A Concept Analysis of Substance Misuse to Inform Contemporary Terminology

Misuse of Prescribed and Nonprescribed Substances Among U.S. Cancer Survivors

BACKGROUND

Substance misuse is common among cancer survivors and can negatively impact cancer outcomes.

METHODS

We conducted a cross-sectional study using National Survey on Drug Use and Health data for 2015 to 2020. We included adult respondents with a history of solid tumor cancer. We calculated the weighted prevalence and corresponding SEs (both expressed as percentages) of substance (alcohol, opioid, sedative, stimulant, other) misuse for respondents with any history of solid tumor cancer and, in secondary analyses, respondents diagnosed with cancer in the prior 12 months.

RESULTS

The study included 6,101 respondents with any history of cancer, 1,437 diagnosed in the prior 12 months. Alcohol was the most commonly misused substance. The average prevalence of alcohol misuse was 14.4% (SE 0.60%) across cancer types; it was markedly more common among people with a history or cervical (24.2% [3.0%]) or head and neck cancer (27.4% [7.1%]). The next most common form of substance misuse was opioid misuse (average prevalence: 2.7% [0.25%]). As with alcohol misuse, the prevalence of opioid misuse was higher among those with a lifetime history of cervical cancer (5% [1%]) or head and neck cancer (5% [3%]). Results were generally consistent among cancer survivors diagnosed in the prior 12 months.

CONCLUSIONS

There is a clear opportunity to address substance misuse-particularly alcohol misuse-among cancer survivors. Such efforts should focus on populations with a high prevalence of substance misuse (e.g., cervical and head and neck cancer survivors) and have strong potential to improve cancer-specific and overall health outcomes.

Expert consensus-based guidance on approaches to opioid management in individuals with advanced cancer-related pain and nonmedical stimulant use

BACKGROUND

Clinicians treating cancer-related pain with opioids regularly encounter nonmedical stimulant use (i.e., methamphetamine, cocaine), yet there is little evidence-based management guidance. The aim of the study is to identify expert consensus on opioid management strategies for an individual with advanced cancer and cancer-related pain with nonmedical stimulant use according to prognosis.

METHODS

The authors conducted two modified Delphi panels with palliative care and addiction experts. In Panel A, the patient's prognosis was weeks to months and in Panel B the prognosis was months to years. Experts reviewed, rated, and commented on the case using a 9-point Likert scale from 1 (very inappropriate) to 9 (very appropriate) and explained their responses. The authors applied the three-step analytical approach outlined in the RAND/UCLA to determine consensus and level of clinical appropriateness of management strategies. To better conceptualize the quantitative results, they thematically analyzed and coded participant comments.

RESULTS

Consensus was achieved for all management strategies. The 120 Experts were mostly women (47 [62%]), White (94 [78%]), and physicians (115 [96%]). For a patient with cancer-related and nonmedical stimulant use, regardless of prognosis, it was deemed appropriate to continue opioids, increase monitoring, and avoid opioid tapering. Buprenorphine/naloxone transition was inappropriate for a patient with a short prognosis and of uncertain appropriateness for a patient with a longer prognosis.

CONCLUSION

Study findings provide urgently needed consensus-based guidance for clinicians managing cancer-related pain in the context of stimulant use and highlight a critical need to develop management strategies to address stimulant use disorder in people with cancer.

PLAIN LANGUAGE SUMMARY

Among palliative care and addiction experts, regardless of prognosis, it was deemed appropriate to continue opioids, increase monitoring, and avoid opioid tapering in the context of cancer-related pain and nonmedical stimulant use. Buprenorphine/naloxone transition as a harm reduction measure was inappropriate for a patient with a short prognosis and of uncertain appropriateness for a patient with a longer prognosis.

Continuum beliefs of mental illness: a systematic review of measures

PURPOSE

The continuum of mental health/illness has been subject to scientific debate for decades. While current research indicates that continuum belief interventions can reduce mental health stigma and improve treatment seeking in affected populations, no study has yet systematically examined measures of continuum beliefs.

METHODS

This preregistered systematic review summarizes measures of continuum beliefs. Following the PRISMA statement, three scientific databases (PubMed, PsycInfo and PsycArticles via EBSCOhost, Web of Science) are searched, instruments are described and discussed regarding their scope, and methodological quality.

RESULTS

Overall, 7351 records were identified, with 35 studies reporting relevant findings on 11 measures. Most studies examined general population samples and used vignette-based measures. Schizophrenia and depression were most commonly examined, few studies focused on dementia, ADHD, OCD, eating disorders, and problematic alcohol use, or compared continuum beliefs across disorders. Validity was very good for most measures, but reliability was rarely tested. Measures mostly assessed beliefs in the normality of mental health symptoms or the normality of persons with such symptoms but rarely nosological aspects (i.e., categorical v continuous conceptualization of mental disorders).

CONCLUSIONS

Current research provides psychometrically sound instruments to examine continuum beliefs for a variety of mental disorders. While studies suggest utility for general population samples and mental health professionals, more research is necessary to corroborate findings, for instance, regarding age (e.g., in adolescents), gender, or type of mental disorder. Future research should also compare self-report ratings, and vignette-based measures, include measures of nosological concepts to fully grasp the continuum concept of mental illness.

PREREGISTRATION

PROSPERO: CRD42019123606.

A Student Walks into Class … Vignettes to Identify Substance Use Disorder Models of Illness among College Students

INTRODUCTION

Illness models, including illness recognition, perceived severity, and perceived nature can affect treatment-seeking behaviors. Vignettes are a leading approach to examine models of illness but are understudied for substance use disorders (SUDs). We created vignettes for multiple common DSM-5 SUDs and assessed SUD illness models among college students.

METHODS

Seven vignettes in which the protagonist meets DSM-5 diagnostic criteria for SUDs involving tobacco, alcohol, cannabis, Adderall, cocaine, Vicodin, and heroin were pilot tested and randomly assigned to 216 college students who completed measures related to illness recognition, perceived severity, and perceived nature. MANOVAs with Scheffe post-hoc tests were conducted to examine vignette group differences on models of illness.

RESULTS

Vignettes met acceptable levels of clarity and plausibility. Participants characterized the protagonist's substance use as a problem, a SUD, or an addiction most frequently with Vicodin, heroin, and cocaine and least frequently with tobacco and cannabis. Participants assigned to the Vicodin, heroin, and cocaine vignettes were the most likely to view the protagonist's situation as serious and life-threatening, whereas those assigned to the cannabis vignette were the least likely. Numerically more participants characterized the pattern of substance use as a problem (91%) or an addiction (90%) than a SUD (76%), while only 15% characterized it as a chronic medical condition.

CONCLUSIONS

Illness recognition and perceived severity varied across substances and were lowest for cannabis. Few participants conceptualized SUDs as chronic medical conditions. College students may benefit from psychoeducation regarding cannabis use disorder and the chronic medical condition model of SUDs.

Addressing Bias and Stigma in the Language We Use With Persons With Opioid Use Disorder: A Narrative Review

BACKGROUND: Despite an increase in access to medications for opioid use disorder, less than 20% of individuals with opioid use disorder (OUD) receive treatment. Stigmatizing language has been identified as a potential trigger for explicit and implicit biases that may adversely affect treatment enrollment and quality of care for persons with OUD. AIMS: To conduct a narrative review of the literature on stigmatizing language and OUD, examine how treatment outcomes are affected, and present strategies to reduce bias and promote OUD treatment. METHOD: A narrative review of the literature between 2010 and 2019 was conducted using CINAHL, PubMed, and PsycINFO. Key search terms were opioid use disorder (or substance use disorder), stigma, and language. Fifty-two articles were screened for inclusion, and 17 articles were included in this review. RESULTS: The articles reviewed provide consensus that stigmatizing language toward persons with OUD fosters explicit and implicit bias and impedes engagement in treatment. Four themes emerged: (1) stigma and language, (2) stigma and language used by health care professionals, (3) stigma and language used by the general public, and (4) stigma and language used by people with OUD. CONCLUSIONS: Stigmatizing language is dehumanizing and plays a pivotal role in bias and discrimination that may contribute to unsatisfactory treatment outcomes among persons with OUD. Health care professionals, nursing in particular, must assume an intentional stance against stigma perpetuated toward persons with OUD through advocacy in education, practice, policy, and the media.

Creating an operational definition for prolonged postoperative opioid use through the use of concept analysis

AIM

To develop an evidence-based operational definition for Prolonged Postoperative Opioid Use (PPOU).

BACKGROUND

In the United States, opioids are a mainstay of postoperative pain management, and are prescribed to over 90% of patients following surgery. Recent literature has highlighted the risk for prolonged postoperative opioid use (PPOU) after many surgical procedures. However, reported rates of PPOU vary greatly across studies, due in part to inconsistent operational definitions. Recent literature identified 29 distinct definitions for PPOU, which resulted in incidence ranging from 0.01% to 14.7% when applied to the same cohort of opioid naïve patients.

METHODS

We followed the eight-step method described by Walker & Avant, using an iterative literature search process with the following databases: PubMed, CINAHL, Google Scholar. English-language peer-reviewed publications through August 2020 were included in the analysis.

RESULTS

The four defining attributes of PPOU are (1) use of opioids greater than 90 days following surgery, (2) treatment of postoperative (non-cancer) pain, (3) in opioid-naïve patients, (4) with legal prescription use. We identified four antecedents and four consequences to PPOU.

CONCLUSION

The definition of PPOU in current literature varies greatly and has had significant impact on the interpretation and reliability of research findings. We propose the following working definition: PPOU is the legal prescription use of any opioid for greater than 90 days following surgery, for the purposes of treating post-operative pain, by a patient who opioid naïve in the year prior to surgery.

Palliative care for people who use substances during communicable disease epidemics and pandemics: a scoping review protocol

INTRODUCTION

Communicable disease epidemics and pandemics magnify the health inequities experienced by marginalised populations. People who use substances suffer from high rates of morbidity and mortality and should be a priority to receive palliative care, yet they encounter many barriers to palliative care access. Given the pre-existing inequities to palliative care access for people with life-limiting illnesses who use substances, it is important to understand the impact of communicable disease epidemics and pandemics such as COVID-19 on this population.

METHODS AND ANALYSIS

We will conduct a scoping review and report according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews reporting guidelines. We conducted a comprehensive literature search in seven bibliographical databases from the inception of each database to August 2020. We also performed a grey literature search to identify the publications not indexed in the bibliographical databases. All the searches will be rerun in April 2021 to retrieve recently published information because the COVID-19 pandemic is ongoing at the time of this writing. We will extract the quantitative data using a standardised data extraction form and summarise it using descriptive statistics. Additionally, we will conduct thematic qualitative analyses and present our findings as narrative summaries.

ETHICS AND DISSEMINATION

Ethics approval is not required for a scoping review. We will disseminate our findings to healthcare providers and policymakers through professional networks, digital communications through social media platforms, conference presentations and publication in a scientific journal.

Understanding ED Buprenorphine Initiation for Opioid Use Disorder: A Guide for Emergency Nurses

Opioid use disorder is a critical public health problem that continues to broaden in scope, adversely affecting millions of people worldwide. Significant efforts have been made to expand access to medication therapy for opioid use disorder, in particular buprenorphine. As the emergency department is a critical point of access for many patients with opioid use disorder, the initiation of buprenorphine therapy in the emergency department is increasing, and emergency nurses should be familiar with the care of these vulnerable patients. The purpose of this article is to provide a clinical review of opioid use disorder and opioid withdrawal syndrome, medication treatments for opioid use disorder, best clinical practices for ED-initiated buprenorphine therapy, assessment of withdrawal symptoms, discharge considerations, and concerns for special populations. With expanded understanding of opioid use disorder, withdrawal, and available treatments, emergency nurses will be better prepared to deliver and support life-saving treatments for patients and families suffering from this disease. In addition, emergency nurses are well positioned to play an important role in public health advocacy around opioid use disorder, providing critical support for destigmatization and expanded access to safe and efficacious treatments.

Adapting Palliative Care Skills to Provide Substance Use Disorder Treatment to Patients With Serious Illness

BACKGROUND

The majority of Palliative Care (PC) clinicians report recently caring for a person with a Substance Use Disorder (SUD). The impact of an untreated SUD is associated with significant suffering but many PC clinicians report a lack of confidence in managing this population.

OBJECTIVE

This paper aims to demonstrate existing PC skills that can be adapted to provide primary SUD treatment.

METHODS

A comprehensive literature review was conducted on quality PC domains and core SUD treatment principles. To demonstrate the shared philosophy and skills of PC clinicians and SUD treatment, the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care and resources outlining core Addiction Medicine and Nursing Competencies were used.

RESULTS

There is an abundance of overlapping domains in PC and SUD treatment. This paper focuses on the domains of communication, team-based care, quality of life considerations, addressing social determinants of health, and adherence to ethical principles. In each section, the shared domain in PC and SUD treatment is discussed and steps to expand PC clinician's skills are provided.

CONCLUSION

PC clinicians may be among the last healthcare touchpoint for persons with SUD, by naming the shared skills required in PC and evidenced-based SUD treatment, we challenge the field to undertake primary SUD treatment as part of its constant pursuit to better serve people living with serious illness.

Personal and professional attitudes associated with nurses' motivation to work with patients with opioid use and opioid use-related problems

BACKGROUND

Opioid use and opioid use-related problems contribute significantly to increased morbidity rates and premature deaths as well as an increased economic burden. Nurses have key roles in providing care to this patient population; however, they often report low motivation toward working with these patients. Examining personal and professional attitudes associated with nurses' motivation to work with this population can present a valuable opportunity to enhance their willingness to intervene at an earlier stage when patients do not have a diagnosable opioid use disorder. Methods: A descriptive, correlational design was used. Nurses were recruited from four hospital settings in Southwestern Pennsylvania. Data on nurses' demographic/background characteristics, personal attitudes, professional attitudes, and motivation related to working with patients with opioid use and opioid use-related problems were collected via a paper/pencil survey and analyzed using linear regression. Results: A sample of 234 nurses were included in the final analyses. Personal attitudes associated with nurses' motivation included personal experience with a family member related to alcohol and/or other drugs, and stigma perceptions (familiarity, perceived dangerousness, fear, social distance and personal responsibility beliefs). Professional attitudes associated with nurses' motivation included working experience with substance use (SU), SU education as continuing education or other educational resources, role security, therapeutic commitment, role responsibility, and self-efficacy. Conclusions: This study's findings provide valuable information regarding the bivariate relationships between nurses' personal attitudes, professional attitudes, and motivation to work with patients with opioid use and opioid use-related problems. The study provides a base for future studies aimed at developing interventions to enhance nurses' motivation to work with this patient population particularly related to preventing the progression of opioid use to a diagnosable disorder.

Leaving "Drug Abuse" behind: A Theoretical and Methodological Heuristic to Selecting "Problem Drug Use" or "Drug Misuse" as Alternative Terms

Background: Historically, drug abuse described the negative consequences of drug use as a proxy measure of maladaptive behavior that manifests within the addiction process. Negative consequences can span multiple domains including physical (e.g., blacking out), psychological (e.g., mood shifts), interpersonal (e.g., relationship problems), social (e.g., drinking and driving), and economic (e.g., job loss) problems. Objective: In determining the appropriate terminology to describe the phenomenon under investigation, researchers should consider (1) the theoretical objective (i.e., substance use construct under investigation) and (2) the research methodology being employed. Results: Problem substance use is appropriate for describing the outcome of interest when conducting cross-sectional, or pre-post, designs where investigators are interested in a snapshot of problems associated with substance use behavior. Conversely, substance misuse reflects a pattern of negative consequences over time and is appropriate when conducting longitudinal research with three or more time points. Here, substance misuse captures a pattern of substance use problems over time that may be indicative of a substance use disorder. These terms should be distinguished from studies investigating the frequency (how often) and quantity (how much) of a substance is being used where risky substance use is appropriate for cross-sectional studies and heavy substance use is appropriate for longitudinal studies. Conclusion: This framework is intended to describe the phenomena being investigated (i.e., the variable) and not the person or people experiencing a substance use problem. We should continue the dialogue of semantics in science realizing that our choice of words has important "real world" ramifications for the populations we serve.

Psychometric Properties of the Person-Centered Version of the Alcohol and Alcohol Problems Perceptions Questionnaire (PC-AAPPQ)

Aims

Given the importance of addressing provider attitudes toward individuals with unhealthy alcohol use and the current emphasis on person-centered language to help decrease stigma and mitigate negative attitudes, the aim of this study was to evaluate the psychometric properties of a contemporary version of the Alcohol and Alcohol Problems Perception Questionnaire (AAPPQ) that uses person-centered language and addresses the spectrum of alcohol use.

Methods

The authors created a person-centered version of the AAPPQ (PC-AAPPQ) and conducted a cross-sectional study of its psychometric properties in academic settings in the Northeastern United States. The PC-AAPPQ was administered to 651 nursing students. Reliability analysis of the new instrument was performed using the total sample. Only surveys with complete data (n = 637) were randomly split into two datasets, one used for the exploratory factor analysis (EFA) (n = 310) and the other for confirmatory factor analysis (CFA) (n = 327).

Results

Compared to all the models generated from the EFA, neither the original six-factor structure nor the five-factor structure was superior to any of the other models. The results indicate that a seven-factor structure with all 30 items is the best fit for the PC-AAPPQ.

Conclusions

The PC-AAPPQ represents a positive effort to modernize the four-decade-old AAPPQ. This 30-item instrument, which adds one additional subscale, offers a means to assess providers’ attitudes using respectful wording that avoids perpetuating negative biases and reinforces efforts to affirm the worth and dignity of the population being treated.

Nurses and Fetal Alcohol Spectrum Disorders Prevention

Women of reproductive age who are drinking alcohol and not using effective contraception are at-risk for an alcohol-exposed pregnancy, which could result in a child with a fetal alcohol spectrum disorder (FASD). Nurses are an important partner in addressing at-risk alcohol use. It is imperative for alcohol education to be incorporated into nursing curricula so that future nurses have the tools to identify at-risk alcohol use. Three universities have worked together to create Fetal Alcohol Spectrum Disorders: A Toolkit. This toolkit was designed for nurses to facilitate the recognition and prevention of FASD and address gaps that exists around alcohol use.

Can Screening, Brief Intervention, and Referral to Treatment Education and Clinical Exposure Affect Nursing Students' Stigma Perception Toward Alcohol and Opioid Use?

BACKGROUND: Alcohol and/or opioid stigma perceptions are barriers to screening, brief intervention, and referral to treatment (SBIRT) implementation. AIM: To examine SBIRT education and clinical exposure efficacy at decreasing nursing students' stigma perceptions toward caring for patients affected by alcohol and/or opioid use problems. METHOD: A single-sample, pretest-posttest design with N = 124 nursing students. The students had a 1.5-hour SBIRT education session and a 12-week clinical experience with some patients who had alcohol and/or opioid use problems. RESULTS: The participants' stigma perceptions improved toward patients who had alcohol and/or opioid use problems. CONCLUSIONS: SBIRT education and clinical exposure may provide a basis for promoting understanding of alcohol and/or opioid use-related stigma and can be used as an intervention to decrease some of stigma's negative effects.

Variants in GABBR1 Gene Are Associated with Methamphetamine Dependence and Two Years' Relapse after Drug Rehabilitation

Methamphetamine (MA) use disorder is a growing global health challenge marked by a steady increase worldwide. GABAergic system plays an important role in the mechanism of drug dependence, however few studies about the association between methamphetamine use disorder and genes in GABAergic system. Concerning GABBR1 gene which encoding the GABAB receptor subunit 1 is an important regulator in the GABAergic system. The aim of the study is to explore whether GABBR1 gene play a role in methamphetamine dependence and relapse after rehabilitation. Three single nucleotide polymorphisms (SNPs, rs2076483, rs29221, rs715044) of the GABBR1 gene were genotyped in 791 participants with MA use disorder and 448 healthy controls. The distribution of genotypes and alleles of the three SNPs between the two groups and their subgroups (dependence and abuse) was been analyzed. The multivariate logistic model was used to identify factors associate with relapse of MA use disorder during the following 2 years after drug rehabilitation. It was found that the C allele frequency of rs715044 of the GABBR1 gene was associated with MA use disorder and MA dependence. The CGA (rs2076483- rs29221- rs715044) was negatively associated with MA use disorder. The drug use years and rs29221 GG genotype were associated with relapse during the following 2 years after drug rehabilitation. GABBR1 gene may be associated with the susceptibility for MA use disorder and relapse and it indicates that the GABAergic system may play a role in the MA use disorder. Graphical Abstract GABBR1 gene may be associated with the susceptibility for MA use disorder and relapse and it indicates that the GABAergic system may play a role in the MA use disorder.