Laboratory-induced stress and craving among individuals with prescription opioid dependence

Endocannabinoids and related lipids linked to social exclusion in individuals with chronic non-medical prescription opioid use

Opioid-related overdose deaths are still on the rise in North America, emphasizing the need to better understand the underlying neurobiological mechanisms regarding the development of opioid use disorder (OUD). Recent evidence from preclinical and clinical studies indicate that the endocannabinoid system (ECS) may play a crucial role in stress and reward, both involved in the development and maintenance of substance use disorders. Animal models demonstrate a specific crosstalk between the ECS and the endogenous opioid system. However, translational studies in humans are scarce. Here, we investigated basal plasma levels of the endocannabinoids anandamide (AEA) and 2-arachidonoyglycerol (2-AG), and eight endocannabinoid-related lipids, including oleoylethanolamide (OEA) and palmitoylethanolamide (PEA), as well as whole blood fatty acid amide hydrolase (FAAH) activity in chronic non-medical prescription opioid users (NMPOU; n = 21) compared to opioid-naïve healthy controls (n = 29) considering age, sex, and cannabis use as potential confounders. Additionally, the association of endocannabinoids and related lipids with the participants' response to experimentally induced social exclusion was examined. We found significantly elevated basal AEA, OEA, and PEA levels in NMPOU compared to controls, but no differences in FAAH activity, 2-AG, or other endocannabinoid-related lipids. Within NMPOU, higher AEA levels were associated with lower perception of social exclusion. Robust positive correlations within N-acylethanolamines (i.e., AEA, OEA, and PEA) indicate strong metabolic associations. Together with our recent findings of elevated basal 2-AG levels in dependent cocaine users, present results indicate substance-specific alterations of the ECS that may have implications in the search for novel therapeutic interventions for these populations.

Opioid craving does not incubate over time in inpatient or outpatient treatment studies: Is the preclinical incubation of craving model lost in translation?

Within addiction science, incubation of craving is an operational label used to describe time-dependent increases in drug seeking during periods of drug deprivation. The purpose of this systematic review was to describe the preclinical literature on incubation of craving and the clinical literature on craving measured over extended periods of abstinence to document this translational homology and factors impacting correspondence. Across the 44 preclinical studies that met inclusion criteria, 31 reported evidence of greater lever pressing, nose pokes, spout licks, or time spent in drug-paired compartments (i.e., drug seeking) relative to neutral compartments after longer periods of abstinence relative to shorter periods of abstinence, labelled as "incubation of craving." In contrast, no clinical studies (n = 20) identified an increase in opioid craving during longer abstinence periods. The lack of clinical evidence for increases in craving in clinical populations weakens the translational utility of operationalizing the time-dependent increase in drug-seeking behavior observed in preclinical models as models of incubation of "craving".

Noninvasive Vagal Nerve Stimulation for Opioid Use Disorder

Background

Opioid Use Disorder (OUD) is an escalating public health problem with over 100,000 drug overdose-related deaths last year most of them related to opioid overdose, yet treatment options remain limited. Non-invasive Vagal Nerve Stimulation (nVNS) can be delivered via the ear or the neck and is a non-medication alternative to treatment of opioid withdrawal and OUD with potentially widespread applications.

Methods

This paper reviews the neurobiology of opioid withdrawal and OUD and the emerging literature of nVNS for the application of OUD. Literature databases for Pubmed, Psychinfo, and Medline were queried for these topics for 1982-present.

Results

Opioid withdrawal in the context of OUD is associated with activation of peripheral sympathetic and inflammatory systems as well as alterations in central brain regions including anterior cingulate, basal ganglia, and amygdala. NVNS has the potential to reduce sympathetic and inflammatory activation and counter the effects of opioid withdrawal in initial pilot studies. Preliminary studies show that it is potentially effective at acting through sympathetic pathways to reduce the effects of opioid withdrawal, in addition to reducing pain and distress.

Conclusions

NVNS shows promise as a non-medication approach to OUD, both in terms of its known effect on neurobiology as well as pilot data showing a reduction in withdrawal symptoms as well as physiological manifestations of opioid withdrawal.

Impact of cannabidiol on reward- and stress-related neurocognitive processes among individuals with opioid use disorder: A pilot, double-blind, placebo-controlled, randomized cross-over trial

Introduction

Opioid use disorder (OUD) continues to be a significant public health concern. Medications for OUD (MOUD) such as buprenorphine reduce overdose mortality, but relapses occur often, leading to adverse outcomes. Preliminary data suggest that cannabidiol (CBD) may be a potential adjunctive treatment to MOUD by attenuating cue-reactivity. This pilot study sought to evaluate the impact of a single dose of CBD on reward- and stress-related neurocognitive processes implicated in relapse among those with OUD.

Methods

The study was a pilot, double-blind, placebo-controlled, randomized cross-over trial aimed at assessing the effects of a single dose of CBD (Epidiolex®) 600 mg or matching placebo administered to participants with OUD receiving either buprenorphine or methadone. Vital signs, mood states, pain, opioid withdrawal, cue-induced craving, attentional bias, decision-making, delayed discount, distress tolerance, and stress-reactivity were examined at each testing session on two separate testing days at least 1 week apart.

Results

Ten participants completed all study procedures. Receipt of CBD was associated with a significant decrease in cue-induced craving (0.2 vs. 1.3, p = 0.040), as well as reduced attentional bias toward drug-related cues as measured by the visual probe task (-80.4 vs. 100.3, p = 0.041). No differences were found among all the other outcomes examined.

Discussion

CBD may have promise as an adjunct to MOUD treatment by attenuating the brain response to drug-related cues, which, in turn, may reduce the risk of relapse and overdoses. Further research is warranted to evaluate the potential for CBD as an adjunctive therapy for individuals in treatment for OUD.

Clinical Trial Registration

https://clinicaltrials.gov/ct2/show/NCT04982029.

Blunted cortisol and normal sympathetic nervous system responses to an acute psychosocial stressor in internet addiction

Studies have demonstrated that addiction leads to blunted responses of cortisol and sympathetic nervous system (SNS) to acute stressors; however, limited studies have examined the neuroendocrine and SNS stress responses in Internet addiction (IA). To examine acute stress responses in IA, the current study recruited a total of 76 Japanese university students and staff members (51 females and 25 males, mean age = 22.4 years, SD = 4.7), and measured the salivary cortisol, salivary alpha-amylase (sAA), and blood pressure (BP) responses to an acute stressor under stress or a nonstress placebo conditions in IA and non-IA groups. The results revealed that patients with IA showed a blunted cortisol response to a stressor. In contrast, no differences were found in the sAA and BP responses between the IA and non-IA groups. These results suggest that IA may be characterized by blunted cortisol responses in acute stress settings.

Cue-induced cocaine craving enhances psychosocial stress and vice versa in chronic cocaine users

Stress and craving, it has been found, contribute to the development and maintenance of and relapse in cocaine use disorder. Chronic cocaine users (CU), previous research has shown, display altered physiological responses to psychosocial stress and increased vegetative responding to substance-related cues. However, how psychosocial stress and cue-induced craving interact in relation to the CU's physiological responses remains largely unknown. We thus investigated the interaction between acute psychosocial stress and cocaine-cue-related reactivity in 47 CU and 38 controls. In a crossed and balanced design, the participants were randomly exposed to a video-based cocaine-cue paradigm and the Trier Social Stress Test (TSST) or vice versa to investigate possible mutually augmenting effects of both stressors on physiological stress responses. Over the course of the experimental procedure, plasma cortisol, ACTH, noradrenaline, subjective stress, and craving were assessed repeatedly. To estimate the responses during the cocaine-cue paradigm and TSST, growth models and discontinuous growth models were used. Overall, though both groups did not differ in their endocrinological responses to the TSST, CU displayed lower ACTH levels at baseline. The TSST did not elevate craving in CU, but when the cocaine-cue video was shown first, CU displayed an enhanced cortisol response to the subsequent TSST. In CU, cocaine-cues robustly evoked craving but no physiological stress response, while cue-induced craving was intensified after the TSST. Taken together, though CU did not show an altered acute stress response during the TSST, stress and craving together seemed to have mutually augmenting effects on their stress response.

Central sensitization in opioid use disorder: a novel application of the American College of Rheumatology Fibromyalgia Survey Criteria

Central sensitization may be an underlying mechanism linking chronic pain and opioid use disorder associated with opioid use disorder onset, maintenance, escalation, treatment delay, and relapse.

Introduction:

Central sensitization (CS) involves dysfunctional central nervous system pain modulation resulting in heightened pain perception. Central sensitization is not commonly assessed among patients with opioid use disorder (OUD), despite the fact that pain has been implicated in the development, maintenance, and relapse of OUD and chronic opioid use may produce opioid-induced hyperalgesia. Central sensitization is a plausibly important mechanism underlying the complex relationship between OUD and chronic pain. However, this premise is largely untested.

Methods:

Participants with OUD (n = 141) were recruited from an academic addiction treatment center in Columbus, Ohio. An established surrogate measure of CS, the American College of Rheumatology 2011 Fibromyalgia Survey Criteria, was administered using electronic survey. Participants also responded to questions about pain interference (Brief Pain Inventory), quality of life (RAND-36), and items regarding pain beliefs and expectations of pain and addiction treatment. Descriptive analyses, Spearman rho correlations, and Mann–Whitney U tests were performed.

Results:

Hypothesized relationships were confirmed between degree of CS, pain interference, and health-related quality of life. Degree of CS was also positively correlated with greater endorsement of pain as a reason for the onset, maintenance, and escalation of OUD; treatment delay; and OUD relapse. Participants with the American College of Rheumatology 2011 Fibromyalgia Survey Criteria ≥13 had significantly greater endorsement of pain as a reason for delaying OUD treatment, continuing and increasing opioid use, and precipitating OUD relapse.

Conclusions:

This study provides early evidence CS may underlie previously observed connections between clinically salient features of chronic pain and OUD, potentially informing future mechanistic research and precision treatment.

Effects of arousal modulation via resonance breathing on craving and affect in women with substance use disorder

BACKGROUND

Craving for alcohol and other drugs is a complex in-the-moment experience that involves within-person changes in physiological arousal and affect. We evaluated the utility of a just-in-time, self-administered resonance breathing smartphone application (app) to reduce craving and improve affect in women during outpatient treatment for substance use disorders (SUD).

METHODS

Women (N = 57) receiving outpatient addiction treatment were randomized to practice either cardiovascular resonance breathing (0.1 Hz/6 breaths per minute) or a sham (∼0.23 Hz/14 breaths per minute) in the face of urges over an 8-week intervention. Craving (Penn Alcohol Craving Scale) and affect (Positive and Negative Affect Scale) were collected weekly throughout the intervention. App data were uploaded weekly to assess frequency of use. Generalized Estimated Equations modeled craving and affect as a function of group randomization and app use frequency across the 8-week intervention.

FINDINGS

Higher levels of craving were associated with more frequent app use. The group X app use interaction was significant for craving. Frequent app use during the intervention phase was associated with lower craving levels in the resonance breathing group relative to the sham group over the 8-week intervention. There was no effect of app use frequency on affect measures.

CONCLUSIONS

Women assigned to practice sham breathing who used the intervention frequently experienced elevations in craving that are commonly reported during outpatient SUD treatment. Women assigned to resonance breathing who used the intervention frequently did not experience such increases. Resonance breathing may be protective against triggers in outpatient treatment. Physiological mechanisms are discussed.

Heightened autonomic reactivity to negative affective stimuli among active duty soldiers with PTSD and opioid-treated chronic pain

Within military populations, chronic pain conditions and posttraumatic stress disorder (PTSD) frequently co-occur, however, little research has examined the psychophysiological correlates of this comorbidity among active-duty soldiers. The current study examined physiological reactivity to negative affective stimuli among 30 active duty soldiers with chronic pain conditions treated with long-term opioid therapy. Participants completed a diagnostic interview and self-report measures. Then, their heart rate and skin temperature were recorded during an affective picture-viewing task. Soldiers with PTSD exhibited greater increases in the ratio of low-to-high frequency heart rate variability (LF/HF HRV) while viewing negative affective images than soldiers without PTSD. PTSD symptom severity was positively associated with LF/HF HRV reactivity and negatively associated with skin temperature reactivity. Additionally, opioid craving was associated with LF/HF HRV and skin temperature reactivity among soldiers with PTSD. Taken together, the results of the present study provide evidence for heightened sympathetic nervous system reactivity among soldiers with comorbid chronic pain and PTSD, underscoring the importance of intervening on potential risk factors for these conditions.

Relationship between alcohol craving dimensions and features of comorbid mental health in an alcohol dependent sample

BACKGROUND AND AIMS

Negative affect and alcohol craving are common features of Alcohol Use Disorder (AUD). Both independently contribute to AUD severity and poorer treatment outcomes, but their relationship is poorly understood. Multidimensional alcohol craving measures now allow for examination of key dimensions of craving. This study explored the relationship between depression, anxiety, stress, and the alcohol craving dimensions of intensity, imagery and intrusiveness.

METHOD

Five-hundred and twenty-five treatment seeking AUD patients (mean age of 39.79 years, SD = 11.57 years, 67% male) completed the Depression Anxiety Stress Scales (DASS), Alcohol Use Disorder Identification Test-Consumption items (AUDIT-C), and Alcohol Craving Experience (ACE-F) questionnaire, which measured the frequency of craving intensity, imagery and intrusiveness. Regression models predicted main effects of predictors and moderation by alcohol consumption.

RESULTS

Higher levels of stress were independently associated with increased craving intensity, imagery and intrusiveness. Significant positive associations were also found between anxiety and craving imagery. The association between depression and craving was not significant after controlling for other predictors.

CONCLUSIONS

AUD patients experienced higher cravings when stressed and greater imagery when anxious. These results support the need to consider the relationships between stress and craving when managing alcohol dependence.

Motives for prescription opioid use: The role of alexithymia and distress tolerance

BACKGROUND AND OBJECTIVES

Prescription opioid (PO) use disorder is a national public health crisis. Distress tolerance and alexithymia are two separate but related components of emotion regulation that are known to impact substance use disorders. No studies to date, however, have examined the role of distress tolerance and alexithymia in PO use disorder. Thus, the current study examined the association between distress tolerance, alexithymia, and specific motivations for PO use.

METHODS

Participants were non-treatment-seeking individuals with current PO use disorder (N = 81; average age = 35.0). Assessments included the Distress Tolerance Scale, Toronto Alexithymia Scale, and the Inventory of Drug Taking Situations.

RESULTS

The findings indicate that distress tolerance mediated the association between alexithymia and PO use in negative situations. Specifically, distress tolerance mediated the association between alexithymia and unpleasant emotions, testing personal control, and conflict with others.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

The results provide novel information regarding emotional states that may contribute to PO use and are malleable intervention targets. Additionally, this study adds to existing literature exploring the relationship between distress tolerance and substance use and is the first to expand upon the connection between alexithymia and distress tolerance in an opioid-using population. Implications for clinical practice and future research are discussed.

Sleep moderates the relationship between stress and craving in individuals with opioid use disorder

Opioid use disorder (OUD) is a national public health concern. Craving, stress, and exposure to conditioned drug cues are implicated in risk of relapse to opioids. Although impaired sleep has been implicated in risk of relapse to other substances of misuse, little research to date has examined the relationship between sleep and craving in individuals with OUD. The present study examined sleep as a moderator of the relationship between craving and stress in a randomized controlled human laboratory study. Individuals with current OUD (N = 39) completed a 1-night hospital stay to control for factors that may affect craving, stress, and sleep. Sleep was monitored via an actigraphy watch and the Pittsburgh Sleep Quality Index. The next morning, participants were randomized to a 15-min laboratory stress task or a no-stress condition. All participants were then exposed to a 15-min opioid cue paradigm, and craving was measured via self-report. Moderation models were conducted to evaluate whether the sleep indices moderated the relationship between stress condition (independent variable) and craving (dependent variable). Average self-reported nightly sleep duration moderated the relationship between stress condition and craving for participants in the no-stress condition (b = 0.95, p < .05). Specifically, participants in the no-stress condition with lower average nightly sleep duration exhibited significantly greater craving following the opioid cue paradigm. Although preliminary, the findings add to the literature on craving, stress, and sleep among individuals with OUD. Sleep impairment may be an important target of a comprehensive, long-term treatment plan for some patients with OUD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Laboratory-induced stress and craving predict opioid use during follow-up among individuals with prescription opioid use disorder

BACKGROUND

Opioid use disorder (OUD) remains a public health crisis in the USA. Although stress and craving are common precipitants of substance use, no research to date has investigated the impact of laboratory-induced stress and craving on subsequent opioid use.

METHOD

Participants (N = 31) were individuals with prescription OUD who completed a human laboratory study followed by a one-month follow-up visit. Participants were randomly assigned to either a stress task (i.e., Trier Social Tress Task; TSST) or a no-stress condition, and then all participants completed an opioid cue paradigm. Measures of subjective (e.g., stress, craving), and neuroendocrine (e.g., cortisol, dehydroepiandrosterone) reactivity were assessed before and after each task. Survival and regression models tested the association between reactivity to the laboratory tasks and a) time to first opioid use and b) amount of opioid use during follow-up.

RESULTS

On average, participants first used opioids 3.65 (SD = 2.08) days following the study. Craving after the opioid cue paradigm (B = 0.44, Exp(B) = 1.55, 95 % CI [1.06, 2.28], p = .02) and after the TSST/no-stress condition plus opioid cue paradigm (B = 1.06, Exp(B) = 2.88, 95 % CI [1.70, 4.85], p < .001) predicted time to first use. Additionally, there was a significant interaction between randomization to the TSST, stress reactivity, and amount of opioids used.

CONCLUSIONS

Findings demonstrate that elevated cue-induced craving, either in the context of a stressor or not, is associated with shortened time to opioid use, whereas stress reactivity impacts the amount of opioids consumed. Preliminary findings add to the literature on stress, craving and opioid use and implicate treatment.

Responses to social evaluative stress in regular cannabis smokers

BACKGROUND

Aspects of the canonical stress response differ in stimulant, opioid, and alcohol users relative to controls, and dysregulated responses to stress may contribute to continued use of these drugs. Little prior research has focused on stress responses in regular cannabis smokers. We assessed responses to a standardized laboratory social stress assay (the Trier Social Stress Task; TSST) in regular cannabis smokers (CANs) compared with controls (CONs).

METHODS

Healthy, non-treatment-seeking adult CANs (⩾4×/week; smoking cannabis as usual) and demographically matched CONs completed the TSST. Outcome measures were subjective mood, heart rate, and salivary cortisol.

RESULTS

Nineteen CANs (1 female) and 20 CONs (2 female) participated; groups were matched on trauma exposure, sex, race, and age. CANs smoked cannabis 6.4 ± 1.1 days/week. Eight CANs and one CON smoked tobacco cigarettes daily. Overall, the TSST produced expected increases in anxiety, negative mood states, cortisol, and heart rate. CANs had blunted subjective response to stress relative to CONs, but they did not differ in physiological (cortisol and cardiovascular) stress responding.

CONCLUSION

These results indicate that CANs have blunted mood responses to social stress, but normative physiological stress responding. Observed differences could be due to residual effects of cannabis, reluctance to endorse negative mood states, or to issues related to identifying (i.e., emotional identification) or feeling (i.e., interoception) stress-related affective states. Further research is warranted to characterize the mechanisms of these differences and assess implications for daily functioning and treatment outcomes.

Behavioral predictors of individual differences in opioid addiction vulnerability as measured using i.v. self-administration in rats

BACKGROUND

Like other forms of psychopathology, vulnerability to opioid addiction is subject to wide individual differences. Animal behavioral models are valuable in advancing our understanding of mechanisms underlying vulnerability to the disorder's development and amenability to treatment.

METHODS

This review provides an overview of preclinical work on behavioral predictors of opioid addiction vulnerability as measured using the intravenous (i.v.) self-administration (SA) model in rats. We also highlight several new approaches to studying individual differences in opioid addiction vulnerability in preclinical models that could have greater sensitivity and lead to more clinically relevant findings.

RESULTS AND CONCLUSIONS

Evidence for the relationship between various behavioral traits and opioid SA in the preclinical literature is limited. With the possible exceptions of sensitivity to opioid agonist/withdrawal effects and stress reactivity, predictors of individual differences in SA of other drugs of abuse (e.g. sensation-seeking, impulsivity) do not predict vulnerability to opioid SA in rats. Refinement of SA measures and the use of multivariate designs and statistics could help identify predictors of opioid SA and lead to more clinically relevant studies on opioid addiction vulnerability.

Stress Reactivity to the Trier Social Stress Test in Traditional and Virtual Environments: A Meta-Analytic Comparison

OBJECTIVE

The traditional Trier Social Stress Test (TSST) is a widely used standardized stress induction protocol and has recently been adapted in a variety of virtual reality environments (V-TSST). Research has demonstrated the ability of the V-TSST to induce a stress reactivity response measured via cortisol, heart rate, and self-report. However, research comparing stress reactivity induced via the V-TSST to the traditional TSST across neuroendocrine, cardiovascular, and self-report variables has not yet been systematically and quantitatively reviewed.

METHODS

In this meta-analytic review, the existing studies that used V-TSST were gathered, and each was age and sex matched with samples using the traditional TSST. These studies were then meta-analytically synthesized to determine if there was a moderating effect of TSST type (traditional TSST or V-TSST) on multiple measures of stress reactivity (i.e., cortisol, heart rate, and self-report).

RESULTS

Examining the pre-post stress induction, the V-TSST studies demonstrated comparable effect sizes (ESs) for stress reactivity (cortisol ES = 0.61, heart rate ES = 0.98, self-reported stress ES = 0.94) to traditional TSST study ESs (cortisol ES = 0.79, heart rate ES = 0.85, self-reported stress ES = 0.85).

CONCLUSIONS

The TSST type differences between ESs were not statistically significant, indicating that the V-TSST is as effective as the traditional TSST at eliciting a physiological and self-reported stress reactivity response. Implications and limitations of this meta-analysis are discussed, and recommendations for future research are provided.

Ambulatory Assessment Methods to Examine Momentary State-Based Predictors of Opioid Use Behaviors

PURPOSE OF REVIEW

Addiction scientists have begun using ambulatory assessment methods-including ecological momentary assessment (EMA), experience sampling, and daily diaries-to collect real-time or near-real-time reports of participants' internal states in their natural environments. The goal of this short review is to synthesize EMA findings from our research group, which has studied several hundred outpatients during treatment for opioid-use disorder (OUD). (We cite pertinent findings from other groups, but have not tried to be comprehensive.) One of our main goals in using EMA is to examine momentary changes in internal states that proximally predict, or concurrently mark, events such as lapses to opioid use.

RECENT FINDINGS

We summarize findings evaluating several classes of momentary markers or predictors (craving, stress, negative and positive moods, and physical pain/discomfort) of lapses and other states/behaviors. Craving and some negatively valenced mood states are concurrently and prospectively associated with lapses to opioid use during treatment. Craving is also concurrently and prospectively associated with momentary changes in stress and mood. Convincing evidence has not yet emerged for stress as a robust redictor of lapse to opioid use; it appears to be contributory, but neither necessary nor sufficient.

SUMMARY

Ambulatory assessment can capture changes in internal states and drug-related behaviors in situ and at high temporal resolution. We recommend research strategies that may increase the clinical and prognostic utility of ambulatory assessment, including denser sampling (i.e., more assessments per day) and more attention to heterogeneity across people and across populations.

DHEA as a Biomarker of Stress: A Systematic Review and Meta-Analysis

Background: Psychosocial stress is a significant public health problem inducing consequences for quality of life. Results about the use of dehydroepiandrosterone (DHEA) as a biomarker of acute stress are conflicting. We conducted a systematic review and meta-analysis to demonstrate that DHEA levels could be a biomarker of stress. Methods: PubMed, Cochrane Library, Embase, and ScienceDirect databases were searched on March 19, 2021 using the keywords "acute stress" AND "DHEA" OR "Dehydroepiandrosterone." Articles needed to describe our primary outcome, i.e., induction of acute stress and at least two measures of DHEA. Results: We included 14 studies, with a total of 631 participants, in our meta-analysis. The DHEA levels increased overtime after acute stress [standardized mean difference (SMD) = 1.56, 95%CI = 1.13-1.99]. Stratification by time showed a main peak at the end of stress (SMD = 2.43, 95%CI = 1.59-3.27), followed by a progressive decrease (coefficient = -0.11, 95%CI = -0.19 to -0.17, p = 0.020). There was no significant change 1 h after the end of acute stress. Metaregressions showed an impact of mental stress (SMD = 2.04, 95%CI = 1.43-2.65), sex (SMD = 0.02, 95%CI = 0.00-0.04), age (SMD = -0.12, 95%CI = -0.2 to -0.05), and obesity (SMD = 0.31, 95%CI = -0.00 to 0.63). There was no difference whatever the type of fluid (blood or saliva) and the measurement technique used. Conclusions: DHEA is a biomarker of acute stress, with a short-term increase (1 h). DHEA increases following acute mental stress, whatever the type and duration of mental stress. Women, young people, and obese individuals had a higher response. Blood and saliva measures were comparable.

The Impact of Co-occurring Post-traumatic Stress Disorder and Substance Use Disorders on Craving: A Systematic Review of the Literature

The frequent co-occurrence of post-traumatic stress disorder (PTSD) and substance use disorders (SUDs) leads to manifestations of both conditions that are more severe and more resistance to treatment than single disorders. One hypothesis to explain this synergy is the impact of intrusive memories on craving which, in turn, increases the risk of relapse among patients with substance use disorders. The aim of this systematic review is to examine this possibility by assessing the impact of PTSD and its symptoms on craving among dual disorder patients. Using PRISMA criteria, four databases were comprehensively searched up to June, 2021, in order to identify all candidate studies based on broad key words. Resulting studies were then selected if they examined the impact of PTSD or PTSD symptoms on craving, and if they used standardized assessments of PTSD, SUD, and craving. Twenty-seven articles matched the selection criteria and were included in this review. PTSD was found to be significantly associated with increased craving levels among patients with alcohol, cannabis, cocaine, tobacco, and other substance use disorders. Exposition to traumatic cues among dual disorder patients was also shown to trigger craving, with an additive effect on craving intensity when exposure to substance-related cues occurred. In addition, certain studies observed a correlation between PTSD symptom severity and craving intensity. Concerning mechanisms underlying these associations, some findings suggest that negative emotional states or emotion dysregulation may play a role in eliciting craving after traumatic exposure. Moreover, these studies suggest that PTSD symptoms may, independently of emotions, act as powerful cues that trigger craving. These findings argue for the need of dual disorder treatment programs that integrate PTSD-focused approaches and emotion regulation strategies, in addition to more traditional interventions for craving management.

Salivary measurement and mindfulness-based modulation of prescription opioid cue-reactivity

BACKGROUND

Chronic pain patients on long-term opioid therapy (LTOT) may be at elevated risk for developing conditioned opioid cue-reactivity as their prescribed dosing schedules simultaneously function as fixed reinforcement schedules. Since opioids are typically consumed orally during LTOT, it stands to reason that opioid cue exposure might elicit conditioned salivary responses. However, no study has examined salivary cue-reactivity among opioid users during in-vivo exposure to their own prescription opioid medication.

METHODS

Two samples (N = 68, N = 39) of chronic pain patients on LTOT were recruited from primary care and specialty care clinics. Study 1 aimed to determine whether chronic pain patients receiving LTOT exhibited salivary cue-reactivity to their prescribed opioid. Study 2 was a pilot study that aimed to assess the effects of behavioral treatment on chronic pain patients' salivary cue-reactivity.

RESULTS

In Study 1, exposure to the patient's own prescribed opioid resulted in significantly greater increases in salivation and cue-elicited craving than exposure to a neutral cue. In Study 2 participants who were randomized to an 8-week Mindfulness-Oriented Recovery Enhancement intervention evidenced significantly greater decreases in opioid cue-reactivity than participants in an active control condition as evidenced by both reduced salivation and craving ratings.

CONCLUSIONS

Study findings demonstrate salivation may serve as a useful, objective index of opioid cue-reactivity. With further refinement of this task, conditioned salivary response could be used to identify especially vulnerable patients, who then could be targeted with a personalized medicine approach for selective and intensive prevention/treatment interventions to preempt escalation of opioid use to opioid misuse and OUD.

Emotionally valenced stimuli impact response inhibition in those with substance use disorder and co-occurring anxiety and depression symptoms

BACKGROUND

Substance use disorder (SUD) is associated with impaired response inhibition. Given the deficits in emotion regulation associated with SUD, it is unclear if this impairment is exacerbated by emotionally valenced stimuli. Co-occurring conditions may further exacerbate these impairments as many co-occurring conditions further impact emotion regulation. It was hypothesized that negative stimuli may further impact response inhibition for this population.

METHODS

The current study used the stop-signal task to examine response inhibition to negative, neutral and positive stimuli in a sample of those with a history of SUD and co-occurring depression and anxiety symptoms.

RESULTS

Response inhibition was poorer for negative stimuli relative to neutral stimuli. There was no difference between negative and positive stimuli. Depression severity moderated the difference between response inhibition for negative and neutral stimuli. At elevated depression, response inhibition was worse and there was no difference across emotional stimuli. At low depression, there was a significant difference between negative and neutral stimuli. This effect was not found for anxiety symptoms.

LIMITATIONS

Study participants presented with polysubstance use of varying duration and amount. It is unclear whether findings are attributed to specific substances, or substance use broadly. Additionally, happy, angry, and calm facial emotions were used to represent positive, negative, and neutral valences respectively. It is unclear whether these findings are generalizable to other emotional expressions.

CONCLUSION

Results suggested that emotionally valenced stimuli affected response inhibition among those with low symptom severity. At elevated symptom severity, response inhibition to all stimuli were impaired.

Negative Affect-Related Factors Have the Strongest Association with Prescription Opioid Misuse in a Cross-Sectional Cohort of Patients with Chronic Pain

OBJECTIVE

Increased opioid prescription to relieve pain among patients with chronic pain is associated with increased risk for misuse, potentially leading to substance use disorders and overdose death. We aimed to characterize the relative importance and identify the most significant of several potential risk factors for the severity of self-reported prescribed opioid misuse behaviors.

METHODS

A sample of 1,193 patients (mean age ± SD = 50.72 ± 14.97 years, 64.04% female) with various chronic pain conditions completed a multidimensional registry assessing four pain severity measures and 14 physical, mental, and social health status factors using the National Institutes of Health's Patient-Reported Outcomes Measurement Information System (PROMIS). A validated PROMIS measure of medication misuse was completed by 692 patients who endorsed currently taking opioid medication. Patients taking opioid medications were compared across all measures with those who do not take opioid medications. Subsequently, a data-driven regression analysis was used to determine which measures best explained variability in severity of misuse. We hypothesized that negative affect-related factors, namely anxiety, anger, and/or depression, would be key predictors of misuse severity due to their crucial role in chronic pain and substance use disorders.

RESULTS

Patients taking opioid medications had significantly greater impairment across most measures. Above and beyond demographic variables, the only and most significant predictors of prescribed opioid misuse severity were as follows: anxiety (β = 0.15, P = 0.01), anger (β = 0.13, P = 0.02), Pain Intensity-worst (β = 0.09, P = 0.02), and depression (β = 0.13, P = 0.04).

CONCLUSIONS

Findings suggest that anxiety, anger, and depression are key factors associated with prescribed opioid misuse tendencies in patients with chronic pain and that they are potential targets for therapeutic intervention.

Opioid Craving in Human Laboratory Settings: a Review of the Challenges and Limitations

There are many factors that need to be taken into consideration when measuring craving in a human laboratory study. This review summarizes and discusses some of the major challenges researchers are faced with when assessing opioid craving in clinical research. First, there are wide range of available assessments that have been developed for measuring craving and depending on the research questions or the underlying constructs targeted, some may be more appropriate than others. In addition to establishing the methodological point of departure for designing a study with craving, there are also different participant conditions and characteristics that need to be evaluated when selecting among the large selection of assessments available. Participant conditions/characteristics can influence the degree or frequency of opioid craving experienced. Lastly, there can be contextual conditions that affect opioid cravings such as a stressful environment that may alter cue saliency. It is recommended that researchers carefully consider the different constituents that contribute to opioid craving and to ensure a comprehensive evaluation when assessing each participant. A more thorough consideration of these challenges can help us to understand the optimal ways to measure one important and complex component of addiction.

The Opioid-Addicted Tetrapartite Synapse

Opioid administration in preclinical models induces long-lasting adaptations in reward and habit circuitry. The latest research demonstrates that in the nucleus accumbens, opioid-induced excitatory synaptic plasticity involves presynaptic and postsynaptic elements as well as adjacent astroglial processes and the perisynaptic extracellular matrix. We outline opioid-induced modifications within each component of the tetrapartite synapse and provide a neurobiological perspective on how these adaptations converge to produce addiction-related behaviors in rodent models. By incorporating changes observed at each of the excitatory synaptic compartments into a unified framework of opioid-induced glutamate dysregulation, we highlight new avenues for restoring synaptic homeostasis that might limit opioid craving and relapse vulnerability.

Craving and opioid use disorder: A scoping review

INTRODUCTION

The subjective experience of drug craving is a prominent and common clinical phenomenon for many individuals diagnosed with opioid use disorder (OUD), and could be a valuable clinical endpoint in medication development studies. The purpose of this scoping review is to provide an overview and critical analysis of opioid craving assessments located in the published literature examining OUD.

METHOD

Studies were identified through a search of PubMed, Embase, and PsychInfo databases and included for review if opioid craving was the focus and participants were diagnosed with or in treatment for OUD.

RESULTS

Fifteen opioid craving assessment instruments were identified across the 87 studies included for review. The most common were the Visual Analog Scale (VAS, 41 studies), Desires for Drug Questionnaire (DDQ, 12 studies), Heroin Craving Questionnaire (HCQ, 10 studies), and Obsessive-Compulsive Drug Use Scale (OCDUS, 10 studies). Craving assessments varied considerably in their format, content, time frame, and underlying subscales, and only 6 of 15 had been psychometrically evaluated.

DISCUSSION

This review identified a variety of opioid craving assessments, but few had been evaluated for their psychometric properties making it difficult to ascertain whether craving is being assessed optimally in studies of OUD. Thus, the development of a reliable and valid opioid craving assessment would be worthwhile and could be guided by recently published Food and Drug Administration Clinical Outcome Assessment (COA) guidelines. Importantly, a COA focused on opioid craving could be a valuable addition to research studies designed to evaluate novel treatments for OUD.

Stress and opioid use disorder: A systematic review

Medication assisted treatment (MAT) is highly effective in reducing illicit opioid use and preventing overdose in individuals with opioid use disorder (OUD); however, treatment retention of patients engaged in MAT is a significant clinical concern. The experience of stress may contribute to a decision to drop out of treatment. The current study is a systematic review conducted across multiple databases of empirical studies on primary appraisal of stress and its relationship to opioid craving, opioid use, and OUD treatment outcomes. Primary appraisal of stress is defined as an explicit inquiry into individual perception of feeling stressed using a self-report measure administered in laboratory, clinical, or naturalistic environment. A total of 21 included studies were organized into three categories: observed stress, experimentally-induced stress, and stress-focused interventions. Appraised stress was generally associated with greater craving, but associations with opioid use and treatment retention were mixed. All but one study included MAT samples and every study sample included some form of drug counseling. These findings suggest that individuals experience considerable stress in spite of receiving standard treatment for OUD. Psychopharmacological interventions targeting stress were promising, but no behavioral interventions specific to stress management were found. The preliminary results with clonidine and lofexidine targeting stress in individuals with OUD warrant further studies. To better understand the impact of stress in OUD, future research should consider using repeated assessment of stress in the context of daily life. Utilization of behavioral treatments specifically targeting stress could have benefits in improving OUD outcomes.

Psycho-physiological response to pain among individuals with comorbid pain and opioid use disorder: Implications for patients with prolonged abstinence

Background: Individuals with comorbid opioid addiction and pain (COAP) relapse 3-5 times more often than patients with opioid use disorder (OUD) but without pain. However, psychophysiological responses to pain among a COAP population are unknown. Objectives: We hypothesized that those on Medications for Opioid Use Disorder (MOUD) with chronic pain, relative to opioid-naïve chronic pain individuals, would show greater psycho-physiological pain reactivity and slower recovery when exposed to acute pain. Methods: Four groups with chronic pain were recruited (N = 120; 60% Female): 1) MOUD-methadone; 2) MOUD-buprenorphine; 3) history of completed MOUD with prolonged opioid abstinence (PA; M_abstinence = 121 weeks; SD = 23.3); and 4) opioid-naïve. We assessed heart rate (HR), galvanic skin conductance (GSC), peripheral temperature, and frontalis electromyography (EMG) during a cold pain task. Results: MOUD subjects had delayed HR reactivity to pain compared to those not on MOUD (PA & opioid-naïve; F(3,119) = 2.87, p < .04). The PA group showed a normal HR reactivity pattern, but had higher HR compared to the opioid-naïve group. The GSC group x time analysis showed the PA group had greater baseline levels and pain reactivity than the other groups (F(3,119) = 3.84, p < .02). The opioid-naïve group had lower reactivity on peripheral temperature compared to other groups (F(3,119) = 9.69, p < .001). Conclusion: Greater psychophysiological reactivity to pain was experienced by co-morbid OUD/chronic pain subjects who had been opioid abstinent for an extended period, possibly due to the lack of a buffering effect of opioid agonists. These subjects may develop coping skills to tolerate pain distress, thereby avoiding relapse in response to pain triggers. Understanding how pain creates more intense psychophysiological responses among COAP patients may lead to better treatments.

Gender differences in subjective stress and neuroendocrine response to a stress task among individuals with opioid dependence: A pilot study

BACKGROUND

Opioid dependence is a significant public health problem in the United States and the number of opioid overdose deaths among women has increased dramatically in comparison to men in the last few years. In this context, understanding the biological mechanisms underlying gender differences in vulnerability to opioid dependence is essential.

METHODS

The current pilot study examined gender differences in subjective stress, heart rate (HR), and cortisol/dephydroepiandrosterone (DHEA) response to a laboratory stressor (Trier Social Stress Test; TSST) or a no-stress condition, and drug cue paradigm among men (n = 21) and women (n = 18) with opioid dependence.

RESULTS

Significant group (TSST vs. no stress) differences emerged in self-reported stress [F(1,35) = 23.8, p < .001], HR [F(1,31) = 12.3; p = .001] and cortisol (F1,34 = 5.0; p = .032) response, such that the TSST group was more reactive than the no-stress group. Women reported greater subjective stress [F(1,35) = 6.5, p <= .015] in response to the TSST compared to men. However, men evidenced marginally greater cortisol and DHEA responses to the TSST compared to women [F(1,34) = 2.7; p = .113 and F(1,31) = 3.4; p = .073, respectively].

CONCLUSIONS

Although women with opioid dependence reported greater subjective stress when exposed to a laboratory stress paradigm as compared to men, the neuroendocrine response was more robust in men. This pattern was similar to gender findings in men and women with cocaine and tobacco use disorders. The blunted cortisol combined with an increased subjective response among women may be a sign of HPA axis dysregulation which could increase vulnerability to relapse in women.

Non-medical prescription opioid users exhibit dysfunctional physiological stress responses to social rejection

Non-medical prescription opioid use (NMPOU) recently increased dramatically, especially in the U.S. Although chronic opioid use is commonly accompanied by deficits in social functioning and dysregulation of the hypothalamic-pituitary adrenergic (HPA) stress axis, little is known about the impact of NMPOU on psychosocial stress responses. Therefore, we measured physiological responses of the autonomic nervous system and the HPA axis to social rejection using the Cyberball paradigm. We compared 23 individuals with NMPOU, objectively confirmed by hair and urine analyses, with 29 opioid-naïve, healthy controls. As expected, heart rate variability (HRV), an index of parasympathetic activity, increased significantly during exclusion within controls, while in the NMPOU group only a trend in the same direction was found. However, increased HRV was robustly moderated by opioid craving indicating worse emotion regulation to social exclusion specifically in individuals with high opioid craving. Greater levels of the adrenocorticotropic hormone and cortisol responses to social rejection were found in the NMPOU group indicating hyperreactivity of the HPA axis to social exclusion. Self-ratings suggest that opioid users were aware of rejection, but less emotionally affected by exclusion. Furthermore, controls showed greater negative mood after the Cyberball confirming the task's validity. Moreover, NMPOU individuals reported a smaller social network size compared to controls. Present findings suggest that chronic NMPOU is associated with dysfunctional physiological responses to psychosocial stressors such as social rejection. In sum, NMPOU was associated with poorer regulation of the parasympathetic nervous system, especially under opioid craving highlighting its potential importance in relapse prevention.

Impact of early life adversity on the stress biobehavioral response during nicotine withdrawal

Exposure to early life adversity (ELA) is associated with increased subsequent risk for addiction and relapse. We examined changes in psychobiological responses to stress in dependent smokers and nonsmoking controls and evaluated how history of early adversity may exacerbate acute changes during nicotine withdrawal and acute stress. Smokers were randomly assigned to one of two conditions; 24 h withdrawal (66 smokers) from smoking and all nicotine-containing products or smoking ad libitum (46 smokers) prior to an acute laboratory stress induction session; and 44 nonsmokers provided normal referencing. The laboratory session included a baseline rest, stress and recovery periods. Plasma and saliva samples for the measurement stress hormones and cardiovascular and self-report mood measures were collected multiple times during the session. Multivariate analysis confirmed that all groups showed stress-related increases in negative mood, cardiovascular measures and stress hormones, particularly smokers in the withdrawal condition. Individuals with high ELA showed greater adrenocorticotropic hormone (ACTH), but lower plasma and salivary cortisol levels, than those with low ELA. Cortisol differences were abolished during tobacco withdrawal. These findings demonstrate that ELA moderates the effects of withdrawal on stress-related biobehavioral changes.

Social defeat stress and escalation of cocaine and alcohol consumption: Focus on CRF

Both the ostensibly aversive effects of unpredictable episodes of social stress and the intensely rewarding effects of drugs of abuse activate the mesocorticolimbic dopamine systems. Significant neuroadaptations in interacting stress and reward neurocircuitry may underlie the striking connection between stress and substance use disorders. In rodent models, recurring intermittent exposure to social defeat stress appears to produce a distinct profile of neuroadaptations that translates most readily to the repercussions of social stress in humans. In the present review, preclinical rodent models of social defeat stress and subsequent alcohol, cocaine or opioid consumption are discussed with regard to: (1) the temporal pattern of social defeat stress, (2) male and female protocols of social stress-escalated drug consumption, and (3) the neuroplastic effects of social stress, which may contribute to escalated drug-taking. Neuroadaptations in corticotropin-releasing factor (CRF) and CRF modulation of monoamines in the ventral tegmental area and the bed nucleus of the stria terminalis are highlighted as potential mechanisms underlying stress-escalated drug consumption. However, the specific mechanisms that drive CRF-mediated increases in dopamine require additional investigation as do the stress-induced neuroadaptations that may contribute to the development of compulsive patterns of drug-taking.

Gender moderates the association between distress tolerance and alcohol use among individuals with opioid use disorder

BACKGROUND

Alcohol use among individuals with opioid use disorder (OUD) can be dangerous, and understanding factors contributing to alcohol use in this population is important. The current study examined alcohol use among individuals with prescription OUD based on distress tolerance. It was hypothesized that individuals with greater distress tolerance abilities would have a lower frequency and quantity of alcohol use compared to individuals with less distress tolerance. It was also hypothesized that this association would differ based on gender.

METHODS

A total of 122 individuals with prescription OUD participated in the current study. Participants completed questionnaires regarding demographics, distress tolerance, mental health symptoms, and frequency and quantity of alcohol in the past 30 days. A regression model was conducted using the alcohol-related variables as outcomes.

RESULTS

There was a significant interaction between gender and distress tolerance on alcohol use frequency. Greater distress tolerance was associated with fewer alcohol use days in women, but there was no association between distress tolerance and alcohol use days in men.

CONCLUSIONS

The findings suggest that distress tolerance skills may be key to reducing alcohol use in women with prescription OUD.

Exacerbated Craving in the Presence of Stress and Drug Cues in Drug-Dependent Patients

In addiction, risk factors for craving and use include stress and drug-related cues. Stress and cues have additive or more-than-additive effects on drug seeking in laboratory animals, but, surprisingly, seem to compete with one another (ie, exert less-than-additive effects) in human laboratory studies of craving. We sought heretofore elusive evidence that human drug users could show additive (or more-than-additive) effects of stress and cues on craving, using ecological momentary assessment (EMA). Outpatients (N=182) maintained on daily buprenorphine or methadone provided self-reports of stress, craving, mood, and behavior on electronic diaries for up to 16 weeks. In three randomly prompted entries (RPs) per day, participants reported the severity of stress and craving and whether they had seen or been offered opioids, cocaine, cannabis, methamphetamine, alcohol, or tobacco. In random-effects models controlling for between-person differences, we tested effects of momentary drug-cue exposure and stress (and their interaction) on momentary ratings of cocaine and heroin craving. For cocaine craving, the Stress × Cue interaction term had a positive mean effect across participants (M=0.019; CL95 0.001-0.036), denoting a more-than-additive effect. For heroin, the mean was not significantly greater than 0, but the confidence interval was predominantly positive (M=0.019; CL95 -0.007-0.044), suggesting at least an additive effect. Heterogeneity was substantial; qualitatively, the Stress × Cue effect appeared additive for most participants, more than additive for a sizeable minority, and competitive in very few. In the field, unlike in human laboratory studies to date, craving for cocaine and heroin is greater with the combination of drug cues and stress than with either alone. For a substantial minority of users, the combined effect may be more than additive.

Problematic internet users' skin conductance and anxiety increase after exposure to the internet

INTRODUCTION

To examine the impact of cessation of an internet session on skin conductance responses and anxiety of higher and lower problem internet users, in order to explore possible physiological withdrawal effects.

METHOD

Participants were measured in terms of their skin conductance before (15min), during (15min), and after (15min) an internet session, and completed self-report measures of state anxiety and problematic internet use.

RESULTS

Higher, but not lower, problem users showed increased skin conductance after internet use was stopped, relative to before their internet session. Higher problem users' GSR scores increased, as the time from internet cessation became longer. Higher problem users also showed increased levels of anxiety, following their internet session, which correlated with their skin conductance scores.

CONCLUSIONS

These results suggest that, following termination of an internet session, withdrawal-like effects are seen, both psychologically and physiologically.

Development of an integrated cognitive behavioral therapy for anxiety and opioid use disorder: Study protocol and methods

Opioid use disorder is a highly disabling psychiatric disorder, and is associated with both significant functional disruption and risk for negative health outcomes such as infectious disease and fatal overdose. Even among those who receive evidence-based pharmacotherapy for opioid use disorder, many drop out of treatment or relapse, highlighting the importance of novel treatment strategies for this population. Over 60% of those with opioid use disorder also meet diagnostic criteria for an anxiety disorder; however, efficacious treatments for this common co-occurrence have not be established. This manuscript describes the rationale and methods for a behavioral treatment development study designed to develop and test an integrated cognitive-behavioral therapy for those with co-occurring opioid use disorder and anxiety disorders. The aims of the study are (1) to develop and pilot test a new manualized cognitive behavioral therapy for co-occurring opioid use disorder and anxiety disorders, (2) to test the efficacy of this treatment relative to an active comparison treatment that targets opioid use disorder alone, and (3) to investigate the role of stress reactivity in both prognosis and recovery from opioid use disorder and anxiety disorders. Our overarching aim is to investigate whether this new treatment improves both anxiety and opioid use disorder outcomes relative to standard treatment. Identifying optimal treatment strategies for this population are needed to improve outcomes among those with this highly disabling and life-threatening disorder.