Sexual Violence, Mental Health, and Prescription Opioid Use and Misuse

Sexually Transmitted Infection (STI) Incidence, STI Screening, and Human Immunodeficiency Virus Preexposure Prophylaxis Uptake in United States Veterans With Opioid Use Disorder in Long Island, New York

Background

Opioid use disorder (OUD) confers increased risk of contracting bloodborne and sexually transmitted infections (STIs). Limited data exist on infectious disease screening and preexposure prophylaxis (PrEP) usage among United States Veterans (USVs) with OUD, including persons who inject drugs (PWID). This study aimed to evaluate the epidemiology of human immunodeficiency virus (HIV), hepatitis C virus (HCV), bacterial STIs, and PrEP uptake in USVs with OUD, including PWID.

Methods

A retrospective chart review of USVs with OUD seeking care at Northport Veterans Affairs Medical Center between 2012 and 2022 was completed. Sociodemographics, HIV, HCV, STI testing rates and diagnosis, and PrEP uptake were compared between USVs, stratified by injection drug use history.

Results

We identified 502 USVs with OUD; 43% had a history of injection drug use. Overall, 2.2% of USVs had HIV and 28.7% had HCV. An STI was diagnosed in 10% of USVs, most frequently syphilis (1.8%). PWID were more likely to be tested for HIV (93.5% PWID vs. 73.1% non-PWID; P < .001), HCV (95.8% PWID vs. 80.8% non-PWID; P < .001), and syphilis (80% PWID vs. 69.2% non-PWID; P = .006). Total gonorrhea and chlamydia testing rates were 31.9% and 33.7%, respectively, without difference between the groups. PrEP was prescribed in 1.2% of USVs.

Conclusions

In USVs with OUD, gonorrhea and chlamydia screening occurred less frequently than syphilis, HCV, and HIV. PWID were more likely to be screened for HIV, HCV, and syphilis. PrEP uptake was low. Both PWID and non-PWID may benefit from increased STI screening and linkage to PrEP.

Association Between Adverse Childhood Experiences and Opioid Use-Related Behaviors: A Systematic Review

As opioid use-related behaviors continue at epidemic proportions, identifying the root causes of these behaviors is critical. Adverse childhood experiences (ACEs) are shown to be an important predictor of opioid initiation, opioid dependence, and lifetime opioid overdose. The purpose of this systematic review is to examine the association between ACEs and opioid use-related behaviors later in life and to discuss implications for policy, practice, and research regarding ACEs and opioids. Five databases (PubMed, PsycINFO, CINAHL, Medline, and Scopus) were used to identify studies investigating the association between ACEs and opioid use-related behaviors. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, 20 studies out of the initial 428 met the inclusion criteria for this review. Among the included 20 studies, 15 focused on the relationship between ACEs and lifetime opioid use-related behaviors, and five focused on current opioid use-related behaviors. All studies found statistical associations between ACEs and lifetime or current opioid use-related behaviors. Five studies found a significant gradient effect; that is, as the number of ACEs increased, the risk of opioid use-related behaviors also increased. A significant dose-response relationship exists between ACEs and opioid use-related behaviors. Hence, it is essential for clinicians to screen for ACEs before prescribing opioid medications, for opioid treatment to incorporate trauma-informed methods, and for messaging around opioid use interventions to include information about ACEs. The current review points to a critical need to implement standardized ACE screening instruments in clinical and research settings.

"My Goal is…to get Through the Day Without Pain": A Qualitative Study on Chronic Pain Experiences and Treatment Needs Among Child Caregiving Women

INTRODUCTION

We aimed to understand connections between pain, caregiving, physical and behavioral health treatment needs, and motivations for prescription opioid use among child caregiving women with chronic pain.

METHODS

We conducted in-depth, semi-structured interviews with 12 women (average age 48 years; 58% Black) in child caregiving roles, including women who were pregnant or trying to become pregnant and were caring for children or grandchildren < 18 years, and who received treatment at an outpatient pain management clinic. We used thematic text analysis to identify qualitative themes related to caregiving, pain, treatment, substance use, coping strategies, and sources of support.

RESULTS

A diverse sample of women reported high levels of stress and pain, substance use, interpersonal violence, depression, and financial strain. Most described difficulties at work, interacting with children or grandchildren, and engaging routine, daily activities due to their pain. Most indicated that they spent less time with family and friends due to their pain and had limited sources of support to help them navigate both caregiving and pain. Many described barriers to receiving appropriate healthcare, including prescription opioids, due to stigma or logistics, though most also reported positive healthcare experiences. Women also reported added daily-life, physical, mental health, and interpersonal stressors and difficulty navigating the healthcare system to receive needed care.

DISCUSSION

For women with chronic pain in child caregiver roles, results highlight the importance of care tailored to the physical needs of child caregiving and of trauma-informed approaches given the prevalence of comorbid conditions and trauma.

Sexual assault and the matrix of harm: Sexual assault survivors narrate their whole lives in more negative ways

This paper uses data from the American Voices Project, an interview study based on a random population sample, to explore the relationship between assault experiences and how people narrate their lives. Using quantitative sentiment analysis, we find that survivors of assault express significantly greater negative sentiment when asked to tell their life stories. These negative sentiments are observable throughout the entire interview, including before questions of assault are asked. Survivors of assault narrate their experiences with more anger, disgust, fear, and sadness, and less anticipation, joy, and trust than those who do not report assault experiences. We provide evidence that the negative sentiment associated with sexual violence is greater than having lost a parent and less than having experienced a significant financial hardship within the last month. We contextualize these findings with a qualitative evaluation of the interview transcripts, further substantiating our finding. Overall, this paper suggests that sexual violence is part of what we have called, drawing inspiration from the work of Beth Richie, a "matrix of harm" that structures people's lives. While our finding is consistent with what we might expect given the negative life experiences and sequalae associated with sexual assault, it has important implications. Sentimental differences in narrating life experience are an important yet relatively understudied phenomenon, and experiences of assault are rarely asked about yet may be consequential to both quantitative and qualitative accounts of social processes.

Observational evidence linking psychotropic medicines to the dispensing of opioid agents in later life

BACKGROUND

The use of opioid medicines is common in developed countries, particularly among older adults and those with mental health disorders. It is unclear if the association between mental disorders and opioid medicines is causal, or is due to reverse causality or confounding.

METHODS

We used a 10% random sample of the Australian Pharmaceutical Benefits Scheme (years 2012-2022) to examine the cross-sectional, case-control and longitudinal association between the dispensing of antidepressants, anxiolytics, hypnotics, antipsychotics and lithium, and opioid medicines. We used logistic regression, structural equation models (SEM), and Cox regression to analyze the data. Analyses were adjusted for age (years), sex, and number of non-psychotropic medicines dispensed during the year.

RESULTS

The 2022 file contained 804 334 individuals aged 50 years or over (53.1% women), of whom 181 690 (22.6%) received an opioid medicine. The adjusted odds ratio of being dispensed opioid medicines was 1.44 (99% CI = 1.42-1.46) for antidepressants, 1.97 (99% CI = 1.92-2.03) for anxiolytics, 1.55 (99% CI = 1.51-1.60) for hypnotics, 1.32 (99% CI = 1.27-1.38) for antipsychotics, and 0.60 (99% CI = 0.53-0.69) for lithium. Similar associations were noticed when we compared participants who were or not dispensed opioid medicines in 2022 for exposure to psychotropic agents between 2012 and 2021. SEM confirmed that this association was not due to reverse causality. The dispensing of antidepressants was associated with increased adjusted hazard (HR) of subsequent dispensing of opioid medicines (HR = 1.29, 99% CI = 1.27-1.30). Similar associations were observed for anxiolytics, hypnotics and antipsychotics, but not lithium.

CONCLUSIONS

The dispensing of opioid medicines is higher among older individuals exposed to antidepressants, anxiolytics, hypnotics and antipsychotics than those who are not. These associations are not due to reverse causality or study design. Preventive strategies seeking to minimise the risk of inappropriate use of opioid medicines in later life should consider targeting this high-risk population.

Identifying patterns of pain, depression, anxiety, interpersonal trauma exposure, and nonmedical prescription opioid use: Latent class analysis among patients with chronic pain

BACKGROUND

Chronic pain in the context of certain factors may be associated with potential for nonmedical prescription opioid use; however, identifying this risk can be challenging and complex. Several variables alone have been associated with non-prescribed opioid use, including depression, anxiety, pain interference, and trauma exposure. Prior research has often failed to integrate these assessments together, which is important as these factors may cluster together in important and complex ways. The current study aimed to identify classes of patients with chronic pain who have differential risk for use of nonmedical prescription opioid use, depression and anxiety, and pain severity, interference, and catastrophizing, and interpersonal violence exposure.

METHODS

Self-report and medical record data from patients (N = 211; Mage = 48, 69.0% women, 69.0% white) at a pain management center were collected.

RESULTS

Latent class analysis revealed 3 classes with (1) low probability of clinically significant depression, anxiety, pain, and nonmedical prescription opioid use (44.7%), (2) high probability of clinically significant depression, anxiety, pain, pain catastrophizing, trauma, and nonmedical prescription opioid use (41.3%), and (3) high probability of severe pain and nonmedical prescription opioid use (14.0%).

CONCLUSIONS

High-risk classes had either high levels of depression and anxiety, pain catastrophizing, and interpersonal violence exposure, or pain severity and interference. Future research should continue to explore these classes in large, diverse samples, and prospective study designs. Finally, results underscore that opioid use is complex, not easily identified by a single factor, and may be motivated by complex unmet clinical needs.

Interpersonal Violence and Mental Health, Drug use, and Treatment Utilization among Patients with Co-Occurring Opioid use and Mental Health Disorders

Interpersonal violence is a common type of trauma experienced by people with opioid use disorder (OUD), especially for people with co-occurring OUD and mental illness (COD). However, little is known about demographic and clinical characteristics of individuals with COD who have experienced an interpersonal violence traumatic event compared to those who have experienced a non-violent trauma, and how experiences of interpersonal violence are associated with treatment utilization. Data presented are from a randomized clinical trial testing collaborative care for COD in primary care. Of the 797 patients enrolled in the larger study, 733 (92%) were included in this analysis because they reported a traumatic event. In this sample, 301 (41%) participants experienced a traumatic event involving interpersonal violence. Participants who experienced interpersonal violence were more likely to be younger and female. Among the 301 people who experienced interpersonal violence, 30% experienced child sexual abuse, 23% experienced physical violence, 19% experienced domestic violence, and 28% experienced sexual assault. Those who experienced physical violence were significantly less likely to be female (28.6% vs 74.2% to 88.2% in other groups). Those who reported domestic violence had significantly fewer days of drug use (4.1 days vs 9.0 to 11.5 in the other groups) and lower opioid use severity scores (mean = 13.0 vs 16.6 to 19.5 in the other groups). Multivariable regression results examining the associations between interpersonal violence experiences on treatment utilization revealed no statistically significant differences. Rates of receipt were high for medication for opioid use disorder (∼80%) in this sample while rates of mental health counseling were around 35% and rates of receiving mental health medication around 48%. These findings make an important contribution to understanding the associations between patient characteristics and traumatic experiences, and receipt of treatment for OUD and mental health problems among a sample of patients with COD.

Clinical trial registration

clinicalTrials.gov ID: NCT04559893.

A Harm Reduction Framework for Integrated Treatment of Co-Occurring Opioid Use Disorder and Trauma-Related Disorders

The opioid epidemic has exposed a gulf in mental health research, treatment, and policy: Most patients with comorbid trauma-related disorder (TRD) and opioid use disorder (OUD) (TRD + OUD) remain undiagnosed or unsuccessfully treated for the combination of TRD symptoms and opioid use. TRD treatments tend to be psychotherapies that are not accessible or practical for many individuals with TRD + OUD, due to TRD treatment models not systematically incorporating principles of harm reduction (HR). HR practices prioritize flexibility and unequivocally improve outcomes and save lives in the treatment of OUD. Considering the urgent need to improve TRD + OUD treatment and outcomes, we propose that the OUD and TRD fields can be meaningfully reconciled by integrating HR principles with classic phasic treatment for TRD. Adding a "prestabilization" phase of treatment for TRD - largely analogous to the precontemplation Stage of Change - creates opportunities to advance research, clinical practice, and policies and potentially improve patient outcomes.

The impact of exposure to physical and sexual violence on opioid consequences among trauma-exposed individuals recruited from the community who use opioids

Interpersonal violence and opioid use disorder are significant and intersecting public health concerns in the USA. The current study evaluated the consequences associated with opioid use (e.g., physical, social, interpersonal, intrapersonal, and impulse control) as a function of a history of exposure to interpersonal trauma, specifically physical and sexual violence. Participants were 84 trauma-exposed individuals recruited from the community who use opioids (M age = 43.5 50% men; 55% white). Whereas no significant differences emerged in the consequences of opioid use based on a history of physical violence, individuals with a history of sexual violence demonstrated higher levels of impulsive consequences of opioid use compared to individuals without a history of sexual violence. These data highlight the importance of considering the role of exposure to sexual violence in the context of opioid use disorder treatment.

Guideline No. 443a: Opioid Use Throughout Women's Lifespan: Fertility, Contraception, Chronic Pain, and Menopause

OBJECTIVE

To provide health care providers with the best evidence on opioid use and women's health. Areas of focus include general patterns of opioid use and safety of use; care of women who use opioids; stigma, screening, brief intervention, and referral to treatment; hormonal regulation; reproductive health, including contraception and fertility; sexual function; perimenopausal and menopausal symptoms; and chronic pelvic pain syndromes.

TARGET POPULATION

The target population includes all women currently using or contemplating using opioids.

OUTCOMES

Open, evidence-informed dialogue about opioid use will lead to improvements in patient care and overall health.

BENEFITS, HARMS, AND COSTS

Exploring opioid use through a trauma-informed approach offers the health care provider and patient with an opportunity to build a strong, collaborative, and therapeutic alliance. This alliance empowers women to make informed choices about their own care. It also allows for the diagnosis and possible treatment of opioid use disorders. Use should not be stigmatized, as stigma leads to poor "partnered care" (i.e., the partnership between the patient and care provider). Therefore, health care providers and patients must understand the potential role of opioids in women's health (both positive and negative) to ensure informed decision-making.

EVIDENCE

A literature search was designed and carried out in PubMed and the Cochrane Library databases from August 2018 until March 2023 using following MeSH terms and keywords (and variants): opioids, illicit drugs, fertility, pregnancy, breastfeeding, and aging.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

All health care providers who care for women.

TWEETABLE ABSTRACT

Opioid use can affect female reproductive function; health care providers and patients must understand the potential role of opioids in women's health to ensure informed decision-making.

SUMMARY STATEMENTS

RECOMMENDATIONS.

The Impact of Physical and Sexual Violence on Opioid Consequences among Trauma- exposed Individuals Recruited from the Community who Use Opioids

Interpersonal violence and opioid use disorder are significant and intersecting public health concerns in the United States. The current study evaluated the consequences associated with opioid use as a function of history of interpersonal trauma, specifically physical and sexual violence. Participants were 84 trauma-exposed individuals recruited from the community who use opioids (M age = 43.5 50% men; 55% white). Whereas no significant differences emerged in the consequences of opioid use based on a history of physical violence, individuals with a history of sexual violence demonstrated higher levels of impulsive consequences of opioid use compared to individuals without a history of sexual violence. These data highlight the importance of considering the role of sexual violence in the context of opioid use disorder treatment.

Promoting Prescription Drug Safety Skills in School: Evaluating the Effectiveness of a Technology-Based Curriculum

Background

Prescription drug misuse among youth aged 12–18 remains high in the United States. Grounded in Social Norms Theory, school-based curricula have been shown to effectively challenge students’ misperceptions of peer norms and safety regarding prescription drug misuse (PDM).

Objective

The present study is a quasi-experimental evaluation of a brief, no cost, school-based prescription drug safety program.

Methods

Participants included 94 teachers and their students (n = 2325) in grades 8 through 12. Teachers (and their students) were assigned to experimental or control conditions. Using a pre-/post-survey design, we examined whether the curriculum promoted growth in five key student outcomes: Personal Responsibility, Social Norms, Knowledge, Future Actions, and Refusal Skills. Student demographic characteristics and prescription drug history were examined as moderators of growth. Within the experimental group, variation in implementation factors such as teachers’ prior experience with the program and perceptions of student engagement were examined as moderators of the effectiveness of the curriculum.

Results

Multilevel models demonstrated equitable growth in Personal Responsibility, Social Norms, Knowledge, Future Actions, and Refusal Skills across gender, race, and other demographic characteristics. Students’ prescription drug history was not associated with growth on the five key outcomes. Growth in Personal Responsibility, Social Norms, Knowledge, and Future Actions was maintained in a one-month follow-up survey. Teacher perceptions of student engagement were associated with lower growth in Social Norms.

Conclusions

The findings suggest promising implications for the scalability of an effective, brief, no cost, technology-based intervention targeting adolescent PDM.

Why Young Women Who Use Opioids Are at Risk for Rape: The Impact of Social Vulnerabilities and Sexually Coercive Drug Using Contexts

This study tests a theoretically informed model to understand why women who use opioids (WWUO) are at risk of rape while using drugs. Structured interviews were conducted with 168 WWUO. Three domains were hypothesized to increase risk: the sexually coercive context of drug use, women's social vulnerability, and drug use severity. Logistic regression examined the odds of being raped by domain. One-third of WWUO had been raped while using drugs. The sexually coercive context and social vulnerability domains significantly increased women's odds of being raped. Prevention efforts should target social and contextual factors.

An Illustrative Review of Substance Use-Specific Insights From the National Longitudinal Study of Adolescent to Adult Health

PURPOSE

The purpose of this illustrative, thematic review was to demonstrate the utility of data from the National Longitudinal Study of Adolescent to Adult Health (Add Health) for substance use research and to describe substance use-specific insights gained from Add Health research over the past 2 decades.

METHODS

We searched multiple electronic databases (PubMed, PsycInfo, and Web of Science) and selected an illustrative sample of 40 articles that used Add Health data and longitudinally examined a measure of alcohol, marijuana, or illicit drug use or prescription drug misuse as the exposure or outcome in association with diverse domains of additional factors assessed (social, emotional, behavioral, contextual, biological, and genetic).

RESULTS

Included articles identified several key associations between substance use behaviors and additional factors from a wide range of domains. For example, results from several studies indicated that experiences of sexual violence, adolescent dating violence, and intimate partner violence are associated with an increased likelihood of later prescription opioid misuse, heavy drinking, and marijuana use, with some differences by biological gender and race/ethnicity. Results from other studies showed that bidirectional associations between substance use and mental health differ by specific type of substance and mental health condition.

DISCUSSION

Existing research using Add Health data has provided valuable insights regarding substance use by leveraging the study's longitudinal design, the prospective nature of data collection, the breadth and depth of substance use questions assessed from adolescence to adulthood, the size and diversity of the cohort, and the wide range of additional factors measured over time.

Epidemiology of opioid use in pregnancy

The world has been experiencing an opioid epidemic for over 20 years, and rates of use and overdose among women, including during pregnancy, have risen markedly. Women receive more prescriptions for opioids compared to men. Data suggest that 20% of women filled at least one prescription for an opioid during their pregnancy, and the prevalence of prenatal exposure averaged 14%. Opioid use by women, especially during pregnancy and while breastfeeding, and management and treatment is complex for healthcare providers, especially related to methadone treatment, pain management during labour, neonatal opioid withdrawal syndrome, nutritional issues and maternal withdrawal. Opioid use during pregnancy has been associated with maternal, foetal and infant complications, and overdose has become a leading cause of death in post-partum women in some countries. Universal screening for opioid use disorder (OUD) is recommended in pregnancy, and prevention and treatment programs that meet the specific needs of women are important to understand and consider as the world continues to try to anticipate and respond to the realities of the opioid epidemic.

Current and emerging pharmacotherapies for opioid dependence treatments in adults: a comprehensive update

INTRODUCTION

Opioid use disorder (OUD) is characterized by compulsive opioid seeking and taking, intense drug craving, and intake of opioids despite negative consequences. The prevalence of OUDs has now reached an all-time high, in parallel with peak rates of fatal opioid-related overdoses, where 15 million individuals worldwide meet the criteria for OUD. Further, in 2020, 120,000 opioid-related deaths were reported worldwide with over 75,000 of those deaths occurring within the United States.

AREAS COVERED

In this review, we highlight pharmacotherapies utilized in patients with OUDs, including opioid replacement therapies, and opioid antagonists utilized for opioid overdoses and deterrent of opioid use. We also highlight newer treatments, such as those targeting the neuroimmune system, which are potential new directions for research given the recently established role of opioids in activating neuroinflammatory pathways, as well as over the counter remedies, including kratom, that may mitigate withdrawal.

EXPERT OPINION

To effectively treat OUDs, a deeper understanding of the current therapeutics being utilized, their additive effects, and the added involvement of the neuroimmune system are essential. Additionally, a complete understanding of opioid-induced neuronal alterations and therapeutics that target these abnormalities - including the neuroimmune system - is required to develop effective treatments for OUDs.

Associations Among Military Sexual Trauma, Opioid Use Disorder, and Gender

INTRODUCTION

Opioid use disorder and high-risk opioid prescription increase the risks for overdose and death. In Veterans, military sexual trauma is associated with increased risk for assorted health conditions. This study evaluates the association of military sexual trauma with opioid use disorder and high-risk opioid prescription and potential moderation by gender.

METHODS

In a national sample of Veterans Health Administration outpatients receiving care from October 1, 2009 to August 1, 2017, logistic regression models were fit to evaluate the associations between military sexual trauma and opioid use disorder and high-risk opioid prescription, adjusting for demographic and clinical covariates. A second set of models included a gender X military sexual trauma interaction. Analyses were conducted in 2020-2021.

RESULTS

Patients with history of military sexual trauma (n=327,193) had 50% higher odds of opioid use disorder diagnosis (AOR=1.50, 95% CI=1.45, 1.54, p<0.001) and 5% higher odds of high-risk opioid prescription (AOR=1.05, 95% CI=1.04, 1.07, p<0.001) than those without history of military sexual trauma (n=7,738,665). The effect of military sexual trauma on opioid use disorder was stronger in men than in women . The predicted probability of opioid use disorder among men with history of military sexual trauma (1.5%) was nearly double that of women with history of military sexual trauma (0.8%).

CONCLUSIONS

Military sexual trauma was a significant risk factor for opioid use disorder and high-risk opioid prescription, with the former association particularly strong in men. Clinical care for Veterans with military sexual trauma should consider elevated risk of opioid use disorder and high-risk opioid prescription.

Effect of Preoperative Chronic Opioid Use on Mortality and Morbidity in Vascular Surgical Patients

Introduction

Opioid derivates are an essential part of everyday clinical pain management practice. They have excellent analgesic, sedative, and sympatholytic effects and are widely used in various conditions. Beyond advantageous aspects, there are numerous problems with the chronic use of these agents. Dependency and life-threatening complications are the biggest problems with both illegal and prescribed opioid derivates. In our current study, effects of chronic opioid use were observed on mortality and life quality in the case of vascular surgery.

Methods

This prospective, observational study was conducted between 2014 and 2017. After obtaining informed consent, all participants were asked to fill a questionnaire containing different psychological tests. Perioperative data, chronic medical therapy, and anthropometric data were also collected. Opioid user and non-user patients’ psychological results were compared with non-parametrical tests. The effect of chronic opioid administration was investigated with logistic regression method with bootstrapping.

Results

Finally, the data of 164 patients were analyzed. 64.0% of participants were male, the mean age was 67.05 years, and the standard deviation was 9.48 years. The median follow-up time was 1312 days [interquartile range (IQR): 930-1582 days]. During the follow-up time, 42 patients died (25.6%). In the examined patient cohort, the frequency of opioid derivate use was 3.7% (only six patients). In the non-survived group, opioid use was significantly higher (1.6% vs. 9.5%, p=0.019). Significant differences were found in the aspect of cognitive performance measured by Mini-Mental State Examination (MMSE), opioid users have had lower points [25.5 (IQR: 24.5-26.0) vs. 28.0 (IQR: 27.0-29.0) p=0.008]. Opioid users have showed higher score on Beck Depression Inventory (BDI) [15.5 (IQR: 10.0-18.0) vs. 6.0 (IQR: 3.0-11.0), p=0.030). In a multivariate Cox regression model built up from registered preoperative medical treatment, opioids were found as a risk factor for all-cause mortality [adjusted hazard ratio (AHR): 4.31, 95% CI: 1.77-10.55, p=0.001].

Conclusion

Our current findings suggest that chronic, preoperative use of opioids could associate with increased mortality. Furthermore, both decrease in cognitive performance and increased depression symptoms were found in the opioid user cohorts which emphasize the importance of further risk stratification of these patients.