Workshops and Papers

The New Multidisciplinary Medical Advocacy Team for Traumatized, Medical Complex Addicted Patients: Addiction Psychiatry, Medicine and Ada Lawyers

Chairperson: Michelle Lofwall, MD, Professor in the Departments of Behavioral Science and Psychiatry and the Bell Alcohol and Addictions Endowed Chair and the medical director of Robert Straus and First Bridge Clinics at the University of Kentucky (UK)

Co-Chair: Laura Fanucchi, MD, MPH

Presenters: Anna-Maria South, MD, Health Equity and Advocacy thread leader for the College of Medicine, University of Kentucky, Rebekah Joab, Senior Staff Attorney at the Legal Action Center (LAC), and Laurence Westreich, MD, Associate Professor of Clinical Psychiatry in the Division of Alcoholism and Drug Abuse, Department of Psychiatry, New York University School of Medicine and serves as Consultant on Behavioral Health and Addiction to the Commissioner of Major League Baseball

Hospitalizations due to severe injection-related infections (e.g., endocarditis) are increasing with the opioid crisis. Trauma related to these illnesses and other life events is often unrecognized and impacts patients’ ability to self-advocate. Stigma also impacts treatment options presented to patients. For example, patients with substance use disorder (SUD) and infections requiring prolonged IV antibiotics are often required to remain hospitalized for the entire antibiotic course without offering treatment alternatives. These patients often have significant life traumas, post-traumatic stress disorder (PTSD), and life-threatening infections plus prolonged hospitalizations contribute to further trauma. The University of Kentucky has an ongoing clinical trial evaluating home IV antibiotics in patients with severe infections and OUD on buprenorphine, while also assessing for trauma and PTSD. During the study, additional barriers emerged such as residential treatment facilities and carceral settings not providing patients access to OUD medications (MOUD), leading to severe withdrawal, increased risk of death and other complications. This practice violates the Americans with Disabilities Act (ADA) and other laws, something that physicians and patients generally do not realize. Addiction psychiatrists can spark change and educate other physicians about the ADA as an effective advocacy tool, advocate for patient-centered treatment of injection-related infections and increase screening and treatment of SUD/other psychiatric comorbidity in this vulnerable patient population. We will review the basics of the ADA relevant to physician advocacy and successful collaborations between physicians with addiction expertise, ADA lawyers and advocacy groups to help improve health outcomes for people with SUDS and comorbid psychiatric disorders.

Learning Objectives

• Participants will be able to explain how anti-discrimination laws protect people with SUDs and name two advocacy strategies and resources
• Describe types of trauma common among hospitalized patients with infections and SUD during a prolonged hospitalization
• Identify situations/risk factors where discrimination is likely occurring among addiction psychiatry patients

Diagnosis and Management of Cannabis Use Disorder and Other Cannabis-Related Problems

Chairperson: Michael Hsu, MD, Addiction Psychiatrist at Greater Los Angeles VA Medical Center

Presenters: Kevin Hill, MD, Director of Addiction Psychiatry at Beth Israel Deaconess Medical Center (BIDMC) an Associate Professor of Psychiatry at Harvard Medical School, Smita Das, MD, PhD, MPH, Board Certified in Psychiatry, Addiction Psychiatry and Addiction Medicine, Arthur Robin Williams, MD, MBE, Assistant Professor in the Department of Psychiatry, Division on Substance Use Disorders, at Columbia University and a Research Scientist II at New York State Psychiatric Institute and Michael Hsu, MD, Addiction Psychiatrist at Greater Los Angeles VA Medical Center

Perceptions of the potential harmful effects of cannabis has dramatically decreased especially among adolescents and young adults. In parallel, cannabis use and the prevalence of cannabis use disorder continue to rise in the United States. This increased use was likely attributable to social isolation during the COVID-19 pandemic, heightened excitement around potential psychomedical uses of cannabis, social media, and increased legalization. However, many clinicians feel ill-equipped to discuss cannabis with their patients. Clinicians may feel that they lack the knowledge or experience with managing cannabis use or have concerns that broaching the topic may compromise their relationship with the patient. However, it remains vital for clinicians to discuss patients’ cannabis use in a non-judgmental manner in order to understand their patients’ use and provide education and evidence-based treatments to address the potential harms.

In this workshop, presenters will review how to identify and diagnose cannabis use disorder and other cannabis-related problems such as cannabis-induced psychosis, cannabis withdrawal, and cannabis hyperemesis syndrome. Presenters will discuss various cannabinoids such as delta-8 and delta-9 THC, CBD, and synthetic cannabinoids, as well as delivery mechanisms. Potential hazards
and psychomedical contraindications to recreational cannabis use will be discussed. Potential psychopharmacologic interventions for cannabis use disorder such as gabapentin, n-acetylcysteine (NAC), dronabinol, and CBD as well as psychotherapeutic interventions such as contingency management, CBT, and motivational interviewing will be reviewed.

Learning Objectives

• To identify common cannabis-related problems such as cannabis use disorder, cannabis withdrawal, cannabis hyperemesis syndrome, and cannabis-induced psychosis
• To discuss cases of cannabis use disorder in order to practice MI-consistent techniques and evidence-based interventions
• To learn how to apply psychopharmacologic and psychotherapeutic treatments for cannabis use disorder

The Emerging Threat of Xylazine: Substance Use and Wound Care Basics

Chairperson: Michael Chaple, PhD, Assistant Professor at Columbia University Irving Medical Center (CUIMC)

Presenters: Kellie Bryant, NP, Assistant Dean of Clinical Affairs and Simulation and Associate Professor at Columbia school of nursing’s accredited Helene Fuld Health Trust Simulation Center, and Fernando Montero, PhD, Chief T32 Postdoctoral Research Fellow at the HIV Center for Clinical and Behavioral Studies at Columbia University

Opioid use disorder, along with injection drug use (IDU) and its associated complications, have developed into an urgent, nationwide public health crisis. Wounds and skin and soft tissue infections (SSTIs) are common complications of IDU that disproportionately affect people who inject drugs (PWID) and are a major source of morbidity and mortality for this population. More recently, there has been a steep increase reported in the prevalence of xylazine detected in post-mortem toxicology tests among fatal overdose victims and fentanyl screen-positive urine samples. The emergence of xylazine adds novel health risks. In addition to the manner in which it complicates risk for overdose, chronic use of xylazine can progress vasoconstriction and skin oxygenation deficit, leading to SSTIs, including abscesses, skin ulceration, and cellulitis. Such complications have been documented over various body parts irrespective of the injection site. Providing early wound care intervention can reduce morbidity and mortality and related health care costs by reducing the number of SSTIs and injection-related wounds that require hospital admission. This workshop will provide an opportunity to further your knowledge and experience regarding wound care intervention for persons who use drugs (PWUD). This includes an overview of best practices for screening and identifying wounds, as well as best practice recommendations for basic wound care intervention that could be administered by non-medically trained personnel in the context of routine outreach. Participants will have the opportunity to practice basic wound care intervention with certified wound care nurse specialists.

Learning Objectives

• Understand the unique risks of xylazine pertaining to soft skin tissue infections (SSTIs)
• Differentiate between healthy wounds and wounds that require medical intervention
• Demonstrate basic wound care proficiency using supplies from a wound care kit

Methamphetamine-Associated Psychosis (MAP): Clinical Challenges and Approaches to Management

Chairperson: Michael Zito, MD, UCLA Semel Institute

Presenters: Larissa Mooney, MD, Professor of Clinical Psychiatry and Director of the Addiction Psychiatry Division in the Department of Psychiatry and Biobehavioral Sciences at UCLA, and Jose Flores, MD, PhD, MPH, Child and Adolescent Psychiatry fellow at the University of California, Los Angeles (UCLA)

This workshop will review recent trends associated with methamphetamine in the United States. Specifically, changes in prevalence of methamphetamine use will be discussed, as well as observed changes in the methamphetamine product itself (e.g. potency, purity, price) which may have an impact on psychosis. Background on the clinical characteristics of methamphetamine-associated psychosis (MAP) will be explored, as well as its association with schizophrenia, and its hypothesized pathophysiology. Clinical strategies to differentiate MAP from schizophrenia will also be provided. Treatment approaches to MAP will be described, ranging from a general review of evidence-based treatments for MUD, to specific treatments for the psychotic symptoms within MAP. Finally, panel members will share perspectives on the clinical approach to MAP informed by experience and a mix of published and unpublished data.

Learning Objectives

• Discuss the methamphetamine epidemic, focusing on the changing characteristics and pharmacology of methamphetamine, its production, and its use, on a national scale (Meth 2.0)
• Describe the background of methamphetamine-associated psychosis, including its possible pathophysiology and relationship to schizophrenia
• Discuss treatment strategies that specifically target psychosis among individuals who use methamphetamine

Caring for Yourself and Others while Advocating for Addiction Psychiatry--A Conversation with Female Leaders in Addiction Psychiatry

Chairperson: Amy Yule, MD, Vice Chair of Addiction Psychiatry at Boston Medical Center and an Assistant Professor at the Boston University School of Medicine

Co-Chair: Inbal Gafni, MD, MSc, University of Toronto, Women’s College Hospital

Presenters: Ismene Petrakis, MD, Professor of Psychiatry at the Yale University School of Medicine and has been the Chief of Psychiatry and Mental Health Services at VA Connecticut Healthcare System, Adina Bowe, MD, Assistant Professor of the Internal Medicine and Psychiatry Resident training program in Charleston West Virginia, Alena Balasanova, MD, Associate Professor at the University of Nebraska Medical Center (UNMC) in the Department of Psychiatry and also holds an appointment in the College of Allied Health Professions, and Amber Edinoff, MD, Addiction Psychiatrist at McLean Hospital and an Instructor of Psychiatry at Harvard Medical School

Although the percentage of female medical students and physicians within the workforce has increased within the United States and beyond, gender disparities within academic medicine and leadership positions have persisted (1). A contributing factor to these disparities is the disproportionately high prevalence of burnout among female physicians that leads many women to scale back or leave their clinical practice (2). Furthermore, attention to well-being has recently been highlighted as an important attribute for effective leadership (3). This workshop will address these issues by providing an opportunity for attendees to interact with female leader role models along the career continuum. Workshop panelists will discuss their leadership experiences, discuss strategies to manage competing professional and personal demands, and strategies to prioritize their own well-being.

Learning Objectives

• To provide several representative models of female leaders within Addiction Psychiatry at different time points along the career trajectory
• To understand the balance and interplay between self-care, professional advancement, and expected developmental milestones within a female professional’s personal life
• To provide an opportunity for female professionals within the audience to ask questions, gain support, and network with other female professionals

Extended-Release Buprenorphine for Vulnerable Populations with Opioid Use Disorder: Clinical Challenges, Pharmacokinetics, and Outcomes

Chairperson: Manesh Gopaldas, MD, Addiction Psychiatrist and NIDA-funded T32 postdoctoral fellow at Columbia University

Co-Chair: Sandra Springer, MD, Yale School of Medicine

Presenters: Rachel Luba, PhD, Clinical Psychologist and post-doctoral research fellow in the division on Substance Use Disorders at Columbia University/NY State Psychiatric Institute, Michelle Strong, DNP, MSN, FNP- BC, CARN-AP, Family Nurse Practitioner, certified in Addiction Medicine, at the Prisma Health Addiction Medicine Center in Greenville, SC, Alain Litwin, MD, MPH, Vice Chair of Academics and Research and Professor of Medicine at Prisma Health, University of South Carolina School of Medicine – Greenville, and Clemson University School of Health Research where he serves as the Executive Director of the Prisma Health Addiction Medicine Center.Edward Nunes, MD, Professor of Psychiatry at Columbia University Medical Center and New York State Psychiatric Institute (NYSPI), Principal Investigator (multiple PI) of the Greater New York node of the NIDA Clinical Trials Network (CTN), and a practicing psychiatrist Board Certified in Addiction Psychiatry and Addiction Medicine, Manesh Gopaldas, MD, Addiction Psychiatrist and NIDA-funded T32 postdoctoral fellow at Columbia University Frances Levin, MD, Kennedy-Leavy Professor of Psychiatry at Columbia University and the Chief of the Division on Substance Use Disorders at NYSPI/CUIMC

This workshop will focus on clinical challenges associated with initiating medication for opioid use disorder (MOUD) in medically complicated patients, such as those with injection-related infections. The utility of extended-release buprenorphine (XR-BUP) and issues with its management in this population will be explored. Several challenges will be discussed, including the impact of fentanyl and other high-potency synthetic opioids, as well as patient concerns regarding XR-BUP effectiveness. Additionally, it will examine the pharmacokinetic and pharmacodynamic properties of XR-BUP and their relationship to high-potency synthetic opioid use and MOUD initiation. Preliminary findings from an ongoing trial [NCT04180020] will be presented, and the workshop will facilitate discussions on lessons learned and the clinical implications for optimizing MOUD delivery.

Learning Objectives

• Discuss the pharmacokinetic and pharmacodynamic properties of extended-release buprenorphine (XR-BUP), and the impact of high-potency synthetic opioid use on MOUD initiation and treatment response
• Identify the challenges of initiating XR-BUP in medically complicated patients with OUD, including the impact of fentanyl and other high-potency synthetic opioids, and patient concerns related to XR-BUP effectiveness
• Recognize the importance of improving MOUD access and treatment delivery for vulnerable populations, including those with co-occurring OUD and severe infections

Cannabis/THC Use Pregnancy and Young Motherhood

Chairperson: Gregory Bunt, MD, Clinical Assistant Professor of Psychiatry at NYU Medical Center

Presenters: Kevin Hill, MD, Director of Addiction Psychiatry at Beth Israel Deaconess Medical Center (BIDMC) an Associate Professor of Psychiatry at Harvard Medical School, Nadejda Bespalova, MD, Professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington and Gregory Bunt, MD, Clinical Assistant Professor of Psychiatry at NYU Medical Center

This workshop will describe and address the important role of the addiction psychiatrist in advising, educating and treating pregnant women and young mothers as well as educating the public and policymakers about the use of cannabis/THC/CBD during pregnancy and breastfeeding. Given the stark magnitude of the numbers of pregnant women and young mothers using cannabis and the lack of clarity among physicians and the public about the science of cannabis/THC/CBD use during this critical period, it will behoove addiction psychiatrists to learn about the current state-of-the -art science regarding cannabinoids from AAAP authority on the subject Kevin Hill, MD, and Nadejda Bespaloa, MD, an expert in perinatal psychiatry and Gregory Bunt, MD, an experienced addiction psychiatrist for pertinent clinical perspectives. Their presentations will be followed by an audience poll on the subject with an interactive question-and-answer period that promises to be vibrant and lively with a discussion of diverse professional opinions on this critically important subject.

Learning Objectives

• Participants will learn about the current scientific evidence and controversies about cannabis/THC use during pregnancy and breastfeeding
• Participants will learn about clinical perspectives regarding cannabis/THC/CBD during pregnancy and breastfeeding
• Participants will learn about viewpoints of their colleagues regarding cannabis/THC during pregnancy and breastfeeding

No Wrong Door: Engaging The Difficult To Engage Patient

Chairperson: Alexis Ritvo, MD, MPH, Assistant Professor of Psychiatry and the Addiction Psychiatry Fellowship Program Director at the University of Colorado (CU) School of Medicine

Co-Chair: Alena Balasanova, MD, Associate Professor at the University of Nebraska Medical Center (UNMC) in the Department of Psychiatry and also holds an appointment in the College of Allied Health Professions

Presenters: Michael Dawes, MD, Professor of Psychiatry, and Program Director for the BU/VA Addiction Psychiatry Fellowship, John Renner, MD, Professor of Psychiatry, Boston University School of Medicine, and Associate Chief of Psychiatry for the VA Boston Healthcare System, Alena Balasanova, MD, Associate Professor at the University of Nebraska Medical Center (UNMC) in the Department of Psychiatry and also holds an appointment in the College of Allied Health Professions, and Alexis Ritvo, MD, MPH, Assistant Professor of Psychiatry and the Addiction Psychiatry Fellowship Program Director at the University of Colorado (CU) School of Medicine

According to National Survey on Drug Use and Health, 16.5% of U.S. adults had a substance use disorder (SUD) in 2021. Despite this high prevalence, up to 93.7% of adults with SUD do not receive treatment. In the past year, 96.8% of adults with a SUD who did not receive treatment at a specialty facility did not think they needed treatment. If only 3.2% of people with SUD feel they need treatment, how do we engage the other 96.8% of people who may not acknowledge a need for and/or be ready to seek care? This workshop is will begin by reviewing current epidemiological trends on pursuit and receipt of treatment by individuals with SUD. Next, we will review social determinants of health (SDoH), including race and ethnicity, as they relate to SUDs. We will consider the importance of recognizing and addressing SDoH in patients with SUD as a strategy to engage and retain patients in care. We will then illustrate the concept of ‘no wrong door’ and ‘meeting patients where they are at’ through motivational interviewing (MI). We will showcase MI skills for engaging patients who may otherwise be deemed ‘difficult’ to engage. We will conclude with a robust interactive discussion of cases by participants and presenters. This workshop is a collaboration between the AADPRT Addictions Committee and AAAP Education Committee in an ongoing effort to strengthen partnerships between the organizations.

Learning Objectives

• Review current epidemiological trends regarding substance use disorders prevalence and treatment rates.
• Examine social determinants of health, including race and ethnicity, and identify their relevance to SUD treatment access and retention
• Outline motivational interviewing skills that can be incorportated into clinical practice in order to engage even more difficult to engage patients

Phosphatidylethanol: The "Hemoglobin A1c" for Alcohol Use Disorder?

Chairperson: Gerald Winder, MD, Associate Clinical Professor in the Departments of Psychiatry, Surgery, and Neurology at the University of Michigan

Co-Chair: Joji Suzuki, MD

Presenter: Akhil Shenoy, MD, MPH, Director of Transplant Psychiatry at Columbia University Medical Center and an Associate Professor of Psychiatry

Excessive alcohol use kills 140,000 Americans each year and is the leading risk for premature death and disability for adults under 50. Most alcohol use disorder (AUD) care is directed toward drinking-related consequences (e.g., motor vehicle injuries, cirrhosis, heart disease, stroke, HIV/AIDs, cancer, violence, acts of self-harm and overdose) while AUD frequently goes
unaddressed. Here, addiction psychiatrists can play a vital role using a sensitive and specific biomarker detecting recent alcohol use: phosphatidylethanol (PEth).

PEth is analogous to Hemoglobin A1c (HgbA1c) in that it forms in red blood cells, is obtained via serum, and provides a quantitative estimate of recent ethanol exposure (e.g., <20=minimal alcohol use; 20-200=moderate; >200=heavy). PEth has a narrower detection window (2-4 weeks) than HgbA1c (8-12 weeks). PEth's clinical use has expanded. It is now recognized as a gold standard for alcohol detection in forensics and for safety assurance among high-stakes service personnel (e.g., airline pilots, physicians).

Addiction psychiatrists may order the assay or be asked to interpret it during patient care. Its sensitivity is 70-100%, outperforming other alcohol biomarkers. For example, in pre- and post-transplant liver patients use of PEth doubled the alcohol detection rate of drinking within the last week. PEth has been validated in cirrhotic patients with or without kidney disease, and no sources of false positives have been identified, which may broaden its use and clinical implications. In this 90-minute workshop, 3 psychiatrists from different institutions address pertinent and practical aspects of this biomarker relevant to all addiction clinicians.

Learning Objectives

• Explain phosphatidylethanol (PEth) physiology, technical specifications, indications for use, safety implications, and interpretation
• Define interpersonal aspects of PEth use: therapeutic communication and results interpretation for patients, families, and medical teams
• Apply PEth knowledge to various patient populations with whom addiction psychiatrists may interact: inpatients and outpatients with substance use disorders, transplant candidates and recipients, impaired health professionals, and patients with altered mental status

Conceptualizing Addiction in Clinical Practice: Choice, Compulsion, and Responsibility

Chairperson: Jungjin Kim, MD, Medical Director of Alcohol, Drugs, and Addiction Inpatient Program at McLean Hospital

Presenters: Reuben Hendler, MD, Attending Psychiatrist providing dual diagnosis care in inpatient, residential, and consult settings at McLean Hospital, Zoe Karavolis, PharmD, RPh, BCPP, Clinical Psychiatric Pharmacist working at the McLean Alcohol and Drug Abuse Treatment Program (ADATP), and Amanda Sedgewick, DO, Psychiatrist at McLean Hospital’s Alcohol, Drug, and Addiction Treatment Program

There remains considerable debate about the nature of addiction, even among addiction psychiatrists. On one side stand those who see addiction as a chronic and relapsing brain disease characterized by intense cravings and compulsion to which the individual with addiction has no choice but to relinquish control. On the other side stand those who see addictive behavior as a choice – a constrained one perhaps, but fundamentally an intentional and conscious act subject to self-control. Both views carry intuitive appeal but also seem to conflict with one another and raise challenging questions. If addiction is a brain disease, how can we hold people responsible for addictive behavior? If addictive behavior reflects choice, how can we explain recurrent akrasia (acting against one’s best judgment) in the face of self-destruction? The practice of addiction psychiatry often benefits from educating patients and the public about addiction, and treatment decisions are often informed implicitly or explicitly by beliefs about the nature of addiction. Reflecting on how to conceptualize addiction is therefore of practical use to clinicians. In this interactive workshop, we use a series of clinical vignettes drawn from psychopharmacology, psychotherapy, trauma-informed treatment, and the Anglo-American law to examine and challenge our understandings of the nature of addiction. Participants will draw from their clinical experience, neuroscience and behavioral psychology knowledge, and philosophical/ethical reasoning to work through these cases. Throughout, participants will engage in a series of discussions with peers to attain a deeper and more sophisticated understanding of the nature of addiction.

Learning Objectives

• Consider two different ways of conceptualizing addiction, the advantages and disadvantages of each, and how to reconcile them
• Clarify one's own beliefs about the nature of addiction and reflect on how these beliefs influence one's clinical practice
• Practice applying different ways of conceptualizing addiction to optimize clinical care through case discussions that bring together psychopharmacology, psychotherapy, trauma-informed treatment, and the law

Clinical Challenges of Medications for Opioid Use Disorder in Pregnant Patients

Chairperson: Youssef Mahfoud, MD, OTP Medical Director at the Cleveland VA and an Assistant Professor of Psychiatry at CWRU

Co-Chair: Jaina Amin, MD, Perinatal and Reproductive Psychiatrist in Cleveland, OH

Presenters: Jessica Mulhollan, PharmD, Clinical Pharmacist Practitioner specializing in Substance Use Disorders at the VA Northeast Ohio Healthcare System in Cleveland, OH, Jaina Amin, Perinatal and Reproductive Psychiatrist in Cleveland, OH and Youssef Mahfoud, MD, OTP Medical Director at the Cleveland VA and an Assistant Professor of Psychiatry at CWRU

Clinical guidance from both the American College of Obstetricians and Gynecologists and the Substance Abuse and Mental Health Services Administration includes recommendations for medications for opioid use disorder (MOUD) in lieu of supervised withdrawal to improve outcomes and reduce the risk of relapse. In this workshop, we will discuss the clinical use of MOUD in pregnant patients to include methadone, buprenorphine, buprenorphine/naloxone, buprenorphine extended-release injection, and naltrexone extended-release injection. We will educate the audience regarding clinical indications for use, dosing and dosing adjustments, adverse effects, and clinical outcomes. We will review several challenging clinical cases requiring audience participation. Our clinical expertise will be compared with the audience’s experience with pregnant patients on MOUD in various settings. The goal is to solidify audience knowledge to become more comfortable prescribing and managing pregnant patients on MOUD to increase availability of this treatment option and improve outcomes.

Learning Objectives

• pharmacology, dosing, and adverse effects of MOUD in pregnant patients
• Select the most appropriate MOUD for pregnant patients
• Develop a treatment plan for pregnant patients with opioid use disorder

The Addictive Potential and Challenges with "Smart Drugs": Nootropics

Chairperson: Akhil Anand, MD, Assistant Professor and Director of the University Hospitals Cleveland Medical Center Addiction Psychiatry Fellowship Program

Presenters: Jeremy Weleff, DO, Addiction psychiatrist and public psychiatry fellow at Yale University School of Medicine, Julian Raffoul, MD, PhD, MBA, MS, Addiction Psychiatry Fellow at Vanderbilt University Medical Center, and Akhil Anand, MD, Assistant Professor and Director of the University Hospitals Cleveland Medical Center Addiction Psychiatry Fellowship Program

The fourth wave of the opioid epidemic is characterized by the rise of fentanyl derivatives, psychostimulants, designer benzodiazepines, and other novel psychoactive substances (NPSs). Many of these compounds are uniquely novel, but many are older or repurposed medications that continue as prescription drugs in countries outside of the United States. Nootropics, colloquially known as "smart drugs," are one group of these NPSs. Nootropics are deceptively marketed as cognitive enhancers for improving memory, concentration, and alertness despite having little evidence that they benefit cognition. The most common of these drugs is kratom. And while nootropics are marketed as "dietary supplements," others are prescription medications such as methylphenidate, amphetamines, and modafinil which come with their own risks.

In this 90-minute workshop, we will engage learners to discuss nootropics in order to identify and treat the misuse of these substances in our patient population. We want to familiarize attendees with four specific nootropics: tianeptine, phenibut, kratom, and modafinil. We will review the pharmacological and psychological properties of these substances. We will describe their prevalence, addictive potential, withdrawal symptoms, toxicity presentations, and management, including the potential use of medication-assisted treatment solutions. We will also discuss how manufacturers exploit poor FDA oversight and legal loopholes to market these compounds as "dietary supplements." Lastly, we will discuss the international reaction to these compounds, knowledge gaps, and areas for future research.

Learning Objectives

• Review the pharmacological and psychological properties of nootropics
• Describe the medical, psychiatric, and addictive consequences of nootropics. Identify and treat intoxications, withdrawals, and potential maintenance treatment options
• Discuss the national and global nootropic laws and regulations

Benzodiazepines: Challenges and Solutions

Chairperson: Christopher Blazes, MD, Associate Professor of Psychiatry at OHSU

Presenters: Christopher Blazes, MD, Associate Professor of Psychiatry at OHSU, Alexis Ritvo, MD, MPH, Program Director for the Addiction Psychiatry Fellowship at the University of Colorado (CU) School of Medicine where she is an Assistant Professor of Psychiatry, and Jeffrey Gold, BCPP, PharmD, Psychiatric Clinical Pharmacy Practitioner and Psychopharmacologist, Rocky Mountain Regional Veteran Affairs Medical Center in Colorado

Benzodiazepines have been referred to as the next prescription drug epidemic. Caring for patients who chronically use prescription benzodiazepines present many challenges to clinicians. Profound psychological attachments as well as idiosyncratic aspects of physiologic dependence contribute to these challenges. In this session we will explore the newly described and closely related concepts of “benzodiazepine induced neurological dysfunction” (BIND) and "complex persistent benzodiazepine dependence” (CPBD). BIND describes a constellation of functionally limiting neurologic symptoms aAAnd adverse life consequences that are the result of neuroadaptation and/or neurotoxicity resulting from benzodiazepine exposure. CPBD refers specifically to the significant psychiatric instability and functional decline, with or without new aberrant behaviors, that manifests during attempted benzodiazepine deprescribing and may be misinterpreted as benzodiazepine use disorder (BUD).

These heuristics can help clinicians develop a better understanding of complex often confusing clinical situations in patients with chronic benzodiazepine use. We will also discuss the nuances of benzodiazepine tapers, when they are indicated, when they are not indicated, and options for implementation. Finally we will review how to utilize motivational interviewing skills to engage patients in a discussion about goals of care including possible benzodiazepine deprescribing.

Learning Objectives

• Participants will Develop understanding of BIND (Benzodiazepine Induced Neurologic Dysfunction)
• Participants will learn diversified strategies for tapering of benzodiazepines
• Develop understanding of Complex Persistent Benzodiazepine Dependence

Treatment of Alcohol Use Disorder (AUD) in Patients with Alcohol-Associated Liver Disease (ALD)

Chairperson: Akhil Shenoy, MD, MPH, Director of Transplant Psychiatry at Columbia University Medical Center and an Associate Professor of Psychiatry

Presenters: Candace Hatten-Powell, MD, Consultation Liaison Psychiatry team at Montefiore, Akhil Shenoy, MD, MPH, Director of Transplant Psychiatry at Columbia University Medical Center and an Associate Professor of Psychiatry and Mashal Khan, MD, Assistant Professor of Clinical Psychiatry at New York Presbyterian-Weill Cornell Medicine

Excessive alcohol use leads to many preventable medical comorbidities with the most common being alcohol-associated liver disease (ALD)1. Alcohol addiction, or DSM-V defined alcohol use disorder (AUD), is being recognized by hepatologists and other physicians as a treatable condition to prevent ALD2.

Addiction specialists have an opportunity to help their hepatology colleagues but may not be familiar with AUD treatment in the setting of ALD. Novel multi-disciplinary clinics to manage both the addiction and hepatology care together have been proposed and implemented to help addiction care to be incorporated into general medical practice3. AUD Treatment plans that can be more readily adopted by gastroenterologists and hepatologists will be essential.

Learning Objectives

• Interpret the current knowledge on safety and efficacy of individualized pharmacotherapy for AUD in ALD
• Recognize the proven psychotherapies for AUD and evaluate the role for innovative technology assisted interventions that are being offered to patients with AUD in the context of ALD
• Construct a bio-psycho-social-cultural approach to AUD treatment planning in the setting of ALD

Induction without Withdrawal: Low-Dose Buprenorphine Inductions

Chairperson: James Wong, MSc, BSc, with the Complex Pain and Addiction Service of Vancouver General Hospital, Vancouver, British Columbia, Canada

Co-Chair: Martha Ignaszewski, MD, Education Lead for the VGH CPAS service, and Senior Medical Director of Substance Use and Concurrent Disorders, British Columbia Children's Hospital/Vancouver General Hospital

Presenters: Pouya Azar, FRCPC, MD, Head of the Complex Pain and Addiction Service (CPAS), a consult service under the Department of Psychiatry at Vancouver Coastal Health, British Columbia, Canada, Nickie Mathew, FRCPC, MD, MSc, Medical Director of Complex Mental Health and Substance Use Services at the Provincial Health Services Authority in British Columbia, Canada, Clinical Associate Professor at the University of British Columbia (UBC) Department of Psychiatry and Martha Ignaszewski, MD, Education Lead for the VGH CPAS service, and Senior Medical Director of Substance Use and Concurrent Disorders, British Columbia Children's Hospital/Vancouver General Hospital

Buprenorphine is a recommended treatment for opioid use disorder due to its similar efficacy and superior safety profile compared to other opioid agonist treatment medications. However, because of its high binding affinity at μ-opioid receptors (μORs) and its high lipophilicity, buprenorphine abruptly displaces other opioids from μORs and has persistent but lower intrinsic efficacy at brain μORs compared with full agonists, which can lead to precipitated withdrawal. To avoid this outcome, patients are instructed to abstain from opioids and experience at least moderate withdrawal before initiating buprenorphine. This requirement of prior withdrawal and risk of precipitated withdrawal, which can lead to treatment dropout, relapse with unregulated opioids, and subsequent overdose, are major barriers to buprenorphine use among patients and healthcare staff. Low-dose inductions (also known as micro-dosing, micro-inductions) involve the administration of small, frequent does of buprenorphine negating the need for a period of withdrawal and opioid abstinence prior to the start of treatment and aims to reduce the risk of precipitated withdrawal. Building upon the Bernese method, we have developed novel, more rapid methods of low-dose buprenorphine inductions involving sublingual, transdermal, and subcutaneous formulations. Utilizing practical real-life cases as well as patient testimonial videos, we will teach low-dose induction techniques (low-dose induction, rapid low-dose induction, ultra-rapid low-dose induction, rapid transdermal buprenorphine induction onto buprenorphine/naloxone and buprenorphine extended-release) for varied patient populations (e.g., chronic pain, geriatric, child and adolescent) and clinical scenarios (e.g., mechanically ventilated patient, inpatient and outpatient settings).

Learning Objectives

• Utilize sublingual buprenorphine/naloxone low-dose inductions in inpatient and outpatient settings
• Utilize buprenorphine/naloxone low-dose inductions in the chronic pain/prescription opioid tolerant setting, and in varied populations, such as geriatric patients, youth, and adolescents
• Utilize transdermal buprenorphine to rapidly initiate patients onto buprenorphine/naloxone and buprenorphine extended-release

Analysis of Suicide Attempts and Demographic Characteristics of US Military Veterans with Opioid Use Disorder: A Retrospective and Descriptive VA Medical Center Study

Brian Fuehrlein, MD, PhD, Yale University; Danielle Cosentino, BS, VA Connecticut Healthcare System; and Muhammet Celik, MD, VA Connecticut Healthcare System

Suicide and opioid use disorder (OUD) frequently co occur, and veterans are at a high risk for both conditions. This study aims to determine the characteristics of a cohort of veterans with co occurring OUD and suicide attempts.

The clinical, demographic, and other characteristics of 353 veterans who were registered at a VA medical center with a diagnosis of OUD and at least one suicide attempt between January 1, 2010, and December 31, 2021, were analyzed retrospectively using descriptive statistics.

Learning Objectives:

• To summarize the existing literature on suicides among OUD patients.
• To analyze the prevalence and patterns of suicide attempts among veterans with OUD.
• To identify the demographic characteristics and comorbid psychiatric conditions associated with co occurring OUD and suicide attempts.

Assessing Problematic Pornography Use in University Students and Associated Internalizing Symptoms and Behavioral Addictions

Riley Wagner, MD, Kirk Kerkorian School of Medicine at UNLV

The proposed study aimed to investigate the relationship between internalizing symptoms and problematic pornography use (PPU), as well as the interaction effect of gender on this relationship. The study collected data from 1,528 college students in the U.S. who reported watching pornography in the past year. Measures included the Brief Pornography Screen (BPS) to assess PPU, the DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure for internalizing symptoms, and additional measures for substance use, internet gaming, and compulsive sexual behavior. Internalizing symptoms measured included depression and anxiety scores.

Learning Objectives:

• To explore the interaction effect of gender on the relationship of PPU and psychopathology/behavioral addictions.
• To examine the relationship between internalizing symptoms and PPU, and behavioral addictions and PPU.

The Association between Cannabis Use and Lifetime Suicidal Ideation and Attempts

Adeolu Oladunjoye, MD, MPH, Baylor College of Medicine; Alan Swann, MD, Baylor College of Medicine, Houston, TX; Thomas Kosten, MD, Baylor College of Medicine, Houston, TX; Michelle Patriquin, PhD, ABPP, Baylor College of Medicine, Houston, TX; Timothy Bigdeli, PhD, SUNY Downstate Health Sciences University, Brooklyn, NY; Peter Barr, PhD, SUNY Downstate Health Sciences University, Brooklyn, NY; Mark Harding, BA, Baylor College of Medicine, Houston, TX; David Nielsen, PhD, Baylor College of Medicine, Houston, TX; and David Graham, MD, MACG, Baylor College of Medicine, Houston, TX

Suicide is a global public health concern worldwide and ranks as one of the leading causes of death in the United States. With legislation of marijuana in communities across the US, the use is on the rise while the public perception of its harmful effect continues to decrease. This concerning statistic underscores the importance of identifying factors which significantly influences the association between cannabis use and suicidality. These factors are generally under researched, and our study will be the first to investigate those factors that influence the association between cannabis use and suicidal intensity.

Learning Objectives:

• To show that higher levels of cannabis use as measured by the ASSIST cannabis total score will be associated with higher suicidal intensity.
• To show that elevated emotional dysregulation and lower levels of psychological flexibility will influence the associations between cannabis use and suicidal intensity.
• To show that a common genetic pathway using an externalizing polygenic risk score assessment will indirectly influence the association between cannabis use and suicidal intensity.

The Influence of Childhood Trauma on the Effects of Delta-9-Tetrahydrocannabinol in Persons with Opioid Use Disorder: Insights from a Randomized, Placebo-Controlled, Crossover Clinical Trial

Julio Nunes, MD, Yale University; Michael Rogan, Yale University; and João P. de Aquino, MD, Yale University

Childhood trauma may modulate the acute effects of cannabis and its constituent cannabinoids among patients with opioid use disorder (OUD). In this post hoc analysis of a randomized, placebo-controlled clinical trial administering delta-9 tetrahydrocannabinol (THC) — the main psychoactive constituent of cannabis — among patients receiving methadone therapy for OUD, we demonstrate that higher levels of childhood trauma are associated with reduced perceptions of THC’s aversive effects. This information may contribute to decision-making processes regarding the therapeutic potential of cannabinoids for OUD.

Learning Objective: To discuss the relationship between childhood trauma and the perception of cannabinoids' adverse effects in patients with OUD.

A Randomized Controlled Trial of Varenicline for Cannabis Use Disorder: Main Efficacy Findings

Kevin Gray, MD, Medical University of South Carolina; Nathaniel Baker, Medical University of South
Carolina; Amanda Wagner, Medical University of South Carolina; Elizabeth Chapman, Medical University of South Carolina; Alonzo Steplight, Medical University of South Carolina; Bryan Tolliver, Medical University of South Carolina; Erin McClure, Medical University of South Carolina; and Aimee McRae-Clark, Medical University of South Carolina

The proposed paper presentation will summarize methods, main efficacy findings, and clinical practice implications of a recently completed clinical trial of varenicline for cannabis use disorder (CUD). The presentation will include a review of established evidence-based treatments for CUD and a brief summary of CUD pharmacotherapy development efforts to date. The rationale, methods and findings of a recently completed trial of varenicline for CUD will be presented. Findings will be discussed in clinical context, with the goal of conveying actionable information for incorporation in front-line clinical practice.

Learning Objectives:

• At the conclusion of the educational session, the audience will be able to summarize the current evidence base for treating CUD.
• At the conclusion of the educational session, the audience will be able to describe the methods and main efficacy findings of a clinical trial of varenicline for CUD.
• At the conclusion of the educational session, the audience will be able to indicate the clinical practice implications of the study’s main efficacy findings.

The Impact of Buprenorphine Training and X-Waiver Removal on Knowledge, Attitudes, and Prescribing Patterns of Buprenorphine among Hospitalists

Rashmi Bharadwaj, MD, University of Kentucky, College of Medicine; Anthony Mangino, University of Kentucky, Department of Biostatistics; James Troy, University of Kentucky, Division of Hospital Medicine; Kathryn Ruf, UK Healthcare, Office of Pharmacy Value and Analytics; Paula Bailey, University of Kentucky, Division of Hospital Medicine; Laura Fanucchi, MD, MPH, University of Kentucky, Division of Hospital Medicine; and Anna-Maria South, MD, University of Kentucky, Division of Hospital Medicine

Hospital-based clinicians frequently encounter and care for patients with opioid use disorder (OUD), and the Society of Hospital Medicine recommends that all these clinicians should receive training to provide medication for opioid use disorder (MOUD) (1). This study aimed to the impact of X-waiver training on hospitalists’ attitudes and knowledge of OUD and MOUD, and prescribing patterns of MOUD at a large hospital with a dedicated addiction medicine consult service (ACES). Upon the removal of the X-waiver in January 2023, it also assessed whether the aim to access to MOUD translated to an increase in buprenorphine prescribing among hospitalists.

Learning Objectives:

• Understand the impact of knowledge and attitudes on buprenorphine prescribing before and after buprenorphine training for hospital medicine physicians
• Assess changes in prescribing patterns of buprenorphine at time of discharge for patients with opioid use disorder from a hospital medicine service after removal of the X-waiver on a federal level
• Compare changes in knowledge and attitude after buprenorphine training to changes in prescribing patterns

Co-Occurring Illicit Fentanyl Use and Psychiatric Disorders among Emergency Department Patients

Li Li, MD, PhD, University of Alabama

The current study aimed to describe the characteristics of emergency department (ED) with illicit fentanyl use who have concurrent psychiatric disorder. A retrospective, cross-sectional medical record review was conducted among ED patients with a fentanyl-positive urine drug screening from June 1, 2021, through November 30, 2021 in a tertiary medical center. Our study demonstrates that illicit fentanyl use was common among ED patients, ~1% of all ED visits. We also find out that co occurring psychiatric disorders were common and concurrent marijuana use was high among ED patients with illicit fentanyl use. This patient population with co-occurring illicit fentanyl use and psychiatric disorders had higher .repeat ED visits and/or hospital admissions at six months The opioid overdose epidemic, which has been markedly exacerbated by illicit fentanyl, highlights the urgency for ED providers to be well versed on the proper screening for it and management of potentially opioid use disorder. Co-occurring psychiatric disorders among patients presenting to the ED with illicit fentanyl use is associated with distinct sociodemographic and increased healthcare utilization. Improved identification, treatment, and referral for individuals with illicit fentanyl use (potentially opioid use disorder) and psychiatric disorders are needed to engage them in effective interventions, decrease ED use, and improve patient outcomes.

Learning Objectives:

• Describe the prevalence of illicit fentanyl use among emergency department patients.
• Characterize patients with illicit fentanyl use and psychiatric disorders in the emergency department.
• Discuss the impact of co occurring illicit fentanyl use and psychiatric disorders on healthcare utilization.

Emergency Admissions and the Prescribing of Buprenorphine, Methadone, and Psychotropic Medications in People with Sickle Cell Disease: An Analysis of National Insurance Claims

Shiyuan Anabeth Liu, MD, Washington University School of Medicine, Division of Hospital Medicine, Department of Medicine; Tashalee R. Brown, MD, PhD, UCLA Semel Institute for Neuroscience and Human B ehavior; Lewei (Allison) Lin, MD, University of Michigan Medical School, Department of Psychiatry; Allison King, MD, MPH, PhD, Washington University School of Medicine, Division of Hematology/Oncology, Department of Medicine, Department of Pediatrics;
Richard A. Grucza, PhD, MPE, Saint Louis University School of Medicine; and Kevin Xu, MD, MPH, Washington University School of Medicine, Department of Psychiatry

Chronic opioid medications are necessary and well tolerated in patients with sickle cell disease (SCD) for the treatment of vaso-occlusive pain crises. However, amid the endemic of structural racism and drug related poisonings in the US, people with SCD with physiologic opioid dependence or tolerance face tremendous stigmatization and barriers to the comprehensive management of acute and chronic pain. Real-world data is lacking on adverse health outcomes such as emergency admissions for drug related poisoning events in people with SCD and physiologic opioid dependence or tolerance. To address this gap in research, our study uses national administrative claims in the US to quantify the burden of acute iatrogenic events (i.e., respiratory depression requiring naloxone reversal) in a cohort of people with SCD and physiologic opioid dependence or tolerance or opioid use disorder. We also calculated the prevalence of opioid and CNS acting prescriptions in people with SCD and physiologic opioid dependence or tolerance or opioid use disorder. Overall, our data show a high rate of emergency or acute care utilization (>60%) and a significant burden of psychiatric comorbidity in a cohort of people with SCD and physiologic opioid dependence or tolerance. The prescribing of potentially safer opioids, such as buprenorphine, was uncommon (less than 5%) in the cohort. Further research is urgently needed to optimize opioid treatment strategies, combat stigma, and improve the comprehensive management of pain and co-occurring disorders in the SCD population.

Learning Objectives:

• Understand the burden of acute care utilization for iatrogenic adverse events in people with sickle cell disease (SCD) and physiologic opioid tolerance/dependence or opioid use disorder.
• Describe the burden of psychiatric comorbidity and CNS-acting medication receipt in people with sickle cell disease and physiologic opioid tolerance/dependence or opioid use disorder.
• Recognize that potentially safer opioids such as buprenorphine are uncommonly prescribed in people with sickle cell disease and physiologic opioid tolerance/dependence or opioid use disorder.

Prescription Psychostimulant Use in Pregnant People with Opioid Use Disorder: An Analysis of Treatment Initiation, Retention, and Acute Substance Use Disorder-Related Admissions

Kevin Xu, MD, MPH, Washington University School of Medicine, Department of Psychiatry; Tiffani Berkel, MD, Washington University School of Medicine, Department of Psychiatry; Caitlin Martin, MD, MPH, Virginia Commonwealth University, Department of Obstetrics and Gynecology; Hendree Jones, MD, University of North Carolina School of Medicine, Department of Obstetrics and Gynecology; Ebony Carter, MD, MPH, Washington University School of Medicine, Department of Obstetrics and Gynecology; University of North Carolina School of Medicine, Department of Obstetrics and Gynecology; Jeannie Kelly, MD, MS, Washington University School of Medicine, Department of Obstetrics and Gynecology; Frances Levin, MD, Columbia University Vagelos College of Physicians and Surgeons, Department of Psychiatry & New York State Psychiatric Institute; Carrie Mintz, MD, Washington University School of
Medicine, Department of Psychiatry; and Richard Grucza, PhD, MPE, Saint Louis University School of Medicine, Advanced Health Data Institute

The United States (U.S.) has experienced significant increases in the number of pregnant people with opioid use disorder (OUD). Yet, less than 50% receive medications such as buprenorphine and methadone to treat their OUD. In non-pregnant populations, data has shown that psychostimulant treatment of underlying attention deficit hyperactivity disorder (ADHD) may decrease the burden of substance use disorder (SUD)-related acute care utilization, boost outpatient SUD treatment engagement, and improve buprenorphine retention.

Learning Objectives:

• Understand how pregnant people receiving buprenorphine and methadone differ with regards to their likelihood of receiving psychostimulants for the treatment of ADHD.
• Describe the association between psychostimulant receipt and retention in OUD treatment.
• Recognize that psychostimulant receipt (for the treatment of ADHD) does not translate into increased risk of emergency admission/hospitalization for drug-related poisonings in pregnant people with OUD.

Semi-Structured Manualized Treatment Program (SSMTP) for Substance Use Disorders Among Patients in a Canadian Forensic Psychiatric Program

Kyle Fediuk, MD, McMaster University; Peter Sheridan, McMaster University & St. Joseph's Healthcare Hamilton Forensic Psychiatry Program; Christina Oliveira-Picado, St. Joseph's Healthcare Hamilton Forensic Psychiatry Program; John Bradford, McMaster University & St. Joseph's Healthcare Hamilton Forensic Psychiatry Program; Gary Chaimowitz, McMaster University & St. Joseph's Healthcare Hamilton Forensic Psychiatry Program; and Andrew Olagunju, MD, McMaster University, St. Joseph's Healthcare Hamilton Forensic Psychiatry Program, & University of Adelaide Discipline of Psychiatry

This paper will highlight how semi-structured manualized treatment programs (SSMTPs) based on motivational enhancement and cognitive behavioral models may increase recognition and degree of steps taken toward substance use cessation and abstinence in forensic populations with concurrent disorders. This provides a point-of-care perspective to inform future assessments and treatment, which is important given substance abuse is disproportionately prevalent among individuals in the criminal justice system and is linked with criminal behaviour. Co-existing substance use disorders with major mental disorders in forensic patients can complicate diagnosis, treatment, and rehabilitation for community re-integration. Psychosocial therapy is integral for substance use treatments but can be limited in ensuring abstinence and may lack efficacy if not well-designed to target patient risk factors and resources.

Learning Objectives:

• Learners will be provided with an overview on the prevalence of substance abuse in individuals with concurrent disorders involved in the criminal justice system to inform their practice and recognize unmet patient needs related to substance use.
• Learners will understand the beneficial effects of talk-based treatment in the form of a semi-structured manualized treatment program (SSMTP) on the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) scores among forensic psychiatry patients with concurrent disorders to highlight the value of its implementation in concurrent disorder care.
• We will discuss lessons learned from implementing an SSMTP and the factors associated with good outcomes so that learners can consider the feasibility of implementing similar interventions while accounting for important contextual factors in their addiction care environment.