Changes in US Lifetime Heroin Use and Heroin Use Disorder: Prevalence From the 2001-2002 to 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions

Heroin and healthcare: patient characteristics and healthcare prior to overdose

OBJECTIVES

To estimate heroin overdose trends among insured individuals and characterize patients and healthcare utilization preceding overdose to inform scale-up of effective prevention and treatment.

STUDY DESIGN

Retrospective descriptive analysis.

METHODS

We analyzed 2010 to 2014 IBM MarketScan Databases and calculated annual heroin overdose rates. For a subset of patients, we describe their comorbidities, where they accessed health services, and select prescription histories prior to their first heroin overdose.

RESULTS

Heroin overdose rates were much lower, but increased faster, among the commercially insured compared with Medicaid enrollees from 2010 to 2014 (270.0% vs 94.3%). By 2012, rates among the commercially insured aged 15 to 24 years reached the overall rates in the Medicaid population. All patients had healthcare encounters in the 6 months prior to their first heroin overdose; two-thirds of commercially insured patients had outpatient visits, whereas two-thirds of Medicaid patients had emergency department visits. One month prior to overdose, 24.5% of Medicaid and 8.6% of commercially insured patients had opioid prescriptions. Fewer Medicaid patients had buprenorphine prescriptions (17.8% vs 27.3%) despite similar rates of known substance-related disorders. A higher proportion of Medicaid patients had non-substance-related comorbidities.

CONCLUSIONS

Heroin overdose rates were persistently higher among the Medicaid population than the commercially insured, with the exception of those aged 15 to 24 years. Our findings on healthcare utilization, comorbidities, and where individuals access services could inform interventions at the point of care prior to a first heroin overdose. Outpatient settings are of particular importance for the growing cohort of young, commercially insured patients with opioid use disorders.

A Comparison of Substance Use Patterns Among Lifetime Heroin-Injecting Individuals By Racial Groups

BACKGROUND

Studies have identified differential substance use patterns by racial groups. One of the most commonly reported differences is a higher rate of injection drug use (IDU) among Non-Hispanic Whites compared to African Americans, but this is complicated by factors related to IDU (e.g., earlier drug-use initiation) that overlap with being White.

OBJECTIVE

We explored differential substance use-patterns by racial groups within a sample of injection heroin users.

METHODS

Substance-use data were collected from 373 not-in-treatment heroin users who endorsed any lifetime injection use (69.4% male). We examined differences in substance-use patterns (e.g., age of initiation, gateway adherence) by racial groups. Multiple t-tests with Bonferroni correction were conducted to understand which demographic and substance-use characteristics varied by racial groups.

RESULTS

Relative to Non-Hispanic Whites, African Americans (45.8% of sample) were more likely to start using heroin earlier in their life, but also more likely to experience a longer delay between starting and regularly using heroin. We also identified differences in the degree of (injection) heroin-use consequences by racial groups. After correcting for multiple comparisons and controlling for age and gender, we observed differences for six substance-use and demographic characteristics by racial group. White participants were younger, started cocaine use earlier, and experienced more heroin-use consequences across two separate domains.

CONCLUSIONS

After controlling for injection use, we observed differential substance-use characteristics by racial groups. The findings could be used to develop targeted prevention and harm-reduction strategies.

Trends in Opioid Prescribing for Adolescents and Young Adults in Ambulatory Care Settings

BACKGROUND

Adolescents and young adults are at high risk for opioid misuse after exposure from medical treatment. However, the epidemiology of opioid prescribing among outpatient adolescents and young adults remains poorly described. We aimed to characterize opioid prescribing in adolescents and young adults receiving care in emergency departments (EDs) and outpatient clinics.

METHODS

We analyzed National Hospital Ambulatory Medical Care Survey and National Ambulatory Medical Care Survey data from 2005 to 2015. We included visits to EDs and outpatient clinics for adolescents (13-17 years old) and young adults (18-22 years old). Rates of opioid prescribing were calculated with 95% confidence intervals (CIs), and linear trends over time were examined with logistic regression models.

RESULTS

Nearly 57 million visits (5.7%; 95% CI 5.4% to 6.0%) by adolescents and young adults were associated with an opioid prescription. The rate of opioid prescribing was 14.9% (95% CI 14.4% to 15.6%) for ED visits and 2.8% (95% CI 2.5% to 3.1%) for outpatient clinic visits. There was a small but significant decrease in the rate of opioid prescriptions among ED visits (odds ratio 0.96; 95% CI 0.95 to 0.98); no change was seen for outpatient clinic visits. Among ED visits, opioid-prescribing rates were highest among adolescents and young adults with dental disorders (59.7% and 57.9%, respectively), followed by adolescents with clavicle (47.0%) and ankle fractures (38.1%).

CONCLUSIONS

Rates of opioid prescribing in EDs and outpatient clinics remain high for adolescents and young adults, especially for certain emergency conditions. These findings inform targeted educational campaigns aiming to ensure judicious use of opioids in this high-risk population.

HIV/HCV Co-infection: Burden of Disease and Care Strategies in Appalachia

PURPOSE OF REVIEW

The purpose of this review is to address infection with HIV and hepatitis C in the Appalachian region of the USA and the driving forces underlying this epidemic. We seek to discuss epidemiology of disease and the possible interventions to reduce incidence and burden of disease in this resource-limited area.

RECENT FINDINGS

The rise of the opioid crisis has fueled a rise in new hepatitis C infection, and a rise in new HIV infection is expected to follow. Injection drug use has directly contributed to the epidemic and continues to remain a risk factor. Men who have sex with men remains a significant risk factor for HIV acquisition as well. Progress has been made in the battle against HIV and, to a lesser extent, hepatitis C, but much more can be done. Limited data on co-infection with HIV/HCV are currently available for this at-risk region, but it is clear that Appalachia is highly vulnerable to co-infection outbreaks. A multipronged approach that includes advances in assessment of co-infection and education for both patients and clinicians can help to recognize, manage, and ideally prevent these illnesses.

Factors Associated with Frequency of Recent Initiation of Others into Injection Drug Use Among People Who Inject Drugs in Los Angeles and San Francisco, CA, USA, 2016-17

Objective: Drug injection initiation is often assisted by a person who injects drugs (PWID). How often PWID provide this assistance has not been examined. We examine frequency of injection initiation assistance and factors associated with high (4+) and low frequency (1-3) initiation assistance as compared to no initiation assistance among PWID. Methods: Participants were 979 Californian PWID. PWID were interviewed about providing injection initiation assistance in the last 6 months among other items. Multinomial regression analysis was used to examine factors associated with levels of frequency of injection initiation assistance. Results: Among participants, 132 (14%) had initiated 784 people into injection (mean = 5.94 [standard deviation = 20.13]; median = 2, interquartile range = 1,4) in the last 6 months. PWID engaged in high frequency initiation (26% of sample) assisted 662 new initiates (84% of total). Using multinomial regression analysis with no initiating as the referent group, we found that high frequency initiating was statistically associated with higher injection frequency, having a paying sex partner, taking someone to a shooting gallery, and providing injection assistance. Lower frequency initiation was statistically associated with having a paying sex partner, illegal income source, and providing injection assistance. Conclusion: Differences between high and low frequency initiators were not found. Sex work and assisting with drug injection were linked to initiating others. Individual-level interventions that reduce this behavior among PWID and structural interventions such as safe consumption sites and opioid medication treatments that interrupt the social process of injection initiation should be considered as ways to reduce injection initiations.

Comparing Buprenorphine-Prescribing Physicians Across Nonmetropolitan and Metropolitan Areas in the United States

PURPOSE

Although there is a tremendous need to increase the use of buprenorphine for the treatment of opioid use disorder in rural areas, little is known about current rural/urban differences in treatment practices. We aimed to examine physician characteristics, treatment practices, and concordance with treatment guidelines among buprenorphine prescribers across different locations of practice.

METHODS

A national random sample of buprenorphine physician prescribers was surveyed (n = 1,174, response rate = 33%) from July 2014 to January 2017. Analyses examined buprenorphine treatment across locations of practice (categorized as nonmetropolitan, small metropolitan, and large metropolitan).

RESULTS

Among buprenorphine prescribers surveyed, 11.2% (n = 132) practiced in nonmetropolitan/rural areas, 32.5% (n = 382) in small metropolitan areas, and 56.2% (n = 660) in large metropolitan areas. Buprenorphine prescribers in nonmetropolitan areas were much more likely to be primary care physicians, accept Medicaid, and less likely to work in an individual practice. Overall, buprenorphine prescribers across the rural/urban continuum were similar in many of their treatment practices, including induction, frequency of visits, dosing, and use of psychosocial treatment, which were generally consistent with buprenorphine treatment recommendations.

CONCLUSIONS

There are important differences in characteristics of buprenorphine prescribers in nonmetropolitan areas compared with more urban areas, including the fact that the majority of nonmetropolitan physicians are primary care physicians. Although treatment access in rural areas is an ongoing challenge, buprenorphine treatment practices are similar. Understanding buprenorphine prescribers and their treatment practices may help inform tailored strategies to address treatment needs in different locations.

Cannabis use in Switzerland 2015-2045: A population survey based model

BACKGROUND

Alternative cannabis regulation models are discussed and implemented worldwide. A baseline scenario under the assumption of no policy or market changes may prove useful to forecast cannabis use and treatment demand and evaluate changes in legislation.

METHODS

Based on data of the Continuous Rolling Survey of Addictive Behaviours and Related Risks on cannabis use, age, gender and nationality from 2011 to 2015, we used general estimating equation analysis to model lifetime and 30-days prevalence from 2015 to 2045 in Switzerland accounting for demographic trends.

RESULTS

Lifetime prevalence of cannabis use is projected to grow from 28.3% (CI 95% 27.8-28.8) in 2015 to 42.0% (CI 95% 41.0-43.0) in 2045. 30-days prevalence would increase slightly from 2.70% (CI 95% 2.53-2.88) to 3.39% (CI 95% 3.11-3.66). Due to population growth, absolute numbers with past 30-day cannabis use are estimated to increase from 202,784 (CI 95% 189,534-216,035) to 314,302 (CI 95% 288,504-340,100). Among those aged under 30 years no substantial change in lifetime and 30-days prevalence of cannabis use is projected. Larger changes are estimated to occur in the age group 30+. The mean age of past 30-day cannabis users would increase for men with Swiss nationality from 30.3 to 38.7 years.

DISCUSSION

Population-based survey data and demographic projections can be used to develop baseline scenarios of future cannabis use. Assuming no changes in cannabis legislation, growing absolute numbers of users will likely increase treatment demand. Cannabis use is estimated to increase among the group aged >30 years, which is currently underrepresented in clinical treatment and research. Our findings highlight the need for prospective baseline scenarios to evaluate the impact of legislative changes on cannabis use. Moreover, in Switzerland effective prevention and treatment interventions for cannabis use disorders are required even if cannabis legislation remains unchanged.

Study protocol for the targeting effective analgesia in clinics for HIV (TEACH) study - a cluster randomized controlled trial and parallel cohort to increase guideline concordant care for long-term opioid therapy among people living with HIV

Background: People living with HIV (PLWH) frequently experience chronic pain and receive long-term opioid therapy (LTOT). Adherence to opioid prescribing guidelines among their providers is suboptimal. Objective: This paper describes the protocol of a cluster randomized trial, targeting effective analgesia in clinics for HIV (TEACH), which tested a collaborative care intervention to increase guideline-concordant care for LTOT among PLWH. Methods: HIV physicians and advanced practice providers (n = 41) were recruited from September 2015 to December 2016 from two HIV clinics in Boston and Atlanta. Patients receiving LTOT from participating providers were enrolled through a waiver of informed consent (n = 187). After baseline assessment, providers were randomized to the control group or the year-long TEACH intervention involving: (1) a nurse care manager and electronic registry to assist with patient management; (2) opioid education and academic detailing; and (3) facilitated access to addiction specialists. Randomization was stratified by site and LTOT patient volume. Primary outcomes (≥2 urine drug tests, early refills, provider satisfaction) were collected at 12 months. In parallel, PLWH receiving LTOT (n = 170) were recruited into a longitudinal cohort at both clinics and underwent baseline and 12-month assessments. Secondary outcomes were obtained through patient self-report among participants enrolled in both the cohort and the RCT (n = 117). Conclusions: TEACH will report the effects of an intervention on opioid prescribing for chronic pain on both provider and patient-level outcomes. The results may inform delivery of care for PLWH on LTOT for chronic pain at a time when opioid practices are being questioned in the US.

The University of Vermont Wellness Environment: Feasibility and Initial Results of a College Undergraduate Health-Promoting Program

The University of Vermont Wellness Environment program is a neuroscience-inspired, incentive-based behavioral change program designed to improve health and academic outcomes in college-age students. The program uses health promotion and illness prevention delivered in classrooms, residential halls, and via a customized App that incentivizes healthy behaviors and monitors the use of health-promoting activities. This article presents feasibility data on participation of college students in ongoing data collection about key outcomes related to health and well-being. The data collection component were easily implemented in college students and yielded high-quality data.

Gender-specific predictors of methadone treatment outcomes among African Americans at an urban clinic

Background: African American patients with opioid use disorder (OUD) have demonstrated poorer methadone maintenance treatment (MMT) outcomes compared with white patients. This issue is further complicated in urban settings, where African Americans experience high rates of poverty and publicly funded treatment. Despite interrelated factors that disadvantage African Americans, the literature focusing on this population is scant. To address this shortcoming, we conducted the first investigation of gender differences and gender-specific MMT outcome predictors among African Americans (or any racial minority population). This study provides gender-specific findings to improve African American MMT outcomes. Methods: We studied 211 African American patients (male: n = 137, 64.9%) at an urban, university-affiliated MMT clinic. We used existing intake data to assess baseline demographic, substance use, mental health, and interpersonal factors. Primary outcomes were 3-month drug⁺ (positive) urine drug screen (UDS) results and treatment retention. Results: Women were more likely (than men) to endorse histories of interpersonal violence, substance abuse in their social network, and mental health problems. Men reported a greater likelihood (than women) for early opioid-use onset and a lack of prior MMT. There were no gender differences in 3-month drug⁺ UDS or treatment retention. In multivariable analyses among women, no baseline factors predicted 3-month opioid⁺ UDS and physical abuse history predicted a higher proportion of 3-month cocaine⁺ UDS. Among men, primary injection opioid use and older age best predicted a higher proportion of 3-month cocaine⁺ UDS and parent substance abuse predicted shorter retention. In both gender-stratified analyses, higher proportions of 3-month opioid⁺ UDS and cocaine⁺ UDS predicted shorter retention. Conclusions: This study offers an analysis of gender differences in risk factors, MMT outcomes, and gender-specific predictors among African American patients. MMT clinics should tailor assessment and treatment protocols to address gender-specific needs.

Time trends in US cannabis use and cannabis use disorders overall and by sociodemographic subgroups: a narrative review and new findings

Background: Due to significant comorbidity and impairment associated with cannabis use and cannabis use disorder, understanding time trends in cannabis use and cannabis use disorder is an important public health priority.Objectives: To identify trends in cannabis use and cannabis use disorder overall, and by sociodemographic subgroup.Methods: Narrative review of published findings on trends in cannabis use and cannabis use disorders in data from repeated cross-sectional US general population surveys. In addition, in National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; 2002-2002) and NESARC-III (2012-2013) data, logistic regression was used to examine whether trends differed between subgroups of adults.Results: The review showed that in adults, cannabis use increased over the past decade overall and within sociodemographic subgroups (gender, age, race/ethnicity, income, education, marital status, urbanicity, region, pregnancy status, disability status), with greater increases in men and disabled adults. Most sources also indicated significant increases in cannabis use disorders. New analysis showed significantly greater increases in adult cannabis use and cannabis use disorder in men (p ≤ .0001); young adults (p < .05); Blacks (vs. Whites, p < .01); low income groups (p < .001); never-married p ≤ .0001), and urban residents (p < .05). In adolescents, cannabis use generally decreased, although recent increases were observed in older and non-White adolescents.Conclusion: Cannabis use and cannabis use disorder are increasing in adults, with specific sociodemographic groups at higher risk, and may be increasing in some adolescent subgroups. Studies should determine mechanisms for differential trends to provide information to policymakers and enable informed decisions on cannabis legalization and service planning.

Changes in the prevalence and correlates of cocaine use and cocaine use disorder in the United States, 2001-2002 and 2012-2013

To present nationally representative data on changes in the prevalences of 12-month cocaine use, cocaine use disorder (CocUD) and 12-month CocUD among 12-month cocaine users between 2001 and 2002 and 2012-2013. Data were derived from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) and the 2012-2013 NESARC-III. Between 2001 and 2002 and 2012-2013, prevalences of 12-month cocaine use and DSM-IV CocUD significantly increased and 12-month CocUD among 12-month users significantly decreased. Increases in risk of cocaine use were seen across nearly all sociodemographic subgroups while increases in CocUD were observed among women, those in the oldest age group, Whites, individuals with the lowest incomes and highest education, and those residing in urban areas. Prevalence of CocUD among users significantly declined overall and among men, individuals aged 30-44 years old, the never-married, respondents with incomes between $20,000 and $34,000, and those residing in the Midwest. Increases in coca cultivation in Colombia in recent years together with increases in the purity of cocaine entering the U.S. portend more significant increases in the rates of cocaine use and CocUD in the U.S. along with increases in cocaine-related morbidity and mortality. The results of this study support the continued monitoring of cocaine use and CocUD in the U.S., especially in view of the narrowing of the gender gap and shifts in race-ethnic, age and socioeconomic differentials seen between 2001 and 2002 and 2012-2013.

Inadequate prenatal care utilization among women with and without methadone-treated opioid use disorders in Taiwan

AIMS

The present study aims to investigate the utilization pattern of prenatal care and correlates for women with opioid use disorders (OUD) in Taiwan.

METHOD

Using the data linkage between the Methadone Maintenance Treatment (MMT) register with national health insurance, national birth notification system, and birth registration system, we identified 1712 pregnancies with 20 or more gestational weeks from women enrolled in the MMT (heroin-exposed: receiving no methadone treatment during pregnancy, n = 1053 by 882 women; methadone-treated: receiving methadone for at least one day during pregnancy, n = 659 by 574 women) and their 1:10 matched pregnancies from 17,060 women without substance use disorder in the period of 2004-2013. The generalized linear mixed models with negative binomial and logit distributions were performed to evaluate the relationship between individual sociodemographic, health, and addiction treatment characteristics with the number of prenatal visits and receiving prenatal care in the first trimester (i.e., early entry).

FINDINGS

Eighteen percent of pregnancies by women with OUD received no prenatal services and 21% had started prenatal care in the first trimester as compared with 1% and 46% in pregnancies by women without substance use disorders. For pregnancies by women with OUD, methadone treatment was not linked associated with prenatal care visits (adjusted relative risk [aRR] = 1.02; 95% = 0.92, 1.12). For methadone-treated pregnancies, treatment enrollment before pregnancy and spousal methadone treatment elevated prenatal visits by 8% and 18% (0.48 and 1.08 visits, respectively). Additionally, HIV infection (adjusted odds ratio [aOR] = 0.30, 95% CI = 0.10, 0.83) and prior delivery (aOR = 0.05, 95% CI = 0.01, 0.19) significantly reduced the odds of early entry into prenatal care.

CONCLUSION

Integrating addiction treatment programs with prenatal care is urgently needed to increase adequate prenatal care for pregnant women with OUD, especially the multiparous ones.

Opioid Prescription Rates And Child Removals: Evidence From Florida

A critical aspect of the opioid epidemic is its effect on the ability of opioid-dependent parents to care for their children. In this article we investigate the association between the rate of removals of children from their homes and the opioid prescription rate in Florida counties during 2012-15. We performed a panel data analysis of opioid prescriptions that also controlled for the prescription rates of benzodiazepines and stimulants and for other risk factors for child removal. We found that a one-standard-deviation increase in the opioid prescription rate was associated with a 32 percent increase in the removal rate for parental neglect. When we obtained subset samples by percentage of white residents, the estimated relationships were approximately twice as large in the counties with the highest concentration of whites than in the counties with the lowest. Policy makers should consider the opioid epidemic's effects on child welfare when determining the appropriate public health response.

Opioid distribution trends (2006-2017) in the US Territories

Background

The US mainland is experiencing an epidemic of opioid overdoses. Unfortunately, the US Territories (Guam, Puerto Rico, and the Virgin Islands) have often been overlooked in opioid pharmacoepidemiology research. This study examined common prescription opioids over the last decade.

Methods

The United States Drug Enforcement Administration’s Automation of Reports and Consolidated Orders System (ARCOS) was used to report on ten medical opioids: buprenorphine, codeine, fentanyl, hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, and oxymorphone, by weight from 2006 to 2017. Florida and Hawaii were selected as comparison areas.

Results

Puerto Rico had the greatest Territorial oral morphine mg equivalent (MME) per capita (421.5) which was significantly higher (p < .005) than the Virgin Islands (139.2) and Guam (118.9) but significantly lower than that of Hawaii (794.6) or Florida (1,509.8). Methadone was the largest opioid by MMEs in 2017 in most municipalities, accounting for 41.1% of the total in the Virgin Islands, 37.9% in Florida, 36.6% in Hawaii but 80.8% in Puerto Rico. Puerto Rico and Florida showed pronounced differences in the distribution patterns by pharmacies, hospitals, and narcotic treatment programs for opioids.

Conclusions

Continued monitoring of the US Territories is needed to provide a balance between appropriate access to these important agents for cancer related and acute pain while also minimizing diversion and avoiding the opioid epidemic which has adversely impacted the US mainland.

Physicians as Mediators of Health Policy: Acceptance of Medicaid in the Context of Buprenorphine Treatment

Increasing numbers of individuals with opioid use disorder (OUD) are insured by Medicaid. Little is known about whether providers of buprenorphine, an evidence-based OUD pharmacotherapy, accept this type of payment. Data are scant regarding whether Medicaid acceptance varies by physician and state-level characteristics. To address these gaps, national survey data from 1174 buprenorphine-prescribing physicians (BPPs) and state characteristics were examined in a multi-level model of Medicaid acceptance. Only 52.0% of BPPs accepted Medicaid for buprenorphine-related office visits. Specialists in addiction and psychiatry were significantly less likely to accept Medicaid than other specialties, as were BPPs delivering buprenorphine in individual medical practice. Perceived adequacy of Medicaid reimbursement was positively associated with accepting Medicaid. Medicaid acceptance was not associated with states' implementation of the Medicaid expansion. Individuals who are covered by Medicaid may face barriers to accessing buprenorphine treatment, which has high public health significance given the ongoing opioid epidemic.

A crisis of opioids and the limits of prescription control: United States

A rise in addiction and overdose deaths involving opioids in the United States has spurred a series of initiatives focused on reducing opioid risks, including several related to prescription of opioids in care of pain. Policy analytical scholarship provides a conceptual framework to assist in understanding this response. Prior to 2011, a 'policy monopoly' of regulators and pharmaceutical manufacturers allowed and encouraged high levels of opioid prescribing. This permissive policy fell apart in the face of adverse outcomes brought to public attention by an 'advocacy coalition' consisting of officials, thought leaders, journalists and interest groups who shared common beliefs. This coalition has generated a more cautious prescribing regimen that has incentivized involuntary termination of opioids in otherwise stable patients, with resultant reports of harm. Its emphasis on dose reduction, regardless of outcomes, mirrors in some ways the prior focus on minimizing pain scores, regardless of outcomes. Central to the present analysis is that policies cannot be comprehensively rational; rather, they emerge from a range of actors and agencies constrained in their ability to assimilate complex data, evaluate the data objectively and to command necessary resources in an iterative, rapid response fashion. The imbalance between strong prescription control and weak pain and addiction treatment expansion exemplifies the policy scholar's notion of 'bounded rationality'. Results have been suboptimum: opioid prescriptions have fallen, but harms to pain patients and overdose deaths have risen. US policymakers could revise the course through a more thoroughgoing engagement with patients, families and communities now coping with both pain and addiction.

Clinician identified barriers to treatment for individuals in Appalachia with opioid use disorder following release from prison: a social ecological approach

BACKGROUND

The non-medical use of opioids has reached epidemic levels nationwide, and rural areas have been particularly affected by increasing rates of overdose mortality as well as increases in the prison population. Individuals with opioid use disorder (OUD) are at increased risk for relapse and overdose upon reentry to the community due to decreased tolerance during incarceration. It is crucial to identify barriers to substance use disorder treatment post-release from prison because treatment can be particularly difficult to access in resource-limited rural Appalachia.

METHODS

A social ecological framework was utilized to examine barriers to community-based substance use treatment among individuals with OUD in Appalachian Kentucky following release from prison. Semi-structured qualitative interviews with 15 social service clinicians (SSCs) employed by the Department of Corrections were conducted to identify barriers at the individual, interpersonal, organizational/institutional level, community, and systems levels. Two independent coders conducted line-by-line coding to identify key themes.

RESULTS

Treatment barriers were identified across the social ecological spectrum. At the individual-level, SSCs highlighted high-risk drug use and a lack of motivation. At the interpersonal level, homogenous social networks (i.e., homophilious drug-using networks) and networks with limited treatment knowledge inhibited treatment. SSC's high case load and probation/parole officer's limited understanding of treatment were organizational/institutional barriers. Easy access to opioids, few treatment resources, and a lack of community support for treatment were barriers at the community level. SSC's noted system-level barriers such as lack of transportation options, cost, and uncertainty about the implementation of the Affordable Care Act.

CONCLUSIONS

More rural infrastructure resources as well as additional education for family networks, corrections staff, and the community at large in Appalachia are needed to address barriers to OUD treatment. Future research should examine barriers from the perspective of other key stakeholders (e.g., clients, families of clients) and test interventions to increase access to OUD treatment.

State-level variation in the relationship between child removals and opioid prescriptions

BACKGROUND

One of the most devastating impacts of the U.S. opioid crisis is the challenge it creates for dependent parents to care for their children, potentially leading to the child being removed from their home. However, existing studies of the link between child removals and opioid prescriptions have either focused on a single state or estimated a national average.

OBJECTIVE

To estimate state-level associations between child removals and opioid prescriptions.

PARTICIPANTS AND SETTING

U.S. counties from 2010 to 2015.

METHODS

We performed longitudinal regression analysis in which the rates for all removals and removals associated with parental drug abuse were employed as dependent variables. In addition to the opioid prescription rate, additional explanatory variables included child removal risk factors, county fixed effects, year fixed effects, and state-specific time trends. Interaction variables were used to estimate state-specific relationships.

RESULTS

We found substantial variation in the association between child removals and opioid prescriptions. Twenty-three states had a positive association, fifteen had a negative association, and twelve did not have a statistically significant association. A one-standard deviation increase in the prescription rate was associated with a 37% (p < .001) increase in the removal rate for parental drug abuse in Illinois, while in New Hampshire it was associated with a 28% (p < .001) decrease.

CONCLUSIONS

The substantial variation in state-level relationships between child removals and opioid prescriptions may reflect differences in the extent to which states have experienced the opioid crisis and indicate the need for interventions that account for those differences.

Civil commitment experiences among opioid users

INTRODUCTION

Civil commitment is an increasingly used policy intervention to combat the opioid epidemic. Yet little is known about persons who get committed and outcomes following commitment for opioid use. In the current cross-sectional study, we compared the characteristics of persons with and without a history of civil commitment, and the correlates of post-commitment abstinence.

METHODS

Between October 2017 and May 2018, we surveyed consecutive persons entering a brief, inpatient opioid detoxification (n = 292) regarding their lifetime experiences with civil commitment for opioid use.

RESULTS

Participants averaged 34.6 years of age, 27.1% were female, and 78.1% were White. Seventy-eight (26.7%) experienced civil commitment for opioid use at least once in their lifetime. Committed individuals had significantly higher rates of fentanyl, heroin, and injection drug use, drug overdoses, past incarceration, current criminal justice involvement, and past medication treatment for opioid use (p < .05). The average time to relapse following commitment was 72 days, although 33.8% relapsed on the same day of their release. Longer post-commitment abstinence was significantly associated with post-commitment medication treatment, higher perceived procedural justice (i.e., fairness) during the commitment hearing, positive attitude and higher motivation at the end of commitment, and improvement in attitude during commitment (p < .05).

CONCLUSION

Opioid users who experience civil commitment constitute an especially high risk group. A positive commitment experience and post-commitment medication treatment are associated with longer post-commitment abstinence.

Tracking narcotics consumption at a Southwestern U.S. university campus by wastewater-based epidemiology

Wastewater-based epidemiology (WBE) was applied to estimate the consumption of twelve narcotics within a Southwestern U.S. university campus. Seven consecutive 24-hour composite raw wastewater samples (n = 80) were obtained once per month from sampling locations capturing >95% of campus-generated wastewater. Samples were analyzed for indicators of consumption of morphine, codeine, oxycodone, heroin, fentanyl, methadone, buprenorphine, amphetamine, methylphenidate, alprazolam, cocaine, and MDMA using LC-MS/MS. Eleven indicator compounds (oxycodone, codeine, norcodeine, 6-acetylmorphine, EDDP, amphetamine, alprazolam, alpha-hydroxyalprazolam, cocaine, benzoylecgonine, and MDMA) occurred at 100% detection frequency across the study, followed by morphine-3-glucuronide (98%), noroxycodone (95%), methylphenidate (90%), heroin (7%), norfentanyl (7%), and fentanyl (5%). Estimates of average narcotics consumption ranked as follows in units of mg/day/1000 persons: heroin (474 ± 32), cocaine (551 ± 49), amphetamine (256 ± 12), methylphenidate (236 ± 28), methadone (72 ± 8), oxycodone (80 ± 6), alprazolam (60 ± 2), MDMA (88 ± 35), codeine (50 ± 4), and morphine (18 ± 3). This campus-based WBE study yielded baseline data on 12 narcotics for a U.S. campus and demonstrated for the first time the feasibility of detecting the fentanyl metabolite norfentanyl in this setting.

Treatment outcome disparities for opioid users: Are there racial and ethnic differences in treatment completion across large US metropolitan areas?

BACKGROUND

The present study examined racial/ethnic disparities in initial treatment episode completion for adult clients reporting opioids as their primary problem substance in large US metropolitan areas.

METHODS

Data were extracted from the 2013 TEDS-D dataset (Treatment Episode Dataset-Discharge) for the 42 largest US metropolitan statistical areas (MSAs). Fixed effects logistic regression controlling for MSA was used to estimate the effect of race/ethnicity on the likelihood of treatment completion. The model was repeated for each individual MSA in a stratified design to compare the geographic variation in racial/ethnic disparities, controlling for gender, age, education, employment, living arrangement, treatment setting, medication-assisted treatment, referral source, route of administration, and number of substances used at admission.

RESULTS

Only 28% of clients completed treatment, and the results from the fixed effects model indicate that blacks and Hispanics are less likely to complete treatment compared to whites. However, the stratified analysis of individual MSAs found only three of the 42 MSAs had racial/ethnic disparities in treatment completion, with the New York City (NYC) MSA largely responsible for the disparities in the combined sample. Supplementary analyses suggest that there are greater differences between whites and minority clients in the NYC MSA vs. other cities on characteristics associated with treatment completion (e.g., residential treatment setting).

CONCLUSION

This study underscores the need for improving treatment retention for all opioid using clients in large metropolitan areas in the US, particularly for minority clients in those localities where disparities exist, and for better understanding the geographic context for treatment outcomes.

Internet searches for opioids predict future emergency department heroin admissions

BACKGROUND

For a number of fiscal and practical reasons, data on heroin use have been of poor quality, which has hampered the ability to halt the growing epidemic. Internet search data, such as those made available by Google Trends, have been used as a low-cost, real-time data source for monitoring and predicting a variety of public health outcomes. We aimed to determine whether data on opioid-related internet searches might predict future heroin-related admissions to emergency departments (ED).

METHODS

Across nine metropolitan statistical areas (MSAs) in the United States, we obtained data on Google searches for prescription and non-prescription opioids, as well as Substance Abuse and Mental Health Services Administration (SAMHSA) data on heroin-related ED visits from 2004 to 2011. A linear mixed model assessed the relationship between opioid-related Internet searches and following year heroin-related visits, controlling for MSA GINI index and total number of ED visits.

RESULTS

The best-fitting model explained 72% of the variance in heroin-related ED visits. The final model included the search keywords "Avinza," "Brown Sugar," "China White," "Codeine," "Kadian," "Methadone," and "Oxymorphone." We found regional differences in where and how people searched for opioid-related information.

CONCLUSIONS

Internet search-based modeling should be explored as a new source of insights for predicting heroin-related admissions. In geographic regions where no current heroin-related data exist, Internet search modeling might be a particularly valuable and inexpensive tool for estimating changing heroin use trends. We discuss the immediate implications for using this approach to assist in managing opioid-related morbidity and mortality in the United States.

Risk of Heroin Dependence in Newly Incident Heroin Users

This study assesses data from the 2002 to 2016 US National Survey on Drug Use and Health data sets to determine the percentage of newly incident heroin users who became heroin dependent.

Premature mortality projections in the USA through 2030: a modelling study

BACKGROUND

Although life expectancy has been projected to increase across high-income countries, gains for the USA are anticipated to be among the smallest, and overall US death rates actually increased from 2014 to 2015, with divergence for specific US populations. Therefore, projecting future premature mortality is essential for clinical and public health service planning, curbing rapidly increasing causes of death, and sustaining progress in declining causes of death. We aimed to project premature mortality (here defined as deaths of individuals aged 25-64 years) trends through 2030, and to estimate the total number of projected deaths, the projected number of potential years of life lost due to premature mortality, and the effect of reducing projected accidental death rates by 2% per year.

METHODS

We obtained death certificate data for the US population aged 25-64 years for 1990-2015 from the US Centers for Disease Control and Prevention (CDC) National Center for Health Statistics. We obtained US mortality data for 2016 for non-American Indian or Alaska native groups from CDC WONDER; data for 2016 were not available for American Indians or Alaska natives. Our analysis focused on all-cause premature mortality and the commonest causes of premature death (cancer, heart disease, accidents, suicide, and chronic liver disease or cirrhosis) among white, black, Hispanic, Asian or Pacific islanders, and American Indian or Alaska native men and women. We estimated age-standardised premature mortality and corresponding annual percentage changes for 2017-30 by sex and race or ethnic origin by use of age-period-cohort forecasting models. We also did a sensitivity analysis projecting future mortality from cross-sectional mortality and a JoinPoint of the (log) period rate ratio curve. We calculated absolute death counts by use of corresponding age-specific and year-specific US census population projections, and estimated years of potential life lost.

FINDINGS

During 2017-30, all-cause deaths are projected to increase among white women and American Indians or Alaska natives, resulting in 239 700 excess premature deaths relative to 2017 rates (a 10% increase). Mortality declines in white men and black, Hispanic, and Asian or Pacific islander men and women will result in 945 900 fewer deaths (a 14% reduction). Cancer mortality rates are projected to decline among white, black, Hispanic, and Asian or Pacific islander women and men, with the largest declines among black women (age-standardised premature mortality rate 2016: 104·5 deaths per 100 000 woman-years; 2030: 77·1 per 100 000 woman-years) and men (2016: 116·8 per 100 000 man-years; 2030: 81·6 per 100 000 man-years). Heart disease death rates are projected to increase in American Indian or Alaska native men (2015: 150·9 per 100 000 man-years; 2030: 175·9 per 100 000 man-years) and decline in other groups, albeit only slightly in white (2016: 35·6 per 100 000 woman-years; 2030: 31·1 per 100 000 woman-years) and American Indian or Alaska native women (2015: 64·4 per 100 000 woman-years; 2030: 62·8 per 100 000 woman-years). Accidental death rates are projected to increase in all US populations except Asian or Pacific islander women, and will increase most rapidly among white women (2030: 60·5 per 100 000 woman-years) and men (2030: 101·9 per 100 000 man-years) and American Indian or Alaska native women (2030: 97·5 per 100 000 woman-years) and men (2030: 298·7 per 100 000 man-years). Suicide rates are projected to increase for all groups, and chronic liver disease and cirrhosis deaths are projected to increase for all groups except black men. A 2% per year reduction in projected accidental deaths would eliminate an estimated 178 700 deaths during 2017-30.

INTERPRETATION

To reduce future premature mortality, effective interventions are needed to address rapidly rising mortality rates due to accidents, suicides, and chronic liver disease and cirrhosis.

FUNDING

National Cancer Institute Intramural Research Program.

Pain and Addiction: An Integrative Therapeutic Approach

The current opioid crisis highlights an urgent need for better paradigms for prevention and treatment of chronic pain and addiction. Although many approach this complex clinical condition with the question, "Is this pain or is this addiction?," it is more than the sum of its parts. Chronic pain among those with dependence and addiction often evolves into a complex disabling condition with pain at multiple sites, psychosocial dysfunctions, medical and psychiatric disorders, polypharmacy, and polysubstance use, all interacting with each other in complex ways (multimorbidity). The authors offer an integrative therapeutic approach to manage this complex clinical scenario.

Frontline Science: Buprenorphine decreases CCL2-mediated migration of CD14+ CD16+ monocytes

HIV infection of the CNS causes neuroinflammation and damage that contributes to the development of HIV-associated neurocognitive disorders (HAND) in greater than 50% of HIV-infected individuals, despite antiretroviral therapy (ART). Opioid abuse is a major risk factor for HIV infection. It has been shown that opioids can contribute to increased HIV CNS pathogenesis, in part, by modulating the function of immune cells. HIV enters the CNS within two weeks after peripheral infection by transmigration of infected monocytes across the blood brain barrier (BBB). CD14⁺ CD16⁺ monocytes are a mature subpopulation that is increased in number in the peripheral blood of HIV-infected people. Mature monocytes can be productively infected with HIV, and they transmigrate preferentially across the BBB in response to CCL2, a chemokine elevated in the CNS and CSF of HIV-infected people even with ART. Buprenorphine, an opioid derivate, is an opioid replacement therapy for heroin addiction. It is a partial agonist of μ-opioid receptor and full antagonist of κ-opioid receptor. The effects of buprenorphine on CCL2-mediated CD14⁺ CD16⁺ monocytes transmigration across the BBB, a critical mechanism that promotes neuroinflammation and HAND, have not been characterized. We showed for the first time that buprenorphine decreases several steps of CCL2-mediated human mature monocyte transmigration. We propose that buprenorphine treatment in the context of HIV infection could serve a dual purpose, to treat opioid addiction and also to reduce neuroinflammation. Additionally, buprenorphine may be used as a treatment for HAND not only in the context of opioid abuse.

Perceptions and practices addressing diversion among US buprenorphine prescribers

BACKGROUND

While there has been a dramatic increase in prescribing of buprenorphine for the treatment of opioid use disorder in the US, little is known about prescribers' attitudes and practices regarding buprenorphine diversion and how they relate to prescriber characteristics.

METHODS

A national random sample of buprenorphine prescribers (N = 1174) completed surveys from July 2014 to January 2017. Analyses examined relationships between prescriber and practice characteristics and prescriber perceptions and approaches regarding diversion.

RESULTS

Among this sample of buprenorphine prescribers, 79.0% (N = 898) reported assessing all patients for risk of buprenorphine diversion and misuse. A third of prescribers described diversion as a significant or very significant concern in their community. The majority of prescribers reported seeing patients on average at least every other week during the first 60 days of treatment, and the majority reported testing urine for buprenorphine to assess for diversion. Perceptions of diversion being a greater problem in their community (AOR 1.212, 95% CI 1.073-1.369) and use of medication counts (AOR 1.006, 95% CI 1.003-1.009) were associated with increased likelihood of terminating patients when diversion was suspected, while having expertise in addiction (AOR 0.526, 95% CI 0.406-0.682) or psychiatry (AOR 0.714, 95% CI 0.558-0.914) were associated with decreased odds of terminating treatment for suspected diversion.

CONCLUSIONS

Buprenorphine prescribers report diversion is an important issue, and most prescribers report that they assess patients for diversion, though specific practices differ based on prescriber and practice characteristics.

Epidemiology of Adult DSM-5 Major Depressive Disorder and Its Specifiers in the United States

IMPORTANCE

No US national data are available on the prevalence and correlates of DSM-5-defined major depressive disorder (MDD) or on MDD specifiers as defined in DSM-5.

OBJECTIVE

To present current nationally representative findings on the prevalence, correlates, psychiatric comorbidity, functioning, and treatment of DSM-5 MDD and initial information on the prevalence, severity, and treatment of DSM-5 MDD severity, anxious/distressed specifier, and mixed-features specifier, as well as cases that would have been characterized as bereavement in DSM-IV.

DESIGN, SETTING, AND PARTICIPANTS

In-person interviews with a representative sample of US noninstitutionalized civilian adults (≥18 years) (n = 36 309) who participated in the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions III (NESARC-III). Data were collected from April 2012 to June 2013 and were analyzed in 2016-2017.

MAIN OUTCOMES AND MEASURES

Prevalence of DSM-5 MDD and the DSM-5 specifiers. Odds ratios (ORs), adjusted ORs (aORs), and 95% CIs indicated associations with demographic characteristics and other psychiatric disorders.

RESULTS

Of the 36 309 adult participants in NESARC-III, 12-month and lifetime prevalences of MDD were 10.4% and 20.6%, respectively. Odds of 12-month MDD were significantly lower in men (OR, 0.5; 95% CI, 0.46-0.55) and in African American (OR, 0.6; 95% CI, 0.54-0.68), Asian/Pacific Islander (OR, 0.6; 95% CI, 0.45-0.67), and Hispanic (OR, 0.7; 95% CI, 0.62-0.78) adults than in white adults and were higher in younger adults (age range, 18-29 years; OR, 3.0; 95% CI, 2.48-3.55) and those with low incomes ($19 999 or less; OR, 1.7; 95% CI, 1.49-2.04). Associations of MDD with psychiatric disorders ranged from an aOR of 2.1 (95% CI, 1.84-2.35) for specific phobia to an aOR of 5.7 (95% CI, 4.98-6.50) for generalized anxiety disorder. Associations of MDD with substance use disorders ranged from an aOR of 1.8 (95% CI, 1.63-2.01) for alcohol to an aOR of 3.0 (95% CI, 2.57-3.55) for any drug. Most lifetime MDD cases were moderate (39.7%) or severe (49.5%). Almost 70% with lifetime MDD had some type of treatment. Functioning among those with severe MDD was approximately 1 SD below the national mean. Among 12.9% of those with lifetime MDD, all episodes occurred just after the death of someone close and lasted less than 2 months. The anxious/distressed specifier characterized 74.6% of MDD cases, and the mixed-features specifier characterized 15.5%. Controlling for severity, both specifiers were associated with early onset, poor course and functioning, and suicidality.

CONCLUSIONS AND RELEVANCE

Among US adults, DSM-5 MDD is highly prevalent, comorbid, and disabling. While most cases received some treatment, a substantial minority did not. Much remains to be learned about the DSM-5 MDD specifiers in the general population.

The rise of the opioid epidemic and hepatitis C-positive organs: A new era in liver transplantation

The use of hepatitis C virus (HCV)-positive organs in liver transplantation (LT) has increased in the era of direct-acting antiviral therapy. A rising demand for organs, the increased ability to effectively treat HCV infection in the transplant setting, and an unprecedented increase in HCV-positive donors have all contributed to this trend. A recent abrupt rise in opioid use in the United States has resulted in a surge of injection drug use, transmission of HCV, and opioid-related overdose deaths. Geographical areas most affected by the opioid epidemic have experienced a rapid increase in recovery and utilization of HCV-positive donor organs, in which the proportion of deceased donor LTs in the United States from donors who are HCV positive has increased nearly 2-fold within the last 3 years. The prospect of expanding the organ donor pool with HCV-positive donors and achieving acceptable posttransplant outcomes has generated much interest in the areas of liver, kidney, and thoracic transplantation, including the potential for transplanting organs from HCV positive donors into HCV-negative recipients. Developing strategies to ensure appropriate selection of potential recipients of HCV-positive organs, initiating timely antiviral therapy, and defining associated risks will be critical in achieving optimal posttransplant outcomes in this setting. (Hepatology 2018;67:1600-1608).

Differences in time to injection onset by drug in California: Implications for the emerging heroin epidemic

BACKGROUND

Heroin use is increasing in the US. Heroin use may predispose users towards injection routes of drug administration as compared to other illicit substances.

OBJECTIVE

To explore the relationship between heroin use and drug injection, we compared time from first use to first injection (referred to as time to injection onset by drug [TTIOD]) of heroin, methamphetamine/speed, cocaine, and crack cocaine among people who inject drugs (PWID).

METHODS

Age of first use and first injection by drug was collected from 776 PWID. Survival analyses were used to determine TTIOD and to examine demographic factors associated with TTIOD. Cox regression analysis was used to determine demographic factors associated with drug-specific injection onset.

RESULTS

The eventual injection onset rate by the drug was 99% for participants who used heroin, 85% for participants who used methamphetamine/speed, 80% for participants who used powder cocaine, and 38% for participants who used crack cocaine. Hazard ratios for injection use within one year of first use by drug were: 1.37 (median survival time [MST] = 0.61 years) for heroin, 0.66 (MST = 1.10 years) for methamphetamine/speed, 0.50 (MST = 2.93 years) for powder cocaine, and 0.12 (MST = 39.59 years) for crack cocaine. Demographic differences in TTIOD were found for each drug. Demographic differences were found for eventual injection by drug for all substances except heroin.

CONCLUSION

Among PWID, heroin use was associated with a more rapid transition to injection and a higher rate of eventual heroin injection regardless of demographics. More robust, innovative efforts to reduce heroin use and prevent injection initiation are urgently needed.

Commentary on Kerr et al. (2018): Marijuana, drug use, and mental health in the United States-a tale of two generations

Adults and adolescents in the United States are experiencing unprecedented increases in depression and suicide, yet while marijuana and other drug use are increasing among adults, they are decreasing among adolescents. The causes and, therefore the remedies, of this public health burden may be fundamentally different between the two generations.

Post-Discharge Opioid Prescribing and Use after Common Surgical Procedure

BACKGROUND

The number of deaths from prescription opioids in the US continues to increase and remains a major public health concern. Opioid-related deaths parallel prescribing trends, and postoperative opioids are a significant source of opioids in the community. Our objective was to identify opioid prescribing and use patterns after surgery to inform evidence-based practices.

STUDY DESIGN

Data from a 340-bed academic medical institution and its affiliated outpatient surgical facility included retrospective medical record data and prospective telephone questionnaire and medical record data. Retrospective data included patients discharged after 1 of 19 procedure types, from July 2015 to June 2016 (n = 10,112). Prospective data included a consecutive sample of general and orthopaedic surgery and urology patients undergoing 1 of 13 procedures, from July 2016 to February 2017 (n = 539). Primary outcomes were the quantity of opioid prescribed and used in morphine milligram equivalents (MME), and the proportion of patients receiving instructions on disposal and nonopioid strategies.

RESULTS

In the retrospective dataset, 76% of patients received an opioid after surgery, and 87% of prescriptions were prescribed by residents or advanced practice providers. Median prescription size ranged from 0 to 503 MME, with wide interquartile ranges (IQR) for most procedures. In the prospective dataset, there were 359 participants (67% participation rate). Of these, 92% of patients received an opioid and the median proportion used was 27%, or 24 MME (IQR 0 to 96). Only 18% of patients received disposal instructions, while 84% of all patients received instructions on nonopioid strategies.

CONCLUSIONS

Median opioid use after surgery was 27% of the total prescribed, and only 18% of patients reported receiving disposal instructions. Significant variability in opioid prescribing and use after surgery warrants investigation into contributing factors.

High willingness to use rapid fentanyl test strips among young adults who use drugs

BACKGROUND

Synthetic opioid overdose mortality among young adults has risen more than 300% in the USA since 2013, primarily due to the contamination of heroin and other drugs with illicitly manufactured fentanyl. Rapid test strips, which can be used to detect the presence of fentanyl in drug samples (before use) or urine (after use), may help inform people about their exposure risk. The purpose of this study was to determine whether young adults who use drugs were willing to use rapid test strips as a harm reduction intervention to prevent overdose. We hypothesized that those who had ever overdosed would be more willing to use the test strips.

METHODS

We recruited a convenience sample of young adults who use drugs in Rhode Island from May to September 2017. Eligible participants (aged 18 to 35 with past 30-day drug use) completed an interviewer-administered survey. The survey assessed participant's socio-demographic and behavioral characteristics, overdose risk, as well as suspected fentanyl exposure, and willingness to use take-home rapid test strips to detect fentanyl contamination in drugs or urine. Participants were then trained to use the test strips and were given ten to take home.

RESULTS

Among 93 eligible participants, the mean age was 27 years (SD = 4.8), 56% (n = 52) of participants were male, and 56% (n = 52) were white. Over one third (n = 34, 37%) had a prior overdose. The vast majority (n = 86, 92%) of participants wanted to know if there was fentanyl in their drug supply prior to their use. Sixty-five (70%) participants reported concern that their drugs were contaminated with fentanyl. After the brief training, nearly all participants (n = 88, 95%) reported that they planned to use the test strips.

CONCLUSIONS

More than 90% of participants reported willingness to use rapid test strips regardless of having ever overdosed, suggesting that rapid fentanyl testing is an acceptable harm reduction intervention among young people who use drugs in Rhode Island. Study follow-up is ongoing to determine whether, how, and under what circumstances participants used the rapid test strips and if a positive result contributed to changes in overdose risk behavior.

Long-acting intramuscular naltrexone for opioid use disorder: Utilization and association with multi-morbidity nationally in the Veterans Health Administration

BACKGROUND

Long acting intramuscular (IM) naltrexone is an effective treatment for opioid use disorder (OUD), but rates and correlates of its use have not been studied.

METHODS

National administrative from the Veterans Health Administration (VHA) from Fiscal Year 2012 identified only 16 VHA facilities that prescribed IM naltrexone to 5 or more veterans diagnosed with OUD. Data from these facilities were used to identify sociodemographic, diagnostic, and service use characteristics, including use of psychotropic medication, that were characteristic of veterans who filled prescriptions for IM naltrexone. This was in comparison to users of opiate agonist treatments (methadone or buprenorphine) or veterans with no pharmacologic treatment for OUD. Comparisons were made using both bi-variate analyses and multivariable logistic regression.

RESULTS

Only 179 of 16,402 veterans with OUD (1%) at these 16 facilities filled a prescription for IM naltrexone and only 256 of 99,394 (0.26%) nationally. These veterans were characterized by past homelessness, co-morbid alcohol use disorder, multiple psychiatric disorders, and a greater likelihood of psychiatric hospitalization, as well as mental health outpatient and antidepressant medication use.

CONCLUSIONS

IM naltrexone is rarely used for OUD and is primarily used for patients with multiple co-morbidities, especially alcohol use disorder and serious mental illness. The use of this treatment illustrates many of the principles identified by the emerging focus on multi-morbidity as a critical feature of clinical practice.

Injection drug use and overdose among young adults who use prescription opioids non-medically

INTRODUCTION

Non-medical prescription opioid (NMPO) use is a critical public health problem in the United States, with 2.1 million new initiates annually. Young adult NMPO users are at high risk for initiating injection drug use. We assessed correlates of injection drug use among young adult NMPO users in Rhode Island, a state heavily impacted by opioid overdose.

METHODS

We used data from the Rhode Island Young Adult Prescription Drug Study (RAPiDS), which recruited 199 residents aged 18-29 who reported past-30-day NMPO use (65.3% male). We compared individuals who reported ever having injected with individuals who reported never injecting, using logistic regression to identify independent correlates of injection.

RESULTS

Among eligible participants, the mean age was 24.6years and 61.3% were white. Over one-quarter (n=59, 29.6%) of the sample had ever injected drugs. The majority (n=46, 78.0%) of participants who had ever injected drugs reported injecting heroin as her/his first drug; the majority also reported previously snorting her/his first drug that was injected (n=46, 78.0%). In multivariable analyses, white race, older age, lifetime homelessness, and ever having overdosed or seen someone overdose were independently associated with an increased likelihood of ever injecting drugs.

CONCLUSIONS

These findings demonstrate a high prevalence of lifetime injection drug use among young adults who use prescription opioids non-medically. Given the observed associations between injection drug use and witnessing as well as experiencing overdose, interventions are urgently needed to improve overdose education and naloxone distribution to young adult NMPO users who inject drugs.

A police-led addiction treatment referral program in Gloucester, MA: Implementation and participants' experiences

BACKGROUND

The increasing rates of opioid use disorder and resulting overdose deaths are a public health emergency, yet only a fraction of individuals in need receive treatment.

OBJECTIVE

To describe the implementation of and participants' experiences with a novel police-led addiction treatment referral program.

METHODS

Follow-up telephone calls to participants in the Gloucester Police Department's Angel Program from June 2015-May 2016. Open-ended survey questionnaires assessed experiences of program participants and their close contacts, confirmed police-reported placement, and queried self-reported substance use and treatment outcomes.

RESULTS

Surveys were completed by 198 of 367 individuals (54% response rate) who participated 214 times. Reasons for participation included: the program was a highly-visible entry point to the treatment system, belief that placement would be obtained, poor prior treatment system experiences, and external pressure to seek treatment. Most participants reported positive experiences citing the welcoming, non-judgmental services. In 75% (160/214) of the encounters, entry into referral placement was confirmed. Participants expressed frustration when they did not meet program entry requirements and had difficulty finding sustained treatment following initial program placement. At a mean follow-up time of 6.7months, 37% of participants reported abstinence since participation, with no differences between participants who entered referral placement versus those who did not.

CONCLUSIONS

A police-led referral program was feasible to implement and acceptable to participants. The program was effective in finding initial access to treatment, primarily through short-term detoxification services. However, the program was not able to overcome a fragmented treatment system focused on acute episodic care which remains a barrier to long-term recovery.

Prevalence of 12-Month Alcohol Use, High-Risk Drinking, and DSM-IV Alcohol Use Disorder in the United States, 2001-2002 to 2012-2013: Results From the National Epidemiologic Survey on Alcohol and Related Conditions

IMPORTANCE

Lack of current and comprehensive trend data derived from a uniform, reliable, and valid source on alcohol use, high-risk drinking, and DSM-IV alcohol use disorder (AUD) represents a major gap in public health information.

OBJECTIVE

To present nationally representative data on changes in the prevalences of 12-month alcohol use, 12-month high-risk drinking, 12-month DSM-IV AUD, 12-month DSM-IV AUD among 12-month alcohol users, and 12-month DSM-IV AUD among 12-month high-risk drinkers between 2001-2002 and 2012-2013.

DESIGN, SETTING, AND PARTICIPANTS

The study data were derived from face-to-face interviews conducted in 2 nationally representative surveys of US adults: the National Epidemiologic Survey on Alcohol and Related Conditions, with data collected from April 2001 to June 2002, and the National Epidemiologic Survey on Alcohol and Related Conditions III, with data collected from April 2012 to June 2013. Data were analyzed in November and December 2016.

MAIN OUTCOMES AND MEASURES

Twelve-month alcohol use, high-risk drinking, and DSM-IV AUD.

RESULTS

The study sample included 43 093 participants in the National Epidemiologic Survey on Alcohol and Related Conditions and 36 309 participants in the National Epidemiologic Survey on Alcohol and Related Conditions III. Between 2001-2002 and 2012-2013, 12-month alcohol use, high-risk drinking, and DSM-IV AUD increased by 11.2%, 29.9%, and 49.4%, respectively, with alcohol use increasing from 65.4% (95% CI, 64.3%-66.6%) to 72.7% (95% CI, 71.4%-73.9%), high-risk drinking increasing from 9.7% (95% CI, 9.3%-10.2%) to 12.6% (95% CI, 12.0%-13.2%), and DSM-IV AUD increasing from 8.5% (95% CI, 8.0%-8.9%) to 12.7% (95% CI, 12.1%-13.3%). With few exceptions, increases in alcohol use, high-risk drinking, and DSM-IV AUD between 2001-2002 and 2012-2013 were also statistically significant across sociodemographic subgroups. Increases in all of these outcomes were greatest among women, older adults, racial/ethnic minorities, and individuals with lower educational level and family income. Increases were also seen for the total sample and most sociodemographic subgroups for the prevalences of 12-month DSM-IV AUD among 12-month alcohol users from 12.9% (95% CI, 12.3%-17.5%) to 17.5% (95% CI, 16.7%-18.3%) and 12-month DSM-IV AUD among 12-month high-risk drinkers from 46.5% (95% CI, 44.3%-48.7%) to 54.5% (95% CI, 52.7%-56.4%).

CONCLUSIONS AND RELEVANCE

Increases in alcohol use, high-risk drinking, and DSM-IV AUD in the US population and among subgroups, especially women, older adults, racial/ethnic minorities, and the socioeconomically disadvantaged, constitute a public health crisis. Taken together, these findings portend increases in many chronic comorbidities in which alcohol use has a substantial role.

Stigma and substance use disorders: an international phenomenon

PURPOSE OF REVIEW

To collect and update published information on the stigma associated with substance abuse in nonclinical samples, which has not been recently reviewed.

RECENT FINDINGS

Searching large databases, a total of only 17 articles were published since 1999, with the majority of studies conducted outside the United States. Using major stigma concepts from a sociological framework (stereotyping, devaluation in terms of status loss, discrimination, and negative emotional reactions), the studies reviewed predominantly indicated that the public holds very stigmatized views toward individuals with substance use disorders (SUDs), and that the level of stigma was higher toward individuals with SUDs than toward those with other psychiatric disorders.

SUMMARY

The prevalence of SUDs is increasing in the US general population, but these disorders remain seriously undertreated. Stigma can reduce willingness of policymakers to allocate resources, reduce willingness of providers in nonspecialty settings to screen for and address substance abuse problems, and may limit willingness of individuals with such problems to seek treatment. All of these factors may help explain why so few individuals with SUDs receive treatment. Public education that reduces stigma and provides information about treatment is needed.

Racial and ethnic differences in opioid agonist treatment for opioid use disorder in a U.S. national sample

BACKGROUND

Opioid Agonist Treatment (OAT) is the standard of care for the treatment of opioid use disorders. However, most people in treatment do not receive OAT. This study evaluated whether there are racial and/or ethnic differences in OAT receipt among adults entering specialty treatment for opioid use disorders in publicly-funded treatment programs across the U.S.

METHODS

Using data from the national Treatment: Episode Data Base, odds of OAT receipt were compared among black, Hispanic and white clients. Mediation analyses were used to explore whether any racial/ethnic differences in OAT receipt were explained by variation in clinical need or by other treatment, sociodemographic, or geographic characteristics. Interaction terms were used to assess whether this association was modified by primary opioid type.

RESULTS

Only 28.7% of clients received OAT. Odds of OAT receipt were significantly higher odds among blacks (OR: 2.27(2.14-2.41)) and Hispanics (OR: 1.98(1.88-2.09)), compared to whites. Differences in clinical need accounted for a substantial portion of this difference (76.79% and 49.74%, respectively). Differences persisted after accounting for other potential explanatory variables (adjusted OR: 1.37 (1.24-1.52); 1.21(1.11-1.32)), but were only evident for primary heroin users (adjusted OR: 1.50 (1.34-1.69); 1.29 (1.17-1.42)) and not other opioid users.

CONCLUSIONS

OAT receipt in treatment programs is low overall and particularly lacking among white heroin users. Differences in OAT receipt cannot be fully explained by differences in clinical need. More research is needed to understand and address barriers that underpin these differences so more patients with opioid use disorder can access evidenced-based treatment.

US regional and demographic differences in prescription opioid and heroin-related overdose hospitalizations

BACKGROUND

US opioid overdose death rates have increased between 2000 and 2014. While, the increase in prescription opioid use has been linked to the increase in heroin use, there are reasons to view this relationship as a partial explanation for the recent increase in heroin-related harms. This study documents the differences in trends in prescription opioid overdose-related (POD) and heroin overdose-related (HOD) hospitalizations.

METHODS

Data come from the National Inpatient Sample (NIS) for the years 2000 through 2014. POD and HOD hospitalizations were abstracted from ICD-9 codes. Rates of POD and HOD by census region and census division were constructed along with separate rates for age and race. Regression analysis analyzing trends across region were estimated along with graphs for documenting differences in POD and HOD rates.

RESULTS

POD hospitalization rates were highest in the South and lowest in the Northeast. HOD hospitalization rates were highest in the Northeast region and grew the fastest in the Midwest. There was statistically significant heterogeneity in HOD trends but not POD trends across the four regions between 2000 and 2014. Between 2012 and 2014 POD rates decreased in eight of the nine census divisions, with only New England showing an increase. HOD hospitalization rates increased in all nine census divisions between 2012 and 2014. Both POD and HOD rates show different demographic patterns across the nine census divisions.

CONCLUSION

Comparing POD and HOD hospitalization trends reveals significant disparities in geographic as well as demographic distributions. These epidemics are evolving and the simple opioid-to-heroin transition story is both supported and challenged by this paper. The opioid pill, heroin and fentanyl crises are intertwined yet increasingly have drivers and outcomes that support examining them as distinct. Addressing these complex and interrelated epidemics will require innovative public health research and interventions which need to consider local and regional contexts.

Screening, brief intervention, and referral to treatment for opioid and other substance use during infertility treatment

Opioid use and misuse have reached epidemic proportions in the United States, especially in women of childbearing age, some of whom seek infertility treatments. Substance use is much more common than many of the conditions routinely screened for during the preconception period, and it can have devastating consequences for the woman and her family. Substance use can worsen infertility, complicate pregnancy, increase medical problems, and lead to psychosocial difficulties for the woman and her family. The reproductive endocrinologist thus has an ethical and medical duty to screen for substance use, provide initial counseling, and refer to specialized treatment as needed. This article provides an overview of screening, brief intervention, and referral to treatment (SBIRT), a public health approach shown to be effective in ameliorating the harms of substance use.

US Adult Illicit Cannabis Use, Cannabis Use Disorder, and Medical Marijuana Laws: 1991-1992 to 2012-2013

Importance

Over the last 25 years, illicit cannabis use and cannabis use disorders have increased among US adults, and 28 states have passed medical marijuana laws (MML). Little is known about MML and adult illicit cannabis use or cannabis use disorders considered over time.

Objective

To present national data on state MML and degree of change in the prevalence of cannabis use and disorders.

Design, Participants, and Setting

Differences in the degree of change between those living in MML states and other states were examined using 3 cross-sectional US adult surveys: the National Longitudinal Alcohol Epidemiologic Survey (NLAES; 1991-1992), the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; 2001-2002), and the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III; 2012-2013). Early-MML states passed MML between NLAES and NESARC ("earlier period"). Late-MML states passed MML between NESARC and NESARC-III ("later period").

Main Outcomes and Measures

Past-year illicit cannabis use and DSM-IV cannabis use disorder.

Results

Overall, from 1991-1992 to 2012-2013, illicit cannabis use increased significantly more in states that passed MML than in other states (1.4-percentage point more; SE, 0.5; P = .004), as did cannabis use disorders (0.7-percentage point more; SE, 0.3; P = .03). In the earlier period, illicit cannabis use and disorders decreased similarly in non-MML states and in California (where prevalence was much higher to start with). In contrast, in remaining early-MML states, the prevalence of use and disorders increased. Remaining early-MML and non-MML states differed significantly for use (by 2.5 percentage points; SE, 0.9; P = .004) and disorder (1.1 percentage points; SE, 0.5; P = .02). In the later period, illicit use increased by the following percentage points: never-MML states, 3.5 (SE, 0.5); California, 5.3 (SE, 1.0); Colorado, 7.0 (SE, 1.6); other early-MML states, 2.6 (SE, 0.9); and late-MML states, 5.1 (SE, 0.8). Compared with never-MML states, increases in use were significantly greater in late-MML states (1.6-percentage point more; SE, 0.6; P = .01), California (1.8-percentage point more; SE, 0.9; P = .04), and Colorado (3.5-percentage point more; SE, 1.5; P = .03). Increases in cannabis use disorder, which was less prevalent, were smaller but followed similar patterns descriptively, with change greater than never-MML states in California (1.0-percentage point more; SE, 0.5; P = .06) and Colorado (1.6-percentage point more; SE, 0.8; P = .04).

Conclusions and Relevance

Medical marijuana laws appear to have contributed to increased prevalence of illicit cannabis use and cannabis use disorders. State-specific policy changes may also have played a role. While medical marijuana may help some, cannabis-related health consequences associated with changes in state marijuana laws should receive consideration by health care professionals and the public.