Gender and nonmedical prescription opioid use and DSM-5 nonmedical prescription opioid use disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions - III

Sex differences in sensitivity to fentanyl effects in mice: Behavioral and molecular findings during late adolescence

PURPOSE

Sex differences play a crucial role in understanding vulnerability to opioid addiction, yet there have been limited preclinical investigations of this effect during the transition from adolescence to adulthood. The present study compared the behaviors of male and female rodents in response to fentanyl treatment and targeted molecular correlates in the striatum and medial prefrontal cortex.

MATERIALS AND METHODS

Thirty adolescent C57BL/6J mice underwent a 1-week fentanyl treatment with an escalating dose. In addition to evaluating locomotor activity and anxiety-related parameters, we also assessed naloxone-induced fentanyl acute withdrawal jumps. We employed real-time quantitative PCR (qPCR) to assess overall gene expression of dopaminergic receptors (Drd1, Drd2, Drd4 and Drd5) and the μ-opioid receptor Oprm1. The levels of epigenetic base modifications including 5-methylcytosine (5mC) and 5-hydroxymethylcytosine (5hmC) were assessed on CpG islands of relevant genes.

RESULTS

Females had higher locomotor activity than males after chronic fentanyl treatment, and they exhibited higher fentanyl withdrawal jumping behavior induced by naloxone. Females also presented lower Drd4 gene expression and DNA methylation (5mC + 5hmC) in the striatum. We found that locomotor activity and fentanyl withdrawal jumps were negatively correlated with Drd4 methylation and gene expression in the striatum, respectively.

CONCLUSIONS

The findings suggested that female mice displayed heightened sensitivity to the effects of fentanyl treatment during the transition from adolescence to adulthood. This effect may be associated with molecular alterations related to the Drd4 gene.

Associated factors to non-medical and medical use of psychoactive medication among Mexican adolescents and adults in a national household survey

BACKGROUND

Non-medical use of psychoactive medication is a public health problem. Studies in other contexts indicate that individual sociodemographic characteristics are associated with non-medical use, but these associations have not been assessed in the Mexican context.

OBJECTIVES

To estimate the prevalence non-medical and medical use of psychoactive medication among Mexican adolescents and adults' medication users and to estimate the associations between sociodemographic characteristics and non-medical use of psychoactive medication, using data from a nationally representative sample.

METHODS

Secondary analysis of data collected from the National Survey of Drug, Alcohol, and Tobacco Consumption (ENCODAT) 2016 to 2017. The analytical sample included people aged 12 to 65 years. The sample was stratified into two age categories: adolescents (12-17 years) and adults (18-65 years). Sub-analyses were performed to describe prevalence of use and non-medical use of psychoactive medication at the state-level. Descriptive statistics and multinomial logistic regression models were used to estimate associations between sociodemographic characteristics and medical, non-medical, and non-use of psychoactive medication in adolescents and adults.

RESULTS

Among Mexican medication users in 2016, the national prevalence of non-medical use of psychoactive drugs was 19.6%; 22.2% among adolescents and 19.4% among adults. States adjacent to the US-Mexico border reported the highest levels of non-medical use of psychoactive medication. Illicit drug consumption was associated with non-medical use. Sociodemographic characteristics associated with non-medical use varied between adolescents and adults.

CONCLUSIONS

There is a high proportion of non-medical use of psychoactive drugs among Mexican medication users, especially among young people. Understanding factors associated with the misuse of psychoactive medications in Mexico can inform policy for prevention and treatment.

Gender differences in the prevalence of stimulant misuse in the United States: 2015-2019

BACKGROUND AND OBJECTIVES

The gender gap in prevalence of substance-use disorders has narrowed. However, gender differences in stimulant misuse have not been well-characterized in recent years. The aim of this study was to quantify gender differences in past-year stimulant misuse and stimulant-use disorder, separated by stimulant type (cocaine/crack, prescription stimulants, and methamphetamine). In an exploratory aim, we investigated whether gender differences were moderated by age or sexual orientation.

METHODS

We combined data from the National Survey on Drug Use and Health from 2015 to 2019 (unweighted N = 282,768) to test gender differences in the prevalence of past-year stimulant misuse.

RESULTS

Results indicated that stimulant misuse was significantly more prevalent in men than women for all stimulant types for both past-year use and past-year use disorder. The magnitude of this sex difference was smallest for prescription stimulants, where men had 1.37 times higher odds of past-year misuse and no gender difference was observed in the prevalence of prescription stimulant-use disorder. The magnitude of gender differences also varied based on both age and sexual orientation.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Illicit stimulant misuse continues to be more common in men than in women; however, gender differences are more modest for prescription stimulant misuse, suggesting a narrowing of this historical gender difference.

Blood Oxygenation and Heart Rate Changes After Diamorphine Intravenous Injection During Opioid Agonist Treatment for Outpatients With Heroin Dependence

OBJECTIVES

More than 60 million people use opioids each year, and many countries have declared an opioid overdose crisis. Heroin, one of the most commonly used opioids, has depressant effects on autonomic functioning; however, few studies have been able to examine the effects of heroin or its pharmaceutically prepared equivalent, diamorphine, in human clinical populations. The present study examined heart rate and oxygen saturation in the minutes immediately after acute diamorphine administration in outpatients with heroin dependence.

METHODS

The sample was a subset of participants (N = 36) in the German Project of Heroin Assisted Treatment of Opiate Dependent Patients Trial in Bonn, Germany. Patients were given 3 daily doses of intravenous diamorphine. Doses were determined on an individual basis by study physicians. Pulse oximetry was recorded at baseline and at 30-second intervals from 0 to 450 seconds after diamorphine administration.

RESULTS

Heart rate was significantly higher than baseline at 30 seconds after diamorphine administration and significantly lower than baseline at 270 seconds onward. Oxygen saturation was significantly lower than baseline at 60 seconds onward.

CONCLUSIONS

Results are consistent with other studies in which depressant effects of opioids were observed. Our findings suggest that even therapeutic doses of diamorphine may have rapid and significant-predominantly depressant-effects on oxygenation and heart rate in populations that frequently use opioids. Monitoring of potential adverse opioid effects would be beneficial even in populations presumed to have developed physiological tolerance.

Nativity and the risk of opioid use disorder among Hispanic/Latinx women in primary care in Los Angeles, CA

BACKGROUND

While rates of opioid use disorder (OUD) are lower among women compared to men, nativity may have disproportionate impacts on OUD risk among Hispanic/Latinx women but remain understudied.

OBJECTIVE

To assess the association between country of birth and reported OUD risk among low-income Hispanic/Latinx women in primary care in Los Angeles, CA.

METHODS

This was a cross-sectional study of 1189 non-pregnant, Hispanic/Latinx women attending two federally qualified health centers in Los Angeles between March and July 2013. OUD risk was assessed using the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST), and moderate-to-high risk was defined as ASSIST score ≥ 4.

RESULTS

Overall, 4.2% of women (n = 49) were at moderate-to-high risk for OUD. Risk for OUD was higher among US-born women compared to foreign-born women (6.7 vs. 1.7%; p < .01), those who reported 2+ chronic medical conditions (p < .01), and those who were at moderate-to-high risk for other substance use disorders (p < .01). In multivariable logistic regression analyses, being U.S.-born was independently associated with being at moderate-to-high risk for OUD among Hispanic/Latinx women as compared to those who were foreign-born (AOR = 2.8; 95% CI 1.2-6.8).

CONCLUSION

Among low-income Hispanic/Latinx women presenting to primary care, one in twenty patients is at-risk for OUD. The odds of moderate-high risk of OUD were three times as high in US-born compared to foreign-born women, and higher among those with chronic medical conditions and those at risk of other substance use disorders. Gender-specific and culturally-tailored screening for OUD may inform overdose prevention interventions for US-born Hispanic/Latinx women.

Functional genomic mechanisms of opioid action and opioid use disorder: a systematic review of animal models and human studies

In the past two decades, over-prescription of opioids for pain management has driven a steep increase in opioid use disorder (OUD) and death by overdose, exerting a dramatic toll on western countries. OUD is a chronic relapsing disease associated with a lifetime struggle to control drug consumption, suggesting that opioids trigger long-lasting brain adaptations, notably through functional genomic and epigenomic mechanisms. Current understanding of these processes, however, remain scarce, and have not been previously reviewed systematically. To do so, the goal of the present work was to synthesize current knowledge on genome-wide transcriptomic and epigenetic mechanisms of opioid action, in primate and rodent species. Using a prospectively registered methodology, comprehensive literature searches were completed in PubMed, Embase, and Web of Science. Of the 2709 articles identified, 73 met our inclusion criteria and were considered for qualitative analysis. Focusing on the 5 most studied nervous system structures (nucleus accumbens, frontal cortex, whole striatum, dorsal striatum, spinal cord; 44 articles), we also conducted a quantitative analysis of differentially expressed genes, in an effort to identify a putative core transcriptional signature of opioids. Only one gene, Cdkn1a, was consistently identified in eleven studies, and globally, our results unveil surprisingly low consistency across published work, even when considering most recent single-cell approaches. Analysis of sources of variability detected significant contributions from species, brain structure, duration of opioid exposure, strain, time-point of analysis, and batch effects, but not type of opioid. To go beyond those limitations, we leveraged threshold-free methods to illustrate how genome-wide comparisons may generate new findings and hypotheses. Finally, we discuss current methodological development in the field, and their implication for future research and, ultimately, better care.

Clinical and psychosocial outcomes by sex among individuals prescribed buprenorphine-naloxone (BUP-NX) or extended-release naltrexone (XR-NTX) for opioid use disorder

BACKGROUND AND OBJECTIVES

Limited research has explored sex differences in opioid use disorder medication (MOUD) treatment outcomes. The purpose of this study was to examine MOUD initiation onto buprenorphine-naloxone (BUP-NX) versus extended-release naltrexone (XR-NTX) by sex, and sex differences in clinical and psychosocial outcomes.

METHODS

Using data from a 24-week open-label comparative effectiveness trial of BUP-NX or XR-NTX, this study examined MOUD initiation (i.e., receiving a minimum one XR-NTX injection or first BUP-NX dose) and 24-week self-report outcomes. We used regression models to estimate the probability of MOUD initiation failure among the intent-to-treat sample (N = 570), and the main and interaction effects of sex on outcomes of interest among the subsample of participants who successfully initiated MOUD (n = 474).

RESULTS

In the intent-to-treat sample, the odds of treatment initiation failure were not significantly different by sex. In the subsample of successful MOUD initiates, the effect of treatment on employment at week 24 was significantly moderated by sex (p = .003); odds of employment were not significantly different among males by MOUD type; females randomized to XR-NTX versus BUP-NX had 4.63 times greater odds of employment (p < .001). Males had significantly lower odds of past 30-day exchanging sex for drugs versus females (adjusted odds ratios [aOR] = 0.10, p = .004), controlling for treatment and baseline outcomes.

DISCUSSION AND CONCLUSIONS

Further research should explore how to integrate employment support into OUD treatment to improve patient outcomes, particularly among women.

SCIENTIFIC SIGNIFICANCE

The current study addressed gaps in the literature by examining sex differences in MOUD initiation and diverse treatment outcomes in a large, national sample.

Overdose mortality rates for opioids and stimulant drugs are substantially higher in men than in women: state-level analysis

Drug overdoses from opioids and stimulants are a major cause of mortality in the United States. It is unclear if there are stable sex differences in overdose mortality for these drugs across states, whether these differ across the lifespan, and if so, whether they can be accounted for by different levels of drug misuse. This was a state-level analysis of epidemiological data on overdose mortality, across 10-year age bins (age range: 15-74), using the CDC WONDER platform for decedents in the United States in 2020-1. The outcome measure was rate of overdose death (per 100,000) for: synthetic opioids (e.g., fentanyl), heroin, psychostimulants with potential for misuse (e.g., methamphetamine), and cocaine. Multiple linear regressions controlled for ethnic-cultural background, household net worth, and sex-specific rate of misuse (from NSDUH, 2018-9). For all these drug categories, males had greater overall overdose mortality than females, after controlling for rates of drug misuse. The mean male/female sex ratio of mortality rate was relatively stable across jurisdictions: synthetic opioids (2.5 [95% CI, 2.4-7]), heroin, (2.9 [95% CI, 2.7-3.1], psychostimulants (2.4 [95% CI, 2.3-5]), and cocaine (2.8 [95% CI, 2.6-9]). With data stratified in 10-year age bins, the sex difference generally survived adjustment (especially in the 25-64 age range). Results indicate that males are significantly more vulnerable than females to overdose deaths caused by opioid and stimulant drugs, taking into account differing state-level environmental conditions and drug misuse levels. These results call for research into diverse biological, behavioral, and social factors that underlie sex differences in human vulnerability to drug overdose.

Trauma and Resilience in Adolescents and Young Adults With Opioid Use and Eating Disorders

Substance use disorders and feeding and eating disorders (FEDs) often manifest in early adolescence, are difficult to treat, and tend to co-occur. Despite their co-occurrence, little is known about their shared risk factors. A cross-sectional study was conducted to compare standardized measures of adverse childhood experiences (ACEs) and protective factors among 90 adolescents and young adults seeking outpatient treatment for either opioid use disorder (OUD) or an FED. These were assessed using the Modified Adverse Childhood Experience Survey and Southern Kennebec Healthy Start Resilience Survey. Reported ACEs were high in both groups compared with the national average, and those with OUD were more likely to endorse ≥4 resilience factors. Meanwhile, the prevalence of emotional neglect, household mental illness, and peer victimization/isolation/rejection was similar between groups. Opioid use disorder patients were also less likely to endorse ≥9 resilience factors. Health providers should be mindful to assess for trauma and resiliency in both these populations.

To be aware, or to accept, that is the question: Differential roles of awareness of automaticity and pain acceptance in opioid misuse

BACKGROUND

Individuals with chronic low back pain (CLBP) are commonly prescribed long-term opioid therapy (LTOT) for analgesia, placing this population at increased risk for opioid misuse and opioid use disorder. Acceptance of aversive experiences (e.g., chronic pain) and awareness of automatic thoughts and behaviors (i.e., automaticity) are two facets of dispositional mindfulness that may serve as protective mechanisms against opioid misuse risk. Therefore, the aim of the current study was to examine the differential contributions of these constructs to opioid misuse risk among adults with CLBP receiving LTOT.

METHODS

Data were obtained from a sample of 770 adults with opioid-treated CLBP. Bivariate correlations and hierarchical linear regression analyses were used to determine whether chronic pain acceptance and awareness of automatic thoughts and behaviors explained a statistically significant portion of variance in opioid misuse risk after accounting for the effects of other relevant confounders.

RESULTS

Hierarchical regression results revealed that chronic pain acceptance and awareness of automatic thoughts and behaviors contributed a significant portion in the variance of opioid misuse risk. Awareness of automatic thoughts and behaviors was negatively associated with opioid misuse risk, such that individuals with lower levels of awareness of automaticity were at higher risk of opioid misuse. By contrast, pain acceptance was not associated with opioid misuse.

CONCLUSIONS

Findings suggest that awareness of automaticity may buffer against opioid misuse risk. Interventions designed to strengthen awareness of automaticity (e.g., mindfulness-based interventions) might be especially efficacious among this population.

Sex differences in the associations of non-medical use of prescription drugs with depressive and anxiety symptoms among undergraduates in China

BACKGROUND

Non-medical use of prescription drugs (NMUPD) and their association with depression and anxiety are becoming global concerns. Biological sex may introduce differential exposure to NMUPD or depressive/anxiety symptoms. However, few studies have investigated the potential sex differences in the associations of NMUPD with depressive/anxiety symptoms.

METHODS

Data were drawn from the 2019 School-based Chinese College Students Health Survey. A total of 30,039 undergraduates (mean age: 19.8 [SD: 1.3] years) from sixty universities/colleges in China completed standard questionnaires and were included in the study (response rate: 97.7 %).

RESULTS

In the final adjusted model, non-medical use of opioids (experimenters: β = 1.10, [95 % CI, 0.62 to 1.57]) or sedatives (frequent users: β = 2.98, [95 % CI, 0.70 to 5.26]) was associated with depressive symptoms, while non-medical use of opioids (frequent users: β = 1.37, [95 % CI, 0.32 to 2.42]) or sedatives (frequent users: β = 1.19, [95 % CI, 0.35 to 2.03]) was also associated with anxiety symptoms. Sex-stratified analyses indicated that lifetime opioids misuse was associated with depressive symptoms in both sexes but with anxiety symptoms only in males (β = 0.39, [95 % CI, 0.09 to 0.70]). The association of lifetime sedative misuse with depressive symptoms was greater in males, while the significant association with anxiety symptoms remained only in female (β = 0.52, [95 % CI, 0.14 to 0.91]).

LIMITATIONS

Causal inference cannot be made due to the cross-sectional nature of the data.

CONCLUSIONS

Our study suggests NMUPD is associated with depressive and anxiety symptoms among Chinese undergraduates, and the associations may differ by sex.

Concurrent and proximal associations among PTSD symptoms, prescription opioid use, and co-use of other substances: Results from a daily monitoring study

OBJECTIVE

Posttraumatic stress disorder (PTSD) and nonmedical prescription opioid use (NMPOU) are linked. Much of the research documenting this association uses cross-sectional or longitudinal designs that describe patterns of use over extended intervals. The present study used a daily monitoring design to examine how daily fluctuations in PTSD symptoms predicted patterns of prescription opioid use (both medical and nonmedical) and co-use of other substances. This approach has distinct advantages for understanding proximal temporal relations between PTSD symptom variation and substance use patterns.

METHOD

Forty adults with clinical or subclinical PTSD and past-month NMPOU completed daily measures of PTSD symptoms, physical pain, prescription opioid use, and other substance use for 28 days using a smartphone application.

RESULTS

Same day co-use of prescription opioids and at least one other substance was common. Higher-than-typical PTSD symptoms on a given day (within-person) was associated with an increased likelihood of reporting NMPOU (overall and with co-use of one or more additional substances) on the same day. This association was specific to PTSD alterations in arousal and reactivity symptoms (Criteria E). Neither total PTSD symptoms nor individual PTSD symptom clusters prospectively predicted next-day prescription opioid use (overall or with co-use). Use of prescription opioids also did not predict next-day PTSD symptom severity.

CONCLUSION

This is the first study to demonstrate positive associations between day-to-day fluctuations in PTSD symptoms and NMPOU. Results from the current study also highlight the importance of examining polysubstance use patterns among individuals with PTSD who use prescription opioids. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Burden of disease due to amphetamines, cannabis, cocaine, and opioid use disorders in South America, 1990-2019: a systematic analysis of the Global Burden of Disease Study 2019

BACKGROUND

South America's substance use profile, poverty, income inequality, and cocaine-supplier role make it a unique place for substance use research. This study investigated the burden of disease attributable to amphetamine use disorder, cannabis use disorder (CAD), cocaine use disorder, and opioid use disorder (OUD) in South America from 1990 to 2019, on the basis of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019.

METHODS

GBD 2019 estimated the incidence, prevalence, mortality, years of life lost (YLL), years of life lived with disability (YLD), and disability-adjusted life-years (DALYs) due to substance use disorders in each of the 12 South American countries (Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Guyana, Paraguay, Peru, Suriname, Uruguay, and Venezuela). Data were modelled using standardised tools (ie, the Cause of Death Ensemble model, spatio-temporal Gaussian process regression, and disease modelling meta-regression) to generate estimates of each quantity of interest by sex, location, and year. The analysis included comparisons by sex and country, and against regional and global estimates.

FINDINGS

In 2019, the highest amphetamine use disorder burden per 100 000 population in South America was in Peru (66 DALYs). CAD DALY rates per 100 000 in South America were stable between 1990 and 2019, except in Chile and Colombia, which had the highest rates in 2019 (19 DALYs for Chile and 18 DALYs for Colombia). OUD DALYs per 100 000 increased during the period in Brazil and Peru, which in 2019 had the highest rates in South America (82 DALYs for Brazil and 70 DALYs for Peru). In 2019, Brazil had the highest cocaine use disorder DALYs per 100 000 (45 DALYs), nearly double its rate in 1990. DALY rates were higher in males than females for each substance use disorder, except in Paraguay. The overall burden of substance use disorders was higher in males than in females, mainly because of cocaine use disorder and CAD, whereas for amphetamine use disorder, the difference between sexes was minimal, and for OUD there was no difference. For males and females, the highest rate of substance use disorders DALYs per 100 000 was for OUD except in Argentina (in males, 58 DALYs for cocaine use disorder vs 52 DALYs for OUD) and in Paraguay (in females, 77 for amphetamine use disorder vs 50 for OUD). CAD DALY rates were generally the lowest among the substance use disorders for males and females. Amphetamine use disorder YLD rates were reasonably stable throughout the period and were highest in Peru, Paraguay, and Uruguay (>40 YLD per 100 000). For CAD, YLD rates were stable in all countries except Chile and Colombia. Cocaine use disorder YLD rates per 100 000 for the top four countries (Argentina, Uruguay, Chile, and Brazil) increased from 1990 to 2010 (eg, from 19 to 33 in Brazil), but decreased between 2010 and 2019 (eg, from 36 to 31 in Chile). For OUD, YLD rates showed a slight increase in most countries apart from Brazil, which increased from 52 in 1990 to 80 in 2019 and was top among the countries. Amphetamine use disorder YLL rates per 100 000 were highest in Suriname and Peru during the period, although in Suriname it increased from 2·7 in 2010 to 3·2 in 2019, whereas in Peru it decreased from 2·1 to 1·7. The highest YLL rate for cocaine use disorder was in Brazil, which increased from 3·7 in 1990 to 18·1 in 2019. Between 2000 and 2019, Chile and Uruguay showed the highest OUD YLL rates (11·6 for Chile and 10·9 for Uruguay). A high incidence of CAD was found in Chile, Colombia, Guyana, and Suriname. There were high incidences of amphetamine use disorder in Paraguay, cocaine use disorder in Argentina, and OUD in Ecuador. A decrease in annual prevalence for substance use disorders during the period was observed in Venezuela (amphetamine use disorder, CAD, and OUD), Brazil (CAD and amphetamine use disorder), Colombia (amphetamine use disorder and cocaine use disorder), Peru (amphetamine use disorder and cocaine use disorder), Chile and Suriname (amphetamine use disorder), Uruguay (CAD), and Bolivia (OUD). Overall, the cocaine use disorder burden stabilised then decreased. OUD was less prevalent than other substance use disorders but its burden was the highest.

INTERPRETATION

The decrease in the burden of cocaine use disorder probably reflects the success of national standardised treatment programmes. Programmes for amphetamine use disorder, CAD, and OUD management should be improved. We did not find an increase in CAD burden in Uruguay, the country with the highest degree of cannabis decriminalisation in the region. Countries in South America should improve monitoring of substance use disorders, including regular surveys to provide more accurate data on which to base policy decisions.

FUNDING

The Bill & Melinda Gates Foundation.

The State of the Research on Opioid Outcomes Among Lesbian, Gay, Bisexual, Transgender, Queer, and Other Sexuality- and Gender-Diverse Populations: A Scoping Review

Purpose: Research on opioid misuse, opioid use disorder (OUD), and overdose (i.e., opioid outcomes) among lesbian, gay, bisexual, transgender, queer, and other populations within the LGBTQ umbrella (LGBTQ+) remains sparse. The purpose of this scoping review was to characterize the state of the research on opioid outcomes among LGBTQ+ populations, and identify gaps in the extant literature and areas for future research. Methods: We conducted a scoping review of peer-reviewed, English language articles published between 2011 and 2020 that examined opioid outcomes among LGBTQ+ populations in the CINAHL, Embase, PubMed, and PsycINFO databases. We extracted data from articles that focused on opioid outcomes within their specific aims or purpose. We include a general summary for articles that secondarily described opioid outcomes among LGBTQ+ populations. Results: Of 113 published studies that examined opioid outcomes among LGBTQ+ populations, 10% (n = 11) were specifically designed to focus on this topic. Across studies, bisexual populations, particularly women, were at highest risk for opioid misuse and OUD. Few studies examined opioid outcomes by more than one dimension of sexual orientation (n = 3, 27%), race and/or ethnicity (n = 3, 27%), or age (n = 5, 45%). Only two included transgender or gender diverse samples; only one explicitly measured gender identity. Conclusions: Future research is needed to understand the impact of the opioid epidemic on LGBTQ+ people, particularly transgender and other gender diverse individuals, and the intersectional role of race, ethnicity, and age in opioid disparities among LGBTQ+ individuals. Additional research could contribute to the development of much-needed affirming OUD treatment and other services for LGBTQ+ people.

Gender differences among persons entering medication treatment for opioid use disorder in the community

BACKGROUND AND OBJECTIVES

We evaluated gender differences among persons initiating medications for opioid use disorder (MOUD).

METHODS

Analyses of baseline assessments for a study evaluating the impact of MOUD on outcomes included: demographics, DSM-5 diagnoses, depression severity, quality of life (QoL), and medication history (N = 125).

RESULTS

When compared to men, women had a greater prevalence of generalized anxiety and posttraumatic stress disorders; and worse psychological QoL. Women were less likely to be prescribed psychiatric medications.

DISCUSSION AND CONCLUSIONS

Women may benefit from tailored multidisciplinary programs with MOUD.

SCIENTIFIC SIGNIFICANCE

This study identified that women with OUD seeking MOUD in the community had greater sedative hypnotic nonprescribed medication use and psychiatric comorbidity than men, all of which can contribute to poorer retention on MOUD and higher risk of morbidity and mortality. Thus, concurrent psychiatric disorder screening and treatment integrated with MOUD may improve retention on MOUD, opioid relapse and overdose for women.

Predicting the Onset of Opioid Use Disorder in the Swedish General Population

OBJECTIVE

Given the public health importance of opioid use disorder (OUD), we sought to understand better its risk predictors in the Swedish general population.

METHOD

We examined the Swedish population, born 1950-1970 (n = 2,092,359), and followed through 2018. Using Cox, logistic, and co-sibling models, we explored associations between a wide range of putative risk factors and a first onset of OUD--assessed through medical, criminal, and pharmacy registers--in the entire cohort and in the cohort wherein prior cases of drug use disorder (DUD) were censored.

RESULTS

OUD was predicted by the following four risk factor domains: (a) externalizing syndromes, especially prior non-opioid DUD; (b) psychopathology; (c) psychosocial factors, including social class and immigrant and marital status; and (d) serious injuries and pain diagnoses. When predicting OUD as the first form of DUD, the importance of pain diagnoses as a predictor increased. Co-sibling analyses suggested that the association of some of these risk factors with OUD onset was likely largely causal, whereas others were a mixture of causal effects and familial confounding. An aggregate risk score from these individual risk factors had reasonable receiver operating characteristic (ROC) curve performance.

CONCLUSIONS

OUD is a multifactorial syndrome for which risk can be meaningfully predicted by prior externalizing syndromes, internalizing and psychotic psychopathology, indicators of psychosocial status, and predictors of pain diagnoses. Some important differences were seen in the prediction of any OUD onset versus OUD onset as the first form of DUD. Much of the effect of these predictors appear, in co-sibling analyses, to likely reflect causal influences.

Health harms of non-medical prescription opioid use: A systematic review

ISSUES

Non-medical prescription opioid use (NMPOU) contributes substantially to the global burden of morbidity. However, no systematic assessment of the scientific literature on the associations between NMPOU and health outcomes has yet been undertaken.

APPROACH

We undertook a systematic review evaluating health outcomes related to NMPOU based on ICD-10 clinical domains. We searched 13 electronic databases for original research articles until 1 July 2021. We employed an adaptation of the Oxford Centre for Evidence-Based Medicine 'Levels of Evidence' scale to assess study quality.

KEY FINDINGS

Overall, 182 studies were included. The evidence base was largest on the association between NMPOU and mental and behavioural disorders; 71% (129) studies reported on these outcomes. Less evidence exists on the association of NMPOU with infectious disease outcomes (26; 14%), and on external causes of morbidity and mortality, with 13 (7%) studies assessing its association with intentional self-harm and 1 study assessing its association with assault (<1%).

IMPLICATIONS

A large body of evidence has identified associations between NMPOU and opioid use disorder as well as on fatal and non-fatal overdose. We found equivocal evidence on the association between NMPOU and the acquisition of HIV, hepatitis C and other infectious diseases. We identified weak evidence regarding the potential association between NMPOU and intentional self-harm, suicidal ideation and assault.

DISCUSSION AND CONCLUSIONS

Findings may inform the prevention of harms associated with NMPOU, although higher-quality research is needed to characterise the association between NMPOU and the full spectrum of physical and mental health disorders.

Opioid-related risk perceptions in chronic pain: influence of patient gender and previous misuse behaviors

ABSTRACT

Little is known about the factors that influence providers' perceptions of patient risk for aberrant opioid use. Patient gender may interact with previous opioid misuse to influence these perceptions. We asked 131 physicians to view videos and vignettes for 8 virtual patients with chronic pain. Gender (male/female) and previous prescription opioid misuse (present/absent) varied across patients; the vignettes were otherwise balanced on demographic and clinical characteristics. For each patient, providers assessed 4 risk domains: opioid-related adverse events, opioid misuse or abuse, opioid addiction, and opioid diversion. Results indicated a significant gender-by-misuse interaction for risk of opioid misuse orabuse. When previous misuse behaviors were absent, providers rated men at higher risk; there was no gender difference when previous misuse behaviors were present. A significant gender-by-misuse interaction was found for risk of opioid-related adverse events. Providers perceived men to be at higher risk when previous misuse behaviors were absent; there was no gender difference when previous misuse behaviors were present. A significant gender-by-misuse interaction was found for risk of opioid addiction. Providers rated women at higher risk when previous misuse behaviors were present and men at higher risk when previous misuse behaviors were absent. There were significant main effects of gender and misuse for risk of opioid diversion. Providers rated men and those with previous misuse behaviors at higher risk. These results demonstrate that patient gender and previous opioid misuse have unique and interactive effects on provider perceptions of prescription opioid-related risks. Studies are needed to identify the mechanisms underlying these effects, such as gender-based stereotypes about risk-taking and drug abuse.

Medications for opioid use disorder during pregnancy: Access and continuity in a state women's prison facility, 2016-2019

BACKGROUND

Although medications to treat opioid use disorder (MOUD) are the standard of care during pregnancy, there are many potential gaps in the cascade of care for pregnant people experiencing incarceration.

METHODS

We conducted a retrospective cohort study of pregnant people with opioid use disorder incarcerated in a Southeastern women's prison from 2016 to 2019. The primary outcomes were access to MOUD during incarceration and continuity in the community. We used descriptive statistics to summarize aspects of our sample and logistic regression to identify predictors of MOUD receipt during incarceration.

RESULTS

Of the 279 pregnant people with OUD included in the analysis, only 40.1% (n = 112) received MOUD during incarceration, including 67 (59.8%) who received methadone and 45 (40.1%) who received buprenorphine. Less than one-third of the participants were referred to a community MOUD provider (n = 83, 30%) on return to the community. Significant predictors of MOUD receipt included medium/close custody level during incarceration, incarceration during the latter portion of the study period, pre-incarceration heroin use, and receipt of pre-incarceration MOUD.

CONCLUSIONS

Although prisons can serve as an important site of retention in MOUD for some pregnant people, there were substantial gaps in initiation of MOUD and retention in MOUD among pregnant people with OUD imprisoned in the Southeast during the study period.

Diagnostic and Predictive Capacity of the Spanish Versions of the Opioid Risk Tool and the Screener and Opioid Assessment for Patients with Pain-Revised: A Preliminary Investigation in a Sample of People with Noncancer Chronic Pain

INTRODUCTION

Accurate assessment of the risk of opioid abuse and misuse in people with noncancer chronic pain is crucial for their prevention. This study aimed to provide preliminary evidence of the diagnostic and predictive capacity of the Spanish versions of the Opioid Risk Tool (ORT) and the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R).

METHODS

We used the Current Opioid Misuse Measure (COMM) as criterion measure to assess the capacity of each tool to identify patients misusing opioids at the time of the assessment. Eighteen months later, we used the COMM and the Drug Abuse Screening Test-10 (DAST-10) to assess their predictive capacity. In total, 147 people with noncancer chronic pain participated in the diagnostic study, and 42 in the predictive study.

RESULTS

Receiver operating curve analysis showed that the SOAPP-R had an excellent capacity to identify participants who were misusing opioids at the time of assessment (area under the curve [AUC] = 0.827). The diagnostic capacity of the ORT was close to acceptable (AUC = 0.649-0.669), whereas its predictive capacity was poor (AUC = 0.522-0.554). The predictive capacity of the SOAPP-R was close to acceptable regarding misuse (AUC = 0.672) and poor regarding abuse (AUC = 0.423).

CONCLUSION

In the setting of Spanish-speaking communities, clinicians should be cautious when using these instruments to make decisions on opioid administration. Further research is needed on the diagnostic and predictive capacity of the Spanish versions of both instruments.

“Where There Are Stars, There Is Also Darkness”: Young Icelandic Men’s Experience of Prescription Drug Misuse

Misuse of prescription drugs is a public health problem in many places around the world, including Iceland. It is considered most common among 18- to 25-year-olds, various risk factors and motives explain this trend. The purpose of this study was to examine young Icelandic men’s experience of prescription drug misuse. Participants in this study were seven Icelandic males, 18–26 years old, mean age was 20.9. Data were collected through 14 interviews and then processed using a qualitative methodological approach based on Vancouver’s school of phenomenology. The overriding theme of the study “ Where there are stars, there is also darkness” refers to the common thread in participants’ experiences of misuse of prescription drugs that were initially positive but quickly turned negative. Four main themes were identified: influence factors, reasons, onset, and continued drug misuse. The influencing factors were social influence, social group, lack of knowledge, and curiosity. The main reasons for the drug misuse were to suppress distress, improve capacity and efficiency, or have fun and avoid boredom. The onset of prescription drug misuse was characterized by quick fixes, misuse of one’s own medication or medication from a friend/family member. Continued misuse was characterized by a vicious circle, black market, medical visits on false pretenses, and symptoms of dependence and addiction. It is necessary to highlight this public health problem that prescription drug misuse among young Icelandic males appear to be and it needs to be considered as a multifarious problem as the results indicate that its nature is truly complex.

The Impact of Traumatic Stress, Social Support, and Substance Problems on Graduation Among Female Offenders in a Prescription Drug Court Program

Trauma exposure and comorbid substance use are highly prevalent among female drug court participants. Despite the pervasiveness of the issue, few studies have investigated the impact of posttraumatic stress symptoms (PTSS) and nonmedical prescription drug use among this specific population. The present study examined the impact of posttraumatic stress, social support, and nonmedical prescription drug use on graduation outcomes among female participants in a specialized drug court program (N = 210). Participants either received motivational enhancement therapy/cognitive behavioral therapy (MET-CBT; N = 210) or both MET-CBT and Seeking Safety through intensive outpatient treatment (n = 109). The findings indicated that graduation was negatively correlated with posttraumatic stress, r = -.19, p = .007, d = 0.40; past 90-day nonmedical prescription painkiller, opiate, and analgesic use, r = -.19, p = .001, d = 0.44; tangible social support, r = -.24, p = < .001, d = 0.51; and past-month substance use problems, r = -.25, p < .001, d = .50. In addition, past-month substance use problems, OR = 0.84, 95% CI [0.72, 0.97]; PTSS, OR = 0.90, 95 % CI [0.82, 0.99]; and tangible social support, OR = 0.94, 95% CI [0.89, 0.98], were significant negative predictors of graduation. These results speak to the importance of facilitating the development of specialized evidence-based drug court interventions that target and improve comorbid substance use and trauma outcomes among female drug court participants to reduce recidivism and set a precedent for future research to replicate and expand upon these findings.

Treatment-seeking behaviour among people with opioid use disorder in the high-income countries: A systematic review and meta-analysis

OBJECTIVES

To determine treatment seeking behaviour in those with opioid use disorder (OUD) in the high-income countries.

METHODS

Five databases were searched in November 2019 for quantitative studies that reported OUD treatment seeking behaviour. Data analysis involved determining an overall pooled proportion estimate of treatment seeking behaviour for the two base groups, lifetime treatment and past 12-month or less treatment using the IVhet effect model. Subgroup analysis included heroin OUD, prescription OUD and general OUD. The sensitivity analysis included removal of outliers, separating adults and adolescents and the metaXL sensitivity analysis (studies are excluded if outside the pooled proportion confidence interval of the base case). Systematic review Prospero database registration number [CRD42020159531].

RESULTS

There were 13 quantitative studies included in the systematic review, with all studies being from the United States of America (USA). IVhet models showed that 40% (95% CI: 23%, 58%) and 21% (95% CI: 16%, 26%) sought treatment in their lifetime and past 12 months respectively. Sub-group analysis found that lifetime treatment seeking for prescription OUD, 29% (95% CI: 27%, 31%), was less than for heroin plus combined OUD, 54% (95% CI: 26%, 82%). Most of the pooled results had high heterogeneity statistics except for results of lifetime treatment seeking for prescription OUD and past 12-month treatment seeking for prescription OUD.

CONCLUSION

All included studies in this meta-analysis were from the USA and indicate modest levels of treatment seeking for those with OUD. In particular, this review found that in the USA one in five people with OUD sought OUD treatment in the previous 12 months and two in five people with OUD sought OUD treatment in their lifetime. Further research is urgently required to explore the barriers and facilitators that can improve this low treatment seeking in those with OUD.

Gender differences in the prevalence of heroin and opioid analgesic misuse in the United States, 2015-2019

OBJECTIVES

Gender differences in the prevalence of opioid misuse continue to evolve and have not been well characterized in recent years. Our objective was to investigate gender differences in the prevalence of opioid misuse and use disorder in the US over the 5-year period from 2015 to 2019.

METHODS

We used annual survey data from the 2015-2019 National Survey on Drug Use and Health to estimate gender differences in the prevalence of opioid misuse. We examined past-year opioid analgesic misuse initiation, opioid analgesic misuse, heroin use, opioid analgesic use disorder and heroin use disorder. Logistic regression models were used to test gender differences, adjusting for sociodemographic variables.

RESULTS

In adjusted analyses, women had higher odds of having initiated opioid analgesic misuse in the past year compared to men. In contrast, men had higher odds of misuse of opioid analgesics, heroin use, and an opioid analgesic or heroin use disorder.

CONCLUSIONS

Although opioid misuse has historically been more prevalent in men, the gender difference in opioid analgesic misuse continues to narrow, with more women initiating misuse than men including higher rates of misuse in adolescent girls. Heroin use continues to be approximately twice as common in men as women.

Examining adolescents' opioid knowledge and likelihood to Utilize an educational game to promote medication safety

BACKGROUND

Adolescents' knowledge on opioids is seldom studied, despite the fact young people are one of the groups most affected by the opioid crisis within the United States. There is a need to understand adolescents' perceptions about opioid misuse and safety to create the necessary tools to educate adolescents on safe opioid use.

OBJECTIVE

This study sought to understand adolescents' knowledge and perceptions of opioid use and safety as well as their receptiveness to using an educational game for improving medication safety knowledge.

METHODS

A 67-item survey was developed to assess adolescents' opioid perceptions, knowledge, and the likelihood of an educational game to enhance their opioid medication safety. A nationally representative sample of US adolescents aged 12 to 18 were recruited via a Qualtrics participant panel to complete the online survey from October through November 2020. Survey questions were grouped into 10 categories to represent key concepts and summarized into concept scores. Concepts were described through means, median, and range as well as percent correct for individual questions. Differences between groups were assessed using Kruskal-Wallis tests. Concept scores and their relation to the participant's age were described by the Pearson's correlation coefficient and the linear model coefficient.

RESULTS

A total of 592 responses were analyzed. Male and older participants reported greater perceived opioid knowledge than females. White participants reported higher rates of perceived opioid knowledge, behavioral intent, and knowledge of safe medication disposal than any other racial group. About 80% of participants were receptive to the use of an educational game to increase their opioid safety knowledge.

CONCLUSIONS

There are discrepancies in adolescents' knowledge on opioid safety and harm amongst genders, race, and age. Study findings support the use of an educational game to increase adolescents' opioid knowledge. Future studies should design an educational game intended for a diverse audience.

Association of Opioid Use Disorder With 2016 Presidential Voting Patterns: Cross-sectional Study in New York State at Census Tract Level

Background

Opioid overdose-related deaths have increased dramatically in recent years. Combating the opioid epidemic requires better understanding of the epidemiology of opioid poisoning (OP) and opioid use disorder (OUD).

Objective

We aimed to discover geospatial patterns in nonmedical opioid use and its correlations with demographic features related to despair and economic hardship, most notably the US presidential voting patterns in 2016 at census tract level in New York State.

Methods

This cross-sectional analysis used data from New York Statewide Planning and Research Cooperative System claims data and the presidential voting results of 2016 in New York State from the Harvard Election Data Archive. We included 63,958 patients who had at least one OUD diagnosis between 2010 and 2016 and 36,004 patients with at least one OP diagnosis between 2012 and 2016. Geospatial mappings were created to compare areas of New York in OUD rates and presidential voting patterns. A multiple regression model examines the extent that certain factors explain OUD rate variation.

Results

Several areas shared similar patterns of OUD rates and Republican vote: census tracts in western New York, central New York, and Suffolk County. The correlation between OUD rates and the Republican vote was .38 (P<.001). The regression model with census tract level of demographic and socioeconomic factors explains 30% of the variance in OUD rates, with disability and Republican vote as the most significant predictors.

Conclusions

At the census tract level, OUD rates were positively correlated with Republican support in the 2016 presidential election, disability, unemployment, and unmarried status. Socioeconomic and demographic despair-related features explain a large portion of the association between the Republican vote and OUD. Together, these findings underscore the importance of socioeconomic interventions in combating the opioid epidemic.

Association of opioid misuse with anxiety and depression: A systematic review of the literature

The opioid epidemic is a public health problem associated with a host of negative outcomes. Although clinicians recognize covariation between opioid misuse with anxiety and depressive symptoms and disorders, research on this topic has only recently accumulated. Progress in this domain is impeded by the lack of systematic and integrative research to better understand and treat these co-occurring problems. This paper represents the first attempt to systematically review the empirical literature examining relations between opioid use and misuse, and anxiety and depression. In the first section, we define key terms and describe the article selection strategy. In the second section, we review the prevalence of anxiety and depressive symptoms among individuals who use and misuse prescription and illicit opioids. In the third section, we review the magnitude of associations between anxiety and depressive symptoms and disorders with opioid misuse, as well as highlight studies examining the longitudinal and temporal sequence of the relations between these variables. In the fourth section, we focus on experimental therapeutics, reviewing what is known about individual difference and transdiagnostic vulnerability factors for anxiety and depression that might contribute to opioid misuse and its symptoms. Finally, we discuss current knowledge gaps and present a heuristic model to guide future research.

Opioid use in pregnant women with mental health-related disabilities

PURPOSE

The purpose of this study was to examine associations between opioid use and the degree of mental health-related disability due to emotional/behavioral problems as measured by the World Health Organization Disability Assessment Schedule (WHODAS) instrument in a national sample of pregnant women.

METHODS

We used data from the National Survey on Drug Use and Health 2014-2017 which included 2,888 pregnant women 18 years or older. The WHODAS instrument was utilized to measure disability as the degree of functional impairment due to emotional/behavioral problems experienced by the respondent. Multinomial logistic regression models were built to assess the magnitude and direction of the association between severity of mental health-related disability with opioid use and abuse/dependency in the past year.

RESULTS

Approximately 30% of pregnant women suffered from moderate/severe mental health-related disability, and 2% reported opioid abuse/dependency. Compared to those with no opioid use, the odds of opioid use in the past year for individuals with moderate/severe mental health-related disability were 1.73 (95% CI 1.36, 2.21) times higher than those with no/mild disability. Similarly, the odds of opioid abuse/dependency were at least three times higher (OR 3.51; 95% CI 1.80, 6.84) among those with moderate/severe mental health-related disability relative to pregnant women with no/mild disability.

CONCLUSIONS

Clinicians should consider screening for both opioid use and mental health conditions and related disabilities using screening tools such as the WHODAS during the initial prenatal visits.

Overdose deaths from nonprescribed prescription opioids, heroin, and other synthetic opioids in Medicare beneficiaries

IMPORTANCE

Opioid use disorder in the United States' Medicare population increased from 10 to 24 per 1000 from 2012 to 2018. Understanding the changes in the patterns of opioid overdose mortality over time holds broad clinical and public health relevance.

OBJECTIVE

To examine trends and correlates of opioid overdose deaths from nonprescribed prescription opioids, heroin, and other synthetic opioids.

DESIGN, SETTING AND PARTICIPANTS

The study used Medicare-National Death Index linked data from a 20% national sample to identify a retrospective cohort who died from opioid overdose in 2012-2016. The study analyzed data from December 2019 to March 2020.

MAIN OUTCOME AND MEASURES

We examined type of opioid overdose deaths; percentage of opioid deaths without documented opioid prescriptions in the prior 6 months; and percentage of deaths from heroin or synthetic opioids among people on long-term prescription opioids whose prescribers reduced or subsequently discontinued their opioids. The study also calculated the proportion receiving medication for addiction treatment. The study included demographic characteristics and 15 chronic or potentially disabling conditions associated with overall opioid overdose deaths.

RESULTS

Among 6932 Medicare enrollees who died from opioid overdose in 2012-2016, the mean (SD) age was 52.9 (12.1) years, 45.4% were women, and 82.4% were white. The number of opioid overdose deaths increased from 1159 in 2012 to 1697 in 2016. In the adjusted analyses, opioid deaths occurring in 2016 were 2.6 times more likely to be due to heroin or other synthetic opioids than opioid deaths occurring in 2012. The prescription opioid deaths occurring without a documented opioid prescription in the 6 months before death increased from 6.8% in 2012 to 11.7% in 2016. Factors associated with such deaths, assessed in a stepwise logistic regression model, included metropolitan or rural residence and diagnosis of opioid use disorder. Among people with long-term opioid use whose prescription opioids were reduced in the 6 months before death, the percentage of deaths attributable to heroin and other synthetic opioids increased from 17% in 2012 to 47% in 2016. Factors associated with such deaths, assessed in a stepwise logistic regression model, included diagnosis of hepatitis and opioid use disorder. Less than 10% of these enrollees received medication for addiction treatment.

CONCLUSION

There were substantial increases in patients' obtaining opioid analgesics from unlicensed sources and in overdose deaths from nonprescribed opioids during the study period (2012-2016). Increased access to pain management and opioid use disorder treatments is critical to reducing the opioid overdose deaths in the United States.

Identifying Predictors of Recommendations for and Participation in Multimodal Nonpharmacological Treatments for Chronic Pain Using Patient-Reported Outcomes and Electronic Medical Records

OBJECTIVE

High-quality chronic pain care emphasizes multimodal treatments that include medication and nonpharmacological treatments. But it is not clear which patients will participate in nonpharmacological treatments, such as physical therapy or mental health care, and previous research has shown conflicting evidence.

METHODS

We used the Patient Outcomes Repository for Treatment (PORT) registry, which combines patient-reported outcomes data with electronic medical records. In this retrospective observational study, we performed two separate multinomial regression analyses with feature selection to identify PORT variables that were predictive of 1) recommendation of a nonpharmacological treatment by the provider and 2) patient participation in nonpharmacological treatments. Two hundred thirty-six patients were recommended (REC) or not recommended (NO REC) a nonpharmacological treatment, and all REC patients were classified as participating (YES) or not participating (NO) in the recommendations.

RESULTS

Female gender and a diagnosis of Z79 "Opioid drug therapy" were significant positive and negative predictors of nonpharmacological treatment recommendations, respectively. Schedule II opioid use at initial presentation and recommendations for rehabilitation therapy were significant predictors of nonparticipation.

CONCLUSIONS

Patients using opioids are less likely to be recommended nonpharmacological treatments as part of multimodal chronic pain care and are less likely to participate in nonpharmacological treatments once recommended. Males are also less likely to be recommended nonpharmacological treatments. Patients referred for rehabilitation therapies are less likely to comply with those recommendations. We have identified patients in vulnerable subgroups who may require additional resources and/or encouragement to comply with multimodal chronic pain treatment recommendations.

Do Sex Differences Among Adults With Opioid Use Disorder Reflect Sex-specific Vulnerabilities? A Study of Behavioral Health Comorbidities, Pain, and Quality of Life

OBJECTIVES

Studies suggest that men and women have different vulnerabilities to a number of substance use disorders (SUDs). We examined whether differences between women and men with opioid use disorder (OUD) are significantly different from those without OUD for selected sociodemographic and health outcomes.

METHODS

We used a cross-sectional survey design using data from 2012 to 2013 National Epidemiological Survey on Alcohol and Related Conditions Wave III, which surveyed nationally representative samples of non-institutionalized adults (n = 36,309 unweighted). Past-year OUD and other behavioral co-morbidities were defined using DSM-5 criteria. In bivariate analyses, we investigated sex differences in socio-demographic factors, behavioral co-morbidities, pain, and health-related quality of life (HRQOL) between women and men with past-year OUD, and then those without past-year OUD. We further used logistic regression analyses to evaluate interactions between effect of sex and past-year OUD status on behavioral co-morbidities, pain, and HRQOL.

RESULTS

When extrapolated, about 2.1 million US adults met diagnostic criteria for past-year OUD. Women with OUD had a higher likelihood of having several past-year psychiatric disorders, and a lower likelihood of having any past-year SUDs compared to male counterparts. However, similar relationships were observed among those without OUD and significant interaction effects were not found on behavioral co-morbidities, pain, and HRQOL, indicating that general sex differences are not specific to OUD.

CONCLUSIONS

Although sex differences are not specific to OUD, concurrent disorders are not uncommon among women, as well as men, with OUD. There is a need to treat concurrent behavioral health conditions from a multimorbidity perspective in the treatment of OUD in both sexes.

Fifty Years of Research on Prenatal Substances: Lessons Learned for the Opioid Epidemic

Current efforts to design research on developmental effects of prenatal opioid exposure can benefit from knowledge gained from 50 years of studies of fetal alcohol and prenatal drug exposures such as cocaine. Scientific advances in neurobiology, developmental psychopathology, infant assessments, genetics, and imaging support the principles of developmental neurotoxicology that guide research in prenatal exposures. Important to research design is accurate assessment of amount, frequency, and timing of exposure which benefits from accurate self-report and biomarkers of exposure. Identifying and control of pre- and postnatal factors that impact development are difficult and dependent on appropriate research design and selection of comparison groups and measurement of confounding, mediating, and moderating variables. Polysubstance exposure has increased due to the number of prescribed and nonprescribed substances used by pregnant women and varying combinations of drugs may have differential effects on the outcome. Multiple experimental and clinical assessments of infant behavior have been developed but predicting outcome before 18-24 months of age remains difficult. With some exceptions, prenatal substance exposure effect sizes have been small, and cognitive and behavioral effects tend to be specific rather than global. Studies require large sample sizes, adequate retention, and support for social services in at-risk samples. The ethical and legal contexts and stigma associated with drug/alcohol use disorder should be considered in order to prevent harm to families in research programs. Recognition of the pervasive use of addictive substances in this nation should lead to broad scientific efforts to understand how substances affect child outcomes and to initiate prevention and intervention where needed.

Risk factors for prescription drug diversion among people living with HIV: a systematic scoping review

BACKGROUND

In addition to numerous infections and frequent pain constantly affecting people living with HIV (PLWH), various risk factors might contribute to prescription drug diversion. The purpose of the study is to map existing evidence on risk factors contributing to prescription drug diversion among PLWH.

METHODS

Arksey and O'Malley's framework and the recommendation by Levac et al. (2010) guided this study. We searched for relevant literature from the following databases: PubMed; Google Scholar; EBSCOhost (Academic Search Complete, MEDLINE and Newspaper Source), Cochrane, WHO, HIV, ScienceDirect and Open Access Theses and Dissertations. Studies reporting evidence on risk factors contributing to prescription drug diversion and published in the period January 1996 to July 2017 were included. Thematic content analysis was performed to summarize the findings.

RESULTS

The search identified 734 studies. After full-text screening of the eligible studies, risk factors contributing to prescription drug diversion among PLWH were reported in 20 included studies. It was found that there is limited research on prescription drug diversion among PLWH in low-middle-income countries (LMICs). Risk factors contributing to prescription drug diversion were being a substance user or substance dependent; being male; young in age; being stigmatized; not disclosed HIV status; diagnosed with mental health problems; being HIV infected; poor health and well being; being White; being homeless or not owing a home; having low educational level; having history of diversion, misuse or abuse; in possession of addictive prescriptions; being unemployed and living in high neighbourhood disorder.

CONCLUSION

Evidence shows that there is limited research on prescription drug diversion among PLWH in LMICs. The study findings show that the risk factors contributing to prescription drug diversion are related with risk factors for HIV transmission and infection.

PROSPERO REGISTRATION NUMBER

CRD42017074076.

Medications for opioid use disorder in pregnancy in a state women's prison facility

BACKGROUND

Medication for opioid use disorder (MOUD) improves both maternal and neonatal outcomes for pregnant women with opioid use disorder (OUD). Although correctional policies often state that incarcerated pregnant women with OUD should receive MOUD, implementation data is scant. Our aims were to 1) quantify the extent to which pregnant women in a Southeastern prison received MOUD during their incarceration; 2) to describe the medications and doses used during incarceration and frequency of MOUD referral after incarceration; and 3) identify associations between maternal characteristics and receipt of MOUD in order to identify points of intervention for clinical policy change.

METHODS

We conducted a retrospective chart review of pregnant women with OUD in a North Carolina state women's prison from 2016-2018. We collected MOUD, demographic, custody, pregnancy, and pre-incarceration substance use data. We used descriptive statistics, chi square tests, and logistic regression.

RESULTS

There were 179 pregnant women with OUD. During incarceration, 11.7 % received buprenorphine, 17.8 % methadone, 22.8 % oxycodone, and 47.8 % did not receive any opioid medications. Of those who received buprenorphine, methadone, and no MOUD, respectively, 65 %, 51.2 %, and 3.2 % were referred for community MOUD. Women were more likely to receive MOUD during incarceration if they had received MOUD pre-incarceration.

CONCLUSIONS

There was significant unmet need for MOUD and MOUD referral among pregnant women imprisoned in North Carolina from 2016-2018. Our findings suggest that the initial assessment for MOUD and referral to a community MOUD provider may represent opportunities to improve MOUD access for this population.

Post-traumatic stress disorder and risk of prescription opioid use, over-use, and misuse among World Trade Center Health Registry enrollees, 2015-2016

BACKGROUND

Among veterans, post-traumatic stress disorder (PTSD) has been shown to be associated with the use and misuse of prescription opioids. Less is known about PTSD among the general population and PTSD resulting from non-combat related trauma. We sought to determine if PTSD following exposure to the World Trade Center (WTC) disaster is associated with the recent use, over use, or misuse of prescription opioids.

METHODS

This study, conducted in 2018, examined 26,840 individuals from the WTC Health Registry. PTSD symptoms were assessed on multiple surveys (2003-2016) using the PCL Checklist-17. Three categories of post-9/11 PTSD were derived: never, past, and current. Self-reported opioid use outcomes (past year, 2015-2016) were defined as (yes/no): recent use (use of a prescription opioid), over-use (use of a prescribed opioid in a manner other than prescribed) and misuse (use of a prescription opioid prescribed to someone else).

RESULTS

Opioid use, over-use, and misuse prevalence was highest among those with current PTSD (prevalence: 12.2 %-46.1 %) compared to past PTSD (prevalence: 6.7 %-35.8 %) and never PTSD (prevalence: 3.6 %-22.9 %). In adjusted models, individuals with past and current PTSD had a greater risk of all opioid outcomes compared to never PTSD.

CONCLUSIONS

Past and current 9/11-related PTSD is a risk factor for opioid use and misuse among the general population, findings which may assist in improving screening and surveillance measures.

"Alcohol During Pregnancy? Nobody Does That Anymore": State Legislators' Use of Evidence in Making Policy on Alcohol Use in Pregnancy

OBJECTIVE

In recent years, U.S. states have passed many laws addressing alcohol use in pregnancy, despite limited evidence on the impact of such policies. This study explores how state legislators use evidence when making policy on alcohol use in pregnancy.

METHOD

Study data are drawn from semistructured interviews with 29 state lawmakers and their aides in Maryland, North Carolina, and Virginia, conducted in March through July 2017. Interview transcripts were coded and analyzed by inductive and deductive methods.

RESULTS

Despite evidence on the harms of alcohol use in pregnancy, most lawmakers did not express concern about this topic. Instead, they expressed concern about opioid use in pregnancy. Personal experiences, anecdotes, and known contacts influenced legislators' views on substance use in pregnancy, whereas evidence, for the most part, did not. The intermediaries who typically bring evidence about problems and solutions to legislators did not appear to be raising the issue of alcohol use in pregnancy on legislators' agenda.

CONCLUSIONS

Basic evidence on the prevalence and harms of alcohol use in pregnancy did not appear to influence state lawmakers' policy priorities. Concern over opioid use in general may provide a window of opportunity to educate legislators on the relative scope and harms of alcohol and opioid use in pregnancy. It remains unclear why states are passing alcohol-in-pregnancy policies. More research is needed to explore how state lawmakers form their understanding of substance use in pregnancy and related policies.

Childhood adversity and mental health comorbidity in men and women with opioid use disorders

INTRODUCTION

To examine gender differences in associations between mental health comorbidity and adverse childhood experiences (ACE) among adults with DSM-5 lifetime opioid use disorders (OUD).

METHODS

In 2018, we analyzed 2012-13 nationally-representative data from 388 women and 390 men with OUD (heroin, prescription opioid misuse). Using weighted multinomial logistic regression, we examined factors associated with mental health comorbidity, tested a gender-by-childhood-adversity interaction term, and calculated predicted probabilities, controlling for covariates.

RESULTS

Among adults with OUD, women are more likely than men to have comorbid mood or anxiety disorders (odds ratio [95% CI] 1.72 [1.20, 2.48]), and less likely to have conduct disorders. More women than men have prescription OUD (3.72 [2.24, 6.17]), and fewer have heroin use disorder (0.39 [0.27, 0.57]). Among both genders, ACE prevalence is high (>80%) and more than 40% are exposed to ≥3 types of ACE. Women more than men are exposed to childhood sexual abuse (4.22 [2.72, 6.56]) and emotional neglect (1.84 [1.20, 2.81]). Comorbid mood or anxiety disorders are associated with female gender (1.73 [1.18, 2.55]) and exposure to ≥3 types of ACE (3.71 [2.02, 6.85]), controlling for covariates. Moreover, exposure to more ACE elevates risk for comorbid mood or anxiety disorders more among women than men.

CONCLUSION

Among adults with OUD, ACE alters the gender gap in risk for comorbid mood or anxiety disorders. Using gender-tailored methods to address the harmful effects ACE on the mental health of individuals with OUD may help to prevent and ameliorate the current opioid epidemic.

Individuals with spinal cord injury have greater odds of substance use disorders than non-sci comparisons

BACKGROUND

Individuals with spinal cord injury (SCI) are disproportionately affected by numerous physical and behavioral health disparities, but the literature lacks a clear understanding of the association between SCI and substance use disorders. Identifying such behavioral health disparities in persons with disabilities is an increasingly central focus for public health researchers and represents a critical first step for prevention.

METHOD

The present study utilized a large database of deidentified electronic health records to examine the association between SCI and substance use disorders related to alcohol, cannabis, opioid, and nicotine. Examining data from patients 16 years or older who had patient encounters at the Penn State Hershey Medical Center from January 1, 1997 to April 30, 2018, the current study included data from 1,466,985 unique patients - 6192 of which held SCI diagnoses. Age-adjusted odds ratios were calculated using logistic regression.

RESULTS

Compared to non-SCI patients, individuals with SCI were at increased odds of having alcohol use disorder (OR: 4.19, 95% CI [3.67, 4.80]), cannabis use disorder (OR: 7.83, 95% CI [6.32, 9.69]), opioid use disorder (OR: 7.97, 95% CI [6.59, 9.66]), and nicotine use disorder (OR: 4.66, 95% CI [4.40, 4.94]). Patient sex did not moderate any of the four associations.

CONCLUSION

This study provides early indication that individuals with SCI may be disproportionately at-risk for substance use disorders and provides a foundation for future mechanistic and translational research. This evidence is a valuable step towards improving the health and quality of life for individuals with SCI.

Prescription drug monitoring programs operational characteristics and fatal heroin poisoning

BACKGROUND

Prescription drug monitoring programs (PDMP), by reducing access to prescribed opioids (POs), may contribute to a policy environment in which some people with opioid dependence are at increased risk for transitioning from POs to heroin/other illegal opioids. This study examines how PDMP adoption and changes in the characteristics of PDMPs over time contribute to changes in fatal heroin poisoning in counties within states from 2002 to 2016.

METHODS

Latent transition analysis to classify PDMPs into latent classes (Cooperative, Proactive, and Weak) for each state and year, across three intervals (1999-2004, 2005-2009, 2010-2016). We examined the association between probability of PDMP latent class membership and the rate of county-level heroin poisoning death.

RESULTS

After adjustment for potential county-level confounders and co-occurring policy changes, adoption of a PDMP was significantly associated with increased heroin poisoning rates (22% increase by third year post-adoption). Findings varied by PDMP type. From 2010-2016, states with Cooperative PDMPs (those more likely to share data with other states, to require more frequent reporting, and include more drug schedules) had 19% higher heroin poisoning rates than states with Weak PDMPs (adjusted rate ratio [ARR] = 1.19; 95% CI = 1.14, 1.25). States with Proactive PDMPs (those more likely to report outlying prescribing and dispensing and provide broader access to law enforcement) had 6% lower heroin poisoning rates than states with No/Weak PDMPs (ARR = 0.94; 95% CI = 0.90, 0.98).

CONCLUSION

There is a consistent, positive association between state PDMP adoption and heroin poisoning mortality. However, this varies by PDMP type, with Proactive PDMPs associated with a small reduction in heroin poisoning deaths. This raises questions about the potential for PDMPs to support efforts to decrease heroin overdose risk, particularly by using proactive alerts to identify patients in need of treatment for opioid use disorder. Future research on mechanisms explaining the reduction in heroin poisonings after enactment of Proactive PDMPs is merited.

The Opioid Epidemic and Psychiatry: The Time for Action Is Now

The number of people with opioid use disorder and the number of overdose deaths in the United States have increased dramatically over the past 20 years. U.S. Congress passed the SUPPORT for Patients and Communities Act, which was signed into law in 2018, authorizing almost $8 billion to address the crisis. As experts in the treatment of central nervous systems disorders, psychiatrists can play a leading role in expanding treatment for people with opioid use disorder and in advocating for policy changes to support community treatment for this group.

Female-male differences in prescription pain reliever dependence levels: Evidence on newly incident adolescent and young adult users in the United States, 2002-2014

BACKGROUND

A comprehensive epidemiology of dependence on prescription opioid pain relievers requires evidence about age-specific female-male differences, possibly manifest during adolescent and early adult years. In this study, we identified newly incident extra-medical users of prescription pain relievers (EMPPR), all observed with onsets before the 22nd birthday. We then quantified female-male differences in clinical features or manifestations of opioid dependence (OD), devised a measurement-equivalent OD dimension, and estimated age-specific female-male differences in OD levels.

METHOD

The population under study included 12-to-21-year-old non-institutionalized civilian community residents of United States sampled for recent nation-scale surveys. Confidential computer-assisted self-interviews identified newly incident EMPPR users (n = 10,188). Analysis-weighted estimation procedures yielded cumulative incidence proportions for each OD feature, evaluated measurement non-equivalence across subgroups, and estimated female-male differences age-by-age.

RESULTS

(1) Tolerance and salience ('spending a lot of time') are most common OD features. (2) Measurement non-equivalence (bias) was found across sex- and onset-age groups. (3) With biasing features removed, we can see elevated OD levels for female new initiates, age-by-age. Subsidiary analyses suggested possibly accelerated progression toward higher OD levels when extra-medical PPR use starts before age 18.

CONCLUSIONS

Dimensional approaches to OD and other drug use disorders have gained popularity but can be fragile when differential measurement biases are left uncontrolled. This study's bias-corrected dimensional view of female-male differences shows elevated OD levels among newly incident female EMPPR users relative to new male initiates. Future studies can check for accelerated progression to higher OD levels when EM use starts before age 18 years.

Diverse diagnostic profiles associated with prescription opioid use disorder in a nationwide sample: One crisis, multiple needs

OBJECTIVE

The opioid crisis has had devastating effects on individuals and communities, and it has rapidly increased in severity. However, we still lack nationally representative information on the diversity of comorbidity patterns among prescription opioid use disorder (P-OUD), other substance use disorders (SUDs), and psychopathology using the newest edition of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013). This impedes planning for multiple aspects of intervention, including society-wide allocation of treatment resources, program design at individual treatment centers, and personalized care to individual patients.

METHOD

To address this critical gap in information, we evaluated clinical profiles of American adults via latent class analysis in a large, recently collected epidemiological dataset that uses structured diagnostic assessment for DSM-5 psychopathology (National Epidemiologic Survey on Alcohol and Related Conditions-III; N = 36,309). Variables considered for profiles included lifetime diagnosis for multiple SUDs, various externalizing and internalizing conditions, and demographic variables. We then associated clinical profiles with demographic variables and functional impairment.

RESULTS

Comorbid psychopathology and other SUDs were common in latent classes with elevated and very high rates of P-OUD. To illustrate, alcohol use disorder rates were greater than 45%, and posttraumatic stress disorder rates were greater than 28% in classes with higher P-OUD rates. Higher P-OUD rates were associated with White/non-Hispanic and American Indian/Alaska Native populations. Relationships between P-OUD rates and functional impairment were inconsistent.

CONCLUSION

Many current treatment delivery systems are not designed to accommodate the heterogeneous profiles associated with high P-OUD rates. We provide specific suggestions for improvements to the mental health service system, individual clinical care programs, and future research approaches. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Evaluation of Treatment and Other Factors That Lead to Drug Court Success, Substance Use Reduction, and Mental Health Symptomatology Reduction Over Time

Adults presenting with substance use and mental health disorders in the criminal justice system is well documented. While studies have examined drug courts and medication-assisted treatment (MAT), few have examined social and behavioral health indicators, and even fewer have multiple study periods. This study employed a comprehensive approach to studying the MAT contribution to drug court success; reduce substance use, mental health symptoms, and risky behaviors; and the role that violence or trauma plays in mental health symptomatology. Using three time points, our findings indicated that MAT did not play a significant role in the reduction of substance use, risky behaviors, or mental health symptoms or increasing the odds of successful court graduation. However, there was an overall improvement from intake to termination in reduction of substance use, risky behaviors, and mental health symptomatology. Other factors, including social support, may play a role in drug court graduation. Policy implications are discussed.

Molecular Imaging of Opioid and Dopamine Systems: Insights Into the Pharmacogenetics of Opioid Use Disorders

Opioid use in the United States has steadily risen since the 1990s, along with staggering increases in addiction and overdose fatalities. With this surge in prescription and illicit opioid abuse, it is paramount to understand the genetic risk factors and neuropsychological effects of opioid use disorder (OUD). Polymorphisms disrupting the opioid and dopamine systems have been associated with increased risk for developing substance use disorders. Molecular imaging studies have revealed how these polymorphisms impact the brain and contribute to cognitive and behavioral differences across individuals. Here, we review the current molecular imaging literature to assess how genetic variations in the opioid and dopamine systems affect function in the brain's reward, cognition, and stress pathways, potentially resulting in vulnerabilities to OUD. Continued research of the functional consequences of genetic variants and corresponding alterations in neural mechanisms will inform prevention and treatment of OUD.

Sex differences in the prevalence and correlates of emergency department utilization among adults with prescription opioid use disorder

BACKGROUND

The emergency department (ED) is well-suited as an opportunity to increase treatment access for prescription opioid use disorder (POUD). We examined sex differences in ED utilization among individuals with POUD to understand potential sex-specific treatment barriers and needs.

METHODS

Data from the 2005-2014 National Surveys on Drug use and Health were analyzed to examine the prevalence and correlates of past-year ED utilization among male and female adults aged 18 or older with POUD (n = 4412).

RESULTS

Overall, 58.2% of adults with POUD reported past-year ED utilization. Adjusted logistic regression revealed that females (vs. males) with POUD were more likely to report past-year ED utilization. Among females with POUD, older age, lower income, obtaining opioids from a physician, major depressive episode, and greater POUD severity were associated with increased odds of ED utilization. Among males with POUD, public insurance and obtaining opioids from a physician were associated with ED utilization. A larger proportion of males with POUD reporting ED use had multiple substance use disorders than those with no ED use. Treatment history (lifetime or past-year) for alcohol, drugs, or opioid use was associated with increased odds of ED use among males and females with POUD. Conclusions/Importance: Males and females with POUD presenting to the ED may have distinct predisposing, enabling, and need-related correlates. Sex-specific screening and intervention strategies may be useful to maximize the utility of the ED to address POUD.

Disability status and prescription drug misuse among U.S. adults

BACKGROUND

The U.S. is in the midst of a public health crisis related to drug overdose deaths. Largely responsible for the dramatic increase in overdose deaths is the misuse of prescription drugs such as opioids and benzodiazepines. While much research attention has focused on correlates of prescription drug misuse in recent years, notable gaps in the literature remain. The current research addresses one of these gaps by examining the relationship between disability status and prescription drug misuse.

METHOD

We examine data from the 2015 National Survey on Drug use and Health, a leading source of epidemiological data on drug use in the United States that added questions related to disability status to the 2015 survey. The current research assessed the relationship between disability status (i.e. activities of daily living and instrumental activities of daily living) and prescription drug misuse (i.e. opioids and benzodiazepines) among adults.

RESULTS

Findings from multinomial logistic regression analysis showed that a disability related to activities of daily living was correlated with opioid misuse, while a disability associated with instrumental activities of daily living was associated with benzodiazepine misuse and misuse of both. In addition, health related measures had a greater impact on the relationship between disability status and prescription drug misuse than did the social engagement/isolation measures.

CONCLUSION

Findings indicated that disability status is a significant correlate of prescription drug misuse. However, this relationship was largely mediated by measures associated with poor health and social engagement/isolation.

The Adjective Rating Scale for Withdrawal: Validation of its ability to assess severity of prescription opioid misuse

BACKGROUND

Withdrawal symptoms have been widely shown to be a useful indicator of the severity of opioid dependence. One of the most used instruments to assess them is the Adjective Rating Scale for Withdrawal (ARSW). However, there is a lack of adaptations and validations for its use with prescription opioids, even less for chronic pain patients under treatment with these analgesics. Thus, the aims of this study were to analyse the psychometric properties and invariance across gender of the ARSW in a sample of chronic noncancer pain patients.

METHODS

Data were collected from 208 consumers of opioid medication, chronic noncancer pain patients. Participants completed sociodemographic, ARSW, prescription opioid dependence (DSM-IV-TR) and prescription opioid-use disorder (DSM-5) measurements. Gender invariance was assessed through multigroup confirmatory factor analysis (CFA).

RESULTS

The ARSW showed a unidimensional factor structure and high internal consistency (Cronbach's alpha = 0.85). Multigroup CFA showed configural, metric, scalar and strict invariances of ARSW across gender. Predictive validity analyses indicated that ARSW has good capacity for identifying the severity of prescription opioid-use disorder, using both DSM-IV-TR and DSM-5 criteria.

CONCLUSIONS

These findings show that the ARSW is a valid and reliable tool for use in the assessment of the withdrawal of prescription opioids in chronic pain patients under treatment with these analgesics, regardless of their gender.

SIGNIFICANCE

Findings supported the reliability and validity of the ARSW to assess withdrawal of prescription opioids in individuals with chronic noncancer pain. The instrument can be applied indistinctly in men and women. An increase in the ARSW scores could be used as an indicator of potential risk of prescription opioid-use disorder during long-term treatments.