Polysubstance use trends and variability among individuals with opioid use disorder in rural versus urban settings

Recent and lifetime maternal substance use: Rurality and economic distress

Research on opioid use disorder (OUD) in pregnancy has mainly considered women in urban areas receiving treatment, with less known about women in rural areas. We sought to describe demographics and substance use characteristics of pregnant women with OUD and to compare the women based on urbanicity, in a state (Kentucky) with unfavorable economic conditions in many rural counties; we hypothesized that pregnant women in rural areas would have greater adversity, broadly defined, related to substance use. Using data collected from a larger project between 2017 and 2020, we analyzed characteristics of 93 pregnant women (59 rural and 34 urban) with OUD; we examined data in medical, employment, substance use, legal, family history, relationship, and psychiatric health domains, both overall and within rural (population <50,000) and urban (population ≥50,000) strata. Pregnant women with OUD from rural and urban areas were similar on almost all attributes. Among the few significant differences, 30% from urban areas perceived inadequate prenatal care versus 11% from rural areas (p = 0.024); 21% of urban women used amphetamines/methamphetamines in the month before delivery versus 0% of rural women (p < 0.001); and rural women had longer most recent abstinence from substance use than their urban counterparts (medians 7.0 and 2.8 months, p = 0.049). The few significant differences that were discovered favored rural women. These findings, contrary to our hypothesis, suggest that tailoring interventions may require more than focusing on geography. The participants in this study were pregnant women being treated for OUD, and as such there is patient contribution of data.

Rural communities face more than an opioid crisis: Reimagining funding assistance to address polysubstance use, associated health problems, and limited rural service capacity

PURPOSE

Rural communities in the United States face unique challenges related to the opioid epidemic. This paper explores the substances and substance-related health problems that pose the greatest concern to rural communities that received funding to address the opioid epidemic and examines their reported capacity to address these challenges.

METHODS

This paper analyzed data collected as part of quarterly progress reporting from multisector consortiums across 2 cohorts of grantees funded to reduce the morbidity and mortality of opioids. Consortium project directors ranked the top 3 issues in their community in each of the following categories: (1) drugs of concern; (2) drugs with the least capacity to address; (3) related problem areas of concern (eg, neonatal abstinence syndrome [NAS]); and (4) related problem areas with the least capacity to address.

FINDINGS

Methamphetamines, fentanyl, and alcohol were the substances rated as most problematic in rural communities funded to address the opioid epidemic across all reporting periods. Over 40% of respondents ranked methamphetamine as a top concern and the substance they had the least capacity to address. This was nearly double the percentage of the next highest-ranked substance (fentanyl). Overdoses, NAS, and viral hepatitis constituted the top-ranking related concerns, with limited capacity to address them.

CONCLUSIONS

Multiple drug and concomitant problems coalesced on rural communities during the opioid epidemic. Funding communities to address substance use disorders and related problems of concern, rather than targeting funding toward a specific type of drug, may result in better health outcomes throughout the entire community.

Differential Effects of Cocaine and Morphine on the Diurnal Regulation of the Mouse Nucleus Accumbens Proteome

Substance use disorders are associated with disruptions in sleep and circadian rhythms that persist during abstinence and may contribute to relapse risk. Repeated use of substances such as psychostimulants and opioids may lead to significant alterations in molecular rhythms in the nucleus accumbens (NAc), a brain region central to reward and motivation. Previous studies have identified rhythm alterations in the transcriptome of the NAc and other brain regions following the administration of psychostimulants or opioids. However, little is known about the impact of substance use on the diurnal rhythms of the proteome in the NAc. We used liquid chromatography coupled to tandem mass spectrometry-based quantitative proteomics, along with a data-independent acquisition analysis pipeline, to investigate the effects of cocaine or morphine administration on diurnal rhythms of proteome in the mouse NAc. Overall, our data reveal cocaine and morphine differentially alter diurnal rhythms of the proteome in the NAc, with largely independent differentially expressed proteins dependent on time-of-day. Pathways enriched from cocaine altered protein rhythms were primarily associated with glucocorticoid signaling and metabolism, whereas morphine was associated with neuroinflammation. Collectively, these findings are the first to characterize the diurnal regulation of the NAc proteome and demonstrate a novel relationship between the phase-dependent regulation of protein expression and the differential effects of cocaine and morphine on the NAc proteome. The proteomics data in this study are available via ProteomeXchange with identifier PXD042043.

High suicidality predicts overdose events among people with substance use disorder: A latent class analysis

Introduction

Suicide is the tenth leading cause of death in the United States and continues to be a major public health concern. Suicide risk is highly prevalent among individuals with co-occurring substance use disorders (SUD) and mental health disorders, making them more prone to adverse substance use related outcomes including overdose. Identifying individuals with SUD who are suicidal, and therefore potentially most at risk of overdose, is an important step to address the synergistic epidemics of suicides and overdose fatalities in the United States. The current study assesses whether patterns of suicidality endorsement can indicate risk for substance use and overdose.

Methods

Latent class analysis (LCA) was used to assess patterns of item level responses to the Concise Health Risk Tracking Self-Report (CHRT-SR), which measures thoughts and feelings associated with suicidal propensity. We used data from 2,541 participants with SUD who were enrolled across 8 randomized clinical trials in the National Drug Abuse Treatment Clinical Trials Network from 2012 to 2021. Characteristics of individuals in each class were assessed, and multivariable logistic regression was performed to examine class membership as a predictor of overdose. LCA was also used to analyze predictors of substance use days.

Results

Three classes were identified and discussed: Class (1) Minimal Suicidality, with low probabilities of endorsing each CHRT-SR construct; Class (2) Moderate Suicidality, with high probabilities of endorsing pessimism, helplessness, and lack of social support, but minimal endorsement of despair or suicidal thoughts; and Class (3) High Suicidality with high probabilities of endorsing all constructs. Individuals in the High Suicidality class comprise the highest proportions of males, Black/African American individuals, and those with a psychiatric history and baseline depression, as compared with the other two classes. Regression analysis revealed that those in the High Suicidality class are more likely to overdose as compared to those in the Minimal Suicidality class (p = 0.04).

Conclusion

Suicidality is an essential factor to consider when building strategies to screen, identify, and address individuals at risk for overdose. The integration of detailed suicide assessment and suicide risk reduction is a potential solution to help prevent suicide and overdose among people with SUD.

Predictors and motives of polydrug use in opioid users. A narrative review

PURPOSE OF REVIEW

To review the recent literature on predictors and personal motives of polydrug use in opioid users with a focus on combined use of opioids with stimulants, benzodiazepines and gabapentinoids.

RECENT FINDINGS

In North America, methamphetamine is now the most prevalent co-drug in opioid users and is responsible for high mortality rates. In Europe, opioids are rather combined with either cocaine, benzodiazepines or gabapentionoids, but recent data are lacking.Main personal motives of opioid users to combine opioids with methamphetamine or cocaine is to boost the opioid high, inhibit the withdrawal effects of heroin and have a cheaper alternative to maintain the opioid high. Risk factors of polydrug use by opioid users included being male, younger age, homelessness, high-risk sexual behavior, needle sharing, incarceration, poor mental health and recent use of cocaine or prescription opioids. The motives for co-use of opioids and gabapentinoids also include seeking a better high, lower price and to self-medicate pain/physical symptoms, including those resulting from withdrawal.

SUMMARY

When treating opioid users with polydrug drug use, special attention should be paid to dosing when in opioid agonist methadone/buprenorphine treatment and to the presence of physical pain. The validity of part of the personal motives seems questionable which deserves attention when counselling opioid users with polydrug use.

Differential Effects of Cocaine and Morphine on the Diurnal Regulation of the Mouse Nucleus Accumbens Proteome

Substance use disorders (SUDs) are associated with disruptions in sleep and circadian rhythms that persist during abstinence and may contribute to relapse risk. Repeated use of substances such as psychostimulants and opioids may lead to significant alterations in molecular rhythms in the nucleus accumbens (NAc), a brain region central to reward and motivation. Previous studies have identified rhythm alterations in the transcriptome of the NAc and other brain regions following the administration of psychostimulants or opioids. However, little is known about the impact of substance use on the diurnal rhythms of the proteome in the NAc. We used liquid chromatography coupled to tandem mass spectrometry-based (LC-MS/MS) quantitative proteomics, along with a data-independent acquisition (DIA) analysis pipeline, to investigate the effects of cocaine or morphine administration on diurnal rhythms of proteome in the mouse NAc. Overall, our data reveals cocaine and morphine differentially alters diurnal rhythms of the proteome in the NAc, with largely independent differentially expressed proteins dependent on time-of-day. Pathways enriched from cocaine altered protein rhythms were primarily associated with glucocorticoid signaling and metabolism, whereas morphine was associated with neuroinflammation. Collectively, these findings are the first to characterize the diurnal regulation of the NAc proteome and demonstrate a novel relationship between phase-dependent regulation of protein expression and the differential effects of cocaine and morphine on the NAc proteome.

A scoping review of community-based post-opioid overdose intervention programs: implications of program structure and outcomes

BACKGROUND

An emergent intervention to address the opioid epidemic is the use of multidisciplinary outreach teams which connect an individual in the community to healthcare resources after the experience of an opioid overdose. While these interventions are receiving federal funding, less is known empirically to inform future interventions. Understanding the process and outcomes of these interventions is advisable due to the novel partnerships of public health and law enforcement agencies who sometimes hold divergent goals. The objective of the present review was to describe program structure and evaluated outcomes of community-based post-overdose interventions.

RESULTS

A search of PubMed, PsycInfo, and Web of Science yielded 5 peer-reviewed articles that detail the implementation and outcomes of interventions delivered in the United States published from 2001 to July 2021. Most interventions used a multidisciplinary outreach team and referenced first responder data to contact individuals who recently experienced an overdose at their residence. Services offered often included referral to substance use treatment, recovery coaches, and social services. Method of outreach, evaluation measures, and outcomes varied. From the available literature, facilitators of program engagement included communication, information sharing, and leadership buy-in among multidisciplinary partners.

CONCLUSIONS

Future studies could benefit from exploration of service provision in rural areas, for family affected by overdose, and for minoritized populations. Community-based post-overdose interventions utilizing a law enforcement partnership are emergent with promising yet limited examples in empirical literature.

Cycles of Chronic Opioid Therapy Following Mandatory Prescription Drug Monitoring Program Legislation: A Retrospective Cohort Study

BACKGROUND

Mandates for prescriber use of prescription drug monitoring programs (PDMPs), databases tracking controlled substance prescriptions, are associated with reduced opioid analgesic (OA) prescribing but may contribute to care discontinuity and chronic opioid therapy (COT) cycling, or multiple initiations and terminations.

OBJECTIVE

To estimate risks of COT cycling in New York City (NYC) due to the New York State (NYS) PDMP mandate, compared to risks in neighboring New Jersey (NJ) counties.

DESIGN

We estimated cycling risk using Prentice, Williams, and Peterson gap-time models adjusted for age, sex, OA dose, payment type, and county population density, using a life-table difference-in-differences design. Failure time was duration between cycles. In a subgroup analysis, we estimated risk among patients receiving high-dose prescriptions. Sensitivity analyses tested robustness to cycle volume considering only first cycles using Cox proportional hazard models.

PARTICIPANTS

The cohort included 7604 patients dispensed 12,695 prescriptions.

INTERVENTIONS

The exposure was the August 2013 enactment of the NYS PDMP prescriber use mandate.

MAIN MEASURES

We used monthly, patient-level data on OA prescriptions dispensed in NYC and NJ between August 2011 and July 2015. We defined COT as three sequential months of prescriptions, permitting 1-month gaps. We defined recurrence as re-initiation of COT after at least 2 months without prescriptions. The exposure was enactment of the PDMP mandate in NYC; NJ was unexposed.

KEY RESULTS

Enactment of the NYS PDMP mandate was associated with an adjusted hazard ratio (HR) for cycling of 1.01 (95% CI, 0.94-1.08) in NYC. For high-dose prescriptions, the risk was 1.16 (95% CI, 1.01-1.34). Sensitivity analyses estimated an overall risk of 1.01 (95% CI, 0.94-1.11) and high-dose risk of 1.09 (95% CI, 0.91-1.31).

CONCLUSIONS

The PDMP mandate had no overall effect on COT cycling in NYC but increased cycling risk among patients receiving high-dose opioid prescriptions by 16%, highlighting care discontinuity.

Substance use disorders and social determinants of health from electronic medical records obtained during Kentucky's "triple wave"

Social determinants of health (SDOH) play a critical role in the risk of harmful drug use. Examining SDOH as a means of differentiating populations with multiple co-occurring substance use disorders (SUDs) is particularly salient in the era of prevalent opioid and stimulant use known as the "Third Wave". This study uses electronic medical records (EMRs) from a safety net hospital system from 14,032 patients in Kentucky from 2017 to 2019 in order to 1) define three types of SUD cohorts with shared/unique risk factors, 2) identify patients with unstable housing using novel methods for EMRs and 3) link patients to their residential neighborhood to obtain quantitative perspective on social vulnerability. We identified patients in three cohorts with statistically significant unique risk factors that included race, biological sex, insurance type, smoking status, and urban/rural residential location. Adjusting for these variables, we found a statistically significant, increasing risk gradient for patients experiencing unstable housing by cohort type: opioid-only (n = 7385, reference), stimulant-only (n = 4794, odds ratio (aOR) 1.86 95 % confidence interval (CI): 1.66-2.09), and co-diagnosed (n = 1853, aOR = 2.75, 95 % CI: 2.39 to 3.16). At the neighborhood-level, we used 8 different measures of social vulnerability and found that, for the most part, increasing proportions of patients with stimulant use living in a census tract was associated with more social vulnerability. Our study identifies potentially modifiable factors that can be tailored by substance type and demonstrates robust use of EMRs to meet national goals of enhancing research on social determinants of health.

Suicidality as a Predictor of Overdose among Patients with Substance Use Disorders

Increasing rates of overdose and overdose deaths are a significant public health problem. Research has examined co-occurring mental health conditions, including suicidality, as a risk factor for intentional and unintentional overdose among individuals with substance use disorder (SUD). However, this research has been limited to single site studies of self-reported outcomes. The current research evaluated suicidality as a predictor of overdose events in 2541 participants who use substances enrolled across eight multi-site clinical trials completed within the National Drug Abuse Treatment Clinical Trials Network between 2012 to 2021. The trials assessed baseline suicidality with the Concise Health Risk Tracking Self-Report (CHRT-SR). Overdose events were determined by reports of adverse events, cause of death, or hospitalization due to substance overdose, and verified through a rigorous adjudication process. Multivariate logistic regression was performed to assess continuous CHRT-SR score as a predictor of overdose, controlling for covariates. CHRT-SR score was associated with overdose events (p = 0.03) during the trial; the likelihood of overdose increased as continuous CHRT score increased (OR 1.02). Participants with lifetime heroin use were more likely to overdose (OR 3.08). Response to the marked rise in overdose deaths should integrate suicide risk reduction as part of prevention strategies.

Association of Methamphetamine and Opioid Use With Nonfatal Overdose in Rural Communities

Importance

Overdoses continue to increase in the US, but the contribution of methamphetamine use is understudied in rural communities.

Objective

To estimate the prevalence of methamphetamine use and its correlates among people who use drugs (PWUD) in rural US communities and to determine whether methamphetamine use is associated with increased nonfatal overdoses.

Design, Setting, and Participants

From January 2018 through March 2020, the National Rural Opioid Initiative conducted cross-sectional surveys of PWUD in rural communities in 10 states (Illinois, Kentucky, New Hampshire, Massachusetts, North Carolina, Ohio, Oregon, Vermont, West Virginia, and Wisconsin). Participants included rural PWUD who reported any past-30-day injection drug use or noninjection opioid use to get high. A modified chain-referral sampling strategy identified seeds who referred others using drugs. Data analysis was performed from May 2021 to January 2022.

Exposures

Use of methamphetamine alone, opioids alone, or both.

Main Outcomes and Measures

Unweighted and weighted prevalence of methamphetamine use, any past-180-day nonfatal overdose, and number of lifetime nonfatal overdoses.

Results

Among the 3048 participants, 1737 (57%) were male, 2576 (85%) were White, and 225 (7.4%) were American Indian; the mean (SD) age was 36 (10) years. Most participants (1878 of 2970 participants with any opioid or methamphetamine use [63%]) reported co-use of methamphetamine and opioids, followed by opioids alone (702 participants [24%]), and methamphetamine alone (390 participants [13%]). The estimated unweighted prevalence of methamphetamine use was 80% (95% CI, 64%-90%), and the estimated weighted prevalence was 79% (95% CI, 57%-91%). Nonfatal overdose was greatest in people using both methamphetamine and opioids (395 of 2854 participants with nonmissing overdose data [22%]) vs opioids alone (99 participants [14%]) or methamphetamine alone (23 participants [6%]). Co-use of methamphetamine and opioids was associated with greater nonfatal overdose compared with opioid use alone (adjusted odds ratio, 1.45; 95% CI, 1.08-1.94; P = .01) and methamphetamine use alone (adjusted odds ratio, 3.26; 95% CI, 2.06-5.14; P < .001). Those with co-use had a mean (SD) of 2.4 (4.2) (median [IQR], 1 [0-3]) lifetime overdoses compared with 1.7 (3.5) (median [IQR], 0 [0-2]) among those using opioids alone (adjusted rate ratio, 1.20; 95% CI, 1.01-1.43; P = .04), and 1.1 (2.9) (median [IQR], 0 [0-1]) among those using methamphetamine alone (adjusted rate ratio, 1.81; 95% CI, 1.45-2.27; P < .001). Participants with co-use most often reported having tried and failed to access substance use treatment: 827 participants (44%) for both, 117 participants (30%) for methamphetamine alone, and 252 participants (36%) for opioids alone (χ22 = 33.8; P < .001). Only 66 participants (17%) using methamphetamine alone had naloxone.

Conclusions and Relevance

These findings suggest that harm reduction and substance use disorder treatment interventions must address both methamphetamine and opioids to decrease overdose in rural communities.

Behavior change, health, and health disparities 2021: Rural addiction and health

This Special Issue of Preventive Medicine (PM) is the 8th in a series on behavior change, health, and health disparities. This is a topic of critical importance to improving U.S. population health. There is broad consensus that personal behavior patterns or lifestyle such as substance abuse, poor food choices, physical inactivity, and non-adherence with medical regimens are among the most important modifiable causes of chronic disease and premature death and contributors to recent decreases in U.S. longevity. While no U.S region is free of these problems, they disproportionately impact rural communities. As in prior Special Issues in this series, we devote considerable space to the ongoing U.S. opioid epidemic while also examining selected issues in rural health disparities involving tobacco use, cancer, and cardiovascular disease. Across each of these topics we have recruited contributions from accomplished investigators, clinicians, and policymakers to acquaint readers with recent advances while also noting knowledge gaps and unresolved challenges.

Shifting Pathways of Stimulant Use Among Individuals With Opioid Use Disorder: A Retrospective Analysis of the Last Thirty Years

Background: Stimulant use among individuals with opioid use disorder has recently increased, driven by changes in drug distribution channels. However, our understanding of polysubstance use is often limited by a need to provide targeted treatment to a primary drug of addiction. Yet there is a crucial need to better understand pathways to addiction, and how the use of multiple substances may differ between populations, as well as time periods. Methods: Using a national opioid surveillance system, we analyzed survey data from new entrants to 124 opioid use disorder treatment centers from 2017 to 2020. Age of first use was collected for prescription opioids, illicit opioids, prescription stimulants, crack/cocaine, and methamphetamines. Year of initial use of an opioid or stimulant was calculated and grouped by 5 year blocs, inclusive of initial use starting from 1991 and ending in 2020 (n = 6,048). Results: Lifetime exposure to stimulants was 82.5% among individuals with opioid use disorder. Mean age of initiation increased for all drugs in 2016-2020, in particular prescription opioids (22.3 to 31.8). Stimulants were initiating drugs for a substantial proportion of individuals with opioid use throughout the analyzed time period. Those initiating opioid/stimulant use from 1991 to 1995 had a mean average of 6.8 years between first and second drug exposure, which steadily decreased to 1.5 years between exposures in 2016-2020. Sankey plots depict significantly more drug transitions in those initiating use from 1991 to 2000 (65.1% had at least two drug transitions) compared to 2010-2020 (16.0%). Opioid-stimulant use increased over time among racial/ethnic minorities, sexual minorities, and those with an educational attainment of high school or less. Conclusion: These data highlight not only the substantial prevalence of stimulant use among individuals who develop opioid use disorder, but also the variability through which pathways of use occur. Prevention and intervention efforts need to take into account increasing ages of initial drug exposures, demographic shifts in stimulant-using populations, and more rapid drug transitions between opioid and stimulants. But at a broader level, prevention, harm reduction ideology, and addiction medicine needs to take into account the ubiquity of polysubstance use among individuals with substance use disorders.