Extreme marginalization: addiction and other mental health disorders, stigma, and imprisonment

Posttraumatic stress disorder in people who use drugs: syringe services program utilization, treatment need, and preferences for onsite mental health care

BACKGROUND

Syringe services programs (SSPs) are critical healthcare access points for people with opioid use disorder (OUD) who face treatment utilization barriers. Co-locating care for common psychiatric comorbidities, like posttraumatic stress disorder (PTSD), at SSPs may reduce harms and enhance the health of individuals with OUD. To guide the development of onsite psychiatric care at SSPs, we collected quantitative survey data on the prevalence of PTSD, drug use patterns, treatment experiences associated with a probable PTSD diagnosis, and attitudes regarding onsite PTSD care in a convenience sample of registered SSP clients in New York City.

METHODS

Study participants were administered the PTSD Checklist for the DSM-5 (PCL-5) and asked about sociodemographic characteristics, current drug use, OUD and PTSD treatment histories, and desire for future SSP services using a structured interview. Probable PTSD diagnosis was defined as a PCL-5 score ≥ 31.

RESULTS

Of the 139 participants surveyed, 138 experienced at least one potentially traumatic event and were included in the present analysis. The sample was primarily male (n = 108, 78.3%), of Hispanic or Latinx ethnicity (n = 76, 55.1%), and middle-aged (M = 45.0 years, SD = 10.6). The mean PCL-5 score was 35.2 (SD = 21.0) and 79 participants (57.2%) had a probable PTSD diagnosis. We documented frequent SSP utilization, significant unmet PTSD treatment need, and high interest in onsite PTSD treatment.

CONCLUSIONS

Study findings point to the ubiquity of PTSD in people with OUD who visit SSPs, large gaps in PTSD care, and the potential for harm reduction settings like SSPs to reach people underserved by the healthcare system who have co-occurring OUD and PTSD.

Exploration of Psychiatry Residents' Attitudes toward Patients with Substance Use Disorder, Bipolar Disorder and Schizophrenia in Saudi Arabia

Stigmatizing attitudes of psychiatry professionals toward patients with various mental disorders may negatively impact treatment-seeking behaviors. However, in Saudi Arabia, little is known about psychiatry residents' attitudes toward individuals with a specific disease/disorder. Therefore, the purpose of this study was to assess psychiatry residents' attitudes toward patients with substance use disorder (SUD), bipolar disorder and schizophrenia in Saudi Arabia. Data for this cross-sectional study were collected from psychiatry residents (N = 79) in Saudi Arabia with a structured questionnaire containing sociodemographic and attitude-related variables. The 11-item Medical Condition Regard Scale (MCRS) for individuals with three conditions was used to assess participants' attitudes. A linear regression model was fitted to investigate the association. Based on the MCRS (on a scale of 11 to 66), participants' mean attitude scores were 41.59 (SD: 8.09), 54.53 (SD: 5.90) and 54.20 (SD: 6.60) for SUD, bipolar disorder and schizophrenia, respectively. Adjusted regression analysis demonstrated that senior residents, an age ≥ 27 years and a high confidence level were significantly associated with psychiatry residents' positive attitudes toward patients with the three conditions. Psychiatry residents' attitude scores were relatively lower (i.e., negative attitudes) for patients with SUD than for those with bipolar disorder and schizophrenia. Future longitudinal studies are recommended to explore the factors behind psychiatry residents' negative attitudes toward patients with addictive behaviors and mental illnesses.

Racial and Ethnic Disparities in Alcohol-Attributed Deaths in the United States, 1999-2020

The disparities in alcohol-attributed death rates among different racial and ethnic groups in the United States (US) have received limited research attention. Our study aimed to examine the burden and trends in alcohol-attributed mortality rates in the US by race and ethnicity from 1999 to 2020. We used national mortality data from the Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) database and employed the ICD-10 coding system to identify alcohol-related deaths. Disparity rate ratios were calculated using the Taylor series, and Joinpoint regression was used to analyze temporal trends and calculate annual and average annual percentage changes (APCs and AAPCs, respectively) in mortality rates. Between 1999 and 2020, 605,948 individuals died from alcohol-related causes in the US. The highest age-adjusted mortality rate (AAMR) was observed among American Indian/Alaska Natives, who were 3.6 times more likely to die from alcohol-related causes than Non-Hispanic Whites (95% CI: 3.57, 3.67). An examination of trends revealed that recent rates have leveled among American Indians/Alaska Natives (APC = 17.9; 95% CI: -0.3, 39.3) while increasing among Non-Hispanic Whites (APC = 14.3; 95% CI: 9.1, 19.9), Non-Hispanic Blacks (APC = 17.0; 95% CI: 7.3, 27.5), Asians/Pacific Islanders (APC = 9.5; 95% CI: 3.6, 15.6), and Hispanics (APC = 12.6; 95% CI: 1.3, 25.1). However, when the data were disaggregated by age, sex, census region, and cause, varying trends were observed. This study underscores the disparities in alcohol-related deaths among different racial and ethnic groups in the US, with American Indian/Alaska Natives experiencing the highest burden. Although the rates have plateaued among this group, they have been increasing among all other subgroups. To address these disparities and promote equitable alcohol-related health outcomes for all populations, further research is necessary to gain a better understanding of the underlying factors and develop culturally sensitive interventions.

“They’re all struggling as well”: social and economic barriers and facilitators to self-managing chronic illness among marginalized people who use drugs

Purpose

Self-management is recommended for addressing chronic conditions, and self-management programmes improve health behaviours and outcomes. However, social and economic factors have been neglected in self-management research, despite their relevance for marginalized groups. Thus, we aimed to explore barriers and facilitators that influence self-management among socioeconomically marginalized people who use drugs (PWUD).

Methods

Using community-based participatory methods, we developed a qualitative interview guide and conducted peer-led recruitment. Participants were admitted into the study after self-identifying as using non-prescribed drugs, having a chronic health issue, and experiencing socioeconomic marginalization. Data were analysed using reflexive thematic analysis, taking a relational autonomy lens.

Results

Participants highlighted substantial barriers to managing their health issues, mostly stemming from their social and economic environments, such as unstable housing, low income, lack of supportive social networks, and negative healthcare experiences. Participants also described how their ability to self-manage their chronic conditions benefited from specific aspects of social interactions, including close relationships, community connectedness, and engaging in peer support.

Conclusions

Our findings suggest that structural interventions are needed to support self-management among marginalized PWUD, especially stable housing. Self-management supports for PWUD would benefit from including a range of low-barrier community-based options, peer work opportunities, and advocacy for needs.

Podcasts as a Method to Deliver Education on Stigma Surrounding Opioid Use Disorder

The objective of this research was to evaluate the effectiveness of a podcast miniseries to reduce stigma surrounding opioid use disorder (OUD) among student pharmacists. Students in their second and third professional years from two schools of pharmacy listened to five, 10-23 min podcasts incorporated into their coursework. The podcasts highlighted: (1) interviews with OUD professionals and those with lived experiences; (2) types of stigma and how it affects health outcomes; (3) OUD disease state processes, and (4) harm reduction strategies. Surveys assessed changes in perception of OUD and its associated stigma and included free-response and Likert scale questions. Subjects (n = 121) who completed a pre- and post-podcast survey were included. Paired t-tests assessed changes in survey responses from baseline and a content analysis was performed on all free-responses. There was a statistically significant change from baseline for each survey question, demonstrating a decrease in stigma towards OUD. Free-responses were categorized into four learning domains: (1) Impact of stigma on access to care; (2) Compassion and empathy; (3) Resources and support; and (4) Call to action. Podcasts can be an effective tool to reduce student pharmacist stigma associated with OUD.

Resuscitation simulation among people who are likely to witness opioid overdose: Experiences from the SOONER Trial

The opioid crisis is a growing public health emergency and increasing resources are being directed towards overdose education. Simulation has emerged as a novel strategy for training overdose response, yet little is known about training non-clinicians in bystander resuscitation. Understanding the perspectives of individuals who are likely to experience or witness opioid overdose is critical to ensure that emergency response is effective. The Surviving Opioid Overdose with Naloxone Education and Resuscitation (SOONER) study evaluates the effectiveness of a novel naloxone education and distribution tool among people who are non-clinicians and likely to witness opioid overdose. Participants’ resuscitation skills are evaluated using a realistic overdose simulation as the primary outcome of the trial. The purpose of our study is to describe the experience of participants with the simulation process in the SOONER study. We employed a semi-structured debriefing interview and a follow up qualitative interview to understand the experience of participants with simulation. A qualitative content analysis was performed using data from 21 participants who participated in the SOONER study. Our qualitative analysis identified 5 themes and 17 subthemes which described the experience of participants within the simulation process. These themes included realism, valuing practical experience, improving self-efficacy, gaining new perspective and bidirectional learning. Our analysis found that simulation was a positive and empowering experience for participants in the SOONER trial, most of whom are marginalized in society. Our study supports the notion that expanding simulation-based education to non-clinicians may offer an acceptable and effective way of supplementing current opioid overdose education strategies. Increasing the accessibility of simulation-based education may represent a paradigm shift whereby simulation is transformed from a primarily academic practice into a patient-based community resource.

Identification of socially vulnerable cancer patients - development of a register-based index (rSVI)

BACKGROUND

Social vulnerability is a complex construct which is beyond relying on single measures. If socially vulnerable patients should be identified, we need a composite measure capturing the patient's overall circumstances. This study presents the development of a social vulnerability index (rSVI) for cancer patients based on administrative data from population-based registers.

METHODS

All patients, who died from cancer within 5 years after the cancer diagnosis during 2013-2018 (n = 44,187), were identified and divided in four subcohorts according to survival; index cohort surviving 3-5 years (n = 3044 surviving 3-5 years), cohort 1 (n = 27,170 surviving < 1 year), cohort 2 (n = 9450 surviving 1-2 years), and cohort 3 (n = 4523 surviving 2-3 years). Variables from ten registries on health and social issues were linked to each individual patient. Variables of interest were weighted to construct the rSVI using the index-cohort. rSVI was subsequently tested on the three other cohorts for validation.

RESULTS

The rSVI included weighted values for marital status, ethnicity, education, income, unemployment, psychiatric comorbidity, and somatic comorbidity. The validity of the rSVI was supported by the expected trend in proportions of vulnerable patients when applied on the other cohorts. Single social measures appeared insufficient in identification of vulnerable patients when compared with the rSVI.

CONCLUSION

The rSVI provides a tool for identification of socially vulnerable cancer patients using administrative data. The index requires further validation in other patient groups and is tested against other measures of vulnerability. Future perspectives are to use the rSVI as predictor of advanced cancer patients' use of healthcare services.

High Proportion of Blood-Borne and Sexually Transmitted Infections Among People Deprived of Liberty in a Central Male Prison in Thailand: A Cross-Sectional Study 2018-2019

Data are lacking or outdated on burden of HIV, viral hepatitis infection, and sexually transmitted infections such as syphilis among people deprived of liberty in the Asia-Pacific region. We aimed to evaluate the proportion of viral hepatitis B (HBV), hepatitis C (HCV), HIV, and syphilis infections, and factors associated with HCV, HBV, and HIV infection in a central male prison. A cross-sectional study was performed among 1,028 people deprived of liberty from a central male prison in Bangkok, Thailand. People deprived of liberty were screened for HIV, HBV, HCV, and syphilis infections during 2018-2019. HBV and HCV were defined as positive hepatitis B surface antigen and positive anti-HCV antibody, respectively. Proportions (95% confidence interval [CI]) of infections were calculated based on the binomial distribution. HBV proportion was reported for different age groups. Risk factors associated with HCV infections were evaluated by logistic regression model. The median age was 38 (interquartile range, 32-50) years, and 6.9% reported use of injection drugs. The proportion of HIV, HBV, anti-HCV, HCV RNA, and syphilis was 2.9% (95% CI, 1.9-4.1), 6.4% (5-8.1), 5.9% (4.6-7.6), 4.2% (3-5.6), and 4.8% (3.5-6.3), respectively. One (0.1%), 7 (0.6%), and 2 (3%) were co-infected with HIV/HBV, HIV/HCV, and HDV/HBV, respectively. HBV proportion differed across age groups: 3.7% in <30 years, 7% in 31-40 years, 9.7% in 41-50 years, and 5.5% in >50 years. Factors associated with HCV infection were older age, lower education level, previous incarceration, and injection drug use. In multivariable models, older age was associated with HBV infection, and men having sex with men was associated with HIV infection. The proportion of blood-borne infections was higher among males than among the general population. HBV vaccination, routine HCV screening, and treatment with pan-genotypic direct-acting antivirals with minimal specialist requirements should be implemented in Thai prisons.

What Can be Done to Reduce the Public Stigma of Gambling Disorder? Lessons from Other Stigmatised Conditions

Gambling is embedded in Australian cultural history, and perceived as a normal, legitimate leisure activity. Despite this normalisation, people who experience gambling problems are heavily stigmatised which can lead to a variety of harms that extend beyond the individual. The stigma from the general public appears to be based on a stereotype of a typical "problem gambler"-selfish, greedy, impulsive and irresponsible. However, research suggests that people experiencing gambling problems have widely varying characteristics and do not conform to this stereotype. Regardless of whether the stigma is justified, it is both present and problematic. Gamblers experiencing problems delay help-seeking due to feelings of shame and, not unwarranted, expectations of negative judgement because of the heavy stigma associated with the stereotype. As stigma is a primary barrier to treatment and a reason why gambling problems can take longer to acknowledge, it is important to understand and address how stigma can be reduced to minimise the negative consequences of gambling on individuals, their families and friends and the wider community. There is little research on reducing gambling-related stigma, so there is a need to examine strategies used in other stigmatised conditions, such as mental health, to understand the general principles of effective stigma reduction measures. Because gambling disorder is unique, well-hidden and consequently not well understood, there is a need to recognise that techniques used in other domains may differ in their effectiveness within the context of gambling stigma.

The complex neurobiology of resilient functioning after childhood maltreatment

BACKGROUND

Childhood maltreatment has been associated with significant impairment in social, emotional and behavioural functioning later in life. Nevertheless, some individuals who have experienced childhood maltreatment function better than expected given their circumstances.

MAIN BODY

Here, we provide an integrated understanding of the complex, interrelated mechanisms that facilitate such individual resilient functioning after childhood maltreatment. We aim to show that resilient functioning is not facilitated by any single 'resilience biomarker'. Rather, resilient functioning after childhood maltreatment is a product of complex processes and influences across multiple levels, ranging from 'bottom-up' polygenetic influences, to 'top-down' supportive social influences. We highlight the complex nature of resilient functioning and suggest how future studies could embrace a complexity theory approach and investigate multiple levels of biological organisation and their temporal dynamics in a longitudinal or prospective manner. This would involve using methods and tools that allow the characterisation of resilient functioning trajectories, attractor states and multidimensional/multilevel assessments of functioning. Such an approach necessitates large, longitudinal studies on the neurobiological mechanisms of resilient functioning after childhood maltreatment that cut across and integrate multiple levels of explanation (i.e. genetics, endocrine and immune systems, brain structure and function, cognition and environmental factors) and their temporal interconnections.

CONCLUSION

We conclude that a turn towards complexity is likely to foster collaboration and integration across fields. It is a promising avenue which may guide future studies aimed to promote resilience in those who have experienced childhood maltreatment.

Divergent behavioral responses in protracted opioid withdrawal in male and female C57BL/6J mice

Persons suffering from opioid use disorder (OUD) experience long-lasting dysphoric symptoms well into extended periods of withdrawal. This protracted withdrawal syndrome is notably characterized by heightened anxiety and hyperkatifeia. Here, we investigated if an exacerbated withdrawal model of acute morphine dependence results in lasting behavioral adaptation 6 weeks into forced abstinence in C57BL/6J mice. We found that our exacerbated morphine withdrawal paradigm produced distinct alterations in behavior in elevated plus maze (EPM), open field, and social interaction tests in male and female mice. Following protracted withdrawal male mice showed enhanced exploration of the open arms of the EPM, reduced latency to enter the corner of the OF, and a social interaction deficit. In contrast, female mice showed enhanced thigmotaxis in the OF. In both sexes, protracted withdrawal enhanced locomotor behavior in response to subsequent morphine challenge, albeit at different doses. These findings will be relevant for future investigation examining the neural mechanisms underlying these behaviors and will aid in uncovering physiological sex differences in response to opioid withdrawal.

Exploration of Intervention Strategies to Reduce Public Stigma Associated with Gambling Disorder

Stigma associated with gambling disorder is complex, and is a key obstacle that prevents sufferers from seeking early help for their condition. However, little research has addressed how best to reduce gambling stigma. This study explored the effectiveness of video intervention styles, that have been used to reduce public stigma for conditions such as mental illness and substance use disorders. This was done to determine which would be most suitable, considering the unique characteristics of gambling disorder. An online survey of 164 people living in Australia was conducted which examined attitudes toward gamblers experiencing problems before and after an intervention. Participants were randomly allocated to one of three interventions (contact, education, advocacy) or a control video. The study found that each intervention was associated with changes to different components of stigma. Importantly, the education intervention increased labelling, but reduced stereotype endorsement and anger. Advocacy also reduced anger, attributions of character flaws, and anticipated discrimination and recoverability. While these interventions were generally effective at reducing stigma, the contact intervention was mixed, effectively intervening for some aspects of stigma, but increasing stigma on others. No single intervention reduced all aspects of stigma, suggesting that a complementary approach utilising specific elements of each intervention style could be used to deliver relevant information and effectively reduce stigma. Taken together, this suggests that research should be conducted into comprehensive, combined interventions, that include aspects of all three intervention styles, in an attempt to reduce more aspects of stigma simultaneously.

Mental Health Risk Factors and Parole Decisions: Does Inmate Mental Health Status Affect Who Gets Released

Parole decision-the decision to release an incarcerated individual from prison conditionally-is one of the most critical decisions across justice systems around the world. The decision carries with it significant consequences: for the freedom of the individual awaiting release (the parolee); for the safety of the community in which they will return; and for the correctional system overall, especially its organizational capacity. The current study attempts to add to the parole decision-making literature by specifically analyzing the role that mental health factors may play in explaining parole decisions. Research to date is inconclusive on whether or not mental illness is a risk factor for criminal behavior; despite this, individuals with mental health problems generally fare worse on risk assessment tools employed in justice decisions. The study relies on a 1000+ representative sample of parole-eligible individuals in Pennsylvania, United States. To increase reliability, the analyses test for several mental health factors based on information from different sources (i.e., self-reported mental health history; risk assessment tool employed by the Parole Board; and risk assessment tool employed by the Department of Corrections). To address validity concerns, the study controls for other potential correlates of parole decisions. Although the multivariate models explained a considerable amount of variance in parole decisions, the inclusion of mental health variables added relatively little to model fit. The results provide insights into an understudied area of justice decision making, suggesting that despite the stigmatization of mental illness among criminal justice populations, parole board members in Pennsylvania, United States, appear to follow official guidelines rather than to consider more subjective notions that poor mental health should negate parole release.

Attitudes toward defendants with substance-related charges: An analysis of a national sample of criminal defense attorneys

BACKGROUND AND OBJECTIVES

While a large percentage of criminal offenders suffer from substance use disorders (SUDs), virtually nothing is known about the attitudes criminal defense attorneys possess toward their clients who are facing substance-related charges. This is a serious concern, as the burden of steering individuals with SUDs into treatment often falls to criminal defense attorneys. The goal of this study was to examine the attitudes of criminal defense attorneys toward individuals who have been accused of drug crimes.

METHODS

A questionnaire was sent to criminal defense attorneys (N = 1,933) from all 50 U.S. states and the District of Columbia. It was comprised of (i) demographic information and (ii) a version of the 11-item Medical Condition Regard Scale (MCRS).

RESULTS

Criminal defense attorneys held generally positive attitudes toward clients with substance-related charges, but there was a significant divergence in attitudes between private and public attorneys, with the latter showing both greater familiarity with and better attitudes toward this same group of clients. These differences were impactful: worse attitudes toward clients strongly correlated with greater predictions that the clients would reoffend.

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

Given the magnitude of the incarcerated population with SUDs and the centrality of defense attorneys in the treatment process, especially its initiation, the divergence in attitudes between private and public criminal defense attorneys is concerning. There is a clear need for increased collaboration between physicians and attorneys, with an aim of increasing the number of individuals with SUDs receiving proper treatment (Am J Addict 2018;XX:1-7).

Association Between Employment and Mental Health Service Use Among Justice-Involved Individuals

Using a nationally representative sample of justice-involved persons (N = 1525), the present study examined the extent to which employment status was associated with mental health service use by various service providers. The findings indicate that the rate of mental health service use by general health care providers among the unemployed was higher than that of the employed. Factors associated with mental health service use varied by type of provider. Our findings suggest that employment may be critical for justice-involved people in enhancing their mental health status, which could result in their successful community integration.

Examining the Application of the Opening Minds Survey in the Community Health Centre Setting

OBJECTIVE

Stigma has been identified as a complex and problematic issue. It acts as a major barrier to accessing care and can exacerbate the experience of a health condition, particularly for clients with mental illness and substance use issues. Scales designed to assess stigmatising attitudes towards those with mental illness and substance use problems among health care providers are necessary to evaluate programs designed to reduce that stigma. The goal of this study was to evaluate the internal reliability and external validity of the Opening Minds Survey for Health Care Providers (OMS-HC).

METHODS

The current study examined the use of the OMS-HC in assessing stigma held by Community Health Centre (CHC) staff towards clients with mental and/or substance use problems. Participants represented staff from 6 CHCs in the Greater Toronto Area ( n = 190).

RESULTS

The OMS-HC was found to have acceptable internal reliability for the 15-item version of the scale (α = 0.766) and mixed reliability for its subscales (α = 0.792-0.673). Confirmatory factor analysis showed good absolute (root mean square error of approximation = 0.013) and relative fit (Tucker-Lewis index = 0.996) for the current data. The OMS-HC was also shown to correlate with a series of scales commonly used in stigma research.

CONCLUSIONS

After testing for internal validity and comparing the OMS-HC to other commonly used scales for assessing stigma and attitudes concerning recovery, the scale was found to be appropriate for the CHC setting and may be advantageous over the use of multiple scales.

In vivo structural imaging in rats reveals neuroanatomical correlates of behavioral sub-dimensions of cocaine addiction

Cocaine addiction is a multi-dimensional behavioral disorder characterized by a loss of control over cocaine taking despite of detrimental consequences. Structural MRI studies have revealed association between cocaine consumption and gray matter volume (GMV) in cocaine-addicted patients. However, the behavioral correlates of GMV in cocaine addiction are poorly understood. Here, we used a DSM-IV-based rat model of cocaine addiction with high face validity for structural imaging. According to three behavioral sub-dimensions of addiction, rats were separated into two groups showing either addict-like or non-addict-like behavior. These behavioral sub-dimensions were (1) the inability to refrain from drug-seeking and taking, (2) high motivation for the drug, and (3) maintained drug use despite negative consequences. In these rats, we performed structural MRI with voxel-based morphometry and analyzed the interaction of GMV with behavioral sub-dimensions in cocaine-addicted rats. Our major findings are that GMV differentially correlate with the inability to refrain from drug-seeking and taking in addict-like and non-addict-like rats within the somatosensory cortices and the amygdala. High motivation for the drug differentially correlates with GMV in addict-like and non-addict-like rats within the medial prefrontal cortex, and maintained drug use despite negative consequences differentially correlates with GMV in these two groups of rats within the periaqueductal gray. Our results demonstrate that the behavioral differences characterizing addict-like and non-addict-like rats in each behavioral sub-dimension of addiction are reflected by divergent covariance with GMV. We conclude that structural imaging provides specific neuroanatomical correlates of behavioral sub-dimensions of addiction.

Partnering with Psychiatry to Close the Education Gap: An Approach to the Addiction Epidemic

Addiction has reached epidemic proportions in the U.S., yet the workforce prepared to care for this population is woefully inadequate. Of the 23 million Americans suffering from addiction, only 11% receive treatment, creating a substantial treatment gap. There have been calls to improve addiction education at all levels of training in order to prepare medical providers with the skills to identify patients with substance use, briefly treat if indicated, and/or refer more complex cases to specialty care. These calls have been put forth to address the education gap, wherein physicians in training are exposed to numerous patients who are suffering from addiction but have few curricular hours dedicated to the identification and management of this population. We propose that strategic partnerships between psychiatry and internal medicine can address the education gap that exists with regard to addiction, ultimately addressing the treatment gap which is plaguing this country.

Medications for substance use disorders (SUD): emerging approaches

INTRODUCTION

Substance use disorders are a group of chronic relapsing disorders of the brain, which have massive public health and societal impact. In some disorders (e.g., heroin/prescription opioid addictions) approved medications have a major long-term benefit. For other substances (e.g., cocaine, amphetamines and cannabis) there are no approved medications, and for alcohol there are approved treatments, which are not in wide usage. Approved treatments for tobacco use disorders are available, and novel medications are also under study. Areas covered: Medication-based approaches which are in advanced preclinical stages, or which have reached proof-of concept clinical laboratory studies, as well as clinical trials. Expert opinion: Current challenges involve optimizing translation between preclinical and clinical development, and between clinical laboratory studies to therapeutic clinical trials. Comorbidities including depression or anxiety are challenges for study design and analysis. Improved pharmacogenomics, biomarker and phenotyping approaches are areas of interest. Pharmacological mechanisms currently under investigation include modulation of glutamatergic, GABA, vasopressin and κ-receptor function, as well as inhibition of monoamine re-uptake. Other factors that affect potential market size for emerging medications include stigma, availability of treatment settings, adoption by clinicians, and the prevalence of persons with SUD who are not actively treatment-seeking.

Drug use Discrimination Predicts Formation of High-Risk Social Networks: Examining Social Pathways of Discrimination

Experiences of discrimination, or social marginalization and ostracism, may lead to the formation of social networks characterized by inequality. For example, those who experience discrimination may be more likely to develop drug use and sexual partnerships with others who are at increased risk for HIV compared to those without experiences of discrimination. This is critical as engaging in risk behaviors with others who are more likely to be HIV positive can increase one's risk of HIV. We used log-binomial regression models to examine the relationship between drug use, racial and incarceration discrimination with changes in the composition of one's risk network among 502 persons who use drugs. We examined both absolute and proportional changes with respect to sex partners, drug use partners, and injecting partners, after accounting for individual risk behaviors. At baseline, participants were predominately male (70%), black or Latino (91%), un-married (85%), and used crack (64%). Among those followed-up (67%), having experienced discrimination due to drug use was significantly related to increases in the absolute number of sex networks and drug networks over time. No types of discrimination were related to changes in the proportion of high-risk network members. Discrimination may increase one's risk of HIV acquisition by leading them to preferentially form risk relationships with higher-risk individuals, thereby perpetuating racial and ethnic inequities in HIV. Future social network studies and behavioral interventions should consider whether social discrimination plays a role in HIV transmission.

Pain Management in the Opioid-Dependent Pregnant Woman

Opioid dependence is an epidemic in the United States, and the percentage of pregnant women who are opioid dependent has increased dramatically in the last decade. Pain management, already a concern for intrapartum and postpartum care, is complicated in the context of opioid dependence. This clinical review surveys the literature on pain management in opioid-dependent pregnant women to summarize current consensus and evidence to guide clinical practice. Points of consensus for pain management in opioid-dependent pregnant women include continual opioid maintenance therapy throughout the pregnancy and the postpartum period; adequate management of acute pain; the contraindication of opioid agonist-antagonists for pain management; and the need for interdisciplinary teams using a multimodal approach to provide optimal care to opioid-dependent pregnant women.

Improving Psychiatry Residents' Attitudes Toward Individuals Diagnosed with Substance Use Disorders

Special attention needs to be paid to the attitudes of psychiatry residents toward individuals diagnosed with substance use disorders. The attitudes of trainees may be worse toward these individuals than toward individuals with other diagnoses, and these attitudes may worsen over time. While psychiatry residencies are increasingly teaching residents about how to diagnosis and treat individuals diagnosed with substance use disorders, more attention needs to be paid to educating residents about common attitudes toward these individuals. We recommend that psychiatry residency programs start with basic educational didactics and reflection exercises on attitudes toward individuals diagnosed with substance use disorders and that programs try to form a positive "hidden curriculum" in their institutions.