Addressing Confusion and Inconsistencies Surrounding the Provider Role in Medical Cannabis Programs.

ABSTRACT: More than 40 states in the United States have established medical Cannabis programs that authorize the use of Cannabis for specific medical conditions. Initially, these medical Cannabis programs aimed to offer compassionate care primarily for terminal or rare, untreatable conditions. However, the scope of these programs has broadened to include nonterminal and more common conditions, including various medical and mental disorders. This expansion introduces several health care challenges: a lack of robust research evidence for many listed conditions, a sense of unpreparedness among providers, and a disparity in provider roles, expectations, and responsibilities across different states, leading to potential confusion. To address these issues, medical organizations need to develop expert consensus or guidelines that underscore evidence-based shared decision-making and patient monitoring standards. Medical education should also include such training. Concurrently, medical providers must prioritize evidence-based treatment over public opinion, exercise clinical judgment, and take responsibility for their recommendations.

Open-label Study of Injectable Extended-release Naltrexone (XR-NTX) in Healthcare Professionals With Opioid Dependence.

OBJECTIVES: Healthcare professionals (HCPs) with opioid dependence are at risk for relapse and death, particularly in the first year of recovery; however, maintenance treatment with opioid agonists is controversial in this safety-sensitive group. We evaluated long-term safety, tolerability, and treatment outcomes of injectable, intramuscular, extended-release naltrexone (XR-NTX) in opioid-dependent HCPs. METHODS: This single-arm, multisite, open-label study was conducted in opioid-dependent HCPs who had been detoxified from opioids for at least 2 weeks. Subjects received monthly XR-NTX injections for up to 24 months, combined with counseling via intensive outpatient substance abuse treatment programs. Assessments included monthly urine opioid drug tests and routine safety assessments, along with a trimonthly short form (36) Health Survey, opioid craving questionnaire, and Treatment Satisfaction Questionnaire for Medication. RESULTS: Of 49 opioid-dependent HCPs screened, 38 enrolled and received at least 1 XR-NTX injection. Most were female (n = 31) and nurses or nursing assistants (n = 30). More than half (n = 21; 55.3%) received at least 12 injections. Seven discontinued due to adverse events (3 anxiety, 2 headache, 1 injection-site mass, 1 derealization). None experienced relapses to opioid dependence necessitating detoxification, overdose, or death during treatment. At 24 months, mean opioid craving fell by 45.2%, and short form (36) mental component scores improved by 31.1% from baseline and approached normal levels. Of 22 unemployed subjects at baseline, 45.5% improved employment status at 24 months. CONCLUSIONS: Long-term (2 years) XR-NTX was associated with no new safety concerns, and, compared with shorter-term studies in the general population, similar or better rates of retention, opioid-negative urines, opioid craving reduction, mental health functional quality of life improvement, and re-employment.

Addiction to propofol: a study of 22 treatment cases.

OBJECTIVE: To review and report the history and clinical presentation of a cohort of health care professionals (HCPs) who have abused the drug propofol. METHODS: The authors queried a clinical database (the HCP Database) that contained information about HCPs treated at a large addiction center between 1990 and 2010. Patients who reported propofol use were removed from the HCP Database and placed in a second database referred to herein as the Propofol Database. The medical records of each of the cases in the Propofol Database were pulled and carefully reviewed; a clinical case history of each case was prepared. The Propofol Database was expanded by this chart review, adding demographics, drugs used, course of substance use, other clinical history, presenting signs, diagnoses, and comorbid conditions. At this point, the case histories and databases and were anonymized. When variables were present in both data sets, significance was tested between the HCP Database and the Propofol Database. When comparable data were not present in the HCP Database, the authors reported simple percentages within the Propofol Database. This study focused on gender, medical education and specialty, drugs used, course of illness, and comorbid conditions. RESULTS: Compared with the composite treatment population of HCPs during the same time, records showed that the propofol group was more likely to work in the operating theater, be female, and have training as an anesthesiologist or certified registered nurse anesthetist. Presentation into treatment from the propofol cohort more commonly occurred soon after beginning propofol use, often presenting in a dramatic fashion such as motor vehicle accidents or other physical injuries. When such injuries occurred, it was a direct result of acute propofol intoxication. The number of cases arriving in treatment increased over the duration of the study. The propofol group frequently suffered with a depressive illness and had a history of earlier life trauma. They had a high frequency of biological relatives with substance dependence. The most common subjective response as to why they began using propofol was to induce sleep. Most of these patients identified propofol as one of their preferred drugs of abuse. CONCLUSIONS: This study suggests the incidence and/or detection rate of propofol abuse in HCPs is increasing. Women and anesthesia personnel were overrepresented in the propofol cohort. Propofol-dependent patients commonly have a history of depression and earlier life trauma. A rapid downhill course and physical injury are common adverse effects of propofol abuse. The time from initial use to treatment entry is often contracted when compared with other drugs of abuse making the diagnosis of a true dependence disorder and disposition after treatment more difficult.