Pathways to heroin dependence: time to re-appraise self-medication

Patterns of care contacts in the final year of life among opioid overdose fatalities in southern Sweden: a latent class analysis

BACKGROUND

Understanding the heterogeneity of opioid overdose fatalities is critical to developing effective preventive interventions. This study examines patterns of care contacts among people who subsequently died from opioid overdose. The aim was to identify distinct groups of deceased individuals, based on their contacts with different care agencies in their last year of life.

METHODS

A retrospective registry study was conducted in Skåne, Southern Sweden. All recorded opioid overdose fatalities during the study period were included, n = 191. Latent class analysis was used to identify patterns of care contacts in the last year of life.

RESULTS

Three distinct classes were identified: "Few care contacts," with limited interaction with any services; "Social service contacts," comprising individuals who predominantly had contacts with the social services and, to a lesser extent, with prison and probation services; and "Numerous care contacts," with extensive contacts with both healthcare and social services. The "few care contacts" class comprises about half of the population. This is an important finding, since this group has not been clearly visible in previous research. The analysis indicates significant gaps in service provision, particularly regarding substance use treatment and mental health support.

CONCLUSIONS

Using a person-centred approach, this article offers a novel way of analysing care contacts among people who subsequently died from opioid overdose. The identification of distinct groups, particularly a large group of people with minimal contact with the community care system, highlights the need for more targeted outreach and support work. Developing targeted interventions in emergency and inpatient care settings may provide an opportunity to reach the group with few care contacts.

Gene × environment effects and mediation involving adverse childhood events, mood and anxiety disorders, and substance dependence

Adverse childhood events (ACEs) contribute to the development of mood and anxiety disorders and substance dependence. However, the extent to which these effects are direct or indirect and whether genetic risk moderates them is unclear. We examined associations among ACEs, mood/anxiety disorders and substance dependence in 12,668 individuals (44.9% female, 42.5% African American/Black, 42.1% European American/white). Using latent variables for each phenotype, we modelled direct and indirect associations of ACEs with substance dependence, mediated by mood/anxiety disorders (the forward or 'self-medication' model) and of ACEs with mood/anxiety disorders, mediated by substance dependence (the reverse or 'substance-induced' model). In a subsample, we tested polygenic scores for the substance dependence and mood/anxiety disorder factors as moderators in the mediation models. Although there were significant indirect paths in both directions, mediation by mood/anxiety disorders (the forward model) was greater than that by substance dependence (the reverse model). Greater genetic risk for substance use disorders was associated with a weaker direct association between ACEs and substance dependence in both ancestry groups (reflecting gene × environment interactions) and a weaker indirect association in European-ancestry individuals (reflecting moderated mediation). We found greater evidence that substance dependence reflects self-medication of mood/anxiety disorders than that mood/anxiety disorders are substance induced. Among individuals at higher genetic risk for substance dependence, ACEs were less associated with that outcome. Following exposure to ACEs, multiple pathways appear to underlie the associations between mood/anxiety disorders and substance dependence. Specification of these pathways could inform individually targeted prevention and treatment approaches.

"You get stuck in it": Young people's accounts of attempting to quit non-medical tramadol use

Aim: Non-medical use of tramadol and other prescription opioid use has become a great concern in many countries, including Sweden. This study examines key components in young people's accounts of attempting to quit drugs, focusing on non-medical use of tramadol. Methods: Repeated qualitative interviews were conducted with 12 individuals aged 19-24 years with experiences of problems related to non-medical tramadol use. The analysis used the concepts of autonomy, competence, and relatedness from self-determination theory. Results: Three themes emerged from the young people's accounts: (1) quitting initiated by parents and professionals; (2) being willing, but unable; and (3) between ambivalence and determination. These themes demonstrate conflicting emotions towards drug use along with a significant external pressure to quit, but also difficulties in quitting due to experiences of dependence, withdrawal symptoms, and mental health issues. For most participants, however, an increasing autonomous will and ability to abstain from drugs gradually developed, with the support from trusted relationships with professionals, family, and friends playing a crucial role. Conclusion: The process of trying to quit non-medical tramadol use can be challenging and involve a complex interaction between willingness and capability, where external influence can be either facilitating or hindering. This study highlights the importance of taking into account young people's own perspectives in treatment efforts, where trust is a key component.

'The Addiction Was Making Things Harder for My Mental Health': A Qualitative Exploration of the Views of Adults and Adolescents Accessing a Substance Misuse Treatment Service

The relationship between substance use and mental health is complex, and both constitute a global public health burden. In the UK, the estimated annual financial costs of alcohol-related harm and illicit drug use are GBP 21.5 billion and GBP 10.7 billion, respectively. This issue is magnified in the North East of England, where treatment access is low and a large proportion of individuals experience socioeconomic deprivation. The present study aimed to explore the experiences of adults and adolescents accessing a substance misuse treatment service in the North East, in order to inform policy makers, commissioners, and providers of substance misuse treatment and prevention. Semi-structured qualitative interviews were conducted with an opportunistic sample of n = 15 adult participants (aged 18 years and over) and n = 10 adolescent participants (aged between 13 and 17 years). Interviews were audio-recorded, transcribed, anonymised, and analysed thematically. Five key themes were identified: (1) initiation of substance use, (2) early life experiences, (3) the bi-directional relationship of mental health and substance use, (4) cessation of substance use, and (5) accessing treatment. Future preventative interventions should focus on providing support to individuals who have been exposed to adverse childhood experiences, with treatment provision for individuals experiencing co-occurring mental health and substance use issues taking a more holistic approach.

“I'm putting a Band-Aid on a bullet hole the only way I know how:” a qualitative study of barriers and facilitators to opioid misuse and recovery in Nevada

Nevada, like the rest of the United States, is undergoing substantial challenges with opioid misuse and overdose deaths, further exacerbated by the COVID-19 pandemic. While much of the attention around opioid overdose prevention is centered on treatment and recovery, it is important to understand the factors that influence initiation of use, and the function opioids play in people’s everyday lives. We conducted qualitative semi-structured individual interviews using purposive and snowball sampling among 35 people across Nevada with a current or prior history of illegal opioid or nonmedical opioid use. Our study aimed to understand why people start to use drugs, why they continue to use, what motivates them to continue to use or to seek treatment, and why individuals maintain recovery or return to use. We found five significant themes as perceived by the participants: that trauma is a risk factor for drug misuse; that the function of opioids in everyday life is a source of temporary relief but highly disruptive in the longer term; that recovery is most often a complicated and nonlinear process; that there are many barriers to accessing services that are both logistical and psychosocial; and that compassion, hope, and having a sense of purpose are crucial to the recovery process. The experiences of the study participants portray opioid use as a rational choice to escape the emotional ramifications of trauma. However, due to the physiological dependence and physical risk of opioids, drug policies that criminalize addiction, societal stigma, and the barriers to timely access of harm reduction, treatment, and recovery services, opioid users often become trapped in a distressing and dangerous cycle. Lastly, respondents indicated that hope, value, belonging, and purpose are powerful factors in cultivating intrinsic motivation for making positive changes and fostering resilience in the recovery process. Opioid misuse services should help meet basic needs and incorporate holistic approaches to recovery that acknowledge past trauma and the complexity of the recovery process.

Are prescription misuse and illicit drug use etiologically distinct? A genetically-informed analysis of opioids and stimulants

BACKGROUND

Drug classes are grouped based on their chemical and pharmacological properties, but prescription and illicit drugs differ in other important ways. Potential differences in genetic and environmental influences on the (mis)use of prescription and illicit drugs that are subsumed under the same class should be examined. Opioid and stimulant classes contain prescription and illicit forms differentially associated with salient risk factors (common route of administration, legality), making them useful comparators for addressing this etiological issue.

METHODS

A total of 2410 individual Australian twins [Mage = 31.77 (s.d. = 2.48); 67% women] were interviewed about prescription misuse and illicit use of opioids and stimulants. Univariate and bivariate biometric models partitioned variances and covariances into additive genetic, shared environmental, and unique environmental influences across drug types.

RESULTS

Variation in the propensity to misuse prescription opioids was attributable to genes (41%) and unique environment (59%). Illicit opioid use was attributable to shared (71%) and unique (29%) environment. Prescription stimulant misuse was attributable to genes (79%) and unique environment (21%). Illicit stimulant use was attributable to genes (48%), shared environment (29%), and unique environment (23%). There was evidence for genetic influence common to both stimulant types, but limited evidence for genetic influence common to both opioid types. Bivariate correlations suggested that prescription opioid use may be more genetically similar to prescription stimulant use than to illicit opioid use.

CONCLUSIONS

Prescription opioid misuse may share little genetic influence with illicit opioid use. Future research may consider avoiding unitary drug classifications, particularly when examining genetic influences.

Sports- and Physical Activity-Related Concussions, Binge Drinking and Marijuana Use among Adolescents: The Mediating Role of Depression and Suicidal Ideation

BACKGROUND

Although past studies have examined the adverse impact of sports- and physical activity-related concussions (SPACs) on health and mental health outcomes, there is a dearth of research investigating the association between SPACs and binge drinking and marijuana use.

OBJECTIVE

The objective of this study is to examine the cross-sectional association between SPACs and binge drinking and marijuana use among adolescents and whether symptoms of depression and suicidal ideation mediate this association.

METHODS

Data for this study came from the 2017 and 2019 National Youth Risk Behavior Survey. An analytic sample of 17,175 adolescents aged 14-18 years (50.2% male) was analyzed using binary logistic regression.

RESULTS

Of the 17,175 adolescents, 13.7% engaged in binge drinking and 19.3% used marijuana 30 days preceding the survey date. Approximately one in seven (14.1%) adolescents had SPACs during the past year. Upon controlling for the effects of other factors, adolescents who had SPACs had 1.74 times higher odds of engaging in binge drinking (AOR = 1.74, p<.001, 95% CI = 1.47-2.06) and 1.42 times higher odds of using marijuana (AOR = 1.42, p<.001, 95% CI = 1.24-1.62) than those who did not have SPACs. Symptoms of depression and suicidal ideation explained 12% of the association between SPACs and binge drinking, and 19% of the association between SPACs and marijuana use.

CONCLUSIONS

Understanding the association between SPACs and substance use and mental health could contribute to early identification of adolescents who may engage in substance use.

Assessing Drug Consumption Rooms and Longer Term (5 Year) Impacts on Community and Clients

BACKGROUND

Drug consumption rooms (DCRs) and supervised injecting facilities (SIFs) provide a safe environment in which people who inject drugs (PWIDs) can inject under hygienic and supervised conditions. Numerous reviews have documented the benefits of these facilities; however, there is a lack of clarity surrounding their long-term effects.

PURPOSE

To conduct, with a systematic approach, a literature review, of published peer-reviewed literature assessing the long-term impacts of DCRs/SIFs.

METHODS

A systematic search of the PubMed and Embase database was performed using the keywords: ("SUPERVISED" OR "SAFE*") AND ("CONSUMPTION" OR "INJECT*" OR "SHOOTING") AND ("FACILITY*" OR "ROOM*" OR "GALLERY*" OR "CENTRE*" OR "CENTER*" OR "SITE*"). Included studies were original articles reporting outcomes for five or more years and addressed at least one of the following client or community outcomes; (i) drug-related harms; (ii) access to substance use treatment and other health services; (iii) impact on local PWID population; (iv) impact on public drug use, drug-related crime and violence; and (v) local community attitudes to DCRs.

RESULTS

Four publications met our inclusion criteria, addressing four of the five outcomes. Long-term data suggested that while the health of PWID naturally declined over time, DCRs/SIFs helped reduce injecting-related harms. The studies showed that DCRs/SIFs facilitate drug treatment, access to health services and cessation of drug injecting. Local residents and business owners reported less public drug use and public syringe disposal following the opening of a DCR/SIF.

CONCLUSION

Long-term evidence on DCRs/SIFs is consistent with established short-term research demonstrating the benefits of these facilities. A relative paucity of studies was identified, with most evidence originating from Sydney and Vancouver. The overall body of evidence would be improved by future studies following outcomes over longer periods and being undertaken in a variety of jurisdictions and models of DCRs/SIFs.

An Overview of the Psychodynamics of Addiction

The author provides an overview of the psychodynamics of addiction, diverging from outdated conceptualizations such as orality and regression, and emphasizing the clinical relevance of the self-medication hypothesis. Rado and Bion paved the way for Khantzian's self-medication hypothesis by describing the drug user's need to escape unpleasure and seek self- containment. The author reviews research corroborating the relevance of the self-medication hypothesis and other relevant constructs such as self-deceptive attempts at adaptation, inability to prioritize self-care or delay gratification, excessive hedonism and novelty seeking, and impulsivity. Adverse childhood experiences, abuse and neglect are known to cause epigenetic changes altering gene expression, which may endure throughout life and be transmitted intergenerationally. Effective psychotherapeutic interventions have the potential to reverse DNA methylation and other epigenetic changes triggered by trauma and co-morbid psychopathology. Lastly, this editorial also introduces the psychodynamically informed clinical recommendations of Baurer and Gottdiener, further described in separate articles in this issue of Psychodynamic Psychiatry.

Early Life Stress and Risks for Opioid Misuse: Review of Data Supporting Neurobiological Underpinnings

A robust body of research has shown that traumatic experiences occurring during critical developmental periods of childhood when neuronal plasticity is high increase risks for a spectrum of physical and mental health problems in adulthood, including substance use disorders. However, until recently, relatively few studies had specifically examined the relationships between early life stress (ELS) and opioid use disorder (OUD). Associations with opioid use initiation, injection drug use, overdose, and poor treatment outcome have now been demonstrated. In rodents, ELS has also been shown to increase the euphoric and decrease antinociceptive effects of opioids, but little is known about these processes in humans or about the neurobiological mechanisms that may underlie these relationships. This review aims to establish a theoretical model that highlights the mechanisms by which ELS may alter opioid sensitivity, thereby contributing to future risks for OUD. Alterations induced by ELS in mesocorticolimbic brain circuits, and endogenous opioid and dopamine neurotransmitter systems are described. The limited but provocative evidence linking these alterations with opioid sensitivity and risks for OUD is presented. Overall, the findings suggest that better understanding of these mechanisms holds promise for reducing vulnerability, improving prevention strategies, and prescribing guidelines for high-risk individuals.

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

BACKGROUND

Experience of childhood maltreatment (CM) is a risk factor for opioid use disorder (OUD). CM is also associated with comorbid mental disorders and poor treatment outcomes among people with OUD. To our knowledge, this is the first systematic review and meta-analysis to estimate the prevalence of CM among people with OUD.

METHODS

We searched MEDLINE, EMBASE, and PsycINFO to identify observational studies that evaluated CM among people with OUD from January 1990 to June 2020. Prevalence of each CM type, sample characteristics, and methodological factors were extracted from each eligible study. Random-effects meta-analyses were used to pool prevalence estimates. Stratified meta-analyses were used to assess heterogeneity.

RESULTS

Of the 6,438 publications identified, 113 studies reported quantitative CM data among people with OUD and 62 studies (k = 62; N = 21,871) were included in primary analyses. Among people with OUD, the estimated prevalence of sexual abuse was 41% (95% CI 36-47%; k = 38) among women and 16% (95% CI 12-20%; k = 25) among men. Among all people with OUD, prevalence estimates were 38% (95% CI 33-44%; k = 48) for physical abuse, 43% (95% CI 38-49%; k = 31) for emotional abuse, 38% (95% CI 30-46%; k = 17) for physical neglect, and 42% (95% CI 32-51%; k = 17) for emotional neglect. Sex, history of injecting drug use, recruitment methods, and method of assessing CM were associated with substantial heterogeneity.

CONCLUSIONS

People with OUD frequently report the experience of CM, supporting the need for trauma-informed interventions among this population. Future research should consider the impact of CM on OUD presentations and when assessment is appropriate, use of validated instruments.

Supportive-Expressive Psychodynamic Psychotherapy for the Treatment of Opioid Use Disorder

The United States is in the midst of an opioid epidemic with over 200,000 deaths per year due to opioid overdoses. There are numerous psychotherapeutic and medication-assisted approaches to treating opioid use disorder, but psychodynamic approaches remain underappreciated and underused. The self-medication hypothesis of substance use disorders is a psychodynamic model, which argues that all substance use disorders serve to defend against intolerable affects. In the case of opioid use disorders, opioids are thought to help defend against intense intolerable feelings of rage and depression associated with trauma. Supportive-expressive psychodynamic psychotherapy is an empirically supported psychodynamic treatment for a wide range of psychological problems, including opioid use disorders. Supportive-expressive psychodynamic psychotherapy focuses on transference analysis using an operationalized conceptualization of transference called the core conflictual relational theme method. This article describes supportive-expressive psychodynamic psychotherapy for opioid use disorders and provides clinical examples of its use in practice. The article describes and illustrates the three phases of supportive-expressive psychodynamic psychotherapy, the formulation of the core conflictual relationship theme, how it is applied when treating people with an opioid use disorder, and how supportive-expressive psychodynamic psychotherapy can be used with other therapies, such as medication-assisted treatments and 12-step programs. Last, this article encourages psychodynamic therapists who are not involved in treating people with an opioid use disorder to engage in treating people with one using supportive-expressive psychodynamic psychotherapy.

COVID-19 and the health of people who use drugs: What is and what could be?

SARS-CoV-2, the virus that causes COVID-19, has changed the world as we know it, and continues to do so. How COVID-19 affects people who use drugs, the environments in which they live, and capacities of response, warrants immediate attention. This special issue begins to map how COVID-19 is altering the health of people who use drugs, including in relation to patterns of drug use, service responses, harms that may relate to drug use, interventions to reduce risk of harms, COVID-19 health, and drug policies. We emphasise the need to envisage COVID-19 and its effects as a matter of intersecting ‘complex adaptive systems’: that is, the impacts of COVID-19 extend beyond the virus and related illness conditions to encompass multiple social, cultural, economic, policy and political effects; and these affect the health of people who use drugs directly as well as indirectly by altering the risk and enabling environments in which they live. We synthesize emergent evidence on the impact of COVID-19 on the health of people who use drugs. A key concern we identify is how to sustain policy and service delivery improvements prompted by COVID-19. We need to maintain an ethos of emergent adaptation and experimentation towards the creation of safer environments in relation to the health of people who use drugs.

Trauma, violence and recovery in the life stories of people who have injected drugs

This paper reports qualitative data about violence and trauma amongst drug injectors in Scotland, collected using a life story method with 55 drug injectors currently in recovery. It focusses on different types of violence and trauma that occurred whilst using drugs. Stories told of very severe and repeated traumas often involving extreme violence. One motive for escalating and continuing drug use was avoidant coping to deaden the emotions and thoughts regarding these traumas. Many traumas were due partly to the criminal drug milieu, so respondents were in a vicious cycle of using opiates and other sedative drugs to cope with the consequences of being involved in a lifestyle of using, supplying and obtaining illegal sedative drugs. Drugs were used as a dynamic method of self-medication or avoidant coping to cope with life in a criminal milieu. Traumatic events were more often described as worsening the lifestyle than as being motives for quitting. Amongst the traumas recounted were many incidents of extreme violence. Using drugs to block the psychological effects of such traumas may help explain why people persist using opiates despite experiencing evident serious harms. Interventions need to recognise this, be trauma-aware and appreciate that violence and trauma have severe adverse effects on drug injectors even when they are themselves hardened and violent.

Situating the Continuum of Overdose Risk in the Social Determinants of Health: A New Conceptual Framework

Policy Points This article reconceptualizes our understanding of the opioid epidemic and proposes six strategies that address the epidemic's social roots. In order to successfully reduce drug-related mortality over the long term, policymakers and public health leaders should develop partnerships with people who use drugs, incorporate harm reduction interventions, and reverse decades of drug criminalization policies.

CONTEXT

Drug overdose is the leading cause of injury-related death in the United States. Synthetic opioids, predominantly illicit fentanyl and its analogs, surpassed prescription opioids and heroin in associated mortality rates in 2016. Unfortunately, interventions fail to fully address the current wave of the opioid epidemic and often omit the voices of people with lived experiences regarding drug use. Every overdose death is a culmination of a long series of policy failures and lost opportunities for harm reduction.

METHODS

In this article, we conducted a scoping review of the opioid literature to propose a novel framework designed to foreground social determinants more directly into our understanding of this national emergency. The "continuum of overdose risk" framework is our synthesis of the global evidence base and is grounded in contemporary theories, models, and policies that have been successfully applied both domestically and internationally.

FINDINGS

De-escalating overdose risk in the long term will require scaling up innovative and comprehensive solutions that have been designed through partnerships with people who use drugs and are rooted in harm reduction.

CONCLUSIONS

Without recognizing the full drug-use continuum and the role of social determinants, the current responses to drug overdose will continue to aggravate the problem they are trying to solve.

Trends in opioid initiation among people who use opioids in three US cities

INTRODUCTION AND AIMS

The increased availability of prescription opioids (PO) and non-medical prescription opioids (NMPO) has fundamentally altered drug markets and typical trajectories from initiation to high-risk use among people who use opioids (PWUO). This multi-site study explores trends in opioid initiation in three US cities and associations with sociodemographic factors, current drug use and overdose risk.

DESIGN AND METHODS

We analysed survey data from a cross-sectional study of PWUO in Baltimore, Maryland (n = 173), Boston, Massachusetts (n = 80) and Providence, Rhode Island (n = 75). Age of first exposure to PO, NMPO and heroin was used to calculate opioid of initiation, and multinomial regression was employed to explore correlates of initiating with each.

RESULTS

Thirty-three percent of PWUO initiated with heroin, 24% with PO, 18% with NMPO and 24% with multiple opioids in their first year of use. We observed a reduction in heroin initiation and gradual replacement with PO/NMPO over time. Women were more likely to initiate with NMPO [relative risk ratio (RRR) 2.4; 95% confidence interval (CI) 1.1, 5.0], PO (RRR 2.2, 95% CI 1.1, 4.4) or multiple opioids (RRR 2.1, 95% CI 1.1, 4.2), than heroin. PWUO initiating with NMPO had significantly higher current benzodiazepine use, relative to those initiating with heroin (RRR 3.2, 95% CI 1.4, 7.4), and a high prevalence of current fentanyl use (30%).

DISCUSSION AND CONCLUSIONS

Our study highlights women and PWUO initiating with NMPO as key risk groups amid the changing landscape of opioid use and overdose, and discusses implications for targeted prevention and treatment.

Opioid use disorder

Opioid use disorder (OUD) is a chronic relapsing disorder that, whilst initially driven by activation of brain reward neurocircuits, increasingly engages anti-reward neurocircuits that drive adverse emotional states and relapse. However, successful recovery is possible with appropriate treatment, although with a persisting propensity to relapse. The individual and public health burdens of OUD are immense; 26.8 million people were estimated to be living with OUD globally in 2016, with >100,000 opioid overdose deaths annually, including >47,000 in the USA in 2017. Well-conducted trials have demonstrated that long-term opioid agonist therapy with methadone and buprenorphine have great efficacy for OUD treatment and can save lives. New forms of the opioid receptor antagonist naltrexone are also being studied. Some frequently used approaches have less scientifically robust evidence but are nevertheless considered important, including community preventive strategies, harm reduction interventions to reduce adverse sequelae from ongoing use and mutual aid groups. Other commonly used approaches, such as detoxification alone, lack scientific evidence. Delivery of effective prevention and treatment responses is often complicated by coexisting comorbidities and inadequate support, as well as by conflicting public and political opinions. Science has a crucial role to play in informing public attitudes and developing fuller evidence to understand OUD and its associated harms, as well as in obtaining the evidence today that will improve the prevention and treatment interventions of tomorrow.

Clinical Correlates of Alcohol Use Disorder in Depressed Patients with Unipolar and Bipolar Disorder

OBJECTIVE

Alcohol use disorder (AUD) is one of the most frequent comorbid conditions in mood disorders. We aimed to examine the relationships between clinical phenotypes of acutely depressed subjects and co-occurring AUD.

METHODS

Clinical assessment including diagnosis of mood disorder and co-occurring AUD, the severity of depressive or manic symptoms, and affective temperaments were conducted in 137 subjects suffering from a major depressive episode. According to the presence of AUD, clinical variables were compared between the two groups. Using binary logistic regression models, the effects of mood symptoms and affective temperaments on the risk of AUD were determined.

RESULTS

Severity of manic symptoms, suicidal ideation, and childhood trauma were higher in the AUD group than in the non-AUD group. Scores for irritable and hyperthymic temperament were higher and the score for anxious temperament was lower in the AUD group. In regression models adjusting confounders, anxious temperament was an independent protector against AUD. On the other hand, the diagnosis of bipolar disorder and the irritable manic symptom dimension increased the risk of AUD.

CONCLUSION

Anxious temperament decreased the AUD risk, whereas irritable manic symptoms increased the risk during depression. AUD in mood disorders may be an expression of manic psychopathology.

Persistence and Subtype Stability of ADHD Among Substance Use Disorder Treatment Seekers

Objective: To examine ADHD symptom persistence and subtype stability among substance use disorder (SUD) treatment seekers. Method: In all, 1,276 adult SUD treatment seekers were assessed for childhood and adult ADHD using Conners' Adult ADHD Diagnostic Interview for Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; CAADID). A total of 290 (22.7%) participants met CAADID criteria for childhood ADHD and comprise the current study sample. Results: Childhood ADHD persisted into adulthood in 72.8% (n = 211) of cases. ADHD persistence was significantly associated with a family history of ADHD, and the presence of conduct disorder and antisocial personality disorder. The combined subtype was the most stable into adulthood (78.6%) and this stability was significantly associated with conduct disorder and past treatment of ADHD. Conclusion: ADHD is highly prevalent and persistent among SUD treatment seekers and is associated with the more severe phenotype that is also less likely to remit. Routine screening and follow-up assessment for ADHD is indicated to enhance treatment management and outcomes.

Changes in psychological well-being among heroin-dependent adolescents during psychologically supported opiate substitution treatment

AIM

Heroin-dependent adolescents demonstrate high rates of comorbid psychological problems. Among heroin-dependent adults, opiate substitution treatment (OST) programmes appear to reduce mental health problems. We sought to examine the impact of OST on psychological well-being in adolescents, as this is unknown.

METHODS

We conducted a prospective study examining psychological well-being in heroin dependent adolescents, aged 18 years or younger, engaged in outpatient psychologically supported OST. Patients were treated with either methadone or buprenorphine. This was complimented with individual key working, counselling (motivational interviewing and cognitive behavioral therapy) and group work focusing on life skills. The Beck Youth Inventory was used to measure psychological well-being at treatment entry and repeated after 4 months of treatment.

RESULTS

Among 55 consecutive treatment episodes, we examined the 32 episodes where the patient persisted with the OST programme. Polysubstance use was the norm at treatment entry. At follow-up, the median doses of methadone and buprenorphine were 50 mgs and 8 mgs, respectively. Only three patients were treated with antidepressant medication. There was significant improvement in the mean depression (65.0 to 57.9, P = 0.001), anxiety (61.7 to 57.0, P = 0.006) and anger (57.8 to 54.6, P = 0.009) subscale scores. The self-concept and disruptive behaviour subscale scores did not improve significantly.

CONCLUSION

In this relatively short-term follow-up, psychosocially assisted OST appears to be associated with improved psychological well-being in heroin-dependent adolescents, especially in the area of depressive and anxiety symptoms.

Evidence that anhedonia is a symptom of opioid dependence associated with recent use

BACKGROUND

Anhedonia is prevalent among substance-dependent populations. The hedonic allostasis model suggests this is due to the effects of addictive substances on neural substrates of reward processing. However, previous research may have been confounded by other factors likely to influence anhedonia, including tobacco use, psychopathology, and history of trauma and other stressors. Thus it remains unclear whether elevated anhedonia in substance-dependent populations is caused by substance use itself, or is due to other correlates of substance dependence.

METHODS

Multivariate analysis of covariance was conducted to test whether opioid-dependent participants' anhedonia scores were elevated, relative to a non-dependent control group, after controlling for psychosocial factors likely to influence anhedonia. Correlational analyses within opioid-dependent participants were also conducted to examine whether anhedonia was associated with recent illicit opioid use or duration of abstinence.

RESULTS

There was a modest, but significant, elevation in anhedonia in opioid-dependent participants, relative to controls (Partial η²=0.034, p=0.041) after controlling for psychosocial variables that were associated with anhedonia. Depressive symptoms and history of post-traumatic stress disorder also remained significantly associated with anhedonia in the adjusted model. Among participants on opioid pharmacotherapy, there were significant associations between frequency of recent illicit opioid use and scores on anhedonia measures (all r_s>0.25, p<0.013), but among abstinent opioid-dependent participants, relationships between duration of abstinence and anhedonia were not significant (all r_s<0.24, p>0.22).

CONCLUSION

These findings support the hypothesis that use of opioids can cause anhedonia, although other psychosocial factors may also contribute to the high prevalence of anhedonia among opioid-dependent populations.

The Role of Gender in Suicidal Ideation among Long-term Opioid Users

OBJECTIVE

This study aims to examine factors associated with suicidal ideation among people with opioid dependence and to explore whether these factors are gender-specific.

METHODS

Cross-sectional data were collected among long-term opioid-dependent individuals ( n = 176; 46.0% women). Lifetime histories of suicidal ideation were measured using the Composite International Diagnostic Interview, and additional data were collected regarding sociodemographic characteristics, drug use, health, and adverse life events. Multivariable logistic regression was used to determine the relationships between these variables and suicidal ideation for the full study sample and separately for women and men to explore the potential role of gender.

RESULTS

A total of 43.8% ( n = 77) of participants reported a lifetime history of suicidal ideation. Among those with suicidal ideation, 49.3% were women and the overall average age of first ideation was 19.82 years (SD, 11.66 years). Results from multivariable analyses showed that a history of depression, anxiety, and childhood emotional neglect and the number of lifetime traumatic events were significantly associated with higher odds of suicidal ideation. The gender-based analysis suggested that histories of depression and anxiety remained independently associated with lifetime suicidal ideation among women, whereas for men, childhood emotional neglect and the number of lifetime potentially traumatic events were independently associated with lifetime suicidal ideation.

CONCLUSIONS

This study offers a critical first step to understanding factors associated with suicidal ideation among long-term opioid-dependent men and women and the potential importance of gender-sensitive approaches for suicidal behavior interventions. These data inform further research and clinical opportunities aiming to better respond to the psychological health needs of this population.

Traumatic experiences, alexithymia, and Internet addiction symptoms among late adolescents: A moderated mediation analysis

The association between traumatic experiences, alexithymia, and substance abuse is well established. Less is known about the role of traumatic experiences and alexithymia in the onset and maintenance of Internet-related disorders. In the present study, self-report measures on traumatic experiences, alexithymia, and problematic Internet use were administered to 358 high school students (57% females) aged 18-19years old, to test whether alexithymic traits mediated the relationship between traumatic experiences and Internet addiction symptoms, and whether gender moderated the proposed mediation in the sample. While partial mediation occurred in the entire sample, gender directly affected the relationship between the investigated constructs: Internet addiction symptoms were independently related to traumatic experiences among males, and to alexithymic traits among females. Therefore, the results of this study suggest that trauma memories among males, and problems with affect regulation among females, may increase the risk of problematic Internet use during late adolescence. Such findings might have relevant implications to inform any treatment plan for late adolescent students who are overinvolved with online activities, pointing out that tailored approaches to their problems and difficulties are particularly needed in clinical practice.

Non-medical use of olanzapine by people on methadone treatment

Aims and method We examined non-medical use (NMU) of olanzapine among adults on methadone treatment. Information was collected on patient demographics and NMU of olanzapine. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) was administered to assess risk among current users of olanzapine. Results Ninety-two clients participated and 30% reported lifetime history of NMU of olanzapine. Nine people reported doses of 30 mg or higher on a typical day of use, with three typically using 100 mg. The most common reasons for use were to relieve anxiety and to aid sleep, but a quarter used it to 'get stoned'. Eleven participants (12%) reported NMU of olanzapine in the preceding month. Eight completed the ASSIST with four scoring in the high-risk zone. Clinical implications Self-medication is the dominant motivator for NMU of olanzapine, but hedonic motivations also occur. A small minority show features of dependency. All doctors should be aware of the potential NMU of olanzapine, especially among patients with history of addiction.

Abnormal interhemispheric resting state functional connectivity of the insula in heroin users under methadone maintenance treatment

Abnormal interhemispheric functional connectivity is attracting more and more attention in the field of substance use. This study aimed to examine 1) the differences in interhemispheric functional connections of the insula with the contralateral insula and other brain regions between heroin users under methadone maintenance treatment (MMT) and healthy controls, and 2) the association between heroin users' interhemispheric insular functional connectivity using resting functional magnetic resonance imaging (fMRI) and the results of urine heroin analysis. Sixty male right-handed persons, including 30 with heroin dependence under MMT and 30 healthy controls, were recruited to this study. Resting fMRI experiments and urine heroin analysis were performed. Compared with the controls, the heroin users had a significantly lower interhemispheric insular functional connectivity. They also exhibited lower functional connectivity between insula and contralateral inferior orbital frontal lobe. After controlling for age, educational level and methadone dosage, less deviation of the interhemispheric insula functional connectivity was significantly associated with a lower risk of a positive urine heroin analysis result. Our findings demonstrated that the heroin users under MMT had abnormal long-range and interhemispheric resting functional connections. Those with a less dysfunctional interhemispheric insula functional connectivity had a lower risk of a positive urine heroin test.

Further evidence of self-medication: personality factors influencing drug choice in substance use disorders

According to Khantzian's (2003) self-medication hypothesis (SMH), substance dependence is a compensatory means to modulate affects and self-soothe in response to distressing psychological states. Khantzian asserts: (1) Drugs become addicting because they have the power to alleviate, remove, or change human psychological suffering, and (2) There is a considerable degree of specificity in a person's choice of drugs because of unique psychological and physiological effects. The SMH has received criticism for its variable empirical support, particularly in terms of the drug-specificity aspect of Khantzian's hypothesis. We posit that previous empirical examinations of the SMH have been compromised by methodological limitations. Also, more recent findings supporting the SMH have yet to be replicated. Addressing previous limitations to the research, this project tested this theory in a treatment sample of treatment-seeking individuals with substance dependence (N = 304), using more heterogeneous, personality-driven measures that are theory-congruent. Using an algorithm based on medical records, individuals were reliably classified as being addicted to a depressant, stimulant, or opiate by two independent raters. Theory-based a priori predictions were that the three groups would exhibit differences in personality characteristics and emotional-regulation strategies. Specifically, our hypotheses entailed that when compared against each other: (1) Individuals with a central nervous system (CNS) depressant as drug of choice (DOC) will exhibit defenses of repression, over-controlling anger, and emotional inhibition to avoid acknowledging their depression; (2) Individuals with an opiate as DOC will exhibit higher levels of aggression, hostility, depression, and trauma, greater deficits in ego functioning, and externalizing/antisocial behavior connected to their use; and (3) Individuals with a stimulant as DOC will experience anhedonia, paranoia, have a propensity to mania, and display lower levels of emotional inhibition. MANOVAs were used to test three hypotheses regarding drug group differences on the personality variables that were in keeping with the SMH. The MANOVAs for Hypothesis I (Depressant group) and Hypothesis II (Opiate group) were statistically significant. Findings partially support the SMH, particularly in its characterization of personality functioning in those addicted to depressants and opiates.

Understanding How People with Mental Health Difficulties Experience Substance Use

BACKGROUND

Quantitative studies dominate research exploring reasons for substance use and experiences of substance use by people with mental health difficulties. This limits the depth of understanding which can be gained about these experiences.

OBJECTIVES

In the present article, we synthesized current qualitative research in this area to provide enhanced theoretical knowledge of these experiences.

METHODS

Following a systematic literature search, we identified 12 studies which explored how people with mental health difficulties experienced using substances, and which met additional inclusion criterion. We used Noblit and Hare's metaethnographic approach to qualitatively synthesize these studies.

RESULTS

Synthesis led to the development of two themes; "substance use mediates acceptance and social inclusion" and "substance use provides perceived opportunities for control and power."

CONCLUSIONS/IMPORTANCE

The findings suggest that in the studies reviewed people's motivation for substance use was embedded in social and psychological contexts. It indicated that substance use could provide perceived benefits such as mediating the impact of mental health stigma, enabling the development of alternative identities, increasing their sense of power and providing opportunities for social inclusion. Mental health and substance use workers should therefore aim to develop alternative opportunities for people with co-occurring disorders to gain such benefits, and seek to challenge mental health stigma.

Psychotropic induced sexual dysfunction for people with a dual diagnosis

Purpose

– The purpose of this paper is: first, to consider the reported problems in sexual function caused by psychotropic medication. Second, the complex undertaking of completing an assessment of sexual functioning. Third, the role of the pharmaceutical industry is explored. Finally, implications for future research and practice are suggested.

Design/methodology/approach

– As a commentary this paper draws on the available literature to synthesise what is already known about the relationship between psychoactive substances and sexual functioning.

Findings

– The limited literature and lack of research attention given to psychotropic induced sexual dysfunction limits our collective understanding of how many people are affected and in what way.

Research limitations/implications

– A greater focus on psychotropic induced sexual dysfunction is needed for people with a dual diagnosis. There has been an over reliance on single case studies and self-reporting. Large scale epidemiological investigation would help understand the extent and nature of the problem more fully. The demographic shift particularly in relation to an ageing population should be considered as psychotropic substances effect individuals in different ways as they grow older.

Practical implications

– There is scope for workers to engage more fully in a conversation with clients about their experience of using psychotropic substances and how this has impacted their sexual functioning. The literature suggests that clients want to talk about this issue but staff are unwilling or unable to discuss the topic.

Originality/value

– To the authors’ knowledge this is the first paper that draws on the available literature to explore the known and likely implications of psychotropic induced sexual dysfunction for this client group.

Comparison of outcomes after 3-month methadone maintenance treatment between heroin users with and without HIV infection: a 3-month follow-up study

Background

The aim of this study was to compare the changes in primary (heroin use-related) and secondary (depressive symptoms and quality of life, QOL) outcome indicators of 3-month methadone maintenance treatment (MMT) between heroin users with and without HIV infection.

Methods

A total of 242 intravenous heroin-dependent individuals (30 with and 212 without HIV infection) receiving MMT were recruited. Primary (severity of heroin dependence, harm caused by heroin use and current heroin use) and secondary (depressive symptoms and QOL) outcome indicators were determined before and after receiving 3-month MMT. Changes in primary and secondary outcome indicators between the two groups were compared using mixed-model analysis.

Results

Heroin users both with and without HIV infection showed significant improvement in three primary outcome indicators after 3-month MMT, and there was no difference in the changes of these primary outcome indicators between the two groups. However, improvements in depressive symptoms and the physical domain of QOL among HIV-infected heroin users were poorer than in those without HIV infection.

Conclusions

The results of this study indicated that heroin users with HIV infection did improve in the primary but not the secondary outcomes after 3-month MMT.

Does adolescent's exposure to parental intimate partner conflict and violence predict psychological distress and substance use in young adulthood? A longitudinal study

Little is known about the extent to which parental conflict and violence differentially impact on offspring mental health and substance use. Using data from a longitudinal birth cohort study this paper examines: whether offspring exposure to parental intimate partner violence (involving physical violence which may include conflicts and/or disagreements) or parental intimate partner conflict (conflicting interactions and disagreements only) are associated with offspring depression, anxiety and substance use in early adulthood (at age 21); and whether these associations are independent of maternal background, depression and anxiety and substance use. Data (n=2,126 women and children) were taken from a large-scale Australian birth-cohort study, the Mater University of Queensland Study of Pregnancy (MUSP). IPC and IPV were measured at the 14-year follow-up. Offspring mental health outcomes--depression, anxiety and substance use--were assessed at the 21-year follow-up using the Composite International Diagnostic Interview (CIDI). Offspring of women experiencing IPV at the 14-year follow-up were more likely to manifest anxiety, nicotine, alcohol and cannabis disorders by the 21-year follow-up. These associations remained after adjustment for maternal anxiety, depression, and other potential confounders. Unlike males who experience anxiety disorders after exposure to IPV, females experience depressive and alcohol use disorders. IPV predicts offspring increased levels of substance abuse and dependence in young adulthood. Gender differences suggest differential impact.

The association of childhood physical abuse with the onset and extent of drug use among regular injecting drug users

AIMS

To determine whether childhood physical abuse (CPA) histories were associated with age of onset of psychoactive substance use and injecting, and the extent of polydrug use among injecting drug users (IDU).

DESIGN

Cross-sectional.

SETTING

Sydney, Australia.

PARTICIPANTS AND MEASUREMENTS

A total of 300 IDU were administered a structured interview examining the prevalence and severity of CPA and drug use histories.

FINDINGS

Of the participants, 40.3% had experienced severe abuse (SA), 34.0% mild-moderate abuse (MMA) and 25.7% no abuse history (NA). After controlling for other variables, a history of severe CPA was a significant independent correlate of an earlier age at first alcohol intoxication compared to both the NA (β = -0.23, P < 0.01) and MMA (β = 0.20, P < 0.01) groups. Severe CPA was also a significant independent correlate of an earlier age at first illicit drug use compared to both the NA (β = -0.16, P < 0.05) and MMA (β = -0.15, P < 0.05) groups. In contrast, CPA histories were not independently associated with the onset of injecting drug use. After controlling for potential confounders, both the MMA (β = 0.28, P < 0.001) and SA (β = 0.27, P < 0.001) groups were associated with more extensive life-time polydrug use, but did not differ from each other (P = 0.82). After controlling for potential confounders, both MMA (β = 0.20, P < 0.01) and SA (β = 0.33, P < 0.001) group membership were associated with more extensive recent polydrug use but, again, did not differ significantly from each other (P = 0.08).

CONCLUSIONS

Severe childhood physical abuse severity is associated with an earlier initiation into drug use. Any level of abuse is associated with more extensive life-time and recent polydrug use.

Childhood physical abuse, non-suicidal self-harm and attempted suicide amongst regular injecting drug users

BACKGROUND

Childhood physical abuse (CPA), non-suicidal self-harm and attempted suicide are all highly prevalent amongst injecting drug users (IDU). This paper reported on the association of CPA with self-harm and attempted suicide.

METHODS

Cross-sectional study, with 300 IDU administered a structured interview examining the prevalence of CPA, non-suicidal self-harm and suicide attempts.

RESULTS

CPA was reported by 74.3%, and severe CPA by 40.3%. A history of non-suicidal self-harm was reported by 23.7%, and 25.7% had attempted suicide. Non-suicidal self-harm preceded the suicide attempt in 83.3% of cases where both had occurred. Independent correlates of non-suicidal self-harm were: female gender (OR 3.62), avoided home due to conflict (OR 2.28) and more extensive polydrug use (OR 1.32). Independent correlates of attempted suicide were: severe CPA (OR 3.18), frequent CPA (OR 2.54), avoided home due to conflict (OR 3.95), female gender (OR 2.99), a positive screen for Conduct Disorder (OR 3.53), and more extensive polydrug use (OR 1.52).

CONCLUSIONS

Those presenting to treatment agencies are highly likely to have a history of CPA, that may still influence their behaviours. Screening for histories of CPA and non-suicidal self-harm appears warranted when determining suicide risk for this population. At the population level, reductions in the rate of CPA, could possibly reduce the rate of subsequent suicidality.

The behavioral effects of acute Δ⁹-tetrahydrocannabinol and heroin (diacetylmorphine) exposure in adult zebrafish

The use of psychotropic drugs in clinical and translational brain research continues to grow, and the need for novel experimental models and screens is becoming widely recognized. Mounting evidence supports the utility of zebrafish (Danio rerio) for studying various pharmacological manipulations, as an alternative model complementing the existing rodent paradigms in this field. Here, we explore the effects of acute 20-min exposure to two commonly abused psychotropic compounds, Δ(9)-tetrahydrocannabinol (THC) and heroin, on adult zebrafish behavior in the novel tank test. Overall, THC administration (30 and 50 mg/L) produces an anxiogenic-like reduction of top swimming, paralleled with a slower, continuous bottom swimming. In contrast, heroin exposure (15 and 25 mg/L) evoked a hyperlocomotor response (with rapid bouts of bottom swimming and frequent 'bouncing' motions) without altering anxiety-sensitive top/bottom endpoints. The behavioral effects of these two compounds in zebrafish seem to parallel the respective rodent and human findings. Collectively, this emphasizes the growing significance of novel emerging aquatic models in translational drug abuse research and small molecule screening.