The life course perspective on drug use: a conceptual framework for understanding drug use trajectories

A scoping review of social determinants of health's impact on substance use disorders over the life course

BACKGROUND

Substance use is a public crisis in the U.S. Substance use can be understood as a series of events in the life course, from initiation to mortality. Social Determinants of Health (SDoH) have increasingly been recognized as essential contributors to individuals' health. This scoping review aims to examine available evidence of SDoH impact on the life course of substance use disorder (SUD).

METHODS

This study identified peer-reviewed articles that reported longitudinal studies with SDoH factors as independent variables and substance use and disorders as dependent variables from PubMed, Embase, and Web of Science. The reported associations between SDoH and substance use stages over the life course were narratively and graphically summarized.

RESULTS

Among the 50 studies identified, ten revealed parental monitoring/support and early childhood education as protective factors, while negative peer influences and neighborhood instability were risk factors of substance use initiation. Nineteen articles reported factors associated with escalation in substance use, including unemployment, neighborhood vulnerability, negative peer influence, violence/trauma, and criminal justice system (CJS) involvement. Ten articles suggested that employment, social support, urban living, and low-barrier medication treatment facilitated treatment participation, while stigma and CJS involvement had negative impact on treatment trajectory. Social support and employment could foster progress in recovery and CJS involvement and unstable housing deterred recovery. Four studies suggested that unemployment, unstable housing, CJS involvement, and lack of social support were associated with overdose and mortality.

CONCLUSIONS

This review underscores the influence of social networks and early life experiences on the life course of SUD. Future SDoH research should investigate overdose and mortality and the impact of broader upstream SDoH on SUD. Interventions addressing these social factors are needed to mitigate their detrimental effects on the trajectories of SUD over the life course.

"You have to drink with a little bit of shame": Alcohol and other drug use among young people from migrant and ethnic minority backgrounds in Melbourne, Australia

Migrant and ethnic minority groups are underrepresented in alcohol and other drug (AOD) research. This qualitative study explored AOD use among young people from migrant and ethnic minority backgrounds in Melbourne, Australia. We conducted one focus group and 16 interviews and thematically analyzed data drawing on the social-ecological model of health. Theme one showed AOD use was considered a "normal" part of youth identity, particularly for participants who had grown up with peer groups in Australia. Theme two highlighted participant's sense of responsibility to meet expectations and make informed decisions about AOD use to protect themselves and their friends. Theme three highlighted participant's risk of experiencing AOD-related stigma through negative stereotypes and fear of consequences within families and communities, particularly among female participants. Participants' perceptions and experiences differed by individual factors, interpersonal relationships, AOD accessibility across settings and broader gender, cultural and religious norms. Interventions developed with young people from migrant and ethnic minority backgrounds are needed to target the social-ecological factors underpinning AOD use, particularly stigma.

Substance use and treatment disparities among Asian Americans, Native Hawaiians, and Pacific Islanders: A systematic review

BACKGROUND

The increasing relevance of substance use disorder (SUD) within the Asian American, Native Hawaiian, and Pacific Islander (AA&NH/PI) communities, particularly amidst rising anti-Asian hate incidents and the disproportionate health and economic challenges faced by the NH/PI community during the COVID-19 pandemic, underscores the urgency of understanding substance use patterns, treatment disparities, and outcomes.

METHODS

Following PRISMA guidelines, 37 out of 231 studies met the search criteria. Study characteristics, study datasets, substance use rates, SUD rates, treatment disparities, treatment quality, completion rates, and analyses disaggregated by the most specific AA&NH/PI ethnic group reported were examined.

RESULTS

Despite increased treatment admissions over the past two decades, AA&NH/PI remain underrepresented in treatment facilities and underutilize SUD care services. Treatment quality and completion rates are also lower among AA&NH/PI. Analyses that did not disaggregate AA and NHPI as distinct groups from each other or that presented aggregate data only within AA or NHPI as a whole were common, but available disaggregated analyses reveal variations in substance use and treatment disparities among ethnic groups. There is also a lack of research in exploring within-group disparities, including specific case of older adults and substance use.

CONCLUSION

To address disparities in access to substance use treatment and improve outcomes for AA&NH/PI populations, targeted interventions and strategic data collection methods that capture diverse ethnic groups and languages are crucial. Acknowledging data bias and expanding data collection to encompass multiple languages are essential for fostering a more inclusive approach to addressing SUD among AA&NH/PI populations.

"You rise up and then you start pulling people up with you": Patient experiences with a peer-delivered behavioral activation intervention to support methadone treatment

BACKGROUND

Although medications for opioid use disorder (MOUD) are efficacious treatments for opioid use disorder, retention remains low. Peer recovery specialists (PRSs), individuals with lived substance use and recovery experience, may be particularly well-suited to support patients receiving MOUD. While PRSs are rarely trained in evidence-based behavioral interventions other than motivational interviewing, preliminary evidence suggests that peers can deliver brief behavioral interventions, such as behavioral activation, with efficacy and fidelity. This qualitative study sought to explore patient perspectives on receiving an adapted PRS-delivered behavioral activation intervention (Peer Activate) to support patients receiving methadone treatment.

METHODS

The sample (N = 26) included patients recently starting or demonstrating challenges with adherence at a community-based methadone treatment program who received the Peer Activate intervention in a pilot trial. Participants were invited to participate in in-depth, semi-structured interviews at study completion or discontinuation, assessing perceived acceptability and feasibility of Peer Activate, and stigma-related barriers. Interview transcripts were coded using codebook/template thematic analysis.

RESULTS

Analysis revealed the importance of two areas to promote intervention acceptability: 1) connection with intervention content and skill building, and 2) valued PRS-specific qualities. Intervention flexibility was found to promote feasibility of the intervention in the context of chaotic and challenging life circumstances. Additionally, participants described stigma towards substance use and methadone treatment as potential barriers to engaging in methadone treatment.

CONCLUSION

Results support the acceptability and feasibility to patients of this PRS-delivered behavioral activation intervention in the context of outpatient MOUD treatment among a low-income, majority racially minoritized patient population. Future intervention adaptation and implementation should focus on incorporating content related to relationships and interpersonal skills; balancing behavioral intervention content with system navigation support; maintaining flexibility; and further investigation of the impact of individual PRS attributes, including shared lived experiences, on intervention acceptability and shifts in stigma.

Testing Cross-Generational Effects of the Raising Healthy Children Intervention on Young Adult Offspring of Intervention Participants

This study tested whether effects of a preventive intervention delivered in elementary school showed benefits for the young adult offspring of intervention recipients over 20 years later. The Raising Healthy Children (RHC) intervention, trialed in 18 public schools in Seattle, Washington, from 1980-1986 (grades 1-6), sought to build strong bonds to family and school to promote school success and avoidance of substance use and illegal behavior. Four intervention groups were constituted: full, late, parent training only, and control. Participants were followed through 2014 (age 39 years). Those who became parents were enrolled in an intergenerational study along with their oldest offspring (10 assessments between 2002 and 2018). This study includes young adult offspring (ages 18-25 years; n = 169; 52% female; 4% Asian, 25% Black, 40% multiracial, 4% Native American, 2% Native Hawaiian/Pacific Islander, 25% White, and 14% Hispanic/Latinx) of participants in the original RHC trial. Offspring outcome measures included high school noncompletion, financial functioning, alcohol misuse, cannabis misuse, cigarette use, criminal behavior, internalizing behavior, social skills, and social bonding. A global test across all young adult outcome measures showed that offspring of parents who received the full RHC intervention reported better overall functioning compared to offspring of control group parents. Analyses of individual outcomes showed that offspring of full intervention group parents reported better financial functioning than offspring of control group parents. Findings show the potential of universal preventive interventions to provide long-term benefits that reach into the next generation. ClinicalTrials.gov Identifier: NCT04075019; retrospectively registered in 2019.

Do adverse experiences predict unemployment and need of psychiatric help after treatment for drug use disorders?

Background: This study prospectively examined the association between adverse experiences (physical abuse, sexual abuse and parental substance use problems [SUPs]), not being employed, in education or training (NEET) and being in need of acute psychiatric help among patients receiving treatment for substance use disorders. Methods: A total of 580 adolescents and early adults aged 15-25 years enrolled in treatment for drug use disorders were included in the analyses. Treatment data were linked to participants' register data on employment, education and acute contact to psychiatric services for the following two years. Multivariable logistic regression models were used to examine associations between the three adverse experiences, NEET and need of acute psychiatric help, adjusting for confounders such as age, gender, ethnicity, treatment response and treatment condition. Results: More than half of the participants were NEET two years after treatment enrolment. After controlling for demographics and treatment conditions, NEET was predicted by parental substance use problems (odds ratio [OR] = 1.89, 95% confidence interval [CI] 1.31- 2.70), exposure to physical abuse (OR = 1.48, 95% CI 1.03-2.13) and non-abstinence (abstinence was negatively associated with NEET, OR = 0.53, 95% CI 0.37-0.76). Being exposed to two (OR = 3.17, 95% CI 1.93-5.21) and three types of adverse experiences (OR = 3.14, 95% CI = 1.47-6.70) predicted NEET more strongly than exposure to one type. One out of 10 participants sought acute care from psychiatric services at least once within two years after treatment. Only sex and ethnic minority status were associated with contacting psychiatric services acutely. Conclusion: The present study suggests that adverse experiences, such as being exposed to parental problematic substance use and physical abuse, may be important predictors for NEET after treatment for SUDs.

Understanding the Process of Drug Addiction Recovery Through First-Hand Experiences: A Qualitative Study in the Netherlands Using Lifeline Interviews

Understandings of drug addiction recovery are still being debated. Research on perspectives from first-hand experiences with recovery is rare and often contains short-term experiences in the context of a treatment setting. We aim to gain further understanding of recovery by analyzing autobiographical data from persons in different stages of drug addiction recovery who are not linked to any specific treatment service. We conducted 30 in-depth qualitative interviews with participants from various parts of the Netherlands. Participants self-identified as being "in recovery" or "recovered" from drug addiction for at least 3 months. Men and women are equally represented, and the sample consists of an equal number of participants in early (<1 year, n = 10), sustained (1-5 years, n = 10), and stable (>5 years, n = 10) recovery. We undertook a data-driven thematic analysis. Participants described that recovery is a broad process of change because addiction is interwoven with everything (theme 1); that recovery is reconsidering identity, seeing things in a new light (theme 2); that recovery is a staged long-term process (theme 3); and that universal life processes are part of recovery (theme 4). Thus, Drug addiction recovery is experienced as an interwoven long-term process, including identity change and common or universal life processes. Policy and clinical practice should therefore be aimed at supporting long-term tailored recovery goals and disseminating first-hand recovery experiences to enhance long-term outcomes and reduce stigmatization.

Individual, Social, and Environmental Factors Associated with Different Patterns of Stimulant Use: A Cross-Sectional Study from Five European Countries

INTRODUCTION

Amphetamine-type stimulants (ATSs) are the second most commonly consumed class of illicit drugs globally, but there is limited understanding of the precise factors associated with problematic versus controlled ATS consumption. This exploratory study aimed to identify which individual, social, and environmental factors are associated with different patterns of ATS use over time.

METHODS

Cross-sectional surveys were conducted in Germany, England, The Netherlands, Poland, and the Czech Republic via face-to-face computer-assisted personal interviews to collect data on different user groups. 1,458 adults (18+) reported exposure to but no ATS use (n = 339); former rare/moderate ATS use (n = 242); current rare/moderate ATS use (n = 273); former frequent/dependent ATS use (n = 201); current frequent/dependent ATS use (n = 403). Extent of ATS/other substance use was assessed by number of consumption days (lifetime, past year, past month) and Severity of Dependence Scale. To identify factors associated with group membership, data were also collected on previous injecting drug use (IDU) and consumption setting/rules. Psychological distress was measured using the Brief Symptom Inventory, with additional data collected on self-reported adverse life events and physical/mental health.

RESULTS

Currently, using frequent/dependent ATS users experienced more frequent unstable living conditions (27.5%) and psychological distress (59.8%) compared to other groups. A multinomial logistic regression showed that currently abstinent rare/moderate users were more likely to abstain from methamphetamine use {odds ratio (OR) = 2.48 (confidence interval [CI] = 1.32-4.68)} and from IDU (OR = 6.33 [CI = 2.21-18.14]), to avoid ATS use during working hours (OR = 6.67 [CI = 3.85-11.11]), and not to use ATS for coping reasons (OR = 4.55 [CI = 2.50-6.67]) compared to the reference group of currently using frequent/dependent users.

CONCLUSIONS

People who use ATS frequently and/or at dependent levels are more likely to have experienced social and economic adversity compared to infrequent ATS users. On the other hand, there is a substantial share of users, which show a controlled use pattern and are able to integrate ATS use into their lives without severe consequences.

The Effect of Neighborhood Disorganization on Care Engagement Among Children With Chronic Conditions Living in a Large Urban City

Neighborhood context plays an important role in producing and reproducing current patterns of health disparity. In particular, neighborhood disorganization affects how people engage in health care. We examined the effect of living in highly disorganized neighborhoods on care engagement, using data from the Coordinated Healthcare for Complex Kids (CHECK) program, which is a care delivery model for children with chronic conditions on Medicaid in Chicago. We retrieved demographic data from the US Census Bureau and crime data from the Chicago Police Department to estimate neighborhood-level social disorganization for the CHECK enrollees. A total of 6458 children enrolled in the CHECK between 2014 and 2017 were included in the analysis. Families living in the most disorganized neighborhoods, compared with areas with lower levels of disorganization, were less likely to engage in CHECK. Black families were less likely than Hispanic families to be engaged in the CHECK program. We discuss potential mechanisms through which disorganization affects care engagement. Understanding neighborhood context, including social disorganization, is key to developing more effective comprehensive care models.

Illicit drug use in university students in the UK and Ireland: a PRISMA-guided scoping review

BACKGROUND

Interest in the health and well-being of university students has increased in the UK and Ireland in the past two decades as their numbers have grown. Recent high-profile deaths of students after using illicit drugs have highlighted the importance of the topic for policy makers. This scoping review maps the state of the existing literature evaluating use of illicit drugs in university students in the UK and Ireland. It aims to highlight research gaps and inform policy.

METHOD

We conducted a systematic search of papers related to psychoactive drug use in university students in the UK and Ireland published before August 2021. The 18 extracted study characteristics included author(s); year of publication; journal; location of data collection; study design; delivery method (e.g., online survey, in-person, postal survey); number of participants; response rate; participant course of study, year of study, degree level (i.e., undergraduate, postgraduate), gender and age; time-period assessed (e.g., lifetime, current use, past 12 months); primary aim; primary outcome; ethical approval; and funding source.

RESULTS

The PRISMA-guided search strategy identified 1583 papers for abstract review; of 110 papers retained for full-text review, 54 studies met criteria for inclusion for this paper. Primary outcomes were coded into five groups: prevalence and patterns of drug use; factors associated with drug use; attitudes and knowledge about, and motivation for, drug use; supply of drugs; consequences of drug use. The results show that there is no coherent body of research in this area. The prevalence of reported drug use has crept up and the range of substances reported has broadened over time, and attitudes to drugs on average have normalised. However, there are significant methodological limitations that limit the utility of these findings. There was little evidence of published work on prevention of, or intervention to reduce, drug-related harms.

CONCLUSION

The domains identified offer a framework for university administrators, researchers and policy makers to understand the potential response to drug use in university students in the UK and Ireland. Recommendations are made to fill the gaps in the research evidence base.

The role of substance use in the lives of incarcerated older adults: A qualitative study

Background

The prevalence of drug abuse among older adults has grown over the last decade. Despite the expanding development of a body of research dedicated to studying this phenomenon, drug abuse by incarcerated older adults has been marginalized. Thus, the aim of the present study was to explore drug abuse patterns in the lives of incarcerated older adults.

Method

Semi-structured interviews were conducted with 28 incarcerated older adults, and an interpretive analysis was used to analyze the participants’ narratives.

Findings

Four themes emerged: (1) Growing up around drugs; (2) Prison onset; (3) Professionals, and (4) Lifelong substance abuse.

Conclusion

The study findings reveal a unique typology of drug-related themes in the lives of incarcerated older adults. This typology sheds light on the interplay between aging, drug use, and incarceration and the way these three socially marginalized positions may intersect.

Being better than well at the University of Birmingham

Ongoing recovery from addiction often happens outside of formal "treatment" settings. Collegiate recovery programs (CRPs) have existed in higher education institutions in the United States since the 1980s as part of vital "recovery ready ecosystems" (Ashford et al., 2020) for those with educational aspirations. Aspiration often begins with inspiration and Europeans are now beginning their own journeys with CRPs. In this narrative piece, I use my own lived experience of addiction and recovery through a life course that highlights mechanisms of change that are entwined with academia. This life course narrative maps well on to extant literature on recovery capital and illuminates some of the stigma-based boundaries that still stand in the way of progress in this field. The hope is that this narrative piece will inspire aspirations for both individuals and organizations thinking about setting up CRPs in Europe, and further a field, and also inspire people in recovery to consider education as an aspiration for their continued growth and healing.

Exploring Problematic Substance use Trajectory in Hong Kong: A Life Course Perspective

The purpose of this study is to take a life course perspective to explore how experiences at different life course stages of substance users and contextual factors influence their drug use behaviors. Using the life history narrative approach to interview 31 persons who were taking part in rehabilitation treatment in Hong Kong, this study maps out substance use trajectory into four stages (onset, persistence, escalation, and desistance) addressing three interrelated themes: (1) substance use behavior characteristics, (2) critical life events, (3) and social and structural factors. The results showed an interaction between substance use behaviors and their experience in different life stages. Because substance use has become more hidden in the stage of persistence and escalation, particularly in dense cities like Hong Kong, early social support is advocated to be provided in prevention and rehabilitation, such as offering better vocational training support and follow-up service to rebuild relationships with families.

The Impact of Childhood Trauma on Problematic Alcohol and Drug Use Trajectories and the Moderating Role of Social Support

Adverse childhood experiences (ACE) have a strong association with alcohol and drug use; however, more research is needed to identify protective factors for this association. The present study assesses the longitudinal impact of ACE on problematic alcohol and drug use and the potential moderating effect of perceived social support. Data (n = 1404) are from a sample of Hispanic youth surveyed in high school through young adulthood. Linear growth curve models assessed the effect of ACE and perceived social support over time on problematic alcohol and drug use. Results indicated youth with ACE (vs. those without ACE) report more problematic alcohol and drug use in adolescence and have increased rates into young adulthood. Additionally, findings suggest that social support in high school may moderate the effects of ACE on problematic use over time. Among youth with high levels of support, the association of ACE with problematic alcohol and drug use was diminished. Although ACE can have a persistent impact on problematic alcohol and drug use from adolescence into adulthood, high social support during adolescence may mitigate the negative effects of ACE, lowering early problematic alcohol and drug use, offering the potential for lasting benefits.

Motivations for Change in Drug Addiction Recovery: Turning Points as the Antidotes to the Pains of Recovery

Painful life events have been highlighted as being instrumental in promoting change during drug addiction recovery. This paper attempts to integrate the ‘pains of desistance’ approach into a recovery capital framework. It explores the life courses of 30 people in drug addiction recovery who had previously had a problem with an illicit substance to explore the role of the pains of recovery (potential push factors) alongside different forms of recovery capital (pull factors) at key turning points of change during recovery. Findings demonstrate that pull factors linked to CHIME were significant in promoting positive changes. Turning points acted as antidotes to pains experienced in early recovery. Three antidotes appeared to be gender specific. Implications highlight the need for greater access to community capital pathways. It advocates the need to dispel the myth for a rock bottom moment and for a more macro conceptualisation of drug addiction recovery.

Disparities in substance use treatment retention: An exploration of reasons for discharge from publicly funded treatment

Although Delaware is the seventh smallest state in the country (including Washington, D.C.) in terms of population size, it has the second highest drug overdose death rate. The Delaware Division of Substance Abuse and Mental Health has increased attention in identifying disparities in treatment outcomes. We explored reasons for discharge from publicly-funded treatment in Delaware with special attention to populations at risk for health inequities, with a focus on covariates of treatment non-completion. Using secondary data collected from publicly-funded treatment providers, we analyzed data from individuals that were admitted to substance use treatment between 2015 and 2019 and had been discharged in 2019. We did this by using logistic and multinomial regression, focusing on non-completion treatment outcomes such as failure to meet requirements, loss of contact, and treatment refusal. Clients who were Black or African American, compared to white clients, were more likely to be lost contact with, administratively discharged, or marked as failing to meet treatment requirements than having a completed treatment discharge. Women were 30% less likely than men to have "failed to meet treatment requirements" compared to completing treatment. Further investigation is needed into these patterns. While treatment quality cannot be assessed using this data, the results point to a need for closer study of disparities in treatment related to race, ethnicity, gender, employment, criminal justice involvement, and type of drug used. Treatment providers should be made aware of culturally informed care, as well as client-created goals, in order to reduce disparities in exit from treatment.

“I Had No Problems and Just Felt So Fabulous”: The “Storylines” of Methamphetamine Initiation in Aotearoa/New Zealand

This qualitative life course-based study analyses the key circumstances preceding methamphetamine initiation. This paper utilizes Agnew’s “storylines” concept to analyse the background and situational factors that led 42 Aotearoa/New Zealanders to initiate methamphetamine. Multiple exposure to adversity across multiple life domains placed participants at heightened risk of early-onset drug use. Preceding methamphetamine initiation, the impact of social bonds and social roles were identified within the domains of family, romantic relationships, friendship and work. Whilst drug use onset broadly follows the stage theory sequence of drug use, participants did not initiate methamphetamine until age 27 on average. Initial use typically took place in a private setting among friends, family and co-workers. The initial effect was typically very positive, which greatly contributed to escalating use. Analysis revealed four main storylines, which highlight the importance of psychological state, social bonds, romantic attachments and social functioning in methamphetamine initiation.

Commentary on Adams et al.: using administrative big data for the public good

Adams et al demonstrate why US states should learn from Massachusetts on how to build “administrative big data” warehouses for the public good. However, these and other existing data resources must include detailed information on criminal-legal-carceral experiences. Offering buprenorphine treatment in syringe service programs would remove healthcare obstacles and save lives.

Peer recovery specialist-delivered, behavioral activation intervention to improve retention in methadone treatment: Results from an open-label, Type 1 hybrid effectiveness-implementation pilot trial

BACKGROUND

Despite the efficacy of methadone to treat opioid use disorder (OUD), retention is an urgent priority, particularly among low-income, minoritized populations. Peer recovery specialists are well-positioned to engage vulnerable patients, particularly when trained in an evidence-based intervention to promote retention. This hybrid effectiveness-implementation pilot trial aimed to demonstrate the proof of concept of a peer recovery specialist-delivered behavioral activation and problem solving-based approach (Peer Activate) to improve methadone retention.

METHODS

Implementation outcomes included feasibility, acceptability, and fidelity. Feasibility and acceptability were defined by the percentage of participants who initiated the intervention (≥75%) and completed ≥75% of core sessions, respectively. Fidelity was assessed via independent rating of a randomly selected 20% of sessions. The primary effectiveness outcome was methadone retention at three-months post-intervention vs. a comparison cohort initiating methadone during the same time period. Secondary outcomes included methadone adherence, substance use frequency, and substance use-related problems.

RESULTS

Benchmarks for feasibility and acceptability were surpassed: 86.5% (32/37) initiated the intervention, and 81.3% of participants who initiated attended ≥75% of core sessions. The mean independent rater fidelity score was 87.9%, indicating high peer fidelity. For effectiveness outcomes, 88.6% of participants in Peer Activate were retained in methadone treatment at three-months post-intervention-28.9% higher than individuals initiating methadone treatment alone in the same time period [χ2(1) = 10.10, p = 0.001]. Among Peer Activate participants, urine-verified methadone adherence reached 97% at post-intervention, and there was a significant reduction in substance use frequency from 48% of past two-week days used at baseline to 31.9% at post-intervention [t(25) = 1.82, p = .041]. Among participants who completed the core Peer Activate sessions (n = 26), there was a significant reduction in substance use-related problems [t(21) = 1.84, p = 0.040].

CONCLUSION

Given the rapid scale-up of peer recovery specialist programs nationwide and the urgent need to promote methadone retention, these results, although preliminary, have important potential clinical significance. The next steps are to conduct a Type 1 hybrid effectiveness-implementation randomized trial with a larger sample size and longer-term follow-up to further establish the implementation and effectiveness of the Peer Activate approach.

Trajectories and correlates of opioid prescription receipt among patients experiencing interpersonal violence

Interpersonal violence increases vulnerability to the deleterious effects of opioid use. Increased opioid prescription receipt is a major contributor to the opioid crisis; however, our understanding of prescription patterns and risk factors among those with a history of interpersonal violence remains elusive. This study sought to identify 5-year longitudinal patterns of opioid prescription receipt among patients experiencing interpersonal violence within a large healthcare system and sociodemographic and clinical characteristics associated with prescription patterns. This secondary analysis examined electronic health record data from January 2004–August 2019 for a cohort of patients (N = 1,587) referred for interpersonal violence services. Latent class growth analysis was used to estimate trajectories of opioid prescription receipt over a 5-year period. Standardized differences were calculated to assess variation in sociodemographic and clinical characteristics between classes. Our cohort had a high prevalence of prescription opioid receipt (73.3%) and underlying co-morbidities, including chronic pain (54.6%), substance use disorders (39.0%), and mental health diagnoses (76.9%). Six prescription opioid receipt classes emerged, characterized by probability of any prescription opioid receipt at the start and end of the study period (high, medium, low, never) and change in probability over time (increasing, decreasing, stable). Classes with the highest probability of prescription opioids also had the highest proportions of males, chronic pain diagnoses, substance use disorders, and mental health diagnoses. Black, non-Hispanic and Hispanic patients were more likely to be in low or no prescription opioid receipt classes. These findings highlight the importance of monitoring for synergistic co-morbidities when providing pain management and offering treatment that is trauma-informed, destigmatizing, and integrated into routine care.

Neuropsychiatric Model of Addiction Simplified

While substance experimentation typically begins in adolescence, substance use disorders (SUDs) usually develop in late teens or early adulthood, often in individuals who are vulnerable because of biological and socioeconomic risk factors. Severe SUDs-synonymous with addiction-involve changes in limbic and prefrontal brain areas after chronic drug exposure. These changes involve learned associations between drug reward and cues that trigger the anticipation of that reward (known as incentive salience), as well as heightened dysphoria during withdrawal and weakened prefrontal circuits needed for inhibiting habitual responses.

Predictors of Emergency Department Opioid Use Among Adolescents and Young Adults

OBJECTIVE

It is well established that adolescents and young adults are increasingly vulnerable to the effects of early opioid exposures, with the emergency department (ED) playing a critical role in such introduction. Our objective was to identify predictors of ED opioid administration (ED-RX) and prescribing at discharge (DC-RX) among adolescent and young adults using a machine learning approach.

METHODS

We conducted a secondary analysis of ED visit data from the National Hospital Ambulatory Medical Care Survey from 2014 to 2018. Visits where patients were aged 10 to 24 years were included. Predictors of ED-RX and DC-RX were identified via machine learning methods. Separate weighted logistic regressions were performed to determine the association between each predictor, and ED-RX and DC-RX, respectively.

RESULTS

There were 12,693 ED visits identified within the study time frame, with the majority being female (58.6%) and White (70.7%). Approximately 12.3% of all visits were administered an opioid during the ED visit, and 11.5% were prescribed one at discharge. For ED-RX, the strongest predictors were fracture injury (odds ratio [OR], 5.24; 95% confidence interval [CI], 3.73-7.35) and Southern geographic region (OR, 3.01; 95% CI, 2.14-4.22). The use of nonopioid analgesics significantly reduced the odds of ED-RX (OR, 0.46; 95% CI, 0.37-0.57). Fracture injury was also a strong predictor of DC-RX (OR, 5.91; 95% CI, 4.24-8.25), in addition to tooth pain (OR, 5.47; 95% CI, 3.84-7.69).

CONCLUSIONS

Machine learning methodologies were able to identify predictors of ED-RX and DC-RX, which can be used to inform ED prescribing guidelines and risk mitigation efforts among adolescents and young adults.

Readmission Prediction for Patients with Heterogeneous Medical History: A Trajectory-Based Deep Learning Approach

Hospital readmission refers to the situation where a patient is re-hospitalized with the same primary diagnosis within a specific time interval after discharge. Hospital readmission causes $26 billion preventable expenses to the U.S. health systems annually and often indicates suboptimal patient care. To alleviate those severe financial and health consequences, it is crucial to proactively predict patients’ readmission risk. Such prediction is challenging because the evolution of patients’ medical history is dynamic and complex. The state-of-the-art studies apply statistical models which use static predictors in a period, failing to consider patients’ heterogeneous medical history. Our approach – Trajectory-BAsed DEep Learning (TADEL) – is motivated to tackle the deficiencies of the existing approaches by capturing dynamic medical history. We evaluate TADEL on a five-year national Medicare claims dataset including 3.6 million patients per year over all hospitals in the United States, reaching an F1 score of 87.3% and an AUC of 88.4%. Our approach significantly outperforms all the state-of-the-art methods. Our findings suggest that health status factors and insurance coverage are important predictors for readmission. This study contributes to IS literature and analytical methodology by formulating the trajectory-based readmission prediction problem and developing a novel deep-learning-based readmission risk prediction framework. From a health IT perspective, this research delivers implementable methods to assess patients’ readmission risk and take early interventions to avoid potential negative consequences.

‘Making Ground’: An Ethnography of ‘Living With’ Harmful Methamphetamine Use and the Plurality of Recovery

The trajectories of people attempting to reduce harmful methamphetamine use are frequently understood within a binary framework of transitioning between states of health and disease. This framework can often be reinforced by service interactions informed by these dominant narratives of recovery and addiction. In this paper, we draw on a critical interactionist analysis of ethnographic fieldwork conducted with people who use methamphetamine, to examine how their experiences could undermine this binary, observing the ways participants experienced growth, change, and progress, without necessarily maintaining abstinence. These findings support a more diverse understanding of drug use trajectories, and we explore the concept of ‘living with drug use’, similar to how people live with other chronic conditions by finding ‘health in illness’. Participant experiences are also interpreted within the context of counter public health, arguing for the recognition and integration of values and goals which are divergent from the implicit aims of public health practice.

Strengthening Communities: A Qualitative Assessment of Opportunities for the Prevention of Adverse Childhood Experiences in the Wake of the Opioid Crisis

The opioid crisis is a significant challenge for health and human service systems that serve children, youth, and families across the United States. Between 2000 and 2017, the number of foster care entries, a type of adverse childhood experience (ACE), attributable to parental drug use increased by 147%. Nevertheless, there is variation in the burden of opioid overdose and foster care rates across the U.S., suggesting community supports and systems to support families affected by substance use also vary. This qualitative study sampled communities experiencing high and low rates of overdose mortality and foster care entries (i.e., a qualitative comparison group) to better understand what might protect some counties from high overdose mortality and foster care entries. The sample included six counties from three states that were selected based on their rates of opioid overdose mortality and foster care entries. Using purposive sampling within counties, interview and discussion group participants included multi-sector community partners, parents whose children had been removed due to parental substance use, and caregivers caring for children who had been removed from their homes. Across all counties, prevention was not front-of-mind. Yet, participants from communities experiencing high rates of overdose mortality and foster care entries identified several factors that might help lessen exposure to substance use and ACEs including more community-based prevention services for children and youth. Both parents and caregivers across all communities also described the need for additional supports and services. Participants also described the impact of COVID-19 on services, including greater utilization of mental health and substance use treatment services and the challenges with engaging children and youth on virtual platforms. The implications for prevention are discussed, including the need to encourage primary prevention programs in communities.

Adolescent Antecedents of Young Adult Homelessness: a Cross-national Path Analysis

Adolescent and young adult health, development, and behavior lay a foundation for future population health. Increasing rates of young adult homelessness mean there is a need for research which generates evidence to support a stronger focus on population-level prevention. Using longitudinal data from a population-based sample of young adults participating in the cross-nationally matched International Youth Development Study, we examined adolescent antecedents of young adult homelessness in Washington State in the USA and in Victoria, Australia. Participants were surveyed using a modified version of the Communities That Care youth survey. Analyses of prospective, longitudinal data from 1945 participants, recruited as state-representative secondary school samples at grade 7 (average age 13, 2002) and longitudinally compared at young adulthood (average age 25, 2014), showed that young adults in Washington State reported higher rates of past year homelessness (5.24%) compared to those in Victoria (3.25%). Path modeling showed less positive family management strategies at age 13 uniquely increased risk for age 25 homelessness. This effect remained after accounting for age 15 antecedents in peer-group, school, and community environments. Friends' drug use, school suspension, academic failure, and low neighborhood attachment at age 15 mediated the association between less positive family management strategies at age 13 and age 25 homelessness. Despite observing some cross-national differences in levels of family, peer-group, school, and community antecedents, we found that these factors equally increased risk for age 25 homelessness in both states, suggesting similar cross-national influences for young adult homelessness. The findings indicate cross-nationally common adolescent antecedents for young adult homelessness that could be targeted by prevention strategies across international settings.

Long-Term Outcomes for Young People With Substance Use Problems in Outpatient Treatment: Gender-Specific Patterns

This study presents the results of a longitudinal research project focusing on long-term outcomes among young people after initiation of outpatient treatment for substance use problems (SUP) in Sweden. Young people are defined with the age group 13-25 years. A clinical sample of 451 young people (29% girls, median age 17 years) completed a structured interview at baseline and was followed using official records one, two, and 3 years after initiation of treatment. Gender-specific patterns at intake were described and bivariate associations and logistic regressions were calculated to analyse the links between risk factors at treatment start and indications of substance use problems 3 years later. Significantly more boys than girls displayed indications of continued SUP at 3-year follow-up. More specifically, 49% of the boys vs. 35% of the girls were identified through records as still having problems with substance use. Predictive risk factors also displayed gender-specific patterns. Primary drug use frequency and age at intake predicted indications of SUP among boys but not among girls. Placement in foster care/residential homes, depression, and early drug debut had significant predictive value regarding indications of SUP among females but not among males. Girls also displayed a greater psychosocial burden at treatment start, but a more favorable treatment outcome at follow-up. Youths with a heavy risk load at treatment start (i.e., over six risk factors) did not display a greater risk of SUP at 3-year follow-up, although our results suggest that this subgroup has indications of continued problems with mental health. Consequently, future studies should further explore gender-specific treatment pathways for young people with substance use problems. Since women and girls seem to have different risk factors, co-occurring psychiatric problems and more experiences of trauma compared to men, they might need multidimensional and more comprehensive treatment interventions that run over a longer period of time.

The "high cost of low living": Substance use recovery among older formerly homeless adults

BACKGROUND

The population of older homeless substance-using adults is growing considerably, and we sought to understand how such individuals gain control of problematic substance use amidst other life problems.

Methods: Data were collected in an NIMH-funded study in which four in-depth interviews were conducted over 18 months with formerly homeless adults living in permanent supportive housing. The study subsample was comprised of 15 predominantly African American individuals over age 45 who were in recovery for at least six months. Cross-case analyses used a template approach followed by inductive sub-theme analyses.

Results: Three themes drawn from the literature yielded seven sub-themes as follows. Theme #1: Acute life stressors: (a) "substance use as primary"; (b) "acute life events and substance use"; (c) "incarceration as turning point." Theme #2: Attributions of recovery: (a) "quitting as personal decision"; (b) "I just got to stay on top of it"; Theme #3: Social relationships: (a) "I have associates, not friends"; (b) "taking a cautious approach."

Conclusion: Participants viewed substance use as the primary problem in their lives despite other adversity. Recovery was viewed as a personal decision, but maintaining recovery involved positive social relationships. Policies and practices related to recovery should address the complexities of lives-as-lived.

Prescription opioid use and employment: A nationwide Finnish register study

BACKGROUND

The secular decline in labor market participation and the concurrent increase in opioid use in many developed countries have sparked a policy debate on the possible connection between these two trends. We examined whether the use of prescription opioids was connected to labor market outcomes relating to participation, employment and unemployment among the Finnish population.

METHODS

The working-age population (aged 19-64 years) living in Finland during the period 1995-2016 was used in the analyses (consisting of 67 903 701 person-year observations). Lagged values of prescription opioid use per capita were used as the exposure. Instrumental variables (IV) estimation method was used to identify causal effects, where opioid use per capita for the elderly (65-95-year-old) was used as an instrument for the opioid use per capita for the working-age population of the same gender, education and region.

RESULTS

Increased opioid use led to worse labor market outcomes in the long run, with the effect size of 16 % and 20 %, compared to the standard deviation of the employment and participation rates. On the contrary, in the short run, increased opioid use had positive employment effects.

CONCLUSIONS

Policymakers should take the contradictory short- and long-term effects into account while considering regulation and monitoring of opioid use. Regulating and monitoring long-term prescription opioids is crucial for reducing their negative labor market consequences.

Barriers and Motivators to Opioid Treatment Among Suburban Women Who Are Pregnant and Mothers in Caregiver Roles

Women of childbearing age who misuse opioids are a particularly vulnerable population, and their barriers to treatment are unique because of their caregiver roles. Research on treatment for opioid use generally draws from urban and rural areas. This study fills a gap in research that focuses on barriers and motivators to opioid treatment in suburban areas. The aim of this study was to give voice to suburban pregnant women and mothers caring for children while using opioids. Ethnographic methods were used for recruitment, and 58 in-depth interviews were analyzed using a modified grounded theory approach. Barriers to medication-assisted treatment (MAT) included stigma, staff attitudes, and perceptions the women had about MAT treatment. Barriers associated with all types of treatment included structural factors and access difficulties. Relationships with partners, friends, family, and providers could be barriers as well as motivators, depending on the social context of the women’s situation. Our findings suggest increasing treatment-seeking motivators for mothers and pregnant women by identifying lack of resources, more empathetic consideration of social environments, and implementing structural changes to overcome barriers. Findings provide a contemporary understanding of how suburban landscapes affect mothers’ treatment-seeking for opioid dependence and suggest the need for more focus on emotional and structural resources rather than strict surveillance of women with opioid dependence who are pregnant or caring for children.

Experimental (Re)structuring: The Clinical Trial as Turning Point Among Medical Research Participants

Amid the growth of addiction medicine randomized controlled trials (RCTs), scholars have begun examining participants' study experiences, highlighting facilitators and barriers to enrollment. However, this work can overlook the interplay between trial participation and social-structural dimensions among people with substance use disorders linked to the social nature of use, socioeconomic marginalization, and time demands of substance procurement and use. To effectively conduct RCTs with this unique population, it is necessary to examine the broader social context of study participation. We conducted nested qualitative interviews with 22 participants involved in an RCT testing a treatment for alcohol and opioid use disorders in HIV clinics. Thematic analyses revealed social-structural circumstances shaping RCT participation as well as how participation constitutes a turning point, prompting individuals to reconfigure social networks, reorient to spatial environments, and reorganize day-to-day life-with implications for how substance use disorder RCTs should be approached by researchers.

Pre-incarceration polysubstance use involving opioids: A unique risk factor of postrelease return to substance use

OBJECTIVE

Justice-involved populations are at increased risk of overdose following release from prison and jail. This risk is exacerbated by polysubstance use, including the use of opioids with other substances. This study explored pre-incarceration polysubstance use involving opioids as a unique risk factor for postrelease return to substance use.

METHODS

The study examined data from a cohort of 501 justice-involved persons who were enrolled in a therapeutic community treatment program while incarcerated. Latent profile validation identified profiles of polysubstance use involving opioids prior to incarceration. Multivariate logistic regression examined return to substance use, defined as self-reported relapse, and a time series model examined time in the community until a relapse event occurred.

RESULTS

A latent profile validation found six unique polysubstance opioid patterns prior to incarceration. Two of these profiles, primarily alcohol and primarily buprenorphine, were at increased and accelerated risk for relapse postrelease relative to a less polysubstance use profile. Both profiles at increased risk had pre-incarceration co-use of marijuana (≈45% of month) and nonmedical use of opioids (≈40% of month) but were unique in their respective near daily use of alcohol and nonmedical buprenorphine.

CONCLUSIONS

Among persons who use opioids returning to the community, return to substance use occurs along a continuum of risk. Providers' consideration of polysubstance use patterns during treatment may assist in mitigating adverse outcomes for patients postrelease.

Why we stopped using the term 'aftercare'

The words we choose to describe alcohol and other drug (AOD) treatments and interventions reveal assumptions about how we understand AOD use. Moreover, they have important implications for how the treatment is imagined, implemented and funded. Service provision which follows engagement in an intensive (usually residential) program is often called 'aftercare' in the international AOD field. In this commentary, we argue that the term 'aftercare' fails to articulate the nature of ongoing care required by people who are managing AOD use. We maintain that 'aftercare' positions post-residential care as being less important than other treatment modalities, rather than as integral to a continuum of care. It is a term that implies that care should be acute, like much treatment delivered through a medical model, and assumes that people follow linear pathways in managing their AOD use. Assumptions embedded in the term 'aftercare' such as these may disincline governments from funding ongoing services for people exiting intensive programs. Alternative terms including 'continuing coordinated care' more aptly signal the integrated and ongoing service provision that should be available to support people in sustaining changes initiated through other AOD interventions.

The "black box" of treatment: Patients' perspective on what works in opioid maintenance treatment for opioid dependence

BACKGROUND

A lack of conceptual modeling of how the components of opioid maintenance treatment (OMT) for opioid dependence (OD) work causes it to occasionally be labeled the "black-box" of treatment. This study had a two-fold objective: First, to analyze which factors related to OMT for OD contribute to the abstinence of problematic use of non-prescribed opioids and sustain recovery, from the patients' perspective; second, to understand which changes OMT produced in the individuals' lives might significantly contribute to relapse prevention.

METHODS

We used qualitative methods of design, inquiry, and analysis from a convenience sample of 19 individuals in a Swedish treatment setting.

RESULTS

All the participants reported previous cycles of problematic use of non-prescribed opioids and other non-prescribed psychoactive substances, treatment, abstinence, recovery, and relapse before starting the current OMT program. During the pre-treatment stage, specific events, internal processes, and social environments enhanced motivation toward abstinence and seeking treatment. During the treatment stage, participants perceived the quality of the human relationships established with primary social groups as important as medication and the individual plan of care in sustaining recovery. From the participants' perspective, OMT was a turning point in their life course, allowing them a sense of self-fulfillment and the reconstruction of personal and social identity. However, they still struggled with the stigmatization produced by a society that values abstinence-oriented over medication-assisted treatments.

CONCLUSION

OMT is not an isolated event in individuals' lives but rather a process occurring within a specific social context. Structural factors and the sense of acceptance and belonging are essential in supporting the transformation. Treatment achievements and the risk for relapse vary over time, so the objectives of the treatment plan must account for characteristics of the pre-treatment stage and the availability and capacity of individuals to restructure their social network, besides the opioid maintenance treatment and institutional social care.

Examining the Coevolution of Drug Use Variety and Different Types of Offending Frequency Among Justice-Involved Adolescents

Past research demonstrates a strong link between drug use and crime among justice-involved adolescents, yet little is known about the joint development between drug use variety and various types of criminal offending frequencies from adolescence to young adulthood. Using a sample of male adolescent offenders ( N = 842), this article examines the coevolution of drug use variety and three separate types of offending frequencies. First, four group-based trajectory models identify unique group developmental patterns for drug use variety, drug sales offending, property offending, and violent offending. Next, three dual-trajectory models examine the coevolution between drug use variety and each type of criminal offending. Findings reveal a general pattern of desistance for both drug use and offending, while also illustrating notable variability in group trajectory patterns for drug use variety and criminal behavior. This article concludes that adolescents with elevated drug use variety make up a large proportion of frequent offenders.

Trajectories of Symptom Severity in Children with Autism: Variability and Turning Points through the Transition to School

This study examined the trajectories of autistic symptom severity in an inception cohort of 187 children with ASD assessed across four time points from diagnosis to age 10. Trajectory groups were derived using multivariate cluster analysis. A two trajectory/cluster solution was selected. Change in trajectory slopes revealed a turning point marked by plateauing in symptom reduction during the period of transition to school (age 6) for one of the two trajectories. Trajectories were labelled: Continuously Improving (27%) and Improving then Plateauing (73% of sample). Children in the two trajectories differed in levels of symptom severity, language, cognitive, and adaptive functioning skills. Study findings can inform the development of more personalized services for children with ASD transitioning into the school system.

Sex-specific risk profiles for substance use among college students

INTRODUCTION

Growing evidence indicates sex and gender differences exist in substance use. Framed by a lifecourse perspective, we explored prospectively by sex the effects of distal and proximal factors on the initiation of drug use in college.

METHODS

College students without prior drug use (n = 5,120 females; n = 2,951 males) were followed longitudinally across 4 years. Analyses were estimated as a multigroup survival analysis separately by sex within a latent variable SEM framework with illicit drug use (6 or more times in past year) as the latent factor.

RESULTS

More males initiated drug use (8.5%) than females (6.4%, χ2 (1) = 10.351, p = .001), but less so for Black males (AOR 0.33, 95% CI [0.18, 0.60]) and females (0.35 [0.23, 0.54]). Students initiating drug use more likely included students smoking cigarettes at baseline (males 1.40 [1.23, 1.59]; females 1.43 [1.24, 1.64]), using alcohol (males 1.04 [1.02, 1.06]; females 1.04 [1.02, 1.06]), or having cannabis using peers (males 1.79 [1.52, 2.11]; females 1.70 [1.49, 1.93]). Impulsivity domain associations differed by sex [negative urgency: females (1.23 [1.02, 1.49) and sensation seeking: males (1.33 [1.01, 1.75])]. History of unwanted/uncomfortable sexual experience predicted drug use for males (1.60 [1.09, 2.35]) and females (1.95 [1.45, 2.62]) but physical assault only for females (1.45 [1.08, 1.94]). Mood symptoms predicted drug use only for males [depression (0.73 [0.56, 0.95]); anxiety (1.40 [1.04, 1.89])].

CONCLUSIONS

Risk factors for initiating drug use during college differ by sex. As substance use during early age predisposes one for addiction, sex- and gender-informed interventions for young adults are needed.

Motivations for opioid and stimulant use among drug using black sexual minority men: A life course perspective

INTRODUCTION

HIV-related disparities persist among U.S. Black sexual minority men (BSMM). Generational differences in drug use trends and the HIV/AIDS epidemic have created different risk trajectories for BSMM. This study explored age-related differences in the profiles, motivations, and contexts of opioid and stimulant use among drug using BSMM.

METHODS

Participants were recruited using active and passive strategies and in-depth qualitative interviews were conducted among 30 BSMM in Baltimore, MD from December 2018 to March 2019. Exploratory drug testing was conducted to confirm drug use and identify the presence of synthetic materials. Thematic analysis was conducted guided by Life Course theoretical domains.

RESULTS

Participants' ages ranged from 25-63 (mean age 41, SD = 12.4); 40 % were under age 35, 60 % were age 35 and older. Most (86.7 %) were living with HIV. Older BSMM attributed drug use initiation to social trends and sexual partners; younger men shared that prescription painkiller use led to misuse to address emotional pain. Across age groups, childhood sexual abuse and other major events along the life course increased BSMM's drug use as a coping strategy.

DISCUSSION AND CONCLUSION

HIV and drug use interventions should support BSMM through targeted mental health services and trauma-informed healthcare models.

Personalising Outcome Measurement in Substance Misuse Treatment: the Feasibility and Psychometrics of Two Individualised Outcome Measures

Individualised information in substance misuse treatment complements standardised outcome measures. However, few studies investigate the use of individualised measures and their robustness in terms of quantifying outcomes. In this study, we analysed the psychometrics and feasibility of two individualised outcome measures (PQ and PSYCHLOPS). We followed a cross-sectional methodology, administering the individualised measures and three additional standardised measures (TOP, a measure of psychological health within addiction services; PHQ-9; CORE-OM) to a sample of 93 patients entering substance misuse treatment in four clinical services. The results showed high levels of patient acceptability of the two individualised measures (response rates > 95%). The internal reliability was good for both PQ and PSYCHLOPS (Cronbach’s alpha, .79 and .72, respectively). Convergent validity of PQ with standardised measures was weak: Pearson’s r values for TOP (psychological health), PHQ-9 and CORE-OM were .21, .22 and .27, respectively. In contrast, convergent validity of PSYCHLOPS was moderate: r = .40, .39 and .50, respectively. Convergence between PQ and PSYCHLOPS was weak (r = .28). Experience of previous treatment episodes was associated with higher PQ and PSYCHLOPS scores; PSYCHLOPS but not PQ scores were higher among those opting to complete the questionnaires in written rather than verbal format. Our findings demonstrated that PQ and PSYCHLOPS are reliable and feasible individualised outcome measures for use in substance misuse treatment units, although the lack of strong convergent validity indicates that they may be measuring different underlying constructs. Optimal outcome measurement may involve combining individualised and standardised measures.

Cocaine use and overdose mortality in the United States: Evidence from two national data sources, 2002-2018

BACKGROUND

Cocaine-involved overdose mortality has recently risen in the United States (US), yet it is unclear to what extent patterns in cocaine-involved overdose mortality parallel patterns in cocaine use. This study: examined time trends (2002-2018) in past-year cocaine use and cocaine-involved overdose mortality in the US; and compared demographics and drug involvement of adults who reported past-year cocaine use versus adults who died of a cocaine-involved overdose.

METHODS

Data from two sources were utilized: (1) the National Survey on Drug Use and Health (n = 1,334 adults self-reporting cocaine use in 2018); and (2) the Multiple Cause of Death dataset of the National Center for Health Statistics (N = 14,630 adults who died of a cocaine-involved overdose in 2018). The study examined prevalence of past-year cocaine use, mortality rates for cocaine-involved overdose, 2002-2018 trends, demographic characteristics, and involvement of other drugs.

RESULTS

Results of Joinpoint Regression indicated that the prevalence of past-year cocaine use increased after 2011, with an annual percent change of 5.13, while age-adjusted cocaine-involved overdose mortality rates escalated after 2012, with an annual percent change of 26.54. In 2018, prevalence of past-year cocaine use did not significantly differ (p = 0.09) by racial/ethnic group, yet Non-Hispanic Blacks had an age-adjusted cocaine-involved overdose mortality rate more than double the rate in Non-Hispanic Whites and significantly higher (p < 0.001) than in any other group.

CONCLUSIONS

While the prevalence of cocaine use has increased modestly, cocaine-involved overdose mortality has risen dramatically. Cocaine-involved overdose mortality is disproportionately affecting individuals who are Black, older, or with lower educational attainment.

A critical scoping review about the impact of music in the lives of young adults who use drugs

ISSUES

Music is among the most frequently used medium to promote young adults' well-being. To that aim, the efficiency of music is explained by its capacity to modulate emotions through its effect on the brain's reward pathways. Hence, music could help individuals suffering from dysregulations in these pathways, whose experience of positive emotions is often inhibited. Such dysregulations are particularly present in individuals with problematic psychoactive substance (PAS) use, who are overrepresented in the context of homelessness. While few of them initiate treatment, they successfully rely on their own resources to promote their well-being, including music, though its impact in this context remains under-studied.

APPROACH

This scoping review describes the impact of music on the well-being, PAS use and addictive trajectory of young housed and homeless individuals with problematic PAS use. Eleven French and English databases were screened for peer-reviewed articles using concepts and keywords related to music, PAS and well-being. From the 3697 results, 39 were reviewed. Results were organised according to the observed impact of music and analysed critically.

KEY FINDINGS

Literature shows that PAS users value the impact of music in meeting emotional, psychological and social needs, especially when they experience homelessness. Yet, research has been highly limited to the harmful consequences of music, limiting our knowledge of its potential benefits.

IMPLICATIONS AND CONCLUSION

To deepen our understanding about the impact of music, future research should endorse a broader perspective and consider the personal and contextual experiences accompanying the involvement in music, factors that were traditionally overlooked.

Economic Effects of Adolescent to Adult Patterns of Cannabis Use: Full-Time Employment and Employment Stability

Research has yet to examine stability in employment as a function of cannabis use once an individual transitions into full-time work. Using data from the Rochester Youth Development Study, trajectories of cannabis use spanning ages 14 to 30 were identified among a sample of predominantly minorities (>80%; 68% African American). After hard-classifying individuals by patterns of cannabis use, probabilities of full-time employment and conditional probabilities of full-time employment were calculated and compared across patterns of use. Abstention or rare cannabis use was associated with a higher likelihood of full-time employment compared with other cannabis use patterns. Full-time employment stability was high for each pattern of cannabis use (>89%) and differences decreased with age and prior periods of employment. The results indicate that patterns of cannabis use spanning adolescence to adulthood have limited impact on the ability to retain full-time employment once employed and are interpreted in light of growing legalization of cannabis use.

Avoiding the stigma. A qualitative study of socially included women's experiences of drug use and dealing, health services and the police in France

The figure of drug user and dealer is stigmatized, linked to violence and illness. This is due to a reductionist discourse which implements othering processes generating scapegoat figures in the drug world. All drug users and sellers are assimilated with these spoiled identities in the media or in drug policies, while the reality is much more diverse. This article draws on relational sociology to focus on figures who are the antithesis of stereotypes: socially integrated women who use or sell drugs (WUSD) and are invisible to the health and control enforcement agencies. By seeking to avoid the stigma of the drug user's and dealer's identities, how do socially included WUSD distance themselves from the control enforcement agencies and health institutions? This qualitative research is based on 26 semi-structured interviews conducted with socially included WUSD in France. Participants were recruited using a snowball sampling strategy. It appears that the participants normalized their drug use and integrated it into their professional and personal lives. Some were drug user-dealers and had social supply practices, selling the drugs they used to their friends in order to finance their consumption. None of the participants have ever been in contact with harm reduction and addiction services, both because they do not identify with the users of these services, and because these services are not designed to support this population. With the police, the participants play gender games and show their social inclusion to protect themselves from arrest. In both cases, the stigmatized figure of the drug user and drug seller alienate the participants from the health systems and control enforcement agencies. One of the consequences of the othering process is the invisibility of those who do not want to be identified as "others" by the health and law enforcement services. Rethinking drug policy is essential to reach populations that may need information and support.

Predictors of premature treatment termination in a large residential addiction medicine program

BACKGROUND

While inpatient programs are a common setting for addiction treatment, patients' premature termination is a major concern. Predicting premature treatment termination has the potential to substantially improve patient outcomes by identifying high-risk profiles and suggesting care paths that might reduce dropout. The current study examined the predictors of premature termination from an inpatient addiction medicine service.

METHODS

In 1082 patients admitted to a large inpatient addiction medicine service, we used intake assessments of severity of alcohol use disorder, illicit drug use disorder, post-traumatic stress disorder (PTSD), anxiety disorders, and major depressive disorder to predict planned termination (n = 922) or premature termination (n = 160). We used two complementary analytic approaches-traditional binary logistic regression and a data-driven latent profile analysis (LPA).

RESULTS

Binary logistic regression revealed that alcohol use severity, illicit drug use severity, and PTSD severity significantly predicted termination status, although alcohol use severity notably exhibited an inverse relationship. The LPA revealed four distinct profiles, with one profile exhibiting a significantly higher rate of premature termination and another exhibiting a significantly lower rate of premature termination. The high-risk profile was characterized by high drug severity, high comorbid psychopathology (PTSD, depression, and anxiety symptoms), but low alcohol severity. The low-risk profile was characterized by high alcohol severity, but low drug use and low comorbid psychopathology.

CONCLUSIONS

These results provide converging evidence that illicit drug severity and psychiatric severity, and particularly PTSD, were associated with premature termination. Moreover, the LPA revealed distinct latent subgroups of patients with meaningfully higher and lower risk of premature termination, suggesting that addiction services should develop strategies for identifying high-risk individuals or develop care paths for high-risk symptom clusters. Approaches that are trauma-informed or otherwise focus on the management of comorbid psychiatric conditions may be particularly appropriate for reducing premature termination.

Australian treatment outcome study: protocol for the 18-20-year follow-up of a prospective longitudinal cohort examining the natural history of heroin dependence and associated mortality, psychiatric and physical health, and health service use

INTRODUCTION

Opioid dependence is a global health priority, currently making the biggest contribution to drug-related deaths. The chronic, long-term persistence of heroin dependence over the life course requires investigation in prospective longitudinal studies, to better understand patterns and predictors of remission and relapse, as well as the impact of changes in substance use on a range of physical and mental health outcomes. Such knowledge is critical in order to identify modifiable risk factors that can be targeted for intervention. Crucial unanswered questions include the following: What are the long-term rates of mortality? What are the long-term patterns and predictors of heroin use, remission, psychiatric health and health service use? What are the long-term physical health consequences of heroin use?

METHODS AND ANALYSIS

The 18-20-year follow-up of the Australian Treatment Outcome Study (ATOS) cohort will examine the natural history of heroin dependence of an existing cohort of 615 people with heroin dependence, who were recruited into the study in 2001-2002. Five waves of follow-up interviews have since been completed, at 3-month, 1-year, 2-year, 3-year and 10-11-year post-baseline. At the 18-20-year follow-up, the ATOS cohort is (on average) approaching their 50s and an average of 30 years have passed since they first used heroin. The 18-20-year follow-up will consist of: (1) a structured interview; (2) physical health assessment; and (3) data linkage. The results of this follow-up will improve our understanding and management of age-related disorders in this population, which if not addressed in the immediate future, has the capacity to overwhelm treatment centres and aged care facilities.

ETHICS AND DISSEMINATION

Ethical approval has been granted for the study (Sydney Local Health District Royal Prince Alfred Zone, Human Research Ethics Committee X18-0512 & HREC/18/RPAH/733). The results of the study will be disseminated through published manuscripts, bulletins and technical reports, as well as conference, seminars, webinar and workshop presentations.

Identifying optimal level-of-care placement decisions for adolescent substance use treatment

BACKGROUND

Adolescents respond differentially to substance use treatment based on their individual needs and goals. Providers may benefit from guidance (via decision rules) for personalizing aspects of treatment, such as level-of-care (LOC) placements, like choosing between outpatient or inpatient care. The field lacks an empirically-supported foundation to inform the development of an adaptive LOC-placement protocol. This work begins to build the evidence base for adaptive protocols by estimating them from a large observational dataset.

METHODS

We estimated two-stage LOC-placement protocols adapted to individual adolescent characteristics collected from the Global Appraisal of Individual Needs assessment tool (n = 10,131 adolescents). We used a modified version of Q-learning, a regression-based method for estimating personalized treatment rules over time, to estimate four protocols, each targeting a potentially distinct treatment goal: one primary outcome (a composite of ten positive treatment outcomes) and three secondary (substance frequency, substance problems, and emotional problems). We compared the adaptive protocols to non-adaptive protocols using an independent dataset.

RESULTS

Intensive outpatient was recommended for all adolescents at intake for the primary outcome, while low-risk adolescents were recommended for no further treatment at followup while higher-risk patients were recommended to inpatient. Our adaptive protocols outperformed static protocols by an average of 0.4 standard deviations (95 % confidence interval 0.2-0.6) of the primary outcome.

CONCLUSIONS

Adaptive protocols provide a simple one-to-one guide between adolescents' needs and recommended treatment which can be used as decision support for clinicians making LOC-placement decisions.

Living a normal life? Follow-up study of women who had been in opioid maintenance treatment during pregnancy

BACKGROUND

There are few longitudinal follow-up studies of patients in opioid maintenance treatment (OMT). For this reason we performed a follow-up study of a cohort of 67 women who had used OMT-medications during pregnancy an average of ten years earlier. The aim of our study was to explore how the women were doing over time regarding OMT medication adherence and use of other legal and illegal substances, as well as to evaluate the mortality for the women and custody situation for the children in the cohort.

METHODS

Participants were recruited from two cohorts in our previous pregnancy study covering women who gave birth from 2004 to 2009. Sixty-seven women agreed to be interviewed, which is 73% of the eligible women from our original study. We developed a questionnaire, which we used in the interview, that focused primarily on these women's current life situation (custody of child they had delivered, the use of medications in OMT and other legal and illegal substances, and several other health and social aspects of the participants' lives).

RESULTS

Two women had died prior to the follow-up. Eighty-one percent of the women had custody of the child they had delivered in our pregnancy study and half the women were single parents. Fifty-four percent of the women were employed. At follow-up, 42% of the women were in methadone maintenance treatment (MMT), 39% were in buprenorphine maintenance treatment (BMT), and 19% had left OMT. One-third of the women had changed their OMT medication during the follow-up period. The majority (77%) were satisfied with their current OMT medication. The women in MMT seemed to be more severe substance dependent than the rest of the participants. There was little use of legal and illegal substances at follow-up, especially among women with custody of their child. The frequency of substance use was low. Fourteen percent of the women were in the process of leaving OMT and another half of the women wanted to leave OMT, but had no plan for how and when.

CONCLUSION

This follow-up study describes a predominantly well rehabilitated cohort of women who had given birth while in OMT ten years earlier. The majority of the women had custody of their children and used very few legal and illegal drugs. Our findings may be explained partly from a life course perspective, with the women having experienced turning points when starting OMT or becoming mothers.

"Becoming myself": how participants in a longitudinal substance use disorder recovery study experienced receiving continuous feedback on their results

BACKGROUND

Being a participant in longitudinal follow-up studies is not commonly a factor considered when investigating useful self-change aspects for individuals attempting recovery from substance use disorder (SUD). This study reports on how ongoing monitoring, and feedback on data results in a longitudinal follow-up study of SUD recovery were perceived by individuals who had achieved long-term abstinence and social recovery.

METHODS

Interviewers with first-hand experience with the topic conducted interviews with 30 participants and analysed the data using a thematic analytic approach within an interpretative-phenomenological framework.

RESULTS

Analyses resulted in the following themes. 1) Ongoing short text messaging (SMS) monitoring: helped participants by offering recovery milestones and reminders of the past. 2) Feedback on data results helped participants track physical and cognitive recovery: "I am more like myself". 3) Using feedback in treatment: understanding the importance of a functional brain to participants may help with long-term retention in treatment.

CONCLUSIONS

Self-changes that were challenging to detect on a day-to-day basis were available for reflection through longitudinal study participation, including ongoing monitoring and feedback on the results, allowing personal consolidation of change processes. Clinical services could benefit from continuing development and implementation of such technology for ongoing monitoring and feedback on assessments to motivate self-change in SUD recovery. The development of guidelines for providing the results of research assessments to individuals could help reduce attrition in research projects and support recovery and healthy choices for study participants.

Using life course charts to assess and compare trajectories of amphetamine type stimulant consumption in different user groups: a cross-sectional study

Background

Amphetamine-type stimulants (ATS) are the second most commonly used illicit drugs in Europe and globally. However, there is limited understanding of what shapes patterns of ATS use over the life course. The ATTUNE project “Understanding Pathways to Stimulant Use: a mixed methods examination of the individual, social and cultural factors shaping illicit stimulant use across Europe” aims to fill this gap. Here we report initial findings from the life course chart exercise conducted as part of qualitative interviews with ATS users and nonusers.

Methods

Two hundred seventy-nine in-depth qualitative interviews were conducted with five ATS user groups (current and former dependent users;current and former frequent users;non-frequent users) and one group of exposed non-ATS users in five European countries (Germany, UK, Poland, Netherlands and Czech Republic). As part of the interviews, we used life course charts to capture key life events and substance use histories. Life events were categorised as either positive, neutral or negative, and associated data were analysed systematically to identify differences between user groups. We applied statistical analysis of variance (ANOVA) and analysis of covariance (ANCOVA) to test for group differences.

Results

Out of 3547 life events documented, 1523 life events were categorised as neutral, 1005 life events as positive and 1019 life events as negative. Current and formerly dependent ATS users showed more negative life events for the entire life course after age adjustment. Although some group differences could be attributed to the individuals’ life course prior to first ATS use, most negative life events were associated with periods of ATS usage. A detailed analysis of the specific life domains reveals that dominantly, the social environment was affected by negative life events.

Conclusions

For non-dependent, frequent and non-frequent ATS users, negative life events from the period of ATS use do not become obvious in our analysed data. Besides preventing a pathway into ATS dependency, the aim of an intervention should be to reduce the harm by for example drug testing which offers also the opportunity for interventions to prevent developing a substance use dependency.

For the group of dependent ATS users, our study suggests holistic, tailored interventions and specialist treatment services are needed, as a single, simple intervention is unlikely to cover all the life domains affected.