30 mg/kg, p < .05). Furthermore, fisetin attenuated reinstatement of ethanol-induced CPP (30 mg/kg, p < .05).Conclusions: Fisetin appears to diminish the rewarding properties of ethanol, as indicated by its inhibitory effect and facilitation of extinction in ethanol-induced CPP. These findings imply a potential therapeutic application of fisetin in preventing ethanol-seeking behavior, promoting extinction, and reducing the risk of relapse.

Baseline Characteristics and Postdischarge Outcomes by Medication for Opioid Use Disorder Status Among Women with Polysubstance Use in Residential Treatment

Background

Within residential treatment, medication for opioid use disorder (MOUD) is rarely offered, so little is known about group differences by MOUD status. This study characterizes samples of women receiving and not receiving MOUD and explores postdischarge outcomes.

Methods

This is a secondary exploratory analysis of a residential clinical trial comparing women receiving treatment as usual (TAU) with those who also received computer-based training for cognitive behavioral therapy (CBT4CBT). Participants were N = 41 adult women with substance use disorder (SUD) who self-reported lifetime polysubstance use. Because 59.0% were prescribed MOUD (MOUD n = 24, no MOUD n = 17), baseline variables were compared by MOUD status; outcomes at 12 weeks postdischarge were compared by MOUD status and treatment condition using chi square and Mann-Whitney U tests.

Results

Participants were middle-aged (41.7 ± 11.6 years) and non-Latinx Black (80.4%). Most used substances in the No MOUD group were alcohol, cocaine, and cannabis, and in the MOUD group, most used substances were opioids, cannabis, and cocaine. Women in the MOUD group tended to have more severe SUD. Postdischarge substance use recurrence rates were twice as high in the MOUD group than in the No MOUD group. Among the women in the No MOUD group, those in the CBT4CBT condition increased the number of coping strategies twice as much as those receiving TAU.

Conclusion

Postdischarge substance use recurrence differed by MOUD status. CBT4CBT may be a helpful adjunct to personalized residential SUD treatment. The parent study is registered at [www.clinicaltrials.gov (ClinicalTrials.gov identifier: NCT03678051)].

Effects of brief cognitive behavioral therapy on mental health in substance-related disorder: a randomized controlled trial

BACKGROUND & OBJECTIVES

Population and aging are major contributing factors influencing the increase in substance use disorder (SUD), which in itself affects mental health, particularly anxiety and depression. Cognitive behavioral therapy (CBT) and pharmacotherapy co-treatment are considered the gold standard for the treatment of SUD. Thus, the present study has been carried out to investigate the efficacy of brief CBT on the general health of opioid users.

METHODS

A randomized controlled trial (RCT) was conducted with forty opioid users whose addiction was dully confirmed by a psychiatrist at the drop-in center of the Ahvaz Jundishapur University of Medical Sciences. The patients were then randomly divided into two equal groups (n = 20). The control group was treated solely using methadone maintenance therapy (MMT); however, the intervention group underwent four sessions of CBT in addition to MMT. The general health questionnaire (GHQ) consisting of 28 items (Goldberg, 1979) was applied to both groups at the beginning and end of the study. The collected data was analyzed using IBM SPSS ver. 26, and data analysis was carried out using chi-square, t-test, Mann-Whitney, and Poisson regression model. P < 0.05 was statistically significant for all the aforementioned tests.

RESULTS

The mean age for the control and intervention groups were 37.95 ± 7.64 and 43.85 ± 9.92, respectively (p = 0.042). There was no statistically significant difference in terms of gender and levels of education (p = 0.311 and p = 0.540). Both groups differed statistically regarding marital status and occupation (p = 0.025 and 0.002). There was no significant statistical difference in all subclasses and the total scores of GHQ-28 for both groups, except for anxiety and insomnia in the intervention group (p = 0.038). After applying a Likert scale with a 23-point cut-off score, there was no statistically significant difference in terms of psychosis after intervention in the intervention group (p = 0.077).

CONCLUSION

The results of the current study show that brief CBT is effective on psychiatric health, especially anxiety and sleep disorders, whereas brief CBT fails to affect the patient's depression, somatic symptoms, and social dysfunction.

TRIAL REGISTRATION

The Iranian Registry of Clinical Trials (IRCT) approved the study design (IRCT registration number: IRCT20190929044917N1, registration date: 13/01/2020).

Alcohol consumption, alcohol use disorder and organ transplantation

In the present experience we have evaluated the link alcohol consumption/alcohol use disorder (AUD) and organ transplantation (OT) in order to provide adequate suggestions. The data used for the preparation of these recommendations are based on a detailed analysis of the scientific literature published before August 31, 2022 (Web of Science, Scopus, Google Scholar). Furthermore, in the process of developing this work, we consulted the guidelines/position papers of the scientific societies. With regard to the liver transplantation, there are position papers/guidelines that clearly define indications and contraindications for including the AUD patient in the transplant list. One of the major difficulties in this area is psychosocial assessment which can be influenced by stigma. To solve this problem, it is necessary to use objective tools. However, this assessment should be carried out after providing the patient and family adequate tools to be able to create or recreate reliable socio-family support. This behavior should also be used in the case of other OTs. For the latter, however, adequate guidelines must be created which at the moment do not exist or if there are, as in the case of heart transplantation, they are not sufficient. Even in the absence of obvious alcohol addiction, it is recommended to use alcohol use disorder identification test and to include the addiction specialist in the multidisciplinary transplant team. Besides, providing family members with the tools necessary to better support the patient is essential. They are patients with alcohol use disorder/ possible presence of psychopathological manifestations and alcohol-related pathology (cirrhosis, cardiomyopathy, liver-kidney disfunction, etc.). A cardiovascular and oncologic surveillance post-OT is recommended. For the selection of patients to be included in the list for non-LT (heart, lung, kidney, multivisceral, etc.) it is mandatory to include the diagnosis and treatment of AUDs in the guidelines. What has already been indicated for LT may be useful. Timing of alcoholic abstention in relation to clinical severity, optimal psychosocial activity, anticraving therapy in relation to the type of underlying disease and clinical severity. Close collaboration between scientific societies is required to better manage AUD patients who need OT.

Measuring the importance of different barriers to opioid agonist treatment using best-worst scaling in an Australian setting

OBJECTIVE

Opioid agonist treatment (OAT) is an effective treatment for opioid use disorder (OUD), however several client barriers to OAT are reported. Client importance of these barriers using economic preference elicitation measures have not been identified. This paper determines the most important OAT barriers using best-worst scaling (BWS) and compares the results of BWS to Likert scale.

METHODS

Cross-sectional self-completed survey with 191 opioid dependent clients who attended Australian needle and syringe sites. Participants were presented 15 Likert scale barriers and 15 BWS barrier scenarios. The BWS data was presented using count analysis, multinomial logit and mixed logit models. The ranking of barrier items was completed using three BWS methods and one Likert scale method, with share preference results (BWS) or mean scores (Likert) used to rank the 15 barriers.

RESULTS

The most important client barriers were 'enjoy using opioids', 'lack of support services' and 'hard to access'. The four ranking methods produced different barrier rankings for the most important barriers, but similar results for the least important barriers.

CONCLUSION

Policies around OAT as a harm reduction approach, increased support services and increased availability of OAT services would be beneficial in improving OAT uptake. Comparing BWS and Likert methods produced different highest ranked barriers, indicating the method used to identify preferences has significant implications on the type of intervention prioritised.

Efficacy of Repetitive Transcranial Magnetic Stimulation (rTMS) Combined with Psychological Interventions: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

(1) Background: Psychological interventions are effective in alleviating neuropsychiatric symptoms, though results can vary between patients. Repetitive transcranial magnetic stimulation (rTMS) has been proven to improve clinical symptoms and cognition. It remains unclear whether rTMS can augment the efficacy of psychological interventions. (2) Methods: We examined the effects of rTMS combined with psychological interventions on clinical, functional, and cognitive outcomes from randomized controlled trials conducted in healthy and clinical populations. We searched PubMed, EMBASE, Cochrane Library, and PsycINFO databases up to April 2023. (3) Results: Twenty-seven studies were ultimately included. Compared to sham rTMS combined with psychological interventions, active rTMS combined with psychological interventions significantly improved overall clinical symptoms (k = 16, SMD  =  0.31, CIs 0.08 to 0.54, p  <  0.01). We found that 10 or more sessions of rTMS combined with cognitive behavioural therapy significantly improved clinical outcomes overall (k = 3, SMD  =  0.21, CIs  0.05 to 0.36, Z = 2.49, p  <  0.01). RTMS combined with cognitive training (CT) significantly improved cognition overall compared to sham rTMS combined with CT (k = 13, SMD  =  0.28, CIs 0.15 to 0.42, p  <  0.01), with a significant effect on global cognition (k = 11, SMD  =  0.45, CIs 0.21 to 0.68, p  < 0.01), but not on the other cognitive domains. (4) Conclusion: The current results provide preliminary support for the augmentation effects of active rTMS on clinical and cognitive outcomes across diverse populations. Future clinical trials are required to confirm these augmentation effects for specific psychological interventions in specific clinical populations.

Neurobiology and the Treatment of Alcohol Use Disorder: A Review of the Evidence Base

Alcohol use disorder (AUD) is a significant public health concern, accounting for a majority of substance use disorder cases in the United States. Treatment for AUD is complex, with multiple intervention points that may be further complicated by genotype and phenotype, resulting in diverse outcomes. In order to better understand the current landscape of AUD treatment, the present review considers different etiological models of AUD and assesses the evidence base of current treatment options. The first section of this review summarizes various etiological models of AUD and presents different approaches to classifying the disorder. Various theories, including neurobiological models, are discussed. The second section presents a comprehensive analysis of available treatment options for AUD, encompassing behavioral and pharmacological interventions and their current evidence base. Finally, this review discusses the ongoing treatment gap and significant factors contributing to low treatment utilization. Together, this review provides an overview of different etiological processes and mechanisms of AUD, as well as summarizes the literature on key treatment approaches. By integrating historical, theoretical, and empirical data, this review aims to inform both researchers and providers with valuable insights to advance AUD treatment approaches and narrow the treatment gap.

The Therapeutic Potential of Amphetamine-like Psychostimulants

This review delves into the therapeutic applications of amphetamine-type stimulants such as lisdexamphetamine dimesylate, mixed amphetamine salts, 3,4-methylenedioxymethamphetamine (MDMA), dextroamphetamine, and phentermine. These compounds have been investigated for their potential in treating a range of psychiatric disorders, including attention deficit hyperactivity disorder (ADHD), drug dependence, post-traumatic stress disorder (PTSD), and obesity. Lisdexamphetamine dimesylate has shown promise in effectively treating ADHD symptoms in both children and adults. Additionally, it has been explored as a potential treatment for drug dependency and withdrawal, demonstrating encouraging results. Mixed amphetamine salts have also exhibited efficacy in reducing ADHD symptoms in adults. Future research should explore their potential use in treating bipolar disorder and cocaine dependence, considering the associated risks and benefits. MDMA-assisted psychotherapy has emerged as an innovative approach to treating PTSD, leading to sustained reductions in symptoms and even promoting post-traumatic growth. Furthermore, it has shown promise in managing anxiety related to life-threatening illnesses. Dextroamphetamine and phentermine have demonstrated efficacy in treating cocaine and opioid dependence, ADHD, and obesity. However, careful consideration and monitoring by medical professionals are essential due to the potential risks and benefits associated with them. In conclusion, amphetamine-type stimulants present a promising avenue for therapeutic interventions in various psychiatric conditions. Nevertheless, further research is necessary to comprehensively understand their mechanisms of action, dosage requirements, and long-term effects in different patient populations.

Psychodynamic Therapies for the Treatment of Substance Addictions: A PRISMA Meta-Analysis

The aim of this meta-analysis was to compare psychodynamic with other treatments in studies of substance addiction. The literature search was conducted using the PubMed, Web of Science, Cohcrane library, SCOPUS, and Onesearch databases. All studies comparing psychodynamic therapy with other types of psychological interventions for Substance Use Disorder were eligible. Three outcomes were considered to compare intervention performance: substance use, participation in treatment and other symptomatic conditions (OSCs). Hedges' G was used to measure effect size. The Revised Cochrane Risk of Bias tool for randomized trials was used to assess quality of evidence and possible bias, Egger regression analyses for publication bias, and Q and I-square statistics were used to assess heterogeneity. The alcohol group showed no differences between treatments on the three outcomes. The cocaine group showed no significant differences in the two outcomes, while for OSCs, available data was insufficient. The opioids group showed small but significant differences regarding participation in favor of non-psychodynamic interventions and no significant results for other outcomes. Based on the three measures of recovery considered in this meta-analysis, psychodynamic interventions were shown to be as effective as other psychological treatments in treating substance dependence and proved to be an empirically-supported treatment for the above addictions.

Promoting alcohol treatment engagement post-hospitalization with brief intervention, medications and CBT4CBT: protocol for a randomized clinical trial in a diverse patient population

BACKGROUND

Alcohol use disorder (AUD) commonly causes hospitalization, particularly for individuals disproportionately impacted by structural racism and other forms of marginalization. The optimal approach for engaging hospitalized patients with AUD in treatment post-hospital discharge is unknown. We describe the rationale, aims, and protocol for Project ENHANCE (ENhancing Hospital-initiated Alcohol TreatmeNt to InCrease Engagement), a clinical trial testing increasingly intensive approaches using a hybrid type 1 effectiveness-implementation approach.

METHODS

We are randomizing English and/or Spanish-speaking individuals with untreated AUD (n = 450) from a large, urban, academic hospital in New Haven, CT to: (1) Brief Negotiation Interview (with referral and telephone booster) alone (BNI), (2) BNI plus facilitated initiation of medications for alcohol use disorder (BNI + MAUD), or (3) BNI + MAUD + initiation of computer-based training for cognitive behavioral therapy (CBT4CBT, BNI + MAUD + CBT4CBT). Interventions are delivered by Health Promotion Advocates. The primary outcome is AUD treatment engagement 34 days post-hospital discharge. Secondary outcomes include AUD treatment engagement 90 days post-discharge and changes in self-reported alcohol use and phosphatidylethanol. Exploratory outcomes include health care utilization. We will explore whether the effectiveness of the interventions on AUD treatment engagement and alcohol use outcomes differ across and within racialized and ethnic groups, consistent with disproportionate impacts of AUD. Lastly, we will conduct an implementation-focused process evaluation, including individual-level collection and statistical comparisons between the three conditions of costs to providers and to patients, cost-effectiveness indices (effectiveness/cost ratios), and cost-benefit indices (benefit/cost ratios, net benefit [benefits minus costs). Graphs of individual- and group-level effectiveness x cost, and benefits x costs, will portray relationships between costs and effectiveness and between costs and benefits for the three conditions, in a manner that community representatives also should be able to understand and use.

CONCLUSIONS

Project ENHANCE is expected to generate novel findings to inform future hospital-based efforts to promote AUD treatment engagement among diverse patient populations, including those most impacted by AUD.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT05338151.

Naltrexone engages a brain reward network in the presence of reward-predictive distractor stimuli in males

The non-selective opioid receptor antagonist, naltrexone is one of the most prescribed medications for treating alcohol and opioid addiction. Despite decades of clinical use, the mechanism(s) by which naltrexone reduces addictive behavior remains unclear. Pharmaco-fMRI studies to date have largely focused on naltrexone's impact on brain and behavioral responses to drug or alcohol cues or on decision-making circuitry. We hypothesized that naltrexone's effects on reward-associated brain regions would associate with reduced attentional bias (AB) to non-drug, reward-conditioned cues. Twenty-three adult males, including heavy and light drinkers, completed a two-session, placebo-controlled, double-blind study testing the effects of acute naltrexone (50 mg) on AB to reward-conditioned cues and neural correlates of such bias measured via fMRI during a reward-driven AB task. While we detected significant AB to reward-conditioned cues, naltrexone did not reduce this bias in all participants. A whole-brain analysis found that naltrexone significantly altered activity in regions associated with visuomotor control regardless of whether a reward-conditioned distractor was present. A region-of-interest analysis of reward-associated areas found that acute naltrexone increased BOLD signal in the striatum and pallidum. Moreover, naltrexone effects in the pallidum and putamen predicted individual reduction in AB to reward-conditioned distractors. These findings suggest that naltrexone's effects on AB primarily reflect not reward processing per se, but rather top-down control of attention. Our results suggest that the therapeutic actions of endogenous opioid blockade may reflect changes in basal ganglia function enabling resistance to distraction by attractive environmental cues, which could explain some variance in naltrexone's therapeutic efficacy.

Predictors of polysubstance use in patients with severe alcohol use disorder: the role of reward craving

BACKGROUND

Different craving typologies (i.e., reward, relief, obsessive) have been identified in alcohol use disorder (AUD) but have been less investigated in specific populations like AUD patients with polysubstance use (PSU). The role of dysfunctional personality traits and reward pathways has been reported in both AUD and PSU. We hypothesized that patients with AUD-PSU might show a prevalent reward craving, alongside specific sociodemographic, clinical, and personality features, and aimed at investigating differences in 423 severe AUD outpatients with and without PSU.

METHODS

One hundred fifteen patients (27.1% of the sample, 67% males, 42 ± 11.6 years old) displayed PSU. Sociodemographic, clinical features and psychopathological/personality dimensions were assessed through: Craving Typologies Questionnaire (CTQ); Obsessive-Compulsive Drinking Scale (OCDS); UPPS-P Impulsive Behavior Scale (S-UPPS-P); Difficulties in Emotion Regulation Scale (DERS). A binomial logistic regression explored factors associated with PSU.

RESULTS

We found higher CTQ 'reward' scores (p < 0.001) in AUD-PSU patients, and a significant association between reward craving and PSU through logistic regression (OR:1.13; p = 0.005). Earlier AUD onset (p < 0.001), greater rates of binge drinking (p = 0.029), more legal problems (p = 0.015), but no significantly higher S-UPPS-S and DERS scores, were detected in AUD-PSU patients.

CONCLUSIONS

Reward craving was associated with increased risk for PSU in severe AUD patients. Given AUD-PSU participants greater severity and detrimental treatment responses imputed to PSU, identifying prevalent craving types among risk factors for PSU in AUD may help to implement therapeutic strategies. Addressing neurobiological and behavioral mechanisms through combined psychotherapies, pharmacological and neuromodulation treatments could support tailored interventions with better long-term outcome.

Determinants of outpatient substance use disorder treatment length-of-stay and completion: the case of a treatment program in the southeast U.S

Successful outcomes of outpatient substance use disorder treatment result from many factors for clients-including intersections between individual characteristics, choices made, and social determinants. However, prioritizing which of these and in what combination, to address and provide support for remains an open and complex question. Therefore, we ask: What factors are associated with outpatient substance use disorder clients remaining in treatment for > 90 days and successfully completing treatment? To answer this question, we apply a virtual twins machine learning (ML) model to de-identified data for a census of clients who received outpatient substance use disorder treatment services from 2018 to 2021 from one treatment program in the Southeast U.S. We find that primary predictors of outcome success are: (1) attending self-help groups while in treatment, and (2) setting goals for treatment. Secondary predictors are: (1) being linked to a primary care provider (PCP) during treatment, (2) being linked to supplemental nutrition assistance program (SNAP), and (3) attending 6 or more self-help group sessions during treatment. These findings can help treatment programs guide client choice making and help set priorities for social determinant support. Further, the ML method applied can explain intersections between individual and social predictors, as well as outcome heterogeneity associated with subgroup differences.

The impact of organisational factors on treatment outcomes for those seeking alcohol or other drug treatment: A systematic review

INTRODUCTION

Organisational factors have been found to be associated with health outcomes in a number of health-care settings. Despite likely being an important influence on the quality of care provided within alcohol and other drug (AOD) treatment centres, the impact of organisational factors on AOD treatment outcomes have not been extensively explored. This systematic literature review examines the characteristics, methodological quality and findings of published studies exploring the association between organisational factors and client AOD treatment outcomes.

METHODS

Medline, Embase, PsycINFO and the Cochrane database were searched from 2010 to March 2022 for relevant papers. Studies meeting the inclusion criteria underwent quality assessment using the Joanna Brigg's Institute critical appraisal tool for cross-sectional studies, followed by data extraction of key variables pertaining to the aims. A narrative summary was used to synthesise the data.

RESULTS

Nine studies met the inclusion criteria. Organisational factors examined included cultural competency, organisational readiness for change, directorial leadership, continuity of care practices, service access, service to needs ratios, dual diagnosis training, therapeutic optimism and the funding model/health-care system that treatment was delivered in. Outcome measures included duration, completion or continuation of treatment; AOD use; and patient perceptions of treatment outcomes. Seven out of nine papers found a significant interaction between at least one organisational variable and AOD treatment outcomes.

DISCUSSION AND CONCLUSIONS

Organisational factors are likely to impact treatment outcomes for patients seeking treatment for AOD. Further examination of the organisational factors that influence AOD outcomes is needed to inform systemic improvements to AOD treatment.

Medications for treating alcohol use disorder: A narrative review

Chronic heavy alcohol use impacts all major neurotransmitter systems and is associated with multiple medical, psychiatric, and social problems. Available evidence-based medications to treat alcohol use disorder (AUD) are underutilized in clinical practice. These medications promote abstinence or reduce alcohol consumption, though there are questions regarding their optimal dosage, length of treatment, and utility in combination with one another. Pharmacogenetic approaches, which use a patient's genetic make-up to inform medication selection, have garnered great interest but have yet to yield results robust enough to incorporate them in routine clinical care. This narrative review summarizes the evidence both for medications approved by the Food and Drug Administration (disulfiram, oral naltrexone, acamprosate, and extended-release naltrexone) and those commonly used off-label (e.g., gabapentin, baclofen, and topiramate) for AUD treatment. We discuss these drugs' mechanisms of action, clinical use, pharmacogenetic findings, and treatment recommendations. We conclude that the most consistent evidence supporting the pharmacotherapy of AUD is for the opioid antagonists, naltrexone and nalmefene (which is not approved in the United States), and topiramate. These medications demonstrate consistent small or moderate effects in reducing the frequency of drinking and/or heavy drinking. Lastly, we make suggestions for research needed to refine and expand the current literature on effective pharmacotherapy for AUD.