The Developmental Origins of Opioid Use Disorder and Its Comorbidities

Evaluating a mobile app's effects on depression and anxiety in medication-treated opioid use disorder

Depression and anxiety frequently co-occur with opioid use disorder (OUD) yet are often overlooked in standard OUD treatments. This study evaluated the feasibility, acceptability, and preliminary effectiveness of a mobile application designed to address these symptoms in individuals receiving medications for OUD (MOUD). A randomized controlled trial recruited N = 63 adults with OUD who received MOUD and screened positive for moderate depression or generalized anxiety. Participants were randomized to an app-based digital intervention or treatment-as-usual for 4 weeks, and completed follow-ups at 4 and 8 weeks. Primary outcomes were self-reported severity measures for depression and generalized anxiety, and urine drug screens (UDS). Secondary outcomes included self-reported OUD severity, craving intensity, and digital biomarkers derived from passive smartphone sensors. The application was well-received (median app rating = 4/5 stars). The intervention group showed significant reductions in depressive and generalized anxiety symptoms post-intervention and at 8 weeks follow-up (d > 0.70), with large (d = 0.78) and moderate (d = 0.38) effect sizes, respectively, compared to controls. Both groups exhibited substantial decreases in self-reported severity of opioid use symptoms (d > 2.50). UDS suggested similar between-group adherence to MOUD, with a marginal decrease in opioid (MOP) use in the intervention group and increase in controls, yielding medium between group effect sizes (d = 0.44). Passive sensor data suggested significant increases in social connectedness in the intervention group, evidenced by a significant rise in incoming and outgoing calls and text connections. Initial evidence supports the feasibility and acceptability of a digital intervention for treating anxiety and depressive symptoms in persons receiving MOUD. While underpowered to confidently determine statistical significance beyond directionality, the intervention showed promise in reducing depressive and anxiety symptoms, suggesting its potential as a cost-effective and scalable adjunctive therapy alongside standard OUD treatment. Due to the preliminary nature of this pilot study, further research with sample sizes permitting greater statistical power is needed to confirm findings and explore long-term effects.

Sex-Specific Effects of Early Life Unpredictability on Hippocampal and Amygdala Responses to Novelty in Adolescents

Background

Unpredictable childhood experiences are an understudied form of early life adversity that impacts neurodevelopment in a sex-specific manner. The neurobiological processes by which exposure to early-life unpredictability impacts development and vulnerability to psychopathology remain poorly understood. The present study investigates the sex-specific consequences of early-life unpredictability on the limbic network, focusing on the hippocampus and the amygdala.

Methods

Participants included 150 youth (54% female). Early life unpredictability was assessed using the Questionnaire of Unpredictability in Childhood (QUIC). Participants engaged in a task-fMRI scan between the ages of 8 and 17 (223 total observations) measuring BOLD responses to novel and familiar scenes.

Results

Exposure to early-life unpredictability associated with BOLD contrast (novel vs. familiar) in a sex-specific manner. For males, but not females, higher QUIC scores were associated with lower BOLD activation in response to novel vs. familiar stimuli in the hippocampal head and amygdala. Secondary psychophysiological interaction (PPI) analyses revealed complementary sex-specific associations between QUIC and condition-specific functional connectivity between the right and left amygdala, as well as between the right amygdala and hippocampus bilaterally.

Conclusion

Exposure to unpredictability in early life has persistent implications for the functional operations of limbic circuits. Importantly, consistent with emerging experimental animal and human studies, the consequences of early life unpredictability differ for males and females. Further, impacts of early-life unpredictability were independent of other risk factors including lower household income and negative life events, indicating distinct consequences of early-life unpredictability over and above more commonly studied types of early life adversity.

A state-level analysis of macro-level factors associated with hospital readmissions

Investigation of the factors that contribute to hospital readmissions has focused largely on individual level factors. We extend the knowledge base by exploring macrolevel factors that may contribute to readmissions. We point to environmental, behavioral, and socioeconomic factors that are emerging as correlates to readmissions. Data were taken from publicly available reports provided by multiple agencies. Partial Least Squares-Structural Equation Modeling was used to test the association between economic stability and environmental factors on opioid use which was in turn tested for a direct association with hospital readmissions. We also tested whether hospital access as measured by the proportion of people per hospital moderates the relationship between opioid use and hospital readmissions. We found significant associations between Negative Economic Factors and Opioid Use, between Environmental Factors and Opioid Use, and between Opioid Use and Hospital Readmissions. We found that Hospital Access positively moderates the relationship between Opioid Use and Readmissions. A priori assumptions about factors that influence hospital readmissions must extend beyond just individualistic factors and must incorporate a holistic approach that also considers the impact of macrolevel environmental factors.

Sex differences in oxycodone-taking behaviors are linked to disruptions in reward-guided, decision-making functions

Problematic opioid use that emerges in a subset of individuals may be due to pre-existing disruptions in the biobehavioral mechanisms that regulate drug use. The identity of these mechanisms is not known, but emerging evidence suggests that suboptimal decision-making that is observable prior to drug use may contribute to the pathology of addiction and, notably, serve as a powerful phenotype for interrogating biologically based differences in opiate-taking behaviors. The current study investigated the relationship between decision-making phenotypes and opioid-taking behaviors in male and female Long Evans rats. Adaptive decision-making processes were assessed using a probabilistic reversal-learning task and oxycodone- (or vehicle, as a control) taking behaviors assessed for 32 days using a saccharin fading procedure that promoted dynamic intake of oxycodone. Tests of motivation, extinction, and reinstatement were also performed. Computational analyses of decision-making and opioid-taking behaviors revealed that attenuated reward-guided decision-making was associated with greater self-administration of oxycodone and addiction-relevant behaviors. Moreover, pre-existing impairments in reward-guided decision-making observed in female rats was associated with greater oxycodone use and addiction-relevant behaviors when compared to males. These results provide new insights into the biobehavioral mechanisms that regulate opiate-taking behaviors and offer a novel phenotypic approach for interrogating sex differences in addiction susceptibility and opioid use disorders.

Annual Research Review: The power of predictability - patterns of signals in early life shape neurodevelopment and mental health trajectories

The global burden of early life adversity (ELA) is profound. The World Health Organization has estimated that ELA accounts for almost 30% of all psychiatric cases. Yet, our ability to identify which individuals exposed to ELA will develop mental illness remains poor and there is a critical need to identify underlying pathways and mechanisms. This review proposes unpredictability as an understudied aspect of ELA that is tractable and presents a conceptual model that includes biologically plausible mechanistic pathways by which unpredictability impacts the developing brain. The model is supported by a synthesis of published and new data illustrating the significant impacts of patterns of signals on child development. We begin with an overview of the existing unpredictability literature, which has focused primarily on longer patterns of unpredictability (e.g. years, months, and days). We then describe our work testing the impact of patterns of parental signals on a moment-to-moment timescale, providing evidence that patterns of these signals during sensitive windows of development influence neurocircuit formation across species and thus may be an evolutionarily conserved process that shapes the developing brain. Next, attention is drawn to emerging themes which provide a framework for future directions of research including the evaluation of functions, such as effortful control, that may be particularly vulnerable to unpredictability, sensitive periods, sex differences, cross-cultural investigations, addressing causality, and unpredictability as a pathway by which other forms of ELA impact development. Finally, we provide suggestions for prevention and intervention, including the introduction of a screening instrument for the identification of children exposed to unpredictable experiences.

The Association Between Self-Reported Anxiety and Retention in Opioid Agonist Therapy: Findings From a Canadian Pragmatic Trial

BACKGROUND

Prescription-type opioid use disorder (POUD) is often accompanied by comorbid anxiety, yet the impact of anxiety on retention in opioid agonist therapy (OAT) is unclear. Therefore, this study investigated whether baseline anxiety severity affects retention in OAT and whether this effect differs by OAT type (methadone maintenance therapy (MMT) vs. buprenorphine/naloxone (BNX)).

METHODS

This secondary analysis used data from a pan-Canadian randomized trial comparing flexible take-home dosing BNX and standard supervised MMT for 24 weeks. The study included 268 adults with POUD. Baseline anxiety was assessed using the Beck Anxiety Inventory (BAI), with BAI ≥ 16 indicating moderate-to-severe anxiety. The primary outcomes were retention in assigned and any OAT at week 24. In addition, the impact of anxiety severity on retention was examined, and assigned OAT was considered an effect modifier.

RESULTS

Of the participants, 176 (65%) reported moderate-to-severe baseline anxiety. In adjusted analyses, there was no significant difference in retention between those with BAI ≥ 16 and those with BAI < 16 assigned (29% vs. 28%; odds ratio (OR) = 2.03, 95% confidence interval (CI) = 0.94-4.40; P = 0.07) or any OAT (35% vs. 34%; OR = 1.57, 95% CI = 0.77-3.21; P = 0.21). In addition, there was no significant effect modification by OAT type for retention in assigned (P = 0.41) or any OAT (P = 0.71). In adjusted analyses, greater retention in treatment was associated with BNX (vs. MMT), male gender identity (vs. female, transgender, or other), enrolment in the Quebec study site (vs. other sites), and absence of a positive urine drug screen for stimulants at baseline.

CONCLUSIONS

Baseline anxiety severity did not significantly impact retention in OAT for adults with POUD, and there was no significant effect modification by OAT type. However, the overall retention rates were low, highlighting the need to develop new strategies to minimize the risk of attrition from treatment.

CLINICAL TRIAL REGISTRATION

This study was registered in ClinicalTrials.gov (NCT03033732).

Increases in primary opioid use disorder diagnoses co-occurring with anxiety or depressive disorder diagnoses in mental health treatment in the United States, 2015-2019

BACKGROUND

Opioid use disorders (OUDs) often co-occur with anxiety and depressive disorders. While the proportion of mental health (MH) treatment facilities providing substance use treatment has increased, the proportion of these facilities able to simultaneously treat MH and substance use decreased. This warrants investigation into the integrated treatment needs of persons with a primary OUD diagnosis treated in MH treatment facilities.

METHODS

Using the Mental Health Client Level Data, we examined a sample of N = 83,975 adults with OUD as their primary diagnosis who received treatment from a MH treatment facility in the United States from 2015 to 2019. Joinpoint regression was used to examine annual trends of the number of individuals with co-occurring anxiety or depression diagnoses.

RESULTS

Most of the sample were men (53.7%) and received treatment in a community-based program (93.3%). Approximately 17% of the sample had either an anxiety or depressive disorder diagnosis. Approximately 9% of our sample had an anxiety disorder diagnosis, and 10% had a depressive disorder diagnosis. An increase in the number of individuals with a co-occurring anxiety disorder diagnosis from 2015 to 2019 was identified (annual percent change (APC) = 61.4; 95% confidence interval (CI) = [10.0, 136.9]; p =.029). An increase in the number of individuals with a co-occurring depressive disorder diagnosis from 2015 to 2019 was identified (APC = 39.0; 95% CI = [7.4; 79.9]; p =.027).

CONCLUSIONS

This study highlights increases in adults receiving MH treatment for OUD having co-occurring anxiety or depression diagnoses, furthering the importance of integrated dual disorder treatment.

The effect of stress on opioid addiction-related behaviors: A review of preclinical literature

Opioid misuse is a critical public health crisis in the United States that results in over 50,000 deaths per year and a substantial economic burden to society. Human epidemiological data suggest that exposure to stress is one of many risk factors for opioid misuse; however, opioid abusers tend to have multiple risk factors and use other drugs in addition to opioids. To identify causal mechanisms by which stress may increase risk, preclinical animal experiments provide a means to conduct experimental manipulations and maintain precise controls over environmental and drug exposures. The current review examines how stressful experiences alter opioid addiction-related behaviors in animal models, with a focus on how age of stress exposure affects drug outcomes. The findings summarized here suggest that neonatal or adult stress increase behaviors indicative of opioid intake and reward in rodent models, but that adolescent social stress may protect against later opioid addiction-related behaviors, which contradicts human epidemiological literature. We highlight three important areas to consider across this body of literature: the species and/or strain used, stressor type, and inclusion of both sexes. Finally, we suggest areas where additional research is warranted. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Oxytocin level among patients with opioid use disorder and its correlation with personality traits and perceived childhood trauma

Background

Personality traits and perceived childhood maltreatment are of the predictors of substance use disorder development. Many studies have discussed oxytocin effect on personality traits and its relation with childhood trauma and how both affect the addictive process. The main aim was to compare oxytocin level between patients with opioid use disorder and controls and the potential association of oxytocin level with the basic dimensions of personality traits and perceived childhood adverse experiences in patients group. Forty male patients with opioid use disorder and 40 healthy controls matched in age and gender were assessed and compared regarding serum oxytocin level by ELISA, personality traits using Temperament and character inventory - revised (TCI- R) scale, and childhood adverse events using childhood trauma questionnaire.

Results

A significant difference between the patient group and the control group regarding the serum oxytocin level was found. Negative correlation with p-value <0.05 between oxytocin level and each of novelty seeking, and harm avoidance, in addition to a positive correlation between oxytocin level and each of reward dependence, self-directedness, and cooperativeness items of (TCR-R), among cases were found. Cases did not show statistically significant difference in oxytocin level between different Childhood Trauma Questionnaire (CTQ) items.

Conclusions

The interaction between serum oxytocin levels, personality traits, and childhood trauma has to be considered in management with heroin-dependent patients as it plays a crucial role.

Effects of prenatal opioid exposure on synaptic adaptations and behaviors across development

In this review, we focus on prenatal opioid exposure (POE) given the significant concern for the mental health outcomes of children with parents affected by opioid use disorder (OUD) in the view of the current opioid crisis. We highlight some of the less explored interactions between developmental age and sex on synaptic plasticity and associated behavioral outcomes in preclinical POE research. We begin with an overview of the rich literature on hippocampal related behaviors and plasticity across POE exposure paradigms. We then discuss recent work on reward circuit dysregulation following POE. Additional risk factors such as early life stress (ELS) could further influence synaptic and behavioral outcomes of POE. Therefore, we include an overview on the use of preclinical ELS models where ELS exposure during key critical developmental periods confers considerable vulnerability to addiction and stress psychopathology. Here, we hope to highlight the similarity between POE and ELS on development and maintenance of opioid-induced plasticity and altered opioid-related behaviors where similar enduring plasticity in reward circuits may occur. We conclude the review with some of the limitations that should be considered in future investigations. This article is part of the Special Issue on 'Opioid-induced addiction'.

Improving Uptake of Emergency Department-initiated Buprenorphine: Barriers and Solutions

Emergency departments (ED) are increasingly providing buprenorphine to persons with opioid use disorder. Buprenorphine programs in the ED have strong support from public health leaders and emergency medicine specialty societies and have proven to be clinically effective, cost effective, and feasible. Even so, few ED buprenorphine programs currently exist. Given this imbalance between evidence-based practice and current practice, proven behavior change approaches can be used to guide local efforts to expand ED buprenorphine capacity. In this paper, we use the theory of planned behavior to identify and address the 1) clinician factors, 2) institutional factors, and 3) external factors surrounding ED buprenorphine implementation. By doing so, we seek to provide actionable and pragmatic recommendations to increase ED buprenorphine availability across different practice settings.

Enduring disruption of reward and stress circuit activities by early-life adversity in male rats

In humans, early-life adversity (ELA) such as trauma, poverty, and chaotic environment is linked to increased risk of later-life emotional disorders including depression and substance abuse. These disorders involve underlying disruption of reward circuits and likely vary by sex. Accordingly, we previously found that ELA leads to anhedonia for natural rewards and cocaine in male rodents, whereas in females ELA instead increases vulnerability to addiction-like use of opioid drugs and palatable food. While these findings suggest that ELA-induced disruption of reward circuitry may differ between the sexes, the specific circuit nodes that are influenced by ELA in either sex remain poorly understood. Here, in adult male Sprague-Dawley rats, we ask how ELA impacts opioid addiction-relevant behaviors that we previously tested after ELA in females. We probe potential circuit mechanisms in males by assessing opioid-associated neuronal activation in stress and reward circuit nodes including nucleus accumbens (NAc), amygdala, medial prefrontal cortex (mPFC), and paraventricular thalamus. We find that ELA diminishes opioid-seeking behaviors in males, and alters heroin-induced activation of NAc, PFC, and amygdala, suggesting a potential circuit-based mechanism. These studies demonstrate that ELA leads to behavioral and neurobiological disruptions consistent with anhedonia in male rodents, unlike the increased opioid seeking we previously saw in females. Our findings, taken together with our prior work, suggest that men and women could face qualitatively different mental health consequences of ELA, which may be essential for individually tailoring future intervention strategies.

Neurodevelopmental origins of substance use disorders: Evidence from animal models of early-life adversity and addiction

Addiction is a chronic relapsing disorder with devastating personal, societal, and economic consequences. In humans, early-life adversity (ELA) such as trauma, neglect, and resource scarcity are linked with increased risk of later-life addiction, but the brain mechanisms underlying this link are still poorly understood. Here, we focus on data from rodent models of ELA and addiction, in which causal effects of ELA on later-life responses to drugs and the neurodevelopmental mechanisms by which ELA increases vulnerability to addiction can be determined. We first summarize evidence for a link between ELA and addiction in humans, then describe how ELA is commonly modeled in rodents. Since addiction is a heterogeneous disease with many individually varying behavioral aspects that may be impacted by ELA, we next discuss common rodent assays of addiction-like behaviors. We then summarize the specific addiction-relevant behavioral phenotypes caused by ELA in male and female rodents and discuss some of the underlying changes in brain reward and stress circuits that are likely responsible. By better understanding the behavioral and neural mechanisms by which ELA promotes addiction vulnerability, we hope to facilitate development of new approaches for preventing or treating addiction in those with a history of ELA.

Impact of Early Life Stress on Reward Circuit Function and Regulation

Early life stress - including experience of child maltreatment, neglect, separation from or loss of a parent, and other forms of adversity - increases lifetime risk of mood, anxiety, and substance use disorders. A major component of this risk may be early life stress-induced alterations in motivation and reward processing, mediated by changes in the nucleus accumbens (NAc) and ventral tegmental area (VTA). Here, we review evidence of the impact of early life stress on reward circuit structure and function from human and animal models, with a focus on the NAc. We then connect these results to emerging theoretical models about the indirect and direct impacts of early life stress on reward circuit development. Through this review and synthesis, we aim to highlight open research questions and suggest avenues of future study in service of basic science, as well as applied insights. Understanding how early life stress alters reward circuit development, function, and motivated behaviors is a critical first step toward developing the ability to predict, prevent, and treat stress-related psychopathology spanning mood, anxiety, and substance use disorders.

What Are the Correlates of Global Variations in the Prevalence of Opioid Use Disorders? An Analysis of Data From the Global Burden of Disease Study, 2019

Introduction

The recent opioid crisis in North America has brought the problem of opioid use disorders (OUD) into clinical and public health focus, with experts warning that other countries or regions may be at future risk of experiencing such crises. The existing literature suggests that a wide range of social, cultural and economic factors may be associated with the onset, course and outcome of OUD in individuals. The current study uses data on the estimated prevalence of OUDs across 115 countries, obtained from the Global Burden of Disease Study, 2019, to examine the bivariate and multivariate associations between national prevalence of OUD and these factors.

Methods

Data on the estimated prevalence of OUDs was obtained via a database query from the Global Burden of Disease (GBD) Collaborative Network database for the year 2019. Recent (2018-2019) data on 10 relevant variables identified in the literature (gross national income, economic inequality, urbanization, social capital, religious affiliation and practice, unemployment, divorce, cultural individualism, and prevalence of depression) were obtained from the GBD, World Bank and Our World in Data databases. After transformation to a normal distribution, bivariate and univariate analyses were conducted to identify the significance and strength of the associations between these variables and the prevalence of OUD.

Results

Of the 10 variables studied, all variables except the divorce rate and religious affiliation were significantly correlated with the prevalence of OUD on bivariate analyses, though the strength of these associations was in the poor to fair range. On multivariate analysis, a significant association was observed only for the prevalence of depression, with trends towards a positive association for cultural individualism and unemployment, and a protective trend observed for religious practice.

Discussion

Though subject to certain limitations inherent in cross-sectional analyses, these results suggest that certain variables may be associated with a higher prevalence of OUD at the national level. Replication and refinement of these analyses may prove useful in identifying countries or regions at risk of a future opioid epidemic or crisis, which could facilitate the institution of preventive measures or early intervention strategies.

The Paraventricular Thalamus: A Potential Sensor and Integrator of Emotionally Salient Early-Life Experiences

Early-life experiences influence a broad spectrum of behaviors throughout the lifespan that contribute to resilience or vulnerability to mental health disorders. Yet, how emotionally salient experiences early in life are encoded, stored, and processed and the mechanisms by which they influence future behaviors remain poorly understood. The paraventricular nucleus of the thalamus (PVT) is a key structure in modulating positive and negative experiences and behaviors in adults. However, little is known of the PVT's role in encoding and integrating emotionally salient experiences that occur during neonatal, infancy, and childhood periods. In this review, we (1) describe the functions and connections of the PVT and its regulation of behavior, (2) introduce novel technical approaches to elucidating the role of the PVT in mediating enduring changes in adult behaviors resulting from early-life experiences, and (3) conclude that PVT neurons of neonatal rodents are engaged by both positive and negative emotionally salient experiences, and their activation may enduringly govern future behavior-modulating PVT activity during emotionally salient contexts.