Building workforce capacity to address substance use in primary health care: preliminary results from a mixed-methods pilot program

BACKGROUND

Primary health care is critical to the prevention of alcohol, tobacco and other drug-related harms. Scaling-up screening, brief intervention and referral to treatment (SBIRT) within primary health care can reduce the burden of substance-related diseases, and improve downstream healthcare services. Building knowledge, skills and confidence among general practitioners (GPs), particularly in rural, regional and remote areas, to deliver SBIRT is an essential step. Therefore, this study aimed to pilot test a skills-based training program for GPs designed to build capacity for SBIRT delivery.

METHODS

This pilot study investigated the acceptability of a structured, educational skills-based training program among GPs, as well as its preliminary effectiveness in inducing changes in confidence to deliver SBIRT, and in increasing knowledge about low-risk alcohol guidance. The training package was designed by experts in addiction medicine and public health, and involved a series of online webinars and in-person workshops at four locations across the South Eastern NSW Primary Healthcare Network catchment.

RESULTS

A total of 18 GPs registered for the training, with six completing the final webinar. The GPs who completed all sessions demonstrated increases in confidence to deliver SBIRT and alcohol guidance knowledge from baseline. Qualitative feedback found the program acceptable, and GPs were able to successfully implement learnings into practice, and promote to colleagues.

CONCLUSIONS

The results indicated the potential of this program at a national level, but highlighted the need for a range of additional incentives to encourage uptake and ongoing implementation.

Test-Retest Reliability of Self-Reported Substance Use and Sexual Risk Behavior Among at-Risk Adolescents

Adolescents often engage in behaviors such as substance use and risky sexual activity that can lead to negative health and psychological consequences for themselves and others. Accurate measurement of these behaviors in surveys is challenging given that the behaviors are often viewed as undesirable and/or are illegal, so it is important to test the psychometric properties of instruments used to assess adolescent risk behaviors. The current study aimed to assess the test-retest reliability of a widely used measure of youth risk-taking behavior, the Youth Risk Behavior Survey (YRBS). A sample of 156 at-risk adolescents aged 16-18 years (81% male; 61% White) completed the YRBS retrospectively across intervals ranging from 3 to 12 days during their stay in a residential program at which they were under close supervision and had limited ability to engage in new risk behaviors. Participants were asked to complete the YRBS based on their "typical" (pre-program) behavior at both administrations, which were 10-14 weeks into their stay. The reliability of responses was assessed using kappa and weighted kappa analyses. Findings indicate moderate to substantial reliability for nearly all items, suggesting that at-risk youth reliably reported their engagement in health risk behaviors across multiple administrations and supporting the psychometric strength of the YRBS measure for use with this population.

Negative urgency, distress tolerance, and symptoms of substance use, eating, and borderline personality disorders in treatment-seeking young people

OBJECTIVE

Negative urgency (NU) and distress tolerance (DT) are two similar yet distinct constructs with putative transdiagnostic relevance, particularly across psychopathology characterized by impulsivity (e.g., substance use disorders [SUD], eating disorders featuring binging and/or purging ED-B/P, and borderline personality disorder [BPD]). Yet, there remains a lack of research into NU and DT across SUD, ED-B/P, and BPD symptomatology in clinical populations. The present study sought to elucidate the transdiagnostic utility of NU and DT across impulsive-type psychology by examining the unique and interactive roles of NU and DT across SUD, ED-B/P, and BPD symptomatology within a treatment-seeking sample of young people.

METHOD

Participants (N = 385; 62.3% female; aged 16-25 years) were recruited from youth health services across Melbourne, Australia. Participants completed an online survey including self-report measures of NU and DT as well as SUD, ED-B/P, and BPD symptoms. Mixed effects logistic regression was used to explore unique and interactive associations of NU and DT with symptoms.

RESULTS

Both NU (adjusted odds ratio [ORadj ] = 1.22; 95% confidence interval [CI] = [1.16, 1.28]) and global DT (ORadj  = 0.59; 95% CI = [0.47, 0.74]) uniquely predicted symptoms. However, associations with global DT and most of its components differed across psychopathology types. No significant interactions between NU and DT in predicting symptoms were found.

CONCLUSIONS

These results support the transdiagnostic utility of NU across SUD, ED-B/P, and BPD, while suggesting the role of DT across these disorders is more nuanced. These findings have important implications for NU and DT as potential intervention targets.

[Black box: Attenders with psychosocial needs in the emergency department]

OBJECTIVES

The aims are (a) assessment of the prevalence of psychosocial emergencies in the emergency department (ED), (b) determination of the proportion of cases not coded as diagnosis (unreported cases), and (c) characterization of identified patients.

METHODS

In a retrospective study, psychosocial emergencies in one week were identified from routine documentation of the central ED of the Charité - Universitätsmedizin Berlin, Charité Campus Mitte (CCM). After exclusion of planned admitted cases, 862 patients were included in the study. The identified psychosocial emergencies were descriptively analyzed with regard to their sociodemographic and clinical characteristics and compared with other emergencies.

RESULTS

The prevalence of psychosocial emergencies in the reported period was 11.9% (n = 103). A large proportion of psychosocial emergencies were not coded (35.9%) or not fully coded (20.4%) as an ICD diagnosis (unreported cases). There was a statistically relevant difference in gender distribution with a significantly higher proportion of males among psychosocial emergencies (70.9%) compared to other emergencies (50.7%; p < 0.0001). The two most common treatment causes among psychosocial emergencies were substance abuse (66.0%) and homelessness (20.4%).

CONCLUSIONS

This study shows a relevant proportion of psychosocial emergencies among all treatments in ED routine data and a high proportion of cases not captured in the coded diagnoses. EDs thus represent an important point of contact for vulnerable patient groups but standardized screening and identification are still lacking.

Substance Use Disorder

Substance use disorders (SUDs) present a challenge in the emergency department (ED) setting. This article provides an overview of SUDs, their clinical assessment, legal considerations in drug testing, diagnosis, and treatment approaches. SUDs are prevalent and coexist with mental health disorders, necessitating comprehensive evaluation and management. Clinical assessment involves screening tools, substance use history, and identification of comorbidities. Diagnosis relies on a thorough evaluation of substance abuse patterns and associated medical conditions. Treatment approaches encompass a multidisciplinary approach, incorporating counseling, medications, and social support. Effective management of SUDs in the ED requires a comprehensive understanding of these complex disorders.

Using the Alcohol, Smoking and Substance Involvement Screening Test to predict substance-related hospitalisation after release from prison: A cohort study

BACKGROUND AND AIMS

Poor substance use-related health outcomes after release from prison are common. Identifying people at greatest risk of substance use and related harms post-release would help to target support at those most in need. The Alcohol Smoking and Substance Involvement Screening Test (ASSIST) is a validated substance use screener, but its utility in predicting substance-related hospitalisation post-release is unestablished. We measured whether screening for moderate/high-risk substance use on the ASSIST was associated with increased risk of substance-related hospitalisation.

DESIGN

A prospective cohort study.

SETTING

Prisons in Queensland and Western Australia.

PARTICIPANTS

Participants were incarcerated and within 6 weeks of expected release when recruited. A total of 2585 participants were followed up for a median of 873 days.

MEASUREMENTS

Baseline survey data were combined with linked unit record administrative hospital data. We used the ASSIST to assess participants for moderate/high-risk cannabis, methamphetamine and heroin use in the 3 months prior to incarceration. We used International Classification of Diseases (ICD) codes to identify substance-related hospitalisations during follow-up. We compared rates of substance-related hospitalisation between those classified as low/no-risk and moderate/high-risk on the ASSIST for each substance. We estimated adjusted hazard ratios (aHR) by ASSIST risk group for each substance using Weibull regression survival analysis allowing for multiple failures.

FINDINGS

During follow-up, 158 (6%) participants had cannabis-related, 178 (7%) had opioid-related and 266 (10%) had methamphetamine-related hospitalisation. The hazard rates of substance-related hospitalisation after prison were significantly higher among those who screened moderate/high-risk compared with those screening low risk on the ASSIST for cannabis (aHR 2.38, 95% confidence interval [CI] 1.74, 3.24), methamphetamine (aHR 2.23, 95%CI 1.75, 2.84) and heroin (aHR 5.79, 95%CI 4.41, 7.60).

CONCLUSIONS

Incarcerated people with an Alcohol Smoking and Substance Involvement Screening Test (ASSIST) screening of moderate/high-risk substance use appear to have a significantly higher risk of post-release substance-related hospitalisation than those with low risk. Administering the ASSIST during incarceration may inform who has the greatest need for substance use treatment and harm reduction services in prison and after release from prison.

Availability of substance use screening and treatment within HIV clinical sites across seven geographic regions within the IeDEA consortium

BACKGROUND

Overwhelming evidence highlights the negative impact of substance use on HIV care and treatment outcomes. Yet, the extent to which alcohol use disorder (AUD) and other substance use disorders (SUD) services have been integrated within HIV clinical settings is limited. We describe AUD/SUD screening and treatment availability in HIV clinical sites participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium.

METHODS

In 2020, 223 IeDEA HIV clinical sites from 41 countries across seven geographic regions completed a survey on capacity and practices related to management of AUD/ SUD. Sites provided information on AUD and other SUD screening and treatment practices.

RESULTS

Sites were from low-income countries (23%), lower-middle-income countries (38%), upper-middle income countries (17%) and high-income counties (23%). AUD and SUD screening using validated instruments were reported at 32% (n=71 located in 12 countries) and 12% (n=27 located in 6 countries) of the 223 sites from 41 countries, respectively. The North American region had the highest proportion of clinics that reported AUD screening (76%), followed by East Africa (46%); none of the sites in West or Central Africa reported AUD screening. 31% (n=69) reported both AUD screening and counseling, brief intervention, psychotherapy, or Screening, Brief Intervention, and Referral to Treatment; 8% (n=18) reported AUD screening and detox hospitalization; and 10% (n=24) reported both AUD screening and medication. While the proportion of clinics providing treatment for SUD was lower than those treating AUD, the prevalence estimates of treatment availability were similar.

CONCLUSIONS

Availability of screening and treatment for AUD/SUD in HIV care settings is limited, leaving a substantial gap for integration into ongoing HIV care. A critical understanding is needed of the multilevel implementation factors or feasible implementation strategies for integrating screening and treatment of AUD/SUD into HIV care settings, particularly for resource-constrained regions.

Prevalence of probable substance use disorders among children in Ugandan health facilities

BACKGROUND

Globally, there is a concerning surge in the prevalence of substance use among adolescents and children, creating a substantial public health problem. Despite the magnitude of this issue, accessing healthcare explicitly for substance use remains challenging, even though many substance users frequently visit healthcare institutions for other health-related issues. To address this gap, proactive screening for substance use disorders has emerged as a critical strategy for identifying and engaging patients at risk of substance use. The purpose of this study was to investigate the prevalence of probable alcohol and other substance use disorders, and associated factors, among children aged 6 to 17 years old attending health facilities in Mbale, Uganda.

METHODS

We conducted a health facility cross-sectional study, involving 854 children aged 6-17 years. The prevalence of probable alcohol and other substance use disorders was assessed using a validated Car, Relax, Alone, Forget, Friends, Trouble (CRAFFT) screening tool. Univariable and multivariable modified Poisson regression analyses were performed using STATA 15 software.

RESULTS

The overall prevalence of probable alcohol use disorders (AUD) and other substance use disorders (SUD) was 27.8% (95% CI 1.24-1.31) while that of probable AUD alone was 25.3% (95% CI 1.22-1.28). Peer substance use (APR = 1.24, 95% CI 1.10-1.32), sibling substance use (APR = 1.14, 95% CI 1.06-1.23), catholic caregiver religion (APR = 1.07 95% CI 1.01-1.13), caregiver income of more than $128 (APR = 0.90, 95% CI 0.82-0.98), having no parental reprimand for substance use (APR = 1.05, 95% CI 1.01-1.10) and having no knowledge of how to decline an offer to use substances (APR = 1.06, 95% CI 1.01-1.12) were found to be significantly associated with probable AUD/SUD.

CONCLUSIONS

Our findings suggest a high prevalence of probable AUD and SUD among children and adolescents visiting healthcare facilities for other conditions, along with a strong link between AUD and SUD prevalence and social factors. The implication for our healthcare system is to actively screen for and treat these conditions at primary healthcare facilities.

Initial Validation of a Computerized Adaptive Test for Substance Use Disorder Identification in Adolescents

PURPOSE

Computerized adaptive tests (CATs) are highly efficient assessment tools that couple low patient and clinician time burden with high diagnostic accuracy. A CAT for substance use disorders (CAT-SUD-E) has been validated in adult populations but has yet to be tested in adolescents. The purpose of this study was to perform initial evaluation of the K-CAT-SUD-E (i.e., Kiddy-CAT-SUD-E) in an adolescent sample compared to a gold-standard diagnostic interview.

METHODS

Adolescents (N = 156; aged 11-17) with diverse substance use histories completed the K-CAT-SUD-E electronically and the substance related disorders portion of a clinician-conducted diagnostic interview (K-SADS) via tele-videoconferencing platform. The K-CAT-SUD-E assessed both current and lifetime overall SUD and substance-specific diagnoses for nine substance classes.

RESULTS

Using the K-CAT-SUD-E continuous severity score and diagnoses to predict the presence of any K-SADS SUD diagnosis, the classification accuracy ranged from excellent for current SUD (AUC = 0.89, 95% CI = 0.81, 0.95) to outstanding (AUC = 0.93, 95% CI = 0.82, 0.97) for lifetime SUD. Regarding current substance-specific diagnoses, the classification accuracy was excellent for alcohol (AUC = 0.82), cannabis (AUC = 0.83) and nicotine/tobacco (AUC = 0.90). For lifetime substance-specific diagnoses, the classification accuracy ranged from excellent (e.g., opioids, AUC = 0.84) to outstanding (e.g., stimulants, AUC = 0.96). K-CAT-SUD-E median completion time was 4 min 22 s compared to 45 min for the K-SADS.

CONCLUSIONS

This study provides initial support for the K-CAT-SUD-E as a feasible accurate diagnostic tool for assessing SUDs in adolescents. Future studies should further validate the K-CAT-SUD-E in a larger sample of adolescents and examine its acceptability, feasibility, and scalability in youth-serving settings.

A four-way patient search method for the retrospective identification of poisoning patients

When studying emergency department (ED) visits, electronic health record systems of hospitals provide a good basis for retrospective studies. However, many intoxication patients presenting to the ED, may not be identified retrospectively if only a single search method is applied. In this study, a new four-way combined patient search method was used to retrospectively identify intoxication patients presenting to the ED. The search included reason for admission to the ED, laboratory results related to intoxication diagnostics, ICD-10 codes, and a novel free word search (FWS) of patient records. After the automated search, the researcher read the medical records of potential substance abuse patients to form comprehensive profiles and remove irrelevant cases. The addition of a free word search identified 36% more substance abuse patients than the combination of the other three methods mentioned above. Patients identified by the FWS search alone were generally admitted to the ED for trauma or mental health problems and were often found to be heavily under the influence of alcohol and/or drugs. The main intoxicants were ethanol and benzodiazepines. The free word search was highly complementary to traditional patient search methods, highlighting the importance of the combined patient search method in retrospective data collection.

Improving the quality of antenatal screening and early intervention for alcohol and other drug use: protocol for a multi-stage approach to systems reform

BACKGROUND

Alcohol, tobacco and illicit drug use during pregnancy can cause significant harm to women and their developing fetuses. Despite recommendations for abstinence during pregnancy, some women continue to use, making screening for substance use during antenatal clinic attendances an important strategy for reducing risk. This study aims to improve the rates of screening and intervention for substance use among pregnant women, including appropriate referral for those who may be substance-dependent. The protocol outlined here focuses on a multi-stage implementation study.

METHODS

This study will occur in four phases. Phase 1 will identify a baseline rate of screening and subsequent care at the antenatal clinics of two, South Australian hospital-based maternity services, through a retrospective case note audit. Rates of self-reported substance use identified in the case notes will also be compared against representative data from Adelaide Primary Health Network to establish rates of over or underreporting. Phase 2 will involve an online Training Needs Analysis of midwifery staff working at those services, to assess their knowledge, attitudes, beliefs, and commitment to the care of women who use substances during pregnancy. Phase 3 will involve a training package for all midwifery staff at those services, focused on routine screening for substance use, and how to provide appropriate care. Outcome measures from phase 2 will be reassessed during phase 3 and any changes since training will be evaluated. Phase 4 will then repeat phase 1 to compare the changes in rates of both screening and any associated intervention before and after training.

DISCUSSION

From a public health perspective, this project has the potential to make a significant impact on reducing risk of harm from substance use disorders among pregnant women, and contribute to better health outcomes for their children.

TRIAL REGISTRATION

 This trial has been pre-registered under the Open Science Framework.

REGISTRATION

https://doi.org/10.17605/OSF.IO/73FDZ .

The acceptability and feasibility of a virtual mantram program for patients with posttraumatic stress disorder and substance use disorders: mixed method results

BACKGROUND

There is a need for expanded options for therapeutic interventions for patients with posttraumatic stress disorder (PTSD) and substance use disorder (SUD). The study aimed to examine evidence for the feasibility, safety, and acceptability of a virtual Mantram Repetition Program for adults with PTSD and SUD.

METHODS

This project utilized mixed-method design (explanatory sequential design) to collect quantitative and qualitative data to evaluate the program in terms of its feasibility and acceptability. The program took place over Webex, an encrypted virtual platform. The group ran over 8 weeks, was 90 min in length, and facilitated by two individuals per cohort. Each group had 4-5 participants given each group cycle. The study used the Mantram Repetition Program which is a brief mindfulness based non-tramua focused group intervention.

RESULTS

Out of 43 participants enrolled, 5 people (11.6%) did not commence the program and 8 (18.6%) participants dropped out after commencing the program, resulting in 35 completers (81.4% retention rate). Treatment completion and retention were above 70%. Qualitative data explained several aspects of the program's acceptability including delivery methods, informative material provided and gaining a practical mindful tool to manage symptoms.

CONCLUSIONS

This study showed quantitative and qualitative evidence of the Mantram Repetition Program's feasibility, acceptability and safety to be used with individuals with PTSD-SUD. Although further evaluation of virtual Mantram Program to control group in longitudinal trials is needed to identify how it compares with other interventions in the field.

CLINICAL TRIAL REGISTRATION NUMBER

NCT05058963, (28/09/2021).

Hepatitis C and obstetrical morbidity in a substance use disorder clinic: a role for telemedicine?

BACKGROUND

Hepatitis C infection often co-occurs with substance use disorders in pregnancy. Accessing hepatitis C treatment is challenging because of loss to follow-up in the postpartum period, attributable to social and financial barriers to care. Telemedicine has been explored as a means of increasing routine postpartum care, but the potential impact on retention in and completion of care for postpartum hepatitis C has not been assessed.

OBJECTIVE

This study aimed to evaluate the impact of hepatitis C on obstetrical morbidity in a substance use disorder-specific prenatal clinic, and the effect of Infectious Disease telemedicine consultation on subsequent treatment delivery.

STUDY DESIGN

We performed a retrospective cohort study of all patients in our substance use disorder prenatal clinic from June 2018 to February 2023. Telemedicine consults for hepatitis C diagnoses began in March 2020 and included electronic chart review by Infectious Disease when patients were unable to be seen. Our primary outcome was composite obstetrical morbidity (preterm birth, preeclampsia, fetal growth restriction, fetal anomaly, abruption, postpartum hemorrhage, or chorioamnionitis) compared between patients with and without active hepatitis C. We additionally evaluated rates of completed referral and initiation of hepatitis C treatment before and after implementation of telemedicine consult.

RESULTS

A total of 224 patients were included. Of the 222 patients who underwent screening, 71 (32%) were positive for active hepatitis C. Compared with patients without hepatitis C, a higher proportion of patients with hepatitis C were White (80% vs 58%; P=.02), had a history of amphetamine use (61% vs 32%; P<.01), injection drug use (72% vs 38%; P<.01), or overdose (56% vs 29%; P<.01), and were on methadone (37% vs 18%; P<.01). There was no difference in the primary outcome of composite obstetrical morbidity. The rate of hepatitis C diagnosis was not statistically significantly different between the pre- and posttelemedicine cohorts (N=29 [41%], N=42 [27%]), and demographics of hepatitis C virus-positive patients were similar, with most being unemployed, single, and publicly insured. A lower proportion of patients in the posttelemedicine group reported heroin use compared with the pretelemedicine cohort (62% vs 90%; P=.013). After implementation of telemedicine, patients were more likely to attend the visit (19% vs 44%; P=.03), and positive patients were much more likely to receive treatment (14% vs 57%; P<.01); 100% of visits in the posttelemedicine group occurred via telemedicine. There were 7 patients who were prescribed treatment by their obstetrician after chart review by Infectious Disease.

CONCLUSION

Patients with and without hepatitis C had similar maternal and neonatal outcomes, with multiple indicators of social and financial vulnerability. Telemedicine Infectious Disease consult was associated with increased follow-up and hepatitis C treatment, and obstetricians were able to directly prescribe. Because patients with substance use disorders and hepatitis C may have increased barriers to care, telemedicine may represent an opportunity for intervention.

Detection of 41 Drugs and Metabolites in Urine with Internal Hydrolysis Control by Liquid Chromatography-Tandem Mass Spectrometry

Regular monitoring of pain management and substance use disorder patients through urine drug screening is important for assessing patient compliance with prescribed drugs and abstinence from non-prescribed drugs. Sample analysis is commonly performed by liquid chromatography-tandem mass spectrometry (LC-MS/MS) as multiple drugs and metabolites can be monitored from one sample. However, challenges faced in developing an LC-MS/MS method for multiple analytes in urine include variability in matrix and concentration from sample to sample and variable chemistry of many pain management drugs and associated metabolites affecting accuracy and precision of results. We describe here an LC-MS/MS method for analysis of 41 drugs and metabolites commonly prescribed for pain management patients. The developed method uses enzymatic hydrolysis followed by cation exchange solid phase extraction. Resorufin-glucuronide is used as an internal hydrolysis control to monitor hydrolysis in each patient sample and minimize false negatives. Analysis was performed using an Agilent 6470 mass spectrometer in dynamic multiple reaction monitoring mode.

Validity of the revised Diagnostic and Statistical Manual of Mental Disorders-5 cross-cutting symptom measure as implemented in community mental health settings

BACKGROUND

The purpose of this study was to validate the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) Cross-Cutting Symptom Measure (CCSM) as a screening tool for a wide variety of disorders within busy community outpatient mental health settings.

METHOD

Participants (N = 851) were referred for coordinated specialty care services (mean age = 20.26 years (SD = 2.97); 82.5 % Caucasian, 7.5 % African American, 0.7 % Native American, 0.7 % Pacific Islander, 0.8 % Asian, 7.8 % Multiracial; 15.1 % Latinx; 53.1 % female, 45.5 % male, 1.4 % other gender).

RESULTS

At optimal cut-score, specificity ranged from 57 to 77 % for depression, anxiety, substance use and psychosis domains; sensitivity ranged from 63 to 72 %. Scores for depression, anxiety, substance use and psychosis domains differed significantly by groups with and without diagnoses. Correlations among domains were larger where expected (r = 0.52, depression-suicidal ideation), and relatively smaller where expected (r = 0.28, suicidal ideation-inattention). Depression, anxiety, substance use and psychosis domains evidenced incremental validity for their respective diagnoses (change in explained variance, 3-15 %). Psychometric features of CCSM were broadly supported.

LIMITATIONS

Criterion measures did not have inter-rater reliabilities as this is generally prohibitive in clinic settings.

CONCLUSION

The CCSM could provide a first step in screening for multiple disorders; however, it cannot replace structured interviews for making diagnoses related to these conditions.

The Concordance of Electronic Health Record Diagnoses and Substance use Self-Reports Among Reproductive Aged Women Enrolled in a Community-Based Addiction Reduction Program

Substance use disorders among reproductive aged women are a major public health issue. There is little work investigating the validity and reliability of electronic health record (EHR) data for measuring substance use in this population. This study examined the concordance of self-reported substance use with clinical diagnoses of substance use, substance abuse and substance use disorder in EHR data. Reproductive age women enrolled in the Community-Based Addiction Reduction (CARE) program were interviewed by peer recovery coaches (PRC) at enrollment. That survey data was linked with EHR data (n = 102). Concordance between self-reported substance use and clinical diagnoses in the EHR was examined for opioids, cannabis/THC, and cocaine. Cohen's kappa, sensitivity, and specificity were calculated. The survey captured a higher number of women who use substances compared to the EHR. The concordance of self-report with EHR diagnosis varied by substance and was higher for opioids (17.6%) relative to cannabis/THC (8.8%), and cocaine (3.0%). Additionally, opioids had higher sensitivity (46.2%) and lower specificity (76.2%) relative to cannabis/THC and cocaine. Survey data collected by PRCs captured more substance use than EHRs, suggesting that EHRs underestimate substance use prevalence. The higher sensitivity and lower specificity of opioids was due to a larger number of women who had a diagnosis of opioid use in the EHR who did not self-report opioid use in the self-report survey relative to cannabis/THC and cocaine. Opioid self-report and diagnosis may be influenced by research setting, question wording, or receipt of medication for opioid use disorder.

Identification, synthesis and quantification of eutylone consumption markers in a chemsex context

Eutylone is a cathinone-derived synthetic amphetamine scheduled by the World Health Organization and European Monitoring Centre for Drugs and Drug Addiction since 2022 due to its growing consumption. We report here an eutylone intoxication involving a 38-year-old man and a 29-year-old woman in a chemsex context. A bag containing a white crystalline powder labelled as a research product was found in their vehicle. Nuclear magnetic resonance and liquid chromatography-high-resolution mass spectrometry (LC-HRMS) analyses identified the powder as eutylone and confirmed purity superior to 99%. LC-HRMS data analysis using molecular networking allowed to propose new eutylone metabolites in blood samples in a graphical manner. We described 16 phase I (e.g. hydroxylated or demethylated) and phase II metabolites (glucuroconjugates and sulfoconjugates). The same metabolites were found both in male and female blood samples. Toxicological analyses measured eutylone concentration in blood samples at 1374 ng/mL and 1536 ng/mL for the man and the woman, respectively. A keto-reduced metabolite (m/z 238.144) was synthesized to permit its quantification at 67 ng/mL and 54 ng/mL in male and female blood samples, respectively. Overall, the identification of these metabolites will increase the knowledge of potential drug consumption markers and allow to implement mass spectrometry databases to better monitor future drug abuse or consumption.

Evaluating the agreement between different substance use recall periods in multiple HIV cohorts

BACKGROUND

This study aims to evaluate the agreement in substance use on both binary and ordinal scales between 3-month and 6-month recall periods with samples from different communities, demographic backgrounds, and HIV status.

METHODS

We administered the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) to 799 participants from three different North American cohorts focused on substance use and HIV. We conducted a within-person agreement analysis by calculating the agreement levels and Kappa statistic between data collected using the 3-month recall ASSIST and 6-month custom substance use surveys as well as different terminology for each substance in multiple cohorts.

RESULTS

For all drugs studied, the agreement on the binary use or ordinal frequency of use metrics showed a high agreement level between 80.4% and 97.9% and an adequate adjusted kappa value between 0.61 and 0.96, suggesting substantial agreement. According to the agreement criteria we proposed, substance use data collected using different recall periods and with variation in drug names can be harmonized across cohorts.

CONCLUSIONS

This study is the first to evaluate the feasibility of data harmonization of substance use by demonstrating high level of agreement between different recall periods in different cohorts. The results can inform data harmonization efforts in consortia where data are collected from cohorts using different questions and recall periods.

Recovery Support and Capacity Assessment Using the Calculating an Adequate System Tool: Two Case Studies

BACKGROUND

There are multiple, reliable, and authoritative federally managed data sources for understanding the incidence and prevalence of substance use disorder (SUD) and its sequela. However, there remains a gap in metrics representing the need and capacity for treatment and related supports within local communities. To address this challenge, Calculating an Adequate System Tool (CAST) was developed in 2016 by an interdisciplinary group of researchers at the Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality to assess the capacity of the SUD care system within a defined geographic area. It allows for risk assessment of local social and community determinants of substance abuse, as well as an assessment of local service needs across the continuum of SUD care.

METHODS

This article describes the application of the CAST to 2 counties in Ohio and 1 county in Montana. The purpose of using CAST for each area, results of the application, and experiences in utilizing the tool are described.

RESULTS

Application of the CAST demonstrated unique findings within each of the geographic areas. In Ohio, recovery support services were lacking in both counties assessed, while differences in crime rate and alcohol outlet density were attributed to varying rates of drug-related hospitalization. Notable findings in Montana included an oversaturation of coalitions focused on substance use prevention and gaps in the areas of detoxification services, partial day treatment, recovery residences, and peer support specialists.

CONCLUSIONS

CAST is a useful tool for guiding decision-making relative to substance use care needs and capacities for local geographic areas. Findings should be interpreted thoughtfully and in the context of data availability. CAST continues to be enhanced and further expanded for assessing capacity of local and statewide substance use care systems.

Evidence-Based Assessment of Substance Use Disorder

The current review describes updated information on the evidence-based assessment of substance use disorder. We offer an overview of the state of the science for substance-related assessment targets, instruments (screening, diagnosis, outcome and treatment monitoring, and psychosocial functioning and wellbeing) and processes (relational and technical) as well as recommendations for each of these three components. We encourage assessors to reflect on their own biases, beliefs, and values, including how those relate to people that use substances, and to view the individual as a whole person. It is important to consider a person's profile of symptoms and functioning inclusive of strengths, comorbidities, and social and cultural determinants. Collaborating with the patient to select the assessment target that best fits their goals and integration of assessment information in a holistic manner is critical. We conclude by providing recommendations for assessment targets, instruments, and processes as well as recommendations for comprehensive substance use disorder assessment, and describe future directions for research.

N-desethyl isotonitazene detected in polydrug users admitted to hospital in Birmingham, United Kingdom

INTRODUCTION

Nitazenes are potent synthetic opioids and N-desethyl isotonitazene, a metabolite of isotonitazene, has emerged as a drug in its own right.

METHODS

This is an observational case series of patients with suspected or declared substance use who were admitted to hospitals in the Sandwell and West Birmingham National Health Service Trust between July and October 2023. All patients were found on toxicological screening to have been exposed to N-desethyl isotonitazene.

RESULTS

Twenty presentations involving 19 patients who tested positive for N-desethyl isotonitazene were included in the study. In 19 presentations, multiple substances were detected on toxicological screening. The number of patients testing positive for other substances were: 19 for cocaine and its main metabolite benzoylecgonine, 13 for morphine, 11 for the heroin-specific metabolite 6-monoacetylmorphine, ten for xylazine, eight for gabapentinoids (pregabalin and/or gabapentin), seven for methadone and/or the metabolite, 2-ethylidene-1, 5-dimethyl-3, 3-diphenylpyrrolidine, six for benzodiazepines and five for the synthetic cannabinoid MDMB-4en-PINACA. Only one patient had no other substances detected apart from N-desethyl isotonitazene. This patient presented with coma, miosis, bradypnoea and hypercapnia and responded to naloxone. In this cohort, the median concentration of N-desethyl isotonitazene was 1.53 µg/L (n = 14; range 0.59-5.48) in whole blood and 27.75 µg/L (n = 16; range 0.51-91.53) in urine.

DISCUSSION

The majority of the patients in this cohort presented with features typical of an opioid overdose, which is unsurprising as they were all experienced users of diamorphine. Although these features are also consistent with the known effects of N-desethyl isotonitazene, in only one case is it possible to attribute the patient's features to N-desethyl isotonitazene toxicity alone.

CONCLUSIONS

This case series highlights the need for toxicovigilance in the illicit drug market as patterns of substance misuse evolve and novel psychoactive substances continue to emerge.

Characteristics of drug-involved black women under community supervision; implications for retention in HIV clinical trials and healthcare

This study examined retention and its relationship to mental health, substance use, and social determinants of health in a randomized clinical trial of a behavioral HIV/sexually transmitted infection prevention intervention with drug-involved Black women (N = 348) under community supervision programs in New York City. Using secondary analysis, we used logistic models to test the association between factors related to mental health, substance use, and social determinants of health and follow-up assessment completion (three, six, and 12 months). Participants who were diagnosed with schizophrenia had lower odds of retention. Participants who misused prescription opiates during their lifetime or food insecure in the past 90 days had higher odds of retention throughout the intervention.

Electrophysiological biomarkers in dual pathology

INTRODUCTION

The co-occurrence of substance use disorder with at least one other mental disorder is called dual pathology, which in turn is characterised by heterogeneous symptoms that are difficult to diagnose and have a poor response to treatment. For this reason, the identification and validation of biomarkers is necessary. Within this group, possible electroencephalographic biomarkers have been reported to be useful in diagnosis, treatment and follow-up, both in neuropsychiatric conditions and in substance use disorders. This article aims to review the existing literature on electroencephalographic biomarkers in dual pathology.

METHODS

A narrative review of the literature. A bibliographic search was performed on the PubMed, Science Direct, OVID, BIREME and Scielo databases, with the keywords: electrophysiological biomarker and substance use disorder, electrophysiological biomarker and mental disorders, biomarker and dual pathology, biomarker and substance use disorder, electroencephalography, and substance use disorder or comorbid mental disorder.

RESULTS

Given the greater amount of literature found in relation to electroencephalography as a biomarker of mental illness and substance use disorders, and the few articles found on dual pathology, the evidence is organised as a biomarker in psychiatry for the diagnosis and prediction of risk and as a biomarker for dual pathology.

CONCLUSIONS

Although the evidence is not conclusive, it suggests the existence of a subset of sites and mechanisms where the effects of psychoactive substances and the neurobiology of some mental disorders could overlap or interact.

Predictors and Correlates of Positive Urine Drug Screening in a Retrospective Cohort Analysis of Child and Adolescent Psychiatry Inpatients Throughout the COVID-19 Pandemic

BACKGROUND AND OBJECTIVES

Youth substance use is associated with significant psychological, neurological, and medical complications. Risk factors for substance use among children and adolescents in the general population include peer and/or parental substance use, certain psychiatric illnesses (eg, Attention-Deficit/Hyperactivity Disorder, depression), and history of maltreatment. Co-occurring substance use and psychiatric illness have been associated with increased suicidality, but few prior studies have characterized substance use among child/adolescent inpatients. As such, it remains unclear how substance use contributing to acute psychiatric presentations has changed since the start of the COVID-19 pandemic.

METHODS

This is a retrospective cohort study of 816 unique child/adolescent psychiatry inpatients with urine drug screening (UDS) results from a diverse urban setting. Charts of patients hospitalized between June 1, 2018 and November 30, 2021 were reviewed for sociodemographic characteristics, indication for admission, psychiatric history, hospital course, treatment plan, and discharge diagnosis. Differences in sociodemographic and clinical characteristics, such as age, race, and diagnoses, between patients with and without positive UDS were explored throughout various periods of the COVID-19 pandemic. Descriptive and comparative statistics were performed, as well as a logistic regression model to identify the predictors of positive UDS.

RESULTS

Of the study sample, 18% had a positive UDS. Older age, diagnosis of impulsive or behavioral disorder, and a history of violence were found to be predictors of positive UDS. Asian/South Asian or Hispanic/LatinX race and history of a developmental or intellectual disability were found to be negative predictors. The frequency of positive UDS in this population did not change based on COVID-19.

DISCUSSION AND CONCLUSIONS

Multiple factors may predispose children and adolescents to substance use. Though no impact of COVID-19 was found in this sample, longer-term studies are needed.

SCIENTIFIC SIGNIFICANCE

This study identifies independent predictors of active substance use in the child and adolescent psychiatric inpatient population.