Gender and comorbidity among individuals with opioid use disorders in the NESARC study

Treating Opioid Dependence with Buprenorphine in the Safety Net: Critical Learning from Clinical Data

Research has examined the safety, efficacy, feasibility, and cost-effectiveness of buprenorphine for the treatment of opioid dependence, but few studies have examined patient and provider experiences, especially in community health centers. Using de-identified electronic health record system (EHRS) data from 70 OCHIN community health centers (n = 1825), this cross-sectional analysis compared the demographics, comorbidities, and service utilization of patients receiving buprenorphine to those not receiving medication-assisted treatment (MAT). Compared to non-MAT patients, buprenorphine patients were younger and less likely to be Hispanic or live in poverty. Buprenorphine patients were less likely to have Medicaid insurance coverage, more likely to self-pay, and have private insurance coverage. Buprenorphine patients were less likely to have problem medical comorbidities or be coprescribed high-risk medications. It is important for providers, clinic administrators, and patients to understand the clinical application of medications for opioid dependence to ensure safe and effective care within safety net clinics.

Gender differences in trends for heroin use and nonmedical prescription opioid use, 2007-2014

BACKGROUND

Trends in the current opioid epidemic in the United States show that use of heroin is increasing while nonmedical use of prescription opioids is slowing. Understanding gender differences in these trends is essential to efforts to address the opioid epidemic. This study compared gender difference in trends in heroin and nonmedical prescription opioid use in the U.S. between 2007 and 2014.

METHODS

Data from the National Survey on Drug Use and Health (NSDUH) were used to trace prevalence and to estimate risk for heroin and nonmedical prescription opioid use in the last year for women and men.

RESULTS

Prevalence rates in the total sample (N = 447,188) indicate a notable increase in heroin use and a steady decline in the nonmedical use of prescription opioids between 2007 and 2014 for both women and men. Women are increasing heroin use at a faster rate than men but decreasing nonmedical prescription opioid use at a slower rate than men. Overall, risk factors for both heroin use and nonmedical prescription opioid use are similar to other illicit substances, but the magnitude of associations indicates that women may be at greater risk for the nonmedical use of prescription opioids than for the use of heroin.

CONCLUSIONS

Trend analyses reveal a linear increase in heroin use and a quadratic decline in nonmedical prescription opioid use at the population level. The differential rates of change between men and women in use of both opioids highlight the need for comprehensive, gender-sensitive approaches to prevention and treatment for both heroin and nonmedical prescription opioid use. Future research should continue to explore gender differences in treatment access, including access to medication-assisted treatments and treatments integrated with health and social services, especially for women.

State-Targeted Funding and Technical Assistance to Increase Access to Medication Treatment for Opioid Use Disorder

OBJECTIVE

As the United States grapples with an opioid epidemic, expanding access to effective treatment for opioid use disorder is a major public health priority. Identifying effective policy tools that can be used to expand access to care is critically important. This article examines the relationship between state-targeted funding and technical assistance and adoption of three medications for treating opioid use disorder: oral naltrexone, injectable naltrexone, and buprenorphine.

METHODS

This study draws from the 2013-2014 wave of the National Drug Abuse Treatment System Survey, a nationally representative, longitudinal study of substance use disorder treatment programs. The sample includes data from 695 treatment programs (85.5% response rate) and representatives from single-state agencies in 49 states and Washington, D.C. (98% response rate). Logistic regression was used to examine the relationships of single-state agency targeted funding and technical assistance to availability of opioid use disorder medications among treatment programs.

RESULTS

State-targeted funding was associated with increased program-level adoption of oral naltrexone (adjusted odds ratio [AOR]=3.14, 95% confidence interval [CI]=1.49-6.60, p=.004) and buprenorphine (AOR=2.47, 95% CI=1.31-4.67, p=.006). Buprenorphine adoption was also correlated with state technical assistance to support medication provision (AOR=1.18, 95% CI=1.00-1.39, p=.049).

CONCLUSIONS

State-targeted funding for medications may be a viable policy lever for increasing access to opioid use disorder medications. Given the historically low rates of opioid use disorder medication adoption in treatment programs, single-state agency targeted funding is a potentially important tool to reduce mortality and morbidity associated with opioid disorders and misuse.

Gender-related psychopathology in opioid use disorder: Results from a representative sample of Italian addiction services

AIMS

Gender and psychiatric comorbidity seem to influence patients' inter-individual response to Opioid Substitution Treatments (OST) in Opioid Use Disorder (OUD) management. The aim of the study was to assess psychopathological dimensions in an Italian sample of OUD individuals entering a methadone/buprenorphine maintenance program; secondary, we evaluated the possible gender-specific differences within the psychopathological profiles.

METHODS

In a cross-sectional study, we recruited 1052 (792 male; 260 female) OUD subjects receiving OST. All patients underwent a clinical and psychometric evaluation assessing demographics, psychiatric history, psychopathological features via the Symptom Checklist-90-Revised (SCL-90-R), and were prescribed psychopharmacological treatments.

RESULTS

Our results reveal gender-specific differences in a real-world sample of opioid-maintained OUD individuals attending public addiction services in Italy. Compared to men, women reported higher scores in both General Symptomatic Index (GSI) and in all the SCL-90-R sub-scales. No impact of pharmacological treatment was detected. Finally, regression analysis revealed that being in methadone-maintenance group was significantly associated with high GSI scores in the male, but not female, group.

CONCLUSIONS

Increasing the knowledge of psychopathological dimensions in patients with OST, with relevance to gender differences, is important for a better understanding of factors that influence the outcome and for further development in gender-tailored strategies.

Kappa opioid receptor antagonism and chronic antidepressant treatment have beneficial activities on social interactions and grooming deficits during heroin abstinence

Addiction is a chronic brain disorder that progressively invades all aspects of personal life. Accordingly, addiction to opiates severely impairs interpersonal relationships, and the resulting social isolation strongly contributes to the severity and chronicity of the disease. Uncovering new therapeutic strategies that address this aspect of addiction is therefore of great clinical relevance. We recently established a mouse model of heroin addiction in which, following chronic heroin exposure, 'abstinent' mice progressively develop a strong and long-lasting social avoidance phenotype. Here, we explored and compared the efficacy of two pharmacological interventions in this mouse model. Because clinical studies indicate some efficacy of antidepressants on emotional dysfunction associated with addiction, we first used a chronic 4-week treatment with the serotonergic antidepressant fluoxetine, as a reference. In addition, considering prodepressant effects recently associated with kappa opioid receptor signaling, we also investigated the kappa opioid receptor antagonist norbinaltorphimine (norBNI). Finally, we assessed whether fluoxetine and norBNI could reverse abstinence-induced social avoidance after it has established. Altogether, our results show that two interspaced norBNI administrations are sufficient both to prevent and to reverse social impairment in heroin abstinent animals. Therefore, kappa opioid receptor antagonism may represent a useful approach to alleviate social dysfunction in addicted individuals.

Comparison of demographic characteristics and psychiatric comorbidity among methamphetamine-, heroin- and methamphetamine-heroin co- dependent males in Hunan, China

BACKGROUND

There is little research of psychiatric comorbidity differences among people with different types of drug dependence in Chinese population. We explored demographic and comorbid psychiatric differences among methamphetamine- dependent males (MDs), heroin-dependent males (HDs) and methamphetamine and heroin co-dependent males (M/HDs) in Hunan province, China.

METHODS

A cross-sectional, structured and clinical interview method was used to examine differences in DSM-IV-TR Axis I Disorders among 346 MDs, 698 HDs and 247 M/HDs from three compulsory rehabilitation centers and two voluntary rehabilitation centers in Hunan.

RESULTS

MDs and M/HDs were younger, more likely to choose inhalation administration, less likely to have a family history of substance use, less likely to have undergone detoxification treatment, had higher incomes and shorter duration of drug use than HDs. Overall, methamphetamine-dependence related to higher rates of current and lifetime psychotic disorders, lifetime hallucinogen use disorders. Heroin-dependence related to higher rates of current and lifetime substance-induced mood disorders, sedative/hypnotic/anxiolytic and other drug use disorders and current alcohol use disorder. For M/HDs, they were more likely to have any other lifetime substance use disorders than MDs and HDs.

CONCLUSIONS

There were substantial differences in epidemiological characteristics and comorbidity among MD, HD and M/HD groups, which highlights the urgent need to develop treatment services and policies for drug-specific users in China.

The association between age of onset of opioid use and comorbidity among opioid dependent patients receiving methadone maintenance therapy

Background

Opioid use disorder (OUD) affects approximately 21.9 million people worldwide. This study aims to determine the association between age of onset of opioid use and comorbid disorders, both physical and psychiatric, in patients receiving methadone maintenance treatment (MMT) for OUD. Understanding this association may inform clinical practice about important prognostic factors of patients on MMT, enabling clinicians to identify high-risk patients.

Methods

This study includes data collected between June 2011 and August 2016 for the Genetics of Opioid Addiction research collaborative between McMaster University and the Canadian Addiction Treatment Centers. All patients were interviewed by trained health professionals using the Mini-International Neuropsychiatric Interview and case report forms. Physical comorbidities were verified using patients’ electronic medical records. A multi-variable logistic regression model was constructed to determine the strength of the association between age of onset of opioid use and the presence of physical or psychiatric comorbidity while adjusting for current age, sex, body mass index, methadone dose and smoking status.

Results

Data from 627 MMT patients with a mean age of 38.8 years (SD = 11.07) were analyzed. Individuals with an age of onset of opioid use younger than 18 years were found to be at higher odds for having a physical or psychiatric comorbid disorder compared to individuals with an age of onset of opioid use of 31 years or older (odds ratio 2.94, 95% confidence interval 1.20, 7.19, p = 0.02). A significant association was not found between the risk of having a comorbidity and an age of onset of opioid use between 18 and 25 years or 26 and 30 years, compared to an age of onset of opioid use of 31 years or older.

Conclusion

Our study demonstrates that the younger one begins to use opioids, the greater their chance of having a physical or psychiatric co-morbidity. Understanding the risk posed by an earlier onset of opioid use for the later development of comorbid disorders informs clinical practice about important prognostic predictors and aids in the identification of high-risk patients.

Comorbidity of bipolar and substance use disorders in national surveys of general populations, 1990-2015: Systematic review and meta-analysis

BACKGROUND

Substance use disorders (SUDs) are common in people with a bipolar disorder (BD). This systematic review and meta-analysis aimed to estimate the prevalence rates of SUDs in persons with BD based on national or international surveys of household populations.

METHODS

Studies published from 1990 to Dec 31, 2015 were identified from MEDLINE, EMBASE. psychINFO, and CINAHL databases and reference lists. We calculated prevalence rates and conducted meta-analysis with random-effects model.

RESULTS

We identified 9 unique surveys of which two surveys were repeated 10 years later using independent samples. The total sample size was 218,397 subjects. The mean prevalence for any illicit drug use disorder was 17%, for alcohol use disorder (AUD) it was 24% and SUD it was 33%. The strongest associations were found between BD and illicit drug use (pooled odds ratio (OR) 4.96, 95% CI 3.98-6.17) followed closely by BD and AUD (OR 4.09, 95% CI 3.37-4.96). The association was higher for BD respondents using illicit drugs compared to bipolar II respondents (ORs 7.48 vs. 3.30).

LIMITATIONS

Some of the meta-analysis grouped illicit substances together without taking into consideration types of substance use which may differ widely between countries and over time. All included studies were cross-sectional so onset and causality can not be determined.

CONCLUSIONS

The meta-analysis revealed that people with an alcohol use disorder were 4.1 times of greater risk of having a BD compared to those without an AUD. The risks were even higher for illicit drug users where they were 5.0 times of greater risk of having BD compared to non-users. These data confirm strong associations between co-occurring SUDs and BD, indicating a need for more informative studies to help develop better interventions in treating persons with BD and comorbid SUDs.

Psychiatric comorbidities in opioid-dependent patients undergoing a replacement therapy programme in Spain: The PROTEUS study

Opioid-dependent patients show a high rate of psychiatric comorbidities. The prevalence and characteristics of patients with dual diagnosis have not been well established in Spanish opioid agonist treatment (OAT) programmes. Thus, 621 opioid-dependent patients enrolled in OAT programmes were assessed, using the EuropASI questionnaire, for psychiatric comorbidities, which were detected in 67% of patients (anxiety 53%, mood disorders 48%, sleep disorders 41%, substance-related disorders 36%). In addition, compared with patients without a dual diagnosis, patients with dual pathology were significantly older, used benzodiazepines and cannabis in significantly greater percentages, and showed significantly more frequent infectious and non-infectious comorbidities, worse overall working status, a lower proportion of drivers and higher levels of severity regarding medical, employment, alcohol, legal, family and psychological issues. Therefore, the data showed a very high prevalence of psychiatric comorbidity in opioid-dependent patients receiving OAT in Spain and several problems frequently associated with patients with dual diagnosis. Physicians treating opioid-dependent patients should be aware of these facts to correctly identify and manage patients with a dual diagnosis.

Past year non-medical opioid use and abuse and PTSD diagnosis: Interactions with sex and associations with symptom clusters

INTRODUCTION

Few studies have examined the associations between posttraumatic stress disorder (PTSD) and non-medical opioid use (NMOU), particularly in general U.S.

METHODS

We analyzed data from wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative sample of non-institutionalized adults, to examine (1) the relationship between PTSD diagnosis with NMOU, Opioid Use Disorder diagnosis, and average monthly frequency of NMOU; and (2) the relationship between PTSD symptom clusters with NMOU, Opioid Use Disorder diagnosis, and average monthly frequency of NMOU. We also explored sex differences among these associations.

RESULTS

In the adjusted model, a past year PTSD diagnosis was associated with higher odds of past year NMOU for women and men, but the association was stronger for women. In addition, PTSD was associated with higher odds of an Opioid Use Disorder diagnosis for women, but not for men. With regard to the relationship between specific symptom clusters among those with a past year PTSD diagnosis, important sex differences emerged. For women, the avoidance symptom cluster was associated with higher odds of NMOU, an Opioid Use Disorder diagnosis, and higher rate of average monthly frequency of NMOU, while for men the arousal/reactivity cluster was associated with higher odds of NMOU, an Opioid Use Disorder diagnosis, and a higher rate of average monthly frequency of NMOU. In addition, for men, the avoidance symptom cluster was associated with higher odds of an Opioid Use Disorder diagnosis, but a lower rate of average monthly frequency of NMOU.

CONCLUSIONS

Results add to the literature showing an association between PTSD and NMOU and suggest that PTSD is more strongly associated with substance use for women than men. Further, results based on individual symptom clusters suggest that men and women with PTSD may be motivated to use substances for different reasons.

Impulsivity and addiction severity in cocaine and opioid dependent patients

BACKGROUND

Impulsivity as a personality trait is a risk factor for the development and maintenance of cocaine and opioid dependence. The objective of this study is to analyze the relationship between impulsivity and addiction severity in cocaine and opioid dependent patients.

METHODS

A cross-sectional, observational study of 526 patients with lifetime cocaine dependence (CD, n=351), opiate dependence (OD, n=51) and comorbid cocaine and opiate dependence (COD, n=124) to throughout life, according to DSM-IV-TR, was conducted. The sample was recruited at the Addiction and Dual Diagnosis Unit of Vall d'Hebron University Hospital from January 2006 to April 2013. Patients were evaluated with the EuropASI, the SCID I and II interviews, and the Barratt Impulsivity Scale (BIS-11). Descriptive statistics of the main variables (including mean, standard deviation) was performed. Chi square test was used to compare categorical variables and Kruskal-Wallis test to compare continuous variables. Spearman correlation was used to analyze the relationship between EuropASI scores and BIS-11 scores.

RESULTS

The mean age of the patients was 36.37years±8.08 (19-66). CD and COD were more impulsive and had higher addiction severity than OD. OD patients had worse medical status than CD and COD patients while COD patients had more severe drug use and legal problems than the other groups. However, impulsivity and addiction severity were only positively correlated in CD patients.

CONCLUSIONS

Impulsivity should be appropriately screened and addressed in cocaine dependents as it may be related to addiction severity.

Comparisons of Cocaine-Only, Opioid-Only, and Users of Both Substances in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)

BACKGROUND

Cocaine and opioid co-use is a notable public health concern, but little is known about correlates of this behavior. Most prior findings come from treatment samples and concern cocaine and heroin. Findings from a nationally representative sample involving primarily prescription opioid misuse would expand knowledge.

METHODS

Past-12-month cocaine and/or opioid users in Wave 1 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) formed the sample (N = 839). Cocaine-only, opioid-only, and cocaine/opioid co-users were compared regarding sociodemographics, other substance involvement, psychiatric, and medical conditions/events.

RESULTS

Opioid-only users were the largest group (n = 622), followed by cocaine-only (n = 144) and co-users (n = 73). The vast majority of opioid misuse was of prescription opioids (1.4% with past-12-month use of heroin). Notably, co-users did not differ from single drug users in frequency of use of either drug. Co-users did not have significantly greater incidence of any psychiatric conditions, medial conditions, or events. In preliminary analyses, co-users were more likely than either single use group to report several classes of other drug use. However, for most comparisons, opioid use did not add substantial risk beyond cocaine use. Differences on multiple sociodemographic variables suggested opioid-only users were at lowest risk of negative outcomes. These results may relate to a finding that opioid-only users were less likely to have sought treatment.

CONCLUSIONS/IMPORTANCE

This sample of past-12-month cocaine and/or opioid users had greater involvement with other substances, more psychiatric and medical conditions compared to the general population. Co-users had greater involvement with other substances than opioid-only users in particular.

The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Waves 1 and 2: review and summary of findings

PURPOSE

The NESARC, a "third-generation" psychiatric epidemiologic survey that integrated detailed measures of alcohol and drug use and problems has been the data source for over >850 publications. A comprehensive review of NESARC findings and their implications is lacking.

METHOD

NESARC was a survey of 43,093 participants that covered alcohol, drug and psychiatric disorders, risk factors, and consequences. Wave 1 of the NESARC was conducted in 2001-2002. Three years later, Wave 2 follow-up re-interviews were conducted with 34,653 of the original participants. Scopus and Pubmed were used to search for NESARC papers, which were sorted into topic areas and summarized.

RESULT

The most common disorders were alcohol and posttraumatic stress disorders, and major depression. Females had more internalizing disorders and males had more externalizing disorders, although the preponderance of males with alcohol disorders (the "gender gap") was less pronounced than it was in previous decades. A race/ethnic "paradox" (lower risk among disadvantaged minorities than whites) remains unexplained. Younger participants had higher risk for substance and personality disorders, but not unipolar depressive or anxiety disorders. Psychiatric comorbidity was extensive and often formed latent trans-diagnostic domains. Since 1991-1992, risk for marijuana and prescription drug disorders increased, while smoking decreased, although smoking decreases were less pronounced among those with comorbidity. A nexus of comorbidity, social support, and stress predicted transitions in diagnostic status between Waves 1 and 2. Childhood maltreatment predicted psychopathology. Alcohol and drug use disorders were seldom treated; attitudinal barriers (little perceived need, perceived alcoholism stigma, pessimism about efficacy) were more important in predicting non-treatment than financial barriers.

CONCLUSIONS

Understanding comorbidity and the effects of early stressors will require research incorporating biologic components, e.g., genetic variants and brain imaging. The lack of treatment for alcohol and drug disorders, predicted by attitudinal rather than financial variables, suggests an urgent need for public and professional education to reduce the stigma associated with these disorders and increase knowledge of treatment options.

Persistent Adaptations in Afferents to Ventral Tegmental Dopamine Neurons after Opiate Withdrawal

Protracted opiate withdrawal is accompanied by altered responsiveness of midbrain dopaminergic (DA) neurons, including a loss of DA cell response to morphine, and by behavioral alterations, including affective disorders. GABAergic neurons in the tail of the ventral tegmental area (tVTA), also called the rostromedial tegmental nucleus, are important for behavioral responses to opiates. We investigated the tVTA-VTA circuit in rats after chronic morphine exposure to determine whether tVTA neurons participate in the loss of opiate-induced disinhibition of VTA DA neurons observed during protracted withdrawal. In vivo recording revealed that VTA DA neurons, but not tVTA GABAergic neurons, are tolerant to morphine after 2 weeks of withdrawal. Optogenetic stimulation of tVTA neurons inhibited VTA DA neurons similarly in opiate-naive and long-term withdrawn rats. However, tVTA inactivation increased VTA DA activity in opiate-naive rats, but not in withdrawn rats, resembling the opiate tolerance effect in DA cells. Thus, although inhibitory control of DA neurons by tVTA is maintained during protracted withdrawal, the capacity for disinhibitory control is impaired. In addition, morphine withdrawal reduced both tVTA neural activity and tonic glutamatergic input to VTA DA neurons. We propose that these changes in glutamate and GABA inputs underlie the apparent tolerance of VTA DA neurons to opiates after chronic exposure. These alterations in the tVTA-VTA DA circuit could be an important factor in opiate tolerance and addiction. Moreover, the capacity of the tVTA to inhibit, but not disinhibit, DA cells after chronic opiate exposure may contribute to long-term negative affective states during withdrawal.

SIGNIFICANCE STATEMENT

Dopaminergic (DA) cells of the ventral tegmental area (VTA) are the origin of a brain reward system and are critically involved in drug abuse. Morphine has long been known to affect VTA DA cells via GABAergic interneurons. Recently, GABAergic neurons caudal to the VTA were discovered and named the tail of VTA (tVTA). Here, we show that tVTA GABA neurons lose their capacity to disinhibit, but not to inhibit, VTA DA cells after chronic opiate exposure. The failure of disinhibition was associated with a loss of glutamatergic input to DA neurons after chronic morphine. These findings reveal mechanisms by which the tVTA may play a key role in long-term negative affective states during opiate withdrawal.

Dissociation of heroin-induced emotional dysfunction from psychomotor activation and physical dependence among inbred mouse strains

RATIONALE

Opiate addiction is a brain disorder emerging through repeated intoxication and withdrawal episodes. Epidemiological studies also indicate that chronic exposure to opiates may lead in susceptible individuals to the emergence of depressive symptoms, strongly contributing to the severity and chronicity of addiction. We recently established a mouse model of heroin abstinence, characterized by the development of depressive-like behaviors following chronic heroin exposure.

OBJECTIVES

While genetic factors regulating immediate behavioral responses to opiates have been largely investigated, little is known about their contribution to long-term emotional regulation during abstinence. Here, we compared locomotor stimulation and physical dependence induced by heroin exposure, as well as emotional dysfunction following abstinence, across mice strains with distinct genetic backgrounds.

METHODS

Mice from three inbred strains (C57BL/6J, Balb/cByJ, and 129S2/SvPas) were exposed to an escalating chronic heroin regimen (10-50 mg/kg). Independent cohorts were used to assess drug-induced locomotor activity during chronic treatment, naloxone-precipitated withdrawal at the end of chronic treatment, and emotional-like responses after a 4-week abstinence period.

RESULTS

Distinct behavioral profiles were observed across strains during heroin treatment, with no physical dependence and low locomotor stimulation in 129S2/SvPas. In addition, different behavioral impairments developed during abstinence across the three strains, with increased despair-like behavior in 129S2/SvPas and Balb/cByJ, and low sociability in 129S2/SvPas and C57BL/6J.

CONCLUSIONS

Our results indicate that depressive-like behaviors emerge during heroin abstinence, whatever the severity of immediate behavioral responses to the drug. In addition, inbred mouse strains will allow studying several aspects of mood-related deficits associated with addiction.

Profiles of psychiatric disorders among heroin dependent individuals in Changsha, China

BACKGROUND

The strong comorbidity of psychiatric and substance use disorders is well documented outside of China, however it has not been studied extensively among drug using individuals in China. This study evaluated patterns of co-occurring psychiatric and substance use disorders among heroin dependent individuals in Changsha, China.

METHODS

Participants were 1002 individuals consecutively admitted between March 10 and October 30, 2008 into two compulsory and one voluntary drug rehabilitation centers in Changsha. The Structured Clinical Interview for DSM-IV-TR Axis I Disorders-Patient Edition (SCID-I/P) and the Structured Clinical Interview for DSM-IV-TR Axis II personality Disorders (SCID-II) were used.

RESULTS

Mental health disorders were highly prevalent among study participants: 29.6% had at least one lifetime DSM-IV Axis I and 19.5% had at least one current (past month) Axis I mental health disorder. Antisocial (40.7%) and Borderline (22.6%) Personality Disorders were most prevalent DSM-IV Axis II lifetime diagnoses and a mood disorder (19.1%) was the most prevalent Axis I lifetime disorder; 57.8% had other substance use disorder in addition to opioid dependence. Study results indicate that females in compulsory settings have lower socio-economic status than males in compulsory settings, and that males in compulsory settings have higher rates of co-morbidities, including personality, mood disorders, substance use co-morbidities, and lower socio-economic status than males in the voluntary setting.

CONCLUSIONS

The study findings suggest an urgent need to expand and improve diagnostic and treatment capabilities in compulsory rehabilitation settings in China and a need for additional services and interventions specific for female rehabilitants.

Long-term course of opioid addiction

Opioid addiction is associated with excess mortality, morbidities, and other adverse conditions. Guided by a life-course framework, we review the literature on the long-term course of opioid addiction in terms of use trajectories, transitions, and turning points, as well as other factors that facilitate recovery from addiction. Most long-term follow-up studies are based on heroin addicts recruited from treatment settings (mostly methadone maintenance treatment), many of whom are referred by the criminal justice system. Cumulative evidence indicates that opioid addiction is a chronic disorder with frequent relapses. Longer treatment retention is associated with a greater likelihood of abstinence, whereas incarceration is negatively related to subsequent abstinence. Over the long term, the mortality rate of opioid addicts (overdose being the most common cause) is about 6 to 20 times greater than that of the general population; among those who remain alive, the prevalence of stable abstinence from opioid use is low (less than 30% after 10-30 years of observation), and many continue to use alcohol and other drugs after ceasing to use opioids. Histories of sexual or physical abuse and comorbid mental disorders are associated with the persistence of opioid use, whereas family and social support, as well as employment, facilitates recovery. Maintaining opioid abstinence for at least five years substantially increases the likelihood of future stable abstinence. Recent advances in pharmacological treatment options (buprenorphine and naltrexone) include depot formulations offering longer duration of medication; their impact on the long-term course of opioid addiction remains to be assessed.

Factors associated with depression and anxiety among patients attending community-based methadone maintenance treatment in China

AIM

To estimate the prevalence of, and identify factors associated with, depression and anxiety among community-based methadone maintenance treatment (MMT) clients in China.

DESIGN

A cross-sectional survey.

SETTING

Nine MMT clinics, three each from three Chinese provinces (Yunnan, Anhui and Jiangsu) between October 2008 and February 2009.

PARTICIPANTS

A total of 1301 MMT clients.

MEASUREMENTS

A questionnaire, including the Zung Self-Rating Depression Scale (SDS) and Zung Self-Rating Anxiety Scale (SAS), and on-site urine drug testing.

FINDINGS

The prevalence of depression (SDS score≥53) and anxiety (SAS score≥50) in our sample was 38.3% [95% confidence interval (CI)=35.7, 40.9] and 18.4% (95% CI=16.3, 20.5), respectively, with 14.2% (95% CI=12.3, 16.1) displaying symptoms of both. Sample prevalence rates for depression [mean=49.69, standard deviation (SD)=10.34] and anxiety (mean=40.98, SD=10.66) were higher than the national average for each (t(0.05/2, 1300)=19.2, P<0.001 and t(0.05/2, 1300)=8.0, P<0.001, respectively). Employing multi-level modelling techniques, gender (P=0.03) and employment status (P<0.001) were found to be associated significantly with depression in a single-level model; however, in a multi-level mixed model, only employment status (P<0.001) was associated with depression. Gender (P=0.03), education level (P=0.02), marital status (P=0.04), employment status (P<0.001), positive urine drug test results (P=0.02) and daily methadone dose (P<0.001) were found to be associated significantly with anxiety in a single-level model, while only employment status (P<0.01) and positive results for the urine drug test (P=0.04) were associated with anxiety in a multi-level mixed model.

CONCLUSIONS

A considerable proportion of methadone maintenance treatment clients in China have experienced depression and anxiety during treatment. There is a need to provide tailored mental health interventions for this high-risk population.

Prescription opioid misuse and mental health among young injection drug users

BACKGROUND

Prescription opioid (PO) misuse is a significant concern in the United States.

OBJECTIVES

This study describes the prevalence and timing of PO misuse, diagnoses of opiate abuse and dependence, and their associations with psychiatric disorders in a sample of young people who inject drugs (PWID).

METHODS

Participants were 570 young (18-25 years) PWID, primarily heroin users, recruited through outreach and respondent-driven sampling. Trained interviewers administered a semi-structured psychiatric interview. Diagnoses of substance use and mental disorders were based on DSM-IV diagnostic criteria.

RESULTS

Estimated rates of lifetime PO abuse and dependence were 19% and 17%, respectively. Past year PO misuse was significantly associated with anti-social personality disorder (ASPD, OR = 2.15, 95% CI 1.43-3.24), past year substance-induced major depression (SIMD, OR = 1.81, 95% CI 1.16-2.83), and prior post-traumatic stress disorder (PTSD, OR = 2.45, 95% CI 1.31-4.60). Among male PO users, PTSD was a significant predictor of PO abuse (prior, OR = 7.62, 95% CI 2.16-26.88; past year, OR = 21.67 95% CI 2.46-190.75), and dependence (prior, OR = 4.82, 95% CI 1.48-15.67; past year, OR = 9.65, 95% CI 1.75-53.32).

CONCLUSION

Among young PWID, PTSD is a significant risk factor for PO misuse for both men and women, and men with PTSD are in addition at increased risk for PO abuse and dependence. These findings have implications for harm reduction and substance abuse prevention efforts.

A review of treatment options for co-occurring methamphetamine use disorders and depression

Co-occurring methamphetamine use and depression interferes with treatment outcomes. Female methamphetamine users are known to have higher rates of depression than male methamphetamine users, although this is also true for the general population. There are limited treatment options for the management of depression among methamphetamine users. In this integrative review, we summarize data on treatment strategies for co-occurring depression and methamphetamine use disorders. English-language articles were identified from PsychINFO, CINAHL, PubMed, and Medline as well as from reference lists of key articles. Search terms included "methamphetamine," "depression," and "treatment." Research articles describing psychological (n = 3), pharmacological (n = 6), nutritional supplement (n = 1), and psychological combined with pharmacological (n = 3) approaches for the treatment of methamphetamine use or withdrawal and/or depression are included in this review. Psychological and combination of psychological with pharmacological approaches have not been shown to be effective in treating these co-occurring conditions. Antidepressants have been determined to be ineffective and/or to introduce side effects. Gender differences with response to treatment were examined in only one of the published studies. There is a large gap in knowledge regarding treatment of co-occurring methamphetamine use disorders and depression. Considering that female methamphetamine users experience higher rates of depression than men, a focus on gender-specific treatment approaches is warranted.

Feasibility of applying the life history calendar in a population of chronic opioid users to identify patterns of drug use and addiction treatment

Uncovering patterns of drug use and treatment access is essential to improving treatment for opioid dependence. The life history calendar (LHC) could be a valuable instrument for capturing time-sensitive data on lifetime patterns of drug use and addiction treatment. This study describes the methodology applied when collecting data using the LHC in a sample of individuals with long-term opioid dependence and aims to identify specific factors that impact the feasibility of administering the LHC interview. In this study, the LHC allowed important events such as births, intimate relationships, housing, or incarcerations to become reference points for recalling details surrounding drug use and treatment access. The paper concludes that the administration of the LHC was a resource-intensive process and required special attention to interviewer training and experience with the study population. These factors should be considered and integrated into study plans by researchers using the LHC in addiction research.

Prevalence of antisocial personality disorder among Chinese individuals receiving treatment for heroin dependence: a meta-analysis

Background

Studies from Western countries consistently report very high rates of comorbid Antisocial Personality Disorder (ASPD) among individuals with heroin addiction, but the reported proportion of Chinese individuals with heroin addiction who have co-morbid ASPD varies widely, possibly because Chinese clinicians do not consider personality issues when treating substance abuse problems.

Aim

Conduct a meta-analysis of studies that assessed the proportion of Chinese individuals with heroin dependence who have comorbid ASPD.

Methods

We searched for relevant studies in both Chinese databases (China National Knowledge Infrastructure, Wanfang Data Knowledge Service Platform, Taiwan Electronic Periodical Services) and western databases (PubMed, EMBASE, and PsycInfo). Two authors independently retrieved the literature, identified studies that met pre-defined inclusion and exclusion criteria, assessed the quality of included studies, and extracted the data used in the analysis. Statistical analysis was performed using StatsDirect 3.0 and R software.

Results

The search yielded 15 eligible studies with a total of 3692 individuals with heroin dependence. Only 2 of the studies were rated as high-quality studies. All studies were conducted in rehabilitation centers or hospitals. The pooled lifetime prevalence of ASPD in these subjects was 30% (95%CI: 23%-38%), but the heterogeneity of results across studies was great (I² =95%, p<0.001). Men had a higher prevalence than women (44% vs. 21%), and injection heroin users had higher prevalence than those who smoked heroin (44% vs. 27%). Studies that were methodologically stronger had higher reported prevalence of ASPD among heroin dependent individuals.

Conclusions

There are substantial methodological problems in the available literature about ASPD in Chinese individuals receiving treatment for heroin dependence, but we estimate that about one-third of them meet criteria for ASPD. Further work is needed to increase clinicians’ awareness of this issue; to compare the pathogenesis, treatment responsiveness and recidivism of those with and without ASPD; and to develop and test targeted interventions for this difficult-to-treat subgroup of individuals with heroin dependence.

Impact of lifetime psychiatric diagnosis on long-term retention and survival of former opiate addicts in methadone maintenance treatment

OBJECTIVES

To characterize lifetime psychiatric diagnosis groups among methadone maintenance treatment (MMT) patients and associations of diagnosis to long-term (up to 20 years) retention and survival either during treatment or post discontinuation.

METHODS

A total of 758 patients with available psychiatric diagnosis (98% of those ever admitted between June 1993 and June 2012) were followed-up until June 2013. Lifetime psychiatric diagnosis was assessed according to DSM-IV-TR (Axis I, II, I & II, or none). Observed urine samples at 1 and 13 months were positive for drugs if at least one was positive. Survival data were based on the Israel National Population Registry. Survival and retention in MMT were compared (Kaplan Meier) between groups.

RESULTS

The Axis II (personality disorders) group had the worst mean long-term retention (5.8 years, 95% Confidence Interval (CI) 5.0-6.5) compared with the Axis I, Axis I & II or no psychiatric diagnosis groups (9.6 years, 95% CI 8.8-10.4) (P < 0.0005). Mean survival since admission (16.4 years, 95% CI 15.9-16.9) was similar for all groups. Axis II patients included more males, more drug injectors, were younger at initial opiate use and more likely left treatment before 1 year.

CONCLUSIONS

Personality and coping mechanisms (Axis II) could be significant obstacles to the success of MMT, warranting special interventions to overcome them.

Distinct mu, delta, and kappa opioid receptor mechanisms underlie low sociability and depressive-like behaviors during heroin abstinence

Addiction is a chronic disorder involving recurring intoxication, withdrawal, and craving episodes. Escaping this vicious cycle requires maintenance of abstinence for extended periods of time and is a true challenge for addicted individuals. The emergence of depressive symptoms, including social withdrawal, is considered a main cause for relapse, but underlying mechanisms are poorly understood. Here we establish a mouse model of protracted abstinence to heroin, a major abused opiate, where both emotional and working memory deficits unfold. We show that delta and kappa opioid receptor (DOR and KOR, respectively) knockout mice develop either stronger or reduced emotional disruption during heroin abstinence, establishing DOR and KOR activities as protective and vulnerability factors, respectively, that regulate the severity of abstinence. Further, we found that chronic treatment with the antidepressant drug fluoxetine prevents emergence of low sociability, with no impact on the working memory deficit, implicating serotonergic mechanisms predominantly in emotional aspects of abstinence symptoms. Finally, targeting the main serotonergic brain structure, we show that gene knockout of mu opioid receptors (MORs) in the dorsal raphe nucleus (DRN) before heroin exposure abolishes the development of social withdrawal. This is the first result demonstrating that intermittent chronic MOR activation at the level of DRN represents an essential mechanism contributing to low sociability during protracted heroin abstinence. Altogether, our findings reveal crucial and distinct roles for all three opioid receptors in the development of emotional alterations that follow a history of heroin exposure and open the way towards understanding opioid system-mediated serotonin homeostasis in heroin abuse.

Gender differences in prevalence and correlates of antisocial personality disorder among heroin dependent users in compulsory isolation treatment in China

BACKGROUND

Little is known about gender difference in correlates of antisocial personality disorder (ASPD) among drug users.

OBJECTIVE

To detect gender difference in correlates of ASPD in a Chinese heroin dependent sample.

METHODS

Structured interviews were conducted among 882 heroin dependent users in two compulsory isolation settings in Changsha, China. Descriptive statistics were employed to report sample characteristics by gender. Bivariate relationships were examined between co-occurring ASPD and variables measuring demographic, drug use, and psychiatric co-morbidities. Multivariate logistic regressions with stepwise forward method were conducted to determine independent predictors for co-occurring ASPD. All analyses examining correlates of co-occurring ASPD were conducted for the total, the male and the female participants respectively to detect both the common and the unique correlates of ASPD by gender.

RESULTS

Of the total participants, 41.4% (54.2% of males and 15.4% of females) met the DSM-IV criteria of ASPD. For male participants, lower educational level, unemployment, unmarried, younger age at first heroin use, previous history of compulsory treatment, larger amounts of heroin used per day and poly-drug abuse during past month before admission, as well as psychiatric co-morbidities of lifetime major depressive disorder and borderline personality disorder were independent predictors for co-occurring ASPD; while for female participants, only three variables: younger age at first heroin use, paranoid personality disorder and borderline personality disorder were independent predictors for co-occurring ASPD.

CONCLUSIONS

Gender differences in prevalence and correlates of ASPD among heroin dependent users were detected. The findings highlight a need for gender-specific interventions.

Substance Use and Associated Health Conditions throughout the Lifespan

A life stage perspective is necessary for development of age-appropriate strategies to address substance use disorders (SUDs) and related health conditions in order to produce better overall health and well-being. The current review evaluated the literature across three major life stages: adolescence, adulthood, and older adulthood.

FINDINGS

1) Substance use is often initiated in adolescence, but it is during adulthood that prevalence rates for SUDs peak; and while substance involvement is less common among older adults, the risk for health complications associated with use increases. 2) Alcohol, tobacco, marijuana, and, increasingly, prescription medications, are the most commonly misused substances across age groups; however, the use pattern of these and other drugs and the salient impact vary depending on life stage. 3) In terms of health outcomes, all ages are at risk for overdose, accidental injury, and attempted suicide. Adolescents are more likely to be in vehicular accidents while older adults are at greater risk for damaging falls. Adulthood has the highest rates of associated medical conditions (e.g., cancer, sexually transmitted disease, heart disease) and mental health conditions (e.g., bipolar disorder, anxiety disorders, antisocial personality disorder).

CONCLUSION

Prolonged heavy use of drugs and/or alcohol results in an array of serious health conditions. Addressing SUDs from a life stage perspective with assessment and treatment approaches incorporating co-occurring disorders are necessary to successfully impact overall health.

Static and dynamic predictors of criminal involvement among people with heroin dependence: findings from a 3-year longitudinal study

BACKGROUND

The link between heroin use and crime has been well established; however, there has been little opportunity to examine this relationship longitudinally. This study examines the relationship between static and dynamic predictors of criminal involvement, and the degree to which changes in dynamic risk factors moderate the risk of criminal involvement over time.

METHOD

Data were collected as part of the Australian treatment outcome study, a 3-year longitudinal study of 615 people with heroin dependence conducted in Sydney, Australia. Past-month criminal involvement (property crime, drug dealing, fraud, violent crime), demographic, drug use and mental health characteristics were assessed at each interview.

RESULTS

Criminal involvement was consistently and independently predicted by lack of wage/salary as a main source of income, (OR 2.17), meeting diagnostic criteria for anti-social personality disorder (OR 1.91) and major depression (OR 1.41), screening positive for borderline personality disorder (OR 1.47), male sex (OR 1.44), a criminal history (OR 1.33), greater severity of dependence (OR 1.21), more extensive heroin use (OR 1.09), and younger age (OR 0.96) over the 3-year period.

CONCLUSIONS

These findings provide strong evidence of the robust nature of the association between more extensive heroin use, severity of dependence, the co-occurrence of mental health conditions, and an individual's capacity for employment, and criminal involvement. Interventions aimed at increasing an individual's employability and improving mental health in particular, may reduce the risk of criminal involvement among people with heroin dependence.

Axis II disorders and cigarette smoking among adults from the general population

The present study examined whether personality disorders (PDs) are associated with cigarette smoking, and the possible influence of nicotine dependence, sociodemographic variables, and the presence of any lifetime Axis I mental disorder in these relationships. The sample was made up of 1,081 adult participants from the Spanish general population and was stratified by smoking status (519 smokers and 562 nonsmokers). PDs were assessed by means of the International Personality Disorder Examination Questionnaire, Module DSM-IV. Results indicated that participants with a paranoid, a narcissistic, a borderline, an antisocial, or an obsessive-compulsive PD had a higher probability for being smokers and for being nicotine-dependent. The only exception was the schizoid PD, because participants with this Axis II disorder had a lower probability for being nicotine-dependent smokers. The association between PDs and smoking was maintained even after adjusting for all covariates. Findings are discussed in relation to the influence of Axis II disorders on smoking cessation interventions.

Prevalence and key covariates of non-medical prescription opioid use among the general secondary student and adult populations in Ontario, Canada

INTRODUCTION AND AIMS

To assess the prevalence and key covariates of non-medical prescription opioid use (NMPOU) in two representative surveys of adults (Centre for Addiction and Mental Health Monitor, CM) and secondary-school students (Ontario Student Drug Use and Health Survey, OSDUHS).

DESIGN AND METHODS

Data from the 2010 and 2011 cycles (n = 4023) of CM--a stratified, multi-stage, random-digit-dialling telephone survey of adults (18 years and older)--and the 2011 cycle of OSDUHS (n = 3266)--a self-administered written questionnaire-based survey of grade 7-12 public system students--were used. Besides NMPOU prevalence, associations were assessed by univariate and multi-step multivariate (logistic regression) analyses. NMPOU and key socioeconomic (i.e. sex, age, Aboriginal ethnicity, household location, income, subjective social status), health indicators (physical health status, psychological distress, suicidal ideation), drug use (cigarette smoking, binge drinking, cannabis use, other drug use) were measured.

RESULTS

NMPOU (past year) prevalence was 15.5% in students and 5.9% in adults. Various univariate associations with social, health and drug use factors were found in both populations, with differences by sex. Based on multivariate analyses, other drug use (male students) and rural residence, subjective social status, other drug use and suicidal ideation (female students); marital status and cannabis use (male adults) and binge drinking (female adults) were independently associated with NMPOU in the respective study populations.

DISCUSSION AND CONCLUSIONS

NMPOU was high in adults and especially students. Independent predictors of NMPOU were largely inconsistent by sex. Notably, NMPOU is widely distributed across socio-demographic and -economic strata, and thus requires broad-based interventions.

Gender differences in a clinical trial for prescription opioid dependence

Although gender differences in substance use disorders have been identified, few studies have examined gender differences in prescription drug dependence. The aim of this study was to examine gender differences in clinical characteristics and treatment outcomes in a large clinical trial for prescription opioid dependence. Despite no pre-treatment differences in opioid dependence severity, women reported significantly greater functional impairment, greater psychiatric severity, and higher likelihood of using opioids to cope with negative affect and pain than men. Women were also more likely than men to have first obtained opioids via a legitimate prescription and to use opioids via the intended route of administration. Men reported significantly more alcohol problems than women. There were no significant gender differences in medication dose, treatment retention, or opioid outcomes. Thus, despite the presence of pre-treatment gender differences in this population, once the study treatment was initiated, women and men exhibited similar opioid use outcomes.

A history of chronic morphine exposure during adolescence increases despair-like behaviour and strain-dependently promotes sociability in abstinent adult mice

A crucial issue in treating opiate addiction, a chronic relapsing disorder, is to maintain a drug-free abstinent state. Prolonged abstinence associates with mood disorders, strongly contributing to relapse. In particular, substance use disorders occurring during adolescence predispose to depression later in adulthood. Using our established mouse model of opiate abstinence, we characterized emotional consequences into adulthood of morphine exposure during adolescence. Our results indicate that morphine treatment in adolescent mice has no effect on anxiety-like behaviours in adult mice, after abstinence. In contrast, morphine treatment during adolescence increases behavioural despair in adult mice. We also show that morphine exposure strain-dependently enhances sociability in adult mice. Additional research will be required to understand where and how morphine acts during brain maturation to affect emotional and social behaviours into adulthood.

Suicidal ideation and suicide attempt across stages of nonmedical prescription opioid use and presence of prescription opioid disorders among U.S. adults

OBJECTIVE

This study compares the likelihood of suicidal ideation and suicide attempt across stages of nonmedical prescription opioid use and by presence of prescription opioid disorders (dependence and/or abuse) among adult respondents.

METHOD

In the 2009 National Survey on Drug Use and Health, 37,933 adult respondents were asked if they had thought about suicide or had attempted suicide in the past year. The likelihood of ideation and attempt were compared across the following four categories: (a) those who never used prescription opioids, (b) former users, (c) persistent users, and (d) recent-onset users. Weighted multinomial logistic regressions were used to examine if these stages and presence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for prescription opioid disorders were associated with suicidal ideation and suicide attempt.

RESULTS

Five percent of respondents (n = 2,021) reported suicidal ideation; of these, 15% (n = 310) reported attempt. Former and persistent nonmedical prescription opioid users had greater odds of suicidal ideation than those who never used these medications nonmedically. The stages of prescription opioid use were not associated with suicide attempt. Presence of prescription opioid disorders among past-year prescription opioid users was associated with suicidal ideation but not suicide attempt.

CONCLUSIONS

The risk for suicidal ideation was greater in those who no longer used prescription opioids, in persistent users, and among nonmedical users who had a prescription opioid disorder compared with users without the disorder. The results suggest a need to continue monitoring for suicide risk even among those who have stopped using prescription opioids.

Mood and anxiety disorders and their association with non-medical prescription opioid use and prescription opioid-use disorder: longitudinal evidence from the National Epidemiologic Study on Alcohol and Related Conditions

BACKGROUND

Non-medical use of prescription opioids represents a national public health concern of growing importance. Mood and anxiety disorders are highly associated with non-medical prescription opioid use. The authors examined longitudinal associations between non-medical prescription opioid use and opioid disorder due to non-medical opioid use and mood/anxiety disorders in a national sample, examining evidence for precipitation, self-medication and general shared vulnerability as pathways between disorders.

METHOD

Data were drawn from face-to-face surveys of 34 653 adult participants in waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. Logistic regression models explored the temporal sequence and evidence for the hypothesized pathways.

RESULTS

Baseline lifetime non-medical prescription opioid use was associated with incidence of any mood disorder, major depressive disorder (MDD), bipolar disorder, any anxiety disorder and generalized anxiety disorder (GAD in wave 2, adjusted for baseline demographics, other substance use, and co-morbid mood/anxiety disorders). Lifetime opioid disorder was not associated with any incident mood/anxiety disorders. All baseline lifetime mood disorders and GAD were associated with incident non-medical prescription opioid use at follow-up, adjusted for demographics, co-morbid mood/anxiety disorders, and other substance use. Baseline lifetime mood disorders, MDD, dysthymia and panic disorder were associated with incident opioid disorder due to non-medical prescription opioid use at follow-up, adjusted for the same covariates.

CONCLUSIONS

These results suggest that precipitation, self-medication as well as shared vulnerability are all viable pathways between non-medical prescription opioid use and opioid disorder due to non-medical opioid use and mood/anxiety disorders.

Latent classes of heroin and cocaine users predict unique HIV/HCV risk factors

BACKGROUND

Patterns of heroin and cocaine use vary and may be associated with unique risk factors for bloodborne infections.

METHODS

Latent class analysis identified sub-populations of 552 heroin and cocaine users in Baltimore, Maryland. Using latent class regression, these classes were analyzed for associations with demographic characteristics, risky behaviors, Hepatitis C, and HIV.

RESULTS

Three classes were found: Crack/Nasal-Heroin users (43.5%), Polysubstance users (34.8%), and Heroin Injectors (21.8%). Compared to Polysubstance users, Crack/Nasal-Heroin users were almost 7 times more likely to identify as Black (OR=6.97, 95% CI=4.35-11.2). Sharing needles was over 2.5 times more likely among Polysubstance users than among Heroin Injectors (OR=2.66, 95% CI=1.49-4.75). Crack/Nasal-Heroin users were 2.5 times more likely than Polysubstance users to exchange drugs for sex (OR=2.50, 95% CI=1.22-5.13). Crack/Nasal-Heroin users were less likely than Heroin Injectors to have Hepatitis C (OR=0.10, 95% CI=0.06-0.18), but no significant differences were found for HIV.

CONCLUSIONS

Subpopulations of cocaine and heroin users differed in demographic classifications, HIV-risk behaviors, and Hepatitis C infection. All subpopulations included substantial numbers of HIV-positive individuals. Findings provide further evidence that non-injection drug users face significant infectious disease risk.

Gender differences in physical and mental health outcomes among an aging cohort of individuals with a history of heroin dependence

BACKGROUND

This paper examines the health status and functioning of an aging cohort of individuals with a history of heroin dependence with a focus on gender differences.

METHOD

Study subjects were originally sampled from methadone maintenance clinics in California in the 1970s and completed follow-up interviews in 2005-09. Out of the original study sample (N=914), 343 participants (44.3% female) were interviewed (70.6% of those not deceased). Bivariate analyses examined gender differences in participants' overall health status and physical and mental health problems. Scores on SF-36 scales were compared with general population norms by gender and age, as well as between participants in the study sample who did and did not report past-year drug use.

RESULTS

Average age of the study sample was 58.3 (SD=4.9) years for males and 55.0 (SD=4.1) years for females. There were no significant gender differences in past-year drug use (38% of sample) or injection drug use (19%). Women reported significantly more chronic health problems and psychological distress compared with men, and overall poorer health and functioning compared with general population norms. Men under 65 had poorer physical health and social functioning compared with population norms. Men in the study sample reporting past-year substance use had poorer physical functioning, but less bodily pain, than non-users, whereas women with past-year substance use had poorer mental health than other women.

CONCLUSION

Individuals with a history of heroin dependence have poorer health and functioning than their counterparts in the general population. At a younger age, women reported poorer overall health status and more chronic health and mental health problems than men. Study findings may inform interventions for this population, particularly related to gender-specific treatment needs.

Influence of Site Differences between Urban and Rural American and Central European Opioid-Dependent Pregnant Women and Neonatal Outcome Characteristics

BACKGROUND

Multi-center trials enable the recruitment of larger study samples, although results might be influenced by site-specific factors.

METHODS

Site differences of a multi-center prospective double-blind, double-dummy randomized controlled trial (7 centers: Central Europe (Vienna)/USA (3 urban/3 rural centers)) comparing safety and efficacy of methadone and buprenorphine in pregnant opioid-dependent women and their neonates.

RESULTS

Urban US women had the highest rate of concomitant opioid (p = 0.050) and cocaine consumption (p = 0.003), the highest dropout rate (p = 0.001), and received the lowest voucher sums (p = 0.001). Viennese neonates had significantly higher Apgar scores 1 min (p = 0.001) and 5 min after birth (p < 0.001) and were more often born by cesarean section (p = 0.024). Rural US newborns had a significantly shorter neonatal abstinence syndrome treatment duration compared to Viennese and urban US sites (p = 0.006), in addition to other site-specific differences, suggesting a more severely affected group of women in the urban US sites.

CONCLUSION

This clinical trial represents a role model for pharmacological treatment in this unique sample of pregnant women and demonstrates the clinical importance of considering site-specific factors in research and clinical practice.

30-year trajectories of heroin and other drug use among men and women sampled from methadone treatment in California

BACKGROUND

This study examines 30-year trajectories of heroin and other drug use among men and women who were in methadone maintenance treatment in California in the late 1970s and interviewed in 1978-1981.

METHODS

Nearly half (N=428; 46.8%) of the original study sample (N=914) was deceased. Of the remaining 486 subjects, 343 (44.3% female) completed a follow-up interview in 2005-2009 (70.6% of those not deceased). Average age at follow-up was 58.3 (SD=4.9) years for males and 55.0 (SD=4.1) years for females. Longitudinal data was obtained on their drug use, treatment participation, and criminal justice status over the follow-up period. Trajectory group modeling was used to identify distinctive trajectory groups based on monthly averages of heroin and other drug use per year; group differences were examined.

RESULTS

Four heroin and five alcohol and other drug (AOD) trajectory groups were identified. A greater proportion of women (60%) were in the "rapid decrease" heroin group (odds of use less than 10% by 10 years following initiation of use) as compared with the other groups. More rapid decrease of heroin use was associated with increases in AOD use, whereas a gradual decrease in heroin use was associated with a gradual decrease in AOD use. More school problems and earlier age at onset of heroin use and first arrest were associated with more persistent heroin use.

CONCLUSION

Heroin-use trajectories were linked with changes in AOD use. Childhood antecedents of heroin-use trajectories were identified as well as gender differences.

Subtypes of nonmedical opioid users: results from the national epidemiologic survey on alcohol and related conditions

AIMS

To identify subtypes of nonmedical opioid users, gender variations in psychiatric disorders, and quality of life in a representative sample of adults.

METHODS

Analyses of data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (N=43,093). Latent class analysis (LCA) and multinomial logistic regression procedures examined subtypes of nonmedical opioid users.

RESULTS

Approximately 5% (n=1815) of adults used nonmedical opioids. LCA identified four subtypes: opioid-marijuana users (33%), opioid-other prescription drug users (9%), opioid-marijuana-hallucinogen users (28%), and opioid-polydrug users (30%). Subtypes were distinguished by race/ethnicity, gender, familial substance abuse, personal history of substance abuse treatment, and patterns of psychiatric disorders. Whites and men had increased odds of being in the opioid-polydrug and opioid-marijuana-hallucinogen subtypes. The opioid-other prescription drug use subtype had disproportionately affected women who were characterized by high rates of mood/anxiety disorders and low quality of life. Across all subtypes, women and men had similarly problematic substance use disorders; however, women had more major depression and disability in the mental health domain.

CONCLUSIONS

The generally high prevalence of psychiatric disorders among nonmedical opioid users, particularly women, underscores the need for comprehensive assessment and coordinated delivery of services to match needs with treatment, as well as continued monitoring of trends in opioid use and related problems.

Rates of mood and anxiety disorders and contributors to continued heroin use in methadone maintenance patients: A comparison by HIV status

The frequency of mood and anxiety disorders is elevated among individuals with a history of intravenous drug abuse and among those with human immunodeficiency virus (HIV), and these disorders are associated with continued substance use despite treatment. The present study examined rates of mood and anxiety disorders, and recent heroin use, among HIV-infected and HIV-noninfected patients receiving methadone maintenance therapy. Participants were 160 (80 HIV-infected, 80 HIV-noninfected) methadone patients. Clinician-administered, semistructured interviews were used to identify unipolar and bipolar depression, and four major anxiety disorders (panic disorder with agoraphobia [PDA], generalized anxiety disorder [GAD], post-traumatic stress disorder [PTSD], and social anxiety disorder [SAD]). Toxicology screens and self-reporting were used to assess heroin, cocaine, marijuana, and alcohol use over the past month. The entire sample met criteria for at least one psychiatric disorder other than substance dependence. Substantial proportions of participants met criteria for major depressive disorder (55.6%), bipolar I, bipolar II, or cyclothymia (6.4%), PDA (34.4%), GAD (22.5%), SAD (16.9%), and PTSD (34.4%). A greater proportion of HIV-infected participants met criteria for SAD (χ² = 5.03), and a greater proportion of HIV-noninfected participants met criteria for GAD (χ² = 5.39, P < 0.01). About 14% of participants continued to use heroin over the past month, a significantly greater proportion of whom were HIV-infected. In adjusted analyses, none of the mood or anxiety disorders emerged as significant predictors of recent heroin use, but being HIV-infected did. This study highlights the high rate of psychopathology and continued heroin use despite substance abuse treatment, and underscores the need for interventions that help mitigate these problems among methadone patients.

Gender-related influences of parental alcoholism on the prevalence of psychiatric illnesses: analysis of the National Epidemiologic Survey on Alcohol and Related Conditions

BACKGROUND

Offspring of individuals with alcoholism are at increased risk for psychiatric illness, but the effects of gender on this risk are not well known. In this study, we tested the hypothesis that the gender of the parent with alcoholism and the gender of offspring affect the association between parental alcoholism and offspring psychiatric illness.

METHOD

We analyzed the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) data to examine the gender-specific prevalence of axis I and axis II disorders in 23,006 male and 17,368 female respondents with and without a history of paternal or maternal alcoholism. Adjusted odds ratios were calculated for the disorders based on gender and presence of maternal or paternal alcoholism.

RESULTS

Maternal or paternal alcoholism was associated with a higher prevalence of every disorder examined, regardless of the gender of offspring. Gender-related differences in prevalences were present in nearly all examined disorders, and the association between parental alcoholism and offspring psychiatric disorders was significantly different in men and women. These differences included stronger associations in female offspring of men with alcoholism (alcohol abuse without dependence); in female offspring of women with alcoholism (mania, nicotine dependence, alcohol abuse, and schizoid personality disorder); in male offspring of men with alcoholism (mania); and in male offspring of women with alcoholism (panic disorder).

CONCLUSIONS

Interactions between gender and parental alcoholism were specific to certain disorders but varied in their effects, and in general female children of women with alcoholism appear at greatest risk for adult psychopathology.

Substance use and women's health

Scientific findings show that substance abuse in women yields a higher risk of a variety of health problems than substance abuse in men. Research suggests that women experience addiction telescoping when they abuse alcohol, tobacco, specific stimulants, and possibly opioids. Medical side effects also develop more rapidly in women than men when they abuse many substances. Cancer and cardiac complications, specifically, pose a significant threat for women who abuse almost all types of substances. However, the physical consequences are not the only ones women suffer when they engage in substance abuse. Research on substance abuse in women ties opioids to mood and anxiety disorders, heroin to neurological deficiencies, cocaine to immune system suppression, and alcohol to intimate partner abuse. Additionally, female substance abusers, on average, have a lower level of education and lower rates of employment. In light of these gender-specific concerns, physicians should give particular consideration to detecting substance abuse in women.

Ethnic disparities in accessing treatment for depression and substance use disorders in an integrated health plan

OBJECTIVE

This study examined ethnic differences in accessing treatment for depression and substance use disorders (SUDs) among men and women in a large integrated health plan, and explored factors potentially contributing to health care disparities.

METHODS

Participants were 22,543 members ages 20 to 65 who responded to health surveys in 2002 and 2005. Survey questions were linked to provider-assigned diagnoses, electronic medication, psychiatry, and chemical dependency program records.

RESULTS

Among women diagnosed with depression, Latinas (p < .01) and Asian-Americans (p < .001) were less likely than Whites to fill an antidepressant prescription. Among men diagnosed with depression, African Americans (p < .01) were less likely than Whites to do so. Among women diagnosed with an SUD, African Americans (p < .05) were less likely than Whites to have one or more chemical dependency program visits.

CONCLUSIONS

Results demonstrated ethnic differences in accessing depression and SUD treatment among patients diagnosed with these disorders, which persisted after controlling for education, income, having a regular health care provider and length of health plan enrollment. Findings highlight potential gender differences in ethnic disparities, lower antidepressant utilization among Asian Americans, and the effects of co-occurring disorders in accessing behavioral health care.