Post-traumatic stress disorder among people with heroin dependence in the Australian treatment outcome study (ATOS): prevalence and correlates

Improving assessment and management of suicide risk among people who inject drugs: A mixed methods study conducted at the Medically Supervised Injecting Centre, Sydney

INTRODUCTION

People who inject drugs are 13 times more likely to die by suicide than the general population. Guidelines for responding to risk in this population are limited. Harm reduction services attended by people who inject drugs require targeted strategies to address the complexities of suicide risk among this population.

METHODS

Co-design, engaging health professionals and people with lived experience informed the study. Mixed methods were used to understand the experience of managing suicide risk among clients attending the Medically Supervised Injecting Centre (MSIC) in Sydney. A survey was administered to assess staff confidence in managing risk. Focus groups were conducted with health professionals and MSIC clients to explore experiences of suicide management, response and opportunities for improvement.

RESULTS

Half (N = 17) the MSIC staff surveyed reported over 10 years' experience working with this population. Confidence in managing suicide risk was low. Three key themes emerged from focus groups (N = 17): (i) Autonomy and the need to involve clients in the assessment process; (ii) Trust between clients and health professionals, and transparency in decision-making; and (iii) System barriers, described by health professionals as inadequate referral pathways for clients in distress, and by clients as negative experiences of care, including involuntary admission and not receiving medication (e.g. methadone).

DISCUSSION AND CONCLUSIONS

Revised assessment guidelines and a tailored safety plan were developed. These resources are also suitable for other alcohol and other drug services. The challenge in managing suicide risk in harm reduction services is balancing duty of care with staff-client relationships and client engagement.

Posttraumatic stress disorder in people who use drugs: syringe services program utilization, treatment need, and preferences for onsite mental health care

BACKGROUND

Syringe services programs (SSPs) are critical healthcare access points for people with opioid use disorder (OUD) who face treatment utilization barriers. Co-locating care for common psychiatric comorbidities, like posttraumatic stress disorder (PTSD), at SSPs may reduce harms and enhance the health of individuals with OUD. To guide the development of onsite psychiatric care at SSPs, we collected quantitative survey data on the prevalence of PTSD, drug use patterns, treatment experiences associated with a probable PTSD diagnosis, and attitudes regarding onsite PTSD care in a convenience sample of registered SSP clients in New York City.

METHODS

Study participants were administered the PTSD Checklist for the DSM-5 (PCL-5) and asked about sociodemographic characteristics, current drug use, OUD and PTSD treatment histories, and desire for future SSP services using a structured interview. Probable PTSD diagnosis was defined as a PCL-5 score ≥ 31.

RESULTS

Of the 139 participants surveyed, 138 experienced at least one potentially traumatic event and were included in the present analysis. The sample was primarily male (n = 108, 78.3%), of Hispanic or Latinx ethnicity (n = 76, 55.1%), and middle-aged (M = 45.0 years, SD = 10.6). The mean PCL-5 score was 35.2 (SD = 21.0) and 79 participants (57.2%) had a probable PTSD diagnosis. We documented frequent SSP utilization, significant unmet PTSD treatment need, and high interest in onsite PTSD treatment.

CONCLUSIONS

Study findings point to the ubiquity of PTSD in people with OUD who visit SSPs, large gaps in PTSD care, and the potential for harm reduction settings like SSPs to reach people underserved by the healthcare system who have co-occurring OUD and PTSD.

Prolonged exposure therapy for PTSD in individuals with opioid use disorder: A randomized pilot study

OBJECTIVE

Nearly all individuals with opioid use disorder (OUD) report lifetime trauma exposure and one-third meet diagnostic criteria for posttraumatic stress disorder (PTSD). Although prolonged exposure (PE) therapy is a first-line treatment for PTSD, little is known about the effects of PE in individuals with co-occurring OUD. Furthermore, its efficacy is commonly undermined by poor therapy attendance. This pilot study evaluated the feasibility and initial efficacy of a novel PE protocol for improving PE attendance and PTSD symptoms among buprenorphine- or methadone-maintained adults with PTSD.

METHOD

Thirty participants with co-occurring PTSD and OUD were randomized to receive either: (a) continued medications for OUD (MOUD) treatment as usual (TAU), (b) Prolonged Exposure therapy (PE), or (c) PE with financial incentives delivered contingent upon PE session attendance (PE+). Primary outcomes included PE session attendance, PTSD symptom severity, and use of opioids other than prescribed MOUD.

RESULTS

PE+ participants attended significantly more therapy sessions vs. PE (87% vs. 35%; p <.0001). PTSD symptom reductions were also significantly greater in the PE+ vs. TAU group (p =.046). Participants in the two PE conditions submitted significantly fewer urine samples that tested positive for opioids than TAU participants (0% vs. 22%; p =.007).

CONCLUSIONS

These findings provide preliminary support for the efficacy of PE+ for improving PE attendance and PTSD symptoms without prompting opioid relapse in individuals with co-occurring PTSD and OUD. These promising results justify a larger scale randomized clinical trial to more rigorously evaluate this novel treatment approach.

A retrospective chart review of trauma-related documentation in an Australian substance use treatment service

INTRODUCTION

Trauma exposure among clients of substance use treatment services is almost universal and rates of trauma-related symptoms are correspondingly high. This study examined one aspect of clinical care-clinical documentation-and sought to systematically assess the documentation of trauma-related comorbidities and their treatment in a substance use treatment setting.

METHODS

A retrospective chart review was conducted on a sample of 300 patient records in a public substance use treatment setting. Rates of documentation of trauma-related events, symptoms and treatment, along with variables influencing the documentation of these issues, were examined.

RESULTS

Trauma-related documentation was present in 45.3% of records. There were documented trauma-related symptoms in 15.3% of records, although treatment activities addressing trauma were only present in 2.3% of records. Being female (odds ratio [OR] 2.58, 95% confidence interval [CI] 1.42, 4.69), having prior mental health treatment (OR 1.82, 95% CI 1.05, 1.12) and having more treatment sessions (OR 1.08, 95% CI = 1.05, 1.12) increased the odds of trauma-related documentation being present, while being in the first episode of treatment (OR 0.49, 95% CI = 0.28, 0.84) decreased the odds.

DISCUSSION AND CONCLUSIONS

This study highlights significant under documentation of trauma-related comorbidities in substance-use treatment. There is limited evidence of consideration of trauma-related symptoms or diagnoses, and trauma-related comorbidities are rarely included in treatment planning activities. The lack of documented trauma-related information has important clinical and medico-legal implications for patients, and provides evidence to suggest a lack of integration of treatment for trauma-related disorders in substance use settings.

Examining associations between impulsivity, opioid use disorder, and posttraumatic stress disorder: The additive relation between disorders

Impulsivity is a key feature of opioid use disorder (OUD) and other psychiatric conditions, including posttraumatic stress disorder (PTSD). The relationship between disorders and impulsivity may be additive, such that individuals with multiple disorders exhibit greater impulsivity than those with a single disorder. However, the association between impulsivity, OUD, and PTSD is unclear. Accordingly, this study compared individuals with concurrent OUD and PTSD (OUD + PTSD; n = 55), OUD without PTSD (OUD-PTSD; n = 34), PTSD without OUD (n = 32), and healthy controls (HCs; n = 55) on the Short Urgency, Premeditation, Perseverance, Sensation Seeking, Positive Urgency Impulsive Behavior Scale (SUPPS-P), and the 27-item Monetary Choice Questionnaire (MCQ). With respect to the SUPPS-P, the OUD + PTSD, OUD-PTSD, and PTSD without OUD groups reported more impulsivity on the negative urgency, positive urgency, and lack of premeditation subscales compared to HCs (ps < .001). The OUD + PTSD group also reported greater negative urgency compared to the OUD-PTSD group (p = .001) and HCs (p < .001), but not the PTSD without OUD group (p = .07). Furthermore, participants with OUD + PTSD exhibited greater discounting of delayed rewards on the MCQ than those in the PTSD without OUD group and HCs (p's < .001). However, no significant differences were observed between the two OUD groups (p = .86). These results support impulsivity as a mechanism underlying both OUD and PTSD. Future research should examine whether interventions targeting impulsivity, emotion regulation, and delay discounting are associated with meaningful improvements in functioning among individuals with OUD and PTSD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Posttraumatic stress disorder symptoms, work-related trauma exposure, and substance use in first responders

BACKGROUND

Posttraumatic stress disorder (PTSD) symptoms have been shown to increase the likelihood of substance use in the general population. First responders (e.g., EMTs, paramedics, and firefighters) are routinely exposed to potentially traumatic events (PTEs) as part of their regular duties, increasing their risk for a range of adverse mental health outcomes including PTSD symptoms. However, no study to our knowledge has explored the relationship between PTEs, PTSD symptoms, and substance use in this population. In the current study, we examined whether PTSD symptoms were associated with alcohol and drug use in first responders above and beyond demographic variables, job-related characteristics, social support, and cumulative work-related PTE exposure, and whether work-related PTE exposure had an indirect effect on substance use via PTSD symptoms.

METHODS

Participants (N = 885; mean age = 37.13; 59.0% male; 91.5% White) were recruited from all 50 U.S. states, the Virgin Islands, and Puerto Rico to complete an online survey.

RESULTS

In hierarchical regression analyses, PTSD symptoms were significantly associated with alcohol and drug use above and beyond all the other variables. Work-related PTE exposure was not a significant predictor of either outcome once PTSD symptoms were included, suggesting that PTEs confer risk for substance use via their association with PTSD symptoms. This finding was confirmed by an analysis showing that PTE exposure had a significant indirect effect on both alcohol and drug use via PTSD symptoms.

CONCLUSION

Results support the need for periodic assessment of both PTSD symptoms and substance use in first responders.

Sexual Abuse as a Risk Factor for Opioid Misuse in Pregnancy

The purpose of this study was to identify a potential relationship between childhood sexual abuse and opioid misuse in pregnancy and to illustrate the need for better integration and collaboration between the medical and psychological disciplines to combat the opioid crisis. We sampled 93 pregnant women at a high-risk pregnancy clinic within a university medical center who were in their second trimester or beyond. Fifty-five women were considered high-risk due to opioid misuse and 38 women were considered high-risk due to medical reasons other than drug use. Our findings reveal both presence of and severity of sexual abuse were significantly associated with opioid misuse in pregnancy, while physical abuse, emotional abuse, and neglect were not. While childhood sexual abuse is a significant risk factor for opioid misuse in pregnancy, most doctors do not feel comfortable asking about trauma history. A public health approach to opioid misuse in pregnancy must consider how "diseases of despair" disproportionately impact women with limited access to adequate psychological and medical care. A preventative model of care, which targets screenings for ACEs in primary care and gynecological visits may help decrease the impact of sexual abuse.

[Comorbidity of posttraumatic stress disorder and addiction from a biopsychosocial perspective]

Posttraumatic stress disorder and substance use disorder often co-occur within the health care system. Their comorbidity is associated with more serious acute clinical symptomatology, more frequent hospital admissions in state of emergency and significantly lower chances of improvement by psychological and pharmacological treatment. Their comorbidity contributes to dramatically unfavourable courses of illness as regards all biopsychosocial levels. The survey presented will discuss empirical findings from various perspectives: general epidemiology, substance use disorder as risk factor of trauma and PTSD, trauma and PTSD as risk factor of SUD, neurobiological effects of SUD converging towards neurobiology of PTSD, shared common factors of genetics/epigenetics, personality traits, and early developmental stress and trauma. The main focus of analysis will be put on processes that are intrinsically linked to the development and course of both disorders.

Posttraumatic stress disorder in individuals seeking treatment for opioid use disorder in Vermont

Posttraumatic stress disorder (PTSD) and opioid use disorder (OUD) may be associated with poor outcomes in rural areas where access to mental health services and opioid agonist treatment (OAT) is limited. This study examined the characteristics associated with a history of PTSD among a sample of individuals seeking buprenorphine treatment for OUD in Vermont, the second-most rural state in the US. Participants were 89 adults with OUD who participated in one of two ongoing randomized clinical trials examining the efficacy of an interim buprenorphine dosing protocol for reducing illicit opioid use during waitlist delays to OAT. Thirty-one percent of participants reported a history of PTSD. Those who did (PTSD+; n = 28) and did not (PTSD-; n = 61) report a history of PTSD were similar on sociodemographic and drug use characteristics. However, the PTSD+ group was less likely to have received prior OUD treatment compared to the PTSD- group (p = .02) despite being more likely to have a primary care physician (p = .009) and medical insurance (p = .002). PTSD+ individuals also reported greater mental health service utilization, more severe psychiatric, medical and drug use consequences, and greater pain severity and interference vs. PTSD- individuals (ps < 0.05). These findings indicate that a history of PTSD is prevalent and associated with worse outcomes among individuals seeking treatment for OUD in Vermont. Dissemination of screening measures and targeted interventions may help address the psychiatric and medical needs of rural individuals with OUD and a history of PTSD.

Do people with opioid use disorder and posttraumatic stress disorder benefit from dding Individual opioid Drug Counseling to buprenorphine?

BACKGROUND AND PURPOSE

Large randomized trials have found that behavioral therapy for opioid use disorder (e.g., Individual Drug Counseling, Cognitive Behavioral Therapy for Opioid Use Disorder) does not improve buprenorphine maintenance outcomes, on average, for individuals with opioid use disorder. However, recent studies indicate that certain subgroups of patients may benefit from the addition of behavioral therapy to buprenorphine. In particular, people with more complex and severe psychosocial needs may benefit from the addition of behavioral therapy for opioid use disorder.

METHODS

In this study, we conducted a secondary analysis of a large, multi-site randomized trial (N = 357) of buprenorphine maintenance with and without individual Opioid Drug Counseling (ODC) for the treatment of opioid use disorder. We hypothesized that participants with posttraumatic stress disorder (PTSD) would benefit from the addition of ODC.

RESULTS

Logistic regression models indicated a significant PTSD by treatment condition interaction. Specifically, 67% of those with PTSD had a successful opioid use disorder treatment outcome when they were assigned to receive both ODC and buprenorphine, compared to a 36% response rate among those who received buprenorphine alone.

CONCLUSIONS

Although these results require replication, our findings provide initial indication that ODC is an important complement to buprenorphine maintenance treatment for people with co-occurring PTSD and opioid use disorder.

Treatment outcomes in individuals diagnosed with comorbid opioid use disorder and Posttraumatic stress disorder: A review

OBJECTIVES

Opioid use disorder (OUD) is a public health emergency. Evidence suggests that posttraumatic stress disorder (PTSD) is common among individuals with OUD; however, few studies evaluate whether concurrent diagnoses affect treatment outcomes. This review examines the impact of concurrent diagnoses of OUD and PTSD on treatment outcomes.

METHODS

A search was performed using articles identified through June 30, 2020 in PubMed, PsycINFO, and EMBASE. Included peer-reviewed articles evaluated individuals with OUD and a PTSD diagnosis via standardized assessment and/or medical record diagnoses, and reported relationships between diagnosis and treatment outcomes and/or other psychiatric conditions.

RESULTS

Out of 412 articles, 17 studies met inclusion criteria for this review (from 13 databases). Articles included had a total of n = 2190 with OUD, with n = 79 non-OUD comparison participants. Studies examining individuals with OUD revealed comorbid PTSD was associated with more severe addiction, higher rates of depression, attempted suicide, and psychosocial problems.

CONCLUSIONS

Among individuals with OUD, presence of PTSD is associated with multiple mental health problems. The impact of PTSD on drug use is inconclusive. Although only 5 studies examined psychosocial PTSD treatment, all found PTSD-focused treatment to be effective for those with comorbid OUD. Overall, results suggest the need to better identify PTSD among those with OUD, and to develop and evaluate interventions that are brief, integrative, and easy to implement in clinical settings.

The impact of poly-traumatization on treatment outcomes in young people with substance use disorders

BACKGROUND

It is believed that clients with psychological trauma experiences have a poor prognosis with regard to treatment participation and outcomes for substance use disorders. However, knowledge on the effect of the number of trauma experiences is scarce.

METHODS

Using data from drug use disorder (DUD) treatment in Denmark, we assessed the impact of having experienced multiple potentially traumatic experiences on DUD treatment efficacy. Baseline and follow-up data from 775 young participants (mean age = 20.2 years, standard deviation = 2.6) recruited at nine treatment centers were included in analyses.

RESULTS

Analyses showed that participants who were exposed multiple trauma experiences also reported a significantly higher intake of cannabis at treatment entry, and a lower well-being score than participants who reported less types or no types of victimization experiences. During treatment, patients with multiple types of trauma experiences showed a slower rate of reduction of cannabis than patients with few or no trauma experiences. The number of trauma types was not associated with number of sessions attended or the development of well-being in treatment.

CONCLUSION

Overall, the results show that although traumatized youth in DUD treatment show up for treatment, helping them to reduce substance use during treatment is uniquely challenging.

TRIAL REGISTRATION

ISRCTN88025085 , date of registration: 29.08.2016, retrospectively registered.

Putting it into Words: A Clinical and Linguistic Analysis of Trauma Narratives in Two Short-Term Exposure Therapies for Co-Morbid PTSD and SUD

Nearly half of the individuals who experience Posttraumatic Stress Disorder (PTSD) will also have a Substance Use Disorder (SUD) in their lifetimes. Prolonged Exposure Therapy (PE), considered the "gold standard" in treating PTSD, has been increasingly used and studied as an intervention for PTSD, yet little is known about the mechanisms of change in this type of treatment. In PE for PTSD, participants tell and re-tell the story of their primary trauma many times over. This re-telling is called an "Imaginal Exposure." When efficacious, this type of treatment allows for habituation, and PTSD symptom severity begins to dissipate. This paper seeks to better understand the psychological and linguistic processes that occur in such a treatment in order to contemplate for whom such a treatment might be beneficial, and why, (This article is a distillation of the doctoral dissertation by Zachary Kahn, "Words of Change: How Linguistic Shifts Over the Course of a Short-Term Exposure Therapy Represent Movement Towards Psychological Health" (2017).) by exploring the clinical and linguistic differences in the narratives of a treatment responder (decreased PTSD and SUD severity) and a treatment non-responder. A qualitative analysis of portions of the narratives (which were recorded and transcribed) demonstrated that there were clear clinical differences between the responder and non-responder. A linguistic analysis of the narratives using measures of the referential process showed that the treatment responder increasingly engaged in the referential process during exposures over the course of treatment, whereas the non-responder engaged in the referential process less frequently over the course of the treatment and less consistently throughout.

Can the migration process influence the clinical expression of heroin use disorder in migrants to Italy?

BACKGROUND

For some time now, there has been a strong consensus that the migration process can influence the onset, course, development, outcome, and clinical aspects of psychiatric pathologies.

METHODS

In this study, we have analyzed the influence of the migration process on the clinical expression of heroin use disorder (HUD). In a naturalistic case-control study, we compared, both at univariate and multivariate level, 30 migrant HUD (M-HUD) patients with 30 age/gender-matched Italian HUD (IT-HUD) patients. We also analyzed demographic data, drug addiction history, psychopathological symptoms, addictive behavior, and emotional reactivity to life events.

RESULTS

Compared with IT-HUD pairs, at HUD Agonist Opioid Treatment, M-HUD patients were characterized by inadequate income and the presence of legal problems. They were more frequently at stage 3 of heroin addiction, with a concomitantly less frequent use of stimulants. Their age at the onset of heroin use was greater than that of subjects in the IT-HUD group. HUD post-traumatic stress disorder spectrum was present and was more severe in all M-HUD patients, but grief reactions and maladaptive behavior were the most discriminant traits. No differences were found in terms of addictive behaviors related to heroin craving or with respect to the severity/typology of psychopathology specific to HUD.

CONCLUSIONS

The migratory process does not seem to be correlated with addictive behaviors or with psychopathology specific to HUD. It partly affects HUD history, and specifically correlates with emotional reactivity to loss and traumatic life events, so suggesting that in M-HUD individuals, the link between the migratory syndrome and HUD is very close.

Cannabis use disorder and post-traumatic stress disorder: The prevalence of comorbidity in veterans of recent conflicts

AIMS

Veterans have high rates of cannabis use, and rates of cannabis use disorder (CUD) are rising among this population. These rising rates are particularly true for veterans with post-traumatic stress disorder (PTSD), which is common among veterans of recent conflicts, Operations Enduring Freedom, Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND). Although prior work has documented links between PTSD and cannabis use, a better understanding of the intersection among CUD, PTSD, and other disorders in real-world clinical practice can inform prevention and treatment efforts. This study examined the prevalence and comorbidities of CUD and PTSD in OFE/OIF/OND veterans.

METHOD

The study analyzed data from the Veterans Affairs Corporate Data Warehouse (2010-2016) for returning war veterans who were diagnosed with CUD (N = 46,268). The study determined prevalence of PTSD, and examined additional differences in comorbidities.

RESULTS

The prevalence of a comorbid PTSD diagnosis among OEF/OIF/OND veterans with a CUD diagnosis was 72.3%. Further analysis revealed additional co-occurring disorders. Veterans with a diagnosis of CUD and PTSD were more likely to have a comorbid diagnosis of depression (odds ratio, 1.69; 95% CI, 1.62-1.71), panic disorder (odds ratio; 1.58; 95% CI, 1.43-1.75), alcohol use disorder (odds ratio; 1.30; 95% CI, 1.24-1.35), opioid use disorder (odds ratio; 1.52; 95% CI, 1.43-1.62), and insomnia (odds ratio; 1.74; 95% CI, 1.65-1.84) than veterans without a PTSD diagnosis.

CONCLUSIONS

Findings highlight that the majority of returning war veterans with CUD are highly complex. Our findings substantiate the need for urgent, comprehensive care for veterans with co-occurring CUD and PTSD, including integrated and transdiagnostic treatment approaches.

Preference for and Efficacy of a PrEP Decision Aid for Women with Substance Use Disorders

BACKGROUND

Women with substance use disorders (SUDs) are a key population for HIV prevention with pre-exposure prophylaxis (PrEP), though uptake is limited by awareness of PrEP, misestimation of personal HIV risk, and minimally integrated HIV prevention and addiction treatment services. Patient-centered decision aids (DA) could address these barriers to PrEP, but no extant DA for PrEP has been published, including for women with SUDs.

METHODS

We developed a patient-centered PrEP DA for women in addiction treatment. In a pilot randomized preference trial, we compared the DA to enhanced standard of care (eSOC) providing standardized information. The primary outcome was opting to receive more information through the DA; we also assessed the impact of the DA on PrEP decisional preference and PrEP uptake over 12 months.

RESULTS

A total of 164 enrolled participants (DA: 83; eSOC: 81) were similar in terms of HIV risk and demographics, which are representative of women in addiction treatment programs nationally, and most (92%) had opioid use disorder. Half of participants were PrEP eligible, though 37% underestimated their personal HIV risk. Independent correlates of selecting the PrEP DA relative to eSOC included higher alcohol use severity (aOR 4.13, 95% CI 1.05-16.28, p=0.04) and perception of high risk for HIV (aOR 2.95, 95% CI 1.19-7.35, p=0.02). For those selecting the DA, interest in PrEP increased significantly from 25% to 89%. DA participants were also significantly more likely than eSOC participants to see a provider for PrEP during follow-up (15.7% vs 6.2%; p=0.05).

CONCLUSION

Half of the women selected to use the DA, and those who did significantly increased their engagement in the HIV prevention cascade through increased interest in and initiation of PrEP. Future iterations should accelerate the HIV prevention cascade for women with SUDs by integrating PrEP decision aids into existing addiction treatment services and actively linking women to PrEP.

Opioid overdose in the age of fentanyl: Risk factor differences among subpopulations of overdose survivors

BACKGROUND

Although fentanyl is the drug most frequently implicated in overdose deaths, the association between overdose risk and attitudes and behaviors surrounding fentanyl in opioid-using communities has remained understudied. Possible subpopulation differences in fentanyl-related overdose risk remain equally unexamined. This paper addresses these gaps by exploring the association between overdose and fentanyl-related attitudes/behaviors in three subpopulations of overdose survivors.

METHODS

In this cross-sectional study, we sampled 432 individuals who currently or recently used opioids from New Jersey methadone and acute residential detoxification programs. Using multinomial regression analysis, we compared overdose risk factors, including fentanyl-related attitudes/behaviors, of those who never overdosed with three subgroups of overdose survivors who experienced: 1. recent overdoses occurring after, but not before, fentanyl expansion; 2. past overdoses occurring before, but not after, fentanyl expansion; 3. persistent overdoses occurring before and after fentanyl expansion.

RESULTS

Forty percent of respondents had knowingly used fentanyl and 38% deliberately sought overdose-implicated drugs. Respondents with persistent overdoses represented under 10% of the sample but accounted for 44% of all lifetime overdoses (x̅ =8.03 vs. 1.71 for the full sample). This was also the only subgroup for whom PTSD (AOR=3.84; 95%CI=1.45-10.16; p=.01) and fentanyl-seeking (AOR=1.50; 95% CI=1.16-1.94; p=.01) were significant overdose risk factors. Those with recent overdoses engaged in frequent drug combining (AOR=2.28; 95% CI=1.19-6.98; p=.05), which could have led to inadvertent fentanyl use. Those with past overdoses were not at overdose risk from fentanyl-seeking or drug combining and had rates of methadone treatment comparable to rates of those with no overdoses.

CONCLUSION

Harm reduction strategies will need to address consumers' evolving drug preferences as fentanyl continues to saturate local drug markets. Targeting comprehensive interventions, including mental health treatment, to the small group of opioid users with longstanding overdose histories may reduce the burden of overdose in opioid-using communities.

Secondary traumatic stress in Norwegian SUD-therapists: Symptoms and related factors

This study examined the prevalence of secondary traumatic stress (STS) among substance-abuse therapists in relation to burnout, work-related stressors, as well as peer and leader support.

PTSD as a Risk Factor Predicting Polydrug Use: A Dual Systems of Self-Control Mediation Model

Post-traumatic stress disorder (PTSD) is associated with increased risk for polydrug use. Low self-control is a key characteristic of the disorder and is predictive of polydrug use. However, there is a dearth of research focused on the relevance of a dual systems model delineation of self-control into the constructs of risk-seeking and impulsivity as it pertains to polydrug use and PTSD. This study tested dual systems mediation of this relationship. Generalized structural equation modeling was used to test for mediation effects. Results indicated that more PTSD symptoms predicted increased drug use variety (coefficient = 0.024; confidence interval [CI] = [0.001, 0.046]). Inclusion of dual systems constructs fully attenuated this relationship. The total indirect effect achieved marginal significance (coefficient = 0.005; CI = [>−0.001, 0.009]). Sensitivity analyses of the specific indirect effect of impulsivity as the sole mediator indicated significant mediation. These results provide some indication that impulsivity-based programming may help to treat polydrug use among those with severe PTSD.

Australian treatment outcome study: protocol for the 18-20-year follow-up of a prospective longitudinal cohort examining the natural history of heroin dependence and associated mortality, psychiatric and physical health, and health service use

INTRODUCTION

Opioid dependence is a global health priority, currently making the biggest contribution to drug-related deaths. The chronic, long-term persistence of heroin dependence over the life course requires investigation in prospective longitudinal studies, to better understand patterns and predictors of remission and relapse, as well as the impact of changes in substance use on a range of physical and mental health outcomes. Such knowledge is critical in order to identify modifiable risk factors that can be targeted for intervention. Crucial unanswered questions include the following: What are the long-term rates of mortality? What are the long-term patterns and predictors of heroin use, remission, psychiatric health and health service use? What are the long-term physical health consequences of heroin use?

METHODS AND ANALYSIS

The 18-20-year follow-up of the Australian Treatment Outcome Study (ATOS) cohort will examine the natural history of heroin dependence of an existing cohort of 615 people with heroin dependence, who were recruited into the study in 2001-2002. Five waves of follow-up interviews have since been completed, at 3-month, 1-year, 2-year, 3-year and 10-11-year post-baseline. At the 18-20-year follow-up, the ATOS cohort is (on average) approaching their 50s and an average of 30 years have passed since they first used heroin. The 18-20-year follow-up will consist of: (1) a structured interview; (2) physical health assessment; and (3) data linkage. The results of this follow-up will improve our understanding and management of age-related disorders in this population, which if not addressed in the immediate future, has the capacity to overwhelm treatment centres and aged care facilities.

ETHICS AND DISSEMINATION

Ethical approval has been granted for the study (Sydney Local Health District Royal Prince Alfred Zone, Human Research Ethics Committee X18-0512 & HREC/18/RPAH/733). The results of the study will be disseminated through published manuscripts, bulletins and technical reports, as well as conference, seminars, webinar and workshop presentations.

The impact of trauma characteristics on post-traumatic stress disorder and substance use disorder outcomes across integrated and substance use treatments

Proponents of complex post-traumatic stress disorder (PTSD) constructs suggest that specific trauma characteristics, such as earlier age of first trauma (trauma age) and higher number of traumas (trauma count), may obstruct PTSD symptom reduction in treatment. PTSD and substance use disorders (SUD) commonly co-occur, but the impact of trauma age and count on PTSD treatment responses in a comorbid PTSD and SUD sample is unclear. Further, no studies have examined the impact of trauma characteristics on SUD treatment outcomes or whether their impact on either PTSD or SUD outcomes varies if PTSD is directly addressed. A secondary analysis of a randomized controlled trial was conducted to examine: (1) whether trauma age and count influence comorbid PTSD and SUD (PTSD+SUD) responses during and following treatment; and (2) whether these effects differed across an exposure-based, integrated PTSD+SUD treatment (Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure; COPE) and a SUD-only focused treatment (Relapse Prevention Therapy; RPT). Individuals with PTSD+SUD randomized to COPE (n = 39) or RPT (n = 43) provided weekly measurements of PTSD and SUD. Across COPE and RPT, earlier trauma age predicted reduced SUD improvement (B = -0.01, standard error = 0.00). Trauma count did not predict changes in PTSD or SUD during or following treatment. These findings suggest that excluding individuals from exposure-based, integrated treatments on the basis of trauma characteristics is not empirically supported. However, individuals with earlier trauma ages may require additional or unique clinical attention to improve their SUD outcomes.

Alcohol misuse to down-regulate positive emotions: A cross-sectional multiple mediator analysis among US military veterans

INTRODUCTION

The co-occurrence of posttraumatic stress disorder (PTSD) and alcohol misuse presents a pervasive and clinically relevant concern among US military veterans.

OBJECTIVE

The current investigation sought to examine the role of positive emotion dysfunction in the relation between PTSD symptomatology and alcohol misuse. To do so, we examined the separate and sequential roles of positive emotional intensity and positive emotional avoidance in the relation between PTSD symptoms and alcohol misuse among US military veterans.

METHOD

Cross-sectional data were collected from 468 US military veterans (M age = 37.74, 70.5% male, 69.0% White) who responded to an online survey.

RESULTS

Findings suggest that positive emotional avoidance, separately, and positive emotional intensity and positive emotional avoidance, sequentially, mediated the relation between PTSD symptoms and alcohol misuse.

CONCLUSIONS

Findings advance theory on the role of positive emotions and related processes in the co-occurrence of PTSD and alcohol misuse, and highlight important avenues for future research and treatment focused on the PTSD-alcohol misuse co-occurrence.

A novel theory on the predictive value of variation in the β-endorphin system on the risk and severity of PTSD

Despite growing interest in genetic and psychosocial indicators of heightened susceptibility to posttraumatic stress disorder (PTSD), a predictive model, which explains why some individuals develop PTSD in response to life-threatening traumatic events, while others, when faced with the same or similar experiences, do not, has thus far remained out of reach. In this paper, we review the literature on gene-environment interactions in β-endorphin system functioning with regard to PTSD and suggest that variation, both genetic and with regard to environmental stimuli, in systems which, like the β-endorphin system, distort human perception of life-threatening traumatic experiences may account for some of the variance in resilience to the disorder. Given the role of β-endorphin in both social connections and physical exercise, this becomes especially relevant with regard to military selection, training, and leadership processes.

Rumination and problematic substance use among individuals with a long-term history of illicit drug use

BACKGROUND

Rumination is a cognitive process that is implicated in the development and maintenance of various forms of psychopathology, including problematic substance use. Most studies on the role of rumination in substance use have been conducted among community samples or individuals with alcohol use disorders and have predominately focused on overall rumination rather than differentiating between its subtypes, ruminative brooding and ruminative reflection. The current study therefore aimed to investigate i) whether rumination subtypes are associated with problematic substance use among people with a long-term history of illicit drug use independently of related psychological disorders (depression and post-traumatic stress disorder [PTSD]), and ii) whether gender moderates these relationships.

METHODS

This cross-sectional study used data from the Australian Treatment Outcome Study (ATOS); a naturalistic prospective cohort study of people with heroin dependence. At the 11-year follow-up of ATOS, a total of 380 participants completed measures of rumination, depression, PTSD, and indices of problematic substance use.

RESULTS

Hierarchical logistic regression analyses indicated that higher brooding scores were associated with current heroin dependence (OR = 1.11, CI: 1.01-1.22), polydrug use (OR = 1.16, CI: 1.06-1.28) and experience of injection related health problems (OR = 1.08, CI: 1.00-1.17), independently of depression, PTSD, and other covariates. Reflection was not related to any of the substance use measures. These results were not moderated by gender.

CONCLUSIONS

Findings indicate that ruminative brooding is related to a poorer substance use profile among people with long-term illicit drug use and highlight the potential benefits of targeting brooding during substance use treatment.

Effects of childhood emotional maltreatment on depressive symptoms through emotion dysregulation in treatment-seeking patients with heroin-dependence

BACKGROUND

Although individuals who experience childhood emotional maltreatment (CEM) are more likely to use maladaptive emotion regulation strategies, resulting in vulnerability to depression, no research has examined whether emotion dysregulation may explain the association between CEM and current depressive symptoms in a clinical sample of heroin-dependent individuals.

OBJECTIVES

The current study aimed to assess the direct effect of CEM on current depressive symptoms and its indirect effect via emotion dysregulation in a treatment-seeking sample of males with heroin dependence. In a cross-sectional design, participants (N = 350) completed the Childhood Trauma Questionnaire-Short Form (CTQ-SF), the Difficulties in Emotion Regulation Scale (DERS), the Obsessive-Compulsive Drug Use Scale (OCDUS), and the Beck Depression Inventory-II (BDI-II).

RESULTS

Emotional abuse and neglect severity had significant direct effects on current depressive symptoms and significant indirect effects through emotion dysregulation after controlling for clinical factors related to heroin use.

LIMITATIONS

Study limitations include the cross-sectional design and use of self-report scales.

CONCLUSIONS

Findings suggest emotion dysregulation may increase depressive symptoms in heroin users who experienced CEM. Training in emotion regulation strategies may decrease depressive symptoms in heroin-dependent individuals with CEM. Additional research with a longitudinal design to confirm these results is warranted.

OPRD1 gene affects disease vulnerability and environmental stress in patients with heroin dependence in Han Chinese

Exposure to stress not only increases the vulnerability to heroin dependence (HD) but also provokes relapse. The etiology of HD and the role of life stress remain unclear, but prior studies suggested that both genetic and environmental factors are important. Opioid related genes, including OPRM1, OPRD1, OPRK1, and POMC, are obvious candidates for HD. Therefore, this study was conducted to explore whether the genetic polymorphisms of the candidates could affect vulnerability to HD and response to life stress in patients with HD. Ten polymorphisms of the opioid related genes were analyzed in 801 patients and 530 controls. The Life Event Questionnaire was used to assess the perspective and response to life stress in the past year. The genotype distribution and allelic frequency analyses showed that the minor C allele of rs2234918 in OPRD1 is over-represented in the HD group (P = .006 and P = .002, respectively). This finding was further confirmed by logistic regression analysis, showing that C allele carriers have a 1.42 times greater risk for HD compared to T/T homozygotes. A subgroup of 421 patients and 135 controls were eligible for life stress assessment. Patients with HD have a higher occurrence of negative events (No), negative events score (Ns), and average negative event score (Na) than those of controls (all P < .001), but there was no difference regarding positive recent events between the two groups. Gene-stress assessment in the HD group showed that T/T homozygotes of OPRD1 rs2236857 have more severe stress than C allele carriers (Ns, P = .004 and Na, P = .047). Our results indicate that the OPRD1 gene may not only play a role in the pathogenesis of HD but also affect the response to life stress among patients with HD in our Han Chinese population. Patients with the risk genotype may need additional psychosocial intervention for relapse prevention.

A multisite randomized controlled trial of Seeking Safety vs. Relapse Prevention Training for women with co-occurring posttraumatic stress disorder and substance use disorders

Background: Co-occurring posttraumatic stress disorder (PTSD) and substance use disorders (SUD) are associated with a more severe course and worse outcome than either disorder alone. In Europe, few treatments have been evaluated for PTSD and SUD. Seeking Safety, a manualized, integrated, cognitive-behavioural treatment, has been shown to be effective in studies in the USA. Objective: To test the efficacy of Seeking Safety plus treatment as usual (TAU) in female outpatients with PTSD and SUD compared to Relapse Prevention Training (RPT) plus TAU and TAU alone. Method: In five German study centres a total of N = 343 women were randomized into one of the three study conditions. PTSD severity (primary outcome), substance use, depression and emotion dysregulation (secondary outcomes) were assessed at baseline, post-treatment, as well as at three months and six months post-treatment. Results: Treatment participants attended M = 6.6 sessions (Seeking Safety) and M = 6.1 sessions (RPT). In an intent-to-treat analysis, Seeking Safety plus TAU, RPT plus TAU and TAU alone showed comparable decreases in PTSD severity over the course of the study. Seeking Safety plus TAU showed superior efficacy to TAU alone on depression and emotion regulation and RPT plus TAU was more effective than TAU alone on number of substance-free days and alcohol severity. Minimum-dose analyses suggest additional effects of both programmes among participants who attended at least eight group sessions. Conclusions: With respect to PTSD symptoms, a brief dose of Seeking Safety and RPT in addition to TAU was not superior to TAU alone in women with PTSD and SUD. However, Seeking Safety and RPT showed greater reductions than TAU alone in other domains of psychopathology and substance use outcomes respectively. Future studies should investigate further variables, such as what aspects of each treatment appeal to particular patients and how best to disseminate them.

Association between childhood maltreatment and non-medical prescription opioid use among Chinese senior high school students: The moderating role of gender

BACKGROUND

Non-medical prescription opioid use (NMPOU) and childhood maltreatment are currently serious problems among adolescents worldwide, and childhood maltreatment may be associated with the increased rates of NMPOU. This study examined the specific associations between particular types of childhood maltreatment and lifetime NMPOU and assessed whether gender has a moderating effect on these associations.

METHODS

A 3-stage, stratified cluster, randomized sampling method was used to collect data from 11,194 high school students in Chongqing.

RESULT

The prevalence of the lifetime NMPOU among senior high school students in Chongqing was 7.7%. Physical abuse (AOR = 1.11, 95% CI = 1.07-1.14), emotional abuse (AOR = 1.05, 95% CI = 1.03-1.08), sexual abuse (AOR = 1.04, 95% CI = 1.01-1.07), physical neglect (AOR = 1.06, 95% CI = 1.04-1.09), and emotional neglect (AOR = 1.03, 95% CI = 1.02-1.04) were all positively associated with lifetime NMPOU. The moderating effects of gender on emotional abuse (P = 0.004) and sexual abuse (P = 0.019) were statistically significant in the adjusted model of lifetime NMPOU. According to the stratification analyses in which the male and female students were analyzed separately, female students who previously experienced emotional/sexual abuse had a higher prevalence of lifetime NMPOU.

LIMITATIONS

The study sample only contained school students and cross-sectional design limited our ability to make causal inferences.

CONCLUSION

Childhood maltreatment was positively associated with lifetime NMPOU, and gender had a moderating effect on the associations between childhood maltreatment and lifetime NMPOU. Early identification of and intervention for childhood maltreatment victims, particularly female victims, may help reduce the lifetime risk of NMPOU.

The impact of co-occurring opioid misuse and PTSD on response inhibition

BACKGROUND

Posttraumatic Stress Disorder (PTSD) and opioid misuse are commonly co-occurring disorders. Both disorders are associated with deficits in response inhibition; however, these associations have not considered their comorbidity. Response inhibition has not been examined in a sample with comorbid PTSD and opioid misuse. The present study examined the effect of PTSD symptom severity on response inhibition in current and past opioid misusers.

METHODS

Participants were currently (used within the last month) misusing opioids (56.6%) or in recovery (43.4%). All participants met DSM 5 criteria for PTSD. Response inhibition was measured with the stop signal task.

RESULTS

Response inhibition was associated with increased PTSD symptom severity for those in recovery but not among current users. Additionally, across both groups, there were deficits in response inhibition when withholding automatic responses for a threatening stimulus compared to a neutral stimulus.

CONCLUSIONS

PTSD Symptoms may exert a stronger effect on response inhibition among those in recovery as opposed to those who are actively using opioids.

Differential relationships of PTSD and childhood trauma with the course of substance use disorders

A large body of research documents the link between Posttraumatic Stress Disorder (PTSD) and the course of Substance Use Disorders (SUD). Similar relationships have been reported between Childhood Trauma (CT) and the course of illness in patients with SUD even in the absence of PTSD, but few studies have examined differential effects of PTSD and CT (independent of PTSD) in this population. We used the International Diagnostic Checklist (IDCL) and the Posttraumatic Diagnostic Scale (PDS) to diagnose PTSD in a sample of patients with SUD (N = 459). The Childhood Trauma Questionnaire (CTQ) and the European Addiction Severity Index (EuropASI) were administered to assess childhood trauma and addiction related problems including comorbid psychopathological symptoms. The sample was divided into three groups: patients with experiences of CT and PTSD (CT-PTSD), experiences of CT without PTSD (CT-only), and neither experiences of CT nor PTSD (No trauma) to examine their differential associations with the course and severity of SUD. Patients of both the CT-PTSD (n = 95) and the CT-only group (n = 134) reported significantly higher levels of anxiety and depression as well as more suicidal thoughts and suicide attempts during their lifetime than the No trauma group (n = 209). Regarding most variables a graded association became apparent, with the highest level of symptoms in the CT-PTSD group, an intermediate level in the CT-only group and the lowest level in the No trauma group. The CT-PTSD group also differed in almost all substance use variables significantly from the No trauma group, including a younger age at first use of alcohol and cannabis, more cannabis use in the last month, and more lifetime drug overdoses. Our results confirm the relationships of both CT and PTSD with psychiatric symptoms in patients with SUD. Thus, it seems important to include both domains into the routine assessment of SUD patients. Specific treatments for comorbid PTSD but also for other consequences of childhood trauma should be integrated into SUD treatment programs.

Profiles of childhood adversities in pathological gamblers - A latent class analysis

Despite of high rates of adverse childhood experiences (ACEs) in pathological gamblers, researchers have rarely studied which types of ACEs often co-occur and how these profiles of ACEs are related to current psychopathology. We aimed to identify profiles of ACEs in pathological gamblers and examined how these profiles were related to gambling-related characteristics and current general psychopathology. In 329 current or lifetime pathological gamblers, diagnosed with the Composite Diagnostic Interview for DSM-IV, 10 types of ACEs were measured using the Adverse Childhood Experiences Questionnaire. Global psychopathology was assessed using the Symptom Checklist SCL-27. ACE profiles were identified using latent class analysis. Differences between ACE profiles in gambling-related characteristics and global psychopathology were analyzed using MANOVA. We found that four out of five gamblers (n=257, 78.1%) reported at least one ACE. Four distinct ACE profiles were identified: 'Low ACE', 'High ACE', 'Physical and emotional abuse', and 'Neglect'. The number of the fulfilled pathological gambling criteria and the severity of current global psychopathology differed between the ACE profiles: Gamblers with a 'High ACE' profile fulfilled more pathological gambling criteria and showed a more severe current psychopathology than gamblers of the 'Low ACE' profile. Gamblers with a 'Physical and emotional abuse' or an 'Emotion neglect' profile showed an intermediate severity of psychopathology. Our findings indicate that four different ACE profiles can be distinguished in pathological gamblers that differed in their gambling-related characteristics and current psychopathology. Systematic assessment of profiles of ACEs in pathological gamblers may inform about the severity of current global psychopathology that might be important to be addressed in addition to gambling-specific treatment.

Fear Memory Recall Potentiates Opiate Reward Sensitivity through Dissociable Dopamine D1 versus D4 Receptor-Dependent Memory Mechanisms in the Prefrontal Cortex

Disturbances in prefrontal cortical (PFC) dopamine (DA) transmission are well established features of psychiatric disorders involving pathological memory processing, such as post-traumatic stress disorder and opioid addiction. Transmission through PFC DA D4 receptors (D4Rs) has been shown to potentiate the emotional salience of normally nonsalient emotional memories, whereas transmission through PFC DA D1 receptors (D1Rs) has been demonstrated to selectively block recall of reward- or aversion-related associative memories. In the present study, using a combination of fear conditioning and opiate reward conditioning in male rats, we examined the role of PFC D4/D1R signaling during the processing of fear-related memory acquisition and recall and subsequent sensitivity to opiate reward memory formation. We report that PFC D4R activation potentiates the salience of normally subthreshold fear conditioning memory cues and simultaneously potentiates the rewarding effects of systemic or intra-ventral tegmental area (VTA) morphine conditioning cues. In contrast, blocking the recall of salient fear memories with intra-PFC D1R activation, blocks the ability of fear memory recall to potentiate systemic or intra-VTA morphine place preference. These effects were dependent upon dissociable PFC phosphorylation states involving calcium-calmodulin-kinase II or extracellular signal-related kinase 1-2, following intra-PFC D4 or D1R activation, respectively. Together, these findings reveal new insights into how aberrant PFC DAergic transmission and associated downstream molecular signaling pathways may modulate fear-related emotional memory processing and concomitantly increase opioid addiction vulnerability.SIGNIFICANCE STATEMENT Post-traumatic stress disorder is highly comorbid with addiction. In this study, we use a translational model of fear memory conditioning to examine how transmission through dopamine D1 or D4 receptors, in the prefrontal cortex (PFC), may differentially control acquisition or recall of fear memories and how these mechanisms might regulate sensitivity to the rewarding effects of opioids. We demonstrate that PFC D4 activation not only controls the salience of fear memory acquisition, but potentiates the rewarding effects of opioids. In contrast, PFC D1 receptor activation blocks recall of fear memories and prevents potentiation of opioid reward effects. Together, these findings demonstrate novel PFC mechanisms that may account for how emotional memory disturbances might increase the addictive liability of opioid-class drugs.

The Association between Intentional Overdose and Same-Sex Sexual Intercourse in a Cohort of People who Inject Drugs in Melbourne, Australia

BACKGROUND

People who inject drugs (PWID) are at disproportionately high risk of suicidal behaviors, as are individuals who report same-sex attraction or experience. However, there is little evidence of compounded risk of suicide for individuals who report same-sex sexual intercourse (SSI) and are PWID.

OBJECTIVES

To explore the associations of lifetime intentional overdose amongst a cohort of PWID, with particular attention to those reporting SSI.

METHODS

The sample included 529 participants, from an ongoing cohort of 757 PWID. An "ever" SSI variable was created for participants who reported sexual intercourse with a same-sex partner at any longitudinal interview. We explored the adjusted associations between SSI and lifetime intentional overdose using logistic regression.

RESULTS

Ninety-one (17%) participants reported ever experiencing an intentional overdose. Forty-one (8%) participants reported SSI at any interview. Three hundred and sixty (68%) participants reported diagnosis of a mental health condition. Diagnosis of a mental health condition (AOR = 2.02, 95% CIs: 1.14, 3.59) and SSI (AOR = 2.58, 95% CIs: 1.22, 5.48) significantly increased the odds of lifetime intentional overdose. Conclusions/Importance: We found a heightened risk of intentional overdose amongst PWID reporting SSI, after controlling for diagnosis of a mental health condition. Services need to be aware of this heightened risk and target interventions appropriately.

EMDR as Add-On Treatment for Psychiatric and Traumatic Symptoms in Patients with Substance Use Disorder

Background: Substance use disorders (SUD) are patterns of substance use leading to severe impairment on social, working and economic levels. In vivo and clinical findings have enhanced the role of the brain's stress-related system in maintaining SUD behaviors. Several studies have also revealed a high prevalence of post-traumatic symptoms among SUD patients, suggesting that a trauma-informed treatment approach could lead to better treatment outcomes. However, only few studies have evaluated the use of eye movement desensitization and reprocessing (EMDR) in SUD without consistent results. The aim of the present pilot study was to assess the efficacy of a combined trauma-focused (TF) and addiction-focused (AF) EMDR intervention in treating post-traumatic and stress-related symptoms of patients with SUD.

Methods: Forty patients with different SUD were enrolled in the study. Twenty patients underwent treatment as usual (TAU), the other 20 patients were treated with TAU plus 24 weekly sessions of EMDR. All patients were assessed before and after intervention for several psychological dimensions using specific tools (i.e., BDI-II, DES, IES-R, STAI, and SCL-90-GSI). A repeated measure MANOVA was performed to evaluate both between groups (TAU + EMDR vs. TAU) and within group (pre- vs. post-intervention) effects and interactions. A secondary outcome was the dichotomous variable yielded by the urine drug testing immunoassay (yes/no).

Results: The RM-MANOVA revealed both a significant pre–post main effect (p < 0.001), and a significant group-by-time main effect (p < 0.001). Significant improvements on IES-R, DES, and SCL-90-GSI scales were shown in both groups according to time effects (p < 0.05). However, significant greater effects were found for TAU + EMDR group than TAU group. No differences were found between TAU and TAU + EMDR groups in terms of urine drug immunoassay results before and after the interventions.

Conclusions: The TAU + EMDR group showed a significant improvement of post-traumatic and dissociative symptoms, accompanied by a reduction in anxiety and overall psychopathology levels, whereas TAU group showed a significant reduction only in post-traumatic symptoms. Although our results can only be considered preliminary, this study suggests that a combined TF- and AF- EMDR protocol is an effective and well-accepted add-on treatment for patients with SUD.

The Role of Gender in Suicidal Ideation among Long-term Opioid Users

OBJECTIVE

This study aims to examine factors associated with suicidal ideation among people with opioid dependence and to explore whether these factors are gender-specific.

METHODS

Cross-sectional data were collected among long-term opioid-dependent individuals ( n = 176; 46.0% women). Lifetime histories of suicidal ideation were measured using the Composite International Diagnostic Interview, and additional data were collected regarding sociodemographic characteristics, drug use, health, and adverse life events. Multivariable logistic regression was used to determine the relationships between these variables and suicidal ideation for the full study sample and separately for women and men to explore the potential role of gender.

RESULTS

A total of 43.8% ( n = 77) of participants reported a lifetime history of suicidal ideation. Among those with suicidal ideation, 49.3% were women and the overall average age of first ideation was 19.82 years (SD, 11.66 years). Results from multivariable analyses showed that a history of depression, anxiety, and childhood emotional neglect and the number of lifetime traumatic events were significantly associated with higher odds of suicidal ideation. The gender-based analysis suggested that histories of depression and anxiety remained independently associated with lifetime suicidal ideation among women, whereas for men, childhood emotional neglect and the number of lifetime potentially traumatic events were independently associated with lifetime suicidal ideation.

CONCLUSIONS

This study offers a critical first step to understanding factors associated with suicidal ideation among long-term opioid-dependent men and women and the potential importance of gender-sensitive approaches for suicidal behavior interventions. These data inform further research and clinical opportunities aiming to better respond to the psychological health needs of this population.

Trajectories of heroin use: 10-11-year findings from the Australian Treatment Outcome Study

AIMS

To identify trajectories of heroin use in Australia, predictors of trajectory group membership and subsequent outcomes among people with heroin dependence over 10-11 years.

DESIGN

Longitudinal cohort study.

SETTING

Sydney, Australia.

PARTICIPANTS

A total of 615 participants were recruited between 2001 and 2002 as part of the Australian Treatment Outcome Study (66.2% male; mean age 29 years). The predominance of the cohort (87.0%) was recruited upon entry to treatment (maintenance therapies, detoxification and residential rehabilitation), and the remainder from non-treatment settings (e.g. needle and syringe programmes). This analysis focused upon 428 participants for whom data on heroin use were available over 10-11 years following study entry.

MEASUREMENTS

Structured interviews assessed demographics, treatment history, heroin and other drug use, overdose, criminal involvement, physical health and psychopathology. Group-based trajectory modelling was used to: (i) identify trajectory groups based on use of heroin in each year, (ii) examine predictors of group membership and (iii) examine associations between trajectory group membership and 10-11-year outcomes.

FINDINGS

Six trajectory groups were identified [Bayesian Information Criterion (BIC) = -1927.44 (n = 4708); -1901.07 (n = 428)]. One in five (22.1%) were classified as having 'no decrease' in heroin use, with the probability of using remaining high during the 10-11 years (> 0.98 probability of use in each year). One in six (16.1%) were classified as demonstrating a 'rapid decrease to maintained abstinence'. The probability of heroin use among this group declined steeply in the first 2-3 years and continued to be low (< 0.01). The remaining trajectories represented other fluctuating patterns of use. Few baseline variables were found to predict trajectory group membership, but group membership was predictive of demographic, substance use and physical and mental health outcomes at 10-11 years.

CONCLUSIONS

Long-term trajectories of heroin use in Australia appear to show considerable heterogeneity during a decade of follow-up, with few risk factors predicting group membership. Just more than a fifth continued to use at high levels, while fewer than a fifth become abstinent early on and remained abstinent. The remainder showed fluctuating patterns.

Patients with non-substance-related disorders report a similar profile of childhood trauma experiences compared to heroin-dependent patients

BACKGROUND AND OBJECTIVES

Exposure to traumatic events is common among patients with substance use disorders (SUD). In patients with non-substance-related disorders, especially with gambling disorders (GD) and internet addiction (IA), traumatic childhood experiences have not been investigated extensively. The objective of this study was to compare trauma histories in patients with GD and IA to patients with heroin dependence.

METHODS

Cross-sectional surveys including the childhood trauma questionnaire (CTQ) and clinical data among 107 participants; 59 patients with non-substance-related disorders (GD [n = 39]; IA [n = 20]) were compared to 28 patients prescribed injectable heroin for opioid dependence in heroin-assisted treatment (HAT) and to a healthy control group (HC) (n = 20).

RESULTS

The findings revealed a high prevalence of trauma exposure in all three clinical groups, with 74.4% of patients with GD, 80.0% of patients with IA, and 93.0% of patients in HAT compared to 40% in HC. All three groups (GD, IA, HAT) reported significantly higher levels of "emotional neglect" compared to HC.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

The results provide clinically relevant information suggesting that the burden of childhood traumatic experiences may be as common in patients with GD and IA as in patients with heroin dependence. These findings could pose an important starting-point for treatment. (Am J Addict 2017;26:215-220).

Integrated Exposure-Based Therapy for Co-Occurring Post Traumatic Stress Disorder (PTSD) and Substance Dependence: Predictors of Change in PTSD Symptom Severity

This paper examines factors associated with change in PTSD symptom severity among individuals randomised to receive an integrated exposure-based psychotherapy for PTSD and substance dependence–Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE). Outcomes examined include change in PTSD symptom severity as measured by the Clinician Administered PTSD Scale (CAPS), and the reliability and clinical significance of change in PTSD symptom severity. Factors examined include patient baseline characteristics, treatment characteristics, and events over follow-up. The mean difference in CAPS score was 38.24 (SE 4.81). Approximately half (49.1%) demonstrated a reliable and clinically significant improvement in PTSD symptom severity. No one was classified as having demonstrated clinically significant worsening of symptoms. Three independent predictors of reductions in PTSD symptom severity were identified: baseline PTSD symptom severity (β 0.77, SE 0.23, p = 0.001), number of traumas experienced prior to baseline (β −0.30, SE 0.15, p = 0.049), and number of sessions attended (β 2.05, SE 0.87, p = 0.024). The present study provides further evidence regarding the safety of the COPE treatment and factors associated with improvement in PTSD symptom severity. The identification of only a small number of predictors of the outcome points to the broad applicability of the COPE treatment to PTSD and substance use disorder (SUD) patients.

"You Never Know What Happens Next" - Young Adult Service Users' Experience with Mental Health Care and Treatment through One Year

Fragmented services are a well-known problem in the mental health sector. Mental health service users’ experiences of treatment and care can provide knowledge for developing more user-oriented continuity of care. We followed nine young adults with mental health illnesses and complex needs, conducting four interviews with each informant in the course of a year. The aim was to capture their experiences and views about treatment and care, focusing on (dis)continuities and episodes occurring through that year. The users’ experiences were affected by shifts and transitions between institutions, units and practitioners while their need was predictability and stability. A good and stable patient-provider relationship was considered highly useful but difficult to establish. The participants had a strong desire for explanation, adequate treatment and progress, but very different perceptions of the usefulness of diagnoses. Some felt rejected when they tried to tell the therapist about their trauma. Lack of user-involvement characterized many of the participants’ stories while they desired to become more engaged and included in important decisions concerning treatment and medication.

The participants’ experiences stand in contrast to key policy goals of coherent mental health services. The article discusses what may explain the gap between policy and reality, and how continuity of care may be improved.

Past year non-medical opioid use and abuse and PTSD diagnosis: Interactions with sex and associations with symptom clusters

INTRODUCTION

Few studies have examined the associations between posttraumatic stress disorder (PTSD) and non-medical opioid use (NMOU), particularly in general U.S.

METHODS

We analyzed data from wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative sample of non-institutionalized adults, to examine (1) the relationship between PTSD diagnosis with NMOU, Opioid Use Disorder diagnosis, and average monthly frequency of NMOU; and (2) the relationship between PTSD symptom clusters with NMOU, Opioid Use Disorder diagnosis, and average monthly frequency of NMOU. We also explored sex differences among these associations.

RESULTS

In the adjusted model, a past year PTSD diagnosis was associated with higher odds of past year NMOU for women and men, but the association was stronger for women. In addition, PTSD was associated with higher odds of an Opioid Use Disorder diagnosis for women, but not for men. With regard to the relationship between specific symptom clusters among those with a past year PTSD diagnosis, important sex differences emerged. For women, the avoidance symptom cluster was associated with higher odds of NMOU, an Opioid Use Disorder diagnosis, and higher rate of average monthly frequency of NMOU, while for men the arousal/reactivity cluster was associated with higher odds of NMOU, an Opioid Use Disorder diagnosis, and a higher rate of average monthly frequency of NMOU. In addition, for men, the avoidance symptom cluster was associated with higher odds of an Opioid Use Disorder diagnosis, but a lower rate of average monthly frequency of NMOU.

CONCLUSIONS

Results add to the literature showing an association between PTSD and NMOU and suggest that PTSD is more strongly associated with substance use for women than men. Further, results based on individual symptom clusters suggest that men and women with PTSD may be motivated to use substances for different reasons.

Improving Access to Long-Acting Contraceptive Methods and Reducing Unplanned Pregnancy Among Women with Substance Use Disorders

Much has been written about the consequences of substance use in pregnancy, but there has been far less focus on the prevention of unintended pregnancies in women with substance use disorders (SUDs). We examine the literature on pregnancy incidence for women with SUDs, the clinical and economic benefits of increasing access to long-acting reversible contraceptive (LARC) methods in this population, and the current hurdles to increased access and uptake. High rates of unintended pregnancies and poor physical and psychosocial outcomes among women with SUDs underscore the need for increased access to, and uptake of, LARC methods among these women. A small number of studies that focused on improving access to contraception, especially LARC, via integrated contraception services predominantly provided in drug treatment programs were identified. However, a number of barriers remain, highlighting that much more research is needed in this area.

Post-traumatic stress disorder and opioid use disorder: A narrative review of conceptual models

Post-traumatic stress disorder is highly prevalent among individuals who suffer from opioid use disorder. Compared to individuals with opioid use disorder alone, those with post-traumatic stress disorder have a worse course of illness, occupational functioning, and physical health. The neurobiological pathways underlying each disorder overlap substantially, and there are multiple pathways through which these disorders may interact. This narrative review explores evidence underpinning 3 explanatory perspectives on comorbid post-traumatic stress disorder and opioid use disorder: The opioid susceptibility model (a.k.a.: the Self-Medication Hypothesis), the post-traumatic stress disorder susceptibility model, and the common factors model. Diagnostic implications, treatment implications, and directions for future research are discussed.

The shared and specific relationships between exposure to potentially traumatic events and transdiagnostic dimensions of psychopathology

The experience of traumatic events has been linked to the development of psychopathology. Changing perspectives on psychopathology have resulted in the hypothesis that broad dimensional constructs account for the majority of variance across putatively distinct disorders. As such, traumatic events may be associated with several disorders due to their relationship with these broad dimensions rather than any direct disorder-specific relationship. The current study used data from 8871 Australians to test this hypothesis. Two broad dimensions accounted for the majority of relationships between traumatic events and mental and substance use disorders. Direct relationships remained between post-traumatic stress disorder and six categories of traumatic events in the total population and between drug dependence and accidents/disasters for males only. These results have strong implications for how psychopathology is conceptualized and offer some evidence that traumatic events are associated with an increased likelihood of experiencing psychopathology in general.

What can be done to improve outcomes for prisoners with a dual diagnosis?

Purpose

– The purpose of this paper is to review the literature on offenders with a dual diagnosis and discuss how prison-based services can improve to better meet the needs of prisoners with co-occurring substance misuse and mental health disorders.

Design/methodology/approach

– A comprehensive literature search of PsycINFO, JSTOR, PubMed and Google Scholar, reviewing international studies on dual diagnosis amongst offender and community samples spanning the last three decades, supplemented by international policy, guidance papers and reports was conducted to explore how services can be improved.

Findings

– It was found that research into dual diagnosis amongst prisoners internationally was scarce. However, from the evidence available, several consistent factors emerged that led to the following recommendations: integrated treatment needs to be coordinated and holistic, staged and gender-responsive; increased availability of “low level”, flexible interventions; transitional support and continuity of care upon release with the utilisation of peer mentors; comprehensive assessments in conducive settings; mandatory dual diagnosis training for staff; and increased funding for female/gender-responsive services.

Practical implications

– The recommendations can inform commissioners, funders and service providers of areas where support must be improved to address the needs of prisoners with a dual diagnosis.

Social implications

– Improved outcomes for prisoners with a dual diagnosis would likely have a positive effect on society, with improvements in mental health and substance misuse treatment impacting on rates of reoffending.

Originality/value

– This paper brings originality and value to the sector because it reviews relevant research on dual diagnosis and translates it into practical implications for policy makers.