Association of current and past opioid use disorders with health-related quality of life and employment among US adults

Impact of opioid overdoses on US life expectancy and years of life lost, by demographic group and stimulant co-involvement: a mortality data analysis from 2019 to 2022

Background

The United States' opioid crisis is worsening, with the number of deaths reaching 81,806 in 2022 after more than tripling over the past decade. This study aimed to comprehensively characterize changes in burden of opioid overdose mortality in terms of life expectancy reduction and years of life lost between 2019 and 2022, including differential burden across demographic groups and the contribution of polysubstance use.

Methods

Using life tables and counts for all-cause and opioid overdose deaths from the National Center for Health Statistics, we constructed cause-eliminated life tables to estimate mortality by age in the absence of opioid-related deaths. We calculated the loss in life expectancy at birth (LLE) and total years of life lost (YLL) due to opioid overdose deaths by state of residency, sex, racial/ethnic group, and co-involvement of cocaine and psychostimulants.

Findings

Opioid-related deaths in the US led to an estimated 3.1 million years of life lost in 2022 (38 years per death), compared to 2.0 million years lost in 2019. Relative to a scenario with no opioid mortality, we estimate that opioid-related deaths reduced life expectancy nationally by 0.67 years in 2022 vs 0.52 years in 2019. This LLE worsened in all racial/ethnic groups during the study period: 0.76 y-0.96 y for white men, 0.36 y-0.55 y for white women, 0.59 y-1.1 y for Black men, 0.27 y-0.53 y for Black women, 0.31 y-0.82 y for Hispanic men, 0.19 y-0.31 y for Hispanic women, 0.62 y-1.5 y for American Indian/Alaska Native (AI/AN) men, 0.43 y-1 y for AI/AN women, 0.09 y-0.2 y for Asian men, and 0.08 y-0.13 y for Asian women. Nearly all states experienced an increase in years of life lost (YLL) per capita from 2019 to 2022, with YLL more than doubling in 16 states. Cocaine or psychostimulants with abuse potential (incl. methamphetamines) were involved in half of all deaths and years of life lost in 2022, with substantial variation in the predominant drug class by state and racial/ethnic group.

Interpretation

The burden of opioid-related mortality increased dramatically in the US between 2019 and 2022, coinciding with the period of the COVID-19 pandemic and the associated disruptions to social, economic, and health systems. Opioid overdose deaths are an important contributor to decreasing US life expectancy, and Black, Hispanic, and Native Americans now experience mortality burdens approaching or exceeding white Americans.

Funding

None.

Reducing overdose deaths among persons with opioid use disorder in connecticut

BACKGROUND

People in Connecticut are now more likely to die of a drug-related overdose than a traffic accident. While Connecticut has had some success in slowing the rise in overdose death rates, substantial additional progress is necessary.

METHODS

We developed, verified, and calibrated a mechanistic simulation of alternative overdose prevention policy options, including scaling up naloxone (NLX) distribution in the community and medications for opioid use disorder (OUD) among people who are incarcerated (MOUD-INC) and in the community (MOUD-COM) in a simulated cohort of people with OUD in Connecticut. We estimated how maximally scaling up each option individually and in combinations would impact 5-year overdose deaths, life-years, and quality-adjusted life-years. All costs were assessed in 2021 USD, employing a health sector perspective in base-case analyses and a societal perspective in sensitivity analyses, using a 3% discount rate and 5-year and lifetime time horizons.

RESULTS

Maximally scaling NLX alone reduces overdose deaths 20% in the next 5 years at a favorable incremental cost-effectiveness ratio (ICER); if injectable rather than intranasal NLX was distributed, 240 additional overdose deaths could be prevented. Maximally scaling MOUD-COM and MOUD-INC alone reduce overdose deaths by 14% and 6% respectively at favorable ICERS. Considering all permutations of scaling up policies, scaling NLX and MOUD-COM together is the cost-effective choice, reducing overdose deaths 32% at ICER $19,000/QALY. In sensitivity analyses using a societal perspective, all policy options were cost saving and overdose deaths reduced 33% over 5 years while saving society $338,000 per capita over the simulated cohort lifetime.

CONCLUSIONS

Maximally scaling access to naloxone and MOUD in the community can reduce 5-year overdose deaths by 32% among people with OUD in Connecticut under realistic budget scenarios. If societal cost savings due to increased productivity and reduced crime costs are considered, one-third of overdose deaths can be reduced by maximally scaling all three policy options, while saving money.

Measuring the importance of different barriers to opioid agonist treatment using best-worst scaling in an Australian setting

OBJECTIVE

Opioid agonist treatment (OAT) is an effective treatment for opioid use disorder (OUD), however several client barriers to OAT are reported. Client importance of these barriers using economic preference elicitation measures have not been identified. This paper determines the most important OAT barriers using best-worst scaling (BWS) and compares the results of BWS to Likert scale.

METHODS

Cross-sectional self-completed survey with 191 opioid dependent clients who attended Australian needle and syringe sites. Participants were presented 15 Likert scale barriers and 15 BWS barrier scenarios. The BWS data was presented using count analysis, multinomial logit and mixed logit models. The ranking of barrier items was completed using three BWS methods and one Likert scale method, with share preference results (BWS) or mean scores (Likert) used to rank the 15 barriers.

RESULTS

The most important client barriers were 'enjoy using opioids', 'lack of support services' and 'hard to access'. The four ranking methods produced different barrier rankings for the most important barriers, but similar results for the least important barriers.

CONCLUSION

Policies around OAT as a harm reduction approach, increased support services and increased availability of OAT services would be beneficial in improving OAT uptake. Comparing BWS and Likert methods produced different highest ranked barriers, indicating the method used to identify preferences has significant implications on the type of intervention prioritised.

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

INTRODUCTION

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

AIM

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

METHODS

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

RESULTS

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

DISCUSSION

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

IMPLICATIONS FOR PRACTICE

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

Health-related quality of life and recovery capital among recovery residents taking medication for opioid use disorder in Texas

Background

Recovery from opioid use disorder (OUD) includes improvements in health-related quality of life (HRQOL) and is supported by recovery capital (RC). Little is known about RC and HRQOL among recovery residents taking medication for OUD. We described HRQOL and RC and identified predictors of HRQOL.

Methods

Project HOMES is an ongoing longitudinal study implemented in 14 recovery homes in Texas. This is a cross-sectional analysis of data from 358 participants' on HRQOL (five EQ-5D-5L dimensions-mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) and RC (Assessment of Recovery Capital scores) collected from April 2021 to June 2023. Statistical analyses were conducted using T-, Chi-squared, and Fisher's exact tests.

Results

Most participants were 35 years/older (50.7%), male (58.9%), non-Hispanic White (68.4%), heterosexual (82.8%), and reported HRQOL problems, mainly anxiety/depression (78.4%) and pain/discomfort (55.7%). Participants who were 35 years/older [mean (SD) = 42.6 (7.3)] were more likely to report mobility and pain/discomfort problems than younger participants. Female participants were more likely to report pain/discomfort problems than male participants. Sexual minorities were more likely to report anxiety/depression problems than heterosexual participants. Married participants and those in committed relationships were more likely to report problems conducting self-care than single/never-married participants. Comorbid conditions were associated with mobility, pain/discomfort, and usual activities problems. Most participants reported high social (65.4%), personal (69.0%), and total (65.6%) RC. Low personal RC was associated with mobility (aOR = 0.43, CI = 0.24-0.76), self-care (aOR = 0.13, CI = 0.04-0.41), usual activities (aOR = 0.25, CI = 0.11-0.57), pain/discomfort (aOR = 0.37, CI = 0.20-0.68), and anxiety/depression (aOR = 0.33, CI = 0.15-0.73) problems. Low total RC was associated with problems conducting self-care (aOR = 0.20, CI = 0.07-0.60), usual activities (aOR = 0.43, CI = 0.22-0.83), pain/discomfort problems (aOR = 0.55, CI = 0.34-0.90), and anxiety/depression (aOR = 0.20, CI = 0.10-0.41) problems. Social RC was not associated with HRQOL.

Conclusion

Personal and total RC and comorbid conditions predict HRQOL. Although the opioid crisis and the increasing prevalence of comorbidities have been described as epidemics, they are currently being addressed as separate public health issues. Our findings underscore the importance of ensuring residents are provided with interprofessional care to reduce the burden of comorbidities, which can negatively impact their OUD recovery. Their RC should be routinely assessed and enhanced to support their recovery and improve HRQOL.

Voluntary alcohol intake alters the motivation to seek intravenous oxycodone and neuronal activation during the reinstatement of oxycodone and sucrose seeking

Opioid-alcohol polysubstance use is prevalent and worsens treatment outcomes. Here we assessed whether co-consumption of oxycodone and alcohol influence the intake of one another, demand for oxycodone, and the neurocircuitry underlying cue-primed reinstatement of oxycodone-seeking. Male and female rats underwent oxycodone intravenous self-administration (IVSA) with homecage access to alcohol (20% v/v) and/or water immediately after the IVSA session. Next, economic demand for intravenous oxycodone was assessed while access to alcohol and/or water continued. Control rats self-administered sucrose followed by access to alcohol and/or water. Rats underwent a cue-primed reinstatement test and brains were processed for c-fos mRNA expression. While both sexes decreased oxycodone intake if they had access to alcohol, and decreased alcohol intake if they had access to oxycodone, only female oxycodone + alcohol rats exhibited decreased demand elasticity and increased cue-primed reinstatement. Alcohol consumption increased the number of basolateral and central amygdala neurons activated during sucrose and oxycodone reinstatement and the number of ventral and dorsal striatum neurons engaged by sucrose reinstatement. Nucleus accumbens shell dopamine 1 receptor expressing neurons displayed activation patterns consistent with oxycodone reinstatement. Thus, alcohol alters the motivation to seek oxycodone in a sex-dependent manner and the neural circuitry engaged by cue-primed reinstatement of sucrose and oxycodone-seeking.

Characterization of quality of life among individuals with current treated, untreated, and past alcohol use disorder

Background: Understanding health-related quality of life (HRQOL) among those who seek treatment for their alcohol use disorder (AUD) and those not seeking AUD treatment is critical to decreasing morbidity and mortality, yet HRQOL in these groups has been little characterized.Objectives: Characterize HRQOL among those who meet diagnostic criteria for AUD, both receiving and not receiving treatment.Methods: This analysis used the NESARC-III database (n = 36,309; female = 56.3%), a nationally representative survey of US adults, to compare four groups: those treated for current AUD; those untreated for current AUD; those with past AUD only; and those who never met criteria for AUD. Multiple regression analysis was used to account for differences in sociodemographic and other behavioral factors across these groups. HRQOL was operationalized using annual quality-adjusted life years (QALYs).Results: Patients treated for past-year AUD had a deficit of 0.07 QALYs/year compared to those who never met criteria for AUD (P < .001). They retained a still clinically meaningful 0.03 QALYs/year deficit after controlling for concomitant psychiatric disorders and other behavioral health factors (P < .001). Those with past-year untreated AUD or past AUD had a near-zero difference in QALYs compared with those who never met criteria for AUD.Conclusion: These findings suggest that previously-reported differences in HRQOL associated with AUD may be due to the problems of the relatively small sub-group who seek treatment. Clinicians seeking to treat those with currently untreated AUD may do better to focus on the latent potential health effects of AUD instead of current HRQOL concerns.

Opioid coping motives and pain intensity among adults with chronic low back pain: associations with mood, pain reactivity, and opioid misuse

Chronic low back pain (CLBP) is a significant public health problem that is associated with opioid misuse and use disorder. Despite limited evidence for the efficacy of opioids in the management of chronic pain, they continue to be prescribed and people with CLBP are at increased risk for misuse. Identifying individual difference factors involved in opioid misuse, such as pain intensity as well as reasons for using opioids (also known as motives), may provide pertinent clinical information to reduce opioid misuse among this vulnerable population. Therefore, the aims of the current study were to examine the relationships between opioid motives-to cope with pain-related distress and pain intensity, in terms of anxiety, depression, pain catastrophizing, pain-related anxiety, and opioid misuse among 300 (Mage= 45.69, SD = 11.17, 69% female) adults with CLBP currently using opioids. Results from the current study suggest that both pain intensity and motives to cope with pain-related distress with opioids were associated with all criterion variables, but the magnitude of variance explained by coping motives was larger than pain intensity in terms of opioid misuse. The present findings provide initial empirical evidence for the importance of motives to cope with pain-related distress with opioids and pain intensity in efforts to better understand opioid misuse and related clinical correlates among adults with CLBP.

Metabolic profiles associated with opioid use and opioid use disorder: a narrative review of the literature

Purpose of Review

Opioid use disorder (OUD) is a chronic, relapsing condition that is epidemic in the USA. OUD is associated with serious adverse consequences, including higher incarceration rates, impaired medical and mental health, and overdose-related fatalities. Several medications with demonstrated clinical efficacy in reducing opioid use are approved to treat OUD. However, there is evidence that medications for OUD cause metabolic impairments, which raises concerns over the long-term metabolic health of individuals recovering from OUD. Here, we summarize the scientific literature on the metabolic effects of the use of opioids, including medications for treating OUD.

Recent Findings

Our findings showed lower body weight and adiposity, and better lipid profiles in individuals with OUD. In individuals with diabetes mellitus, opioid use was associated with lower blood glucose levels. In contrast, among individuals without underlying metabolic conditions, opioids promoted insulin resistance. Treatment of OUD patients with the agonists methadone or buprenorphine caused weight gain, increased liking and intake of sugar, and impaired lipid profile and glucose metabolism, whereas treatment with the antagonist naltrexone demonstrated evidence for reduced sweet preferences.

Summary

Our findings highlighted a gap in knowledge regarding the safety of medications for OUD. Further research is needed to determine how best to reduce the risk of metabolic disorder in the treatment of OUD with opioid agonists versus antagonists.

Association between body mass index and treatment completion in extended-release naltrexone-treated patients with opioid dependence

Background

Excessive consumption of opioids is associated with impaired metabolic function including increased body mass index (BMI). Opioid antagonist naltrexone (NTX) is an effective treatment for opioid use disorder (OUD) that has the potential to mitigate such metabolic disturbances. Understanding the relationship between treatment adherence and BMI in NTX-treated OUD patients may provide valuable insights into optimizing clinical outcomes.

Methods

Patients with opioid dependence were offered up to three monthly injections of extended-release (XR) NTX. Treatment completers (n = 41) were defined as those who had received all three XR-NTX injections, and non-completers (n = 20) as those missing at least one injection. Logistic regression was performed to examine the association between pre-treatment BMI and treatment completion.

Results

BMI was positively associated with treatment completion. This association remained significant after adjusting for potentially confounding variables.

Conclusion

Our findings suggest that baseline BMI may serve as a potential predictor of XR-NTX treatment adherence in patients with OUD and could help healthcare providers and policy makers alike in developing strategies to improve retention and tailor interventions for specific patient subgroups.

Voluntary alcohol intake alters the motivation to seek intravenous oxycodone and neuronal activation during the reinstatement of oxycodone and sucrose seeking

Opioid-alcohol polysubstance use is prevalent and worsens treatment outcomes. Here we assessed whether co-consumption of oxycodone and alcohol would influence intake of one another, demand for oxycodone, and the neurocircuitry underlying cue-primed reinstatement of oxycodone-seeking. Male and female rats underwent oxycodone intravenous self-administration (IVSA) with access to either alcohol (20% v/v) and water or only water immediately after the IVSA session. Next, economic demand for intravenous oxycodone was assessed while access to alcohol and/or water continued. Control rats self-administered sucrose followed by access to alcohol and/or water. Rats underwent extinction training and brains were processed for c-fos mRNA expression immediately following a cue-primed reinstatement test. While both sexes decreased oxycodone intake if they had access to alcohol, and decreased alcohol intake if they had access to oxycodone, female oxycodone+alcohol rats exhibited decreased demand elasticity for intravenous oxycodone and increased cue-primed reinstatement while male rats did not. Spontaneous withdrawal signs were correlated with oxycodone intake while alcohol intake was correlated with anxiety-like behavior. Alcohol consumption increased the number of basolateral and central amygdala neurons activated during sucrose and oxycodone reinstatement and the number of ventral and dorsal striatum neurons engaged by sucrose reinstatement. Nucleus accumbens shell dopamine 1 receptor containing neurons displayed activation patterns consistent with oxycodone reinstatement. Thus, alcohol alters the motivation to seek oxycodone in a sex-dependent manner and alters the neural circuitry engaged by cue-primed reinstatement of sucrose and oxycodone-seeking.

Characteristics of patients undergoing medication-assisted -treatment for opioid use disorder and their interest in Tai Chi practice

OBJECTIVES

(1) To explore the characteristics of patients with opioid use disorder (OUD) maintained on either methadone or buprenorphine and (2) to determine the relative acceptability of integrating Tai Chi (TC) practice into an ongoing medication-assisted treatment for opioid use disorder (MOUD) program.

DESIGN

Survey study.

SETTING

The University of Arkansas for Medical Sciences Center for Addiction Services and Treatment Program.

PATIENTS

97 patients receiving MOUD treatment.

MAIN OUTCOMES

Drug use history, treatment status, physical limitation, mental health, pain, and whether participants were interested in using TC to improve health outcomes.

RESULTS

At least 30.9 percent of the sample reported moderate or higher level of limitation in performing rigorous physical activities, pain intensity, and pain interference. Between 37.1 and 61.5 percent of the sample reported various psychiatric symptoms. Methadone patients reported higher levels of physical limitations, especially in rigorous activities (p = .012), climbing several flights of stairs (p = .001), and walking more than a mile (p = .011), but similar levels of pain (ps = .664-.689) and psychiatric symptoms (ps = .262-.879) relative to buprenorphine patients. At least 40.2 percent of participants expressed moderate or higher level of interest in TC for improving health outcomes, with methadone patients more interested in participating to ease mental and sleep problems (p = .005) and improve physical fitness (p = .015) compared to buprenorphine patients.

CONCLUSIONS

High prevalence of physical limitation, pain, and psychiatric comorbidities were found in OUD patients. Since patients were interested in TC to improve their health outcomes, this low-cost intervention, if proven effective, can be integrated into ongoing MOUD programs to improve health in this population.

Disrupted resting-state functional connectivity of frontal network in opium use disorder

Opioid use disorder (OUD) as a chronic relapsing disorder is initially driven by dysfunction of brain reward networks and associated with several psychiatric disorders. Resting-state EEG was recorded in 24 healthy participants as well as 31 patients with OUD. Healthy participants do not meet OUD criteria. After pre-processing of the raw EEG, functional connectivity in the frontal network using eLORETA and all networks using graph analysis method were calculated. Patients with OUD had higher electrical neuronal activity compared to healthy participants in higher frequency bands. The statistical analysis revealed that patients with OUD had significantly decreased phase synchronization in β1 and β2 frequency bands compared with the healthy group in the frontal network. Regarding global network topology, we found a significant decrease in the characteristic path length and an increase in global efficiency, clustering coefficient, and transitivity in patients compared with the healthy group. These changes indicated that local specialization and global integration of the brain were disrupted in OUD and it suggests a tendency toward random network configuration of functional brain networks in patients with OUD. Disturbances in EEG-based brain network indices might reflect an altered cortical functional network in OUD. These findings might provide useful biomarkers to understand cortical brain pathology in opium use disorder.

Telehealth for management of chronic non-cancer pain and opioid use disorder in safety net primary care

BACKGROUND

The SARS-CoV-2 (COVID-19) pandemic increased use of telehealth for the management of opioid use disorder and chronic non-cancer pain in primary care safety net clinical systems. Significant barriers to telehealth exist, little is known about how these barriers impact urban safety net, primary care providers and their patients. The objective of this study was to qualitatively assess the benefits and challenges of telehealth for management of chronic non-cancer pain, opioid use disorder, and multi-morbidity in primary care, safety net clinical systems.

METHODS

We interviewed patients with chronic non-cancer pain and history of substance use (n = 22) and their primary care clinicians (n = 7) in the San Francisco Bay Area, March-July 2020. We recorded, transcribed, coded, and content analyzed interviews.

RESULTS

COVID-19 shelter-in-place orders contributed to increases in substance use and uncontrolled pain, and posed challenges for monitoring opioid safety and misuse through telehealth. None of the clinics used video visits due to low digital literacy/access. Benefits of telehealth included decreased patient burden and missed appointments and increased convenience and control of some chronic conditions (e.g., diabetes, hypertension). Telehealth challenges included loss of contact, greater miscommunication, and less comprehensive care interactions.

CONCLUSIONS

This study is one of the first to examine telehealth use in urban safety net primary care patients with co-occurring chronic non-cancer pain and substance use. Decisions to continue or expand telehealth should consider patient burden, communication and technology challenges, pain control, opioid misuse, and medical complexity.

Association of current and remitted bipolar disorders with health-related quality of life: Findings from a nationally representative sample in the US

BACKGROUND

The associations of current and remitted bipolar disorder (BD) with health-related quality of life (HRQOL) have been under-studied, and we aim to address these gaps.

METHODS

The 2012-2013 National Epidemiological Survey on Alcohol and Related Conditions III (NESARC III) surveyed a nationally representative sample of non-institutionalized adults in the US. Using DSM-5 criteria, three groups were operationalized as: 1) adults who met criteria for BD in the past year (i.e., current BD; n = 566 unweighted); and 2) adults who met criteria for BD previously but not in the past year (i.e., BD in remission; n = 187); and 3) adults with no BD in their lifetime (n = 35,556). HRQOL and quality-adjusted life years (QALYs) were compared by these groups. Multivariable-adjusted regression analyses were used to adjust for and examine the role of covariates.

RESULTS

Overall, 1.5 % of the study sample, representing 3.6 million adults nationwide, met criteria for current BD, and 0.5 %, representing 1.3 million adults, met criteria for BD in remission. Adults with current BD and BD in remission had lower mental HRQOL and QALYs, as compared to adults who never had BD. However, these differences were no longer significant when adjusted for behavioral co-morbidities (e.g., psychiatric and substance use disorders).

CONCLUSION

Both current BD and BD in remission were adversely associated with HRQOL and QALYs, while these associations were not independent of behavioral co-morbidities. Because behavioral co-morbidities are common in individuals with current BD or those with BD in remission, they should be treated together to improve HRQOL.

When a pandemic and epidemic collide: Lessons learned about how system barriers can interrupt implementation of addiction research

Background

Telehealth technologies are now featured more prominently in addiction treatment services than prior to the COVID-19 pandemic, but system barriers should be carefully considered for the successful implementation of innovative remote solutions for medication management and recovery coaching support for people with opioid use disorder (OUD).

Method

The Centers for Disease Control and Prevention funded a telehealth trial prior to the COVID-19 pandemic with a multi-institution team who attempted to implement an innovative protocol during the height of the pandemic in 2020 in Tampa, Florida. The study evaluated the effectiveness of a mobile device application, called MySafeRx, which integrated remote motivational recovery coaching with daily supervised dosing from secure pill dispensers via videoconference, on medication adherence during buprenorphine treatment. This paper provides a participant case example followed by a reflective evaluation of how the pandemic amplified both an existing research-to-practice gap and clinical system barriers during the implementation of telehealth clinical research intervention for patients with OUD.

Findings

Implementation challenges arose from academic institutional requirements, boundaries and role identity, clinical staff burnout and lack of buy-in, rigid clinical protocols, and limited clinical resources, which hampered recruitment and intervention engagement.

Conclusions

As the urgency for feasible and effective telehealth solutions continues to rise in response to the growing numbers of opioid-related deaths, the scientific community may use these lessons learned to re-envision the relationship between intervention implementation and the role of clinical research toward mitigating the opioid overdose epidemic.

Patient-centered quality measurement for opioid use disorder: Development of a taxonomy to address gaps in research and practice

Background: Evidence-based treatment is provided infrequently and inconsistently to patients with opioid use disorder (OUD). Treatment guidelines call for high-quality, patient-centered care that meets individual preferences and needs, but it is unclear whether current quality measures address individualized aspects of care and whether measures of patient-centered OUD care are supported by evidence. Methods: We conducted an environmental scan of OUD care quality to (1) evaluate patient-centeredness in current OUD quality measures endorsed by national agencies and in national OUD treatment guidelines; and (2) review literature evidence for patient-centered care in OUD diagnosis and management, including gaps in current guidelines, performance data, and quality measures. We then synthesized these findings to develop a new quality measurement taxonomy that incorporates patient-centered aspects of care and identifies priority areas for future research and quality measure development. Results: Across 31 endorsed OUD quality measures, only two measures of patient experience incorporated patient preferences and needs, while national guidelines emphasized providing patient-centered care. Among 689 articles reviewed, evidence varied for practices of patient-centered care. Many practices were supported by guidelines and substantial evidence, while others lacked evidence despite guideline support. Our synthesis of findings resulted in EQuIITable Care, a taxonomy comprised of six classifications: (1) patient Experience and engagement, (2) Quality of life; (3) Identification of patient risks; (4) Interventions to mitigate patient risks; (5) Treatment; and (6) Care coordination and navigation. Conclusions: Current quality measurement for OUD lacks patient-centeredness. EQuIITable Care for OUD provides a roadmap to develop measures of patient-centered care for OUD.

Quality of Life and Opioid Use Motives: Direct and Indirect Associations with Risky Opioid Use in a Community Sample of Adults

Purpose: The opioid epidemic in the United States has resulted in mass mortality and economic costs exceeding $1 trillion. Poor health-related quality of life is evident among individuals entering treatment for opioid use disorder (OUD). Yet, little research has examined the influence of quality of life on risky opioid use among non-treatment-seeking adults. To help inform OUD prevention efforts, this study examined the association among quality of life domains, opioid use motives, and risky opioid behaviors in a community sample of opioid users. Methods: Participants (N = 278) were adults who endorsed past month opioid use and were not currently in treatment for OUD. Participants responded to questions regarding their opioid use and misuse, opioid use motives, opioid use consequences, and quality of life. Results: The physical health domain of quality of life was associated with risky opioid use. Specifically, poorer physical health predicted risky opioid use and this relationship was partially explained by more social and pain motives to use opioids. Surprisingly, no other quality of life domains predicted risky opioid use. Conclusion: This study represents a meaningful first step in identifying optimal targets for OUD prevention efforts with community samples. Our findings suggest that physical health is an important quality of life indicator to prevent opioid-related harm and development of OUD.

Opioid epidemic: lessons learned and updated recommendations for misuse involving prescription versus non-prescription opioids

INTRODUCTION

In the past decades, the opioid crisis has heavily impacted parts of the US society and has been followed by an increase in the use of opioids worldwide. It is of paramount importance that we explore the origins of the US opioid epidemic to develop best practices to tackle the rising tide of opioid overdoses.

AREAS COVERED

In this expert review, we discuss opioid (over)prescription, change in perception of pain, and false advertisement of opioid safety as the leading causes of the US opioid epidemic. Then, we review the evidence about opioid dependence and addiction potential and provide current knowledge about predictors of aberrant opioid-related behavior. Lastly, we discuss different approaches that were considered or undertaken to combat the rising tide of opioid-related deaths by regulatory bodies, pharmaceutical companies, and health-care professionals. For this expert review, we considered published articles relevant to the topic under investigation that we retrieved from Medline or Google scholar electronic database.

EXPERT OPINION

The opioid epidemic is a dynamic process with many underlying mechanisms. Therefore, no single approach may be best suited to combat it. In our opinion, the best way forward is to employ multiple strategies to tackle different underlying mechanisms.

The Opioid Epidemic and Children's Living Arrangements in the United States, 2000-2018

Although the detrimental effects of the opioid epidemic on health and wellbeing have been well documented, we know little about how it has affected the family contexts in which children live. Using data from the 2000 Census, the 2005-2018 American Community Survey (ACS) and restricted Vital Statistics, we assess how the opioid epidemic, as measured by a rise in the opioid overdose death rate, affected the rates of children living in different family arrangements: two married parents, two cohabiting parents, single mother, single father, or another configuration. According to local fixed-effects models, a higher opioid overdose death rate is associated with fewer children living with two married parents and an increase in children living in family structures that tend to be less stable, such as those led by cohabiting parents or a single father. These changes in family arrangements have potential long-term implications for the wellbeing of future generations.

Why are women more likely to attempt suicide than men? Analysis of lifetime suicide attempts among US adults in a nationally representative sample

OBJECTIVE

While it is well-known that women are more likely to attempt suicide than men, little is known about risk and protective factors underlying this difference.

METHODS

Using data from the National Epidemiologic Survey on Alcohol and Related Conditions Wave III (NESARC-III), we compared women and men with and without self-reported lifetime suicide attempts to identify sociodemographic, clinical, and behavioral characteristics that were associated with suicide attempts for each gender. We then examined the interaction of gender and risk factors to identify specific factors that have a significantly different association with the risk of suicide attempts by gender. Multivariate analyses identified factors that were independently associated with a significant interaction of gender and risk of suicide attempt and the extent to which these interactions accounted for the greater risk of suicide attempts among women.

RESULTS

In unadjusted analysis, women had 1.78 greater odds of self-reported lifetime suicide attempts than men (95% confidence interval (CI), 1.61-1.96). While men and women shared similar risk and protective factors for suicide attempts, several factors were associated with significantly different risks for women than men. In multivariate analysis, these factors only partially accounted for the gender difference in lifetime risk of suicide attempt (adjusted odds ratio, 1.53; 95% CI, 1.12-2.08).

CONCLUSIONS

Several risk factors for suicide attempts appear to have significantly different magnitude of association among women and men; however, these differences only partially account for gender difference in risk for suicide attempts, suggesting that other factors, not measured in this study, are at play.

Substance use treatment services for older adults in five states in the Southern United States: a state-by-state comparison of available treatment services

Objectives: Substance use disorders (SUD) among older adults have become a serious public health concern. The purpose of this study was to assess which states in the Southern U.S. are more responsive to SUD treatment needs of older adults.Methods: This study is a secondary data analysis of the N-SSATS-2019 dataset.Results: There were 1,215 substance treatment facilities in the five states. Kentucky had the highest number of substance use treatment facilities (n = 449, 37%), followed by Georgia (357, 29%), Alabama (153, 13%), Louisiana (146, 12%) and then Mississippi (110, 9%). Out of the 1,215 facilities, only 20% (n = 244) indicated that they had programs specifically tailored for older adults. Kentucky had the largest number of facilities per 1 million older adults while Mississippi had the highest number of facilities per 1 million older adults offering detoxification services. Alabama had the lowest number of services per 1 million adults in all categories examined.Conclusion: Across the U.S., most adults with SUD do not have access to substance use treatment; in the southeastern region of the country, higher rates of poverty, rural geography and stigma, and lack of treatment availability may further complicate individuals' ability to access substance use-related medical care.

Effects of Unemployment on Opioid Use Treatment Trajectories: Impact of the COVID-19 Pandemic

ABSTRACT

Living with an opioid use disorder (OUD) can make finding and sustaining employment a significant challenge and is only expected to get worse in the COVID-19 environment. For most individuals in OUD treatment, being employed is an important part of their recovery journey. Employment has several benefits, including reductions in preoccupation with symptoms, social isolation, risk of suicide, hopelessness, and economic instability, which if not addressed often result in homelessness. Therefore, employment is an important social determinant of health, especially among those with OUD. Employment success and OUD, however, may vary based on race, age, gender, and socioeconomic status. Return to work support as states begin to reopen will be critically important to improve treatment outcomes for individuals with OUD in a post-COVID-19 environment, requiring utilizations of evidence-based interventions. Nurses, particularly psychiatric mental health and addiction nurses, should routinely screen for employment needs of their patients with OUD and connect them to the necessary support services. Finally, nurses should advocate for regulatory reform that allows for employment support services to be billable and integrated in psychiatric and behavioral health services just like other mental health services.

Prevalence of adult ADHD in patients with substance use disorder in North East India

BACKGROUND

Attention deficit and hyperactive disorder (ADHD) often co-exist with substance use disorders (SUD) both in adolescents and adults. Untreated ADHD can lead to multiple relapses, sociooccupational dysfunction and may worsen the outcome of SUD. ADHD is often underdiagnosed in the adult population. Therefore, the present study was intended to determine the types, patterns, and factors related to drug dependence among different age groups and to estimate the prevalence of adult ADHD in SUD patients in North East India.

MATERIALS AND METHODS

This is a cross-sectional hospital-based study carried out in patients diagnosed with SUD as per the Diagnostic and Statistical Manual Disorders, 5^th Edition. Adult ADHD Self-Report Scale (v1.1) Symptom Checklist was applied to screen for symptoms of adult ADHD in the patients.

RESULTS

In the age group of 18-29 years, 82.7% of patients were diagnosed with opioid use disorder (OUD), while 63.9% of the subjects in the age group of 30-49 years patients suffered from Alcohol Use Disorder (AUD). All patients of age 50 years and above were AUD. Our study showed that 24.3% of the total study population had the presence of adult ADHD. Symptoms of Adult ADHD were found in a higher proportion among OUD (28.7%) in comparison to OUD (11.5%).

CONCLUSION

The association of adult ADHD with OUD has been around three times than the AUD group. Hence young people (18-29 years) diagnosed with OUD need to be screened for adult ADHD and should be treated for the same for better abstinence and to prevent complications.

The Inclusion of Patients' Reported Outcomes to Inform Treatment Effectiveness Measures in Opioid Use Disorder. A Systematic Review

Introduction

Patient centred care is needed now more than ever in the treatment of opioid use disorder. Trials, policy makers, and service providers have most often used treatment retention and opioid urine screens as measures of treatment effectiveness. However, patients receiving medication for opioid use disorder treatment (MOUD) may prioritise the use of different ways to assess treatment success.

Objective

The aim of this review is to synthesize literature examining the self-reported goals patients would like to achieve in MOUD for opioid use disorder.

Methods

We searched MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Cochrane Library, Cochrane Clinical Trials Registry, the National Institutes for Health Clinical Trials Registry, and the WHO International Clinical Trials Registry Platform from inception until April 30th, 2021. No restrictions were placed on language, age, or type of MOUD. A qualitative synthesis is presented given that a meta-analysis was not possible.

Results

The search yielded a total of 21,082 records from which 8 met criteria for inclusion in the qualitative synthesis. We identified a total of 43 patient-reported treatment goals from the 8 studies. Twelve domains were created from the 43 goals reported. These domains cover a range of important areas for patients' goals related to living a normal life, physical health, mental health, treatment, and substance use specific areas.

Conclusion

This review highlights several patient goals that they would like to achieve during treatment for opioid use disorder that are not commonly considered as markers of treatment effectiveness. Goals related to health, living a normal life, and overall substance use concerns by patients should be taken into consideration by clinical trialists, researchers, policy makers, service providers, patients, and communities engaged in developing and tailoring treatment plans for opioid use disorder.

Systematic Review Registration

PROSPERO CRD42018095553.

Health-related quality of life in outpatients with substance use disorder: evolution over time and associated factors

Background

Health-related quality of life (HRQoL) is an important element of patient care and clinical research. The aim of this study was to describe HRQoL changes and identify associated factors during a 6-month follow-up of outpatients starting care for alcohol or opioid dependence.

Methods

HRQoL was measured at baseline and 3 and 6 months later using the SF-12. Data on the patients’ sociodemographics, clinical characteristics and levels of anxiety and depression were collected using the Hospital Anxiety and Depression Scale (HADS). Repeated-measures analyses were performed to assess factors associated with global HRQoL differences and the evolution of HRQoL indicated by both physical and mental scores (PCS and MCS, respectively).

Results

The mean PCS and MCS scores were initially low at 45.4 (SD = 8.6) and 36.0 (SD = 10.9), respectively. The improvement in HRQoL was rapid in the first 3-month period and then slowed and remained stable over the subsequent 3-month period. Being employed (p = 0.012), having no comorbidities (p = 0.014) and having no depression (p = 0.004) were associated with significant differences in the average PCS scores at the 3 time points. Patients who had lower overall HRQoL MCS scores on average were those for whom a medication was initiated (p = 0.009), as was the case for patients with anxiety (p < 0.001) and depression (p < 0.001). Patients with depression at baseline were also those for whom a significantly greater increase in MCS score during the 6 months of follow-up was observed.

Conclusion

Our findings highlight the importance of screening early psychological distress and considering other factors associated with HRQoL changes in outpatients after the first 3-month period of treatment for substance use disorder.

Prevalence of Self-Reported Prescription Opioid Use and Illicit Drug Use Among U.S. Adults: NHANES 2005-2016

OBJECTIVE

To estimate the self-reported prevalence of prescription opioid use and illicit drug use in the United States.

METHODS

Self-reported prescription opioid use and illicit drug use (mostly nonopioid) were obtained for adults and adult workers (NHANES 2005-2016).

RESULTS

Prevalence (95% CI) of prescription opioid use was 6.5% (6.0-7.0) (adults) and 4.1% (3.7-4.5) (workers). Prevalence of illicit drug use was 9.5% (8.8-10.1) (adults) and 10.2% (9.4-11.1) (workers). Among occupations, prevalence of prescription opioid use was highest in personal care (6.5%; 4.1-10.4) and healthcare practitioners (5.9%; 3.8-9.0); for illicit drug use, construction/extraction (18.0%; 15.1-21.3) and food preparation (15.8%; 12.5-19.7).

CONCLUSION

The prevalence of prescription opioid use was elevated among some occupations. Judicious prescription strategies and targeted interventions are both needed. The prevalence of illicit drug use among certain occupational groups suggests the need to ensure access to therapy.

Genetic liability for substance use associated with medical comorbidities in electronic health records of African- and European-ancestry individuals

Polygenic risk scores (PRS) represent an individual's summed genetic risk for a trait and can serve as biomarkers for disease. Less is known about the utility of PRS as a means to quantify genetic risk for substance use disorders (SUDs) than for many other traits. Nonetheless, the growth of large, electronic health record-based biobanks makes it possible to evaluate the association of SUD PRS with other traits. We calculated PRS for smoking initiation, alcohol use disorder (AUD), and opioid use disorder (OUD) using summary statistics from the Million Veteran Program sample. We then tested the association of each PRS with its primary phenotype in the Penn Medicine BioBank (PMBB) using all available genotyped participants of African or European ancestry (AFR and EUR, respectively) (N = 18,612). Finally, we conducted phenome-wide association analyses (PheWAS) separately by ancestry and sex to test for associations across disease categories. Tobacco use disorder was the most common SUD in the PMBB, followed by AUD and OUD, consistent with the population prevalence of these disorders. All PRS were associated with their primary phenotype in both ancestry groups. PheWAS results yielded cross-trait associations across multiple domains, including psychiatric disorders and medical conditions. SUD PRS were associated with their primary phenotypes; however, they are not yet predictive enough to be useful diagnostically. The cross-trait associations of the SUD PRS are indicative of a broader genetic liability. Future work should extend findings to additional population groups and for other substances of abuse.

A population-wide perspective on the reach of substance use disorders: Parental exposure, diagnostic remission, and current disorders

BACKGROUND AND OBJECTIVES

Parental substance use disorder (SUD) increases the risk for childhood adversities. Lifetime and current SUDs are associated with functional impairment and psychiatric comorbidity. Research shows that these abate with diagnostic remission. However, a hierarchically ordered heuristic profile of adult subpopulations affected by SUDs has not been explored.

METHODS

We used data from the National Epidemiologic Survey on Alcohol and Related Conditions Wave III (NESARC-III; N = 36,309) to compare four subpopulations defined by the following hierarchy: (1) neither parental nor lifetime SUD (un-affected group); (2) parental SUD but no personal SUD; (3) past but not current SUD (diagnostic remission); and (4) current SUD. We conducted bivariate comparisons and multivariable-adjusted logistic regression to identify characteristics independently differentiating each group.

RESULTS

Almost half of the US adult population (108.9 million) were at risk from SUDs. Relative to the unaffected group (56.1%), the parental-exposure-only group (13.9%) experienced diverse parental and childhood adversities and increased risk for psychiatric disorders. Compared to the parental-exposure-only group those in the remitted group (14.1%) were more likely to report behavioral problems and lifetime psychiatric multimorbidities. Those with current SUD (15.9%) had a poorer mental health-related quality of life.

DISCUSSION AND CONCLUSIONS

This heuristic SUD hierarchy is associated with increasing adversities affecting almost half the US population, although only 15.9% meet the criteria for a current disorder.

SCIENTIFIC SIGNIFICANCE

Our findings provide a rigorous population-based estimate of the staggering public health impact of SUDs in the United States and suggest that almost half of the US population is either directly or indirectly affected by SUDs.

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.

Preferences for research design and treatment of comorbid depression among patients with an opioid use disorder: A cross-sectional discrete choice experiment

BACKGROUND

Up to 74 % of people with an opioid use disorder (OUD) will experience depression in their lifetime. Understanding and addressing the concept of preference for depression treatments and clinical trial designs may serve as an important milestone in enhancing treatment and research outcomes. Our goal is to evaluate preferences for depression treatments and clinical trial designs among individuals with an OUD and comorbid depression.

METHODS

We evaluated preferences for depression treatments and clinical trial designs using an online cross-sectional survey including a best-best discrete choice experiment. We recruited 165 participants from opioid agonist treatment clinics and community-based services in Calgary, Charlottetown, Edmonton, Halifax, Montreal, Ottawa, Quebec City, St. John's and Trois-Rivières, Canada.

RESULTS

Psychotherapy was the most accepted (80.0 %; CI: 73.9-86.1 %) and preferred (31.5 %; CI: 24.4-38.6 %) treatment. However, there was a high variability in acceptability and preferences of depression treatments. Significant predictors of choice for depression treatments were administration mode depending on session duration (p < 0.001), access mode (p < 0.001) and treatment duration (p < 0.001). Significant predictors of choice for clinical trial designs were allocation type (p = 0.008) and monetary compensation (p = 0.033). Participants preferred participating in research compared to non-participation (p < 0.001).

CONCLUSIONS

Accessibility and diversity of depression interventions, including psychotherapy, need to be enhanced in addiction services to ensure that all patients can receive their preferred treatment. Ensuring proper monetary compensation and comparing an intervention of interest with an active treatment might increase participation of depressed OUD patients in future clinical research initiative.

Emergency Department Visits by Patients with Substance Use Disorder in the United States

INTRODUCTION

We aimed to characterize emergency department (ED) utilization and clinical characteristics of patients with substance use disorder (SUD) seeking emergency care for all reasons.

METHODS

Using 2016-2017 ED data from the National Hospital Ambulatory Medical Care Survey, we investigated demographics, ED resource utilization, and clinical characteristics of patients with SUD vs those without SUD.

RESULTS

Of all adult ED visits (N = 27,609) in the US in 2016-2017, 11.1% of patients had SUD. Among ED patients with SUD, they were mostly non-Hispanic White (62.5%) and were more likely to be male (adjusted odds ratio [aOR] 1.80 confidence interval [CI], 1.66-1.95). Emergency department patients with SUD were also more likely to return to the ED within 72 hours (aOR 1.32, CI, 1.09-1.61) and more likely to be admitted to the hospital (aOR 1.28, CI, 1.14-1.43) and intensive care unit (aOR 1.40, CI, 1.05-1.85).

CONCLUSION

Patients with SUD have specific demographic, socioeconomic, and clinical characteristics associated with their ED visits. These findings highlight the importance of recognizing co-existing SUD as risk factors for increasing morbidity in acutely ill and injured patients, and the potential role of the ED as a site for interventions aimed at reducing harm from SUD.

Opioid analgesic use and its sequelae: Opioid and other substance use disorders

OBJECTIVES

While use of opioids is a well-established risk factor for opioid use disorder (OUD), its association with lifetime use of other addictive substances and the emergence of other lifetime substance use disorders (SUDs) has not been studied.

METHODS

We used data from 36 309 US adults in the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions III to identify those with lifetime opioid use (n = 4090; 11.3%). Of these individuals, we quantified use of other addictive substances; development of OUD and other SUDs; and whether use of opioids and development of OUD came before or after use of other substances and the emergence of other SUDs.

RESULTS

Of the 11.3% of adults who reported any opioid use, 98.2% of such users reported use of other addictive substances. Of these opioid users, 18.1% met criteria for lifetime OUD but only 3.5% had OUD alone; 47.6% had SUDs other than OUD and 14.6% had OUD plus another SUD. In most instances, opioid use followed use of other substances and OUD followed development of other SUDs.

CONCLUSION

Opioid use is typically linked to use of multiple substances and while less than 20% developed OUD, more than half developed either OUD or another SUD. Opioid use and OUD most often followed other substance use and the emergence of other SUDs. Early intervention in OUD should consider potential complications of other present or past SUDs, and both prevention and treatment development efforts should focus on the multi-morbid dimensions of the current opioid epidemic.

Gender Differences in Psychiatric and Behavioral Health Burden Among Adults With Alcohol and Other Substance Use Disorders in the United States

OBJECTIVES

Studies report that women with opioid use disorder experience more comorbid psychiatric disorders and behavioral health burdens than men. We broadened the study of this phenomenon to alcohol use disorder (AUD) and other substance use disorders (SUDs) using national epidemiologic data.

METHODS

Data from the National Epidemiological Survey on Alcohol and Related Conditions Wave-III identified 2491 women and 3317 men with DSM-5 AUD or SUDs, and 30,501 men and women without such disorders. Women and men with AUD and SUDs were compared to those without such disorders on 22 measures of DSM-5 psychiatric disorders and behavioral histories (eg, incarceration and suicide attempt). The interaction of female sex and AUD in relation to these measures was evaluated and we repeated analyses for SUDs.

RESULTS

Separate analyses of female and male adults with and without AUD or SUDs showed AUD and SUDs in both sexes were strongly associated with psychiatric disorders and behavioral histories. In pooled analyses, the interaction of female sex and AUD showed women with AUD had significantly greater likelihood than men of: borderline personality disorder, pain; parental history of incarceration; traumatic events; incarceration; and lifetime homelessness (P < 0.05 for all), but not for psychiatric diagnoses. Interaction of female sex with SUDs showed women had increased likelihood of all personality disorders, traumatic events, and past incarceration (P < 0.05 for all).

CONCLUSIONS

Certain personality disorders and behavioral histories, but not psychiatric diagnoses, may play a distinct role in leading to SUDs among women when compared to men.

Associations of Current and Remitted Cannabis Use Disorder With Health-related Quality of Life and Employment Among US Adults

BACKGROUND

The associations of current and remitted cannabis use disorder (CUD) with health-related quality of life (HRQOL) and employment have not been studied, and we aim to address these gaps.

METHODS

The 2012-2013 National Epidemiological Survey on Alcohol and Related Conditions III (NESARC III) surveyed a nationally representative sample of non-institutionalized civilian US adults (≥18 years) (n = 36,309 unweighted). Using DSM-5 criteria, adults with current CUD were compared with those with CUD in remission and no history of CUD on standard measures of the mental and physical component scores of HRQOL and of quality-adjusted life years (QALYs) along with employment in the past 12 months. Multivariable-adjusted regression analyses were used to adjust for and examine the role of covariates.

RESULTS

Overall, 2.5% of the study sample, representing 6.0 million adults nationwide, met criteria for current CUD, and 3.7%, representing 8.8 million adults, met the criteria for CUD in remission. Adults with current or past CUD had lower mental HRQOL and QALYs, as compared to adults who never had CUD. However, these differences were no longer significant when adjusted for behavioral co-morbidities and personal histories. Current CUD was associated with lower odds of being employed (Adjusted odds ratio AOR = 0.76; 95% confidence intervals [CI], 0.60-0.96), but CUD in remission with a greater likelihood of employment (Adjusted odds ratio = 1.53; 95% CI, 1.23-1.91), both as compared to those never experiencing CUD.

CONCLUSIONS

Both current CUD and past CUD are adversely associated with HRQOL and current CUD with not being employed; Since CUD associations are not independent of comorbidities, treatment must take a wide-ranging approach.

Longitudinal assessment of mental health and well-being in patients being treated with medications for opioid use disorder in primary care

Opioid use disorder (OUD) continues to be a significant problem in the United States, contributing to overdose and death. Recent efforts to expand access to treatment of OUD in primary care have increased the availability of medications for OUD (MOUDs). However, OUD is often accompanied by poor mental health and well-being, and it is not known if treatment with MOUDs alone is associated with improved psychological well-being. This study's purpose was to examine changes in mental health and well-being in the first 6 months of treatment with MOUDs in a family medicine residency clinic. Patients (N = 126; M age = 34.6 years, SD = 10.6; 54.8% male; 71.4% white) completed validated screeners of mental health and well-being (depression, anxiety, anger, loneliness, perceived stress, meaning in life, and life satisfaction) at baseline (induction visit for buprenorphine), 1-month, and 6-months. Results indicated that the mental health and well-being indices did not significantly change over the first 6 months of treatment on MOUDs. There were initial decreases in depression and anxiety at 1-month; however, both increased and were equivalent to baseline levels at 6-months. These results suggest that MOUD treatment alone does not significantly impact mental health or well-being in patients with OUD. Additional treatments or supports are clearly needed to address the comorbid mental health and well-being challenges in this population, as these factors can be both antecedents and consequences of substance misuse.

Diversity of social networks versus quality of social support: Which is more protective for health-related quality of life among older adults?

Both social networks and social support are important in addressing bio-psycho-social events in older adults. Their associations with health-related quality of life (HRQOL), however, are not well understood. This study aims to examine the associations of diversity of social networks and perceived quality of social support with HRQOL in older adults. We used data from 2012 to 2013 National Epidemiological Survey on Alcohol and Related Conditions Wave III (NESARC-III), and included respondents aged 65 or older (n = 5799 unweighted). We used the Social Network Index (SNI) to measure diversity of social connections and the Interpersonal Support Evaluation List (ISEL-12) to measure perceived quality of social support. We also constructed HRQOL (mental component summary (MCS) and physical component summary (PCS)) and quality-adjusted life years (QALYs). We characterized socio-demographic, behavioral, and clinical factors, and HRQOL and QALYs by type of social support. We also used multivariable-adjusted regression analyses to assess the associations of diversity of social networks and perceived quality of social support with HRQOL and QALYs, respectively. Older adults with greater diversity of social networks, regardless of perceived quality of social support, had higher mean scores in HRQOL domains, although effect sizes were small. In multivariable-adjusted analyses, diversity of social networks was positively associated with HRQOL-MCS (coefficient = 0.59; 95% confidence intervals [CI], 0.08-1.09), HRQOL-PCS (coefficient = 1.00; 95% CI, 0.38-1.61), and QALYs (coefficient = 0.01; 95% CI, 0.00-0.02). Perceived quality of social support was not associated with HRQOL. The diversity of social networks, more than perceived quality of social support, may be protective for HRQOL in older adults.

Barriers to accessing opioid substitution treatment for opioid use disorder: A systematic review from the client perspective

OBJECTIVES

To update the existing evidence to identify specific barriers to initiation of opioid substitution therapy (OST) for those with opioid use disorder (OUD).

METHODS

The review follows Preferred Reporting Items for Systematic Reviews andMeta-Analyses (PRISMA) guidelines. Six databases were initially searched in November 2019, with the search updated on 11 November 2020, for qualitative or quantitative studies reporting the barriers to initiating OST from the client with OUD perspective. Thematic analysis of the barriers to OST was undertaken to determine barrier themes and subthemes.

RESULTS

There were 37 studies included in the review; 18 were qualitative, 15 were quantitative and four were mixed methods. The barrier themes identified were stigma and fear, regulatory, logistical, attitudinal and social factors. Within these barrier themes 19 barrier subthemes were identified. The most reported OST barrier subthemes were negative treatment perceptions, cost, stigma and lack of flexibility.

CONCLUSION

This review discusses important barriers to OST and examines reported barriers from the client perspective. OST guidelines and programs would benefit by introducing programs that reduce stigma, increase treatment knowledge and health literacy, reduce treatment costs, increase treatment flexibility and allow for easier treatment access.

Opioid and Other Medication Use and General Health Status in a Cohort of Older Adults

OBJECTIVE

The aim of this study was to determine whether the use of opioids and other medications in a cohort of older adults was associated with self-reported health status.

METHODS

Among participants in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Screening Trial linked to Medicare Part D claims data and answering a quality-of-life questionnaire, we examined the relationship between medication use over a 5-year period and various self-reported health status variables assessed several years later, including overall health status (STATUS) and trouble with activities of daily living (TADL). Multivariable logistic regression was used to estimate odds ratios (ORs) for the health status variables and metrics of medication use, including >60-day use, and for opiates, chronic use, with models controlling for demographics (model I), additionally for chronic conditions (model II), and additionally for other medication use (model III).

RESULTS

The study cohort included 22,844 PLCO participants (56% women, 90% non-Hispanic whites); 4.2% had chronic opioid use and 12.5% used for >60 days. Fair-poor STATUS was reported in 37.9% of participants with chronic opioid use versus 15.0% of participants without (p < 0.001). ORs for chronic opioid use for fair-poor STATUS (compared to good-excellent) were significantly elevated in all models but decreased from model I (OR = 3.6; 95% CI :3.1-4.1) to model II (OR = 2.7; 95% CI :2.3-3.1) to model III (OR = 2.1; 95% CI :1.8-2.5). ORs for TADL were generally similar to those for STATUS. Other drug classes also had significantly elevated model III ORs for fair-poor versus good-excellent STATUS (range 1.1-1.6).

CONCLUSION

Frequent use of various medication classes correlated with measures of future health status in an elderly population, with opioids having the strongest association. The magnitude of the association decreased after controlling for concurrent chronic conditions but remained elevated. Future research should consider how the use of opioids and other medications impact measures of health-related quality of life.

Patient Centeredness in Orthognathic Surgery

Patient centeredness in planning treatment and research has become paramount. The goal of this report was to describe a complex case in which untreated chronic pain was not properly addressed to reflect on the need to establish alternative protocols for controlling chronic orofacial pain. When a female underwent orthognathic surgery to correct her occlusion, she not only ended up with a worse occlusion, she developed chronic orofacial pain that could not be treated by opioids and only improved after the use of neuropathic medication, and finally disappeared after the use of low-level laser therapy. There is a need to incorporate alternative nonpharmacological approaches to manage chronic pain. Further, what the patient’s goals are for their treatments should be given priority in case of elective procedures.

Stages of major depressive disorder and behavioral multi-morbidities: Findings from nationally representative epidemiologic study

OBJECTIVE

To present a three stage-model of major depressive disorder (MDD) and evaluate differences in behavioral histories/experiences and multi-morbidities between stages.

METHODS

We used data from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III, a nationally representative cross-sectional survey of US adults (n = 36,309). Based on DSM-5 diagnostic criteria, we identified and compared three groups of adults with MDD histories: 1) new onset MDD (n = 509; 5.6%); 2) chronic MDD (n = 3,871; 46.1%); and 3) recovered from MDD (n = 3,673; 48.3%). Multivariable analyses tested independent group differences in behavioral histories/experiences and diagnostic multi-morbidities between 1) recovered MDD vs. new onset MDD; 2) chronic MDD vs. new onset MDD; and 3) recovered MDD vs. chronic MDD.

RESULTS

Adults who have recovered from MDD as compared to those with chronic MDD were 2.5 times more likely to have recovered from two or more psychiatric disorders in addition to MDD (95% confidence intervals [CI]=1.76-3.61) and from alcohol use disorder (adjusted odds ratio [AOR]=1.28; 95% CI=1.08-1.52). They were also less likely than those with chronic MDD to have borderline personality disorder (p<0.001), pain (p<0.001), or medical co-morbidity (p = 0.003). Adults with new onset MDD were younger than other groups, and more likely than those who have recovered to have borderline personality disorder and concurrent psychiatric or substance use disorders (p<0.05 for all).

CONCLUSION

Behavioral histories/experiences and multi-morbidities differ significantly across stages of MDD. These concurrent problems may impede recovery and foster chronicity and should therefore be an integral focus of treatment.

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.

Major depressive disorder and impaired health-related quality of life among US older adults

OBJECTIVES

To examine the association of current and past major depressive disorder (MDD) and measures of health-related quality of life (HRQOL) in a nationally representative sample of older adults.

METHODS

Cross-sectional analysis of the 2012 to 2013 National Epidemiological Survey on Alcohol and Related Conditions Wave III (NESARC-III) was used. NESARC-III is a nationally representative health interview survey on substance use and mental health in the US, and we limited our sample to survey respondents aged 65 or older (n = 5806 unweighted). Using DSM-5 criteria, we identified older adults with current MDD, past MDD (ie, prior but not current MDD), and no history of MDD. Using standardized algorithms, we also constructed HRQOL measures: mental component summary (MCS), physical component summary (PCS), and quality-adjusted life years (QALYs). We performed multivariable-adjusted linear regression analyzes to assess the associations of MDD types with HRQOL measures while adjusting for socio-demographics and clinical co-morbidities.

RESULTS

Overall, 14.4% of the older adults, representative of 6.0 million nationwide, met criteria for lifetime MDD. About 2.2 million older adults (5.4%) had current MDD and 3.7 million older adults (9.0%) had past MDD. Older adults with current or past MDD had a moderate difference in HRQOL measures compared with never depressed (Cohen's d measures ranging from -1.02 to -0.07). When controlling for other covariates, MCS and QALYs measures were lowest in the current MDD group.

CONCLUSION

Current MDD is associated with significantly lower HRQOL than never MDD, while adults with past MDD had minor (often insignificant) residual impairment in HRQOL.

Why are black adults over-represented among individuals who have experienced lifetime homelessness? Oaxaca-Blinder decomposition analysis of homelessness among US male adults

BACKGROUND

Non-Hispanic black adults experience homelessness at higher rates than non-Hispanic white adults in many studies. We aim to identify factors that could account for this disparity.

METHODS

We used national survey data on non-Hispanic black and white men with complete data from the National Epidemiological Survey on Alcohol and Related Conditions Wave III. Using the Oaxaca-Blinder decomposition analysis, we examined race-based disparities in correlates of risk for lifetime homelessness.

RESULTS

In our analysis, 905 of 11 708 (7.7%) respondents, representing 6 million adults nationwide, reported lifetime homelessness. Black adults were 1.41 times more likely to have been homeless than white adults (95% CI 1.14 to 1.73; p=0.002). Overall, 81.6% of race-based inequality in lifetime homelessness were explained by three main variables with black adults having: lower incomes, greater incarceration histories since age of 18 and a greater risk of traumatic events (p<0.01 for each). They also had more antisocial personality disorder, younger age and parental drug use (p<0.05 for each).

CONCLUSION

Although previous studies suggested that black homeless men have higher rates of drug abuse than white homeless men, our findings highlight the fact that black-white disparities in lifetime homeless risk are associated with socio-structural factors (eg, income and incarceration) and individual adverse events (eg, traumatic events), and not associated with psychiatric or substance use disorders.

Spillover Effects of Job Skills Training on Substance Misuse Among Low-Income Youths With Employment Barriers: A Longitudinal Cohort Study

Objectives. To examine spillover effects of job skills training (vs basic services only [e.g., adult basic education, job readiness training]) on substance misuse among low-income youths with employment barriers.Methods. Data came from the National Longitudinal Survey of Youth 1997, a longitudinal cohort study of youths born between 1980 and 1984 in the United States. Based on respondents' reports of substance misuse (past-month binge drinking and past-year marijuana and other illicit drug use) from 2000 to 2016, we estimated substance misuse trajectories of job skills training (n = 317) and basic services (n = 264) groups. We accounted for potential selection bias by using inverse probability of treatment weighting.Results. Compared with the basic services group, the job skills training group showed notable long-term reductions in its illicit drug misuse trajectory, translating to a 56.9% decrease in prevalence rates from 6.5% in year 0 to 2.8% in year 16.Conclusions. Job skills training can be an important service component for reducing substance misuse and improving employment outcomes among youths with economic disadvantages and employment barriers.

Alcohol Use Disorder Among Adults Recovered From Substance Use Disorders

BACKGROUND AND OBJECTIVES

Alcohol use is often overlooked and underestimated among patients recovered from substance dependence. The prevalence and correlates of alcohol use disorder (AUD) among adults recovered from substance use disorders (SUDs) are estimated in this study.

METHODS

A nationally representative cross-sectional analysis of the National Epidemiological Survey on Alcohol and Related Conditions Wave-III was used in this study. Survey respondents, aged 18 or older, who recovered from SUDs, based on Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria (n = 2061 unweighted), were included. A total of three comparison groups were identified using DSM-5 criteria (1) current AUD, (2) former AUD, and (3) never had AUD. The prevalence of these groups was estimated; medical and psychiatric comorbidities and health-related quality of life were compared; and factors associated with having a current AUD when compared with those with former AUD and those who never had AUD were examined, controlling for other covariates.

RESULTS

About 5.7% of US adults, nationally representative of 14.2 million, have been reported to have recovered from past SUDs. Of these, 28.9% met criteria for current AUD and 48.4% had former AUD. When compared with those who never had AUD, factors associated with having a current AUD included the following: living in urban areas (P = .019), having a bipolar 1 disorder (P < .001), and a history of lifetime incarceration (P = .004).

DISCUSSION AND CONCLUSION

Nearly one-third of adults recovered from SUDs had current AUD, and several behavioral factors were associated with having a current AUD when compared with those who never had AUD.

SCIENTIFIC SIGNIFICANCE

Our study highlights the substantial risk of AUD in adults who have successfully recovered from SUDs. (Am J Addict 2020;00:00-00).

Use of Drug Treatment Services Among Adults With Opioid Use Disorder: Rates, Patterns, and Correlates

OBJECTIVES

The study examined rates, patterns, and correlates of drug treatment services use among adults with opioid use disorder compared with adults with other drug use disorders.

METHODS

Data were from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III, which surveyed a nationally representative sample of noninstitutionalized U.S. civilian adults. The proportions reporting drug treatment services use were compared between those with opioid use disorder and those with other drug use disorders. Multivariable-adjusted regression analyses identified factors associated with service use.

RESULTS

Adults with opioid use disorder (N=330, unweighted) reported a very low rate of any drug-related health services use (17.3%), although the rate was higher than among adults with other drug use disorders (7.4%) (p<0.001). Crisis-related services were the most common type of service used among adults with opioid use disorder (6.2%)-significantly higher than the rate among those with other drug use disorders (0.6%) (p<0.001). Few (3.3%) adults with opioid use disorder used outpatient drug treatment services. Among all adults with drug use disorders, opioid use disorder was associated with greater odds of using drug treatment services (adjusted odds ratio=2.43; 95% confidence interval=1.38-4.28). Living in the West and reporting moderate to extreme pain were associated with a lower likelihood of service use among all adults with drug use disorders (p<0.05 for each).

CONCLUSIONS

Most adults with opioid use disorder remain untreated, much less received outpatient treatment to address their addiction. Interventions are needed to improve access to and motivation for care among these vulnerable adults.