Systematic review of prospective studies investigating "remission" from amphetamine, cannabis, cocaine or opioid dependence

The Impact of Cannabis Use on Clinical Outcomes in Inflammatory Bowel Disease: A Population-based Longitudinal Cohort Study

BACKGROUND

Cannabis use is common in inflammatory bowel disease (IBD). Recent studies demonstrated that use of cannabis may relieve symptoms; however, it is still unclear how safe cannabis and its derivatives are for IBD patients. We performed this study to evaluate the impact of cannabis use on several key clinical outcomes in IBD.

METHODS

We performed a retrospective study using the TriNetX Diamond Network. Cannabis use and noncannabis use subcohorts were identified for 3 patient groups: (1) IBD, (2) Crohn's disease (CD), and (3) ulcerative colitis (UC). Baseline differences between subcohorts for each group were controlled by propensity score matching. In each group, we compared relative incidence of emergency department (ED) visits, hospitalization, corticosteroid use, opioid use, IBD-related surgery, and death between cannabis users and noncannabis users.

RESULTS

Inflammatory bowel disease cannabis users demonstrated an increased risk for corticosteroid use (risk ratios [R],1.095; 95% CI, 1.021-1.174; P = .011), ED visits (RR, 2.143; 95% CI, 2.034-2.257; P < .001), hospitalizations (RR, 1.925; 95% CI, 1.783-2.079; P < .001) and opioid use (RR, 1.35; 95% CI, 1.14-1.6); P < .001), but not an increased risk of IBD-related surgery or death. The CD and UC groups exhibited similar outcomes, except only CD demonstrated an increased risk for corticosteroid and opioid use.

CONCLUSIONS

Cannabis use in IBD patients is associated with several poor clinical outcomes, including increased risk of corticosteroid and opioid use, ED visits and hospitalization, though not IBD-related surgery or death. It is not clear what drives these risks or whether they are directly related to IBD-associated disease activity or other factors. Further prospective studies are warranted to more carefully investigate these relationships.

A Dynamic Model of Opioid Overdose Deaths in Canada during the Co-Occurring Opioid Overdose Crisis and COVID-19 Pandemic

With over 40,000 opioid-related overdose deaths between January 2016 and June 2023, the opioid-overdose crisis is a significant public health concern for Canada. The opioid crisis arose from a complex system involving prescription opioid use, the use of prescription opioids not as prescribed, and non-medical opioid use. The increasing presence of fentanyl and its analogues in the illegal drugs supply has been an important driver of the crisis. In response to the overdose crisis, governments at the municipal, provincial/territorial, and federal levels have increased actions to address opioid-related harms. At the onset of the COVID-19 pandemic, concerns emerged over how the pandemic context may impact the opioid overdose crisis. Using evidence from a number of sources, we developed a dynamic mathematical model of opioid overdose death to simulate possible trajectories of overdose deaths during the COVID-19 pandemic. This model incorporates information on prescription opioid use, opioid use not as prescribed, non-medical opioid use, the level of fentanyl in the drug supply, and a measure of the proportion deaths preventable by new interventions. The simulated scenarios provided decision makers with insight into possible trajectories of the opioid crisis in Canada during the COVID-19 pandemic, highlighting the potential of the crisis to take a turn for the worse under certain assumptions, and thus, informing planning during a period when surveillance data were not yet available. This model provides a starting point for future models, and through its development, we have identified important data and evidence gaps that need to be filled in order to inform future action.

Not Two Sides of the Same Coin: A Qualitative Comparative Analysis of Post-Treatment Abstinence and Relapse

Purpose

Substance use disorder (SUD) can be a chronic relapsing condition with poor treatment outcomes. Studies exploring factors associated with abstinence or relapse after treatment are often quantitative in nature, applying linear statistical approaches, while abstinence and relapse result from non-linear, complex, dynamic and synergistic processes. This study aims to explore these underlying dynamics using qualitative comparative analysis (QCA) as a mixed methods approach to further our understanding of factors contributing to post-treatment abstinence and relapse.

Patients and Methods

In a prospective study, we gathered both qualitative and quantitative data pertaining to post-treatment substance use and the factors linked to substance use outcomes. These factors encompassed psychiatric comorbidity, intellectual disability, social disintegration, post-treatment support, and engagement in activities among patients who had undergone inpatient treatment for severe SUD (n = 58). QCA, a set-theoretic approach that considers the complex interplay of multiple conditions, was applied to discern which factors were necessary or sufficient for the occurrence of either abstinence or relapse.

Results

We found two solutions predicting abstinence, and five for relapse. Post-treatment conditions (support and engagement in activities) were important for retaining abstinence. For relapse, individual baseline characteristics (intellectual disability, social disintegration, psychiatric comorbidity) combined with (post-)treatment factors (post-treatment support, activities) were important.

Conclusion

Although abstinence and relapse represent opposing outcomes, they each exhibit distinct dynamics. To gain a comprehensive understanding of these dynamics, it is advisable to examine them as separate outcomes. For clinical practice, it can be worthwhile to recognize that fostering the conditions conducive to abstinence may differ from preventing the factors that trigger relapse.

Dysregulation of the endogenous cannabinoid system following opioid exposure

Rates of opioid-related deaths and overdoses in the United States are at record-high levels. Thus, novel neurobiological targets for the treatment of OUD are greatly needed. Given the close interaction between the endogenous opioid system and the endocannabinoid system (ECS), targeting the ECS may have therapeutic potential in OUD. The various components of the ECS, including cannabinoid receptors, their lipid-derived endogenous ligands (endocannabinoids [eCBs]), and the related enzymes, present potential targets for developing new medications in OUD treatment. The purpose of this paper is to review the clinical and preclinical literature on the dysregulation of the ECS after exposure to opioids. We review the evidence of ECS dysregulation across various study types, exposure protocols, and measurement protocols and summarize the evidence for dysregulation of ECS components at specific brain regions. Preclinical research has shown that opioids disrupt various ECS components that are region-specific. However, the results in the literature are highly heterogenous and sometimes contradictory, possibly due to variety of different methods used. Further research is needed before a confident conclusion could be made on how exposure to opioids can affect ECS components in various brain regions.

Longitudinal latent polysubstance use patterns among a cohort of people who use opioids in Vancouver, Canada

INTRODUCTION

Polysubstance use (PSU) practices are increasing among people who use opioids (PWUO). However, several aspects of longitudinal PSU patterns among PWUO remain understudied. This study aims to identify person-centred longitudinal patterns of PSU among a cohort of PWUO.

METHODS

Using longitudinal data (2005-2018) from three prospective cohort studies including people who use drugs in Vancouver, Canada, we used repeated measures latent class analysis to identify different PSU classes among PWUO. Multivariable generalised estimating equations models weighted by the respective posterior membership probabilities were applied to identify covariates of membership in different PSU classes over time.

RESULTS

Overall, 2627 PWUO (median age at baseline: 36 [quartile 1-3: 25-45]) were included between 2005 and 2018. We found five distinct PSU patterns, including low/infrequent probability of regular substance use (Class 1; 30%), primarily opioid and methamphetamine use (Class 2; 22%), primarily cannabis use (Class 3; 15%), primarily opioid and crack use (Class 4; 29%) and frequent PSU (Class 5; 4%). Membership in Class 2, 4 and 5 was positively associated with several behavioural and socio-structural adversities.

DISCUSSION AND CONCLUSIONS

Findings of this longitudinal study suggest PSU is the norm among PWUO and highlights the heterogeneous characteristics of PWUO. The diversities within the population of PWUO need to be recognised in addiction care and treatment as well as optimising resource allocation in the response to the overdose crisis.

Risk factors for relapse among methamphetamine users receiving a joint legal-medical treatment program as a diversion intervention: A one-year follow-up study

BACKGROUND

Methamphetamine (METH) is a Schedule II illicit drug in Taiwan. A 12-month legal-medical joint intervention program has been developed for first-time METH offenders during deferred prosecution. Risk factors associated with METH relapse use among these individuals were unknown.

METHODS

We enrolled a total of 449 METH offenders referred by the Taipei District Prosecutor's Office to Taipei City Psychiatric Center. The study defines relapse as having any positive urine toxicology result or self-report of METH use during 12-month treatment. We compared demographic and clinical variables between a relapse group and nonrelapse group and used a Cox proportional hazards model to determine variables associated with time to relapse.

RESULTS

Of all participants, 37.8 % relapsed to use METH and 23.2 % were noncompleters in the one-year follow-up. Compared to the nonrelapse group, the relapse group had lower educational attainment, more severe psychological symptoms, longer duration of METH use, higher odds of polysubstance use, higher craving severity, and higher odds of positive baseline urine. The Cox analysis revealed individuals with positive urine results and higher craving severity at baseline were at higher risks of METH relapse (hazard ratio [95 % CI]: 3.85 [2.61-5.68] and 1.71 [1.19-2.46], respectively, p < 0.001). Baseline positive urine results and high craving could also predict a shorter length of time to relapse than their respective counterparts.

CONCLUSIONS

Positive urine screening for METH at baseline and high craving severity are two indicators of an increased risk of drug relapse. Tailored treatment plans incorporating these findings to prevent relapse are warranted in our joint intervention program.

Prevalence of mental disorders among people with opioid use disorder: A systematic review and meta-analysis

BACKGROUND

Opioid use disorder (OUD) and mental disorders are major public health issues and comorbidity is common. Among people with OUD, comorbid mental disorders are associated with poorer health outcomes. To our knowledge, this is the first systematic review and meta-analysis to estimate prevalence of specific mental disorders among people with OUD.

METHODS

We searched Embase, MEDLINE, and PsycInfo from 1990 to 2021 for observational studies of depression, anxiety, post-traumatic stress disorder (PTSD), bipolar, personality, and other pre-specified mental disorders among people with OUD. We pooled current and lifetime estimates of each disorder using random-effects meta-analyses with 95% Confidence Intervals (CIs). Meta-regressions and stratified analyses were used to assess heterogeneity of prevalence estimates by methodological factors and sample characteristics.

FINDINGS

Of the 36,971 publications identified, we included data from 345 studies and 104,135 people with OUD in at least one pooled estimate. Among people with OUD, the prevalence of current depression was 36.1% (95%CI 32.4-39.7%), anxiety was 29.1% (95%CI 24.0-33.3%), attention-deficit/hyperactivity disorder was 20.9% (95%CI 15.7-26.2%), PTSD was 18.1% (95%CI 15.4-20.9%), and bipolar disorder was 8.7% (95%CI 6.7-10.7%). Lifetime prevalence of anti-social personality disorder was 33.6% (95%CI 29.1-38.0%) and borderline personality disorder was 18.2% (95% CI 13.4-23.1%). Sample characteristics and methodological factors, including sex, were associated with variance of multiple prevalence estimates.

INTERPRETATION

Our findings emphasise the need for access to mental disorder treatment among people with OUD. Specific mental disorder estimates may inform clinical guidelines, treatment services, and future research for people with OUD, including subpopulations with distinct treatment needs.

Association between Polymorphism rs1799732 of DRD2 Dopamine Receptor Gene and Personality Traits among Cannabis Dependency

Compared to other addictive substances, patients with cannabis addiction are significantly outnumbered by those who report dependence on other, more addictive substances. Unfortunately, most cannabis addiction goes untreated, and among those who choose treatment, the requirements are much higher for adolescents and young adults.

THE AIM OF THE STUDY

To examine the relationship of cannabinoid dependency in the genetic context-the association between the rs1799732 polymorphism of the DRD2 gene and psychological traits and anxiety.

METHODS

The study group consisted of 515 male volunteers. Of these, 214 patients were diagnosed with cannabis addiction and 301 were non-addicted. Patients were diagnosed with NEO Five-Factor Personality Inventory (NEO-FFI), and State-Trait Anxiety Inventory (STAI) questionnaires. The interactions between personality traits and polymorphisms in the DRD2 rs1799732 gene were investigated in a group of cannabis-addicted patients and non-addicted controls using the real-time PCR method.

RESULTS

Compared to the control group, the case group obtained significantly higher scores on the STAI State, STAI Trait, Neuroticism and Openness scales, as well as lower scores on the Extraversion, Agreeableness, and Conscientiousness scales. There was no statistically significant difference between addicts and the control group in the frequency of genotypes, but there was a statistically significant difference between addicts and the control group in the frequency of the DRD2 allele rs179973. The multivariate ANOVA analysis showed a statistically significant influence of the DRD2 rs1799732 genotype on the NEO-FFI agreeableness scale and a statistically significant effect of addiction to cannabinoids or its absence on the NEO-FFI agreeableness scale score.

CONCLUSIONS

Studying homogeneous subgroups-as in our study-seems reasonable, particularly when combined with genetic determinants and psychological traits. In multigenic and multifactorial entities, such a strategy has a future.

A comprehensive mobile health intervention to prevent and manage the complexities of opioid use

OBJECTIVES

The Opioid Use crisis continues to be an epidemic with multiple known influencing and interacting factors. With the need for suitable opioid use interventions, we present a conceptual design of an m-health intervention that addresses the various known interacting factors of opioid use and corresponding evidence-based practices. The visualization of the opioid use complexities is presented as the "Opioid Cube".

METHODS

Following Stage 0 to Stage IA of the NIH Stage Model, we used guidelines and extant health intervention literature on opioid apps to inform the Opioid Intervention (O-INT) design. We present our design using system architecture, algorithms, and user interfaces to integrate multiple functions including decision support. We evaluate the proposed O-INT using analytical modeling.

RESULTS

The conceptual design of O-INT supports the concept of collaborative care, by providing connections between the patient, healthcare professionals, and their family members. The evaluation of O-INT shows a preference for specific functions, such as overdose detection and potential for high system reliability with minimal side effects. The Opioid Cube provides a visualization of various opioid use states and their influencing and interacting factors.

CONCLUSIONS

O-INT is a promising design with a holistic approach to manage opioid use and prevent and treat misuse. With several needed functionalities, O-INT design serves as a decision support system for patients, healthcare professionals, researchers, and policy makers. Together, O-INT and the Opioid Cube may serve as a foundation for development and adoption of highly effective m-health interventions for opioid use.

The relation between cannabis use, dependence severity and white matter microstructure: A diffusion tensor imaging study

Despite the significant societal and personal burden of cannabis use, the impact of long‐term use and Cannabis Use Disorder (CUD) on white matter microstructure is still unclear. Previous studies show inconsistent findings, in part due to heterogeneity in methodology, variable severity of cannabis use, and potential confounding effects of other mental health issues and substance use. The goal of this diffusion tensor imaging (DTI) study was to compare whole‐brain white matter microstructure between 39 near daily cannabis users and 28 controls closely matched on age, sex, alcohol use, cigarette use and mental health. Within the group of cannabis users, associations between white matter microstructure and recent cannabis use, dependence severity, and age of onset and duration of weekly use were investigated. White matter microstructure did not differ between cannabis users and controls and did not covary with recent cannabis use, dependence severity, or duration of use. Earlier onset of weekly cannabis use was related to lower fractional anisotropy (FA) in various sections of the right inferior longitudinal fasciculus and uncinate fasciculus. These findings suggest that long‐term near‐daily cannabis use does not necessarily affect white matter microstructure, but vulnerability may be higher during adolescence. These findings underscore the importance of sample composition and warrant further studies that investigate the moderating role of age of onset in the impact of cannabis on the brain.

Marijuana use experiences and expectancies of urban youth in India

Objective:

To gain information on the marijuana experiences and expectancies of youth in an urban Indian area, which may be used for forming the framework for the development of effective primary prevention strategies in the future.

Method:

This was a cross-sectional study conducted in various colleges of Mumbai; 260 students from three colleges who were above 18 years were selected by systematic random sampling. The participant had to fill a sociodemographic questionnaire and marijuana effect expectancy questionnaire (MEEQ-B) and it was analyzed by using the SPSS software.

Results:

A significant association was found between negative marijuana expectancies and type of family, with cannabis users and non-users, who want to try cannabis and those who are aware of the legal issues and harmful effects of cannabis.

Conclusion:

Preventive drug education should begin in early adolescence and should deter or delay drug use through changes in knowledge, attitude, behavior, and expectation. Adolescent drug education must meet the needs of those naive to drugs as well as those experiencing initial drug exposure. This is the first study which highlights the youth experiences and expectancies about marijuana in India.

What is the short-term remission rate for people with untreated depression? A systematic review and meta-analysis

BACKGROUND

Depression is one of the prevalent mental illnesses and leading cause of global disease burden. However, most people with depression do not access treatment. Remission without treatment may occur in some cases of depression. This study aimed to estimate the short-term remission (natural recovery) from untreated depression.

METHODS

A systematic review and meta-analysis was registered on PROSPERO and conducted following PRISMA guidelines. EMBASE, PsycINFO, and PubMed were searched, supplemented with an additional hand search to identify studies reporting natural recovery from untreated depression. Study selection and screening were carried out by three independent reviewers. Methodological quality assessment of the included studies was conducted. Remission was defined as no longer meeting the diagnostic criteria or scoring below the cut off points of the validated tools as reported by the included studies. The data were synthesized using narrative summary and random-effects meta-analysis.

RESULTS

Sixteen waitlist-controlled trial studies were included in the systematic review and meta-analysis. The duration of follow-up ranged from 4 to 12 weeks with a median duration of 8 weeks. The overall pooled remission from untreated depression was 12.5%, 95% confidence interval (7.8, 18.0%). Due to lack of published data, we were unable to determine if the severity of depression symptoms was associated with remission rates.

CONCLUSIONS

Short-term remission from depression without treatment is uncommon. Across studies, 8 - 18% of people remitted without treatment within 12 weeks. Waitlist control groups may not represent all persons with depression.

Review, Assess, Classify, and Evaluate (RACE): a framework for studying m-health apps and its application for opioid apps

OBJECTIVE

The proliferation of m-health interventions has led to a growing research area of app analysis. We derived RACE (Review, Assess, Classify, and Evaluate) framework through the integration of existing methodologies for the purpose of analyzing m-health apps, and applied it to study opioid apps.

MATERIALS AND METHODS

The 3-step RACE framework integrates established methods and evidence-based criteria used in a successive manner to identify and analyze m-health apps: the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, inter-rater reliability analysis, and Nickerson-Varshney-Muntermann taxonomy.

RESULTS

Using RACE, 153 opioid apps were identified, assessed, and classified leading to dimensions of Target Audience, Key Function, Operation, Security & Privacy, and Impact, with Cohen's kappa < 1.0 suggesting subjectivity in app narrative assessments. The most common functions were education (24%), prescription (16%), reminder-monitoring-support (13%), and treatment & recovery (37%). A majority are passive apps (56%). The target audience are patients (49%), healthcare professionals (39%), and others (12%). Security & Privacy is evident in 84% apps.

DISCUSSION

Applying the 3-step RACE framework revealed patterns and gaps in opioid apps leading to systematization of knowledge. Lessons learned can be applied to the study of m-health apps for other health conditions.

CONCLUSION

With over 350 000 existing and emerging m-health apps, RACE shows promise as a robust and replicable framework for analyzing m-health apps for specific health conditions. Future research can utilize the RACE framework toward understanding the dimensions and characteristics of existing m-health apps to inform best practices for collaborative, connected and continued care.

Is the relapse concept in studies of substance use disorders a 'one size fits all' concept? A systematic review of relapse operationalisations

ISSUES

Relapse is a theoretical construct and empirical object of inquiry. It is unclear how relapse is operationalised with regard to the various phases in substance use disorders (SUD). The aim was to investigate relapse operationalisations in SUDs studies after short- and long-term abstinence and remission, recovery and slip/lapse.

APPROACH

Systematic review using the following databases: Epistemonikos, Cochrane Central Register of Controlled Trials (CENTRAL and DARE), MEDLINE, EMBASE, Google Scholar, CINAHL, Web of Science and PsycINFO. Search returned 3426 articles, with 276 meeting the following inclusion criteria: empirical study published in English in a peer-reviewed journal; samples meet diagnostic criteria for dependence syndrome or moderate-severe drug use disorder or alcohol use disorder; reports relapse, abstinence, recovery, remission, slip or lapse. Review protocol registration: PROSPERO (CRD42020154062).

KEY FINDINGS

Thirty-two percent of the studies had no definition of 'relapse'. Most relapse operationalisations were defined according to measure (26%), time (17%), use (26%) and amount and frequency (27%). Of the 16 studies with a follow-up duration of up to 2 years, one (6%) contained a definition of 'long-term abstinence'. Of the 64 studies with a follow-up duration of more than 2 years, four (6%) contained a definition of 'long-term abstinence'. Of those, one (2%) mentioned 'early relapse' and one (2%) mentioned 'late relapse'.

IMPLICATIONS

Future research is needed to explore the possible difference between early and late relapse. Moreover, working to increase consensus on relapse operationalisations in SUD research is warranted.

CONCLUSIONS

We identified no consensus on relapse operationalisations nor agreement on the differentiation between early and late relapse. The clinical utility of current relapse operationalisations seems low and may compromise knowledge accumulation about relapse and implementation of research into treatment.

Cannabis, Cannabinoide und Cannabiskonsumstörungen

Keine Droge führt derzeit zu so intensiven, teilweise leidenschaftlich geführten Diskussionen wie Cannabis. Welche gesundheitlichen und sozialen Risiken birgt die Substanz, wenn sie zu Rauschzwecken gebraucht wird? Dieser Beitrag beschreibt die wichtigsten Cannabinoide, das endogene Cannabissystem sowie mögliche kurzund langfristige Risiken. Er zeigt zudem psychotherapeutische Behandlungsoptionen von Cannabismissbrauch und -abhängigkeit auf.

Pre-incarceration polysubstance use involving opioids: A unique risk factor of postrelease return to substance use

OBJECTIVE

Justice-involved populations are at increased risk of overdose following release from prison and jail. This risk is exacerbated by polysubstance use, including the use of opioids with other substances. This study explored pre-incarceration polysubstance use involving opioids as a unique risk factor for postrelease return to substance use.

METHODS

The study examined data from a cohort of 501 justice-involved persons who were enrolled in a therapeutic community treatment program while incarcerated. Latent profile validation identified profiles of polysubstance use involving opioids prior to incarceration. Multivariate logistic regression examined return to substance use, defined as self-reported relapse, and a time series model examined time in the community until a relapse event occurred.

RESULTS

A latent profile validation found six unique polysubstance opioid patterns prior to incarceration. Two of these profiles, primarily alcohol and primarily buprenorphine, were at increased and accelerated risk for relapse postrelease relative to a less polysubstance use profile. Both profiles at increased risk had pre-incarceration co-use of marijuana (≈45% of month) and nonmedical use of opioids (≈40% of month) but were unique in their respective near daily use of alcohol and nonmedical buprenorphine.

CONCLUSIONS

Among persons who use opioids returning to the community, return to substance use occurs along a continuum of risk. Providers' consideration of polysubstance use patterns during treatment may assist in mitigating adverse outcomes for patients postrelease.

Cannabis use disorder trajectories and their prospective predictors in a large population-based sample of young Swiss men

BACKGROUND AND AIMS

Cannabis use disorder (CUD) is frequent in adolescence and often goes into remission towards adulthood. This study aimed to estimate trajectories of CUD severity (CUDS) in Swiss men aged from 20 to 25 years and to identify prospective predictors of these trajectories.

DESIGN

Latent class growth analysis of self-reported CUDS in a cohort study with three data collection waves.

SETTING

A general population sample of young Swiss men.

PARTICIPANTS

A total of 5987 Swiss men assessed longitudinally at the mean ages of 20, 21.5 and 25 years.

MEASUREMENTS

Latent CUDS in the last 12 months was measured at each wave with the Cannabis Use Disorders Identification Test-Revised (CUDIT-R). Predictors of CUDS trajectories, measured at age 20, were from six domains: factors related to cannabis use, family, peers, other substance use, mental health and personality.

FINDINGS

We distinguished four CUDS trajectories: stable-low (88.2%), decreasing (5.2%), stable-high (2.6%) and increasing (4.0%). Predictors were generally associated with higher odds of membership in the decreasing and stable-high trajectory (versus the stable-low), and to a lesser degree with higher odds of membership in the increasing trajectory. Bivariate predictors of persistent high CUDS (stable-high versus decreasing trajectory) were major depression severity [odds ratio (OR) = 1.19, 95% confidence interval (CI) = 1.01, 1.40], attention deficit hyperactivity disorder severity (OR = 1.25, 95% CI = 1.04, 1.51), antisocial personality disorder severity (OR = 1.18, 95 % CI = 1.04, 1.34), relationship with parents (OR = 0.74, 95% CI = 0.63, 0.88), number of friends with drug problems (OR = 1.33, 95% CI = 1.11, 1.60) and the personality dimensions neuroticism-anxiety (OR = 1.35, 95% CI = 1.11, 1.65) and sociability (OR = 0.78, 95% CI = 0.62, 0.97).

CONCLUSIONS

Factors associated with persistent cannabis use disorder in young Swiss men include cannabis use, cannabis use disorder severity, mental health problem severity, relationship with parents (before the age of 18), peers with drug problems and the personality dimensions neuroticism-anxiety and sociability at or before age 20. Effect sizes may be small, and predictors are mainly associated with persistence via higher severity at age 20 years.

Understanding the Relationship Between Complicated Grief Symptoms and Patterns of Personality Disorders in a Substance Users' Sample: A Network Analysis Approach

BACKGROUND

The presence of personality disorders is greatly prevalent among substance users. Personality disorders could increase vulnerability to complicated grief symptoms. Bereavement is commonly overlooked among substance users. We used network analysis to estimate the structure of relations between patterns of personality disorders and complicated grief symptoms among a bereaved substance-using population.

METHODS

Complicated grief and personality disorders were assessed in a sample of 196 bereaved substance users. We use the graphical least absolute shrinkage selection operator (LASSO) to compute a regularized partial correlation network revealing associations among different patterns of personality disorders and complicated grief symptoms.

RESULTS

In a network involving nodes for personality disorders and symptomatology of complicated grief, patterns of depressive and paranoid personality disorder showed small relationships to complicated grief symptoms. All other personality disorders showed negligible to no relationship to complicated grief symptoms. Further, in the overall network, complicated grief showed the lowest level of centrality, suggesting that it is independent of personality disorders, whereas depressive and paranoid personality disorder symptoms showed the highest centrality.

CONCLUSION

Network analysis can be used to understand the relationships among higher-level constructs such as disorders. We found that complicated grief is largely independent of patterns of personality disorders with the exception of depressive and paranoid. Findings have implications for assessment and appropriate treatment of complicated grief symptoms and substance use disorder.

Forecasting Opioid Use Disorder at 25 Years of Age in 16-Year-Old Adolescents

OBJECTIVE

To evaluate the accuracy of detecting 16-year-old male (n = 465) and female (n = 162) youths who subsequently manifest opioid use disorder (OUD) at 25 years of age. We hypothesized that the combined measures of 2 components of etiology, heritable risk, and substance use, accurately detect youths who develop OUD.

STUDY DESIGN

Heritable risk was measured by the transmissible liability index (TLI). Severity of the prodrome presaging OUD was quantified by the revised Drug Use Screening Inventory containing the consumption frequency index (CFI) documenting substance use events during the past month and the overall problem density (OPD) score indicating co-occurring biopsychosocial problems. Diagnosis of OUD was formulated by a clinical committee based on results of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition in conjunction with medical and social history records.

RESULTS

Bivariate analysis shows that the TLI, CFI, and OPD scores at 16 years of age predict OUD at 25 years. Multivariate modeling indicates that the TLI combined with the CFI predict OUD with 86% accuracy (sensitivity = 87%; specificity = 62%). The TLI and CFI at 16 years of age mediate the association between parental substance use disorder and OUD in offspring at 25 years of age, indicating that these measures respectively evaluate risk and prodrome.

CONCLUSIONS

These results demonstrate the feasibility of identifying youths requiring intervention to prevent OUD.

How individuals make choices explains addiction's distinctive, non-eliminable features

In keeping with the goals of this Special Issue, this paper poses the following questions: What are addiction's non-eliminable features and can they be explained by one or more general principles? I have added the qualifier "distinctive" to these goals, as in "distinctive non-eliminable features." The result is a highly heterogeneous list, which includes features of addiction's natural history, such as its high remission rates, its unique idioms (e.g., "kicking the habit"), and its patented interventions, such as Alcoholics Anonymous. I show that each of these distinctive features reflects how individuals make choices. In particular, they reflect the competing claims of two basic choice processes: global maximizing of the sort assumed in introductory economics textbooks and Herrnstein's matching law, which has empirical rather than theoretical roots. These are basic choice processes, which apply to all decision making, not just drugs and not just addicts. Nevertheless, they can result in addiction when one of the options has the capacity to undermine the value of competing interests and undermine global maximizing. Conversely, the analyses also show that the two basic choice processes combine so as to predict that addiction is a semi-stable state that is biased to resolve in favor of remission. These predictions are supported by the high rates of addiction, by the high rates of remission from addiction, and by the fact that remission is often unassisted or "spontaneous." The analyses fail to support the idea that pathological psychological processes lead to addiction. Rather they show that addiction emerges from the interactions of normal choice processes and the behaviorally toxic effects of drugs.

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

ISSUES

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

APPROACH

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

KEY FINDINGS

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

CONCLUSION

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

Temporal changes in non-fatal opioid overdose patterns among people who use drugs in a Canadian setting

Background and Aims: Little is known about how the expansion of opioid agonist therapy (OAT) and emergence of fentanyl in the illicit drug supply in North America has influenced non-fatal opioid overdose (NFOD) risk. Therefore, we sought to identify patterns of substance use and addiction treatment engagement (i.e., OAT, other inpatient or outpatient treatment) prior to NFOD, as well as the trends and correlates of each pattern among people who use drugs (PWUD) in Vancouver, Canada. Methods: Data were derived from participants in three prospective cohorts of PWUD in Vancouver in 2009-2016. Observations from participants reporting opioid-related NFOD in the previous six months were included. A latent class analysis was used to identify classes based on substances used at the time of last NFOD and addiction treatment engagement in the month prior to the last NFOD. Multivariable generalized estimating equations estimated the correlates of each class membership. Results: In total, 889 observations from 570 participants were included. Four distinct classes were identified: (1) polysubstance use (PSU) and addiction treatment engagement; (2) PSU without treatment engagement; (3) exposure to unknown substances, mostly without treatment engagement; and (4) primary heroin users without treatment engagement. The class of exposure to unknown substances appeared in 2015 and became the dominant group (76.9%) in 2016. In multivariable analyses, the odds of membership in the class of primary heroin users decreased over time (adjusted odds ratio [AOR]: 0.74, 95% confidence interval [CI]: 0.68-0.81). Conclusions: Changing profiles of PWUD reporting opioid-related NFOD were seen over time. Notably, there was a sudden increase in reports of overdose following exposure to unknown substances since 2015, the majority of whom reported no recent addiction treatment engagement. Further study into patterns of substance use and strategies to improve addiction treatment engagement is needed to improve and focus overdose prevention efforts.

Five-year Changes in Methamphetamine Use, Dependence, and Remission in a Community-recruited Cohort

OBJECTIVES

Investigate patterns of methamphetamine use over time, specifically factors associated with remission from dependent and harmful patterns of use; and examine drug treatment and health/support service utilization pathways among people who use methamphetamine.

METHODS

People who regularly use methamphetamine were recruited from nontreatment settings in Melbourne, Australia, in 2010, and followed up twice over 5 years. Trajectories of past-month methamphetamine use and methamphetamine dependence were mapped. Random-effects logistic regression modeling identified factors associated with these outcomes.

RESULTS

Overall, past-month methamphetamine use and methamphetamine dependence decreased among the cohort over the study period. Variability in methamphetamine use and dependence trajectories was observed; 56% of participants achieved past-month abstinence; however, 14% subsequently relapsed and 44% reported past-month use at every time-point. During the study period, 27% of participants were never classified methamphetamine-dependent, 30% remitted from dependence, and 23% were consistently classified dependent. Factors independently associated with past-month methamphetamine use included male sex and poor physical health. Factors independently associated with methamphetamine dependence included poor physical health, low self-perceived social support, current mental health medication prescription, and current engagement with drug treatment services for methamphetamine use. Engagement with treatment and health/support services remained low (12%-22%) over the study period.

CONCLUSIONS

Our findings indicate people who remit from methamphetamine dependence, reduce their frequency of use or cease entirely can maintain this over long periods. Initiatives addressing social determinants of health could be optimal for combating methamphetamine dependence. Community-based frontline service providers should be educated in relation to appropriately addressing methamphetamine use.

Is Recovery from Cannabis Dependence Possible? Factors that Help or Hinder Recovery in a National Sample of Canadians with a History of Cannabis Dependence

Objectives

To identify among Canadian adults who have ever been dependent upon cannabis, the prevalence of risk and protective factors associated with (1) cannabis remission, (2) the absence of psychiatric disorders or addictions in the past year (APD), and (3) positive mental health (PMH).

Method

Data from Statistics Canada's nationally representative 2012 Canadian Community Health Survey-Mental Health (n = 20, 777, of whom 336 have a history of cannabis dependence) was used. Chi-square tests and logistic regression analyses were conducted. The World Health Organization Composite International Diagnostic Interview (WHO-CIDI) measures were used to determine lifetime cannabis dependence, past-year remission from cannabis depression, and the absence of psychiatric disorders in the past year (APD) (i.e., no suicidal ideation, depressive episodes, anxiety disorders, bipolar disorders, or any substance dependence). PMH is comprised of three factors: APD, happiness or life satisfaction and social and psychological well-being.

Results

Among those with a history of cannabis dependence, 72% were in remission from cannabis dependence. Although 53% were free of major psychiatric disorders and any substance dependence and 43% of respondents were in PMH, these percentages were dramatically lower than those without a history of cannabis dependence (92% and 74%, respectively). Positive outcomes were more common among women, older respondents, those with higher levels of social support, and those who had never had major depressive disorder or generalized anxiety disorder.

Conclusion

Although many Canadians with a history of cannabis dependence achieve remission and a large minority are truly resilient and achieve PMH, many are failing to thrive. Targeted outreach is warranted for the most vulnerable individuals with a history of cannabis dependence (e.g., men, younger respondents, those with low social support and a history of mental illness).

Heavy cannabis use, dependence and the brain: a clinical perspective

AIMS

To summarize and evaluate our knowledge of the relationship between heavy cannabis use, cannabis use disorder (CUD) and the brain.

METHODS

Narrative review of relevant literature identified through existing systematic reviews, meta-analyses and a PubMed search. Epidemiology, clinical representations, potential causal mechanisms, assessments, treatment and prognosis are discussed.

RESULTS

Although causality is unclear, heavy and dependent cannabis use is consistently associated with a high prevalence of comorbid psychiatric disorders and learning and memory impairments that seem to recover after a period of abstinence. Evidence regarding other cognitive domains and neurological consequences, including cerebrovascular events, is limited and inconsistent. Abstinence after treatment is only achieved in a minority of cases; treatment targeted at reduction in use appears have some success. Potential moderators of the impact of CUD on the brain include age of onset, heaviness of use, CUD severity, the ratio of ∆9-tetrahydrocannabinol to cannabidiol and severity of comorbid disorders.

CONCLUSIONS

Current evidence of long-term effects of daily cannabis use and cannabis use disorder on brain-related outcomes is suggestive rather than conclusive, but use is associated with psychiatric morbidity and with cognitive impairments that recover after a period of abstinence.

The Neuroscience of Drug Reward and Addiction

Drug consumption is driven by a drug's pharmacological effects, which are experienced as rewarding, and is influenced by genetic, developmental, and psychosocial factors that mediate drug accessibility, norms, and social support systems or lack thereof. The reinforcing effects of drugs mostly depend on dopamine signaling in the nucleus accumbens, and chronic drug exposure triggers glutamatergic-mediated neuroadaptations in dopamine striato-thalamo-cortical (predominantly in prefrontal cortical regions including orbitofrontal cortex and anterior cingulate cortex) and limbic pathways (amygdala and hippocampus) that, in vulnerable individuals, can result in addiction. In parallel, changes in the extended amygdala result in negative emotional states that perpetuate drug taking as an attempt to temporarily alleviate them. Counterintuitively, in the addicted person, the actual drug consumption is associated with an attenuated dopamine increase in brain reward regions, which might contribute to drug-taking behavior to compensate for the difference between the magnitude of the expected reward triggered by the conditioning to drug cues and the actual experience of it. Combined, these effects result in an enhanced motivation to "seek the drug" (energized by dopamine increases triggered by drug cues) and an impaired prefrontal top-down self-regulation that favors compulsive drug-taking against the backdrop of negative emotionality and an enhanced interoceptive awareness of "drug hunger." Treatment interventions intended to reverse these neuroadaptations show promise as therapeutic approaches for addiction.

The effect of entry and retention in opioid agonist treatment on contact with the criminal justice system among opioid-dependent people: a retrospective cohort study

BACKGROUND

Evidence on the effectiveness of opioid agonist treatment (OAT) in reducing crime is mixed. We aimed to assess the effect of OAT on crime in terms of delaying time to first charge and reducing overall charge rates, as well as the relationship between OAT retention and overall charge rates.

METHODS

We did a retrospective cohort study of opioid-dependent people who entered OAT for the first time between Jan 1, 2004, and Dec 30, 2010, in New South Wales (NSW), Australia. We used three linked NSW and national administrative datasets. Data on OAT were obtained from the Pharmaceutical Drugs of Addiction System, data on charges were obtained from the Reoffending Database, and data on mortality were obtained from the National Death Index. The cohort was followed up until Dec 31, 2011. Time-dependent OAT exposure was modelled using Cox proportional hazards models (time to first charge) and Andersen-Gill intensity models (total charge-days). Retention in OAT was modelled using two features of treatment engagement, number of OAT episodes and proportion of follow-up time in OAT (presented in quartile groupings: lowest, low-mid, low-high, highest) using zero-inflated negative binomial regression (total charges). All models were adjusted for sociodemographic, criminographic, and treatment-related variables.

FINDINGS

10 744 new OAT entrants were included in the study. 5751 (53·5%) people were charged with an offence. In adjusted analyses, OAT was associated with an initial benefit in delaying the time to first charge (hazard ratio 0·43, 95% CI 0·33-0·55) and reducing total charge-days (0·39, 95% CI 0·30-0·52); however, these protective effects reduced over time. Total charge rates were higher as the number of OAT episodes increased (incident rate ratio [IRR] 1·13, 95% CI 1·11-1·15), and when relatively lower proportions of time were spent in OAT (IRR among the lowest three quartiles ranged from 1·11 [95% CI 1·02-1·21] to 1·22 [95% CI 1·12-1·33]).

INTERPRETATION

OAT was associated with a reduction in overall charge rates and was more protective as treatment engagement increased. Maximising treatment retention is crucial to achieving long-term health and social benefits of OAT.

FUNDING

Australian National Health and Medical Research Council, Australian Institute of Criminology, National Institute on Drug Abuse, Australian Government Department of Health, UNSW Sydney.

Predicting Substance Use Patterns Among Rural Adults: The Roles of Mothers, Fathers, and Parenthood

This study examined the role of parenthood and parental influences on substance use patterns for 710 stimulant users age 18-61 living in the rural Midwest and Mid-south U.S. Longitudinal growth analyses showed that a maternal history of drug use was associated with increased baseline drug use severity, lesser declines in severity, and greater plateau of drug use severity over time. Parental conflict was associated with lesser declines in drug use severity, and drug use severity declined more steeply for participants who were themselves parents. Participants with two parents having a history of alcohol use had a greater baseline severity of alcohol use, with paternal history of drug use associated with lower baseline alcohol use severity. These findings demonstrate the importance of identifying parental influences in evaluating adult substance use, and point to the inclusion of parents in efforts to prevent and treat substance use disorders.

Relapse after inpatient substance use treatment: A prospective cohort study among users of illicit substances

AIMS

The main aim was to investigate the relative roles of mental distress and intrinsic motivation for relapse after inpatient substance use disorder (SUD) treatment, while adjusting for demographics and treatment variables.

METHODS

The study is based on a prospective multicenter study with a baseline gross sample of 607 patients with SUD (response rate = 84%) admitted to an inpatient stay at one of five specialized SUD treatment centers in Norway. The analytical sample consisted of patients with illicit drug use (n = 374) who took part in a follow-up interview three months after discharge from inpatient treatment (n = 249) (retention rate = 67%). Data were collected using information from electronic medical records, a self-report questionnaire at treatment entry, and a follow-up interview.

RESULTS

Relapse occurred among 37% of the sample by three-month follow-up. Results of multivariable analysis showed that younger age and having a psychiatric diagnosis were associated with an elevated relapse risk. Patients who received treatment at a short-term clinic (2-4 months), as opposed to a long-term clinic (>6 months) were also at increased risk of relapse, regardless of their length of stay. Reduced risk of relapse was predicted by having completed the inpatient treatment stay.

CONCLUSION

Identifying the treatment needs of young patients and patients with co-occurring psychiatric diagnoses during and following inpatient SUD treatment may contribute to reduced post-treatment relapse rates. Further research is needed to illuminate the treatment-related factors that contribute to reduced risk of relapse after inpatient SUD treatment.

An update on cannabis use disorder with comment on the impact of policy related to therapeutic and recreational cannabis use

Confusion and controversy related to the potential for cannabis use to cause harm, or alternatively to provide benefit, continues globally. This issue has grown in intensity and importance with the increased recognition of the public health implications related to the escalation of the legalization of cannabis and cannabinoid products. This selective overview and commentary attempt to succinctly convey what is known about one potential consequence of cannabis use, the development of cannabis use disorder (CUD). Such knowledge may help guide a reasonable and objective public health perspective on the potential impact of cannabis use and CUD. Current scientific data and clinical observation strongly support the contention that cannabis use, like the use of other substances such as alcohol, opioids, stimulants, and tobacco, can develop into a use disorder (addiction) with important clinical consequences. Epidemiological data indicate that the majority of those who use cannabis do not have problems related to their use, but a substantial subset (10-30%) do report experiencing symptoms and consequences consistent with a CUD. Treatment seeking for CUD comprises a substantial proportion of all substance use treatment admissions, yet treatment response rates show much room for improvement. Changing cannabis policies related to its therapeutic and recreational use are likely to impact the development of CUD and its course; however, definitive data on such effects are not yet available. Clearly, the development of more effective prevention and treatment strategies is needed for those vulnerable to developing a CUD and for those with a CUD.

Predictors of transitions across stages of heroin use and dependence prior to treatment-seeking among people in treatment for opioid dependence

BACKGROUND AND AIMS

Little is known about transition pathways among heroin users prior to treatment. This study examined the demographic and clinical predictors of transition speed from heroin use, to dependence, to first treatment episode.

METHODS

1149 heroin-dependent participants recruited from opioid agonist treatment clinics in Sydney, Australia, underwent a structured interview. Age of onset (AOO) was collected for heroin use, dependence and treatment-seeking, childhood maltreatment, psychiatric history and other substance dependence. Discrete-time survival analyses modelled years from onset of use to dependence, and from dependence to treatment-seeking, including demographic and clinical covariates.

FINDINGS

Median AOO for first heroin use, dependence and treatment-seeking was 18 years (inter-quartile range, or IQR = 6), 21 years (IQR = 7), and 24 years (IQR = 10) respectively. In adjusted models, younger birth cohorts (vs. born <1960), greater childhood maltreatment and later AAO of first heroin use were associated with more rapid transitions from heroin use to dependence. Living independently, parental violence, and alcohol dependence were associated with slower transitions. Earlier treatment-seeking was associated with younger birth cohorts, having dependent children and later AOO of dependence. Delayed treatment-seeking was associated with <10 years school education, living independently, depression and alcohol dependence.

CONCLUSIONS

In this treatment sample, onset of heroin use occurred during late adolescence, suggesting the need for targeted interventions in mid-adolescence. Transitions to heroin dependence, then treatment-seeking, occurred during early adulthood. Rapid transitions from use to dependence were associated with younger birth cohorts, greater exposure to childhood maltreatment, and later onset of use.

Emerging Evidence for Cannabis' Role in Opioid Use Disorder

Introduction: The opioid epidemic has become an immense problem in North America, and despite decades of research on the most effective means to treat opioid use disorder (OUD), overdose deaths are at an all-time high, and relapse remains pervasive. Discussion: Although there are a number of FDA-approved opioid replacement therapies and maintenance medications to help ease the severity of opioid withdrawal symptoms and aid in relapse prevention, these medications are not risk free nor are they successful for all patients. Furthermore, there are legal and logistical bottlenecks to obtaining traditional opioid replacement therapies such as methadone or buprenorphine, and the demand for these services far outweighs the supply and access. To fill the gap between efficacious OUD treatments and the widespread prevalence of misuse, relapse, and overdose, the development of novel, alternative, or adjunct OUD treatment therapies is highly warranted. In this article, we review emerging evidence that suggests that cannabis may play a role in ameliorating the impact of OUD. Herein, we highlight knowledge gaps and discuss cannabis' potential to prevent opioid misuse (as an analgesic alternative), alleviate opioid withdrawal symptoms, and decrease the likelihood of relapse. Conclusion: The compelling nature of these data and the relative safety profile of cannabis warrant further exploration of cannabis as an adjunct or alternative treatment for OUD.

Persistence/recurrence of and remission from DSM-5 substance use disorders in the United States: Substance-specific and substance-aggregated correlates

This study examined demographic and psychosocial correlates associated with persistence/recurrence of and remission from at least one of ten DSM-5 substance use disorders (SUDs) and three substance-specific SUDs (i.e., alcohol, cannabis, and prescription opioids). Data were collected from structured diagnostic interviews and national prevalence estimates were derived from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions. An estimated 25.4% of the U.S. population had at least one prior-to-past-year (prior) SUD. Among individuals with any prior SUDs, the prevalence of past-year substance use and DSM-5 symptomology was as follows: abstinence (14.2%), asymptomatic use (36.9%), symptomatic use (10.9%), and persistent/recurrent SUD (38.1%). Among individuals with prior SUDs, design-based multinomial logistic regression analysis revealed that young adulthood, higher educational attainment, higher personal income, never having been married, being divorced/separated/widowed, lack of lifetime substance use treatment, and stressful life events predicted significantly greater odds of past-year persistent/recurrent SUDs, relative to abstinence. In addition, remission from a prior tobacco use disorder decreased the probability of past-year persistent/recurrent SUD, relative to abstinence. Stressful life events were the only common correlates across the aggregation of all SUDs and each substance-specific SUD, but differences were found for specific stressful life events between drug classes. Nearly half (49%) of adults with prior DSM-5 SUDs continued to report past-year symptomatic substance use, while only one in seven individuals were abstinent. The findings suggest the value of examining remission associated with both substance-specific SUDs and aggregation of SUDs based on the shared and unique correlates of persistent/recurrent SUDs; this is especially true for stressful life events, which could be useful targets for enhancing clinical care and interventions.

Canadian trends in opioid-related mortality and disability from opioid use disorder from 1990 to 2014 through the lens of the Global Burden of Disease Study

Introduction:

Several regions in Canada have recently experienced sharp increases in opioid overdoses and related hospitalizations and deaths. This paper describes opioidrelated mortality and disability from opioid use disorder in Canada from 1990 to 2014 using data from the Global Burden of Disease (GBD) study.

Methods:

We used data from the GBD study to describe temporal trends (1990–2014) in opioid-related mortality and disability from opioid use disorder using common metrics: disability-adjusted life years (DALY), deaths, years of life lost (YLL) and years lived with disability (YLD). We also compared age-standardized YLL and DALY rates per 100 000 population between Canada, the USA and other regions.

Results:

The age-standardized opioid-related DALY rate in Canada was 355.5 per 100 000 population in 2014, which was higher than the global rate of 193.2, but lower than the rate of 767.9 in the United States. Between 1990 and 2014, the age-standardized opioid-related YLL rate in Canada increased by 142.2%, while globally this rate decreased by 10.1%. In comparison with YLL, YLD accounted for a larger proportion of the overall opioid-related burden across all age groups. Health loss was greater for males than females, and highest among those aged 25 to 29 years.

Conclusion:

The health burden associated with opioid-related mortality and disability from opioid use disorder in Canada is significant and has increased dramatically from 1990 to 2014. These data point to a need for public health action including enhanced monitoring of a range of opioid-related harms.

Prediction of drug abuse recurrence: a Swedish National Study

BACKGROUND

Relapse from drug abuse (DA) is common, but has rarely been studied in general population samples using a wide range of objective predictors.

METHOD

Using nationwide registries, we ascertained 44 523 subjects first registered for DA between the ages of 15 and 40 in 1998 to 2004 and followed for 8 years. We predicted relapse in subjects defined as a second DA registration. We also predicted DA relapse in relative pairs concordant for DA but discordant for relapse.

RESULTS

In multivariate regression analyses, the strongest predictors for relapse were prior criminal behavior, male sex, being on social welfare, low school achievement, prior alcoholism, and a high-risk father. A risk index trained from these analyses on random split-halves demonstrated a risk ratio of 1.11 [95% confidence intervals (CIs) 1.10-1.11] per decile and an ROC value of 0.70 (0.69-0.71). Co-relative analyses indicated that a modest proportion of this association was causal, with the remainder arising from familial confounders. A developmental structural equation model revealed a complex interviewing of risk pathways to DA with three key mediational hubs: low educational attainment, early age at first registration, and being on social welfare.

CONCLUSIONS

In a general population sample, using objective registry information, DA relapse is substantially predictable. However, the identified risk factors may not be valid targets for interventions because many index familial risk and may not impact causally on probability of relapse. Risk for DA relapse may reflect an inter-weaving, over developmental time, of genetic-temperamental vulnerability, indices of externalizing behaviors and social factors reflecting deprivation.

The impact of cohort substance use upon likelihood of transitioning through stages of alcohol and cannabis use and use disorder: Findings from the Australian National Survey on Mental Health and Wellbeing

INTRODUCTION AND AIMS

We used population-level Australian data to estimate prevalence, age of onset and speed of transitions across stages of alcohol and cannabis use, abuse and dependence, and remission from disorder, and consider the potential impacts that an individual's age cohort's level of substance use predicted transitions into and out of substance use.

DESIGN AND METHODS

Data on use, DSM-IV use disorders, and remission from these disorders were collected from participants (n = 8463) in the 2007 Australian National Survey of Mental Health and Wellbeing using the Composite International Diagnostic Interview.

RESULTS

Lifetime prevalence (95% confidence interval) of alcohol use, regular use, abuse and dependence were 94.1% (93.3-94.8%), 64.5% (62.9-66.2%), 18.7% (17.4-19.9%) and 4.0% (3.4-4.6%). Lifetime prevalence of cannabis use, abuse and dependence were 19.8% (18.6-20.9%), 4.4% (3.8-5.0%) and 1.9% (1.5-2.4%). Among those with the disorder, rates of remission from cannabis abuse, alcohol abuse, cannabis dependence and alcohol dependence were 90.5% (87.4-93.6%), 86.2% (83.8-88.7%), 79.6% (71.1-88.1%) and 53.8% (46.6-61.0%). Increases in the estimated proportion of people in the respondent's age cohort who used alcohol/cannabis as of a given age were significantly associated with most transitions from use through to remission beginning at the same age.

DISCUSSION AND CONCLUSIONS

Clear associations were documented between cohort-level prevalence of substance use and personal risk of subsequent transitions of individuals in the cohort from use to greater substance involvement. This relationship remained significant over and above associations involving the individual's age of initiation. These findings have important implications for our understanding of the causal pathways into and out of problematic substance use.

Tulsa 1000: a naturalistic study protocol for multilevel assessment and outcome prediction in a large psychiatric sample

INTRODUCTION

Although neuroscience has made tremendous progress towards understanding the basic neural circuitry underlying important processes such as attention, memory and emotion, little progress has been made in applying these insights to psychiatric populations to make clinically meaningful treatment predictions. The overall aim of the Tulsa 1000 (T-1000) study is to use the NIMH Research Domain Criteria framework in order to establish a robust and reliable dimensional set of variables that quantifies the positive and negative valence, cognition and arousal domains, including interoception, to generate clinically useful treatment predictions.

METHODS AND ANALYSIS

The T-1000 is a naturalistic study that will recruit, assess and longitudinally follow 1000 participants, including healthy controls and treatment-seeking individuals with mood, anxiety, substance use and eating disorders. Each participant will undergo interview, behavioural, biomarker and neuroimaging assessments over the course of 1 year. The study goal is to determine how disorders of affect, substance use and eating behaviour organise across different levels of analysis (molecules, genes, cells, neural circuits, physiology, behaviour and self-report) to predict symptom severity, treatment outcome and long-term prognosis. The data will be used to generate computational models based on Bayesian statistics. The final end point of this multilevel latent variable analysis will be standardised assessments that can be developed into clinical tools to help clinicians predict outcomes and select the best intervention for each individual, thereby reducing the burden of mental disorders, and taking psychiatry a step closer towards personalised medicine.

ETHICS AND DISSEMINATION

Ethical approval was obtained from Western Institutional Review Board screening protocol #20101611. The dissemination plan includes informing health professionals of results for clinical practice, submitting results to journals for peer-reviewed publication, presenting results at national and international conferences and making the dataset available to researchers and mental health professionals.

TRIAL REGISTRATION NUMBER

NCT02450240; Pre-results.

Self-guided Change: The most common form of long-term, maintained health behavior change

Millions of people change risky, health-related behaviors and maintain those changes. However, they often take years to change, and their unhealthy behaviors may harm themselves and others and constitute a significant cost to society. A review-similar in nature to a scoping review-was done of the literature related to long-term health behavior change in six areas: alcohol, cocaine and heroin misuse, gambling, smoking, and overeating. Based on the limited research available, reasons for change and strategies for changing and for maintaining change were also reviewed. Fifty years of research clearly indicate that as people age, in the case of alcohol, heroin and cocaine misuse, smoking, and gambling, 80-90 percent moderate or stop their unhealthy behaviors. The one exception is overeating; only 20 percent maintain their weight loss. Most of these changes, when they occur, appear to be the result of self-guided change. More ways to accelerate self-guided, health-related behavior change need to be developed and disseminated.

Seroprevalence of HCV and HIV infection among clients of the nation's longest-standing statewide syringe exchange program: A cross-sectional study of Community Health Outreach Work to Prevent AIDS (CHOW)

BACKGROUND

The Community Health Outreach Work to Prevent AIDS (CHOW) Project is the first and longest-standing statewide integrated and funded needle and syringe exchange program (SEP) in the US. Initiated on O'ahu in 1990, CHOW expanded statewide in 1993. The purpose of this study is to estimate the prevalences of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) infection, and to characterize risk behaviors associated with infection among clients of a long-standing SEP through the analysis of the 2012 CHOW evaluation data.

METHODS

A cross-sectional sample of 130 CHOW Project clients was selected from January 1, 2012 through December 31, 2012. Questionnaires captured self-reported exposure information. HIV and HCV antibodies were detected via rapid, point-of-care FDA-approved tests. Log-binomial regressions were used to estimate prevalence proportion ratios (PPRs). A piecewise linear log-binomial regression model containing 1 spline knot was used to fit the age-HCV relationship.

RESULTS

The estimated seroprevalence of HCV was 67.7% (95% confidence interval [CI]=59.5-75.8%). HIV seroprevalence was 2.3% (95% CI=0-4.9%). Anti-HCV prevalence demonstrated age-specific patterns, ranging from 31.6% through 90.9% in people who inject drugs (PWID) <30 to ≥60 years respectively. Age (continuous/year) prior to spline knot at 51.5 years (adjusted PPR [APPR]=1.03; 95% CI=1.02-1.05) and months exchanging syringes (quartiles) (APPR=1.92; 95% CI=1.3-3.29) were independently associated with anti-HCV prevalence.

CONCLUSION

In Hawai'i, HCV prevalence among PWID is hyperendemic demonstrating age- and SEP duration-specific trends. Relatively low HIV prevalence compared with HCV prevalence reflects differences in transmissibility of these 2 blood-borne pathogens and suggests much greater efficacy of SEP for HIV prevention.

Remission from substance use disorders: A systematic review and meta-analysis

OBJECTIVE

This paper presents a systematic review and meta-analysis of available evidence on remission rates for substance use disorders (SUDs), providing weighted mean estimates of SUD remission rates. The review also explores study-level characteristics that may explain variations in remission rates across studies.

METHODS

A comprehensive search strategy identified studies published between 2000 and 2015 with follow-up periods of at least three years or reported lifetime remission outcomes for potential inclusion in the review. Remission was defined as not meeting diagnostic criteria for abuse or dependence for a minimum period of six months, as of final follow-up. A single-group summary meta-analysis was performed. Pooled estimated annual remission rates (PEARRs) were calculated. Meta-regression techniques and subgroup analyses were used to explore the association between study remission rates and key selected variables.

RESULTS

Of 8855 studies identified, 21 met the eligibility criteria. The results suggested that 35.0% to 54.4% of individuals with SUDs achieved remission, and this occurred after a mean follow-up period of 17 years. The PEARRs projected few cases of SUD remission, between 6.8% and 9.1% in any given year. Studies that reported higher remission rates had longer follow-up periods, and lower sample retention rates.

CONCLUSIONS

Results support the contention that SUDs are more likely to be "chronic" or long term disorders than acute disorders for a substantial number of individuals. However, more longitudinal research is required. Treatment geared to chronicity, such as assertive community treatment and intensive case management, needs to be more readily available for SUD populations.

Stressful Events and Other Predictors of Remission from Drug Dependence in the United States: Longitudinal Results from a National Survey

This study examined stressful life events and other predictors associated with remission from DSM-IV drug dependence involving cannabis, cocaine, hallucinogens, heroin, inhalants, non-heroin opioids, sedatives, stimulants, tranquilizers, or other drugs. Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions were used to examine the prevalence and predictors of past-year remission status. Among U.S. adults with previous (i.e., prior-to-past-year) drug dependence (n=921) at baseline (wave 1), the prevalence of past-year remission status at wave 1 was: abstinence (60.5%), asymptomatic drug use (18.8%), partial remission (7.1%), and still drug dependent (13.5%). Similarly, the prevalence of past-year remission status three years after baseline at wave 2 was: abstinence (69.1%), asymptomatic drug use (15.5%), partial remission (8.4%), and still drug dependent (7.0%). Remission three years after baseline at wave 2 was much more likely among formerly drug dependent U.S. adults who abstained from drug use at baseline (wave 1) relative to those who reported asymptomatic drug use, partial remission, or remained drug dependent. Design-based weighted multinomial logistic regression analysis showed that relative to abstinence, past-year stressful events at baseline (wave 1) predicted higher odds of partial remission and drug dependence at both waves 1 and 2. This is the first national study to examine the potential role of stressful life events associated with remission from drug dependence. Although the majority of those who reported previous drug dependence transitioned to full remission, a sizeable percentage were either still drug dependent or in partial remission. Higher levels of stressful life events appear to create barriers to remission and should remain a focus for relapse prevention programs.

The natural history of substance use disorders

PURPOSE OF REVIEW

Illicit drugs, alcohol, and tobacco use disorders contribute substantially to the global burden of disease. Knowledge about the major elements of the natural history of substance use disorders (incidence, remission, persistence, and relapse) is crucial to a broader understanding of the course and outcomes of substance use disorders.

RECENT FINDINGS

Prospective cohort studies in nonclinical samples indicate that externalizing psychopathology in earlier life, including early disordered substance use, delinquency, and personality disorders, are related to substance use disorders later in life and chronic course. Externalizing psychopathology may be initiated by early adverse experiences, for example, childhood maltreatment and stressful life events. After controlling for confounders, 'age at first use' as a causal factor for alcohol use disorder later in life and the 'drug substitution' hypothesis are not supported in general population data.

SUMMARY

Future research should focus on elaborating the causal framework that leads to the development and persistence of severe substance use disorders, with an emphasis on identifying modifiable factors for intervention by policy makers or health professionals. More research is needed on the natural history of substance use disorders in low-income and middle-income countries.

Evaluation of medication-assisted treatment of opioid dependence-The physicians' perspective

BACKGROUND

There is controversy about which outcome parameters should be employed to assess substance use treatment. Subjective measures of medication-assisted treatment (MAT) of opioid dependence are increasingly important. However, while patients' perspectives have been examined, the caregivers' views remain largely unknown. Here, we explore how physicians evaluate MAT, and which predictors are most relevant.

METHODS

We conducted a retrospective cohort study of all MAT episodes with oral opioid agonists in the canton of Zurich between 1998 and 2013 using a case register. Termination forms of the register include a physician-completed assessment on the course of the treatment episode. Mixed model analysis was applied to determine relevant predictors.

RESULTS

The analysis was based on 17,234 episodes from 7432 patients. Mean global assessment of the course of MAT was 'moderate'. The most important predictors for treatment evaluation by physicians were treatment break off as reason for termination (p<0.0001), psychological improvement throughout treatment (p<0.0001), wish for abstinence from the substitute (p<0.0001), social integration index at termination (p<0.0001), and social (p<0.0001) as well as medical (p<0.0001) improvement. The negative association of treatment break off with MAT assessment was more pronounced in semi-rural than urban areas (p<0.0001).

CONCLUSION

Predictors relating to the well-being and functioning of the patient as well as the reasons underlying treatment termination appear to be more important for the treating physician's evaluation of medication-assisted treatment episodes than on-going substance use. Coming off the opioid medication plays a central role, independent of ongoing illicit substance use.

Differences in polysubstance use patterns and drug-related outcomes between people who inject drugs receiving and not receiving opioid substitution therapies

AIMS

To test if polysubstance use profiles and drug-related outcomes differ between those receiving and not receiving opioid substitution therapies (OST) among people who inject drugs (PWID).

DESIGN

An annual cross-sectional, sentinel sample of PWID across Australia.

SETTING

Data came from 3 years (2011-13) of the Illicit Drug Reporting System (IDRS).

PARTICIPANTS

A total of 2673 participants who injected drugs from the combined national IDRS samples of 2011 (n = 868), 2012 (n = 922) and 2013 (n = 883).

MEASUREMENTS

Latent class analysis (LCA) was used to summarize participants' self-reported use of 18 types of substances, with the resulting polysubstance use profiles then associated with participant experience of a number of drug-related outcomes.

FINDINGS

Polysubstance use profiles exhibiting a broad range of substance use were generally at increased risk of negative drug-related outcomes, whether or not participants were receiving OST, including thrombosis among OST receivers [odds ratio (OR) = 2.13, 95% confidence intervals (CI) = 1.09-4.17], injecting with used needles among OST receivers and non-receivers, respectively (OR = 2.78, 95% CI = 1.50-5.13; OR = 2.15, 95% CI = 1.34-3.45) and violent criminal offences among OST receivers and non-receivers, respectively (OR =2.30, 95% CI = 1.16-4.58; OR = 1.87, 95% CI = 1.14-3.07). An important exception was non-fatal overdose which was related specifically to a class of PWID who were not receiving OST and used morphine frequently (OR = 1.83, 95% CI = 1.06-3.17) CONCLUSION: Regardless of opioid substitution therapies usage, people who inject drugs who use a broad-range of substances experience greater levels of injecting-related injuries and poorer health outcomes and are more likely to engage in criminal activity than other groups of people who inject drugs.

Associations Between Religiosity, Perceived Social Support, and Stimulant Use in an Untreated Rural Sample in the U.S.A

BACKGROUND

Religiosity and perceived social support (SS) may serve as protective factors for more severe substance use in adults.

OBJECTIVES

This study sought to examine whether aspects of religiosity and SS are associated with longitudinal reductions in stimulant use over three years in an untreated sample of rural drug users.

METHODS

Respondent-driven sampling was used to recruit stimulant users (N = 710) from Arkansas, Kentucky, and Ohio. Follow-up interviews were conducted at 6-month intervals for 36 months.

RESULTS

Our bivariate findings indicate that higher religiosity was associated with lower odds and fewer days of methamphetamine and cocaine use. After controlling for covariates, higher religiosity was associated with fewer days of crack cocaine use, but more days of methamphetamine use among a small sample of users in the two final interviews. Higher SS from drug-users was also associated with higher odds and days of methamphetamine and powder cocaine use, while higher SS from nondrug users was associated with fewer days of methamphetamine use.

CONCLUSIONS/IMPORTANCE

Our bivariate findings suggest that higher levels of religiosity may be helpful for some rural individuals in reducing their drug use over time. However, our multivariate findings suggest a need for further exploration of the potential effects of religiosity on longer-term drug use, especially among those who continue to use methamphetamine and/or remain untreated. Our findings also highlight the potential deleterious effect of SS from drug users on the likelihood and frequency of methamphetamine and powder cocaine use over time among untreated rural drug users.

The increasing global health priority of substance use in young people

Substance use in young people (aged 10-24 years) might disrupt key periods of transition that occur as the adolescent brain undergoes cognitive and emotional development, and key psychosocial transitions are made. Adolescence is the peak time for initiation of substance use, with tobacco and alcohol usually preceding the use of illicit drugs. Substantial variation is noted between countries in the levels, types, and sequences of substance use in young people, indicating that a young person's use of substances depends on their social context, drug availability, and their personal characteristics. The Global Burden of Disease (GBD) 2013 study suggests that the burden attributable to substance use increases substantially in adolescence and young adulthood. In young men aged 20-24 years, alcohol and illicit substance use are responsible for 14% of total health burden. Alcohol causes most health burden in eastern Europe, and illicit drug burden is higher in the USA, Canada, Australia, New Zealand, and western Europe. Large gaps exist in epidemiological data about the extent of drug use worldwide and much of what we know about the natural history of substance use comes from cohort studies in high-income countries undertaken decades ago, which hinders effective global policy responses. In view of the global epidemiological transitions from diseases of poverty to non-communicable diseases, the burden of disease and health risks among adolescents and young adults is likely to change substantially, in ways that will no doubt see substance use playing an increasingly large part.

Stimulant dependence and stimulant-associated psychosis: clinical characteristics and age of onset in a native American community sample

OBJECTIVES

Native Americans experience some of the highest rates of Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) stimulant dependence (SD) of all US ethnic groups. The present report examined the clinical characteristics and age of onset of stimulant use, SD, remission from SD, and stimulant-associated psychosis (SAP) in a Native American community sample.

METHODS

Demographic information, stimulant (methamphetamine or cocaine) use, and lifetime Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) psychiatric disorder diagnoses were assessed in 858 Native Americans. Logistic regression was used to assess the associations of demographic, stimulant use, and psychiatric disorder variables with SD, remission from SD, and SAP. Kaplan-Meier survival analyses were used to assess time from first use to the onset of SD.

RESULTS

The overall rate of SD was 33%, of remission from SD 73%, and of SAP 17%. Stimulant dependence was associated with older age, less current annual household income, fewer lifetime years of education, intravenous stimulant use, and earlier age of first stimulant use. Remission from SD was associated with older age, currently being married, and never having used stimulants intravenously. Attention-deficit/hyperactivity disorder (assessed as a lifetime disorder), increased number of years of daily stimulant use, and intravenous use were independently associated with SAP. Younger age at first use was significantly associated with shorter survival to the onset of SD.

CONCLUSIONS

Stimulant dependence is prevalent in this population and is associated with less income and education and an earlier age at first use. Intravenous stimulant use adds additional risk for SD, nonremission, and psychosis.