BACKGROUND:Hospitalized patients with opioid use disorder commonly experience undertreated withdrawal, leading to increases in patient-directed discharge and readmission. Short-acting opioids can mitigate withdrawal in patients who are unwilling to trial buprenorphine or methadone, or need additional symptom control during up-titration. OBJECTIVES:This study assessed the safety and efficacy of a short-acting opioid protocol for opioid withdrawal. METHODS:A retrospective cohort study was conducted on hospitalized patients with opioid use disorder who received a short-acting opioid protocol for withdrawal with intravenous hydromorphone or oral oxycodone. The primary endpoint was the incidence of severe withdrawal. Secondary endpoints included naloxone use, patient-directed discharge, and length of stay. A paired cohort was analyzed where patients' hospital outcomes were compared pre- versus post-protocol. RESULTS:Naloxone use after protocol initiation was 0% and severe withdrawal occurred in one patient (1%). The patient-directed discharge and 30-day readmission rates were 38% and 30%, respectively. Fifty-one percent of patients had a prior hospitalization within two years without use of the short-acting opioid protocol and were included in the paired cohort analysis. The pre- versus post-protocol patient-directed discharge rate was 47% vs. 43% (p = 0.774) and length of stay was 3 vs. 5 days (p = 0.180). CONCLUSIONS:Our findings provide preliminary evidence for the safety of a short-acting opioid protocol for opioid withdrawal. There was no significant difference in patient-directed discharge rate or length of stay in the paired cohort of patients' encounters with or without short-acting opioid protocol use. Larger studies are necessary to draw conclusions regarding safety and efficacy.
Craving is a subjective, poorly characterized phenomenon strongly associated with return to use in alcohol use disorder and remains difficult to manage. Extended-release naltrexone is a U.S. Food and Drug Administration-approved, evidence-based treatment, yet some patients experience brief, intense "breakthrough" craving despite adherence. Although expert guidance references oral naltrexone supplementation as an option during extended-release naltrexone maintenance, published peer-reviewed case descriptions documenting this clinical scenario are lacking. We describe three adults with severe alcohol use disorder receiving monthly extended-release naltrexone who reported late-cycle breakthrough craving and were offered adjunct, as-needed oral naltrexone. All patients reported subjective improvement in craving control and continued engagement in treatment. These cases highlight a clinically observed pattern of late-cycle breakthrough craving that warrants prospective evaluation.
Background: Alcohol Use Disorder is a heterogeneous condition where standard severity measures often fail to predict individual treatment responses. Precision medicine requires identifying distinct biopsychosocial profiles to guide targeted interventions.Objectives: To identify clinically meaningful Alcohol Use Disorder profiles using k-means clustering based on eight baseline biopsychosocial variables and validate their prognostic utility by comparing treatment outcomes.Methods: A retrospective observational study included 102 patients at a tertiary care center in India. K-means clustering was applied to baseline variables: age, Alcohol use duration, alcohol severity, craving, co-occurring psychiatric conditions, self-efficacy, education, and occupation. Cluster stability was assessed via bootstrap resampling. The primary outcome was 3-month abstinence, corroborated by GGT levels.Results: Three distinct profiles emerged: (1) Late-Onset (n = 38), with older age and lowest craving, achieving 65.8% abstinence; (2) High-Functioning (n = 34), defined by high socioeconomic status and zero co-occurring disorders; and (3) Severe (n = 30), characterized by early onset, high co-occurring psychiatric conditions (73.3%), and intense craving. Despite similar alcohol severity scores (p = 0.215), the Severe profile group had poorer outcomes (36.7% abstinence; p = 0.004) and a steep return to use trajectory.Conclusion: Identifying three distinct Alcohol Use Disorder profiles through k-means cluster analysis advances precision medicine in substance use treatment. Return to use risk was driven by craving and co-occurring conditions rather than AUD severity. These findings support a stratified approach, where Severe profile group patients require immediate, intensive "front-loaded" intervention.
Residential substance use treatment programs deliver a wide range of evidence-based interventions addressing biological, psychological, and social dimensions of recovery. Despite this comprehensive approach, care across phases of treatment often becomes fragmented, limiting clinical coherence and obscuring residual risk of return to use at key transition points. This article introduces the Four Dimensions of Resilience, a whole-person organizing structure designed to integrate multidisciplinary care across intake, treatment planning, and discharge in residential substance use treatment. The model conceptualizes recovery capacity across four interacting domains: resilient biology, emotional tone, cognitive orientation, and interpersonal connection. Rather than proposing new interventions, the model functions as an organizing structure that integrates existing evidence-based practices into a unified clinical map, supporting interdisciplinary communication and continuity of care. Practical applications across the residential continuum-including assessment, treatment planning, and discharge evaluation-are described. By providing a shared language for whole-person recovery, this approach may help treatment programs enhance clinical coherence and improve identification of residual vulnerability to return to use.
AIM:To investigate the association between drinking patterns and multimorbidity in Chinese adults. METHODS:In this 2022 nationwide cross-sectional study of 30,505 participants from 31 provinces, drinking status was categorized as: nondrinkers (never consumed alcohol), constant drinkers (individuals with regular uninterrupted use), current drinkers (individuals with recently initiated), and ex-drinkers (with no alcohol consumption in the past 12 months). Multimorbidity was defined as ≥2 concurrent chronic conditions. Associations were assessed using binary and multinomial logistic regression. Subgroup analyses were conducted among constant drinkers to evaluate age at initiation, daily intake, and beverage type; furthermore, a dedicated analysis was performed among those with alcohol use disorder (AUD) to identify specific risk factors within this subgroup. RESULTS:Compared with individuals who never drank, individuals who were constant drinkers, current drinkers, and ex-drinkers had higher odds of having multimorbidity (AORs = 1.41, 95%CI:1.29-1.56; AORs = 1.24, 95%CI:1.08-1.41; AORs = 2.04,95%CI:1.85-2.26). Additionally, individuals who were ex-drinkers also exhibited the highest risk for a greater number of chronic conditions (AORs = 2.00; 95%CI:1.82-2.19). Among individuals who were constant drinkers, the presence of AUD was associated with higher odds of multimorbidity (AORs = 1.69, 95% CI:1.35-2.21). In a dedicated analysis of this AUD subgroup, moderate daily consumption was linked to lower odds, while retirement and former smoking were linked to higher odds. In this comprehensive model, factors such as age at drinking initiation and other sociodemographic factors were not independently associated with risk (p > 0.05). CONCLUSIONS:This study confirms the association between alcohol use and multimorbidity in China, identifying former drinkers and individuals with AUD as high-risk groups. The findings suggest that interventions for these groups should address broader health and social risks, beyond alcohol consumption alone.
BACKGROUND:Transcranial direct current stimulation (tDCS) is increasingly explored as an adjunctive intervention for Tobacco Use Disorder (TUD). Studies typically employ single-site stimulation protocols, and reported effects on craving and relapse have varied. OBJECTIVE:To examine whether sequential dual-target tDCS could influence smoking behavior and relapse-relevant mechanisms in TUD. METHODS:In this case series, three adults with TUD underwent a two-week sequential tDCS protocol targeting the left dorsolateral prefrontal cortex and pre-supplementary motor area. Assessments were conducted at baseline, post-intervention, and at 1- and 6-month follow-up characterize clinical, biological, and cognitive trajectories over time. RESULTS:All cases showed reductions in cigarette consumption across the six-month follow-up, accompanied by decreases in biochemical exposure markers. Trajectories were heterogeneous across participants. Two individuals achieved abstinence at follow-up, while one maintained sustained reduction. Craving and withdrawal symptoms declined, and inhibitory control improved alongside reductions in exposure markers. The nicotine metabolite ratio remained stable across assessments, consistent with its role as an index of metabolic phenotype. CONCLUSIONS:Sequential dual-target tDCS was associated with longitudinal improvements in smoking behavior and relapse-related clinical and cognitive markers. These findings support further investigation of dual-target neuromodulation as a potential adjunctive strategy for smoking cessation.
Hospitalized patients with opioid use disorder present unique clinical challenges, including higher rates of patient-directed discharge (PDD), incomplete treatment courses, and frequent readmissions. To compare outcomes in hospitalized patient encounters involving OUD and bacteremia that were ordered medications for opioid use disorder versus high-dose opioid agonist therapy (HDOAT) alone. This single-center, retrospective study included 268 OUD patients, 383 encounters, and 303 cases of bacteremia admitted to Temple University Hospital from Jan 1, 2020 through Dec 31, 2022. Outcomes of interest included PDD, 7 and 30-day readmission, inpatient mortality, length of stay (LOS), one year mortality and antibiotic completion. Bacteremia is a serious illness and requires long term treatment, thus it is an optimal model for this work. Of 383 encounters, 234 involved MOUD, and 149 involved HDOAT alone. Among the HDOAT group, doses were up to 2,070 MMEs/day. MOUD included buprenorphine and methadone. HDOAT included non-MOUD full agonist such as oxycodone and/or hydromorphone. For case-level outcomes, MOUD was associated with higher antibiotic completion (35.0% vs 23.3%, OR 1.77, p < 0.05). For encounter-level outcomes, MOUD was associated with lower PDD rates (38.5% vs 69.8%, OR 0.27, p < 0.0001) and longer LOS (8d vs 3d), seven-days readmission and inpatient mortality rates were similar between groups. However, 30-day readmission rate was lower in the MOUD group (32.9% vs 43.0%, OR 0.65, p < 0.05). PDD, readmission and mortality were similar regardless of timing of MOUD initiation (<72 h vs > 72h) or severity of opioid dependence. Notably, 23% of HDOAT cases successfully completed antibiotics, often across multiple encounters. MOUD initiation was associated with lower PDD and higher antibiotic completion rates. Timing of MOUD initiation did not affect outcomes. HDOAT may serve as a second-line approach to support continuity of care in patients declining MOUD.
BACKGROUND:Smoking cessation is often assessed using clinical and self-report measures that may not capture autonomic changes. Wearables allow continuous monitoring. METHODS:Twenty-eight smokers underwent 10 days of monitoring of sleep duration, resting heart rate, and HRV. Cotinine-confirmed relapse (n = 15) and maintained cessation (n = 13) groups were compared across physiological, clinical, and wearable index measures. RESULTS:Participants who returned to tobacco use showed shorter sleep duration, higher resting heart rate, and lower HRV (all p-values < 0.05). The wearable index was higher in the relapse group (p = 0.016, g = 0.97). CONCLUSIONS:Wearable measures may complement clinical and self-report assessments during smoking cessation.
Some individuals use substances to cope with their post-traumatic stress disorder symptoms. The emotional, behavioral, and spiritual experience of both their post-traumatic stress disorder and substance use disorder is manifested in a sense of powerlessness, which is caused by the inability to stop using despite negative consequences related to continued use. Thus, powerlessness is a prominent factor in recovery from substance use disorder. The aims of the present theoretical article were to (a) present the consequences of the co-morbid post-traumatic stress disorder and substance use disorder that can lead to powerlessness, (b) discuss powerlessness as empowering in recovery from substance use disorder based on Alcoholic Anonymous and Narcotic Anonymous programs and post-traumatic growth theory, and (c) present a model of overcoming powerlessness in recovery from substance use disorder. The present conceptual model is based on the premise that powerlessness is multidimensional and manifested on three levels: behavioral, mental, and spiritual. Addressing powerlessness effectively requires relating to these aspects, which is in alignment with the broad view of change in personality, social, and spiritual aspects in the post-traumatic growth approach. This article contributes to the field by presenting the intrapersonal, interpersonal, and spiritual aspects associated with powerlessness and by addressing its multilevel nature in a meaningful way.
BACKGROUND:Prevailing models of addiction emphasize reward dysregulation, stress neuroadaptation and impaired executive control, but typically treat metabolic disturbance as secondary. Convergent evidence across neuroimaging, physiological and endocrine domains suggests that instability in energy mobilization and utilization may play a more central role in addiction-related neuroadaptation than is currently formalized. OBJECTIVE:To develop a structured theory-synthesis reconceptualizing addiction as a disorder of metabolic-arousal regulation. METHODS:A theory-synthesis approach was applied to integrate findings from addiction neuroscience, metabolic physiology and stress psychology, mapped onto the Koob-Volkow addiction cycle. Evidence relating to cerebral glucose metabolism, autonomic regulation, endocrine function, inflammation and temporal cognition was synthesized within a unified framework. MODEL:Two dynamically interacting states are proposed. Hyperarousal, characterized as anticipatory mobilization or "living in the future," involves increased metabolic demand, sympathetic predominance and cue-driven salience. Hypoarousal, characterized as energetic constraint or "living in the past," involves reduced metabolic availability, cortical hypometabolism and ruminative cognition. These states are hypothesized to map onto phases of the addiction cycle and to be measurable via biomarkers including cerebral glucose metabolism, heart-rate variability, cortisol dynamics and inflammatory indices. CONCLUSIONS:Addiction may be usefully conceptualized as a disorder of metabolic-arousal regulation that organizes, rather than replaces, established neurobiological accounts. The model integrates findings across levels of analysis and generates testable predictions for biomarker-informed, phase-specific intervention.
Opioid use disorder (OUD) is a major public health challenge with high overdose mortality and healthcare utilization. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) offer cardiometabolic and neurobiological benefits, including modulation of reward pathways linked to addiction. Preclinical and early clinical data suggest GLP-1RAs may reduce substance-seeking behaviors, but realworld outcomes in OUD remain unclear. We conducted a retrospective cohort study using the TriNetX US Collaborative Network to identify adults aged ≥18 years diagnosed with OUD between January 1, 2016, and October 30, 2025. GLP-1RA exposure was defined as a prescription within 1 month up to the date of OUD diagnosis. Propensity score matching (1:1) balanced demographic and clinical covariates, including medication for opioid use disorder (MOUD) treatments. Primary outcomes were all-cause mortality and opioid overdose; secondary outcomes included inpatient admissions and emergency department (ED) visits over 6-month to 5-year intervals. Among 473,906 individuals with OUD, 8,737 (1.8%) received a GLP-1RA; after propensity score matching, 8,052 patients remained in each cohort with wellbalanced baseline characteristics (all standardized mean differences ≤0.10). GLP-1RA use was associated with lower 5-year all-cause mortality (4.9% vs 10.9%; HR 0.63, p < 0.001) and reduced overdose risk (3.0% vs 4.8%; HR 0.81, p = 0.01). In addition, GLP-1RA therapy was linked to fewer inpatient admissions (HR 0.73) and ED visits (HR 0.83), both with p < 0.001. These findings suggest that GLP-1RA use was associated with lower mortality, overdose risk, and healthcare utilization, supporting further investigation of GLP-1RAs as potential adjunctive therapies for OUD.
Stigmatizing language describing substance use behaviors in clinical documentation and in patient education materials can harm patients and their families. Recent literature has discouraged the use of stigmatizing language in treatment settings and medical documentation. However, large language models (LLMs) generate output using previously generated text, including sources such as electronic health records which may include stigmatizing language. While artificial intelligence (AI) developers continue to update and create LLM products, these developers might prioritize other issues over reducing stigmatizing language surrounding substance use disorders. These diverging priorities make it possible that updated and new LLMs might not eliminate the problem of stigmatizing language in LLM output, even as researchers explore methods to reduce the impact of stigmatizing language in AI models. The potential for LLM output to include stigmatizing language warrants caution on the part of clinicians as AI developers release products intended to facilitate clinical documentation. This article identifies stigmatizing language regarding substance use disorders and explores the potential for LLM output to include stigmatizing language. The author also discusses several challenges that clinicians may face in preventing stigmatizing language from transferring from LLM output into medical records, including randomness inherent in LLM output, balancing appropriate versus inappropriate uses of potentially stigmatizing language, and the need for continued human review of medical documentation even in the face of potentially increased patient volumes. Finally, the author proposes that practicing clinicians be included in an ongoing, active process of iterative refinement of LLM output for clinical use to reduce the risk of perpetuating stigmatizing language regarding substance use disorders.
Alcohol may confound or complicate diagnosis of Metabolic Dysfunction Associated Steatotic Liver Disease (MASLD). Though phosphatidylethanol (PETH) testing is widely available, its use among patients with MASLD has not been well established. This study set out to determine both the frequency of PETH testing and the rate of positive PETH tests among patients initially diagnosed with MASLD. We conducted a retrospective cohort study at a single institution of patients diagnosed with MASLD. Patient demographics, metabolic comorbidities, labs, and rate of PETH testing were collected. We compared characteristics of patients with and without PETH testing as well as those with positive results. LASSO regression was then used to identify predictive factors of a positive PETH test. We identified 10,208 patients who met the inclusion criteria; PETH testing was performed in only 700 patients (6.9%). Among those who underwent PETH testing, 275 patients (39.6%) had a positive PETH. Positive PETH results were associated with younger age, male sex, a lower BMI, the absence of diabetes, and elevated AST, ALT, and MCV values. However, using patient factors, the LASSO model demonstrated a poor ability to predict a positive PETH (AUC 0.64). Although PETH testing was only sent in a minority of patients diagnosed with MASLD, over a third were elevated. We found that patient and laboratory parameters were insufficient to predict potentially injurious alcohol use. These findings suggest that use of PETH testing may better inform care of patients with MASLD.
Buprenorphine micro-induction enables a gradual transition from full opioid agonists without requiring abstinence, minimizing the risk of precipitated withdrawal. This approach is particularly beneficial for older adults with chronic pain who remain on long-term opioid therapy and may be reluctant or medically unfit to undergo traditional induction protocols. A 68-year-old woman with Ehlers-Danlos Syndrome, complex surgical history, and severe opioid use disorder who was taking 280 (Morphine Milligram Equivalents per Day), including prescribed morphine and illicit hydromorphone. She underwent an outpatient buprenorphine-naloxone micro-induction while continuing full agonist use until target dose was reached. Doses were titrated over seven days with minimal withdrawal symptoms. She successfully transitioned to buprenorphine-naloxone 4-1 mg QID (Four Times Per Day), reporting improved pain, mobility, and overall functioning. Outpatient micro-induction can be safely implemented in older adults with chronic opioid exposure, particularly those receiving prescription opioids from outside prescribers for chronic pain. This case underscores the utility of pharmacogenomics, trauma-informed care, and interdisciplinary coordination to facilitate successful transition to MOUD.
BACKGROUND:Gamma-hydroxybutyrate (GHB) is frequently misused for its sedative and euphoric effects. Abrupt cessation may result in severe withdrawal; however, neuroimaging correlates of withdrawal-related neurotoxicity remain poorly defined. CASE PRESENTATION:A 33-year-old male developed acute delirium, visual hallucinations, and autonomic instability after abruptly discontinuing frequent and high-dose GHB use. Routine toxicology screening was negative. Brain MRI revealed a focal splenial cytotoxic lesion of the corpus callosum (CLOCCs). He was clinically diagnosed with sedative, hypnotic, or anxiolytic withdrawal; sedative-, hypnotic-, or anxiolytic-induced anxiety disorder; and sedative, hypnotic, or anxiolytic use disorder, severe. His symptoms rapidly resolved with supportive care, and he was discharged without neurological sequelae. CONCLUSION:CLOCCs may represent an important radiological indicator of GHB withdrawal-related neurotoxicity.
Harm reduction vending machines (HRVMs) are increasingly implemented across the United States and Canada as low‑barrier, 24‑hour distribution mechanisms for life‑saving supplies such as naloxone, drug‑checking tools, sterile equipment, and hygiene items. As these machines have become more visible within public health infrastructure, social media platforms have emerged as key arenas where HRVMs are framed, debated, and politicized. This commentary examines dominant themes in social media coverage of harm reduction vending machines, including narratives emphasizing overdose prevention and accessibility, as well as stigmatizing claims that portray machines as enabling substance use or social disorder. Drawing on program reports, implementation reviews, and media monitoring analyses, the paper situates online discourse within the existing evidence base and public health guidance. Social media discussions frequently amplify misinformation, yet they also function as channels for disseminating evidence‑based education, utilization data, and digital toolkits produced by public health agencies and advocacy organizations. Viral controversies surrounding HRVMs have demonstrated tangible consequences, including policy reviews and service disruptions, underscoring the influence of digital narratives on real‑world access to harm reduction resources. For clinicians and public health practitioners, understanding and engaging with social media representations of HRVMs is essential for effective patient counseling, community engagement, and program sustainability. Strategic, evidence‑based digital communication offers an opportunity to counter stigma, align public narratives with clinical guidance, and reinforce harm reduction vending machines as a routine and equitable component of overdose prevention and public health practice.
BACKGROUND:The 5A and 5R counselling models are widely recommended frameworks for smoking cessation; however, their implementation in primary care remains inconsistent. OBJECTIVE:This multicenter cross-sectional study assessed the use of these models among 203 family physicians in Istanbul and examined the factors associated with counselling performance. METHOD:A structured questionnaire was used to evaluate demographics, smoking-related behaviors, knowledge of cessation methods, and the frequency of applying each step of the 5A and 5R models (10-item dichotomous responses with excellent internal consistency; KR-20 = 0.83, α = 0.83, and strong item-total correlations r = 0.46-0.75). Logistic regression and machine learning clustering were used to identify the predictors and patterns of counselling behavior. RESULTS:Physicians most frequently implemented the Ask (52.7%) and Advise (70.9%) steps, whereas the Assess, Assist, and Arrange steps were applied infrequently. Among the 5R components, Relevance (70.0%) and Risks (54.7%) were more commonly used than Rewards, Repetition, or Roadblocks. While 12.8% of physicians frequently performed very brief interventions (Ask-Advise-Assess), adherence declined markedly for more comprehensive models, with only 5.9% applying all 5A steps, 17.2% all 5R components, and 5.4% the full 5A-5R framework. Current smoking was 8.9%, and 15.8% of participants reported intermittent tobacco use. Older age (≥30 years) increased the likelihood of applying Ask and Reward, whereas exposure to parental smoking during childhood reduced the likelihood of using the Assist step. Male physicians were less likely to use repetition. Knowledge of motivational interviewing was consistently associated with higher adherence to several 5A and 5R steps. Machine learning revealed three counselling clusters, with 83.7% of physicians demonstrating low counseling competence. CONCLUSION:Adherence to smoking cessation counselling models among family physicians remains suboptimal, showing a gap between guidelines and practice. These findings provide baseline data before the nationwide cessation training program for 26,000 family physicians in Türkiye, highlighting areas for targeted interventions.
INTRODUCTION:Patients who inject drugs disproportionately experience frequent patient-directed discharge and readmissions. Assessment of quality of life may provide insight into individual barriers limiting health and addiction treatment. The relationship between QoL and discharge outcomes is unclear, particularly in the context of PWID in the inpatient setting. OBJECTIVES:This study aimed to characterize the relationship between QoL, discharge outcomes, and treatment decisions of PWID in the inpatient setting. METHODS:This was a single-centered study conducted at an urban tertiary care center during a six-month period. Patients self-administered a modified Drug User QoL scale. Demographic information, disposition, and medication therapies were obtained retrospectively. Comparisons were made based on disposition and treatment. RESULTS:Of 58 eligible participants, 36 completed the DUQOL. The median age was 38 years; 48% were male, and 54% reported homelessness. DUQOL scores were lower for PDD patients than non-PDD patients. Patients who initiated medications of opioid use disorder inpatient had higher DUQOL scores compared to those who declined. Initiation of MOUD was associated with significantly lower odds of PDD; however, there was no significant difference in 30-day readmission. DUQOL domains that had a discordance between importance and satisfaction on the DUQOL included "Housing," "Health," "Sense of Future," "Feeling Good," and "Being Useful." CONCLUSION:Higher QoL was observed to have better clinical outcomes and MOUD acceptance. DUQOL scores, particularly domains where there is a high discordance between satisfaction and importance, may serve as an important tool in predicting clinical outcomes and guiding treatment decisions.
