Adverse childhood experience effects on opioid use initiation, injection drug use, and overdose among persons with opioid use disorder

Online Delivery of Interprofessional Adverse Childhood Experiences Training to Rural Providers: Usability Study

Background

The population health burden of adverse childhood experiences (ACEs) reflects a critical need for evidence-based provider training. Rural children are also more likely than urban children to have any ACEs. A large proportion of providers are unaware of the detrimental effects of ACEs. There is a significant documented need for training providers about ACEs and trauma-informed care, in addition to a demand for that training.

Objective

The objective was to develop, implement, and evaluate an online ACEs training curriculum tailored to Missouri providers, particularly those in rural areas given the higher prevalence of ACEs.

Methods

From July 2021 to June 2022, we conducted literature reviews and environmental scans of training videos, partner organizations, clinical practice guidelines, and community-based resources to curate appropriate and tailored content for the course. We developed the ACEs training course in the Canvas learning platform (Instructure) with the assistance of an instructional designer and media designer. The course was certified for continuing medical education, as well as continuing education for licensed professional counselors, psychologists, and social workers. Recruitment occurred via key stakeholder email invitations and snowball recruitment.

Results

Overall, 135 providers across Missouri requested enrollment, with 72.6% (n=98) enrolling and accessing the training. Of the latter, 49% (n=48) completed course requirements, with 100% of respondents agreeing that the content was relevant to their work, life, or practice; they intend to apply the content to their work, life, or practice; they feel confident to do so; and they would recommend the course to others. Qualitative responses supported active intent to translate knowledge into practice.

Conclusions

This study demonstrated the feasibility, acceptability, and effectiveness of interprofessional workforce ACEs training. Robust interest statewide reflects recognition of the topic's importance and intention to translate knowledge into practice.

Interprofessional perspectives on ACEs: Results from a statewide interprofessional training program

BACKGROUND

Adverse childhood experiences (ACEs) are pervasive and well-recognized as having lasting deleterious effects on the physical and mental health of those who experience them, particularly with accumulated exposure.

OBJECTIVE

This study seeks to identify the perspectives of interprofessional health providers on their personal and professional experiences with ACEs, ACEs screening, how to work with people with ACEs, and make recommendations for the field.

PARTICIPANTS AND SETTING

Sixty-two health professionals and PhD students who completed at least one module of an online course and at least one of the accompanying discussion board sub-prompts.

METHODS

Responses to five course discussion board assignments, each with multiple sub-prompts, were coded to determine and refine major themes and merged with demographic and other background data. From the 561 responses, six themes were identified and used to analyze response patterns.

RESULTS

Twenty-nine percent of responses reflected a macro perspective on ACEs; 29 % of responses reflected workplace experiences; 28 % of responses reflected ACEs complexity, 8 % of responses reflected a personal relationship to ACEs, 3 % reflected perspectives on resilience; and 3 % were related to the course. Participants communicated complex understandings of ACEs, demonstrating the relevance and importance of the topic for public health training.

CONCLUSIONS

Integrating ACEs training into the practice setting provides opportunities to improve the health and lives of those suffering from ACEs, especially when incorporating provider voice and perspectives.

Which Social Media Platforms Provide the Most Informative Data for Monitoring the Opioid Crisis?

Background and Aims

Social media can provide real-time insight into trends in substance use, addiction, and recovery. Prior studies have leveraged data from platforms such as Reddit and X (formerly Twitter), but evolving policies around data access have threatened their usability in opioid overdose surveillance systems. Here, we evaluate the potential of a broad set of platforms to detect emerging trends in the opioid crisis.

Design

We identified 72 online platforms with a substantial global user base or prior citations in opioid-related research. We evaluated each platform's fit with our definition of social media, size of North American user base, and volume of opioid-related discourse. We created a shortlist of 11 platforms that met our criteria. We documented basic characteristics, volume and nature of opioid discussion, official policies regulating drug-related discussion, and data accessibility of shortlisted platforms.

Setting

USA and Canada.

Measurements

We quantified the volume of opioid discussion by number of platform-specific Google search hits for opioid terms. We captured informal language by including slang generated using a large language model. We report the number of opioid-related hits and proportion of opioid-related hits to hits for common nouns.

Findings

We found that TikTok, YouTube, and Facebook have the most potential for use in opioid-related surveillance. TikTok and Facebook have the highest relative amount of drug-related discussions. Language on TikTok was predominantly informal. Many platforms offer data access tools for research, but changing company policies and user norms create instability. The demographics of users varies substantially across platforms.

Conclusions

Social media data sources hold promise for detecting trends in opioid use, but researchers must consider the utility, accessibility, and stability of data on each platform. A strategy mixing several platforms may be required to cover all demographics suffering in the epidemic.

Association Between Adverse Childhood Experiences and Opioid Use-Related Behaviors: A Systematic Review

As opioid use-related behaviors continue at epidemic proportions, identifying the root causes of these behaviors is critical. Adverse childhood experiences (ACEs) are shown to be an important predictor of opioid initiation, opioid dependence, and lifetime opioid overdose. The purpose of this systematic review is to examine the association between ACEs and opioid use-related behaviors later in life and to discuss implications for policy, practice, and research regarding ACEs and opioids. Five databases (PubMed, PsycINFO, CINAHL, Medline, and Scopus) were used to identify studies investigating the association between ACEs and opioid use-related behaviors. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, 20 studies out of the initial 428 met the inclusion criteria for this review. Among the included 20 studies, 15 focused on the relationship between ACEs and lifetime opioid use-related behaviors, and five focused on current opioid use-related behaviors. All studies found statistical associations between ACEs and lifetime or current opioid use-related behaviors. Five studies found a significant gradient effect; that is, as the number of ACEs increased, the risk of opioid use-related behaviors also increased. A significant dose-response relationship exists between ACEs and opioid use-related behaviors. Hence, it is essential for clinicians to screen for ACEs before prescribing opioid medications, for opioid treatment to incorporate trauma-informed methods, and for messaging around opioid use interventions to include information about ACEs. The current review points to a critical need to implement standardized ACE screening instruments in clinical and research settings.

The Impact of Childhood Adversity on Life Course Alcohol Use Patterns and Health Status Among People Living with HIV

Adverse childhood experiences (ACEs) and financial hardship are associated with increased likelihood of heavier alcohol use and health challenges in adulthood among persons living with HIV (PWH). We examined whether retrospectively captured lifetime drinking trajectories are a pathway through which childhood hardships affect current health in a sample of 365 adult PWH. Childhood economic hardship and ACEs were used as main predictors. Measures of alcohol use included age at first drink and lifetime drinking trajectories. Health indicators included health-related quality of life, frailty, number of comorbidities, and symptoms of anxiety, depression, and post-traumatic stress disorder (PTSD). Structural equation modeling (SEM) was applied to estimate both direct and indirect pathways between childhood hardship and physical and mental health. Participants were mostly male; Black (84%); and averaged 48 years of age. SEM results supported both direct and indirect pathways between childhood experiences and adult health. ACEs were connected to physical health directly and mental health both directly and indirectly through age at first drink and drinking heaviness during ages 10-20. Childhood economic hardship related to mental health indirectly through higher drinking levels during ages 10-20. Childhood adverse experiences, economic hardship, and early drinking patterns appear to accumulate, resulting in later life physical and mental health concerns for PWH. Findings support taking a life course approach to health. This includes considering individual trauma histories in HIV care engagement and taking preventative approaches which support the economic and social well-being of vulnerable children to improve health in subsequent decades.

Mixed-methods analysis of satisfaction during a 12-session mindfulness-based intervention for women with a substance use disorder and trauma symptomatology

Satisfaction with an intervention influences the uptake of behavior changes and the long-term efficacy of the intervention. Therefore, it is crucial to assess satisfaction by participant profile when creating and adapting behavior interventions for minoritized populations. Qualitative and quantitative data on participant trauma symptom severity and intervention satisfaction were collected through self-report surveys from 54 women. The sample was 59.3% Hispanic, with an average age of 33.21 (SD = 10.42), who were in residential treatment for substance use disorders (SUDs) and participated in a 12-session mindfulness-based intervention. Qualitative responses were coded using thematic analysis, and an integrative mixed-methods approach was used to compare qualitative theme frequency between high-trauma (N = 28) and low-trauma (N = 26) groups at session 2 and session 11. High- and low-trauma groups were determined by interquartile ranges (bottom 25% = low; top 75% = high). In session 2, the low-trauma group reported significantly higher satisfaction (M = 4.20, SD = 0.55) than the high-trauma group (M = 3.77, SD = 0.89); t(43) = 1.90, p = 0.03. In session 11, there was no significant difference between groups. The mixed-methods analysis revealed that "trouble focusing" appeared more frequently in the high-trauma group than in the low-trauma group during session 2, but the theme was not present in either group at session 11, suggesting that this might pose an initial barrier for individuals with high trauma but subsides as the intervention progresses. This speaks to the importance of retention strategies tailored for participants with SUDs and high trauma while they adjust to the intervention. Assessing initial challenges with satisfaction may help facilitators intervene to increase participant satisfaction.

Gene × environment effects and mediation involving adverse childhood events, mood and anxiety disorders, and substance dependence

Adverse childhood events (ACEs) contribute to the development of mood and anxiety disorders and substance dependence. However, the extent to which these effects are direct or indirect and whether genetic risk moderates them is unclear. We examined associations among ACEs, mood/anxiety disorders and substance dependence in 12,668 individuals (44.9% female, 42.5% African American/Black, 42.1% European American/white). Using latent variables for each phenotype, we modelled direct and indirect associations of ACEs with substance dependence, mediated by mood/anxiety disorders (the forward or 'self-medication' model) and of ACEs with mood/anxiety disorders, mediated by substance dependence (the reverse or 'substance-induced' model). In a subsample, we tested polygenic scores for the substance dependence and mood/anxiety disorder factors as moderators in the mediation models. Although there were significant indirect paths in both directions, mediation by mood/anxiety disorders (the forward model) was greater than that by substance dependence (the reverse model). Greater genetic risk for substance use disorders was associated with a weaker direct association between ACEs and substance dependence in both ancestry groups (reflecting gene × environment interactions) and a weaker indirect association in European-ancestry individuals (reflecting moderated mediation). We found greater evidence that substance dependence reflects self-medication of mood/anxiety disorders than that mood/anxiety disorders are substance induced. Among individuals at higher genetic risk for substance dependence, ACEs were less associated with that outcome. Following exposure to ACEs, multiple pathways appear to underlie the associations between mood/anxiety disorders and substance dependence. Specification of these pathways could inform individually targeted prevention and treatment approaches.

Characteristics of Adolescents with and without a Family History of Substance Use Disorder from a Minority Cohort

Family history (FH+) of substance use disorder (SUD) is an established risk factor for offspring SUD. The extent to which offspring psychological traits or the family environment, each of which may be relevant to familial transmission of SUD risk, vary by FH+ in socioeconomically disadvantaged populations is less clear. We compared the family/social environmental and psychological characteristics of 73 FH+ and 69 FH- youth ages 12-16, from a study of parental criminal justice system involvement in a primarily low-income, minority urban population. A latent profile analysis (LPA) empirically identified groups of subjects with similar psychological characteristics, which were then compared by FH+. FH+ youths were found to have greater mean household size, greater parental psychological aggression, and a higher mean number of adverse childhood experiences, even without considering parental SUD. FH+ individuals had lower report card grades according to parental report and were more likely to have a history of externalizing disorders than FH- individuals. However, FH+ was not significantly associated with many psychological characteristics or with the class membership from the LPA. In conclusion, among a population of low-income, minority urban youth, FH+ was associated with differences in the family environment and only subtle differences in individual psychological characteristics.

Adverse Childhood Experience-Related Conditions and Substance Use in Adolescents: A Secondary Analysis of Cross-Sectional Survey Data

BACKGROUND

Adverse childhood experiences (ACEs) cluster within children. In addition to standardized ACE measures, there exist "ACE-related" measures that are either directly or indirectly related to the standardized ACE constructs. This study aimed to identify ACE-related latent classes of adolescents and describe past-month substance use in each class by sex and race/ethnicity.

METHODS

Data from the 2018 Indiana Youth Survey (N = 70,703), which is a repeated self-administered, cross-sectional survey, were used. Latent class analysis was conducted using ACE-related family (parent incarceration, insulting/yelling within family, inability to discuss personal problems) and school (hate being in school, feeling unsafe, inability to talk to teachers one-on-one) items. Dependent variable combined past 30-day use-frequency of 17 substances. Two-way analysis of variances examined ACE by sex and race/ethnicity interaction.

RESULTS

Four ACE-related classes emerged: "Family-Only" (11.2%), "School-Only" (16.5%), "Family-School" (8.0%), and "No-ACE" (64.3%). Substance use was highest in "Family-School" (mean = 0.67); lowest in "No-ACE" (mean = 0.21). Significant race/ethnicity (F = 27.06; p < .0001), ACE * sex interaction (F = 12.13; p < .0001) and ACE * race/ethnicity interaction (F = 4.57; p < .0001) effects emerged. Within each ACE-related class, substance use was lowest for Asians and highest for Hispanics.

CONCLUSIONS

Adverse childhood experience-related items cluster within children across school and family environments and clustering differs by race/ethnicity, but not by sex. Incorporating ACE-related items into school surveys enhances the ability to implement interventions that target relationships between ACEs and substance use.

Psychotherapies in opioid use disorder: toward a step-care model

Opioid use disorder (OUD) is characterized by a lack of control in opioid use, resulting in psychological distress and deficits in interpersonal and social functioning. OUD is often associated with psychiatric comorbidities that increase the severity of the disorder. The consequences of OUD are dramatic in terms of increased morbi-mortality. Specific medications and psychotherapies are essential tools not only in the treatment of OUD but also in the prevention of suicide and overdoses. In our review, we assess the different types of psychotherapies (counseling, motivational interviewing, contingency management, cognitive-behavioral therapy, and dialectical-behavior therapy) that are delivered to opioid users, either associated or un-associated with OUD medications and/or medications for psychiatric disabilities. We describe the application of these therapies first to adult opioid users and then to adolescents. This work led us to propose a stepped-care model of psychotherapies for OUD which provided information to assist clinicians in decision-making regarding the selection of psychotherapeutic strategies according to patients' OUD severity.

Adverse childhood experiences and early initiation of substance use: A survival analysis

OBJECTIVE

Early adversity, such as adverse childhood experiences (ACEs), is a risk factor for the development of substance use disorder (SUD). ACEs are associated with earlier initiation of substance use. This study examined the relationship between ACEs and age of initiation of substance use using survival analysis. It is hypothesized that individuals with higher ACEs will have an earlier age of initiation.

METHOD

Participants were recruited from the University of Kentucky's Laboratory for Human Behavioral Pharmacology. Participants were 18 years or older, English speaking, and actively engaged in substance use. Participants were not in substance abuse treatment nor were they seeking treatment. ACE scores were calculated, and age of substance use initiation was recorded. A Cox proportional hazard model was used to examine the effect of ACE score on age of substance use initiation.

RESULTS

A total of 107 participants completed the study. An average number of 2.3 ACEs (SD = 2.2) were endorsed with 24% of participants reporting 4 or more ACEs. Higher ACE scores were associated with cigarette smoking and non-medical prescription opioid use onset ( hazard ratio (HR) = 1.14, 95% CI=1.02-1.28, p = 0.02, and HR=1.19, 95% CI = 1.04-1.37, p = 0.01, respectively.

CONCLUSIONS

A significant association was found between higher ACE scores and earlier initiation of cigarette and non-medical prescription opioid use, consistent with prior research. Primary prevention of ACEs, screening for ACEs during childhood, and interventions for ACEs if detected, may help to reduce the risk of substance use/SUD in adulthood.

An in-depth analysis of the polyvagal theory in light of current findings in neuroscience and clinical research

The polyvagal theory has led to the understanding of the functions of the autonomic nervous system in biological development in humans, since the vagal system, a key structure within the polyvagal theory, plays a significant role in addressing challenges of the mother-child dyad. This article aims to summarize the neurobiological aspects of the polyvagal theory, highlighting some of its strengths and limitations through the lens of new evidence emerging in several research fields-including comparative anatomy, embryology, epigenetics, psychology, and neuroscience-in the 25 years since the theory's inception. Rereading and incorporating the polyvagal idea in light of modern scientific findings helps to interpret the role of the vagus nerve through the temporal dimension (beginning with intrauterine life) and spatial dimension (due to the numerous connections of the vagus with various structures and systems) in the achievement and maintenance of biopsychosocial well-being, from the uterus to adulthood.

At a Crossroads: Opioid Use Disorder, the X-Waiver, and the Road Ahead

Background: Buprenorphine/naloxone (Suboxone) is widely considered the first-line treatment for opioid use disorder (OUD), which causes significant morbidity and mortality in the United States, but prior to 2023, practitioners interested in prescribing buprenorphine/naloxone for OUD needed a special Drug Enforcement Administration certification (the X-Waiver) that imposed a patient cap and other limitations. The Consolidated Appropriations Act of 2023 considerably decreased the restrictions on prescribing practitioners. Buprenorphine/naloxone can now be prescribed like any other prescription opioid, excluding methadone. The historic context for the opioid crisis, OUD, the X-Waiver, and additional initiatives that may be needed beyond legislative change to effectively address OUD are the subjects of this review. Methods: To develop this review of the opioid crisis, OUD, and OUD treatment, we conducted a literature search of the PubMed database and constructed a timeline of the opioid crisis and changes in OUD treatment, specifically the X-Waiver, to characterize the historic context of OUD and the X-Waiver against the background of the opioid crisis. Results: The opioid crisis has had pervasive public health and economic impacts in the United States. Major changes to the treatment of OUD have occurred as a result of the Drug Addiction Treatment Act of 2000 that imposed the X-Waiver and the Consolidated Appropriations Act of 2023 that repealed the X-Waiver. Conclusion: The repeal of the X-Waiver is predicted to increase the accessibility of buprenorphine/naloxone in the United States. However, additional work beyond legislative change, including institutional support and reduction of stigma and disparities, is needed to substantially improve outcomes for OUD patients.

Comorbidity of Lifetime History of Abuse and Trauma With Opioid Use Disorder: Implications for Nursing Assessment and Care

BACKGROUND

Opioid use disorder (OUD) is a public health crisis and is challenging to treat. Previous research has shown correlations between OUD, abuse/trauma, and chronic pain.

AIMS

The purpose of this study was to investigate history of lifetime sexual, physical, and/or emotional abuse among participants in a medication-assisted treatment (MAT) program for OUD, and to investigate associations between abuse history and chronic pain.

METHODS

This is a secondary analysis of intake data from a 2-year, nonexperimental cohort treatment program of patients with OUD in rural Colorado. De-identified data were provided by 476 adult MAT patients using the Adult Addiction Severity Index (ASI-6). The ASI-6 includes three yes/no questions about history of abuse (emotional, physical, and sexual), with separate scoring for "past 30 days" and "lifetime" abuse.

RESULTS

Lifetime history among MAT program for OUD patients was 23% for sexual abuse, 43% for physical abuse, and 58% for emotional abuse. History of physical abuse was significantly associated with having a chronic pain diagnosis, χ2 = 4.49, p = .03, and also with higher reported pain levels, t(460) = 2.71, p = .007.

CONCLUSION

Lifetime history of physical abuse was associated with OUD and chronic pain, yet standard pain assessments do not assess these factors. In health care settings, the implementation of standardized trauma-informed screening tools, prompt recognition of abuse/trauma history, and adjunct psychological interventions may reduce stigma, reduce opioid use escalation, and help patients overcome OUD.

Adverse childhood experiences, risk of opioid misuse and its pathway among students at a public university

OBJECTIVE

We examine role of ACEs and pathways to risk of opioid misuse among young adults. Participants and Methods: A cross-sectional survey of validated measures of ACEs, risk of opioid misuse, and health conditions with a sample of 1,402 students from a large public university followed by multivariate logistic regression and pathway analysis. Results: Majority (61%) of participants reported at least one ACE. A dose-response relationship between numbers of ACEs with risk for opioid misuse was present. Compared to participants with no ACEs, participants with ≥4 ACEs and 0-3 ACEs were 2.93 (95% CI: 1.95, 4.39; p < 0.001) and 1.96 (95% CI: 1.46, 2.65; p < 0.001) times more likely to be at risk for opioid misuse, respectively. Having at least one existing or past health condition significantly mediated the association. Conclusions: Our findings suggest need to include assessment of ACEs as a screening criterion for opioid prescription and administration among college-aged individuals.

The impact of exposure to physical and sexual violence on opioid consequences among trauma-exposed individuals recruited from the community who use opioids

Interpersonal violence and opioid use disorder are significant and intersecting public health concerns in the USA. The current study evaluated the consequences associated with opioid use (e.g., physical, social, interpersonal, intrapersonal, and impulse control) as a function of a history of exposure to interpersonal trauma, specifically physical and sexual violence. Participants were 84 trauma-exposed individuals recruited from the community who use opioids (M age = 43.5 50% men; 55% white). Whereas no significant differences emerged in the consequences of opioid use based on a history of physical violence, individuals with a history of sexual violence demonstrated higher levels of impulsive consequences of opioid use compared to individuals without a history of sexual violence. These data highlight the importance of considering the role of exposure to sexual violence in the context of opioid use disorder treatment.

Adverse Childhood Events, Mood and Anxiety Disorders, and Substance Dependence: Gene x Environment Effects and Moderated Mediation

Background

Adverse childhood events (ACEs) contribute to the development of mood and anxiety disorders and substance dependence. However, the extent to which these effects are direct or indirect and whether genetic risk moderates them is unclear.

Methods

We examined associations among ACEs, mood/anxiety disorders, and substance dependence in 12,668 individuals (44.9% female, 42.5% African American/Black, 42.1% European American/White). We generated latent variables for each phenotype and modeled direct and indirect effects of ACEs on substance dependence, mediated by mood/anxiety disorders (forward or "self-medication" model) and of ACEs on mood/anxiety disorders, mediated by substance dependence (reverse or "substance-induced" model). In a sub-sample, we also generated polygenic scores for substance dependence and mood/anxiety disorder factors, which we tested as moderators in the mediation models.

Results

Although there were significant indirect effects in both directions, mediation by mood/anxiety disorders (forward model) was greater than by substance dependence (reverse model). Greater genetic risk for substance dependence was associated with a weaker direct effect of ACEs on substance dependence in both the African- and European-ancestry groups (i.e., gene-environment interaction) and a weaker indirect effect in European-ancestry individuals (i.e., moderated mediation).

Conclusion

We found greater evidence that substance dependence results from self-medication of mood/anxiety disorders than that mood/anxiety disorders are substance induced. Among individuals at higher genetic risk for substance dependence who are more likely to develop a dependence diagnosis, ACEs exert less of an effect in promoting that outcome. Following exposure to ACEs, multiple pathways lead to mood/anxiety disorders and substance dependence. Specification of these pathways could inform individually targeted prevention and treatment approaches.

Adverse Childhood Events, Mood and Anxiety Disorders, and Substance Dependence: Gene X Environment Effects and Moderated Mediation

Background

Adverse childhood events (ACEs) contribute to the development of mood and anxiety disorders and substance dependence. However, the extent to which these effects are direct or indirect and whether genetic risk moderates them is unclear.

Methods

We examined associations among ACEs, mood/anxiety disorders, and substance dependence in 12,668 individuals (44.9% female, 42.5% African American/Black, 42.1% European American/White). We generated latent variables for each phenotype and modeled direct and indirect effects of ACEs on substance dependence, mediated by mood/anxiety disorders (forward or "self-medication" model) and of ACEs on mood/anxiety disorders, mediated by substance dependence (reverse or "substance-induced" model). In a sub-sample, we also generated polygenic scores for substance dependence and mood/anxiety disorder factors, which we tested as moderators in the mediation models.

Results

Although there were significant indirect effects in both directions, mediation by mood/anxiety disorders (forward model) was greater than by substance dependence (reverse model). Greater genetic risk for substance dependence was associated with a weaker direct effect of ACEs on substance dependence in both the African- and European-ancestry groups (i.e., gene-environment interaction) and a weaker indirect effect in European-ancestry individuals (i.e., moderated mediation).

Conclusion

We found greater evidence that substance dependence results from self-medication of mood/anxiety disorders than that mood/anxiety disorders are substance induced. Among individuals at higher genetic risk for substance dependence who are more likely to develop a dependence diagnosis, ACEs exert less of an effect in promoting that outcome. Following exposure to ACEs, multiple pathways lead to mood/anxiety disorders and substance dependence. Specification of these pathways could inform individually targeted prevention and treatment approaches.

Patterns and perceptions of nicotine use among U.S. adolescents and young adults receiving medication treatment for opioid use disorder

Nicotine use among U.S. youth is cause for concern, as previous studies have shown that nicotine use in adolescence increases the risk of developing substance use disorders later in life. This exploratory study aimed to understand patterns of nicotine use and perceptions of various nicotine products among adolescents and young adults (AYA) receiving medication treatment for opioid use disorder (MOUD). We administered an adapted version of the National Youth Tobacco Survey via REDCap to AYA (n = 32) receiving outpatient care in the Medication-Assisted Treatment of Addiction at Nationwide Children's Hospital in Columbus, Ohio, U.S.A. Thirty (97%) participants had tried a combustible cigarette and 27 (90%) had tried an electronic cigarette. By age 13, nineteen (61%) participants had tried combustible cigarettes and eight (25%) had tried opioids. Twenty-two (71%) participants reported smoking combustible cigarettes every day for the past 30 days, and 15 (48%) reported smoking more than 10 cigarettes per day on average. Only ten (32%) participants reported e-cigarette use in the last 30 days. Participants universally agreed that tobacco products are dangerous, and twenty (67%) current tobacco users reported that they planned to quit in the next year. Nicotine use patterns among AYA receiving MOUD differ from that previously shown in the general population, primarily by high prevalence of nicotine use in early adolescence and high current combustible cigarette use. Interventions such as universal screening for nicotine use before age 13 and tailored smoking cessation programs for AYA with OUD may help optimize care for these individuals.

Childhood abuse and opioid prescription use in adulthood: Differences between non-Hispanic Whites and non-Hispanic Blacks in the United States

Despite the rapid rise in opioid prescription medication usage, little research has examined the role of early life adversity, such as childhood abuse, particularly in the context of race, in opioid prescription usage in adulthood. Guided by the life course perspective, the current study investigates whether experiencing childhood abuse increases the risk of opioid prescription use in adulthood and whether this association varies by race. Data were sourced from the second wave of the Midlife in the United States (MIDUS) study (2004-2005). The analytic sample consisted of two groups: non-Hispanic Whites (n = 714) and non-Hispanic Blacks (n = 151). Opioid prescription use was identified from the participants' medication list using the MULTUM Lexicon Drug Database Classification System. Three types of childhood abuse-emotional, physical, and sexual-were assessed via summary scales derived from the Childhood Trauma Questionnaire. The results indicate a significant interaction between childhood physical abuse and race. Among non-Hispanic Whites, higher exposure to physical abuse during childhood was associated with greater odds of opioid prescription use in adulthood, even after adjusting for chronic pain, physical and mental health, and sociodemographic characteristics. However, the association between childhood physical abuse and opioid prescription use in adulthood was non-significant among non-Hispanic Black individuals. These findings underscore the long-term adverse health effects of physical abuse in childhood, particularly for non-Hispanic Whites, and suggest support for developing and implementing tailored intervention strategies.

Early COVID-Related pandemic impacts and subsequent opioid outcomes among persons receiving medication for opioid use disorder: a secondary data analysis of a Type-3 hybrid trial

BACKGROUND

Opioid overdoses have continued to increase since the start of the COVID-19 pandemic. The pathways through which the COVID-19 pandemic has affected trajectories of opioid use and opioid-related problems are largely unknown. Using the Epidemic-Pandemic Impacts Inventory (EPII), a novel instrument that assess pandemic-related impacts across multiple life domains, we tested the hypothesis that COVID-related impacts (on e.g., interpersonal conflict, employment, infection exposure, and emotional health) experienced in the early months of the pandemic would predict changes in opioid use and opioid-related problems at follow-up.

METHODS

This analysis was embedded within a cluster randomized type 3 implementation-effectiveness hybrid trial that had enrolled 188 patients across eight opioid treatments prior to the start of the pandemic. Participants had all been recently inducted on medication for opioid use disorder and were actively receiving treatment. Participants reported on their opioid use and opioid-related problems at baseline and 3-, 6-, and 9-month post-baseline assessments. Between May and August 2020, participants were sent an optional invitation to complete the EPII.

RESULTS

One hundred thirty-three respondents completed the EPII and 129 had sufficient data to analyze the EPII and at least one subsequent follow-up. In logistic and zero-inflated negative binomial analyses adjusting for covariates, each endorsed pandemic impact in the interpersonal conflict domain was associated with 67% increased odds of endorsement of any opioid use, and each impact in the employment and infection exposure-domains was associated with 25% and 75% increases in number of endorsed opioid-related problems, respectively.

CONCLUSIONS

Mitigating the effect of the pandemic on patients' interpersonal relationships and employment, and promoting greater infection control in opioid treatment programs, could be protective against negative opioid-related outcomes. Trial registration The present study describes secondary data analysis on a previously registered clinical trial: clinicaltrials.gov/ct2/show/NCT03931174.

Using the Recovery Capital Model to Explore Barriers to and Facilitators of Recovery in Individuals with Substance Use Disorder, Psychiatric Comorbidity and Mild-to-Borderline Intellectual Disability: A Case Series

Recovery capital (RC) encompasses the wide range of resources individuals can employ to recover from Substance Use Disorder (SUD). It consists of five subdomains: human, social, cultural, financial, and community RC. Negative recovery capital (NRC) represents the obstacles to recovery. Research on (N)RC in complex multimorbid populations is scarce. This study offers an initial exploration of the viability of (N)RC in three individuals with SUD, psychiatric comorbidities, and an intellectual disability (a triple diagnosis) in inpatient addiction treatment. We collected case file data, ranked recovery goals, and conducted follow-up interviews. The data were subjected to template analysis, using (N)RC domains as codes. All domains were prevalent and relevant, showing dynamic and reciprocal effects, influenced by critical life events acting as catalysts. Notably, during treatment, patients prioritized individual skill development despite challenges in other domains. RC emerges as a valuable concept for mapping recovery barriers and facilitators in individuals with a triple diagnosis, serving as an alternative to the medical model and complementing the biopsychosocial model. It provides a systematic framework to assess critical factors for recovery in complex cases and accordingly align interventions. Future studies should explore the intersections of NRC domains and the dynamic nature of (N)RC to enhance the understanding of the challenges faced by individuals with a triple diagnosis.

Adverse childhood experiences and prescription opioid use during pregnancy: an analysis of the North and South Dakota PRAMS, 2019-2020

OBJECTIVES

This study assesses the association between adverse childhood experiences (ACEs) and prescription opioid use during pregnancy.

METHODS

This study uses data on 2,999 individuals from the 2019 and 2020 Pregnancy Risk Assessment Monitoring System (PRAMS) from North Dakota and South Dakota. The relationship between ACEs and prescription opioid use during pregnancy is examined using multiple logistic regression.

RESULTS

The prevalence of prescription opioid use increases alongside more ACE exposure. Compared to those with no ACEs, recent mothers with three or more ACEs have a 2.4 greater odds of prescription opioid use during pregnancy (aOR [adjusted odds ratio] = 2.437; 95% CI [confidence interval] = 1.319, 4.503).

CONCLUSION

Exposure to three or more ACEs are associated with a higherrisk of prescription opioid use during pregnancy. Additional research is needed better understand the mechanisms that link ACEs and prescription opioid use during pregnancy, as well as how to best support those with ACEs exposure in a trauma-informed manner to reduce the risk of substance use.

Early life adversity: Epigenetic regulation underlying drug addiction susceptibility

Drug addiction is a leading cause of disability worldwide, with more than 70,000 Americans dying from drug overdose in 2019 alone. While only a small percentage of chronic drug users escalate to drug addiction, little is understood on the precise mechanisms of this susceptibility. Early life adversity is causally relevant to adult psychiatric disease and may contribute to the risk of addiction. Here we review recent pre-clinical evidence showing that early life exposure to stress and/or drugs regulates changes in behavior, gene expression, and the epigenome that persist into adulthood. We summarize the major findings and gaps in the preclinical literature, highlighting studies that demonstrate the often profound differences between female and male subjects.

Adverse Childhood Experiences and Prescription Opioid Use During Pregnancy: An Analysis of the North and South Dakota PRAMS, 2019-2020

Objectives: This study assesses the association between adverse childhood experiences (ACEs) and prescription opioid use during pregnancy. Methods: This study uses data on 2,999 individuals from the 2019 and 2020 Pregnancy Risk Assessment Monitoring System (PRAMS) from North Dakota and South Dakota. The relationship between ACEs and prescription opioid use during pregnancy is examined using multiple logistic regression. Results: The prevalence of prescription opioid use increases alongside accumulating ACEs. Compared to those with no ACEs, recent mothers with three or more ACEs have a 2.4 greater odds of prescription opioid use during pregnancy (aOR [adjusted odds ratio] = 2.437; 95% CI [confidence interval] = 1.319, 4.503). Conclusion: Accumulating ACEs are associated with an increased risk of prescription opioid use during pregnancy. Additional research is needed better understand the mechanisms that link ACEs and prescription opioid use during pregnancy, as well as how to best support those with ACEs exposure in a trauma-informed manner to reduce the risk of substance use.

Psychosocial Correlates of Opioid Use Profiles among Young Adults in a Longitudinal Study across 6 US Metropolitan Areas

Background: Examining opioid use profiles over time and related factors among young adults is crucial to informing prevention efforts. Objectives: This study analyzed baseline data (Fall 2018) and one-year follow-up data from a cohort of 2,975 US young adults (Mage=24.55, 42.1% male; 71.7% White; 11.4% Hispanic). Multinomial logistic regression was used to examine: 1) psychosocial correlates (i.e. adverse childhood experiences [ACEs], depressive symptoms, parental substance use) of lifetime opioid use (i.e. prescription use vs. nonuse, nonmedical prescription [NMPO] use, and heroin use, respectively); and 2) psychosocial correlates and baseline lifetime use in relation to past 6-month use at one-year follow-up (i.e. prescription use vs. nonuse and NMPO/heroin use, respectively). Results: At baseline, lifetime use prevalence was: 30.2% prescription, 9.7% NMPO, and 3.1% heroin; past 6-month use prevalence was: 7.6% prescription, 2.5% NMPO, and 0.9% heroin. Compared to prescription users, nonusers reported fewer ACEs and having parents more likely to use tobacco, but less likely alcohol; NMPO users did not differ; and heroin users reported more ACEs and having parents more likely to use cannabis but less likely alcohol. At one-year follow-up, past 6-month use prevalence was: 4.3% prescription, 1.3% NMPO, and 1.4% heroin; relative to prescription users, nonusers were less likely to report baseline lifetime opioid use and reported fewer ACEs, and NMPO/heroin users were less likely to report baseline prescription opioid use but more likely heroin use. Conclusions: Psychosocial factors differentially correlate with young adult opioid use profiles, and thus may inform targeted interventions addressing different use patterns and psychosocial risk factors.

The effect of stress on opioid addiction-related behaviors: A review of preclinical literature

Opioid misuse is a critical public health crisis in the United States that results in over 50,000 deaths per year and a substantial economic burden to society. Human epidemiological data suggest that exposure to stress is one of many risk factors for opioid misuse; however, opioid abusers tend to have multiple risk factors and use other drugs in addition to opioids. To identify causal mechanisms by which stress may increase risk, preclinical animal experiments provide a means to conduct experimental manipulations and maintain precise controls over environmental and drug exposures. The current review examines how stressful experiences alter opioid addiction-related behaviors in animal models, with a focus on how age of stress exposure affects drug outcomes. The findings summarized here suggest that neonatal or adult stress increase behaviors indicative of opioid intake and reward in rodent models, but that adolescent social stress may protect against later opioid addiction-related behaviors, which contradicts human epidemiological literature. We highlight three important areas to consider across this body of literature: the species and/or strain used, stressor type, and inclusion of both sexes. Finally, we suggest areas where additional research is warranted. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Substance Use Among Patients With Incident Crohn's Disease in the United States, 2010 to 2019: A Medicaid Observational Study

BACKGROUND AND AIMS

Substance use among persons with Crohn's disease (CD) is associated with symptomatic exacerbation and poorer quality of life. However, data on the prevalence of substance use among individuals with CD are limited. Therefore, our study aimed to estimate the burden of alcohol and drug use among individuals with incident CD in the United States. We also assessed the associations between CD-related interventions and substance use after CD diagnosis.

METHODS

Our retrospective cohort study of the national Medicaid databases from 2010 to 2019 identified participants with newly diagnosed CD and defined substance use (ie, alcohol, opioids, cocaine, amphetamine, and cannabis) using diagnosis codes. Multivariable logistic regression models assessed the associations between CD-related interventions and substance use after CD diagnosis.

RESULTS

Overall, 16.3% of Medicaid enrollees with incident CD had substance ever-use, most commonly alcohol or opioids (each 8.0%). Any substance use saw an absolute decrease of 3.8% after CD diagnosis, but changes were less than 1% in either direction for each substance. CD-related hospitalization was associated with increased alcohol or opioid use post-CD diagnosis. Surgery was associated with lower use post-CD of opioids but not alcohol. CD medications (except steroids) were generally associated with decreased post-CD alcohol or opioid use.

CONCLUSION

Among Medicaid enrollees with incident CD, alcohol and opioid use were more frequent than previously published estimates for the general US population (6% and 4%, respectively, in 2019). Consequently, medical communities must be more aware of substance use by patients with CD to provide quality patient-centered care.

The Impact of Physical and Sexual Violence on Opioid Consequences among Trauma- exposed Individuals Recruited from the Community who Use Opioids

Interpersonal violence and opioid use disorder are significant and intersecting public health concerns in the United States. The current study evaluated the consequences associated with opioid use as a function of history of interpersonal trauma, specifically physical and sexual violence. Participants were 84 trauma-exposed individuals recruited from the community who use opioids (M age = 43.5 50% men; 55% white). Whereas no significant differences emerged in the consequences of opioid use based on a history of physical violence, individuals with a history of sexual violence demonstrated higher levels of impulsive consequences of opioid use compared to individuals without a history of sexual violence. These data highlight the importance of considering the role of sexual violence in the context of opioid use disorder treatment.

Differential prevalence of Adverse Childhood Experiences (ACEs) by gender and substance used in individuals with cannabis, cocaine, opioid, and tobacco use disorders

Background: Adverse childhood experiences (ACEs) show a graded association with the development of substance use disorders (SUDs) and engagement in risky substance use behaviors. Women are overrepresented among individuals with more severe childhood adversity (≥4 types of ACEs) and may be at particular risk for aberrant substance use.Objectives: To assess the prevalence of ACEs among men and women with cannabis, opioid, cocaine, and tobacco use disorders.Methods: Non-treatment-seeking individuals participating in clinical addiction research at a single site completed the ACE questionnaire and provided a detailed substance use history. Data were analyzed using proportional odds models and logistic regression.Results: Most participants (424/565; 75%) reported at least one ACE, and more than one-quarter (156/565; 27%) reported severe childhood adversity. Relative to men (n = 283), women (n = 282) reported more ACEs (OR = 1.49; p = .01) and more experiences of emotional/physical abuse (OR = 1.52; p = .02), sexual abuse (OR = 4.08; p = .04), and neglect (OR = 2.30; p < .01). Participants in the cocaine (OR = 1.87; n = .01) and opioid (OR = 2.21; p = .01) use disorder, but not cannabis use disorder (OR = 1.46; p = .08), studies reported more severe adversity relative to the tobacco group. Relative to tobacco users, emotional/physical abuse (OR = 1.92; p = .02) and neglect (OR = 2.46; p = .01) scores were higher in cocaine users and household dysfunction scores were higher in opioid users (OR = 2.67; p = .01).Conclusion: The prevalence of ACEs differs with respect to both participant gender and primary substance used. Novel SUD treatment strategies that incorporate ACEs may be uniquely beneficial in specific subpopulations of people with SUDs.

Childhood Adversity, Addiction Severity, and Comorbidity Among Patients Receiving Opioid Use Disorder Treatment: The Role of Emotion Regulation

Patients in opioid use disorder (OUD) treatment report high rates of childhood adversity, and women experience greater exposure to certain types of childhood adversity ( e.g. , sexual abuse). Childhood adversity is associated with clinical severity, but the mechanisms explaining this association are not well understood. Participants ( N = 171) in opioid agonist treatment completed measures of childhood adversity, emotion regulation, and clinical severity ( i.e. , addictive behaviors, depression, and anxiety). Women endorsed greater childhood adversity and higher current psychopathology than men. The association between childhood adversity and clinical severity varied as a function of symptom type, although emotion regulation was a strong predictor in all models. Women reported higher levels of anxiety after controlling for covariates, childhood adversity, and emotion dysregulation. Future research should investigate treatment strategies to address emotion dysregulation among patients in OUD treatment, particularly women who may present with greater childhood adversity exposure and anxiety.

The effects of childhood trauma and mental disorders on treatment engagement, contact with the criminal justice system, and mortality among people with opioid dependence

BACKGROUND

Childhood trauma and mental disorders increase the risk of opioid dependence. We aimed to examine whether childhood trauma and mental disorders are associated with opioid agonist treatment (OAT) engagement, contact with the criminal justice system, and mortality among people with opioid dependence.

METHODS

This observational study linked survey data from 1482 people receiving OAT in Sydney, Australia (2004-2008) to administrative data on OAT, crime, and mortality through 2017. We used survey data to assess childhood trauma, depression, panic disorder, post-traumatic stress disorder (PTSD), borderline personality disorder, anti-social personality disorder (ASPD), and comorbid substance dependence. We used discrete-time analysis to examine time from opioid dependence onset to OAT entry and mortality. Poisson regressions were used to analyze time receiving OAT and number of charges.

RESULTS

Participants with extensive childhood trauma histories and ASPD were less likely to enter OAT and those with depression were more likely to enter OAT in any given year after opioid dependence onset. Panic disorder, PTSD, and borderline personality disorder were associated with less time in OAT. Extensive histories of childhood trauma, PTSD, ASPD, and comorbid substance dependence increased risk of charges for any offence. There were no significant associations between the exposure variables and mortality.

CONCLUSIONS

Our findings suggest that childhood trauma and mental disorders increase the risk of adverse treatment and social outcomes among people with opioid dependence. Interventions that aim to reduce harm among people with opioid dependence may consider the effect of childhood trauma and mental disorders on OAT engagement and crime.

Adverse Childhood Experiences Are Associated With History of Overdose Among Patients Presenting for Outpatient Addiction Care

OBJECTIVES

Adverse childhood experiences (ACEs) are associated with mental health issues and substance use. Having a substance use disorder increases the risk of overdose (OD). Research on ACEs and risk of OD is limited. This study examined the relationship between ACE scores and a self-reported history of OD among patients in an addiction and mental health outpatient setting.

METHODS

This single-center, cross-sectional design included adults in a dual-diagnosis addiction and mental health outpatient recovery and treatment program from November 2017 to August 2020. Patients (N = 115) were assessed with self-report questionnaires, which included ACEs and history of OD. Bivariate and multivariable logistic regression was used to determine factors associated with self-reported OD history. We assessed the reliability and validity of the ACEs scale.

RESULTS

Of the 115 participants, 26 (22.6%) reported a past OD at intake. The mean ACE score for participants with an OD history, as compared with those with no history of OD, was 4.0 (standard deviation, 2.7) vs 2.3 (standard deviation, 2.2). In the multivariable regression, a higher ACE score was associated with history of OD (adjusted odds ratio, 1.23; 95% confidence interval, 1.00-1.50; P = 0.0456).

CONCLUSIONS

Given the observed association between OD and higher ACE scores, patients presenting for treatment in outpatient dual-diagnosis clinics should be screened for ACEs and OD history, providing the opportunity for treatment with trauma-informed care and/or referral to appropriate services.

The Martinsburg Initiative: A Collaboration Between Public Safety, Public Health, and Schools to Address Trauma and Substance Use

The Martinsburg Initiative (TMI) is a community-based model developed in Martinsburg, West Virginia, that implements a comprehensive approach to adverse childhood experiences and substance use prevention and mitigation by leveraging partnerships in public health and health care, public safety, and education. TMI receives coordinated federal funding and technical assistance from the Centers for Disease Control and Prevention, the Washington-Baltimore High Intensity Drug Trafficking Agency, and the National Association of County and City Health Officials to integrate evidence-based and promising strategies. It advances such strategies by translating them for implementation within the community, evaluating the reach and potential impact of the model, and by engaging key stakeholders. Preliminary results describing program reach and short-term outcomes collected for a subset of the interventions during implementation are presented. The model uses touchpoints across multiple community sectors in the city of Martinsburg to break the cycle of trauma and substance use across the life span.

Effects of Early Life Trauma on Risks for Adult Opioid Use Disorder Are Mediated by Stress and Occur Independent of Depression and Anxiety

OBJECTIVES

Adverse childhood experiences, or early life trauma (ELT), may be a potential risk factor for opioid use disorders (OUDs) that could be further influenced by depression, anxiety, and stress. The prevalence and strength of these associations are largely unknown.

METHODS

This study examined the association between current OUD severity and lifetime history of ELT, and the degree to which current depression, anxiety, and stress influenced this association, in persons (n = 310) with at least 1 lifetime exposure to opioids using an online survey.

RESULTS

Ninety-three percent of respondents experienced at least 1 trauma in their lifetime, and 65% met the criteria for OUD. Early life trauma was largely unassociated with demographics but demonstrated an almost "dose-dependent" association among all forms of ELT (total, general, physical, emotional, sexual), whereby more ELT was associated with more severe current OUD. A multivariate mediation model found perceived stress to be a robust mediator of this association. Current psychiatric functioning did not significantly moderate the relationship between ELT and OUD, suggesting that ELT may impact OUD severity at varying levels of psychiatric functioning.

CONCLUSIONS

These data support existing evidence that greater ELT may influence adult OUD severity and identify perceived stress as a potential mechanistic contributor to this association. Results are preliminary in nature but support continued research into mechanisms underlying the association between ELT and OUD, particularly conformational changes in the stress system resultant from ELT, and interventions to mitigate the impact of ELT on OUD development and/or develop trauma-informed OUD treatment approaches.

Evaluating the association between urine drug screening frequency and retention in opioid agonist treatment in Ontario, Canada: a retrospective cohort study

OBJECTIVE

The objective of this study was to evaluate how urine drug screening (UDS) frequency is associated with retention in opioid agonist treatment (OAT).

METHODS

Data for this retrospective cohort study of 55 921 adults in OAT in Ontario, Canada, were derived from administrative sources between 1 January 2011 and 31 December 2015. All patient information was linked anonymously across databases using encrypted health card numbers. Descriptive statistics were calculated for comparing UDS frequency groups using standardised differences (d) where d less than 10% indicated a statistically significant difference. A logistic regression model was then used to calculate ORs adjusting for baseline covariates, including sex, age, location of residence, income quintile, mental disorders, HIV status and deep tissue infections.

RESULTS

Over 70% of the cohort had four or more UDS tests per month (weekly or more UDS). Significant associations were observed between UDS frequency and 1-year treatment retention in OAT biweekly (adjusted OR (aOR)=3.20, 95% CI 2.75 to 3.75); weekly UDS (aOR=6.86, 95% CI 5.88 to 8.00) and more than weekly (aOR=8.03, 95% CI 6.87 to 9.38) using the monthly or less groups as the reference.

CONCLUSION

This study identified an association between weekly UDS and 1-year treatment retention in OAT. There is an active discussion within Canada about the utility of UDS. The lack of evidence for the impact of UDS on retention has left it open to some to argue they simply provide a barrier to patient engagement. Therefore, it is timely of this study to demonstrate that more frequent urine testing is not associated with a reduction in treatment retention.

The representation of females in clinical trials for substance use disorder conducted in the United States (2010-19)

BACKGROUND AND AIMS

Women have historically been under-represented in clinical research, but the extent to which this is true for substance use disorder (SUD) trials is unknown. We aimed to determine the ratio of female:male participation in clinical trials for SUDs and describe the reporting of sex-specific outcomes from 2010 to 2019.

DESIGN

A retrospective cohort review of clinical trials involving people with SUD.

SETTING

United States.

PARTICIPANTS

Clinical trials including people with SUD registered in clinicaltrials.gov and completed between 1 January 2010 and 31 December 2019 were reviewed. Trials were excluded if they had < 30 participants, focused on SUD prevention, were conducted outside the United States and/or did not report data on participant sex or gender.

MEASUREMENTS

The following were extracted for each trial: primary outcome, number of participants enrolled, analytical sample size, percentage of participants who were female, inclusion of transgender participants, whether sex-based analyses were performed, funding source, type of SUD and type of intervention. Relative representation in trials was examined using the female:male ratio, reported using median ratios and by year of trial completion. The proportion of females participating was adjusted using the underlying disease prevalence among females using National Survey on Drug Use and Health data.

FINDINGS

A total of 316 trials met inclusion criteria: 274 were mixed-sex, 12 enrolled only males and 30 only females. In 274 mixed-sex trials, 40% of 57 544 participants were female. Only 22 trials (8%) reported any sex-specific analyses; four studies (1.5%) reported inclusion of transgender participants. Females represented 35% of participants in trials targeting illicit drug use disorder, 52% in nicotine use disorder and 29% in alcohol use disorder. Accounting for underlying disease prevalence revealed that women had the lowest relative enrollment in alcohol use disorder trials (median participation to prevalence ratio in 2017: 0.58; 95% confidence interval: 0.13, 0.91).

CONCLUSIONS

A review of 316 US clinical trials for alcohol, nicotine and illicit substance use disorders completed between 2010 and 2019 showed that females were enrolled at lower rates than males overall. Only 8% of the trials reviewed reported sex-specific analyses and 1.5% reported transgender participants.

Distinguishing clinical factors associated with unintentional overdose, suicidal ideation, and attempted suicide among opioid use disorder in-patients

Opioid and other drug-related overdoses and suicides are leading causes of injury death and represent a significant public health threat in the United States (U.S.). This study examined clinical factors of three patient groups from two inpatient addiction treatment facilities in Appalachian West Virginia (n = 66). Patients were classified as having: 1) unintentional overdose(s) (OD), 2) suicidal ideation or suicide attempt(s) (SI/SA), and 3) suicidal ideation or suicide attempt, and unintentional overdose (SI/SA/OD). Multinomial logistic regression models were used to determine whether adverse childhood experiences, self-injurious behaviors, substance use history, overdose history, and past year stressful life events were differentially associated with history of SI/SA/OD. Participants in the OD group were more likely to have used heroin in the 24-h preceding their most recent overdose compared to either the SI/SA or SI/SA/OD groups. The multivariable model found participants with history of SI/SA had higher adverse childhood experience scores and more participants with history of SI/SA endorsed childhood physical abuse and teen dating violence. Overall, there are characteristics that distinguish unintentional overdose from suicidal ideation and attempt. Patients with SI/SA/OD appear to have greater clinical severity. More thorough evaluation of drugs involved in overdose and history of self-injury may help distinguish future risk and inform treatment planning.

The effects of disability status and perceived neighbourhood cohesion and safety on adverse childhood experiences among college students

Adverse childhood experiences (ACEs) are early traumatic events that can have adverse long-term developmental effects on a person's health and well-being. Individuals with disabilities are at a greater risk of all types of ACEs. However, the impact of having a disability and neighbourhood context on ACEs is under-researched, and even less is known about whether neighbourhood cohesion and safety affect the relationship between disability status and ACEs. The purpose of this study is to examine the direct and indirect pathways between disability status, childhood neighbourhood environment and ACEs. The final study sample of this study was 2,049 college students, consisting of 494 students with disabilities and 1,555 students without disabilities from six universities in the U.S. and Canada between March 2016 and June 2017. Data analysis included Pearson correlations and structural equation modelling procedures using Stata 16 software to test a partial mediation model. Having a disability has both a direct effect and an indirect effect through the neighbourhood environment on ACEs after controlling for socio-demographic characteristics associated with neighbourhood environment or ACEs. The findings suggest that neighbourhood cohesion and safety can be a mediator between disability status and ACEs, and the potential cumulative risk and protective factors that can contribute to ACEs. To elucidate the relationship between disability status and a higher risk for ACEs fully and prevent ACEs that can negatively impact the long-term health outcomes, greater attention to environmental risk and protective factors is urgently needed.

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.

Enduring disruption of reward and stress circuit activities by early-life adversity in male rats

In humans, early-life adversity (ELA) such as trauma, poverty, and chaotic environment is linked to increased risk of later-life emotional disorders including depression and substance abuse. These disorders involve underlying disruption of reward circuits and likely vary by sex. Accordingly, we previously found that ELA leads to anhedonia for natural rewards and cocaine in male rodents, whereas in females ELA instead increases vulnerability to addiction-like use of opioid drugs and palatable food. While these findings suggest that ELA-induced disruption of reward circuitry may differ between the sexes, the specific circuit nodes that are influenced by ELA in either sex remain poorly understood. Here, in adult male Sprague-Dawley rats, we ask how ELA impacts opioid addiction-relevant behaviors that we previously tested after ELA in females. We probe potential circuit mechanisms in males by assessing opioid-associated neuronal activation in stress and reward circuit nodes including nucleus accumbens (NAc), amygdala, medial prefrontal cortex (mPFC), and paraventricular thalamus. We find that ELA diminishes opioid-seeking behaviors in males, and alters heroin-induced activation of NAc, PFC, and amygdala, suggesting a potential circuit-based mechanism. These studies demonstrate that ELA leads to behavioral and neurobiological disruptions consistent with anhedonia in male rodents, unlike the increased opioid seeking we previously saw in females. Our findings, taken together with our prior work, suggest that men and women could face qualitatively different mental health consequences of ELA, which may be essential for individually tailoring future intervention strategies.

Adverse Childhood Experiences and Overdose: Lessons From Overdose Data to Action

INTRODUCTION

Adverse childhood experiences and overdose are linked in a cycle that affects individuals and communities across generations. The Centers for Disease Control and Prevention's Overdose Data to Action cooperative agreement supports a comprehensive public health approach to overdose prevention and response activities across the U.S. Exposure to traumatic events during childhood can increase the risk for myriad health outcomes, including overdose; therefore, many Overdose Data to Action recipients leveraged funds to address adverse childhood experiences.

METHODS

In 2021, an inventory of Overdose Data to Action‒funded activities implemented in 2019 and 2020 showed that 34 of the 66 recipients proposed overdose prevention activities that support people who have experienced adverse childhood experiences or that focus on preventing the intergenerational transmission of adverse childhood experiences. Activities were coded by adverse childhood experience prevention strategy, level of the social ecology, and whether they focused on neonatal abstinence syndrome.

RESULTS

Most activities among Overdose Data to Action recipients occurred at the community level of the social‒ecologic model and under the intervene to lessen harms adverse childhood experience prevention strategy. Of the 84 adverse childhood experience‒related activities taking place across 34 jurisdictions, 44 are focused on neonatal abstinence syndrome.

CONCLUSIONS

Study results highlight the opportunities to expand the breadth of adverse childhood experience prevention strategies across the social ecology. Implementing cross-cutting overdose and adverse childhood experience‒related activities that span the social‒ecologic model are critical for population-level change and have the potential for the broadest impact. Focusing on neonatal abstinence syndrome also offers a unique intervention opportunity for both adverse childhood experience and overdose prevention.

A comprehensive mobile health intervention to prevent and manage the complexities of opioid use

OBJECTIVES

The Opioid Use crisis continues to be an epidemic with multiple known influencing and interacting factors. With the need for suitable opioid use interventions, we present a conceptual design of an m-health intervention that addresses the various known interacting factors of opioid use and corresponding evidence-based practices. The visualization of the opioid use complexities is presented as the "Opioid Cube".

METHODS

Following Stage 0 to Stage IA of the NIH Stage Model, we used guidelines and extant health intervention literature on opioid apps to inform the Opioid Intervention (O-INT) design. We present our design using system architecture, algorithms, and user interfaces to integrate multiple functions including decision support. We evaluate the proposed O-INT using analytical modeling.

RESULTS

The conceptual design of O-INT supports the concept of collaborative care, by providing connections between the patient, healthcare professionals, and their family members. The evaluation of O-INT shows a preference for specific functions, such as overdose detection and potential for high system reliability with minimal side effects. The Opioid Cube provides a visualization of various opioid use states and their influencing and interacting factors.

CONCLUSIONS

O-INT is a promising design with a holistic approach to manage opioid use and prevent and treat misuse. With several needed functionalities, O-INT design serves as a decision support system for patients, healthcare professionals, researchers, and policy makers. Together, O-INT and the Opioid Cube may serve as a foundation for development and adoption of highly effective m-health interventions for opioid use.

Neurodevelopmental origins of substance use disorders: Evidence from animal models of early-life adversity and addiction

Addiction is a chronic relapsing disorder with devastating personal, societal, and economic consequences. In humans, early-life adversity (ELA) such as trauma, neglect, and resource scarcity are linked with increased risk of later-life addiction, but the brain mechanisms underlying this link are still poorly understood. Here, we focus on data from rodent models of ELA and addiction, in which causal effects of ELA on later-life responses to drugs and the neurodevelopmental mechanisms by which ELA increases vulnerability to addiction can be determined. We first summarize evidence for a link between ELA and addiction in humans, then describe how ELA is commonly modeled in rodents. Since addiction is a heterogeneous disease with many individually varying behavioral aspects that may be impacted by ELA, we next discuss common rodent assays of addiction-like behaviors. We then summarize the specific addiction-relevant behavioral phenotypes caused by ELA in male and female rodents and discuss some of the underlying changes in brain reward and stress circuits that are likely responsible. By better understanding the behavioral and neural mechanisms by which ELA promotes addiction vulnerability, we hope to facilitate development of new approaches for preventing or treating addiction in those with a history of ELA.

The effect of social network strain on suicidal ideation among middle-aged adults with adverse childhood experiences in the US: A twelve-year nationwide study

Objective

Building on literature that measured the association between social network strain (SNS) and suicidal ideation using conventional regression analyses, we examined the effect of SNS, due to adverse childhood experiences (ACEs), on suicidal ideation using instrumental variables (IV) to eliminate the potential biases that may have occurred in earlier studies due to residual confounding.

Methods

This retrospective cohort study linked longitudinal data from the National Survey of Midlife Development in the United States (MIDUS) Refresher Biomarker Project (2012–2016), the MIDUS Refresher Project (2011–2014), the MIDUS 2 Biomarker Project (2004–2009), and the MIDUS 2 Project (2004–2006). Participants completed a phone interview, self-administered survey, and biomarker data collection. Exposure indicators included self-reported suicidal ideation, ACEs, and SNS from family, spouse, and friends. IV analysis was used to evaluate the continuous local average treatment effect of SNS on suicidal ideation when SNS only varied due to variation in ACEs.

Results

Our sample included 1703 middle-aged adults (52.9% females), which were followed up for 12 years. An IV probit model controlling for sociodemographic characteristics found a one-standard-deviation reduction in SNS reduced suicidal ideation by 22.6% (p < 0.01). A comprehensively controlled IV probit model found that a one-standard-deviation reduction in SNS is associated with a 21.4% (p = 0.05) decrease in suicidal ideation.

Conclusions

The causal pathway from SNS (due to ACEs) to suicidal ideation among middle-aged adults was established using IV analysis in this large-scale longitudinal study. The magnitude of this effect is sufficient to warrant the development of programs to improve social network relationships among family, friends, and spouses/partners. Suicide prevention programs addressing SNS may significantly reduce suicidal ideation among middle-aged Americans who have experienced ACEs.

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Social Network Strain (SNS) from family, spouse, and friends is common.

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SNS derives from demands, criticisms, disappointments, and irritations.

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SNS varies strongly with Adverse Childhood Experiences (ACEs).

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Reductions in SNS due to fewer ACEs decrease suicidal ideation.

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A one standard-deviation reduction in SNS lowers suicidal ideation by 20%.

Social Determinants of Health: What Are They and How Do We Screen

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity report recognizes nurses' impact on the medical and social factors that drive health outcomes (National Academies of Sciences, Engineering, and Medicine [NASEM], 2021). The report calls for nursing to take bold steps to address individual and structural level social determinants of health (SDoH)-or social and environmental factors contributing to poor health, poor health outcomes, and health disparities (NASEM, 2021, p. 5). Nurses must recognize the significance of SDoH on patient health outcomes in order to advance health equity and employ nursing interventions to affect positive change for our patients. SDoH are part of our patients' stories, and holistic nursing means we know the whole patient story. Although it is now widely recognized that SDoH affect health outcomes, a key challenge for nurses is that they represent an enormous range of factors-from food and housing insecurity to personal safety and environmental exposures-that may be more or less able to change with interventions in clinical settings. Furthermore, concerns have been raised that screening for SDoH-especially when not done with sensitivity, cultural competence, or ready intervention-may compromise therapeutic relationships and marginalize patients (Wallace et al., 2020). However, despite these concerns, healthcare systems are widely adopting SDoH assessments, generally through electronic health record screening questions, and attempting to implement associated workflows and interventions. Given this landscape, the purpose of this article, within this special issue of Orthopaedic Nursing, is to provide an overview of SDoH factors, identify best practices related to screening and referral, and highlight nurse-directed interventions in clinical settings.

Opioid use disorder in anaesthesia and intensive care: Prevention, diagnosis and management

Opioid misuse is common, as is opioid agonist treatment of opioid dependence. Almost 3% of Australians and over 3.5% of those living in New Zealand report misuse of analgesics. Over 50,000 Australians receive opioid agonist treatment with methadone or buprenorphine for management of severe opioid use disorder.The perioperative period is an opportunity to identify pre-existing opioid misuse, and to introduce interventions to reduce the risk of development of opioid use disorder. Challenges of acute perioperative pain management or intensive care management of patients receiving opioid agonist treatment include opioid tolerance and ongoing prescribing of methadone or buprenorphine. There has been some ambiguity about the optimal perioperative management of buprenorphine, a partial agonist at the mu receptor.In this article, a framework to identify emerging opioid misuse problems, identify risk of overdose and to manage the opioid-dependent patient on opioid agonist treatment perioperatively or in the intensive care unit is provided. Diagnostic criteria and risk stratification criteria are presented. Management strategies include trauma-informed care, care planning and care coordination with community practitioners and opioid agonist treatment providers. Continuing methadone or buprenorphine perioperatively with additional opioid and non-opioid analgesia is generally recommended. Increased opioid agonist treatment doses may be required on discharge. An algorithm for decisions about opioid agonist treatment management in the intensive care unit based on the risks of opioid withdrawal and toxicity is considered. Strategies for managing the opioid-dependent patient who is not in treatment are also discussed.