Long-term course of opioid addiction

Living a normal life? Follow-up study of women who had been in opioid maintenance treatment during pregnancy

BACKGROUND

There are few longitudinal follow-up studies of patients in opioid maintenance treatment (OMT). For this reason we performed a follow-up study of a cohort of 67 women who had used OMT-medications during pregnancy an average of ten years earlier. The aim of our study was to explore how the women were doing over time regarding OMT medication adherence and use of other legal and illegal substances, as well as to evaluate the mortality for the women and custody situation for the children in the cohort.

METHODS

Participants were recruited from two cohorts in our previous pregnancy study covering women who gave birth from 2004 to 2009. Sixty-seven women agreed to be interviewed, which is 73% of the eligible women from our original study. We developed a questionnaire, which we used in the interview, that focused primarily on these women's current life situation (custody of child they had delivered, the use of medications in OMT and other legal and illegal substances, and several other health and social aspects of the participants' lives).

RESULTS

Two women had died prior to the follow-up. Eighty-one percent of the women had custody of the child they had delivered in our pregnancy study and half the women were single parents. Fifty-four percent of the women were employed. At follow-up, 42% of the women were in methadone maintenance treatment (MMT), 39% were in buprenorphine maintenance treatment (BMT), and 19% had left OMT. One-third of the women had changed their OMT medication during the follow-up period. The majority (77%) were satisfied with their current OMT medication. The women in MMT seemed to be more severe substance dependent than the rest of the participants. There was little use of legal and illegal substances at follow-up, especially among women with custody of their child. The frequency of substance use was low. Fourteen percent of the women were in the process of leaving OMT and another half of the women wanted to leave OMT, but had no plan for how and when.

CONCLUSION

This follow-up study describes a predominantly well rehabilitated cohort of women who had given birth while in OMT ten years earlier. The majority of the women had custody of their children and used very few legal and illegal drugs. Our findings may be explained partly from a life course perspective, with the women having experienced turning points when starting OMT or becoming mothers.

Relapse to substance use: A concept analysis

The concept of relapse is ubiquitous in the health literature related to addiction. Nevertheless, relapse is-and has been-described and measured under various definitions, which precipitates confusion, inconsistency, and stigma. This study aimed to (a) clarify the meaning of relapse and (b) present a comprehensive definition of relapse vis-à-vis substance use. Walker and Avant's method of concept analysis was followed to analyze the relapse using CINAHL, PsychINFO, and PubMed databases. Three key attributes of relapse were identified: (a) interruption of abstinence, (b) vulnerability to uncontrollable substance-related behavior and/or cues, (c) a transition to potential progression or regression. Antecedents and consequences of attributes were identified, followed by the construction of the model and additional cases. Relapse is defined conceptually as either a transition to regression or a progression in the process of recovery, prompted by a return to the previous behavior of substance use, despite the intention to stay abstinent. A standardized definition and understanding of relapse not only minimize confusion, inconsistency, and social and self-stigma associated with the term but also helps provide relapse-sensitive care with accurate methods of assessment and evaluation.

How often are outcomes other than change in substance use measured? A systematic review of outcome measures in contemporary randomised controlled trials

ISSUES

Recovery is a theoretical construct and empirical object of inquiry. The aim was to review whether outcome measures used in randomised controlled trials of drug treatment reflect a comprehensive conceptualisation of recovery.

APPROACH

Systematic review using the following databases: Cochrane Database of Systematic Reviews, Cochrane Controlled Register of Trials, Database of Abstracts of Reviews of Effect, Web of Science, MEDLINE, Embase and PsycINFO. Search returned 6556 original articles and 504 met the following inclusion criteria: randomised controlled trial in English-language peer-reviewed journal; sample meets criteria for drug dependence or drug use disorder; reports non-substance use treatment outcomes. Review protocol registration: PROSPERO (CRD42018090064).

KEY FINDINGS

3.8% of the included studies had a follow up of 2 years or more. Withdrawal/craving was present in 31.1% of short-term versus 0% of long-term studies. Social functioning in 8% of short-term versus 36.8% of long-term studies. Role functioning (0.9 vs. 26.3%), risk behaviour (15.6 vs. 36.8%) and criminality (3.8 vs. 21.1%) followed a similar pattern. Housing was not examined short-term and unregularly long-term (2.0%). 'Use of health-care facilities', clinical psychological, behavioural factors were frequently reported. Physiological or somatic health (15.2 vs. 10.5%), motivation (14.2 vs. 15.8%) and quality of life (7.1 vs. 0%) were less frequently reported.

CONCLUSION

The short time interval of the follow up and lack of information on relevant factors in recovery prevents the development of evidence-based approaches to improve these factors. Particularly, measures of social and role functioning should be added to reflect an adequate conceptualisation of recovery.

Individual and county-level variation in outcomes following non-fatal opioid-involved overdose

BACKGROUND

A lack of large-scale, individually linked data often has impeded efforts to disentangle individual-level variability in outcomes from area-level variability in studies of many diseases and conditions. This study investigated individual and county-level variability in outcomes following non-fatal overdose in a state-wide cohort of opioid overdose patients.

METHODS

Participants were 24 031 patients treated by emergency medical services or an emergency department for opioid-involved overdose in Indiana between 2014 and 2017. Outcomes included repeat non-fatal overdose, fatal overdose and death. County-level predictors included sociodemographic, socioeconomic and treatment availability indicators. Individual-level predictors included age, race, sex and repeat non-fatal opioid-involved overdose. Multilevel models examined outcomes following non-fatal overdose as a function of patient and county characteristics.

RESULTS

10.9% (n=2612) of patients had a repeat non-fatal overdose, 2.4% (n=580) died of drug overdose and 9.2% (n=2217) died overall. Patients with a repeat overdose were over three times more likely to die of drug-related causes (OR=3.68, 99.9% CI 2.62 to 5.17, p<0.001). County-level effects were limited primarily to treatment availability indicators. Higher rates of buprenorphine treatment providers were associated with lower rates of mortality (OR=0.82, 95% CI 0.68 to 0.97, p=0.024), but the opposite trend was found for naltrexone treatment providers (OR=1.20, 95% CI 1.03 to 1.39, p=0.021). Cross-level interactions showed higher rates of Black deaths relative to White deaths in counties with high rates of naltrexone providers (OR=1.73, 95% CI 1.09 to 2.73, p=0.019).

CONCLUSION

Although patient-level differences account for most variability in opioid-related outcomes, treatment availability may contribute to county-level differences, necessitating multifaceted approaches for the treatment and prevention of opioid abuse.

Psychosocial intervention utilization and substance abuse treatment outcomes in a multisite sample of individuals who use opioids

BACKGROUND

There are several relatively safe and effective FDA-approved medications for Opioid Use Disorder (OUD). Despite the existence of these medications, the rate of returning to opioid use after treatment is relatively high, underscoring the need for continued enhancement of treatments. Adjunctive psychosocial interventions paired with medication have been shown to improve OUD treatment outcomes. However, studies have yet to conclusively examine the distinct effects of the most widely utilized psychosocial treatment modalities. The current study will investigate the relationship between individual counseling, group therapy, and 12-Step participation and illicit opioid abstinence at the end of treatment, 1 and 3 months after treatment.

METHOD

A secondary analysis was conducted with data from a sample of 570 individuals diagnosed with OUD who were recruited from eight substance abuse treatment centers in the United States. Participants were enrolled in a two-group randomized, controlled trial testing buprenorphine-naloxone versus extended-release naltrexone for OUD. A two-level hierarchical linear growth model was used to examine the effects of individual counseling, group therapy, and 12-Step participation on illicit opioid abstinence (urinanalyses) 1- and 3-months post-treatment.

RESULTS

Hours of individual counseling and 12-Step participation significantly predicted abstinence at follow-up (p < .001, b = -0.59, 95% CI [0.42, 0.74]; p < .01, b = -0.05, 95% CI [0.92, 0.98]). There was a significant interaction between individual counseling and 12-Step participation (p < .01, b = -0.06, 95% CI [1.02, 1.10]). Additionally, participant age and employment status were significant predictors of illicit opioid abstinence (p < .01, b = -0.02, 95% CI [0.97, 0.99]; p < .01, b = -0.38, 95% CI [0.52, 0.90]). Hours of group therapy was not found to significantly predict illicit opioid abstinence.

CONCLUSIONS

Findings suggest that greater levels of individual therapy and 12-Step participation may be beneficial for individuals receiving medication treatment for OUD.

Childhood adversity and mental health comorbidity in men and women with opioid use disorders

INTRODUCTION

To examine gender differences in associations between mental health comorbidity and adverse childhood experiences (ACE) among adults with DSM-5 lifetime opioid use disorders (OUD).

METHODS

In 2018, we analyzed 2012-13 nationally-representative data from 388 women and 390 men with OUD (heroin, prescription opioid misuse). Using weighted multinomial logistic regression, we examined factors associated with mental health comorbidity, tested a gender-by-childhood-adversity interaction term, and calculated predicted probabilities, controlling for covariates.

RESULTS

Among adults with OUD, women are more likely than men to have comorbid mood or anxiety disorders (odds ratio [95% CI] 1.72 [1.20, 2.48]), and less likely to have conduct disorders. More women than men have prescription OUD (3.72 [2.24, 6.17]), and fewer have heroin use disorder (0.39 [0.27, 0.57]). Among both genders, ACE prevalence is high (>80%) and more than 40% are exposed to ≥3 types of ACE. Women more than men are exposed to childhood sexual abuse (4.22 [2.72, 6.56]) and emotional neglect (1.84 [1.20, 2.81]). Comorbid mood or anxiety disorders are associated with female gender (1.73 [1.18, 2.55]) and exposure to ≥3 types of ACE (3.71 [2.02, 6.85]), controlling for covariates. Moreover, exposure to more ACE elevates risk for comorbid mood or anxiety disorders more among women than men.

CONCLUSION

Among adults with OUD, ACE alters the gender gap in risk for comorbid mood or anxiety disorders. Using gender-tailored methods to address the harmful effects ACE on the mental health of individuals with OUD may help to prevent and ameliorate the current opioid epidemic.

How the evolving epidemics of opioid misuse and HIV infection may be changing the risk of oral sexually transmitted infection risk through microbiome modulation

The epidemiology of sexually transmitted infections (STI) is constantly evolving, and the mechanisms of infection risk in the oral cavity (OC) are poorly characterized. Evidence indicates that microbial community (microbiota) compositions vary widely between the OC, genitalia and the intestinal and rectal mucosa, and microbiome-associated STI susceptibility may also similarly vary. The opioid misuse epidemic is at an epidemic scale, with >11 million US residents misusing in the past 30 days. Opioids can substantially influence HIV progression, microbiota composition and immune function, and these three factors are all mutually influential via direct and indirect pathways. While many of these pathways have been explored independently, the supporting data are mostly derived from studies of gut and vaginal microbiotas and non-STI infectious agents. Our purpose is to describe what is known about the combination of these pathways, how they may influence microbiome composition, and how resultant oral STI susceptibility may change. A better understanding of how opioid misuse influences oral microbiomes and STI risk may inform better mechanisms for oral STI screening and intervention. Further, the principles of interaction described may well be applied to other aspects of disease risk of other health conditions which may be impacted by the opioid epidemic.

"Becoming myself": how participants in a longitudinal substance use disorder recovery study experienced receiving continuous feedback on their results

BACKGROUND

Being a participant in longitudinal follow-up studies is not commonly a factor considered when investigating useful self-change aspects for individuals attempting recovery from substance use disorder (SUD). This study reports on how ongoing monitoring, and feedback on data results in a longitudinal follow-up study of SUD recovery were perceived by individuals who had achieved long-term abstinence and social recovery.

METHODS

Interviewers with first-hand experience with the topic conducted interviews with 30 participants and analysed the data using a thematic analytic approach within an interpretative-phenomenological framework.

RESULTS

Analyses resulted in the following themes. 1) Ongoing short text messaging (SMS) monitoring: helped participants by offering recovery milestones and reminders of the past. 2) Feedback on data results helped participants track physical and cognitive recovery: "I am more like myself". 3) Using feedback in treatment: understanding the importance of a functional brain to participants may help with long-term retention in treatment.

CONCLUSIONS

Self-changes that were challenging to detect on a day-to-day basis were available for reflection through longitudinal study participation, including ongoing monitoring and feedback on the results, allowing personal consolidation of change processes. Clinical services could benefit from continuing development and implementation of such technology for ongoing monitoring and feedback on assessments to motivate self-change in SUD recovery. The development of guidelines for providing the results of research assessments to individuals could help reduce attrition in research projects and support recovery and healthy choices for study participants.

Opioid use disorder

Opioid use disorder (OUD) is a chronic relapsing disorder that, whilst initially driven by activation of brain reward neurocircuits, increasingly engages anti-reward neurocircuits that drive adverse emotional states and relapse. However, successful recovery is possible with appropriate treatment, although with a persisting propensity to relapse. The individual and public health burdens of OUD are immense; 26.8 million people were estimated to be living with OUD globally in 2016, with >100,000 opioid overdose deaths annually, including >47,000 in the USA in 2017. Well-conducted trials have demonstrated that long-term opioid agonist therapy with methadone and buprenorphine have great efficacy for OUD treatment and can save lives. New forms of the opioid receptor antagonist naltrexone are also being studied. Some frequently used approaches have less scientifically robust evidence but are nevertheless considered important, including community preventive strategies, harm reduction interventions to reduce adverse sequelae from ongoing use and mutual aid groups. Other commonly used approaches, such as detoxification alone, lack scientific evidence. Delivery of effective prevention and treatment responses is often complicated by coexisting comorbidities and inadequate support, as well as by conflicting public and political opinions. Science has a crucial role to play in informing public attitudes and developing fuller evidence to understand OUD and its associated harms, as well as in obtaining the evidence today that will improve the prevention and treatment interventions of tomorrow.

Recurrent Necrotizing Soft Tissue Infections with Atypical Pathogens after Injection Drug Abuse: Another Manifestation of the Opioid Crisis

Background: The United States is in the midst of an opioid crisis. Injection drug use is a major risk factor for necrotizing soft tissue infections (NSTI) by introducing bacteria into the soft tissues. Repetitive infection and atypical pathogens may be tangible manifestations of the opioid crisis. Methods: We describe recidivism in two cases of NSTI involving opioid abuse and atypical pathogens at a single institution and review pertinent international literature. Results: Repetitive NSTI is rare. Patients with chronic injection drug use, however, may be at particular risk of repetitive NSTI and infections with atypical organisms. Conclusions: Care providers must have a heightened awareness of infections with atypical pathogens and risk of repetitive infection in patients with injection drug use. Aggressive surgical management and antibiotic coverage tailored to culture and susceptibility data are necessary for a successful short-term outcome. A successful long-term outcome mandates identification and management of co-existent behavioral health issues.

Sexual Abuse and Future Mental Health Hospitalization in a Swedish National Sample of Men Who Use Opioids

Experiences of trauma, specifically sexual abuse, have been linked to both mental health and substance use disorders. This study used 14 years of Swedish health registry data to select a sample of adult men who reported frequent opioid use and assessed if those with a self-reported history of sexual abuse had a higher likelihood of hospitalization for a mental health disorder.

The Association of Preoperative Opioid Usage With Patient-Reported Outcomes, Adverse Events, and Return to Work After Lumbar Fusion: Analysis From the Michigan Spine Surgery Improvement Collaborative (MSSIC)

BACKGROUND

It is important to delineate the relationship between opioid use and spine surgery outcomes.

OBJECTIVE

To determine the association between preoperative opioid usage and postoperative adverse events, patient satisfaction, return to work, and improvement in Oswestry Disability Index (ODI) in patients undergoing lumbar fusion procedures by using 2-yr data from a prospective spine registry.

METHODS

Preoperative opioid chronicity from 8693 lumbar fusion patients was defined as opioid-naïve (no usage), new users (&lt;6 wk), short-term users (6 wk-3 mo), intermediate-term users (3-6 mo), and chronic users (&gt;6 mo). Multivariate generalized estimating equation models were constructed.

RESULTS

All comparisons were to opioid-naïve patients. Chronic opioid users showed less satisfaction with their procedure at 90 d (Relative Risk (RR) 0.95, P = .001), 1 yr (RR 0.89, P = .001), and 2 yr (RR 0.89, P = .005). New opioid users were more likely to show improvement in ODI at 90 d (RR 1.25, P &lt; .001), 1 yr (RR 1.17, P &lt; .001), and 2 yr (RR 1.19, P = .002). Short-term opioid users were more likely to show ODI improvement at 90 d (RR 1.25, P &lt; .001). Chronic opioid users were less likely to show ODI improvement at 90 d (RR 0.90, P = .004), 1 yr (RR 0.85, P &lt; .001), and 2 yr (RR 0.80, P = .003). Chronic opioid users were less likely to return to work at 90 d (RR 0.80, P &lt; .001).

CONCLUSION

In lumbar fusion patients and when compared to opioid-naïve patients, new opioid users were more likely and chronic opioid users less likely to have improved ODI scores 2 yr after surgery. Chronic opioid users are less likely to be satisfied with their procedure 2 yr after surgery and less likely to return to work at 90 d. Preoperative opioid counseling is advised.

"A Life More Ordinary" Processes of 5-Year Recovery From Substance Abuse. Experiences of 30 Recovered Service Users

Background: Studies investigating the subjective experiences of long-term recovery from substance use disorder are scarce. Particularly, functional and social factors have received little attention. Objectives: To investigate what long-term recovered service users found to build recovery from substance use disorder. Material and Methods: The study was designed as a phenomenological investigation subjected to thematic analysis. We interviewed 30 long-term recovered adult service users. Results: Our thematic analysis resulted in five themes and several subthemes: 1) paranoia, ambivalence and drug cravings: extreme barriers to ending use; 2) submitting to treatment: a struggle to balance rigid treatment structures with a need for autonomy; 3) surrendering to trust and love: building a whole person; 4) a life more ordinary: surrendering to mainstream social responsibilities; and 5) taking on personal responsibility and gaining autonomy: it has to be me, it cannot be you. Conclusions: Our study sample described long-term recovery as a developmental process from dependency and reactivity to personal autonomy and self-agency. The flux of surrendering to and differentiating from authority appeared to be a driving force in recovery progression. Participants called for treatment to focus on early social readjustment.

Opioid use and misuse: health impact, prevalence, correlates and interventions

Objective: To provide a broad overview of the state of drug misuse research, particularly focusing on opioid drug use in the U.S.A. Design: An overview of published reviews of the literature. Results: Prescription opioid use has increased globally from 2008 to 2013, while use of opiates such as heroin and opium have remained stable in many countries, although, decreases have been observed in parts of Europe. Opioid misuse is highest in the United States; approximately 11.8 million Americans misused opioids in 2016. Demographic, genetic, psychosocial and structural/environmental factors all play a role in determining who will become an opioid misuser. Strategies such as increased prescribing of non-opioid derived pain relievers, expansion of medication treatment, distribution of naloxone for overdose reversal and supervised consumption sites are some of the solutions posed to reduce the spread and consequences of opioid misuse. Conclusion: Research focused on understanding of opioid neurobiology, as well as empirically based, effective alternatives to pain management and implementation studies on combined prevention and treatment approaches are needed. It will take the combined effort of community members, healthcare professionals, policymakers and researchers in order to prevent and treat opioid misuse.

The Impact of the Opioid Epidemic on Children and Adolescents

Although an epidemic of opioid-related overdose deaths has continued to increase in the United States for 2 decades, the impact of opioid use disorders (OUDs) on children and families receives minimal attention. The purpose of this commentary was to provide an overview of the impact of the opioid epidemic on children and adolescents, as well as to summarize challenges to improving outcomes for children. Children and adolescents who grow up in households with opioid misuse and OUDs may experience a myriad of adverse consequences, including: increased risk of mental health problems and drug use; accidental opioid poisoning; increased risk of developing a substance use disorder; and family dissolution that results from parents' incarceration, foster care placement, or loss of parent to an opioid overdose. Parental drug use may result in child neglect or deficits in parent-child attachment, and parents with an OUD may be less likely to be reunified with their children. OUD treatment is effective at reducing parental opioid use and improving child outcomes; however, stigma and cross-system collaboration may limit access to treatment and timely reunification of families. Children are the most vulnerable witnesses of the opioid epidemic, and further research is urgently needed to expand prevention interventions.

Engaging an unstably housed population with low-barrier buprenorphine treatment at a syringe services program: Lessons learned from Seattle, Washington

Background: Clinic-imposed barriers can impede access to medication for opioid use disorder (MOUD). We evaluated a low-barrier buprenorphine program that is co-located with a syringe services program (SSP) in Seattle, Washington, USA. Methods: We analyzed medical record data corresponding to patients who enrolled into the buprenorphine program in its first year of operation. We used descriptive statistics and tests of association to longitudinally evaluate retention, cumulative number of days buprenorphine was prescribed, and toxicology results. Results: Demand for buprenorphine among SSP clients initially surpassed programmatic capacity. Of the 146 enrolled patients, the majority (82%) were unstably housed. Patients were prescribed buprenorphine for a median of 47 days (interquartile range [IQR] = 8-147) in the 180 days following enrollment. Between the first and sixth visits, the percentage of toxicology tests that was positive for buprenorphine significantly increased (33% to 96%, P < .0001) and other opioids significantly decreased (90% to 41%, P < .0001) and plateaued thereafter. Toxicology test results for stimulants, benzodiazepines, and barbiturates did not significantly change. Conclusions: SSP served as an effective point of entry for a low-barrier MOUD program. A large proportion of enrolled patients demonstrated sustained retention and reductions in opioid use, despite housing instability and polysubstance use.

Opioid agonist treatment reduces losses in quality of life and quality-adjusted life expectancy in heroin users: Evidence from real world data

BACKGROUND

This study estimated the long-term changes of opioid agonist treatment (OAT) in quality of life (QOL) and quantified the quality-adjusted life years (QALY) from the loss of quality-adjusted life expectancy (QALE) in heroin users.

METHODS

A total of 1283 heroin users stratified by OAT were linked to the National Mortality Registry for 8 years (2006-2014) to obtain survival functions, which were extrapolated to lifetime by applying a rolling extrapolation algorithm to survival ratio between the sub-cohorts and age- and sex-matched referents simulated from vital statistics of Taiwan. We performed cross-sectional measurement of EQ-5D on 349 participants, including those with a valid state of OAT or non-OAT plus newly recruited consecutive patients, during 2015-2017 for utility values, while the QOL of referents were abstracted from the 2009 National Health Interview Survey. The QALE was calculated by summing the products of the mean QOL and survival rate throughout life. The QALE difference between the cohort and corresponding referents was the loss-of-QALE.

RESULTS

QOL of the OAT group was significantly better than that of the non-OAT group in every domain of the EQ-5D, which was quantified to be 0.23 for utility after controlling for other variables. After extrapolation to 70 years, the estimated QALE and loss-of-QALE were 17.8 and 18.2 QALY for OAT subjects, respectively, while those of the non-OAT group were 9.2 and 27.9 QALY.

CONCLUSIONS

Receiving OAT could reduce QALE lost by 9.7 QALYs compared with non-OAT after accounting for QOL differences along time and different age and sex distributions.

Criminal justice outcomes over 5 years after randomization to buprenorphine-naloxone or methadone treatment for opioid use disorder

AIMS

To compare long-term criminal justice outcomes among opioid-dependent individuals randomized to receive buprenorphine or methadone.

DESIGN, SETTING AND PARTICIPANTS

A 5-year follow-up was conducted in 2011-14 of 303 opioid-dependent participants entering three opioid treatment programs in California, USA in 2006-09 and randomized to receive either buprenorphine/naloxone or methadone.

INTERVENTION AND COMPARATOR

Participants received buprenorphine/naloxone (BUP; n = 179) or methadone (MET; n = 124) for 24 weeks and then were tapered off their treatment over ≤ 8 weeks or referred for ongoing clinical treatment. Midway through the study, the randomization scheme was switched from 1 : 1 BUP : MET to 2 : 1 because of higher dropout in the BUP arm.

MEASUREMENTS

Study outcomes included arrests and self-reported incarceration. Predictors included randomization condition (buprenorphine versus methadone), age, gender, race/ethnicity, use of cocaine, drug injection in the 30 days prior to baseline and study site. Treatment status (buprenorphine, methadone, none) during follow-up was included as a time-varying covariate.

FINDINGS

There was no significant difference by randomization condition in the proportion arrested (buprenorphine: 55.3%, methadone: 54.0%) or incarcerated (40.9%, 47.3%) during follow-up. Among methadone-randomized individuals, arrest was less likely with methadone treatment (0.50, 0.35-0.72) during follow-up (relative to no treatment) and switching to buprenorphine had a lower likelihood of arrest than those receiving no treatment (0.39, 0.18-0.87). Among buprenorphine-randomized individuals, arrest was less likely with receipt of buprenorphine (0.49, 0.33-0.75) during follow-up and switching to methadone had a similar likelihood of arrest as methadone-randomized individuals receiving no treatment. Likelihood of arrest was also negatively associated with older age (0.98, 0.96-1.00); it was positively associated with Hispanic ethnicity (1.63, 1.04-2.56), cocaine use (2.00, 1.33-3.03), injection drug use (2.19, 1.26-3.83), and study site.

CONCLUSIONS

In a US sample of people treated for opioid use disorder, continued treatment with either buprenorphine or methadone was associated with a reduction in arrests relative to no treatment. Cocaine use, injection drug use, Hispanic ethnicity and younger age were associated with higher likelihood of arrest.

Justice involvement patterns, overdose experiences, and naloxone knowledge among men and women in criminal justice diversion addiction treatment

Background

Persons in addiction treatment are likely to experience and/or witness drug overdoses following treatment and thus could benefit from overdose education and naloxone distribution (OEND) programs. Diverting individuals from the criminal justice system to addiction treatment represents one treatment engagement pathway, yet OEND needs among these individuals have not been fully described.

Methods

We characterized justice involvement patterns among 514 people who use opioids (PWUO) participating in a criminal justice diversion addiction treatment program during 2014–2016 using a gender-stratified latent class analysis. We described prevalence and correlates of naloxone knowledge using quasi-Poisson regression models with robust standard errors.

Results

Only 56% of participants correctly identified naloxone as an opioid overdose treatment despite that 68% had experienced an overdose and 79% had witnessed another person overdose. We identified two latent justice involvement classes: low involvement (20.3% of men, 46.5% of women), characterized by older age at first arrest, more past-year arrests, and less time incarcerated; and high involvement (79.7% of men, 53.5% of women), characterized by younger age at first arrest and more lifetime arrests and time incarcerated. Justice involvement was not associated with naloxone knowledge. Male participants who had personally overdosed more commonly identified naloxone as an overdose treatment after adjustment for age, race, education level, housing status, heroin use, and injection drug use (prevalence ratio [95% confidence interval]: men 1.5 [1.1–2.0]).

Conclusions

All PWUO in criminal justice diversion programs could benefit from OEND given the high propensity to experience and witness overdoses and low naloxone knowledge across justice involvement backgrounds and genders.

Electronic supplementary material

The online version of this article (10.1186/s12954-019-0317-3) contains supplementary material, which is available to authorized users.

Age related medication for addiction treatment (MAT) use for opioid use disorder among Medicaid-insured patients in New York

BACKGROUND

Medication for addiction treatment (MAT) has received much attention in recent years for treating individuals with opioid use disorders (OUD). However, these medications have been significantly underused among particular subgroups. In this paper, we describe the age distribution of treatment episodes for substance use disorder among Medicaid beneficiaries in New York and corresponding MAT use.

METHODS

Using New York Medicaid claims, we identified individuals with OUD that received treatment for substance use disorder in 2015. The type of substance use treatment is the primary outcome measure, which includes methadone, buprenorphine, naltrexone or other non-medication treatment.

RESULTS

A total of 88,637 individuals were diagnosed with OUD and received treatment for substance use disorder and 56,926 individuals received some type of MAT in 2015, with 40.2% receiving methadone, 21.9% receiving buprenorphine and 2.2% receiving naltrexone while 21.9% received non-medication based treatment. Young adults (ages 18-29) were a large proportion (25%) of individuals in treatment for OUD yet were the least likely to receive MAT. Relative to young adults, 30-39 year olds (adjusted odds ratio [AOR] = 1.62, 95% CI = 1.56-1.68), 40-49 year olds (AOR = 1.90, 95% CI = 1.82-1.99), 50-59 year olds (AOR = 2.65, 95% CI = 2.52-2.78), and 60-64 year olds (AOR = 5.03, 95% CI = 4.62-5.48) were more likely to receive MAT.

CONCLUSIONS

These preliminary findings highlight high numbers of young adults in treatment for OUD and low rates of MAT, which is not consistent with treatment guidelines. Significant differences exist in the type of medication prescribed across age. More attention is needed to address the treatment needs among individuals of different age, notably young adults.

Accelerating the Pace of Science: Improving Parenting Practices in Parents with Opioid Use Disorder

A public health emergency exists in the United States as a result of rising overdose deaths related to Opioid Use Disorder (OUD). With the rise of OUD has also come an increase in the number of children exposed to parents who suffer from an OUD. There is a pressing need for parenting interventions for individuals with OUD to provide safe environments for the children being reared in the face of this epidemic. Research on parenting with an OUD is sparse, but it is impractical to move linearly from basic research to program development and implementation given the urgent need for intervention - a trajectory that prior research has established takes approximately 17 years. We have created an outline of strategies that can be used to accelerate the pace of science so that parenting practices are more immediately improved for this population. First, we summarize what is already known about OUD and parenting to characterize mechanisms that existing interventions have targeted and optimal settings for the wide dissemination of implementable interventions. Next, we identify existing interventions that either specifically target parents with OUD or mechanisms specific to parents with OUD. We describe four different approaches for accelerating the pace of science to improve the lives of parents with OUD and their children. By doing so, we hope to provide a roadmap for future researchers and practitioners to deliver more timely evidence-based interventions to address the additional burden placed on families and communities due to the rise in OUD in the United States.

The relationship among social support, self-esteem, affect balance and loneliness in individuals with substance use disorders in China

This study analyzed the potential mediating role of self-esteem and affect balance on the relationship between social support and loneliness. Respondents were 426 substabce use disorders from the Shifosi and Dalianshan rehab facilities in China who had completed the Multidimensional Scale of Perceived Social Support, Rosenberg Self-Esteem Scale, Positive and Negative Affect Scales, and UCLA Loneliness Scale. The results indicated that self-esteem and affect balance fully mediated the relationship between perceived social support and loneliness and all the paths, ranging from social support through self-esteem and affect balance to loneliness, were significant. Finally, we analyzed possible approaches to decreasing individuals with substance use disorders' loneliness.

Integrated Models of Care for Individuals with Opioid Use Disorder: How Do We Prevent HIV and HCV?

Purpose of Review

To describe models of integrated and co-located care for opioid use disorder (OUD), hepatitis C (HCV), and HIV.

Recent Findings

The design and scale-up of multidisciplinary care models that engage, retain, and treat individuals with HIV, HCV, and OUD are critical to preventing continued spread of HIV and HCV. We identified 17 models within primary care (N = 3), HIV specialty care (N = 5), opioid treatment programs (N = 6), transitional clinics (N = 2), and community-based harm reduction programs (N = 1), as well as two emerging models.

Summary

Key components of such models are the provision of (1) medication-assisted treatment for OUD, (2) HIV and HCV treatment, (3) HIV pre-exposure prophylaxis, and (4) behavioral health services. Research is needed to understand differences in effectiveness between co-located and fully integrated care, combat the deleterious racial and ethnic legacies of the “War on Drugs,” and inform the delivery of psychiatric care. Increased access to harm reduction services is crucial.

Electronic supplementary material

The online version of this article (10.1007/s11904-018-0396-x) contains supplementary material, which is available to authorized users.

Opioid Therapy for Chronic Pain: Overview of the 2017 US Department of Veterans Affairs and US Department of Defense Clinical Practice Guideline

Description

The US Department of Veterans Affairs (VA) and US Department of Defense (DoD) revised the 2010 clinical practice guideline (CPG) for the management of opioid therapy for chronic pain, considering the specific needs of the VA and DoD and new evidence regarding prescribing opioid medication for non-end-of-life-related chronic pain. This paper summarizes the major recommendations and compares them with the US Centers for Disease Control and Prevention (CDC) guideline for prescribing opioids.

Patient Population

This Opioid Therapy CPG was developed for VA-DoD service members, veterans, and their families.

Methods

The VA/DoD Evidence-Based Practice Work Group convened a VA/DoD guideline renewal development effort and conformed to the guidelines established by the VA/DoD Joint Executive Council (JEC) and VA/DoD Health Executive Council (HEC). The panel developed questions, searched and evaluated the literature, developed recommendations using GRADE methodology, and developed algorithms. Passage of the CARA Act by Congress compelled consideration and comparison with the CDC opioid therapy guideline mid-development.

Results

There were 18 recommendations made. This article focuses on guideline development and key recommendations with CDC comparisons taken from four major areas, including: initiation and continuation of opioids;type, dose, follow-up, and taper of opioids;risk mitigation;acute pain.

Conclusions

Guideline development and recommendations are presented. There was substantial overlap with the CDC opioid guideline. Additionally, there were items particularly relevant to the VA-DoD, including risk mitigation, suicide prevention, and preventing opioid use disorder in young patients. Our guideline highlights avoiding opioid therapy longer than 90 days as a critical juncture.

Exploring health-care providers’ experiences in the care of clients on opioid agonist treatment in two western Canadian clinics

Introduction

Prescribing methadone as part of opioid agonist therapy is a common treatment approach to manage opioid use disorder. Unfortunately, many clients prematurely discontinue opioid agonist therapy because of restrictions attached to the therapy.

Purpose

The purpose of this study was to explore health-care provider experiences as they worked with clients on opioid agonist therapy in a western Canadian city.

Methods

In this descriptive, qualitative study, we interviewed 18 health-care providers working in an opioid agonist therapy setting. The focus of the interviews was on the organization of opioid agonist therapy care at their clinic, their personal experiences and challenges faced when providing care to their clients. Interviews were recorded electronically and transcribed verbatim and thematic analysis was completed using NVIVO software.

Results

The following three themes emerged from the data relate to the care organization and health care provider (HCP)-clients dynamics. These are: (1) fragmentation of care for a complex problem, (2) enforcing compliance to treatment, and (3) the importance of a therapeutic alliance to improve overall care.

Conclusion

The opioid agonist therapy model is biocentric and emphasizes abstinence which can create tension between providers and clients. Making the model of care more patient centred might help to improve client retention rates and successful treatment outcomes.

Psychiatry and the Opioid Overdose Crisis

For the third year in a row, the Centers for Disease Control and Prevention reported an unprecedented decline in life expectancy for the United States, a decline attributable mainly to drug overdose deaths and suicides. Drug overdoses have continued to rise and are now estimated to account for 70,237 deaths in 2017. The root causes of the modern opioid crisis are complex and traceable to at least 30 factors. A prime driver has been the health care system. Pressure on medical practitioners to resort to opioids for managing chronic pain led to a nation awash with prescription opioids. In 2017, an unprecedented action was taken by President Donald J. Trump as he signed an executive order establishing the President's Commission on Combating Drug Addiction and the Opioid Crisis, tasked with producing guidance on reversing the crisis. The 56 recommendations of the President's Commission report were grounded in advanced strategies for prevention, treatment, rescue, recovery support, research, improved data analytics, and accountability. With a focus on the quality of treatment services and recovery homes, the report calls for implementing high standards of care for treatment. Specialists in addiction medicine and addiction psychiatry are best positioned to develop and implement high-quality care.

One size does not fit all-evolution of opioid agonist treatments in a naturalistic setting over 23 years

BACKGROUND AND AIMS

Opioid agonist treatment (OAT) is currently the most effective treatment for people with opioid dependence. In most countries, however, access to the whole range of effective medications is restricted. This study aims to model the distribution of different OAT medications within a naturalistic and relatively unrestricted treatment setting (Zurich, Switzerland) over time, and to identify patient characteristics associated with each medication.

METHODS

We used generalized estimating equation analysis with data from the OAT register of Zurich and the Swiss register for heroin-assisted treatment (HAT) to model and forecast the annual proportion of opioids applying exponential distributions until 2018 and patient characteristics between 1992 and 2015.

RESULTS

Data from 11 895 patients were included in the analysis. Methadone remains the mainstay of OAT, being prescribed to two-thirds of patients. Following its approval, the proportion of HAT increased rapidly and is now constant at 12.16% [95% confidence interval (CI) = 11.15-13.17]. The initial increase of proportions of buprenorphine or slow-release oral morphine (SROM) following their approval for OAT was slower. While in 2014 both medications had a proportion of 10.2% and 10.3%, respectively, our model predicts a further increase of SROM to 19.9% in 2018, with a ceiling level of 25.19% (21.40-28.98%) thereafter. SROM patients display characteristics similar to those treated with methadone; buprenorphine patients show the highest social integration; and HAT patients are the most homogeneous group, with highest mean age, most widespread injecting experience and lowest social integration.

CONCLUSIONS

Based on data from Zurich, Switzerland from 1992 to 2015, there is no evidence for an excessive demand for a single medication in a naturalistic and liberal opioid agonist treatment setting. Rather, the specific patient characteristics associated with each medication underline the need for diversified treatment options for opioid dependence.

Pharmacological and Behavioral Treatment of Opioid Use Disorder

Objective:

Opioid use disorder (OUD) in the United States has surged, with an estimated 2.5 million needing treatment. The aim of this article is to provide a clinical overview of the key pharmacological and behavioral treatments for OUD.

Methods:

A nonsystematic review of the literature was conducted to investigate OUD treatments, including their mechanism of action, efficacy, clinical guidelines in the United States, and consideration of frequently occurring comorbid conditions.

Results:

Food and Drug Administration (FDA)–approved pharmacotherapies for OUD include methadone, buprenorphine, and naltrexone, each of which has different actions on opioid receptors. Although these medications all show efficacy in some dosages and formulations, barriers to accessibility may be most pronounced for methadone, whereas treatment retention poses greater challenges for naltrexone and, to a lesser extent, buprenorphine. Lofexidine, an α₂‐adrenergic agonist, has recently been approved by the FDA for treatment of opioid withdrawal symptoms. OUD is commonly treated with medication‐assisted treatment (MAT), which offers pharmacotherapy in the context of counseling and/or behavioral treatments. Behavioral therapies, rarely offered as stand‐alone treatments for OUD, are generally used in the context of MAT, in structured settings or to prevent relapse after detoxification and stabilization. The aim of behavioral interventions is to improve medication compliance and target problems not addressed with medication alone. Individuals with OUD commonly have other comorbid psychiatric and substance use conditions, which are not exclusionary for initiating MAT but should be carefully evaluated and monitored because they may reduce treatment effectiveness.

Conclusions:

MAT is the first‐line treatment for patients with OUD and should be provided in combination with behavioral interventions. Treatment retention remains challenging in this population. Future studies should focus on approaches that will serve the complex needs of patients with OUD, including those with comorbid psychiatric and substance use conditions.

Correlates of Long-Term Opioid Abstinence After Randomization to Methadone Versus Buprenorphine/Naloxone in a Multi-Site Trial

Opioid use disorder (OUD) is a chronic, relapsing condition with severe negative health consequences. Previous studies have reported that 5-year opioid abstinence is a good predictor of reduced likelihoods of relapse, but factors that shape long-term opioid abstinence are poorly understood. The present study is based on data from a prospective study of 699 adults with OUD who had been randomized to either methadone or buprenorphine/naloxone and who were followed for at least 5 years. During the 5 years prior to the participants' last follow-up interview, 232 (33.2%) had achieved 5-year abstinence from heroin. Of those 232, 145 (20.7% of the total) had remained abstinent from both heroin and other opioids (e.g., hydrocodone, oxycodone, other opioid analgesics, excluding methadone or buprenorphine). Compared to non-abstinent individuals, those in both categories of opioid abstinence had lower problem severity in health and social functioning at the final follow-up. Logistic regression results indicated that cocaine users and injection drug users were less likely to achieve 5-year heroin abstinence, whereas Hispanics (vs. whites) and those treated in clinics on the West Coast (vs. East) were less likely to achieve 5-year abstinence from heroin and other opioids. For both abstinence category groups, abstinence was positively associated with older age at first opioid use, lower impulsivity, longer duration of treatment for OUD, and greater social support. Reducing cocaine use and injection drug use and increasing social support and retention in treatment may help maintain long-term abstinence from opioids among individuals treated with agonist pharmacotherapy.

EMS naloxone administration as non-fatal opioid overdose surveillance: 6-year outcomes in Marion County, Indiana

BACKGROUND AND AIMS

Despite rising rates of opioid overdose in the United States, few studies have examined the frequency of non-fatal overdose events or mortality outcomes following resuscitation. Given the widespread use of naloxone to respond to overdose-related deaths, naloxone administration may provide a useful marker of overdose events to identify high-risk users at heightened risk of mortality. We used naloxone administration by emergency medical services as a proxy measure of non-fatal overdose to examine repeat events and mortality outcomes during a 6-year period.

METHODS

We conducted a retrospective investigation of all cases in Marion County, Indiana between January 2011 and December 2016 where emergency medical services used naloxone to resuscitate a patient. Cases were linked to vital records to assess mortality and cause of death during the same time-period. We used Cox regression survival analysis to assess whether repeat non-fatal overdose events during the study period were associated with the hazard of mortality, both overall and by cause of death.

RESULTS

Of 4726 patients administered naloxone, 9.4% (n = 444) died an average of 354 days [standard deviation (SD) = 412.09, range = 1-1980] following resuscitation. Decedents who died of drug-related causes (34.7%, n = 154) were younger and more likely to have had repeat non-fatal overdose events. Patients with repeat non-fatal overdose events (13.4%, n = 632) had a ×2.07 [95% confidence interval (CI) = 1.59, 2.71] higher hazard of all-cause mortality and a ×3.06 (95% CI = 2.13, 4.40) higher hazard of drug-related mortality.

CONCLUSIONS

Among US emergency medical service patients administered naloxone for opioid overdose, those with repeat non-fatal opioid overdose events are at a much higher risk of mortality, particularly drug-related mortality, than those without repeat events.

The Next Stage of Buprenorphine Care for Opioid Use Disorder

Buprenorphine has been used internationally for the treatment of opioid use disorder (OUD) since the 1990s and has been available in the United States for more than a decade. Initial practice recommendations were intentionally conservative, were based on expert opinion, and were influenced by methadone regulations. Since 2003, the American crisis of OUD has dramatically worsened, and much related empirical research has been undertaken. The findings in several important areas conflict with initial clinical practice that is still prevalent. This article reviews research findings in the following 7 areas: location of buprenorphine induction, combining buprenorphine with a benzodiazepine, relapse during buprenorphine treatment, requirements for counseling, uses of drug testing, use of other substances during buprenorphine treatment, and duration of buprenorphine treatment. For each area, evidence for needed updates and modifications in practice is provided. These modifications will facilitate more successful, evidence-based treatment and care for patients with OUD.

The Cholinergic System as a Treatment Target for Opioid Use Disorder

Opioid overdoses recently became the leading cause of accidental death in the US, marking an increase in the severity of the opioid use disorder (OUD) epidemic that is impacting global health. Current treatment protocols for OUD are limited to opioid medications, including methadone, buprenorphine, and naltrexone. While these medications are effective in many cases, new treatments are required to more effectively address the rising societal and interpersonal costs associated with OUD. In this article, we review the opioid and cholinergic systems, and examine the potential of acetylcholine (ACh) as a treatment target for OUD. The cholinergic system includes enzymes that synthesize and degrade ACh and receptors that mediate the effects of ACh. ACh is involved in many central nervous system functions that are critical to the development and maintenance of OUD, such as reward and cognition. Medications that target the cholinergic system have been approved for the treatment of Alzheimer's disease, tobacco use disorder, and nausea. Clinical and preclinical studies suggest that medications such as cholinesterase inhibitors and scopolamine, which target components of the cholinergic system, show promise for the treatment of OUD and further investigations are warranted.

Effectiveness, safety and feasibility of extended-release naltrexone for opioid dependence: a 9-month follow-up to a 3-month randomized trial

BACKGROUND AND AIM

This is a follow-up study of a previously published randomized clinical trial conducted in Norway that compared extended-release naltrexone (XR-NTX) to buprenorphine-naloxone (BP-NLX) over 3 months. At the conclusion of the trial, participants were offered their choice of study medication for an additional 9 months. While BP-NLX was available at no cost through opioid maintenance treatment programmes, XR-NTX was available only through study participation, accounting for why almost all participants chose XR-NTX in the follow-up. The aim of this follow-up study was to compare differences in outcome between adults with opioid dependence continuing XR-NTX and those inducted on XR-NTX for a 9-month period, on measures of effectiveness, safety and feasibility.

DESIGN

In this prospective cohort study, participants were either continuing XR-NTX, changed from BP-NLX to XR-NTX or re-included into the study and inducted on XR-NTX treatment.

SETTING

Five urban, out-patient addiction clinics in Norway.

PARTICIPANTS

Opioid-dependent adults continuing (n = 54) or inducted on (n = 63) XR-NTX.

INTERVENTION

XR-NTX administrated as intramuscular injections (380 mg) every fourth week.

MEASUREMENTS

Data on retention, use of heroin and other illicit substances, opioid craving, treatment satisfaction, addiction-related problems and adverse events were reported every fourth week.

FINDINGS

Nine-month follow-up completion rates were 51.9% among participants continuing XR-NTX in the follow-up and 47.6% among those inducted on XR-NTX. Opioid abstinence rates were, respectively, 53.7 and 44.4%. No significant group differences were found in use of heroin and other opioids.

CONCLUSIONS

Opioid-dependent individuals who elect to switch from buprenorphine-naltrexone treatment after 3 months to extended-release naltrexone treatment for 9 months appear to experience similar treatment completion and abstinence rates and similar adverse event profiles to individuals who had been on extended-release naltrexone from the start of treatment.

Treatment of opioid dependence with buprenorphine: current update

Opioid maintenance treatment is the first-line approach in opioid dependence. Both the full opioid agonist methadone (MET) and the partial agonist buprenorphine (BUP) are licensed for the treatment of opioid dependence. BUP differs significantly from MET in its pharmacology, side effects, and safety issues. For example, the risk of respiratory depression is lower than with MET. The risk of diversion and injection of BUP have been reduced by also making it available as a tablet containing the opioid antagonist naloxone. This review summarizes the clinical effects of BUP and examines possible factors that can support decisions regarding the use of BUP or MET in opioid-dependent people.

Determining the Initiation of Opiate Misuse Resulting in Opioid Use Disorder in Pregnant Women

The aim of this study was to explore the "opiate misuse footprint" made by obstetrics and gynecology physicians in prescribing opioid medications for postpartum pain control that led to opioid misuse and opioid use disorder. Data were collected using intake information and anonymous surveys administered to pregnant women at local methadone clinics in Indianapolis, Indiana, in 2016-2017. Results from this study revealed that 40% of the 33 participants stated that the first drug they became addicted to was prescription opioids; 71% stated that the first opiate they became addicted to was a prescription pain medication. Prescription opioids were mainly obtained from emergency medicine physicians and friends. Reported use of opioids within the past four months was high, with the most commonly used drugs being methadone (57.6%) and heroin (42.4%). A majority of participants also endorsed a history of sexual and physical abuse, recent incarceration, and mental health disorders. As a large number of pregnant women with opioid use disorder reported their initial drug of misuse as prescription pain medications, it is important to avoid overprescribing opioids in reproductive-age women.

An investigation of an open-access model for scaling up methadone maintenance treatment

AIMS

To examine retrospectively patient and programmatic outcomes following the development and implementation of an 'open-access' model in which prospective patients were enrolled rapidly in methadone maintenance treatment, irrespective of ability to pay, and provided real-time access to multiple voluntary treatment options.

DESIGN

Medical and administrative records were abstracted to compare data for 1 year before and 9 years after initiating the implementation of an open-access treatment model in May 2007.

SETTING

Methadone maintenance treatment center in Connecticut, USA.

PARTICIPANTS

Individuals with opioid use disorder entering treatment between July 2006 and June 2015. In June 2015, 64% (n = 2594) of the sample were men and 80% (n = 3133) reported that they were white.

INTERVENTION

The Network for the Improvement of Addiction Treatment-informed open-access treatment model uses process improvement strategies to improve treatment access and capacity.

MEASUREMENTS

Census, waiting time, retention, non-medical opioid use, patient mortality and financial sustainability (net income and state-block grants as proportions of revenue).

FINDINGS

In the 9 years following the initial implementation of the open-access model, patient census increased by 183% from 1431 to 4051, and average waiting-time days decreased from 21 to 0.3 (same day) without apparent deleterious effects on rates of retention, non-medical opioid use or mortality. Between fiscal years (FY) 06 and FY 15, net operating margin rose from 2 to 10%, while state-block grant revenues declined 14% and the proportion of total revenue from state-block grant revenue decreased from 49 to 24%.

CONCLUSIONS

An open-access model for rapid enrolment of people with opioid use disorder in methadone treatment appears to improve treatment access, capacity, and financial sustainability without evidence of deleterious effects on treatment outcomes.

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.

Not just heroin: Extensive polysubstance use among US high school seniors who currently use heroin

BACKGROUND

Heroin-related deaths are on the rise in the US and a large portion of heroin overdoses involve co-use of other drugs such as benzodiazepines. A better understanding of heroin polysubstance use patterns could help discern better prevention measures.

METHODS

Data were examined from past-month ("current") heroin users from a nationally representative sample of high school seniors in the Monitoring the Future study (2010-2016, n = 327). We examined how past-month use and frequency of use of various drugs relate to frequency of current heroin use using chi-square and multivariable ordinal logistic regression.

RESULTS

Prevalence of any past-month use of various other drugs (and past-month use 10+ times) tends to increase as the frequency of heroin use increases; however, other drug use tends to decline among those reporting the use of heroin 40+ times in the past month. In multivariable models controlling for demographic characteristics, most levels of alcohol use were associated with decreased odds of higher-frequency heroin use (ps<.05). Nonmedical opioid (aOR = 5.84, p = .037) and tranquilizer (aOR = 14.63, p = .045) use 40+ times in the past month were associated with increased odds of higher-frequency heroin use.

CONCLUSIONS

High school seniors who use heroin also use multiple other drugs. Increases in the frequency of heroin use are associated with shifts in the nature and frequency of polysubstance use, with a higher frequency of heroin use associated with the highest percentage and frequency of use of depressants (nonmedical opioid and benzodiazepine use), compounding the risk of overdose. Prevention measures should consider polysubstance use patterns among heroin-using adolescents.

Preventing Opioid Overdose in the Clinic and Hospital: Analgesia and Opioid Antagonists

Drawing from existing opioid prescribing guidelines, this article describes how medical providers can reduce the risk of overdose. Through primary prevention, providers can prevent initial exposure and associated risks by educating patients, using risk stratification, minimizing opioid dose and duration, and avoiding coprescribing with sedatives. Secondary prevention efforts include monitoring patients with urine toxicology and prescription monitoring programs, and screening for opioid use disorders. Tertiary prevention includes treating opioid use disorders and providing naloxone to prevent overdose death. Specific preventive strategies may be required for those with psychiatric disorders or substance use disorders, adolescents, the elderly, and pregnant women.

Linking Individuals with Substance Use Disorders (SUDs) in Primary Care to SUD Treatment: the Recovery Management Checkups-Primary Care (RMC-PC) Pilot Study

Linking individuals in primary care settings with substance use disorders (SUDs) to SUD treatment has proven to be challenging, despite the widespread use of Screening, Brief Intervention, and Referral to Treatment (SBIRT). This paper reports findings from a pilot study that examined the efficacy of the Recovery Management Checkups intervention adapted for primary care settings (RMC-PC), for assertively linking and engaging patients from Federally Qualified Health Centers into SUD treatment. Findings showed that patients in the RMC-PC (n=92) had significantly higher rates of SUD treatment entry and received more days of SUD treatment compared with those who receive the usual SBIRT referral (n=50). Receipt of RMC-PC had both direct and indirect effects, partially mediated through days of SUD treatment, on reducing days of drug use at 6 months post intake. RMC-PC is a promising intervention to address the need for more assertive methods for linking patients in primary care to SUD treatment.

Peripheral levels of BDNF and opiate-use disorder: literature review and update

Several neurobiological factors are related to opiate-use disorder (OUD), and among them, neurotrophins have a relevant role. Brain-derived neurotrophic factor (BDNF) is a central neurotrophin involved in many neuronal processes, and it has been related to several psychiatric diseases and addictive disorders. BDNF can be measured in plasma and serum; its levels may reflect BDNF concentrations in the central nervous system (CNS) and, indirectly, CNS processes. Hence, peripheral BDNF could be a biomarker in clinical practice. This manuscript explores the findings about peripheral BDNF and OUD in humans. Opiates induce neurotoxicity in the CNS, which may be correlated with modifications in BDNF expression. Thus, basal levels of peripheral BDNF in OUD patients may be altered, which could be modified with abstinence. Also, opiates may modify epigenetic processes that may be associated with peripheral concentrations of BDNF, and in this line, withdrawal could reflect recovering processes in the CNS. Additionally, treatment modifies the peripheral concentrations of BDNF, but the clinical implications of those changes are yet not elucidated. No specific conclusion can be performed and more investigation in this area is necessary to elucidate the real potential of peripheral BDNF as a biomarker.