Alcohol use disorders in opioid maintenance therapy: prevalence, clinical correlates and treatment

Divergent gene expression patterns in alcohol and opioid use disorders lead to consistent alterations in functional networks within the Dorsolateral Prefrontal Cortex

Substance Use Disorders (SUDs) manifest as persistent drug-seeking behavior despite adverse consequences, with Alcohol Use Disorder (AUD) and Opioid Use Disorder (OUD) representing prevalent forms associated with significant mortality rates and economic burdens. The co-occurrence of AUD and OUD is common, necessitating a deeper comprehension of their intricate interactions. While the causal link between these disorders remains elusive, shared genetic factors are hypothesized. Leveraging public datasets, we employed genomic and transcriptomic analyses to explore conserved and distinct molecular pathways within the dorsolateral prefrontal cortex associated with AUD and OUD. Our findings unveil modest transcriptomic overlap at the gene level between the two disorders but substantial convergence on shared biological pathways. Notably, these pathways predominantly involve inflammatory processes, synaptic plasticity, and key intracellular signaling regulators. Integration of transcriptomic data with the latest genome-wide association studies (GWAS) for problematic alcohol use (PAU) and OUD not only corroborated our transcriptomic findings but also confirmed the limited shared heritability between the disorders. Overall, our study indicates that while alcohol and opioids induce diverse transcriptional alterations at the gene level, they converge on select biological pathways, offering promising avenues for novel therapeutic targets aimed at addressing both disorders simultaneously.

Improvements in recovery capital are associated with decreased alcohol use in a primary opioid use disorder treatment-seeking cohort

BACKGROUND AND OBJECTIVES

Comorbid substance use can negatively impact multiple aspects of treatment for patients with an opioid use disorder (OUD). We investigated if treatment for OUD led to improvements in patients' recovery capital (RC) overtime, and whether there were associated changes in co-occurring alcohol use.

METHODS

Participants (n = 133) were patients with OUD seeking outpatient treatment, who completed the Assessment of Recovery Capital (ARC) and reported drinking days per 30-day period thrice over the 6-month study. No specific treatments targeting alcohol were used. Two different models were employed to assess changes in total ARC score and adjusted odds ratio (aOR) for past 30-day abstinence.

RESULTS

Baseline mean ARC scores were 36.6 and significantly increased to mean score of 41.2 at study end. Ninety-one participants (68.4%) reported no alcohol use at baseline, and 97 (78.9%) reported no use in the previous 30 days at study endpoint. For each increase in ARC, there was an aOR 1.07 (confidence interval [CI]: 1.02-1.13) for past 30-day abstinence. Considering ARC standard deviation of 10.33 over all measurements, this equates to an aOR of 2.10 (CI: 1.22-3.62) for past 30-day abstinence.

DISCUSSION AND CONCLUSIONS

We saw significantly increased aOR for past 30-day abstinence as RC improved in an OUD treatment-seeking population. This difference was not caused by differences in ARC between study completers and noncompleters.

SCIENTIFIC SIGNIFICANCE

Showcases how RC growth may be protective of past 30-day alcohol use in an OUD cohort and adds specific aOR for abstinence per ARC increase.

Opioid agonist therapy and mortality among First Nations and other residents with concurrent alcohol use disorder in British Columbia, Canada: A population-based cohort study

BACKGROUND

Despite the prevalence of alcohol use among people with opioid use disorder (PWOUD) engaged in opioid agonist therapy (OAT), clinical care guidance for concurrent alcohol use disorder (AUD) and OUD is scarce. We assessed the prevalence and risk of mortality for concurrent AUD among PWOUD who accessed OAT in British Columbia (BC).

METHODS

Data were obtained from six linked population-level health administrative datasets to identify PWOUD from January 1996 to March 2020. All-cause age and sex standardized mortality ratios (SMR) were calculated to determine the mortality risk by OAT status (on vs. discontinued), stratified by First Nations and other residents with concurrent AUD and OUD. Adjusted risk ratios compared the relative risk of mortality by AUD status (AUD detected vs. not) among First Nations and other residents.

RESULTS

We identified 62,110 PWOUD who received OAT, including 6305 (10.2%) First Nations. OAT substantially lowered the SMR among First Nations (SMR=6.6, 95% CI: 5.4-8.1) and other residents (SMR=6.6; 95% CI: 6.2-7.0) with concurrent AUD and OUD, compared to those who discontinued (SMR=22.7, 95% CI: 20.4-25.1, SMR=17.5, 95% CI: 16.8-18.2 respectively). The risk of mortality was 1.9 (95% CI: 1.6-2.2) times higher for First Nations and 2.0 (95% CI: 1.8-2.2) times higher for other residents with concurrent OUD and AUD compared to those without an indication of AUD.

CONCLUSIONS

The protective effect of OAT remained despite the presence of a concurrent AUD among both First Nations and other residents with OUD. Findings have implications for clinical care management of concurrent disorders.

Gender differences in physical morbidity in opioid agonist treatment patients: population-based cohort studies from the Czech Republic and Norway

BACKGROUND

Physical diseases represent a significant burden for opioid agonist treatment (OAT) patients. This study described physical morbidity in two national cohorts of OAT patients focusing on gender differences.

METHODS

This population-based cohort study linking multiple health registers investigated physical diseases (ICD-10) in patients receiving OAT in the Czech Republic (N = 4,280) and Norway (N = 11,389) during 2010-2019. Gender-stratified analysis was performed.

RESULTS

Overall, we found a large burden of physical morbidity across gender groups in OAT patients. In the Czech Republic and Norway, women in OAT had a significantly higher prevalence of physical diseases across most diagnostic chapters, notably genitourinary diseases and neoplasms. Injuries/external causes and infectious/parasitic diseases were among the most common diseases in both women and men. Viral hepatitis accounted for over half of infectious morbidity in women and men in both cohorts.

CONCLUSIONS

Our findings support the need for early screening, detection, and treatment of diseases and conditions across organ systems and the integration of health promotion activities to reduce physical morbidity in OAT patients. The gender differences underline the need for a tailored approach to address specific medical conditions.

Cause-Specific Mortality among Patients in Treatment for Opioid Use Disorder in Multiple Settings: A Prospective Comparative Cohort Study

INTRODUCTION

Among people receiving current or previous opioid maintenance treatment (OMT), the leading cause of premature death is an opioid overdose. However, other causes of mortality remain high in this group. An understanding of causes of deaths across multiple settings can be useful in informing more comprehensive prevention responses. The aim of this study was to describe all non-overdose causes of death in three national cohorts (Czechia, Denmark, and Norway) among OMT patients and to explore associations of non-overdose mortality with age and gender.

METHODS

This prospective comparative cohort study used national mortality registry databases for OMT patients from Czechia (2000-2019), Denmark (2000-2018), and Norway (2010-2019). Crude mortality rates and age-standardized mortality rates (ASMRs) were calculated as deaths per 1,000 person years for cause-specific mortality.

RESULTS

In total, 29,486 patients were included, with 5,322 deaths recorded (18%). We found variations in causes of death among the cohorts and within gender and age groups. The leading non-overdose causes of death were accidents in Czechia and Denmark, and neoplasms in Norway. Cardiovascular deaths were highest in Czechia, particularly for women in OMT (ASMR 3.59 vs. 1.24 in Norway and 1.87 in Denmark).

CONCLUSION

This study found high rates of preventable death among both genders and all age groups. Different demographic structures, variations in risk exposure, as well as variations in coding practices can explain the differences. The findings support increased efforts towards screening and preventative health initiatives among OMT patients specific to the demographic characteristics in different settings.

Prevalence of alcohol consumption among clients of opioid agonist treatment (OAT) centers in Golestan province, Iran

Introduction

Opioid agonist treatments (OATs) with methadone and buprenorphine are known to be effective treatments for people with opioid use disorder (OUD). However, concomitant use of other substances such as alcohol can negatively affect OAT outcomes. This study aimed to determine the prevalence of alcohol use among clients of OAT centers in the Golestan province in the northern part of Iran.

Materials and methods

This is a secondary analysis of a sample of 706 clients who were receiving OATs from certified OAT centers in Golestan province in 2015. They had been on OATs for at least 1 month and were randomly selected for the study. Data were collected via interviews with selected OAT clients. The main indicators studied in the present study were lifetime history of alcohol consumption, alcohol consumption during last month, lifetime history of excessive alcohol use on one occasion, and years of regular alcohol consumption.

Results

The prevalence of lifetime history of alcohol consumption was estimated at 39.2%. Prevalence of alcohol consumption during last month and lifetime history of excessive alcohol use on one occasion was 6.9 and 18.8%, respectively.

Conclusion

Despite a total ban on alcohol consumption in Iran, a sub-sample of participants admitted past-month alcohol use concurrent with their OATs. The estimated past-month prevalence of alcohol use was lower than the reported prevalence in countries where the production, distribution, and consumption of alcohol are legal.

Effects of a trauma‐informed mindful recovery program on comorbid pain, anxiety, and substance use during primary care buprenorphine treatment: A proof‐of‐concept study

BACKGROUND

A mindfulness-based intervention that reduces comorbid pain, anxiety, and substance use during office-based opioid treatment (OBOT) could enhance retention and prevent overdose. We conducted a pilot study of the Mindful Recovery OUD Care Continuum (M-ROCC), a 24-week trauma-informed program with a motivationally-sensitive curriculum.

METHODS

Patients prescribed buprenorphine (N = 18) enrolled in M-ROCC. We collected urine toxicology biweekly. At 0, 4, and 24 weeks, participants completed PROMIS-Pain, PROMIS-Anxiety, Mindfulness (FFMQ), Experiential Avoidance (BEAQ), Interoceptive Awareness (MAIA), and Self-Compassion (SCS-SF) scales. We estimated changes over time using mixed models. Participants completed qualitative interviews at 4 and 24 weeks.

RESULTS

Positive urine toxicology decreased over time for cocaine (β = -.266, p = .008) and benzodiazepines (β = -.208, p = .028). M-ROCC reduced PROMIS-Pain (Z = -2.29; p = .022), BEAQ (Z = -2.83; p = .0005), and increased FFMQ (Z = 3.51; p < .001), MAIA (Z = 3.40; p = .001), and SCS-SF (Z = 2.29; p = .022). Participants with co-morbid anxiety had decreased PROMIS-Anxiety (Z = -2.53; p = .012). Interviewed participants commonly used mindfulness practices for stress and anxiety (12/12, 100%), and to reduce pain catastrophizing and rumination (7/12, 58%).

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

This is the first study to report the effects of a 24-week mindfulness program during buprenorphine treatment on common comorbidities, including pain interference, anxiety, cocaine, and benzodiazepine use. The findings that M-ROCC is associated with reduced experiential avoidance, as well as increased interoceptive awareness and self-compassion, align with proposed mechanisms that are now extended to OUD treatment. Future larger randomized controlled trials are needed before effectiveness can be established and the role of these mechanisms can be confirmed.

Post-Combat-Injury Opioid Prescription and Alcohol Use Disorder in the Military

INTRODUCTION

Previous studies have identified combat exposure and combat traumatic experience as problematic drinking risk factors. Increasing evidence suggests that opioid use increases the risk of alcohol use disorder. This study investigated the association between opioid prescription use after injury and (1) alcohol use disorder and (2) severity of alcohol use disorder among deployed military servicemembers.

METHODS

Deidentified health records data of 9,029 deployed servicemembers from a retrospective cohort study were analyzed. Data were randomly selected from the Department of Defense Trauma Registry and included servicemembers with combat injuries during deployment in Iraq or Afghanistan (2002-2016). Pharmacy records and International Classification of Diseases, Ninth and Tenth Revision diagnosis codes were used. Three groups were identified (no opioid prescription use, nonpersistent opioid prescription use, and persistent opioid prescription use) and were compared on the basis of alcohol use disorder risk using Cox proportional hazard models. Data analyses were performed in 2021.

RESULTS

Of the 9,029 servicemembers with combat injury, 2,262 developed alcohol use disorder (1,322 developed severe alcohol use disorder). Compared with no opioid prescription use, increased alcohol use disorder risk was associated with persistent opioid prescription use, with a hazard ratio of 1.13 (95% CI=1.02, 1.26). After covariate adjustment, increased risk remained statistically significant (hazards ratio=1.24; 95% CI=1.10, 1.39). There was no significant difference in alcohol use disorder risk between no opioid prescription use and nonpersistent opioid prescription use. The risk of severe alcohol use disorder did not vary by opioid use among servicemembers with alcohol use disorder diagnosis.

CONCLUSIONS

The findings of the study suggest that the incidence of alcohol use disorder was higher among injured servicemembers with persistent opioid prescription use than among those without opioid use. If replicated in prospective studies, the findings highlight the need for clinicians to consider the current and history of alcohol use of patients in initiating treatment involving opioids.

Gabapentin increases the abuse liability of alcohol alone and in combination with oxycodone in participants with co-occurring opioid and alcohol use disorder

BACKGROUND

People who have co-occurring Alcohol Use Disorder (AUD) and Opioid Use Disorder (OUD) carry a higher risk of adverse outcomes, including drug overdose. Early clinical and preclinical studies suggested that gabapentin may be effective in treating both disorders. The present study was designed to assess the effects of gabapentin on the subjective and physiological effects of oxycodone (OXY) and alcohol (ALC), alone and in combination.

METHODS

During an 8-week, inpatient, within-subject, randomized, double-blind, placebo-controlled crossover study, non-treatment seeking participants (N = 13; 12 M/1F; 44.1 ± 3 years of age) with OUD and AUD were maintained on oral morphine (120 mg daily). Under gabapentin (1800 mg/day) and placebo (0 mg/day) maintenance, participants completed nine separate test sessions (three sessions per week) during which they received an oral solution containing 0, 15, or 30 mg/70 kg OXY in combination with 0, 0.5, or 0.75 g/kg ALC. During test sessions, subjective effects and physiological responses were assessed repeatedly on 100-mm visual analog scales (VAS). The primary outcome variable was the VAS rating of drug liking after receiving the drug challenge.

RESULTS

Alcohol alone (but not oxycodone alone) produced dose-related increases in several positive subjective responses, including drug liking. Gabapentin significantly increased drug liking when given in combination with ALC and OXY + ALC (p < 0.05). Gabapentin did not clinically compromise respiration or other vital functions.

CONCLUSIONS

Gabapentin may increase the abuse liability of ALC and OXY + ALC in those with co-occurring OUD and AUD.

Feasibility of a Brief Intervention to Decrease Harmful Alcohol Use Among Methadone Maintenance Treatment Clients in Shanghai: A Randomized Controlled Trial

OBJECTIVES

In this study, we aimed to examine the prevalence of alcohol consumption among methadone maintenance treatment (MMT) clients in Shanghai and to determine whether a brief intervention (BI) affects drinking among them.

METHODS

A total of 837 clients from 14 local MMT clinics were invited to complete the Alcohol Use Disorders Identification Test (AUDIT). One hundred one were included in the study and randomly assigned to the BI group or the control group. Clients in the BI group received a BI and general health education, whereas clients in the control group received the general health education only. Baseline and postintervention assessments were conducted by using the AUDIT, the Drinking Attitude Questionnaire, the Depression Module of the Patient Health Questionnaire, the Generalized Anxiety Disorder Scale, and the General Well-Being Schedule.

RESULTS

Two hundred fifty-nine (30.9%) reported drinking during the last year, and 103 (12.3%) met the criteria for harmful use. At the 3-month follow-up, the AUDIT scores of the 2 groups were significantly decreased, and the time effect was statistically significant ( F = 6.224, P = 0.018), but there was no group difference in AUDIT scores ( F = 1.953, P = 0.172). Both groups had a main time effect of time on the improvement of depression ( F = 8.044, P = 0.008), anxiety ( F = 9.650, P = 0.004), and general well-being ( F = 5.056, P = 0.033). However, there was no statistical difference between the 2 groups ( P > 0.05), and no statistical difference in the time ( F = 1.738, P = 0.198) and group ( F = 0.658, P = 0.424) effect of drinking attitude.

CONCLUSIONS

Alcohol consumption is common among MMT clients in China. Brief intervention, in its current form, could not effectively help them reduce their alcohol consumption.

The effect of concurrent access to alcohol and oxycodone on self-administration and reinstatement in rats

RATIONALE

Although polysubstance use is highly prevalent, preclinical studies that assess voluntary consumption of multiple substances at the same time are rather uncommon. Overlooking drug taking patterns commonly observed in humans may limit the translational value of preclinical models.

OBJECTIVES

Here, we aimed to develop a model of polysubstance use that could be used to assess oral operant self-administration patterns under concurrent access to alcohol and the prescription opioid oxycodone.

METHODS

After a training period where animals associated specific cues and levers with each drug, rats self-administered alcohol and oxycodone solutions concurrently in daily sessions. Oxycodone was then removed to assess potential changes in alcohol consumption. The role of cues and stress on alcohol consumption and oxycodone seeking was also examined under reinstatement conditions.

RESULTS

We found that females consumed more alcohol and oxycodone than males when given access to both drugs, and this effect on alcohol intake persisted when oxycodone was removed. Additionally, re-exposure to oxycodone cues in combination with the administration of the pharmacological stressor yohimbine drove reinstatement of oxycodone seeking in females but did not have a strong effect in males, possibly due to low levels of oxycodone intake during active self-administration in male rats. Additionally, yohimbine drove increased alcohol consumption, in line with prior findings from our group and others.

CONCLUSIONS

Taken together, this study demonstrates that rats will concurrently self-administer both oxycodone and alcohol in operant chambers, and this procedure can serve as a platform for future investigations in polysubstance use and relapse-like behavior.

Evaluation of alcohol use pattern among OST patients using alcohol biomarkers: Report from community clinics in India

BACKGROUND

Opioid-dependent patients undergoing opioid substitution therapy (OST) consume alcohol in a hazardous pattern which adversely affects their treatment outcome. This study aims to measure alcohol biomarkers to screen for secondary alcohol use in OST patients.

METHODS

A pilot study was planned to measure alcohol biomarkers (AST, ALT, GGT, and CDT) to assess alcohol use in OST patients from three community clinics. The biomarkers were categorized based on the reported frequency of alcohol use. The association of the biomarkers with the frequency of alcohol consumption was determined using the post hoc (Mann-Whitney) test.

RESULTS

Forty-five patients with a mean (SD) age of 37.04 (10.7) years were included in the study. Alcohol intake was reported in daily, weekly, and monthly patterns by 22, 63, and 16% of the patients, respectively. High levels of ALT, GGT, and CDT were measured in patients with daily use of alcohol. Serum CDT levels significantly differentiate daily and weekly use from monthly consumption of alcohol.

CONCLUSIONS

Alcohol biomarkers significantly predict the pattern of alcohol use among OST patients. These results can be prudent in low-resource community clinics to improve the overall outcomes of OST in India.

Substance use disorder is associated with alcohol-associated liver disease in patients with alcohol use disorder

BACKGROUND AND AIMS

Substance use disorder (SUD) commonly associates with alcohol use disorder (AUD), and certain substances have independently been shown to drive liver injury. In this work, we sought to determine if co-existing SUD in patients with AUD associated with the presence of alcohol-associated liver disease (ALD).

METHODS

We performed a cross-sectional analysis using the Mass General Brigham Biobank to identify patients based on ICD-10 codes. We performed multivariate analyses accounting for a wide range of demographic and clinical variables to evaluate the association between SUD and ALD. We subsequently used the same method to evaluate the association between SUD and hepatic decompensation.

RESULTS

We identified 2848 patients with a diagnosis of AUD, 9.0% of which had ALD. 25.2% had a history of SUD. In multivariate analyses, patients with SUD were more frequently diagnosed with ALD compared to those without SUD (OR = 1.95, P = 0.001). Furthermore, the number of concurrent SUDs was positively associated with the diagnosis of ALD (OR: 1.33, P < 0.001). Independent of the presence of other SUDs, opioid use disorder in patients with AUD was associated with ALD (OR = 1.902, P = 0.02). In subsequent analyses, we found that sedative use disorder was associated with hepatic decompensation (OR: 2.068, P = 0.03).

CONCLUSIONS

In patients with AUD, SUD, and in particular opioid use disorder, was independently associated with the diagnosis of ALD.

Substance use disorders among primary care patients screening positive for unhealthy alcohol use

BACKGROUND

Despite high prevalence of polysubstance use, recent data on concurrent alcohol use in patients with specific substance use disorders (SUDs) are lacking.

OBJECTIVE

To examine associations between specific SUDs and alcohol consumption levels.

METHODS

Using electronic health record data, we conducted a cross-sectional study of 2,720,231 primary care adults screened for alcohol use between 2014 and 2017 at Kaiser Permanente Northern California. Alcohol consumption levels were categorized as no reported use, low-risk use, and unhealthy use (exceeding daily, weekly, or both recommended drinking limits). Using multinomial logistic regression, and adjusting for sociodemographic and health characteristics, we examined the odds of reporting each alcohol consumption level in patients with a prior-year SUD diagnosis (alcohol, cannabis, cocaine, inhalant, opioid, sedative/anxiolytic, stimulant, other drug, nicotine, any SUD except nicotine) compared to those without.

RESULTS

The sample was 52.9% female, 48.1% White; the mean age was 46 years (SD = 18). Patients with SUDs were less likely to report low-risk alcohol use relative to no use compared with patients without SUDs. Patients with alcohol or nicotine use disorder had higher odds of reporting unhealthy alcohol use relative to no use; however, patients with all other SUDs (except cocaine) had lower odds. Among patients who reported any alcohol use (n = 861,427), patients with SUDs (except opioid) had higher odds of exceeding recommended limits than those without.

CONCLUSION

The associations of unhealthy alcohol use and SUDs suggest that screening for both alcohol and drug use in primary care presents a crucial opportunity to prevent and treat SUDs early.

Opioid agonist treatment initiation and linkage for hospitalized patients seen by a substance use disorder consultation service

Background

Facilitating opioid agonist treatment (OAT) for opioid use disorder (OUD) is an important role of hospital substance use disorder (SUD) consultation services. In the NavSTAR trial, hospital patients receiving SUD consultation who were randomly assigned to patient navigation services for 3 months post-discharge had fewer readmissions compared to usual care.

Methods

This secondary analysis examined hospital-based OAT initiation (pre-randomization) and community-based OAT linkage (post-discharge) among NavSTAR trial participants with OUD (N=314). Associations between OAT initiation and linkage, and patient demographics, housing status, comorbid SUD diagnoses, recent substance use, and study condition were examined using multinomial and dichotomous logistic regression.

Results

Overall, 57.6% initiated OAT during hospitalization (36.3% methadone, 21.3% buprenorphine). Compared to participants not initiating OAT, participants who received methadone were more likely to be female (Relative Risk Ratio [RRR]=2.05, 95% CI=1.11, 3.82, p=0.02), while participants who received buprenorphine were more likely to report homelessness (RRR=2.57, 95% CI=1.24, 5.32, p=0.01). Compared to participants initiating methadone, participants initiating buprenorphine were more likely to be non-White (RRR=3.89; 95% CI=1.55, 9.70; p=0.004) and to report prior buprenorphine treatment (RRR=2.57; 95% CI=1.27, 5.20; p=0.009). OAT linkage within 30-days post-discharge was associated with hospital-based buprenorphine initiation (Adjusted Odds Ratio [AOR]=3.86, 95% CI=1.73, 8.61, p=0.001) and patient navigation intervention (AOR=2.97, 95% CI=1.60, 5.52, p=0.001).

Conclusions

OAT initiation differed by sex, race, and housing status. Hospital-based OAT initiation and patient navigation were independently associated with linkage to community-based OAT. Hospitalization is a reachable moment to begin OAT to alleviate withdrawal and facilitate treatment continuity post-discharge.

Prevalence and correlates of intentional substance use to reduce illicit opioid use in a Canadian setting

Background

While preliminary evidence has begun to document intentional use of one substance to reduce the use of another, the phenomenon of drug substitution among people who use illicit opioids remains understudied. Therefore, we sought to estimate the prevalence and correlates of intentional substance use to reduce illicit opioid use among persons who use drugs (PWUD).

Methods

We analysed data from three prospective cohorts of PWUD in Vancouver, Canada, using multivariable generalized estimating equations (GEE).

Results

Between June 2012 and June 2016, 1527 participants were recruited and contributed 4991 interviews. Of those, 336 (22%) illicit opioid-using participants self-reported substitution to reduce illicit opioid use at least once during study period contributing 467 (9.4%) interviews. Among those interviews, substances substituted for opioids were alcohol (15 participants, 3.2%), stimulants (235, 50.3%), cannabis (129, 27.6%), benzodiazepines (21, 4.5%), and others (20, 4.3%). In multivariable GEE model adjusted for socio-demographic factors, reporting substitution to reduce illicit opioid use was positively associated with greater likelihood of daily cannabis use (Adjusted Odds Ratio = 1.56, 95% Confidence Interval: 1.24-1.96].

Conclusions

While daily cannabis use was associated with reporting opioid substitution attempts, additional study is needed to examine potential of cannabis/cannabinoids to reduce illicit opioid use.

Is extended release naltrexone superior to buprenorphine-naloxone to reduce drinking among outpatients receiving treatment for opioid use disorder? A secondary analysis of the CTN X:BOT trial

BACKGROUND

The comparative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X:BOT) trial showed that following induction, treatment with the sublingual agonist (buprenorphine-naloxone, BUP-NX) or injected antagonist (extended release naltrexone, XR-NTX) produced similar reductions in opioid relapse in injection users with opioid use disorder (OUD). Because XR-NTX reduces drinking in alcohol use disorder (AUD), we conducted a secondary analysis of the X:BOT sample of patients successfully inducted onto treatment to determine whether XR-NTX (n = 204) was superior to BUP-NX (n = 270) in reducing drinking or heavy drinking in patients with OUD.

METHODS

Standard drink units consumed were measured using the Timeline Follow-back method. Mixed-models regression was used to examine the monthly frequency of any drinking and heavy drinking over 6 months of treatment. We used a proportional hazard survival analysis to examine the time to first drink.

RESULTS

Both treatment groups reduced drinking from baseline to posttreatment (small to medium effect), but no differences between groups were detected. However, only 29% (n = 136) of the sample had AUD and 19% (n = 26/136) of those were abstinent before treatment. Analysis of a subsample enriched for possible drinking included 136 individuals with an AUD diagnosis plus 43 who did not have AUD, but reported at least one day of heavy drinking prior to the study. However, this subsample reported only 32% of days of any drinking with a median of only 13% of days designated as "heavy." Within this subsample, at baseline, the BUP-NX group reported more mean drinks per drinking day than the XR-NTX group (p = 0.03); however, there were no other significant group differences on drinking observed before, during, or at the end of treatment.

CONCLUSIONS

There was an overall reduction in drinking during treatment of OUD using both agonist and antagonist medications, so that the hypothesis that XR-NTX would be superior to BUP-NX was not supported. The study is limited by low levels of comorbid AUD or heavy drinking observed in X:BOT trial participants seeking treatment for OUD.

Use of methamphetamine and alcohol among people with opioid use disorder and HIV in Vietnam: a qualitative study

BACKGROUND

Heroin use continues to drive HIV transmission in Vietnam, but methamphetamine and alcohol use are growing rapidly and, as in other countries, polysubstance use is widespread. The objective of this study was to understand the interplay between heroin, methamphetamine, and alcohol use among people with opioid use disorder (OUD) and HIV in Vietnam.

METHODS

We conducted 44 in-depth, face-to-face qualitative interviews with people with OUD and HIV who participated in the BRAVO trial of buprenorphine versus methadone in five Vietnam HIV clinics. Interviews probed participants' experiences of heroin, methamphetamine, and alcohol use and their interplay with HIV/OUD treatment. Interviews were professionally transcribed and analyzed using a thematic analysis approach.

RESULTS

Of 44 participants interviewed 42 were male, on average 38.8 years of age, with 30 reporting a history of methamphetamine use and 33 reporting a history of alcohol use. Several themes emerged: 1) Methamphetamine and alcohol were perceived to have lower addiction potential than heroin 2) Social settings were key facilitators of alcohol and methamphetamine use 3) Some participants, but not all, used methamphetamine to help quit heroin 4) Consuming alcohol blunted the effects of heroin, while paradoxically serving as a catalyst for heroin use 5) Use of methamphetamine was perceived by many participants to be incompatible with treatment for HIV.

CONCLUSIONS

Participant experiences reflected a significant impact of polysubstance use on treatment of HIV and OUD. Patterns of polysubstance use are subject to common preconceptions of alcohol and methamphetamine as having a low addictive potential, and these substances are deeply enmeshed in the social life of many people with OUD in Vietnam. Interventions to address complex social norms and potential harms of polysubstance use are urgently needed as the population of people receiving medication for OUD (MOUD) increases in Vietnam and globally.

TRIAL REGISTRATION

BRAVO - NCT01936857 , September 2013.

An examination between treatment type and treatment retention in persons with opioid and co-occurring alcohol use disorders

BACKGROUND AND AIMS

Persons with opioid use disorder (OUD) and co-occurring alcohol use disorder (AUD) are understudied. We identified whether co-occurring AUD was associated with OUD treatment type, compared associations between treatment type and six-month treatment retention and determined whether co-occurring AUD moderated these relationships.

METHODS

We used an observational cohort study design to analyze insurance claims data from 2011 to 2016 from persons aged 12-64 with an opioid abuse or opioid dependence diagnosis and OUD treatment claim. Our unit of analysis was the treatment episode; we used logistic regression for analyses.

RESULTS

Of 211,047 treatment episodes analyzed, 14 % had co-occurring alcohol abuse or dependence diagnoses. Among persons with opioid dependence, persons with co-occurring alcohol dependence were 25 % less likely to receive medication treatment relative to those without AUD. Further, alcohol dependence was associated with decreased likelihood of treatment with buprenorphine (AOR 0.47, 95 % CI 0.44-0.49) or methadone (AOR 0.31, 95 % CI 0.28-0.35) and increased likelihood of treatment with extended-release (AOR 1.36, 95 % CI 1.21-1.54) or oral (AOR 1.73, 95 % CI 1.57-1.90) naltrexone relative to psychosocial treatment. Buprenorphine and methadone were associated with highest retention prevalence regardless of OUD or AUD severity. Co-occurring alcohol abuse or dependence did not meaningfully change retention prevalence associated with buprenorphine or methadone. Co-occurring AUD was not associated with improved retention among persons receiving either formulation of naltrexone.

CONCLUSIONS

Buprenorphine and methadone are associated with relatively high likelihood of treatment retention among persons opioid and alcohol dependence, but are disproportionately under-prescribed.

Parental status and characteristics of women in substance use treatment services: Analysis of electronic patient records

BACKGROUND

Many women receiving substance use treatment services are mothers. Despite this, research has not proved whether substance use treatment services are addressing the specific needs of mothers. This study explored differences in sociodemographic, psychological, patterns of substance use, and treatment characteristics between mothers and women without children, and between mothers whose children were in alternative care.

METHOD

The study extracted data from electronic patient records (EPRs) of women who attended South London and Maudsley (SLaM) National Health Services (NHS) Foundation Trust addiction services between 2013 and 2020 (N = 4370).

RESULTS

The study identified 1730 participants (39.6%) as mothers, of whom 1340 (77.4%) had dependent children. The average number of births was 1.83 (SD = 1.0). Of the participants, 54.3% of mothers did not disclose whether their dependent child(ren) was under their care and 37.5% of mothers indicated that at least one of their child(ren) was in alternative care. Alcohol was the most reported type of substance used in the past 28 days. Mothers also highly reported suicide attempts and hospitalization due to mental health problems. Compared to women without children, mothers were more likely to be young, experience housing problems, use opioids and/or crack-cocaine in the past 28 days and experience lifetime domestic violence victimizations. Mothers were also less likely to have alcohol-related problems, experience overdose, and social isolation than women without children.

CONCLUSION

The study highlights the need for substance use services to invest in approaches to improve mothers' disclosure of parenting and childcare issues. It also demonstrates that EPRs can identify key characteristics of mothers.

Association of Opioid Use Disorder Treatment With Alcohol-Related Acute Events

IMPORTANCE

Persons with opioid use disorder (OUD) and co-occurring alcohol use disorder (AUD) are understudied and undertreated. It is unknown whether the use of medications to treat OUD is associated with reduced risk of alcohol-related morbidity.

OBJECTIVE

To determine whether the use of OUD medications is associated with decreased risk for alcohol-related falls, injuries, and poisonings in persons with OUD with and without co-occurring AUD.

DESIGN, SETTING, AND PARTICIPANTS

This recurrent-event, case-control, cohort study used prescription claims from IBM MarketScan insurance databases from January 1, 2006, to December 31, 2016. The sample included persons aged 12 to 64 years in the US with an OUD diagnosis and taking OUD medication who had at least 1 alcohol-related admission. The unit of observation was person-day. Data analysis was performed from June 26 through September 28, 2020.

EXPOSURES

Days of active OUD medication prescriptions, with either agonist (ie, buprenorphine or methadone) or antagonist (ie, oral or extended-release naltrexone) treatments compared with days without OUD prescriptions.

MAIN OUTCOMES AND MEASURES

The primary outcome was admission for any acute alcohol-related event defined by International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes. Conditional logistic regression was used to compare OUD medication use between days with and without an alcohol-related event. Stratified analyses were conducted between patients with OUD with and without a recent AUD diagnostic code.

RESULTS

There were 8 424 214 person-days of observation time among 13 335 participants who received OUD medications and experienced an alcohol-related admission (mean [SD] age, 33.1 [13.1] years; 5884 female participants [44.1%]). Agonist treatments (buprenorphine and methadone) were associated with reductions in the odds of any alcohol-related acute event compared with nontreatment days, with a 43% reduction for buprenorphine (odds ratio [OR], 0.57; 95% CI, 0.52-0.61) and a 66% reduction for methadone (OR, 0.34; 95% CI, 0.26-0.45). The antagonist treatment naltrexone was associated with reductions in alcohol-related acute events compared with nonmedication days, with a 37% reduction for extended-release naltrexone (OR, 0.63; 95% CI, 0.52-0.76) and a 16% reduction for oral naltrexone (OR, 0.84; 95% CI, 0.76-0.93). Naltrexone use was more prevalent among patients with OUD with recent AUD claims than their peers without AUD claims.

CONCLUSIONS AND RELEVANCE

These findings suggest that OUD medication is associated with fewer admissions for alcohol-related acute events in patients with OUD with co-occurring AUD.

Hospitalisations for non-fatal overdose among people with a history of opioid dependence in New South Wales, Australia, 2001-2018: Findings from the OATS retrospective cohort study

BACKGROUND

To examine, among a cohort of opioid dependent people with a history of opioid agonist treatment (OAT), the frequency and incidence rates of non-fatal overdose (NFOD) hospital separations over time, by age and sex.

METHODS

Retrospective cohort study of people with a history of OAT using state-wide linked New South Wales (NSW) data. The incidence of NFOD hospital separations involving an opioid, sedative, stimulant or alcohol was defined according to the singular or combination of poisoning/toxic effect using ICD-10-AM codes. Crude incidence rates were calculated by gender, age group and calendar year.

RESULTS

There were 31.8 (31.3-32.3) NFOD per 1,000 person-years (PY). Opioid NFOD incidence was higher in women than men: incidence rate ratio (IRR) 1.11 per 1,000PY; 95 %CI: [1.06-1.17]; women had higher sedative NFOD rates than men, IRR 1.27 per 1,000PY [1.21-1.34]. Participants ≤25 years, 26-30yrs, and 31-35yrs had higher incidence of opioid NFOD compared to 46+yrs, with IRRs of: 1.45 per 1,000PY; [1.32-1.59]; 1.20 per 1,000PY; [1.11-1.30] and 1.22 per 1,000PY; [1.13-1.32], respectively. Between 2006-7 and 2016-17, the cohort accounted for 19 % of NSW opioid NFOD episodes, 12 % of sedative, 14 % of stimulant and 5 % of acute alcohol-related NFOD.

CONCLUSIONS

Hospital stays due to NFOD are a relatively frequent occurrence among opioid-dependent people. There are clear differences in rates and substances involved by sex, age and over time. Evidence-based interventions that prevent overdose among people who are opioid dependent need to be delivered to scale, including widespread community provision of naloxone.

Fifty Years of Research on Prenatal Substances: Lessons Learned for the Opioid Epidemic

Current efforts to design research on developmental effects of prenatal opioid exposure can benefit from knowledge gained from 50 years of studies of fetal alcohol and prenatal drug exposures such as cocaine. Scientific advances in neurobiology, developmental psychopathology, infant assessments, genetics, and imaging support the principles of developmental neurotoxicology that guide research in prenatal exposures. Important to research design is accurate assessment of amount, frequency, and timing of exposure which benefits from accurate self-report and biomarkers of exposure. Identifying and control of pre- and postnatal factors that impact development are difficult and dependent on appropriate research design and selection of comparison groups and measurement of confounding, mediating, and moderating variables. Polysubstance exposure has increased due to the number of prescribed and nonprescribed substances used by pregnant women and varying combinations of drugs may have differential effects on the outcome. Multiple experimental and clinical assessments of infant behavior have been developed but predicting outcome before 18-24 months of age remains difficult. With some exceptions, prenatal substance exposure effect sizes have been small, and cognitive and behavioral effects tend to be specific rather than global. Studies require large sample sizes, adequate retention, and support for social services in at-risk samples. The ethical and legal contexts and stigma associated with drug/alcohol use disorder should be considered in order to prevent harm to families in research programs. Recognition of the pervasive use of addictive substances in this nation should lead to broad scientific efforts to understand how substances affect child outcomes and to initiate prevention and intervention where needed.

Alcohol Drinking in Chinese Methadone-maintained Clients: A Self-medication for Depression and Anxiety?

Objectives:

Unhealthy alcohol use is associated with negative health outcomes in clients attending methadone maintenance therapy (MMT) programs. However, debates exist regarding the methadone dose of drinkers, and little is known about the health outcomes of drinkers with other types of alcohol use. This study examined the drinking pattern and its association with methadone dose, and depressive and anxiety symptoms in Chinese clients undergoing MMT.

Methods:

A secondary data analysis was conducted with data from a large-scale cross-sectional survey of 549 clients of 3 MMT clinics in Wuhan, China. Depression, anxiety, and alcohol dependence were measured with Zung Self-rating Depression Scale, Zung Self-rating Anxiety Scale, and Alcohol Dependence Scale, respectively. Drinking pattern was assessed using 3 indicators: weekly amount of alcohol consumed, weekly frequency of alcohol consumed, and severity of alcohol dependence.

Results:

The prevalence of current drinking, hazardous drinking, regular drinking, and alcohol abuse/dependence was 29.0%, 10.4%, 14.2%, and 8.7%, respectively. In adjustment analyses, relative to nondrinkers, drinkers had significantly lower weight-based methadone dose (β = −0.136, P = 0.008); hazardous drinkers, irregular drinkers, and drinkers without alcohol abuse/dependence had less severe depression (β = −3.67, P = 0.004; β = −2.37, P = 0.034; β = −3.20, P = 0.001) and anxiety (β = −4.90, P < 0.001; β = −3.24, P = 0.006; β = −4.52, P < 0.001), but drinkers with alcohol abuse/dependence had more severe depression (β = 5.55, P < 0.001) and anxiety (β = 4.31, P = 0.005).

Conclusion:

In Chinese MMT clinics, drinkers may use alcohol to compensate for inadequate MMT and self-medicate negative emotions. Compared with nondrinkers, the severities of depression and anxiety were lower among drinkers without alcohol abuse/dependence, but higher among those with alcohol abuse/dependence.

Changes in substance use in relation to opioid agonist therapy among people who use drugs in a Canadian setting

BACKGROUND

Although previous studies have shown that opioid agonist therapy (OAT) is linked to reductions in illicit opioid use, less is known about how OAT impacts the use of other psychoactive substances. We aimed to examine the changes in use of different substances by comparing patterns before and after initiating OAT.

METHODS

Data for this study was derived from three ongoing prospective cohorts involving people who use drugs in Vancouver, Canada from 1996 to 2018. We assessed use patterns for heroin, illicit prescription opioid, cocaine, crack cocaine, crystal methamphetamine, cannabis, daily alcohol use, and benzodiazepines. Segmented regression was conducted to compare the trends of substance use between pre-treatment and post-treatment periods.

RESULTS

The study included 1107 participants. After OAT engagement, we observed an immediate decline in the proportion as well as a decreasing trend for heroin (Adjusted Odds Ratio (AOR): 0.80, 95% confidence interval (CI): 0.77, 0.83), illicit prescription opioid (AOR: 0.87, 95% CI: 0.83, 0.90), and benzodiazepines (AOR: 0.73, 95 % CI: 0.67, 0.80). There was no significant difference comparing the pre-treatment and post-treatment trends for cocaine, crack cocaine, crystal methamphetamine, and cannabis. However, higher growth slope was noted during the post-treatment period for daily alcohol use (P = 0.016).

CONCLUSIONS

We observed significant reduction in illicit opioids use following OAT initiation, but not for stimulant and cannabis. The increasing problematic use of alcohol may pose challenges to the safety and effectiveness of OAT. Development of comprehensive and tailored treatment strategies is needed for poly-substance users accessing OAT.

Untreated alcohol use disorder in people who inject drugs (PWID) in France: a major barrier to HCV treatment uptake (the ANRS-FANTASIO study)

BACKGROUND AND AIMS

Although people who inject drugs (PWID) are the core at-risk population in the hepatitis C virus (HCV) epidemic in industrialized countries, few initiate treatment. Alcohol use disorder (AUD), common within this population, has been identified as a barrier to HCV treatment uptake in the general population. We investigated whether the arrival of new and well-tolerated HCV treatments (direct-acting antivirals: DAA) has improved HCV treatment uptake in French PWID compared with former treatments (pegylated interferon-based treatments: Peg-IFN).

DESIGN

Using discrete-time Cox proportional hazards models based on exhaustive care delivery data, we tested for associations between AUD (defined by AUD-related long-term illness status, diagnosis coding during hospitalization and/or AUD pharmacological treatment) and first HCV treatment delivery, after adjusting for gender, age, complementary universal health cover, liver disease severity and type of opioid agonist therapy (OAT) received. Separate analyses were performed for 2012-13 (Peg-IFN era) and 2014-16 (DAA era).

SETTING

France.

PARTICIPANTS

All French people chronically HCV-infected who received OAT at least once during 2012-16 and were covered by the national health insurance (n = 24 831).

MEASUREMENTS

Incidence rate of HCV treatment uptake, hazard ratios associated with AUD and other covariates.

FINDINGS

Incidence rate (IR) of HCV treatment uptake per 100 person-years was 6.56, confidence interval (CI) = 6.30-6.84; and IR = 5.70, 95% CI = 5.51-5.89 for Peg-IFN-based treatment (2012-13) and DAA (2014-16), respectively. After multiple adjustment, people with AUD not receiving related medication had 30 and 14% lower Peg-IFN-based treatment and DAA uptake, respectively, than those without AUD [hazard ratio (HR) = 0.70, 95% CI = 0.62-0.80 and HR = 0.86, 95% CI = 0.78-0.94]. No difference was observed between those treated for AUD and those without AUD.

CONCLUSIONS

Despite the benefits of direct-acting antiviral treatment, untreated alcohol use disorder appears to remain a major barrier to hepatitis C virus treatment access for people who inject drugs in France.

An Inverse Relationship Between Alcohol and Heroin Use in Heroin Users Post Detoxification

Background

Given that fewer than 50% of countries provide Opioid Agonist Maintenance Therapies (OAMT), it is important to assess whether other substances act as a substitute for heroin in recovering heroin users who receive detoxification models of treatment. There is a dearth of prospective studies from low-and-middle-income countries evaluating these patterns of substance use.

Methods

300 heroin users from the Gauteng province of South Africa were assessed on entry into inpatient detoxification and then followed-up 3 and 9 months after leaving treatment. Treatment consisted of 1 week of detoxification followed by 6-8 weeks of psychosocial therapy. We measured the overall changes in the prevalence of heroin, alcohol and other drug use at baseline and postrehabilitation. Comparison of these outcomes at enrolment, 3 months and 9 months was performed by a Generalised Estimating Equation (GEE) with the outcome as the dependent variable, observation point as the independent variable, and participant as the repeated measure. Injecting status and treatment completion were included as covariates. We also measured the individual pathways between heroin and alcohol use in the 210 participants that were seen at all three timepoints.

Results

Of the original cohort, 252 (84.0%) were re-interviewed at 3 months and 225 (75.0%) at 9 months. From baseline to 3 months, the proportion of past month heroin users decreased significantly to 65.5%; however, during this time, the proportion of past month alcohol users increased from 16.3% to 55.2% (p<0.0001). When assessing the pathways between heroin and alcohol use at an individual level, 55.4% (n-97) of those who were past month alcohol abstinent prior to rehabilitation were using alcohol at 3 months. From 3 to 9 months the proportion of heroin users increased to 72.4% (p<0.0001), and during this time, the proportion of alcohol users decreased.

Conclusion

After detoxification, a significant reduction in heroin use was observed with a concomitant increase in alcohol consumption. Under these circumstances, alcohol may have acted as a substitute for heroin in the short term. The initial reduction in heroin use 3 months postrehabilitation was followed by increased consumption 6 months later. This observation supports the need for interventions to prevent, monitor and treat high levels of alcohol use in heroin users post detoxification. The provision of OAMT is a necessary consideration to address both the risk of increased alcohol intake as well as the decline in heroin abstinence rates.

Psycho-Social Correlates of Opioid Use Disorder among the US Adult Population: Evidence from the National Survey on Drug Use and Health, 2015-2018

The United States (US) has experienced an opioid epidemic over the last two decades. Drug overdose deaths increased by 21% from 2015 to 2016, with two-thirds of these deaths attributed to opioid use disorder (OUD). This study assessed the psycho-social correlates associated with OUD over 2015-2018 in the US. Methods: This study used data collected from 171,766 (weighted = 245,838,163) eligible non-institutionalized US adults in the pooled National Survey on Drug Use and Health from 2015-2018. Survey-weighted descriptive, bivariate, and multivariable analyses were performed to assess the psycho-social correlates of OUD. Results: About 0.85% of the respondents reported having OUD in the past year. About one-quarter (26.3%), one-sixth (14.8%), and half (47.3%) of the respondents with OUD reported alcohol, marijuana, and nicotine dependence, respectively. One-sixth (16.7%) had a criminal justice involvement history, and almost one-third (30.8%) experienced a major depressive episode (MDE) in the past year. In multivariable analysis, ≤64 years, White race, male gender, lower educational attainment, unemployment, large metro area residence, history of alcohol, marijuana, nicotine use disorder, history of criminal justice involvement, and MDE in previous year were associated with higher odds of OUD. In contrast, being married, non-Hispanic African American, non-Hispanic Other, and Hispanic ethnicity, good physical health, private health insurance, and higher risk perception about addictive substance use were associated with lower odds of OUD. Conclusions: OUD is more prevalent among certain sociodemographic groups in the US. Targeted interventions focusing on young, White, unmarried, male, and uninsured/Medicaid/Medicare populations should be implemented to reduce the OUD.

Diverse diagnostic profiles associated with prescription opioid use disorder in a nationwide sample: One crisis, multiple needs

OBJECTIVE

The opioid crisis has had devastating effects on individuals and communities, and it has rapidly increased in severity. However, we still lack nationally representative information on the diversity of comorbidity patterns among prescription opioid use disorder (P-OUD), other substance use disorders (SUDs), and psychopathology using the newest edition of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013). This impedes planning for multiple aspects of intervention, including society-wide allocation of treatment resources, program design at individual treatment centers, and personalized care to individual patients.

METHOD

To address this critical gap in information, we evaluated clinical profiles of American adults via latent class analysis in a large, recently collected epidemiological dataset that uses structured diagnostic assessment for DSM-5 psychopathology (National Epidemiologic Survey on Alcohol and Related Conditions-III; N = 36,309). Variables considered for profiles included lifetime diagnosis for multiple SUDs, various externalizing and internalizing conditions, and demographic variables. We then associated clinical profiles with demographic variables and functional impairment.

RESULTS

Comorbid psychopathology and other SUDs were common in latent classes with elevated and very high rates of P-OUD. To illustrate, alcohol use disorder rates were greater than 45%, and posttraumatic stress disorder rates were greater than 28% in classes with higher P-OUD rates. Higher P-OUD rates were associated with White/non-Hispanic and American Indian/Alaska Native populations. Relationships between P-OUD rates and functional impairment were inconsistent.

CONCLUSION

Many current treatment delivery systems are not designed to accommodate the heterogeneous profiles associated with high P-OUD rates. We provide specific suggestions for improvements to the mental health service system, individual clinical care programs, and future research approaches. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Use of Filter Paper to Measure Alcohol Biomarkers among Opioid-Dependent Patients on Agonist Maintenance Treatment: A Community-Based Study

BACKGROUND

Harmful Alcohol use is frequent among opioid dependents patients undergoing agonist maintenance treatment. The objective assessment of harmful alcohol use can be done using laboratory measures of serum biomarkers. For community-based patients, there is often a requirement of an alternative method due to lack of onsite laboratory services. The aim of the study was to examine filter paper as a matrix to measure serum biomarkers of harmful alcohol use.

METHODS

The initial phase involved standardization of the filter-paper-based assay. Conditions were optimised for extraction and estimation of alcohol biomarkers (Aspartate Aminotransferase; AST, Alanine Aminotransferase; ALT, Gamma Glutamyl transferase; GGT and Carbohydrate Deficient Transferrin; CDT) from the filter paper. For clinical validation, serum samples were collected from community clinics. Biomarker levels obtained from both the methods were correlated using linear regression analysis. Limits of agreement between the two methods was estimated using the Intraclass Correlation Coefficient (ICC).

RESULTS

The extraction of enzymes (AST, ALT and GGT) from filter paper was carried out using the substrate buffer available with the reagent kit (Randox, UK). CDT was readily extracted from filter paper using deionised water. Serum biomarker levels measured from samples collected from community clinics correlated well with filter paper extracted levels (ICC 0.97-0.99). More than 90% of alcohol biomarker levels were recovered from the filter paper matrix using this method.

CONCLUSION

Filter paper has the potential to be used as a matrix to objectively measure alcohol biomarkers among opioid-dependent patients from community settings lacking onsite laboratory facilities.

Opioid epidemic and liver disease

Opioid use in the United States and in many parts of the world has reached epidemic proportions. This has led to excess mortality as well as significant changes in the epidemiology of liver disease. Herein, we review the impact of the opioid epidemic on liver disease, focusing on the multifaceted impact this epidemic has had on liver disease and liver transplantation. In particular, the opioid crisis has led to a significant shift in incident hepatitis C virus infection to younger populations and to women, leading to changes in screening recommendations. Less well characterized are the potential direct and indirect hepatotoxic effects of opioids, as well as the changes in the incidence of hepatitis B virus infection and alcohol abuse that are likely rising in this population as well. Finally, the opioid epidemic has led to a significant rise in the proportion of organ donors who died due to overdose. These donors have led to an overall increase in donor numbers, but also to new considerations about the better use of donors with perceived or actual risk of disease transmission, especially hepatitis C. Clearly, additional efforts are needed to combat the opioid epidemic. Moreover, better understanding of the epidemiology and underlying pathophysiology will help to identify and treat liver disease in this high-risk population.

Disulfiram attenuates morphine or methadone withdrawal syndrome in mice

Taking opioids is often accompanied by the development of dependence. Unfortunately, treatment of opioid dependence is difficult, particularly because of codependence - for example, on alcohol or other drugs of abuse. In the presented study, we analyzed the potential influence of disulfiram, a drug used to aid the management of alcoholism, on opioid abstinence syndrome, which occurs as a result of opioid withdrawal. Opioid dependence in mice was induced by subcutaneous administration of either morphine or methadone at a dose of 48 mg/kg for 10 consecutive days. To trigger a withdrawal syndrome, the opioid receptor antagonist, naloxone, was administered at a dose of 1 mg/kg (subcutaneous), and the severity of withdrawal signs was assessed individually. Interruption of chronic treatment with morphine or methadone by naloxone has led to the occurrence of opioid abstinence signs such as jumping, paw tremor, wet-dog shakes, diarrhea, teeth chattering, ptosis, and piloerection. Importantly, pretreatment with disulfiram (25, 50, and 100 mg/kg) reduced the intensity of withdrawal signs induced by naloxone in morphine or methadone-treated mice. These findings show the effectiveness of disulfiram in reducing opioid abstinence signs.

Alcohol use disorder and motives for prescription opioid misuse: A latent class analysis

Introduction: Among those who misuse prescription opioids, alcohol use disorder (AUD) is associated with progression to opioid use disorder, risk of overdose, and poor treatment outcomes. However, little is known about co-occurring AUD and prescription opioid misuse. Motives, or reasons, for substance use are important factors in substance use initiation and maintenance; characterizing common motives can help inform treatment targets. The aims of the present study were to (1) identify patterns of motives for prescription opioid misuse, and (2) examine the association between AUD and motives. Methods: Data were extracted from the 2015 National Survey on Drug Use and Health. Analyses included adult respondents with past-year prescription opioid misuse (N = 2,627), of which 24.2% had a co-occurring AUD. Latent class analysis was utilized to identify patterns of motives for prescription opioid misuse. AUD was included as a predictor of class membership. Results: We identified three classes: (1) pain relief (56.1% of the sample), (2) recreational (e.g., to get high; 29.3%), and (3) mixed motives (e.g., coping, pain relief, recreational; 14.6%). AUD was associated with greater odds of membership in the recreational (OR = 2.05, 95% CI = 1.36, 3.10, p = .001) and mixed motives (OR = 2.11, 95% CI = 1.21, 3.67, p = .008) classes, as compared to the pain relief class. Results: Pain relief was the most commonly endorsed motive for opioid misuse among those with and without AUD. These results underscore the need to improve pain management among those who misuse prescription opioids. Those with co-occurring AUD might also benefit from interventions targeting negative affect and/or positive outcome expectancies.

Prevalence of Coaddictions and Rate of Successful Treatment Among a French Sample of Opioid-Dependent Patients With Long-Term Opioid Substitution Therapy: The OPAL Study

Background: Opioid use disorder (OUD) is a worldwide major health concern due to increased early mortality and morbidity. Opioid substitution therapy (OST) is approved in the context of a global OUD treatment (OUDT), in conjunction with psychosocial interventions. Many factors can explain why unsuccessful treatment rates remain high. While the phenomenon of addiction switching is often proposed, it is not known whether this also includes gambling addiction. The primary objective of the OPAL study was to determine the prevalence of coaddictions, including problem gambling, among patients with OUDT. Secondary objectives were to assess the rate of unsuccessful OUDT and to characterize the associated factors. Methods: For this observational transversal multicenter study, patients with OUDT including OST for at least 6 months were recruited. Clinical assessment was based on a clinically structured interview and a set of self-reported questionnaires. Coaddictions were screened using the Fagerström, the CRAFFT, and the Lie/Bet questionnaires. Unsuccessful OUDT was defined as the persistence of opioid use and/or the worsening of another substance use or gambling practice. After a descriptive analysis, a multivariate analysis was performed to identify the factors associated with unsuccessful OUDT. Results: The sample consisted of 263 patients. Prevalence of coaddictions reached 97% of the sample. Problem gambling was associated with 10% of the patients. OUDT was considered as "unsuccessful" for 60% of the patients. Associated factors included having drug-using friends, psychiatric and professional negative consequences related to opioid use, more than one OST-prescribing physician, and impulsivity, especially high scores for lack of premeditation and sensation seeking. Conclusions: This study provides further evidence of the need to consider coaddictions and the usefulness of global addictive evaluations. Poor prognostic factors must alert the clinician to initiate more sustained care. Further implications are discussed.

Craving in Opioid Use Disorder: From Neurobiology to Clinical Practice

Opioid use disorder (OUD) is a major public health issue that has reached epidemic levels in some parts of the world. It is a chronic and complex neurobiological disease associated with frequent relapse to drug taking. Craving, defined as an overwhelmingly strong desire or need to use a drug, is a central component of OUD and other substance use disorders. In this review, we describe the neurobiological and neuroendocrine pathways that underpin craving in OUD and also focus on the importance of assessing and treating craving in clinical practice. Craving is strongly associated with patients returning to opioid misuse and is therefore an important treatment target to reduce the risk of relapse and improve patients' quality of life. Opioid agonist therapies (OAT), such as buprenorphine and methadone, can significantly reduce craving and relapse risk, and it is essential that patients are treated optimally with these therapies. There is also evidence to support the benefits of non-pharmacological approaches, such as cognitive behavioral therapy and mindfulness-based interventions, as supplementary treatments to opioid agonist therapies. However, despite the positive impact of these treatments on craving, many OUD patients continue to suffer with negative affect and dysphoria. There is a clear need for further studies to progress our understanding of the neurobiological basis of craving and addiction and to identify novel therapeutic strategies as well as to optimize the use of existing treatments to improve outcomes for the growing numbers of patients affected by OUD.

Mechanisms and Clinical Features of Co-occurring Opioid and Nicotine Use

Purpose of review

To review the literature addressing shared pathophysiological and clinical features of opioid and nicotine use to inform etiology and treatment, and highlight areas for future research.

Recent findings

Opioid and nicotine use co-occur at an alarmingly high rate, and this may be driven in part by interactions between the opioid and cholinergic systems underlying drug reward and the transition to dependence. Pain, among other shared risk factors, is strongly implicated in both opioid and nicotine use and appears to play an important role in their co-occurrence. Additionally, there are important sex/gender considerations that require further study. Regarding treatment, smoking cessation can improve treatment outcomes in opioid use disorder, and pharmacological approaches that target the opioid and cholinergic systems may be effective for treating both classes of substance use disorders.

Summary

Understanding overlapping etiological and pathophysiological mechanisms of opioid and nicotine use can aid in understanding their co-occurrence and guiding their treatment.

Neuroimmune signaling in alcohol use disorder

Alcohol use disorder (AUD) is a widespread disease with limited treatment options. Targeting the neuroimmune system is a new avenue for developing or repurposing effective pharmacotherapies. Alcohol modulates innate immune signaling in different cell types in the brain by altering gene expression and the molecular pathways that regulate neuroinflammation. Chronic alcohol abuse may cause an imbalance in neuroimmune function, resulting in prolonged perturbations in brain function. Likewise, manipulating the neuroimmune system may change alcohol-related behaviors. Psychiatric disorders that are comorbid with AUD, such as post-traumatic stress disorder, major depressive disorder, and other substance use disorders, may also have underlying neuroimmune mechanisms; current evidence suggests that convergent immune pathways may be involved in AUD and in these comorbid disorders. In this review, we provide an overview of major neuroimmune cell-types and pathways involved in mediating alcohol behaviors, discuss potential mechanisms of alcohol-induced neuroimmune activation, and present recent clinical evidence for candidate immune-related drugs to treat AUD.

Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users

BACKGROUND

Problem alcohol use is common among people who use illicit drugs (PWID) and is associated with adverse health outcomes. It is also an important factor contributing to a poor prognosis among drug users with hepatitis C virus (HCV) as it impacts on progression to hepatic cirrhosis or opioid overdose in PWID.

OBJECTIVES

To assess the effectiveness of psychosocial interventions to reduce alcohol consumption in PWID (users of opioids and stimulants).

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group trials register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, and PsycINFO, from inception up to August 2017, and the reference lists of eligible articles. We also searched: 1) conference proceedings (online archives only) of the Society for the Study of Addiction, International Harm Reduction Association, International Conference on Alcohol Harm Reduction and American Association for the Treatment of Opioid Dependence; and 2) online registers of clinical trials: Current Controlled Trials, ClinicalTrials.gov, Center Watch and the World Health Organization International Clinical Trials Registry Platform.

SELECTION CRITERIA

We included randomised controlled trials comparing psychosocial interventions with other psychosocial treatment, or treatment as usual, in adult PWIDs (aged at least 18 years) with concurrent problem alcohol use.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included seven trials (825 participants). We judged the majority of the trials to have a high or unclear risk of bias.The psychosocial interventions considered in the studies were: cognitive-behavioural coping skills training (one study), twelve-step programme (one study), brief intervention (three studies), motivational interviewing (two studies), and brief motivational interviewing (one study). Two studies were considered in two comparisons. There were no data for the secondary outcome, alcohol-related harm. The results were as follows.Comparison 1: cognitive-behavioural coping skills training versus twelve-step programme (one study, 41 participants)There was no significant difference between groups for either of the primary outcomes (alcohol abstinence assessed with Substance Abuse Calendar and breathalyser at one year: risk ratio (RR) 2.38 (95% confidence interval [CI] 0.10 to 55.06); and retention in treatment, measured at end of treatment: RR 0.89 (95% CI 0.62 to 1.29), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was very low.Comparison 2: brief intervention versus treatment as usual (three studies, 197 participants)There was no significant difference between groups for either of the primary outcomes (alcohol use, measured as scores on the Alcohol Use Disorders Identification Test (AUDIT) or Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) at three months: standardised mean difference (SMD) 0.07 (95% CI -0.24 to 0.37); and retention in treatment, measured at three months: RR 0.94 (95% CI 0.78 to 1.13), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was low.Comparison 3: motivational interviewing versus treatment as usual or educational intervention only (three studies, 462 participants)There was no significant difference between groups for either of the primary outcomes (alcohol use, measured as scores on the AUDIT or ASSIST at three months: SMD 0.04 (95% CI -0.29 to 0.37); and retention in treatment, measured at three months: RR 0.93 (95% CI 0.60 to 1.43), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was low.Comparison 4: brief motivational intervention (BMI) versus assessment only (one study, 187 participants)More people reduced alcohol use (by seven or more days in the past month, measured at six months) in the BMI group than in the control group (RR 1.67; 95% CI 1.08 to 2.60). There was no difference between groups for the other primary outcome, retention in treatment, measured at end of treatment: RR 0.98 (95% CI 0.94 to 1.02), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was moderate.Comparison 5: motivational interviewing (intensive) versus motivational interviewing (one study, 163 participants)There was no significant difference between groups for either of the primary outcomes (alcohol use, measured using the Addiction Severity Index-alcohol score (ASI) at two months: MD 0.03 (95% CI 0.02 to 0.08); and retention in treatment, measured at end of treatment: RR 17.63 (95% CI 1.03 to 300.48), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was low.

AUTHORS' CONCLUSIONS

We found low to very low-quality evidence to suggest that there is no difference in effectiveness between different types of psychosocial interventions to reduce alcohol consumption among people who use illicit drugs, and that brief interventions are not superior to assessment-only or to treatment as usual. No firm conclusions can be made because of the paucity of the data and the low quality of the retrieved studies.

Pharmacological and Behavioral Treatment of Opioid Use Disorder

Objective:

Opioid use disorder (OUD) in the United States has surged, with an estimated 2.5 million needing treatment. The aim of this article is to provide a clinical overview of the key pharmacological and behavioral treatments for OUD.

Methods:

A nonsystematic review of the literature was conducted to investigate OUD treatments, including their mechanism of action, efficacy, clinical guidelines in the United States, and consideration of frequently occurring comorbid conditions.

Results:

Food and Drug Administration (FDA)–approved pharmacotherapies for OUD include methadone, buprenorphine, and naltrexone, each of which has different actions on opioid receptors. Although these medications all show efficacy in some dosages and formulations, barriers to accessibility may be most pronounced for methadone, whereas treatment retention poses greater challenges for naltrexone and, to a lesser extent, buprenorphine. Lofexidine, an α₂‐adrenergic agonist, has recently been approved by the FDA for treatment of opioid withdrawal symptoms. OUD is commonly treated with medication‐assisted treatment (MAT), which offers pharmacotherapy in the context of counseling and/or behavioral treatments. Behavioral therapies, rarely offered as stand‐alone treatments for OUD, are generally used in the context of MAT, in structured settings or to prevent relapse after detoxification and stabilization. The aim of behavioral interventions is to improve medication compliance and target problems not addressed with medication alone. Individuals with OUD commonly have other comorbid psychiatric and substance use conditions, which are not exclusionary for initiating MAT but should be carefully evaluated and monitored because they may reduce treatment effectiveness.

Conclusions:

MAT is the first‐line treatment for patients with OUD and should be provided in combination with behavioral interventions. Treatment retention remains challenging in this population. Future studies should focus on approaches that will serve the complex needs of patients with OUD, including those with comorbid psychiatric and substance use conditions.

Gender moderates the association between distress tolerance and alcohol use among individuals with opioid use disorder

BACKGROUND

Alcohol use among individuals with opioid use disorder (OUD) can be dangerous, and understanding factors contributing to alcohol use in this population is important. The current study examined alcohol use among individuals with prescription OUD based on distress tolerance. It was hypothesized that individuals with greater distress tolerance abilities would have a lower frequency and quantity of alcohol use compared to individuals with less distress tolerance. It was also hypothesized that this association would differ based on gender.

METHODS

A total of 122 individuals with prescription OUD participated in the current study. Participants completed questionnaires regarding demographics, distress tolerance, mental health symptoms, and frequency and quantity of alcohol in the past 30 days. A regression model was conducted using the alcohol-related variables as outcomes.

RESULTS

There was a significant interaction between gender and distress tolerance on alcohol use frequency. Greater distress tolerance was associated with fewer alcohol use days in women, but there was no association between distress tolerance and alcohol use days in men.

CONCLUSIONS

The findings suggest that distress tolerance skills may be key to reducing alcohol use in women with prescription OUD.

Opioid Misuse as a Predictor of Alcohol Treatment Outcomes in the COMBINE Study: Mediation by Medication Adherence

BACKGROUND

Alcohol is often consumed with opioids and alcohol misuse interferes with treatment for opioid use disorder (OUD). Drug misuse is associated with worse alcohol use disorder (AUD) treatment outcomes, yet no studies have investigated the role of opioid misuse in AUD treatment outcomes.

METHODS

We conducted secondary analyses of the medication conditions of the COMBINE study (n = 1,226), a randomized clinical trial of medications (acamprosate and/or naltrexone) and behavioral interventions (medication management and/or behavioral intervention) for alcohol dependence. We examined associations between baseline opioid misuse and the use of cannabis and other drugs with time to first drinking day, time to first heavy drinking day, and the frequency and intensity of drinking during treatment and 1 year following treatment, based on latent profile analysis. Opioid misuse was defined as use of illicit or prescription opioids without a prescription or not as directed in the previous 6 months, in the absence of OUD. Self-reported cannabis and other drug use were also examined. Seventy individuals (5.7%) met the opioid misuse definition and 542 (44.2%) reported use of cannabis or other drugs without opioid misuse. We also examined medication adherence as a potential mediator.

RESULTS

Baseline opioid misuse significantly predicted the time to first heavy drinking day (OR = 1.38 [95% CI: 1.13, 1.64], p = 0.001) and a higher probability of being in a heavier and more frequent drinking profile at the end of treatment (OR = 2.90 [95% CI: 1.43, 5.90], p = 0.003), and at 1 year following treatment (OR = 2.66 [95% CI: 1.26, 5.59], p = 0.01). Cannabis and other drug use also predicted outcomes. Medication adherence partially mediated the association between opioid misuse, cannabis use, other drug use, and treatment outcomes.

CONCLUSIONS

Opioid misuse and other drug use were associated with poorer AUD treatment outcomes, which was partially mediated by medication adherence. Clinicians and researchers should assess opioid misuse and other drug use in patients undergoing AUD treatment.

Factors associated with discontinuation of methadone maintenance therapy (MMT) among persons who use alcohol in Vancouver, Canada

BACKGROUND

We sought to examine the factors associated with discontinuation of MMT among persons on methadone who use alcohol.

METHODS

We evaluated the impact of drug-related and other factors on discontinuation of MMT among persons enrolled in MMT and who reported any use of alcohol versus those who were enrolled in two community-recruited prospective cohorts of people who use illicit drugs (PWUD). Extended Cox models with time-dependent variables identified factors independently associated with time to first MMT discontinuation.

RESULTS

Between December 2005 and 2015, 823 individuals on MMT who also reported using alcohol at least once were included in these analyses. During the study period, 391 (47.5%) discontinued methadone. Daily heroin injection (Adjusted Hazard Ratio [AHR] = 2.67, 95% Confidence Interval [CI]: 2.10-3.40) and homelessness (AHR = 1.42, 95% CI: 1.10-1.83) were positively associated with MMT discontinuation, whereas receiving other concurrent addiction treatment in addition to MMT (AHR = 0.07, 95% CI: 0.05-0.08), as well as >60 mg methadone dose (AHR = 0.48, 95% CI: 0.39-0.60), Hepatitis C virus seropositivity (AHR = 0.65, 95% CI: 0.47-0.90), and HIV seropositivity (AHR = 0.72, 95% CI: 0.57-0.91) were negatively associated with MMT discontinuation. Any/heavy alcohol use was not independently associated with MMT discontinuation.

CONCLUSIONS

This study reinforces the known risks of continued heroin injection and homelessness for MMT discontinuation among individuals who also consume alcohol and highlights the protective effect of both MMT dose and receipt of concurrent addiction treatment.

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

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

Monitoring people at risk of drinking by a rapid urinary ethyl glucuronide test

Alcohol and illicit drug abuse are major public health problems worldwide. Since alcohol is the predominant substance of choice in polydrug abusers, monitoring its use, along with urinary drug screening in patients in rehabilitation programs, appeared to be crucial in identifying patients at risk of alcohol disorders leading to impaired quality of life. Ethyl β-D-6-glucuronide, a non-oxidative, non-volatile, stable and minor direct ethanol metabolite, has a 6h to 4 day window of detection in urine after the last alcohol intake. Each of the 119 subjects (85 males, 34 females) registered with the Public Health Service for Drug Dependence Treatment provided a urine sample for ethylglucoronide (EtG) determination in an immunochemical test with a 500 ng/ml cutoff. All results were evaluated with confirmation criteria of a fully validated gas chromatography/mass spectrometry assay. The diagnostic performance of the EtG immunochemical test was assessed using Receiver Operating Characteristic Curve analysis. The immunochemical test specificity was 100% for EtG urinary values above 500 ng/ml. No false positive results were found. With levels below 500 ng/ml, 12% of the samples were classified as negative. The average consumption of the incorrectly classified subjects was 171 ng/ml, with a misclassification error of 6.5% to 18.5%. High agreement between EtG as determined in an immunochemical test and gas chromatography/mass spectrometry, suggests that the rapid EtG test is a reliable, cost-effective alcohol monitoring assay for patient management in many non-forensic settings, such as drug rehabilitation programs.

Prevalence of Heavy Alcohol Use Among People Receiving Methadone Following Change to Methadose

BACKGROUND

A recent switch in methadone formulation from methadone (1 mg/mL) to Methadose (10 mg/mL) in British Columbia (BC), Canada, was associated with increased reports of opioid withdrawal and increases in illicit opioid use. Impacts on other forms of drug use have not been assessed. Since alcohol use is common among people receiving Medication-Assisted Treatment (MAT), we assessed if switch was associated with increased prevalence of heavy alcohol use.

METHODS

Drawing on data from two open prospective cohort studies of people who inject drugs in Vancouver, BC, generalized estimating equations (GEE) model examined relationship between methadone formulation change and heavy alcohol use, defined by National Institute for Alcohol Abuse and Alcoholism (NIAAA). A sub-analysis examined relationship with heavier drinking defined as at least eight drinks per day on average in last six months.

RESULTS

Between June 2013 and May 2015, a total of 787 participants on methadone were eligible for the present analysis, of which 123 (15.6%) reported heavy drinking at least once in last six months. In an unadjusted GEE model, Methadose use was not significantly associated with an increased likelihood of heavy drinking [Odds Ratio (OR) = 1.03; 95% Confidence interval (CI) = 0.87-1.21]. Methadose use was not significantly associated with an increased likelihood of drinking at least eight drinks daily on average (OR = 1.09, 95% CI = 0.72-1.65).

CONCLUSIONS

Despite reported changes in opioid use patterns coinciding with the change, there appeared to be no effect of the methadone formulation change on heavy drinking in this setting.

Increasing availability of illicit and prescription opioids among people who inject drugs in a Canadian setting, 2010-2014

BACKGROUND

Nonmedical use of prescription opioid and illicit opioid has been increasing at an alarming rate in North America over the past decade.

OBJECTIVE

We sought to examine the temporal trends and correlates of the availability of illicit and prescription opioids among people who inject drugs (PWID) in Vancouver, Canada.

METHODS

Data were derived from three prospective cohort studies of PWID in Vancouver between 2010 and 2014. In semiannual interviews, participants reported the availability of five sets of illicit and prescription opioids: (1) heroin; (2) Percocet (oxycodone/acetaminophen), Vicodin (hydrocodone/acetaminophen), or Demerol (meperidine); (3) Dilaudid (hydromorphone); (4) Morphine; (5) oxycontin/OxyNEO (controlled-release oxycodone). We defined perceived availability as immediate (e.g., available within 10 minutes) versus no availability/available after 10 minutes. The trend and correlation of immediate availability were identified by multivariable generalized estimating equations logistic regression.

RESULTS

Among 1584 participants, of which 564 (35.6%) were female, the immediate availability of all illicit and prescribed opioids (except for oxycontin/OxyNEO) increased over time, independent of potential confounders. The Adjusted Odds Ratios of immediate availability associated with every calendar year increase were between 1.09 (95% confidence interval 1.05-1.12) (morphine and Dilaudid) and 1.13 (95% confidence interval 1.09-1.17) (Percocet/Vicodin/Demerol) (all p-values <0.05).

CONCLUSION

The availability of most prescription opioids had continued to increase in recent years among our sample of PWID in Vancouver. Concurrent increases in the availability of heroin were also observed, raising concerns regarding combination of both illicit and prescription opioid use among PWID that could potentially increase the risk of overdose.