Addiction Medicine

The Role of Cannabis Use in Suicidal Ideation Among Patients With Opioid Use Disorder Objectives: Cannabis use is associated with suicide risk in the general population; however, it is unknown if this association is also present in patients with opioid use disorder (OUD). The purpose of this study is to investigate the association between cannabis use and suicidal ideation in patients with OUD. Methods: We conducted a multivariable logistic regression analysis to assess the association between cannabis use and suicidal ideation, amongst a large cohort of patients with OUD. Current cannabis use and suicidal ideation over the past 30 days were obtained by self-report. Results: Cross-sectional data from 2335 participants with OUD were included in the analysis, of whom 51% report current cannabis use. We found a positive association between cannabis use and suicidal ideation (OR = 1.41, 95% CI 1.11, 1.80, P = 0.005). We found that men (OR = 1.84, 95% CI 1.44, 2.35, P < 0.001), younger individuals (OR = 1.02, 95% CI 1.01, 1.03), P = 0.004), and that those with more symptoms of anxiety or depression (OR = 1.16, 95% CI 1.15, 1.18, P < 0.001) were more likely to report suicidal ideation. Conclusions: Cannabis use is associated with a heightened propensity for suicidal ideation amongst patients with OUD, who are already a high-risk population. Further research into the potential harms of cannabis use in this population is required given the prevalence of its use and potential benefits in mitigating opioid withdrawal. Send correspondence to Zainab Samaan, MBChB, MSc, DMMD, MRCPSych, PhD, Associate Professor Psychiatry and Behavioural Neurosciences, McMaster University Director, Clinician Investigator Program, Mood Disorders Program, St. Joseph's Healthcare Hamilton, 100 West 5th St, G104, Hamilton, Ontario L8N 3K7, Canada. E-mail: samaanz@mcmaster.ca. Received 29 June, 2020 Accepted 30 October, 2020 Dr. Samaan is supported by grants from CIHR Awards #156306 and #155404. The authors report no conflicts of interest. 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 © 2020 American Society of Addiction Medicine

Low Uptake of Secure Messaging Among Veterans With Experiences of Homelessness and Substance Use Disorders Objectives: Persons who are homeless have significant health challenges and barriers accessing care. Secure messaging supports communication between patients and their providers through a web-based portal, but the acceptability of this technology among patients with high prevalence of substance use disorders (SUDs) is unknown. We examined secure messaging use among veterans with experiences of homelessness (VEHs), and determined factors associated with messaging use. Methods: We conducted a cross-sectional analysis of responses to a national survey of VEHs, administered by mail from March to October 2018 (response rate = 40.2%). One item assessed secure messaging use and satisfaction. We used multivariable logistic regressions to model secure messaging use, controlling for sociodemographics, medical conditions, housing indicators, and mental health and SUD diagnoses. Results: Of 5072 VEHs, 21% had ever used secure messaging and 87% of the subsample found messaging to be useful. Secure messaging was more commonly used by VEHs who were female, had some college education, those with ≥3 chronic medical conditions, depression, or posttraumatic stress disorder (all P < 0.001). Messaging was much less common for VEHs ages 55 to 64 or older, non-Latino Blacks, those receiving homeless-tailored primary care, and those with SUDs (all P < 0.001). VEHs with opioid use disorder were even less likely than those with other SUDs to use secure messaging (P = 0.047). Conclusions: Persons with homeless experiences might require assistance to engage with secure messaging technology. As health systems limit in-person care during a national pandemic, alternative solutions may be needed to facilitate health communications and prevent care disruptions for patients experiencing homelessness and SUDs. Send correspondence to Audrey L. Jones, PhD, Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, 500 Foothill Drive, MC151 Research, Salt Lake City, UT 84148. E-mail: Audrey.Jones3@va.gov. Received 6 May, 2020 Accepted 8 November, 2020 Supported by the Department of Veterans Affairs (VA) Health Services Research and Development (IIR 15–095); the VA, Veterans Health Administration, National Center on Homelessness Among Veterans; and the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR002538 and KL2TR002539. Dr. Varley reported receiving income from Heart Rhythm Clinical Research Solutions. Dr. Kertesz and Dr. Gordon reported receiving personal fees from UpToDate, the California Society of Addiction Medicine, the Howard Center, the Centre for Addiction and Mental Health, and Ascension/St. Vincent's Health System; owning stock in CVS Health, Thermo Fisher Scientific, and Zimmer Biomet; and that his spouse privately owns stock in Abbott, Merck and Co, and Johnson & Johnson. No other disclosures were reported. The authors thank Ms. April Hoge (VA Birmingham Medical Center) and Dr. Young-il Kim (University of Alabama at Birmingham School of Medicine) for project assistance, data management, and statistical guidance. The supporting organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, the National Institutes of Health, or the United States government. Audrey L. Jones ORCID ID: 0000-0003-1533-7469; Adam J. Gordon ORCID ID: 0000-0002-2453-8871; Stefan G. Kertesz ORCID ID: 0000-0001-6101-8421. The authors report no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.journaladdictionmedicine.com). © 2020 American Society of Addiction Medicine

Use of Electronic Health Record Data to Estimate the Probability of Alcohol Withdrawal Syndrome in a National Cohort of Hospitalized Veterans Objectives: Inpatient alcohol withdrawal syndrome (AWS) is common and early treatment improves outcomes, but no prior study has used electronic health record (EHR) data, available at admission, to predict the probability of inpatient AWS. This study estimated the probability of inpatient AWS using prior-year EHR data, hypothesizing that documented alcohol use disorder (AUD) and AWS would be strongly associated with inpatient AWS while exploring associations with other patient characteristics. Methods: The study investigated patients hospitalized ≥24 hours on medical services in the Veterans Health Administration during 2013 using EHR data extracted from the Veterans Health Administration Corporate Data Warehouse. ICD-9-CM diagnosis code, demographic, and healthcare utilization data documented in the year before admission defined prior-year AUD, AWS, and other factors associated with inpatient AWS. The primary outcome, inpatient AWS, was defined by inpatient ICD-9-CM codes. Results: The unadjusted probability of AWS was 5.0% (95% CI 4.5%–5.4%) among 209,151 medical inpatients overall, 26.4% (95% CI 24.4%–28.4%) among those with prior-year AUD, and 62.5% (95% CI 35.2%–39.7%) among those with prior-year AWS. Of those with AWS, 86% had documented prior-year AUD and/or AWS. Other patient characteristics associated with increased probability of inpatient AWS (P < 0.001) were: male sex, single relationship status, homelessness, seizure, and cirrhosis. Conclusions: Although inpatient providers often use history to predict AWS, this is the first study in hospitalized patients to inform and validate this practice, showing that prior-year diagnosis of AUD and/or AWS in particular, can identify the majority of inpatients who should be monitored for AWS. Send correspondence to Tessa L. Steel, MD, MPH, Seattle-Denver Center of Innovation (COIN), VA Puget Sound Health Care System, Seattle Division, 1660 South Columbian Way S-152, Seattle, WA 98108. E-mail: tessita@uw.edu, @tessaLsteel. Received 14 September, 2020 Accepted 8 November, 2020 Supported by VA Puget Sound Health Care System Research & Development Associate Chief of Staff (ACOS) Pilot Grant Program, the Center of Excellence for Substance Abuse Treatment & Education (CESATE), and K24AA022128. The authors report no conflicts of interest. All authors had access to the data supporting this study and a role in writing the manuscript. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.journaladdictionmedicine.com). © 2020 American Society of Addiction Medicine

COVID-19 and Cannabidiol (CBD) COVID-19 pandemic has resulted in devastating mortality and morbidity consisting of socioeconomic and health effects that have included respiratory/pulmonary, cardiovascular, mental health and neurological consequences such as anxiety, depression, and substance use. Extensive efforts are underway to develop preventive vaccines and therapeutics such as remdesivir, dexamethasone, convalescent plasma, and others to treat COVID-19 but many report residual mental health problems after recovery. Cannabis products such as cannabidiol (CBD) are being advertised for the treatment of COVID-19 associated mental health problems and substance use disorders. This commentary will briefly clear the myth that CBD can ameliorate a wide range of COVID-19 associated health effects including anxiety, depression, or any substance use disorder, and show that there is a clear lack of sufficient unbiased clinical evidence from well-designed double-blind, placebo-controlled clinical trials to prove the antianxiety or antidepression therapeutic properties of CBD and support its wide use as medicine to treat COVID-19- associated mental health conditions or substance use disorders. Finally, we suggest that addiction physicians must play an important role in dealing with their patients requesting CBD prescription for treating any of these conditions. Send correspondence to Jag H. Khalsa, MS, PhD, 24924 McNair Place, ALDIE, VA 20105-5572. E-mail: jkhalsa@yahoo.com; jag.khalsa@gmail.com; jag.khalsa@nih.gov. Received 12 July, 2020 Revised 8 October, 2020 Accepted 14 October, 2020 Support by GB: Samaritan/Day Top Village; SBM: R01NS066801; R01AG 054325; SK: Grant 5R01DA 043396. Research grants to the institution from Merck, Inc., Gillead Sciences, and Airbutus pharmaceuticals. Other authors report no conflicts of interest. © 2020 American Society of Addiction Medicine

COVID-19 Social Distancing and Online Mutual Help Engagement for Alcohol Use Recovery Introduction: COVID-19 and associated social distancing has presented challenges for individuals engaging in face-to-face mutual help groups (MHGs) such as Alcoholics Anonymous for alcohol use recovery. Online MHGs may be particularly appealing to individuals with limited access or inclination to attend in-person MHGs. We examined engagement within the popular "StopDrinking" online MHG, hypothesizing that engagement would increase due to demand for virtual peer support as COVID-19 social distancing progressed. Methods: We collected publicly available engagement data for StopDrinking from February 19, 2018 through April 30, 2020 while considering March and April of 2020 as months initially impacted by voluntary or mandated COVID-19 social distancing. Using seasonal autoregressive integrated moving average models, we predicted daily engagement for this social distancing time period based on all available engagement data collected before April 2020. Kalman filtering with 95% prediction limits was employed to define significant thresholds for observed data to reside within. Results: All days of observed engagement in March and April 2020 were lower than corresponding predicted values. Observed engagement fell below the lower 95% prediction limit for 36% of days, with 15 days in March and 7 days in April having significantly lower than predicted engagement. Conclusions: Relatively low activity on StopDrinking may signal broader population trends of problematic alcohol use and recovery disengagement during the initial COVID-19 social distancing timeframe. Continued investigation of online MHGs is needed to understand their potential for monitoring population health trends and to understand how such groups might support alcohol use recovery in contexts of crisis and isolation. Send correspondence to Jason B. Colditz, MEd, 230 McKee Place, #600, Pittsburgh, PA 15213. E-mail: colditzjb@pitt.edu. Received 23 July, 2020 Accepted 21 November, 2020 The authors report no conflicts of interest. © 2020 American Society of Addiction Medicine

Understanding Contraceptive Needs of Women Who Inject Drugs in Orange County: A Qualitative Study Objectives: Women with opioid use disorder experience higher rates of unintended pregnancy compared with the general US population. Our aim was to examine the factors that may affect access to desired contraception for women who use injection drugs. Methods: Using purposive sampling, we conducted semi-structured interviews pertaining to contraceptive use with 14 women ages 18 to 44 who were current users of injection drugs living in Orange County, CA between March and December 2019. Interviews were transcribed, coded, and analyzed using grounded theory. Results: Participants discussed logistical barriers, including homelessness and lack of transportation, as well as perceived barriers, such as a belief in the inability to become pregnant while using drugs, that affect access to contraceptive care. Women also discussed the factors that motivate them to use contraception despite these barriers, including the desire for sobriety before becoming pregnant and fear of harming a fetus while using substances. Some participants expressed feeling uncomfortable disclosing substance use to their healthcare providers out of concern for stigmatization. Several points of access for contraceptive care were elucidated, including visits for primary and postpartum care, as well as in carceral spaces. Finally, participants expressed a desire to obtain contraceptive services at a local syringe exchange program due to trusting relationships with providers and increased ease of access. Conclusions: Our findings highlight several causative factors for the unmet contraceptive need among women who use injection drugs, and suggest that syringe exchange programs represent a unique access point for the provision of contraceptive care for this population. Send correspondence to Orli K. Florsheim, MD, University of New Mexico School of Medicine, Department of Family and Community Medicine, 1 University of New Mexico, Albuquerque, NM 87131, United States. E-mail: oflorsheim@salud.unm.edu. Received 15 August, 2020 Accepted 15 November, 2020 This work was supported by the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant UL1TR0001414. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The authors have no conflicts of interest to disclose. © 2020 American Society of Addiction Medicine

Cannabis Use During the COVID-19 Pandemic in Canada: A Repeated Cross-sectional Study Objectives: In the context of the ongoing coronavirus disease pandemic in Canada, we aimed to (1) characterize trends in cannabis use in the overall population; and (2) characterize patterns of and identify risk characteristics associated with an increase in cannabis use among those who used cannabis. Methods: Data were obtained from three waves of an online, repeated cross-sectional survey of adults residing in Canada (May 08–June 23, 2020; N = 3012). Trends were assessed using Cochran-Armitage and chi-square tests, and risk characteristics were identified using logistic regression analyses. Results: Cannabis use in the overall population remained stable during the months of May and June. Among those who used cannabis, about half increased their cannabis use compared to before the start of the pandemic. This proportion of an increase in cannabis use among those who used cannabis remained consistent across the survey waves. Risk characteristics associated with higher odds of an increase in cannabis use included residence in the central region (Odds ratio, 95% confidence intervals: 1.93, 1.03–3.62), being 18 to 29 years old (2.61, 1.32–5.17) or 30 to 49 years old (1.85, 1.07–3.19), having less than college or university education (1.86, 1.13–3.06) and being somewhat worried about the pandemic's impact on personal finances (1.73, 1.00–3.00). Conclusions: A large proportion of those who used cannabis have increased cannabis use during the pandemic, suggesting a need for interventions to limit increased cannabis use, policy measures to address cannabis-attributable harms, and continued monitoring of cannabis use during and after the pandemic. Send correspondence to Sameer Imtiaz, PhD, Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, 2035B - 33 Russell Street, Toronto, Ontario, M5S 2S1, Canada. E-mails: sameer.imtiaz@camh.ca, sameer.imtiaz@gmail.com. Received 16 July, 2020 Accepted 21 November, 2020 Delvinia provided in-kind support for the data collection. Sameer Imtiaz, Samantha Wells, Hayley Hamilton, and Tara Elton-Marshall acknowledge funding from the Canadian Institutes of Health Research and Canadian Centre on Substance Use and Addiction (Partnerships for Cannabis Policy Evaluation Team Grant), and Sameer Imtiaz, Jürgen Rehm and Tara Elton-Marshall acknowledge funding from the Canadian Institutes of Health Research's Institute of Neurosciences, Mental Health and Addiction (Canadian Research Initiative on Substance Misuse Ontario Node Grant [SMN-13950]). The funders had no role in study design, data collection, and analysis, decision to publish, or preparation of the manuscript. The authors report no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.journaladdictionmedicine.com). © 2020 American Society of Addiction Medicine

Barriers and Facilitators to Buprenorphine Prescribing for Opioid Use Disorder in the Veterans Health Administration During COVID-19 No abstract available

Discontinuing Methadone and Buprenorphine: A Review and Clinical Challenges This paper offers a review and recommendations for clinicians working with patients interested in discontinuing opioid agonist treatment. As buprenorphine/naloxone has gained widespread acceptance for opioid addiction, many treatment providers and patients have a range of hopes and expectations about its optimal use. A surprising number assume buprenorphine/naloxone is primarily useful as a medication to transition off illicit opioid use, and success is partially defined by discontinuing the medication. Despite accumulating evidence that a majority of patients will need to remain on medication to preserve their gains, clinicians often have to address a patient's fervent desire to taper. Using the concept of "recovery capital," our review addresses (1) the appropriate duration of opioid agonist treatment, (2) risks associated with discontinuing, (3) a checklist that guides the patient through self-assessment of the wisdom of discontinuing opioid agonist treatment, and (4) shared decision making about how to proceed. Send correspondence to Joan E. Zweben, PhD, 714 Spruce Street Berkeley, CA 94707; E-mail: joan.zweben@gmail.com Received 21 April, 2020 Accepted 10 November, 2020 Supported in part by the second author's Fulbright-Canada Fellowship while at the University of Calgary, Calgary, Alberta, Canada. Additional support through NIH U10DA15815, R25DA028567, and R25DA035163. The authors report no conflicts of interest. Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a "work of the United States Government" for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government. © 2020 American Society of Addiction Medicine

Impacts of the COVID-19 Shutdown on Gambling Patterns in Australia: Consideration of Problem Gambling and Psychological Distress Objectives: The COVID-19 pandemic reduced access to gambling and contributed to widespread psychological distress. Psychological distress is a known risk factor for problem gambling as it can motivate excessive gambling as a coping response. The availability of gambling is considered a factor in maintaining problems. This paper aimed to investigate the impact of the shutdown of gambling venues on Australians, particularly among those vulnerable to mental health problems and gambling disorder. Methods: Australian adults who had gambled at least once in the past 12 months (N = 764, 85.2% male) completed an online cross-sectional survey. Self-report measures retrospectively assessed typical monthly gambling frequency and expenditure before and after the COVID-19 venue shutdown, problem gambling, and psychological distress. Results: Significant median decreases in gambling frequency were observed, both online and overall. No relationship was found between psychological distress and baseline or increases in gambling. Greater problem gambling severity was related to higher baseline gambling, but not to increases in gambling. Exploratory analysis showed that individuals engaged in moderate-risk gambling, but not problem gambling, were more likely to report increased gambling frequency compared to nonproblem and low-risk gamblers combined. Conclusions: Findings provide important insights into how changes in availability influence gambling participation, and for understanding the effectiveness of forced restrictions and venue exclusion strategies. Most people moderated their gambling when venue-based gambling was unavailable and opportunities for sports betting were limited. However, harms experienced by individuals with some gambling problems may have been exacerbated during the period of limited access. Policies to enhance prevention and treatment of gambling problems are necessary even when availability is reduced. Send correspondence to Sally M. Gainsbury, PhD, Faculty of Science, School of Psychology, Brain and Mind Centre, Gambling Treatment and Research Clinic, The University of Sydney, 94 Mallett Street, Camperdown NSW 2050, Australia. E-mail: sally.gainsbury@sydney.edu.au Received 13 August, 2020 Accepted 15 November, 2020 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). Supported by the Gambling Treatment and Research Clinic at the University of Sydney. Over the last three years (2017–2020), Dr. Gainsbury has worked on projects that have been received funding and in-kind support through her institution from Australian Research Council, NSW Liquor and Gaming, Svenska Spel Research Council, Responsible Wagering Australia, Australian Communication and Media Authority, Commonwealth Bank of Australia, National Association for Gambling Studies, GameCo, ClubsNSW, Crown Resorts, Wymac Gaming. Dr. Gainsbury is currently a member (2019–20) of the National Council on Problem Gambling International Advisory Board (Singapore) and receives an honorarium for this role as well as travel expenses to attend an annual meeting. She is a member of the Steering Committee for Remote Gambling Research and the Independent Research Oversight Panel both run by GambleAware, which provide an honorarium. Dr. Gainsbury has received honorarium directly and indirectly for research, presentations, and advisory services from Credit Suisse, Oxford University, ClubsNSW, Clubs4Fun, Centrecare WA, Gambling Research Exchange Ontario, Crown, Department of Social Services, Community Clubs Victoria, Financial and Consumer Rights Council, Australian Communications and Media Authority, Manitoba Gambling Research Program, VGW Holdings, Nova Scotia Provincial Lotteries and Casino Corporation, Ministry of Health, Clayton Utz, Greenslade, Generation Next. Dr. Gainsbury has received travel expenses to attend meetings from Franklin Women, GambleAware, Community Clubs Victoria, Centrecare WA, Financial and Consumer Rights Council, Stiftelsen Nordiska Sällskapet för Upplysning om Spelberoende, Generation Next, Alberta Gambling Research Institute, QLD Treasury, Responsible Gambling Council. Thomas Swanton has received a PhD scholarship and research grant funded under the NSW Government's Responsible Gambling Fund Research Capacity Grants, with support from the NSW Office of Responsible Gambling. He has received honoraria for research advisory services from GambleAware, an independent UK charity that seeks to minimize gambling harms and which receives voluntary donations from the gambling industry. Alexander Blaszczynski has conducted research funded directly by the Australian or international government, or government-related funding agencies, and industry operators. These include Gambling Research Exchange Ontario, ClubsNSW, Dooleys Club Lidcombe, Aristocrat Leisure Industries, Australian Communications Media Authority, Gaming Technologies Association, Gambling Research Australia, Responsible Wagering Australia, Commonwealth Bank, NSW Department of Trade and Investment (NSW Office of Liquor, Gaming and Racing), La Loterie Romande (Switzerland), Camelot (United Kingdom), La Française des Jeux (France), Loto-Quebec (Canada), and National Lottery (Belgium), and the National Association for Gambling Studies. He is on the responsible gambling advisory panel for Crown Casino. He has received honorariums from Manitoba Gambling Research Program and GambleAware (formerly UK Responsible Gambling Trust) for grant reviews, and royalties from several publishers for books and book chapters. He has also received travel and accommodation expenses from Leagues Clubs, Gambling Research Exchange Ontario, USA National Council on Problem Gambling, Japan Medical Society for Behavioural Addiction, Le Comité d'organisation Congrès international sur les troubles addictifs, Victorian Responsible Gambling Foundation, North American Association of State and Provincial Lotteries, and New Horizons (British Columbia Lottery Corporation to attend conferences and meetings. Martin T Burgess reports no conflicts of interest. The University of Sydney Human Research Ethics Committee provided ethical approval for the study (protocol number 2019/213). Author contributions: SG: Conceptualisation; Methodology; Investigation; Writing – Original Draft, Review & Editing; Supervision. TS: Conceptualisation; Methodology; Investigation; Formal analysis; Writing – Original Draft, Review & Editing; Project administration. MB: Methodology; Formal analysis; Writing – Review & Editing; Visualisation. AB: Conceptualisation; Methodology; Investigation; Writing – Review & Editing; Supervision. Preregistration statement: The hypotheses and confirmatory analysis plan relating to this study were preregistered on Open Science Framework before analysis of the data: https://osf.io/tskdq. © 2020 American Society of Addiction Medicine

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