Summary
This presentation will explore the effects of delta-9-tetrahydrocannabinol (THC), the primary psychoactive component of cannabis, on individuals with opioid use disorder. By employing an experimental, randomized, placebo-controlled, crossover design, the study enables precise dosing and detailed measurement of THC’s impact on various addiction-related outcomes. The findings from this research have significant implications across various domains.

In clinical practice, the results can inform clinicians about the potential benefits or risks of THC use in patients with opioid use disorder, guiding treatment plans and harm reduction strategies. For research, this study contributes to the growing body of evidence on the interactions between cannabis and opioids, identifying areas for further investigation and potential therapeutic targets.

Educationally, the insights gained can be integrated into medical and therapeutic training programs, enhancing understanding of cannabis’ role in opioid addiction. Regarding policy, the findings can inform public health guidelines on cannabis use among individuals receiving treatment for opioid use disorder. 

Background
The opioid and cannabinoid receptor systems are inextricably linked—overlapping at the anatomical, functional and behavioral levels. Preclinical studies have reported that cannabinoid and opioid agonists produce synergistic anti-nociceptive effects. Still, there are no experimental data on the effects of cannabinoid agonists among humans who receive opioid agonist therapies for opioid use disorder. 

Methods
We conducted an experimental study to investigate the acute effects of the delta-9-tetrahydrocannabinol (THC) among persons receiving methadone therapy for OUD. Using a within-subject, crossover, human laboratory design, 25 persons on methadone therapy for OUD (24% women) were randomly assigned to receive single oral doses of THC (10 or 20 mg, administered as dronabinol) or placebo, during three separate 5-h test sessions. Measures of experimental and self-reported pain sensitivity, abuse potential, cognitive performance and physiological effects were collected. Mixed-effects models examined the main effects of THC dose and interactions between THC (10 and 20 mg) and methadone doses (low-dose methadone defined as <90 mg/day; high dose defined as >90 mg/day).  

Results
Results demonstrated that, for self-reported rather than experimental pain sensitivity measures, 10 mg THC provided greater relief than 20 mg THC, with no substantial evidence of abuse potential, and inconsistent dose-dependent cognitive adverse effects. There was no indication of any interaction between THC and methadone doses. 

Conclusion
Collectively, these results provide valuable insights for future studies aiming to evaluate the risk–benefit profile of cannabinoids to relieve pain among individuals receiving opioid agonist therapy for OUD, a timely endeavor amidst the opioid crisis. 

Scientific Significance
Findings from this study suggest that lower doses of dronabinol can provide pain relief with minimal abuse potential and manageable cognitive effects, without interacting adversely with methadone. However, higher doses did not enhance pain relief and presented inconsistent cognitive effects. These insights highlight the potential benefits and risks of cannabinoids as a complementary pain management strategy for OUD patients, emphasizing the need for balanced evaluation in future research amid the opioid crisis.  

Learning Objectives

1. Understand Basic Cannabis Pharmacology and Regulatory Changes: Gain a basic understanding of the dose-dependent properties of cannabis and its THC, and stay informed about recent policy changes affecting their clinical use, particularly in the treatment of opioid use disorder. 
2. Understand the State of the Evidence on Cannabinoids’ Effects in Opioid Use Disorder: Explore the potential pain-relieving, opioid-withdrawal suppressing, and opioid-sparing effects of cannabinoids, providing a well-rounded view of the current evidence in this area. 
3. Apply Research Insights on Cannabinoids in Opioid Use Disorder Treatment: Learn to apply the research findings on the effects of THC in OUD treatment, focusing on clinical implications and factors influencing patient response to these treatments.

Keywords

• Cannabis
• Opioids
• Pain Management
• Methadone Treatment
• Pharmacology

Presenter
Joao De Aquino, MD

   

Dr. De Aquino is an Assistant Professor of Psychiatry at the Yale University School of Medicine. In addition to treating persons with substance use disorders and co-occurring medical and psychiatric disorders, he uses behavioral pharmacology, computerized assessment of pain, and clinical trial approaches to develop novel therapeutics for persons living with chronic pain and opioid addiction. 

Summary
Management of alcohol withdrawal syndrome (AWS) is a critical aspect of the continuum of care for patients with alcohol use disorder (AUD). Despite how common this syndrome is, there remains ongoing debate and uncertainty about best practices and significant variability among services and providers. An environmental scan was developed and disseminated nationally to assess the landscape of alcohol withdrawal management at VA facilities. The scan evaluated access to resources, clinical tools and protocols utilized, gaps in practice, and approaches to training. The scan also asked facilities to submit their local standard operating procedures (SOP), policies, training materials, and order sets. There was a 100% response rate. Every facility submitted at least one response and there were 250 responses total from 140 facilities. Responders were physicians (n=161), nurses (n=31), psychologists (n=16), social workers (n=12), APRNs (n=7), pharmacist (n=1) and other (n=20). Other represented administrative officers, service chiefs, etc. They represented psychiatry (n=99), medicine (n=68), ER (n=15), ICU (n=4), primary care (n=3) and other (n=58). When asked about challenges or limitations faced when managing patients with acute alcohol withdrawal, the most common response was “lack of availability of ambulatory detox” (n=119). Other very common responses include “lack of availability of residential treatment options for AUD” (n=92), “inconsistency across units” (n=92), “inconsistency across disciplines” (n=83), “stigma” (n=72), “lack of ancillary support staff” (n=60), “inadequate training” (n=52) and “lack of access to experts” (n=37). Responders were asked to submit model standard operating procedures (SOPs), policies, order sets, and training modules. Note that graphical/chart representations of data will be presented in the paper/poster along with model SOPs, policies, order  sets and training modules (time permitting). 

Background
Management of alcohol withdrawal syndrome (AWS) is a critical aspect of the continuum of care for patients with alcohol use disorder (AUD). Despite how common this syndrome is, there remains ongoing debate and uncertainty about best practices and significant variability among services and providers. The Department of Veterans Affairs (VA) is the nation’s largest integrated healthcare system and manages countless cases of alcohol withdrawal annually. A large retrospective VA study of 594 patients being treated for alcohol withdrawal found significant practice variability across facilities.1 For example, the most commonly used medication to treat moderately severe AWS was symptom-triggered lorazepam, inconsistent with the most recent Clinical Practice Guidelines recommending use of long-acting benzodiazepines.2 There was also inconsistent treatment for underlying AUD and variability in referrals to variability in referrals to residential and intensive outpatient treatment at discharge. A large, multi-disciplinary team led by the national director of hospital medicine was convened. The team consisted of leaders from the fields of hospital medicine, critical care medicine, psychiatry, addiction medicine/psychiatry, emergency medicine, nursing, and pharmacy. The goal was to identify gaps and improve management of alcohol withdrawal by standardizing care, training, and data management across the VA enterprise. 

Methods
An environmental scan was developed and disseminated nationally to assess the landscape of alcohol withdrawal management at VA facilities. The scan evaluated access to resources, clinical tools and protocols utilized, gaps in practice, and approaches to training. The  scan also asked facilities to submit their local standard operating procedures (SOP), policies, training materials, and order sets. 

Results
There was a 100% response rate. Every facility submitted at least one response and there were 250 responses total from 140 facilities. Responders were physicians (n=161), nurses (n=31), psychologists (n=16), social workers (n=12), APRNs (n=7), pharmacist (n=1) and other (n=20). Other represented administrative officers, service chiefs, etc. They represented psychiatry (n=99), medicine (n=68), ER (n=15), ICU (n=4), primary care (n=3) and other (n=58). Various challenges were submitted, including lack of availability of ambulatory detox. The majority of responders reported identified gaps in training. Model standard operating procedures (SOPs), policies, order sets, and training modules were submitted. Note that graphical/chart representations of data will be presented in the paper/poster along with model SOPs, policies, order sets and training modules (time permitting for a paper presentation). 

Conclusion
- This is a healthcare system-wide scan of all VA facilities with a 100% response rate.
- Ambulatory withdrawal management is a critical part of the spectrum of care though is not a resource that is widely available.
- Referral to residential level of care for treatment for AUD is not consistent.
- The AUDIT-PC was the most common way to assess alcohol withdrawal risk.
- Most people reported gaps in training and there were many suggestions about the type of training that should be offered.
- Model examples of SOPs, policies, order sets and training modules were developed based on user submitted information. These will be demonstrated 

Scientific Significance
Management of alcohol withdrawal syndrome (AWS) is a critical aspect of the continuum of care for patients with alcohol use disorder (AUD). Despite how common this syndrome is, there remains ongoing debate and uncertainty about best practices and significant variability among services and providers. This work shows the current state of the art of the nations largest healthcare system based upon an environmental scan with 100% response rate among VA facilities. This work can be used by other healthcare systems interested in improving management of alcohol withdrawal.   

Learning Objectives

1. To be able to create an environmental scan to survey a large hospital system about clinical practice. 
2. To learn the results of the national scan and be able to apply it to your own system of care.
3. To be familiar with national model examples of standard operating procedures, policies, EHR order sets and training modules.

Keywords

• Alcohol Withdrawal
• Electronic Health Records
• Alcohol Use Disorder

Presenter
Matthew Johnson, DO



Dr. Matthew Johnson is a graduate of Yale University's psychiatry residency where he served as Chief Resident based at the West Haven VA Psych ER. He is a Marine Corps veteran himself, and the owner of Encompass Psychiatry, LLC, through which he completes independent consultations for veterans. Dr. Johnson is also the Medical Director for the eating disorders program at Robert Wood Johnson (RWJ) University Hospital Somerset and is an Assistant Clinical Professor at Rutgers RWJ Medical School. 

Co-Authors: Nitigna Desai, MD,  Robert LaPointe, Elizabeth Czekanski, Mel Anderson, Amir Meiri, Jeydith Gutierrez, Brian Fuehrlein, MD