Trends and key correlates of prescription opioid injection misuse in the United States

Leveraging Parents and Peer Recovery Supports to Increase Recovery Capital in Emerging Adults With Polysubstance Use: Protocol for a Feasibility, Acceptability, and Appropriateness Study of Launch

BACKGROUND

Emerging adults (aged 18-26 years) are the most at-risk yet underserved age group among people with substance use disorder, especially rural emerging adults, and polysubstance use is common. Recovery capital is lower among emerging adults than older adults, and evidence-based treatments are typically unavailable or not developmentally tailored, especially in rural areas. Both supportive parents (or parental figures) and peer recovery support services (PRSS) can be leveraged to better support these emerging adults. Previous research indicates parents can be engaged to deliver contingency management (CM), an extensively researched evidence-based intervention for substance use.

OBJECTIVE

This protocol describes a funded pilot of Launch, a novel, scalable service package that pairs web-based coaching for parents to deliver CM for emerging adults (CM-EA) at home and in-person PRSS with educational and vocational goal setting. Specifically, this protocol describes feasibility, acceptability, and appropriateness testing (implementation-related outcomes) and steps taken to prepare for a future large-scale trial of Launch.

METHODS

Upon the recruitment of 48 emerging adult and parent pairs from sites serving primarily rural clients, participants will be randomized into 1 of 3 conditions for this randomized controlled trial: virtual parent coaching to deliver CM-EA, in-person PRSS for emerging adults, or both sets of services. Emerging adult eligibility includes polysubstance use, a substance use disorder, and availability of a consenting parent. Emerging adults will be interviewed at baseline and 6 months about substance use, quality of life, recovery capital, parental relationship, and Launch implementation-related outcomes (6-month follow-up only). Parents, peer workers delivering PRSS, and parent CM-EA coaches will be interviewed about implementation-related outcomes at the end of the study period. Peer workers and CM-EA coaches will be asked to complete checklists of services delivered after each session. Finally, payers and providers will be interviewed for additional insights into Launch implementation and to identify key outcomes of Launch. Data analysis for emerging adult outcomes will be primarily descriptive, but parent CM-EA training adherence will be assessed using nested mixed-effects regression models of repeated measures.

RESULTS

Launch is currently ongoing, with funding received in August 2023, and is expected to end in September 2025, with data analysis and results in December 2026. Participants are expected to begin enrolling in June 2024.

CONCLUSIONS

While this pilot is limited by the small sample size and restriction to emerging adults with an involved parent, this is mitigated by the study's strengths and is appropriate for the pilot stage. Launch uses an innovative combination of existing strategies to generate better outcomes for emerging adults while remaining scalable. This pilot will provide insights into the feasibility and acceptability of Launch from the perspectives of service recipients, providers, and payers to inform a larger-scale effectiveness trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06414993; https://clinicaltrials.gov/study/NCT06414993.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/60671.

Implementation outcomes from a pilot study of training probation officers to deliver contingency management for emerging adults with substance use disorders

INTRODUCTION

Emerging adults (EAs) in the criminal legal system are at high risk for substance use and related negative outcomes. EAs also have low levels of engagement in treatment services, a pattern exacerbated for those living in rural communities. This pilot study investigated implementation outcomes of task-shifting an evidence-based substance use intervention, via a developmentally targeted program, provided by probation officers (POs) to selected EA clients.

METHODS

Ten POs recruited from two counties in Oregon who provide services to rural clients were trained and supported in delivering contingency management for EAs (CM-EA) to 17 EAs on their current caseloads. The pilot took place entirely during the COVID-19 pandemic. POs submitted session audiotapes and checklists from meetings with participating EA clients and participated in focus groups. EA clients completed baseline interviews and agreed to have their adult criminal records collected. Ten semi-structured interviews were completed with probation/parole administration and staff from four rural counties across three states highly impacted by the opioid epidemic about the barriers and facilitators for delivering a program like CM-EA in their offices.

RESULTS

Based on self-reports and observational coding, POs demonstrated fidelity and adoption as they delivered all CM-EA components and engaged in CM-EA quality assurance protocols. Penetration was demonstrated by the selection of EAs reflecting the demographics of their local offices (i.e., White, non-Hispanic, balanced across sex), struggling with polysubstance use, and primarily holding felony convictions. Emerging themes from focus groups and interviews revealed feasibility, acceptability, and appropriateness of CM-EA, including use with clients not currently in the research program and reported intentions to continue CM-EA use. Barriers for future use include those found for the delivery of other programs in rural areas such as resource limitations.

CONCLUSIONS

There is initial support for the implementation outcomes related to task-shifting a program like CM-EA to POs, particularly those serving rural clients, to increase access to evidence-based substance use services for EAs. Future research with larger samples and multiple follow-ups will allow for effectiveness testing and further program refinement for this high-priority population.

Screening Incarcerated Women for Opioid Use Disorder

The overall aim of the present study is to examine the utility of the DSM OUD Checklist and the NM-ASSIST screening tools to identify symptoms consistent with OUD among incarcerated women in county jails. This study contributes to the existing literature because research on screening and assessment approaches for incarcerated women has been limited. The focus of the current study is to describe the screening procedures and study recruitment for a larger parent study focused on increasing treatment linkages. Study findings indicate a positive correlation between indicators of OUD using the two screening tools, as well as a high degree of correlation between street opioid misuse and other high-risk drug indicators (overdose and injection practices). These findings underscore the importance of outreach, screening, and intervention in real-world settings, including jails, in order to increase access to OUD treatment among this vulnerable sample of women.

Assessing Reuse of Hypodermic Needles in Mice by means of Digital Imaging, Photomicrography, Bacterial Culture, Analysis of Nest Building, and Animal Vocalization

Hypodermic needles are sometimes reused in animal research settings to preserve the viability of and to conserve limited quantities of injected material. However, the reuse of needles is strongly discouraged in human medicine to prevent inju- ries and the spread of infectious disease. No official guidelines prohibit needle reuse in veterinary medicine, although the practice may be discouraged. We hypothesized that reused needles would be significantly more blunt than unused needles and that reuse for additional injections would cause more animal stress. To test these ideas, we evaluated mice that were injected subcutaneously in the flank or mammary fat pad to generate cell line xenograft and mouse allograft models. Needles were reused up to 20 times, based on an IACUC-approved protocol. A subset of reused needles was digitally imaged to determine needle dullness based on the area of deformation from the secondary bevel angle; this parameter was not different between new needles and needles that had been reused 20 times. In addition, the number of times a needle was reused was not significantly related to audible mouse vocalization during injection. Finally, nest building scores for mice that were injected with a needle used 0 through 5 times were similar to those of mice injected with a needle had been used 16 through 20 times. Among the 37 reused needles that were tested, 4 were positive for bacterial growth; the only organisms cultured were Staphylococcus spp. Contrary to our hypothesis, reusing needles for subcutaneous injections did not increase animal stress based on analysis of vocalization or nest building.

The release of abuse-deterrent OxyContin and adolescent heroin use

OBJECTIVE

To determine the association between the abuse-deterrent reformulation of OxyContin and adolescent lifetime heroin use in the United States.

METHODS

The quasi-experimental study uses individual survey data from the 1999-2019 Youth Risk Behavior Surveillance System to examine whether the reformulation of OxyContin in August 2010 affected adolescent lifetime heroin use, exploiting heterogeneity in state-level rates of OxyContin misuse before the reformulation. Multiple regression analysis adjusted for state and year fixed effects, adolescent demographics, and time-varying state characteristics and policies.

RESULTS

The release of the abuse-deterrent reformulation of OxyContin was associated with a reduction in adolescents reporting ever using heroin. An adolescent in a state with a one percentage point higher state-level rate of pre-reformulation OxyContin misuse was 1.7% points less likely to report ever using heroin after the reformulation (95% confidence interval, [(CI) = -0.007, -0.027]). These effects are strongest for adolescent males (estimate: -0.028, [(CI) = -0.016, 0.040]) and non-whites (estimate: -0.021, [(CI) = -0.005, -0.037]).

CONCLUSIONS

These results suggest the release of abuse-deterrent OxyContin is associated with a decrease in the likelihood of adolescent lifetime heroin use in states with higher pre-reformulation rates of OxyContin misuse. Pharmaceutical innovations and policies that reduce the likelihood of prescription opioid misuse may be effective in reducing adolescent lifetime heroin use.

Analysis of genetic and clinical factors associated with buprenorphine response

BACKGROUND

Buprenorphine, approved for treating opioid use disorder (OUD), is not equally efficacious for all patients. Candidate gene studies have shown limited success in identifying genetic moderators of buprenorphine treatment response.

METHODS

We studied 1616 European-ancestry individuals enrolled in the Million Veteran Program, of whom 1609 had an ICD-9/10 code consistent with OUD, a 180-day buprenorphine treatment exposure, and genome-wide genotype data. We conducted a genome-wide association study (GWAS) of buprenorphine treatment response [defined as having no opioid-positive urine drug screens (UDS) following the first prescription]. We also examined correlates of buprenorphine treatment response in multivariable analyses.

RESULTS

Although no variants reached genome-wide significance, 6 loci were nominally significant (p < 1 × 10^-5), four of which were located near previously characterized genes: rs756770 (ADAMTSL2), rs11782370 (SLC25A37), rs7205113 (CRISPLD2), and rs13169373 (LINC01947). A higher maximum daily buprenorphine dosage (aOR = 0.98; 95 %CI: 0.97, 0.995), greater number of UDS (aOR = 0.97; 95 %CI: 0.96, 0.99), and history of hepatitis C (HCV) infection (aOR = 0.71; 95 %CI: 0.57, 0.88) were associated with a reduced odds of buprenorphine response. Older age (aOR: 1.01; 95 %CI: 1.000, 1.02) was associated with increased odds of buprenorphine response.

CONCLUSIONS

This study had limited statistical power to detect genetic variants associated with a complex human phenotype like buprenorphine treatment response. Meta-analysis of multiple data sets is needed to ensure adequate statistical power for a GWAS of buprenorphine treatment response. The most robust phenotypic predictor of buprenorphine treatment response was intravenous drug use, a proxy for which was HCV infection.

Changes in Buprenorphine Treatment After Medicaid Expansion

OBJECTIVE

The authors examined changes in buprenorphine treatment following Medicaid expansion, including the contribution of Medicaid-financed prescriptions.

METHODS

Buprenorphine pharmacy claims for patients were identified in the 2012-2018 IQVIA Longitudinal Prescription Data (LRx) data set, including 79.8% of U.S. retail prescriptions in 2012, increasing to 92.0% in 2018. A cohort analysis was used to assess the mean number of patients in a yearly quarter filling one or more buprenorphine prescriptions during preexpansion (2012-2013) and postexpansion (2014-2018) periods in expansion and nonexpansion states. Interrupted time-series analysis estimated associations of Medicaid expansion period with change in Medicaid-financed treatment. Separate analyses evaluated changes in duration and dose of new treatment episodes focused on mean quarterly number of patients treated with buprenorphine and proportions of new treatment episodes ≥180 days long and with ≥16 mg/day.

RESULTS

Between preexpansion and postexpansion, the mean quarterly number of patients taking buprenorphine increased by 93,300 in expansion states and by 84,960 in nonexpansion states. Corresponding changes for Medicaid-financed patients were 28,760 and 4,050, respectively. The fastest growth in Medicaid-financed treatment occurred among patients ages 25-44. Among new Medicaid-financed treatment episodes, little change was found in the proportion reaching the 180-day threshold, and declines were observed in the proportion receiving ≥16 mg/day.

CONCLUSIONS

The findings are consistent with previous research indicating that Medicaid expansion has increased Medicaid-financed buprenorphine treatment. However, because of offsetting changes in other payment groups, the overall increase in expansion states was similar to the increase in nonexpansion states.

Assisted injection provider practices and motivations in Los Angeles and San Francisco California 2016-18

BACKGROUND

Assisted injection is a high-risk and common practice among people who inject drugs (PWID) and occurs for diverse reasons according to qualitative research. To develop interventions for reducing assisted injection risks, it is important to understand the practices of PWID who provide injection assistance, including their motivations for providing assistance.

METHODS

Using follow-up data from an efficacy trial among PWID recruited in Los Angeles and San Francisco, CA (n=601), we present descriptive statistics on motivations for providing injection assistance and use multivariable logistic regression modelling to examine factors associated with these motivations.

RESULTS

PWID provided injection assistance most commonly to friends and acquaintances. A quarter provided assistance on a daily basis. The most common motivations for providing assistance were skill and injury prevention. PWID also provided assistance to stop pestering and for compensation in money or drugs. In separate models examining factors associated with the five main motivations, we found injury prevention to be associated with skill injecting others, neck injection, methamphetamine use, and recycling income. Pestering was associated with injury prevention, neck and hand injection, speedball use, and syringe selling. Skill was associated with injury prevention, neck and hand injection, being physically assaulted, and age. Providing assistance for money was associated with providing assistance for food or drugs, armpit injections, being female, and providing assistance more frequently. Providing assistance for drugs was associated with compensation in food or money, goofball injection, selling drugs, and panhandling.

CONCLUSION

Providing injection assistance is associated with injection needs of recipients and drug scene participation. We urgently need new interventions for reducing assisted injection risks. Since injection providers report being motivated by skill and to prevent injury, interventions such as training in safer injection techniques are likely to be met with enthusiasm.

The Changing Epidemiology of Hepatitis C Virus Infection in the United States During the Years 2010 to 2018

Hepatitis C virus (HCV) infection remains an important cause of morbidity and mortality throughout the world, leading to serious health problems among those who are chronically infected. Since 1992, the Centers for Disease Control and Prevention has been collecting data on the incidence of HCV infection in the United States. In 2018, more than 50 000 individuals were estimated to have acute HCV infection.The most recently reported data on the prevalence of infection indicate that approximately 2.4 million people are living with hepatitis C in the United States. Transmission of HCV occurs predominantly through sharing contaminated equipment for injecting drugs.Two major events have had a significant impact on the incidence and prevalence of hepatitis C in the past few decades: the US opioid crisis and the discovery of curative treatments for HCV infection. To better understand the impact of these events, we examine reported trends in the incidence and prevalence of infection.

Use of Population-Based Surveys for Estimating the Population Size of Persons Who Inject Drugs in the United States

BACKGROUND

In the United States, injection is an increasingly common route of administration for opioids and other substances. Estimates of the number of persons who inject drugs (PWID) are needed for monitoring risk-specific infectious disease rates and health services coverage.

METHODS

We reviewed design and instruments for 4 national household surveys, 2012-2016, for their ability to produce unbiased injection drug use (IDU) prevalence estimates. We explored potential analytic adjustments for reducing biases through use of external data on (1) arrest, (2) narcotic overdose mortality, and (3) biomarker-based sensitivity of self-reported illicit drug use.

RESULTS

Estimated national past 12 months IDU prevalence ranged from 0.24% to 0.59% across surveys. All surveys excluded unstably housed and incarcerated persons, and estimates were based on <60 respondents reporting IDU behavior in 3 surveys. No surveys asked participants about nonmedical injection of prescription drugs. Analytic adjustments did not appreciably change IDU prevalence estimates due to suboptimal specificity of data points.

CONCLUSIONS

PWID population size estimates in the United States are based on small numbers and are likely biased by undercoverage of key populations and self-report. Novel methods as discussed in this article may improve our understanding of PWID population size and their health needs.

Prescription Drug Misuse among African Americans and Afro Caribbeans: Results from the National Survey of American Life

BACKGROUND

The misuse of prescription medications is an understudied topic among the non-Hispanic Black population in the U.S. Even less is known about the prevalence and correlates of misuse among African Americans and Afro-Caribbeans, despite documented differences in their substance use behaviors.

OBJECTIVES

We aimed to examine the prevalence and correlates of lifetime prescription drug misuse among African Americans and Afro Caribbeans using data from the National Survey of American Life.

METHODS

A national household probability sample of non-institutionalized African Americans and Afro Caribbeans from the Collaborative Psychiatric Epidemiology Surveys was used. Pooled and ethnicity-stratified logistic regressions were estimated.

RESULTS

Findings showed no significant differences between African Americans (6.36%) and Afro-Caribbeans (5.71%) in lifetime prescription drug misuse. Several correlates were found to be associated with misuse among only African American or Afro-Caribbean respondents.

CONCLUSIONS

While research has shown prescription drug misuse is an issue among Blacks overall, our results show that the role of ethnicity must not be overlooked, especially when tailoring prevention and intervention programs. Limitations of this study are discussed.

Prescription Opioid Misuse and Use of Alcohol and Other Substances Among High School Students - Youth Risk Behavior Survey, United States, 2019

Adolescence is an important period of risk for substance use initiation and substance use-related adverse outcomes. To examine youth substance use trends and patterns, CDC analyzed data from the 2009-2019 Youth Risk Behavior Survey. This report presents estimated prevalence of current (i.e., previous 30-days) marijuana use, prescription opioid misuse, alcohol use, and binge drinking and lifetime prevalence of marijuana, synthetic marijuana, cocaine, methamphetamine, heroin, injection drug use, and prescription opioid misuse among U.S. high school students. Logistic regression and Joinpoint analyses were used to assess 2009-2019 trends. Prevalence of current and lifetime substance use by demographics, frequency of use, and prevalence of co-occurrence of selected substances among students reporting current prescription opioid misuse are estimated using 2019 data. Multivariable logistic regression analysis was used to determine demographic and substance use correlates of current prescription opioid misuse. Current alcohol, lifetime cocaine, methamphetamine, heroin, and injection drug use decreased during 2009-2019. Lifetime use of synthetic marijuana (also called synthetic cannabinoids) decreased during 2015-2019. Lifetime marijuana use increased during 2009-2013 and then decreased during 2013-2019. In 2019, 29.2% reported current alcohol use, 21.7% current marijuana use, 13.7% current binge drinking, and 7.2% current prescription opioid misuse. Substance use varied by sex, race/ethnicity, grade, and sexual minority status (lesbian, gay, or bisexual). Use of other substances, particularly current use of alcohol (59.4%) and marijuana (43.5%), was common among students currently misusing prescription opioids. Findings highlight opportunities for expanding evidence-based prevention policies, programs, and practices that aim to reduce risk factors and strengthen protective factors related to youth substance use, in conjunction with ongoing initiatives for combating the opioid crisis.

Trends in Indicators of Injection Drug Use, Indian Health Service, 2010-2014 : A Study of Health Care Encounter Data

OBJECTIVES

Hepatitis C virus (HCV) and HIV transmission in the United States may increase as a result of increasing rates of opioid use disorder (OUD) and associated injection drug use (IDU). Epidemiologic trends among American Indian/Alaska Native (AI/AN) persons are not well known.

METHODS

We analyzed 2010-2014 Indian Health Service data on health care encounters to assess regional and temporal trends in IDU indicators among adults aged ≥18 years. IDU indicators included acute or chronic HCV infection (only among adults aged 18-35 years), arm cellulitis and abscess, OUD, and opioid-related overdose. We calculated rates per 10 000 AI/AN adults for each IDU indicator overall and stratified by sex, age group, and region and evaluated rate ratios and trends by using Poisson regression analysis.

RESULTS

Rates of HCV infection among adults aged 18-35 increased 9.4% per year, and rates of OUD among all adults increased 13.3% per year from 2010 to 2014. The rate of HCV infection among young women was approximately 1.3 times that among young men. Rates of opioid-related overdose among adults aged <50 years were approximately 1.4 times the rates among adults aged ≥50 years. Among young adults with HCV infection, 25.6% had concurrent OUD. Among all adults with arm cellulitis and abscess, 5.6% had concurrent OUD.

CONCLUSIONS

Rates of HCV infection and OUD increased significantly in the AI/AN population. Strengthened public health efforts could ensure that AI/AN communities can address increasing needs for culturally appropriate interventions, including comprehensive syringe services programs, medication-assisted treatment, and opioid-related overdose prevention and can meet the growing need for treatment of HCV infection.

Trends and risk factors of adolescent opioid abuse/misuse: understanding the opioid epidemic among adolescents

Over the past decade, opioid abuse/misuse has grown from a local problem into a national crisis, causing the U.S. Health and Human Services (HSS) to declare a public health emergency. The number of those dying from opioid abuse has increased, especially among adolescents. Since 2014, death rates due to opioid overdose have been highest in persons aged 15-19 years. This systematic review examines past and present research concerning opioid abuse/misuse and seeks to bring more attention to the growing opioid epidemic affecting adolescents aged 12-25 years nationwide. Keywords such as "adolescent", "opioid", "overdose", "opioid misuse", and phrases including "opioid use and race", "income status and opioids", were used to find common demographic trends which can be attributed to this population. The process of gathering and disseminating information currently available on this subject helps highlight a somewhat taboo subject involving vulnerable members of our community. It is imperative that healthcare providers, in particular, those who treat adolescents, have access to current research and resources that support efforts to combat this persistent issue. In addition, this information will prove useful to those who have the ability to change policies and how this current crisis is being managed. Results from the research indicate that opioid abuse/misuse in adolescents is rising and race, gender and income play a role in the abuse/misuse of opioids. Likewise, the research proves that more opportunities for education and access to adequate treatment are paramount to ending the prevalence of opioid abuse/misuse.

Prescription opioid injection among young people who inject drugs in New York City: a mixed-methods description and associations with hepatitis C virus infection and overdose

Aim

Evidence is emerging that prescription opioid (PO) injection is associated with increased health risks. This mixed-methods study compares the mechanics of PO and heroin injection and examines the demographic and drug-related correlates of lifetime PO injection in a sample of young people who inject drugs (PWID) in New York City (NYC).

Methods

Qualitative analysis of 46 semi-structured interviews with young adult opioid users ages 18–32. Interview segments describing PO injection were analyzed for common themes. Quantitative analysis of structured interviews with 539 young adult opioid users ages 18–29 recruited via respondent-driven sampling (RDS). Analyses are based on the subsample of 353 participants (65%) who reported having ever injected drugs. All variables were assessed via self-report, except hepatitis C virus status, which was established via rapid antibody testing.

Results

Participants described injecting POs and reported that preparing abuse-deterrent pills for injection is especially cumbersome, requiring extended manipulation and large amounts of water. Injecting POs, in contrast to injecting heroin, requires repeated injections per injection episode. Among RDS-recruited participants, the majority of injectors reported injecting POs, sporadically (33%) or regularly (26%), but often infrequently (≤ 7 days/month). In separate multivariable analyses controlling for syringe- and cooker-sharing, ever injecting POs was a significant predictor of testing HCV antibody-positive (AOR = 2.97) and lifetime experience of non-fatal overdose (AOR = 2.51). Ever injecting POs was independently associated with lifetime homelessness (AOR = 2.93) and having grown up in a middle-income ($51,000–100,000/year vs. ≤ $50,000/year; AOR = 1.86) or a high-income household (> $100,000/year vs. ≤ $50,000/year; AOR = 2.54).

Conclusions

Even in an urban environment like NYC with widespread heroin access, most young PWID have injected POs, although less frequently than heroin. PO injection involves practices that are known to increase risk for blood-borne viral infection (e.g., repeated injections) and predicted testing HCV-positive, as well as overdose. PO injection may also serve as a marker for a subgroup of PWID at elevated risk for multiple drug use-related comorbidities. Programs that provide prevention services to PWID need to tailor harm reduction measures and messaging to the specific practices and harms associated with the injection of POs.

Prescription opioid misuse among adolescents and emerging adults in the United States: A scoping review

The U.S. opioid epidemic is a critical public health problem. As substance use and misuse typically begin in adolescence and emerging adulthood, there is a critical need for prevention efforts for this key developmental period to disrupt opioid misuse trajectories, reducing morbidity and mortality [e.g., overdose, development of opioid use disorders (OUD)]. This article describes the current state of research focusing on prescription opioid misuse (POM) among adolescents and emerging adults (A/EAs) in the U.S. Given the rapidly changing nature of the opioid epidemic, we applied PRISMA Scoping Review (PRISMA-ScR) guidelines to identify empirical articles published in the past 5 years (January 2013-September 2018) from nine databases examining POM among A/EAs (ages 10-25) in the U.S. Seventy-six articles met our inclusion criteria focusing on POM in the following areas: cross-sectional surveys (n = 60), longitudinal cohort studies (n = 5), objective, non-self-reported data sources (n = 9), and interventions (n = 2). Final charted data elements were organized by methodology and sample, with results tables describing design, sample, interventions (where applicable), outcomes, and limitations. Most studies focused on the epidemiology of POM and risk/protective factors, including demographic (e.g., sex, race), individual (e.g., substance use, mental health), and social (e.g., peer substance use) factors. Despite annual national surveys conducted, longitudinal studies examining markers of initiation and escalation of prescription opioid misuse (e.g., repeated overdoses, time to misuse) are lacking. Importantly, few evidence-based prevention or early intervention programs were identified. Future research should examine longitudinal trajectories of POM, as well as adaptation and implementation of promising prevention approaches.

Prescription opioid misuse among heterosexual versus lesbian, gay, and bisexual military veterans: Evidence from the 2015-2017 national survey of drug use and health

BACKGROUND

Little research examines risks of opioid misuse among military veterans, particularly among minority military veterans. The present study examines lifetime and past 12-month prescription opioid misuse among heterosexual versus non-heterosexual military veterans in the United States.

METHOD

Participants comprised 9729 U.S. military veterans aged 18 and older who completed the 2015-2017 National Survey on Drug Use and Health (NSDUH). Sample weights were applied to yield nationally representative estimates in the target population. Design-based multivariable logistic regression analysis was used to examine associations between sociodemographic characteristics and risk of prescription opioid misuse.

RESULTS

Bisexual veterans reported greater lifetime odds of having misused prescription opioids in their lives compared to their heterosexual peers (AOR: 4.04, 95% CI: 1.72-5.38). However, only bisexual women veterans reported elevated risk past 12-month misuse (AOR: 3.47, 95% CI: 1.28, 9.41). Although veterans aged 50 and older reported lower risk of lifetime prescription opioid misuse relative to 18-34 year olds (AOR: 0.33, 95% CI: 0.25-0.44), older veterans showed greater risk of past 12-month misuse (AOR: 1.23, 95% CI: 1.02-1.49).

DISCUSSION

To our knowledge, this study is the first to systematically examine differential risk factors of prescription opioid misuse between heterosexual and non-heterosexual military veterans. Results from this study suggest a critical need for greater investigations into the specific risks of opioid-related substance use for military veterans. This study highlights areas of research and practice that can improve health outcomes for military veterans and their communities.

Estimated effect of US state syringe sale policy on source of last-used injection equipment

BACKGROUND

Many people who inject drugs (PWID) lack access to a new sterile syringe each time they inject, with increased risk of injection-related harms, including spread of communicable diseases. In the United States (US), restricted access is largely due to state laws and policies regulating syringe access. Our aim in this US-focused study is to estimate variations in syringe acquisition behavior in relation to state-level syringe sale policies, drawing upon self-identified PWID in a nationally representative sample survey.

METHODS

Estimates were obtained on the source of the last used syringe from participants of the National Survey on Drug Use and Health (NSDUH) years 2002-2011. States were classified as having restricted syringe policies if they had any restriction on the sale of syringes during the study period (e.g., required a prescription or limited the number being sold).

RESULTS

In states with unrestricted syringe sale policies, PWID were more likely to have obtained their most recently used syringe from a safe source (Difference (%) = 9.8, 95% CI: 1.9, 17.7). This difference was largely driven by a larger percent of injectors obtaining syringes from a pharmacy in unrestricted states (Difference = 20.4, 95% CI: 12.2, 28.6) but was partially offset by fewer injectors obtaining syringes from syringe exchange programs (Difference = -10.7, 95% CI: -16.1, -5.3).

CONCLUSION

These new findings, taken with other evidence, should help promote removal of policy barriers that now thwart syringe acquisition from a safe source. We hope this additional evidence will provoke policy discussions and may influence regulations that promote public health and reduce the spread of communicable diseases.

Mortality, morbidity, and cardiac surgery in Injection Drug Use (IDU)-associated versus non-IDU infective endocarditis: The need to expand substance use disorder treatment and harm reduction services

Background

The addiction crisis is widespread, and unsafe injection practices among people who inject drugs (PWID) can lead to infective endocarditis.

Methods

A retrospective analysis of adult patients with definite or possible infective endocarditis admitted to a tertiary care center in Portland, Maine was performed over three-year period. Our primary objective was to examine differences in demographics, health characteristics, and health service utilization between injection drug use (IDU)-associated infective endocarditis and non-IDU infective endocarditis. The association between IDU and mortality, morbidity (defined as emergency department visits within 3 months of discharge), and cardiac surgery was examined. Bivariate and multivariate analyses were performed. A subgroup descriptive analysis of PWID was also performed to better examine substance use disorder (SUD) characteristics, treatment with medication for opioid use disorder (MOUD) and health service utilization.

Results

One-hundred and seven patients were included in the study, of which 39.2% (n = 42) had IDU-associated infective endocarditis. PWID were more likely to be homeless, uninsured, and lack a primary care provider. PWID were notably younger and had less documented comorbidities, however had similar in-hospital mortality rates (10% vs. 14%, p = 0.30), ED visits (50% vs. 54%, p = 0.70) and cardiac surgery (33% vs. 26%, p = 0.42) compared to those with non-IDU infective endocarditis. Ninety-day mortality was less among PWID (19.0% vs. 36.9%, p = 0.05). IDU was not associated with morbidity (adjusted odds ratio (AOR) 0.73, 95% CI 0.18–3.36), 90-day mortality (AOR 0.72, 95% CI 0.17–3.01), or cardiac surgery (AOR 0.15, 95% CI 0.03–0.69). Ninety-day mortality among PWID who received MOUD was lower (3% vs 15%, p = 0.45), as were ED visits (10% vs. 41%, p = 0.42) compared to those who did not receive MOUD.

Conclusions

Our results highlight existing differences in health characteristics and social determinants of health in people with IDU-associated versus non-IDU infective endocarditis. PWID had less comorbidities and were significantly younger than those with non-IDU infective endocarditis and yet still had similar rates of cardiac surgery, ED visits, and in-hospital mortality. These findings emphasize the need to deliver comprehensive health services, particularly MOUD and other harm reduction services, to this marginalized population.

Medication Treatment For Opioid Use Disorders In Substance Use Treatment Facilities

Medication treatment (MT) is one of the few evidence-based strategies proposed to combat the current opioid epidemic. We examined national trends and correlates of offering MT in substance use treatment facilities in the United States. According to data from national surveys, the proportion of these facilities that offered any MT increased from 20.0 percent in 2007 to 36.1 percent in 2016-mainly the result of increases in offering buprenorphine and extended-release naltrexone. Only 6.1 percent of facilities offered all three MT medications in 2016. Facilities in states with higher opioid overdose death rates, facilities that accepted health insurance overall (and, more specifically, those that accepted Medicaid in states that opted to expand eligibility for Medicaid), and facilities in states with more comprehensive coverage of MT under their Medicaid plans had higher odds of offering MT. The findings highlight the persistent unmet need for MT nationally and the role of expansion of health insurance in the dissemination of these treatments.

Epidemiology of the U.S. opioid crisis: the importance of the vector

The roots of the remarkably lethal U.S. opioid crisis are complex and inextricably entangled with healthcare, especially in its treatment of another serious health problem: pain. Failures of the healthcare system-including lack of both training in pain management and caution in using an addictive class of medications-precipitated the rise in opioid misuse and addiction over the past two decades, but a wider range of social and economic forces has helped perpetuate the crisis and altered its character. The classic epidemiologic host-agent-environment triad can be augmented for the purpose of elucidating the current opioid crisis by addition of the "vector" to emphasize the importance of purveyors of opioids (licit and illicit), leading to our proposing an expanded host-agent-vector-environment model. Interventions addressing multiple components are needed, including solutions that account for behaviors of all vectors associated with the crisis. For prescription opioids, the vectors include clinicians and pharmaceutical-related companies involved in marketing, prescribing, distributing, and dispensing opioid medications; for illicit opioids, they include drug manufacturing and distribution networks. Attending to the vectors of opioids, while simultaneously implementing a full range of public health, clinical, law enforcement, and other approaches to ending the opioid crisis, may help to improve public health outcomes.

A Biopsychosocial Overview of the Opioid Crisis: Considering Nutrition and Gastrointestinal Health

The opioid crisis has reached epidemic proportions in the United States with rising overdose death rates. Identifying the underlying factors that contribute to addiction vulnerability may lead to more effective prevention strategies. Supply side environmental factors are a major contributing component. Psychosocial factors such as stress, trauma, and adverse childhood experiences have been linked to emotional pain leading to self-medication. Genetic and epigenetic factors associated with brain reward pathways and impulsivity are known predictors of addiction vulnerability. This review attempts to present a biopsychosocial approach that connects various social and biological theories related to the addiction crisis. The emerging role of nutrition therapy with an emphasis on gastrointestinal health in the treatment of opioid use disorder is presented. The biopsychosocial model integrates concepts from several disciplines, emphasizing multicausality rather than a reductionist approach. Potential solutions at multiple levels are presented, considering individual as well as population health. This single cohesive framework is based on the interdependency of the entire system, identifying risk and protective factors that may influence substance-seeking behavior. Nutrition should be included as one facet of a multidisciplinary approach toward improved recovery outcomes. Cross-disciplinary collaborative efforts, new ideas, and fiscal resources will be critical to address the epidemic.

The Affordable Care Act and Opioid Agonist Therapy for Opioid Use Disorder

OBJECTIVE

The study examined whether the use of opioid agonist therapy (OAT) for treatment of opioid use disorder in specialty substance use treatment settings increased following Medicaid expansion.

METHODS

Administrative data on 943,430 admissions from the Treatment Episodes Data Set-Admissions (2010-2016) were used to examine the association between Medicaid expansion and the use of OAT and to assess whether this association was mediated by increased proportion of admissions with Medicaid in expansion states.

RESULTS

From 2010-2013 to 2014-2016, OAT use among patients with opioid use disorder increased in both expansion (39.1% and 50.2%, respectively) and nonexpansion (39.9% and 40.5%, respectively) states. The effect of Medicaid expansion on OAT use was mainly mediated through a larger proportion of admissions with Medicaid in expansion states.

CONCLUSIONS

As the nation grapples with the opioid epidemic, expanding Medicaid coverage has the potential to promote greater access to evidence-based treatment.

Substance Use Stigma and Antiretroviral Therapy Adherence Among a Drug-Using Population Living with HIV

Among people living with HIV (PLWH), HIV-related stigma predicts nonadherence to antiretroviral therapy (ART); however, the role of stigma associated with drug use is largely unknown. We examined the association between substance use (SU) stigma and optimal ART adherence in a sample of 172 self-reported HIV-infected drug users. Participants completed surveys on SU, stigma, and ART adherence. The three substance classes with the greatest number of participants exhibiting moderate/high-risk scores were for cocaine/crack cocaine (66.28%), cannabis (64.53%), and hazardous alcohol consumption (65.70%). Multivariable logistic regression was conducted to investigate associations between levels of SU stigma and optimal ART adherence, adjusting for sociodemographic characteristics, severity of illicit drug use (alcohol, smoking and substance involvement screening test) and alcohol use severity (Alcohol Use Disorders Identification Test-C), HIV-related stigma, and social support. The odds of optimal adherence among participants experiencing moderate [Adjusted Odds Ratio (AOR) = 0.36, p = 0.039] and very high (AOR = 0.25, p = 0.010) levels of anticipated SU stigma were significantly lower than participants experiencing low levels of anticipated SU stigma. No other stigma subscales were significant predictors of ART adherence. Interventions aiming to improve ART adherence among drug-using PLWH need to address anticipated SU stigma.

Machine learning for prediction of sustained opioid prescription after anterior cervical discectomy and fusion

BACKGROUND CONTEXT

The severity of the opioid epidemic has increased scrutiny of opioid prescribing practices. Spine surgery is a high-risk episode for sustained postoperative opioid prescription.

PURPOSE

To develop machine learning algorithms for preoperative prediction of sustained opioid prescription after anterior cervical discectomy and fusion (ACDF).

STUDY DESIGN/SETTING

Retrospective, case-control study at two academic medical centers and three community hospitals.

PATIENT SAMPLE

Electronic health records were queried for adult patients undergoing ACDF for degenerative disorders between January 1, 2000 and March 1, 2018.

OUTCOME MEASURES

Sustained postoperative opioid prescription was defined as uninterrupted filing of prescription opioid extending to at least 90-180 days after surgery.

METHODS

Five machine learning models were developed to predict postoperative opioid prescription and assessed for overall performance.

RESULTS

Of 2,737 patients undergoing ACDF, 270 (9.9%) demonstrated sustained opioid prescription. Variables identified for prediction of sustained opioid prescription were male sex, multilevel surgery, myelopathy, tobacco use, insurance status (Medicaid, Medicare), duration of preoperative opioid use, and medications (antidepressants, benzodiazepines, beta-2-agonist, angiotensin-converting enzyme-inhibitors, gabapentin). The stochastic gradient boosting algorithm achieved the best performance with c-statistic=0.81 and good calibration. Global explanations of the model demonstrated that preoperative opioid duration, antidepressant use, tobacco use, and Medicaid insurance were the most important predictors of sustained postoperative opioid prescription.

CONCLUSIONS

One-tenth of patients undergoing ACDF demonstrated sustained opioid prescription following surgery. Machine learning algorithms could be used to preoperatively stratify risk these patients, possibly enabling early intervention to reduce the potential for long-term opioid use in this population.

Syringe services programs: An examination of legal, policy, and funding barriers in the midst of the evolving opioid crisis in the U.S

BACKGROUND

Syringe Services Programs (SSPs) have been proposed as a key intervention to address increasing rates of opioid injection, overdose, and infectious disease transmission in the U.S. In recent years, multiple states and jurisdictions have enacted laws and policies to enable implementation of SSPs. These statutory and regulatory changes have resulted in the expansion of SSPs in a short period of time under a patchwork of different regulations and policies. Understanding how SSPs are responding to this evolving policy environment in the midst of a worsening opioid crisis can inform the development of strategies to maximize the role SSPs play in the response to the opioid crisis.

METHODS

In-depth, semi-structured and audio-recorded interviews were conducted with 25 individuals running 23 SSPs in the U.S. A thematic content analysis was employed to identify and group themes across the domains of interest based on inductive and deductive coding of verbatim interview transcripts.

RESULTS

Despite progress in expanding the number of SSPs in recent years, programs described encountering legal, policy, funding, and community barriers that are limiting the scope, scale, and reach of SSPs. To address these barriers, programs are employing multiple strategies to educate about and advocate for SSPs, engage policymakers and communities, combat pervasive stigma, strengthen funding, and reach at-risk populations.

CONCLUSION

This qualitative study of a geographically diverse sample of SSPs provides key insights into the legal and policy barriers, funding challenges, and contextual factors impacting SSPs and the strategies programs are pursuing to counter these barriers. Coupling these strategies with policy changes that address the underlying legal and financial barriers and advancing efforts to combat stigma around drug use and addiction stand to substantially expand the role of SSPs as part of the public health response to the opioid crisis in the U.S.

Increased HIV diagnoses in West Virginia counties highly vulnerable to rapid HIV dissemination through injection drug use: a cautionary tale

PURPOSE

To investigate HIV transmission potential from a cluster of HIV infections among men who have sex with men to persons who inject drugs in 15 West Virginia counties. These counties were previously identified as highly vulnerable to rapid HIV dissemination through injection drug use (IDU) associated with high levels of opioid misuse.

METHODS

We interviewed persons with 2017 HIV diagnoses about past-year risk behaviors and elicited sexual, IDU, and social contacts. We tested contacts for HIV and assessed risk behaviors. To determine HIV transmission potential from persons with 2017 diagnoses to persons who inject drugs, we assessed viral suppression status, HIV status of contacts, and IDU risk behaviors of persons living with HIV and contacts.

RESULTS

We interviewed 78 persons: 39 with 2017 diagnoses and 39 contacts. Overall, 13/78 (17%) injected drugs in the past year. Of 19 persons with 2017 diagnoses and detectable virus, 9 (47%) had more than or equal to 1 sexual or IDU contacts of negative or unknown HIV status. During the past year, 2/9 had injected drugs and shared equipment, and 1/9 had more than or equal to 1 partner who did so.

CONCLUSIONS

We identified IDU risk behavior among persons with 2017 diagnoses and their contacts. West Virginia HIV prevention programs should continue to give high priority to IDU harm reduction.

Mitigation of IV Abuse Through the Use of Abuse-Deterrent Opioid Formulations: An Overview of Current Technologies

Providers who treat patients with chronic pain face a dual challenge: providing adequate access to opioid therapies for appropriate pain management while adopting strategies to minimize the risk for abuse. Commonly prescribed opioids have substantial abuse potential when administered intravenously, and extended‐release (ER)/long‐acting (LA) opioids may be targeted for intravenous (IV) abuse because of the higher per‐dose medication level. The consequences of IV opioid abuse are severe and increase the risks for adverse outcomes, including mortality due to acute health events, serious infections, and deep vein thrombosis, to name a few. To reduce the potential for abuse of prescription opioids by both recreational and experienced drug abusers, abuse‐deterrent formulations (ADFs) of opioid medications employ either physical/chemical barriers or agonist‐antagonist combinations. Here we review the development and use of opioid ADFs as a harm‐reduction strategy, and their potential for mitigating IV opioid abuse. The approved ER/LA opioids with ADF labeling in the United States include formulations of oxycodone, hydrocodone, and morphine. Findings from in vitro laboratory tests of abuse deterrence for opioid ADFs are described herein, as are data from human abuse potential studies for IV abuse of those ADF products, for which such studies are feasible (ie, abuse‐deterrent agonist‐antagonist formulations). The available ADF opioids may decrease both the attractiveness and the feasibility of IV abuse. The adoption of ADF opioids represents one tactic for providing access to needed medication for patients with chronic pain, while potentially reducing the risk for opioid abuse, in a comprehensive effort to combat the opioid epidemic.

Misuse of prescribed opioids in the United States

PURPOSE

To assess the prevalence and correlates of self-reported misuse of prescribed-opioid medications in the US general population.

METHOD

In 31 068 adult participants of the National Survey on Drug Use and Health (NSDUH) 2015 and 2016 who reported using opioids in the past year, we assessed the prevalence and correlates of self-reported misuse of prescribed opioids, defined as using a larger dose, more frequently, or longer than prescribed. Multivariable logistic-regression models and the machine-learning method of boosted regression were used to identify the correlates of misuse.

RESULTS

On the basis of weighted NSDUH estimates, of more than 89 million US adults who used prescription opioids every year, close to 3.9 million (4.4%) reported misused the prescribed medications. Prescribed-opioid misuse was most strongly associated with co-occurring misuse of opioids without a prescription, misuse of benzodiazepines, other drug-use disorders, history of illegal activity, and psychological distress. Misuse of prescribed opioids was also strongly associated with prescription opioid-use disorder, especially among those who misused more potent opioids or started misusing opioids before the current year.

CONCLUSIONS

Misuse of prescribed opioids is associated with other high-risk behaviors and adverse health outcomes. The findings call for better monitoring of opioid prescription in clinical practice.

The evolving drug epidemic of prescription opioid injection and its association with HCV transmission among people who inject drugs in Montréal, Canada

AIMS

To examine temporal trends in prescription opioid (PO) injection and to assess its association with hepatitis C virus (HCV) seroconversion among people who inject drugs (PWID).

DESIGN

Prospective cohort study spanning 2004 to 2016.

SETTING

Montréal, Canada.

PARTICIPANTS

PWID reporting injection during the past 6 months.

MEASUREMENTS

PWID were recruited between 2004 and 2016. At each 3-6-month follow-up visit, participants completed interview-administered questionnaires and were tested for HCV-antibody.

FINDINGS

Among 1524 PWID [83% males, mean age 38 years, standard deviation (SD) = 10, 34% (31-36) prescription opioid (PO) injection past month] included in trends analyses, PO injection use expanded between 2004 and 2009, and plateaued between 2010 and 2016 (trend tests < 0.001 and 0.335, respectively). Of the 432 HCV-seronegative PWIDs followed at least once (81% males, mean age 34, SD 9.8, 38% injection PO), 153 became HCV-antibody-positive during 1230 years of follow-up, for an incidence of 12.4 per 100 person-years [95% confidence interval (CI) = 10.6, 14.6]. PO injectors were 3.9 times more likely to seroconvert to HCV, relative to non-PO injectors. In a multivariate analysis, a stronger association between PO injection and HCV seroconversion was found post-2009 [adjusted hazard ratio (aHR) = 5.4, 95% CI = 2.7, 10.8] than before (aHR = 1.5, 95% CI = 0.9, 2.4) (P-value for interaction = 0.001).

CONCLUSION

Prescription opioid injection increased among people who inject drugs in Montréal, Canada from 2004 to 2009, to reach a plateau between 2010 and 2016. The association between prescription opioid injection and HCV seroconversion was stronger during the second period than the first according to the epidemic phase.

Gender Differences in Prescription Opioid Misuse Among U.S. Black Adults

BACKGROUND

Prescription opioid misuse (POM) is a significant problem among U.S. adults, including Blacks, as indicated by past research. Despite potential gender differences in POM among Black adults, previous research has yet to examine this possibility.

OBJECTIVES

This study identified the prevalence and unique correlates of POM among both Black men and Black women. Results were compared to those of Whites.

METHODS

We used data from 2015-2016 National Survey on Drug Use and Health (N = 60,133). Weighted logistic regression models stratified by race and gender were estimated. One model was stratified by gender only, with race serving as the primary predictor.

RESULTS

Findings revealed 3.4% of Black women, 4.9% of Black men, 4.1% of White women, and 5.4% of White men reported past-year POM; although, no significant differences were found. Among Black women only, lower socioeconomic status increased odds of POM. Higher educational attainment, residence in rural areas and older age lowered odds of POM. Encounters with drug dealers, illicit drug, marijuana, and tobacco use, other prescription drug misuse, and poor health were associated with increased odds of POM among Black men. In the gender stratified models, White men were more likely to report POM than Black men. However, White women were not more likely to report POM compared to Black women.

CONCLUSIONS

Clear gender differences exist in the prevalence and correlates of POM among Black adults. Prevention and intervention strategies must be cognizant of these differences when developing programs to decrease POM.

Do more opioid policies reduce opioid dispensing in traditional medicaid?: A national analysis

BACKGROUND

Several Medicaid programs have implemented approaches to ensure the appropriateness of opioid utilization and decrease opioid dispensing.

OBJECTIVE

To evaluate whether Medicaid opioid harm reduction strategies (OHRS) resulted in a decrease in opioid claims, costs, or units reimbursed per beneficiary.

METHODS

The number of OHRS was determined for each state's fee-for-service (FFS) Medicaid program according to previously published data. Publically available FFS Medicaid data were tabulated by state for opioid claims, costs, and units reimbursed in state fiscal years 2016 and 2017. Multivariable generalized estimating equation (GEE) models were utilized to analyze the data.

RESULTS

GEE results indicated that OHRS intensity or change in OHRS did not impact opioid claims or units reimbursed in Medicaid FFS programs. A significant finding on reduction in beneficiary-adjusted opioid costs was observed for states with two OHRS compared to states with no OHRS. There were no significant differences in opioid claims, units reimbursed, and costs based on states with 3 or fewer OHRS versus those with four or more. When examining the differential effect of each individual type of OHRS, there were no significant differences in opioid claims, units reimbursed, nor medication costs.

CONCLUSIONS

The number of OHRS may not be associated with opioid dispensing or utilization in FFS Medicaid programs. Other factors may have led to the decrease in opioid claims for Medicaid.

Frontline Science: Buprenorphine decreases CCL2-mediated migration of CD14+ CD16+ monocytes

HIV infection of the CNS causes neuroinflammation and damage that contributes to the development of HIV-associated neurocognitive disorders (HAND) in greater than 50% of HIV-infected individuals, despite antiretroviral therapy (ART). Opioid abuse is a major risk factor for HIV infection. It has been shown that opioids can contribute to increased HIV CNS pathogenesis, in part, by modulating the function of immune cells. HIV enters the CNS within two weeks after peripheral infection by transmigration of infected monocytes across the blood brain barrier (BBB). CD14⁺ CD16⁺ monocytes are a mature subpopulation that is increased in number in the peripheral blood of HIV-infected people. Mature monocytes can be productively infected with HIV, and they transmigrate preferentially across the BBB in response to CCL2, a chemokine elevated in the CNS and CSF of HIV-infected people even with ART. Buprenorphine, an opioid derivate, is an opioid replacement therapy for heroin addiction. It is a partial agonist of μ-opioid receptor and full antagonist of κ-opioid receptor. The effects of buprenorphine on CCL2-mediated CD14⁺ CD16⁺ monocytes transmigration across the BBB, a critical mechanism that promotes neuroinflammation and HAND, have not been characterized. We showed for the first time that buprenorphine decreases several steps of CCL2-mediated human mature monocyte transmigration. We propose that buprenorphine treatment in the context of HIV infection could serve a dual purpose, to treat opioid addiction and also to reduce neuroinflammation. Additionally, buprenorphine may be used as a treatment for HAND not only in the context of opioid abuse.