Drug Legalization and Decriminalization Beliefs Among Substance-using and Nonusing Individuals Objectives: There has been advocacy for legalization of abusable substances, but systematic data on societal beliefs regarding such legalization are limited. People who use substances may have unique beliefs about legalization, and this study assessed whether they would be in favor of drug legalization/decriminalization. It was hypothesized that those who use particular drugs (especially marijuana) would support its legalization/decriminalization, but that this would not be the case across all classes (especially opioids and stimulants). Methods: A nationwide sample of 506 adults were surveyed online to assess demographic characteristics, substance misuse, and beliefs regarding drug legalization/decriminalization. Legalization/decriminalization beliefs for specific drugs were assessed on an 11-point scale (0, strongly disagree; 10, strongly agree). Results: For persons with opioid misuse (15.4%), when asked about their agreement with: “heroin should be legalized,” the mean score was 4.6 (SEE = 0.4; neutral). For persons with stimulant misuse (12.1%), when asked about their agreement with: “cocaine should be legalized,” the score was 4.2 (0.5). However, for persons with marijuana misuse (34.0%), when asked about their agreement with: “medical marijuana should be legalized” the score was 8.2 (0.3; indicating agreement), and for “recreational marijuana” the score was also 8.2 (0.3). Conclusions: These results suggest that persons who used marijuana strongly support the legalization of both recreational and medical marijuana, whereas persons who primarily have opioid or stimulant misuse have less strongly held beliefs about legalization of substances within those respective categories. By including those who misuse drugs, these data assist in framing discussions of drug legalization and have the potential to inform drug policy considerations. Send correspondence to Alexis S. Hammond, MD, PhD, Behavioral Pharmacology Research Unit (BPRU), Department of Psychiatry and Behavioral Sciences, the Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224. E-mail: Ahammon9@jhmi.edu. Received 30 August, 2018 Accepted 13 March, 2019 This work was supported by internal funding from the Johns Hopkins University School of Medicine. The authors report no conflicts of interest. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (www.journaladdictionmedicine.com). © 2019 American Society of Addiction Medicine

Sociodemographic Characteristics and the Stigmatization of Prescription Opioid Addiction Objectives: The aim of this study was to investigate the relationship between participants’ sociodemographic characteristics and the degree to which they stigmatize people with an opioid addiction. Methods: A randomized, between-subjects case vignette study (n = 2605) was conducted with a nationwide online survey. We investigated how the stigmatization toward a hypothetical individual who misused prescription opioids differed across participants’ sociodemographic factors (ie, age, gender, education, race, and income). Results: Our results showed that study participants who were male, white, low-income, college graduates, and younger rated the hypothetical individual with an opioid addiction with lower stigma. In addition, we showed that participant gender moderated the relationship between information given about initiation of opioid use (received prescription opioids from a doctor vs took prescription opioids from a friend) and opioid stigma perceptions. Conclusions: Our results support previous findings that stigmatizing attitudes towards drug use vary across participant sociodemographic characteristics. The findings from our study provide a better understanding of how stigmatizing attitudes towards prescription opioid use differ across sociodemographic characteristics and can serve to improve negative perceptions of those with an opioid addiction. Send correspondence to Kimberly Goodyear, PhD, Department of Behavioral and Social Sciences, Brown University, Providence, RI. E-mail: kimberly_goodyear@brown.edu Received 10 January, 2019 Accepted 26 May, 2019 Funding: This study was funded by Connecticut College, faculty support account 152-10000-202380 (PI: Dr. Chavanne). Dr Goodyear is supported by the 5T32AA007459 training grant at NIAAA. Conflict of interest: The authors report no biomedical financial interests or potential conflicts of interest. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (www.journaladdictionmedicine.com). © 2019 American Society of Addiction Medicine

Recovery From Opioid Problems in the US Population: Prevalence, Pathways, and Psychological Well-Being Objectives: Research has enhanced our understanding of opioid misuse prevalence and consequences, but few studies have examined recovery from opioid problems. Estimating national recovery prevalence and characterizing individuals who have resolved opioid problems can inform policy and clinical approaches to address opioid misuse. Methods: We conducted a cross-sectional investigation of a nationally-representative sample of US adults who reported opioid problem resolution (OPI). For reference, OPI was compared with an alcohol problem resolution group (ALC). Analyses estimated OPI/ALC prevalence, differences in treatment/recovery service use, and psychological well-being, within 2 recovery windows: <1 year (early recovery) and 1 to 5 years (mid-recovery) since OPI/ALC problem resolution. Results: Of those who reported alcohol or drug use problem resolution, weighted problem resolution prevalence was 5.3% for opioids (early recovery 1.2%, mid-recovery 2.2%) and 51.2% for alcohol (early recovery 7.0%, mid-recovery 11.5%). In mid-recovery, lifetime use of formal treatment, pharmacotherapy, recovery support services, mutual help, and current pharmacotherapy were more prevalent in OPI than ALC. Service utilization did not differ between early-recovery OPI and ALC. Common services used by OPI included inpatient treatment (37.8%) and state/local recovery organizations (24.4%) in mid-recovery; outpatient treatment (25.7%) and recovery community centers (27.2%) in early recovery; Narcotics Anonymous (40.2%–57.8%) and buprenorphine-naloxone (15.3%–26.7%) in both recovery cohorts. Regarding well-being, OPI reported higher self-esteem than ALC in early recovery, and lower self-esteem than ALC in mid-recovery. Conclusions: An estimated 1.2 million American adults report resolving an opioid problem. Given the service use outcomes and longer-term problem resolution of mid-recovery OPI, early-recovery OPI may require encouragement to utilize additional or more intensive services to achieve longer-term recovery. OPI beyond recovery-year 1 may need enhanced support to address deficient self-esteem and promote well-being. Send correspondence to Lauren A. Hoffman, PhD, Recovery Research Institute, 151 Merrimac Street, 6th Floor, Boston, MA 02114. E-mail: lhoffman1@mgh.harvard.edu Received 23 February, 2019 Accepted 11 July, 2019 Funding: This research was supported by the Recovery Research Institute at the Massachusetts General Hospital, Harvard Medical School. Financial disclosures: Dr Hoffman was supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Number F32 DA047741. Dr. Vilsaint and Dr Kelly were supported by the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health under Award Numbers F32AA025823 and K24AA022136, respectively. The authors declare no financial or other conflict of interests that could affect the integrity or veracity of this work. © 2019 American Society of Addiction Medicine

Patient and Physician Perspectives on Treating Tobacco Dependence in Hospitalized Smokers With Substance Use Disorders: A Mixed Methods Study Objective: Individuals with substance use disorders have a high prevalence of smoking cigarettes. Hospitalization represents an opportunity to deliver concurrent treatment for tobacco and other substances. Using a sequential explanatory mixed methods design, we characterized practices and perspectives of patients and physicians about smoking cessation counseling during inpatient addiction medicine consultations. Methods: We abstracted data from 694 consecutive inpatient addiction consult notes to quantify how often physicians addressed tobacco dependence using the guideline-recommended 5As framework. We conducted semi-structured interviews with 9 addiction medicine physicians and 20 hospitalized smokers with substance use disorders. We analyzed transcripts to explore physicians’ and patients’ perspectives on smoking cessation conversations during inpatient addiction consultations, physician-perceived barriers and facilitators to engaging inpatients in tobacco treatment, and strategies to improve tobacco treatment in this context. Results: 75.5% (522/694) of hospitalized substance use disorder patients were current smokers. Among smokers, 20.9% (109/522) were offered nicotine replacement while hospitalized, but only 5.4% (28/522) received the full guideline-recommended 5As. Patients and physicians reported minimal discussion about tobacco addiction during hospitalization. Physicians cited tobacco not being an immediate health threat and the perception that quitting tobacco is not a priority to patients as barriers, often limiting thorough counseling to patients with smoking-related admissions. Physicians and patients offered strategies to integrate treatment of tobacco dependence and other substances. Conclusions: Inpatient addiction consultations represent a missed opportunity to counsel patients with substance use disorders to quit smoking. System-level changes are needed to coordinate treatment of tobacco and other drug dependence in hospitalized smokers. Send correspondence to Hasmeena Kathuria, MD, Pulmonary Center, 72 E. Concord St R304, Boston, MA 02118. E-mail: hasmeena@bu.edu. Received 10 July, 2018 Accepted 14 November, 2018 Primary Source of Funding: This work was supported by the Boston University Evans Center for Implementation and Improvement Sciences (CIIS) and supported in part by resources from the Edith Nourse Rogers Memorial VA Hospital. Conflicts of interest: Dr. Kathuria has consulted for Remedy Partners on relevance of codes for pulmonary services. The authors have no other conflicts of interests to disclose. Disclaimer: The views expressed in this article do not necessarily represent the views of the Department of Veterans Affairs or the United States Government. The funding organizations had no role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; or the preparation, review, or approval of the manuscript. © 2019 American Society of Addiction Medicine

Opioid Toxidrome Following Grapefruit Juice Consumption in the Setting of Methadone Maintenance Background: Methadone is a synthetic mu-opioid receptor agonist used in the treatment of chronic pain and opioid dependence. Methadone is metabolized by several cytochrome P450 isoenzymes; primarily CYP3A4, CYP2B6, and CYP2D6 before renal and fecal elimination. Exposure to substances like grapefruit juice, that inhibit these isoenzymes may result in increased blood levels of methadone, and thus may manifest clinically as unexpected opioid toxicity. Case: A 51-year-old male was found unresponsive. He was hypoxic and bradypneic with pinpoint pupils. Multiple boluses followed by infusion of naloxone were required before improvement of respiratory status. Upon awakening, the patient reported participating in an opioid treatment program where he is administered 90 mg of oral methadone daily and denied any other substance use. On further questioning, he admitted to drinking grapefruit juice (estimated to be approximately 500 mL/day) every day for 3 consecutive days before presentation. The patient was discharged home after being counseled to stop drinking grapefruit juice. Discussion: Grapefruit juice is known to be an inhibitor of the CYP3A4 isoenzyme. Various studies demonstrate that through CYP3A4 inhibition, grapefruit juice increases serum levels of opioids, such as methadone, though no clinically significant effects have been reported. Conclusions: Grapefruit juice inhibits the metabolism of methadone, raising its serum levels. To our knowledge, this is the first reported case in which the interaction between grapefruit juice and methadone was significant enough to cause an opioid toxidrome. It is, therefore, recommended that opioid treatment programs (OTPs) advise patients about this interaction before administering methadone. Send correspondence to Muhammed Ershad, MD, Hahnemann University Hospital, Philadelphia, PA 19102. E-mail: docershad@gmail.com Received 4 February, 2019 Accepted 11 March, 2019 The authors report no conflicts of interest. © 2019 American Society of Addiction Medicine

Multivisceral Failure in a Context of Serotonin Syndrome Induced by MDMA: The Investigation of a Unique and Nationwide Network The occasional ingestion of 3,4-methylenedioxy-N-methylamphetamine (MDMA) presents serious risks of side effects including death through multivisceral failure in a context of serotonin syndrome. The significant increasing evolution of illicit MDMA street dosages over the past 2 decades and the difficulty for physicians to know what quantity the patients may have consumed, make MDMA a drug with unpredictable effects. Through this case report of a 16-year-old Caucasian, we made use of a unique and nationwide French health monitoring system called TREND (Recent Trends and New Drugs)—SINTES (National Identification System for Drugs and Substances), which, combined with the hair follicle test, can assist medical practitioners in rapidly establishing a precise diagnosis and consequently provide the most appropriate treatment for each individual case in a timely manner. Send correspondence to Redwan Maatoug, MD, MSc, PhD Candidate, Psychiatrist, Addictologist, La Pitié Salêtrière Hospital, 47-83 Boulevard de l’hôpital, 75013 Paris, France. E-mail: redwanmaatoug@gmail.com Received 13 December, 2018 Accepted 19 April, 2019 Disclosure: All authors declare no competing interest. © 2019 American Society of Addiction Medicine

Adolescent SBIRT Practices Among Pediatricians in Massachusetts Objectives: Adolescent Screening, Brief Intervention, and Referral to Treatment (SBIRT) in primary care is a key strategy to prevent, identify, and respond to substance use problems and disorders, including opioid and other drug addictions. Despite substantial investment in recent years to increase its implementation, few studies have reported on recent levels of SBIRT implementation among pediatricians. We aimed to assess self-reported use of the SBIRT framework with adolescent patients among Massachusetts pediatricians, and describe trends since an earlier survey. Methods: We analyzed responses to a cross-sectional survey mailed in 2017 to a representative sample of pediatricians in Massachusetts. We computed response frequencies for all SBIRT practice questions. We used the chi-square test to compare current data to data collected in 2014, as we found no demographic differences between the 2 samples. Results: Nearly all pediatricians in the 2017 sample (n = 160) reported annual screening of their adolescent patients (99%). The majority reported giving positive reinforcement (87%), brief advice (92%), counseling (90%), and referral to treatment (66%) in response to screen results. Compared with 2014, a significantly higher proportion of pediatricians in 2017 referred patients who screened positively for problematic alcohol use, but perceived barriers to screening and follow-up remain, such as insufficient time to screen and patient refusal to return. Conclusions: Among respondents to a Massachusetts pediatrician survey, we found high rates of delivering SBIRT in accordance with published guidelines, though barriers remain. Whether the content of the counseling adheres to guidelines is unknown. Send correspondence to Sharon Levy, MD, MPH, Director, Adolescent Substance Use and Addiction Program, Boston Children's Hospital, 300 Longwood Avenue, Mailstop 3114, Boston, MA 02115. E-mail: Sharon.Levy@childrens.harvard.edu. Received 7 November, 2018 Accepted 5 May, 2019 Author contributions: Dr Straus, Ms Fluett, and Ms Strother designed the survey and collected data. Dr Harris carried out data analysis. Ms Wiseblatt carried out data analysis and drafted the initial manuscript. Dr Levy designed the survey, collected data, and drafted the initial manuscript. All authors reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. Funding: Centers for Medicaid and Medicare Service, State Innovation Model grant to the Commonwealth of Massachusetts (CMS-1G1-12-001) provided support for the administration of the 2014 and 2017 survey and the analysis of results. The authors have no conflicts of interest to disclose. © 2019 American Society of Addiction Medicine

Poverty and Excess Length of Hospital Stay in Neonatal Opioid Withdrawal Syndrome Objectives: To study the impact of sociodemographic factors on length of stay (LOS) for infants with neonatal opioid withdrawal syndrome (NOWS) secondary to fetal opioid exposure. Methods: In this retrospective cohort study, we included term infants with NOWS, excluding those with other significant medical issues. Comprehensive clinical and sociodemographic data were collected. Multivariate regression modeling was used to identify factors which contributed to excess LOS, which was defined as the number of days beyond the standard monitoring and/or treatment protocol. Results: In all, 129 infants were identified; mean gestational age of 37.9 ± 1.3 weeks and mean body weight of 2880 ± 496 g. Among them, 68% of infants were exposed to opioids; 27% were exposed to methadone; and 67% required pharmacologic treatment. The degree of poverty was assessed using the Area Deprivation Index (ADI) based on the mother's address at the time of birth. Median LOS for treated infants was 23 days versus 8 days for those who did not need pharmacologic treatment. The median excess LOS was 4 days (range 0–24). Excess hospital days were strongly correlated with degree of deprivation in the mother's community (r = 0.55, P < 0.01). ADI remained a strong predictor of excess LOS, even when controlling for pharmacologic treatment, placement in state's custody, race, and gestational age at birth. Conclusions: These results suggest poverty is associated with excess LOS and that early allocation of resources for at-risk families may help to reduce overall length of hospital stay. Send correspondence to: Zachary A. Vesoulis, MD, Department of Pediatrics, Washington University School of Medicine, 1 Children's Place, St. Louis, MO 63110. E-mail: vesoulis_z@kids.wustl.edu. Received 10 January, 2019 Accepted 11 March, 2019 Funding: This work was supported by the following grants: Washington University Institute of Clinical and Translational Sciences KL2 Training Program (NIH/NCATS KL2 TR000450); the Barnes-Jewish Hospital Foundation and the Washington University Institute of Clinical and Translational Sciences Clinical and Translational Funding Program (NIH/NCATS UL1 TR000448). The authors report no conflicts of interest. © 2019 American Society of Addiction Medicine

How Might Maternal Poverty Impact the Course of Neonatal Opioid Withdrawal Syndrome? Neonatal Opioid Withdrawal Syndrome (NOWS) is an increasing problem in the midst of the current opioid epidemic, frequently associated with pharmacologic treatment and prolonged hospitalizations. NOWS is a highly variable condition with many clinical and genetic variables contributing to the clinical course. Social variables such as maternal poverty remain understudied. In this commentary, we review one of the first studies of the association between maternal poverty and infant hospital length of stay in infants with NOWS. This has important implications for designing population level interventions to improve NOWS outcomes. Send correspondence to Elisha M. Wachman, MD, Boston Medical Center, 771 Albany Street, Dowling 4103, Boston, MA 02118. E-mail: Elisha.Wachman@bmc.org Received 26 March, 2019 Accepted 31 March, 2019 Financial disclosures: No funding was provided for this manuscript. Dr Wachman has no conflicts of interest to disclose. © 2019 American Society of Addiction Medicine

The Role of Hospitalists in Treating Opioid Use Disorder No abstract available