Summary
The rising use of telehealth for attention-deficit/hyperactivity disorder (ADHD) diagnosis and treatment necessitates a closer look at potential downstream consequences. This study investigates whether receiving an initial stimulant prescription via telehealth compared to an in-person visit alters the risk for subsequent stimulant use disorder (stimUD) or other substance use disorders (SUD).

A retrospective cohort study was conducted using electronic health record (EHR) data from Mass General Brigham (MGB), a large, nonprofit healthcare system in the Northeastern United States. The analysis encompassed 7944 patients aged ≥12 years with ADHD who received an initial stimulant prescription within the MGB system. Findings revealed that having any prior in-person relationship with the prescribing provider, compared to solely telehealth interactions, did not significantly impact the risk for either stimUD or SUD. However, the modality of the initial stimulant prescribing appointment did show a difference. Patients receiving their initial stimulant prescription via telehealth had a significantly greater risk of subsequent stimulant use disorder but not SUD compared to those who received a prescription during an in-person appointment. This finding requires replication, given that our sample exhibited low rates of the development of stimUD (.05-0.4%). Overall, telehealth prescribing appears similar to in-person in terms of overall SUD; while limited by small sample sizes, further work related to subsequent stimulant use disorders is necessary. 

Background
Individuals with ADHD exhibit a two to three-fold increased likelihood of developing stimulant (methamphetamine or cocaine) and other substance use disorders (SUD) compared to those without ADHD (Groenman, Janssen, & Oosterlaan, 2017). Recent data shows varying outcomes for stimulant-treated ADHD and subsequent SUD development (McCabe et al., 2023; Wilens et al., 2022). However, the field has not examined how stimulant prescription settings (i.e., in-person vs. telehealth) may differentially impact subsequent SUD risk.

The COVID-19 pandemic, federal waivers of the Ryan Haight Act, reimbursement changes, and allowance of interstate virtual visits have increased stimulant prescription via telehealth (Kolbe, White, & Manocchio, 2022). Pre-pandemic studies support telehealth for ADHD as an effective, well-tolerated service delivery model (Spencer, Noyes, & Biederman, 2020; Myers et al., 2015). Nonetheless, changing regulations, increases in stimulant prescriptions (Danielson et al., 2023) and stimulant-related consequences (eg, overdoses) underscore the need to examine telehealth prescribing and health-related outcomes such as SUD.

To this end, we examined the development of a stimUD or SUD following telehealth versus in-person prescribing of stimulants for ADHD since the pandemic’s onset. Using EHR data, the primary aim was (1) to determine whether receiving an initial stimulant prescription from a provider whom the patient had never seen in person relates to risk of developing SUD/stimUD. We also examined a secondary aim (2) if the appointment setting of the initial stimulant prescription (i.e., telehealth or in-person) impacts risk for SUD/stimUD to help inform clinical practice and telehealth flexibility policies. 

Methods
This is a retrospective cohort study utilizing EHR data from March 1, 2020, to August 25, 2023, from a nonprofit, academically affiliated medical system in the Northeastern United States. Eligible subjects were ages ≥12 years with ADHD and with initial receipt of any stimulant prescription during the study period. Exclusion criteria included an initial stimulant order indexed as historical or a non-nicotine SUD diagnosis at the time of an initial stimulant prescription. Logistic regression was used to compute adjusted odds ratios (aOR), controlling for demographic variables (sex, age cohort, race, median income in zip code of residence), pre-existing mental health diagnoses, and other clinical characteristics including provider specialty and observation time. 

Results
The sample included 7944 patients. (Aim 1) 7224 patients had ≥1 in-person visit with the prescriber on the day of/prior to the first encounter where the prescription was written; (Aim 2) 3963 patients had an in-person appointment on the day the 1st stimulant was prescribed. When adjusting for covariates, having any in-person relationship versus telehealth-based relationship did not significantly alter risk for SUD (aOR=1.18 [95% CI: 0.83, 1.66], p=0.34) or stimUD (aOR=0.83 [0.22, 3.08], p=0.78). Having an in-person versus virtual appointment at the time of the initial stimulant prescription did not significantly alter risk for subsequent SUD (aOR=0.87 [0.71, 1.07], p=0.19) but was associated with a significantly lower risk for stimUD (OR=0.30 [0.096, 0.95], p=0.041). 

Conclusion
The current study’s findings suggest that telehealth prescribing of stimulants for ADHD does not increase the risk for subsequent SUD compared to in-person prescribing. Moreover, having any in-person relationship with the prescriber did not alter the risk of developing stimUD or SUD, after accounting for covariates. However, the increased risk for subsequent stimUD based on initial stimulant prescription prescribed at a telehealth appointment is noteworthy. Given that our sample exhibited low rates of the development of stimUD (.05-0.4%), this finding requires replication in larger and diverse samples with greater power to detect meaningful differences in risk likelihood; as well as a better understanding of the potential differences in the characteristics of those who received their initial stimulant prescription at a telehealth visit compared to in-person.  

Scientific Significance
In general, these findings seem to align with the limited literature highlighting telehealth as a generally well-tolerated, effective alternative to in-person care for individuals with ADHD while suggesting the need for additional research. Future research in diverse for-profit and non-profit systems and attention to the characteristics of those choosing in-person compared to telehealth care is necessary.  

Learning Objectives

1. Compared to in-person care, is telehealth prescribing of stimulants for ADHD associated with increased risk for developing substance use disorders (SUD)? 

Keywords

• ADHD
• Substance Use Disorders
• Stimulant Use Disorder
• Telehealth

Presenter
Vinod Rao, MD, PhD

  

Vinod Rao MD PhD is a board-certified addiction psychiatrist practicing at Massachusetts General Hospital, where he serves as medical director for Ambulatory Psychiatry and as medical director for the West End Clinic, caring for adult outpatients with substance use disorders and comorbid medical concerns. After completing his medical degree and his graduate degree (studying the neurobiology of biased decision making) at Washington University in St Louis. He did his psychiatry residency at MGH-McLean and completed his fellowship training at the Partners (now MGB) Addiction Psychiatry Fellowship. He participates in several research projects supported by the FDA and NIH, and also works as a physician informaticist for MGH. 

Co-Authors: Silvia Lanni, Amy Yule, MD, Sean McCabe

Summary
The opioid crisis in the United States continues to escalate as a critical public health challenge into 2024, with opioid overdose deaths rising significantly due to the increased availability and consumption of Highly Potent Synthetic Opioids (HPSOs) such as fentanyl. These substances, significantly more potent and more dangerous than traditional opioids, have led to a surge in fatal overdoses. The widespread availability of these opioids has compounded the challenges faced by healthcare systems, as even tiny dosages can be lethal, making accidental overdoses more common.

One of the barriers to effective treatment for patients with OUD who use Traditional methods of buprenorphine induction often require patients to undergo a period of withdrawal before starting treatment, causing severe withdrawal symptoms due to their use. In contrast, the low-dose approach of buprenorphine (LDB) induction, as demonstrated in various case reports on the Bernese method (Ahmed et al., 2021), consistently shows that it reduces the risk of precipitated withdrawal, making it a more tolerable option for patients transitioning to buprenorphine treatment. Its feasibility and safety across diverse clinical settings, including outpatient environments and during pregnancy, highlight its versatility.

This post-hoc analysis aims to evaluate the efficacy and safety of LDB induction protocols for treating OUD, focusing on their impact on reducing opioid use, managing withdrawal symptoms, and enhancing recovery rates. The objectives are, first, to analyze the relationship between LDB induction and its effectiveness in achieving opioid abstinence and reducing usage. Second, to assess the impact of buprenorphine dosing strategies on withdrawal symptoms and other adverse outcomes. Third, to explore demographic and regional variations in the application and outcomes of LDB protocols. Initial buprenorphine dosing varied, with the mean dose for sublingual administration being 0.5027 (SD: 0.1361) mg, for buccal administration being 0.2357 (SD: 0.0283) mg, and for transdermal administration being 0.0075 ± 0.0035 mg, showing significant variability in dosing strategies (p=0.036).

The outcomes of our analysis shows that out of the 46 subjects, 45 had a successful induction, represented by the green bar. There was only one induction failure, indicated by the red bar. When considering the occurrence of precipitated withdrawal, 4 subjects experienced it (yellow bar), whereas 42 subjects did not (blue bar). The data highlights that the majority of subjects (42 out of 46) did not experience precipitated withdrawal and had a high success rate in induction. Conversely, there was only one case of induction failure, which occurred in the group that experienced precipitated withdrawal.

This study's post-hoc analysis provides critical insights into the efficacy and application of LDB induction for treating OUD. Notably, it identifies significant variations across multiple parameters, including region, age, and dosage, which clinicians must consider when developing tailored treatment plans for their patients. This data analysis shows that most of the participants are from North America, which might indicate either a regional preference or higher reporting rates of buprenorphine use in this region. The ages of the participants varied significantly, with a median age of 44 years, showing that adults are the main group benefiting from this treatment. This could be because adults have longer histories of opioid dependency. 

Background
The opioid crisis in the United States continues to escalate as a critical public health challenge into 2024, with opioid overdose deaths rising significantly due to the increased availability and consumption of Highly Potent Synthetic Opioids (HPSOs) such as fentanyl. These substances, significantly more potent and more dangerous than traditional opioids, have led to a surge in fatal overdoses. The widespread availability of these opioids has compounded the challenges faced by healthcare systems, as even tiny dosages can be lethal, making accidental overdoses more common. The number of overdose deaths involving fentanyl has risen dramatically, with an estimated number exceeding 105,000 over 12 months by November 2023, where 64.0% of deaths involved synthetic opioids like fentanyl (Ahmad FB et al 2024).

In response, several measures have been implemented to reduce opioid overdose fatalities, including making naloxone available over the counter (Messinger et al., 2023), eliminating the X waiver to broaden prescriber eligibility for opioid addiction treatments [LeFevre N et al 2023], and introducing new formulations of buprenorphine (extended-release implants, long-acting injectables, etc.)[Heidbreder C et al 2023; Dhawal A et al 2019; Maremmani I et al 2023] that allow for higher dosages and potentially more effective management of opioid use disorder (OUD).

This crisis has also led to the adoption of new approaches in treatment strategies like buprenorphine micro induction or what we refer to here in this paper as low-dose buprenorphine (LDB) induction to minimize withdrawal discomfort by administering small, incremental doses of buprenorphine/naloxone without necessitating prior opioid abstinence.

One of the barriers to effective treatment for patients with OUD who use HPSOs is that traditional methods of buprenorphine induction often require patients to undergo a period of withdrawal  before starting treatment, causing severe withdrawal symptoms due to their HPSO use. In contrast, LBD induction, as demonstrated in various case reports on the Bernese method (Ahmed et al., 2021), consistently shows that it reduces the risk of precipitated withdrawal, making it a more tolerable option for patients transitioning to buprenorphine treatment. Its feasibility and safety across diverse clinical settings, including outpatient environments and during pregnancy, highlight its versatility. Patients benefit from milder withdrawal symptoms, which enhances adherence and reduces the likelihood of relapse during the induction phase. (Malhi et al., 2017). This method broadens access to treatment by removing the deterrent of severe withdrawal symptoms, making it more acceptable. Adaptability to special populations, such as individuals on high-dose methadone, showcases LDB induction capability to meet unique clinical needs, enhancing its utility in OUD management.

This post-hoc analysis aims to evaluate the efficacy and safety of LDB induction protocols for treating OUD, focusing on their impact on reducing opioid use, managing withdrawal symptoms, and enhancing recovery rates. The objectives are, first, to analyze the relationship between LDB induction and its effectiveness in achieving opioid abstinence and reducing usage. Second, to assess the impact of buprenorphine dosing strategies on withdrawal symptoms and other adverse outcomes. Third, to explore demographic and regional variations in the application and outcomes of LDB protocols. 

Methods
This post hoc analysis protocol was registered in the PROSPERO database. Following the PRISMA 2020 guidelines, we conducted a comprehensive literature search to identify studies involving LDB induction for opioid use disorder. The search covered several databases, including PubMed, Embase, PsycINFO, Web of Science, and the Cochrane Library, with additional searches in Google Scholar and ClinicalTrials.gov to include published studies up to May 1, 2024. The search strategy utilized a blend of keywords, MeSH terms appropriate for each database to retrieve relevant literature thoroughly. Statistical analyses were performed using SPSS version 26. The initial phase involved computing frequencies (N) and percentages (%) for each variable. For inferential statistics, bivariate analyses were conducted to examine the relationships between the study variables. 

Results
Initial buprenorphine dosing varied, with the mean dose for sublingual administration being 0.5027 (SD: 0.1361) mg, for buccal administration being 0.2357 (SD: 0.0283) mg, and for transdermal administration being 0.0075 ± 0.0035 mg, showing significant variability in dosing strategies (p=0.036).

It shows that out of the 46 subjects, 45 had a successful induction, represented by the green bar. There was only one induction failure, indicated by the red bar. When considering the occurrence of  precipitated withdrawal, 4 subjects experienced it (yellow bar), whereas 42 subjects did not (blue bar). The data highlights that the majority of subjects (42 out of 46) did not experience precipitated withdrawal and had a high success rate in induction. 

Conclusion
Our data analysis provides evidence for the appropriateness and safety of LDB. Although the percentage of participants experiencing precipitated withdrawal was relatively low, the significant difference in initial doses suggests a clear correlation. The statistically significant difference in initial dosing highlights a risk associated with higher starting doses and triggering precipitated withdrawal. Implementing low-dose buprenorphine induction can mitigate this. Evidence supports a shift in clinical practice towards personalized and cautious induction strategies. By starting with lower doses, clinicians can allow for a more gradual transition from full agonists like fentanyl to buprenorphine, reducing the likelihood of precipitated withdrawal. This approach enhances patient comfort and increases the likelihood of successful induction, as patients are less likely to abandon treatment due to discomfort or adverse effects. 

Scientific Significance
This post hoc analysis supports the effectiveness of low-dose induction of Suboxone. It demonstrates its potential to improve patient outcomes, manage withdrawal symptoms more effectively, and address the co-administration of multiple substances commonly used alongside buprenorphine. This approach, combined with comprehensive care strategies, could significantly enhance the management and treatment of OUD. Additionally, long-term strategies are essential to sustain recovery and address ongoing challenges in achieving complete remission of OUD. The recovery rates, though substantial, highlight ongoing challenges in achieving complete remission of opioid use disorder (OUD) and emphasize the need for long-term strategies to sustain recovery. In this context, we emphasize that low-dose induction (LDB) of buprenorphine presents an underutilized intervention. 

Learning Objectives

1. To learn about the problems surrounding traditional Buprenorphine Induction  
2. To learn about Low Dose Buprenorphine Induction and dosing regimens 
3. To learn about the outcomes of Low Dose Buprenorphine Induction 

Keywords

• Low-dose Buprenorphine Initiation
• Opioid Use Disorder
• Opioid Withdrawal
• Opioid Treatment Programs

Presenter
Justin Morales, MD

  

I am a PGY4 psychiatry resident at NYU. 

Co-Authors: Aaron Garcia, Zouina Sarfraz, Luis Velez, Souparno Mitra, MD, Lakshit Jain, MD, Saeed Ahmed, MD

Summary
We aim to study the prevalence of substance use disorders among hospitalized transgender patients in the United States (U.S.). 

Background
Previous studies have showed increased co-occurrence of substance use disorders among transgender adults [1]. However, national population studies are scarce on the prevalence of various types of substance use disorders in hospitalized transgender patients in the U.S. 

Methods
We obtained data from the National Inpatient Sample (NIS) 2016 & 2017 database. The NIS is the largest hospitalization database in the U.S. It is a nationally representative stratified sample of approximately 20% of U.S. community hospitals. Hospitalizations are weighted to provide national estimates. We searched for hospitalizations for adult patients aged ≥18, with and without any diagnosis of “transsexualism” or “personal history of sex reassignment” using ICD-10 codes "F640" & “Z87890” respectively. We used chi-square to compare the prevalence of co-existing substance use disorders among adult hospitalized transgender patients and the general hospitalized population. A p-value of 0.05 was used as the threshold for statistical significance.  STATA, 16 was used for analysis. NIS contains depersonalized data, hence Institutional Board Review review was not sought. 

Results
About 60.6 million hospitalizations for adult patients are contained in the NIS database, out of which 9,800 patients (0.02%) were transgender. Hospitalized transgender patients were mainly whites (65.6%) and privately insured (37.5%) with a mean age of 40 years. Hospitalized transgender patients have a greater prevalence of nicotine use (24.3% vs 17.3%, p<0.0001), alcohol-related disorder (9.2% vs 5.9%, p<0.0001), cannabis-related disorders (10.3% vs 2.6%, p<0.0001), cocaine-related disorders (4.4% vs 1.3%, p<0.0001), opioid-related disorders (4.9% vs 2.5%, p<0.0001), sedative, hypnotic or anxiolytic related disorders (0.8% vs 0.4%, p=0.0188), amphetamine/caffeine-related disorders (3.7% vs 1.1%, p<0.0001), inhalant related disorders (0.05% vs 0.009%, p=0.0416), hallucinogen related disorders (0.26% vs 0.05%, p<0.0001) and polysubstance/indiscriminate substance-related disorders (2.7% vs 0.9%, p<0.0001) compared to the general hospitalized adult population. 

Conclusion
Hospitalized adult transgender patients have an increased prevalence of various substance use disorders compared to the general adult hospitalized population. Hospitalized transgender patients should be screened for substance use disorders during hospitalization. Those who screen positive should be provided counseling and resources to seek help. A multidisciplinary approach involving mental health providers, social workers, and the primary team is essential in addressing this issue.  

Scientific Significance
Hospitalized adult transgender patients have an increased prevalence of various substance use disorders compared to the general hospitalized adult population.  

Learning Objectives

1. To study the prevalence of various types of substance use disorders in hospitalized transgender adult patients compared to the general hospitalized adult population. 

Keywords

• Substance Abuse
• Big Data Analytics
• Claims Data

Presenter
Precious Obehi Eseaton, MD

   

I am Precious Obehi Eseaton, a psychiatry resident at the University of Texas Health Science Center At Houston program. 

Co-Authors: Oyidia Ijioma, Jesse Odion, Gibson Anugwom, MD, Nkechinyere Harry, Philips Okeagu, Ehizogie Edigin