Gender differences in risk factors for aberrant prescription opioid use

Male and female variability in response to chronic stress and morphine in C57BL/6J, DBA/2J, and their BXD progeny

Drug addiction is a multifactorial syndrome in which genetic predispositions and exposure to environmental stressors constitute major risk factors for the early onset, escalation, and relapse of addictive behaviors. While it is well known that stress plays a key role in drug addiction, the genetic factors that make certain individuals particularly sensitive to stress and thereby more vulnerable to becoming addicted are unknown. In an effort to test a complex set of gene x environment interactions-specifically gene x chronic stress -here we leveraged a systems genetics resource: BXD recombinant inbred mice (BXD5, BXD8, BXD14, BXD22, BXD29, and BXD32) and their parental mouse lines, C57BL/6J and DBA/2J. Utilizing the chronic social defeat stress (CSDS) and chronic variable stress (CVS) paradigms, we first showed sexual dimorphism in the behavioral stress response between the mouse strains. Further, we observed an interaction between genetic background and vulnerability to prolonged exposure to non-social stressors. Finally, we found that DBA/2J and C57BL/6J mice pre-exposed to stress displayed differences in morphine sensitivity. Our results support the hypothesis that genetic variation in predisposition to stress responses influences morphine sensitivity and is likely to modulate the development of drug addiction.

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.

[Factors influencing analgesic use patterns in patients with chronic tumor-associated pain. : A qualitative pilot study considering different groups of medications]

BACKGROUND

Patients are surviving tumor diseases longer and longer due to the improvement of tumor-specific therapy and pain is a common symptom. The gold standard for tumor-associated chronic pain is multimodal therapy. Non-adherence causes high costs and may put patients at risk. The aim of this study was to investigate the adherence behavior and subjective treatment compliance of patients with tumor-associated chronic pain. The focus was on the patients' perspective. Different groups of medications, such as NOPA, opioids, co-analgesics and cannabinoids, as well as non-drug treatments were included.

METHODS

Semistructured guided interviews with 10 patients with chronic tumor pain were conducted within a qualitative research approach. The interviews were recorded and transcribed. The evaluation was using a focused content structuring interview analysis according to Kuckartz and Rädiker.

RESULTS

Five main categories were defined. The central category based on the research question was "Adherence behavior from the patient's perspective." The category "Medication therapy" formed the framework of the study. Other main categories were "History of illness", "Relationship with treatment providers" and "Attitudes and beliefs". A total of 77 additional subcategories were formed and interpreted. Adherence behavior from the patients' perspective differed between the different medication groups. A palliative setting influenced treatment decisions and adherence. The medication regimens used were complex and dynamic, especially when there were multiple practitioners involved. Furthermore, there was ambiguity in the use of cannabinoids. Non-drug therapies were marginalized by patients. From the point of view of the patients interviewed, it was not so much the treatment providers who influenced their adherence behavior, but rather their own experiences, attitudes, and convictions.

DISCUSSION

The study included all medication groups and non-drug therapies equally, complementing previous literature in a qualitative setting. Adherence factors known from previous research were reflected in the subjective perception of the group of patients with chronic pain after tumor diseases. Marginalization of non-medication methods could be explained by the fact that multimodal therapy approaches were too rarely constantly used and controlled in the phase of chronification. Therefore, drug and non-drug therapies should be applied even more consistently to patients with tumor-associated pain.

Morphine-context associative memory and locomotor sensitization in mice are modulated by sex and context in a dose-dependent manner

Sex differences in opioid use, development of opioid used disorder, and relapse behaviors indicate potential variations in opioid effects between men and women. The locomotor and interoceptive effects of opioids play essential roles in opioid addiction, and uncovering the neural mechanisms underlying these effects remain crucial for developing effective treatments. In this study, we examined the dose-dependent effects of morphine on locomotor sensitization and the strength and stability of morphine-context associations in the conditioned place preference (CPP) paradigm in male and female mice, as well as the relationships between these measures. We observed that while CPP is similar between sexes, the locomotor effects of repeated morphine administration and withdrawal differentially contributed to the strength and stability of morphine-context associations. Specifically, females exhibited higher morphine-induced hyperlocomotion than males regardless of the context in which morphine was experienced. Greater locomotor sensitization to morphine in females than males emerged in a dose-dependent manner only when there was sufficient context information for CPP to be established. Additionally, the relationships between the locomotor effects of morphine and the strength and stability of CPP were different in males and females. In females, positive acute and sensitizing locomotor effects of morphine were correlated with a higher CPP score, while the opposite direction of this relationship was found in males. These results suggest that different aspects of the subjective experience of morphine intoxication and withdrawal are important for morphine abuse-related behaviors and highlight the importance of sex-specific responses in the context of opioid addiction.

Risk Factors Associated With Prolonged Opioid Use After Revision Total Shoulder Arthroplasty

INTRODUCTION

The purpose of this study was to determine which preoperative factors are associated with prolonged opioid use after revision total shoulder arthroplasty (TSA).

METHODS

The M157Ortho PearlDiver database was used to identify patients undergoing revision TSA between 2010 and 2021. Opioid use for longer than 1 month after surgery was defined as prolonged opioid use. Postoperative opioid use from 1 to 3 months was independently assessed. Multivariable logistic regression was used to evaluate the association between preoperative patient-related risk factors (age, Charlson Comorbidity Index, sex, depression, anxiety, substance use disorder, opioid use between 12 months to 1 week of surgery, tobacco use, hypertension, diabetes mellitus, chronic obstructive pulmonary disease, osteoporosis, previous myocardial infarction, and chronic ischemic heart disease) with prolonged postoperative opioid use. Odds ratios (OR) and their associated 95% confidence intervals (CI) were calculated for each risk factor.

RESULTS

A total 14,887 patients (mean age = 67.1 years) were included. Most of the patients were female (53.3%), and a large proportion were opioid familiar (44.1%). Three months after revision TSA, older age (OR = 0.96, CI 0.96 to 0.97) and male sex (OR = 0.90, CI 0.81 to 0.99) were associated with a decreased risk of prolonged postoperative opioid usage. Patients with preexisting depression (OR = 1.21, CI 1.08 to 1.35), substance use disorder (OR = 1.47, CI 1.29 to 1.68), opioid use (OR = 16.25, CI 14.27 to 18.57), and chronic obstructive pulmonary disorder (OR = 1.24, CI 1.07 to 1.42) were at an increased risk of prolonged postoperative opioid use.

DISCUSSION

Older age and male sex were associated with a decreased risk of prolonged opioid use after revision TSA. Depression, substance use disorder, opioid familiarity, and COPD were associated with prolonged opioid use after revision TSA.

Risk factors for opioid addiction in chronic non-cancer pain

Opioids are very effective pain medications, but they are not without complications. Its use in chronic cancer pain is clearly established, but not in chronic non-cancer pain. Opioid use has increased in recent years, but at the same time, it has been accompanied by an increase in side effects and related complications, including abuse, abuse and opioid addiction. If we look in the literature on the subject there is a global concern to make an adequate therapy with risk reduction, but the samples studied make it difficult to extrapolate results to the general population and even more so if we take into account factors such as psychiatric comorbidity. This leads us to consider the need to study our own population, its characteristics and see how it is being treated, to refine as much as possible on an appropriate prescription. The authors have carried out a cross-sectional study on patients with non-cancer chronic pain referred to psychiatry and the presence of opioid use disorder. We found risk factors related to the biopsychosocial characteristics of the patients and the characteristics of pain and its treatment. Knowing the risk factors, we can avoid yatrogeny, implement primary and secondary prevention and, ultimately, improve the quality of patient care.

Back Pain Consortium (BACPAC): Protocol and Pilot Study Results for a Randomized Comparative-Effectiveness Trial of Antidepressants, Fear Avoidance Rehabilitation, or the Combination for Chronic Low Back Pain and Comorbid High Negative Affect

OBJECTIVE

Patients with chronic low back pain (CLBP) and comorbid depression or anxiety disorders are highly prevalent. Negative affect (NA) refers to a combination of negative thoughts, emotions, and behaviors. Patients with CLBP with high NA have greater pain, worse treatment outcomes, and greater prescription opioid misuse. We present the protocol for SYNNAPTIC (SYNergizing Negative Affect & Pain Treatment In Chronic pain).

DESIGN

A randomized comparative-effectiveness study of antidepressants, fear-avoidance rehabilitation, or their combination in 300 patients with CLBP with high NA. In the antidepressant- or rehabilitation-only arms, SYNNAPTIC includes an adaptive design of re-randomization after 4 months for nonresponders.

SETTING

A multisite trial conducted in routine pain clinical treatment settings: pain clinics and physical and occupational therapy treatment centers.

METHODS

Inclusion criteria include CLBP with elevated depression and anxiety symptoms. Antidepressant and rehabilitation treatments follow validated and effective protocols for musculoskeletal pain in patients with high NA. Power and sample size are based on superior outcomes of combination therapy with these same treatments in a 71-subject 4-arm pilot randomized controlled trial.

CONCLUSIONS

SYNNAPTIC addresses the lack of evidence-based protocols for the treatment of the vulnerable subgroup of patients with CLBP and high NA. We hypothesize that combination therapy of antidepressants plus fear-avoidance rehabilitation will be more effective than each treatment alone.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT04747314.

Females Are More Likely Than Males to Fill an Opioid Prescription in the Year After Anterior Cruciate Ligament Reconstruction

Purpose

To report rates of preoperative and postoperative opioid use between male and female patients and to identify risk factors for extended opioid use following anterior cruciate ligament reconstruction (ACLR).

Methods

Patients undergoing ACLR between 2011 and 2018 were identified from the PearlDiver database. The opioid refill rates for males vs females were compared at monthly intervals for 1 year after ACLR. Patients who filled an opioid prescription <3 months before surgery were classified as opioid users, while those who had never filled one were classified as nonopioid users.

Results

Of 106,995 ACLR patients, 37,890 (35.4%) were opioid users <3 months before surgery, and 37,554 (35.1%) had never filled an opioid prescription. Of the preoperative opioid users, 20,413 (53.9%) were female and 17,477 (46.1%) were male (P < .001). Postoperatively, females were at higher risk of filling an opioid prescription at each monthly interval, except for the first month after surgery. The refill rate for opioid users was also higher than that for nonopioid users at each monthly interval after ACLR. In addition to patient sex, a preoperative diagnosis of anxiety/depression, low back pain, myalgia, a history of drug dependence, alcohol abuse, and tobacco use increased a patient's risk of filling an opioid prescription postoperatively.

Conclusions

This study demonstrated that females are significantly more likely to be opioid users than males prior to ACLR and are more likely to continue to refill an opioid prescription in the year following surgery. Multiple risk factors were associated with prolonged postoperative opioid utilization, including female sex, anxiety/depression, low back pain, myalgia, a history of drug dependence, alcohol abuse, and tobacco use.

Level of Evidence

Level III, retrospective cohort study.

Modeling spontaneous opioid withdrawal in male and female outbred mice using traditional endpoints and hyperalgesia

Opioid withdrawal significantly impacts drug dependence cycles as hyperalgesia associated with withdrawal is often a reason for continued drug use. Animal models of addiction are important tools for studying how drug dependence and withdrawal impact not only normal neurocircuitry but also the effectiveness of potential treatments for dependence and withdrawal. We conducted a study of the time course of spontaneous morphine withdrawal in outbred male and female mice that can be used to examine sex differences in male and female mice using both traditional somatic endpoints and mechanical hyperalgesia as an endpoint of withdrawal. Male and female national institute of health (NIH) Swiss mice were made dependent upon morphine using an escalating dosing schedule. Injections were stopped after 5 days. Withdrawal behavior was assessed at time intervals up to 106 h after the final injection. Numbers of forepaw tremors, wet-dog shakes, jumps and other behaviors were scored to create a global score. Paw pressure readings were then also taken to track changes in sensitivity to a painful stimulus over time. Male and female mice had approximately similar withdrawal severity peaking at 24 h after the final injection as measured by composite global scores. Females did exhibit an earlier and greater frequency of tremors than males. Although males and females showed similar hyperalgesia during withdrawal, females recovered faster. Spontaneous opioid withdrawal peaking at 24 h was demonstrated in male and female NIH Swiss mice. We also successfully demonstrated that hyperalgesia is an endpoint that varies over the course of withdrawal.

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).

Sex-Differences in Pain and Opioid Use Disorder Management: A Cross-Sectional Real-World Study

(1) Background: It is essential to focus attention on sex-specific factors which are clinically relevant in pain management, especially with regards to opioid use disorder (OUD) risk. The aim of this study was to explore potential sex-differences in chronic non-cancer pain (CNCP) outpatients. (2) Methods: An observational cross-sectional study was conducted under CNCP outpatients with long-term prescribed opioids (n = 806), wherein 137 patients had an OUD diagnosis (cases, 64% females) and 669 did not (controls, 66% females). Socio-demographic, clinical, and pharmacological outcomes were analyzed. (3) Results: Female controls presented an older age and less intensive pain therapy but higher psychotropic prescriptions and emergency department visits compared to male controls. Meanwhile, cases demonstrated a younger age, higher work disability, double morphine equivalent daily dose, and benzodiazepine use compared with controls. Here, female cases showed an 8% greater substance use disorder (OR 2.04 [1.11–3.76]) and 24% lower tramadol use, while male cases presented a 22% higher fentanyl use (OR 2.97 [1.52–5.81]) and reported the highest number of adverse drug reactions (24%, OR 2.40 [1.12–5.16]) compared with controls. (4) Conclusions: An OUD individual risk profile was evidenced with sex-differences to take into consideration to design equal prevention programs.

Unique and joint associations of polygenic risk for major depression and opioid use disorder with endogenous opioid system function

Major depressive disorder (MDD) and opioid use disorder (OUD) are common, potentially fatal, polygenic disorders that are moderately heritable and often co-occur. We examined the unique and shared associations of polygenic risk scores (PRS) for these disorders with µ-opioid receptor (MOR) concentration and endogenous opioid response during a stressful stimulus. Participants were 144 healthy European-ancestry (EA) subjects (88 females) who underwent MOR quantification scans with [11C]carfentanil and PET and provided DNA for genotyping. MOR non-displaceable binding potential (BPND) was measured in 5 regions of interest (ROIs) related to mood and addiction. We examined associations of PRS both at baseline and following opioid release calculated as the ratio of baseline and stress-challenge scans, first in the entire sample and then separately by sex. MOR availability at baseline was positively associated with MDD PRS in the amygdala and ventral pallidum. MDD and OUD PRS were significantly associated with stress-induced opioid system activation in multiple ROIs, accounting for up to 14.5% and 5.4%, respectively, of the variance in regional activation. The associations were most robust among females, where combined they accounted for up to 25.0% of the variance among the ROIs. We conclude that there is a pathophysiologic link between polygenic risk for MDD and OUD and opioid system activity, as evidenced by PRS with unique and overlapping regional associations with this neurotransmitter system. This link could help to explain the high rate of comorbidity of MDD and OUD and suggests that opioid-modulating interventions could be useful in treating MDD and OUD, both individually and jointly.

Opioid Consumption in Chronic Pain Patients: Role of Perceived Injustice and Other Psychological and Socioeconomic Factors

BACKGROUND

Chronic pain is a complex biopsychosocial phenomenon. Lifestyle, behavioral, socioeconomic, and psychosocial factors such as depression and perceived injustice are often associated with the development of chronic pain and vice versa. We sought to examine the interaction of these factors with opioid intake.

METHODS

At our institution, 164 patients with chronic pain undergoing an interdisciplinary assessment within a three-month period participated in the study and completed the Injustice Experience Questionnaire (IEQ). Data regarding opioid intake, pain levels, pain diagnosis, depression, anxiety, stress, quality of life, pain-related disability, habitual well-being, occupational status, and ongoing workers compensation litigation were extracted from the patients' charts.

RESULTS

Approximately one-fourth of the patients used opioids. The IEQ total was significantly higher in patients using Schedule III opioids. Depression, but not the anxiety and stress scores, were significantly higher in patients using opioids. There were no significant differences regarding pain-related disability, habitual well-being, and the coded psychosocial diagnoses. In the patient group without opioids, the percentage of employed persons was significantly higher but there were no significant differences regarding work leave, pension application, or professional education.

CONCLUSIONS

Opioid use appears to be more closely related to psychological factors and single social determinants of pain than to somatic factors.

Overlapping needs for sexual and reproductive health and HIV prevention in women with substance use disorders

OBJECTIVES

Women with substance use disorders have high unmet needs for HIV prevention and drug treatment and face challenges accessing care for other unique health issues, including their sexual and reproductive health.

METHODS

We did a cross-sectional evaluation of sexual and reproductive health behaviors and outcomes among women with substance use disorders, who were enrolled in one of two concurrent clinical trials of pre-exposure prophylaxis for HIV prevention. Descriptive analyses and bivariate logistic regression were used to assess factors driving contraceptive use, and other essential sexual and reproductive health services utilization and outcomes.

RESULTS

Among 226 women, 173 (76.5%) were of reproductive age. Most women had histories of unintended pregnancy (79.2%) or miscarriage (45.1%) and high HIV risk behaviors (53.5%). Most (61%) participants did not use any form of contraception at the time of assessment, although few (15%) reported pregnancy intentions. In bivariate models, ongoing criminal justice involvement was associated with 2.22 higher odds of not using contraception (95% confidence interval = 1.09-4.53; p = 0.03) and hazardous drinking was protective against not using contraception (odds ratio = 0.33, 95% confidence interval = 0.13-0.81; p = 0.02). Contraception use was not significantly associated with any other individual characteristics or need factors.

CONCLUSIONS

This is the first study that identifies the unmet sexual and reproductive health needs of women with substance use disorders who are engaging with pre-exposure prophylaxis. We found that women accessed some health services but not in a way that holistically addresses the full scope of their needs. Integrated sexual and reproductive care should align women's expressed sexual and reproductive health intentions with their behaviors and outcomes, by addressing social determinants of health.

Associations between symptoms of posttraumatic stress disorder, pain, and alcohol use disorder among OEF/OIF/OND veterans

BACKGROUND

Alcohol use disorder (AUD) is prevalent among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND) veterans. Pain and posttraumatic stress disorder (PTSD) are highly comorbid and increase risk of AUD. Prior studies linking pain or PTSD to AUD have not explored interactions between pain and PTSD symptoms.

METHODS

OEF/OIF/OND veterans (N = 1230) were recruited from social media websites for a cross-sectional study of health behavior. Pain was assessed using the Pain Outcomes Questionnaire. PTSD symptoms and PTSD symptom clusters were assessed using the Posttraumatic Stress Disorder Checklist for DSM-5. AUD symptoms were assessed with the AUD Identification Test. Linear regression models were used to test for main and interaction effects in the full sample and separately by sex.

RESULTS

Both pain and PTSD symptoms were associated with increased AUD symptomology, though the relationship between pain and AUD was heighted at relatively low PTSD symptoms. With respect to PTSD symptom clusters, re-experiencing and negative cognitions and mood were associated with increased AUD symptomology. Interactions between pain and re-experiencing as well as pain and avoidance were revealed. Results for men mirrored the full sample, while an interaction between pain and negative cognitions and mood was associated with AUD in women.

CONCLUSIONS

Results highlight associations between AUD, PTSD symptoms, and pain among veterans. While the relationship between pain and AUD appeared stronger in the context of low PTSD symptoms, both pain and PTSD symptoms were associated with increased AUD. Clinicians treating veterans with AUD should address the range of potential comorbidities.

Toxicological and pharmacologic sex differences in unintentional or undetermined opioid overdose death

INTRO

Understanding sex differences in toxicological etiologies of opioid-related drug overdose death could inform future sex- and gender-specific approaches to prevention and treatment.

METHODS

A retrospective review of accidental or undetermined opioid-involved overdose deaths in Rhode Island 2016-2019 was performed using the Rhode Island Department of Health State Unintentional Drug Overdose Reporting System (SUDORS) database. Decedent toxicology data was linked with state Prescription Drug Monitoring Program (PDMP) records.

RESULTS

Of 766 cases in the analytical sample, 568 cases were in men (74.2%) and 198 cases were in women (25.6%). Median age was 40.0 years for males and 42.0 years for females. Statistically significant sex-differences in drug exposures were found. Compared to men, women were more likely have exposure to benzodiazepine, antipsychotic, and antidepressant drug classes and less likely to have fentanyl and alcohol co-exposure. No sex differences were found in cocaine and amphetamine exposure. Female decedents were more likely than male decedents to have a prescription for benzodiazepines or opioids in the 30 days before death (40% vs 21%). The proportion of decedents with a benzodiazepine on post-mortem toxicology testing in combination with a benzodiazepine prescription (p < 0.001) or an opioid prescription (p = 0.005) was over two times higher in women than men.

CONCLUSION

Higher rates of controlled substance prescription prior to death and prescription drug co-exposures suggest that female opioid-involved drug overdose decedents are often in contact with the health care system immediately preceding their death, presenting the opportunity to create patient-centric approaches for prevention, harm reduction, and substance use treatment.

Exploring the Psychometric Properties of the Current Opioid Misuse Measure Among Adults With Chronic Pain and Opioid Use

OBJECTIVES

The opioid epidemic is a significant public health problem that is associated with overdose and death. The increase in opioid-related problems can largely be attributed to increases in opioid prescriptions for the treatment of chronic pain. Unfortunately, there is not a consensus on a definition of opioid misuse in the context of chronic pain, making measurement a challenge. One commonly used measure to assess opioid misuse in the context of chronic pain is the Current Opioid Misuse Measure (COMM). The COMM was designed to assess opioid misuse generally, as captured by psychiatric symptoms and aberrant drug use behaviors. Although studies have examined cross-validation using correlations, little psychometric work has been conducted, and therefore it is currently unknown what domains the measure is assessing.

MATERIALS AND METHODS

The current study examined the factor structure of the COMM using confirmatory and exploratory factor analysis among 445 opioid-using adults with chronic pain.

RESULTS

The results did not support the widely accepted 1-factor opioid misuse solution; rather they supported a 2-factor, psychiatric problems and aberrant-drug-use-problems factor structure. Convergent and divergent validity were also examined at the bivariate level.

DISCUSSION

Given the importance and relevance for opioid misuse in the context of chronic pain, it is important for researchers to continue assessing and providing psychometric evidence for the COMM.

Anxiety, Depression, and Opioid Misuse Among Adults With Chronic Pain: The Role of Anxiety Sensitivity

OBJECTIVES

The opioid epidemic is a significant public health problem largely driven by opioid prescriptions for chronic pain. Among those with chronic pain, anxiety and depressive symptoms have been linked to opioid misuse, and individual differences in anxiety and depressive symptoms among adults with chronic pain may be important for better understanding pain. Yet, little work has examined mechanisms that may link anxiety and depressive symptoms to opioid misuse among adults with chronic pain. Anxiety sensitivity (AS), or the fear of anxiety-related physical sensations, may be one candidate construct that has been linked independently to anxiety and depressive symptoms as well as opioid misuse.

METHODS

The current survey-based study examined the indirect association of AS in the relation between anxiety and depressive symptoms and opioid misuse among 429 adults with chronic pain currently using prescription opioid medication (73.9% female, Mage=38.32 y, SD=11.07).

RESULTS

Using structural equation modeling, it appears that AS is a potential construct in the interrelation between anxiety and depressive symptoms and opioid misuse. However, an alternative model found equally strong empirical support, as mental health symptoms may serve as an explanatory factor between AS and opioid misuse.

DISCUSSION

Bi-directional effects are apt to be involved among the studied variables. Prospective research is needed to replicate the study results and isolate the temporal patterning between the studied constructs. Nonetheless, the data overall highlight the importance of both AS and anxiety and depressive symptoms in terms of understanding opioid misuse among adults with chronic pain.

Adolescent Stress Reduces Adult Morphine-Induced Behavioral Sensitization in C57BL/6J Mice

Deaths related to opioid use have skyrocketed in the United States, leading to a public health epidemic. Research has shown that both biological (genes) and environmental (stress) precursors are linked to opioid use. In particular, stress during adolescence-a critical period of frontal lobe development-influences the likelihood of abusing drugs. However, little is known about the biological mechanisms through which adolescent stress leads to long-term risk of opioid use, or whether genetic background moderates this response. Male and female C57BL/6J and BALB/cJ mice were exposed to chronic variable social stress (CVSS) or control conditions throughout adolescence and then tested for morphine locomotor sensitization or morphine consumption in adulthood. To examine possible mechanisms that underlie stress-induced changes in morphine behaviors, we assessed physiological changes in response to acute stress exposure and prefrontal cortex (PFC) miRNA gene expression. Adolescent stress did not influence morphine sensitization or consumption in BALB/cJ animals, and there was limited evidence of stress effects in female C57BL/6J mice. In contrast, male C57BL/6J mice exposed to adolescent CVSS had blunted morphine sensitization compared to control animals; no differences were observed in the acute locomotor response to morphine administration or morphine consumption. Physiologically, C57BL/6J mice exposed to CVSS had an attenuated corticosterone recovery following an acute stressor and downregulation of twelve miRNA in the PFC compared to control mice. The specificity of the effects for C57BL/6J vs. BALB/cJ mice provides evidence of a gene-environment interaction influencing opioid behaviors. However, this conclusion is dampened by limited locomotor sensitization observed in BALB/cJ mice. It remains possible that results may differ to other doses of morphine or other behavioral responses. Long-term differences in stress reactivity or miRNA expression in C57BL/6J mice suggests two possible biological mechanisms to evaluate in future research.

Typologies of illicit drug use in mid-adulthood: a quasi-longitudinal latent class analysis in a community-based sample of twins

AIMS

To identify drug use typologies based on substances used and persistence of use over two time points, use a genetically informed design to explore twin concordance of and genetic influence on the use typologies and compare patterns of declined/discontinued ("desistant") and persistent drug use on drug use correlates.

DESIGN

Latent class analysis was applied to data from a cross-sectional self-report survey on current and past drug use. Use characteristics, use disorder, and psychiatric problems were compared across classes.

SETTING

Computer-assisted telephone interview in respondents' homes.

PARTICIPANTS

A total of 3785 individual twins and siblings (1365 men, 2420 women; M_age  = 32) from the Australian Twin Registry Cohort III.

MEASUREMENTS

A comprehensive interview assessed prior to past year and past year use of cannabis, stimulants, cocaine/crack, hallucinogens, opioids, sedatives, inhalants, dissociatives, and solvents; age of first use; opportunity to use; peer drug use; attention deficit/hyperactivity, conduct, antisocial personality, depressive, and substance use disorders; and suicidality.

FINDINGS

A five-class solution emerged: no/low use (50%), desistant cannabis use (23%), desistant party drug use (18%), persistent prescription drug misuse (4%), and persistent polydrug use (5%). Twin concordances were higher among monozygotic (k = 0.30-0.35) than dizygotic pairs (same-sex k = 0.19-0.20; opposite sex k = 0.07), and biometric modeling suggested that the persistent polydrug use class, in particular, was highly heritable (a²  = 0.94). Conduct disorder (OR = 2.40), antisocial personality disorder (OR = 3.27), and suicidal ideation (OR = 1.98) increased persistent polydrug use risk; depression (OR = 2.38) and lifetime suicide attempt (OR = 2.31) increased persistent prescription misuse risk. Relative to persistent prescription drug misuse, persistent polydrug use was associated with higher rates of cannabis and stimulant use disorder (OR = 6.14-28.01), younger first substance use (OR = 0.82-0.83), more drug use opportunity (OR = 10.66-66.06), and more drug-using peers (OR = 4.66-9.20).

CONCLUSIONS

Unique patterns of declined/discontinued ("desistant") and persistent drug use are differentially heritable and differentially associated with risk factors, psychiatric symptoms, and substance use disorder outcomes.

Prevalence of Problematic Use of Opioids in Patients with Chronic Noncancer Pain: A Systematic Review with Meta-analysis

BACKGROUND AND OBJECTIVE

Opioid prescription for chronic noncancer pain is associated with problematic use. We aimed to review and summarize the evidence on the prevalence of problematic use of opioids in adults with chronic noncancer pain and investigate whether the prevalence rates were changing over time.

DATABASES AND DATA TREATMENT

A systematic review of the literature was undertaken following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. We systematically searched the literature in the electronic databases MEDLINE, SCOPUS, and Web of Science and studies with adult participants with chronic noncancer pain using opioids with indication of one or more of the following terms about problematic opioid use: abuse, misuse, addiction, dependence, problematic use, and aberrant behavior/use were eligible for data extraction. Meta-analysis was performed to estimate the pooled prevalence rates using a random-effects model, and subanalysis was conducted.

RESULTS

Our search identified a total of 784 potentially relevant studies. After a thorough evaluation, 19 papers, mostly from the United States, were included in our qualitative and quantitative synthesis. The majority of the data came from speciality pain clinics. The estimated prevalence of problematic use of opioids in adults with chronic noncancer pain was 36.3% (95% confidence interval: 27.4 to 45.2%; I²  = 99.64%). Problematic opioid use was mostly identified using the questionnaire method. Thirteen studies (68%) presented a low risk of bias.

CONCLUSIONS

Our study presents an alarming estimate regarding the prevalence of problematic use of opioids among patients with noncancer pain. These results deserve special attention from health care professionals and health authorities.

Motives for opioid use explain the relation between borderline personality disorder pathology and opioid use problems

Despite the established relations between borderline personality disorder (BPD) and substance use problems in general, there is a dearth of research on the relation between BPD pathology and opioid use problems, as well as factors that may explain this relation. Therefore, this study examined the indirect relations of BPD pathology to opioid use problems (i.e., prescription opioid misuse, apprehension about prescription opioid use, and opioid cravings) through motives for opioid use (i.e., coping, enhancement, social, and conformity motives) among 68 patients endorsing prescription opioid misuse in a residential correctional substance use disorder (SUD) treatment facility. Participants completed measures of BPD pathology, motives for opioid use, and opioid use problems. Findings revealed significant indirect relations of BPD pathology to opioid misuse through coping and enhancement motives, apprehension about opioid use through coping, enhancement, and social motives, and opioid cravings through coping motives within this SUD sample. Results illustrate the relevance of both emotion- and interpersonal-related motives for opioid use to opioid use problems among patients with BPD pathology in SUD treatment.

Female rats express heroin-induced and -conditioned suppression of peripheral nitric oxide production in response to endotoxin challenge

Opioids and opioid-conditioned stimuli (CS) negatively alter host immunity, impairing the response to pathogens during opioid use and following drug cessation. Using male rats, our laboratory has determined that heroin or heroin-CS exposure preceding a lipopolysaccharide (LPS) challenge markedly suppresses normal induction of peripheral pro-inflammatory biomarkers. Presently, it is unknown if these heroin-induced and -conditioned effects extend to the female immune response. To begin this venture, the current study tested the direct effects of heroin and heroin-CS on LPS-induced peripheral nitric oxide (NO) production in female rats. We focused investigations on peripheral NO as it is a critical pro-inflammatory molecule necessary for pathogen resistance. In Experiment 1, male and female Lewis rats were administered 0 (Saline), 1, or 3 mg/kg heroin subcutaneously (s.c). Sixty minutes later, animals were injected with LPS (1 mg/kg, s.c.). Spleen and plasma samples were collected 6 h later to examine NO production through inducible NO synthase (iNOS) expression and nitrate/nitrite concentration, respectively. In Experiment 2, female Lewis rats underwent five, 60-minute context conditioning sessions with heroin (1 mg/kg, s.c.) or saline. On test day, CS-exposed and control (home cage) animals were injected with LPS (1 mg/kg, s.c.). Tissue was collected 6 h later to examine splenic iNOS expression and plasma nitrate/nitrite concentration. Both heroin administration alone and exposure to heroin-CS suppressed LPS-induced indices of NO production in spleen and plasma. Our results are the first to indicate that, similar to males, female rats express heroin-induced and -conditioned immunomodulation to a LPS challenge.

Exploring transdiagnostic processes for chronic pain and opioid misuse among two studies of adults with chronic pain

Chronic pain is a significant public health problem associated with functional impairment, increased medical expenditures, and opioid misuse. Recent work has suggested that certain transdiagnostic psychosocial factors may be more important than pain intensity to better understand pain and opioid outcomes. Specifically, pain-related anxiety, anxiety sensitivity, emotion dysregulation, and distress tolerance have all been uniquely associated with both pain and opioid outcomes across a range of samples. Yet, no work has examined how these transdiagnostic constructs relate to pain and opioid misuse when accounting for the other constructs. Therefore, the current study employed two independent sample of adults with chronic pain to examine (1) the construct independence of each of these factors using exploratory structural equation modelling (ESEM) and (2) how each of these constructs relates to pain and opioid outcomes in latent structural models. Results from Study 1 provided empirical support for construct independence of the transdiagnostic constructs. Findings from Study 2 indicated that pain-related anxiety was most strongly related to pain intensity, interference, and pain-related negative affect, anxiety sensitivity with opioid misuse, and emotion dysregulation with all studied criterion variables. The current results highlight the importance of assessing and targeting transdiagnostic constructs among adults with pain.

Sexual Violence, Mental Health, and Prescription Opioid Use and Misuse

INTRODUCTION

Previous research indicates that sexual violence is associated with prescription opioid use and misuse. However, this literature is limited by a lack of sex-specific analyses, an inability to establish temporality between experiences of sexual violence and prescription opioid outcomes, and little understanding of mechanisms underlying these associations.

METHODS

Data from Waves IV (2008) and V (2016-2018) of the National Longitudinal Study of Adolescent to Adult Health (N=10,685) were analyzed in March 2020. The association of sexual violence with past 30-day prescription opioid use and misuse among women and men and mediation by depression and anxiety diagnoses were examined using generalized structural equation modeling. Temporality was established using self-reported age at the first experience of sexual violence and age at first depression and anxiety diagnoses.

RESULTS

Sexual violence was associated with an increased likelihood of prescription opioid use and misuse among women (OR=1.68, 95% CI=1.19, 2.39 for use; OR=1.18, 95% CI=0.95, 1.55 for misuse) and men (OR=2.37, 95% CI=1.37, 4.12 for use; OR=1.71, 95% CI=1.06, 2.75 for misuse). Among women, depression (p=0.0420) and anxiety (p=0.0450) diagnoses mediated the association with prescription opioid use, and anxiety diagnosis (p=0.0210) mediated the association with prescription opioid misuse. Among men, anxiety diagnosis (p=0.038) mediated the association with prescription opioid use, and depression diagnosis (p=0.0390) mediated the association with prescription opioid misuse.

CONCLUSIONS

Secondary prevention efforts focused on evidence-based, trauma-informed behavioral health treatment among survivors of sexual violence may prevent prescription opioid use and misuse as strategies for coping with the psychological impact of these traumatic experiences.

Disparities in Prescription Opioid Misuse Affecting Sexual Minority Adults Are Attenuated by Depression and Suicidal Ideation

Purpose: Heightened rates of prescription opioid misuse have been observed among sexual minority (SM) compared with heterosexual populations. In addition, depression and suicidal ideation are risk factors for misuse, and they are also elevated among SM populations. The purpose of this analysis was to examine whether depression and suicidal ideation attenuate disparities in prescription opioid misuse among SM adults. Methods: Data came from a publicly available, nationally representative data set, the National Survey on Drug Use and Health, 2015-2018. Among adults, survey-weighted logistic regression was used to assess the relationship between sexual orientation and past-year opioid misuse adjusting for demographics and either past-year major depressive episode or suicidal ideation. Probabilities of prescription opioid misuse were also assessed under counterfactual rates of depression and suicidal ideation. Analyses were stratified by sex. Results: Among participants in the analytic sample (N = 169,759; SM = 11,268), 9254 (5.5%) reported past-year prescription opioid misuse. The overall rate of opioid misuse decreased from 6.2% in 2015 to 4.6% in 2018. The association between sexual orientation and opioid misuse was attenuated downward for gay men, lesbian women, and bisexual individuals (men and women) after adjusting for either major depressive episode or suicidal ideation, but opioid misuse remained higher among most SM groups. In addition, rates of opioid misuse were found to be lower in counterfactual analyses with a nearly 2.5- and 4-fold decrease in depression and suicidal ideation among gay men and bisexual women, respectively. Conclusion: Efforts to reduce disparities in depression and suicidal ideation affecting SM individuals may reduce disparities in prescription opioid misuse affecting this population.

Cycles of Gender Convergence and Divergence in Drug Overdose Mortality

The United States is 25 years into a large-scale drug overdose epidemic, yet its consequences for gender differences remain largely unexplored. This study finds that drug overdose mortality increased seven- and fivefold for men and women, respectively; accounts for 0.8-year (men) and 0.4-year (women) deficits in life expectancy at birth in 2017; and has made an increasing contribution (from 1 percent to 17 percent) to women's life expectancy advantage at the prime adult ages between 1990 and 2017. I document a distinctive cyclicality to sex differences in drug overdose. During the epidemic's early stages - the heyday of prescription opioids - gender differences narrowed, but once the epidemic transitioned to illicit drugs in 2010, gender differences widened again. This pattern holds across racial/ethnic groups, and in fact may be even stronger among Hispanics and non-Hispanic Blacks than among non-Hispanic Whites. That we observe this gender dynamic across racial/ethnic groups is surprising since very different trends in drug overdose mortality have been observed for Whites versus other groups. The contemporary epidemic is a case of dynamic change in gender differences, and the differential mortality risks experienced by men and women reflect gendered social norms, attitudes towards risk, and patterns of diffusion.

Retrospectively assessed subjective effects of initial opioid use differ between opioid misusers with opioid use disorder (OUD) and those who never progressed to OUD: Data from a pilot and a replication sample

Attempts to identify opioid users with increased risk of escalating to opioid use disorder (OUD) have had limited success. Retrospectively assessed subjective effects of initial opioid misuse were compared in a pilot sample of opioid misusers (nonmedical use ≤60 times lifetime) who had never met criteria for OUD (N = 14) and heroin-addicted individuals in treatment for OUD (N = 15). Relative to opioid misusers without a lifetime OUD diagnosis, individuals with OUD reported greater euphoria and other positive emotions, activation, pruritus, and internalizing symptoms. Consistent with these findings, proxy Addiction Research Center Inventory (ARCI) Amphetamine Group, and Morphine Benzedrine Group scale mean item scores were significantly higher in those with OUD. Replication was attempted in opioid misusers with (N = 25) and without OUD (N = 25) who were assessed as part of an ongoing genetic study. We observed similar significant between-group differences in individual subjective effect items and ARCI scale mean item scores in the replication sample. We, thus confirm findings from prior reports that retrospectively assessed subjective responses to initial opioid exposure differ significantly between opioid users who do, and do not, progress to OUD. Our report extends these findings in comparisons limited to opioid misusers. Additional research will be necessary to examine prospectively whether the assessment of subjective effects after initial use has predictive utility in the identification of individuals more likely to progress to OUD.

Chronic non-cancer pain among adults with substance use disorders: Prevalence, characteristics, and association with opioid overdose and healthcare utilization

BACKGROUND

Chronic non-cancer pain (CNCP) among patients with substance use disorder (SUD) poses a risk for worse treatment outcomes. Understanding the association of CNCP with SUD is important for informing the need and potential benefits of pain assessment/management among those with SUDs.

METHODS

We analyzed electronic health record data from 2013 to 2018 among adults aged ≥18 years (N = 951,533; mean age: 48.4 years; 57.4 % female) in a large academic healthcare system. Adjusted logistic regression models were conducted to estimate the association of CNCP conditions with opioid overdose, emergency department utilization, and inpatient hospitalization stratified by different SUD diagnoses and by gender.

RESULTS

Among the total sample, the prevalence of CNCP was 46.6 % and any SUD was 11.2 %. The majority of patients with a SUD had CNCP (opioid: 74.7 %; sedative: 72.3 %; cannabis: 64.3 %; alcohol: 58.7 %; tobacco: 59.5 %). The prevalence of CNCP was greater in females vs. males for most SUD diagnoses. The presence of CNCP was associated with more mental health disorders and chronic medical conditions among each SUD group. CNCP was associated with significantly decreased odds of overdose among those with opioid use disorder but increased odds of overdose and healthcare utilization among other SUDs. CNCP was positively associated with overdose in females, but not males, with alcohol or non-opioid drug use disorders.

CONCLUSIONS

The direction and magnitude of the association between CNCP and negative health indicators differed as a function of SUD type and gender, respectively. Greater awareness of potential unmet pain treatment need may have implications for improving SUD outcomes.

Changes in Concurrent Opioid and Benzodiazepine Use Following a Low-Touch Prescriber Fax Intervention

BACKGROUND

Concurrent use of opioids and benzodiazepines (COB) can lead to additive respiratory and central nervous system effects, putting patients at increased risk of fatal overdose. In 2016, the Centers for Disease Control and Prevention released an opioid-prescribing guideline recommending against COB, and the Pharmacy Quality Alliance (PQA) endorsed a COB measure in its core opioid set. From May 1, 2017, to December 4, 2017, a California Medicaid plan launched a COB-focused prescriber outreach intervention for members receiving recent opioid and benzodiazepine claims with the intent of decreasing concurrent use.

OBJECTIVE

To assess the effect of a prescriber fax intervention by a Medicaid plan on COB.

METHODS

Two retrospective analyses were conducted using administrative pharmacy claims data: a comparison of the PQA COB rate among selected California Medicaid plans for 2016 and 2017 and a cohort utilization analysis of members identified for the fax intervention compared with controls. Intervention and control members were matched based on 12 pre-index utilization characteristics. Outcomes assessed included proportion of members with resolution of COB in the post-index period, change in mean number of COB days before and after the index date, and proportion of members with decreased benzodiazepine daily dose after the index date. Analyses were also performed for the subgroups of members with < 30 days of COB and ≥ 30 days of COB in the pre-index period.

RESULTS

All California Medicaid plans in the study saw an improvement in the PQA COB rate between 2016 and 2017. In the utilization analysis, 4,182 intervention members were eligible according to study criteria and matched to similar control members. Many differences in medication use existed between the subgroups with < 30 days and ≥ 30 days of COB in the pre-index period, with the latter group consisting of much more chronic, complex users. The intervention cohort had a statistically significant higher proportion of members with complete resolution of COB compared with the control cohort (43.8% vs. 40.0%; P < 0.01), which was also statistically significant for the 2 subgroups. The intervention cohort had a decrease in the mean number of COB days from pre- to post-index periods, but this was only statistically significant for the subgroup with < 30 COB days (-2.5 vs. -1.5; P = 0.0217). No statistically significant differences were detected between cohorts in proportion of members with decreased benzodiazepine dose.

CONCLUSIONS

Our analyses demonstrated that this low-touch prescriber fax intervention produced statistically significant improvements in COB outcomes, despite the overall trend of declining COB among the other California Medicaid plans. Low-touch, targeted prescriber outreach can be an inexpensive yet effective tool to affect prescriber behavior, particularly before COB becomes chronic.

DISCLOSURES

No outside funding was used to support this study. The authors do not have any financial relationships or potential conflicts of interest relevant to this article to disclose. At the time of conducting this research, all authors were employees of MedImpact Healthcare Systems. The results of this study were presented at the AMCP Managed Care & Specialty Pharmacy Annual Meeting 2019; March 25-28, 2019; San Diego, CA.

Sources of Misused Prescription Opioids and Their Association with Prescription Opioid Use Disorder in the United States: Sex and Age Differences

Background: Prescription opioid (PO) misuse and prescription opioid use disorder (POUD) are a national crisis in the USA. To inform strategies for reducing the PO epidemic, research is needed on the sources of misused POs and their association with POUD. Methods: Past-year PO misusers aged ≥12 (N = 6033) from the 2015 to 2016 National Surveys on Drug Use and Health were analyzed. The most recent source of misused POs was assessed. Logistic regression analyses were used to determine the association between the sources of misused POs and past-year POUD. All analyses were stratified by age groups for each sex. Results: Overall, the most common sources of misused POs were obtaining from friends/relatives for free (40.27%) and physicians (36.59%). Males had a higher prevalence of buying POs from friends/relatives or drug dealers/strangers than females. Significant age differences also emerged. Buying POs from drug dealers/strangers (vs. obtaining POs free from friends/relatives) was strong predictor of past-year POUD in both sexes. In the sex- and age-stratified analyses, significant associations of past-year POUD with (1) buying from drug dealers/strangers emerged among males aged 18+ and females aged 26+; (2) buying from friends/relatives emerged among males aged 12+ and females aged 18-25; (3) obtaining from physicians emerged among males aged 18+ and females aged 26+. Conclusions: Our findings indicate different risk profiles for POUD across sex and age groups with different diversion sources. Prevention and treatment programs for POUD should be tailored to consider sex and developmental age differences in sources of opioids.

Examining Relationships between Gender, Opioid Dependence, and Distress Tolerance among Patients in Substance Use Disorder Treatment

Background: Opioid abuse/dependence is associated with multiple negative outcomes relative to other forms of substance abuse/dependence, including relapse. Research identifying modifiable characteristics associated with opioid dependence and associated negative outcomes may inform the development of targeted interventions for this high-risk population. One factor warranting investigation is low distress tolerance (DT). Purpose/Objectives: In a sample of patients in substance use disorder (SUD) treatment, the present study examined DT levels among patients with current opioid dependence versus no history of opioid dependence, as well as the moderating role of gender. We predicted that patients with opioid dependence would exhibit lower DT than those without a history of opioid dependence, and that women with opioid dependence would exhibit lower levels of DT than men with opioid dependence. Methods: A sample of 203 patients in residential SUD treatment were administered a series of diagnostic interviews and a behavioral measure of DT. Results: DT did not differ significantly as a function of opioid dependence. However, there was a significant opioid dependence by gender interaction, such that men with current opioid dependence exhibited significantly lower levels of DT than women with opioid dependence and men without a history of opioid dependence. Conclusions/Importance: Findings highlight a modifiable characteristic associated with opioid dependence among men that may be targeted in interventions.

Utilizing social media to explore overdose and HIV/HCV risk behaviors among current opioid misusers

INTRODUCTION

Opioid misuse has evolved into an American health crisis over the past decade, becoming a public health epidemic. Measures need to be taken to prevent overdoses by opioid misuse as well as prevent the transition into injection drug use, a high risk factor for contracting HIV/HCV. This study utilized social media to survey individuals currently misusing opioids to identify groups of individuals with different risk and use patterns.

METHODS

We recruited participants for our online survey from Reddit. Five risk behaviors were used to characterize overdose and HIV/HCV risk groups. Gender, age, and socioeconomic status were also included in the analyses, as well as items outlining social media use surrounding opioids.

RESULTS

Two groups of participants were characterized by high likelihoods of different combinations of risky behaviors: (1) Overdose Risk Group and (2) Sexual Risk Group. Those in the Overdose Risk Group were more likely to be younger in age and female, and this group was more likely to desire or be ready for treatment relative to the lowest risk group. Those in the Sexual Risk Group were more likely to be of a minority race/ethnicity, to desire or be ready for treatment, and to post more often on Reddit about opioid use.

DISCUSSION

The results of this study illustrate patterns of opioid use and risk behaviors to inform tailored outreach and treatment efforts for groups of opioid misusers and suggests the potential for utilizing social media as a tool to engage these individuals into treatment and recovery activities.

Effect of Sex on the Association Between Nonmedical Use of Opioids and Sleep Disturbance Among Chinese Adolescents: A Cross-Sectional Study

Sleep disturbance and non-medical prescription opioid use (NMPOU) are currently growing public health concerns, and sex differences may result in differential exposure to frequency of NMPOU or sleep disturbance. This study aimed to explore the association between the frequency of lifetime or past-year NMPOU and sleep disturbance and to evaluate whether there was any sex difference in this association among Chinese adolescents. A cross-sectional study was performed in seven randomly selected Chinese provinces through the 2015 School-Based Chinese Adolescents Health Survey. A total of 159,640 adolescents were invited to participate and among them, 148,687 adolescents' questionnaires were completed and qualified for this study (response rate: 93.14%). All analyses were performed for boys and girls separately. There were significant sex differences in the prevalence of lifetime or past-year opioid misuse and sleep disturbance (p < 0.05). Among girls, frequent lifetime NMPOU (adjusted odds ratio [aOR] = 2.09, 95% CI = 1.80-2.44) and past-year NMPOU (aOR = 2.16, 95% CI = 1.68-2.77) were positively associated with sleep disturbance. Among boys, these associations were also statistically significant, while the magnitudes of associations between frequent lifetime NMPOU or past-year NMPOU and sleep disturbance were greater in girls than those in boys. There is a significant sex difference in the prevalence of lifetime or past-year NMPOU and sleep disturbance. Furthermore, exposure to more frequent lifetime or past-year NMPOU is associated with a greater risk of sleep disturbance, especially among girls. Taking into account the sex difference for lifetime or past-year NMPOU may help to decrease the risk of sleep disturbance.

Evaluation of the Preliminary Validity of Misuse of Prescription Pain Medication Items from the Patient-Reported Outcomes Measurement Information System (PROMIS)®

OBJECTIVE

The National Institutes of Health's Patient-Reported Outcomes Measurement Information System (PROMIS)® includes an item bank for measuring misuse of prescription pain medication (PROMIS-Rx Misuse). The bank was developed and its validity evaluated in samples of community-dwelling adults and patients in addiction treatment programs. The goal of the current study was to investigate the validity of the item bank among patients with mixed-etiology chronic pain conditions.

METHOD

A consecutive sample of 288 patients who presented for initial medical evaluations at a tertiary pain clinic completed questionnaires using the open-source Collaborative Health Outcomes Information Registry. Participants were predominantly middle-aged (M [SD] = 51.6 [15.5] years), female (62.2%), and white/non-Hispanic (51.7%). Validity was evaluated by estimating the association between PROMIS-Rx Misuse scores and scores on other measures and testing the ability of scores to distinguish among risk factor subgroups expected to have different levels of prescription pain medicine misuse (known groups analyses).

RESULTS

Overall, score associations with other measures were as expected and scores effectively distinguished among patients with and without relevant risk factors.

CONCLUSION

The study results supported the preliminary validity of PROMIS-Rx Misuse item bank scores for the assessment of prescription opioid misuse in patients visiting an outpatient pain clinic.

Comorbidity of Adult ADHD and Its Subtypes With Substance Use Disorder in a Large Population-Based Epidemiological Study

Objective: The objective of the study is to explore the role and possible substance preference in ADHD and subtypes in substance use disorder (SUD). Method: Using self-report data on ADHD Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) symptoms and SUD (alcohol, illicit drugs, and nicotine) in 18,167 Swedish twins, aged 20 to 45 years, we obtained odds ratios (OR) from mixed effect logistic regression, controlling for age, sex, education, and nonindependence of twin data. Results: Increased ADHD symptoms were significantly associated with increased odds for all SUD. ORs ranged between 1.33 for regular nicotine (95% confidence interval [CI] = [1.12, 1.59]); 2.54 for multiple drug use (95% CI = [2.00, 3.23]), and 3.58 for alcohol dependence (95% CI = [2.86, 4.49]). Conclusion: ADHD symptoms and subtypes in the population are associated with increased risks for all SUD outcomes, with no difference between ADHD subtypes, no substance preference, and no sex differences for the comorbidity. Clinicians need to consider ADHD evaluation and treatment as part of management of SUD in adults.

A gender-based analysis of nonmedical prescription opioid use among people who use illicit drugs

BACKGROUND

Research investigating the unique impacts associated with engaging in nonmedical prescription opioid use (NMPOU) among males and females who also use illicit drugs is needed.

METHODS

Data were collected between 2013 and 2017 from two linked prospective cohort studies in Vancouver: the At-Risk Youth Study and Vancouver Injection Drug Users Study. Generalized estimating equations were used to identify factors associated with engaging in NMPOU among females and males separately.

RESULTS

Among 1459 participants, 534 were female (37%). Similar proportions of females (46%) and males (48%) engaged in NMPOU at their first visit during the study period. In multivariable analyses, factors associated with NMPOU among both males and females included heroin use, overdose, drug dealing, and difficulty accessing health and social services. Among females, those who engaged in NMPOU were more likely to report Caucasian or white ethnicity, cocaine use, crystal methamphetamine use, and sex work; among males, those who engaged in NMPOU were older, reported crack use and engaged in binge drug use (all p < 0.05).

CONCLUSION

The prevalence of NMPOU was similar among males and females who use illicit drugs in Vancouver, and NMPOU was independently associated with markers of vulnerability among both genders. Findings highlight the need for a comprehensive public health approach to address NMPOU that integrates overdose prevention and reversal services, employment opportunities, and better access to services for both women and men.

Medical record-based ascertainment of behaviors suggestive of opioid misuse, diversion, abuse, and/or addiction among individuals showing evidence of doctor/pharmacy shopping

Objectives

Doctor/pharmacy shopping, the practice of seeking prescriptions from multiple healthcare sources without their coordination, may be a measure of prescription medicine abuse. This cross-sectional study examined the relationship between a claims-based doctor/pharmacy shopping definition and medical record documented behaviors suggestive of misuse, diversion, abuse and/or addiction.

Methods

Patients with ≥2 opioid dispensings starting in 2012 in a US administrative claims database were grouped into doctor/pharmacy shopping categories by number of providers and pharmacies used over 18 months: no shopping, minimal shopping, moderate shopping and severe shopping. Medical charts of opioid prescribers were reviewed to identify behaviors suggestive of misuse, diversion, abuse and/or addiction.

Results

Among 581,940 opioid users, 78% were classified as no shopping, 11% minimal shopping, 8% moderate shopping and 3% severe shopping. Almost 40% of severe shopping patients had no medical record documented behaviors (positive predictive value: 24.3%). Compared with no shopping, the odds ratio [OR] of ≥3 behaviors was 1.70 (95% confidence interval [CI] 0.50–5.78) for minimal shopping, 1.81 (95% CI 0.54–6.03) for moderate shopping, and 8.93 (95% CI 3.12–25.54) for severe shopping.

Conclusions

Claims-identified severe doctor/pharmacy shopping was strongly associated with behaviors suggestive of misuse, diversion, abuse and/or addiction, but the proportion of medical records documenting these was low.

Compliance with Opioid Therapy: Distinguishing Clinical Characteristics and Demographics Among Patients with Cancer Pain

Background

Because an increase of patients who misuse opioids has been identified in our cancer clinical setting through urine drug testing (UDT) and the Screener and Opioid Assessment for Patient's with Pain-Short Form (SOAPP-SF), we conducted this retrospective cohort study to identify patient characteristics that are associated with UDT that indicates noncompliance.

Methods

Over a two-year period, 167 of 8,727 patients (2.4%) seen in the pain clinic and who underwent UDT were evaluated to determine compliance with prescribed opioid regimens. Descriptive clinical and demographic data were collected, and group differences based on compliance with opioid therapy were evaluated.

Results

Fifty-eight percent of the patients were noncompliant with their prescribed opioid therapy. Noncompliant patients were younger than compliant patients, with a median age of 46 vs 49 years (P = 0.0408). Noncompliant patients were more likely to have higher morphine equivalent daily doses; however, the difference was not statistically significant. Patients with a history of alcohol (ETOH) (P = 0.0332), illicit drug use (P = 0.1014), and smoking (P = 0.4184) were more likely noncompliant. Univariate regression analysis showed that a history of ETOH use (P = 0.034), a history of anxiety (P = 0.027), younger age (P = 0.07), and a SOAPP-SF score of 4 or higher (P = 0.05) were associated with an abnormal UDT.

Conclusions

History of ETOH use, anxiety, high SOAPP-SF score, and younger age were associated with UDT that indicates noncompliance. Given the very small percentage of UDT testing, it is quite likely that a significant number of patients who did not undergo UDT were also nonadherent with treatment recommendations.

Mechanisms and Clinical Features of Co-occurring Opioid and Nicotine Use

Purpose of review

To review the literature addressing shared pathophysiological and clinical features of opioid and nicotine use to inform etiology and treatment, and highlight areas for future research.

Recent findings

Opioid and nicotine use co-occur at an alarmingly high rate, and this may be driven in part by interactions between the opioid and cholinergic systems underlying drug reward and the transition to dependence. Pain, among other shared risk factors, is strongly implicated in both opioid and nicotine use and appears to play an important role in their co-occurrence. Additionally, there are important sex/gender considerations that require further study. Regarding treatment, smoking cessation can improve treatment outcomes in opioid use disorder, and pharmacological approaches that target the opioid and cholinergic systems may be effective for treating both classes of substance use disorders.

Summary

Understanding overlapping etiological and pathophysiological mechanisms of opioid and nicotine use can aid in understanding their co-occurrence and guiding their treatment.

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

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

Critical Issues in Men's Mental Health

This narrative review highlights key issues in men's mental health and identifies approaches to research, policy and practice that respond to men's styles of coping. Issues discussed are: 1) the high incidence of male suicide (80% of suicide deaths in Canada, with a peak in the mid-50 s age group) accompanied by low public awareness; 2) the perplexing nature of male depression, manifesting in forms that are poorly recognised by current diagnostic approaches and thus poorly treated; 3) the risky use of alcohol among men, again common and taking a huge toll on mental and physical health; 4) the characteristic ways in which men manage psychological suffering, the coping strengths to be recognised, and the gaps to be addressed; 5) the underutilization of mental health services by men, and the implication for clinical outcomes; and 6) male-specific approaches to service provision designed to improve men's accessing of care, with an emphasis on Canadian programs. The main conclusion is that a high proportion of men in Western society have acquired psychological coping strategies that are often dysfunctional. There is a need for men to learn more adaptive coping approaches long before they reach a crisis point. Recommendations are made to address men's mental health through: healthcare policy that facilitates access; research on tailoring interventions to men; population-level initiatives to improve the capacity of men to cope with psychological distress; and clinical practice that is sensitive to the expression of mental health problems in men and that responds in a relevant manner.

Determining the Initiation of Opiate Misuse Resulting in Opioid Use Disorder in Pregnant Women

The aim of this study was to explore the "opiate misuse footprint" made by obstetrics and gynecology physicians in prescribing opioid medications for postpartum pain control that led to opioid misuse and opioid use disorder. Data were collected using intake information and anonymous surveys administered to pregnant women at local methadone clinics in Indianapolis, Indiana, in 2016-2017. Results from this study revealed that 40% of the 33 participants stated that the first drug they became addicted to was prescription opioids; 71% stated that the first opiate they became addicted to was a prescription pain medication. Prescription opioids were mainly obtained from emergency medicine physicians and friends. Reported use of opioids within the past four months was high, with the most commonly used drugs being methadone (57.6%) and heroin (42.4%). A majority of participants also endorsed a history of sexual and physical abuse, recent incarceration, and mental health disorders. As a large number of pregnant women with opioid use disorder reported their initial drug of misuse as prescription pain medications, it is important to avoid overprescribing opioids in reproductive-age women.

Women on the Edge: Opioids, Benzodiazepines, and the Social Anxieties Surrounding Women's Reproduction in the U.S. "Opioid Epidemic"

The current "opioid epidemic" provides an opportunity to identify age-old social anxieties about drug use while opening up new lines of inquiry about how and why drug use epidemics become gendered. This paper reflects on the intertwined phenomena of opioid and benzodiazepine prescribing to U.S. women to examine how gender, race, and class inform social anxieties about reproduction and parenting. Multiple discourses abound about the relationship between women and the "opioid epidemic." Epidemiological reports attribute premature death among White women to the deadly combination of opioids and antianxiety medications. The National Institute on Drug Abuse reports that "every 25 minutes a baby is born suffering from opioid withdrawal," leading to costly hospital stays for infants and the potential for mother-child separation and other forms of family adjudication postpartum. Primary care providers are reluctant to distinguish diagnoses of chronic noncancer pain from anxiety among their female patients. Taken together, these discourses beg the question: What exactly are we worried about? I compare and contrast the narratives of two anxious women on opioids to raise larger structural questions about pregnancy, parenting, and drug use and to interrogate the public narrative that women on opioids threaten the American family and thwart the American Dream.

Serious mental illness among young adult women who use drugs in the club scene: co-occurring biopsychosocial factors

Young women who regularly attend nightclubs are at risk for numerous health and social consequences, including mental distress, sexual and physical victimization and substance dependence. This paper uses a biopsychosocial framework to examine co-occurring mental health problems, victimization, substance dependence, sexual risk and physical pain among a sample of young women who use drugs (N = 222) in Miami's club scene. The majority of women were under 24 years old, Hispanic, and identified as heterosexual. Almost all the women reported past 90-day use of alcohol, ecstasy/MDMA, marijuana, cocaine and prescription opioids and benzodiazepines; 32% of women reported being in a monogamous relationship while 41.9% reported having three or more sexual partners in the past 90 days; 65.3% met DSM-IV criteria for substance dependence; 60.4% met DSM-IV criteria for serious mental illness (SMI) and 59.9% were victimized as minors. Women who had SMI had higher odds of substance dependence, concurrent physical pain, three or more sexual partners in the past 90 days, childhood victimization and severe abuse-related trauma. The high levels of interconnected mental health, victimization, trauma, physical pain, substance dependence and sexual risk factors observed are underreported in the literature, as young women club scene participants appear to be more similar to other marginalized drug-involved populations than previously considered. While further research is needed, it appears these young women are in great need of outreach for primary health, mental health, HIV prevention, increased social support and substance abuse treatment services.

Pain behavior mediates the relationship between perceived injustice and opioid prescription for chronic pain: a Collaborative Health Outcomes Information Registry study

Background and purpose

Perceived injustice has been defined as an appraisal regarding the severity and irreparability of loss associated with pain, blame and a sense of unfairness. Recent findings have identified perceived injustice as an important risk factor for pain-related outcomes. Studies suggest that perceived injustice is associated with opioid prescription in patients with pain conditions. However, the mechanisms by which perceived injustice is linked to opioid prescription are not well understood. The primary objective of this study was to examine the potential mediating roles of pain intensity, depressive symptoms and pain behavior in the association between perceived injustice and opioid prescription among patients with chronic pain.

Methods

This cross-sectional study used a sample of 344 patients with chronic pain being treated at a tertiary pain treatment center. Participants completed measures of perceived injustice, pain intensity, depressive symptoms, pain behavior and opioid prescription. Bootstrapped multiple mediation analyses were used to examine the mediating role of patients’ pain intensity, depressive symptoms and pain behavior in the association between perceived injustice and opioid prescription.

Results

Consistent with previous research, we found a significant association between perceived injustice and opioid prescription. Interestingly, results revealed that pain behavior was the only variable that mediated the association between perceived injustice and opioid prescription.

Conclusion

This study was the first to examine the mechanisms by which perceived injustice is associated with opioid prescription in patients with chronic pain. We found that pain behavior, rather than pain intensity and depressive symptoms, mediated the association between perceived injustice and opioid prescription. Future research in this area should employ a longitudinal research design in order to arrive at clearer causal conclusions about the relationships between pain behavior, perceived injustice and opioid prescription.