Psychiatric distress, risk behavior, and treatment enrollment among syringe exchange participants

Three decades of research in substance use disorder treatment for syringe services program participants: a scoping review of the literature

BACKGROUND

Syringe services programs (SSPs) provide a spectrum of health services to people who use drugs, with many providing referral and linkage to substance use disorder (SUD) treatment, and some offering co-located treatment with medications for opioid use disorder (MOUD). The objective of this study was to review the evidence for SSPs as an entry point for SUD treatment with particular attention to co-located (onsite) MOUD.

METHODS

We performed a scoping review of the literature on SUD treatment for SSP participants. Our initial query in PubMed led to title and abstract screening of 3587 articles, followed by full text review of 173, leading to a final total of 51 relevant articles. Most articles fell into four categories: (1) description of SSP participants' SUD treatment utilization; (2) interventions to link SSP participants to SUD treatment; (3) post-linkage SUD treatment outcomes; (4) onsite MOUD at SSPs.

RESULTS

SSP participation is associated with entering SUD treatment. Barriers to treatment entry for SSP participants include: use of stimulants, lack of health insurance, residing far from treatment programs, lack of available appointments, and work or childcare responsibilities. A small number of clinical trials demonstrate that two interventions (motivational enhancement therapy with financial incentives and strength-based case management) are effective for linking SSP participants to MOUD or any SUD treatment. SSP participants who initiate MOUD reduce their substance use, risk behaviors, and have moderate retention in treatment. An increasing number of SSPs across the United States offer onsite buprenorphine treatment, and a number of single-site studies demonstrate that patients who initiate buprenorphine treatment at SSPs reduce opioid use, risk behaviors, and have similar retention in treatment to patients in office-based treatment programs.

CONCLUSIONS

SSPs can successfully refer participants to SUD treatment and deliver onsite buprenorphine treatment. Future studies should explore strategies to optimize the implementation of onsite buprenorphine. Because linkage rates were suboptimal for methadone, offering onsite methadone treatment at SSPs may be an appealing solution, but would require changes in federal regulations. In tandem with continuing to develop onsite treatment capacity, funding should support evidence-based linkage interventions and increasing accessibility, availability, affordability and acceptability of SUD treatment programs.

Do DSM-5 substance use disorder criteria differ by user care settings? An item response theory analysis approach

AIM

To examine differences in the psychometric characteristics of diagnostic criteria for Substance Use Disorders (SUD) between substance users in harm reduction settings (HR) and substance users seeking treatment (Tx).

METHODS

Differential Item and Test Functioning (DIF & DTF) analysis were performed to examine differences in the difficulty of endorsement and in discrimination of the 11 diagnostic criteria and to test if the criteria set as a whole (the "test") functioned differently by care settings (Tx vs. HR) for alcohol, cocaine, cannabis, opiates and tobacco. To test uniform and nonuniform DIF, multiple indicator multiple cause (MIMIC) structural equation models were used.

RESULTS

Regardless of the substance, the DSM-5 criteria "craving", "large amount", "time spent", "tolerance" and "activities given up" had similar functioning by care settings. Little evidence for DIF was found for other criteria. The criteria set as a whole did not function differently by care settings for alcohol, cocaine and tobacco. At the same trait severity, compared to HR, the Tx subgroup had a greater number of endorsed criteria for cannabis and a smaller number of endorsed criteria for opioids.

CONCLUSION

The unidimensionality of the 11 DSM-5 criteria and applicability of all criteria and diagnosis was confirmed in this large sample of problematic substance users. While the majority of the criteria related to loss of control of substance use, functioned well in both care settings, the criteria related to consequences of substance use had several differential functioning.

Serious Mental Illness Among Young People Who Inject Drugs: An Assessment of Injection Risks and Healthcare Use

BACKGROUND

Data on behavioral correlates of mental illness among young people who inject drugs (PWID) are limited. We examine injection risks and healthcare use among young PWID with probable serious mental illness (PSMI).

METHODS

People who inject drugs were recruited and interviewed in 20 US cities for 2015 National HIV Behavioral Surveillance. Probable serious mental illness was assessed using the Kessler-6 screening scale. Bivariate analyses using log-linked Poisson regression with generalized estimating equations adjusted for design covariates were conducted to examine associations between PSMI and behaviors among PWID ages 18-29 years.

RESULTS

Of 1769 young PWID, 45% had PSMI. Compared to those without PSMI, PWID with PSMI were more likely to report injecting more than once a day, receptive syringe sharing, sharing of other injection equipment, and unmet needs for medical care and substance use disorder (SUD) treatment. Those with PSMI were less likely to use syringe services programs than those without PSMI.

CONCLUSIONS

Approximately half of young PWID had PSMI. People who inject drugs with PSMI engaged in high-risk injection behaviors and encountered barriers to healthcare. Human immunodeficiency virus prevention programs such as Syringe Services Programs (SSPs) could benefit from screening for mental illness among young PWID and strong linkage to healthcare, including mental health and SUD treatment.

Mental distress following inpatient substance use treatment, modified by substance use; comparing voluntary and compulsory admissions

Background

Treatment services to patients with substance use disorders (SUDs), including those mandated to treatment, needs to be evaluated and evidence based. The Norwegian Municipal Health Care Act (NMHCA) calls for compulsory treatment for persons with “severe and life-threatening substance use disorder” if these individuals are not otherwise willing to be voluntarily treated and consequently risk their lives over drug use. Mental distress is known to be high among SUD patients admitted to inpatient treatment. The purpose of this study is to describe changes in mental distress from admission to a 6-month follow-up in patients with SUDs, which underwent either voluntary or compulsory treatment.

Method

This prospective study followed 202 hospitalized patients with SUDs who were admitted voluntarily (VA; n = 137) or compulsorily (CA; n = 65). Levels of mental distress were assessed with SCL-90-R. Of 123 patients followed-up at 6 months, 97 (62 VA and 35 CA) had rated their mental distress at admission, discharge and follow-up. Sociodemographics and substance use severity were recorded with the use of The European Addiction Severity Index (EuropASI). We performed a regression analysis to examine factors associated with changes in psychiatric distress at the 6-month follow-up.

Results

The VA group exhibited higher mental distress than the CA group at admission, but both groups improved significantly during treatment. At the 6-month follow-up, the VA group continued to show reduced distress, but the CA group showed increases in mental distress to the levels observed before treatment. The deterioration appeared to be associated with higher scores that reflected paranoid ideas, somatization, obsessive-compulsive symptoms, interpersonal sensitivity, and depression. Active substance use during follow-up was significantly associated with increased mental distress.

Conclusion

In-patient treatment reduces mental distress for both CA and VA patients. The time after discharge seems critical especially for CA patients regarding active substance use and severe mental distress. A greater focus on continuing care initiatives to assist the CA patients after discharge is needed to maintain the reduction in mental distress during treatment. Continuing-care initiatives after discharge should be intensified to assist patients in maintaining the reduced mental distress achieved with treatment.

Trial registration

ClinicalTrials.gov NCT 00970372 December 02, 2016.

Psychiatric correlates of injection risk behavior among young people who inject drugs

People who inject drugs (PWID) and have mental health conditions, such as major depression, an anxiety disorder, or antisocial or borderline personality disorder, may have elevated risk for HIV and HCV infection. This study examined the associations between psychiatric disorders and risky injection behavior in an out-of-treatment sample of young PWID. We recruited participants through outreach and respondent-driven sampling (RDS). Participants completed a computer-assisted self-interview and a psychiatric interview. Interviews took place at a community-based field site of the Community Outreach Intervention Projects. Participants were 570 young adults (18 to 25 years) who injected drugs in the previous 30 days. Psychiatric diagnoses were based on interviews using the Psychiatric Research Interview for Substance and Mental Disorders (PRISM). Injection behavior was classified into 3 categories: receptive syringe sharing, other equipment sharing only, and no sharing. Associations between injection risk behavior and psychiatric diagnoses were tested using RDS-weighted multinomial regressions. Substance-induced lifetime and past-year major depression, and borderline personality disorder, were significantly associated with a greater likelihood of receptive syringe sharing (p < .001). Substance-induced major depression in the past year was also associated with nonsyringe equipment sharing (p < .01). Primary major depression, antisocial personality disorder, and anxiety disorders other than posttraumatic stress disorder were slightly more prevalent among injectors who shared syringes; however, the associations were not statistically significant. Substance-induced major depression and borderline personality disorder are common among young PWID and are associated with risky injection behavior.

Quality of life of people who inject drugs: characteristics and comparisons with other population samples

PURPOSE

To assess the quality of life (QOL) of persons who inject drugs.

METHODS

Some 483 current injecting drug users visiting a large NSP over a 2-week period in October 2009 were interviewed using a structured questionnaire. QOL was measured using the WHOQOL-BREF. Data were collected on age, gender, injecting patterns, current drug treatment status and hepatitis C status. Participant QOL profiles were compared to published domain scores for a range of other population groups.

RESULTS

People who inject drugs (PWID) experience a very poor QOL irrespective of socio-demographic characteristics, injecting patterns, hepatitis C sero-status and drug treatment status. Sample participants (PWID) experience a QOL below that experienced by many population groups in the community affected by disabling chronic illnesses.

CONCLUSIONS

Injecting drug use is associated with a poor QOL. Some PWID may be self-medicating for chronic non-malignant pain, and it is likely that these people had a low QOL prior to the decision to inject. Despite this caveat, it remains likely that injecting drug use does little to enhance the QOL of the user.

Prospective effects of traumatic event re-exposure and post-traumatic stress disorder in syringe exchange participants

AIM

Determine the effect of traumatic event re-exposure and post-traumatic stress disorder (PTSD) symptom severity on proximal drug use and drug abuse treatment-seeking in syringe exchange participants.

DESIGN

Prospective longitudinal 16-month cohort study of new syringe exchange registrants enrolled in a parent study of methods to improve treatment engagement.

SETTING

Data were collected in a research van next to mobile syringe exchange distribution sites in Baltimore, Maryland.

PARTICIPANTS

Male and female (n = 162) injecting drug users (IDUs) registered for syringe exchange.

MEASUREMENTS

Traumatic event re-exposure was identified each month with the Traumatic Life Events Questionnaire. PTSD symptoms were measured with the Modified PTSD Symptom Scale-Revised, given every 4 months. Outcome measures collected monthly were days of drug use (heroin, cocaine) and drug abuse treatment-seeking behavior (interest, calls to obtain treatment, treatment participation).

FINDINGS

Each traumatic event re-exposure was associated with about 1 more day of cocaine use after accounting for the previous month's cocaine use [same month adjusted B, standard error = 1.16 (0.34); 1 month later: 0.99 (0.34)], while PTSD symptoms had no effect. Traumatic event re-exposure increased interest in drug abuse treatment [same month adjusted odds ratios with 95% confidence intervals = 1.34 (1.11-1.63)] and calling to obtain treatment [same month 1.58 (1.24-2.01); 1 month later 1.34 (1.03-1.75)]. Each 10% increase in PTSD symptom severity was associated with persistent increased interest in treatment [same month 1.25 (1.10-1.42); 1 month later 1.16 (1.02-1.32); 2 months later 1.16 (1.02-1.32)] and calling to obtain treatment [same month 1.16 (1.02-1.32)]. Neither traumatic events nor PTSD symptoms were associated with participants receiving treatment.

CONCLUSIONS

Becoming exposed again to traumatic events among injecting drug users is associated with an increase in cocaine use up to 1 month later, but drug use is not related to post-traumatic stress disorder symptoms. Both traumatic event re-exposure and post-traumatic stress disorder symptoms predict drug abuse treatment-seeking behavior for up to 2 months.

Benefits of concurrent syringe exchange and substance abuse treatment participation

Participation in syringe exchange programs (SEPs) is associated with many individual and public health benefits but may have little impact on reducing drug use without concurrent treatment engagement. This study evaluated rates of drug use, other risk behaviors, and illegal activities in newly registered SEP participants (N = 240) enrolled versus not enrolled in substance abuse treatment over a 4-month observation window and examined the effect of days in treatment on these outcomes. After controlling for baseline differences, SEP registrants enrolled in treatment (n = 113) reported less days of opioid and cocaine use, injection drug use, illegal activities, and incarceration than those not enrolled in treatment (n = 127). For those enrolled in treatment, days of treatment was strongly correlated with each of these outcomes. These findings provide good evidence for a dose-response effect of treatment in syringe exchangers and suggest that substance abuse treatment significantly expands the harm reduction benefits of SEP participation.