Recovery From Opioid Problems in the US Population: Prevalence, Pathways, and Psychological Well-Being

Public perceptions of opioid misuse recovery and related resources in a nationally representative sample of United States adults

AIMS

To understand how the US public defines recovery from opioid misuse and the recovery-related resources it views as most helpful, and to compare differences by opioid misuse history and demographic characteristics.

DESIGN

Observational study of data from the nationally representative AmeriSpeak® Panel survey administered in October/November 2021.

SETTING

United States.

PARTICIPANTS

6515 adults (≥ 18 years).

MEASUREMENTS

Respondents ranked 10 definitions of recovery (religious in nature; spiritual in nature; physical/mental in nature; contributing to society; enhanced quality of life; seeking professional help; having a sense of purpose; moderate/controlled substance use; no drug use; abstaining from all substance use) and 9 resources that might contribute to recovery (primary care physician; intensive inpatient program; residential rehabilitation program; self-help group; therapist/psychologist/social worker; prescribed medication; talking to family/friends; spiritual/natural healer; faith-based organization). We explored differences in rankings by opioid misuse history (personal vs. family/friend vs. no history) and demographic characteristics (race, sex, age) using multivariable ordinal logistic regression.

FINDINGS

Seeking professional help was the most endorsed recovery definition overall [mean (M) = 6.97, standard error (SE) = 0.03]. Those with personal opioid misuse history ranked enhanced quality of life (B = 0.16, P = 0.049) and having a sense of purpose (B = 0.16, P = 0.029) significantly higher, and ranked abstaining from substance use (B = -0.20, P = 0.009) significantly lower as recovery definitions than those without a history of opioid misuse. Compared with White respondents, Black (B = 0.60, P < 0.001) and Hispanic (B = 0.55, P < 0.001) respondents defined recovery as more religious in nature. Residential rehabilitation program was identified as the most helpful resource for recovery (M = 7.16, SE = 0.02), while prescribed medication received a relatively low ranking overall (M = 4.05, SE = 0.03). Those with family/friend opioid misuse history ranked prescribed medication as less helpful than others (B = -0.14, P = 0.003).

CONCLUSIONS

The general US public's views around recovery from opioid misuse appear to focus on abstinence and formal treatment receipt, while people with a history of opioid misuse place less emphasis on abstinence and greater emphasis on other aspects of well-being.

Recovery from opioid use on a neuropsychoanalytic service

Background

Little is known about recovery from opioid use disorder (OUD) or outcomes of detoxification and drug-free treatment of chronic opioid therapy (COT). Harm reduction with medications for opioid use disorder (MOUD) is regarded as the only legitimate treatment.

Methods

The Institutional Review Board (IRB) approved reporting deidentified outcomes. Patients seen over a 10-year period whose records suggested recovery were called and interviewed.

Results

Overall, 69/86 (80%) confirmed that they had been sober for at least a year, including 41 patients with OUD (75%) and 28 COT patients (90%). 91% were drug-free, and 9% were on MOUD. 79% preferred a psychotherapy approach. 21% preferred MOUD. Coming for more treatment and abstinence from tobacco were significantly correlated with recovery.

Conclusion

This is the first report that we are aware of regarding the frequency of recovery from OUD and COT. We have complicated the discussion about what is the best treatment for patients with OUD and patients on COT. Advising that maintenance is the only legitimate treatment for patients who suffer from OUD or who are on COT seems both premature and jeopardizes the ability of treaters to individualize treatment recommendations.

A network immuno-epidemiological model of HIV and opioid epidemics

In this paper, we introduce a novel multi-scale network model of two epidemics: HIV infection and opioid addiction. The HIV infection dynamics is modeled on a complex network. We determine the basic reproduction number of HIV infection, $ \mathcal{R}_{v} $, and the basic reproduction number of opioid addiction, $ \mathcal{R}_{u} $. We show that the model has a unique disease-free equilibrium which is locally asymptotically stable when both $ \mathcal{R}_{u} $ and $ \mathcal{R}_{v} $ are less than one. If $ \mathcal{R}_{u} > 1 $ or $ \mathcal{R}_{v} > 1 $, then the disease-free equilibrium is unstable and there exists a unique semi-trivial equilibrium corresponding to each disease. The unique opioid only equilibrium exist when the basic reproduction number of opioid addiction is greater than one and it is locally asymptotically stable when the invasion number of HIV infection, $ \mathcal{R}^{1}_{v_i} $ is less than one. Similarly, the unique HIV only equilibrium exist when the basic reproduction number of HIV is greater than one and it is locally asymptotically stable when the invasion number of opioid addiction, $ \mathcal{R}^{2}_{u_i} $ is less than one. Existence and stability of co-existence equilibria remains an open problem. We performed numerical simulations to better understand the impact of three epidemiologically important parameters that are at the intersection of two epidemics: $ q_v $ the likelihood of an opioid user being infected with HIV, $ q_u $ the likelihood of an HIV-infected individual becoming addicted to opioids, and $ \delta $ recovery from opioid addiction. Simulations suggest that as the recovery from opioid use increases, the prevalence of co-affected individuals, those who are addicted to opioids and are infected with HIV, increase significantly. We demonstrate that the dependence of the co-affected population on $ q_u $ and $ q_v $ are not monotone.

Role of Peer Coaches in Digital Interventions for MOUD Initiation and Maintenance

Millions of Americans suffer from opioid use disorder (OUD) in the United States, resulting in thousands of deaths. The ongoing opioid crisis necessitates novel approaches to reduce the morbidity and mortality associated with misusing opioids. Studies using peer support models show success in engaging persons living with OUD in initiating treatment and decreasing relapse. Although most studies have focused on patients in clinical settings, community studies integrating peer community leaders also show promise. This viewpoint paper explores the use of peer coaches in online interventions in the community setting.

Long-term recovery from opioid use disorder: recovery subgroups, transition states and their association with substance use, treatment and quality of life

BACKGROUND AND AIMS

Limited information exists regarding individual subgroups of recovery from opioid use disorder (OUD) following treatment and how these subgroups may relate to recovery trajectories. We used multi-dimensional criteria to identify OUD recovery subgroups and longitudinal transitions across subgroups.

DESIGN, SETTING AND PARTICIPANTS

In a national longitudinal observational study in the United States, individuals who previously participated in a clinical trial for subcutaneous buprenorphine injections for treatment of OUD were enrolled and followed for an average of 4.2 years after participation in the clinical trial.

MEASUREMENTS

We identified recovery subgroups based on psychosocial outcomes including depression, opioid withdrawal and pain. We compared opioid use, treatment utilization and quality of life among these subgroups.

FINDINGS

Three dimensions of the recovery process were identified: depression, opioid withdrawal and pain. Using these three dimensions, participants were classified into four recovery subgroups: high-functioning (minimal depression, mild withdrawal and no/mild pain), pain/physical health (minimal depression, mild withdrawal and moderate pain), depression (moderate depression, mild withdrawal and mild/moderate pain) and low-functioning (moderate/severe withdrawal, moderate depression and moderate/severe pain). Significant differences among subgroups were observed for DSM-5 criteria (P < 0.001) and remission status (P < 0.001), as well as with opioid use (P < 0.001), treatment utilization (P < 0.001) and quality of life domains (physical health, psychological, environment and social relationships; Ps < 0.001, Cohen's fs ≥ 0.62). Recovery subgroup assignments were dynamic, with individuals transitioning across subgroups during the observational period. Moreover, the initial recovery subgroup assignment was minimally predictive of long-term outcomes.

CONCLUSIONS

There appear to be four distinct subgroups among individuals in recovery from OUD. Recovery subgroup assignments are dynamic and predictive of contemporaneous, but not long-term, substance use, substance use treatment utilization or quality of life outcomes.

Prevalence of mental disorders among people with opioid use disorder: A systematic review and meta-analysis

BACKGROUND

Opioid use disorder (OUD) and mental disorders are major public health issues and comorbidity is common. Among people with OUD, comorbid mental disorders are associated with poorer health outcomes. To our knowledge, this is the first systematic review and meta-analysis to estimate prevalence of specific mental disorders among people with OUD.

METHODS

We searched Embase, MEDLINE, and PsycInfo from 1990 to 2021 for observational studies of depression, anxiety, post-traumatic stress disorder (PTSD), bipolar, personality, and other pre-specified mental disorders among people with OUD. We pooled current and lifetime estimates of each disorder using random-effects meta-analyses with 95% Confidence Intervals (CIs). Meta-regressions and stratified analyses were used to assess heterogeneity of prevalence estimates by methodological factors and sample characteristics.

FINDINGS

Of the 36,971 publications identified, we included data from 345 studies and 104,135 people with OUD in at least one pooled estimate. Among people with OUD, the prevalence of current depression was 36.1% (95%CI 32.4-39.7%), anxiety was 29.1% (95%CI 24.0-33.3%), attention-deficit/hyperactivity disorder was 20.9% (95%CI 15.7-26.2%), PTSD was 18.1% (95%CI 15.4-20.9%), and bipolar disorder was 8.7% (95%CI 6.7-10.7%). Lifetime prevalence of anti-social personality disorder was 33.6% (95%CI 29.1-38.0%) and borderline personality disorder was 18.2% (95% CI 13.4-23.1%). Sample characteristics and methodological factors, including sex, were associated with variance of multiple prevalence estimates.

INTERPRETATION

Our findings emphasise the need for access to mental disorder treatment among people with OUD. Specific mental disorder estimates may inform clinical guidelines, treatment services, and future research for people with OUD, including subpopulations with distinct treatment needs.

Recovery from opioid use disorder: A 4-year post-clinical trial outcomes study

BACKGROUND

Opioid use disorder (OUD) seriously impacts public health in the United States. However, few investigations of long-term outcomes following treatment with medication for OUD exist. Additionally, these studies have prioritized opioid use and treatment utilization outcomes, and a gap in knowledge regarding long-term, multidimensional trajectories of OUD recovery exists. This study investigated a diverse array of outcomes for individuals with OUD at an average of 4.2 years post clinical trial participation.

METHODS

Individuals who previously participated in long-acting buprenorphine subcutaneous injection clinical trials (NCT023579011; NCT025100142; NCT02896296) and enrolled in The Remission from Chronic Opioid Use-Studying Environmental and SocioEconomic Factors on Recovery (RECOVER; NCT03604861) Study participated in a follow up assessment (n = 216). Substance use, psychosocial, opioid dependence, and delay discounting outcomes were assessed. Regression analyses were conducted to determine significant associations between psychosocial/opioid dependence variables and both recent opioid use and delay discounting.

RESULTS

The majority of participants reported abstinence from opioids since the last RECOVER study assessment (mean 2.26 years; 55%) and in the past 30 days (69%). Participants reported low levels of depression and psychological distress. Positive associations between depression and opioid craving with past 30-day opioid misuse and delay discounting, and negative associations between quality of life and treatment effectiveness with these outcomes were observed.

CONCLUSIONS

This study examined longer term OUD recovery outcomes. Participants reported high levels of abstinence from opioids and psychosocial functioning. These encouraging results highlight the multidimensional nature of recovery from OUD, and further support the effectiveness of buprenorphine as an OUD treatment.

Attitudes toward opioid use disorder pharmacotherapy among recovery community center attendees

BACKGROUND

Despite their proven efficacy, medications for opioid use disorder (MOUD) are underutilized. Negative beliefs and attitudes toward MOUD are quite common, yet rapidly expanding recovery community centers (RCCs) may offer a promising venue for fostering MOUD support as they operate under the maxim, "many pathways [to recovery], all should be celebrated" and are utilized mainly by those with opioid use disorder. The current study provides a first look at MOUD attitudes and their correlates in RCC attendees.

METHODS

The study conducted a cross-sectional survey (N = 320) of recovering adults attending 31 RCCs across New England, assessing demographic, treatment, and recovery-relevant factors, as well attitudes (positive vs. negative) toward the use of agonist and antagonist MOUD. The study used frequencies and confidence intervals to obtain prevalence estimates for positive and negative attitudes toward agonist and antagonist MOUD, and to examine differences between them. Spearman correlations identified correlates of MOUD attitudes (at p < 0.10), and significant correlates were assessed for unique contributions via multivariable logistic regression.

RESULTS

Positive attitudes were common and more prevalent than negative attitudes for both agonist (positive: 71.4 [66.1, 76.3]%; negative: 28.6 [23.7, 33.9]%) and antagonist (positive: 76.5 [71.4, 81.1]%; negative: 23.5 [18.9, 28.6]%) MOUD, which did not differ. The study identified several correlates of MOUD attitudes at the p < 0.10 level, but only four variables emerged as unique predictors controlling for other correlates. Lifetime history of agonist MOUD treatment was uniquely associated with positive agonist attitudes (p = 0.008), whereas greater social support for recovery was associated with positive antagonist attitudes (p = 0.007). Lower educational attainment was uniquely associated with negative antagonist attitudes (p = 0.005), and a greater degree of spirituality was related to negative attitudes toward both agonists (p = 0.005) and antagonists (p = 0.01).

CONCLUSIONS

Findings reveal very high rates of positive MOUD attitudes among RCC participants, highlighting the potential for this growing tier of recovery support to foster acceptance and peer support for medication-facilitated recovery pathways. Correlates of attitudes further reveal opportunities for facilitating MOUD acceptance within and beyond the RCC network.

Recovery community centers: Characteristics of new attendees and longitudinal investigation of the predictors and effects of participation

OBJECTIVE

Recovery community centers (RCCs) have expanded across the U.S., serving as social "recovery hubs" that increase recovery capital (e.g., employment, housing) by providing resources that clinical care does not provide. While research supports RCCs' general utility, little is known about new participants' characteristics, predictors of engagement, services used, and benefits derived. Greater knowledge would inform the field about RCCs' clinical and public health potential.

METHOD

Prospective, single-group study of individuals (N = 275) starting at RCCs (k = 7) in the northeastern U.S. and reassessed 3 months later regarding the services these individuals used and the benefits they derived (e.g., reduced substance problems, enhanced quality of life [QOL]). Regression and longitudinal models tested theorized relationships.

RESULTS

Participants were mostly young to middle-aged, racially diverse, single, unemployed, men and women, with low education and income, suffering from opioid or alcohol use disorder, with a history of psychiatric problems, low QOL, and prior treatment/mutual-help participation. Attendance varied greatly, but on average, was 1-2 times/week, with greater RCC engagement predicted by Hispanic ethnicity, shorter travel time, prior treatment, lower initial social support, and relatively greater baseline QOL (QOL was low overall). Commonly used and highly valued services included social support infrastructures (e.g., recovery coaching/meetings), and technological and employment assistance. In longitudinal analyses (n = 138), the study observed improvements in duration of abstinence, substance problems, psychological well-being, and QOL, but not in recovery assets.

CONCLUSION

Findings generally are consistent with prior observations that RCCs engage and provide benefits for individuals facing the greatest challenges in terms of clinical pathology and low QOL and resources.

Impact of 12 step mutual help groups on drug use disorder patients across six clinical trials

BACKGROUND

12 step mutual help groups are widely accessed by people with drug use disorder but infrequently subjected to rigorous evaluation. Pooling randomized trials containing a condition in which mutual help group attendance is actively facilitated presents an opportunity to assess the effectiveness of 12 step groups in large, diverse samples of drug use disorder patients.

METHODS

Data from six federally-funded randomized trials were pooled (n = 1730) and subjected to two-stage instrumental variables modelling, and, fixed and random effects regression models. All trials included a 12 step group facilitation condition and employed the Addiction Severity Index as a core measure.

RESULTS

The ability of 12 step facilitation to increase mutual help group participation among drug use disorder patients was minimal, limiting ability to employ two-stage instrumental variable models that correct for selection bias. However, traditional fixed and random effect regression models found that greater 12 step mutual help group attendance by drug use disorder patients predicted reduced use of and problems with illicit drugs and also with alcohol.

CONCLUSION

Facilitating significant and lasting involvement in 12 step groups may be more challenging for drug use disorder patients than for alcohol use disorder patients, which has important implications for clinical work and for effectiveness evaluations. Though selection bias could explain part of the results of traditional regression models, the finding that participation in 12 step mutual help groups predicts lower illicit drug and alcohol use and problems in a large, diverse, sample of drug use disorder patients is encouraging.

One-Stop Shopping for Recovery: An Investigation of Participant Characteristics and Benefits Derived From U.S. Recovery Community Centers

BACKGROUND

Recovery community centers (RCCs) are the "new kid on the block" in providing addiction recovery services, adding a third tier to the 2 existing tiers of formal treatment and mutual-help organizations (MHOs). RCCs are intended to be recovery hubs facilitating "one-stop shopping" in the accrual of recovery capital (e.g., recovery coaching; employment/educational linkages). Despite their growth, little is known about who uses RCCs, what they use, and how use relates to improvements in functioning and quality of life. Greater knowledge would inform the field about RCC's potential clinical and public health utility.

METHODS

Online survey conducted with participants (N = 336) attending RCCs (k = 31) in the northeastern United States. Substance use history, services used, and derived benefits (e.g., quality of life) were assessed. Systematic regression modeling tested a priori theorized relationships among variables.

RESULTS

RCC members (n = 336) were on average 41.1 ± 12.4 years of age, 50% female, predominantly White (78.6%), with high school or lower education (48.8%), and limited income (45.2% <$10,000 past-year household income). Most had either a primary opioid (32.7%) or alcohol (26.8%) problem. Just under half (48.5%) reported a lifetime psychiatric diagnosis. Participants had been attending RCCs for 2.6 ± 3.4 years, with many attending <1 year (35.4%). Most commonly used aspects were the socially oriented mutual-help/peer groups and volunteering, but technological assistance and employment assistance were also common. Conceptual model testing found RCCs associated with increased recovery capital, but not social support; both of these theorized proximal outcomes, however, were related to improvements in psychological distress, self-esteem, and quality of life.

CONCLUSIONS

RCCs are utilized by an array of individuals with few resources and primary opioid or alcohol histories. Whereas strong social supportive elements were common and highly rated, RCCs appear to play a more unique role not provided either by formal treatment or by MHOs in facilitating the acquisition of recovery capital and thereby enhancing functioning and quality of life.

Defining a recovery-oriented cascade of care for opioid use disorder: A community-driven, statewide cross-sectional assessment

BACKGROUND

In light of the accelerating and rapidly evolving overdose crisis in the United States (US), new strategies are needed to address the epidemic and to efficiently engage and retain individuals in care for opioid use disorder (OUD). Moreover, there is an increasing need for novel approaches to using health data to identify gaps in the cascade of care for persons with OUD.

METHODS AND FINDINGS

Between June 2018 and May 2019, we engaged a diverse stakeholder group (including directors of statewide health and social service agencies) to develop a statewide, patient-centered cascade of care for OUD for Rhode Island, a small state in New England, a region highly impacted by the opioid crisis. Through an iterative process, we modified the cascade of care defined by Williams et al. for use in Rhode Island using key national survey data and statewide health claims datasets to create a cross-sectional summary of 5 stages in the cascade. Approximately 47,000 Rhode Islanders (5.2%) were estimated to be at risk for OUD (stage 0) in 2016. At the same time, 26,000 Rhode Islanders had a medical claim related to an OUD diagnosis, accounting for 55% of the population at risk (stage 1); 27% of the stage 0 population, 12,700 people, showed evidence of initiation of medication for OUD (MOUD, stage 2), and 18%, or 8,300 people, had evidence of retention on MOUD (stage 3). Imputation from a national survey estimated that 4,200 Rhode Islanders were in recovery from OUD as of 2016, representing 9% of the total population at risk. Limitations included use of self-report data to arrive at estimates of the number of individuals at risk for OUD and using a national estimate to identify the number of individuals in recovery due to a lack of available state data sources.

CONCLUSIONS

Our findings indicate that cross-sectional summaries of the cascade of care for OUD can be used as a health policy tool to identify gaps in care, inform data-driven policy decisions, set benchmarks for quality, and improve health outcomes for persons with OUD. There exists a significant opportunity to increase engagement prior to the initiation of OUD treatment (i.e., identification of OUD symptoms via routine screening or acute presentation) and improve retention and remission from OUD symptoms through improved community-supported processes of recovery. To do this more precisely, states should work to systematically collect data to populate their own cascade of care as a health policy tool to enhance system-level interventions and maximize engagement in care.