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

Trends in Opioid Use Disorder in the Veterans Health Administration, 2005-2022

Importance

Given the personal and social burdens of opioid use disorder (OUD), understanding time trends in OUD prevalence in large patient populations is key to planning prevention and treatment services.

Objective

To examine trends in the prevalence of OUD from 2005 to 2022 overall and by age, sex, and race and ethnicity.

Design, Setting, and Participants

This serial cross-sectional study included national Veterans Health Administration (VHA) electronic medical record data from the VHA Corporate Data Warehouse. Adult patients (age ≥18 years) with a current OUD diagnosis (using International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] and International Statistical Classification of Diseases, Tenth Revision, Clinical Modification [ICD-10-CM] codes) who received outpatient care at VHA facilities from January 1, 2005, to December 31, 2022, were eligible for inclusion in the analysis.

Main Outcomes and Measures

The main outcome was OUD diagnoses. To test for changes in prevalence of OUD over time, multivariable logistic regression models were run that included categorical study year and were adjusted for sex, race and ethnicity, and categorical age.

Results

The final sample size ranged from 4 332 165 to 5 962 564 per year; most were men (89.3%-95.0%). Overall, the annual percentage of VHA patients diagnosed with OUD almost doubled from 2005 to 2017 (0.60% [95% CI, 0.60%-0.61%] to 1.16% [95% CI, 1.15%-1.17%]; adjusted difference, 0.55 [95% CI, 0.54-0.57] percentage points) and declined thereafter (2022: 0.97% [95% CI, 0.97%-0.98%]; adjusted difference from 2017 to 2022, -0.18 [95% CI, -0.19 to -0.17] percentage points). This trend was similar among men (0.64% [95% CI, 0.63%-0.64%] in 2005 vs 1.22% [95% CI, 1.21%-1.23%] in 2017 vs 1.03% [95% CI, 1.02%-1.04%] in 2022), women (0.34% [95% CI, 0.32%-0.36%] in 2005 vs 0.68% [95% CI, 0.66%-0.69%] in 2017 vs 0.53% [95% CI, 0.52%-0.55%] in 2022), those younger than 35 years (0.62% [95% CI, 0.59%-0.66%] in 2005 vs 2.22% [95% CI, 2.18%-2.26%] in 2017 vs 1.00% [95% CI, 0.97%-1.03%] in 2022), those aged 35 to 64 years (1.21% [95% CI, 1.19%-1.22%] in 2005 vs 1.80% [95% CI, 1.78%-1.82%] in 2017 vs 1.41% [95% CI, 1.39%-1.42%] in 2022), and non-Hispanic White patients (0.44% [95% CI, 0.43%-0.45%] in 2005 vs 1.28% [95% CI, 1.27%-1.29%] in 2017 vs 1.13% [95% CI, 1.11%-1.14%] in 2022). Among VHA patients aged 65 years or older, OUD diagnoses increased from 2005 to 2022 (0.06% [95% CI, 0.06%-0.06%] to 0.61% [95% CI, 0.60%-0.62%]), whereas among Hispanic or Latino and non-Hispanic Black patients, OUD diagnoses decreased from 2005 (0.93% [95% CI, 0.88%-0.97%] and 1.26% [95% CI, 1.23%-1.28%], respectively) to 2022 (0.61% [95% CI, 0.59%-0.63%] and 0.82% [95% CI, 0.80%-0.83%], respectively).

Conclusions and Relevance

This serial cross-sectional study of national VHA electronic health record data found that the prevalence of OUD diagnoses increased from 2005 to 2017, peaked in 2017, and declined thereafter, a trend primarily attributable to changes among non-Hispanic White patients and those younger than 65 years. Continued public health efforts aimed at recognizing, treating, and preventing OUD are warranted.

Cannabis Use and Cannabis Use Disorder Among U.S. Adults with Psychiatric Disorders: 2001-2002 and 2012-2013

BACKGROUND

Rates of cannabis use disorder (CUD) have increased disproportionately among Veterans Administration (VA) patients with psychiatric disorders compared to patients with no disorder. However, VA patient samples are not representative of all U.S. adults, so results on disproportionate increases in CUD prevalence could have been biased. To address this concern, we investigated whether disproportionate increases in the prevalence of cannabis outcomes among those with psychiatric disorders would replicate in nationally representative samples of U.S. adults.

METHODS

Data came from two national surveys conducted in 2001-2002 (n = 43,093) and 2012-2013 (n = 36,309). Outcomes were any past-year non-medical cannabis use, frequent non-medical use (≥3 times weekly), and DSM-IV CUD. Psychiatric disorders included mood, anxiety and antisocial personality disorders. Logistic regression was used to generate predicted prevalences of the outcomes, prevalence differences calculated and additive interactions compared differences between those with and without psychiatric disorders.

RESULTS

Cannabis outcomes increased more among those with psychiatric disorders. The difference in prevalence differences included any past-year non-medical cannabis use, 2.45% (95%CI = 1.29-3.62); frequent non-medical cannabis use, 1.58% (95%CI = 0.83-2.33); CUD, 1.40% (95%CI = 0.58-2.21). For most specific disorders, prevalences increased more among those with the disorder.

CONCLUSIONS

In the U.S. general population, rates of cannabis use and CUD increased more among adults with psychiatric disorders than other adults, similar to findings from VA patient samples. Results suggest that although VA patients are not representative of all U.S. adults, findings from this important patient group can be informative. Greater clinical and policy attention to CUD is warranted for adults with psychiatric disorders.

Opioid-stimulant trends in overdose toxicology by race, ethnicity, & gender: An analysis in Delaware, 2013-2019

Recent upticks of stimulant presence in overdose deaths suggest the opioid epidemic is morphing, which raises questions about what drugs are involved and who is impacted. We investigate annual and growth rate trends in combined opioid-stimulant overdose toxicology between 2013 and 2019 for White, Black, and Hispanic male and female decedents in Delaware. During these years, toxicology shifted to illegal drugs for all with fentanyl leading the increase and opioid-cocaine combinations rising substantially. While combined opioid-cocaine toxicology grew among Black and Hispanic Delawareans, White males continue to report the highest rates overall. These findings depart from historical patterns and may challenge existing opioid epidemic policies.

Evaluating the Association between Prenatal Care Visits and Adverse Perinatal Outcome in Pregnancies Complicated by Opioid Use Disorder

OBJECTIVE

This study aimed to evaluate the association between number of prenatal care visits and adverse perinatal outcome among pregnant individuals with opioid use disorder (OUD).

STUDY DESIGN

This is a retrospective cohort of singleton, nonanomalous pregnancies complicated by OUD that delivered from January 2015 to July 2020 at our academic medical center. Primary outcome was the presence of composite adverse perinatal outcome, defined as one or more of the following: stillbirth, placental abruption, perinatal death, neonatal respiratory distress syndrome, need for morphine treatment, and hyperbilirubinemia. Logistic and linear regression estimated the association between the number of prenatal care visits and the presence of adverse perinatal outcome. A Mann-Whitney U test evaluated the association between number of prenatal care visits and length of hospital stay for the neonate.

RESULTS

A total of 185 patients were identified, of which 35 neonates required morphine treatment for neonatal opioid withdrawal syndrome. During pregnancy, most individuals were treated with buprenorphine 107 (57.8%), whereas 64 (34.6%) received methadone, 13 (7.0%) received no treatment, and 1 (0.5%) received naltrexone. The median number of prenatal care visits was 8 (interquartile range: 4-10). With each additional visit per 10 weeks of gestational age, the risk of adverse perinatal outcome decreased by 38% (95% confidence interval [CI]: 0.451-0.854). The need for neonatal intensive care and hyperbilirubinemia also significantly decreased with additional prenatal visits. Neonatal hospital stay decreased by a median of 2 days (95% CI: 1-4) for individuals who received more than the median of eight prenatal care visits.

CONCLUSION

Pregnant individuals with OUD who attend fewer prenatal care visits experience more adverse perinatal outcome. Future research should focus on barriers to prenatal care and interventions to improve access in this high-risk population.

KEY POINTS

· Use of prenatal care affects newborn outcomes.. · More prenatal care shortens neonatal hospital stay.. · Prenatal care reduces certain adverse outcomes..

Gender differences in the prevalence of stimulant misuse in the United States: 2015-2019

BACKGROUND AND OBJECTIVES

The gender gap in prevalence of substance-use disorders has narrowed. However, gender differences in stimulant misuse have not been well-characterized in recent years. The aim of this study was to quantify gender differences in past-year stimulant misuse and stimulant-use disorder, separated by stimulant type (cocaine/crack, prescription stimulants, and methamphetamine). In an exploratory aim, we investigated whether gender differences were moderated by age or sexual orientation.

METHODS

We combined data from the National Survey on Drug Use and Health from 2015 to 2019 (unweighted N = 282,768) to test gender differences in the prevalence of past-year stimulant misuse.

RESULTS

Results indicated that stimulant misuse was significantly more prevalent in men than women for all stimulant types for both past-year use and past-year use disorder. The magnitude of this sex difference was smallest for prescription stimulants, where men had 1.37 times higher odds of past-year misuse and no gender difference was observed in the prevalence of prescription stimulant-use disorder. The magnitude of gender differences also varied based on both age and sexual orientation.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Illicit stimulant misuse continues to be more common in men than in women; however, gender differences are more modest for prescription stimulant misuse, suggesting a narrowing of this historical gender difference.

Transcranial direct current stimulation combined with cognitive training improves decision making and executive functions in opioid use disorder: a triple-blind sham-controlled pilot study

Opioid use disorder (OUD) is a chronic disorder with a considerable amount of morbidity and mortality. Despite remarkable improvement achieved by maintenance programs, an array of treatment goals were still unmet. Mounting evidence suggests that transcranial Direct Current Stimulation (tDCS) improves decision making and cognitive functions in addictive disorders. tDCS paired with a decision making task was depicted to diminish impulsivity as well.

The present study aimed to assess the effect of tDCS combined with cognitive training (CT) in OUD for the first time.

In this triple-blind randomized sham-controlled pilot study, 38 individuals with OUD from the Buprenorphine-Naloxone Maintenance Therapy program were administered 20-minutes of 2 mA active/sham tDCS over the dorsolateral prefrontal cortex with concomitant cognitive training. A selected test battery evaluating decision making under risk and ambiguity as well as executive functions, verbal fluency and working memory was utilized before and after the intervention.

Greater improvements were observed in decision making under ambiguity (p = 0.016), set shifting ability and alternating fluency while no improvements were observed in decision making under risk in the active group, compared to sham.

Deficits of decision making and executive functions have a pivotal role in the perpetuation and the relapse of the OUD. Alleviation of these impairments brought tDCS/CT forth as an expedient neuroscientifically-grounded treatment option that merits further exploration in OUD, Trial registration: NCT05568251.

An Analysis of Social Determinants of Health and Their Implications for Hepatitis C Virus Treatment in People Who Inject Drugs: The Case of Baltimore

Background

Sixty-eight percent of the nearly 3.5 million people living with hepatitis C virus (HCV) in the United States are people who inject drugs (PWID). Despite effective treatments, uptake remains low in PWID. We examined the social determinants of health (SDoH) that affect the HCV care cascade.

Methods

We conducted a secondary analysis of data from 720 PWID in a cluster-randomized trial. We recruited PWID from 12 drug-affected areas in Baltimore. Inclusion criteria were injection in the prior month or needle sharing in the past 6 months. Intake data consisted of a survey and HCV testing. Focusing on SDoH, we analyzed self-report of (1) awareness of HCV infection (in those with active or previously cured HCV) and (2) prior HCV treatment (in the aware subgroup). We used descriptive statistics and logistic regression for statistical analyses.

Results

The 342 participants were majority male and Black with a median age of 52 years. Women were more likely to be aware of their status but less likely to be treated. Having a primary care provider and HIV-positive status were associated with increased awareness and treatment. Unhoused people had 51% lower odds of HCV treatment. People who reported that other PWID had shared their HCV status with them had 2.3-fold higher odds of awareness of their own status.

Conclusions

Further study of gender disparities in HCV treatment access is needed. Increased social support was associated with higher odds of HCV treatment, suggesting an area for future interventions. Strategies to identify and address SDoH are needed to end HCV.

Evidence of "Repeated Admission Bias" Among Those Who Use Injection Drugs Across 2 Decades of US Treatment Admissions: 2000-2020

OBJECTIVES

Encounter-based datasets like the Treatment Episode Dataset-Admissions (TEDS-A) are used for substance use-related research. Although TEDS-A reports the number of previous treatment admissions, a limitation is this reflects encounters, not people. We sought to quantify the methodologic bias incorporated by using all encounters versus initial encounters and assess if this risk is evenly distributed across all routes of drug administration.

METHODS

TEDS-A 2000-2020 dataset with nonmissing primary substance data was used. Of the data, 3.17% were missing the usual administration route, and 11.9% were missing prior admission data. Prior admissions are documented as 0 through 4, then binned for 5 or greater (5+). Risk of admission bias was defined as odds ratio (OR RAB ): odds of total admissions relative to the odds of the first admission. Bootstrap confidence intervals were generated (5000 iterations) across administration routes and demographics; however, their widths were <0.0055 and not reported.

RESULTS

There were 38,238,586 admissions over the 21 years, with 13,865,517 (41.2%) first admissions. Of all admissions, 15.7% indicated injection drug use (IDU); 26.3% of encounters reporting IDU were in the 5+ group. This resulted in an OR RAB of 1.77. White enrollees had an elevated OR RAB (1.05), whereas among Latinos, OR RAB was low (0.74).

CONCLUSIONS

Using encounter-based datasets can introduce bias when including all admissions versus exclusively initial treatment episodes. This report is the first to quantify this bias and shows that individuals with IDU are at highest risk for returning to treatment, thereby over-representing this method of use when all encounters are used.

"I Just Don't Feel Heard": A Case Study on Opioid Use Disorder and Pain Management

The nation's opioid epidemic requires a paradigm shift in the way patients with co-occurring opioid use disorder are treated during episodes of acute pain. Patients are often introduced to prescription opioids after an extremity fracture or sprain or resulting from musculoskeletal back, abdominal, or dental pain. Opioid naive patients who receive their first opioid prescription on discharge from the emergency department may be more likely to develop chronic opioid use compared to patients receiving non-opioid pain medications. This case report will highlight one patient's journey including initial prescription opioid use, escalation into illicit opioids, entry to a recovery and treatment program, discussions with her physician about alternative therapies, and barriers to satisfactory pain relief. A shared decision-making model will be explored.

Prevalence and correlates of DSM-5 opioid withdrawal syndrome in U.S. adults with non-medical use of prescription opioids: results from a national sample

Background: In the U.S. non-medical use of prescription opioids (NMOU) is prevalent and often accompanied by opioid withdrawal syndrome (OWS). OWS has not been studied using nationally representative data.Objectives: We examined the prevalence and clinical correlates of OWS among U.S. adults with NMOU.Methods: We used data from 36,309 U.S. adult participants in the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III, 1,527 of whom reported past 12-month NMOU. Adjusted linear and logistic regression models examined associations between OWS and its clinical correlates, including psychiatric disorders, opioid use disorder (OUD; excluding the withdrawal criterion), medical conditions, and healthcare utilization among people with regular (i.e. ≥3 days/week) NMOU (n = 534).Results: Over half (50.4%) of the sample was male. Approximately 9% of people with NMOU met criteria for DSM-5 OWS, with greater prevalence of OWS (∼20%) among people with regular NMOU. Individuals with bipolar disorder, dysthymia, panic disorder, and borderline personality disorder had greater odds of OWS (aOR range = 2.71-4.63). People with OWS had lower mental health-related quality of life (β=-8.32, p < .001). Individuals with OUD also had greater odds of OWS (aOR range = 26.02-27.77), an association that increased with more severe OUD. People using substance use-related healthcare services also had greater odds of OWS (aOR range = 6.93-7.69).Conclusion: OWS was prevalent among people with OUD and some psychiatric disorders. These findings support screening for OWS in people with NMOU and suggest that providing medication- assisted treatments and behavioral interventions could help to reduce the burden of withdrawal in this patient population.

Natural Polyphenols-Resveratrol, Quercetin, Magnolol, and β-Catechin-Block Certain Aspects of Heroin Addiction and Modulate Striatal IL-6 and TNF-α

We have examined the effects of four different polyphenols in attenuating heroin addiction using a conditioned place preference (CPP) paradigm. Adult male Sprague Dawley rats received heroin (alternating with saline) in escalating doses starting from 10 mg/kg, i.p. up to 80 mg/kg/d for 14 consecutive days. The rats were treated with distilled water (1 mL), quercetin (50 mg/kg/d), β-catechin (100 mg/kg/d), resveratrol (30 mg/kg/d), or magnolol (50 mg/kg/d) through oral gavage for 7 consecutive days, 30 min before heroin administration, starting on day 8. Heroin withdrawal manifestations were assessed 24 h post last heroin administration following the administration of naloxone (1 mg/kg i.p). Heroin CPP reinstatement was tested following a single dose of heroin (10 mg/kg i.p.) administration. Striatal interleukin 6 (IL-6) and tumor necrosis factor alpha (TNF-α) were quantified (ELISA) after naloxone-precipitated heroin withdrawal. Compared to the vehicle, the heroin-administered rats spent significantly more time in the heroin-paired chamber (p < 0.0001). Concomitant administration of resveratrol and quercetin prevented the acquisition of heroin CPP, while resveratrol, quercetin, and magnolol blocked heroin-triggered reinstatement. Magnolol, quercetin, and β-catechin blocked naloxone-precipitated heroin withdrawal and increased striatal IL-6 concentration (p < 0.01). Resveratrol administration was associated with significantly higher withdrawal scores compared to those of the control animals (p < 0.0001). The results of this study show that different polyphenols target specific behavioral domains of heroin addiction in a CPP model and modulate the increase in striatal inflammatory cytokines TNF-α and IL-6 observed during naloxone-precipitated heroin withdrawal. Further research is needed to study the clinical utility of polyphenols and to investigate the intriguing finding that resveratrol enhances, rather than attenuates naloxone-precipitated heroin withdrawal.

Molecular brain differences and cannabis involvement: A systematic review of positron emission tomography studies

BACKGROUND

An increasing number of studies have used positron emission tomography (PET) to investigate molecular neurobiological differences in individuals who use cannabis. This study aimed to systematically review PET imaging research in individuals who use cannabis or have cannabis use disorder (CUD).

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria, a comprehensive systematic review was undertaken using the PubMed, Scopus, PsycINFO and Web of Science databases.

RESULTS

In total, 20 studies were identified and grouped into three themes: (1) studies of the dopamine system primarily found that cannabis use was associated with abnormal striatal dopamine synthesis capacity, which was in turn correlated with clinical symptoms; (2) studies of the endocannabinoid system found that cannabis use and CUD are associated with lower cannabinoid receptor type 1 availability and global reductions in fatty acid amide hydrolase binding; (3) studies of brain metabolism found that individuals who use cannabis exhibit lower normalized glucose metabolism in both cortical and subcortical brain regions, and reduced cerebral blood flow in the lateral prefrontal cortex during experimental tasks. Heterogeneity across studies prevented meta-analysis.

CONCLUSION

Existing PET imaging research reveals substantive molecular differences in cannabis users in the dopamine and endocannabinoid systems, and in global brain metabolism, although the heterogeneity of designs and approaches is very high, and whether these differences are causal versus consequential is largely unclear.

Estimated Clinical Outcomes and Cost-effectiveness Associated With Provision of Addiction Treatment in US Primary Care Clinics

Importance

US primary care practitioners (PCPs) are the largest clinical workforce, but few provide addiction care. Primary care is a practical place to expand addiction services, including buprenorphine and harm reduction kits, yet the clinical outcomes and health care sector costs are unknown.

Objective

To estimate the long-term clinical outcomes, costs, and cost-effectiveness of integrated buprenorphine and harm reduction kits in primary care for people who inject opioids.

Design, Setting, and Participants

In this modeling study, the Reducing Infections Related to Drug Use Cost-Effectiveness (REDUCE) microsimulation model, which tracks serious injection-related infections, overdose, hospitalization, and death, was used to examine the following treatment strategies: (1) PCP services with external referral to addiction care (status quo), (2) PCP services plus onsite buprenorphine prescribing with referral to offsite harm reduction kits (BUP), and (3) PCP services plus onsite buprenorphine prescribing and harm reduction kits (BUP plus HR). Model inputs were derived from clinical trials and observational cohorts, and costs were discounted annually at 3%. The cost-effectiveness was evaluated over a lifetime from the modified health care sector perspective, and sensitivity analyses were performed to address uncertainty. Model simulation began January 1, 2021, and ran for the entire lifetime of the cohort.

Main Outcomes and Measures

Life-years (LYs), hospitalizations, mortality from sequelae (overdose, severe skin and soft tissue infections, and endocarditis), costs, and incremental cost-effectiveness ratios (ICERs).

Results

The simulated cohort included 2.25 million people and reflected the age and gender of US persons who inject opioids. Status quo resulted in 6.56 discounted LYs at a discounted cost of $203 500 per person (95% credible interval, $203 000-$222 000). Each strategy extended discounted life expectancy: BUP by 0.16 years and BUP plus HR by 0.17 years. Compared with status quo, BUP plus HR reduced sequelae-related mortality by 33%. The mean discounted lifetime cost per person of BUP and BUP plus HR were more than that of the status quo strategy. The dominating strategy was BUP plus HR. Compared with status quo, BUP plus HR was cost-effective (ICER, $34 400 per LY). During a 5-year time horizon, BUP plus HR cost an individual PCP practice approximately $13 000.

Conclusions and Relevance

This modeling study of integrated addiction service in primary care found improved clinical outcomes and modestly increased costs. The integration of addiction service into primary care practices should be a health care system priority.

Validity of the DSM-5 craving criterion for alcohol, tobacco, cannabis, cocaine, heroin, and non-prescription use of prescription painkillers (opioids)

BACKGROUND

Although the DSM-5 was adopted in 2013, the validity of the new substance use disorder (SUD) diagnosis and craving criterion has not been investigated systematically across substances.

METHODS

Adults (N = 588) who engaged in binge drinking or illicit drug use and endorsed at least one DSM-5 SUD criterion were included. DSM-5 SUD criteria were assessed for alcohol, tobacco, cannabis, cocaine, heroin, and opioids. Craving was considered positive if "wanted to use so badly that could not think of anything else" (severe craving) or "felt a very strong desire or urge to use" (moderate craving) was endorsed. Baseline information on substance-related variables and psychopathology was collected, and electronic daily assessment queried substance use for the following 90 days. For each substance, logistic regression estimated the association between craving and validators, i.e. variables expected to be related to craving/SUD, and whether association with the validators differed for DSM-5 SUD diagnosed with craving as a criterion v. without.

RESULTS

Across substances, craving was associated with most baseline validators (p values<0.05); neither moderate nor severe craving consistently showed greater associations. Baseline craving predicted subsequent use [odds ratios (OR): 4.2 (alcohol) - 234.3 (heroin); p's ⩽ 0.0001], with stronger associations for moderate than severe craving (p's < 0.05). Baseline DSM-5 SUD showed stronger associations with subsequent use when diagnosed with craving than without (p's < 0.05).

CONCLUSION

The DSM-5 craving criterion as operationalized in this study is valid. Including craving improves the validity of DSM-5 SUD diagnoses, and clinical relevance, since craving may cause impaired control over use and development and maintenance of SUD.

Enumerating contributions of fentanyls and other factors to the unprecedented 2020 rise in opioid overdose deaths: model-based analysis

In 2020, the ongoing US opioid overdose crisis collided with the emerging COVID-19 pandemic. Opioid overdose deaths (OODs) rose an unprecedented 38%, due to a combination of COVID-19 disrupting services essential to people who use drugs, continued increases in fentanyls in the illicit drug supply, and other factors. How much did these factors contribute to increased OODs? We used a validated simulation model of the opioid overdose crisis, SOURCE, to estimate excess OODs in 2020 and the distribution of that excess attributable to various factors. Factors affecting OODs that could have been disrupted by COVID-19, and for which data were available, included opioid prescribing, naloxone distribution, and receipt of medications for opioid use disorder. We also accounted for fentanyls' presence in the heroin supply. We estimated a total of 18,276 potential excess OODs, including 1,792 lives saved due to increases in buprenorphine receipt and naloxone distribution and decreases in opioid prescribing. Critically, growth in fentanyls drove 43% (7,879) of the excess OODs. A further 8% is attributable to first-ever declines in methadone maintenance treatment and extended-released injectable naltrexone treatment, most likely due to COVID-19-related disruptions. In all, 49% of potential excess OODs remain unexplained, at least some of which are likely due to additional COVID-19-related disruptions. While the confluence of various COVID-19-related factors could have been responsible for more than half of excess OODs, fentanyls continued to play a singular role in excess OODs, highlighting the urgency of mitigating their effects on overdoses.

Burden of disease due to amphetamines, cannabis, cocaine, and opioid use disorders in South America, 1990-2019: a systematic analysis of the Global Burden of Disease Study 2019

BACKGROUND

South America's substance use profile, poverty, income inequality, and cocaine-supplier role make it a unique place for substance use research. This study investigated the burden of disease attributable to amphetamine use disorder, cannabis use disorder (CAD), cocaine use disorder, and opioid use disorder (OUD) in South America from 1990 to 2019, on the basis of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019.

METHODS

GBD 2019 estimated the incidence, prevalence, mortality, years of life lost (YLL), years of life lived with disability (YLD), and disability-adjusted life-years (DALYs) due to substance use disorders in each of the 12 South American countries (Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Guyana, Paraguay, Peru, Suriname, Uruguay, and Venezuela). Data were modelled using standardised tools (ie, the Cause of Death Ensemble model, spatio-temporal Gaussian process regression, and disease modelling meta-regression) to generate estimates of each quantity of interest by sex, location, and year. The analysis included comparisons by sex and country, and against regional and global estimates.

FINDINGS

In 2019, the highest amphetamine use disorder burden per 100 000 population in South America was in Peru (66 DALYs). CAD DALY rates per 100 000 in South America were stable between 1990 and 2019, except in Chile and Colombia, which had the highest rates in 2019 (19 DALYs for Chile and 18 DALYs for Colombia). OUD DALYs per 100 000 increased during the period in Brazil and Peru, which in 2019 had the highest rates in South America (82 DALYs for Brazil and 70 DALYs for Peru). In 2019, Brazil had the highest cocaine use disorder DALYs per 100 000 (45 DALYs), nearly double its rate in 1990. DALY rates were higher in males than females for each substance use disorder, except in Paraguay. The overall burden of substance use disorders was higher in males than in females, mainly because of cocaine use disorder and CAD, whereas for amphetamine use disorder, the difference between sexes was minimal, and for OUD there was no difference. For males and females, the highest rate of substance use disorders DALYs per 100 000 was for OUD except in Argentina (in males, 58 DALYs for cocaine use disorder vs 52 DALYs for OUD) and in Paraguay (in females, 77 for amphetamine use disorder vs 50 for OUD). CAD DALY rates were generally the lowest among the substance use disorders for males and females. Amphetamine use disorder YLD rates were reasonably stable throughout the period and were highest in Peru, Paraguay, and Uruguay (>40 YLD per 100 000). For CAD, YLD rates were stable in all countries except Chile and Colombia. Cocaine use disorder YLD rates per 100 000 for the top four countries (Argentina, Uruguay, Chile, and Brazil) increased from 1990 to 2010 (eg, from 19 to 33 in Brazil), but decreased between 2010 and 2019 (eg, from 36 to 31 in Chile). For OUD, YLD rates showed a slight increase in most countries apart from Brazil, which increased from 52 in 1990 to 80 in 2019 and was top among the countries. Amphetamine use disorder YLL rates per 100 000 were highest in Suriname and Peru during the period, although in Suriname it increased from 2·7 in 2010 to 3·2 in 2019, whereas in Peru it decreased from 2·1 to 1·7. The highest YLL rate for cocaine use disorder was in Brazil, which increased from 3·7 in 1990 to 18·1 in 2019. Between 2000 and 2019, Chile and Uruguay showed the highest OUD YLL rates (11·6 for Chile and 10·9 for Uruguay). A high incidence of CAD was found in Chile, Colombia, Guyana, and Suriname. There were high incidences of amphetamine use disorder in Paraguay, cocaine use disorder in Argentina, and OUD in Ecuador. A decrease in annual prevalence for substance use disorders during the period was observed in Venezuela (amphetamine use disorder, CAD, and OUD), Brazil (CAD and amphetamine use disorder), Colombia (amphetamine use disorder and cocaine use disorder), Peru (amphetamine use disorder and cocaine use disorder), Chile and Suriname (amphetamine use disorder), Uruguay (CAD), and Bolivia (OUD). Overall, the cocaine use disorder burden stabilised then decreased. OUD was less prevalent than other substance use disorders but its burden was the highest.

INTERPRETATION

The decrease in the burden of cocaine use disorder probably reflects the success of national standardised treatment programmes. Programmes for amphetamine use disorder, CAD, and OUD management should be improved. We did not find an increase in CAD burden in Uruguay, the country with the highest degree of cannabis decriminalisation in the region. Countries in South America should improve monitoring of substance use disorders, including regular surveys to provide more accurate data on which to base policy decisions.

FUNDING

The Bill & Melinda Gates Foundation.

Race-based differences in drug use prior to onset of opioid use disorder

Rates of opioid use disorder (OUD) have increased dramatically over the past two decades, a rise that has been accompanied by changing demographics of those affected. Early exposure to drugs is a known risk factor for later development of opioid use disorder; but how and whether this risk factor may differ between racial groups is unknown. Our study seeks to identify race differences in self-report of current and past substance use in OUD-diagnosed treatment-seeking individuals. Patients (n = 157) presenting for methadone maintenance treatment at a racially diverse urban opioid treatment program were approached and consented for study involvement. Participants were administered substance use history questionnaires and urine drug screening at intake. Chi-square, t-tests, and rank-sum were used to assess race differences in demographic variables. Logistic and linear regressions assessed the relationship between race and substance use for binary and continuous variables, respectively. 61% of the population identified as Black and 39% as White. Black participants were significantly older; age was thus included as a covariate. Logistic regressions demonstrated that despite similar urine toxicology at intake, White participants were significantly more likely to report having used prescription opioids and psychedelic, stimulant, and sedative substance classes prior to their first use of non-pharmaceutical opioids. Compared to Black participants, White treatment-seeking OUD-diagnosed individuals reported using a wider range of substances ever and prior to first use of non-pharmaceutical opioids. There were no differences, however, in presentation for OUD treatment, suggesting different pathways to OUD, which may carry important clinical implications.

Expanding the scope, reach, and impact of evidence-based psychological treatments

The development and evaluation of evidence-based treatments (EBTs) for mental disorders represent an enormous advance with continued progress designed to understand the techniques and increase their use in clinical practice. This article suggests ways of expanding research along several fronts including the extension of the types of randomized controlled trials that are conducted, the use of more diverse samples to encompass different cultures and countries, the expansion of assessments to better reflect client functioning in everyday life, consideration of the impact of treatments for mental disorders on physical health, the careful evaluation of exceptional responders, the use of mixed-methods research, and the development of versions of EBTs that can be scaled. EBTs have been studied in well-controlled settings and extended to clinical settings, albeit less often. The least attention has been accorded their evaluation on a large scale to reach a greater portion of people in need of services but who do not receive any treatment.

Trajectories of prescription opioid and heroin use in adulthood

BACKGROUND AND OBJECTIVES

Due to a reduction in the availability of prescription opioids in the United States, the potential transition from prescription opioids to heroin is a public health concern. We assessed trajectories of both nonmedical prescription opioid (NMPO) and heroin use from adolescence (age 18) to adulthood (age 50) and how these trajectories were associated with substance use disorder (SUD) in adulthood (age 35-50).

METHODS

A national sample of 26,569 individuals from eleven cohorts of US high school seniors (1976-1986) who were followed until age 50 (2008-2018). The analysis focuses on respondents who engaged in past-year NMPO and heroin use. Outcomes included the endorsement of two or more SUD symptoms.

RESULTS

Among NMPO users, 7.5% had used heroin by the age of 50. The latent profile analyses assessing individuals who reported both NMPO and heroin use during the 32-year study period found four unique trajectory groups: (1) "age 18 concurrent use" (81.2%); (2) "mid-30s NMPO-to-heroin use transition" (10.7%); (3) age 19/20 NMPO-to-heroin use transition, followed by 40s heroin-to-NMPO use transition (4.3%); and (4) "mid-20s NMPO-to-heroin use transition" (3.7%). Respondents in the "mid-30s NMPO-to-heroin use transition" trajectory group had the highest odds of indicating two or more SUD symptoms between ages 35-50.

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

This is the first study to assess NMPO and heroin use trajectories among a national probability-based sample followed from age 18 to 50. The findings suggest that prescription opioid misuse is a risk factor in the development of SUDs and has a long-term impact.

What is the prevalence of and trend in opioid use disorder in the United States from 2010 to 2019? Using multiplier approaches to estimate prevalence for an unknown population size

Opioid-related overdose deaths have increased since 2010 in the U.S., but information on trends in opioid use disorder (OUD) prevalence is limited due to unreliable data. Multiplier methods are a classical epidemiological technique to estimate prevalence when direct estimation is infeasible or unreliable. We used two different multiplier approaches to estimate OUD prevalence from 2010 to 2019. First, we estimated OUD in National Survey on Drug Use and Health (NSDUH), and based on existing capture-recapture studies, multiplied prevalence by 4.5x. Second, we estimated the probability of drug poisoning death among people with OUD (Meta-analysis indicates 0.52/100,000), and divided the number of drug poisoning deaths in the US by this probability. Estimates were weighted to account for increase in drug-related mortality in recent years due to fentanyl. Estimated OUD prevalence was lowest when estimated in NSDUH with no multiplier, and highest when estimated from vital statistics data without adjustment. Consistent findings emerged with two methods: NSDUH data with multiplier correction, and vital statistics data with multiplier and adjustment. From these two methods, OUD prevalence increased from 2010 to 2014; then stabilized and slightly declined annually (survey data with multiplier, highest prevalence of 4.0% in 2015; death data with a multiplier and correction, highest prevalence of 2.35% in 2016). The number of US adolescent and adult individuals with OUD in 2019 was estimated between 6.7-7.6 million. When multipliers and corrections are used, OUD may have stabilized or slightly declined after 2015. Nevertheless, it remains highly prevalent, affecting 6-7 million US adolescents and adults.

Opioid Use Disorder Among Clients of Community Mental Health Clinics: Prevalence, Characteristics, and Treatment Willingness

OBJECTIVE

The authors examined the prevalence of co-occurring opioid use disorder and willingness to engage in treatment among clients of eight Los Angeles County Department of Mental Health outpatient clinics.

METHODS

Adults presenting for an appointment over a 2-week period were invited to complete a voluntary, anonymous health survey. Clients who indicated opioid use in the past year were offered a longer survey assessing probable opioid use disorder. Willingness to take medication and receive treatment also was assessed.

RESULTS

In total, 3,090 clients completed screening. Among these, 8% had a probable prescription (Rx) opioid use disorder and 2% a probable heroin use disorder. Of the clients with probable Rx opioid use or heroin use disorder, 49% and 25% were female, respectively. Among those with probable Rx opioid use disorder, 43% were Black, 33% were Hispanic, and 12% were White, and among those with probable heroin use disorder, 24% were Black, 22% were Hispanic, and 39% were White. Seventy-eight percent of those with Rx opioid use disorder had never received any treatment, and 82% had never taken a medication for this disorder; 39% of those with heroin use disorder had never received any treatment, and 39% had never received a medication. The strongest predictor of willingness to take a medication was believing that it would help stop opioid use (buprenorphine, β=13.54, p=0.003, and naltrexone long-acting injection, β=15.83, p<0.001).

CONCLUSIONS

These findings highlight the need to identify people with opioid use disorder and to educate clients in mental health settings about medications for these disorders.

Nanoarchitectonics for Abused-Drug Biosensors

Rapid, accessible, and highly accurate biosensors for the detection of addictive and abused drugs are needed to reduce the adverse personal and societal impacts of addiction. Modern sensors that utilize next-generation technologies, e.g., nanobiotechnology and nanoarchitectonics, have triggered revolutionary progress in the field as they allow accurate detection and tracking of trace levels of major classes of drugs. This paper reviews advances in the field of biosensors for the detection of commonly abused drugs, both prescribed such as codeine and morphine, and illegal narcotics like cocaine.

The effect of Medicaid expansion on state-level utilization of buprenorphine for opioid use disorder in the United States

BACKGROUND

Research on the impact of Medicaid expansion on buprenorphine utilization has largely focused on the Medicaid program. Less is known about its associations with total buprenorphine utilization and non-Medicaid payers.

METHODS

Monthly prescription data (June 2013-May 2018) for proprietary and generic sublingual as well as buccal buprenorphine products were purchased from IQVIA®. Population-adjusted state-level utilization measures were constructed for Medicaid, commercial insurance, Medicare, cash, and total utilization. A difference-in-differences (DID) approach with population weights estimated the association between Medicaid expansion and buprenorphine utilization, while controlling for treatment capacity.

RESULTS

Monthly total buprenorphine prescriptions increased by 68% overall and increased 283% for Medicaid, 30% for commercial insurance, and 143% for Medicare. Cash prescriptions decreased by 10%. The DID estimate for Medicaid expansion was not statistically significant for total utilization (-19.780, 95% CI = -45.118, 5.558, p = .123). For Medicaid buprenorphine utilization, there was a significant increase of 27.120 prescriptions per 100,000 total state residents (95% CI = 9.458, 44.782, p = .003) in expansion states versus non-expansion states post-Medicaid expansion. Medicaid expansion had a negative effect on commercial insurance (DID estimate = -37.745, 95% CI = -62.946, -12.544, p = .004), cash utilization (DID estimate = -6.675, 95% CI = -12.627, -0.723, p = .029), and Medicare utilization (DID estimate = -1.855, 95% CI = -3.697, -0.013, p = .048).

DISCUSSION

The associations between Medicaid expansion and buprenorphine utilization varied across different types of payers, such that the overall impact of Medicaid expansion on buprenorphine utilization was not significant.

Latent trajectories of anxiety and depressive symptoms among adults in early treatment for nonmedical opioid use

BACKGROUND

Understanding the course of anxiety and depressive symptoms in early opioid use disorder (OUD) treatment may inform efforts to promote positive early treatment response and reduce treatment attrition.

METHODS

Persons in treatment for nonmedical opioid use were identified from 86 addiction treatment facilities. Growth mixture modeling was used to identify trajectories of anxiety and depression symptoms during the first month of treatment among individuals who screened positive for depression (N = 3016) and/or anxiety (N = 2779) at intake.

RESULTS

A three-class solution best fit the data for anxiety symptoms and included the following trajectories: (1) persistent moderate-to-severe anxiety symptoms, (2) remitting severe anxiety symptoms, and (3) persistent minimal-to-mild anxiety symptoms. Similarly, a three-class solution best fit the data for depressive symptoms and included trajectories characterized by (1) persistent moderate-to-severe depressive symptoms, (2) persistent moderate depressive symptoms, and (3) mild/remitting depressive symptoms. Persistent moderate-to-severe anxiety and depressive symptoms were predicted by female gender and heavy past-month benzodiazepine co-use.

LIMITATIONS

Fine grained-information about substance use was not collected. Results may not be generalizable to individuals receiving treatment outside of specialty addiction clinics.

CONCLUSIONS

Analysis of anxiety and depression symptom trajectories in early treatment suggest that a subset of individuals entering treatment for opioid use experienced persistent and significant anxiety and depressive symptoms, whereas others experience a remission of symptoms. Interventions designed to target individuals at the greatest risk, such as women and individuals reporting opioid/benzodiazepine co-use, may help improve mental health symptoms in early OUD treatment.

Standardizing Opioid Prescribing in a Pediatric Hospital: A Quality Improvement Effort

BACKGROUND

Opioids are indicated for moderate-to-severe pain caused by trauma, ischemia, surgery, cancer and sickle cell disease, and vaso-occlusive episodes (SCD-VOC). There is only limited evidence regarding the appropriate number of doses to prescribe for specific indications. Therefore, we developed and implemented an opioid prescribing algorithm with dosing guidelines for specific procedures and conditions. We aimed to reach and sustain 90% compliance within 1 year of implementation.

METHODS

We conducted this quality improvement effort at a pediatric academic quaternary care institution. In 2018, a multidisciplinary team identified the need for a standard approach to opioid prescribing. The algorithm guides prescribers to evaluate the medical history, physical examination, red flags, pain type, and to initiate opioid-sparing interventions before prescribing opioids. Opioid prescriptions written between January 2015 and September 2020 were included. Examples from 2 hospital departments will be highlighted. Control charts for compliance with guidelines and variability in the doses prescribed are presented for selected procedures and conditions.

RESULTS

Over 5 years, 83 037 opioid prescriptions in 53 804 unique patients were entered electronically. The encounters with ≥1 opioid prescription decreased from 48% to 25% between 2015 and 2019. Compliance with the specific guidelines increased to ∼85% for periacetabular osteotomies and SCD-VOC and close to 100% for anterior-cruciate ligament surgery. In all 3 procedures and conditions, variability in the number of doses prescribed decreased significantly.

CONCLUSION

We developed an algorithm, guidelines, and a process for improvement. The number of opioid prescriptions and variability in opioid prescribing decreased. Future evaluation of specific initiatives within departments is needed.

"I'm a Survivor": Perceptions of Chronic Disease and Survivorship Among Individuals in Long-Term Remission from Opioid Use Disorder

BACKGROUND

While opioid use disorder (OUD) is prevalent, little is known about what patients with OUD in sustained remission think about the chronic disease model of OUD and their perspectives of the cause, course, and ongoing treatment needs of their OUD.

OBJECTIVE

To (1) examine patient perceptions of the chronic disease model of addiction and disease identity and (2) use an explanatory model framework to explore how these perceptions inform ongoing treatment needs and help maintain abstinence.

DESIGN

Qualitative study of a cross-sectional cohort of patients with OUD in long-term sustained remission currently receiving methadone or buprenorphine. Participants completed a single in-depth, semi-structured individual interview.

PARTICIPANTS

Twenty adults were recruited from two opioid treatment programs and two office-based opioid treatment programs in Baltimore, MD. Half of the participants were Black, had a median (IQR) age of 46.5 (43-52) years and the median (IQR) time since the last non-prescribed opioid was 12 (8-15) years.

APPROACH

Hybrid deductive-inductive thematic analysis of the transcribed interviews.

KEY RESULTS

Some participants described a chronic OUD disease identity where they continue to live with OUD. Participants who maintain an OUD identity describe inherent traits or predetermination of developing OUD. Maintaining a disease identity helps them remain vigilant against returning to drug use. Others described a post-OUD/survivor identity where they no longer felt they had OUD, but the experience remains. Each perspective informed attitudes about continued treatment with methadone or buprenorphine and strategies to remain in remission.

CONCLUSIONS

The identity that people with OUD in sustained remission maintain was the lens through which they viewed other aspects of their OUD including cause and ongoing treatment needs. An alternative, post-OUD/survivorship model emerged or was accepted by participants who did not identify as currently having OUD. Understanding patient perspectives of OUD identity might improve patient-centered care and improve outcomes.

Simulated Cost-effectiveness and Long-term Clinical Outcomes of Addiction Care and Antibiotic Therapy Strategies for Patients With Injection Drug Use-Associated Infective Endocarditis

IMPORTANCE

Emerging evidence supports the use of outpatient parenteral antimicrobial therapy (OPAT) and, in many cases, partial oral antibiotic therapy for the treatment of injection drug use-associated infective endocarditis (IDU-IE); however, long-term outcomes and cost-effectiveness remain unknown.

OBJECTIVE

To compare the added value of inpatient addiction care services and the cost-effectiveness and clinical outcomes of alternative antibiotic treatment strategies for patients with IDU-IE.

DESIGN, SETTING, AND PARTICIPANTS

This decision analytical modeling study used a validated microsimulation model to compare antibiotic treatment strategies for patients with IDU-IE. Model inputs were derived from clinical trials and observational cohort studies. The model included all patients with injection opioid drug use (N = 5 million) in the US who were eligible to receive OPAT either in the home or at a postacute care facility. Costs were annually discounted at 3%. Cost-effectiveness was evaluated from a health care sector perspective over a lifetime starting in 2020. Probabilistic sensitivity, scenario, and threshold analyses were performed to address uncertainty.

INTERVENTIONS

The model simulated 4 treatment strategies: (1) 4 to 6 weeks of inpatient intravenous (IV) antibiotic therapy along with opioid detoxification (usual care strategy), (2) 4 to 6 weeks of inpatient IV antibiotic therapy along with inpatient addiction care services that offered medication for opioid use disorder (usual care/addiction care strategy), (3) 3 weeks of inpatient IV antibiotic therapy along with addiction care services followed by OPAT (OPAT strategy), and (4) 3 weeks of inpatient IV antibiotic therapy along with addiction care services followed by partial oral antibiotic therapy (partial oral antibiotic strategy).

MAIN OUTCOMES AND MEASURES

Mean percentage of patients completing treatment for IDU-IE, deaths associated with IDU-IE, life expectancy (measured in life-years [LYs]), mean cost per person, and incremental cost-effectiveness ratios (ICERs).

RESULTS

All modeled scenarios were initialized with 5 million individuals (mean age, 42 years; range, 18-64 years; 70% male) who had a history of injection opioid drug use. The usual care strategy resulted in 18.63 LYs at a cost of $416 570 per person, with 77.6% of hospitalized patients completing treatment. Life expectancy was extended by each alternative strategy. The partial oral antibiotic strategy yielded the highest treatment completion rate (80.3%) compared with the OPAT strategy (78.8%) and the usual care/addiction care strategy (77.6%). The OPAT strategy was the least expensive at $412 150 per person. Compared with the OPAT strategy, the partial oral antibiotic strategy had an ICER of $163 370 per LY. Increasing IDU-IE treatment uptake and decreasing treatment discontinuation made the partial oral antibiotic strategy more cost-effective compared with the OPAT strategy. When assuming that all patients with IDU-IE were eligible to receive partial oral antibiotic therapy, the strategy was cost-saving and resulted in 0.0247 additional discounted LYs. When treatment discontinuation was decreased from 3.30% to 2.65% per week, the partial oral antibiotic strategy was cost-effective compared with OPAT at the $100 000 per LY threshold.

CONCLUSIONS AND RELEVANCE

In this decision analytical modeling study, incorporation of OPAT or partial oral antibiotic approaches along with addiction care services for the treatment of patients with IDU-IE was associated with increases in the number of people completing treatment, decreases in mortality, and savings in cost compared with the usual care strategy of providing inpatient IV antibiotic therapy alone.

Association of Cannabis Use-Related Predictor Variables and Self-Reported Psychotic Disorders: U.S. Adults, 2001-2002 and 2012-2013

OBJECTIVE

The authors sought to determine the association of cannabis indicators with self-reported psychotic disorders in the U.S. general population.

METHODS

Participants were from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; 2001-2002; N=43,093) and NESARC-III (2012-2013; N=36,309). Logistic regression was used to estimate standardized prevalences of past-year self-reported psychotic disorders within each survey and to evaluate the association of past-year self-reported psychotic disorders with indicators of nonmedical cannabis use (any use; frequent use [at least three times/week], daily/near-daily use, and DSM-IV cannabis use disorder) compared with those with no past-year nonmedical cannabis use. Whether the strength of associations differed between surveys was indicated by difference-in-difference tests (between-survey contrasts) and ratios of odds ratios between surveys.

RESULTS

Self-reported psychotic disorders were significantly more prevalent among participants with any nonmedical cannabis use than those without (2001-2002: 1.65% compared with 0.27%; 2012-2013: 1.89% compared with 0.68%). In 2001-2002, self-reported psychotic disorders were unrelated to either frequent use or daily/near-daily use. However, in 2012 - 2013, compared with nonusers, self-reported psychotic disorders were more common among participants with frequent use and those with daily/near-daily nonmedical cannabis use (2012-2013: 2.79% and 2.52%, respectively, compared with 0.68% among nonusers). Self-reported psychotic disorders were significantly more prevalent among participants with cannabis use disorder than nonusers in both surveys (2001-2002: 2.55% compared with 0.27%; 2012 - 2013: 3.38% compared with 0.68%). The strength of these associations did not change over time.

CONCLUSIONS

Data from the U.S. general population, especially more recent data, suggest associations between self-reported psychotic disorder and frequent nonmedical cannabis use and cannabis use disorder. Clinicians and policy makers should consider these relationships when monitoring patients and formulating programs.

Clinical impact, costs, and cost-effectiveness of hospital-based strategies for addressing the US opioid epidemic: a modelling study

BACKGROUND

The syndemic of injection drug use and serious injection-related infections is leading to increasing mortality in the USA. Although outpatient treatment with medications for opioid use disorder reduces overdose risk and recurrent infections, hospitalisation remains common. We evaluated the clinical impact, costs, and cost-effectiveness of hospital-based strategies to address the US opioid epidemic.

METHODS

We developed a microsimulation model to compare the cost-effectiveness of: standard hospital care-detoxification for opioids, no addiction consult service (status quo); expanded inpatient prescribing of medications for opioid use disorder, including bridge prescriptions (ie, medication until they can see an outpatient provider) when possible (medications for opioid use disorder with bridge); implementation of addiction consult services within the hospital (addiction consult services alone); and a combined medication for opioid use disorder with addiction consult services strategy (combined). We used clinical trials and observational cohorts to inform model inputs. Outcomes were life-years, discounted costs, incremental cost-effectiveness ratios, hospitalisations, and deaths. We did deterministic sensitivity analyses on key model inputs related to costs and sequelae of drug use and probabilistic sensitivity analysis to further address uncertainty.

FINDINGS

Among people who inject opioids in the USA, we estimated that expanding medications for opioid use disorder with bridge prescriptions would reduce hospitalisations and overdose deaths by 3·2% and 3·6%, respectively, and the combination of expanded medications with opioid use disorder along with addiction consult sevices would reduce hospitalisations and overdoses by 5·2% and 6·6%, respectively, compared with the status quo. Mean lifetime costs ranged from US$731 400 (95% credible interval 447 911-859 189 for the medications for opioid use disorder strategy) to $741 200 (470 930-868 551 for the combined strategy) per person. Assuming a willingness-to-pay threshold of $100 000 per life-year gained, medications for opioid use disorder with bridge and combined strategies were cost-effective ($7600 and $14 300, respectively). A scenario that assumed ideal access to harm reduction services came to the same conclusions as the base case and our results were robust in deterministic and probabilistic sensitivity analyses.

INTERPRETATION

The combined interventions of expanding hospital-based prescribing of medications for opioid use disorder and implementing addiction consult services could improve life expectancy, be cost-effective, and could be the basis for a comprehensive hospital-based strategy for addressing the opioid epidemic in the USA and countries with similar opioid epidemics.

FUNDING

National Institute on Drug Abuse and National Institute of Allergy and Infectious Diseases.

Mechanistic insights into the efficacy of memantine in treating certain drug addictions

The deleterious effects of the drug addiction epidemic are compounded by treatment strategies that are only marginally efficacious. Memantine is a unique glutamatergic medication with proven ability to attenuate drug addiction in preclinical models. However, clinical translational studies are inconsistent. In this review, we summarize preclinical evidences and clinical trials that investigated the efficacy of memantine in treating patients with alcohol, opiate, cocaine, and nicotine use disorders and discuss the results from a mechanistic point of view. Memantine has shown efficacy in reducing alcohol and opiate craving, consumption, and withdrawal severity. However, in cocaine and nicotine use disorders, memantine did not have significant effect on cravings or consumption. Additionally, memantine was associated with increased subjective effects of alcohol, cocaine, and nicotine. We discuss possible mechanisms behind this variability. Since memantine transiently blocks NMDA receptors and protects neurons from overstimulation by excessive synaptic glutamate, its efficacy should be observed in drug phases that cause hyperglutamatergic states, while hypoglutamatergic drug use states would not resolve with blocking NMDA receptors. Second, memantine pharmacokinetic studies have been done in rodents and healthy volunteers, but not in patients with substance use disorder. Memantine, opiates, cocaine, and nicotine share the same transporter family at the blood brain barrier. This shared transport mechanism could impact brain concentrations of memantine and its effects. In conclusion, memantine remains an intriguing compound in our pharmacopeia with controversial results in treating certain aspects of drug addiction. Further studies are needed to understand the clinical and biological correlates of its efficacy.

Long-term Infective Endocarditis Mortality Associated With Injection Opioid Use in the United States: A Modeling Study

BACKGROUND

The expansion of the US opioid epidemic has led to significant increases in infections, such as infective endocarditis (IE), which is tied to injection behaviors. We aimed to estimate the population-level IE mortality rate among people who inject opioids and compare the risk of IE death against the risks of death from other causes.

METHODS

We developed a microsimulation model of the natural history of injection opioid use. We defined injection behavior profiles by both injection frequency and injection techniques. We accounted for competing risks of death and populated the model with primary and published data. We modeled cohorts of 1 million individuals with different injection behavior profiles until age 60 years. We combined model-generated estimates with published data to project the total expected number of IE deaths in the United States by 2030.

RESULTS

The probabilities of death from IE by age 60 years for 20-, 30-, and 40-year-old men with high-frequency use with higher infection risk techniques compared to lower risk techniques for IE were 53.8% versus 3.7%, 51.4% versus 3.1%, and 44.5% versus 2.2%, respectively. The predicted population-level attributable fraction of 10-year mortality from IE among all risk groups was 20%. We estimated that approximately 257 800 people are expected to die from IE by 2030.

CONCLUSIONS

The expected burden of IE among people who inject opioids in the United States is large. Adopting a harm reduction approach, including through expansion of syringe service programs, to address injection behaviors could have a major impact on decreasing the mortality rate associated with the opioid epidemic.

Opioid Use Disorder is Associated With Complications and Increased Length of Stay After Major Abdominal Surgery

OBJECTIVE

The objective of this study was to determine the impact of opioid use disorder (OUD) on perioperative outcomes after major upper abdominal surgeries.

SUMMARY OF BACKGROUND DATA

OUD, defined as dependence/abuse, is a national health epidemic. Its impact on outcomes after major abdominal surgery has not been well characterized.

METHODS

Patients who underwent elective esophagectomy, total/partial gastrectomy, major hepatectomy, and pancreatectomy were identified using the National Inpatient Sample (2003-2015). Propensity score matching by baseline characteristics was performed for patients with and without OUD. Outcomes measured were in-hospital complications, mortality, length of stay (LOS), and discharge disposition.

RESULTS

Of 376,467 patients, 1096 (0.3%) had OUD. Patients with OUD were younger (mean 53 vs 61 years, P < 0.001) and more often male (55.1% vs 53.2%, P < 0.001), black (15.0% vs 7.6%, P < 0.001), Medicaid beneficiaries (22.0% vs 6.4%, P < 0.001), and in the lowest income quartile (32.6% vs 21.3%, P < 0.001). They also had a higher rate of alcohol (17.2% vs 2.8%, P < 0.001) and nonopioid drug (2.2% vs 0.2%, P = 0.023) dependence/abuse. After matching (N = 1077 OUD, N = 2164 no OUD), OUD was associated with a higher complication rate (52.9% vs 37.3%, P < 0.001), including increased pain [odds ratio (OR) 3.5, P < 0.001], delirium (OR 3.0, P = 0.004), and pulmonary complications (OR 2.0, P = 0.006). Additionally, OUD was associated with increased LOS (mean 12.4 vs 10.6 days, P = 0.015) and nonroutine discharge (OR 1.6, P < 0.001). In-hospital mortality did not differ (OR 2.4, P = 0.10).

CONCLUSION

Patients with OUD more frequently experienced complications and increased LOS. Close postoperative monitoring may mitigate adverse outcomes.

Gender differences in the prevalence of heroin and opioid analgesic misuse in the United States, 2015-2019

OBJECTIVES

Gender differences in the prevalence of opioid misuse continue to evolve and have not been well characterized in recent years. Our objective was to investigate gender differences in the prevalence of opioid misuse and use disorder in the US over the 5-year period from 2015 to 2019.

METHODS

We used annual survey data from the 2015-2019 National Survey on Drug Use and Health to estimate gender differences in the prevalence of opioid misuse. We examined past-year opioid analgesic misuse initiation, opioid analgesic misuse, heroin use, opioid analgesic use disorder and heroin use disorder. Logistic regression models were used to test gender differences, adjusting for sociodemographic variables.

RESULTS

In adjusted analyses, women had higher odds of having initiated opioid analgesic misuse in the past year compared to men. In contrast, men had higher odds of misuse of opioid analgesics, heroin use, and an opioid analgesic or heroin use disorder.

CONCLUSIONS

Although opioid misuse has historically been more prevalent in men, the gender difference in opioid analgesic misuse continues to narrow, with more women initiating misuse than men including higher rates of misuse in adolescent girls. Heroin use continues to be approximately twice as common in men as women.

Primary care physicians' preparedness to treat opioid use disorder in the United States: A cross-sectional survey

BACKGROUND

Efforts to increase opioid use disorder (OUD) treatment have focused on primary care. We assessed primary care physicians' preparedness to identify and treat individuals with OUD and barriers to increasing buprenorphine prescribing.

METHODS

We conducted a cross-sectional survey from January-August 2020 which assessed perceptions of the opioid epidemic; comfort screening, diagnosing, and treating individuals with OUD with medications; and barriers to obtaining a buprenorphine waiver and prescribing buprenorphine in their practice. Primary care physicians were sampled from the American Medical Association Physician Master File (n = 1000) and contacted up to 3 times, twice by mail and once by e-mail.

RESULTS

Overall, 173 physicians (adjusted response rate 27.3 %) responded. While most were somewhat or very comfortable screening (80.7 %) and diagnosing (79.3 %) OUD, fewer (36.9 %) were somewhat or very comfortable treating OUD with medications. One third of respondents were in a practice where they or a colleague were waivered and 10.7 % of respondents had a buprenorphine waiver. The most commonly cited barriers to both obtaining a waiver and prescribing buprenorphine included lack of access to addiction, behavioral health, or psychiatric co-management, lack of experience treating OUD, preference not to be inundated with requests for buprenorphine, and the buprenorphine training requirement.

CONCLUSIONS

While most primary care physicians reported comfort screening and diagnosing OUD, fewer were comfortable treating OUD with medications such as buprenorphine and even fewer were waivered to do so. Addressing provider self-efficacy and willingness, and identifying effective, coordinated, and comprehensive models of care may increase OUD treatment with buprenorphine.

Social Stigma toward Persons with Opioid Use Disorder: Results from a Nationally Representative Survey of U.S. Adults

Background: This study seeks to understand the general adult population's knowledge, attitudes, and stigma towards opioid use disorder (OUD), people with histories of opioid misuse, and policies related to OUD. Methods: We conducted a cross-sectional national survey of the U.S. adult population, using AmeriSpeak's® web, probability-based panel. The number of participants were 947 (493 females and 454 males) general population adults ages 19 -89 years old who completed a self-report survey covering: social stigma of OUD, opioid policy attitudes, perceptions of OUD as a crime, knowledge and beliefs about opioids and treatment, personal experience with opioids and the criminal justice (CJ) system, and demographics. Results: Thirteen percent self-reported ever misusing opioids, 3% reported an opioid overdose, and 14% reported personal experience with the CJ system. On average, the general adult population moderately endorses stigmatizing behaviors, agrees that OUD is a medical condition, agrees with policies to increase access to OUD treatment, and is less likely to endorse OUD as a crime. Having a disregard for OUD as a medical condition was most associated with higher levels of stigma, endorsing OUD as a crime, and disagreeing with policies to help people access OUD treatment. Conclusions: Our data provide guidance to policymakers concerning individuals with certain characteristics to target for public education efforts to reduce stigma and draw more support for public heath interventions for OUD. Our data also suggest that the content of this education should include improving understanding of OUD as a medical condition.

Number of opioid overdoses and depression as a predictor of suicidal thoughts

BACKGROUND

Opioid use disorders are associated with increased risk of suicide thoughts, attempts, and death. We explored key variables from two theories of the development of suicidal thoughts and attempts (the interpersonal and three-step theories of suicide) to understand possible mechanisms underlying the association between opioid use and suicide risk. We hypothesized that interpersonal connections, variables reflecting psychological and physical pain, and variables that reduce fear of death (prior overdoses and risk-taking behaviors) would be associated with increased risk of thoughts of suicide.

METHODS

Participants (N = 141) were opioid users recruited from an epicenter of the opioid crisis in Philadelphia using a mobile research center and completed an interview to assess substance use, depression, medical comorbidities, and suicidal thoughts among other variables.

RESULTS

Univariate analyses showed that prior history of overdose, diagnosis of depression, older age, homelessness, and interpersonal connection were each associated with increased likelihood of endorsing thoughts of death/suicide. Multivariable analyses revealed prior history of overdose and depression were the variables most strongly associated with risk for thoughts of suicide.

CONCLUSIONS

Consistent with two theories of the development of suicidal thoughts and attempts, exposure to variables that reduce fear of death (e.g., overdoses) were associated with suicidal thoughts. In contrast, other risk-taking behaviors, medical comorbidities, and substance use were not key predictors of suicidal thoughts in this sample. Implications for targeted risk assessment among clinicians are discussed.

The World Health Organization Risk Drinking Levels Measure of Alcohol Consumption: Prevalence and Health Correlates in Nationally Representative Surveys of U.S. Adults, 2001-2002 and 2012-2013

OBJECTIVE

Little is known about change over time in the prevalence of World Health Organization (WHO) risk drinking levels (very high, high, moderate, low) and their association with health conditions, overall and by gender. The authors used two sets of nationally representative U.S. survey data to determine whether changes over time varied by gender and to examine whether health conditions related to alcohol were associated with WHO risk drinking level within each survey, and whether these associations differed by gender.

METHODS

Data on current drinkers from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; N=26,655) and the 2012-2013 NESARC-III (N=25,659) were analyzed using logistic regression. Prevalence differences between surveys were estimated for each drinking level overall and by gender. Within each survey, prevalence differences by WHO risk drinking level were estimated for alcohol use disorder (AUD), drug use disorders, functional impairment, liver disease, and depressive and anxiety disorders.

RESULTS

In the 2012-2013 survey, the prevalences of moderate, high, and very high risk drinking were 5.9%, 3.2%, and 3.5%, respectively, representing significant increases from the prevalences in the 2001-2002 survey, which were 1.0%, 0.6%, and 0.9%, respectively. The increase for very high risk drinking among men (0.5%) was smaller than the increase among women (1.4%). Within both surveys, compared with low risk, health conditions were significantly associated with very high risk (range of prevalence differences, 2.2%-57.8%), high risk (2.6%-41.3%), and moderate risk (0.6%-29.8%) drinking. Associations were similar by gender, except that there were stronger effects for AUD in men and for functional impairment and depressive and anxiety disorders in women.

CONCLUSIONS

The increase in potentially problematic drinking levels among U.S. adults emphasizes the need for better prevention and treatment strategies. The study results support the validity of the WHO risk drinking levels, which show clinical utility as nonabstinent drinking reduction treatment goals. Such goals could engage more people in treatment, improving public health by decreasing personal and societal consequences of risk drinking.

Big data and predictive modelling for the opioid crisis: existing research and future potential

A need exists to accurately estimate overdose risk and improve understanding of how to deliver treatments and interventions in people with opioid use disorder in a way that reduces such risk. We consider opportunities for predictive analytics and routinely collected administrative data to evaluate how overdose could be reduced among people with opioid use disorder. Specifically, we summarise global trends in opioid use and overdoses; describe the use of big data in research into opioid overdose; consider the potential for predictive modelling, including machine learning, for prevention and monitoring of opioid overdoses; and outline the challenges and risks relating to the use of big data and machine learning in reducing harms that are related to opioid use. Future research for improving the coverage and provision of existing interventions, treatments, and resources for opioid use disorder requires collaboration of multiple agencies. Predictive modelling could transport the concept of stratified medicine to public health through novel methods, such as predictive modelling and emulated trials for evaluating diagnoses and prognoses of opioid use disorder, predicting treatment response, and providing targeted treatment recommendations.

Adverse Childhood Experiences Predict Early Initiation of Opioid Use Behaviors

Introduction: Although a substantial body of research documents a relationship between traumatic stress in childhood and the initiation of substance use later in the life course, only limited research has examined potential linkages between adverse childhood experiences (ACEs) and the initiation of non-medical prescription opioid use and other opioid use behaviors. The present study contributes to this growing body of work by investigating the association of childhood trauma with early initiation of a series of opioid use behaviors. Methods: New York City young adults (n = 539) ages 18-29 who reported non-medical use of prescription opioids or heroin use in the past 30 days were recruited using Respondent-Driven Sampling in 2014-16. Ten ACEs were assessed via self-report with the ACE Questionnaire. Associations between number of ACEs and self-reported ages of initiating seven opioid use behaviors (e.g., non-medical prescription opioid use, heroin use, heroin injection) were estimated with multivariable logistic regression. Results: Eighty nine percent of participants reported at least one ACE, and 46% reported four or more ACEs, a well-supported threshold indicating elevated risk for negative health consequences. Every increase of one trauma was associated with a 12-23% increase in odds of early initiation across the seven opioid use behaviors. Findings also document that the mean age at initiation increased with increasing risk severity across the behaviors, contributing to evidence of a trajectory from opioid pill misuse to opioid injection. Discussion: Increasing number of childhood traumas was associated with increased odds of earlier initiation of multiple opioid misuse behaviors. In light of prior research linking earlier initiation of substance use with increased substance use severity, present findings suggest the importance of ACEs as individual-level determinants of increased opioid use severity. Efforts to prevent onset and escalation of opioid use among at-risk youth may benefit from trauma prevention programs and trauma-focused screening and treatment, as well as increased attention to ameliorating upstream socio-structural drivers of childhood trauma.

Opioid misuse and family structure: Changes and continuities in the role of marriage and children over two decades

BACKGROUND

The opioid crisis is widely felt in the United States. Scholarly attention to the crisis focuses on macro-level processes and largely neglects meso-level explanations such as family structure for opioid use behaviors. We hypothesize that married adults and adults with coresident children are at lower risk of misusing prescription pain relievers (PPR), using heroin, and using needles to inject heroin relative to adults from other family structures.

METHOD

We used National Survey on Drug Use and Health data from 2002-2018 to test our hypotheses with multivariable logistic regression.

RESULTS

We found that married adults have a lower predicted probability of each opioid use behavior relative to nonmarried adults across the study period. We also found that the presence of children is associated with reductions in all three outcomes especially for never married adults.

CONCLUSION

Individuals from all family structures are vulnerable to the opioid crisis, but never married adults without coresident children ("disconnected adults") are especially susceptible to temporal fluctuations and drive the temporal trends in PPR misuse and heroin use. These findings suggest that ongoing demographic trends where disconnected adults are a growing population may result in future rises in opioid use disorders and mortality because of divestment from U.S. social safety nets. Future research should examine the role of U.S. policies that make disconnected adults especially vulnerable to developing opioid use disorders.

Late- and Typical-Onset Heroin Use Among Older Adults Seeking Treatment for Opioid Use Disorder

OBJECTIVE

Analyze 10-year trends in opioid use disorder with heroin (OUD-H) among older persons and to compare those with typical-onset (age <30 years) to those with late (age 30+) onset.

DESIGN

Naturalistic observation using the most recent (2008-2017) Treatment Episode Data Set-Admissions (TEDS-A).

SETTING

Admission records in TEDS-A come from all public and private U.S. programs for substance use disorder treatment receiving public funding.

PARTICIPANTS

U.S. adults aged 55 years and older entering treatment for the first time between 2008 and 2017 to treat OUD-H.

MEASUREMENTS

Admission trends, demographics, substance use history.

RESULTS

The number of older adults who entered treatment for OUD-H nearly tripled between 2007 and 2017. Compared to those with typical-onset (before age 30), those with late-onset heroin use were more likely to be white, female, more highly educated, and rural. Older adults with late-onset were more likely to be referred to treatment by an employer and less likely to be referred by the criminal justice system. Those with late-onset were more likely to use heroin more frequently but less likely to inject heroin than those with typical-onset. Those with typical onset were more likely to receive medication for addiction treatment than those with late-onset.

CONCLUSION

Late-onset heroin use is increasing among older U.S. adults. Research is needed to understand the unique needs of this population better. As this population grows, geriatric psychiatrists may be increasingly called upon to provide specialized care to people with late-onset OUD-H.

Racial/ethnic differences in prescription opioid misuse and heroin use among a national sample, 1999-2018

OBJECTIVE

To characterize racial/ethnic differences in past-year prescription opioid misuse and heroin use.

METHODS

Data on 1,117,086 individuals age 12 and older were from the 1999-2018 National Survey on Drug Use and Health. We compared relative prevalences across 6 racial/ethnic groups for prescription opioid misuse analyses and 4 racial/ethnic groups for heroin analyses. Unadjusted and gender- and age-adjusted prevalences are reported for 5 time periods (1999-2002, 2003-2006, 2007-2010, 2011-2014, 2015-2018). Survey-weighted Poisson regression models with robust variance were used to estimate risk ratios by race/ethnicity and to test for time trends.

RESULTS

Prescription opioid misuse was significantly higher among non-Hispanic White individuals than among Black, Hispanic, and Asian individuals across all time periods, yet was highest among Native American individuals in every time period. The relative difference between White and both Hispanic and Asian individuals significantly widened over time, whereas the gap between Black and White individuals significantly decreased. Early in the study period, heroin use was highest among Black and Hispanic individuals. Heroin use among White individuals first surpassed all other groups in 2007-2010 and continued to steadily increase, more than doubling from 1999-2002 to 2015-2018.

CONCLUSIONS

While heroin use has risen among all racial/ethnic groups, the demographics of heroin use have changed significantly in the past two decades such that prevalence is now highest among White individuals. Opioid prevention and treatment initiatives should both be informed by the changing demographics of heroin use and seek to reduce opioid-related harms and expand treatment access equitably for all racial/ethnic groups.

Substance Use Disorder Detection Rates Among Providers of General Medical Inpatients

BACKGROUND

The prevalence of substance use disorders is higher among medical inpatients than in the general population, placing inpatient providers in a prime position to detect these patients and intervene.

OBJECTIVE

To assess provider detection rates of substance use disorders among medical inpatients and to identify patient characteristics associated with detection.

DESIGN

Data drawn from a cluster randomized controlled trial that tested the effectiveness of three distinct implementation strategies for providers to screen patients for substance use disorders and deliver a brief intervention (Clinical Trials.gov : NCT01825057).

PARTICIPANTS

A total of 1076 patients receiving care from 13 general medical inpatient units in a large teaching hospital participated in this study.

MAIN MEASURES

Data sources included patient self-reported questionnaires, a diagnostic interview for substance use disorders, and patient medical records. Provider detection was determined by diagnoses documented in medical records.

KEY RESULTS

Provider detection rates were highest for nicotine use disorder (72.2%) and lowest for cannabis use disorder (26.4%). Detection of alcohol use disorder was more likely among male compared to female patients (OR (95% CI) = 4.0 (1.9, 4.8)). When compared to White patients, alcohol (OR (95% CI) = 0.4 (0.2, 0.6)) and opioid (OR (95% CI) = 0.2 (0.1, 0.7)) use disorders were less likely to be detected among Black patients, while alcohol (OR (95% CI) = 0.3 (0.0, 2.0)) and cocaine (OR (95% CI) = 0.3 (0.1, 0.9)) use disorders were less likely to be detected among Hispanic patients. Providers were more likely to detect nicotine, alcohol, opioid, and other drug use disorders among patients with higher addiction severity (OR (95% CI) = 1.20 (1.08-1.34), 1.62 (1.48, 1.78), 1.46 (1.07, 1.98), 1.38 (1.00, 1.90), respectively).

CONCLUSIONS

Findings indicate patient characteristics, including gender, race, and addiction severity impact rates of provider detection. Instituting formal screening for all substances may increase provider detection and inform treatment decisions.

An Evaluation of Opioid Use in Black Communities: A Rapid Review of the Literature

BACKGROUND

There are multiple aspects of the opioid crisis among Black people, who have been left out of the broader conversation. Despite evidence of increased opioid overdose deaths, less is known about opioid use among Black people. This review synthesizes research on Black people who use opioids; the goals are to advance knowledge, highlight research gaps, and inform clinical practice.

METHODS

This rapid review investigating opioid use among Black people utilized systematic review methods and was conducted according to a predefined protocol with clear inclusion criteria (PROSPERO ID: 177071). A comprehensive search strategy was used, including published and gray-literature sources (i.e., literature that has not been formally published). A narrative summary of the results is presented.

RESULTS

A total of 76 works were selected for inclusion and full text review. Sex, age, geographic location, and involvement in the carceral system were associated with the use of opioids among Black individuals. Non-epidemiologic factors included treatment-seeking patterns, disparate clinician prescribing, and social determinants.

CONCLUSIONS

Through this rapid review we suggest three main areas of focus: (1) including culturally informed collection methods in epidemiologic surveys to accurately reflect prevalences, (2) funding research that specifically addresses the importance of culture in accessing treatment, and (3) directly studying how social determinants can improve or exacerbate health outcomes. Focusing on the unique needs of Black people who use opioids is warranted to increase treatment initiation and adherence among a population less likely to engage with the traditional health care system.

Symptom severity and medication-assisted treatment for individuals with serious mental illness and a history of heroin use

The study examined associations between medication assisted treatment (MAT) and psychiatric symptom severity, measured by Positive and Negative Symptom Scale (PANSS), among individuals with serious mental illness and a history of heroin use. Of 271 participants, 32% (n=87) reported a history of heroin use and, of those, 14.9% (n=13) reported MAT. Higher scores in PANSS Total, Negative, and Disordered subscales were associated with lower odds, while being on an antipsychotic with higher odds, of receiving MAT. This supports the greater need for clinician attention to different symptom clusters and targeted multidimensional interventions as a way to increase MAT participation.

The changing opioid crisis: development, challenges and opportunities

The current opioid epidemic is one of the most severe public health crisis in US history. Responding to it has been difficult due to its rapidly changing nature and the severity of its associated outcomes. This review examines the origin and evolution of the crisis, the pharmacological properties of opioids, the neurobiology of opioid use and opioid use disorder (OUD), medications for opioid use disorder (MOUD), and existing and promising approaches to prevention. The results of the review indicate that the opioid epidemic is a complex, evolving phenomenon that involves neurobiological vulnerabilities and social determinants of health. Successfully addressing the epidemic will require advances in basic science, development of more acceptable and effective treatments, and implementation of public health approaches, including prevention. The advances achieved in addressing the current crisis should also serve to advance the science and treatment of other substance use disorders.

"You're Always Jumping Through Hoops": Journey Mapping the Care Experiences of Individuals With Opioid Use Disorder-associated Endocarditis

OBJECTIVES

Serious infectious complications of opioid use disorder (OUD), and specifically endocarditis, are becoming more common in the US. Individuals with OUD-associated endocarditis require long periods of complex medical care, often face recurrent addiction- and infection-related complications, and have dismal clinical outcomes. The objective of this study was to perform journey mapping analysis to capture common trajectories and patterns of care for people with OUD-associated endocarditis.

METHODS

This was an analysis of qualitative semi-structured interviews of individuals who received care for OUD-associated endocarditis. Interviews were conducted among individuals receiving care at a single academic healthcare system in Boston, Massachusetts. Ten participants meeting DSM-5 criteria for at least mild OUD and a culture-positive diagnosis of endocarditis who had previously completed care for OUD-associated endocarditis were recruited from inpatient and ambulatory settings. Details of participant's care episodes were extracted and visualized in an iterative journey mapping process. A grounded theory approach was then used to identify shared themes and care patterns among participants' journey maps.

RESULTS

Common patterns of care included early addiction treatment and intensive outpatient care preceding periods without rehospitalization, while leaving outpatient care and return to drug use often directly preceded rehospitalization. Participants frequently left care by choice and proactively reengaged with care.

CONCLUSIONS

Journey mapping is a novel, patient-centered approach to capturing the care experiences and trajectories of a patient population experiencing significant stigma, who engage with the healthcare system in unexpected and fragmented ways. For individuals with OUD-associated endocarditis, we identified critical moments to support and engage patients to prevent return to drug use and rehospitalization.

Preventing HIV outbreaks among people who inject drugs in the United States: plus ça change, plus ça même chose

: This editorial review covers current trends in the epidemiology of HIV among people who inject drugs (PWID) in the United States, including four recent HIV outbreaks. We discuss gaps in the prevention and treatment cascades for HIV and medications for opioid disorder and propose lessons learned to prevent future HIV outbreaks. Over the last decade, North America has been in the throes of a major opioid epidemic, due in part to over-prescribing of prescription opiates, followed by increasing availability of cheap heroin, synthetic opioids (e.g. fentanyl), and stimulants (e.g. methamphetamine). Historically, HIV infection among PWID in the US had predominantly affected communities who were older, urban and Black. More recently, the majority of these infections are among younger, rural or suburban and Caucasian PWID. All four HIV outbreaks were characterized by a high proportion of women who inject drugs and underlying socioeconomic drivers such as homelessness and poverty. We contend that the US response to the HIV epidemic among PWID has been fractured. A crucial lesson is that when evidence-based responses to HIV prevention are undermined or abandoned because of moral objections, untold humanitarian and financial costs on public health will ensue. Restructuring a path forward requires that evidence-based interventions be integrated and brought to scale while simultaneously addressing underlying structural drivers of HIV and related syndemics. Failing to do so will mean that HIV outbreaks among PWID and the communities they live in will continue to occur in a tragic and relentless cycle.