Misuse of Prescription Opioid Medication among Women: A Scoping Review

Inclusion of Sex and Gender Differences in U.S. State Action Plans for Opioid Use and Opioid Use Disorder

Background: States have developed action plans to address the "opioid crisis" over the past several years. While sex- and gender-based differences have been identified in complications of opioid use, risks of addiction to opioids, barriers to treatment of opioid use disorder, and associated stigma, it is unknown if or to what extent opioid plans consider or account for these differences. The objectives of this study were to analyze U.S. state opioid action plans and their inclusion of sex- and gender-specific concerns. Methods: A content analysis of 49 state plans was conducted in June 2020, assessing their inclusion of 14 variables covering provider education, pregnancy-related, and sex- or gender-based differences in opioid addiction and treatment. Results: Neonatal opioid withdrawal syndrome was the most common variable, noted in 57% of plans. Only 14% included pregnancy-related stigma, and 4% identified gender-specific stigma. Contraceptives and family-planning were included in 12% and 10% of plans, respectively. Two states included more than half of the variables and five plans made no mention of sex or gender differences. Conclusions: Few state plans contained sex- or gender-specific information, and those that did focused almost exclusively on childbearing, excluding other unique considerations of opioid-using-women of all ages. The results of this study could improve the care of women using opioids by informing the strategies of state agencies and impacting legislative efforts for prevention initiatives, substance use disorder treatment, and law enforcement programs.

Associations between adverse childhood experiences and substance use: A meta-analysis

BACKGROUND

Adverse childhood experiences (ACEs) can be associated with negative health outcomes such as substance use. However, extant literature assessing this association is mixed.

OBJECTIVE

The present meta-analysis was conducted to obtain a pooled effect size for the association between ACEs and substance use (i.e., smoking, problematic alcohol use, heavy alcohol use, illicit drug use, and cannabis use).

PARTICIPANTS AND SETTING

The present meta-analyses included 102 studies (N = 901,864), where 42.32 % of participants were male, and the mean age was 30.91 years.

METHODS

Searches were conducted in MEDLINE, Embase, and PsycINFO in August 2021 and moderators were examined. Inclusion criteria included studies that measured ACEs prior to age 18 and substance use, and were published in English. All analyses were completed in Comprehensive Meta-Analysis Software, Version 3.0 (Borenstein et al., 2009).

RESULTS

Pooled effect sizes between ACEs and smoking [OR = 1.803 (95 % CI 1.588, 2.048)], problematic alcohol use [OR = 1.812 (95 % CI 1.606, 2.044)], heavy alcohol use [OR = 1.537 (95 % CI 1.344, 1.758)], cannabis use [OR = 1.453 (95 % CI 1.184, 1.786)] and illicit drug use [OR = 1.695 (95 % CI 1.530, 1.878)] were significant. Significant moderators contribute to the understanding of the association between ACEs and substance use, and are discussed extensively.

CONCLUSIONS

ACEs confer risk for substance use and trauma-informed approaches to substance use treatment should be considered. Study limitations and implications are discussed.

Barriers to Assessing and Treating Trauma in Primary Care and Opportunities for Improvement: Perspectives from Prescribers of Medications for Opioid Use Disorder

Background: Medication for Opioid Use Disorder (MOUD) is a best practice for treating individuals with opioid use disorder (OUD), and primary care-based MOUD management can reduce treatment barriers among OUD patients. Individuals with OUD experience disproportionately high rates of trauma and violence, highlighting the importance of addressing trauma, mental health, and substance use concurrently. However, clear guidelines for trauma-informed treatment in a primary care setting remain poorly established. Methods: A qualitative approach was engaged to explore primary care providers' perceptions of barriers and facilitators to assessing and treating trauma among MOUD patients. Twenty in-depth interviews were conducted in 2021 with Baltimore-based MOUD prescribers, including primary care physicians and nurse practitioners. Interview questions assessed experiences with identifying and treating trauma among MOUD patients, including challenges and opportunities. Results: Providers reported extensive histories of trauma experienced by MOUD patients. Barriers to addressing trauma include a lack of standardized protocols/procedures for identifying trauma, insufficient training/time to assess and treat trauma, and the limited availability of external mental health providers and specialty services. Opportunities included building strong, mutually respectful patient-provider relationships, providing individualized, person-centered care, and establishing connections to coordinated multidisciplinary treatment networks. Conclusions: MOUD treatment within primary care is an important way to increase OUD treatment access, but clearer standards are needed for the treatment of trauma within this patient population. These findings demonstrate opportunities to improve standards and systems such that primary care providers are better equipped to assess and treat the complex histories of trauma experienced by individuals with OUD.

Physical pain among Indigenous Peoples in Canada: a scoping review

PURPOSE

Pain is a multifaceted experience shaped by various factors including context of pain, previous life events, and ongoing ethnocultural circumstances. Moreover, the definition of pain is inconsistent across cultures. Western medicine views physical pain (e.g., associated with a bone fracture) and nonphysical mental pain (e.g., depression) as two distinct conditions. Indigenous perspectives are often more wholistic, encompassing mental, spiritual, emotional, and physical hurt. The subjective nature of pain invites ample opportunity for discrimination in both its assessment and management. As such, it is important to consider Indigenous perspectives of pain in research and clinical practice. To investigate which aspects of Indigenous pain knowledge are currently considered by Western research, we conducted a scoping review of the literature on pain in Indigenous Peoples of Canada.

SOURCE

In June 2021, we searched nine databases and downloaded 8,220 papers after removal of duplicates. Two independent reviewers screened abstracts and full-text articles.

PRINCIPLE FINDINGS

Seventy-seven papers were included in the analysis. Using grounded theory, five themes emerged: pain measures/scales (n = 7), interventions (n = 13), pharmaceuticals (n = 17), pain expression/experiences (n = 45), and pain conditions (n = 70).

CONCLUSION

This scoping review shows that there is a paucity of research on pain measurement in Indigenous Peoples of Canada. This finding is concerning in light of numerous studies reporting that Indigenous Peoples experience their pain as ignored, minimized, or disbelieved. Furthermore, a clear disconnect emerged between pain expression in Indigenous Peoples and assessment in medical professionals. We hope that this scoping review will serve to translate current knowledge to other non-Indigenous academics and to initiate meaningful collaboration with Indigenous partners. Future research led by Indigenous academics and community partners is critically needed to better address pain needs in Canada.

Intimate partner violence, substance use, and health comorbidities among women: A narrative review

Exposure to intimate partner violence (IPV), including physical, sexual, and psychological violence, aggression, and/or stalking, impacts overall health and can have lasting mental and physical health consequences. Substance misuse is common among individuals exposed to IPV, and IPV-exposed women (IPV-EW) are at-risk for transitioning from substance misuse to substance use disorder (SUD) and demonstrate greater SUD symptom severity; this too can have lasting mental and physical health consequences. Moreover, brain injury is highly prevalent in IPV-EW and is also associated with risk of substance misuse and SUD. Substance misuse, mental health diagnoses, and brain injury, which are highly comorbid, can increase risk of revictimization. Determining the interaction between these factors on the health outcomes and quality of life of IPV-EW remains a critical need. This narrative review uses a multidisciplinary perspective to foster further discussion and research in this area by examining how substance use patterns can cloud identification of and treatment for brain injury and IPV. We draw on past research and the knowledge of our multidisciplinary team of researchers to provide recommendations to facilitate access to resources and treatment strategies and highlight intervention strategies capable of addressing the varied and complex needs of IPV-EW.

Structural violence and barriers to pain management during an opioid crisis: accounts of women who use drugs in Nigeria

Chronic pain management among marginalised populations have been extensively researched in North America, particularly amidst the opioid crisis. But little published research exists on this subject from Africa. This study explored experiences and management of chronic pain among marginalised women in the context of regulation of opioid prescribing using data from 16 qualitative interviews with women who use drugs (WWUD) in Uyo, Nigeria. Chronic pain was exacerbated by structural and everyday violence that acted to marginalise women and create a context of risk for inadequately managed pain. Participants experienced difficulty accessing biomedical pain management due to structural and systemic barriers, including cost, restrictions on opioid prescribing, stigma and other discriminatory practices, communication barriers and lack of social support. Restrictions on opioid prescribing and systemic discriminations against marginalised WWUD encouraged reliance on informal sources for falsified and substandard medications for pain treatment, which increased the risk of harm. Findings highlight a need for multi-component responses that address structural and systemic barriers to pain management, including improving access to opioid medications.

Nationwide Population-Based Study About Patterns of Prescription Opioid Use and Misuse Among Young Adults in Spain

Objective: Prescription opioid misuse has become one of the most common ways drugs are consumed among young adults. The objective of our study was to describe the prevalence and factors associated with prescription opioid use and misuse among young adults living in Spain.

Methods: A nationwide, cross-sectional epidemiological study on the use and misuse of prescription opioids in Spanish Youngers. We used individualized secondary data provided by the Household Survey on Alcohol and Drugs in Spain 2017–2018.

Results: Prevalence of prescription opioid use among young adults was 4.89%. Misuse among this population reached prevalence values of 13.4%, with higher values observed among women . The variables associated with a greater probability of prescription opioid use and misuse were misuse of tranquilizers, sedatives, and sleeping pills, along with using cannabis and other illicit psychoactive drugs (aOR = 2.99; 95% CI: 1.10–8.15).

Conclusion: Prescription opioid use and misuse in Youngers has important implications for the Spanish public health system, because, even though not currently comparable to the situation in other countries, this drug use could be on the verge of creating similar problems.

Incarceration exposure and prescription opioid use during pregnancy

BACKGROUND

Prior research demonstrates a high prevalence of substance use, including opioid use, among those who have had personal or vicarious contact with the correctional system. Relatedly, alongside patterns of rising opioid use in general, opioid use during pregnancy is becoming a growing public health concern. Still, risk factors for prescription opioid use during pregnancy remain understudied. This study is the first to assess the connection between a women's personal or vicarious exposure to incarceration in the 12 months prior to birth and patterns of prenatal opioid use.

METHODS

Data are from the Pregnancy Risk Assessment Monitoring System (PRAMS) in 2019 (N = 17,551 mothers). Logistic and multinomial logistic regression are used to assess the association between incarceration exposure and patterns of opioid use during pregnancy.

RESULTS

Incarceration-exposed women were more likely to use all eight types of prescription opioids assessed in this study (Hydrocodone, Codeine, Oxycodone, Tramadol, Hydromorphone/Meperidine, Oxymorphone, Morphine, and Fentanyl). After adjustment for control variables, incarceration-exposed women were significantly more likely to report any prescription opioid use during pregnancy (OR = 1.745, 95% CI = 1.194, 2.554). Furthermore, relative to no opioid use, incarceration exposure was also associated with illicit prescription opioid use (RRR = 2.979, 1.533, 5.791).

CONCLUSIONS

Incarceration exposure in the year prior to birth is associated with higher odds of prescription opioid use. These findings add to the burgeoning literature that details a women's exposure to incarceration is a risk marker for substance use and engagement in health risk behaviors that can jeopardize maternal and infant wellbeing.

Opioid Use Disorder and Perinatal Outcomes

OBJECTIVES

Evidence on the perinatal health of mother-infant dyads affected by opioids is limited. Elevated risks of opioid-related harms for people with opioid use disorder (OUD) increase the urgency to identify protective factors for mothers and infants. Our objectives were to determine perinatal outcomes after an OUD diagnosis and associations between opioid agonist treatment and birth outcomes.

METHODS

We conducted a population-based retrospective study among all women with diagnosed OUD before delivery and within the puerperium period in British Columbia, Canada, between 2000 and 2019 from provincial health administrative data. Controlling for demographic and clinical characteristics, we determined associations of opioid agonist treatment on birth weight, gestational age, infant disorders related to gestational age and birth weight, and neonatal abstinence syndrome via logistic regression.

RESULTS

The population included 4574 women and 6720 live births. Incidence of perinatal OUD increased from 166 in 2000 to 513 in 2019. Compared with discontinuing opioid agonist treatment during pregnancy, continuous opioid agonist treatment reduced odds of preterm birth (adjusted odds ratio: 0.6; 95% confidence interval: 0.4-0.8) and low birth weight (adjusted odds ratio: 0.4; 95% confidence interval: 0.2-0.7). Treatment with buprenorphine-naloxone (compared with methadone) reduced odds of each outcome including neonatal abstinence syndrome (adjusted odds ratio: 0.6; 95% confidence interval: 0.4-0.9).

CONCLUSIONS

Perinatal OUD in British Columbia tripled in incidence over a 20-year period. Sustained opioid agonist treatment during pregnancy reduced the risk of adverse birth outcomes, highlighting the need for expanded services, including opioid agonist treatment to support mothers and infants.

Barriers to help-seeking among intimate partner violence survivors with opioid use disorder

Intimate partner violence is common among people with opioid use disorder (OUD), but little research has focussed on identifying barriers survivors with OUD face when trying to leave an abusive relationship. Semi-structured interviews were conducted with 40 postpartum women with OUD. Interview questions were designed to identify barriers to help-seeking and facilitators and supports that have helped survivors make positive changes. Qualitative data were coded and analyzed, using a phenomenological approach to develop emerging themes. Most participants were white, 24-29 years old, single, unemployed, Medicaid insured, and used medications for OUD. All participants (n = 40, 100%) shared that a current or past partner physically, sexually, emotionally, or verbally abused them. Participants identified multiple barriers to help-seeking including abusive partner control of money and resources, fear of retaliatory violence, and concerns related to police and child welfare. Participants also described supports that helped them make positive changes, including being treated with care and support from domestic violence shelters and treatment programs. Finally, survivors offered suggestions for ways providers can better meet survivors' needs. Clinicians and policymakers should prioritize overcoming multiple barriers to service access and engagement faced by survivors and their children.

Addiction among women and sexual minority groups

Gender-related alcohol and drug abuse problems are related not only to biologic differences but also to social and environment factors, all of which can influence the clinical presentation, consequences of use, and treatment approaches. The number of women becoming addicted to alcohol or drugs of abuse has significantly increased with women becoming the fastest-growing group of substance abusers in the United States. Given that women experience a more rapid progression of their addiction than men, it is important that we understand and address the differences to help develop prevention and treatment programs that are tailored for women, incorporating trauma assessment and management, comorbidities, financial independence, pregnancy, and child care.

Neonatal Abstinence Syndrome in Rural Appalachia

As the United States faces the repercussions of the current opioid epidemic, it is important for social workers to be able to identify risks for poor birth outcomes in infants with neonatal abstinence syndrome (NAS). Although some studies have identified single risk factors, no studies have tested associations between total amount of risk (that is, cumulative risk) and birth outcomes in infants with NAS. Authors examined 318 mothers who used opioids during pregnancy and their infants' birthweight, length, head circumference, and Apgar scores (which measure overall infant health after birth). All infants were admitted to a neonatal intensive care unit in Appalachia and were diagnosed with NAS. Authors found that high cumulative risk during pregnancy was associated with lower birthweight and Apgar scores one and five minutes after birth as well as shorter length and smaller head circumference at birth. Social workers are encouraged to assess for the quantity of prenatal adversity experienced by the mothers they serve and to consider multicomponent, comprehensive community-based interventions to reduce cumulative risk.

Alternative use of buprenorphine among people who use opioids in three U.S. Cities

Background: Buprenorphine is an effective treatment for opioid use disorder, yet some persons are concerned with its "alternative use" (i.e., any use unintended by the prescriber). There is limited evidence on the factors associated with alternative use of buprenorphine (AUB); in this study, we examined correlates of recent (past 6 months) AUB. Methods: Multivariable logistic regression was used to analyze survey data from a multi-site, cross-sectional study of people who use drugs (PWUD) (N = 334) in Baltimore, Maryland; Boston, Massachusetts; and Providence, Rhode Island. Results: One-fifth (20%) of the sample reported recent AUB. In adjusted analyses, significant negative correlates of AUB were female gender (adjusted odds ratio [aOR] 0.48, 95% confidence intervals [CI] 0.24-0.95), recent emergency room visit (aOR 0.45, 95% CI 0.23-0.89), and recent injection drug use (aOR 0.41, 95% CI 0.19-0.88). Significant positive correlates were alternative use of other prescription opioids (aOR 8.32, 95% CI 4.22-16.38), three or more overdoses in the past year (aOR 3.74, 95% CI 1.53-9.17), recent buprenorphine use as prescribed (aOR 2.50, 95% CI 1.12-5.55), and recent residential rehabilitation treatment (aOR 3.71, 95% CI 1.50-9.16). Conclusions: Structural and behavioral correlates of AUB may help identify PWUD at high risk of overdose with unmet treatment needs.

A Call to Action to Combat the Opioid Epidemic Among Women

: Acknowledging the needs and challenges of women with opioid use disorder is an essential step to reduce the opioid epidemic in the United States. Efforts that can help women include increasing psychosocial services to address trauma, increasing access to medication treatment for opioid use disorder, reducing barriers and stigma that impede access to and retention on treatment, and addressing structural and policy barriers. This commentary discusses the reasons why women-focused treatment for opioid use disorder is necessary and makes specific recommendations for interventions, treatment, services, and policies that can reduce barriers to care and improve treatment and retention among women.

The Role of Mu-Opioids for Reward and Threat Processing in Humans: Bridging the Gap from Preclinical to Clinical Opioid Drug Studies

PURPOSE OF REVIEW

Opioid receptors are widely expressed in the human brain. A number of features commonly associated with drug use disorder, such as difficulties in emotional learning, emotion regulation and anhedonia, have been linked to endogenous opioid signalling. Whereas chronic substance use and misuse are thought to alter the function of the mu-opioid system, the specific mechanisms are not well understood. We argue that understanding exogenous and endogenous opioid effects in the healthy human brain is an essential foundation for bridging preclinical and clinical findings related to opioid misuse. Here, we will examine psychopharmacological evidence to outline the role of the mu-opioid receptor (MOR) system in the processing of threat and reward, and discuss how disruption of these processes by chronic opioid use might alter emotional learning and reward responsiveness.

RECENT FINDINGS

In healthy people, studies using opioid antagonist drugs indicate that the brain's endogenous opioids downregulate fear reactivity and upregulate learning from safety. At the same time, endogenous opioids increase the liking of and motivation to engage with high reward value cues. Studies of acute opioid agonist effects indicate that with non-sedative doses, drugs such as morphine and buprenorphine can mimic endogenous opioid effects on liking and wanting. Disruption of endogenous opioid signalling due to prolonged opioid exposure is associated with some degree of anhedonia to non-drug rewards; however, new results leave open the possibility that this is not directly opioid-mediated.

SUMMARY

The available human psychopharmacological evidence indicates that the healthy mu-opioid system contributes to the regulation of reward and threat processing. Overall, endogenous opioids can subtly increase liking and wanting responses to a wide variety of rewards, from sweet tastes to feelings of being connected to close others. For threat-related processing, human evidence suggests that endogenous opioids inhibit fear conditioning and reduce the sensitivity to aversive stimuli, although inconsistencies remain. The size of effects reported in healthy humans are however modest, clearly indicating that MORs play out their role in close concert with other neurotransmitter systems. Relevant candidate systems for future research include dopamine, serotonin and endocannabinoid signalling. Nevertheless, it is possible that endogenous opioid fine-tuning of reward and threat processing, when unbalanced by e.g. opioid misuse, could over time develop into symptoms associated with opioid use disorder, such as anhedonia and depression/anxiety.

'Nesef Doctora'-When mothers are considered to be 'half-doctors': Self-medication with antibiotics and gender roles in the Arab society in Israel

This qualitative study focuses on self-medication with antibiotics as it relates to gender roles and traditions in the Arab society in Israel, a collectivist minority with defined traditional gender norms. Its findings draw on the analysis of 116 face-to-face interviews with 60 pharmacists, 27 primary care physicians and 29 community members, mainly mothers and unmarried women, from different geographical localities. The findings describe how mothers are assigned the role of the family health caretakers, expected to abide to a hierarchical power structure, and listen to the advice of 'senior mothers'. These expectations can lead to mothers self-medicating their children and themselves with antibiotics. Traditional constraints associated with sexuality were also found to compel unmarried women to self-medicate. The findings point to a duality of power in family relations: women submit to having limited power in traditional gender roles but are accorded power as medical experts in health-care decision-making. The study concludes with recommendations for considering sociocultural factors of hierarchy, traditions and collectivist orientation when researching self-care patterns and developing interventions to curtail antibiotics overuse. It also points to the importance of recognising pressures exerted on unmarried women and enabling them to use health-care resources in their community for managing sexual health.

A buprenorphine-validated rat model of opioid use disorder optimized to study sex differences in vulnerability to relapse

RATIONALE

Opioid use disorder (OUD) is a major epidemic in the USA. Despite evidence indicating that OUD may be particularly severe for women, preclinical models have yet to establish sex as a major factor in OUD.

OBJECTIVES

Here, we examined sex differences in vulnerability to relapse following intermittent access fentanyl self-administration and protracted abstinence and used buprenorphine, the FDA-approved treatment for OUD, to test the validity of our model.

METHODS

Following acquisition of fentanyl self-administration under one of two training conditions, male and female rats were given extended, 24-h/day access to fentanyl (0.25 μg/kg/infusion, 10 days) using an intermittent access procedure. Vulnerability to relapse was assessed using an extinction/cue-induced reinstatement procedure following 14 days of abstinence; buprenorphine (0 or 3 mg/kg/day) was administered throughout abstinence.

RESULTS

Levels of drug-seeking were high following extended-access fentanyl self-administration and abstinence; buprenorphine markedly decreased drug-seeking supporting the validity of our relapse model. Females self-administered more fentanyl and responded at higher levels during subsequent extinction testing. Buprenorphine was effective in both sexes and eliminated sex and estrous phase differences in drug-seeking. Interestingly, the inclusion of a time-out during training had a major impact on later fentanyl self-administration in females, but not males, indicating that the initial exposure conditions can persistently impact vulnerability in females.

CONCLUSIONS

These findings demonstrate the utility of this rat model for determining sex and hormonal influences on the development and treatment of OUD.

Prescription Opioids and Patient Sex: A National Cross-Sectional Study

Background: Surveillance data suggest that women are prescribed more opioid analgesics than men. It remains unclear whether these sex-related differences solely reflect the associations with other characteristics more prevalent among women (e.g., adverse socioeconomic and health status-related factors, and more contact with the health system). Materials and Methods: We examined the factors associated with opioid prescriptions and sex in a large, nationally representative U.S. sample. This observational analysis of the 2005-2015 Medical Expenditure Panel Survey included all adults aged ≥18 years with prescription and health service utilization data (n = 106,233). Negative binomial regressions examined associations between sex and number of opioid prescriptions. Analyses sequentially adjusted for sociodemographics, health status-related factors, and nonnarcotic prescriptions. Results: Overall, 9,387 women (16.2%) and 5,679 men (11.7%) received opioid prescriptions (female/male incidence rate ratio [IRR] = 1.35 (95% confidence interval [CI] = 1.24-1.44). The IRR was lower with adjustment for sociodemographics (1.23 [95% CI = 1.14-1.31]) and additional adjustment for health status-related factors (1.12 [95% CI = 1.05-1.19]). With further adjustment for number of nonnarcotic prescriptions, the IRR was not significant (0.97 [95% CI = 0.91-1.03). Conclusions: In this nationally representative sample, women received higher rates of prescription opioids, consistent with prior surveillance data. However, this relationship was attenuated with adjustment for sociodemographic and health status-related factors, and nonsignificant with adjustment for higher rates of nonnarcotic prescriptions among women. Higher opioid prescription rates in women may simply be reflective of these other factors, and the overall greater use of health care among women.

Medicine misuse: A systematic review and proposed hierarchical terminology

AIMS

Although medicine misuse is a public health issue, it has multiple meanings in the medical literature. This study aimed to characterize, classify and identify the most appropriate definitions of medicine misuse.

METHODS

A systematic review was performed in Medline, ISI Web of Science, SocINDEX, PsycInfo, PsycArticles and Psychological and Behavioral Sciences Collection, using keywords related to "misuse", "appropriateness" and "medicine" between 1 November 2008 and 25 August 2020. Additional searches were conducted in websites of regulatory agencies and public health institutions. Two authors independently selected studies providing both definitions and examples of misuse, while a third resolved disagreements. Definitions were used to propose a hierarchical classification based on initiator, intent, purpose and context of medicine misuse. The study is registered on PROSPERO: CRD42018115789.

RESULTS

Of 3404 identified records, 51 were included. A total of 71 definitions and 74 examples of misuse were retrieved. When the prescriber is initiator and according to intent, potential medicine misuse referred to "intentional or unintentional prescribing not in line with clinical evidence". Based on context, they could prescribe medicines not clinically justified, i.e. overprescribing, or prescribe indicated medicines incorrectly, i.e. misprescribing. Among other groups of definitions, those overlapping with drug abuse or medication use errors were considered out-of-scope.

CONCLUSION

This systematic review provides a comprehensive overview of the terms and definitions used to characterize medicine misuse and could serve as a basis for a terminology that makes clear distinctions between misuse, abuse and errors.

Prevalence and correlates of substance use among transgender adults: A systematic review

INTRODUCTION

Minority stress theories suggest that high rates of discrimination experienced by transgender people are precipitants of substance use. This risk is likely exacerbated by an inadequate provision of trans-inclusive substance misuse services. However, the exclusion of transgender people from the general substance misuse literature makes it difficult to determine the extent to which transgender status influences substance use. A systematic review was undertaken to better understand the prevalence, patterns and correlates of substance use among this group.

METHODS

In accordance with the PRISMA guidance, a literature search was conducted to 29th May 2019 on PubMed, PsycINFO, Embase and Global Health databases. Primary quantitative studies, published in English, that reported the prevalence, patterns or correlates of substance use by transgender people were included, with no restriction on methodological design.

RESULTS

653 unique records were identified, and 41 studies were included. Half the studies reported on both transgender men and transgender women and half transgender women only. There was high and excess prevalence of substance use among transgender compared with cisgender people, but insufficient evidence to estimate prevalence or quantify the risk for substance use. Correlates of substance use included transphobic discrimination or violence, unemployment and sex work, gender dysphoria, high visual gender non-conformity and intersectional sexual minority status.

CONCLUSIONS

The sparse findings lend support to the minority stress model. However, the overreliance of the literature on disproportionate investigation of transgender women with multiple intersectional disadvantages, means there are significant gaps regarding the wider transgender community. To ensure substance use treatment services are inclusive, gender identity should be recorded and targeted interventions available. Clinicians should be aware of the multiple, complex drivers of substance use and be prepared to ask about substance use and offer support. Given the high prevalence of trauma experienced by transgender people, trauma-informed psychosocial interventions may be useful in the management of problematic substance use in transgender adults.

Sex Differences and the Role of Estradiol in Mesolimbic Reward Circuits and Vulnerability to Cocaine and Opiate Addiction

Although both men and women become addicted to drugs of abuse, women transition to addiction faster, experience greater difficulties remaining abstinent, and relapse more often than men. In both humans and rodents, hormonal cycles are associated with females' faster progression to addiction. Higher concentrations and fluctuating levels of ovarian hormones in females modulate the mesolimbic reward system and influence reward-directed behavior. For example, in female rodents, estradiol (E2) influences dopamine activity within the mesolimbic reward system such that drug-directed behaviors that are normally rewarding and reinforcing become enhanced when circulating levels of E2 are high. Therefore, neuroendocrine interactions, in part, explain sex differences in behaviors motivated by drug reward. Here, we review sex differences in the physiology and function of the mesolimbic reward system in order to explore the notion that sex differences in response to drugs of abuse, specifically cocaine and opiates, are the result of molecular neuroadaptations that differentially develop depending upon the hormonal state of the animal. We also reconsider the notion that ovarian hormones, specifically estrogen/estradiol, sensitize target neurons thereby increasing responsivity when under the influence of either cocaine or opiates or in response to exposure to drug-associated cues. These adaptations may ultimately serve to guide the motivational behaviors that underlie the factors that cause women to be more vulnerable to cocaine and opiate addiction than men.

Perspectives on trauma and the design of a technology-based trauma-informed intervention for women receiving medications for addiction treatment in community-based settings

BACKGROUND

Despite national calls to develop gender-specific interventions for women with opioid use disorder (OUD) with co-occurring trauma and post-traumatic stress disorder (PTSD) symptoms, there remains a dearth of research on what modalities or treatment components would be most feasible for this population. This study interviewed women with OUD receiving medication assisted treatment and addiction treatment providers to explore (a) experiences of barriers to receiving trauma treatment, and (b) both the perceptions and desired design of a prospective technology-delivered, trauma-informed treatment for women with OUD.

METHODS

Women with lifetime OUD (n = 11) and providers (n = 5) at two community substance use clinics completed semi-structured interviews. Interviews were transcribed, coded, and analyzed in NVivo v11 using a grounded theory approach. Women also completed a demographic form and clinical measures.

RESULTS

Clients were primarily women with children reporting histories of multiple trauma exposures, high PTSD symptoms, and polysubstance use. Two themes emerged among clients and one among providers regarding barriers to trauma treatment. Regarding the feasibility and desired attributes of a technology-based intervention, six themes emerged among clients and providers, respectively.

CONCLUSIONS

Themes suggest a high interest by clients and providers for a technology-delivered, trauma informed treatment available by smartphone. Utilizing technology as an adjunct to care, without reducing face-to-face therapy, was important to both clients and providers.

Childhood adversity and mental health comorbidity in men and women with opioid use disorders

INTRODUCTION

To examine gender differences in associations between mental health comorbidity and adverse childhood experiences (ACE) among adults with DSM-5 lifetime opioid use disorders (OUD).

METHODS

In 2018, we analyzed 2012-13 nationally-representative data from 388 women and 390 men with OUD (heroin, prescription opioid misuse). Using weighted multinomial logistic regression, we examined factors associated with mental health comorbidity, tested a gender-by-childhood-adversity interaction term, and calculated predicted probabilities, controlling for covariates.

RESULTS

Among adults with OUD, women are more likely than men to have comorbid mood or anxiety disorders (odds ratio [95% CI] 1.72 [1.20, 2.48]), and less likely to have conduct disorders. More women than men have prescription OUD (3.72 [2.24, 6.17]), and fewer have heroin use disorder (0.39 [0.27, 0.57]). Among both genders, ACE prevalence is high (>80%) and more than 40% are exposed to ≥3 types of ACE. Women more than men are exposed to childhood sexual abuse (4.22 [2.72, 6.56]) and emotional neglect (1.84 [1.20, 2.81]). Comorbid mood or anxiety disorders are associated with female gender (1.73 [1.18, 2.55]) and exposure to ≥3 types of ACE (3.71 [2.02, 6.85]), controlling for covariates. Moreover, exposure to more ACE elevates risk for comorbid mood or anxiety disorders more among women than men.

CONCLUSION

Among adults with OUD, ACE alters the gender gap in risk for comorbid mood or anxiety disorders. Using gender-tailored methods to address the harmful effects ACE on the mental health of individuals with OUD may help to prevent and ameliorate the current opioid epidemic.

The Detection of Opioid Misuse and Heroin Use From Paramedic Response Documentation: Machine Learning for Improved Surveillance

Background

Timely, precise, and localized surveillance of nonfatal events is needed to improve response and prevention of opioid-related problems in an evolving opioid crisis in the United States. Records of naloxone administration found in prehospital emergency medical services (EMS) data have helped estimate opioid overdose incidence, including nonhospital, field-treated cases. However, as naloxone is often used by EMS personnel in unconsciousness of unknown cause, attributing naloxone administration to opioid misuse and heroin use (OM) may misclassify events. Better methods are needed to identify OM.

Objective

This study aimed to develop and test a natural language processing method that would improve identification of potential OM from paramedic documentation.

Methods

First, we searched Denver Health paramedic trip reports from August 2017 to April 2018 for keywords naloxone, heroin, and both combined, and we reviewed narratives of identified reports to determine whether they constituted true cases of OM. Then, we used this human classification as reference standard and trained 4 machine learning models (random forest, k-nearest neighbors, support vector machines, and L1-regularized logistic regression). We selected the algorithm that produced the highest area under the receiver operating curve (AUC) for model assessment. Finally, we compared positive predictive value (PPV) of the highest performing machine learning algorithm with PPV of searches of keywords naloxone, heroin, and combination of both in the binary classification of OM in unseen September 2018 data.

Results

In total, 54,359 trip reports were filed from August 2017 to April 2018. Approximately 1.09% (594/54,359) indicated naloxone administration. Among trip reports with reviewer agreement regarding OM in the narrative, 57.6% (292/516) were considered to include information revealing OM. Approximately 1.63% (884/54,359) of all trip reports mentioned heroin in the narrative. Among trip reports with reviewer agreement, 95.5% (784/821) were considered to include information revealing OM. Combined results accounted for 2.39% (1298/54,359) of trip reports. Among trip reports with reviewer agreement, 77.79% (907/1166) were considered to include information consistent with OM. The reference standard used to train and test machine learning models included details of 1166 trip reports. L1-regularized logistic regression was the highest performing algorithm (AUC=0.94; 95% CI 0.91-0.97) in identifying OM. Tested on 5983 unseen reports from September 2018, the keyword naloxone inaccurately identified and underestimated probable OM trip report cases (63 cases; PPV=0.68). The keyword heroin yielded more cases with improved performance (129 cases; PPV=0.99). Combined keyword and L1-regularized logistic regression classifier further improved performance (146 cases; PPV=0.99).

Conclusions

A machine learning application enhanced the effectiveness of finding OM among documented paramedic field responses. This approach to refining OM surveillance may lead to improved first-responder and public health responses toward prevention of overdoses and other opioid-related problems in US communities.

Sources of Misused Prescription Opioids and Their Association with Prescription Opioid Use Disorder in the United States: Sex and Age Differences

Background: Prescription opioid (PO) misuse and prescription opioid use disorder (POUD) are a national crisis in the USA. To inform strategies for reducing the PO epidemic, research is needed on the sources of misused POs and their association with POUD. Methods: Past-year PO misusers aged ≥12 (N = 6033) from the 2015 to 2016 National Surveys on Drug Use and Health were analyzed. The most recent source of misused POs was assessed. Logistic regression analyses were used to determine the association between the sources of misused POs and past-year POUD. All analyses were stratified by age groups for each sex. Results: Overall, the most common sources of misused POs were obtaining from friends/relatives for free (40.27%) and physicians (36.59%). Males had a higher prevalence of buying POs from friends/relatives or drug dealers/strangers than females. Significant age differences also emerged. Buying POs from drug dealers/strangers (vs. obtaining POs free from friends/relatives) was strong predictor of past-year POUD in both sexes. In the sex- and age-stratified analyses, significant associations of past-year POUD with (1) buying from drug dealers/strangers emerged among males aged 18+ and females aged 26+; (2) buying from friends/relatives emerged among males aged 12+ and females aged 18-25; (3) obtaining from physicians emerged among males aged 18+ and females aged 26+. Conclusions: Our findings indicate different risk profiles for POUD across sex and age groups with different diversion sources. Prevention and treatment programs for POUD should be tailored to consider sex and developmental age differences in sources of opioids.

A gender-based analysis of nonmedical prescription opioid use among people who use illicit drugs

BACKGROUND

Research investigating the unique impacts associated with engaging in nonmedical prescription opioid use (NMPOU) among males and females who also use illicit drugs is needed.

METHODS

Data were collected between 2013 and 2017 from two linked prospective cohort studies in Vancouver: the At-Risk Youth Study and Vancouver Injection Drug Users Study. Generalized estimating equations were used to identify factors associated with engaging in NMPOU among females and males separately.

RESULTS

Among 1459 participants, 534 were female (37%). Similar proportions of females (46%) and males (48%) engaged in NMPOU at their first visit during the study period. In multivariable analyses, factors associated with NMPOU among both males and females included heroin use, overdose, drug dealing, and difficulty accessing health and social services. Among females, those who engaged in NMPOU were more likely to report Caucasian or white ethnicity, cocaine use, crystal methamphetamine use, and sex work; among males, those who engaged in NMPOU were older, reported crack use and engaged in binge drug use (all p < 0.05).

CONCLUSION

The prevalence of NMPOU was similar among males and females who use illicit drugs in Vancouver, and NMPOU was independently associated with markers of vulnerability among both genders. Findings highlight the need for a comprehensive public health approach to address NMPOU that integrates overdose prevention and reversal services, employment opportunities, and better access to services for both women and men.

They Didn't Believe Her Pain: My Education in Interpersonal Violence

In my first year of medical school, I began to care for patients who were survivors of interpersonal violence. As I transitioned from didactics to clinical experiences, I was struck by how common the hidden threads of physical and sexual violence were in my patients' stories of chronic pain, depression, and poor health outcomes. Their symptoms often seemed intangible and challenging to treat, unable to fit neatly into typical diagnostic and therapeutic algorithms. In response, I saw clinicians become frustrated and dissatisfied with their ability to treat these patients. Better care for survivors may begin simply with believing our patients' pain.

Our Life Depends on This Drug: Competence, Inequity, and Voluntary Consent in Clinical Trials on Supervised Injectable Opioid Assisted Treatment

Supervised injectable opioid assisted treament (siOAT) prescribes injectable opioids to individuals for whom other forms of addiction treatment have been ineffective. In this article, we examine arguments that opioid-dependent people should be assumed incompetent to voluntarily consent to clinical research on siOAT unless proven otherwise. We agree that concerns about competence and voluntary consent deserve careful attention in this context. But we oppose framing the issue solely as a matter of the competence of opioid-dependent people and emphasize that it should be considered in the context of inequities in access to siOAT as a medical treatment. Consequently, we suggest that bioethics literature on nonexploitation, which focuses on clinical research in low-income countries, is helpful due to locating ethical issues within systemic social conditions. Finally, we consider the implications of our argument for the ethics of clinical research on siOAT.

Sex differences in prescription opioid use

PURPOSE OF REVIEW

Recent literature focused on prescription opioids has neglected sex differences in use. Here, we evaluated the recent literature (since 2015) examining sex differences in prescription opioid use.

RECENT FINDINGS

Between 2015 and 2016, our review found only eight articles addressing sex differences in prescription opioid use mostly opioid misuse in North America among individuals with chronic pain. Risk factors included depression, pain, and polydrug use. In addition to that review, we had the opportunity to further address sex differences in, and risk factors for, prescription opioid use through a community engagement program, HealthStreet. Among the sample (n = 8525, Mage = 43.7 years, 58.6% women), approximately half reported use of prescription opioids. Women were significantly more likely to report lifetime use (54.9 vs. 42.2%; P < 0.0001) and report cancer compared with men, yet, women with cancer had a significantly reduced risk of using opioids compared with men with cancer (odds ratio: 0.46; 95% confidence interval, 0.36-0.59).

SUMMARY

Only a few recently published studies analyzed sex differences related to prescription opioid use. Findings from the literature and our data suggest women are more likely to use prescription opioids compared with men. There is limited information on sex differences in opioid use risk factors and outcomes and more research in this area is warranted.

Oxycodone self-administration in male and female rats

RATIONALE

Oxycodone is one of the most widely prescribed painkillers in the USA. However, its use is complicated by high abuse potential. As sex differences have been described in drug addiction, the present study tested for sex differences in intravenous oxycodone self-administration in rats.

METHODS

Male and female Sprague-Dawley rats were implanted with jugular vein catheters and trained to self-administer oxycodone (0.03 mg/kg/infusion) under fixed ratio 1 (FR1), FR2, and FR5 schedules of reinforcement followed by a dose-response study to assess sensitivity to the reinforcing effects of oxycodone. In separate rats, sucrose pellet self-administration was assessed under an FR1 schedule to determine whether sex differences in oxycodone self-administration could be generalized across reinforcers. In separate rats, oxycodone distribution to plasma and brain was measured after intravenous drug delivery.

RESULTS

In the first 3 trials under an FR1 schedule of reinforcement, male rats self-administered more oxycodone than females. In contrast, females self-administered more sucrose pellets. Under FR2 and FR5 schedules, no significant sex differences in oxycodone intake were observed, although female rats had significantly more inactive lever presses. Male and female rats showed similar inverted U-shaped dose-effect functions, with females tending to self-administer more oxycodone than males at higher doses. No significant sex differences were observed in plasma or brain oxycodone levels, suggesting that sex differences in oxycodone self-administration behavior were not due to pharmacokinetics.

CONCLUSION

Our results suggest subtle sex differences in oxycodone self-administration, which may influence the abuse liability of oxycodone and have ramifications for prescription opioid addiction treatment.