Mortality among cocaine users: a systematic review of cohort studies

Effect of Social Vulnerability on Cocaine-Related Mortality Rates in U.S. Counties

Cocaine-related mortality rates have risen sharply since 2013 and social vulnerability is a crucial indicator for drug-related mortality rates. Therefore, the purpose of this study was to investigate the relationship between social vulnerability and cocaine-related mortality rates in U.S. counties. The Data were collected from the CDC WONDER, CDC's Social Vulnerability Index (CDC's SVI), and American Community Survey (ACS). The Data were analyzed by spatial autoregression models. According to present results, first, counties with social vulnerability (socioeconomic) were positively related to higher rates of cocaine overdose death (spatial lag: B = 0.323, p < .05; spatial error: B = 0.513, p < .01). Second, counties with social vulnerability (minority status & language) were negatively related to higher rates of cocaine overdose death (spatial lag: B = -0.233, p < .05). Third, counties with social vulnerability (housing type & transportation) were positively related to higher rates of cocaine overdose death (spatial lag: B = 0.413, p < .001; spatial error: B = 0.378, p < .001). In conclusion, the spread of cocaine overdose on U.S. counties with social vulnerabilities demonstrated a disproportionate burden of cocaine-related mortality.

Predictors of abstinence maintenance after cocaine inpatient detoxification: A prospective study

BACKGROUND AND OBJECTIVES

Cocaine is a highly addictive substance, and with no approved medication for cocaine use disorder (CUD), leading to a heavy burden. Despite validated psychosocial treatments, relapse rates after detoxification are very high in CUD. Few consistent factors can predict abstinence after detoxification. Our study, therefore, aimed at identifying factors predicting abstinence among CUD patients after inpatient detoxification.

METHODS

Eighty-one CUD inpatients were included during detoxification and characterized for clinical and sociodemographic data at baseline and at a follow-up of 3 months after discharge, including a standard measure of their abstinence duration from cocaine. We performed Cox univariate analyzes to determine the factors associated with abstinence maintenance, followed by a multivariate Cox regression to identify independent predictors.

RESULTS

Abstinence maintenance was shorter in patients injecting cocaine (hazard ratio [HR] = 5.16, 95% confidence interval [CI]: 2.01-13.27, p < .001) and using cocaine heavily in the month before inclusion (HR = 1.03, 95% CI: 1.00-1.06, p = .046). Conversely, abstinence maintenance was longer in patients with longer inpatient detoxification stays (HR = 0.96, 95% CI: 0.94-0.99, p = .015) and prescribed with selective serotonin reuptake inhibitors (SSRIs) (HR = 0.30, 95% CI: 0.16-0.56, p < .001).

DISCUSSION AND CONCLUSIONS

Patients with severe CUD may require longer inpatient stays to achieve abstinence. Regarding SSRI prescription, more specific studies are needed to provide stronger recommendations about their use in clinical practice.

SCIENTIFIC SIGNIFICANCE

Our findings suggest several modifiable factors to improve inpatient treatment response in CUD. As there are no specific recommendations about the optimal duration of inpatient stay, our results could pave the way for evidence-based guidelines.

Project CHARIOT: study protocol for a hybrid type 1 effectiveness-implementation study of comprehensive tele-harm reduction for engagement of people who inject drugs in HIV prevention services

BACKGROUND

People who inject drugs (PWID) remain a high priority population under the federal Ending the HIV Epidemic initiative with 11% of new HIV infections attributable to injection drug use. There is a critical need for innovative, efficacious, scalable, and community-driven models of healthcare in non-stigmatizing settings for PWID. We seek to test a Comprehensive-TeleHarm Reduction (C-THR) intervention for HIV prevention services delivered via a syringe services program (SSP).

METHODS

The CHARIOT trial is a hybrid type I effectiveness-implementation study using a parallel two-arm randomized controlled trial design. Participants (i.e., PWID; n = 350) will be recruited from a syringe services program (SSP) in Miami, Florida. Participants will be randomized to receive either C-THR or non-SSP clinic referral and patient navigation. The objectives are: (1) to determine if the C-THR intervention increases engagement in HIV prevention (i.e., HIV pre-exposure prophylaxis; PrEP or medications for opioid use disorder; MOUD) compared to non-SSP clinic referral and patient navigation, (2) to examine the long-term effectiveness and cost-effectiveness of the C-THR intervention, and (3) to assess the barriers and facilitators to implementation and sustainment of the C-THR intervention. The co-primary outcomes are PrEP or MOUD engagement across follow-up at 3, 6, 9 and 12 months. For PrEP, engagement is confirmed by tenofovir on dried blood spot or cabotegravir injection within the previous 8 weeks. For MOUD, engagement is defined as screening positive for norbuprenorphine or methadone on urine drug screen; or naltrexone or buprenorphine injection within the previous 4 weeks. Secondary outcomes include PrEP adherence, engagement in HCV treatment and sustained virologic response, and treatment of sexually transmitted infections. The short and long term cost-effectiveness analyses and mixed-methods implementation evaluation will provide compelling data on the sustainability and possible impact of C-THR on comprehensive HIV prevention delivered via SSPs.

DISCUSSION

The CHARIOT trial will be the first to our knowledge to test the efficacy of an innovative, peer-led telehealth intervention with PWID at risk for HIV delivered via an SSP. This innovative healthcare model seeks to transform the way PWID access care by bypassing the traditional healthcare system, reducing multi-level barriers to care, and meeting PWID where they are.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05897099. Trial registry name: Comprehensive HIV and Harm Prevention Via Telehealth (CHARIOT). Registration date: 06/12/2023.

Health utility among people who regularly use opioids in Australia

INTRODUCTION

Studies of health utilities among people who use opioids have mostly been based on in-treatment populations. We aim to report utility-based quality of life by participants' socio-demographic, drug and treatment characteristics, and to examine the determinants of health utility among people who use opioids regularly.

METHODS

Cross-sectional study of participants who used opioids regularly, recruited across New South Wales, Victoria and Tasmania in 2018-2019. Differences in European Quality of Life (EQ-5D-5L) heath utility scores between socio-demographic and clinical subgroups were assessed using non-parametric Kruskal-Wallis test by rank. To address the unique distribution of EQ-5D-5L health utility scores in the current sample, a two-part model was applied to assess factors associated with health utility.

RESULTS

Among 402 participants enrolled in the study, 385 (96%) completed the EQ-5D-5L questionnaire. The mean health utility of the total sample was 0.63 (SD 0.29). Participants who previously received opioid agonist treatment [OAT] (adj marginal effect (ME) -0.11; 95% confidence interval [CI] -0.20 to -0.02) and those currently in OAT (adj ME -0.13; 95% CI -0.22 to -0.06) reported lower health utility than those who had never received OAT. Participants who used both pharmaceutical opioids and benzodiazepines had lower health utility compared to no pharmaceutical opioids and no benzodiazepines use (adj ME -0.17; 95% CI -0.28 to -0.07).

DISCUSSION AND CONCLUSIONS

Findings provide important health utility data for economic evaluations, useful for guiding allocation of resources for treatment strategies among people who use opioids. Lower health utilities among those using benzodiazepines and pharmaceutical opioids suggests interventions targeting these subgroups may be beneficial.

Acute care utilization and its associated determinants among patients with substance-related disorders: A worldwide systematic review and meta-analysis

INTRODUCTION

Identifying determinants of emergency department (ED) use and hospitalization among patients with substance-related disorders (SRDs) can improve health services to address unmet health needs.

AIM

The present study aimed to identify the prevalence rates of ED use and hospitalization, and their associated determinants among patients with SRDs.

METHODS

Studies in English published from January 1, 1995, to December 1, 2022, were searched on PubMed, Scopus, Cochrane Library, and Web of Science to identify primary studies.

RESULTS

The pooled prevalence rates of ED use and hospitalization among patients with SRDs were 36% and 41%, respectively. Patients with SRDs who were the most at risk of being both ED users and hospitalized were those (i) having medical insurance, (ii) having other drug and alcohol use disorders, (iii) having mental health disorders, and (iv) having chronic physical illnesses. A lower level of education increased the risk of ED use only.

DISCUSSION

To decrease ED use and hospitalization, more comprehensive services may be offered to these vulnerable patients with diversified needs.

IMPLICATIONS FOR PRACTICE

Chronic care integrating outreach interventions could be more provided for patients with SRDs after discharge from acute care units or hospitals.

Factors associated with suicide in people who use drugs: a scoping review

BACKGROUND

Suicide is a significant contributor to global mortality. People who use drugs (PWUD) are at increased risk of death by suicide relative to the general population, but there is a lack of information on associated candidate factors for suicide in this group. The aim of this study was to provide a comprehensive overview of existing evidence on potential factors for death by suicide in PWUD.

METHODS

A scoping review was conducted according to the Arksey and O'Malley framework. Articles were identified using Medline, CINAHL, PsycINFO, SOCIndex, the Cochrane Database of Systematic Reviews and the Campbell Collaboration Database of Systematic Reviews; supplemented by grey literature, technical reports, and consultation with experts. No limitations were placed on study design. Publications in English from January 2000 to December 2021 were included. Two reviewers independently screened full-text publications for inclusion. Extracted data were collated using tables and accompanying narrative descriptive summaries. The review was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines.

RESULTS

The initial search identified 12,389 individual publications, of which 53 met the inclusion criteria. The majority (87%) of included publications were primary research, with an uncontrolled, retrospective study design. The most common data sources were drug treatment databases or national death indexes. Eleven potential factors associated with death by suicide among PWUD were identified: sex; mental health conditions; periods of heightened vulnerability; age profile; use of stimulants, cannabis, or new psychoactive substances; specific medical conditions; lack of dual diagnosis service provision; homelessness; incarceration; intravenous drug use; and race or ethnicity. Opioids, followed by cannabis and stimulant drugs were the most prevalent drugs of use in PWUD who died by suicide. A large proportion of evidence was related to opioid use; therefore, more primary research on suicide and explicit risk factors is required.

CONCLUSIONS

The majority of studies exploring factors associated with death by suicide among PWUD involved descriptive epidemiological data, with limited in-depth analyses of explicit risk factors. To prevent suicide in PWUD, it is important to consider potential risk factors and type of drug use, and to tailor policies and practices accordingly.

Trends in Psychotropic Drug-Implicated Cardiovascular Mortality: Patterns in U.S. Mortality, 1999-2020

INTRODUCTION

Psychotropic drug-implicated (PDI) mortality-deaths in which psychotropic drugs were a contributing but not underlying cause of death-increased over two decades, with circulatory mortality as the primary cause leading to such deaths. Trends in PDI circulatory mortality over a 22-year period and its patterning in U.S. deaths are described.

METHODS

Deaths extracted from the Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research Multiple Causes of Death database from 1999 to 2020 were analyzed to generate annual counts and rates for drug-implicated deaths due to diseases of the circulatory system, including by specific drug, sex, race/ethnicity, age, and state.

RESULTS

During a period when overall age-adjusted circulatory mortality rates declined, PDI circulatory mortality more than doubled, from 0.22 per 100,000 in 1999 to 0.57 per 100,000 by 2020, now representing 1 in 444 circulatory deaths. Although PDI deaths from ischemic heart diseases are proportionally aligned with overall circulatory deaths (50.0% vs 48.5%), PDI deaths from hypertensive diseases represent a larger proportion (19.8% vs 8.0%). Psychostimulants generated the greatest escalation for PDI circulatory deaths (0.029-0.332 per 100,000). The sex gap in PDI mortality rates widened (0.291 females, 0.861 males). PDI circulatory mortality is particularly notable for Black Americans and midlife Americans, with considerable geographic variability.

CONCLUSIONS

Circulatory mortality with psychotropic drugs as a contributing cause escalated over 2 decades. Trends in PDI mortality are not evenly distributed across the population. Greater engagement with patients about their substance use is needed to intervene in cardiovascular deaths. Prevention and clinical intervention could contribute to reinvigorating previous trends of declining cardiovascular mortality.

Understanding the laps and relapse process: in-depth interviews with individual who use methamphetamine

OBJECTIVE

The high rate of treatment failure is a common problem in the treatment of methamphetamine use. Therefore, the aim of this research is to identify the most common causes of relapse in methamphetamine users.

METHOD

This is a qualitative study and of content analysis type. Information was collected using purposeful sampling and through semi-structured interviews and focus group discussions. The statistical population consisted of all people with the methamphetamine-use disorder in 2022 who were in the abstinence phase and participated in the meetings of the Narcotics Anonymous (NA) Center of Bojnord. Theoretical sampling continued until data saturation. A total of 10 one-on-one interviews were conducted, each lasting between 45 to 80 min. Additionally, two focus group interviews were conducted with six members in each group, lasting between 95 to 110 min and data saturation was achieved through these interviews. Data analysis was done using the content analysis method (Sterling). Recoding and Holsti's method were used to measure reliability; validity was then calculated through content validity assessment.

FINDINGS

The results of the thematic analysis showed that laps and relapse factors were identified and categorized into 5 organizing themes, including negative emotional states, positive emotional states, negative physical states, interpersonal factors, and environmental factors, consisting of 39 basic themes.

RESULT

Identifying the risk factors leading to laps and relapse in methamphetamine users and increasing the knowledge in this field can lay the groundwork for preventive therapeutic interventions in this community.

A single case report of STN-DBS for severe crack-cocaine dependence: double-blind ON vs. SHAM randomized controlled assessment

Crack-cocaine dependence is a severe condition with a high mortality rate. This single case study report details the first deep brain stimulation (DBS) trial targeting the sub-thalamic nucleus (STN) for crack-cocaine dependence. The investigation aimed to assess the effects of STN-DBS on cocaine craving and cocaine use, as well as STN-DBS safety and tolerance in this indication. In this pilot study, we performed double blind cross-over trials, with "ON-DBS" vs. "SHAM-DBS" for 1-month periods. STN-DBS failed to reduce cocaine craving and use. An episode of DBS-induced hypomania occurred after several weeks of cocaine intake at stimulation parameters previously well tolerated. Future research on cocaine dependence should be conducted after a prolonged abstinence period and/or explore novel types of stimulation patterns.

MicroRNA-423-5p Mediates Cocaine-Induced Smooth Muscle Cell Contraction by Targeting Cacna2d2

Cocaine abuse increases the risk of atherosclerotic cardiovascular disease (CVD) and causes acute coronary syndromes (ACS) and hypertension (HTN). Significant research has explored the role of the sympathetic nervous system mediating the cocaine effects on the cardiovascular (CV) system. However, the response of the sympathetic nervous system alone is insufficient to completely account for the CV consequences seen in cocaine users. In this study, we examined the role of microRNAs (miRNAs) in mediating the effect of cocaine on the CV system. MiRNAs regulate many important biological processes and have been associated with both response to cocaine and CV disease development. Multiple miRNAs have altered expression in the CV system (CVS) upon cocaine exposure. To understand the molecular mechanisms underlying the cocaine response in the CV system, we studied the role of miRNA-423-5p and its target Cacna2d2 in the regulation of intracellular calcium concentration and SMC contractility, a critical factor in the modulation of blood pressure (BP). We used in vivo models to evaluate BP and aortic stiffness. In vitro, cocaine treatment decreased miR-423-5p expression and increased Cacna2d2 expression, which led to elevated intracellular calcium concentrations and increased SMC contractility. Overexpression of miR-423-5p, silencing of its target Cacna2d2, and treatment with a calcium channel blocker reversed the elevated SMC contractility caused by cocaine. In contrast, suppression of miR-423-5p increased the intracellular calcium concentration and SMC contractibility. In vivo, smooth muscle-specific overexpression of miR-423-5p ameliorated the increase in BP and aortic stiffness associated with cocaine use. Thus, miR-423-5p regulates SMC contraction by modulating Cacna2d2 expression increasing intracellular calcium concentrations. Modulation of the miR-423-5p-Cacna2d2-Calcium transport pathway may represent a novel therapeutic strategy to improve cocaine-induced HTN and aortic stiffness.

From Bumps to Binges: Overview of Deaths Associated with Cocaine in England, Wales and Northern Ireland (2000-2019)

The UK, as the "cocaine capital of Europe," currently accounts for ∼75% of all cocaine-related hospital admissions in Europe. This study aims to analyze the trends in cocaine-related deaths in England, Wales and Northern Ireland over 20 years (2000-2019). Cases reported to the National Programme on Substance Abuse Deaths (NPSAD) occurring between 2000 and 2019 where cocaine was detected at post-mortem (PM) were extracted for analysis. A total of 5,339 cases were retrieved, with an increase in the rate of reporting over time. Cocaine was deemed a cause of death and quantified in PM blood samples along with its major metabolite benzoylecgonine in 685 cases. Of these 685 cases, 25% (n = 170/685) occurred following acute use, 22% (n = 154/685) following chronic/binge use, 40% (n = 271/685) in combination with morphine, 4% (n = 29/685) in drug packer/swallower circumstances and 9% (n = 61/685) in a suicide context. Cardiac complications were evident in 22% of cases (n = 154/685). The average concentration of cocaine detected in cardiac cases (900 ng/mL) was considerably lower than that detected in cases where acute (19,100 ng/mL) or chronic/binge (6,200 ng/mL) dosing was evident. This is the first cocaine-related mortality study in these geographical areas. Deaths following cocaine use continue to rise despite its Class A drug listing in the UK. While underlying and external risk factors including polydrug use, cardiac complications and mental health can all contribute to the incidence of fatal drug toxicity following cocaine use, this study demonstrates that the risk of a cocaine overdose cannot be attributed to a specific blood concentration range.

A National Strategy for Preventing Substance and Opioid Use Disorders Through Evidence-Based Prevention Programming that Fosters Healthy Outcomes in Our Youth

The recently released National Drug Control Strategy (2022) from the White House Office of National Drug Control Policy (ONDCP) lays out a comprehensive plan to, not only enhance access to treatment and increase harm reduction strategies, but also increase implementation of evidence-based prevention programming at the community level. Furthermore, the Strategy provides a framework for enhancing our national data systems to inform policy and to evaluate all components of the plan. However, not only are there several missing components to the Strategy that would assure its success, but there is a lack of structure to support a national comprehensive service delivery system that is informed by epidemiological data, and trains and credentials those delivering evidence-based prevention, treatment, and harm reduction/public health interventions within community settings. This paper provides recommendations for the establishment of such a structure with an emphasis on prevention. Systematically addressing conditions known to increase liability for behavioral problems among vulnerable populations and building supportive environments are strategies consistently found to avert trajectories away from substance use in general and substance use disorders (SUD) in particular. Investments in this approach are expected to result in significantly lower rates of SUD in current and subsequent generations of youth and, therefore, will reduce the burden on our communities in terms of lowered social and health systems involvement, treatment needs, and productivity. A national strategy, based on strong scientific evidence, is presented to implement public health policies and prevention services. These strategies work by improving child development, supporting families, enhancing school experiences, and cultivating positive environmental conditions.

Emergency Department Use, Hospitalization, and Their Sociodemographic Determinants among Patients with Substance-Related Disorders: A Worldwide Systematic Review and Meta-Analysis

Background: Identifying the determinants of emergency department (ED) use and hospitalization among patients with substance-related disorders (SRD) can help inform healthcare services and case management regarding their unmet health needs and strategies to reduce their acute care. Objectives: The present study aimed to identify sociodemographic characteristics, type of used drug, and risky behaviors associated with ED use and hospitalization among patients with SRD. Methods: Studies in English published from January 1st, 1995 to April 30th, 2022 were searched from PubMed, Scopus, Cochrane Library, and Web of Science to identify primary studies on ED use and hospitalization among patients with SRD. Results: Of the 17,348 outputs found, a total of 39 studies met the eligibility criteria. Higher ED use and hospitalization among patients with SRD were associated with a history of homelessness (ED use: OR = 1.93, 95%CI = 1.32-2.83; hospitalization: OR = 1.53, 95%CI = 1.36-1.73) or of injection drug use (ED use: OR = 1.34, 95%CI = 1.13-1.59; hospitalization: OR = 1.42, 95%CI = 1.20-1.69). Being female (OR = 1.24, 95%CI = 1.14-1.35), using methamphetamine (OR = 1.99, 95%CI = 1.24-3.21) and tobacco (OR = 1.25, 95%CI = 1.11-1.42), having HIV (OR = 1.70, 95%CI = 1.47-1.96), a history of incarceration (OR = 1.90, 95%CI = 1.27-2.85) and injury (OR = 2.62, 95%CI = 1.08-6.35) increased ED use only, while having age over 30  years (OR = 1.40, 95%CI = 1.08-1.81) and using cocaine (OR = 1.60, 95%CI = 1.32-1.95) increased hospitalization only among patients with SRD. Conclusions: The finding outline the necessity of developing outreach program and primary care referral for patients with SRD. Establishing a harm reduction program, incorporating needle/syringe exchange programs, and safe injection training with the aim of declining ED use and hospitalization, is likely be another beneficial strategy for patients with SRD.

"We want everything in a one-stop shop": acceptability and feasibility of PrEP and buprenorphine implementation with mobile syringe services for Black people who inject drugs

INTRODUCTION

A recent surge in HIV outbreaks, driven by the opioid and stimulant use crises, has destabilized our progress toward targets set forth by Ending the HIV Epidemic: A Plan for America for the high-priority community of people who inject drugs (PWID), particularly Black PWID.

METHODS

In order to ascertain the acceptability and feasibility of using a mobile syringe services program (SSP) for comprehensive HIV prevention via PrEP and medications for opioid use disorder (MOUD), our mixed methods approach included a quantitative assessment and semi-structured qualitative interviews with Black PWID (n = 30) in Miami-Dade County who were actively engaged in mobile syringe services.

RESULTS

Participants felt that delivery of MOUD and PrEP at a mobile SSP would be both feasible and acceptable, helping to address transportation, cost, and stigma barriers common within traditional healthcare settings. Participants preferred staff who are compassionate and nonjudgmental and have lived experience.

CONCLUSIONS

A mobile harm reduction setting could be an effective venue for delivering comprehensive HIV prevention services to Black PWID, a community that experiences significant barriers to care via marginalization and racism in a fragmented healthcare system.

A Chronic Condition Disguised as an Acute Event: the Case for Re-thinking Stimulant Overdose Death

Recent reports indicate that stimulant-related deaths are increasing dramatically. People who die from acute stimulant toxicity have high rates of pre-existing cardiovascular disease (CVD), much of which is undiagnosed. Moreover, people who use stimulants with CVD often remain asymptomatic until presenting to an emergency department with an acute event. Prior research shows that symptoms of stimulant toxicity may occur on a regular basis, and that people who die from stimulant toxicity are older than those who die of opioid toxicity. Taken collectively, the existing evidence suggests that death from acute stimulant toxicity is often an outcome of long-term, cumulative exposure leading to cardiovascular dysfunction rather than acute intoxication. Strategies tailored to the distinct etiology of stimulant overdose are needed. We propose a three-part approach including (1) implementing stimulant use interventions that promote not only abstinence, but also use reduction, (2) treating ongoing stimulant use as a chronic cardiovascular condition, and (3) making stimulant toxicity interventions relevant to the populations most affected, which includes people outside of the traditional health-care system. In short, to reduce stimulant-related fatality, we need to transform our approach in ways that are tailored to address its natural history.

Trends in cannabis or cocaine-related dependence and alcohol/drug treatment in Argentina, Chile, and Uruguay

BACKGROUND

In the context of changing cannabis and other drug policy and regulation, concerns may arise regarding drug treatment access and use. We assessed cannabis/cocaine-related dependence and treatment in Argentina, Chile, and Uruguay.

METHODS

Nationally representative cross-sectional household surveys of people ages 15-64 in Argentina (4 surveys, 2006-2017), Chile (7 surveys, 2006-2018), and Uruguay (4 surveys, 2006-2018) were harmonized. We estimated weighted prevalences of cannabis or cocaine-related (cocaine or cocaine paste) dependence, based on meeting 3+ past-year ICD-10 dependence criteria. We estimated weighted prevalences of past-year alcohol/drug treatment use (Argentina, Chile) or use/seeking (Uruguay) among people with past-year cannabis/cocaine-related dependence. We tested model-based prevalence trends over time and described individual-level treatment correlates by country.

RESULTS

Cannabis/cocaine dependence prevalence increased in the region starting in 2010-2011, driven by cannabis dependence. Adjusted cannabis dependence prevalence increased from 0.7% in 2010 to 1.5% in 2017 in Argentina (aPD=0.8, 95% CI= 0.3, 1.2), from 0.8% in 2010 to 2.8% in 2018 in Chile (aPD=2.0, 95% CI= 1.4, 2.6), and from 1.4% in 2011 to 2.4% in 2018 in Uruguay (aPD=0.9, 95% CI= 0.2, 1.6). Cocaine-related dependence increased in Uruguay, decreased in Argentina, and remained stable in Chile. Among people with past-year cannabis/cocaine dependence, average alcohol/drug treatment use prevalence was 15.3% in Argentina and 6.0% in Chile, while treatment use/seeking was 14.7% in Uruguay. Alcohol/drug treatment prevalence was lower among people with cannabis dependence than cocaine-related dependence. Treatment correlates included older ages in all countries and male sex in Argentina only.

CONCLUSION

Alcohol/drug treatment use among people with cannabis/cocaine-related dependence remained low, signaling an ongoing treatment gap in the context of growing cannabis dependence prevalence in the region. Additional resources may be needed to increase treatment access and uptake. Future studies should assess contributors of low treatment use, including perceived need, stigma, and service availability.

Early Onset Cardiovascular Disease from Cocaine, Amphetamines, Alcohol, and Marijuana

Cardiovascular disease (CVD), a disease typically associated with aging and the definitive leading cause of death worldwide, now threatens the young and middle-aged populations. Recreational abuse of alcohol, marijuana, cocaine and amphetamine-type stimulants has been an escalating public health problem for decades, but now use of these substances has become a significant contributor to early onset CVD. While this remains a global phenomenon, the epicenter of substance abuse is rooted in North America where it has been exacerbated by the COVID-19 pandemic. For the first time in history, the United States (US) crossed 100,000 overdose-related deaths in a calendar year. Sadly, Canada's recreational drug abuse problem closely mirrors that of the US. This is indicative of the larger public health crisis unfolding, as we now know that these substances are cardiotoxic and are contributing to the rising levels of premature chronic CVD, including hypertension, arrhythmias, heart failure, stroke, myocardial infarction, arterial dissection, sudden cardiac death and early mortality.

Substance use related violent deaths among racial/ethnic groups in the United States

While prior research highlights the overlap of substance use and violent death, few examine this overlap among different racial/ethnic groups or how patterns change over time. This study examines how substance use related deaths differ by racial/ethnic groups in the United States. We use data from the National Violent Death Reporting System (NVDRS), which includes violent deaths from 43 states in the U.S., collected for the decade between 2009 and 2019 (N = 226,459). Fixed-effects multivariate models examined whether race/ethnicity was associated with substance use-related death over time, controlling for additional demographic and clinical factors. Results showed a significantly larger rate of increase over time for African American and Hispanic (any race) persons compared to White non-Hispanic persons for most types of substance use-related deaths. While current rates of substance use may show little variability between African American, Hispanic, and White non-Hispanic individuals, this research suggests that the consequences for substance use, including death, may be disproportional.

Utilising data linkage to describe and explore mortality among a retrospective cohort of individuals admitted to residential substance use treatment

INTRODUCTION

Individuals with moderate to severe substance use disorders may seek residential treatment, but outcomes after discharge for this hard-to-reach population are often unknown. Using linked data, we examined mortality outcomes among individuals after residential treatment.

METHODS

We included 1056 individuals admitted to three residential treatment facilities across Queensland, Australia, from 1 January 2014 to 31 December 2016. Records were linked to Queensland death registration data and cause of death records from the Australian Coordinating Registry (1 January-31 December 2018). Standard mortality ratios were assessed, comparing participants to the Queensland, Australia, general population. Causes of death and years of potential life lost (YPLL) were examined.

RESULTS

Thirty-six participants died (3.4%) in 3408 years of follow-up data. The age- and sex-adjusted standard mortality ratios were 3.96 (95% confidence interval: 2.78, 5.48) overall, 8.19 (3.74, 15.55) in females and 3.38 (2.23, 4.92) in males. Two-thirds of deaths were due to suicide/overdose. There was an average of 45.50 YPLL (SD 9.16).

DISCUSSION AND CONCLUSIONS

This study used linked data to quantify mortality following residential substance use treatment. The YPLL and avoidable nature of deaths highlight the need for continuing care following discharge from residential services.

Childhood trauma and the severity of past suicide attempts in outpatients with cocaine use disorders

INTRODUCTION

Suicide attempts have been associated with both cocaine use disorder (CocUD) and childhood trauma. We investigated how childhood trauma is an independent risk factor for serious and recurrent suicide attempts in CocUD. Method: 298 outpatients (23% women) with CocUD underwent standardized assessments of substance dependence (Diagnostic and Statistical Manual-mental disorders, fourth edition, text revised), impulsiveness, resilience, and childhood trauma, using validated tools. Suicide attempts history was categorized as single vs. recurrent or non-serious vs. serious depending on the lifetime number of suicide attempts and the potential or actual lethality of the worst attempt reported, respectively. Bivariate and multinomial regression analyses were used to characterize which childhood trauma patterns were associated with the suicide attempts groups. Results: 58% of CocUD patients reported childhood trauma. Recurrent and serious suicide attempts clustered together and were thus combined into "severe SA." Severe suicide attempt risk increased proportionally to the number of childhood traumas (test for trend, p = 9 × 10^-7). Non-severe suicide attempt risk increased with impulsiveness and decreased with resilience. In multinomial regression models, a higher number of traumas and emotional abuse were independently and only associated with severe vs. non-severe suicide attempts (effect size = 0.82, AUC = 0.7). The study was limited by its cross-sectional design. Conclusion: These preferential associations between childhood trauma and severe suicide attempts warrant specific monitoring of suicide attempts risk in CocUD, regardless of the severity of addiction profiles.

The relationship of frequency of cocaine use to substance and psychiatric disorders in the U.S. general population

BACKGROUND

In clinical trials of pharmacotherapy for substance use, abstinence is the primary endpoint accepted by regulatory agencies. However, this endpoint could be overly restrictive, impeding efforts to identify effective medications for cocaine use disorder. To examine non-abstinent gradations in cocaine use as potential indicators of improvement, we investigated the relationship of frequency of cocaine use to clinical correlates in national survey data.

METHODS

Lifetime cocaine users (n = 2501) were interviewed in the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) in 2001-2002 and re-interviewed in 2004-2005. Adjusted odds ratios (aORs) indicated associations between heaviest frequency of cocaine use and use of other substances, DSM-IV substance use disorders, psychiatric disorders, and change between 2001-2002 and 2004-2005. The reference category for all aORs was non-users.

RESULTS

Greater lifetime cocaine use frequency was associated with lifetime cocaine, alcohol, and cannabis dependence (aOR for a linear trend = 2.80, 1.22, 1.22, respectively) and past-year cocaine, alcohol, and cannabis dependence (aOR = 1.78, 1.13, 1.16, respectively). Greater lifetime cocaine use frequency was associated with past-year depressive, panic, and generalized anxiety disorders (aOR = 1.07, 1.09, 1.12, respectively). Among cocaine users in 2001-2002, compared to the reference group using less than monthly, use ≥1x/week and use 1-3 times a month was associated with cocaine use disorder in 2004-2005 (aOR = 2.13 and aOR = 1.67, respectively).

CONCLUSION

Gradations in risk for dependence on cocaine, other substances and psychiatric disorders by frequency of cocaine use indicates a promising direction for more sensitive outcome measures of treatment effects on cocaine outcomes than binary indicators (e.g., any use vs. none). Study results add to findings suggesting that non-abstinent measures might be useful indicators of treatment efficacy in clinical trials.

Co-exposure of cocaine and cannabinoids and its association with select biological, behavioural and health outcomes: A systematic scoping review of multi-disciplinary studies

Cocaine use entails severe health- and social-related harms globally. Treatment options for cocaine dependence are highly limited. Benefits of cannabinoids for addiction have been documented, making it opportune to examine existing data on the possible outcomes associated with cannabinoids and cocaine co-use. We conducted a systematic scoping review following the PRISMA guidelines of peer-reviewed, English-language studies published from 2000 to 2021 in four databases (Medline, Web-of-Science, CINAHL Plus, and PsycInfo), assessing the co-exposure of cannabis/cannabinoids with cocaine on behavioural, biological or health outcomes. Both quantitative and qualitative, as well as humans and pre-clinical animals' studies (n=46) were included. Pre-clinical studies (n=19) showed mostly protective effects of cannabidiol (CBD) administration on animal models of addiction (e.g., cocaine-craving, -relapse, and -withdrawal) and cocaine-toxicity. Tetrahydrocannabinol (THC) had more inconsistent results, with both protective and counter-protective effects. Human studies (n=27) were more heterogeneous and assessed natural ongoing cannabis and cocaine use or dependence. Quantitative-based studies showed mostly enhanced harms in several outcomes (e.g., cocaine use, mental health); two available clinical trials found no effect upon CBD administration on cocaine-related treatment outcomes. Qualitative data-based studies reported cannabis use as a substitute for or to alleviate harms of crack-cocaine use. While pre-clinical studies suggest a potential of cannabinoids, especially CBD, to treat cocaine addiction, the few trials conducted in humans found no benefits. Cannabis co-use by cocaine users commonly presents a risk factor, entailing enhanced harms for users. More rigorous, controlled trials are still necessary to investigate cannabinoids' potential considering pre-clinical findings and reported benefits from specific drug users.

First-time offenders for recreational ketamine use under a new penalty system in Taiwan: incidence, recidivism and mortality in national cohorts from 2009 to 2017

BACKGROUND AND AIMS

Ketamine has become a new recreational drug of choice among young people in parts of Asia. Using national databases in Taiwan, this study aimed to (1) examine the yearly trend in the ketamine offence rate over time; (2) estimate the 3-year risk of drug-related re-offence and its correlates among the first-time offenders; and (3) estimate the 3-year standardized mortality ratio (SMR) among the first-time offenders.

DESIGN, SETTING AND PARTICIPANTS

Retrospective cohort studies of offenders for recreational ketamine use in a penalty system initiated in 2009. Offenders for recreational ketamine use were identified from the Administrative Penalty System for Schedule III/IV Substances database from 2009 to 2017, and the re-offence rate and mortality among first-time offenders were assessed via record-linkage within the database as well as with both the criminal drug offence database and the national mortality database. The cohort from 2009 to 2016 (n = 39 178) was used for the recidivism analysis and the cohort from 2009 to 2013 (n = 25 357) was used for the 3-year SMR analysis.

MEASUREMENTS

Recidivism was estimated using survival analysis of the event as re-arrest for using ketamine, more serious illicit drugs (Schedules I/II), or any illicit drugs (ketamine or Schedules I/II). SMRs were estimated for overall and cause-specific death within 3 years after the first offence for ketamine use.

FINDINGS

The age-standardized rates for both prevalent (1.38 per 1000) and first-time offenders (0.65 per 1000) peaked in 2013 and then decreased steadily. The 3-year risk of re-offence was 33.85% [95% confidence interval (CI) = 33.23-34.47%) for ketamine use and 39.52% (95% CI = 39.00-40.04%) for any illicit drug use. These first-time offenders had an SMR of 4.9 (95% CI = 4.3-5.4) for overall mortality, 2.1 (95% CI = 1.6-2.7) for natural deaths and 7.6 (95% CI = 6.7-8.6) for unnatural deaths.

CONCLUSIONS

Recreational ketamine use in Taiwan appears to lead not only to high risk for drug-related re-offence but also to excess mortality.

Risk factors for completed suicide among people who use drugs: A scoping review protocol

Background: Research over the past several decades has shown an increased risk for completed suicide among people who use drugs (PWUD). However, no study to date has attempted to summarise the available literature on the variety of risk factors associated with this increased risk. This paper presents a protocol for a scoping review that aims to systematically map and synthesise the extent and nature of published, unpublished and grey literature related to risk factors for suicide among PWUD.

Methods: The following six-stage methodological framework for scoping reviews proposed by Arksey and O’Malley with enhancements by Levac and colleagues will be used: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting/mapping the data, (5) collating, summarising and reporting results and (6) expert consultation. The review will be conducted and reported in accordance with the PRISMA Extension for Scoping Reviews (PRISMA-ScR). Key inclusion and exclusion criteria will be developed to guide literature screening and data charting. Three reviewers will conduct the initial screening of published, unpublished and grey literature. Identified risk factors will be collated, summarised and categorised iteratively by two independent reviewers. Stakeholder consultation will occur with experts from a national steering committee, a national advisory group, a national suicide prevention centre and a European drug monitoring centre.

Conclusion: Collating and thematically categorising the various risk factors for suicide among this high-risk group will hold important implications for future research, policy and practice. The research will be disseminated through publication in a peer-reviewed academic journal and a conference presentation, and by sharing the findings with key stakeholders working within research, policy-making and professional practice contexts.

High-intensity cannabis use and hospitalization: a prospective cohort study of street-involved youth in Vancouver, Canada

BACKGROUND

There is concern that cannabis use negatively affects vulnerable groups such as youth; however, the relationship between cannabis use and health care utilization has not been well characterized in this population. We longitudinally evaluated the association between daily cannabis use and hospitalization among a prospective cohort of street-involved youth.

METHODS

Data were collected from the At-Risk Youth Study (ARYS) in Vancouver, Canada, from September 2005 to May 2015. Participants were interviewed semi-annually and multivariable generalized estimating equation (GEE) logistic regression was used to examine the relationship between daily cannabis use and hospitalization.

RESULTS

A total of 1216 participants (31.2% female) were included in this analysis, and 373 (30.7%) individuals reported hospitalization at some point during the study period. In a multivariable GEE analysis, daily cannabis use was not significantly associated with hospitalization (Adjusted Odds Ratio [AOR] = 1.17, 95% Confidence interval [CI] = 0.84, 1.65). We did observe a significant interaction between daily cannabis use and sex (AOR = 0.51, 95% CI = 0.34, 0.77), whereby cannabis use was associated with a decreased odds of hospitalization among males (AOR = 0.60, 95% CI = 0.47, 0.78), yet was not significantly associated with hospitalization among females (AOR = 1.19, 95% CI = 0.84, 1.67).

CONCLUSIONS

The finding that daily cannabis use was not associated with hospitalization among street-involved youth is encouraging given the high rates of cannabis use in this population and the expansion of cannabis legalization and regulation. Future studies, however, are warranted to monitor possible changes in the consequences of cannabis use as cannabis legalization and regulation increase internationally.

White matter deficits in cocaine use disorder: convergent evidence from in vivo diffusion tensor imaging and ex vivo proteomic analysis

White matter (WM) abnormalities in patients with cocaine use disorder (CUD) have been studied; however, the reported effects on the human brain are heterogenous and most results have been obtained from male participants. In addition, biological data supporting the imaging findings and revealing possible mechanisms underlying the neurotoxic effects of chronic cocaine use (CU) on WM are largely restricted to animal studies. To evaluate the neurotoxic effects of CU in the WM, we performed an in vivo diffusion tensor imaging assessment of male and female cocaine users (n = 75) and healthy controls (HC) (n = 58). Moreover, we performed an ex vivo large-scale proteomic analysis using liquid chromatography-tandem mass spectrometry in postmortem brains of patients with CUD (n = 8) and HC (n = 12). Compared with the HC, the CUD group showed significant reductions in global fractional anisotropy (FA) (p < 0.001), and an increase in global mean (MD) and radial diffusion (RD) (both p < 0.001). The results revealed that FA, RD, and MD alterations in the CUD group were widespread along the major WM tracts, after analysis using the tract-based special statistics approach. Global FA was negatively associated with years of CU (p = 0.0421) and female sex (p < 0.001), but not with years of alcohol or nicotine use. Concerning the fibers connecting the left to the right prefrontal cortex, Brodmann area 9 (BA9), the CUD group presented lower FA (p = 0.006) and higher RD (p < 0.001) values compared with the HC group. A negative association between the duration of CU in life and FA values in this tract was also observed (p = 0.019). Proteomics analyses in BA9 found 11 proteins differentially expressed between cocaine users and controls. Among these, were proteins related to myelination and neuroinflammation. In summary, we demonstrate convergent evidence from in vivo diffusion tensor imaging and ex vivo proteomics analysis of WM disruption in CUD.

Factors associated with crack-cocaine early initiation: a Brazilian multicenter study

BACKGROUND

Crack-cocaine dependence is a serious public health issue, related to several psychiatric and psychosocial problems. Crack-cocaine users are usually embedded in a context of great social vulnerability, often associated with violence, poverty, family conflict and easy and early access to alcohol, tobacco and other drugs.

METHODS

This cross-sectional study enrolled a consecutive sample of 577 patients admitted to 20 therapeutic communities located in Southern Brazil, between September 2012 and September 2013. A structured interview assessed life-time exposure to risk and protective factors for drug use, such as parental monitoring in childhood, deviant behaviors and peer pressure.

RESULTS

Presence of family conflict (p = 0.002), maltreatment (p = 0.016), and deviant behavior prior to age 15 in a bivariate analysis predicted an earlier age of crack-cocaine initiation, whereas adolescents experiencing parental monitoring during adolescence started use later (p < 0.001). In the multivariate model, perceptions related to ease of access of illicit drugs (marijuana: p = 0.028, 95% CI = - 3.81, - 0.22; crack-cocaine: p < 0.001, 95% CI = - 7.40, - 4.90), and deviant behavior (threatening someone with a gun: p = 0.028, 95% CI = - 2.57, - 0.14) remained independent predictors of early age of crack-cocaine initiation.

CONCLUSIONS

Early onset of crack-cocaine use seems to be associated with exposure to family conflict, easy access to drugs and deviant behavior. Treatment and preventive programs should take these factors into account when designing and implementing community interventions.

All-cause and cause-specific mortality among people with regular or problematic cocaine use: a systematic review and meta-analysis

AIMS

To estimate pooled all-cause and cause-specific mortality risk for people with regular or problematic cocaine use.

METHODS

Systematic review and meta-analysis of prospective or retrospective cohort studies or clinical trials (n ≥30) of people with regular or problematic cocaine use with data on all-cause or cause-specific mortality. Of 2808 papers, 28 were eligible and reported on 21 cohorts, with a total 170 019 individuals. Cohorts identified based on acute care for drug poisoning or other severe health presentation were excluded. Title/abstract screening was conducted by one reviewer; a second reviewer independently checked 10% of excluded studies. Two reviewers conducted full-text screening. Data were extracted by one reviewer and checked by a second. A customized review-specific study reporting quality/risk of bias tool was used. Data on crude mortality rates (CMR) and standardized mortality ratios were extracted for both all-cause and cause-specific mortality. Standardized mortality ratios were imputed where not provided by the author using extracted data and information from the Global Burden of Disease Study 2017. Data were pooled using a random-effects model.

RESULTS

The pooled all-cause crude mortality rate was 1.24 per 100 person-years [95% confidence interval (CI) = 0.86, 1.78; n = 16 cohorts], but with considerable heterogeneity (I²  = 98.8%). The pooled all-cause standardized mortality ratio (SMR) was 6.13 (95% CI = 4.15, 9.05; n = 16 cohorts). Suicide (SMR = 6.26, 95% CI = 2.84, 13.80), accidental injury (SMR = 6.36, 95% CI = 4.18, 9.68), homicide (SMR = 9.38, 95% CI 3.45-25.48) and AIDS-related mortality (SMR = 23.12, 95% CI = 11.30, 47.31) were all elevated compared with age and sex peers in the general population.

CONCLUSIONS

There are elevated rates of mortality among people with regular or problematic cocaine use for traumatic deaths and deaths attributable to infectious disease.

Genome-wide association study of phenotypes measuring progression from first cocaine or opioid use to dependence reveals novel risk genes

Aim: Substance use disorders (SUD) result in substantial morbidity and mortality worldwide. Opioids, and to a lesser extent cocaine, contribute to a large percentage of this health burden. Despite their high heritability, few genetic risk loci have been identified for either opioid or cocaine dependence (OD or CD, respectively). A genome-wide association study of OD and CD related phenotypes reflecting the time between first self-reported use of these substances and a first DSM-IV dependence diagnosis was conducted. Methods: Cox proportional hazards regression in a discovery sample of 6,188 African-Americans (AAs) and 6,835 European-Americans (EAs) participants in a genetic study of multiple substance dependence phenotypes were used to test for association between genetic variants and these outcomes. The top findings were tested for replication in two independent cohorts. Results: In the discovery sample, three independent regions containing variants associated with time to dependence at P < 5 x 10-8 were identified, one (rs61835088 = 1.03 x 10-8) for cocaine in the combined EA-AA meta-analysis in the gene FAM78B on chromosome 1, and two for opioids in the AA portion of the sample in intergenic regions of chromosomes 4 (rs4860439, P = 1.37 x 10-8) and 9 (rs7032521, P = 3.30 x 10-8). After meta-analysis with data from the replication cohorts, the signal at rs61835088 improved (HR = 0.87, P = 3.71 x 10-9 and an intergenic SNP on chromosome 21 (rs2825295, HR = 1.14, P = 2.57 x 10-8) that missed the significance threshold in the AA discovery sample became genome-wide significant (GWS) for CD. Conclusions: Although the two GWS variants are not in genes with obvious links to SUD biology and have modest effect sizes, they are statistically robust and show evidence for association in independent samples. These results may point to novel pathways contributing to disease progression and highlight the utility of related phenotypes to better understand the genetics of SUDs.

Genome-wide association study of phenotypes measuring progression from first cocaine or opioid use to dependence reveals novel risk genes

Aim

Substance use disorders (SUD) result in substantial morbidity and mortality worldwide. Opioids, and to a lesser extent cocaine, contribute to a large percentage of this health burden. Despite their high heritability, few genetic risk loci have been identified for either opioid or cocaine dependence (OD or CD, respectively). A genome-wide association study of OD and CD related phenotypes reflecting the time between first self-reported use of these substances and a first DSM-IV dependence diagnosis was conducted.

Methods

Cox proportional hazards regression in a discovery sample of 6,188 African-Americans (AAs) and 6,835 European-Americans (EAs) participants in a genetic study of multiple substance dependence phenotypes were used to test for association between genetic variants and these outcomes. The top findings were tested for replication in two independent cohorts.

Results

In the discovery sample, three independent regions containing variants associated with time to dependence at P < 5 x 10^-8 were identified, one (rs61835088 = 1.03 x 10^-8) for cocaine in the combined EA-AA meta-analysis in the gene FAM78B on chromosome 1, and two for opioids in the AA portion of the sample in intergenic regions of chromosomes 4 (rs4860439, P = 1.37 x 10^-8) and 9 (rs7032521, P = 3.30 x 10^-8). After meta-analysis with data from the replication cohorts, the signal at rs61835088 improved (HR = 0.87, P = 3.71 x 10^-9 and an intergenic SNP on chromosome 21 (rs2825295, HR = 1.14, P = 2.57 x 10^-8) that missed the significance threshold in the AA discovery sample became genome-wide significant (GWS) for CD.

Conclusions

Although the two GWS variants are not in genes with obvious links to SUD biology and have modest effect sizes, they are statistically robust and show evidence for association in independent samples. These results may point to novel pathways contributing to disease progression and highlight the utility of related phenotypes to better understand the genetics of SUDs.

Long-Term Outcomes of Patients With Cocaine Use Disorder: A 18-years Addiction Cohort Study

Objective: Cocaine Use Disorder (CUD) has been associated with multiple complications and premature death. The purpose of the present study was to analyze the relationship between baseline medical comorbidity and long-term medical outcomes (i.e., hospitalization, death) in a cohort of patients primarily admitted for detoxification. In addition, we aimed to analyze cause-specific mortality.

Methods: longitudinal study in CUD patients admitted for detoxification between 2001 and 2018. Substance use characteristics, laboratory parameters and medical comorbidity by VACS Index were assessed at admission. Follow-up and health-related outcomes were ascertained through visits and e-health records. Kaplan-Meier and Cox regression models were used to analyze survival and predictors of hospitalization and death.

Results: 175 patients (77.7% men) were included. Age at admission was 35 years [IQR: 30–41 years], 59.4% of the patients being intranasal users, 33.5% injectors, and 7.1% smokers. Almost 23% of patients had concomitant alcohol use disorder, 39% were cannabis users and 9% opiate users. The median VACS Index score on admission was 10 points [IQR: 0–22]. After 12 years [IQR: 8.6–15 years] of follow-up there were 1,292 (80.7%) ED admissions and 308 (19.3%) hospitalizations. The incidence rate of ED admission and hospitalization was 18.6 × 100 p-y (95% CI: 15.8–21.8 × 100 p-y). Mortality rate was 1.4 × 100 p-y (95% CI: 0.9–2.0 × 100 p-y) and, baseline comorbidity predicted hospitalization and mortality: those with VACS Index >40 were 3.5 times (HR:3.52, 95% CI: 1.19–10.4) more likely to dye with respect to patients with VACS < 20.

Conclusion: addiction care warrants optimal stratification of medical comorbidity to improve health outcomes and survival of CUD patients seeking treatment of the disorder.

Premature mortality associated with severe mental illness or substance use disorder in an integrated health care system

OBJECTIVE

Research has reported shortened lifespans (by 15-30 years) for those with severe mental illness (SMI) or substance use disorder (SUD), particularly among public mental health treatment consumers. We assessed SMI- and SUD-associated mortality in the understudied setting of a large, nonprofit integrated health care system.

METHOD

This retrospective cohort study examined 2010-2017 health system and death records for 564,592 adult patients. Half had SMI/SUD diagnosis; half were a demographically matched comparison group without SMI, other mental health, or SUD diagnoses. We estimated mortality risks, adjusting for demographic and physical health factors.

RESULTS

Having SMI or SUD was associated with higher odds of death (adjusted odds ratio = 1.87) and an average 6.3 years of earlier death relative to comparison individuals. Co-occurring SMI and SUD conferred higher mortality risk from major natural and unnatural causes than did SMI with no SUD.

CONCLUSIONS

Some indicators of premature mortality were lower than those reported for U.S. public mental health consumers, but risk level varied widely by diagnosis. While patients' having insurance and broad access to care may lower risk, access to care may be insufficient to overcome the many patient-, provider-, and system-level factors contributing to poor physical health in SMI and SUD.

Screen of drug use: Diagnostic accuracy for stimulant use disorder

AIMS

Stimulant misuse, overdose, and related deaths have increased dramatically. Identifying and referring individuals with stimulant use disorder to treatment may reduce misuse and overdose. This study validated the 2-item Screen of Drug Use (SoDU; Tiet et al., 2015) to screen for stimulant use disorder (and for cocaine and amphetamine use disorders) in a VA primary care setting, and to establish its concurrent diagnostic validity among diverse subgroups of patients, including age, gender, race/ethnicity, marital status, educational level, and PTSD status.

METHODS

Archival data from 1283 VA primary care patients recruited in California were examined. This predominantly male sample matched general VA primary care patient population characteristics. A total of 79 individuals (6.2%) met criteria for a stimulant use disorder. The criterion for having a stimulant use disorder was a DSM-IV cocaine use disorder and/or amphetamine use disorder diagnosis based on the Mini International Diagnostic Interview.

RESULTS

For stimulant use disorder, the 2-item SoDU was 93.67% sensitive (95% confidence interval [CI], 85.84%-97.91%), and 89.12% specific (95% CI, 87.22%-90.82%). When tested in diverse subgroups of patients, the sensitivity ranged from 66.67% to 100% and specificity ranged from 76.81% to 94.17%. When a follow-up question was added, the sensitivity was unchanged and the specificity was 99%, with lower false positive rate.

CONCLUSIONS

The SoDU, especially with a follow-up question, is an appropriate instrument for routine screening of stimulant use disorder in VA primary care settings. It has good concurrent diagnostic validity for diverse groups of patients.

Risk factors for completed suicide among people who use drugs: A scoping review protocol

Background: Research over the past several decades has shown an increased risk for completed suicide among people who use drugs (PWUD). However, no study to date has attempted to summarise the available literature on the variety of risk factors associated with this increased risk. This paper presents a protocol for a scoping review that aims to systematically map and synthesise the extent and nature of published, unpublished and grey literature related to risk factors for suicide among PWUD. Methods: The following six-stage methodological framework for scoping reviews proposed by Arksey and O’Malley with enhancements by Levac and colleagues will be used: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting/mapping the data, (5) collating, summarising and reporting results and (6) expert consultation. The review will be conducted and reported in accordance with the PRISMA Extension for Scoping Reviews (PRISMA-ScR). Key inclusion and exclusion criteria will be developed to guide literature screening and data charting. Three reviewers will conduct the initial screening of published, unpublished and grey literature. Identified risk factors will be collated, summarised and categorised iteratively by two independent reviewers. Stakeholder consultation will occur with experts from a national steering committee, a national advisory group, a national suicide prevention centre and a European drug monitoring centre. Conclusion: Collating and thematically categorising the various risk factors for suicide among this high-risk group will hold important implications for future research, policy and practice. The research will be disseminated through publication in a peer-reviewed academic journal and a conference presentation, and by sharing the findings with key stakeholders working within research, policy-making and professional practice contexts.

Cocaine, cardiomyopathy, and heart failure: a systematic review and meta-analysis

Although the cardiotoxic effects of cocaine are universally recognized, the association between cocaine and cardiomyopathy and/or heart failure is poorly understood. To conduct a comprehensive review and meta-analysis on the association between cocaine, heart failure, and cardiomyopathy, we first conducted a broad-term search in PubMed, Embase, Web of Science, and Scopus for human studies containing primary data on the relationship between cocaine and heart failure or cardiomyopathy. We were interested in studies with data beyond acute coronary syndromes. Retrieved studies were grouped into different categories based on possible hypotheses to test by meta-analysis. A second search with specific terms was then conducted. For grouped studies with sufficient clinical and methodological homogeneity, effect sizes were calculated and combined for meta-analysis by the Random Effects model. There is in general a need for more primary data studies that investigate heart failure and/or cardiomyopathy in cocaine users for mechanisms independent of ischemia. There were, however, enough studies to combine by meta-analyses that showed that chronic cocaine use is associated with anatomical and functional changes more consistent with diastolic heart failure instead of the commonly taught dilated cardiomyopathy pathway. In patients without a history of ACS, chronic cocaine use was not associated with significantly reduced EF. The few studies on acute cocaine had conflicting results on whether single-dose intravascular cocaine results in acute heart failure. Studies identified that included beta-blockade therapy in cocaine users with cardiac disease suggest that beta-blockers are not unsafe and that may be effective in the treatment of cocaine-associated heart failure. Chronic cocaine use is associated with anatomical and physiological changes of the heart muscle that are potentially reversible with beta-blockade therapy.

Translational study of the whole transcriptome in rats and genetic polymorphisms in humans identifies LRP1B and VPS13A as key genes involved in tolerance to cocaine-induced motor disturbances

Motor disturbances strongly increase the burden of cocaine use disorder (CUDs). The objective of our translational study was to identify the genes and biological pathways underlying the tolerance to cocaine-induced motor effects. In a 5-day protocol measuring motor tolerance to cocaine in rats (N = 40), modeling the motor response to cocaine in patients, whole-genome RNA sequencing was conducted on the ventral and dorsal striatum to prioritize a genetic association study in 225 patients with severe CUD who underwent thorough phenotypic (cocaine-induced hyperlocomotion, CIH; and cocaine-induced stereotypies, CIS) and genotypic [571,000 polymorphisms (SNPs)] characterization. We provide a comprehensive description of the rat striatal transcriptomic response to cocaine in our paradigm. Repeated vs. acute cocaine binge administration elicited 27 differentially expressed genes in the ventral striatum and two in the dorsal striatum. One gene, Lrp1b, was differentially expressed in both regions. In patients, LRP1B was significantly associated with both CIS and CIH. CIH was also associated with VPS13A, a gene involved in a severe neurological disorder characterized by hyperkinetic movements. The LRP1B minor allele rs7568970 had a significant protective effect against CIS (558 SNPs, Bonferroni-corrected p = 0.02) that resisted adjustment for confounding factors, including the amount of cocaine use (adjusted beta = -0.965 and -2.35 for heterozygotes and homozygotes, respectively, p < 0.01). Using hypothesis-free prioritization of candidate genes along with thorough methodology in both the preclinical and human analysis pipelines, we provide reliable evidence that LRP1B and VPS13A are involved in the motor tolerance to cocaine in CUD patients, in line with their known pathophysiology.

I can't get it off my mind: Attentional bias in former and current cocaine addiction

BACKGROUND

Cocaine addiction is a global health issue with limited therapeutic options and a high relapse rate. Attentional bias towards substance-related cues may be an important factor for relapse. However, it has never been compared in former and current cocaine-dependent patients.

METHODS

Attentional bias towards cocaine-related words was assessed using an emotional Stroop task in cocaine-dependent patients (N = 40), long-term abstinent former cocaine-dependent patients (N = 24; mean abstinence: 2 years) and control subjects (N = 28). Participants had to name the colour of cocaine-related words, neutral words and colour names. We assessed response times using an automatic voice-onset detection method we developed and we measured attentional bias as the difference in response times between cocaine-related and neutral conditions.

RESULTS

There was an overall group effect on attentional bias towards cocaine, but no group effect on the colour Stroop effect. Two-by-two comparison showed a difference in attentional bias between cocaine-dependent patients and controls, whereas long-term abstinent former cocaine-dependent patients were not different from either. Although cocaine-dependent patients showed a significant attentional bias, consistent with the literature, neither long-term abstinent former cocaine-dependent patients nor controls showed a significant attentional bias towards cocaine-related words. We found no link between attentional bias size and either addiction severity or craving.

CONCLUSIONS

Cocaine abstinence was associated with an absence of significant attentional bias towards cocaine-related words, which may be interpreted either as an absence of attentional bias predicting success in maintaining abstinence, or as attentional bias being able to disappear with long-term cocaine abstinence. Further research is needed to distinguish the role of attentional bias in maintaining abstinence.

Cocaine-Related Aortic Dissection: what do we know?

Introduction

Cocaine use is known to be associated with an increased risk for vascular diseases. It is likely to trigger or increase the risk for an aortic dissection. We conducted an analysis of 45 cases of cocaine-related aortic dissection to further characterize the clinical features and outcomes of this patient cohort.

Methods

Our study cohort of 45 patients consisted of 11 cases from our institutional database and 34 published case reports.

Results

The observed cases of acute aortic dissection related to cocaine use showed a high proportion of young (41.3±8.67 years) and male (88.9%) patients. Most of the cases (75%) were classified as Stanford type A. Also, in 75% of the cases, cocaine use was prevalent for more than one year. Median time from last cocaine use to onset of symptoms was one hour. In-hospital mortality was 21.4%, while additional 11.9% of the cases died before arriving at the hospital.

Conclusion

Acute aortic dissection related to cocaine use occurs in predominantly young male patients and has a dismal outcome when compared to all comer series.

The association between regular cocaine use, with and without tobacco co-use, and adverse cardiovascular and respiratory outcomes

BACKGROUND

Understanding the potential impact of cocaine use on health is increasingly important as cocaine use rises in the U.S.

OBJECTIVES

This study evaluated the associations of regular cocaine use, with and without tobacco co-use, with cardiovascular and respiratory outcomes.

METHODS

Analysis of a limited dataset obtained through IBM Watson Health Explorys, a platform integrating electronic health record data. Matched controls were defined for: 1) cocaine-using patients (n = 8244; 44 % female); and subgroups of cocaine-using patients: 2) with an encounter diagnosis for tobacco use disorder (TUD; n = 4706); and 3) without a TUD diagnosis (non-TUD; n = 3538). Patients had at least one documented medical evaluation in the MetroHealth System (Cleveland, Ohio). Cocaine-using patients had an encounter diagnosis of cocaine abuse/dependence and/or ≥2 cocaine-positive drug screens. Control patients, with no documented cocaine-use, were matched to the cocaine-using patients on demographics, residential zip code median income, body mass index, and, for the total sample, TUD-status. Outcomes were encounter diagnosis (yes/no) of cerebrovascular accident, heart arrhythmia, myocardial infarction, subarachnoid hemorrhage, asthma, chronic obstructive pulmonary disease (COPD), pneumonia, and all-cause mortality.

RESULTS

TUD-patients had the greatest prevalence of cardiovascular and respiratory disease, regardless of cocaine-use indication. In the total sample, TUD, and non-TUD subgroups, regular cocaine use was significantly associated with greater risk for cerebrovascular accident, arrhythmia, myocardial infarction, asthma, COPD, pneumonia and mortality.

CONCLUSIONS

Cocaine use is associated with significantly greater risk of adverse cardiovascular and respiratory diagnoses and all-cause mortality.

Alterations in nicotinic receptor alpha5 subunit gene differentially impact early and later stages of cocaine addiction: a translational study in transgenic rats and patients

Cocaine addiction is a chronic and relapsing disorder with an important genetic component. Human candidate gene association studies showed that the single nucleotide polymorphism (SNP) rs16969968 in the α5 subunit (α5SNP) of nicotinic acetylcholine receptors (nAChRs), previously associated with increased tobacco dependence, was linked to a lower prevalence of cocaine use disorder (CUD). Three additional SNPs in the α5 subunit, previously shown to modify α5 mRNA levels, were also associated with CUD, suggesting an important role of the subunit in this pathology. To investigate the link between this subunit and CUD, we submitted rats knockout for the α5 subunit gene (α5KO), or carrying the α5SNP, to cocaine self-administration (SA) and showed that the acquisition of cocaine-SA was impaired in α5SNP rats while α5KO rats exhibited enhanced cocaine-induced relapse associated with altered neuronal activity in the nucleus accumbens. In addition, we observed in a human cohort of patients with CUD that the α5SNP was associated with a slower transition from first cocaine use to CUD. We also identified a novel SNP in the β4 nAChR subunit, part of the same gene cluster in the human genome and potentially altering CHRNA5 expression, associated with shorter time to relapse to cocaine use in patients. In conclusion, the α5SNP is protective against CUD by influencing early stages of cocaine exposure while CHRNA5 expression levels may represent a biomarker for the risk to relapse to cocaine use. Drugs modulating α5 containing nAChR activity may thus represent a novel therapeutic strategy against CUD.

Risk factors for completed suicide among people who use drugs: A scoping review protocol

Background: Research over the past several decades has shown an increased risk for completed suicide among people who use drugs (PWUD). However, no study to date has attempted to summarise the available literature on the variety of risk factors associated with this increased risk. This paper presents a protocol for a scoping review that aims to systematically map and synthesise the extent and nature of published, unpublished and grey literature related to risk factors for suicide PWUD. Methods: The following six-stage methodological framework for scoping reviews proposed by Arksey and O’Malley with enhancements by Levac and colleagues will be used: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting/mapping the data, (5) collating, summarising and reporting results and (6) expert consultation. The review will be conducted and reported in accordance with the PRISMA Extension for Scoping Reviews (PRISMA-ScR). Key inclusion and exclusion criteria will be developed to guide literature screening and data charting. Three reviewers will conduct the initial screening of published, unpublished and grey literature. Identified risk factors will be collated, summarised and categorised iteratively by two independent reviewers. Stakeholder consultation will occur with experts from a national steering committee, a national advisory group, a national suicide prevention centre and a European drug monitoring centre. Conclusion: Collating and thematically categorising the various risk factors for suicide among this high-risk group will hold important implications for future research, policy and practice. The research will be disseminated through publication in a peer-reviewed academic journal and a conference presentation, and by sharing the findings with key stakeholders working within research, policy-making and professional practice contexts.

Integrating HIV pre-exposure prophylaxis and harm reduction among men who have sex with men and transgender women to address intersecting harms associated with stimulant use: a modelling study

INTRODUCTION

Among men who have sex with men (MSM) and transgender women (TW), stimulant use is high and has been associated with an increased risk of HIV infection, suicide and cardiovascular disease (CVD) mortality. We used epidemic modelling to investigate these intersecting health harms among MSM/TW in Lima, Peru and assess whether they could be mitigated by prioritizing HIV pre-exposure prophylaxis (PrEP) and harm reduction interventions among MSM/TW who use stimulants.

METHODS

We adapted a dynamic model of HIV transmission among MSM/TW in Lima to incorporate stimulant use and increased HIV risk, suicide and CVD mortality. Among 6% to 24% of MSM/TW using stimulants (mostly cocaine), we modelled an increased risk of unprotected anal sex (RR = 1.35 [95%CI: 1.17 to 1.57]) obtained from local data, and increased risk of suicide (SMR = 6.26 [95%CI: 2.84 to 13.80]) and CVD (SMR = 1.83 [95%CI: 0.39 to 8.57]) mortality associated with cocaine use based on a global systematic review. We estimated the proportion of health harms occurring among MSM/TW who use stimulants in the next year (01-2020/01-2021). We also investigated the 10-year impact (01-2020/01-2030) of: (1) PrEP prioritization for stimulant-using MSM/TW compared to random allocation, and (2) integrating PrEP with a theoretical intervention halving stimulant-associated risk.

RESULTS

MSM/TW in Lima will experience high HIV incidence, suicide mortality and CVD mortality (1.6/100 py, and 0.018/100 py, 0.13/100 py respectively) in 2020. Despite stimulant using MSM/TW comprising an estimated 9.5% (95%CI: 7.8 to 11.5) of all MSM/TW, in the next year, 11% 95%CI (i.e. 2.5% to 97.5% percentile) 10% to 13%) of new HIV infections, 39% (95%CI: 18% to 60%) of suicides and 15% (95%CI: 3% to 44%) of CVD deaths could occur among this group. Scaling up PrEP among all stimulant using MSM/TW could prevent 19% (95%CI: 11% to 31%) more HIV infections over 10 years compared to random allocation. Integrating PrEP and an intervention to halve stimulant-associated risks could reduce new HIV infections by 20% (95%CI: 10% to 37%), suicide deaths by 14% (95%CI: 5% to 27%) and CVD deaths by 3% (95%CI: 0% to 16%) over a decade.

CONCLUSIONS

MSM/TW who use stimulants experience a disproportionate burden of health harms. Prioritizing PrEP based on stimulant use, in addition to sexual behaviour/gender identity criteria, could increase its impact. Integrated substance use, harm reduction, mental health and HIV care among MSM/TW is needed.

Palliative care for patients with substance use disorder and multiple problems: a qualitative study on experiences of healthcare professionals, volunteers and experts-by-experience

BACKGROUND

There is little information about how healthcare professionals feel about providing palliative care for patients with a substance use disorder (SUD). Therefore, this study aims to explore: 1) the problems and needs experienced by healthcare professionals, volunteers and experts-by-experience (HCP/VE) during their work with patients with SUD in a palliative care trajectory and; 2) to make suggestions for improvements using the quality of care model by Donabedian (Structure, Process, Outcome).

METHODS

A qualitative study was conducted, consisting of six focus group interviews which consisted of HCP/VE working with patients with SUD in a palliative care phase. At the end of the focus group interviews, participants structured and summarized their experiences within a Strengths, Weaknesses, Opportunities and Threats (SWOT) framework. Interview transcripts (other than the SWOT) were analysed by the researchers following procedures from the Grounded Theory Approach ('Grounded Theory Lite'). SWOT-findings were not subjected to in-depth analysis.

RESULTS

HCP/VE stated that within the Structure of care, care networks are fragmented and HCP/VE often lack knowledge about patients' multiplicity of problems and the time to unravel these. Communication with this patient group appears limited. The actual care-giving Process requires HCP/VE a lot of creativity and time spent seeking for cooperation with other caregivers and appropriate care settings. The latter is often hindered by stigma. Since no formalized knowledge is available, care-delivery is often exclusively experience-based. Pain-medication is often ineffective due to active substance use. Finally, several Outcomes were brought forward: Firstly, a palliative care phase is often identified only at a late stage. Secondly, education and a (mobile) team of expertise are desired. Thirdly, care for the caregivers themselves is often de-prioritized.

CONCLUSIONS

Better integration and collaboration between the different professionals with extensive experience in addiction, palliative and general curative care is imperative to assure good palliative care for patients with SUD. Currently, the resources for this care appear to be insufficient. Development of an educational program and social mapping may be the first steps in improving palliative care for patients with severe SUD.

Suicidality in Fibromyalgia: A Systematic Review of the Literature

Fibromyalgia (FM), a poorly understood rheumatic condition, is characterized by chronic pain and psychiatric comorbidities, most notably depression and anxiety. Additional symptoms include sleep difficulties, fatigue, and various cognitive impairments. Furthermore, FM is surrounded by social stigma, due to the unclear nature and etiology of this condition. While there is widespread evidence for the emotional and psychological suffering of those with FM, the scope of suicidality, as well as the underlying factors that are associated with suicidal ideation and behavior among this population, are not well understood. The present review, which is the first of its kind, aims to summarize existing data on the prevalence of suicide-related outcomes among FM patients, highlight factors associated with suicidal ideation and behavior in FM, and identify gaps in the literature to better inform research and clinical care. Studies were extracted from the literature that measured suicidal ideation, attempted suicide, and/or completed suicide among FM patients. Results indicated that both suicidal ideation and suicidal behavior were prevalent among individuals suffering from FM. Psychiatric comorbidity, sleep difficulties, and inpatient hospitalization were associated with both suicidal ideation and suicidal behavior. Functional impairment was associated with suicidal ideation in FM. Factors associated with higher levels of suicidal behavior in FM included female gender, unemployment and lower income, medical comorbidity, and drug dependence. While an understanding of currently recognized risk factors is important for improving FM research and clinical care, some clear methodological and conceptual limitations of the reviewed studies were identified. Future work should focus on longitudinal studies, as well as on gaining a better biological and psychological understanding of the underpinnings of FM and suicidality.

Responding to global stimulant use: challenges and opportunities

We did a global review to synthesise data on the prevalence, harms, and interventions for stimulant use, focusing specifically on the use of cocaine and amphetamines. Modelling estimated the effect of cocaine and amphetamine use on mortality, suicidality, and blood borne virus incidence. The estimated global prevalence of cocaine use was 0·4% and amphetamine use was 0·7%, with dependence affecting 16% of people who used cocaine and 11% of those who used amphetamine. Stimulant use was associated with elevated mortality, increased incidence of HIV and hepatitis C infection, poor mental health (suicidality, psychosis, depression, and violence), and increased risk of cardiovascular events. No effective pharmacotherapies are available that reduce stimulant use, and the available psychosocial interventions (except for contingency management) had a weak overall effect. Generic approaches can address mental health and blood borne virus infection risk if better tailored to mitigate the harms associated with stimulant use. Substantial and sustained investment is needed to develop more effective interventions to reduce stimulant use.

Would You Be Surprised If This Patient Died This Year? Advance Care Planning in Substance Use Disorders

Primary care physicians are increasingly incorporating screening tools for substance use disorders (SUDs) and referral to treatment into their practice. Despite efforts to provide access to treatment, patients with SUDs remain at an increased risk of mortality, both from overdose and from general medical conditions. Advance care planning (ACP) is recommended for patients with chronic, progressive medical conditions such as malignancies or heart failure. Though SUDs are widely acknowledged to be chronic diseases associated with an increased risk of mortality, there has been little discussion on ACP in this population. ACP is a discussion regarding future care, often including selection of a surrogate decision-maker and completion of an advanced directive. ACP has been associated with better quality of end-of-life and care more consistent with patient preferences. Studies in other vulnerable populations have shown that marginalized and high-risk individuals may be less likely to receive ACP. Similarly, patients with SUDs may employ different decision-makers than that defined by law (i.e., friend vs. family member), increasing the importance of discussing patient values and social structure. Physicians should routinely conduct ACP conversations with patients with SUDs, especially those with chronic, progressive medical conditions and/or severe, uncontrolled substance use disorders.

Medical complications associated with substance use disorders in patients with type 2 diabetes and hypertension: electronic health record findings

BACKGROUND AND AIMS

Screening for substance use disorder (SUD) in general medical settings may be particularly important in patients with comorbid health conditions exacerbated by SUD. This study evaluated whether SUD is associated with type 2 diabetes mellitus (T2DM) complications in patients with co-occurring T2DM and hypertension.

DESIGN

Analysis of a limited data set obtained through IBM Watson Health Explorys, a platform integrating data from electronic health records. Matched controls were defined for each of five SUDs: tobacco use disorder (TUD), opioid use disorder (OUD), cocaine use disorder, cannabis use disorder (CUD) and alcohol use disorder (AUD) using Mahalanobis distance within propensity score calipers.

SETTING

All patients were seen in the MetroHealth System (Cleveland, OH, USA) and had diagnosis codes for T2DM and hypertension.

PARTICIPANTS

SUD group participants had a diagnosis of abuse/dependence for the substance of interest. Controls for each SUD group had no diagnosis code related to the SUD of interest and were selected to match the SUD patients on demographics, residential zip code median income and body mass index. Total sample sizes for each SUD-control comparison ranged from 1160 for CUD to 22 128 for TUD.

MEASUREMENTS

Outcome was diagnosis (yes/no) of four T2DM complications (cerebrovascular accident, diabetic neuropathy, diabetic renal disease, myocardial infarction) and all-cause mortality.

FINDINGS

Logistic regressions revealed that SUD was significantly associated with greater risk of cerebrovascular accident [TUD odds ratio (OR) = 1.79, OUD-OR = 1.94, cocaine use disorder OR = 2.67], diabetic neuropathy [TUD-adjusted OR (aOR) = 1.47, cocaine use disorder-aOR = 1.35, AUD-aOR = 1.27], diabetic renal disease (TUD-aOR = 1.25, OUD-OR = 1.34), myocardial infarction (TUD-OR = 1.96, OUD-OR = 2.01, cocaine use disorder-OR = 2.68, CUD-OR = 2.48, AUD-OR = 1.42) and mortality (TUD-OR = 1.15, cocaine use disorder-OR = 1.61, CUD-OR = 1.49, AUD-OR = 1.35).

CONCLUSIONS

Among patients in Ohio USA with both type 2 diabetes mellitus (T2DM) and hypertension, those with substance use disorders appear to have greater risk for T2DM complications and all-cause mortality.

Palliative care for people with substance use disorder and multiple problems: a qualitative study on experiences of patients and proxies

Background

Systematic research into palliative care (PC) for people with substance use disorder (SUD) and multiple problems is scarce. The existing literature shows problems in the organizational structure of this care, e.g., lack of clear care pathways. Furthermore, negative attitudes of healthcare professionals (HCPs) and stigmatization surrounding SUD, and patients’ care-avoidance and non-disclosure of substance use are hindering factors in providing timely and person-centered PC. Furthermore, the experiences and needs of patients and proxies themselves are unknown. Therefore, this study aims to explore which problems and needs patients with SUD and multiple problems, and their proxies, experience in a PC phase.

Methods

Data-collection of this qualitative study consisted of semi-structured interviews with patients with SUD and multiple problems in a PC phase, and their proxies, about their experiences in PC and their well-being. Interviews were inductively analyzed.

Results

Nine patients and three proxies were included. Six patients suffered from COPD, one patient from cirrhosis of the liver and two patients from both. Seven patients stayed in a nursing home and two had a room in either a social care service (hostel) or an assisted living home where medical care was provided. Five themes were identified: 1) healthcare delivery (including HCPs behaviour and values); 2) end-of-life (EOL) preferences (mostly concerning only the individual patient and the ‘here-and-the-now’); 3) multidimensional problems; 4) coping (active and passive) and; 5) closed communication. Proxies’ experiences with healthcare differed. Emotionally, they were all burdened by their histories with the patients.

Conclusions

This study shows that talking about and anticipating on PC with this patient-group appears hard due to patients’ closed and avoiding communication. Furthermore, some of patients’ EOL-preferences and needs, and coping-strategies, seem to differ from the more generally-accepted ideas and practices. Therefore, educating HCPs in communicating with this patient-group, is needed.

Electronic supplementary material

The online version of this article (10.1186/s12904-019-0443-4) contains supplementary material, which is available to authorized users.

Sociodemographic factors and social determinants associated with toxicology confirmed polysubstance opioid-related deaths

BACKGROUND AND AIMS

While prescribed and illicit opioid use are primary drivers of the national surges in overdose deaths, opioid overdose deaths in which stimulants are also present are increasing in the U.S. We determined the social determinants and sociodemographic factors associated with opioid-only versus polysubstance opioid overdose deaths in Massachusetts. Particular attention was focused on the role of stimulants in opioid overdose deaths.

METHODS

We analyzed all opioid-related overdose deaths from 2014 to 2015 in an individually-linked population database in Massachusetts. We used linked postmortem toxicology data to identify drugs present at the time of death. We constructed a multinomial logistic regression model to identify factors associated with three mutually exclusive overdose death groups based on toxicological results: opioid-related deaths with (1) opioids only present, (2) opioids and other substances not including stimulants, and (3) opioids and stimulants with or without other substances.

RESULTS

Between 2014 and 2015, there were 2,244 opioid-related overdose deaths in Massachusetts that had accompanying toxicology results. Toxicology reports indicated that 17% had opioids only, 36% had opioids plus stimulants, and 46% had opioids plus another non-stimulant substance. Persons older than 24 years, non-rural residents, those with comorbid mental illness, non-Hispanic black residents, and persons with recent homelessness were more likely than their counterparts to die with opioids and stimulants than opioids alone.

CONCLUSIONS

Polysubstance opioid overdose is increasingly common in the US. Addressing modifiable social determinants of health, including barriers to mental health services and homelessness, is important to reduce polysubstance use and overdose deaths.