Addiction Medicine

The first thing Ann Garment, MD, wants all clinicians to know about buprenorphine is that any prescriber with a DEA registration number “is able to prescribe buprenorphine and should be ready and willing to prescribe” the medication.

“There is no longer any extra paperwork or training required to prescribe buprenorphine,” said Dr. Garment, clinical associate professor at New York University and chief of general internal medicine at Bellevue Hospital in New York City, during a presentation on April 19 at the American College of Physicians (ACP-IM) Internal Medicine Meeting 2024.

Dr. Garment, who specializes in opioid use disorder (OUD), described the current “third wave” of increasing opioid overdose deaths fueled by the increase of synthetic opioids in the drug supply. The third wave started in 2013 with the rise in use of fentanyl and tramadol. The 107,000 number of overdose deaths in the United States in 2021 was more than six times that in 1999, and 75% involved opioids.

“Now, more than ever,” Dr. Garment said, “opioid use disorder should be treated from the primary care setting.”
 

How to Identify OUD

Dr. Garment recommended asking a single question to screen for OUD: “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”

If the patient says any number above zero, that should trigger suspicion of active OUD. “It’s less sensitive for picking up on people who have a prior opioid use disorder history or are only exhibiting risky opioid use that wouldn’t constitute opioid use disorder yet,” she said.

If someone screens positive, to verify OUD, the Diagnostic and Statistical Manual of Mental Disorders identifies criteria for any substance abuse disorder with two general themes: Loss of control and continued use despite negative consequences.

“If you have a patient who is getting prescribed opioids and they have opioid tolerance or withdrawal, that does not mean they have opioid use disorder,” she said.
 

Medication for OUD

Medication is the top treatment for OUD, according to Dr. Garment. Psychosocial treatments can help some but not all people with OUD, she said. “It is not a requirement for a patient to engage in psychosocial treatment in order to get a medication for opioid use disorder, so please do not let that be a barrier for your patients,” she said.

Buprenorphine has advantages over other medications for OUD, including methadone and naltrexone.

Methadone must be obtained daily at a methadone clinic instead of at a local pharmacy. And escalating doses of methadone carry an increased risk for overdose and respiratory problems and potential drug-drug interactions, Dr. Garment added.

One downside with naltrexone is loss of tolerance, she said. If a patient has been using naltrexone to treat OUD and they decide to resume taking opioids, “they no longer can use the same amount of opioids that they were using before” because they have lost their tolerance and now are at a risk for overdose with their usual amount, she said. What’s more, naltrexone has not been shown to reduce overdose deaths.

Finally, she said, buprenorphine, “is an incredibly safe medication. If anyone in this room has ever prescribed coumadin or insulin, I’m going to tell you: This is much safer.”

• The drug is a partial, as opposed to full, opioid agonist, so as the dose increases, the patient experiences less withdrawal and fewer opioid cravings. As a result, they will hit a ceiling effect that avoids euphoria, respiratory depression, or overdose.
• Buprenorphine is “stickier” than other OUD medications: “If I’m taking buprenorphine and I decide to use some [oxycodone], what’s going to happen is that very little of that, if any, is going to get bound to my opioid receptors because buprenorphine is so sticky and adherent, it’s not going to let other opioids on.”
• Most buprenorphine is co-formulated with naloxone, an opioid antagonist. If a patient tries to get high from buprenorphine and tries to snort or inject it, naloxone will kick in and cancel out the buprenorphine.

Dr. Garment said she obtains urine screens ideally twice a year. If other drugs show up on the test, she said, she speaks with the patient about their drug use. “It’s never a reason to discharge someone from a practice,” she said.

Dr. Garment reported no relevant financial conflicts of interest.

A version of this article appeared on Medscape.com.

The first thing Ann Garment, MD, wants all clinicians to know about buprenorphine is that any prescriber with a DEA registration number “is able to prescribe buprenorphine and should be ready and willing to prescribe” the medication.

“There is no longer any extra paperwork or training required to prescribe buprenorphine,” said Dr. Garment, clinical associate professor at New York University and chief of general internal medicine at Bellevue Hospital in New York City, during a presentation on April 19 at the American College of Physicians (ACP-IM) Internal Medicine Meeting 2024.

Dr. Garment, who specializes in opioid use disorder (OUD), described the current “third wave” of increasing opioid overdose deaths fueled by the increase of synthetic opioids in the drug supply. The third wave started in 2013 with the rise in use of fentanyl and tramadol. The 107,000 number of overdose deaths in the United States in 2021 was more than six times that in 1999, and 75% involved opioids.

“Now, more than ever,” Dr. Garment said, “opioid use disorder should be treated from the primary care setting.”
 

How to Identify OUD

Dr. Garment recommended asking a single question to screen for OUD: “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”

If the patient says any number above zero, that should trigger suspicion of active OUD. “It’s less sensitive for picking up on people who have a prior opioid use disorder history or are only exhibiting risky opioid use that wouldn’t constitute opioid use disorder yet,” she said.

If someone screens positive, to verify OUD, the Diagnostic and Statistical Manual of Mental Disorders identifies criteria for any substance abuse disorder with two general themes: Loss of control and continued use despite negative consequences.

“If you have a patient who is getting prescribed opioids and they have opioid tolerance or withdrawal, that does not mean they have opioid use disorder,” she said.
 

Medication for OUD

Medication is the top treatment for OUD, according to Dr. Garment. Psychosocial treatments can help some but not all people with OUD, she said. “It is not a requirement for a patient to engage in psychosocial treatment in order to get a medication for opioid use disorder, so please do not let that be a barrier for your patients,” she said.

Buprenorphine has advantages over other medications for OUD, including methadone and naltrexone.

Methadone must be obtained daily at a methadone clinic instead of at a local pharmacy. And escalating doses of methadone carry an increased risk for overdose and respiratory problems and potential drug-drug interactions, Dr. Garment added.

One downside with naltrexone is loss of tolerance, she said. If a patient has been using naltrexone to treat OUD and they decide to resume taking opioids, “they no longer can use the same amount of opioids that they were using before” because they have lost their tolerance and now are at a risk for overdose with their usual amount, she said. What’s more, naltrexone has not been shown to reduce overdose deaths.

Finally, she said, buprenorphine, “is an incredibly safe medication. If anyone in this room has ever prescribed coumadin or insulin, I’m going to tell you: This is much safer.”

• The drug is a partial, as opposed to full, opioid agonist, so as the dose increases, the patient experiences less withdrawal and fewer opioid cravings. As a result, they will hit a ceiling effect that avoids euphoria, respiratory depression, or overdose.
• Buprenorphine is “stickier” than other OUD medications: “If I’m taking buprenorphine and I decide to use some [oxycodone], what’s going to happen is that very little of that, if any, is going to get bound to my opioid receptors because buprenorphine is so sticky and adherent, it’s not going to let other opioids on.”
• Most buprenorphine is co-formulated with naloxone, an opioid antagonist. If a patient tries to get high from buprenorphine and tries to snort or inject it, naloxone will kick in and cancel out the buprenorphine.

Dr. Garment said she obtains urine screens ideally twice a year. If other drugs show up on the test, she said, she speaks with the patient about their drug use. “It’s never a reason to discharge someone from a practice,” she said.

Dr. Garment reported no relevant financial conflicts of interest.

A version of this article appeared on Medscape.com.

The first thing Ann Garment, MD, wants all clinicians to know about buprenorphine is that any prescriber with a DEA registration number “is able to prescribe buprenorphine and should be ready and willing to prescribe” the medication.

“There is no longer any extra paperwork or training required to prescribe buprenorphine,” said Dr. Garment, clinical associate professor at New York University and chief of general internal medicine at Bellevue Hospital in New York City, during a presentation on April 19 at the American College of Physicians (ACP-IM) Internal Medicine Meeting 2024.

Dr. Garment, who specializes in opioid use disorder (OUD), described the current “third wave” of increasing opioid overdose deaths fueled by the increase of synthetic opioids in the drug supply. The third wave started in 2013 with the rise in use of fentanyl and tramadol. The 107,000 number of overdose deaths in the United States in 2021 was more than six times that in 1999, and 75% involved opioids.

“Now, more than ever,” Dr. Garment said, “opioid use disorder should be treated from the primary care setting.”
 

How to Identify OUD

Dr. Garment recommended asking a single question to screen for OUD: “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”

If the patient says any number above zero, that should trigger suspicion of active OUD. “It’s less sensitive for picking up on people who have a prior opioid use disorder history or are only exhibiting risky opioid use that wouldn’t constitute opioid use disorder yet,” she said.

If someone screens positive, to verify OUD, the Diagnostic and Statistical Manual of Mental Disorders identifies criteria for any substance abuse disorder with two general themes: Loss of control and continued use despite negative consequences.

“If you have a patient who is getting prescribed opioids and they have opioid tolerance or withdrawal, that does not mean they have opioid use disorder,” she said.
 

Medication for OUD

Medication is the top treatment for OUD, according to Dr. Garment. Psychosocial treatments can help some but not all people with OUD, she said. “It is not a requirement for a patient to engage in psychosocial treatment in order to get a medication for opioid use disorder, so please do not let that be a barrier for your patients,” she said.

Buprenorphine has advantages over other medications for OUD, including methadone and naltrexone.

Methadone must be obtained daily at a methadone clinic instead of at a local pharmacy. And escalating doses of methadone carry an increased risk for overdose and respiratory problems and potential drug-drug interactions, Dr. Garment added.

One downside with naltrexone is loss of tolerance, she said. If a patient has been using naltrexone to treat OUD and they decide to resume taking opioids, “they no longer can use the same amount of opioids that they were using before” because they have lost their tolerance and now are at a risk for overdose with their usual amount, she said. What’s more, naltrexone has not been shown to reduce overdose deaths.

Finally, she said, buprenorphine, “is an incredibly safe medication. If anyone in this room has ever prescribed coumadin or insulin, I’m going to tell you: This is much safer.”

• The drug is a partial, as opposed to full, opioid agonist, so as the dose increases, the patient experiences less withdrawal and fewer opioid cravings. As a result, they will hit a ceiling effect that avoids euphoria, respiratory depression, or overdose.
• Buprenorphine is “stickier” than other OUD medications: “If I’m taking buprenorphine and I decide to use some [oxycodone], what’s going to happen is that very little of that, if any, is going to get bound to my opioid receptors because buprenorphine is so sticky and adherent, it’s not going to let other opioids on.”
• Most buprenorphine is co-formulated with naloxone, an opioid antagonist. If a patient tries to get high from buprenorphine and tries to snort or inject it, naloxone will kick in and cancel out the buprenorphine.

Dr. Garment said she obtains urine screens ideally twice a year. If other drugs show up on the test, she said, she speaks with the patient about their drug use. “It’s never a reason to discharge someone from a practice,” she said.

Dr. Garment reported no relevant financial conflicts of interest.

A version of this article appeared on Medscape.com.

People with opioid use disorder (OUD) who have hepatitis C virus (HCV) were twice as likely to be treated and cured of HCV if they received facilitated telemedicine treatment within their opioid treatment program than if they were referred for off-site treatment, the results of a new study showed.

In addition, among cured patients, illicit drug use fell significantly, and there were few reinfections, reported the researchers, led by Andrew Talal, MD, MPH, with the University at Buffalo, State University of New York, Buffalo.

The study was published online in JAMA.

HCV is a major public health concern, especially among people with OUD. Geographic and logistical barriers often prevent this underserved population from accessing treatment; however, telemedicine has the potential to overcome these obstacles.

In a prospective cluster randomized clinical trial, Dr. Talal and colleagues assessed the impact of embedding facilitated telemedicine for HCV care into 12 opioid treatment programs in New York State.

They studied 602 HCV-infected adults (61% male; 51% White) with OUD. Of these, 290 (mean age, 47.1 years) were enrolled in facilitated telemedicine programs onsite, and 312 (mean age, 48.9 years) received an off-site referral (usual care).

Telemedicine participants had an initial telemedicine encounter facilitated by study case managers onsite who also administered a blood test. The telemedicine clinician subsequently evaluated participants and ordered direct-acting antiviral (DAA) medication that was delivered to the opioid treatment program monthly (as refills required) and dispensed along with methadone.

In the telemedicine group, 268 of 290 individuals (92.4%) initiated HCV treatment compared with 126 of 312 (40.4%) in the referral group.

Participants in the telemedicine group were also seen sooner and started treatment faster.

The interval between screening and initial appointments was 14 days with telemedicine vs 18 days with a referral (P = .04). The time between the initial visit and DAA initiation was 49.9 days with telemedicine vs 123.5 days with a referral (P < .001).

Intention-to-treat analysis showed significantly higher HCV cure rates with telemedicine than with referral (90.3% vs 39.4%, respectively). Similarly, the observed cure rates were also higher in the telemedicine group (84.8% vs 34.0%).

Sustained virologic response was durable, with only 13 reinfections (incidence, 2.5 per 100 person-years) occurring during the 2-year follow-up period, the researchers reported.

In addition, illicit drug use decreased significantly among cured patients in both the telemedicine group (P < .001) and the referral group (P = .001). Adults in both groups rated healthcare delivery satisfaction as high or very high.

“Our study demonstrates how telemedicine successfully integrates medical and behavioral treatment,” Dr. Talal said in a statement.

The intervention “builds patient-clinician trust across the screen, and significant decreases in substance use were observed in cured participants with minimal HCV reinfections,” the study team wrote.

Support for this research was provided by the Patient-Centered Outcomes Research Institute and by the Troup Fund of the Kaleida Health Foundation.

A version of this article appeared on Medscape.com .

People with opioid use disorder (OUD) who have hepatitis C virus (HCV) were twice as likely to be treated and cured of HCV if they received facilitated telemedicine treatment within their opioid treatment program than if they were referred for off-site treatment, the results of a new study showed.

In addition, among cured patients, illicit drug use fell significantly, and there were few reinfections, reported the researchers, led by Andrew Talal, MD, MPH, with the University at Buffalo, State University of New York, Buffalo.

The study was published online in JAMA.

HCV is a major public health concern, especially among people with OUD. Geographic and logistical barriers often prevent this underserved population from accessing treatment; however, telemedicine has the potential to overcome these obstacles.

In a prospective cluster randomized clinical trial, Dr. Talal and colleagues assessed the impact of embedding facilitated telemedicine for HCV care into 12 opioid treatment programs in New York State.

They studied 602 HCV-infected adults (61% male; 51% White) with OUD. Of these, 290 (mean age, 47.1 years) were enrolled in facilitated telemedicine programs onsite, and 312 (mean age, 48.9 years) received an off-site referral (usual care).

Telemedicine participants had an initial telemedicine encounter facilitated by study case managers onsite who also administered a blood test. The telemedicine clinician subsequently evaluated participants and ordered direct-acting antiviral (DAA) medication that was delivered to the opioid treatment program monthly (as refills required) and dispensed along with methadone.

In the telemedicine group, 268 of 290 individuals (92.4%) initiated HCV treatment compared with 126 of 312 (40.4%) in the referral group.

Participants in the telemedicine group were also seen sooner and started treatment faster.

The interval between screening and initial appointments was 14 days with telemedicine vs 18 days with a referral (P = .04). The time between the initial visit and DAA initiation was 49.9 days with telemedicine vs 123.5 days with a referral (P < .001).

Intention-to-treat analysis showed significantly higher HCV cure rates with telemedicine than with referral (90.3% vs 39.4%, respectively). Similarly, the observed cure rates were also higher in the telemedicine group (84.8% vs 34.0%).

Sustained virologic response was durable, with only 13 reinfections (incidence, 2.5 per 100 person-years) occurring during the 2-year follow-up period, the researchers reported.

In addition, illicit drug use decreased significantly among cured patients in both the telemedicine group (P < .001) and the referral group (P = .001). Adults in both groups rated healthcare delivery satisfaction as high or very high.

“Our study demonstrates how telemedicine successfully integrates medical and behavioral treatment,” Dr. Talal said in a statement.

The intervention “builds patient-clinician trust across the screen, and significant decreases in substance use were observed in cured participants with minimal HCV reinfections,” the study team wrote.

Support for this research was provided by the Patient-Centered Outcomes Research Institute and by the Troup Fund of the Kaleida Health Foundation.

A version of this article appeared on Medscape.com .

People with opioid use disorder (OUD) who have hepatitis C virus (HCV) were twice as likely to be treated and cured of HCV if they received facilitated telemedicine treatment within their opioid treatment program than if they were referred for off-site treatment, the results of a new study showed.

In addition, among cured patients, illicit drug use fell significantly, and there were few reinfections, reported the researchers, led by Andrew Talal, MD, MPH, with the University at Buffalo, State University of New York, Buffalo.

The study was published online in JAMA.

HCV is a major public health concern, especially among people with OUD. Geographic and logistical barriers often prevent this underserved population from accessing treatment; however, telemedicine has the potential to overcome these obstacles.

In a prospective cluster randomized clinical trial, Dr. Talal and colleagues assessed the impact of embedding facilitated telemedicine for HCV care into 12 opioid treatment programs in New York State.

They studied 602 HCV-infected adults (61% male; 51% White) with OUD. Of these, 290 (mean age, 47.1 years) were enrolled in facilitated telemedicine programs onsite, and 312 (mean age, 48.9 years) received an off-site referral (usual care).

Telemedicine participants had an initial telemedicine encounter facilitated by study case managers onsite who also administered a blood test. The telemedicine clinician subsequently evaluated participants and ordered direct-acting antiviral (DAA) medication that was delivered to the opioid treatment program monthly (as refills required) and dispensed along with methadone.

In the telemedicine group, 268 of 290 individuals (92.4%) initiated HCV treatment compared with 126 of 312 (40.4%) in the referral group.

Participants in the telemedicine group were also seen sooner and started treatment faster.

The interval between screening and initial appointments was 14 days with telemedicine vs 18 days with a referral (P = .04). The time between the initial visit and DAA initiation was 49.9 days with telemedicine vs 123.5 days with a referral (P < .001).

Intention-to-treat analysis showed significantly higher HCV cure rates with telemedicine than with referral (90.3% vs 39.4%, respectively). Similarly, the observed cure rates were also higher in the telemedicine group (84.8% vs 34.0%).

Sustained virologic response was durable, with only 13 reinfections (incidence, 2.5 per 100 person-years) occurring during the 2-year follow-up period, the researchers reported.

In addition, illicit drug use decreased significantly among cured patients in both the telemedicine group (P < .001) and the referral group (P = .001). Adults in both groups rated healthcare delivery satisfaction as high or very high.

“Our study demonstrates how telemedicine successfully integrates medical and behavioral treatment,” Dr. Talal said in a statement.

The intervention “builds patient-clinician trust across the screen, and significant decreases in substance use were observed in cured participants with minimal HCV reinfections,” the study team wrote.

Support for this research was provided by the Patient-Centered Outcomes Research Institute and by the Troup Fund of the Kaleida Health Foundation.

A version of this article appeared on Medscape.com .

Adults with alcohol-related hospitalization who were discharged from the hospital with medication for alcohol use disorder (MAUD) were 51% less likely to be rehospitalized for an alcohol-related issue, new research suggested.

Despite the link to better outcomes, the analysis of 6500 Medicare Part D beneficiaries hospitalized for alcohol-related causes revealed that only 2% of patients were discharged with an MAUD prescription.

“Despite known efficacy, medication treatment for alcohol use disorder is underutilized and rarely initiated in the post-hospitalization setting,” lead author Eden Y. Bernstein, MD, a physician scientist in the Division of General Internal Medicine at Massachusetts General Hospital, Boston, said in a news release.

“Our findings highlight the potential clinical benefit associated with increased uptake of these medications in this setting and suggest a need to support and expand ongoing efforts to improve access to these medications upon hospital discharge,” Dr. Bernstein added.

The study was published online in JAMA Network Open.

MAUD prescribing or referral to addiction treatment at hospital discharge is widely recommended, investigators noted, making hospitalizations “important touch points” for alcohol use disorder (AUD) treatment engagement.

To study the association between discharge MAUD and 30-day rehospitalization, the researchers analyzed Medicare claims data from 2015 to 2017 in a retrospective study designed to emulate a randomized clinical trial of hospitalized patients with AUD.

The analysis included data on 6794 beneficiaries with 9834 hospitalizations for alcohol-related causes (median age, 54 years; 33% female; 72% White).

Researchers controlled for several covariates, including sociodemographic, clinical, and rehospitalization factors.
 

‘Sobering’ Findings

After propensity matching, discharge MAUD initiation was associated with a 42% decreased incidence of rehospitalization within 30 days of discharge (including emergency department visits and readmissions) or death within 30 days (incident rate ratio [IRR], 0.58; 95% CI, 0.45-0.76).

These findings remained consistent among secondary outcomes as well. Mortality was rare in both groups.

MAUD initiation at discharge was associated with a 51% decrease in incidence of alcohol-related return to the hospital (IRR, 0.49; 95% CI, 0.34-0.71).

Patients who received discharge MAUD were 22% more likely to have primary care or mental health follow-up visits (IRR, 1.22; 95% CI, 1.04-1.44).

Limitations noted by the authors include the observational study design and lack of information of nonpharmacologic treatment, such as 12-step facilitation or behavioral interventions.

In an accompanying editorial, Wid Yaseen, MD, of the Department of Medicine, University of Toronto, and coauthors noted that at present, most patients with AUD do not receive evidence-based treatment.

“An important first step might be reframing our mindset to consider AUD as a chronic disease,” they wrote. “We should also ask ourselves: Would we accept the status quo if only 2% of our patients with diabetes were prescribed evidence-based therapy?”

They added, “The insufficient use of MAUD is sobering and is also an enormous opportunity to do better for our patients.”

The study was funded by the Institutional National Research Service Award, Massachusetts General Hospital, the Agency for Healthcare Research and Quality, and the National Institute on Aging. Dr. Bernstein received personal fees from Alosa Health outside the submitted work, and Dr. Yaseen reported no relevant financial relationships. Full disclosures are included in the original articles.
 

A version of this article appeared on Medscape.com.

Adults with alcohol-related hospitalization who were discharged from the hospital with medication for alcohol use disorder (MAUD) were 51% less likely to be rehospitalized for an alcohol-related issue, new research suggested.

Despite the link to better outcomes, the analysis of 6500 Medicare Part D beneficiaries hospitalized for alcohol-related causes revealed that only 2% of patients were discharged with an MAUD prescription.

“Despite known efficacy, medication treatment for alcohol use disorder is underutilized and rarely initiated in the post-hospitalization setting,” lead author Eden Y. Bernstein, MD, a physician scientist in the Division of General Internal Medicine at Massachusetts General Hospital, Boston, said in a news release.

“Our findings highlight the potential clinical benefit associated with increased uptake of these medications in this setting and suggest a need to support and expand ongoing efforts to improve access to these medications upon hospital discharge,” Dr. Bernstein added.

The study was published online in JAMA Network Open.

MAUD prescribing or referral to addiction treatment at hospital discharge is widely recommended, investigators noted, making hospitalizations “important touch points” for alcohol use disorder (AUD) treatment engagement.

To study the association between discharge MAUD and 30-day rehospitalization, the researchers analyzed Medicare claims data from 2015 to 2017 in a retrospective study designed to emulate a randomized clinical trial of hospitalized patients with AUD.

The analysis included data on 6794 beneficiaries with 9834 hospitalizations for alcohol-related causes (median age, 54 years; 33% female; 72% White).

Researchers controlled for several covariates, including sociodemographic, clinical, and rehospitalization factors.
 

‘Sobering’ Findings

After propensity matching, discharge MAUD initiation was associated with a 42% decreased incidence of rehospitalization within 30 days of discharge (including emergency department visits and readmissions) or death within 30 days (incident rate ratio [IRR], 0.58; 95% CI, 0.45-0.76).

These findings remained consistent among secondary outcomes as well. Mortality was rare in both groups.

MAUD initiation at discharge was associated with a 51% decrease in incidence of alcohol-related return to the hospital (IRR, 0.49; 95% CI, 0.34-0.71).

Patients who received discharge MAUD were 22% more likely to have primary care or mental health follow-up visits (IRR, 1.22; 95% CI, 1.04-1.44).

Limitations noted by the authors include the observational study design and lack of information of nonpharmacologic treatment, such as 12-step facilitation or behavioral interventions.

In an accompanying editorial, Wid Yaseen, MD, of the Department of Medicine, University of Toronto, and coauthors noted that at present, most patients with AUD do not receive evidence-based treatment.

“An important first step might be reframing our mindset to consider AUD as a chronic disease,” they wrote. “We should also ask ourselves: Would we accept the status quo if only 2% of our patients with diabetes were prescribed evidence-based therapy?”

They added, “The insufficient use of MAUD is sobering and is also an enormous opportunity to do better for our patients.”

The study was funded by the Institutional National Research Service Award, Massachusetts General Hospital, the Agency for Healthcare Research and Quality, and the National Institute on Aging. Dr. Bernstein received personal fees from Alosa Health outside the submitted work, and Dr. Yaseen reported no relevant financial relationships. Full disclosures are included in the original articles.
 

A version of this article appeared on Medscape.com.

Adults with alcohol-related hospitalization who were discharged from the hospital with medication for alcohol use disorder (MAUD) were 51% less likely to be rehospitalized for an alcohol-related issue, new research suggested.

Despite the link to better outcomes, the analysis of 6500 Medicare Part D beneficiaries hospitalized for alcohol-related causes revealed that only 2% of patients were discharged with an MAUD prescription.

“Despite known efficacy, medication treatment for alcohol use disorder is underutilized and rarely initiated in the post-hospitalization setting,” lead author Eden Y. Bernstein, MD, a physician scientist in the Division of General Internal Medicine at Massachusetts General Hospital, Boston, said in a news release.

“Our findings highlight the potential clinical benefit associated with increased uptake of these medications in this setting and suggest a need to support and expand ongoing efforts to improve access to these medications upon hospital discharge,” Dr. Bernstein added.

The study was published online in JAMA Network Open.

MAUD prescribing or referral to addiction treatment at hospital discharge is widely recommended, investigators noted, making hospitalizations “important touch points” for alcohol use disorder (AUD) treatment engagement.

To study the association between discharge MAUD and 30-day rehospitalization, the researchers analyzed Medicare claims data from 2015 to 2017 in a retrospective study designed to emulate a randomized clinical trial of hospitalized patients with AUD.

The analysis included data on 6794 beneficiaries with 9834 hospitalizations for alcohol-related causes (median age, 54 years; 33% female; 72% White).

Researchers controlled for several covariates, including sociodemographic, clinical, and rehospitalization factors.
 

‘Sobering’ Findings

After propensity matching, discharge MAUD initiation was associated with a 42% decreased incidence of rehospitalization within 30 days of discharge (including emergency department visits and readmissions) or death within 30 days (incident rate ratio [IRR], 0.58; 95% CI, 0.45-0.76).

These findings remained consistent among secondary outcomes as well. Mortality was rare in both groups.

MAUD initiation at discharge was associated with a 51% decrease in incidence of alcohol-related return to the hospital (IRR, 0.49; 95% CI, 0.34-0.71).

Patients who received discharge MAUD were 22% more likely to have primary care or mental health follow-up visits (IRR, 1.22; 95% CI, 1.04-1.44).

Limitations noted by the authors include the observational study design and lack of information of nonpharmacologic treatment, such as 12-step facilitation or behavioral interventions.

In an accompanying editorial, Wid Yaseen, MD, of the Department of Medicine, University of Toronto, and coauthors noted that at present, most patients with AUD do not receive evidence-based treatment.

“An important first step might be reframing our mindset to consider AUD as a chronic disease,” they wrote. “We should also ask ourselves: Would we accept the status quo if only 2% of our patients with diabetes were prescribed evidence-based therapy?”

They added, “The insufficient use of MAUD is sobering and is also an enormous opportunity to do better for our patients.”

The study was funded by the Institutional National Research Service Award, Massachusetts General Hospital, the Agency for Healthcare Research and Quality, and the National Institute on Aging. Dr. Bernstein received personal fees from Alosa Health outside the submitted work, and Dr. Yaseen reported no relevant financial relationships. Full disclosures are included in the original articles.
 

A version of this article appeared on Medscape.com.

Combining D-limonene, a naturally occurring terpene in cannabis, with delta-9-tetrahydrocannabinol (THC), the primary psychoactive component in cannabis, may mitigate THC-induced anxiety, new data from a small study suggested.

Participants who inhaled vaporized D-limonene and THC reported significantly greater decreases in anxiogenic effects than did people who received either component alone or a placebo. Reductions were greater as the dose of the D-limonene was increased.

Investigators noted that the findings could have implications for the use of medicinal or recreational cannabis, which has increased in recent years due to state legalization efforts.

“People use cannabis to help reduce anxiety, depression, and posttraumatic stress disorder, but since THC levels vary widely, if a person overshoots their tolerance of THC, cannabis can induce anxiety rather than relieve it,” senior investigator Ryan Vandrey, PhD, professor of psychiatry and behavioral sciences, Johns Hopkins School of Medicine, Baltimore, said in a news release.

“Our study demonstrates that D-limonene can modulate the effects of THC in a meaningful way and make THC more tolerable to people using it for both therapeutic and non-therapeutic purposes,” he added.

The study was published online in Drug and Alcohol Dependence.
 

Entourage Theory

Cannabis legalization has opened the door to an increased range of medicinal and nonmedicinal uses, but its benefits can be limited by the anxiety and panic some people experience with its use, investigators noted.

Many cannabis plants have been bred to contain higher concentrations of THC, with some dispensaries selling cannabis with more than 20%-30% THC. The plants often include cannabidiol, “minor” cannabinoids, and terpenes, such as D-limonene.

Prior studies pointed to THC as the cause of acute behavioral and psychoactive effects some cannabis users experience. However, a new, untested theory, the “cannabis entourage effect theory,” suggested other components in cannabis, including D-limonene, may contribute to the anxiogenic symptoms.

“We were motivated by scientific publications that hypothesized D-limonene can attenuate the acute anxiogenic effects of cannabis, but for which empirical data did not exist,” Dr. Vandrey said.

Investigators designed a small double-blind, within-subjects crossover study of 20 healthy adults (median age, 26 years; 50% men). About half of participants were Caucasian/non-Hispanic, 30% African American/non-Hispanic, 10% Caucasian/Hispanic, and 10% Asian/non-Hispanic.

All participants completed nine outpatient drug administration sessions, during which they inhaled vaporized D-limonene alone (1 or 5 mg), THC alone (15 or 30 mg), the same doses of THC and D-limonene together, or placebo.

Primary outcomes included subjective drug effects, measured with the Drug Effect Questionnaire (DEQ) and the 20-item state subscale of the State-Trait Anxiety Inventory (STAI-S). Investigators also measured cognitive/psychomotor performance with the Digit Symbol Substitution Task (DSST) and the Paced Serial Addition Task.

Vital signs such as heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), and plasma D-limonene and THC concentrations were also tracked.

Participants’ responses were measured at baseline and then an additional nine times after initial exposure over the course of each 6-hour test session. Blood and urine samples were collected from participants before, during, and after each session.
 

First Evidence

There were no significant differences in outcomes between the D-limonene alone and placebo groups.

Receipt of 15- and 30-mg doses of THC alone was associated with subjective reports of acute cannabis exposure, including cognitive and physiological effects.

A treatment effect was observed for “anxious/nervous” (P < .01), “paranoid” (P < .01), and “heart racing” (P < .0001).

In planned comparisons, ratings of anxiety-like subjective effects qualitatively decreased as D-limonene dose increased, and concurrent administration of 30-mg THC plus 15-mg D-limonene significantly reduced ratings of “anxious/nervous” and “paranoid” on the DEQ compared to 30 mg of THC alone (P < .05).

Findings were similar on the composite score of the STAI-S, and although planned comparisons did not reach the threshold for statistical significance, reductions in anxiety approached significance in the THC plus D-limonene group compared with the THC alone condition (P = .08). The combination group also reported significantly lower subjective ratings of unpleasant drug effects than the THC alone group (P = .03).

In particular, a main effect of treatment was found for the anxious/nervous category on the DEQ (P < .01), as well as the “paranoid” (P < .01) and heart racing (P < .0001) categories.

On the other hand, ratings of anxious/nervous and paranoid categories were significantly lower in the 30-mg THC plus 15-mg D-limonene vs the 30-mg THC alone condition (P < .05, for all).

As for cognition, following drug administration, a significant main effect of treatment was observed for the DSST (P < .05), but no significant differences between THC and THC plus D-limonene combination conditions or between D-limonene alone and placebo were detected.

There were no differences within each THC dose and between D-limonene alone versus placebo conditions. Moreover, there were no main effects of treatment found for SBP or DBP.

The combination condition produced significantly greater concentrations of THC than the THC alone condition (P < .05).

“This study provides the first evidence that there are chemical constituents found naturally in the cannabis plant that can reduce some of the adverse effects of using delta-9-THC,” Dr. Vandrey said.

Although the exact mechanism by which vaporized D-limonene counters the anxiogenic effects of THC is unclear, “our best guess is that D-limonene is producing an anxiolytic effect on its own that is not mediated by cannabinoid receptors,” Dr. Vandrey said.
 

Significant Impact

Commenting on the research, Joshua Lile, PhD, professor, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, noted that the study seems to be the first of its kind to study the influence of terpene on THC response.

The research “makes a significant impact on our field,” and is “among the few controlled clinical studies that have demonstrated interactions between THC and other cannabis constituents, supporting the validity of the ‘entourage’ effect,” said Dr. Lile, who was not involved with the current research.

“This work is particularly important, given the unfounded claims sometimes made by the cannabis industry regarding the effects of different cannabis products,” he added.

Also commenting on the study, Ziva Cooper, PhD, professor and director of the UCLA Center for Cannabis and Cannabinoids, University of California Los Angeles, said the findings “have direct implications for improving the safety of cannabis, whether it’s being used for medical or nonmedical purposes, especially in people and patients who do not have experience with cannabis, a group that is at high risk for experiencing anxiety after using cannabis.”

In addition, “an important aspect to this study is that the effects of limonene in reducing anxiety attributed to delta-9-THC were observed at higher concentrations (or doses) than those usually present in the plant,” Dr. Copper said. “This calls for further investigation into new cannabis formulations specifically designed to leverage the potential protective effects of the terpene.”

This research was supported by the National Institute on Drug Abuse. Dr. Vandrey served as a consultant or received honoraria from Mira1a Therapeutics, Inc.; Jazz Pharmaceuticals; Charlotte’s Web; Syqe Medical Ltd.; and WebMD. The other authors’ disclosures are listed on the original paper. Dr. Lile declared no relevant financial relationships. Dr. Cooper reported receiving study drug from Canopy Growth Corp and True Terpenes, study-related materials from Storz & Bickel, and research support from the National Institute on Drug Abuse, National Center for Complementary and Integrative Health, California Department of Cannabis Control, Center for Medicinal Cannabis Research, and California Highway Patrol.
 

A version of this article appeared on Medscape.com.

Combining D-limonene, a naturally occurring terpene in cannabis, with delta-9-tetrahydrocannabinol (THC), the primary psychoactive component in cannabis, may mitigate THC-induced anxiety, new data from a small study suggested.

Participants who inhaled vaporized D-limonene and THC reported significantly greater decreases in anxiogenic effects than did people who received either component alone or a placebo. Reductions were greater as the dose of the D-limonene was increased.

Investigators noted that the findings could have implications for the use of medicinal or recreational cannabis, which has increased in recent years due to state legalization efforts.

“People use cannabis to help reduce anxiety, depression, and posttraumatic stress disorder, but since THC levels vary widely, if a person overshoots their tolerance of THC, cannabis can induce anxiety rather than relieve it,” senior investigator Ryan Vandrey, PhD, professor of psychiatry and behavioral sciences, Johns Hopkins School of Medicine, Baltimore, said in a news release.

“Our study demonstrates that D-limonene can modulate the effects of THC in a meaningful way and make THC more tolerable to people using it for both therapeutic and non-therapeutic purposes,” he added.

The study was published online in Drug and Alcohol Dependence.
 

Entourage Theory

Cannabis legalization has opened the door to an increased range of medicinal and nonmedicinal uses, but its benefits can be limited by the anxiety and panic some people experience with its use, investigators noted.

Many cannabis plants have been bred to contain higher concentrations of THC, with some dispensaries selling cannabis with more than 20%-30% THC. The plants often include cannabidiol, “minor” cannabinoids, and terpenes, such as D-limonene.

Prior studies pointed to THC as the cause of acute behavioral and psychoactive effects some cannabis users experience. However, a new, untested theory, the “cannabis entourage effect theory,” suggested other components in cannabis, including D-limonene, may contribute to the anxiogenic symptoms.

“We were motivated by scientific publications that hypothesized D-limonene can attenuate the acute anxiogenic effects of cannabis, but for which empirical data did not exist,” Dr. Vandrey said.

Investigators designed a small double-blind, within-subjects crossover study of 20 healthy adults (median age, 26 years; 50% men). About half of participants were Caucasian/non-Hispanic, 30% African American/non-Hispanic, 10% Caucasian/Hispanic, and 10% Asian/non-Hispanic.

All participants completed nine outpatient drug administration sessions, during which they inhaled vaporized D-limonene alone (1 or 5 mg), THC alone (15 or 30 mg), the same doses of THC and D-limonene together, or placebo.

Primary outcomes included subjective drug effects, measured with the Drug Effect Questionnaire (DEQ) and the 20-item state subscale of the State-Trait Anxiety Inventory (STAI-S). Investigators also measured cognitive/psychomotor performance with the Digit Symbol Substitution Task (DSST) and the Paced Serial Addition Task.

Vital signs such as heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), and plasma D-limonene and THC concentrations were also tracked.

Participants’ responses were measured at baseline and then an additional nine times after initial exposure over the course of each 6-hour test session. Blood and urine samples were collected from participants before, during, and after each session.
 

First Evidence

There were no significant differences in outcomes between the D-limonene alone and placebo groups.

Receipt of 15- and 30-mg doses of THC alone was associated with subjective reports of acute cannabis exposure, including cognitive and physiological effects.

A treatment effect was observed for “anxious/nervous” (P < .01), “paranoid” (P < .01), and “heart racing” (P < .0001).

In planned comparisons, ratings of anxiety-like subjective effects qualitatively decreased as D-limonene dose increased, and concurrent administration of 30-mg THC plus 15-mg D-limonene significantly reduced ratings of “anxious/nervous” and “paranoid” on the DEQ compared to 30 mg of THC alone (P < .05).

Findings were similar on the composite score of the STAI-S, and although planned comparisons did not reach the threshold for statistical significance, reductions in anxiety approached significance in the THC plus D-limonene group compared with the THC alone condition (P = .08). The combination group also reported significantly lower subjective ratings of unpleasant drug effects than the THC alone group (P = .03).

In particular, a main effect of treatment was found for the anxious/nervous category on the DEQ (P < .01), as well as the “paranoid” (P < .01) and heart racing (P < .0001) categories.

On the other hand, ratings of anxious/nervous and paranoid categories were significantly lower in the 30-mg THC plus 15-mg D-limonene vs the 30-mg THC alone condition (P < .05, for all).

As for cognition, following drug administration, a significant main effect of treatment was observed for the DSST (P < .05), but no significant differences between THC and THC plus D-limonene combination conditions or between D-limonene alone and placebo were detected.

There were no differences within each THC dose and between D-limonene alone versus placebo conditions. Moreover, there were no main effects of treatment found for SBP or DBP.

The combination condition produced significantly greater concentrations of THC than the THC alone condition (P < .05).

“This study provides the first evidence that there are chemical constituents found naturally in the cannabis plant that can reduce some of the adverse effects of using delta-9-THC,” Dr. Vandrey said.

Although the exact mechanism by which vaporized D-limonene counters the anxiogenic effects of THC is unclear, “our best guess is that D-limonene is producing an anxiolytic effect on its own that is not mediated by cannabinoid receptors,” Dr. Vandrey said.
 

Significant Impact

Commenting on the research, Joshua Lile, PhD, professor, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, noted that the study seems to be the first of its kind to study the influence of terpene on THC response.

The research “makes a significant impact on our field,” and is “among the few controlled clinical studies that have demonstrated interactions between THC and other cannabis constituents, supporting the validity of the ‘entourage’ effect,” said Dr. Lile, who was not involved with the current research.

“This work is particularly important, given the unfounded claims sometimes made by the cannabis industry regarding the effects of different cannabis products,” he added.

Also commenting on the study, Ziva Cooper, PhD, professor and director of the UCLA Center for Cannabis and Cannabinoids, University of California Los Angeles, said the findings “have direct implications for improving the safety of cannabis, whether it’s being used for medical or nonmedical purposes, especially in people and patients who do not have experience with cannabis, a group that is at high risk for experiencing anxiety after using cannabis.”

In addition, “an important aspect to this study is that the effects of limonene in reducing anxiety attributed to delta-9-THC were observed at higher concentrations (or doses) than those usually present in the plant,” Dr. Copper said. “This calls for further investigation into new cannabis formulations specifically designed to leverage the potential protective effects of the terpene.”

This research was supported by the National Institute on Drug Abuse. Dr. Vandrey served as a consultant or received honoraria from Mira1a Therapeutics, Inc.; Jazz Pharmaceuticals; Charlotte’s Web; Syqe Medical Ltd.; and WebMD. The other authors’ disclosures are listed on the original paper. Dr. Lile declared no relevant financial relationships. Dr. Cooper reported receiving study drug from Canopy Growth Corp and True Terpenes, study-related materials from Storz & Bickel, and research support from the National Institute on Drug Abuse, National Center for Complementary and Integrative Health, California Department of Cannabis Control, Center for Medicinal Cannabis Research, and California Highway Patrol.
 

A version of this article appeared on Medscape.com.

Combining D-limonene, a naturally occurring terpene in cannabis, with delta-9-tetrahydrocannabinol (THC), the primary psychoactive component in cannabis, may mitigate THC-induced anxiety, new data from a small study suggested.

Participants who inhaled vaporized D-limonene and THC reported significantly greater decreases in anxiogenic effects than did people who received either component alone or a placebo. Reductions were greater as the dose of the D-limonene was increased.

Investigators noted that the findings could have implications for the use of medicinal or recreational cannabis, which has increased in recent years due to state legalization efforts.

“People use cannabis to help reduce anxiety, depression, and posttraumatic stress disorder, but since THC levels vary widely, if a person overshoots their tolerance of THC, cannabis can induce anxiety rather than relieve it,” senior investigator Ryan Vandrey, PhD, professor of psychiatry and behavioral sciences, Johns Hopkins School of Medicine, Baltimore, said in a news release.

“Our study demonstrates that D-limonene can modulate the effects of THC in a meaningful way and make THC more tolerable to people using it for both therapeutic and non-therapeutic purposes,” he added.

The study was published online in Drug and Alcohol Dependence.
 

Entourage Theory

Cannabis legalization has opened the door to an increased range of medicinal and nonmedicinal uses, but its benefits can be limited by the anxiety and panic some people experience with its use, investigators noted.

Many cannabis plants have been bred to contain higher concentrations of THC, with some dispensaries selling cannabis with more than 20%-30% THC. The plants often include cannabidiol, “minor” cannabinoids, and terpenes, such as D-limonene.

Prior studies pointed to THC as the cause of acute behavioral and psychoactive effects some cannabis users experience. However, a new, untested theory, the “cannabis entourage effect theory,” suggested other components in cannabis, including D-limonene, may contribute to the anxiogenic symptoms.

“We were motivated by scientific publications that hypothesized D-limonene can attenuate the acute anxiogenic effects of cannabis, but for which empirical data did not exist,” Dr. Vandrey said.

Investigators designed a small double-blind, within-subjects crossover study of 20 healthy adults (median age, 26 years; 50% men). About half of participants were Caucasian/non-Hispanic, 30% African American/non-Hispanic, 10% Caucasian/Hispanic, and 10% Asian/non-Hispanic.

All participants completed nine outpatient drug administration sessions, during which they inhaled vaporized D-limonene alone (1 or 5 mg), THC alone (15 or 30 mg), the same doses of THC and D-limonene together, or placebo.

Primary outcomes included subjective drug effects, measured with the Drug Effect Questionnaire (DEQ) and the 20-item state subscale of the State-Trait Anxiety Inventory (STAI-S). Investigators also measured cognitive/psychomotor performance with the Digit Symbol Substitution Task (DSST) and the Paced Serial Addition Task.

Vital signs such as heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), and plasma D-limonene and THC concentrations were also tracked.

Participants’ responses were measured at baseline and then an additional nine times after initial exposure over the course of each 6-hour test session. Blood and urine samples were collected from participants before, during, and after each session.
 

First Evidence

There were no significant differences in outcomes between the D-limonene alone and placebo groups.

Receipt of 15- and 30-mg doses of THC alone was associated with subjective reports of acute cannabis exposure, including cognitive and physiological effects.

A treatment effect was observed for “anxious/nervous” (P < .01), “paranoid” (P < .01), and “heart racing” (P < .0001).

In planned comparisons, ratings of anxiety-like subjective effects qualitatively decreased as D-limonene dose increased, and concurrent administration of 30-mg THC plus 15-mg D-limonene significantly reduced ratings of “anxious/nervous” and “paranoid” on the DEQ compared to 30 mg of THC alone (P < .05).

Findings were similar on the composite score of the STAI-S, and although planned comparisons did not reach the threshold for statistical significance, reductions in anxiety approached significance in the THC plus D-limonene group compared with the THC alone condition (P = .08). The combination group also reported significantly lower subjective ratings of unpleasant drug effects than the THC alone group (P = .03).

In particular, a main effect of treatment was found for the anxious/nervous category on the DEQ (P < .01), as well as the “paranoid” (P < .01) and heart racing (P < .0001) categories.

On the other hand, ratings of anxious/nervous and paranoid categories were significantly lower in the 30-mg THC plus 15-mg D-limonene vs the 30-mg THC alone condition (P < .05, for all).

As for cognition, following drug administration, a significant main effect of treatment was observed for the DSST (P < .05), but no significant differences between THC and THC plus D-limonene combination conditions or between D-limonene alone and placebo were detected.

There were no differences within each THC dose and between D-limonene alone versus placebo conditions. Moreover, there were no main effects of treatment found for SBP or DBP.

The combination condition produced significantly greater concentrations of THC than the THC alone condition (P < .05).

“This study provides the first evidence that there are chemical constituents found naturally in the cannabis plant that can reduce some of the adverse effects of using delta-9-THC,” Dr. Vandrey said.

Although the exact mechanism by which vaporized D-limonene counters the anxiogenic effects of THC is unclear, “our best guess is that D-limonene is producing an anxiolytic effect on its own that is not mediated by cannabinoid receptors,” Dr. Vandrey said.
 

Significant Impact

Commenting on the research, Joshua Lile, PhD, professor, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, noted that the study seems to be the first of its kind to study the influence of terpene on THC response.

The research “makes a significant impact on our field,” and is “among the few controlled clinical studies that have demonstrated interactions between THC and other cannabis constituents, supporting the validity of the ‘entourage’ effect,” said Dr. Lile, who was not involved with the current research.

“This work is particularly important, given the unfounded claims sometimes made by the cannabis industry regarding the effects of different cannabis products,” he added.

Also commenting on the study, Ziva Cooper, PhD, professor and director of the UCLA Center for Cannabis and Cannabinoids, University of California Los Angeles, said the findings “have direct implications for improving the safety of cannabis, whether it’s being used for medical or nonmedical purposes, especially in people and patients who do not have experience with cannabis, a group that is at high risk for experiencing anxiety after using cannabis.”

In addition, “an important aspect to this study is that the effects of limonene in reducing anxiety attributed to delta-9-THC were observed at higher concentrations (or doses) than those usually present in the plant,” Dr. Copper said. “This calls for further investigation into new cannabis formulations specifically designed to leverage the potential protective effects of the terpene.”

This research was supported by the National Institute on Drug Abuse. Dr. Vandrey served as a consultant or received honoraria from Mira1a Therapeutics, Inc.; Jazz Pharmaceuticals; Charlotte’s Web; Syqe Medical Ltd.; and WebMD. The other authors’ disclosures are listed on the original paper. Dr. Lile declared no relevant financial relationships. Dr. Cooper reported receiving study drug from Canopy Growth Corp and True Terpenes, study-related materials from Storz & Bickel, and research support from the National Institute on Drug Abuse, National Center for Complementary and Integrative Health, California Department of Cannabis Control, Center for Medicinal Cannabis Research, and California Highway Patrol.
 

A version of this article appeared on Medscape.com.

Remote cognitive behavioral therapy (CBT) is just as effective as in-person CBT for a range of mental health and somatic disorders, a new review of more than 50 randomized clinical trials (RCTs) showed.

The RCTs included more than 5000 patients receiving CBT for conditions such as mood, anxiety, and body dysmorphic disorders, as well as chronic pain, insomnia, and alcohol use disorder.

“The World Health Organization has designated CBT as essential healthcare, but access remains an important barrier for many people in Canada. Our findings suggest that therapist-guided, remotely delivered CBT can be used to facilitate greater access to evidence-based care,” lead investigator Jason Busse, PhD, McMaster University, Hamilton, Ontario, Canada, said in a press release.

The findings were published online on March 18 in CMAJ.
 

Access Problematic

In Canada, CBT may be provided within existing government-funded healthcare services and by private providers such as registered psychotherapists, social worker, and psychologists who require out-of-pocket expenses.

Access to evidence-based mental healthcare such as CBT can be challenging in a country as geographically large, and as sparsely populated, as Canada. To increase access, some of the provinces have funded Internet-based CBT, but the efficacy of in-person vs remote CBT remains uncertain.

The investigators searched the medical literature for RCTs that enrolled adult patients randomized to receive either therapist-guided remote or in-person CBT.

The study included 52 RCTs with 5463 participants with a mean age of 43 years, and 3354 (61%) were female.

A total of 17 studies focused on the treatment of anxiety and related disorders, 14 on depression and mood disorders, seven on insomnia, six on chronic pain or fatigue syndromes, five on body image or eating disorders, three on tinnitus, and one on alcohol use disorder.

CBT was provided on an individual and group basis. Treatment duration ranged from 5 to 21 sessions, with the median follow-up of 180 days.

Investigators found little to no difference in effectiveness between in-person and therapist-guided remote CBT on primary outcomes (standardized mean difference [SMD], −0.02; 95% CI, −0.11 to 0.07).

Analysis using end scores also showed little to no difference in efficacy between in-person and remote CBT (SMD, −0.01; 95% CI, −0.11 to 0.08).
 

Policy Implications

The authors noted that remote CBT can potentially expand access to care as it is more convenient for patients and potentially more cost-effective.

“Our finding that remote CBT is an effective alternative to in-person delivery has potential policy implications,” they wrote.

The researchers recommended Canadian provinces and territories increase funding to boost access to therapist-guided remote CBT, thereby expanding access to evidence-based care.

Study limitations included the fact that most of the eligible RCTs reviewed in the analysis were conducted in high-income countries with middle-aged patients and followed them for a median 180 days, so generalizability of the findings to older patients living in lower-income patients or for longer follow-up periods was uncertain.

The study was partially funded by the Canadian Institutes of Health Research. Disclosures were noted in the original article.

A version of this article appeared on Medscape.com .

Remote cognitive behavioral therapy (CBT) is just as effective as in-person CBT for a range of mental health and somatic disorders, a new review of more than 50 randomized clinical trials (RCTs) showed.

The RCTs included more than 5000 patients receiving CBT for conditions such as mood, anxiety, and body dysmorphic disorders, as well as chronic pain, insomnia, and alcohol use disorder.

“The World Health Organization has designated CBT as essential healthcare, but access remains an important barrier for many people in Canada. Our findings suggest that therapist-guided, remotely delivered CBT can be used to facilitate greater access to evidence-based care,” lead investigator Jason Busse, PhD, McMaster University, Hamilton, Ontario, Canada, said in a press release.

The findings were published online on March 18 in CMAJ.
 

Access Problematic

In Canada, CBT may be provided within existing government-funded healthcare services and by private providers such as registered psychotherapists, social worker, and psychologists who require out-of-pocket expenses.

Access to evidence-based mental healthcare such as CBT can be challenging in a country as geographically large, and as sparsely populated, as Canada. To increase access, some of the provinces have funded Internet-based CBT, but the efficacy of in-person vs remote CBT remains uncertain.

The investigators searched the medical literature for RCTs that enrolled adult patients randomized to receive either therapist-guided remote or in-person CBT.

The study included 52 RCTs with 5463 participants with a mean age of 43 years, and 3354 (61%) were female.

A total of 17 studies focused on the treatment of anxiety and related disorders, 14 on depression and mood disorders, seven on insomnia, six on chronic pain or fatigue syndromes, five on body image or eating disorders, three on tinnitus, and one on alcohol use disorder.

CBT was provided on an individual and group basis. Treatment duration ranged from 5 to 21 sessions, with the median follow-up of 180 days.

Investigators found little to no difference in effectiveness between in-person and therapist-guided remote CBT on primary outcomes (standardized mean difference [SMD], −0.02; 95% CI, −0.11 to 0.07).

Analysis using end scores also showed little to no difference in efficacy between in-person and remote CBT (SMD, −0.01; 95% CI, −0.11 to 0.08).
 

Policy Implications

The authors noted that remote CBT can potentially expand access to care as it is more convenient for patients and potentially more cost-effective.

“Our finding that remote CBT is an effective alternative to in-person delivery has potential policy implications,” they wrote.

The researchers recommended Canadian provinces and territories increase funding to boost access to therapist-guided remote CBT, thereby expanding access to evidence-based care.

Study limitations included the fact that most of the eligible RCTs reviewed in the analysis were conducted in high-income countries with middle-aged patients and followed them for a median 180 days, so generalizability of the findings to older patients living in lower-income patients or for longer follow-up periods was uncertain.

The study was partially funded by the Canadian Institutes of Health Research. Disclosures were noted in the original article.

A version of this article appeared on Medscape.com .

Remote cognitive behavioral therapy (CBT) is just as effective as in-person CBT for a range of mental health and somatic disorders, a new review of more than 50 randomized clinical trials (RCTs) showed.

The RCTs included more than 5000 patients receiving CBT for conditions such as mood, anxiety, and body dysmorphic disorders, as well as chronic pain, insomnia, and alcohol use disorder.

“The World Health Organization has designated CBT as essential healthcare, but access remains an important barrier for many people in Canada. Our findings suggest that therapist-guided, remotely delivered CBT can be used to facilitate greater access to evidence-based care,” lead investigator Jason Busse, PhD, McMaster University, Hamilton, Ontario, Canada, said in a press release.

The findings were published online on March 18 in CMAJ.
 

Access Problematic

In Canada, CBT may be provided within existing government-funded healthcare services and by private providers such as registered psychotherapists, social worker, and psychologists who require out-of-pocket expenses.

Access to evidence-based mental healthcare such as CBT can be challenging in a country as geographically large, and as sparsely populated, as Canada. To increase access, some of the provinces have funded Internet-based CBT, but the efficacy of in-person vs remote CBT remains uncertain.

The investigators searched the medical literature for RCTs that enrolled adult patients randomized to receive either therapist-guided remote or in-person CBT.

The study included 52 RCTs with 5463 participants with a mean age of 43 years, and 3354 (61%) were female.

A total of 17 studies focused on the treatment of anxiety and related disorders, 14 on depression and mood disorders, seven on insomnia, six on chronic pain or fatigue syndromes, five on body image or eating disorders, three on tinnitus, and one on alcohol use disorder.

CBT was provided on an individual and group basis. Treatment duration ranged from 5 to 21 sessions, with the median follow-up of 180 days.

Investigators found little to no difference in effectiveness between in-person and therapist-guided remote CBT on primary outcomes (standardized mean difference [SMD], −0.02; 95% CI, −0.11 to 0.07).

Analysis using end scores also showed little to no difference in efficacy between in-person and remote CBT (SMD, −0.01; 95% CI, −0.11 to 0.08).
 

Policy Implications

The authors noted that remote CBT can potentially expand access to care as it is more convenient for patients and potentially more cost-effective.

“Our finding that remote CBT is an effective alternative to in-person delivery has potential policy implications,” they wrote.

The researchers recommended Canadian provinces and territories increase funding to boost access to therapist-guided remote CBT, thereby expanding access to evidence-based care.

Study limitations included the fact that most of the eligible RCTs reviewed in the analysis were conducted in high-income countries with middle-aged patients and followed them for a median 180 days, so generalizability of the findings to older patients living in lower-income patients or for longer follow-up periods was uncertain.

The study was partially funded by the Canadian Institutes of Health Research. Disclosures were noted in the original article.

A version of this article appeared on Medscape.com .

On a November morning in 2022, James Messenger opened wide and swallowed a capsule like no other.

Messenger was no stranger to taking pills.

He’d first experimented with prescription opioids as a teenager in Morgantown, West Virginia, battled addiction on-and-off since, and known more than 70 people who had fatally overdosed. So, when asked to test a new “smart pill” that could detect an overdose in progress and call for help, he didn’t hesitate to join the study.

“I’ve lost pretty much every good friend I’ve ever had to this,” said Mr. Messenger. “This pill could save a lot of lives.”

The new Vitals Monitoring capsule he tested is just one example in a growing effort to radically rethink what the humble pill is capable of.

As far back as 1965, scientists introduced the Heidelberg capsule, an electronic pill that measured acidity from within the gut. In 1994, the University of Buffalo coined the term “smart pill” with a device promising to ferry medicine to a precise spot in the intestine, “like the tiny ship in the film Fantastic Voyage.” And in 2001, the US Food and Drug Administration (FDA) approved the first video capsule endoscope, a miniature-camera-toting pill that enabled noninvasive imaging of the small intestine.

Despite these milestones, the smart pill revolution has been slow to catch on due to cost, technological limitations, and some resistance among clinicians and patients.

But now, nearly 300 iterations are in various stages of development, according to a 2022 analysis. Advances in materials, imaging, and artificial intelligence (AI) are helping address everything from sleep apnea to HIV/AIDS to gut disorders via real-time tracking and real-time help.

“These technologies could enable us to shift the paradigm from ‘Let’s wait until the patient comes to us and find out what happened’ to ‘Let’s see how things are changing in real time, intervene now, and personalize that intervention,’ ” said Peter Chai, MD, associate professor of emergency medicine and health technology researcher at Brigham and Women’s Hospital in Boston.
 

Tracking Vitals From the Inside Out

Already, overdose-reversal agents like naloxone are saving lives. But more than 60% of overdoses occur when no one is around to administer them.

“While we need to focus on treatment, we also need to come up with more acute ways to save individuals when treatment doesn’t work or relapse occurs,” said James J. Mahoney III, PhD, director of addictions research at the Rockefeller Neuroscience Institute at West Virginia University (WVU), Morgantown.

Enter Celero Systems, a Massachusetts-based digital health company that has developed a vitamin-sized capsule packed with tiny sensors, microprocessors, and a radio antenna. It can measure breathing, heart rate, and core temperature — all from deep within the gut.

Respiratory distress is a hallmark early sign of an overdose. But it can be hard to monitor from a distance, especially in populations without access to a charged smartwatch.

Dr. Mahoney imagines a day when patients at risk could be given a weekly pill like Celero’s. If their respiratory rate drops below a dangerous level, it could alert loved ones or, better yet, release an overdose-reversal drug.

“It’s early days,” stressed Dr. Mahoney, whose team has been conducting pilot tests of the pill. “But initial data look promising.”

For one study, published in the journal Device in November 2023, the research team administered an overdose of fentanyl to anesthetized pigs with the pill in their stomachs. The capsule was able to detect respiratory depression within a minute and alert researchers via their laptop in time to step in.

When they gave the pill to 10 volunteers undergoing sleep studies at WVU, they found it could detect respiration rate with an accuracy of 93% compared with external monitoring devices — a feature that could also help diagnose sleep apnea or chronic obstructive pulmonary disease without expensive, intrusive tests.

Accuracy for heart rate was nearly 97%.

In another yet-to-be published trial, Dr. Mahoney tested the device with 10 volunteers in a residential treatment center to determine how well it could be tolerated.

Among the participants was Mr. Messenger, who said the thought of being tracked didn’t bother him.

“It was simple — just like taking a multivitamin,” said Mr. Messenger, now 34, sober, and working as a peer recovery support specialist at a hospital in his hometown. “It could be a great way to keep people alive long enough for them to get their head wrapped around the idea of treatment.”
 

Boosting Medication Adherence

At Brigham and Women’s Hospital, Dr. Chai is experimenting with a different smart pill — one he believes could help curb the ongoing HIV/AIDS epidemic.

Developed by Florida-based etectRx, the ID-Cap consists of a gelatin capsule embedded with a tiny radiofrequency transmitter, similar to the kind in retail antitheft devices. The capsule can be filled with a variety of medications. When swallowed, stomach acid dissolves the gel and activates the transmitter, which sends a signal to a receiver on a smartwatch, smartphone, or wall-mounted reader to confirm the medication was taken. If it isn’t, the patient’s smartphone or smart speaker might nudge them with a reminder or a family member might be notified.

In recent trials of men at a high risk for HIV, the system improved adherence to the once-daily prevention regimen pre-exposure prophylaxis (PrEP) by double digits.

“PrEP is almost 99% effective in preventing HIV, but you have to take it,” said Dr. Chai, who led the trials. “That seems like such a simple thing, but anyone who is chronically on medication can tell you just how difficult it can be.”

The pill is not the first designed to improve adherence. In 2017, the FDA approved the first digital ingestion tracking system, Abilify MyCite, for the treatment of schizophrenia and bipolar disorder. But its maker, Proteus Digital Health, filed for bankruptcy in 2020 after struggling to recruit patients willing to be tracked. (Some expressed privacy concerns. Others disliked the uncomfortable patch that received and forwarded the signal.)

More recent designs have been streamlined to ditch the patch, said etectRx senior vice president of operations Chris Carnes, PhD. And the cost of making a pill this kind of “smart” has come down to about a dollar.

So far, said Dr. Chai, in the patients he’s worked with, perceived benefits generally outweigh privacy concerns.

Studies are now underway in patients with heart disease and tuberculosis, and the company hopes to move into the aging and memory care space where medication-adherence is a serious problem.

“For us, or any company in this space, to succeed, you have to have a strong business case,” said Dr. Carnes. “If family members can keep their loved ones at home a little longer at an additional cost of $30 a month, that’s a no-brainer.”
 

Pillcams 2.0

Twenty-three years ago, the first video capsule endoscopy made it possible to image the small intestine via a tiny camera you swallow.

Such “pillcams” offered a more patient-friendly way to diagnose small bowel disorders, such as gastrointestinal bleeding and Crohn’s disease. Rather than undergoing sedation or anesthesia, as required during tube-based endoscopy, patients can go about their day as the pill painlessly passes through their gastrointestinal (GI) tract, capturing and recording data and images.

But the pills have their downsides.

Because they move passively, driven by movement in the intestine, they can miss trouble spots. Their ability to image the esophagus, stomach, and colon has proven limited. And unlike other procedures, like colonoscopy, they can’t intervene with therapy, like removing polyps.

The pillcam “had so much promise, to sort of revolutionize endoscopy, but it never really got the adoption that it seemed like it might,” said Andrew Meltzer, MD, professor of emergency medicine at the GW School of Medicine and Health Sciences in Washington.

That could soon change, he said, thanks to advances in locomotion and AI.

In a recent study of 40 patients, Dr. Meltzer tested a new magnetically controlled capsule endoscopy. Standing at a patient’s side, he could use a joystick to steer the pill around the stomach, capturing images in real time.

The pilot study, published in June 2023, found that the pill clearly identified six key stomach landmarks accurately 95% of the time and didn’t miss any lesions caught with traditional endoscopy. Notably, 80% of the patients preferred the pillcam over the tube.

“They are awake. They can go to work as soon as they leave. And it’s easy for them to tolerate,” Dr. Meltzer said.

More research is necessary, but Dr. Meltzer believes the technology could be particularly useful in the emergency department, allowing doctors to rule out high-risk bleeds in the stomach on the spot without admitting patients unnecessarily or making them return for a traditional scope.

“It has the potential to increase screening and provide more cost-effective care in emergencies,” he said.

It could also be useful in the telemedicine space, allowing a doctor to “drive” the pill from afar to diagnose a distant patient.

Someday, AI could enable the capsule to drive itself, so a doctor could merely press a button and wait. Or it could be adapted to treat what it finds, like administering a drug or cauterizing a bleed.

“If we can come up with a Mars rover which can explore other planets, we should be able to have something that can explore the stomach remotely,” Dr. Meltzer said.
 

Swallowing the Future

At the California Institute of Technology, researchers have developed a “location-aware” smart pill that uses magnetic fields to help pinpoint its location in the twists and turns of intestines. This could be useful for monitoring food in the GI tract to determine why things aren’t moving.

Other researchers are using AI models to enhance the transmission of video from inside the body and reduce the time it takes to interpret images.

One group at the Massachusetts Institute of Technology has developed a vibrating weight loss capsule designed to stimulate receptors in the gut to signal the brain that the person is full.

Not everyone is a fan of the smart-pill revolution. Some critics have raised concerns about privacy. Others fear that doctors risk yielding too much power to technology. Even those who are excited about the pills’ possibilities temper their optimism with caution.

None of these smart pills have gone mainstream yet in clinical practice, said Vivek Kaul, MD, professor of medicine at the University of Rochester Medical Center, Rochester, New York, and secretary general of the World Gastroenterology Organization.

Clinical validation, accessibility, and insurance coverage “will be critical in shaping their role,” he said. “But overall, it would be fair to state that this technology has come of age and the future is bright.”
 

A version of this article appeared on Medscape.com.

On a November morning in 2022, James Messenger opened wide and swallowed a capsule like no other.

Messenger was no stranger to taking pills.

He’d first experimented with prescription opioids as a teenager in Morgantown, West Virginia, battled addiction on-and-off since, and known more than 70 people who had fatally overdosed. So, when asked to test a new “smart pill” that could detect an overdose in progress and call for help, he didn’t hesitate to join the study.

“I’ve lost pretty much every good friend I’ve ever had to this,” said Mr. Messenger. “This pill could save a lot of lives.”

The new Vitals Monitoring capsule he tested is just one example in a growing effort to radically rethink what the humble pill is capable of.

As far back as 1965, scientists introduced the Heidelberg capsule, an electronic pill that measured acidity from within the gut. In 1994, the University of Buffalo coined the term “smart pill” with a device promising to ferry medicine to a precise spot in the intestine, “like the tiny ship in the film Fantastic Voyage.” And in 2001, the US Food and Drug Administration (FDA) approved the first video capsule endoscope, a miniature-camera-toting pill that enabled noninvasive imaging of the small intestine.

Despite these milestones, the smart pill revolution has been slow to catch on due to cost, technological limitations, and some resistance among clinicians and patients.

But now, nearly 300 iterations are in various stages of development, according to a 2022 analysis. Advances in materials, imaging, and artificial intelligence (AI) are helping address everything from sleep apnea to HIV/AIDS to gut disorders via real-time tracking and real-time help.

“These technologies could enable us to shift the paradigm from ‘Let’s wait until the patient comes to us and find out what happened’ to ‘Let’s see how things are changing in real time, intervene now, and personalize that intervention,’ ” said Peter Chai, MD, associate professor of emergency medicine and health technology researcher at Brigham and Women’s Hospital in Boston.
 

Tracking Vitals From the Inside Out

Already, overdose-reversal agents like naloxone are saving lives. But more than 60% of overdoses occur when no one is around to administer them.

“While we need to focus on treatment, we also need to come up with more acute ways to save individuals when treatment doesn’t work or relapse occurs,” said James J. Mahoney III, PhD, director of addictions research at the Rockefeller Neuroscience Institute at West Virginia University (WVU), Morgantown.

Enter Celero Systems, a Massachusetts-based digital health company that has developed a vitamin-sized capsule packed with tiny sensors, microprocessors, and a radio antenna. It can measure breathing, heart rate, and core temperature — all from deep within the gut.

Respiratory distress is a hallmark early sign of an overdose. But it can be hard to monitor from a distance, especially in populations without access to a charged smartwatch.

Dr. Mahoney imagines a day when patients at risk could be given a weekly pill like Celero’s. If their respiratory rate drops below a dangerous level, it could alert loved ones or, better yet, release an overdose-reversal drug.

“It’s early days,” stressed Dr. Mahoney, whose team has been conducting pilot tests of the pill. “But initial data look promising.”

For one study, published in the journal Device in November 2023, the research team administered an overdose of fentanyl to anesthetized pigs with the pill in their stomachs. The capsule was able to detect respiratory depression within a minute and alert researchers via their laptop in time to step in.

When they gave the pill to 10 volunteers undergoing sleep studies at WVU, they found it could detect respiration rate with an accuracy of 93% compared with external monitoring devices — a feature that could also help diagnose sleep apnea or chronic obstructive pulmonary disease without expensive, intrusive tests.

Accuracy for heart rate was nearly 97%.

In another yet-to-be published trial, Dr. Mahoney tested the device with 10 volunteers in a residential treatment center to determine how well it could be tolerated.

Among the participants was Mr. Messenger, who said the thought of being tracked didn’t bother him.

“It was simple — just like taking a multivitamin,” said Mr. Messenger, now 34, sober, and working as a peer recovery support specialist at a hospital in his hometown. “It could be a great way to keep people alive long enough for them to get their head wrapped around the idea of treatment.”
 

Boosting Medication Adherence

At Brigham and Women’s Hospital, Dr. Chai is experimenting with a different smart pill — one he believes could help curb the ongoing HIV/AIDS epidemic.

Developed by Florida-based etectRx, the ID-Cap consists of a gelatin capsule embedded with a tiny radiofrequency transmitter, similar to the kind in retail antitheft devices. The capsule can be filled with a variety of medications. When swallowed, stomach acid dissolves the gel and activates the transmitter, which sends a signal to a receiver on a smartwatch, smartphone, or wall-mounted reader to confirm the medication was taken. If it isn’t, the patient’s smartphone or smart speaker might nudge them with a reminder or a family member might be notified.

In recent trials of men at a high risk for HIV, the system improved adherence to the once-daily prevention regimen pre-exposure prophylaxis (PrEP) by double digits.

“PrEP is almost 99% effective in preventing HIV, but you have to take it,” said Dr. Chai, who led the trials. “That seems like such a simple thing, but anyone who is chronically on medication can tell you just how difficult it can be.”

The pill is not the first designed to improve adherence. In 2017, the FDA approved the first digital ingestion tracking system, Abilify MyCite, for the treatment of schizophrenia and bipolar disorder. But its maker, Proteus Digital Health, filed for bankruptcy in 2020 after struggling to recruit patients willing to be tracked. (Some expressed privacy concerns. Others disliked the uncomfortable patch that received and forwarded the signal.)

More recent designs have been streamlined to ditch the patch, said etectRx senior vice president of operations Chris Carnes, PhD. And the cost of making a pill this kind of “smart” has come down to about a dollar.

So far, said Dr. Chai, in the patients he’s worked with, perceived benefits generally outweigh privacy concerns.

Studies are now underway in patients with heart disease and tuberculosis, and the company hopes to move into the aging and memory care space where medication-adherence is a serious problem.

“For us, or any company in this space, to succeed, you have to have a strong business case,” said Dr. Carnes. “If family members can keep their loved ones at home a little longer at an additional cost of $30 a month, that’s a no-brainer.”
 

Pillcams 2.0

Twenty-three years ago, the first video capsule endoscopy made it possible to image the small intestine via a tiny camera you swallow.

Such “pillcams” offered a more patient-friendly way to diagnose small bowel disorders, such as gastrointestinal bleeding and Crohn’s disease. Rather than undergoing sedation or anesthesia, as required during tube-based endoscopy, patients can go about their day as the pill painlessly passes through their gastrointestinal (GI) tract, capturing and recording data and images.

But the pills have their downsides.

Because they move passively, driven by movement in the intestine, they can miss trouble spots. Their ability to image the esophagus, stomach, and colon has proven limited. And unlike other procedures, like colonoscopy, they can’t intervene with therapy, like removing polyps.

The pillcam “had so much promise, to sort of revolutionize endoscopy, but it never really got the adoption that it seemed like it might,” said Andrew Meltzer, MD, professor of emergency medicine at the GW School of Medicine and Health Sciences in Washington.

That could soon change, he said, thanks to advances in locomotion and AI.

In a recent study of 40 patients, Dr. Meltzer tested a new magnetically controlled capsule endoscopy. Standing at a patient’s side, he could use a joystick to steer the pill around the stomach, capturing images in real time.

The pilot study, published in June 2023, found that the pill clearly identified six key stomach landmarks accurately 95% of the time and didn’t miss any lesions caught with traditional endoscopy. Notably, 80% of the patients preferred the pillcam over the tube.

“They are awake. They can go to work as soon as they leave. And it’s easy for them to tolerate,” Dr. Meltzer said.

More research is necessary, but Dr. Meltzer believes the technology could be particularly useful in the emergency department, allowing doctors to rule out high-risk bleeds in the stomach on the spot without admitting patients unnecessarily or making them return for a traditional scope.

“It has the potential to increase screening and provide more cost-effective care in emergencies,” he said.

It could also be useful in the telemedicine space, allowing a doctor to “drive” the pill from afar to diagnose a distant patient.

Someday, AI could enable the capsule to drive itself, so a doctor could merely press a button and wait. Or it could be adapted to treat what it finds, like administering a drug or cauterizing a bleed.

“If we can come up with a Mars rover which can explore other planets, we should be able to have something that can explore the stomach remotely,” Dr. Meltzer said.
 

Swallowing the Future

At the California Institute of Technology, researchers have developed a “location-aware” smart pill that uses magnetic fields to help pinpoint its location in the twists and turns of intestines. This could be useful for monitoring food in the GI tract to determine why things aren’t moving.

Other researchers are using AI models to enhance the transmission of video from inside the body and reduce the time it takes to interpret images.

One group at the Massachusetts Institute of Technology has developed a vibrating weight loss capsule designed to stimulate receptors in the gut to signal the brain that the person is full.

Not everyone is a fan of the smart-pill revolution. Some critics have raised concerns about privacy. Others fear that doctors risk yielding too much power to technology. Even those who are excited about the pills’ possibilities temper their optimism with caution.

None of these smart pills have gone mainstream yet in clinical practice, said Vivek Kaul, MD, professor of medicine at the University of Rochester Medical Center, Rochester, New York, and secretary general of the World Gastroenterology Organization.

Clinical validation, accessibility, and insurance coverage “will be critical in shaping their role,” he said. “But overall, it would be fair to state that this technology has come of age and the future is bright.”
 

A version of this article appeared on Medscape.com.

On a November morning in 2022, James Messenger opened wide and swallowed a capsule like no other.

Messenger was no stranger to taking pills.

He’d first experimented with prescription opioids as a teenager in Morgantown, West Virginia, battled addiction on-and-off since, and known more than 70 people who had fatally overdosed. So, when asked to test a new “smart pill” that could detect an overdose in progress and call for help, he didn’t hesitate to join the study.

“I’ve lost pretty much every good friend I’ve ever had to this,” said Mr. Messenger. “This pill could save a lot of lives.”

The new Vitals Monitoring capsule he tested is just one example in a growing effort to radically rethink what the humble pill is capable of.

As far back as 1965, scientists introduced the Heidelberg capsule, an electronic pill that measured acidity from within the gut. In 1994, the University of Buffalo coined the term “smart pill” with a device promising to ferry medicine to a precise spot in the intestine, “like the tiny ship in the film Fantastic Voyage.” And in 2001, the US Food and Drug Administration (FDA) approved the first video capsule endoscope, a miniature-camera-toting pill that enabled noninvasive imaging of the small intestine.

Despite these milestones, the smart pill revolution has been slow to catch on due to cost, technological limitations, and some resistance among clinicians and patients.

But now, nearly 300 iterations are in various stages of development, according to a 2022 analysis. Advances in materials, imaging, and artificial intelligence (AI) are helping address everything from sleep apnea to HIV/AIDS to gut disorders via real-time tracking and real-time help.

“These technologies could enable us to shift the paradigm from ‘Let’s wait until the patient comes to us and find out what happened’ to ‘Let’s see how things are changing in real time, intervene now, and personalize that intervention,’ ” said Peter Chai, MD, associate professor of emergency medicine and health technology researcher at Brigham and Women’s Hospital in Boston.
 

Tracking Vitals From the Inside Out

Already, overdose-reversal agents like naloxone are saving lives. But more than 60% of overdoses occur when no one is around to administer them.

“While we need to focus on treatment, we also need to come up with more acute ways to save individuals when treatment doesn’t work or relapse occurs,” said James J. Mahoney III, PhD, director of addictions research at the Rockefeller Neuroscience Institute at West Virginia University (WVU), Morgantown.

Enter Celero Systems, a Massachusetts-based digital health company that has developed a vitamin-sized capsule packed with tiny sensors, microprocessors, and a radio antenna. It can measure breathing, heart rate, and core temperature — all from deep within the gut.

Respiratory distress is a hallmark early sign of an overdose. But it can be hard to monitor from a distance, especially in populations without access to a charged smartwatch.

Dr. Mahoney imagines a day when patients at risk could be given a weekly pill like Celero’s. If their respiratory rate drops below a dangerous level, it could alert loved ones or, better yet, release an overdose-reversal drug.

“It’s early days,” stressed Dr. Mahoney, whose team has been conducting pilot tests of the pill. “But initial data look promising.”

For one study, published in the journal Device in November 2023, the research team administered an overdose of fentanyl to anesthetized pigs with the pill in their stomachs. The capsule was able to detect respiratory depression within a minute and alert researchers via their laptop in time to step in.

When they gave the pill to 10 volunteers undergoing sleep studies at WVU, they found it could detect respiration rate with an accuracy of 93% compared with external monitoring devices — a feature that could also help diagnose sleep apnea or chronic obstructive pulmonary disease without expensive, intrusive tests.

Accuracy for heart rate was nearly 97%.

In another yet-to-be published trial, Dr. Mahoney tested the device with 10 volunteers in a residential treatment center to determine how well it could be tolerated.

Among the participants was Mr. Messenger, who said the thought of being tracked didn’t bother him.

“It was simple — just like taking a multivitamin,” said Mr. Messenger, now 34, sober, and working as a peer recovery support specialist at a hospital in his hometown. “It could be a great way to keep people alive long enough for them to get their head wrapped around the idea of treatment.”
 

Boosting Medication Adherence

At Brigham and Women’s Hospital, Dr. Chai is experimenting with a different smart pill — one he believes could help curb the ongoing HIV/AIDS epidemic.

Developed by Florida-based etectRx, the ID-Cap consists of a gelatin capsule embedded with a tiny radiofrequency transmitter, similar to the kind in retail antitheft devices. The capsule can be filled with a variety of medications. When swallowed, stomach acid dissolves the gel and activates the transmitter, which sends a signal to a receiver on a smartwatch, smartphone, or wall-mounted reader to confirm the medication was taken. If it isn’t, the patient’s smartphone or smart speaker might nudge them with a reminder or a family member might be notified.

In recent trials of men at a high risk for HIV, the system improved adherence to the once-daily prevention regimen pre-exposure prophylaxis (PrEP) by double digits.

“PrEP is almost 99% effective in preventing HIV, but you have to take it,” said Dr. Chai, who led the trials. “That seems like such a simple thing, but anyone who is chronically on medication can tell you just how difficult it can be.”

The pill is not the first designed to improve adherence. In 2017, the FDA approved the first digital ingestion tracking system, Abilify MyCite, for the treatment of schizophrenia and bipolar disorder. But its maker, Proteus Digital Health, filed for bankruptcy in 2020 after struggling to recruit patients willing to be tracked. (Some expressed privacy concerns. Others disliked the uncomfortable patch that received and forwarded the signal.)

More recent designs have been streamlined to ditch the patch, said etectRx senior vice president of operations Chris Carnes, PhD. And the cost of making a pill this kind of “smart” has come down to about a dollar.

So far, said Dr. Chai, in the patients he’s worked with, perceived benefits generally outweigh privacy concerns.

Studies are now underway in patients with heart disease and tuberculosis, and the company hopes to move into the aging and memory care space where medication-adherence is a serious problem.

“For us, or any company in this space, to succeed, you have to have a strong business case,” said Dr. Carnes. “If family members can keep their loved ones at home a little longer at an additional cost of $30 a month, that’s a no-brainer.”
 

Pillcams 2.0

Twenty-three years ago, the first video capsule endoscopy made it possible to image the small intestine via a tiny camera you swallow.

Such “pillcams” offered a more patient-friendly way to diagnose small bowel disorders, such as gastrointestinal bleeding and Crohn’s disease. Rather than undergoing sedation or anesthesia, as required during tube-based endoscopy, patients can go about their day as the pill painlessly passes through their gastrointestinal (GI) tract, capturing and recording data and images.

But the pills have their downsides.

Because they move passively, driven by movement in the intestine, they can miss trouble spots. Their ability to image the esophagus, stomach, and colon has proven limited. And unlike other procedures, like colonoscopy, they can’t intervene with therapy, like removing polyps.

The pillcam “had so much promise, to sort of revolutionize endoscopy, but it never really got the adoption that it seemed like it might,” said Andrew Meltzer, MD, professor of emergency medicine at the GW School of Medicine and Health Sciences in Washington.

That could soon change, he said, thanks to advances in locomotion and AI.

In a recent study of 40 patients, Dr. Meltzer tested a new magnetically controlled capsule endoscopy. Standing at a patient’s side, he could use a joystick to steer the pill around the stomach, capturing images in real time.

The pilot study, published in June 2023, found that the pill clearly identified six key stomach landmarks accurately 95% of the time and didn’t miss any lesions caught with traditional endoscopy. Notably, 80% of the patients preferred the pillcam over the tube.

“They are awake. They can go to work as soon as they leave. And it’s easy for them to tolerate,” Dr. Meltzer said.

More research is necessary, but Dr. Meltzer believes the technology could be particularly useful in the emergency department, allowing doctors to rule out high-risk bleeds in the stomach on the spot without admitting patients unnecessarily or making them return for a traditional scope.

“It has the potential to increase screening and provide more cost-effective care in emergencies,” he said.

It could also be useful in the telemedicine space, allowing a doctor to “drive” the pill from afar to diagnose a distant patient.

Someday, AI could enable the capsule to drive itself, so a doctor could merely press a button and wait. Or it could be adapted to treat what it finds, like administering a drug or cauterizing a bleed.

“If we can come up with a Mars rover which can explore other planets, we should be able to have something that can explore the stomach remotely,” Dr. Meltzer said.
 

Swallowing the Future

At the California Institute of Technology, researchers have developed a “location-aware” smart pill that uses magnetic fields to help pinpoint its location in the twists and turns of intestines. This could be useful for monitoring food in the GI tract to determine why things aren’t moving.

Other researchers are using AI models to enhance the transmission of video from inside the body and reduce the time it takes to interpret images.

One group at the Massachusetts Institute of Technology has developed a vibrating weight loss capsule designed to stimulate receptors in the gut to signal the brain that the person is full.

Not everyone is a fan of the smart-pill revolution. Some critics have raised concerns about privacy. Others fear that doctors risk yielding too much power to technology. Even those who are excited about the pills’ possibilities temper their optimism with caution.

None of these smart pills have gone mainstream yet in clinical practice, said Vivek Kaul, MD, professor of medicine at the University of Rochester Medical Center, Rochester, New York, and secretary general of the World Gastroenterology Organization.

Clinical validation, accessibility, and insurance coverage “will be critical in shaping their role,” he said. “But overall, it would be fair to state that this technology has come of age and the future is bright.”
 

A version of this article appeared on Medscape.com.

Cancer patients with behavioral health disorders are significantly less likely to undergo surgical resections, and more likely to experience poor outcomes when they do have surgery, based on data from a new study of nearly 700,000 individuals.

The reason for this association remains unclear, and highlights the need to address existing behavioral health disorders (BHDs), which can be exacerbated after a patient is diagnosed with cancer, wrote Timothy M. Pawlik, MD, of The Ohio State University, Columbus, and colleagues. A cancer diagnosis can cause not only physical stress, but mental, emotional, social, and economic stress that can prompt a new BHD, cause relapse of a previous BHD, or exacerbate a current BHD, the researchers noted.
 

What is Known About BHDs and Cancer?

Although previous studies have shown a possible association between BHDs and increased cancer risk, as well as reduced compliance with care, the effect of BHDs on outcomes in cancer patients undergoing surgical resection has not been examined, wrote Dr. Pawlik and colleagues.

Previous research has focused on the impact of having a preexisting serious mental illness (SMI) such as schizophrenia and bipolar disorder on cancer care.

A 2023 literature review of 27 studies published in the Journal of Medical Imaging and Radiation Sciences showed that patients with preexisting severe mental illness (such as schizophrenia or bipolar disorder) had greater cancer-related mortality. In that study, the researchers also found that patients with severe mental illness were more likely to have metastatic disease at diagnosis, but less likely to receive optimal treatments, than individuals without SMIs.

Many studies also have focused on patients developing mental health problems (including BHDs) after a cancer diagnosis, but the current study is the first known to examine outcomes in those with BHDs before cancer. 
 

Why Was It Important to Conduct This Study?

“BHDs are a diverse set of mental illnesses that affect an individual’s psychosocial wellbeing, potentially resulting in maladaptive behaviors,” Dr. Pawlik said in an interview. BHDs, which include substance abuse, eating disorders, and sleep disorders, are less common than anxiety/depression, but have an estimated prevalence of 1.3%-3.1% among adults in the United States, he said.

What Does the New Study Add?

In the new review by Dr. Pawlik and colleagues, published in the Journal of the American College of Surgeons (Katayama ES. J Am Coll Surg. 2024 Feb 29. doi: 2024. 10.1097/XCS.0000000000000954), BHDs were defined as substance abuse, eating disorders, or sleep disorders, which had not been the focus of previous studies. The researchers reviewed data from 694,836 adult patients with lung, esophageal, gastric, liver, pancreatic, or colorectal cancer between 2018-2021 using the Medicare Standard Analytic files. A total of 46,719 patients (6.7%) had at least one BHD.

Overall, patients with a BHD were significantly less likely than those without a BHD to undergo surgical resection (20.3% vs. 23.4%). Patients with a BHD also had significantly worse long-term postoperative survival than those without BHDs (median 37.1 months vs. 46.6 months) and significantly higher in-hospital costs ($17,432 vs. 16,159, P less than .001 for all).

Among patients who underwent cancer surgery, the odds of any complication were significantly higher for those with a BHD compared to those with no BHD (odds ratio 1.32), as were the odds of a prolonged length of stay (OR 1.67) and 90-day readmission (OR 1.57).

Dr. Pawlik said he was surprised by several of the findings, including that 1 in 15 Medicare beneficiaries had a BHD diagnosis, “with male sex and minority racial status, as well as higher social vulnerability, being associated with a higher prevalence of BHD.”

Also, the independent association of having a BHD with 30%-50% higher odds of a complication, prolonged length of stay, and 90-day readmission was higher than Dr. Pawlik had anticipated.
 

Why Do Patients With BHDs Have Fewer Surgeries and Worse Outcomes?

The reasons for this association were likely multifactorial and may reflect the greater burden of medical comorbidity and chronic illness in many patients with BHDs because of maladaptive lifestyles or poor nutrition status, Dr. Pawlik said.

“Patients with BHDs also likely face barriers to accessing care, which was noted particularly among patients with BHDs who lived in socially vulnerable areas,” he said. BHD patients also were more likely to be treated at low-volume rather than high-volume hospitals, “which undoubtedly contributed in part to worse outcomes in this cohort of patients,” he added.
 

What Can Oncologists Do to Help?

The take-home message for clinicians is that BHDs are linked to worse surgical outcomes and higher health care costs in cancer patients, Dr. Pawlik said in an interview.

“Enhanced accessibility to behavioral healthcare, as well as comprehensive policy reform related to mental health services are needed to improve care of patients with BHDs,” he said. “For example, implementing psychiatry compensation programs may encourage practice in vulnerable areas,” he said.

Other strategies include a following a collaborative care model involving mental health professionals working in tandem with primary care and mid-level practitioners and increasing use and establishment of telehealth systems to improve patient access to BHD services, he said.
 

What Are the Limitations?

The study by Dr. Pawlik and colleagues was limited by several factors, including the lack of data on younger patients and the full range of BHDs, as well as underreporting of BHDs and the high copays for mental health care, the researchers noted. However, the results suggest that concomitant BHDs are associated with worse cancer outcomes and higher in-hospital costs, and illustrate the need to screen for and target these conditions in cancer patients, the researchers concluded.

What Are the Next Steps for Research?

The current study involved Medicare beneficiaries aged 65 years or older, and more research is needed to investigate the impact of BHDs among younger cancer patients in whom the prevalence may be higher and the impact of BHDs may be different, Dr. Pawlik said in an interview. In addition, the analysis of BHDs as a composite of substance abuse, eating disorders, and sleep disorders (because the numbers were too small to break out data for each disorder, separately) prevented investigation of potential differences and unique challenges faced by distinct subpopulations of BHD patients, he said.

“Future studies should examine the individual impact of substance abuse, eating disorders, and sleep disorders on access to surgery, as well as the potential different impact that each one of these different BHDs may have on postoperative outcomes,” Dr. Pawlik suggested.

The study was supported by The Ohio State University College of Medicine Roessler Summer Research Scholarship. The researchers had no financial conflicts to disclose.

Cancer patients with behavioral health disorders are significantly less likely to undergo surgical resections, and more likely to experience poor outcomes when they do have surgery, based on data from a new study of nearly 700,000 individuals.

The reason for this association remains unclear, and highlights the need to address existing behavioral health disorders (BHDs), which can be exacerbated after a patient is diagnosed with cancer, wrote Timothy M. Pawlik, MD, of The Ohio State University, Columbus, and colleagues. A cancer diagnosis can cause not only physical stress, but mental, emotional, social, and economic stress that can prompt a new BHD, cause relapse of a previous BHD, or exacerbate a current BHD, the researchers noted.
 

What is Known About BHDs and Cancer?

Although previous studies have shown a possible association between BHDs and increased cancer risk, as well as reduced compliance with care, the effect of BHDs on outcomes in cancer patients undergoing surgical resection has not been examined, wrote Dr. Pawlik and colleagues.

Previous research has focused on the impact of having a preexisting serious mental illness (SMI) such as schizophrenia and bipolar disorder on cancer care.

A 2023 literature review of 27 studies published in the Journal of Medical Imaging and Radiation Sciences showed that patients with preexisting severe mental illness (such as schizophrenia or bipolar disorder) had greater cancer-related mortality. In that study, the researchers also found that patients with severe mental illness were more likely to have metastatic disease at diagnosis, but less likely to receive optimal treatments, than individuals without SMIs.

Many studies also have focused on patients developing mental health problems (including BHDs) after a cancer diagnosis, but the current study is the first known to examine outcomes in those with BHDs before cancer. 
 

Why Was It Important to Conduct This Study?

“BHDs are a diverse set of mental illnesses that affect an individual’s psychosocial wellbeing, potentially resulting in maladaptive behaviors,” Dr. Pawlik said in an interview. BHDs, which include substance abuse, eating disorders, and sleep disorders, are less common than anxiety/depression, but have an estimated prevalence of 1.3%-3.1% among adults in the United States, he said.

What Does the New Study Add?

In the new review by Dr. Pawlik and colleagues, published in the Journal of the American College of Surgeons (Katayama ES. J Am Coll Surg. 2024 Feb 29. doi: 2024. 10.1097/XCS.0000000000000954), BHDs were defined as substance abuse, eating disorders, or sleep disorders, which had not been the focus of previous studies. The researchers reviewed data from 694,836 adult patients with lung, esophageal, gastric, liver, pancreatic, or colorectal cancer between 2018-2021 using the Medicare Standard Analytic files. A total of 46,719 patients (6.7%) had at least one BHD.

Overall, patients with a BHD were significantly less likely than those without a BHD to undergo surgical resection (20.3% vs. 23.4%). Patients with a BHD also had significantly worse long-term postoperative survival than those without BHDs (median 37.1 months vs. 46.6 months) and significantly higher in-hospital costs ($17,432 vs. 16,159, P less than .001 for all).

Among patients who underwent cancer surgery, the odds of any complication were significantly higher for those with a BHD compared to those with no BHD (odds ratio 1.32), as were the odds of a prolonged length of stay (OR 1.67) and 90-day readmission (OR 1.57).

Dr. Pawlik said he was surprised by several of the findings, including that 1 in 15 Medicare beneficiaries had a BHD diagnosis, “with male sex and minority racial status, as well as higher social vulnerability, being associated with a higher prevalence of BHD.”

Also, the independent association of having a BHD with 30%-50% higher odds of a complication, prolonged length of stay, and 90-day readmission was higher than Dr. Pawlik had anticipated.
 

Why Do Patients With BHDs Have Fewer Surgeries and Worse Outcomes?

The reasons for this association were likely multifactorial and may reflect the greater burden of medical comorbidity and chronic illness in many patients with BHDs because of maladaptive lifestyles or poor nutrition status, Dr. Pawlik said.

“Patients with BHDs also likely face barriers to accessing care, which was noted particularly among patients with BHDs who lived in socially vulnerable areas,” he said. BHD patients also were more likely to be treated at low-volume rather than high-volume hospitals, “which undoubtedly contributed in part to worse outcomes in this cohort of patients,” he added.
 

What Can Oncologists Do to Help?

The take-home message for clinicians is that BHDs are linked to worse surgical outcomes and higher health care costs in cancer patients, Dr. Pawlik said in an interview.

“Enhanced accessibility to behavioral healthcare, as well as comprehensive policy reform related to mental health services are needed to improve care of patients with BHDs,” he said. “For example, implementing psychiatry compensation programs may encourage practice in vulnerable areas,” he said.

Other strategies include a following a collaborative care model involving mental health professionals working in tandem with primary care and mid-level practitioners and increasing use and establishment of telehealth systems to improve patient access to BHD services, he said.
 

What Are the Limitations?

The study by Dr. Pawlik and colleagues was limited by several factors, including the lack of data on younger patients and the full range of BHDs, as well as underreporting of BHDs and the high copays for mental health care, the researchers noted. However, the results suggest that concomitant BHDs are associated with worse cancer outcomes and higher in-hospital costs, and illustrate the need to screen for and target these conditions in cancer patients, the researchers concluded.

What Are the Next Steps for Research?

The current study involved Medicare beneficiaries aged 65 years or older, and more research is needed to investigate the impact of BHDs among younger cancer patients in whom the prevalence may be higher and the impact of BHDs may be different, Dr. Pawlik said in an interview. In addition, the analysis of BHDs as a composite of substance abuse, eating disorders, and sleep disorders (because the numbers were too small to break out data for each disorder, separately) prevented investigation of potential differences and unique challenges faced by distinct subpopulations of BHD patients, he said.

“Future studies should examine the individual impact of substance abuse, eating disorders, and sleep disorders on access to surgery, as well as the potential different impact that each one of these different BHDs may have on postoperative outcomes,” Dr. Pawlik suggested.

The study was supported by The Ohio State University College of Medicine Roessler Summer Research Scholarship. The researchers had no financial conflicts to disclose.

Cancer patients with behavioral health disorders are significantly less likely to undergo surgical resections, and more likely to experience poor outcomes when they do have surgery, based on data from a new study of nearly 700,000 individuals.

The reason for this association remains unclear, and highlights the need to address existing behavioral health disorders (BHDs), which can be exacerbated after a patient is diagnosed with cancer, wrote Timothy M. Pawlik, MD, of The Ohio State University, Columbus, and colleagues. A cancer diagnosis can cause not only physical stress, but mental, emotional, social, and economic stress that can prompt a new BHD, cause relapse of a previous BHD, or exacerbate a current BHD, the researchers noted.
 

What is Known About BHDs and Cancer?

Although previous studies have shown a possible association between BHDs and increased cancer risk, as well as reduced compliance with care, the effect of BHDs on outcomes in cancer patients undergoing surgical resection has not been examined, wrote Dr. Pawlik and colleagues.

Previous research has focused on the impact of having a preexisting serious mental illness (SMI) such as schizophrenia and bipolar disorder on cancer care.

A 2023 literature review of 27 studies published in the Journal of Medical Imaging and Radiation Sciences showed that patients with preexisting severe mental illness (such as schizophrenia or bipolar disorder) had greater cancer-related mortality. In that study, the researchers also found that patients with severe mental illness were more likely to have metastatic disease at diagnosis, but less likely to receive optimal treatments, than individuals without SMIs.

Many studies also have focused on patients developing mental health problems (including BHDs) after a cancer diagnosis, but the current study is the first known to examine outcomes in those with BHDs before cancer. 
 

Why Was It Important to Conduct This Study?

“BHDs are a diverse set of mental illnesses that affect an individual’s psychosocial wellbeing, potentially resulting in maladaptive behaviors,” Dr. Pawlik said in an interview. BHDs, which include substance abuse, eating disorders, and sleep disorders, are less common than anxiety/depression, but have an estimated prevalence of 1.3%-3.1% among adults in the United States, he said.

What Does the New Study Add?

In the new review by Dr. Pawlik and colleagues, published in the Journal of the American College of Surgeons (Katayama ES. J Am Coll Surg. 2024 Feb 29. doi: 2024. 10.1097/XCS.0000000000000954), BHDs were defined as substance abuse, eating disorders, or sleep disorders, which had not been the focus of previous studies. The researchers reviewed data from 694,836 adult patients with lung, esophageal, gastric, liver, pancreatic, or colorectal cancer between 2018-2021 using the Medicare Standard Analytic files. A total of 46,719 patients (6.7%) had at least one BHD.

Overall, patients with a BHD were significantly less likely than those without a BHD to undergo surgical resection (20.3% vs. 23.4%). Patients with a BHD also had significantly worse long-term postoperative survival than those without BHDs (median 37.1 months vs. 46.6 months) and significantly higher in-hospital costs ($17,432 vs. 16,159, P less than .001 for all).

Among patients who underwent cancer surgery, the odds of any complication were significantly higher for those with a BHD compared to those with no BHD (odds ratio 1.32), as were the odds of a prolonged length of stay (OR 1.67) and 90-day readmission (OR 1.57).

Dr. Pawlik said he was surprised by several of the findings, including that 1 in 15 Medicare beneficiaries had a BHD diagnosis, “with male sex and minority racial status, as well as higher social vulnerability, being associated with a higher prevalence of BHD.”

Also, the independent association of having a BHD with 30%-50% higher odds of a complication, prolonged length of stay, and 90-day readmission was higher than Dr. Pawlik had anticipated.
 

Why Do Patients With BHDs Have Fewer Surgeries and Worse Outcomes?

The reasons for this association were likely multifactorial and may reflect the greater burden of medical comorbidity and chronic illness in many patients with BHDs because of maladaptive lifestyles or poor nutrition status, Dr. Pawlik said.

“Patients with BHDs also likely face barriers to accessing care, which was noted particularly among patients with BHDs who lived in socially vulnerable areas,” he said. BHD patients also were more likely to be treated at low-volume rather than high-volume hospitals, “which undoubtedly contributed in part to worse outcomes in this cohort of patients,” he added.
 

What Can Oncologists Do to Help?

The take-home message for clinicians is that BHDs are linked to worse surgical outcomes and higher health care costs in cancer patients, Dr. Pawlik said in an interview.

“Enhanced accessibility to behavioral healthcare, as well as comprehensive policy reform related to mental health services are needed to improve care of patients with BHDs,” he said. “For example, implementing psychiatry compensation programs may encourage practice in vulnerable areas,” he said.

Other strategies include a following a collaborative care model involving mental health professionals working in tandem with primary care and mid-level practitioners and increasing use and establishment of telehealth systems to improve patient access to BHD services, he said.
 

What Are the Limitations?

The study by Dr. Pawlik and colleagues was limited by several factors, including the lack of data on younger patients and the full range of BHDs, as well as underreporting of BHDs and the high copays for mental health care, the researchers noted. However, the results suggest that concomitant BHDs are associated with worse cancer outcomes and higher in-hospital costs, and illustrate the need to screen for and target these conditions in cancer patients, the researchers concluded.

What Are the Next Steps for Research?

The current study involved Medicare beneficiaries aged 65 years or older, and more research is needed to investigate the impact of BHDs among younger cancer patients in whom the prevalence may be higher and the impact of BHDs may be different, Dr. Pawlik said in an interview. In addition, the analysis of BHDs as a composite of substance abuse, eating disorders, and sleep disorders (because the numbers were too small to break out data for each disorder, separately) prevented investigation of potential differences and unique challenges faced by distinct subpopulations of BHD patients, he said.

“Future studies should examine the individual impact of substance abuse, eating disorders, and sleep disorders on access to surgery, as well as the potential different impact that each one of these different BHDs may have on postoperative outcomes,” Dr. Pawlik suggested.

The study was supported by The Ohio State University College of Medicine Roessler Summer Research Scholarship. The researchers had no financial conflicts to disclose.

An estimated 1 in 100 adolescents ages 12-17 years in the United States have an opioid use disorder (OUD). But fewer than 5% of adolescents with OUD get buprenorphine or naltrexone, though the treatments are recommended by the American Academy of Pediatrics (AAP), new data show.

Meanwhile, adolescent drug overdose deaths more than doubled between 2019 and 2021, with most involving opioids.

Scott E. Hadland, MD, MPH, with the Division of Adolescent and Young Adult Medicine at Mass General for Children in Boston, and colleagues detailed the extent of the treatment gap and barriers to prescribing and caring for youth with OUD in primary care in a research letter published February 26 in JAMA Pediatrics.

Dr. Hadland’s team mailed 1,681 US pediatricians a survey and the response rate was 43.0%. Researchers included in the sample 474 primary care pediatricians who care for adolescents.
 

Who Should Treat OUD?

Most respondents (average age, 49.5; 74.0% female) agreed or strongly agreed that it is their responsibility to identify substance use disorders (93.9%) and refer patients to treatment (97.4%).

Fewer agreed or strongly agreed that it is their responsibility to treat substance use disorders (20.3%) or prescribe medications (12.4%). Fewer than half of the respondents said they felt prepared or very prepared to counsel adolescents on opioid use (48.3%) compared with those comfortable counseling on alcohol (87.1%), cannabis (81.7%), and e-cigarette use (80.1%; P < .001).

Pediatricians were less likely to provide counseling (63.0%) and more likely to refer patients to care off-site (71.8%) for opioid use than for alcohol (87.7% and 51.7%); cannabis (88.9% and 45.4%); or e-cigarette use (91.6% and 26.5%) (P < .001 for all comparisons).
 

Training Lacking in Residency Programs

“These results reveal an opportunity for greater workforce training in line with a 2019 survey showing fewer than 1 in 3 US pediatric residency programs included education on prescribing OUD medications,” the authors wrote. Training focused on treating OUD in primary care, including prescribing medications and addressing possible misperceptions, may be needed,” they noted.

The survey predated the elimination in 2023 of the federal buprenorphine waiver requirement, which made prescribing buprenorphine easier, so these results do not reflect any changes from that elimination, they wrote.

Sharon Levy, MD, MPH, chief of the Division of Addiction Medicine at Boston Children’s Hospital and professor of pediatrics at Harvard Medical School in Boston, who was not part of this study, said more education on addiction medicine is needed for general pediatricians.

She said it’s time to push beyond the current framework of Screening, Brief Intervention, Referral to Treatment (SBIRT), because that doesn’t include “prescribing medications to manage withdrawal or suppress cravings or the use of lab testing, both of which could be accomplished in primary care.”

Dr. Levy said she considers substance use disorders the same way she considers other chronic conditions: Most patients can be treated in primary care. “Specialty care and higher levels of care need to be available for patients who are most complicated and/or having a flare of their condition.”

“In my opinion, most teens with opioid use disorder can and should be treated in primary care. I worry about referring teens with opioid use disorder to get medication somewhere else because there are few places that deliver this service to this age group. Additionally, teens and families are not always willing to pursue a referral, and many will get lost along the way.”
 

Promising Models

At Boston Children’s, she said, the Division of Addiction Medicine has created a consultation call line that primary care providers can call for help with any questions about teen substance use.

After running the consultation for about a year, she said, the program wanted to add ways to help patients directly and hired and trained social workers who can see pediatric patients with substance use problems for counseling via telemedicine. “The program also now supports group therapy for pediatric patients and parents, so that primary care providers can refer patients directly to group therapy,” Dr. Levy said.

The growth of telehealth since the pandemic may allow for new models of care.

“For example, now our Adolescent Substance Use and Addiction Program at Boston Children’s Hospital can provide services, including medication induction and follow-up, virtually,” Dr. Levy said. “This allows us to treat young people anywhere in the state. There have been instances in which a primary care provider referred us patients with OUD and then partnered with us, including performing physicals for teens who could not get to Boston to see us in person. At the end of the day, the more models we can come up with the better.”

Dr. Hadland reported honoraria from the AAP outside the submitted work. Two coauthors reported receiving salary support from the AAP during the conduct of the study. A coauthor reported serving as the chair of the AAP Committee on Substance Use and Prevention outside the submitted work. This work was supported by a grant from the Conrad N. Hilton Foundation via the AAP. Dr. Sharon Levy’s husband, Ofer Levy, MD, PhD, is director of the Precision Vaccines Program at Boston Children’s Hospital.

An estimated 1 in 100 adolescents ages 12-17 years in the United States have an opioid use disorder (OUD). But fewer than 5% of adolescents with OUD get buprenorphine or naltrexone, though the treatments are recommended by the American Academy of Pediatrics (AAP), new data show.

Meanwhile, adolescent drug overdose deaths more than doubled between 2019 and 2021, with most involving opioids.

Scott E. Hadland, MD, MPH, with the Division of Adolescent and Young Adult Medicine at Mass General for Children in Boston, and colleagues detailed the extent of the treatment gap and barriers to prescribing and caring for youth with OUD in primary care in a research letter published February 26 in JAMA Pediatrics.

Dr. Hadland’s team mailed 1,681 US pediatricians a survey and the response rate was 43.0%. Researchers included in the sample 474 primary care pediatricians who care for adolescents.
 

Who Should Treat OUD?

Most respondents (average age, 49.5; 74.0% female) agreed or strongly agreed that it is their responsibility to identify substance use disorders (93.9%) and refer patients to treatment (97.4%).

Fewer agreed or strongly agreed that it is their responsibility to treat substance use disorders (20.3%) or prescribe medications (12.4%). Fewer than half of the respondents said they felt prepared or very prepared to counsel adolescents on opioid use (48.3%) compared with those comfortable counseling on alcohol (87.1%), cannabis (81.7%), and e-cigarette use (80.1%; P < .001).

Pediatricians were less likely to provide counseling (63.0%) and more likely to refer patients to care off-site (71.8%) for opioid use than for alcohol (87.7% and 51.7%); cannabis (88.9% and 45.4%); or e-cigarette use (91.6% and 26.5%) (P < .001 for all comparisons).
 

Training Lacking in Residency Programs

“These results reveal an opportunity for greater workforce training in line with a 2019 survey showing fewer than 1 in 3 US pediatric residency programs included education on prescribing OUD medications,” the authors wrote. Training focused on treating OUD in primary care, including prescribing medications and addressing possible misperceptions, may be needed,” they noted.

The survey predated the elimination in 2023 of the federal buprenorphine waiver requirement, which made prescribing buprenorphine easier, so these results do not reflect any changes from that elimination, they wrote.

Sharon Levy, MD, MPH, chief of the Division of Addiction Medicine at Boston Children’s Hospital and professor of pediatrics at Harvard Medical School in Boston, who was not part of this study, said more education on addiction medicine is needed for general pediatricians.

She said it’s time to push beyond the current framework of Screening, Brief Intervention, Referral to Treatment (SBIRT), because that doesn’t include “prescribing medications to manage withdrawal or suppress cravings or the use of lab testing, both of which could be accomplished in primary care.”

Dr. Levy said she considers substance use disorders the same way she considers other chronic conditions: Most patients can be treated in primary care. “Specialty care and higher levels of care need to be available for patients who are most complicated and/or having a flare of their condition.”

“In my opinion, most teens with opioid use disorder can and should be treated in primary care. I worry about referring teens with opioid use disorder to get medication somewhere else because there are few places that deliver this service to this age group. Additionally, teens and families are not always willing to pursue a referral, and many will get lost along the way.”
 

Promising Models

At Boston Children’s, she said, the Division of Addiction Medicine has created a consultation call line that primary care providers can call for help with any questions about teen substance use.

After running the consultation for about a year, she said, the program wanted to add ways to help patients directly and hired and trained social workers who can see pediatric patients with substance use problems for counseling via telemedicine. “The program also now supports group therapy for pediatric patients and parents, so that primary care providers can refer patients directly to group therapy,” Dr. Levy said.

The growth of telehealth since the pandemic may allow for new models of care.

“For example, now our Adolescent Substance Use and Addiction Program at Boston Children’s Hospital can provide services, including medication induction and follow-up, virtually,” Dr. Levy said. “This allows us to treat young people anywhere in the state. There have been instances in which a primary care provider referred us patients with OUD and then partnered with us, including performing physicals for teens who could not get to Boston to see us in person. At the end of the day, the more models we can come up with the better.”

Dr. Hadland reported honoraria from the AAP outside the submitted work. Two coauthors reported receiving salary support from the AAP during the conduct of the study. A coauthor reported serving as the chair of the AAP Committee on Substance Use and Prevention outside the submitted work. This work was supported by a grant from the Conrad N. Hilton Foundation via the AAP. Dr. Sharon Levy’s husband, Ofer Levy, MD, PhD, is director of the Precision Vaccines Program at Boston Children’s Hospital.

An estimated 1 in 100 adolescents ages 12-17 years in the United States have an opioid use disorder (OUD). But fewer than 5% of adolescents with OUD get buprenorphine or naltrexone, though the treatments are recommended by the American Academy of Pediatrics (AAP), new data show.

Meanwhile, adolescent drug overdose deaths more than doubled between 2019 and 2021, with most involving opioids.

Scott E. Hadland, MD, MPH, with the Division of Adolescent and Young Adult Medicine at Mass General for Children in Boston, and colleagues detailed the extent of the treatment gap and barriers to prescribing and caring for youth with OUD in primary care in a research letter published February 26 in JAMA Pediatrics.

Dr. Hadland’s team mailed 1,681 US pediatricians a survey and the response rate was 43.0%. Researchers included in the sample 474 primary care pediatricians who care for adolescents.
 

Who Should Treat OUD?

Most respondents (average age, 49.5; 74.0% female) agreed or strongly agreed that it is their responsibility to identify substance use disorders (93.9%) and refer patients to treatment (97.4%).

Fewer agreed or strongly agreed that it is their responsibility to treat substance use disorders (20.3%) or prescribe medications (12.4%). Fewer than half of the respondents said they felt prepared or very prepared to counsel adolescents on opioid use (48.3%) compared with those comfortable counseling on alcohol (87.1%), cannabis (81.7%), and e-cigarette use (80.1%; P < .001).

Pediatricians were less likely to provide counseling (63.0%) and more likely to refer patients to care off-site (71.8%) for opioid use than for alcohol (87.7% and 51.7%); cannabis (88.9% and 45.4%); or e-cigarette use (91.6% and 26.5%) (P < .001 for all comparisons).
 

Training Lacking in Residency Programs

“These results reveal an opportunity for greater workforce training in line with a 2019 survey showing fewer than 1 in 3 US pediatric residency programs included education on prescribing OUD medications,” the authors wrote. Training focused on treating OUD in primary care, including prescribing medications and addressing possible misperceptions, may be needed,” they noted.

The survey predated the elimination in 2023 of the federal buprenorphine waiver requirement, which made prescribing buprenorphine easier, so these results do not reflect any changes from that elimination, they wrote.

Sharon Levy, MD, MPH, chief of the Division of Addiction Medicine at Boston Children’s Hospital and professor of pediatrics at Harvard Medical School in Boston, who was not part of this study, said more education on addiction medicine is needed for general pediatricians.

She said it’s time to push beyond the current framework of Screening, Brief Intervention, Referral to Treatment (SBIRT), because that doesn’t include “prescribing medications to manage withdrawal or suppress cravings or the use of lab testing, both of which could be accomplished in primary care.”

Dr. Levy said she considers substance use disorders the same way she considers other chronic conditions: Most patients can be treated in primary care. “Specialty care and higher levels of care need to be available for patients who are most complicated and/or having a flare of their condition.”

“In my opinion, most teens with opioid use disorder can and should be treated in primary care. I worry about referring teens with opioid use disorder to get medication somewhere else because there are few places that deliver this service to this age group. Additionally, teens and families are not always willing to pursue a referral, and many will get lost along the way.”
 

Promising Models

At Boston Children’s, she said, the Division of Addiction Medicine has created a consultation call line that primary care providers can call for help with any questions about teen substance use.

After running the consultation for about a year, she said, the program wanted to add ways to help patients directly and hired and trained social workers who can see pediatric patients with substance use problems for counseling via telemedicine. “The program also now supports group therapy for pediatric patients and parents, so that primary care providers can refer patients directly to group therapy,” Dr. Levy said.

The growth of telehealth since the pandemic may allow for new models of care.

“For example, now our Adolescent Substance Use and Addiction Program at Boston Children’s Hospital can provide services, including medication induction and follow-up, virtually,” Dr. Levy said. “This allows us to treat young people anywhere in the state. There have been instances in which a primary care provider referred us patients with OUD and then partnered with us, including performing physicals for teens who could not get to Boston to see us in person. At the end of the day, the more models we can come up with the better.”

Dr. Hadland reported honoraria from the AAP outside the submitted work. Two coauthors reported receiving salary support from the AAP during the conduct of the study. A coauthor reported serving as the chair of the AAP Committee on Substance Use and Prevention outside the submitted work. This work was supported by a grant from the Conrad N. Hilton Foundation via the AAP. Dr. Sharon Levy’s husband, Ofer Levy, MD, PhD, is director of the Precision Vaccines Program at Boston Children’s Hospital.

For the first time, methamphetamines and cocaine have overtaken heroin and prescription opioids in illicit drug use involving fentanyl nationwide and in nearly every state, a new report suggested.

The use of methamphetamine among people who also use fentanyl reached a record high in 2023, urinary drug tests (UDTs) showed, while the use of prescription opioids in that same group reached an historic low. 

Investigators said the data offer further evidence that the US is experiencing a predicted “fourth wave” of the opioid crisis.

The report came on the heels of new data from the Centers for Disease Control and Prevention (CDC) that showed the preferred method of fentanyl-related illicit drug use shifted from intravenous injection to smoking.

“The rise in cocaine and methamphetamine nationally does not seem to be driven by one or even a few regions of the country,” authors of the 2024 Health Signals Report wrote. “Stimulants are a serious national challenge emphasizing the need for continued progress on the national plan to address methamphetamine supply, use, and consequences.”

The report, published online on February 22 by San Diego–based drug testing lab Millennium Health, is an analysis of urine specimens from 4.1 million unique patients aged ≥ 18 years, collected in all 50 states from 2013 to 2023. 
 

A Year of Firsts

Last year, 60% of specimens that contained fentanyl also contained methamphetamine, an increase of 875% since 2015, according to Millennium’s report. It’s the first time that methamphetamine and cocaine were detected more often in urine drug tests than heroin and prescription opioids.

About a quarter of fentanyl-positive specimens also contained cocaine, 17% heroin and just 7% prescription opioids.

Almost all the fentanyl-positive specimens were positive for at least one additional substance; almost half contained three or more. Xylazine, an animal sedative known as “tranq,” was detected in nearly 14% of fentanyl-positive specimens.

“These combinations increase overdose vulnerability and may lessen responses to overdose reversal agents, making treatment as challenging as any time in history,” Millennium Senior VP and Chief Clinical Officer, Angela G. Huskey, PharmD, CPE, said in a statement.

The Millennium data back up what has been increasingly reported by the CDC and others. As reported in September by this news organization, in 2010, stimulants were co-involved in less than 1% of fentanyl overdose deaths. By 2021, stimulant-fentanyl use accounted for 32% of all fatal fentanyl overdoses.

In July 2023, the CDC reported a significant spike in overdose deaths involving cocaine or other psychostimulants and opioids from 2011 to 2021. In 2021, 79% of overdose deaths involving cocaine also involved an opioid and 66% of overdose deaths involving psychostimulants also involved an opioid, according to the CDC.

There were more overdose deaths from stimulants combined with opioids than from opioids alone in 2022, according to the CDC’s State Unintentional Drug Overdose Reporting System, which includes reports from 30 jurisdictions.
 

Smoking Overtakes Injection

The route of administration for opioids and stimulants — whether used alone or in combination, has also changed, the CDC recently reported. In 2022, just 16% of overdose deaths involved injection drug use, down from 23% in 2020, according to the analysis, which included data from 28 jurisdictions. For deaths involving illegally manufactured fentanyl, just 12% of deaths involved IV drug use.

By 2022, “smoking was the most commonly documented route of use in overdose deaths,” CDC researchers wrote in their report. Almost a quarter of deaths that year involved smoking.

The increase in smoking was seen for all substances, including opioids, fentanyl and combinations of fentanyl and stimulants, reported the agency.

Users might be switching to smoking from injections because there is a perception of fewer adverse health effects such as abscesses, reduced cost and stigma, sense of more control over quantity consumed per use, and “a perception of reduced overdose risk,” the researchers wrote.

Smoking still “carries substantial overdose risk because of rapid drug absorption,” they added.

Some harm reduction programs are adapting to the change in use patterns by providing safer smoking supplies and by changing messaging to warn of the dangers associated with smoking drugs, the CDC report noted.
 

A version of this article appeared on Medscape.com.

For the first time, methamphetamines and cocaine have overtaken heroin and prescription opioids in illicit drug use involving fentanyl nationwide and in nearly every state, a new report suggested.

The use of methamphetamine among people who also use fentanyl reached a record high in 2023, urinary drug tests (UDTs) showed, while the use of prescription opioids in that same group reached an historic low. 

Investigators said the data offer further evidence that the US is experiencing a predicted “fourth wave” of the opioid crisis.

The report came on the heels of new data from the Centers for Disease Control and Prevention (CDC) that showed the preferred method of fentanyl-related illicit drug use shifted from intravenous injection to smoking.

“The rise in cocaine and methamphetamine nationally does not seem to be driven by one or even a few regions of the country,” authors of the 2024 Health Signals Report wrote. “Stimulants are a serious national challenge emphasizing the need for continued progress on the national plan to address methamphetamine supply, use, and consequences.”

The report, published online on February 22 by San Diego–based drug testing lab Millennium Health, is an analysis of urine specimens from 4.1 million unique patients aged ≥ 18 years, collected in all 50 states from 2013 to 2023. 
 

A Year of Firsts

Last year, 60% of specimens that contained fentanyl also contained methamphetamine, an increase of 875% since 2015, according to Millennium’s report. It’s the first time that methamphetamine and cocaine were detected more often in urine drug tests than heroin and prescription opioids.

About a quarter of fentanyl-positive specimens also contained cocaine, 17% heroin and just 7% prescription opioids.

Almost all the fentanyl-positive specimens were positive for at least one additional substance; almost half contained three or more. Xylazine, an animal sedative known as “tranq,” was detected in nearly 14% of fentanyl-positive specimens.

“These combinations increase overdose vulnerability and may lessen responses to overdose reversal agents, making treatment as challenging as any time in history,” Millennium Senior VP and Chief Clinical Officer, Angela G. Huskey, PharmD, CPE, said in a statement.

The Millennium data back up what has been increasingly reported by the CDC and others. As reported in September by this news organization, in 2010, stimulants were co-involved in less than 1% of fentanyl overdose deaths. By 2021, stimulant-fentanyl use accounted for 32% of all fatal fentanyl overdoses.

In July 2023, the CDC reported a significant spike in overdose deaths involving cocaine or other psychostimulants and opioids from 2011 to 2021. In 2021, 79% of overdose deaths involving cocaine also involved an opioid and 66% of overdose deaths involving psychostimulants also involved an opioid, according to the CDC.

There were more overdose deaths from stimulants combined with opioids than from opioids alone in 2022, according to the CDC’s State Unintentional Drug Overdose Reporting System, which includes reports from 30 jurisdictions.
 

Smoking Overtakes Injection

The route of administration for opioids and stimulants — whether used alone or in combination, has also changed, the CDC recently reported. In 2022, just 16% of overdose deaths involved injection drug use, down from 23% in 2020, according to the analysis, which included data from 28 jurisdictions. For deaths involving illegally manufactured fentanyl, just 12% of deaths involved IV drug use.

By 2022, “smoking was the most commonly documented route of use in overdose deaths,” CDC researchers wrote in their report. Almost a quarter of deaths that year involved smoking.

The increase in smoking was seen for all substances, including opioids, fentanyl and combinations of fentanyl and stimulants, reported the agency.

Users might be switching to smoking from injections because there is a perception of fewer adverse health effects such as abscesses, reduced cost and stigma, sense of more control over quantity consumed per use, and “a perception of reduced overdose risk,” the researchers wrote.

Smoking still “carries substantial overdose risk because of rapid drug absorption,” they added.

Some harm reduction programs are adapting to the change in use patterns by providing safer smoking supplies and by changing messaging to warn of the dangers associated with smoking drugs, the CDC report noted.
 

A version of this article appeared on Medscape.com.

For the first time, methamphetamines and cocaine have overtaken heroin and prescription opioids in illicit drug use involving fentanyl nationwide and in nearly every state, a new report suggested.

The use of methamphetamine among people who also use fentanyl reached a record high in 2023, urinary drug tests (UDTs) showed, while the use of prescription opioids in that same group reached an historic low. 

Investigators said the data offer further evidence that the US is experiencing a predicted “fourth wave” of the opioid crisis.

The report came on the heels of new data from the Centers for Disease Control and Prevention (CDC) that showed the preferred method of fentanyl-related illicit drug use shifted from intravenous injection to smoking.

“The rise in cocaine and methamphetamine nationally does not seem to be driven by one or even a few regions of the country,” authors of the 2024 Health Signals Report wrote. “Stimulants are a serious national challenge emphasizing the need for continued progress on the national plan to address methamphetamine supply, use, and consequences.”

The report, published online on February 22 by San Diego–based drug testing lab Millennium Health, is an analysis of urine specimens from 4.1 million unique patients aged ≥ 18 years, collected in all 50 states from 2013 to 2023. 
 

A Year of Firsts

Last year, 60% of specimens that contained fentanyl also contained methamphetamine, an increase of 875% since 2015, according to Millennium’s report. It’s the first time that methamphetamine and cocaine were detected more often in urine drug tests than heroin and prescription opioids.

About a quarter of fentanyl-positive specimens also contained cocaine, 17% heroin and just 7% prescription opioids.

Almost all the fentanyl-positive specimens were positive for at least one additional substance; almost half contained three or more. Xylazine, an animal sedative known as “tranq,” was detected in nearly 14% of fentanyl-positive specimens.

“These combinations increase overdose vulnerability and may lessen responses to overdose reversal agents, making treatment as challenging as any time in history,” Millennium Senior VP and Chief Clinical Officer, Angela G. Huskey, PharmD, CPE, said in a statement.

The Millennium data back up what has been increasingly reported by the CDC and others. As reported in September by this news organization, in 2010, stimulants were co-involved in less than 1% of fentanyl overdose deaths. By 2021, stimulant-fentanyl use accounted for 32% of all fatal fentanyl overdoses.

In July 2023, the CDC reported a significant spike in overdose deaths involving cocaine or other psychostimulants and opioids from 2011 to 2021. In 2021, 79% of overdose deaths involving cocaine also involved an opioid and 66% of overdose deaths involving psychostimulants also involved an opioid, according to the CDC.

There were more overdose deaths from stimulants combined with opioids than from opioids alone in 2022, according to the CDC’s State Unintentional Drug Overdose Reporting System, which includes reports from 30 jurisdictions.
 

Smoking Overtakes Injection

The route of administration for opioids and stimulants — whether used alone or in combination, has also changed, the CDC recently reported. In 2022, just 16% of overdose deaths involved injection drug use, down from 23% in 2020, according to the analysis, which included data from 28 jurisdictions. For deaths involving illegally manufactured fentanyl, just 12% of deaths involved IV drug use.

By 2022, “smoking was the most commonly documented route of use in overdose deaths,” CDC researchers wrote in their report. Almost a quarter of deaths that year involved smoking.

The increase in smoking was seen for all substances, including opioids, fentanyl and combinations of fentanyl and stimulants, reported the agency.

Users might be switching to smoking from injections because there is a perception of fewer adverse health effects such as abscesses, reduced cost and stigma, sense of more control over quantity consumed per use, and “a perception of reduced overdose risk,” the researchers wrote.

Smoking still “carries substantial overdose risk because of rapid drug absorption,” they added.

Some harm reduction programs are adapting to the change in use patterns by providing safer smoking supplies and by changing messaging to warn of the dangers associated with smoking drugs, the CDC report noted.
 

A version of this article appeared on Medscape.com.

TOPLINE:

The use of stimulant therapy by adolescents with attention-deficit/hyperactivity disorder (ADHD) was not associated with later prescription drug misuse (PDM), a new study showed. However, misuse of prescription stimulants during adolescence was associated with significantly higher odds of later PDM.

METHODOLOGY:

• Data came from 11,066 participants in the ongoing Monitoring the Future panel study (baseline cohort years 2005-2017), a multicohort US national longitudinal study of adolescents followed into adulthood, in which procedures and measures are kept consistent across time.
• Participants (ages 17 and 18 years, 51.7% female, 11.2% Black, 15.7% Hispanic, and 59.6% White) completed self-administered questionnaires, with biennial follow-up during young adulthood (ages 19-24 years).
• The questionnaires asked about the number of occasions (if any) in which respondents used a prescription drug (benzodiazepine, opioid, or stimulant) on their own, without a physician’s order.
• Baseline covariates included sex, race, ethnicity, grade point average during high school, parental education, past 2-week binge drinking, past-month cigarette use, and past-year marijuana use, as well as demographic factors.

TAKEAWAY:

• Overall, 9.9% of participants reported lifetime stimulant therapy for ADHD, and 18.6% reported lifetime prescription stimulant misuse at baseline.
• Adolescents who received stimulant therapy for ADHD were less likely to report past-year prescription stimulant misuse as young adults compared with their same-age peers who did not receive stimulant therapy (adjusted odds ratio, 0.71; 95% CI, 0.52-0.99).
• The researchers found no significant differences between adolescents with or without lifetime stimulants in later incidence or prevalence of past-year PDM during young adulthood.
• The most robust predictor of prescription stimulant misuse during young adulthood was prescription stimulant misuse during adolescence; similarly, the most robust predictors of prescription opioid and prescription benzodiazepine misuse during young adulthood were prescription opioid and prescription benzodiazepine misuse (respectively) during adolescence.

IN PRACTICE:

“These findings amplify accumulating evidence suggesting that careful monitoring and screening during adolescence could identify individuals who are at relatively greater risk for PDM and need more comprehensive substance use assessment,” the authors wrote.

SOURCE:

Sean Esteban McCabe, PhD, professor and director, Center for the Study of Drugs, Alcohol, Smoking and Health, University of Michigan School of Nursing, Ann Arbor, was the lead and corresponding author of the study. It was published online on February 7 in Psychiatric Sciences.

LIMITATIONS:

Some subpopulations with higher rates of substance use, including youths who left school before completion and institutionalized populations, were excluded from the study, which may have led to an underestimation of PDM. Moreover, some potential confounders (eg, comorbid psychiatric conditions) were not assessed.

DISCLOSURES:

This study was supported by a research award from the US Food and Drug Administration and research awards from the National Institute on Drug Abuse of the NIH. Dr. McCabe reported no relevant financial relationships. The other authors’ disclosures are listed in the original paper.

A version of this article appeared on Medscape.com.

TOPLINE:

The use of stimulant therapy by adolescents with attention-deficit/hyperactivity disorder (ADHD) was not associated with later prescription drug misuse (PDM), a new study showed. However, misuse of prescription stimulants during adolescence was associated with significantly higher odds of later PDM.

METHODOLOGY:

• Data came from 11,066 participants in the ongoing Monitoring the Future panel study (baseline cohort years 2005-2017), a multicohort US national longitudinal study of adolescents followed into adulthood, in which procedures and measures are kept consistent across time.
• Participants (ages 17 and 18 years, 51.7% female, 11.2% Black, 15.7% Hispanic, and 59.6% White) completed self-administered questionnaires, with biennial follow-up during young adulthood (ages 19-24 years).
• The questionnaires asked about the number of occasions (if any) in which respondents used a prescription drug (benzodiazepine, opioid, or stimulant) on their own, without a physician’s order.
• Baseline covariates included sex, race, ethnicity, grade point average during high school, parental education, past 2-week binge drinking, past-month cigarette use, and past-year marijuana use, as well as demographic factors.

TAKEAWAY:

• Overall, 9.9% of participants reported lifetime stimulant therapy for ADHD, and 18.6% reported lifetime prescription stimulant misuse at baseline.
• Adolescents who received stimulant therapy for ADHD were less likely to report past-year prescription stimulant misuse as young adults compared with their same-age peers who did not receive stimulant therapy (adjusted odds ratio, 0.71; 95% CI, 0.52-0.99).
• The researchers found no significant differences between adolescents with or without lifetime stimulants in later incidence or prevalence of past-year PDM during young adulthood.
• The most robust predictor of prescription stimulant misuse during young adulthood was prescription stimulant misuse during adolescence; similarly, the most robust predictors of prescription opioid and prescription benzodiazepine misuse during young adulthood were prescription opioid and prescription benzodiazepine misuse (respectively) during adolescence.

IN PRACTICE:

“These findings amplify accumulating evidence suggesting that careful monitoring and screening during adolescence could identify individuals who are at relatively greater risk for PDM and need more comprehensive substance use assessment,” the authors wrote.

SOURCE:

Sean Esteban McCabe, PhD, professor and director, Center for the Study of Drugs, Alcohol, Smoking and Health, University of Michigan School of Nursing, Ann Arbor, was the lead and corresponding author of the study. It was published online on February 7 in Psychiatric Sciences.

LIMITATIONS:

Some subpopulations with higher rates of substance use, including youths who left school before completion and institutionalized populations, were excluded from the study, which may have led to an underestimation of PDM. Moreover, some potential confounders (eg, comorbid psychiatric conditions) were not assessed.

DISCLOSURES:

This study was supported by a research award from the US Food and Drug Administration and research awards from the National Institute on Drug Abuse of the NIH. Dr. McCabe reported no relevant financial relationships. The other authors’ disclosures are listed in the original paper.

A version of this article appeared on Medscape.com.

TOPLINE:

The use of stimulant therapy by adolescents with attention-deficit/hyperactivity disorder (ADHD) was not associated with later prescription drug misuse (PDM), a new study showed. However, misuse of prescription stimulants during adolescence was associated with significantly higher odds of later PDM.

METHODOLOGY:

• Data came from 11,066 participants in the ongoing Monitoring the Future panel study (baseline cohort years 2005-2017), a multicohort US national longitudinal study of adolescents followed into adulthood, in which procedures and measures are kept consistent across time.
• Participants (ages 17 and 18 years, 51.7% female, 11.2% Black, 15.7% Hispanic, and 59.6% White) completed self-administered questionnaires, with biennial follow-up during young adulthood (ages 19-24 years).
• The questionnaires asked about the number of occasions (if any) in which respondents used a prescription drug (benzodiazepine, opioid, or stimulant) on their own, without a physician’s order.
• Baseline covariates included sex, race, ethnicity, grade point average during high school, parental education, past 2-week binge drinking, past-month cigarette use, and past-year marijuana use, as well as demographic factors.

TAKEAWAY:

• Overall, 9.9% of participants reported lifetime stimulant therapy for ADHD, and 18.6% reported lifetime prescription stimulant misuse at baseline.
• Adolescents who received stimulant therapy for ADHD were less likely to report past-year prescription stimulant misuse as young adults compared with their same-age peers who did not receive stimulant therapy (adjusted odds ratio, 0.71; 95% CI, 0.52-0.99).
• The researchers found no significant differences between adolescents with or without lifetime stimulants in later incidence or prevalence of past-year PDM during young adulthood.
• The most robust predictor of prescription stimulant misuse during young adulthood was prescription stimulant misuse during adolescence; similarly, the most robust predictors of prescription opioid and prescription benzodiazepine misuse during young adulthood were prescription opioid and prescription benzodiazepine misuse (respectively) during adolescence.

IN PRACTICE:

“These findings amplify accumulating evidence suggesting that careful monitoring and screening during adolescence could identify individuals who are at relatively greater risk for PDM and need more comprehensive substance use assessment,” the authors wrote.

SOURCE:

Sean Esteban McCabe, PhD, professor and director, Center for the Study of Drugs, Alcohol, Smoking and Health, University of Michigan School of Nursing, Ann Arbor, was the lead and corresponding author of the study. It was published online on February 7 in Psychiatric Sciences.

LIMITATIONS:

Some subpopulations with higher rates of substance use, including youths who left school before completion and institutionalized populations, were excluded from the study, which may have led to an underestimation of PDM. Moreover, some potential confounders (eg, comorbid psychiatric conditions) were not assessed.

DISCLOSURES:

This study was supported by a research award from the US Food and Drug Administration and research awards from the National Institute on Drug Abuse of the NIH. Dr. McCabe reported no relevant financial relationships. The other authors’ disclosures are listed in the original paper.

A version of this article appeared on Medscape.com.