Nonreporting of cannabis use: Predictors and relationship to treatment outcome in methadone maintained patients

New Persistent Opioid Use After Orthopaedic Foot and Ankle Surgery: A Study of 348 Patients

INTRODUCTION

The opioid epidemic is a devastating public health issue to which orthopaedic surgery is inextricably linked. The purpose of this study was to identify risk factors for new persistent opioid use after orthopaedic foot and ankle surgery among patients who were opioid naive preoperatively.

METHODS

Patients undergoing orthopaedic foot or ankle surgery at a single institution were identified. Our state's prescription monitoring program was used to track opioid prescriptions filled in the preoperative (6 months to 30 days before surgery), perioperative (30 days before to 14 days after), and postoperative (2 to 6 months after) periods. Patients filling a prescription during the preoperative period were excluded. Baseline characteristics, surgical characteristics, and perioperative morphine milligram equivalents were tested for association with new persistent use during the postoperative period.

RESULTS

A total of 348 opioid-naive patients met the inclusion criteria. Overall, the rate of new persistent postoperative opioid use was 8.9%. Patients reporting recreational drug use had the highest risk, at 26.7% (relative risk [RR] = 3.3, 95% confidence interval, 1.3 to 8.2, P = 0.0141). In addition, patients who had perioperative opioid prescription >160 morphine milligram equivalents were at increased risk (RR = 2.2, 95% confidence interval, 1.1 to 4.5, P = 0.021). Other risk factors included age ≥40 years (RR = 2.2, P = 0.049) and consumption of ≥6 alcoholic beverages per week (RR = 2.1, P = 0.040). New persistent use was not associated with ankle/hindfoot surgery (versus midfoot/forefoot), bone surgery (versus soft-tissue), or chronic condition (versus acute; P > 0.05).

CONCLUSION

The rate of new persistent postoperative opioid use after orthopaedic foot and ankle surgery is high, at 8.9%. Greater perioperative opioid prescription is a risk factor for new persistent use and is modifiable. Other risk factors include recreational drug use, greater alcohol use, and greater age. Orthopaedic foot and ankle surgeons should limit perioperative prescriptions and be cognizant of these other risk factors to limit the negative effects of opioid prescriptions on their patients and communities.

LEVEL OF EVIDENCE

Level III.

Using mobile health technologies to test the association of cocaine use with sexual desire and risky sexual behaviors among people with and without HIV who use illicit stimulants

BACKGROUND

Cocaine use is broadly associated with risky sexual behavior potentially through elevated sexual desire. Understanding the within-person effects of cocaine on sexual desire and risky sexual behavior and the modification of HIV infection may inform primary and secondary HIV interventions.

METHODS

We conducted a mobile health (mHealth) study in a community sample of males and females with (n = 28) and without (n = 32) HIV who use illicit stimulant drugs. Participants completed ecological momentary assessments (EMAs) and daily diaries over 28 days. Mixed effects models were employed to examine the within-person association of cocaine use with sexual desire and risky sexual behavior.

RESULTS

Participants completed 3505 EMA responses, with 36 % involving recent cocaine use, including powder and/or crack cocaine. They completed 1427 daily diary responses, with cocaine use reported on 49 % of these days and sexual behavior on 21 % of these days. Sexual desire was highest in the first hour since cocaine use and gradually decreased with time. Sexual desire was lowest when participants had not used any cocaine in the past 6 h, and it correlated positively with the amount of use. Participants were more likely to have risky sexual behavior on days they used cocaine. These associations were similar for participants with and without HIV.

CONCLUSION

This study demonstrates the dynamic and proximal effects of cocaine use on sexual desire and risky sexual behavior. Our findings support the development of HIV prevention interventions that utilize mHealth technology to reduce sexual risk behavior among persons who use stimulant drugs.

The Influence of Co-Occurring Substance Use on the Effectiveness of Opiate Treatment Programs According to Intervention Type

This systematic review describes the influence of co-occurring substance use on the effectiveness of opiate treatment programs. MEDLINE/PubMed, Embase, PsychINFO, and the Cumulative Index to Nursing and Allied Health Literature were searched from database inception to November 28, 2018, to identify eligible opioid treatment studies in the United States that assessed the relationship between co-occurring substance use and treatment outcome (i.e., opioid abstinence and treatment retention). A total of 34 eligible studies were included. Overall, co-occurring substance use was associated with negative treatment outcomes regardless of intervention type. However, patterns varied by substance and intervention type. In particular, co-occurring use of cocaine or marijuana with opioids was associated with reduced treatment retention and opioid abstinence regardless of intervention type. Co-occurring use of amphetamines, compared with no use or reduced use of amphetamines, decreased treatment retention. Co-occurring use of alcohol was both positively and negatively associated with treatment outcomes. One study reported a significant positive association between sedative use and opioid abstinence. Generally, findings suggest that combined interventions reported better health outcomes compared with pharmacological or behavioral intervention studies alone. The findings of this review emphasize the need to comprehensively study and address co-occurring substance use to improve opiate treatment programs.

Assessment of Co-Occurring Substance Use During Opiate Treatment Programs in the United States

The effectiveness of opiate treatment programs (OTPs) can be significantly influenced by co-occurring substance use, yet there are no standardized guidelines for assessing the influence of co-occurring substance use on treatment outcomes. In this review, we aim to provide an overview on the status of the assessment of co-occurring substance use during participation in OTPs in the United States. We searched 4 databases-MEDLINE/PubMed, EMBASE, PsychINFO, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL)-from database inception to November 2018 to select relevant publications on OTPs that assessed participants' co-occurring substance use. We used a standardized protocol to extract study, intervention, and co-occurring substance use characteristics. Methodological quality was assessed using the Quality in Prognosis Studies tool. Of the 3,219 titles screened, 614 abstracts and 191 full-text original publications were assessed, leaving 85 eligible articles. Co-occurring substance use was most often assessed during opioid treatments using combined (pharmacological and behavioral) (n = 57 studies) and pharmacological (n = 25 studies) interventions. Cocaine, alcohol, marijuana, and benzodiazepines were frequently measured, while amphetamines and tobacco were rarely assessed. Great variation existed between studies in the timing and measurement of co-occurring substance use, as well as definitions for substances and polysubstance/polydrug use. Inconsistencies in the investigation of co-occurring substance use make comparison of results across studies challenging. Standardized measures and consensus on research on co-occurring substance use is needed to produce the evidence required to develop personalized treatment programs for persons using multiple substances and to inform best-practice guidelines for addressing polydrug use during participation in OTPs.

"I's" on the prize: A systematic review of individual differences in Contingency Management treatment response

Contingency Management is an evidence-based treatment for substance use disorders with strong potential for measurement-based customization. Previous work has examined individual difference factors in Contingency Management treatment response of potential relevance to treatment targeting and adaptive implementation; however, a systematic review of such factors has not yet been conducted. Here, we summarize and evaluate the existing literature on patient-level predictors, mediators, and moderators of Contingency Management treatment response in stimulant and/or opioid using outpatients - clinical populations most frequently targeted in Contingency Management research and clinical practice. Our search strategy identified 648 unique, peer-reviewed publications, of which 39 met full inclusion criteria for the current review. These publications considered a variety of individual difference factors, including (1) motivation to change and substance use before and during treatment (8/39 publications), (2) substance use comorbidity and chronicity (8/39 publications), (3) psychiatric comorbidity and severity (8/39 publications), (4) medical, legal, and sociodemographic considerations (15/39 publications), and (5) cognitive-behavioral variables (1/39 publications). Contingency Management was generally associated with improved treatment outcomes (e.g., longer periods of continuous abstinence, better retention), regardless of individual difference factors; however, specific patient-level characteristics were associated with either an enhanced (e.g., more previous treatment attempts, history of sexual abuse, diagnosis of antisocial personality disorder) or diminished (e.g., complex post-traumatic stress symptoms, pretreatment benzodiazepine use) response to Contingency Management. Overall, the current literature is limited but existing evidence generally supports greater benefits of Contingency Management in patients who would otherwise have a poorer prognosis in standard outpatient care. It was also identified that the majority of previous work represents a posteriori analysis of pre-existing clinical samples and has therefore rarely considered pre-specified, hypothesis-driven individual difference factors. We therefore additionally highlight patient-level factors that are currently understudied, as well as promising future directions for measurement-based treatment adaptations that may directly respond to patient traits and states to improve Contingency Management effectiveness across individuals and over time.

Has Self-reported Marijuana Use Changed in Patients Undergoing Total Joint Arthroplasty After the Legalization of Marijuana?

BACKGROUND

Marijuana use has become more accessible since its recent legalization in several states. However, its use in a total joint arthroplasty population to our knowledge has not been reported, and the implications of its use in this setting remain unclear.

QUESTIONS/PURPOSES

We report (1) the self-reported use of marijuana in patients undergoing total joint arthroplasty both before and after its legalization; and (2) clinical and demographic factors associated with marijuana use in patients undergoing total joint arthroplasty.

METHODS

One thousand records of patients undergoing primary total joint arthroplasty (500 consecutive before and 500 consecutive after the legalization of the commercial sale of marijuana in Colorado) were included for analysis. Preoperative medical history and physicals were retrospectively reviewed for self-reported and reasons (medicinal versus recreational) for use. Additionally, patient records were used to determine insurance type, age, gender, smoking status, history of substance abuse, preoperative narcotic use, alcohol intake, and the type of arthroplasty performed.

RESULTS

Self-reported use after legalization dramatically increased from 1% (four of 500) to 11% (55 of 500) (odds ratio [OR], 15.3 [95% confidence interval, 5.5-42.6]; p < 0.001) after legalization. For those reporting use after legalization, 46% (25 of 55) of patients reported recreational use, 26% (14 of 55) medicinal use, 27% (15 of 55) did not report a reason for use, and 2% (one of 55) reported both recreational and medicinal use. Factors associated with use included younger age (with a 10-year mean difference between the groups [p < 0.001]), male gender (36 of 59 users [61%] versus 411 of 941 nonusers [44%]; OR, 2.02; p < 0.01), current smokers (22 of 59 users [37%] versus 54 of 941 [6%] nonusers; OR, 0.09; p < 0.01), a history of substance abuse (eight of 59 users [14%] versus 18 of 941 nonusers [2%]; OR, 8.04; p < 0.001), insurance type (Medicaid only, 28 of 59 [48%] users versus 56 of 941 [6%] nonusers; OR, 20.45; p < 0.01), and preoperative narcotic use (eight of 59 users [14%] versus 17 of 941 nonusers [2%]; OR, 2.4; p < 0.001). We did not find differences with regard to alcohol use, amount of alcohol consumption, or insurance types other than Medicaid.

CONCLUSIONS

These results suggest the legalization of marijuana has led to either more users or more patients who are willing to report its use given the lack of legal ramifications. Despite these findings, the evidence to date precludes the use of marijuana postoperatively in patients undergoing total joint arthroplasty. Further investigation, ideally in a prospective randomized manner, should focus on opioid consumption, nausea, sleep patterns, and outcomes in patients using marijuana who are undergoing total joint arthroplasty before recommendations can be made for its use.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Drug and alcohol problems among Norwegian inmates

Aim & Data

Drug and alcohol problems among Norwegian inmates were explored in this study. Estimates of the portion of drug users among inmates were assessed on the most solid basis to date. The analysis was based on a survey of all Norwegian prisons. During the same week in December 2002 all Norwegian inmates received a questionnaire to survey demographic features, use of alcohol and illicit drugs.

Results

The findings suggest that nearly half of the prison population has regularly used hard drugs before the imprisonment, and a fourth were regular intravenous drug users. Polydrug use is highly prevalent. Almost one-third of the inmates used illicit drugs during the present stay in prison. The proportion of highly frequent drinkers appears to be three to four times that found in the general population.

Real-time assessment of alcohol drinking and drug use in opioid-dependent polydrug users

We investigated relationships between drinking, other drug use, and drug craving, using ecological momentary assessment (EMA), in a sample of polydrug users who were not heavy drinkers. In a prospective longitudinal cohort study, 114 heroin and cocaine users on methadone-maintenance treatment carried handheld electronic diaries during waking hours and were screened for drug and alcohol use for up to 25 weeks. Individuals who fulfilled the Diagnostic and Statistical Manual of Mental Disorders criteria for alcohol abuse or dependence were excluded. Participants responded to 2-5 random prompts per day to report on their moods, cravings, and activities and initiated entries when they used or acutely craved heroin or cocaine. Drinking alcohol was assessed in both types of entries. Breath alcohol was measured three times weekly. Participants reported drinking alcohol in 1.6% of random-prompt entries, 3.7% of event-contingent entries when craving cocaine and/or heroin, and 11.6% of event-contingent entries when using cocaine and/or heroin. Alcohol drinking was also associated with higher craving ratings and prestudy alcohol use. More drinking was detected by ambulatory self-report than by in-clinic breath testing. Even though we had screened out heavy drinkers from our sample of polydrug users, drinking was associated with heroin and cocaine craving and actual use.

Association between cannabis use and treatment outcomes in patients receiving methadone maintenance treatment: a systematic review protocol

BACKGROUND

With the non-medical use of prescription opioids increasingly becoming a method of abuse in Canada, the number of patients requiring methadone maintenance treatment (MMT) for opioid use disorder has increased dramatically. The rate of cannabis use in this population is disproportionately high (~50 %). Because its use is generally perceived as harmless, cannabis use is often not monitored during MMT. Current literature regarding the effects of cannabis use on MMT is conflicting, and the presence and nature of an association has not been clearly established. The primary objective of this review will be to conduct a systematic review of the literature and, if appropriate, a meta-analysis to determine whether there is an association between cannabis use and MMT outcomes. A secondary objective will be to perform subgroup analyses (by age, sex, method of cannabis measurement, and country) to determine whether cannabis use differentially influences MMT outcomes within these subgroups.

METHODS/DESIGN

The search will be conducted on the following electronic databases using a predefined search strategy: MEDLINE, EMBASE, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Two authors (LZ and MB) will independently screen articles using predetermined inclusion/exclusion criteria and will extract data from included articles using a pilot-tested data extraction form. Disagreements at all stages of the screening process will be settled through discussion, and when consensus cannot be reached, a third author (ZS) will be consulted. An assessment of quality and risk of bias will be conducted on all included articles, and a sensitivity analysis will be used to compare results of studies with high and low risk of bias. We will perform random- and fixed-effects meta-analyses, if appropriate, with heterogeneity calculated using the I (2) statistic and formal evaluation of publication bias.

DISCUSSION

Results of this systematic review will elucidate the association between cannabis use and methadone maintenance treatment outcomes. We will provide evidence that will be useful to clinicians regarding whether monitoring cannabis use during MMT is advantageous for optimizing MMT outcomes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015029372.

Concordance of Text Message Ecological Momentary Assessment and Retrospective Survey Data Among Substance-Using Men Who Have Sex With Men: A Secondary Analysis of a Randomized Controlled Trial

Background

Alcohol and illicit drug use is more prevalent among men who have sex with men (MSM) compared to the general population and has been linked to HIV transmission in this population. Research assessing individual patterns of substance use often utilizes questionnaires or interviews that rely on retrospective self-reported information, which can be subject to recall bias. Ecological momentary assessment (EMA) is a set of methods developed to mitigate recall bias by collecting data about subjects’ mental states and behaviors on a near real-time basis. EMA remains underutilized in substance use and HIV research.

Objective

To assess the concordance between daily reports of substance use collected by EMA text messages (short message service, SMS) and retrospective questionnaires and identify predictors of daily concordance in a sample of MSM.

Methods

We conducted a secondary analysis of EMA text responses (regarding behavior on the previous day) and audio computer-assisted self-interview (ACASI) survey data (14-day recall) from June 2013 to September 2014 as part of a randomized controlled trial assessing a pharmacologic intervention to reduce methamphetamine and alcohol use among nondependent MSM in San Francisco, California. Reports of daily methamphetamine use, alcohol use, and binge alcohol use (5 or more drinks on one occasion) were collected via EMA and ACASI and compared using McNemar’s tests. Demographic and behavioral correlates of daily concordance between EMA and ACASI were assessed for each substance, using separate multivariable logistic regression models, fit with generalized estimating equations.

Results

Among 30 MSM, a total of 994 days were included in the analysis for methamphetamine use, 987 for alcohol use, and 981 for binge alcohol use. Methamphetamine (EMA 20%, ACASI 11%, P<.001) and alcohol use (EMA 40%, ACASI 35%, P=.001) were reported significantly more frequently via EMA versus ACASI. In multivariable analysis, text reporting of methamphetamine (adjusted odds ratio 0.06, 95% CI 0.04-0.10), alcohol (0.48, 0.33-0.69), and binge alcohol use (0.27, 0.17-0.42) was negatively associated with daily concordance in the reporting of each respective substance. Compared to white participants, African American participants were less likely to have daily concordance in methamphetamine (0.15, 0.05-0.43) and alcohol (0.2, 0.05-0.54) reporting, and other participants of color (ie, Asian, Hispanic, multi-racial) were less likely to have daily concordance in methamphetamine reporting (0.34, 0.12-1.00). College graduates were more likely to have daily concordance in methamphetamine reporting (6.79, 1.84-25.04) compared to those with no college experience.

Conclusions

We found that methamphetamine and alcohol use were reported more frequently with daily EMA texts compared to retrospective ACASI, concordance varied among different racial/ethnic subgroups and education levels, and reported substance use by EMA text was associated with lower daily concordance with retrospective ACASI. These findings suggest that EMA methods may provide more complete reporting of frequent, discrete behaviors such as substance use.

Neural correlates of adherence to extended-release naltrexone pharmacotherapy in heroin dependence

Injectable extended-release naltrexone (XRNTX) presents an effective therapeutic strategy for opioid addiction, however its utility could be hampered by poor adherence. To gain a better insight into this phenomenon, we utilized blood oxygenation level-dependent functional magnetic resonance imaging (fMRI) in conjunction with a validated cue-induced craving procedure to examine neural correlates of XRNTX adherence. We operationalized treatment adherence as the number of monthly XRNTX injections (range: 0-3) administered to a group of fully detoxified heroin-dependent subjects (n=32). Additional outcomes included urine toxicology screening and self-reported tobacco use. The presented heroin-related visual cues reliably elicited heroin craving in all tested subjects. Nine, five, three and 15 of the participants, respectively, received zero, one, two and three XRNTX injections, predicted by the individual baseline fMRI signal change in response to the cues in the medial prefrontal cortex, a brain region involved in inhibitory self-control and emotional appraisal. The incidence of opioid-positive urines during the XRNTX therapy was low and remained about half the pre-treatment rate after the XRNTX ended. During the treatment, cigarette smoking behaviors followed patterns of opioid use, while cocaine consumption was increased with reductions in opioid use. The present data support the hypothesis that medial prefrontal cortex functions are involved in adherence to opioid antagonist therapy. A potential role of concurrent non-opioid addictive substances consumption during the XRNTX pharmacotherapy warrants further investigation. Our findings set the stage for further bio-behavioral investigations of the mechanisms of relapse prevention in opioid dependence.

Contingency management is efficacious and improves outcomes in cocaine patients with pretreatment marijuana use

BACKGROUND

Marijuana use is common in patients seeking treatment for cocaine use. Nevertheless, few studies have examined effects of marijuana use on treatment outcomes in general, and even fewer with respect to contingency management (CM) treatment, which has been criticized for potentially increasing non-reinforced drug use.

METHODS

Data from three randomized clinical trials of CM versus standard treatment (ST) in cocaine-abusing patients were examined (Petry et al., 2004, 2005a, 2006a; N=393) to assess effects of pretreatment marijuana use on outcomes. Patients were divided into two groups: (1) no self-reported marijuana use (No Pre-M; n=315) and (2) any self-reported marijuana use (Pre-M; n=78) in the 30 days pretreatment.

RESULTS

CM was especially efficacious in enhancing retention in Pre-M patients such that retention nearly doubled among Pre-M patients assigned to CM versus those assigned to ST. In contrast, CM exerted only modest benefits on retention in No Pre-M patients. Pretreatment marijuana use was not related to during-treatment abstinence from cocaine, opioids, and alcohol, or abstinence at a Month 9 follow-up. However, CM treatment and longest duration of abstinence achieved during treatment were significant predictors of Month 9 abstinence. Pre-M patients also evidenced more improvements in drug problems over time when randomized to CM.

CONCLUSIONS

CM was especially efficacious in facilitating retention and improving severity of drug-related problems in those who used marijuana in the month before initiating treatment.