Substance use consequences, mental health problems, and readiness to change among Veterans seeking substance use treatment

Worsening stimulant use disorder outcomes coinciding with off-label antipsychotic prescribing: a commonly unrecognised side effect?

Antipsychotic medications exert their effects via dopamine antagonism and are widely used off-label among persons with substance use disorders (SUD). While dopamine antagonists are recognised to stimulate food craving and weight gain, outside of possibly increasing nicotine craving and use, their impact on other SUD outcomes is poorly recognised. In this context, research has demonstrated that antipsychotic therapy can produce 'supersensitivity' to dopamine, enhancing the motivational effects of addictive drugs. Worsened drug craving and higher rates of substance use have also been observed in double-blind placebo-controlled trials. Nevertheless, widespread off-label antipsychotic prescribing among persons with SUD implies that the risks of worsening SUD outcomes are overall poorly recognised in both primary care and among specialists. We present a typical case of worsening stimulant use disorder in a patient prescribed antipsychotic medication for low mood and insomnia, highlighting that this is likely a widely under-recognised adverse effect of off-label antipsychotic therapy.

Group Cognitive Behavioral Therapy for Substance Use Disorders Among Psychiatric Inpatients in a Medically Underserved Area: An Intervention for Opioid Misuse

OBJECTIVES

Opioid misuse is a serious public health concern, yet few people seek treatment for this condition. Hospitals may be one opportunity to identify those with opioid misuse and to teach them skills to help manage their opioid misuse upon discharge. We tested the relationship between opioid misuse status and motivation to change substance use among patients admitted with substance misuse to an inpatient psychiatric unit in a medically underserved area in Baton Rouge, Louisiana, who attended at least 1 group session of motivation enhancement therapy combined with cognitive behavioral therapy (MET-CBT) from January 29, 2020, through March 10, 2022.

METHODS

Of the 419 patients in our sample, 86 (20.5%) appeared to misuse opioids (62.5% male; mean age, 35.0 y; 57.7% non-Hispanic/Latin White). At the beginning of each session, patients completed 2 measures of motivation-importance and confidence to change substance use-from 0 (not at all) to 10 (most). At the end of each session, patients rated perceived session helpfulness from 1 (extremely hindering) to 9 (extremely helpful).

RESULTS

Opioid misuse was associated with greater importance (Cohen d = 0.12) and confidence (Cohen d = 0.13) to change substance use and with attending more MET-CBT sessions (Cohen d = 0.13). Patients with opioid misuse rated sessions as highly helpful (score of 8.3 of 9), and these ratings did not differ from patients who used other substances.

CONCLUSIONS

Inpatient psychiatry hospitalizations may provide an opportunity to identify patients with opioid misuse and introduce these patients to MET-CBT to learn skills to manage opioid misuse upon discharge.

Discussion of alcohol consequences during a brief motivational intervention session: Comparing those who do and do not increase readiness to change

The present study was designed to take an inductive, qualitative approach to understanding how discussion of alcohol-related consequences during brief motivational interventions (BMI) relate to readiness to change (RTC) prior to versus at the end of a session. Participants were thirty-four adults (35% female) recruited from the emergency room and enrolled in a randomized clinical trial of a BMI for risky alcohol use and risky sex. Seventeen participants both began and remained low on RTC over the course of the session. We selected 17 additional participants, matched on demographics, but who increased RTC over the session. Transcripts were qualitatively coded and analyzed separately within groups. Among participants who increased their RTC relative to participants who remained low on RTC by BMI end, evaluation of alcohol consequences as negative was more typical. In both groups, several consequences were neutrally evaluated. Many who remained low on RTC attributed consequences to something other than alcohol and/or minimized consequence severity. Study findings highlight the value for clinicians in eliciting and maximizing the importance of subjectively negative recent consequences to perhaps increase heavy drinkers' readiness to decrease heavy alcohol use.

Psychiatric comorbidity and treatment outcomes in patients with opioid use disorder: Results from a multisite trial of buprenorphine-naloxone and methadone

BACKGROUND

Individuals treated for opioid use disorder (OUD) have high rates of psychiatric disorders potentially diminishing treatment outcomes. We examined long-term treatment experiences and outcomes by type of psychiatric disorder among participants who participated in the Starting Treatment with Agonist Replacement Therapies (START) study and its follow-up study.

METHODS

We categorized the 593 participants who completed the Mini-International Neuropsychiatric Interview (MINI) during the START follow-up study into four mutually exclusive groups to indicate current psychiatric diagnosis: 1) bipolar disorder (BPD; n = 51), 2) major depressive disorder (MDD; n = 85), 3) anxiety disorder (AXD; n = 121), and 4) no comorbid mental disorder (NMD; n = 336). We compared participants' baseline characteristics and treatment outcomes.

RESULTS

Groups with mental disorders had worse substance use outcomes and poorer psychosocial functioning than the NMD group. Participants with BPD had significantly more self-reported days using opioids (Mean: 8.6 for BPD vs. 3.4 days for NMD, p < 0.01) and heroin (Mean: 6.4 for BPD vs. 2.0 for MDD, 3.1 days for NMD, p < 0.05) in the 30 days prior to the final interview. Compared to patients without mental disorders, patients with MDD spent more time engaged with OUD pharmacotherapy during the ∼16-month period between MINI and final interview (mean: 71.6 % vs. 50.6 %; p < 0.001).

CONCLUSIONS

Our results show that treatment outcomes in individuals with OUD vary by psychiatric comorbidity groups, which supports the need for mental health assessment and treatment for psychiatric conditions in the context of pharmacotherapy for patients with OUD.

Factors influencing readiness to change in patients with alcoholic liver disease: A cross-sectional study

WHAT IS KNOWN ON THE SUBJECT?: Readiness to change has been documented as a factor affecting alcohol treatment attendance, engagement and outcome. Knowledge regarding readiness to change and its influencing factors in patients with alcoholic liver diseases will inform the development of relevant interventions to help these patients to successfully stop drinking. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The scores in all three dimensions of readiness, recognition, ambivalence and taking steps, were low. For the recognition stage, age, drinking severity and stigma are important factors to be considered. For the ambivalence stage, age and drinking severity are important influencing factors. For the taking steps stage, drinking refusal self-efficacy and depression should be the focus. Instead of negative associations, we found that age and drinking severity, self-stigma and depression were positively associated with readiness to change. Patients who are younger and have higher drinking severity, higher self-stigma, higher self-efficacy and severe depression are more likely to change alcohol use. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Age, drinking severity, self-stigma, drinking refusal self-efficacy and depression are important factors to be considered when mental health nurses try to increase psychological preparedness for changing alcohol use in patients with alcoholic liver diseases. Different factors must be considered for patients in different stages of readiness to change. Different alcohol treatments are needed for different patient populations. ABSTRACT: Introduction Readiness to change (RC) refers to the willingness or psychological preparedness for changing alcohol use. Knowledge regarding factors influencing RC is crucial for developing alcohol treatment plans. Aims The study's purpose was to investigate RC and its influencing factors in patients with alcoholic liver disease (ALD). The factors explored include demographics, disease characteristics, drinking severity, self-stigma, depression, social support and self-efficacy. Method This is a cross-sectional study using self-reported questionnaires. Results Eighty-seven patients with ALD were recruited. Their scores in all three dimensions of readiness, recognition, ambivalence and taking steps, were low. Self-stigma, age and drinking severity explained 32.3% variation in recognition. Drinking severity and age explained 21.5% variation in ambivalence. Self-efficacy, depression and age explained 19.3% variation in taking steps. Discussion Instead of negative associations, we found that age, drinking severity, self-stigma and depression were positively associated with RC. Younger patients with higher drinking severity, higher self-stigma, higher self-efficacy and severe depression are more likely to change alcohol use. Implications for practice Mental health nurses should consider factors such as age, drinking severity, self-stigma, self-efficacy and depression, while trying to increase patients' RC. More specifically, strategies to increase self-efficacy and interventions to support coping are needed. Relevance statement Many ALD patients needing treatment for problematic alcohol use can be effectively managed in primary care with appropriate specialist support. An experienced specialist mental health nurse can play this role. Mental health nurses are important members of alcohol addiction treatment teams. Traditionally, most nurses working in alcohol therapy services have been mental health specialists and work in a partnership model with physicians and other healthcare professionals. The influencing factors found in this study can further inform mental health nurses to recognize and work more effectively with ALD patients' alcohol problems.

Cannabis use among military veterans: A great deal to gain or lose?

Policy changes have resulted in dramatic increases in access to cannabis for medical purposes. Veterans are disproportionately affected by conditions for which medical cannabis is often pursued, making an evidence-based perspective on risks versus benefits of high priority. The current review sought to examine the state of the evidence on the correlates and consequences of cannabis use among veterans. Using a comprehensive search strategy, 501 articles were identified and 86 studies met criteria for inclusion. The literature was predominated by cross-sectional studies (67%) of male veterans (71.4%-100% male) from the United States (93.0%). Three overarching themes emerged, comprising cannabis associations with other substance use, mental health, and physical health outcomes. The balance of the evidence associated cannabis use with negative health outcomes, with consistent positive associations with other substance use, psychiatric disorders, and self-harm/suicidality. Few studies examined the therapeutic effects of cannabis, thus limiting the potential to evaluate evidence of efficacy. Priority areas for future research are studies using designs that can examine the directionality of links between cannabis and health in veterans more conclusively, and studies directly examining therapeutic efficacy of cannabis-based therapies in veterans. Methodologically rigorous design will be essential to inform clinical recommendations and practices guidelines in an era of burgeoning access to cannabis.

Legal and social consequences of substance use: Results from a nationwide study in Bangladesh

Substance use is a major public health concern and its consequences can destroy someone's life. This study aimed to explore the legal and social consequences of substance use in Bangladesh. We conducted a nationwide descriptive cross-sectional study among relapse cases of substance use from January to December 2018. We visited 138 drug rehabilitation centers countrywide and were able to recruit 939 relapse cases, from where 28 cases were excluded due to incomplete data. Finally, data from 911 cases were analyzed. The majority (89.3%) of the study participants were 19-45 years old. Most commonly used drugs were amphetamine (76.1%), cannabis (75.0%), alcohol (54.3%), cough sirup (54.2%), heroin (47.0%) and sleeping pills (21.6%). Almost half (49.5%) of the substance users were arrested for drug use and among arrested cases, 52.1% were sent to jail. About 75% of the substance users experienced a lack of family interaction, 70% experienced destroyed family relationships, and 71.4% faced social stigma. Our study also found 60% of the participants were bullied, 50% were deprived or unwilling to have social interactions. Moreover, 13.8% of the participants left home, while 8% got divorced. Our data represented the significant impact of substance use on the legal aspect and social life of individuals. However, with a multi-dimensional treatment, rehabilitation, and social intervention approach, it is not impossible to overcome. Therefore, we believe it is imperative to focus on social awareness and to create a robust platform for health promotion and improve quality of life.

Depression history as a predictor of outcomes during buprenorphine-naloxone treatment of prescription opioid use disorder

BACKGROUND

In the multi-site Prescription Opioid Addiction Treatment Study (POATS), the best predictor of successful opioid use outcome was lifetime diagnosis of major depressive disorder. The primary aim of this secondary analysis of data from POATS was to empirically assess two explanations for this counterintuitive finding.

METHODS

The POATS study was a national, 10-site randomized controlled trial (N = 360 enrolled in the 12-week buprenorphine-naloxone maintenance treatment phase) sponsored by the NIDA Clinical Trials Network. We evaluated how the presence of a history of depression influences opioid use outcome (negative urine drug assays). Using adjusted logistic regression models, we tested the hypotheses that 1) a reduction in depressive symptoms and 2) greater motivation and engagement in treatment account for the association between depression history and good treatment outcome.

RESULTS

Although depressive symptoms decreased significantly throughout treatment (p <.001), this improvement was not associated with opioid outcomes (aOR = 0.98, ns). Reporting a goal of opioid abstinence at treatment entry was also not associated with outcomes (aOR = 1.39, ns); however, mutual-help group participation was associated with good treatment outcomes (aOR = 1.67, p <.05). In each of these models, lifetime major depressive disorder remained associated with good outcomes (aORs = 1.63-1.82, ps = .01-.055).

CONCLUSIONS

Findings are consistent with the premise that greater engagement in treatment is associated with good opioid outcomes. Nevertheless, depression history continues to be associated with good opioid outcomes in adjusted models. More research is needed to understand how these factors could improve treatment outcomes for those with opioid use disorder.

Depression and Outcomes of Methadone and Buprenorphine Treatment Among People with Opioid Use Disorders: A Literature Review

Objective: Depression is the most common psychiatric comorbidity among people with opioid use disorders (OUDs). However, whether and how comorbid depression is associated with the outcomes of opioid agonist therapy (OAT) remains poorly understood. The objective of this review was to identify and describe the association between depression and main outcomes (opioid use and treatment retention) of methadone and buprenorphine treatment among people with OUDs. Methods: A literature review was conducted by searching five electronic databases (MEDLINE, PubMed, Embase, Evidence-Based Medicine Reviews [EBMR], and Cumulative Index of Nursing and Allied Health Literature [CINAHL] Complete) from January 1970 to April 2019. Two independent reviewers screened titles and abstracts of the identified records by using pre-established eligibility criteria. Next, full texts were reviewed and studies that met inclusion criteria were selected. Finally, a descriptive synthesis of extracted data was performed. Results: In total, 12,296 records were identified and 18 studies that met inclusion criteria were retained. Of these, six studies reported reduced opioid use and seven reported increased opioid use during methadone or buprenorphine treatment. In addition, three studies reported an increased retention rate and four documented a decreased retention rate during methadone or buprenorphine treatment. The remaining studies did not find any significant association between depression and opioid use or treatment retention. Overall, the evidence did not demonstrate a consistent association between depression and outcomes of methadone or buprenorphine treatment. Conclusions: Although the inconsistent nature of the current evidence prohibited us from drawing definitive conclusions, we posit that the presence of depression among OUDs patients may not always predict negative outcomes related to retention and drug use during the course of OAT. Particularly, the hypothesis that adequate treatment of depression can improve treatment retention is promising and is in line with the call for increased efforts to provide integrated care for comorbid mental health disorders and addiction. Future studies with rigorous methodology are essential to better characterize the complex interplay between depression, OAT, and OUDs.

Opioid Neurobiology, Neurogenetics and Neuropharmacology in Zebrafish

Despite the high prevalence of medicinal use and abuse of opioids, their neurobiology and mechanisms of action are not fully understood. Experimental (animal) models are critical for improving our understanding of opioid effects in vivo. As zebrafish (Danio rerio) are increasingly utilized as a powerful model organism in neuroscience research, mounting evidence suggests these fish as a useful tool to study opioid neurobiology. Here, we discuss the zebrafish opioid system with specific focus on opioid gene expression, existing genetic models, as well as its pharmacological and developmental regulation. As many human brain diseases involve pain and aberrant reward, we also summarize zebrafish models relevant to opioid regulation of pain and addiction, including evidence of functional interplay between the opioid system and central dopaminergic and other neurotransmitter mechanisms. Additionally, we critically evaluate the limitations of zebrafish models for translational opioid research and emphasize their developing utility for improving our understanding of evolutionarily conserved mechanisms of pain-related, addictive, affective and other behaviors, as well as for fostering opioid-related drug discovery.