Consensus and Controversies Between Pain and Addiction Experts on the Prevention, Diagnosis, and Management of Prescription Opioid Use Disorder Objectives: Prescription opioid use disorder (POUD) is an established public health crisis in many countries, and current evidence indicates it is a growing problem in Europe. Many specialists play a role, including pain and addiction medicine specialists, in the diagnosis and management of POUD, but neither group can fully address these patients’ needs alone. The purpose of this consensus process was to bring together experts from pain and addiction medicine to examine the positions of both specialties. Methods: In all, 13 international pain medicine, addiction medicine, and addiction psychiatry experts convened a meeting to formulate a set of consensus statements on the diagnosis and management of POUD. The statements were further refined by a wider group of 22 European expert clinicians. At a second meeting of all 35 participants, a set of controversy statements was also developed to recognize some of the key areas of divergent opinion. Results/conclusions: There was a high level of agreement between pain and addiction specialists. Key themes that emerged were the need to strengthen interdisciplinary communication, a desire for greater education and training for clinicians in both specialties, and mutual acknowledgment of the importance of multidisciplinary management of POUD. The blurred line between poorly managed pain and POUD was also a subject of much discussion, reflecting the difficulties in defining and diagnosing this complex condition. Send correspondence to Mark Kraus, MD, and Kaitlin Pellicano, MD, 714 Chase Parkway, Waterbury, CT 06708. E-mail: MLK@wsmgct.com; pellicanomd@gmail.com Received 8 October, 2018 Accepted 20 August, 2019 Funding: The authors would like to acknowledge funding support from PharmaComMedia and Indivior for facilitating travel and honoraria for the participants to attend 2 meetings at which the consensus positions were developed. Indivior had no input in the proceedings of the meetings or in the work presented here. The authors have 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

A Light in the Darkness: Repetitive Transcranial Magnetic Stimulation (rTMS) to Treat the Hedonic Dysregulation of Addiction The present paper discusses the potential use of repetitive transcranial magnetic stimulation (rTMS) for the treatment of addiction, within a conceptual framework that includes the “dark side” of addiction. New findings suggest that rTMS may rescue specific reward system dysfunction that underlies the pathophysiology of addiction by exposing widely under-recognized and untreated key clinical and psychopathological aspects of addictive disorders. Our paper sheds light on the relevance of these hidden dimensions for the development of effective treatment interventions. In particular, we argue that rTMS may have an impact on craving by reversing the allostatic load of hedonic dysregulation. Send correspondence to George F. Koob, PhD, National Institute on Alcohol Abuse and Alcoholism, 6700B Rockledge Drive, Room 1209, MSC 6902, Bethesda, MD 20892-6902. E-mail: george.koob@nih.gov Received 28 February, 2019 Accepted 4 July, 2019 The authors report no conflicts of interest. © 2019 American Society of Addiction Medicine

Opioid and Amphetamine Treatment Trends Among American Indians in the Great Plains Objectives: Traditionally underserved populations in the United States, particularly rural and American Indian/Alaska Native (AI/AN) communities, are disproportionately impacted by the opioid and amphetamine epidemics and have a higher risk for substance use disorders. AI/AN communities in the American Great Plains face exceptional health risks. We aim to describe recent trends in opioid and amphetamine treatment admissions for AI/ANs living in the Great Plains relative to that of the general population. Methods: We used data from the 2014 to 2016 Substance Abuse and Mental Health Services Administration (SAMHSA) Drug and Alcohol Services Information System (DASIS) Treatment Episode Data Set (TEDS) for Admissions. We extracted opioid and amphetamine treatment admissions for self-identified AI/AN and non-AI/AN patients living in the Great Plains: North Dakota, South Dakota, Nebraska, and Iowa. Average annual admission rates were calculated and compared from 2014 to 2016 for AI/AN versus non-AI/AN populations. Results: While opioid and amphetamine treatment admissions from 2014 to 2016 increased in both AI/AN (49 vs 80 per 10,000) and non-AI/AN (20 vs 26 per 10,000) populations, the rate of increase was significantly greater among AI/ANs (64% vs 32%; P < 0. 01). These trends are largely reflective of increased amphetamine use treatment admissions observed in both AI/AN and non-AI/AN populations. Conclusions: Treatment admissions for opioid and amphetamine use have increased from 2014 to 2016 for both AI/AN and non-AI/AN individuals in the Great Plains, driven largely by amphetamine use. AI/AN individuals were observed to seek care at a much higher rate. This increase in treatment admissions suggests increasing demand for services, which, in turn, necessitates greater investment of resources into AI/AN health facilities to address opioid and amphetamine use disorder in this underserved population. Send correspondence to Julian A. Mitton, MD, MPH, Massachusetts General Hospital, Division of General Internal Medicine, 100 Cambridge Street, 16th Floor, Boston, MA 02114. E-mail: jmitton@partners.org Received 13 May, 2019 Revised 23 September, 2019 Accepted 3 October, 2019 The authors report no conflicts of interest. © 2019 American Society of Addiction Medicine

Screening, Brief Intervention, and Referral to Treatment for Prenatal Alcohol Use and Cigarette Smoking: A Survey of Academic and Community Health Care Providers Objectives: Prenatal alcohol and cigarette smoking are associated with numerous adverse pregnancy outcomes. Screening, Brief Intervention, and Referral to Treatment (SBIRT) represents a standardized approach; however, implementation in routine pregnancy care remains a challenge. The purpose of the study was to determine current practices, barriers to implementation, and education needs of healthcare providers utilizing SBIRT to address prenatal alcohol and cigarette smoking. Methods: We conducted a survey of 118 providers including family physicians, midwives, and obstetricians practicing at 2 Toronto hospitals: community-based teaching site and fully affiliated academic health sciences center. Results: The response rate was 79%. Almost all providers reported screening every pregnant woman for alcohol and smoking status. Brief intervention was offered by fewer providers. Education and supportive counseling were reported by a higher percentage of providers for prenatal cigarette smoking in comparison to alcohol use. Furthermore, up to 60% referred pregnant women to treatment programs for alcohol and cigarette smoking. A significantly higher number of community-based providers reported referring pregnant women to addiction treatment programs. Barriers to interventions included a perceived lack of appropriate resources, training, and clinical pathways. Conclusion: Healthcare providers report universal screening for prenatal alcohol and cigarette smoking; however, brief intervention and referral to treatment are more limited practices. There is a need for education of all providers regarding effective brief counseling strategies and referral to appropriate treatment resources. Development of clinical care pathways may also increase adoption of all components of SBIRT for prenatal alcohol use and cigarette smoking. Send correspondence to Alice Ordean, MD, St. Joseph's Health Centre, Family Medicine Clinic, 30 The Queensway, Toronto, ON M6R 1B5, Canada. E-mail: Alice.Ordean@unityhealth.to. Received 24 April, 2019 Accepted 17 September, 2019 Funding: This project was supported by grant funding from the University of Toronto Practice-Based Research Network (UTOPIAN), Department of Family and Community Medicine, University of Toronto. The funding source was not involved in study design, collection, analysis and interpretation of data nor in the preparation or submission of this manuscript for publication. Disclosure: Dr Ordean receives salary support for academic work from the Department of Family Medicine at St. Joseph's Health Centre. Dr Ordean has also received honoraria for presentations and development of educational materials relating to substance use in pregnancy. Dr Selby has received commercial funding/grants from Pfizer Inc., Bhasin Consulting Fund Inc., Shoppers Drug Mart, and the Patient-centered Outcomes Research Institute. Dr Selby has also received honorariums from Pfizer Canada Inc., and Bristol-Myers Squibb. Dr Selby has received consulting fees from Pfizer Canada Inc., Evidera Inc., Johnson & Johnson Group of Companies, Medcan Clinic, MedPlan Communications (who organized Pfizer Canada Inc. events), Miller Medical Communications, NVision Insight Group, Sun Life Financial, and Myelin & Associates. Dr Selby has also received drugs free/discounted for study through an open tender process from Pfizer Inc., Novartis, and Johnson & Johnson. Finally, Dr Selby receives salary support as a Clinician Scientist from the Centre for Addiction and Mental Health (CAMH) and the Department of Family & Community Medicine at the University of Toronto. Dr. Milena Forte and Ms. Erin Grennell have no conflict of interest to report. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 © 2019 American Society of Addiction Medicine

Supporting the Use of Medications for Addiction Treatment in US Drug Courts: Opportunities for Health Professionals Drug courts are specialty courts that offer treatment services as alternatives to incarceration for defendants struggling with problems related to substance use. These courts have become major access points in the United States for the treatment of substance use disorders, but drug court participants often have limited access to medications for addiction treatment (MAT). A growing chorus of advocates and organizations have called for expanding access to MAT in drug courts, and health professionals may wonder how to join in these efforts. This article reviews practical ways in which individual health professionals might support access to MAT in drug courts, including working with drug courts, fighting public stigma against MAT, contributing to research on MAT in drug courts, and expanding addiction training among clinicians. Send correspondence to Nathaniel P. Morris, MD, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA. E-mail: npm@stanford.edu Received 30 April, 2019 Accepted 22 June, 2019 Disclosure: The authors declare no conflicts of interest. © 2019 American Society of Addiction Medicine

Health Professionals Should be Involved in Shaping Substance Use Disorder Policy Health professionals should become actively involved in creating evidence based SUD policies as individuals; as members of advisory commissions; as advocates within professional associations and through participation in political campaigns as candidates, donors or activists. Send correspondence to David L Rosenbloom, PhD, Boston University School of Public Health, 715 Albany Street, Boston, MA 02118. E-mail: drosenbloom@bu.edu Received 26 August, 2019 Accepted 17 September, 2019 Disclosure: The authors have no conflicts of interest to disclose. © 2019 American Society of Addiction Medicine

Validity of Self-reported Cannabis Use Among Pregnant Females in Northern California Background: Most clinical and epidemiologic estimates of prenatal cannabis use are based on self-report, and the validity of self-reported cannabis use has not been examined in a large, representative population of pregnant women. We determined the validity of self-reported prenatal cannabis use and predictors of nondisclosure using data from Kaiser Permanente Northern California's (KPNC) healthcare system with universal prenatal cannabis screening during prenatal care. Methods: Validation study using data from 281,025 pregnancies in KPNC among females aged ≥11 years who completed a self-administered questionnaire on prenatal cannabis use and a cannabis urine toxicology test from 2009 to 2017. We calculated sensitivity, specificity, positive predictive value, and negative predictive value of self-reported prenatal cannabis use using urine toxicology testing as the criterion standard, and sensitivity of urine toxicology testing using self-reported use as the criterion standard. We compared sociodemographics of those who disclosed versus did not disclose prenatal cannabis use. Results: Urine toxicology testing identified more instances of prenatal cannabis use than self-report (4.9% vs 2.5%). Sensitivity of self-reported use was low (33.9%). Sensitivity of the toxicology test was higher (65.8%), with greater detection of self-reported daily (83.9%) and weekly (77.4%) than monthly or less use (54.1%). Older women, those of Hispanic race/ethnicity, and those with lower median neighborhood incomes were most likely to be misclassified as not using cannabis by self-reported screening. Conclusions: Given that many women choose not to disclose prenatal cannabis use, clinicians should educate all prenatal patients about the potential risks and advise them to quit cannabis use during pregnancy. Send correspondence to Kelly C. Young-Wolff, PhD, MPH, Research Scientist, Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612. E-mail: Kelly.c.young-wolff@Kp.org Received 21 June, 2019 Accepted 1 September, 2019 All authors assisted in the conceptualization and design of the study. Young-Wolff and Sarovar conducted the literature searches and summaries of previous related work. Tucker and Sarovar extracted the data needed for the study and Sarovar and Alexeeff undertook the statistical analysis. Young-Wolff wrote the first draft of the manuscript, which was revised and edited by all authors. All authors contributed to and have approved the final manuscript. Funding: This study was supported by a NIH NIDA K01 Award (DA043604). The authors have no conflicts of interest to disclose. 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

A Multicenter, Randomized, Double-blind, Parallel, Placebo-controlled Clinical Study to Evaluate the Efficacy and Safety of a Nicotine Mint Lozenge (2 and 4 mg) in Smoking Cessation Objective: To evaluate the efficacy in smoking cessation and safety of 2 and 4 mg nicotine mint lozenges in Chinese adult smokers. Methods: This was a multicenter, randomized, stratified, double-blind, placebo-controlled, parallel-group study. The low-dependence stratum included 483 smokers (241 randomized to active 2 mg nicotine lozenge and 242 to placebo lozenge). The high-dependence stratum included 240 smokers (120 randomized to active 4 mg nicotine lozenge and 120 to placebo lozenge). The primary endpoint was successful smoking cessation at 6 weeks postquit, defined as continuous abstinence from smoking for the 28-day period up to and including the 6-week visit (verified by CO measurement). Cochran–Mantel–Haenszel tests were performed to compare quit rates between active nicotine and placebo separately for the high-dependence and low-dependence strata. Results: The primary analysis showed that in the low-dependence (2 mg) stratum, 59 subjects (24.5%) of 241 in the active nicotine group and 52 subjects (21.5%) of 242 in the placebo group were successful quitters (P = .3851). In the high-dependence (4 mg) stratum, 37 subjects (30.8%) of 120 in the active nicotine group and 24 subjects (20.2%) of 119 in the placebo group were successful quitters (P = .0565). Conclusions: The 4 mg nicotine lozenge provided a directionally significant improvement in smoking cessation rates compared with placebo in Chinese adult smokers with high nicotine dependence for the primary endpoint. The 2 mg nicotine lozenge provided higher, but nonsignificant, smoking cessation rates than placebo. Both nicotine lozenges were generally well tolerated in Chinese adult smokers. Send correspondence to Chen Wang, MD, PhD, China-Japan Friendship Hospital, 2 Yinghuayuan E St, Chaoyang Qu, Beijing, 100029, China. E-mail: cyh-birm@263.net Received 20 September, 2018 Accepted 28 April, 2019 Current affiliation: Accenture, Berwyn, PA, USA. On behalf of the following Principal Investigators: Chunxue Bai (Zhongshan Hospital Fudan University, Shanghai); Kejing Ying (Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou); Ping Chen (General Hospital of Shenyang Military District PLA, Shenyang); Qiang Li (Changhai Hospital, Second Medical Military University, Shanghai); Nanshan Zhong (The First Affiliated Hospital of Guangzhou Medical University, Guangzhou); Gengzhi Ge (The 2nd Hospital of Tainjin Medical University, Tianjin); Jiangtao Lin (China-Japan Friendship Hospital, Beijing); Baoyuan Chen (Tianjin Medical University General Hospital, Tianjin). This study was sponsored by Tianjin Sino-American SmithKline & French Laboratory Ltd. Medical writing assistance was provided by Peloton Advantage, LLC, an OPEN Health company, and was funded by GlaxoSmithKline Consumer Healthcare. GlaxoSmithKline Consumer Healthcare provided a full review of the article. 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

Sustained-release Oral Hydromorphone for the Treatment of Opioid Use Disorder Objectives: In 2017, almost 50,000 Americans and over 4000 Canadians died from an opioid overdose. Accordingly, an urgent need exists to improve access to evidence-based treatment for opioid addiction, and also to develop and evaluate alternative treatment options for opioid use disorder (OUD). We present a case of a patient with OUD who was successfully switched and managed on oral hydromorphone after development of a prolonged QTc interval on methadone. Case: A 51-year-old man with longstanding polysubstance use presented to an urban hospital in Vancouver, Canada, for management of alcohol intoxication and hyponatremia. At the time of admission, the patient was stable on 100 mg of methadone daily, but was found to have a persistently elevated QTc (>550 milliseconds), putting him at increased risk for Torsades de Pointes. In an effort to find an alternative opioid agonist therapy for maintenance, a trial of slow-release oral morphine was attempted, but discontinued due to the development of myoclonus. Once-daily sustained-release oral hydromorphone was then started, which was found to manage cravings well without notable side effects. Discussion: The case presented offers promise for the use of once-daily sustained-release oral hydromorphone as a viable treatment option for patients with OUD for whom first-line therapies are not suitable or tolerated. This case report is the first to our knowledge to demonstrate the successful use of oral hydromorphone for treatment of opioid use disorder. Send correspondence to Seonaid Nolan, MD, Assistant Professor, University of British Columbia, Clinician Scientist, British Columbia Centre on Substance Use, 553B-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada. E-mail: Seonaid.nolan@bccsu.ubc.ca Received 8 July, 2019 Accepted 22 September, 2019 Disclosure: S.N. is supported by a Michael Smith Foundation for Health Research Health Professional Investigator award. The other authors report no conflicts of interest. © 2019 American Society of Addiction Medicine

Sexual Abuse and Future Mental Health Hospitalization in a Swedish National Sample of Men Who Use Opioids Objective: Experiences of trauma, specifically sexual abuse, have been linked to both mental health and substance use disorders. This study used 14 years of Swedish health registry data to select a sample of adult men who reported frequent opioid use and assessed if those with a self-reported history of sexual abuse had a higher likelihood of hospitalization for a mental health disorder. Methods: A Swedish longitudinal (2003–2017) registry study linked Addiction Severity Index (ASI) assessments completed with individuals who sought treatment for substance use disorders with data on hospitalizations for mental health disorders, and assessed associations with self-reported histories of sexual abuse among men who reported sustained and frequent use of opioids (n = 1862). Cox regression methods tested associations and controlled for age, and the 7 ASI composite scores: family and social relationships, employment, alcohol use, drug use, legal, physical health, and mental health. Results: The ASI composite score for mental health (hazard ratio [HR] 16.6, P < 0.001) and a history of sexual abuse (HR 1.93, P < 0.001) were associated with an elevated risk of future mental health hospitalization. Conclusion: Both the ASI composite scores for mental health and self-reported history of sexual abuse reflected complex needs among men who used opioids and increased risk for mental health hospitalization. Treatment providers should strive to provide integrated care and address the negative aspects of victimization. Send correspondence to Marcus Blom Nilsson, Department of Social Work, Umeå University, SE-901 87 Umeå, Sweden. E-mail: Marcus.Blom.Nilsson@umu.se Received 11 February, 2019 Accepted 12 September, 2019 Funding: A grant from the Swedish Research Council for Health, Working Life and Welfare (Grant No. 2016–07213) supported the analysis and manuscript preparation. The contributing authors have no financial interests affecting this manuscript and certify that there are no conflicts of interest, including relationships and affiliations relevant to the subject matter or materials discussed in the manuscript. © 2019 American Society of Addiction Medicine