The added risk of opioid problem use among treatment-seeking youth with marijuana and/or alcohol problem use

Contemporary burden and trends of opioid-overdose mortality in New York State

BACKGROUND

Limited research exists on contemporary opioid overdose mortality burden and trends in New York State, with most studies focusing on New York City. This study aimed to assess opioid overdose burden and death trends in New York State by age, sex, race/ethnicity, geographic area, opioid type, and overdose intent from 1999 to 2020.

METHODS

Mortality data were obtained from the Centers for Disease Control and Prevention's WONDER database. Opioid overdose decedents were identified using relevant International Classification of Diseases, 10th Revision codes. Joinpoint regression analyzed trends, estimating annual and average annual percentage changes in age-adjusted mortality rates (AAMR). 95% confidence intervals were derived using the Parametric Method.

RESULTS

From 1999 to 2020, New York State recorded 34,109 opioid overdose deaths (AAMR = 7.9 per 100,000 persons; 95% CI: 7.8-7.9). The overall trend increased by 12.6% per year (95% CI: 10.8, 14.4) from 2004 to 2020. Subgroups exhibited varying trends, with an 11.1% yearly increase among Non-Hispanic White persons from 2007 to 2020 (95% CI: 9.0, 13.2), a 24.6% annual rise among Non-Hispanic Black persons from 2012 to 2020 (95% CI: 17.7, 31.8), and an 18.3% increase yearly among Hispanic individuals from 2011 to 2020 (95% CI: 14.0, 22.9). Recent trends have worsened in both males and females, across all age groups, in both New York City (NYC) and areas outside NYC, and for heroin, natural and semisynthetic opioids, and synthetic opioids.

CONCLUSIONS

Opioid overdose mortality in New York State has worsened significantly in the last two decades. Further research is essential to identify driving factors for targeted public health interventions.

Psychosocial problems and high amount of opioid administration are associated with opioid dependence and abuse after first exposure for chronic pain patients

Controversy surrounding the use of opioids for the treatment and the unique characteristics of chronic pain heighten the risks for abuse and dependence; however, it's unclear if higher doses of opioids and first exposure are associated with dependence and abuse. This study aimed to identify patients who developed dependence or opioid abuse after exposed to opioids for the first time and what were the risks factors associated with the outcome. A retrospective observational cohort study analyzed 2,411 patients between 2011 and 2017 who had a diagnosis of chronic pain and received opioids for the first time. A logistic regression model was used to estimate the likelihood of opioid dependence/abuse after the first exposure based on their mental health conditions, prior substance abuse disorders, demographics, and the amount of MME per day patients received. From 2,411 patients, 5.5 % of the patients had a diagnosis of dependence or abuse after the first exposure. Patients who were depressed (OR = 2.09), previous non-opioid substance dependence or abuse (OR = 1.59) or received greater than 50 MME per day (OR = 1.03) showed statistically significant relationship with developing opioid dependence or abuse, while age (OR = -1.03) showed to be a protective factor. Further studies should stratify chronic pain patients into groups who is in higher risk in developing opioid dependence or abuse and develop alternative strategies for pain management and treatments beyond opioids. This study reinforces the psychosocial problems as determinants of opioid dependence or abuse and risk factors, and the need for safer opioid prescribing practices.

Examination of Correlates of OUD Outcomes in Young Adults: Secondary Analysis From the XBOT Trial

BACKGROUND AND OBJECTIVES

Opioid use disorder (OUD) treatment outcomes are poorer for young adults than older adults. Developmental differences are broadly implicated, but particular vulnerability factor interactions are poorly understood. This study sought to identify moderators of OUD relapse between age groups.

METHODS

This secondary analysis compared young adults (18-25) to older adults (26+) from a comparative effectiveness trial ("XBOT") that randomized (N = 570) participants to extended-release naltrexone or sublingual buprenorphine-naloxone. We explored the relationship between 25 prespecified patient baseline characteristics and relapse to regular opioid use by age group and treatment condition, using logistic regression.

RESULTS

Young adults (n = 111) had higher rates of 24-week relapse than older adults (n = 459) (70.3% vs 58.8%) and differed on a number of specific characteristics, including more smokers, more intravenous opioid use, and more cannabis use. No significant moderators predicted relapse, in either three-way or two-way interactions.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

No baseline factors were identified as moderating the relationship between age group and opioid relapse, nor any interactions between baseline characteristics, age group, and treatment condition to predict opioid relapse. Poorer treatment outcomes for young adults are likely associated with multiple developmental vulnerabilities rather than any single predominant factor. Although not reaching significance, several characteristics (using heroin, smoking tobacco, high levels of depression/anxiety, or treatment because of family/friends) showed higher odds ratio point estimates for relapse in young adults than older adults. This is the first study to explore moderators of worse OUD treatment outcomes in young adults, highlighting the need to identify predictor variables that could inform treatment enhancements. (Am J Addict 2021;00:1-12).

Drug and sexual HIV-risk behaviors among adolescents and young adults with opioid use disorder

Opioid use disorder (OUD) among adolescents and young adults (youth) is associated with drug use and sexual HIV-related risk behaviors and opioid overdose. This mixed methods analysis assesses risk behaviors among a sample of 15-21-year-olds (N = 288) who were being treated for OUD in a residential drug treatment program in Baltimore, Maryland. Participants were enrolled in a parent study in which they received either extended-release naltrexone (XR-NTX) or Treatment as Usual (TAU), consisting of outpatient counseling with or without buprenorphine, prior to discharge. At baseline, participants were administered the HIV-Risk Assessment Battery (RAB), and clinical intake records were reviewed to determine participants' history of sexual, physical, or other abuse, as well as parental and partner substance use. A sub-sample of study participants completed semi-structured qualitative interviews (N = 35) at baseline, three-, and six-month follow-up periods. This analysis identified gender (e.g., female IRR = 1.63, CI 1.10-2.42, p = .014), the experience of dependence (e.g., previous detoxification IRR = 1.08, CI 1.01-1.15, p = .033) and withdrawal (e.g., severe withdrawal symptoms IRR = 1.41, CI 1.08-1.84, p = .012), and the role of relationships (e.g., using with partner IRR = 2.45, CI 1.15-5.22, p = .021) as influencing high-risk substance use behaviors. Similarly, high-risk sex was influenced by gender (e.g., female IRR = 1.43, CI 1.28-1.59, p < .001), and the role of relationships (e.g., using with partner IRR = 0.78, CI 0.62-0.98, p = .036). These are key targets for future prevention, treatment, and intervention.

Medication Treatments for Youth and Young Adults With Opioid Use Disorder

Opioid use disorder (OUD) and overdose deaths are increasingly prevalent among youth and young adults; however, the evidence-based medication-assisted treatments (MATs) that have U.S. Food and Drug Administration approval for the treatment of adults are not approved for persons aged 16 to 18 years. New guidelines from the American Society of Addiction Medicine provide information on the risks and benefits of MAT with youth and young adults that help guide decision making. Clinical decisions require a thorough physical and psychiatric evaluation, risk/benefit analysis in treatment planning, and collaboration with youth and young adults to engage support systems. The current article presents an overview of the three available maintenance treatments for youth and young adults with OUD. [Journal of Psychosocial Nursing and Mental Health Services, 59(5), 9-13.].

A pilot randomized controlled trial of assertive treatment including family involvement and home delivery of medication for young adults with opioid use disorder

BACKGROUND AND AIMS

Although medications for opioid use disorder (OUD), including extended-release naltrexone (XR-NTX), have demonstrated effectiveness, adherence is often low. We tested the preliminary efficacy of youth opioid recovery support (YORS), a multi-component intervention designed to improve engagement and medication adherence for young adults with OUD.

DESIGN

Single-site randomized controlled trial with 24-week follow-up.

SETTING

Community substance use disorder treatment program in Baltimore, MD, USA.

PARTICIPANTS

Young adults aged 18-26 years enrolled in inpatient/residential OUD treatment intending to pursue outpatient OUD treatment with XR-NTX. Twenty-one participants were randomized to YORS and 20 to treatment as usual (TAU). The analyzed sample was 65.8% male.

INTERVENTION AND COMPARATOR

Components of YORS include: (1) home delivery of XR-NTX; (2) family engagement; (3) assertive outreach; and (4) contingency management for receipt of XR-NTX doses. The comparator was TAU, which consisted of a standard referral to outpatient care following an inpatient stay.

MEASUREMENTS

Primary outcomes were number of XR-NTX doses received over 24 weeks and relapse to opioid use (defined as ≥ 10 days of use within 28 days) at 24 weeks.

FINDINGS

Participants in the YORS condition received more XR-NTX doses [mean = 4.28; standard deviation (SD) = 2.3] compared with those in TAU (mean = 0.70; SD = 1.2), P < 0.01. Participants in the YORS group compared with TAU had lower rates of relapse (61 versus 95%; P < 0.01). Survival analyses revealed group differences on time to relapse with participants in TAU being more likely to relapse sooner compared with participants in the YORS condition [hazard ratio (HR) = 2.72, 95% confidence interval (CI) = 1.26-5.88, P < 0.01].

CONCLUSIONS

The youth opioid recovery support intervention for extended-release naltrexone adherence and opioid relapse prevention among young adults with opioid use disorder appeared to improve treatment and relapse outcomes compared with standard treatment.

Young Adults Have Worse Outcomes Than Older Adults: Secondary Analysis of a Medication Trial for Opioid Use Disorder

PURPOSE

Young adults are disproportionately affected by the current opioid crisis. Although medications for opioid use disorder are broadly effective, with reductions in morbidity and mortality, the particular effectiveness of medications for opioid use disorder among young adults is less well understood.

METHODS

This secondary analysis compared young adults (aged 18-25 years) with older adults (aged ≥26 years) in a large comparative effectiveness trial ("XBOT") that randomized subjects to extended-release naltrexone or sublingual buprenorphine-naloxone for 6 months. Opioid relapse was defined by opioid use over four consecutive weeks or seven consecutive days, using urine testing and self-report.

RESULTS

Among subjects in the intention-to-treat sample (n = 570, all randomized participants), a main effect of age group was found, with higher relapse rates among young adults (70.3%) compared with older adults (58.2%), with an odds ratio of 1.72 (95% confidence interval = 1.08-2.70), p = .02. In the per-protocol sample (n = 474, only participants who started medication), relapse rates were higher among young adults (66.3%) compared with older adults (50.8%), with an odds ratio of 1.91 (95% confidence interval = 1.19-3.06). Among the intention-to-treat sample, survival analysis revealed a significant time-by-age group interaction (p = .01) with more relapse over time in young adults. No significant interactions between age and medication group were detected.

CONCLUSIONS

Young adults have increased rates of relapse compared with older adults, perhaps because of vulnerabilities that increase their risk for treatment dropout and medication nonadherence, regardless of medication assignment. These results suggest that specialized, developmentally informed interventions may be needed to improve retention and successful treatment of opioid use disorder among young adults.

The Roles of Emotion Regulation Difficulties and Impulsivity in the Associations between Borderline Personality Disorder Symptoms and Frequency of Nonprescription Sedative Use and Prescription Sedative/Opioid Misuse

Despite evidence of a strong relationship between BPD and substance use problems in general, little research has examined the associations of BPD symptoms with the misuse of sedatives or opioids, and no studies have explored possible factors that may underlie these associations. Thus, this study examined the relationships of BPD symptoms (i.e., the number of BPD criteria with threshold ratings on a diagnostic interview) to nonprescription sedative use, nonprescription opioid use, and prescription sedative/opioid misuse among 194 patients with alcohol and/or cocaine dependence in a residential substance use disorder treatment facility, as well as the roles of two theoretically-relevant factors in these relationships: emotion regulation (ER) difficulties and impulsivity facets. We found significant positive associations between BPD symptoms and nonprescription sedative use, nonprescription opioid use, and prescription sedative/opioid misuse. We also found significant positive indirect relationships of BPD symptoms to nonprescription sedative use through ER difficulties, ab = .04, 95% CI [.003, .09], and to prescription sedative/opioid misuse through two facets of impulsivity: lack of perseverance, ab = .05, 95% CI [.01, .11], and negative urgency, ab = .03, 95% CI [.002, .07]. Findings highlight the differential relevance of ER difficulties and impulsivity dimensions to the relationships of BPD symptoms to nonprescription sedative use and prescription sedative/opioid misuse, respectively, among patients with alcohol and/or cocaine dependence.

Examining the association between bullying victimization and prescription drug misuse among adolescents in the United States

BACKGROUND

Although studies have examined the association between bullying victimization and adolescent substance behaviors, there is a dearth of research investigating the association between bullying victimization and prescription drug misuse. The objective of this study was to examine the cross-sectional association between bullying victimization and prescription drug misuse among adolescents.

METHODS

Data for this study came from the 2017 Youth Risk Behavior Survey. A sample of 9974 adolescents aged 14-18 years (50.1% female) were analyzed using binary logistic regression with prescription drug misuse as the outcome variable and bullying victimization as the main explanatory variable.

RESULTS

Of the 9,974 adolescents, 13.1% misused prescription drugs. One in ten adolescents were victims of both school bullying and cyberbullying, 5.1% were victims of only cyberbullying, 9% were victims of only school bullying, and 75.8% experienced neither school bullying nor cyberbullying victimization. In the binary logistic regression model, adolescents who experienced both school bullying and cyberbullying victimization had 1.66 times higher odds of misusing prescription drugs (AOR = 1.66, p < .001, 95% CI = 1.34-2.06) and adolescents who experienced only school bullying victimization had 1.30 times higher odds of misusing prescription drugs (AOR = 1.30, p < .05, 95% CI = 1.02-1.64). Being lesbian, gay, or bisexual; feeling sad or hopeless; cigarette smoking; binge drinking; cannabis use; and illicit drug use were statistically significantly associated with prescription drug misuse.

CONCLUSIONS

Understanding the association between bullying victimization and prescription drug misuse could contribute to early identification of adolescents who may misuse prescription drugs.

The utility and impact of the addiction comprehensive health enhancement support system (ACHESS) on substance abuse treatment adherence among youth in an intensive outpatient program

Youth experiencing substance use disorders often are susceptible to relapse because traditional support systems can be expensive, geographically dispersed, operated on limited schedules and lacking in peer support. The continuity of care offered via the digital Addiction Comprehensive Health Enhancement Support System (ACHESS) system holds promise in preventing relapse because of its portability and capability to foster virtually anytime/anywhere, cost-effective access to supportive interventions. The aim of this mixed-methods study was to evaluate the utility and impact of ACHESS on treatment adherence among youth with substance use disorders in an intensive outpatient program in the US Midwest. Data on 28 clients using ACHESS during 2016-17 were compared to retrospective data on 28 carefully-matched others treated without ACHESS during 2014-16. Fifty-four percent of the study group successfully completed treatment as opposed to 42.9% of those in the comparison group. Staff focus group findings highlighted how some features of ACHESS were effectively integrated into the care model and appeared to positively impact outcomes, while other elements of the application offered little utility. We suggest further study of ACHESS among larger samples of youth with substance use disorders in intensive outpatient programs to assess its efficacy in supporting adherence to treatment.

Trends in Single, Dual, and Poly Use of Alcohol, Cigarettes, and Marijuana Among US High-School Students: 1991-2017

Objectives. To evaluate trends in patterns (single, dual, or poly) of current use of alcohol, cigarettes, and marijuana (ACM) among youths in the United States. Methods. I used data from the 1991-2017 Youth Risk Behavior Surveys (n = 203 663) to report average annual percentage change (AAPC) and linear trends of single, dual, and poly use of ACM among youths. Results. From 1991 to 2017, the prevalence of marijuana-only use increased from 0.6% to 6.3% (AAPC = 7.4) while the prevalence of use of alcohol only or cigarettes only significantly declined. Dual use of alcohol and marijuana increased from 3.6% to 7.6% (AAPC = 2.4), while dual use of alcohol and cigarettes declined from 11.8% to 1.7% (AAPC = -7.5). The prevalence of poly use of ACM declined from 9.4% to 4.4%. There is an enlarged disparity in use of marijuana only by race/ethnicity with an increase of 11.5% among non-Hispanic Blacks and an increase of 8.1% among Hispanics, compared with an increase of 3.4% among non-Hispanic Whites. Conclusions. The use patterns of ACM among youths have changed with a surge in use of marijuana only, especially among racial/ethnic minorities.

Alcohol and Opioid Use in Chronic Pain: A Cross-Sectional Examination of Differences in Functioning Based on Misuse Status

Opioid misuse is regularly associated with disrupted functioning in those with chronic pain. Less work has examined whether alcohol misuse may also interfere with functioning. This study examined frequency of opioid and alcohol misuse in 131 individuals (61.1% female) prescribed opioids for the treatment of chronic pain. Participants completed an anonymous survey online, consisting of measures of pain, functioning, and opioid and alcohol misuse. Cut scores were used to categorize individuals according to substance misuse status. Individuals were categorized as follows: 35.9% (n = 47) were not misusing either opioids or alcohol, 22.9% (n = 30) were misusing both opioids and alcohol, 38.2% (n = 50) were misusing opioids alone, and only 3.0% (n = 4) were misusing alcohol alone. A multivariate analysis of variance was performed to examine differences in pain and functioning between groups (after excluding individuals in the alcohol misuse group due to the small sample size). Group comparisons indicated that individuals who were not misusing either substance were less disabled and distressed in comparison to those who were misusing opioids alone or both opioids and alcohol. No differences were indicated between the latter 2 groups. Overall, the observed frequency of opioid misuse was somewhat higher in comparison to previous work (approximately 1 out of every 3 participants), and misuse of both alcohol and opioids was common (approximately 1 out of every 5 participants). While these data are preliminary, they do suggest that issues of substance misuse in those with chronic pain extends beyond opioids alone.

PERSPECTIVE

Opioid and alcohol misuse was examined in 131 individuals prescribed opioids for chronic pain. In total, 35.9% were not misusing either, 22.9% were misusing both, 38.2% were misusing opioids, and 3.1% were misusing alcohol. Individuals not misusing either were generally less disabled and distressed compared to those misusing opioids or both.

Alcohol and Opioid Use, Co-Use, and Chronic Pain in the Context of the Opioid Epidemic: A Critical Review

The dramatic increase in opioid misuse, opioid use disorder (OUD), and opioid-related overdose deaths in the United States has led to public outcry, policy statements, and funding initiatives. Meanwhile, alcohol misuse and alcohol use disorder (AUD) are a highly prevalent public health problem associated with considerable individual and societal costs. This study provides a critical review of alcohol and opioid misuse, including issues of prevalence, morbidity, and societal costs. We also review research on interactions between alcohol and opioid use, the influence of opioids and alcohol on AUD and OUD treatment outcomes, respectively, the role of pain in the co-use of alcohol and opioids, and treatment of comorbid OUD and AUD. Heavy drinking, opioid misuse, and chronic pain individually represent significant public health problems. Few studies have examined co-use of alcohol and opioids, but available data suggest that co-use is common and likely contributes to opioid overdose-related morbidity and mortality. Co-use of opioids and alcohol is related to worse outcomes in treatment for either substance. Finally, chronic pain frequently co-occurs with use (and co-use) of alcohol and opioids. Opioid use and alcohol use are also likely to complicate the treatment of chronic pain. Research on the interactions between alcohol and opioids, as well as treatment of the comorbid disorders is lacking. Currently, most alcohol research excludes patients with OUD and there is lack of measurement in both AUD and OUD research in relation to pain-related functioning. Research in those with chronic pain often assesses opioid use, but rarely assesses alcohol use or AUD. New research to examine the nexus of alcohol, opioids, and pain, as well as their treatment, is critically needed.

Exposure to Advertisements and Marijuana Use Among US Adolescents

Introduction

This study examined whether exposure to marijuana advertisements was associated with current marijuana use and frequency of use among US adolescents in grades 8, 10, and 12.

Methods

Weighted estimates of exposure to marijuana advertisements and marijuana use from the 2014 and 2015 Monitoring the Future studies were investigated. Factors associated with the prevalence and frequency of marijuana use were analyzed by using logistic regression and linear regression models, respectively.

Results

Of all respondents (n = 12,988), 13.8% reported marijuana use in the past 30 days. Exposure to marijuana advertisements was prevalent among adolescents, with 52.8% reporting exposure from internet advertisements, 32.1% from television advertisements, 24.1% from magazine or newspaper advertisements, 19.7% from radio advertisements, 19.0% from advertisements on storefronts, and 16.6% from billboards. In the multivariable analysis, current use of marijuana among adolescents was associated with exposure to marijuana advertisements on storefronts (adjusted odds ratio [OR] = 1.4, P < .001), magazines or newspapers (adjusted OR = 1.6, P < .001), billboards (adjusted OR = 1.4, P = .002), internet (adjusted OR = 1.8, P < .001), television (adjusted OR = 1.4, P < .001) and radio (adjusted OR = 1.7, P < .001). Exposure to marijuana advertisements from the internet was associated with increased use of marijuana (β = 0.3, P = .04).

Conclusion

Exposure to marijuana advertisements was associated with higher odds of current marijuana use among adolescents. Regulations that limit marijuana advertisements to adolescents and educational campaigns on harmfulness of illicit marijuana use are needed.

Home-based delivery of XR-NTX in youth with opioid addiction

Early experience with relapse prevention medications in the treatment of opioid addiction in youth has been positive, but barriers to effectiveness and broader adoption have included problems with adherence and retention, and lack of evidence or consensus about implementation. In particular there is relatively little known about either the effectiveness of extended release naltrexone (XR-NTX) in youth, or optimal models of care for its delivery. The purpose of this study is to report on a pilot initiative to improve the effectiveness of XR-NTX by delivering doses at home with assertive outreach to patients enrolled in a community treatment outpatient program. This is a naturalistic case series based on retrospective chart abstractions of 14 young adults (mean age=20.5), who enrolled in the pilot program, and in particular, the 9 who received home-based doses of XR-NTX. They are compared to a historical group of patients (n=21) prior to the pilot, who were referred to receive standard clinic-based doses of XR-NTX. Home-based administration was viewed favorably by patients and families. Although the small sample size is not amenable to statistical analysis, patients in the home based group, compared to the historical clinic-based group, received a greater number of doses overall and over 16 weeks of treatment, had longer retention, and attended similar numbers of clinic-based counseling sessions. These preliminary findings suggest that home-based delivery of XR-NTX and assertive outreach are feasible and promising in this critical target population, may compare favorably to clinic-based treatment as usual, and should be explored further in more rigorous evaluations.

DSM-5 cannabis use disorder, substance use and DSM-5 specific substance-use disorders: Evaluating comorbidity in a population-based sample

Cannabis use disorder (CUD) is frequently associated with concurrent substance use and/or comorbid substance use disorders (SUDs); however there is little specificity with regard to commonly abused individual drug types/classes. This study therefore aimed to provide insight into the degree of these co-occurring relationships across several specific newer and older generation illicit and prescription drugs. 36,309 adults aged 18+ from wave 3 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III) were assessed. Weighted cross-tabulations and multivariable logistic regression analyses were used to evaluate comorbidity between current DSM-5 CUD, substance use and DSM-5 SUD. Current DSM-5 CUD is associated with greater lifetime use of all examined drug classes, and previous 12-month use of several newer-class illicit and prescription stimulant-based substances (all p< 0.05). Current DSM-5 CUD was similarly associated with increased incidence of a range of DSM-5 SUDs and was independently associated with concurrently reporting current DSM-5; sedative (Adjusted OR= 5.1, 95%CI 2.9-9.0), cocaine (AOR= 9.3, 95%CI 5.6-15.5), stimulant (AOR= 4.3, 95%CI 2.3-7.9), club drug (AOR= 16.1, 95%CI 6.3-40.8), opioid (AOR= 4.6, 95%CI 3.0-6.8) and alcohol-use disorder (AOR= 3.0, 95%CI 2.5-3.7); but not heroin or 'other' drug use disorder (both p>0.05). High comorbidity exists between DSM-5 CUD and many specific DSM-5 SUDs. Newer-class illicit and prescription stimulant-based drug use disorders are overrepresented among those with DSM-5 CUD. These findings underscore the need for tailored treatment programs for those presenting with DSM-5 CUD, and for greater treatment specification where poly-drug use is evident.

Adolescent Community Reinforcement Approach implementation and treatment outcomes for youth with opioid problem use

BACKGROUND

This paper compares adolescents with primary opioid problem use (OPU) to those with primary marijuana or alcohol problem use (MAPU) who received up to six months of Adolescent Community Reinforcement Approach (A-CRA), an empirically supported treatment.

METHODS

Intake clinical characteristics, treatment implementation measures, and clinical outcomes of two substance problem groups (OPU and MAPU) were compared using data from 1712 adolescents receiving A-CRA treatment. Data were collected at intake and 3, 6, and 12 months post-intake.

RESULTS

At intake, adolescents in the OPU group were more likely than those in the MAPU group to be Caucasian, older, female, and not attending school; report greater substance and mental health problems; and engage in social and health risk behaviors. There was statistical equivalence between groups in rates of A-CRA treatment initiation, engagement, retention, and satisfaction. Both groups decreased significantly on most substance use outcomes, with the OPU group showing greater improvement; however, the OPU group had more severe problems at intake and continued to report higher frequency of opioid use and more days of emotional problems and residential treatment over 12 months.

CONCLUSIONS

The feasibility and acceptability of A-CRA for OPUs was demonstrated. Despite significantly greater improvement by the OPU group, they did not improve to the level of the MAPU group over 12 months, suggesting that they may benefit from A-CRA continuing care up to 12 months, medication to address opioid withdrawal and craving, and the inclusion of opioid-focused A-CRA procedures.

Treating Mental Health and Substance Use Disorders in Adolescents: What Is on the Menu?

Specific treatments targeting adolescents with substance use disorders (SUDs) have been developed over the last couple of decades. Despite these developmentally tailored treatments, long-term abstinence rates remain relatively low among adolescents receiving care. Research over the last decade has increasingly focused on adolescents with comorbid substance use and psychiatric disorders, in recognition of the barriers caused by inadequate treatment of co-occurring psychiatric disorders. Treatments targeting dually diagnosed youth are now regarded as essential to improving SUD treatment outcomes, but remain underutilized. A variety of treatment modalities such as behavioral therapy, family therapy, 12-step groups, motivational interviewing, contingency management, and combinations of these interventions have been modified for adolescents. In this article, we review the research on these treatments, as they apply to dually diagnosed youth. Furthermore, we explore the evidence for various treatments targeting comorbid SUD, specific to the presence of externalizing or internalizing disorders. The current evidence base supports the importance of integrated treatment targeting both SUD and psychiatric disorders simultaneously. High-quality treatment programs offering combinations of behavioral and family therapy, particularly with motivational interviewing and contingency management, are particularly well supported. In addition, we review various psychotropic medication treatments that have also been studied in conjunction with adolescent SUD treatment. Finally, we review research on post-treatment, supportive care that has been shown to improve long-term SUD outcomes. Recently conceptualized modular treatments, which offer personalized combinations of evidence-based treatments for specific disorders, have been proposed as a means of improving outcomes. Future research on modular programs must test the efficacy of individualized treatments when applied to combinations of psychiatric and SUDs in adolescents.

Access to substance use treatment among young adults who use prescription opioids non-medically

Background

Non-medical prescription opioid (NMPO) use is a substantial public health problem in the United States, with 1.5 million new initiates annually. Only 746,000 people received treatment for NMPO use in 2013, demonstrating substantial disparities in access to treatment. This study aimed to assess correlates of accessing substance use treatment among young adult NMPO users in Rhode Island, a state heavily impacted by NMPO use and opioid overdose.

Methods

This analysis uses data from a study of 200 Rhode Island residents aged 18 to 29 who reported NMPO use in the past 30 days. We compared individuals who had ever successfully enrolled in a substance use treatment program without ever facing barriers, individuals who had ever attempted to enroll but were unable, and individuals who never attempted to enroll. We used multinomial logistic regression to determine the independent correlates of never attempting and unsuccessfully attempting to access substance use treatment.

Results

Among 200 participants, the mean age was 24.5, 65.5% were male, and 61.5% were white. Nearly half (45.5%) had never attempted to enroll in substance use treatment, while 35.0% had successfully enrolled without ever facing barriers and 19.5% were unsuccessful in at least one attempt to enroll. In multivariable models, non-white participants were more likely to never have attempted to enroll compared to white participants. Previous incarceration, experiencing drug-related discrimination by the medical community, and a monthly income of $501 - $1500 were associated with a decreased likelihood of never attempting to enroll. A history of overdose and a monthly income of $501 - $1500 were associated with an increased likelihood of unsuccessfully accessing treatment. The most commonly reported barriers to accessing treatment were waiting lists (n = 23), health insurance not approving enrollment (n = 20), and inability to pay (n = 16).

Conclusions

This study demonstrates significant disparities in access to treatment among young adults who report NMPO use. A history of overdose was shown to correlate with experiencing barriers to substance use treatment utilization. Interventions are needed to reduce drug-related discrimination in clinical settings and to provide mechanisms that link young adults (particularly with a history of overdose) to evidence-based treatment.

Opioid Use Disorders

Opioid use and addiction in adolescents and young adults is a health problem of epidemic proportions, with devastating consequences for youth and their families. Opioid overdose is a life-threatening emergency that should be treated with naloxone, and respiratory support if necessary. Overdose should always be an opportunity to initiate addiction treatment. Detoxification is often a necessary, but never sufficient, component of treatment for OUDs. Treatment for OUDs is effective but treatment capacity is alarmingly limited and under-developed. Emerging consensus supports the incorporation of relapse prevention medications such as buprenorphine and extended release naltrexone into comprehensive psychosocial treatment including counseling and family involvement.

Marijuana and Other Substance Use Among Motor Vehicle Operators: A Latent Class Analysis

OBJECTIVE

The deleterious effect of multiple-substance use on driving performance is well established, but relatively little research has examined the patterns of drug use among multiple-substance users and its relationship to both alcohol use and adverse driving outcomes.

METHOD

The current study used latent class analysis to examine subgroups of substance users among a population of drivers who screened positively for 2 or more of 13 substances other than alcohol (N = 250). A series of logistic regression analyses was conducted to examine demographic predictors of latent class assignment and class association with adverse driving outcomes.

RESULTS

Four distinct subclasses of users were identified among multiple-substance-using drivers: Class 1 consisted of individuals who demonstrated high levels of all substances indicators (5%). The second class demonstrated high levels of marijuana and cocaine use and lower levels of all other substances (27%). The third class screened high for marijuana and nonmedical prescription opiate analgesics use (36%), whereas the last class demonstrated high nonmedical prescription opiate analgesics and benzodiazepine use (32%). Drivers in Class 2 (marijuana and cocaine users) were more likely to be younger and have a positive breath alcohol concentration than drivers in any other class.

CONCLUSIONS

Because multidrug users show dissimilar characteristics, the propensity of researchers to lump all multiple-substance users together may either erroneously attribute the potentially profound impact of those in the marijuana and cocaine use class to all multiple-substance users or dilute their specific contribution to crash risk.

Relapse prevention medications in community treatment for young adults with opioid addiction

BACKGROUND

Despite the well-known effectiveness and widespread use of relapse prevention medications such as extended release naltrexone (XR-NTX) and buprenorphine for opioid addiction in adults, less is known about their use in younger populations.

METHODS

This was a naturalistic study using retrospective chart review of N = 56 serial admissions into a specialty community treatment program that featured the use of relapse prevention medications for young adults (19-26 years old) with opioid use disorders. Treatment outcomes over 24 weeks included retention and weekly opioid-negative urine tests.

RESULTS

Patients were of mean age 23.1, 70% male, 86% Caucasian, 82% with history of injection heroin use, and treated with either buprenorphine (77%) or XR-NTX (23%). The mean number of XR-NTX doses received was 4.1. Retention was approximately 65% at 12 weeks and 40% at 24 weeks, and rates of opioid-negative urine were 50% at 12 weeks and 39% at 24 weeks, with missing samples imputed as positive. There were no statistically significant differences in retention (t = 1.87, P = .06) or in rates of weekly opioid-negative urine tests (t = 1.96, P = .06) between medication groups, over the course of 24 weeks. The XR-NTX group had higher rates of weekly negative urine drug tests for other nonopioid substances (t = 2.83, P < .05) compared with the buprenorphine group. Males were retained in treatment longer and had higher rates of opioid-negative weeks compared with females.

CONCLUSIONS

These results suggest that relapse prevention medications including both buprenorphine and XR-NTX can be effectively incorporated into standard community treatment for opioid addiction in young adults with good results. Specialty programming focused on opioid addiction in young adults may provide a promising model for further treatment development.

Risk factors associated with mental health issues in adolescents: a integrative review

Objective: To identify the risk factors associated with mental health issues in adolescents. Method: An integrative review was conducted in four databases with publications from 2007 to 2013. The terms Adolescent and Mental Health were used to search adequate articles as DeCs/MeSH bases. Results: Publications were found in different journals in different fields of knowledge and the quantitative research was the most frequent. The mental health issues were categorized as individual factors; drug related factors, school factors, family factors, social factors and STDs/Aids related factors. The most addressed category was individual factors, with 23 publications. Conclusion: The integrative review allowed to point important questions to be addressed in preventive actions by the health professional, including the nurse, to create a space that works with risk conditioning factors in adolescents for mental health aggravation.


Emerging adult age status predicts poor buprenorphine treatment retention

Emerging adults (18-25 years old) are often poorly retained in substance use disorder treatment. Office-based buprenorphine often enhances treatment retention among people with opioid dependence. In this study, we examined the records of a collaborative care buprenorphine treatment program to compare the treatment retention rates of emerging adults versus older adults. Subjects were 294 adults, 71 (24%) aged 18-25, followed in treatment with buprenorphine, nurse care management, and an intensive outpatient program followed by weekly psychosocial treatment. Compared to older adults, emerging adults remained in treatment at a significantly lower rate at 3 months (56% versus 78%) and 12 months (17% versus 45%), and were significantly more likely to test positive for illicit opioids, relapse, or drop out of treatment. Further research into factors associated with buprenorphine treatment retention among emerging adults is needed to improve treatment and long-term outcomes in this group.

Marijuana as a predictor of concurrent substance use among motor vehicle operators

Despite the adverse effects associated with marijuana abuse and dependence, marijuana is becoming more common-place in activities such as driving. Previous literature has discussed the high rates of cocaine, opioid and benzodiazepine use among users of marijuana, but no research has addressed the rates of concurrent use among drivers meeting abuse or dependence criteria. Each of these substances may produce effects detrimental to driving safety which may be compounded by concurrent substance use. This research examines rates of marijuana use, abuse, and dependence among an active sample of drivers (N = 7,734) in the 2007 National Roadside Survey. Mean age of participants was 36.89 years, and the majority were male (60.1%) and identified as White (59.2%). Participants who used marijuana but did not meet diagnostic criteria for abuse (n = 165) or dependence (n = 112) were significantly more likely to test positive for all substances than were those who did not use marijuana. Further, those that met criteria for marijuana abuse or dependence were more likely than those who did not meet criteria to test positive for THC, cocaine, and benzodiazepines and THC, cocaine, and opioids, respectively. The current research has implications for policy development and drugged driving interventions.

A comparison of treatment outcomes for adolescent community reinforcement approach participants with and without co-occurring problems

This study examined the relationship between Adolescent Community Reinforcement Approach (A-CRA) participation with treatment engagement, retention, and satisfaction, and with substance use and emotional problem outcomes. Participants had substance use disorders (SUD) only or co-occurring substance use and psychiatric problems. Those with co-occurring problems reported more days of substance use and emotional problems at intake to treatment than those with SUD only. All groups received equivalent exposure to A-CRA during treatment implementation. At the 12-month follow-up, adolescents classified as externalizers (n = 468) or those with both externalizing and internalizing problems (n = 674) had significantly greater improvement in their days of abstinence and substance problems relative to adolescents with substance use disorders only (n = 666). Additionally, adolescents reporting symptoms of internalizing (n = 154), externalizing, or both externalizing and internalizing disorders had significantly greater improvements in days of emotional problems relative to adolescents with SUD only.

Drug refusal skills training does not enhance outcomes of African American adolescents with substance use problems

In prior research by Witkiewitz and colleagues, African American adults receiving refusal skills training (RST) had fewer heavy drinking days and were categorized as having more successful outcomes. This study extends findings to adolescents receiving the Adolescent Community Reinforcement Approach (A-CRA). Propensity score matching was used to create three groups equivalent on baseline characteristics, including: African Americans receiving refusal skills training (AA+RST; n=214), African Americans not receiving RST (AA-RST; n=212), and Caucasians receiving RST (CA+RST; n=214). In propensity weighted regression models that controlled for overall A-CRA exposure, racial group by RST status was not a significant predictor of substance use frequency or abstinence/early remission outcomes. Higher exposure to A-CRA, however, was a significant predictor of both outcomes. Universal receipt of RST may not improve the outcomes of African American adolescents with substance use problems, and outcomes may be driven more by the overall number of A-CRA procedures received.

Predictors of attrition with buprenorphine/naloxone treatment in opioid dependent youth

BACKGROUND

In opioid dependent youth there is substantial attrition from medication-assisted treatment. If youth at risk for attrition can be identified at treatment entry or early in treatment, they can be targeted for interventions to help retain them in treatment.

METHODS

Opioid dependent adolescents and young adults (n=152), aged 15-21, were randomized to 12 weeks (BUP, n=74) or 2 weeks of detoxification (DETOX, n=78) with buprenorphine/naloxone (Bup/Nal), both in combination with 12 weeks of psychosocial treatment. Baseline and early treatment related predictors of treatment attrition were identified in each group using bivariate and multivariate logistic regression.

RESULTS

In the DETOX group 36% left between weeks 2 and 4, at the end of the dose taper, while in the BUP group only 8% left by week 4. In the BUP group, early adherence to Bup/Nal, early opioid negative urines, use of any medications in the month prior to treatment entry, and lifetime non-heroin opioid use were associated with retention while prior 30-day hallucinogen use was associated with attrition. In the DETOX group, only use of sleep medications was associated with retention although not an independent predictor. A broad range of other pre-treatment characteristics was unrelated to attrition.

CONCLUSIONS

Prompt attention to those with early non-adherence to medication or an early opioid positive urine, markers available in the first 2 weeks of treatment, may improve treatment retention. Extended Bup/Nal treatment appeared effective in improving treatment retention for youth with opioid dependence across a wide range of demographics, and pre-treatment clinical characteristics.

Multiple victimization experiences, resources, and co-occurring mental health problems among substance-using adolescents

This study examined the relationship between multiple types of victimization experiences, psychological and social resources, and co-occurring mental health problems among substance-using adolescents. Data for this cross-sectional study were obtained from a multisite research project in which adolescents ages 11-18 years participated in a comprehensive screening program for substance misuse. Multiple types of victimization, low self-efficacy beliefs, lack of support for victimization issues, and available sources of emotional support were positively related to co-occurring mental health problems. These findings suggest that treatment planning and interventions may focus on helping adolescents cope effectively with their victimization experiences and addressing their mental health needs. Particular emphasis may be placed on enhancing self-efficacy and social skills so that adolescents may benefit from their available sources of social support.

Predictors of abstinence: National Institute of Drug Abuse multisite buprenorphine/naloxone treatment trial in opioid-dependent youth

OBJECTIVE

To examine predictors of opioid abstinence in buprenorphine/naloxone (Bup/Nal)-assisted psychosocial treatment for opioid-dependent youth.

METHOD

Secondary analyses were performed of data from 152 youth (15-21 years old) randomly assigned to 12 weeks of extended Bup/Nal therapy or up to 2 weeks of Bup/Nal detoxification with weekly individual and group drug counseling. Logistic regression models were constructed to identify baseline and during-treatment predictors of opioid-positive urine (OPU) at week 12. Predictors were selected based on significance or trend toward significance (i.e., p < .1), and backward stepwise selection was used, controlling for treatment group, to produce final independent predictors at p ≤ .05.

RESULTS

Youth presenting to treatment with previous 30-day injection drug use and more active medical/psychiatric problems were less likely to have a week-12 OPU. Those with early treatment opioid abstinence (i.e., weeks 1 and 2) and those who received additional nonstudy treatments during the study were less likely to have a week-12 OPU and those not completing 12 weeks of treatment were more likely to have an OPU.

CONCLUSIONS

Youth with advanced illness (i.e., reporting injection drug use and additional health problems) and those receiving ancillary treatments to augment study treatment were more likely to have lower opioid use. Treatment success in the first 2 weeks and completion of 12 weeks of treatment were associated with lower rates of OPU. These findings suggest that youth with advanced illness respond well to Bup/Nal treatment and identify options for tailoring treatment for opioid-dependent youth presenting at community-based settings.

CLINICAL TRIAL REGISTRATION INFORMATION

Buprenorphine/Naloxone-Facilitated Rehabilitation for Opioid Dependent Adolescents; http://www.clinicaltrials.gov; NCT00078130.

Adolescent Community Reinforcement Approach outcomes differ among emerging adults and adolescents

One fifth of all public treatment admissions are emerging adults, and few studies have considered whether treatments are developmentally appropriate. This study compares outcomes between adolescents and emerging adults with substance use disorders who received the Adolescent Community Reinforcement Approach (A-CRA). Propensity score matching was used to create a weighted comparison group of adolescents (n = 151) who had similar demographic characteristics, clinical severity, and treatment retention as the group of emerging adults (n = 152). We examined age differences in abstinence and other psychosocial outcomes at the last available follow-up. Emerging adults and adolescents both reduced their substance use at follow-up. However, emerging adults were less likely to be abstinent and in remission and had more days of alcohol use when compared with adolescents. This study's findings are consistent with prior work on emerging adults. Additional research should examine features of interventions that are most effective in addressing the developmental needs of emerging adults.

The role of the c-statistic in variable selection for propensity score models

The applied literature on propensity scores has often cited the c-statistic as a measure of the ability of the propensity score to control confounding. However, a high c-statistic in the propensity model is neither necessary nor sufficient for control of confounding. Moreover, use of the c-statistic as a guide in constructing propensity scores may result in less overlap in propensity scores between treated and untreated subjects; this may require the analyst to restrict populations for inference. Such restrictions may reduce precision of estimates and change the population to which the estimate applies. Variable selection based on prior subject matter knowledge, empirical observation, and sensitivity analysis is preferable and avoids many of these problems.