Reasons for Benzodiazepine Use Among Persons Seeking Opioid Detoxification

Factors associated with the use of benzodiazepine and opioid prescription drug in the student population: a cross-sectional study

The misuse of benzodiazepines and opioid medications is frequent in students. To improve our understanding of this behavior, we aimed to identify factors associated with separate and concomitant use of these substances. Anonymous self-reported questionnaires were e-mailed to students enrolled at a French university between March and July 2021, covering: sociodemographic characteristics, academics, psychoactive substance use, ADHD symptomatology (adulthood and childhood), and psychiatric/psychological or addiction follow-up. Factors associated with the use of benzodiazepines and opioid medications included female sex (OR = 1.41 [1.08; 1.86]) and OR = 1.38 [1.06; 1.79], respectively), older age (OR = 1.65 [1.04; 2.6] and OR = 2.17 [1.4; 3.36], respectively), current psychiatric/psychological follow-up (OR = 6.53 [5.18; 8.24] and OR= 1.5 [1.12; 2.0], respectively), ADHD symptomatology (OR= 2.33 [1.71;3.16] and OR= 1.61 [1.15; 2.24], respectively), polyconsumption (tobacco use for benzodiazepine users, OR = 1.38 [1.04; 1.82]; alcohol use OR = 1.67 [1.17; 2.39] and tobacco use OR = 1.62 [1.23; 2.14] for opioid users). These factors were even more strongly associated with the concomitant use of benzodiazepines and opioid medications: older age (OR = 3.64 [2.22; 5.99]), female sex (OR = 1.54 [1.1; 2.14]), grade repetition (OR = 1.7 [1.14; 2.54]), psychiatric/psychological follow-up (OR = 4.51 [3.35;6.06]), ADHD symptomatology (OR = 5.3 [3.69; 7.63]), polyconsumption (tobacco use OR = 2.05 [1.39; 3] and cannabis use, OR = 2.07 [1.97; 4.16]. The factors associated with the use of benzodiazepines and prescription opioids identified in this study could lead to the development of targeted prevention methods.

Initial validation of the expectancies for Benzodiazepine Analgesia Scale

Chronic pain populations exhibit greater prevalence of benzodiazepine (BZD) prescription (vs. the general population) and greater likelihood of BZD use not as prescribed and dependence symptoms. Individuals report taking BZDs for pain relief, potentially contributing to maintenance/escalation of BZD use and hazardous couse with prescription opioids. Identifying cognitive factors underlying pain-BZD use relations represents a critical step toward understanding the role of pain in BZD use trajectories. Outcome expectancies for substance-related analgesia have been implicated in pain-substance use comorbidity (e.g., alcohol), and there is reason to believe these processes may extend to BZD use. The present study aimed to examine psychometric properties of a newly adapted Expectancies for Benzodiazepine Analgesia (EBA) scale and probe associations between EBA scores and prescription opioid use behaviors. Participants were 306 adults (38.9% females) endorsing chronic pain and current BZD prescription who completed an online survey. Results provided initial support for psychometric validity of the EBA: evidence of single-factor structure with good model fit (Bollen-Stine bootstrap p = .101), excellent internal consistency (α = .93), and evidence of concurrent validity via correlations with pain variables, likelihood of BZD use not as prescribed, BZD dependence symptoms, and self-reported BZD use for pain relief. Exploratory findings among participants prescribed opioids indicated positive covariation between EBA scores and behaviors associated with higher risk opioid use. This is, to our knowledge, the first study to assess analgesia expectancies for BZD use. BZD analgesic expectancies warrant further study as a treatment target in comorbid pain and BZD use. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Revisiting benzodiazepines (GABA Enhancers):A transdiagnostic and precision medicine approach

Since the mid 1980's, there has been an increased focus on the side effects of benzodiazepines (GABA enhancers), and as a result there has been a decrease in their use. We have systematically reviewed recent studies of GABA enhancers in psychiatry, and highlight evidence of their utility which may impact their negative conceptualization in clinical practice. We propose a new perspective on the appropriate use of these medications and describeclinical reasoning underpinning the use of benzodiazepine (GABA enhancers) based on their effect on specific receptors. A translational approach, involving a more comprehensive characterization of GABA receptors and their neuroscience-based mechanisms allows for a more precise use of this medication class. By adopting a precision person-centered approach, instead of a categorical approach, supports the prescribing of GABA enhancers when a cross-cutting transdiagnostic assessment shows anxiety symptoms associated with clinical impairment.

Alprazolam misuse: Analysis of French Addictovigilance Network data from 2011 to 2020

OBJECTIVES

Alprazolam, a high-potency and short-acting anxiolytic benzodiazepine, is one of the most misused benzodiazepines in France. In the context of various reports on alprazolam misuse during the COVID-19 pandemic, the objective of this study was to assess alprazolam abuse potential by analyzing French addictovigilance and international data.

METHODS

Data collected from 2011 to 2020 using the following epidemiological tools of the French Addictovigilance Network were analyzed: spontaneous reports (SRs), OPPIDUM (addiction care center data), OSIAP (falsified prescriptions), DRAMES (substance-related deaths), and chemical submission surveys. Moreover, the VigiBase™ database was analyzed to evaluate alprazolam abuse liability worldwide.

RESULTS

During the study period, 675 SRs concerning alprazolam misuse were recorded (sex ratio: ̴1; median age: 39 years). The desired effects were intensification of the therapeutic anxiolytic effect, euphoric effect, and management of substance withdrawal. Alprazolam was the third and first benzodiazepine listed in OPPIDUM and OSIAP surveys. Analysis of the SR and OPPIDUM data showed a recent increase in the alprazolam-opioid combination. In DRAMES data, alprazolam was directly linked to 11 deaths (associated with opioids in 10/11). VigiBase™ data analysis highlighted that France was the third country with the most cases of alprazolam misuse. The disproportionality analysis showed that in France, alprazolam was associated with higher risk of misuse and dependence compared with other benzodiazepines: reporting odds ratio=1.43, (95% CI: 1.04-1.95) and=1.97 (95% CI:1.50-2.59), respectively.

CONCLUSIONS

This study highlighted an increase in various signals of alprazolam abuse in France, and an increased use of the alprazolam-opioid combination that was also linked to most of the recorded alprazolam-linked deaths. These signals have been reported also in the international literature, and should be thoroughly investigated.

Benzodiazepine use, quality of life and psychiatric symptom burden in oral and injectable opioid agonist treatment: a cross-sectional study

BACKGROUND

Use of benzodiazepines (BZD) in patients receiving opioid agonist treatment (OAT) is common and associated with a variety of negative health and social outcomes. This cross-sectional study investigates the impact of BZD use in OAT patients on their quality of life (QoL).

METHODS

A convenience sample of patients receiving oral OAT or heroin-assisted treatment in two outpatient centres in Basel, Switzerland was investigated. Participants (n = 141) completed self-report questionnaires on psychiatric symptoms and psychological distress (The Symptom Checklist 27, SCL-27), depressive state (German version of the Center for Epidemiological Studies Depression Scale), quality of life (Lancashire Quality of Life Profile, LQOLP) and use of BZD and other drugs (self-report questionnaire). Substance use was assessed by urine toxicology testing.

RESULTS

In bivariate analysis, total QoL scores were significantly lower for lifetime, current, and prolonged BZD users compared to participants without the respective use patterns. There was no significant relationship between BZD dose and QoL. In multivariable linear regression models controlling for psychiatric symptom load and depressive state, only lifetime use predicted lower QoL, whereas other BZD use patterns were not significantly associated.

CONCLUSIONS

The association of lower QoL and BZD use in OAT patients is strongly confounded by co-occurring depressive state and psychiatric symptoms. Careful diagnosis and treatment of co-occurring mental disorders in OAT is paramount to improve QoL in this patient population and may also help reduce BZD use.

Associations of adolescent psychosocial factors to later benzodiazepine use: a population-based follow-up study of adolescent psychiatric inpatients in Northern Finland

We investigated factors associated with benzodiazepine (BZD) use during late adolescence and early adulthood. The study population consisted of 508 adolescents admitted to psychiatric inpatient care between April 2001 and March 2006. Information on adolescents' family- and school-related factors, suicidality and psychiatric disorders were obtained by semistructured interviews. Data on BZD prescriptions from 1999 to 2012 were collected from the Social Insurance Institution of Finland. In males heavy BZD use associated with adolescent substance-use disorder (OR, 3.5; P  < 0.004) and parents' psychiatric problems (OR, 3.5; P  = 0.029). Among females, conduct disorder (OR, 3.3; P  = 0.016), being a bully/bully-victim (OR, 3.3; P  = 0.019) and parental substance-use problems (OR, 2.6; P  = 0.024) were related to heavy BZD use. The mean (±SD) age of first BZD prescription was significantly lower in heavy, compared with mild users (men: 19.3 ± 2.5 vs. 21.0 ± 2.5 years, P  = 0.027; women: 19.7 ± 2.6 vs. 21.5 ± 3.4 years, P  = 0.027). Heavy, compared with mild, BZD use is associated with female suicide attempts (OR, 5.0; P  = 0.049). Physicians should be cautious when prescribing BZDs to young adults and must allocate treatment to those with carefully evaluated clinical indications.

A double-blind, randomized, placebo-controlled, pilot clinical trial examining buspirone as an adjunctive medication during buprenorphine-assisted supervised opioid withdrawal

Successful management of opioid withdrawal improves long-term treatment outcomes and reduces opioid use-related morbidity and mortality. Mechanistically supported pharmacotherapeutic approaches are needed to effectively manage acute and protracted opioid withdrawal. Buspirone is a D2 antagonist and 5-HT1a agonist that may decrease opioid withdrawal. Individuals (n = 15) admitted to a residential treatment center for opioid use disorder (OUD) were enrolled into a double-blind randomized clinical trial to assess the efficacy and acceptability of buspirone (45 mg/day) as an adjunctive medication to buprenorphine-assisted, supervised opioid withdrawal. Participants completed daily questionnaires which consisted of the Subjective Opiate Withdrawal Scale (SOWS) and a consensus sleep diary, which assessed total sleep time, time to sleep onset, and sleep quality. Total SOWS scores, individual opioid withdrawal symptoms and sleep outcomes were assessed between treatment groups (Placebo and Buspirone) and over time in a repeated measures linear mixed model. Total SOWS scores significantly decreased across study phases for both groups but decreased to a greater extent among individuals assigned to buspirone during both the first and second week of stable buspirone. Greater decreases in withdrawal were observed during Week 2 of stable buspirone relative to Week 1 of stable buspirone. Participants also reported significant increases in sleep duration and significant decreases in latency to sleep onset. This study provides further support that buspirone can help mitigate opioid withdrawal during a supervised opioid taper. Buspirone may confer unique benefits during protracted withdrawal periods. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Benzodiazepine Use and Dependence in Relation to Chronic Pain Intensity and Pain Catastrophizing

Benzodiazepines (BZDs), a class of sedative-hypnotic medications, generated concern as their popularity grew, with particular alarm regarding elevated rates of BZD use among chronic pain populations. Consistent with negative reinforcement/motivational models of substance use, desire for pain alleviation may motivate BZD use. Yet, little is known about relations between pain and addiction-relevant BZD use processes. This cross-sectional survey study aimed to: a) test associations between pain intensity and clinically relevant BZD use patterns, and b) examine the role of pain catastrophizing in hypothesized pain-BZD relations. Participants included 306 adults with chronic musculoskeletal pain and a current BZD prescription who completed an online survey study (Mage = 38.7, 38.9% female). Results indicated that pain intensity was positively associated with past-month BZD use frequency, BZD dependence severity, and likelihood of endorsing BZD misuse behaviors (ps < .05). Pain catastrophizing was positively associated with BZD dependence/likelihood of BZD misuse, covarying for pain intensity (P < .05). These findings build upon an emerging literature by highlighting positive covariation of pain intensity and pain catastrophizing with addiction-relevant BZD use behaviors. Results underscore the need to further investigate high-risk BZD use among individuals with chronic pain, with and without concurrent opioid use, to inform prevention/intervention efforts. PERSPECTIVE: This article presents findings on cross-sectional associations of pain intensity and pain catastrophizing with clinically relevant benzodiazepine (BZD) use outcomes, including dependence and misuse, among individuals with chronic pain. Findings help elucidate the higher burden of BZD misuse/dependence in chronic pain populations and suggest that pain relief may be a common, yet under recognized, self-reported motivation for taking BZDs.

Anhedonia modulates benzodiazepine and opioid demand among persons in treatment for opioid use disorder

Background

Benzodiazepine (BZD) misuse is a significant public health problem, particularly in conjunction with opioid use, due to increased risks of overdose and death. One putative mechanism underlying BZD misuse is affective dysregulation, via exaggerated negative affect (e.g., anxiety, depression, stress-reactivity) and/or impaired positive affect (anhedonia). Similar to other misused substances, BZD consumption is sensitive to price and individual differences. Although purchase tasks and demand curve analysis can shed light on determinants of substance use, few studies have examined BZD demand, nor factors related to demand.

Methods

This ongoing study is examining simulated economic demand for alprazolam (among BZD lifetime misusers based on self-report and DSM-5 diagnosis; n = 23 total; 14 male, 9 female) and each participant's preferred-opioid/route using hypothetical purchase tasks among patients with opioid use disorder (n = 59 total; 38 male, 21 female) who are not clinically stable, i.e., defined as being early in treatment or in treatment longer but with recent substance use. Aims are to determine whether: (1) BZD misusers differ from never-misusers on preferred-opioid economic demand, affective dysregulation (using questionnaire and performance measures), insomnia/behavioral alertness, psychiatric diagnoses or medications, or urinalysis results; and (2) alprazolam demand among BZD misusers is related to affective dysregulation or other measures.

Results

Lifetime BZD misuse is significantly (p < 0.05) related to current major depressive disorder diagnosis, opioid-negative and methadone-negative urinalysis, higher trait anxiety, greater self-reported affective dysregulation, and younger age, but not preferred-opioid demand or insomnia/behavioral alertness. Alprazolam and opioid demand are each significantly positively related to higher anhedonia and, to a lesser extent, depression symptoms but no other measures of negative-affective dysregulation, psychiatric conditions or medications (including opioid agonist therapy or inpatient/outpatient treatment modality), or sleep-related problems.

Conclusion

Anhedonia (positive-affective deficit) robustly predicted increased BZD and opioid demand; these factors could modulate treatment response. Routine assessment and effective treatment of anhedonia in populations with concurrent opioid and sedative use disorder may improve treatment outcomes.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT03696017, identifier NCT03696017.

Self-Administration of Fentanyl-Alprazolam Combinations by Rhesus Monkeys Responding under a Progressive-Ratio Schedule

This study evaluated the reinforcing effects of fentanyl, alone or in combination with the benzodiazepine alprazolam, in rhesus monkeys (3 females, 3 males). Subjects were trained to self-administer the opioid remifentanil (0.3 µg/kg/injection) under a progressive-ratio schedule of reinforcement. The reinforcing effects of fentanyl (0.1-10 µg/kg/injection) or alprazolam (1.0-100 µg/kg/injection) alone, or in combinations of fixed proportions (1:1, 1:3, and 3:1 fentanyl:alprazolam, with 1:1 based on the potencies of drugs alone) were evaluated in single-day test sessions (with double determinations). Dose-equivalence analysis was used to determine the extent to which fentanyl and alprazolam combinations differed from additivity. Fentanyl functioned as a positive reinforcer in all monkeys, while alprazolam was a reinforcer in 3 of 6 monkeys only. Therefore, drug combination data were grouped as "alprazolam-taking" and "non-alprazolam-taking" monkeys. For alprazolam-taking monkeys, we observed additive effects for the 3:1 and 1:3 combinations, and a significant supra-additive interaction for the 1:1 combination of fentanyl and alprazolam. For 2 of the 3 non-alprazolam-taking monkeys, the combination of fentanyl and alprazolam resulted in enhanced reinforcing effects relative to either drug alone. However, the one monkey showed primarily inhibitory, or suppressive effects, with the 3:1 dose combination resulting in a relatively modest rightward shift in the fentanyl dose-response function. In summary, our findings show that combining fentanyl and alprazolam generally result in proportion-dependent additive or supra-additive enhancements. These data raise the possibility that the prevalence of opioid-benzodiazepine polydrug abuse may reflect a unique enhancement of these drugs' reinforcing effects, although individual differences may exist. SIGNIFICANCE STATEMENT: Addressing the critical question of the degree to which benzodiazepines can modulate the abuse-related effects of opioids may provide improved pathways to treatment of this common form of polydrug addiction. In the present study, we show that combinations of the opioid fentanyl and the benzodiazepine alprazolam can be more reinforcing than either drug alone in a rhesus monkey model, suggesting that enhancement of reinforcement processes may underlie this prevalent form of polydrug use disorder.

Validation of the Motivational Inventory Underlying Substance Use Engagement (MI-USE)

Given the growing number of fatalities associated with the use of multiple types of drugs, there is an urgent need for a tool that allows clinicians and researchers to quickly assess diverse reasons for substance use. Here, we sought to validate the Motivational Inventory Underlying Substance Engagement (MI-USE), a new measure that assesses motivations for use across different types of substances. Participants were 538 adults ages 18-60 (48% women) who reported substance use problems and past-year drug or alcohol use. Analyses were conducted to discover and validate the factor structure of the MI-USE and evaluate its construct validity. A 30-item model best fit the MI-USE, with one General Factor capturing overall motivation to engage in substance use and eight motive-specific factors that indexed unique motivations for substance use: Emotional Coping (relief from unpleasant emotions), Pleasure-Seeking (feel pleasurable or exciting emotions and sensations), Dependence Severity (avoid withdrawal and cravings), Expansion (enhance self-insight and spirituality), Social Coping (increase confidence and attractiveness), Advantage (gain a physical or mental advantage), Physical Coping (relief from unpleasant bodily sensations), and Sleep (mitigate sleep problems). Evaluation of the measure's construct validity and internal consistency support the chosen model and interpretation of the motive-specific factors. Results provide initial validation of the MI-USE as a reliable and valid tool for assessing diverse substance use motivations. It improves upon existing measures by allowing clinicians and researchers to simultaneously evaluate motivations for multiple forms of substance use, which facilitates personalized treatment planning and research on polysubstance use.

Differential Experience of Interdose Withdrawal During Long-Term Opioid Therapy and its Association With Patient and Treatment Characteristics: A Latent Class Analysis in Chronic Pain Population

Opioid withdrawal is characterized by a set of physical and psychological symptoms that depend on both opioid and patient specific characteristics. The present study aims to identify different latent classes of chronic pain patients according to the type of opioid withdrawal symptoms experienced, and to analyze the relationships between the classes and demographic, opioid therapy, psychological and substance use variables. This cross-sectional descriptive study included 391 chronic pain patients on long-term opioid therapy. A Latent Class Analysis (LCA) identified 3 classes (BIC = 7051.89, entropy = .87, LRTs P < .01). The mild withdrawal class showed low probabilities of presenting physical and psychological symptoms, the moderate withdrawal class was characterized by experiencing psychological symptoms, and the severe withdrawal class stood out for high probabilities of presenting both types of symptoms. The classes differed from each other, with higher rates of moderate-severe POUD, opioid misuse, anxiety, depression, and greater pain intensity and interference in more severe withdrawal classes (P < .05). The multinomial logistic regression showed that moderate-severe POUD and anxiety were the strongest variables related to moderate (OR_POUD = 3.34, OR_Anxiety = 2.58) and severe withdrawal classes (OR_POUD = 4.26, OR_Anxiety = 5.15). Considering that POUD and anxiety were strongly related to a more severe withdrawal syndrome, the inclusion of psychological interventions in pain management seems critical in this population. PERSPECTIVE: Although interdose opioid withdrawal is common in chronic pain patients, this study shows 3 different patterns in its experience (mild, moderate, and severe withdrawal). A more severe withdrawal may result in reduced effectiveness of opioids in relieving pain and increased negative consequences, such as higher risk of POUD. Findings that could help improve chronic pain management.

Characterizing the Experience of Tapentadol Nonmedical Use: Mixed Methods Study

Background

The prevalence of abuse, diversion, and web-based endorsement of tapentadol (extended-release [ER], immediate-release [IR]) has been characterized as low compared with other prescription opioids. Little is known about individual experience with tapentadol nonmedical use (NMU).

Objective

This study aims to pilot web-based survey technologies to investigate the motivation for tapentadol NMU, sources of procurement, routes of administration, tampering methods, doses used, and impressions of tapentadol products (Nucynta and Nucynta ER).

Methods

Recruitment flyers and banner advertisements were placed on the Bluelight website [DragonByte Technologies Ltd] with a link to a web-based survey (Qualtrics) designed to query about individuals’ lifetime tapentadol NMU. This web-based survey was followed by an interactive web-based chat (Cryptocat) with respondents who were willing to be contacted. Respondents were queried about sources for obtaining tapentadol, motives for use, routes of administration, tampering methods, drugs used in combination, tablet strengths and dosages, and reasons for continued or discontinued use. Desirability and attractiveness for NMU was rated.

Results

Web-based recruitment successfully attracted difficult-to-find study participants. A total of 78 participants reported that tapentadol was obtained from friends and family (ER 11/30, 37%; IR 18/67, 27%), the internet (ER 11/30, 37%; IR 12/67, 18%) or participants’ own prescriptions from a doctor (ER 9/30, 30%; IR 17/67, 25%). It was used nonmedically for pain relief (ER 18/30, 60%; IR 33/67, 49%) and multiple psychotropic effects, including relaxation (ER 13/30, 43%; IR 29/67, 43%), reduction in depression or anxiety (ER 7/30, 23%; IR 30/67, 45%), or getting high (ER 12/30, 40%; IR 33/67, 49%). Tapentadol was primarily swallowed (ER 22/30, 73%; IR 55/67, 82%), although snorting (ER 2/30, 7%; IR 8/67, 12%) and injection (ER 2/30, 7%; IR 5/67, 8%) were also reported. The preferred dose for NMU was 100 mg (both ER and IR). The participants reported tapentadol use with benzodiazepines (ER 12/21, 57%; IR 28/47, 60%). Most participants had discontinued tapentadol NMU at the time of survey completion (ER 22/30, 73%; IR 55/67, 82%). Reasons for discontinued ER NMU included side effects (10/22, 46%) and lack of effective treatment (10/22, 46%). Reasons for discontinued IR NMU included lack of access (26/55, 47%) and better NMU options (IR 21/55, 38%). Few individuals were willing to divulge identifying information about themselves for the interactive chat (8/78, 10%), demonstrating the strength of anonymous, web-based surveys. Interactive chat supported the survey findings. A subgroup of participants (4/78, 5%) reported hallucinogenic side effects with high doses.

Conclusions

Web-based surveys can successfully recruit individuals who report drug NMU and those who are difficult to find. Tapentadol NMU appears to occur primarily for pain relief and for its psychotropic effects. Although it was liked by some, tapentadol did not receive a robust pattern of endorsement for NMU.

Benzodiazepines and Related Sedatives

Benzodiazepine and related sedative use has been increasing. There has been a growing number of unregulated novel psychoactive substances, including designer benzodiazepines. Benzodiazepines have neurobiological and pharmacologic properties that result in a high potential for misuse and physical dependence. Options for discontinuing long-term benzodiazepine use include an outpatient benzodiazepine taper or inpatient withdrawal management at a hospital or detoxification facility. The quality of evidence on medications for benzodiazepine discontinuation is overall low, whereas cognitive behavioral therapy has shown the most benefit in terms of behavioral treatments. Benzodiazepines may also have significant adverse effects, increasing the risk of overdose and death.

Different drugs come with different motives: Examining motives for substance use among people who engage in polysubstance use undergoing methadone maintenance therapy (MMT)

BACKGROUND

Substance use motives (i.e., reasons for using a substance) are thought to be the most proximal variable leading to substance use. These motives have been described by various typologies, the most well known being the four-factor drinking motives model which separates motives into enhancement, social, coping, and conformity (Cooper, 1994). Although extensively studied in adult community samples, motives for use have less commonly been investigated among populations at a later stage of addiction, where polysubstance use is more common. Moreover, because the motives literature has largely focused on drinking motives, it is not clear whether existing findings can also be applied to other substances (Cooper et al., 2016).

METHODS

Using Zero-inflated beta Bayesian linear mixed modeling, we investigated the stability of seven distinct substance use motives (enhancement, social, expansion, coping with anxiety, coping with depression, coping with withdrawal, and conformity) across six different drug categories (tobacco, alcohol, cannabis, opioids, stimulants, and tranquilisers) to determine the extent to which drug class can influence motive endorsement. One-hundred-and-thirty-eight methadone maintenance therapy (MMT) clients (F = 34.1%; M = 65.9%; age = 40.18 years) completed a novel short-form polysubstance motives questionnaire.

RESULTS

External motives (i.e., conformity and social motives) were the most stable across drug categories, while all internal motives (i.e., enhancement, expansion, and all three coping motives) demonstrated varying levels of inter-drug variability.

CONCLUSIONS

These findings have important implications for prevention and intervention strategies among people who engage in polysubstance use, highlighting the importance of both universal and substance-specific programming.

At the intersection of sleep deficiency and opioid use: mechanisms and therapeutic opportunities

Due to the ongoing opioid epidemic, innovative scientific perspectives and approaches are urgently needed to reduce the unprecedented personal and societal burdens of nonmedical and recreational opioid use. One promising opportunity is to focus on the relationship between sleep deficiency and opioid use. In this review, we examine empirical evidence: (1) at the interface of sleep deficiency and opioid use, including hypothesized bidirectional associations between sleep efficiency and opioid abstinence; (2) as to whether normalization of sleep deficiency might directly or indirectly improve opioid abstinence (and vice versa); and (3) regarding mechanisms that could link improvements in sleep to opioid abstinence. Based on available data, we identify candidate sleep-restorative therapeutic approaches that should be examined in rigorous clinical trials.

A Novel Maintenance Therapeutic for Opioid Use Disorder

Opioid use disorder (OUD) is a major socioeconomic burden. An ideal OUD pharmacotherapy will mitigate the suffering associated with opioid-withdrawal, inhibit the effects of high efficacy opioids, and minimize opioid-cravings while being safe and accessible to a diverse patient population. Although current OUD pharmacotherapies inhibit the euphoric effects of opioids of abuse, the extent to which they safely alleviate withdrawal and opioid-cravings corresponds with their intrinsic µ opioid receptor (MOR) efficacy. In addition to inhibiting the euphoric effects of opioids of abuse, the medium efficacy MOR agonist buprenorphine alleviates withdrawal and opioid-cravings, but its intrinsic MOR efficacy is sufficient such that its utility is limited by abuse and safety liabilities. Although the MOR antagonist naltrexone minimizes euphoria and has no abuse liability, it exacerbates suffering associated with withdrawal and opioid cravings. Therefore, a therapeutic with intrinsic MOR activity between the partial agonist (buprenorphine) and the antagonist (naltrexone) would strike a balance between the benefits and liabilities of these two therapeutics. To address this need, we derived RM1490, an MOR agonist based on a nonmorphinan scaffold that exhibits approximately half the intrinsic MOR efficacy of buprenorphine. In a series of preclinical assays, we compared RM1490 with buprenorphine and naltrexone at doses that achieve therapeutic levels of central nervous system MOR occupancy. RM1490 exhibited a behavioral profile consistent with reduced reward, dependence, and precipitated withdrawal liabilities. RM1490 was also more effective than buprenorphine at reversing the respiratory depressant effects of fentanyl and did not suppress respiration when combined with diazepam. SIGNIFICANCE STATEMENT: In preclinical studies, RM1490 has a physiological and behavioral profile suitable for opioid use disorder maintenance therapy.

Prescription Tranquilizer/Sedative Misuse Motives Across the US Population

OBJECTIVES

Roughly 6.5 million US residents engaged in prescription tranquilizer/sedative (eg, benzodiazepines, Z-drugs) misuse in 2018, but tranquilizer/sedative misuse motives are understudied, with a need for nationally representative data and examinations of motives by age group. Our aims were to establish tranquilizer/sedative misuse motives and correlates of motives by age cohort, and whether motive-age cohort interactions existed by correlate.

METHODS

Data were from the 2015 to 2018 US National Survey on Drug Use and Health, with 223,520 total respondents (51.5% female); 6580 noted past-year prescription tranquilizer/sedative misuse motives (2.4% overall, 50.3% female). Correlates included substance use (eg, opioid misuse), mental (eg, suicidal ideation) and physical health variables (e.g., inpatient hospitalization). Design-based, weighted cross-tabulations and logistic regression analyses were used, including analyses of age cohort-motive interactions for each correlate.

RESULTS

Prescription tranquilizer/sedative misuse motives varied by age group, with the highest rates of self-treatment only motives (ie, sleep and/or relax) in those 65 and older (82.7%), and the highest rates of any recreational motives in adolescents (12-17 years; 67.5%). Any tranquilizer/sedative misuse was associated with elevated odds of substance use, mental health, and physical health correlates, but recreational misuse was associated with the highest odds. Age-based interactions suggested stronger relationships between tranquilizer/sedative misuse and mental health in adults 50 and older.

CONCLUSIONS

Any tranquilizer/sedative misuse signals a need for substance use and mental health screening, with intervention needs most acute in those with any recreational motives. Older adult tranquilizer/sedative misuse may be more driven by undertreated insomnia and anxiety/psychopathology than in younger groups.

Nonmedical Prescription Opioid Use among a Sample of College Students: Prevalence and Predictors

Nonmedical use of prescription opioid medication (NMPO) in the United States is a public health crisis, resulting in high rates of emergency room visits, morbidity, and mortality. The purpose of this study was to explore prevalence estimates and correlates of NMPO among a convenience sample of college students in the northeast and southeast regions of the US to help generate directions for future research. Motivations for misuse, age of onset, access, concomitant substance use, and individual factors were investigated among a sample of undergraduate students from two universities. Participants (N = 847) completed a battery of various self-report measures. Findings revealed that 7.7% (Southeastern University) and 12.8% of students (Northeastern University) reported lifetime NMPO, whereas past-month NMPO was reported by 0.8% and 0.9% of participants, respectively. Lifetime history of regularly using alcohol, nonmedical use of benzodiazepine medication, nonmedical use of prescription stimulants, symptoms of depression and anxiety, and executive functioning (i.e., metacognition and behavioral regulation) were significantly related to lifetime history of NMPO in this college sample. These findings offer several potential subsequent lines of investigation regarding the associations between various demographic and psychological factors and NMPO. Future research is needed to help identify college students who are at risk of NMPO.

"It could potentially be dangerous... but nothing else has seemed to help me.": Patient and clinician perspectives on benzodiazepine use in opioid agonist treatment

BACKGROUND

Benzodiazepine use among patients receiving opioid agonist treatment (OAT) presents a conundrum: benzodiazepines increase overdose risk, yet can treat anxiety and insomnia. How best to balance the risks and benefits of benzodiazepines among OAT patients is unclear. Using qualitative methods, we examined patient motivations for benzodiazepine use and understanding of risks, and the context in which benzodiazepine use and prescribing occurs.

METHODS

We conducted semi-structured interviews with 26 OAT patients using benzodiazepines and 10 OAT clinicians. Participants were recruited from an office-based buprenorphine clinic at an academic medical center and a methadone opioid treatment program using purposive sampling. The study team reviewed transcripts and double-coded 100% of interviews. Data analysis combined both deductive and inductive methods.

RESULTS

Major emergent themes were: 1) patients focus on benefits over risks of benzodiazepines, 2) patients can learn to use benzodiazepines safely, 3) patients want to use benzodiazepines now but discontinue in the future, 4) clinicians and patients weigh the risks and benefits of benzodiazepine use differently, 5) clinicians and patient have differences in treatment goals, and 6) clinicians struggle with benzodiazepine discontinuation.

CONCLUSIONS

OAT patients and clinicians can weigh the risks and benefits of benzodiazepines differently leading to a difference in treatment goals. The risk-benefit analysis of benzodiazepine prescribing may depend on whether the patient is engaged in opioid treatment. Future work among patients and clinicians is warranted to determine how to better balance patient and clinician priorities in order to deliver safer prescribing practices and maintain patient engagement in care.

Concomitant drugs with buprenorphine user deaths

BACKGROUND

Buprenorphine is abused in several countries notwithstanding its benefits as an analgesic and as an opioid agonist treatment medication. Benzodiazepines and alcohol have previously been associated with buprenorphine toxicity. This study elucidates the role of emerging concomitant drugs in different groups of buprenorphine user deaths.

METHODS

All cases in the Finnish national post-mortem toxicology database from 2016-2019 in which buprenorphine or norbuprenorphine was a laboratory finding in any post-mortem specimen and age at death of 15-64 years were investigated for cause and manner of death, concurrent drug and alcohol findings, age, and gender.

RESULTS

There were 792 deaths with a buprenorphine finding, of which buprenorphine was implicated in poisoning without other opioids in 271 cases (34 %). In this group of buprenorphine poisoning deaths, concomitant benzodiazepines were found in 94 % (clonazepam 53 %), illicit drugs in 63 %, gabapentinoids in 50 % (pregabalin 41 %), alcohol in 41 %, antidepressants in 32 %, and antipsychotics in 28 % of cases; only three deaths showed no benzodiazepines, alcohol, or gabapentinoids. Polydrug use was common regardless of the cause of death. In the age group 15 to 24 years, concomitant use of benzodiazepines and illicit drugs, and buprenorphine poisoning were more prevalent than in the age group 25-64 years.

CONCLUSIONS

The unprecedentedly high concomitant use of benzodiazepines in buprenorphine user deaths obscures other possible pharmacological risk factors for buprenorphine poisoning that could be relevant for prevention. Higher mortality in the younger age group suggests particularly unsafe drug use patterns that should be addressed.

Concurrent Opioid and Benzodiazepine Utilization Patterns and Predictors Among Community-Dwelling Adults in the United States

OBJECTIVE

Using benzodiazepines and opioids together substantially increases the risk of fatal overdose. Yet, concurrent benzodiazepine and opioid prescribing rates continue to increase amid the opioid overdose epidemic. Therefore, this study sought to identify patterns and predictors associated with self-reported concurrent benzodiazepine and opioid use among community-dwelling adults.

METHODS

This retrospective, cross-sectional study used Medical Expenditure Panel Survey data from 2011, 2013, and 2015. The study population included adults (age ≥18) who did not die during the calendar year. The dependent variable was concurrent benzodiazepine and opioid use, which was identified with Multum Lexicon therapeutic class codes. Multivariable logistic regression analysis was conducted to examine the association of various individual-level factors with concurrent benzodiazepine and opioid use.

RESULTS

The final study sample consisted of 44,808 individuals (unweighted), of which 680 (1.6%) (weighted frequency=7,806,636) reported concurrent benzodiazepine and opioid use. Several individual-level factors were significantly associated with reporting use of this combination. For example, individuals with anxiety were more likely to report using both benzodiazepines and opioids (odds ratio [OR]=9.61, 95% confidence interval [CI]=7.37-12.5), and those with extreme pain levels were more likely to report concurrent use (OR=5.11, 95% CI=2.98-8.78). Other predictors of reporting concurrent benzodiazepine and opioid use were depression, arthritis, region, race-ethnicity, insurance, activities disability, general and mental health status, and smoking status.

CONCLUSIONS

Several individual-level factors were associated with reporting concurrent benzodiazepine and opioid use. Therefore, enhanced educational interventions targeting both clinicians and community-dwelling adults are warranted to minimize use of this high-risk medication combination.

US national treatment admissions with opioids and benzodiazepines

INTRODUCTION AND AIMS

Opioids and benzodiazepines (O/BZD) are increasingly involved in drug overdose deaths in the USA. Expanding treatment capacity may reduce these deaths. Knowledge about co-occurring O/BZD admissions compared to opioid admissions (opioid) is needed to plan this expansion.

DESIGN AND METHODS

US treatment admissions to specialty facilities for 2011-2017 were analysed for trends and 2017 for group differences. Due to 1.9 million admissions in 2017, comparisons between O/BZD and opioid admissions were summarised as effect sizes. Additional analysis compared the administratively pre-coded category 'other opiates and synthetics' to other opiates and synthetics/benzodiazepines admissions to control for possible similarity in drug source. Differences within O/BZD admissions by primary drug were explored.

RESULTS

Although opioid admissions showed a steady increase over time (25.9% to 38.2%), O/BZD admissions showed increases until decline in 2017 (3.2% to 4.0%). In 2017 no factor reached moderate effect size (≥0.2) in group comparisons or within the O/BZD admissions. Heroin was self-reported in 70% of both O/BZD and opioid admissions.

DISCUSSION AND CONCLUSIONS

No meaningful US national differences on data routinely collected were found for O/BZD compared to opioid admissions including the subgroup with other opiates and synthetics only. Efforts to expand existing opioid treatment in specialty treatments may help reduce opioid and O/BZD deaths. However, the analysis could not address whether changes in treatment would improve outcomes.

Not what the doctor ordered: Motivations for nonmedical prescription drug use among people who use illegal drugs

BACKGROUND

Nonmedical Prescription Drug Use (NMPDU) is common among people who use illegal drugs. NMPDU is particularly problematic among this population however, as medications such as benzodiazepines and gabapentinoids can potentiate the harmful effects of opioids. Despite these harms, there is some evidence that NMPDU can have harm reducing and therapeutic potential for some people who use illegal drugs. This study provides further evidence of the harm reducing motives for NMPDU among people who use illegal drugs in community and prison settings in Wales, UK.

METHODS

In depth, semi-structured interviews were conducted with 60 interviewees recruited from statutory and third sector drug treatment providers operating in five towns and cities in Wales, and from two Welsh prisons. Eligibility was based primarily on whether the person was currently (or previously) a user of illegal drugs and had recent experience of NMPDU.

RESULTS

NMPDU was found to be largely driven by insufficient access to certain prescription medications and treatment. In this context, NMPDU played an important role in alleviating legitimate medical concerns and overcoming logistical and regulatory barriers associated with Opioid Substitution Therapy. NMPDU also had everyday practicality and mitigated many of the everyday harms experienced by people who use drugs, including opioid withdrawal and stimulant comedowns.

CONCLUSION

Results suggest that NMPDU has the potential to mitigate a number of legitimate medical concerns in the absence of treatment. Finding nuanced ways of responding to patient need whilst reducing the potential for NMPDU are therefore needed, and harm reduction strategies that harness the knowledge and expertise of people who use drugs should be encouraged. Additional policy measures that attend to the inequities and social-structural factors that produce and maintain the need to consume prescription medications in ways that are not intended are also required.

Benzodiazepine misuse in adults with alcohol use disorder: Prevalence, motives and patterns of use

OBJECTIVE

Benzodiazepines are among the most commonly misused drugs. Despite the known risks of combining benzodiazepines and alcohol, little is known about misuse among people with alcohol use disorder (AUD). Our aim was to characterize the prevalence, correlates, and patterns of misuse of benzodiazepines in adults with AUD.

METHOD

Adults receiving treatment for AUD (N = 258) completed a battery of questionnaires. We used descriptive statistics to characterize the prevalence and patterns of misuse and we used logistic regression models to identify correlates of misuse.

RESULTS

Almost half of the sample reported a history of benzodiazepine prescription and 30% reported a history of misuse. Younger age, female sex, anxiety, and other substance use were associated with misuse. Coping was the most commonly reported reason for misuse. All participants who had misused a benzodiazepine in the past year used concurrently with another substance.

CONCLUSIONS

Benzodiazepine misuse was common in this study, and risky patterns of use, such a co-use with other substances, were prevalent. Coping was the most common reason for misusing benzodiazepines, suggesting that un- or under-treated psychiatric symptoms may contribute to misuse.

Nonmedical use of benzodiazepines and Z-drugs in the UK

AIMS

To estimate prevalence of last 12-month nonmedical use (NMU) of benzodiazepines and Z-drugs (the nonbenzodiazepine hypnotics zaleplon, zolpidem and zopiclone) in the UK.

METHODS

Data were collected using the Non-Medical Use of Prescription Drugs survey with poststratification weighting applied to be representative of the UK population (≥16 years). Participants were questioned about whether they had nonmedically used benzodiazepines and/or Z-drugs in the last 12-months and from where they had obtained the drug (including via a prescription, or illicitly from a friend/family member, a dealer or via the internet). Additional questions were asked about last 12-month use of illicit drugs (cannabis, cocaine, 3,4-methylenedioxymethylamphetamine [MDMA], non-pharmaceutical amphetamine, crack cocaine and/or heroin).

RESULTS

The study included 10 006 eligible participants representing approximately 52 927 000 UK adults. The estimated prevalence of past 12-month NMU of any benzodiazepine and/or Z-drug was 1.2% (95% confidence interval: 1.0-1.5) corresponding to approximately 635 000 adults; amongst this group only an estimated 4.6% (1.2-8.0) had NMU of both a benzodiazepine and a Z-drug. The highest prevalence of NMU for only Z-drugs was among those who had used heroin in the last 12-months (5.4%, 2.7-10.5), whilst the highest prevalence of NMU for only benzodiazepines was among those who had used illicit stimulants in the last 12-months: cocaine (5.9%, 3.8-8.9), amphetamine (5.6%, 3.1-10.0) and MDMA (5.2%, 3.1-8.8). The drug non-medically used was more commonly acquired without than with a prescription for both only benzodiazepines (70.2%, 59.4-81.1 compared to 51.3%, 41.5-64.6) and only Z-drugs (75.6%, 61.6-89.7 compared to 33.9%, 16.9-51.0).

CONCLUSION

There is little overlap between benzodiazepine and Z-drug NMU suggesting distinct nonmedical use of the drugs; future studies need to explore whether this relates to personal preference, drug availability or other factors. A significant proportion are acquiring these drugs for NMU without a prescription, so without guidance and monitoring from a medical practitioner. While the dangers of mixing benzodiazepines and heroin/other opioids are well documented, there is a paucity of data regarding concomitant NMU of benzodiazepines and stimulant drugs, or NMU of Z-drugs and opioids, and, given the prevalence of these combinations, this requires further investigation.

Associations between prescribed benzodiazepines, overdose death and buprenorphine discontinuation among people receiving buprenorphine

BACKGROUND AND AIMS

Benzodiazepines are commonly prescribed to patients with opioid use disorder receiving buprenorphine treatment, yet may increase overdose risk. However, prescribed benzodiazepines may improve retention in care by reducing buprenorphine discontinuation and thus may prevent relapse to illicit opioid use. We aimed to test the association between benzodiazepine prescription and fatal opioid overdose, non-fatal opioid overdose, all-cause mortality and buprenorphine discontinuation.

DESIGN AND SETTING

This was a retrospective cohort study using five individually linked data sets from Massachusetts, United States government agencies.

PARTICIPANTS

We studied 63 389 Massachusetts residents aged 18 years or older who received buprenorphine treatment between January 2012 and December 2015.

MEASUREMENTS

Filled benzodiazepine prescription during buprenorphine treatment was the main independent variable. The primary outcome was time to fatal opioid overdose. Secondary outcomes were time to non-fatal opioid overdose, all-cause mortality and buprenorphine discontinuation. We defined buprenorphine discontinuation as having a 30-day gap without another prescription following the end date of the previous prescription. We used Cox proportional hazards models to calculate hazards ratios that tested the association between receipt of benzodiazepines and all outcomes, restricted to periods during buprenorphine treatment.

FINDINGS

Of the 63 345 individuals who received buprenorphine, 24% filled at least one benzodiazepine prescription during buprenorphine treatment. Thirty-one per cent of the 183 deaths from opioid overdose occurred when individuals received benzodiazepines during buprenorphine treatment. Benzodiazepine receipt during buprenorphine treatment was associated with an increased risk of fatal opioid overdose adjusted hazard ratio (HR) = 2.92, 95% confidence interval (CI) = 2.10-4.06, non-fatal opioid overdose, adjusted HR = 2.05, 95% CI, 1.68-2.50, all-cause mortality, adjusted HR = 1.90, 95% CI, 1.48-2.44 and a decreased risk of buprenorphine discontinuation, adjusted HR = 0.87, 95% CI, 0.85-0.89.

CONCLUSIONS

Benzodiazepine receipt appears to be associated with both increased risk of opioid overdose and all-cause mortality and decreased risk of buprenorphine discontinuation among people receiving buprenorphine.

Auricular neural stimulation as a new non-invasive treatment for opioid detoxification

The recent opioid crisis is one of the rising challenges in the history of modern health care. New and effective treatment modalities with less adverse effects to alleviate and manage this modern epidemic are critically needed. The FDA has recently approved two non-invasive electrical nerve stimulators for the adjunct treatment of symptoms of acute opioid withdrawal. These devices, placed behind the ear, stimulate certain cranial nerves with auricular projections. This neural stimulation reportedly generates a prompt effect in terms of alleviation of withdrawal symptoms resulting from acute discontinuation of opioid use. Current experimental evidence indicates that this type of non-invasive neural stimulation has excellent potential to supplement medication assisted treatment in opioid detoxification with lower side effects and increased adherence to treatment. Here, we review current findings supporting the use of non-invasive neural stimulation in detoxification from opioid use. We briefly outline the neurophysiology underlying this approach of auricular electrical neural stimulation and its role in enhancing medication assisted treatment in treating symptoms of opioid withdrawal. Considering the growing deleterious impact of addictive disorders on our society, further studies on this emerging treatment modality are warranted.

Patterns of Polysubstance Use among Adults with Tranquilizer Misuse

Background: The misuse of benzodiazepine tranquilizers is prevalent and is associated with increased risk of overdose when combined with other substances. Yet, little is known about other substance use among those who misuse tranquilizers. Objectives: This study characterized subgroups of individuals with tranquilizer misuse, based on patterns of polysubstance use. Methods: Data were extracted from the 2015-2017 National Survey on Drug Use and Health; adults with past-month tranquilizer misuse were included (N = 1253). We utilized latent class analysis to identify patterns of polysubstance use in the previous month. Results: We identified three distinct latent classes, including the: (1) limited polysubstance use class (approximately 54.6% of the sample), (2) binge alcohol and cannabis use class (28.5% of the sample), and (3) opioid use class (16.9% of the sample). The binge alcohol and cannabis use class and the opioid use class were characterized by high probabilities of other substance misuse, including cocaine and prescription stimulants. Those in the binge alcohol and cannabis use class and the opioid use class reported more motives for tranquilizer misuse and higher rates of sexually transmitted infection, criminal involvement, and suicidal ideation. Those in the opioid use class also had greater psychological distress and higher rates of injection drug use. Conclusions: Nearly half of those with tranquilizer misuse in a general population sample were categorized into one of two high polysubstance use classes, and these two classes were associated with poorer functioning. Findings from these analyses underscore the need to reduce polysubstance use among those who misuse tranquilizers.

A nationally representative analysis of "twin epidemics": Rising rates of methamphetamine use among persons who use opioids

BACKGROUND

Recent data suggest increases in methamphetamine potency, affordability, and availability in the US. Other data indicate rising rates of methamphetamine use among patients seeking treatment for opioid use disorder. The extent to which similar increases in methamphetamine use have occurred for populations outside of a treatment context and for those reporting other substance use is unknown.

PURPOSE

The current analysis used a nationally representative data source to evaluate recent trends in past month methamphetamine use based on opioid use history.

METHODS

Data from the 2015-2017 National Survey on Drug Use and Health (NSDUH) were analyzed for yearly variations in past month methamphetamine use by opioid use history. Sensitivity analyses assessed if these trends were specific to methamphetamine use and to persons reporting opioid use.

RESULTS

Significant increases in past month methamphetamine use were observed for persons reporting past month heroin use, past year heroin use disorder, and past year prescription opioid use disorder. Among individuals reporting past month heroin use, for example, methamphetamine use tripled from 9.0% in 2015 to 30.2% in 2017. These associations were specific to methamphetamine with little change in other substance use. Similar increases in methamphetamine use were not observed for populations reporting other illicit substance use with the exception of prescription tranquilizers.

CONCLUSIONS

These results provide data corroborating evidence of emergent concerns related to methamphetamine use in the US. Such findings highlight the importance of considering global drivers of substance use to avoid cyclic waves of new and emerging substance use crises.

History of regular nonmedical sedative and/or alcohol use differentiates substance-use patterns and consequences among chronic heroin users

BACKGROUND

Concurrent use of sedating substances (e.g. alcohol or benzodiazepines) with opioids is associated with increased negative consequences of opioid use; however, few studies have attempted to differentiate effects of using sedating substances on heroin-use outcomes. This study examines differences between heroin users who use alcohol or misuse sedatives regularly and those who do not.

METHODS

Substance-use data were collected from 367 non-treatment seeking, chronic heroin-using, 18-to-55 year-old participants. We created 4 groups based on self-reported lifetime history of regular (at least weekly) substance use: heroin only (n = 95), heroin and sedatives (n = 21), heroin and alcohol (n = 151), and heroin, sedative, and alcohol (n = 100). Chi-square analyses and ANOVAs with Bonferroni post hoc tests were used to explore differences between these groups.

RESULTS

Heroin users who denied lifetime alcohol or nonmedical sedative use regularly endorsed fewer consequences associated with any substance they had used. Total adverse consequences of heroin use (e.g. health problems) were significantly higher among those who misused sedatives regularly, irrespective of alcohol use history (F(3,361) = 10.21; p < .001). Regular alcohol use did not independently impact heroin consequences but was associated with increased use of other substances.

CONCLUSIONS

Although polysubstance use is normative among heroin users, the risks depend on the substances used. Regular sedative use is associated with increased heroin consequences whereas regular alcohol use is not. This study refines the investigation of polysubstance use and highlights subgroup differences depending on types of substances used regularly. This knowledge is critical for understanding substance-use motivations and creating avenues for harm reduction.

The epidemiology of benzodiazepine misuse: A systematic review

BACKGROUND

Benzodiazepine misuse is a growing public health problem, with increases in benzodiazepine-related overdose deaths and emergency room visits in recent years. However, relatively little attention has been paid to this emergent problem. We systematically reviewed epidemiological studies on benzodiazepine misuse to identify key findings, limitations, and future directions for research.

METHODS

PubMed and PsychINFO databases were searched through February 2019 for peer-reviewed publications on benzodiazepine misuse (e.g., use without a prescription; at a higher frequency or dose than prescribed). Eligibility criteria included human studies that focused on the prevalence, trends, correlates, motives, patterns, sources, and consequences of benzodiazepine misuse.

RESULTS

The search identified 1970 publications, and 351 articles were eligible for data extraction and inclusion. In 2017, benzodiazepines and other tranquilizers were the third most commonly misused illicit or prescription drug in the U.S. (approximately 2.2% of the population). Worldwide rates of misuse appear to be similar to those reported in the U.S. Factors associated with misuse include other substance use, receipt of a benzodiazepine prescription, and psychiatric symptoms and disorders. Benzodiazepine misuse encompasses heterogeneous presentations of motives, patterns, and sources. Moreover, misuse is associated with myriad poor outcomes, including mortality, HIV/HCV risk behaviors, poor self-reported quality of life, criminality, and continued substance use during treatment.

CONCLUSIONS

Benzodiazepine misuse is a worldwide public health concern that is associated with a number of concerning consequences. Findings from the present review have implications for identifying subgroups who could benefit from prevention and treatment efforts, critical points for intervention, and treatment targets.

Opioid and benzodiazepine prescription among patients with cirrhosis compared to other forms of chronic disease

Objective

Data on patterns and correlates of opioid and benzodiazepines prescriptions among patients with chronic conditions are limited. Given a diminished capacity for hepatic clearance, patients with cirrhosis represent a high risk group for use. The aim of this study was to characterise the patterns and correlates of prescription opioid, benzodiazepine and dual drug prescriptions among individuals with common chronic diseases.

Design

Analysis of Truven Marketscan database to evaluate individuals with drug coverage with cirrhosis (n=169,181), chronic hepatitis C without cirrhosis (n=210 191), congestive heart failure (n=766 840) or chronic obstructive pulmonary disease (n=1 438 798). Pharmacy files were examined for outpatient prescriptions.

Results

Patients with cirrhosis had a significantly higher prevalence of opioid prescriptions (37.1 per 100 person-years vs 24.3–26.0, p≤0.001) and benzodiazepine prescriptions (21.3 per 100 person-years vs 12.1–12.9, p<0.001). High dose opioid prescription (>90 daily oral morphine equivalents) (29.1% vs 14.4%, p<0.001) and dual opioid and benzodiazepine prescription (17.5% vs 9.6%–10.5 %, p<0.001) were also significantly more prevalent in cirrhosis. High dose opioid prescription was greater in men, individuals ages 40–59, in the Western USA, and among those with a mental health or substance abuse condition. Dual opioid and benzodiazepine prescription were highest among those with alcoholic cirrhosis and middle aged-adults.

Conclusion

Persons with cirrhosis have significantly higher rates of prescription opioid and benzodiazepine prescription compared to others with chronic diseases despite their high risk for adverse drug reactions. Demographics and mental health or substance abuse history can help identify high risk groups to target interventions.

Nonmedical prescription sedative/tranquilizer use in alcohol and opioid use disorders

AIMS

Nonmedical prescription sedative/tranquilizer (e.g., benzodiazepines) use (NMSTU) increases risk of overdose when combined with opioids and/or alcohol. Yet, little is known about NMSTU among those with alcohol and opioid use disorders. We aimed to characterize NMSTU and sedative/tranquilizer use disorder among adults with alcohol use disorder (AUD) and/or opioid use disorder (OUD) in a general population sample.

METHODS

We conducted analyses of 2008-2014 National Survey on Drug Use and Health data; adults with past-year AUD-only (n = 27,416), OUD-only (n = 2142), and co-occurring AUD and OUD (n = 1483) were included (total N = 31,041). Multivariable logistic regression models were utilized to examine correlates of past-month NMSTU and past-year sedative/tranquilizer use disorder. Focal independent variables were polysubstance use (i.e., number of substances used in the previous year) and psychiatric distress.

RESULTS

Among those with AUD-only, 27.1% reported lifetime NMSTU, 7.6% reported past-year NMSTU, 2.7% reported past-month NMSTU, and 0.6% met criteria for past-year sedative/tranquilizer use disorder. Corresponding prevalence rates among those with OUD-only were 69.5%, 43.0%, 22.6%, and 11.3%. Those with co-occurring AUD and OUD displayed the highest rates of NMSTU (e.g., 27.5% with past-month NMSTU) and sedative/tranquilizer use disorder (20.2%). Across groups, more severe polysubstance use and psychiatric distress were associated with increased risk of NMSTU and sedative/tranquilizer use disorder.

CONCLUSIONS

Results of this analysis indicate that >25% of adults with AUD and approximately 70% of those with OUD report lifetime NMSTU. Among these populations, individuals with more polysubstance use and greater psychiatric distress might benefit from targeted interventions to reduce NMSTU.

Implementation of an Opioid Detoxification Management Pathway Reduces Emergency Department Length of Stay

OBJECTIVES

With the rise of opioid use in the United States, the increasing demand for treatment for opioid use disorders presents both a challenge and an opportunity to develop new care pathways for emergency department (ED) patients seeking opioid detoxification. We set out to improve the care of patients presenting to our ED seeking opioid detoxification by implementing a standardized management pathway and to measure the effects of this intervention.

METHODS

We conducted a before-after study of the effects of an opioid detoxification management pathway on ED length of stay (EDLOS), use of resources (social worker consultation, laboratory tests obtained), and return visits to the same ED within 30 days of discharge. All data were collected retrospectively by review of the electronic health record.

RESULTS

Ultimately, 107 patients presented to the ED that met criteria, 52 in the intervention period and 55 in the preintervention period. Median EDLOS in the intervention period was 152 (interquartile range [IQR] = 93-237) minutes compared to 312 (IQR = 187-468) minutes in the preintervention period (p < 0.001). Patients in the intervention period less frequently had a social work consultation (32.7% vs. 83.6%, p < 0.001) or had laboratory tests obtained (32.7% vs 74.5%, p < 0.001) and more frequently were prescribed a medication for withdrawal symptoms (57.7% vs. 29.1%, p = 0.003).

CONCLUSIONS

Implementation of an opioid detoxification management pathway reduced EDLOS, reduced utilization of resources, and increased the proportion of patients prescribed medications for symptom relief.

Nonmedical benzodiazepine use in adults with alcohol use disorder: The role of anxiety sensitivity and polysubstance use

BACKGROUND AND OBJECTIVES

The nonmedical use of benzodiazepines-defined as use without a prescription or at a dose or frequency higher than prescribed-is increasing among adults in substance use disorder treatment and is associated with risk for overdose. The aim of the current study was to characterize the prevalence of nonmedical benzodiazepine use among adults seeking treatment for alcohol use disorder and to examine whether nonmedical benzodiazepine use was associated with: (1) polysubstance use and (2) greater anxiety sensitivity.

METHODS

A sample of 461 treatment-seeking adults with alcohol use disorder who were recruited for a cross-sectional study were included in this analysis.

RESULTS

A total of 89 participants (19%) reported nonmedical benzodiazepine use in the previous 30 days. Results of a logistic regression indicated that polysubstance use (number of substances used in the past month) was associated with nonmedical benzodiazepine use. The association between anxiety sensitivity and nonmedical benzodiazepine misuse was moderated by gender; anxiety sensitivity was associated with benzodiazepine use among women, but not men.

DISCUSSION AND CONCLUSIONS

These results replicate findings from research on opioid use disorder suggesting that anxiety sensitivity is associated with nonmedical benzodiazepine use in women and not men.

SCIENTIFIC SIGNIFICANCE

Targeted intervention to those with polysubstance use-including education on overdose risk when benzodiazepines are combined with other substances-is indicated in men and women with alcohol use disorder. Anxiety sensitivity may be a potential therapeutic target to reduce nonmedical benzodiazepine use among women with alcohol use disorder. (Am J Addict 2018;27:485-490).

Sleep Management Among Patients with Substance Use Disorders

Sleep and substance use disorders commonly co-occur. Insomnia is commonly associated with use and withdrawal from substances. Circadian rhythm abnormalities are being increasingly linked with psychoactive substance use. Other sleep disorders, such as sleep-related breathing disorder, should be considered in the differential diagnosis of insomnia, especially in those with opioid use or alcohol use disorder. Insomnia that is brief or occurs in the context of active substance use is best treated by promoting abstinence. A referral to a sleep medicine clinic should be considered for those with chronic insomnia or when another intrinsic sleep disorder is suspected.

Factors associated with sedative use and misuse among heroin users

BACKGROUND

Rates of both opioid and sedative use and misuse are rising. Comorbid opioid and sedative use is associated with especially severe consequences (e.g., overdose and poor health outcomes). Heroin users report multiple motivations for sedative use, including self-medication. We aimed to understand differences in lifetime substance use characteristics between heroin users with different sedative use histories.

METHODS

Substance use data were collected from 385 non-treatment seeking heroin users. Subjects were divided into four lifetime sedative-use groups: no use, medical use only, non-medical use only, and mixed medical and non-medical use. We examined patterns of use of various substances of abuse (tobacco, alcohol, marijuana, cocaine, heroin, and sedatives) and individual characteristics associated with each.

RESULTS

Non-medical sedative use (alone or in addition to medical use) was associated with more negative consequences from using all substances. Medical sedative use alone was not related to increased overdose or emergency room visits associated with heroin use. Non-medical sedative use was associated with increases in 15 of the 21 measured heroin consequences and only one of those - health problems - was also associated with medical sedative use.

CONCLUSIONS

Concomitant non-medical sedative use and heroin use is associated with significantly greater negative outcomes than those experienced by heroin users who report use of sedatives only as prescribed. Understanding these differences offers insight into risks related to using both substances and may help treatment providers create targeted harm reduction interventions for this population.

Prevalence and correlates of benzodiazepine use and misuse among young adults who use prescription opioids non-medically

BACKGROUND

Benzodiazepine use dramatically increases the risk of unintentional overdose among people who use opioids non-medically. However, little is known about the patterns of co-occurring benzodiazepine and opioid use among young adults in the United States.

METHODS

The Rhode Island Young Adult Prescription Drug Study (RAPiDS) was a cross-sectional study from January 2015-February 2016. RAPiDS recruited 200 young adults aged 18-29 who reported past 30-day non-medical prescription opioid (NMPO) use. Using Wilcoxon rank sum test and Fisher's exact test, we examined correlates associated with regular prescribed and non-medical use (defined as at least monthly) of benzodiazepines among NMPO users in Rhode Island.

RESULTS

Among participants, 171 (85.5%) reported lifetime benzodiazepine use and 125 (62.5%) reported regular benzodiazepine use. Nearly all (n=121, 96.8%) reported non-medical use and 43 (34.4%) reported prescribed use. Compared to the 75 participants who did not regularly use benzodiazepines, participants who reported regular use were more likely to be white (66.3% vs. 58.0%, p=0.03), have ever been incarcerated (52.8% vs. 37.3%, p=0.04), and have ever been diagnosed with a psychiatric disorder (bipolar: 29.6% vs. 16.0%, p=0.04; anxiety: 56.8 vs. 36.0%, p=0.01). Although the association was marginally significant, accidental overdose was higher among those who were prescribed the benzodiazepine they used most frequently compared to those who were not (41.9% vs. 24.4%, p=0.06).

CONCLUSION

Benzodiazepine use and misuse are highly prevalent among young adult NMPO users. Harm reduction and prevention programs for this population are urgently needed.

Debate: Are Benzodiazepines Appropriate Treatments for Patients with Substance Use Disorders? Yes

Benzodiazepines are a controversial treatment for anxiety in patients with substance use disorders. Concerns include risk of addiction, overdose, and diversion. But benzodiazepines are among the most effective and well-tolerated treatments for anxiety, and are safe for the majority of patients who take them. Though not appropriate for all cases, particularly in those with an active opioid use disorder, benzodiazepines should be considered as a treatment for patients with substance use disorders after careful weighing of benefits and harms.

Prescribing of benzodiazepines and opioids to individuals with substance use disorders

BACKGROUND

Benzodiazepines are recommended for short-term use due to risk of dependence. This study examined characteristics associated with benzodiazepine and opioid dispensing of 7+ days in a Medicaid population with substance use disorder (SUD).

METHODS

Using 2014 MarketScan^® data, we performed zero-inflated negative binomial regression to ascertain characteristics associated with longer-term use of these medications.

RESULTS

Nearly 14% of those with SUDs received 1+ fills of benzodiazepines of 7+ days. The highest rates were among those aged 45-64 (IRR=2.38, p<0.0001) and with non-alcohol SUDs (IRR=1.12, p<0.0001). Individuals with co-occurring psychiatric disorders, particularly anxiety and depression (IRR=1.41, p<0.0001), had high rates of benzodiazepine fills. Receiving a 7+ day oral opioid fill (IRR=1.30, p<0.0001) coincided with increased benzodiazepine dispensing. Similar results occurred for longer-term prescribing of opioids, with higher rates among those with non-alcohol SUDs (IRR=1.23, p< 0.0001).

CONCLUSIONS

For many people with SUDs, receiving a benzodiazepine or opioid prescription of 7+ days is not a single occurrence; patients in our sample were more likely to receive 2+ fills than to receive one. Longer-term prescribing is most pronounced among those with co-occurring anxiety disorders. This suggests that anxiety in those with SUD should preferentially not be treated using benzodiazepines. Longer-term polypharmacy with benzodiazepines and opioids coincided. Overdoses among those using both drugs are growing and this study provides evidence that attention to the opioid epidemic should include attention to polypharmacy that includes benzodiazepines.

Beliefs about the consequences of using benzodiazepines among persons with opioid use disorder

BACKGROUND

Patients admitted to addiction treatment programs report high rates of concurrent opioid and benzodiazepine (BZD) use. This combination places individuals at high risk for accidental overdose and other serious consequences. However, little is known about the beliefs opioid users have about the consequences of BZD use.

METHODS

We surveyed consecutive persons initiating inpatient opioid detoxification (N=476; 95.0% enrollment) and identified 245 who reported BZD use in the past 30days and/or had a positive toxicology. We compared those who did and did not report BZD use on demographic and substance use variables, and specific beliefs about the potential effects of BZDs.

RESULTS

Participants averaged 32.2years of age, 71.2% were male, 86.6% used heroin, and 68.7% reported injection drug use in the past 30days. Over half (51.5%) used a BZD in the month prior to admission; of these, 26.2% (n=64) reported being prescribed a BZD. Alprazolam (Xanax) was the most commonly used BZD (54%). Benzodiazepine users (versus non-users) were significantly more likely to be female and non-Hispanic White, use concurrent substances, and report past year overdose. Overall, nearly all BZD users endorsed accurate beliefs that BZDs can increase the risk of overdose and can be addictive. However, BZD users, relative to non-users, were significantly less likely to endorse some known adverse consequences of BZDs, such as risk of worsening depression and poor medication-assisted opioid treatment retention.

CONCLUSIONS

Delineating the full array of risks from combining BZDs and opioids should be a high priority in detoxification settings, given the increased risks associated with BZD misuse in this population.