A Comparative Study of Factors Associated with Relapse in Alcohol Dependence and Opioid Dependence

Neuroimaging of the effects of drug exposure or self-administration in rodents: A systematic review

A systematic review of functional neuroimaging studies on drug (self-) administration in rodents is lacking. Here, we summarized effects of acute or chronic drug administration of various classes of drugs on brain function and determined consistency with human literature. We performed a systematic literature search and identified 125 studies on in vivo rodent resting-state functional magnetic resonance imaging (n = 84) or positron emission tomography (n = 41) spanning depressants (n = 27), opioids (n = 23), stimulants (n = 72), and cannabis (n = 3). Results primarily showed alterations in the striatum, consistent with the human literature. The anterior cingulate cortex and (nonspecific) prefrontal cortex were also frequently implicated. Upregulation was most often found after shorter administration and downregulation after long chronic administration, particularly in the striatum. Importantly, results were consistent across study design, administration models, imaging method, and animal states. Results provide evidence of altered resting-state brain function in rodents upon drug administration, implicating the brain's reward network analogous to human studies. However, alterations were more dynamic than previously known, with dynamic adaptation depending on the length of drug administration.

Disruption of positive- and negative-feature morphine interoceptive occasion setters by dopamine receptor agonism and antagonism in male and female rats

RATIONALE

Internally perceived stimuli evoked by morphine administration can form Pavlovian associations such that they can function as occasion setters (OSs) for externally perceived reward cues in rats, coming to modulate reward-seeking behaviour. Though much research has investigated mechanisms underlying opioid-related reinforcement and analgesia, neurotransmitter systems involved in the functioning of opioids as Pavlovian interoceptive discriminative stimuli remain to be disentangled despite documented differences in the development of tolerance to analgesic versus discriminative stimulus effects.

OBJECTIVES

Dopamine has been implicated in many opioid-related behaviours, so we aimed to investigate the role of this neurotransmitter in expression of morphine occasion setting.

METHODS

Male and female rats were assigned to positive- (FP) or negative-feature (FN) groups and received an injection of morphine or saline before each training session. A 15-s white noise conditioned stimulus (CS) was presented 8 times during every training session; offset of this stimulus was followed by 4-s access to liquid sucrose on morphine, but not saline, sessions for FP rats. FN rats learned the reverse contingency. Following stable discrimination, rats began generalization testing for expression of morphine-guided sucrose seeking after systemic pretreatment with different doses of the non-selective dopamine receptor antagonist, flupenthixol, and the non-selective dopamine receptor agonist, apomorphine, combined with training doses of morphine or saline in a Latin-square design.

RESULTS

The morphine discrimination was acquired under both FP and FN contingencies by males and females. Neither flupenthixol nor apomorphine at any dose substituted for morphine, but both apomorphine and flupenthixol disrupted expression of the morphine OS. This inhibition was specific to sucrose seeking during CS presentations rather than during the period before CS onset and, in the case of apomorphine more so than flupenthixol, to trials on which access to sucrose was anticipated.

CONCLUSIONS

Our findings lend support to a mechanism of occasion setting involving gating of CS-induced dopamine release rather than by direct dopaminergic modulation by the morphine stimulus.

FRONTAL WHITE MATTER CHANGES INDICATE RECOVERY WITH INPATIENT TREATMENT IN HEROIN ADDICTION

Importance

Amidst an unprecedented opioid epidemic, identifying neurobiological correlates of change with medication-assisted treatment of heroin use disorder is imperative. Distributed white matter (WM) impairments in individuals with heroin use disorder (iHUD) have been associated with increased drug craving, a reliable predictor of treatment outcomes. However, little is known about the extent of whole-brain structural connectivity changes with inpatient treatment and abstinence in iHUD.

Objective

To assess WM microstructure and associations with drug craving changes with inpatient treatment in iHUD (effects of time/re-scan compared to controls; CTL).

Design

Longitudinal cohort study (12/2020-09/2022) where iHUD and CTL underwent baseline magnetic resonance imaging (MRI#1) and follow-up (MRI#2) scans, (mean interval of 13.9 weeks in all participants combined).

Setting

The iHUD and CTL were recruited from urban inpatient treatment facilities and surrounding communities, respectively.

Participants

Thirty-four iHUD (42.1yo; 7 women), 25 age-/sex-matched CTL (40.5yo; 9 women).

Intervention

Between scans, inpatient iHUD continued their medically-assisted treatment and related clinical interventions. CTL participants were scanned at similar time intervals.

Main Outcomes and Measures

Changes in white matter diffusion metrics [fractional anisotropy (FA), mean (MD), axial (AD), and radial diffusivities (RD)] in addition to baseline and cue-induced drug craving, and other clinical outcome variables (mood, sleep, affect, perceived stress, and therapy attendance).

Results

Main findings showed HUD-specific WM microstructure changes encompassing mostly frontal major callosal, projection, and association tracts, characterized by increased FA (.949<1-p<.986) and decreased MD (.949<1-p<.997) and RD (.949<1-p<.999). The increased FA (r=-0.72, p<.00001) and decreased MD (r=0.69, p<.00001) and RD (r=0.67, p<.0001) in the genu and body of the corpus callosum and the left anterior corona radiata in iHUD were correlated with a reduction in baseline craving (.949<1-p<.999). No other WM correlations with outcome variables reached significance.

Conclusions and Relevance

Our findings suggest whole-brain normalization of structural connectivity with inpatient medically-assisted treatment in iHUD encompassing recovery in frontal WM pathways implicated in emotional regulation and top-down executive control. The association with decreases in baseline craving further supports the relevance of these WM markers to a major symptom in drug addiction, with implications for monitoring clinical outcomes.

Psychological factors predicting patients' risk of relapse after enrollment in drug use treatment: A systematic review

BACKGROUND AND AIMS

Despite high rates of relapse after treatment for drug use, to our knowledge there is no systematic literature identifying psychological factors that predict risk of relapse to drug use (excluding alcohol or tobacco). Our aim was to identify psychological factors that predict risk of relapse to drug use after enrollment in drug use treatment. The identification of such factors can support treatment planning and relapse prevention.

METHODS

We searched for peer-reviewed articles published between 2000 and 2023 in PsycINFO, PsycArticles, Web of Science, and PubMed. The inclusion criteria were: peer-reviewed publications, quantitative studies, in English, adult samples, with a prospective design, and analyses of minimum one psychological factor as predictor of relapse to drug use. All authors were involved in abstract and full-text screening, and in assessing risk of bias. The findings are presented in a narrative synthesis and tables are organized by type of drug.

RESULTS

Of 2226 publications initially identified, 45 were eligible. Twenty-three focused on predicting relapse to stimulants, 15 to opioids, and 7 to unspecified drugs. Substance use at baseline was an important factor predicting risk of relapse to opioids, and possibly stimulants. There was an indication that craving and attention problems potentially predict relapse to use of some drugs. Mental health factors (e.g., psychiatric diagnosis) did not predict relapse. Several psychological factors (e.g., cognition, emotion, personality, motivation) were scarcely examined. Over half of the studies had moderate to high risk of bias.

CONCLUSIONS

Based on the 45 studies, few psychological factors predicted risk of relapse to drug use. Higher comparability between studies and more rigorous methodology are necessary in order to derive more precise recommendations that inform and improve clinical practice.

PRE-REGISTRATION

PROSPERO, CRD42020182839.

"I was already there once": Cumulative attempt capital of marginalized women exiting substance use and street prostitution contributes to their recovery capital

Despite a move to view substance use as a disease of the brain, relapse into drugs is still often viewed as a personal failure. Low recovery capital has been used to explain relapse among certain marginalized populations. Recovery capital is a recent framework that refers to the individual's sum of all internal and external assets that may assist in their recovery process. It includes four categories: physical, human, social, and cultural capital. However, this framework does not relate to the role of actual relapses in the recovery process, despite their common occurrence. To bridge this gap, in-depth interviews with 29 women formerly engaged in substance use and street prostitution in a large urban area were used to probe women about their relapse and recovery experiences. The current study demonstrates the value in repeat recovery setbacks, what I term "cumulative attempt capital": lessons learned from previous recovery attempts. I argue that previous attempts improve women's social and professional networks, help them learn from past mistakes, improve and maintain their health, and provide them with a sense of self-efficacy. This research expands our understanding of the positive role failed attempts play in one's recovery. Such reframing by service providers can alleviate a sense of shame and low self-worth for women in street prostitution and substance use and has implications for policy and program development.

Alcohol use disorder research in India: An update

Background

Despite alcohol use being a risk factor for numerous health-related conditions and alcohol use disorder (AUD) recognized as a disease, there was limited research in India until 2010. This narrative review aims to evaluate AUD-related research in India from 2010 to July 2023.

Methods

A PubMed search used key terms for AUD in India after 2010. Indian and international journals with regional significance that publish alcohol-related research were searched by each author individually. These were then collated, and duplicates were removed. In addition, we also conducted a gray literature search on focused areas related to AUD.

Results

The alcohol-related research in India after 2010 focused on diverse areas associated with alcohol use. Some areas of research have received more attention than others. Two major epidemiological surveys conducted in the past decade reveal that around 5% have a problematic alcohol use pattern. Factors associated with alcohol use, like genetic, neurobiological, psychological, and sociocultural, were studied. The studies focused on the clinical profile of AUD, including their correlates, such as craving, withdrawal, alcohol-related harm, and comorbid psychiatric and medical illnesses. During this period, minimal research was conducted to understand AUD's laboratory biomarkers, course, and prognosis. While there was a focus on generating evidence for different psychological interventions for alcohol dependence in management-related research, pharmacological studies centered on anticraving agents like baclofen. Research on noninvasive brain stimulation, such as rTMS, has shown preliminary usefulness in treating alcohol dependence. Very little research has been conducted regarding alcohol policy.

Conclusion

In the past decade, Indian research on alcohol has focused on diverse areas. Epidemiological and psychological management-related research received maximum attention. Considering the magnitude of the alcohol-related burden, it is essential to prioritize research to other less studied areas like pharmacological management of alcohol dependence and alcohol policy.

A Follow-up Study on Coping Strategies and its Association with Relapse Among Alcohol-dependent Patients

Background

Alcohol Dependence Syndrome is a chronic illness that is relapsing in nature. Past research has shown that coping strategies that are specific to alcohol dependence are useful in preventing long-term relapse. This follow-up study is, therefore, an attempt to understand the coping styles and strategies that are associated with relapse among individuals dependent on alcohol.

Methods

We aimed to cross-sectionally assess the severity of alcohol dependence and coping styles of Alcohol dependent individuals. One hundred and twenty-seven consecutive patients who satisfied the International Classification of Diseases Tenth Edition (ICD 10) criteria for alcohol dependence and who were above the age of 18 years were included. This study was conducted in the de-addiction outpatient services of a Tertiary care center in South India between April 2019 and June 2020. Our Institutional Ethical Committee granted the approval for this study. We used a self-designed proforma for collecting the socio-demographic details. The Severity of Alcohol Dependence Questionnaire (SADQ) and Coping Orientation to Problems Experienced Inventory (Brief - COPE) were administered. Patients were followed up for six months. Motivation Enhancement Therapy was given to all our participants during their monthly follow-up visit. Descriptive analysis was performed using mean and standard deviation. We used the student t-test and chi-squared test to understand the differences in the coping strategies between relapsed and non-relapsed persons. Spearman's correlation was used to assess the correlation between the severity of alcohol dependence and coping strategies. A p value of <.05 was taken as significant.

Results

Non-relapsed individuals had significantly higher scores on active coping (p = .008), emotional support (p = .044), informational support (p = .017), planning (p < .001), acceptance (p = .030), and humor (p = .001). Relapsed individuals had statistically significant scores on denial (p = .005), substance use (p = .024), and self-blame (p = .012). We found a positive correlation between the severity of alcohol dependence and maladaptive coping strategies (p < .01).

Conclusions

Relapsed individuals were found to have significantly higher maladaptive coping strategies. Non-relapsed individuals exhibited greater adaptive coping styles. Maladaptive coping strategies positively correlated with the severity of alcohol dependence.

Implementation of medication for opioid use disorder treatment in Indian health clinics in California: A qualitative evaluation

INTRODUCTION

American Indians and Alaska Native (AIAN) populations are disproportionately affected by opioid misuse. Medication for opioid use disorder (MOUD) is essential to decrease overdose events and overdose deaths. AIAN communities can benefit from MOUD programs that are housed within primary care clinics to improve treatment accessibility. This study aimed to gather information on the needs, barriers, and successes related to implementing MOUD programs in Indian health clinics (IHCs) offering primary care.

METHODS

The study used the Reach, Effectiveness, Adoption, Implementation, and Maintenance Qualitative Evaluation for Systematic Translation (RE-AIM QuEST) evaluation framework to structure key informant interviews with clinic staff who received technical assistance for MOUD program implementation. The study incorporated RE-AIM dimensions into a semi-structured interview guide. We developed the coding approach for analyzing interview data using Braun and Clarke's (2006) reflexive thematic analysis in qualitative research.

RESULTS

Eleven clinics participated in the study. The research team conducted twenty-nine interviews with clinic staff. We found that inadequate education about MOUD, scant resources, and limited availability of AIAN providers adversely impacted reach. Challenges with integrating medical and behavioral care, patient-level barriers (e.g., rural conditions, geographical dispersion), and limited workforce capacity impacted MOUD effectiveness. Stigma at the clinic level was detrimental to MOUD adoption. Implementation was challenging due to a limited number of waivered providers, and the need for technical assistance and MOUD policies and procedures. Staff turnover and restricted physical infrastructure negatively influenced MOUD maintenance.

CONCLUSIONS

Clinical infrastructure should be strengthened. The integration of culture into clinic services must be embraced by staff to support MOUD adoption. Increased representation from AIAN clinical staff is needed to appropriately represent the population being served. Stigma at various levels must be addressed, and the multiple barriers that AIAN communities face must be considered in understanding MOUD program implementation and outcomes.

Presenting Pattern and Psychiatric Comorbidities in Rural versus Urban Substance Dependent Patients: A Hospital-Based Cross-Sectional Study

Background

"Locality" is a significant factor in substance initiation, maintenance, and relapse. The pattern of substance dependence among rural and urban populations varies across studies and is scarcely studied, warranting further research. To compare presenting patterns (sociodemographic and drug-related variables), reasons for substance use, and psychiatric comorbidities (prevalence, type, and severity) between rural and urban substance-dependent groups.

Materials and Methods

This study was a cross-sectional analytical study in a government de-addiction center, including rural and urban patient groups aged 18-65. International Classification of Diseases, Tenth Revision (ICD-10) criteria, and severity of dependence scale were used for diagnosing substance dependence. After detoxification, psychiatric comorbidity was assessed using brief psychiatric rating scale, Young's mania rating scale, and patient health questionnaire - somatic, anxiety, and depression symptoms scale. Post-analysis was performed to assess socioeconomic variables and access to de-addiction services.

Results

The final sample was 500 (250 rural and 250 urban). The post-analysis sample size was 386 (211 rural and 175 urban). The mean age was 38.2 ± 12.4 years, mostly males (n = 495, 99%). Substance frequency was opioids (92%)> benzodiazepines (24.8%) > alcohol (22%) > cannabis (1.6%) for rural and opioids (91.2%) > alcohol (29.6%) > benzodiazepines (14.8%) > cannabis (2%) for urban patients. More than half of patients had comorbid nicotine dependence. Rural patients were more benzodiazepine dependent (P = 0.007), and urban were more opioid + alcohol dependent (P = 0.001). Rural patients had higher age (P = 0.012), less education (P < 0.001), positive family history of substance (P = 0.028), daily wagers, and farmers (P < 0.001) than urban patients who were younger, students (P = 0.002), businessmen and government employed (P < 0.001). Urban patients expended more on drugs (P < 0.001), had higher treatment attempts (P = 0.008), and had better availability and accessibility of de-addiction services (P < 0.001). More rural users initiated substances to "enhance performance," whereas urban ones initiated for "stress relief/novelty" (P < 0.001). For treatment seeking, "External pressure" was a more common reason in urban patients (P < 0.001), who also had more psychiatric comorbidities (P = 0.026).

Conclusion

Significant pattern differences exist between rural and urban substance dependents, warranting emphasis on locality-specific factors for appropriate intervention.

Self-Identified Stage in Recovery and Substance-Use Behaviors among Pregnant and Postpartum Women and People with Opioid Use Disorder

Opioid use among pregnant and postpartum women and people (PPWP) has significant health repercussions. This study explores how substance-use behaviors may vary by stage in recovery among PPWP with opioid use disorder (OUD). We recruited 29 PPWP with OUD. "High-risk" participants self-identified as "not being engaged in treatment" or "new or early in their recovery" (n = 11); "low-risk" participants self-identified as being "well-established" or "in long-term recovery" (n = 18). Participants were queried regarding sociodemographic, mental health, and drug-misuse factors; urine drug screens were collected at baseline. Univariate group comparisons between high-risk and low-risk PPWP were conducted. High-risk PPWP were more likely to self-identify as non-Hispanic African American and more likely to report current opioid use, other illicit drugs, and tobacco. High-risk PPWP had higher opioid cravings versus low-risk PPWP. High-risk PPWP were more likely to screen positive on urine tests for non-opioid drugs and on concurrent use of both non-opioid drugs and opioids versus low-risk participants. PPWP earlier in recovery are at higher-risk for opioid and other illicit drug misuse but are willing to disclose aspects of their recent use. PPWP early in recovery are an ideal population for interventions that can help facilitate recovery during the perinatal period and beyond.

MANEMOS. The Trigger Situations Inventory. Validation of a Measure Helping Relapse Prevention in the Treatment of Alcohol Use Disorders

Background: Relapse Prevention (RP) is a cognitive-behavioral approach that aims to identify situations at high risk of relapse and to support patients with alcohol use disorders (AUDs) in developing coping strategies for the maintenance of desired behavioral changes. Based on this framework, the present study aims to assess and validate the psychometric properties of the MANEMOS, a 24-item inventory of alcohol relapse triggering situations. Methods: The internal consistency and factor structure of the MANEMOS were analyzed in a sample of 313 (27.7% women) in-patients and out-patients, attending alcohol treatment programs in Italian addiction treatment facilities. Results: The results support the internal reliability and validity of the measure. A confirmative factor analysis has revealed the existence of eight distinct dimensions measuring relapse risk situations: namely, Pleasant emotions, Unpleasant emotions, Craving, Conflicts with others, Occasions, Social Pressure, Personal Control, and Physical Discomfort. The patients' assessment of the riskiness of the situation showed some significant differences depending on gender and on type of treatment received. Conclusions: The findings indicate that MANEMOS is a valid measure for identifying and reflecting on patients' high relapse-risk situations. This easy and flexible assessment measure may have important implications for prevention and clinical intervention.

Relapse during opioid use disorder treatment: A pilot study to understand the reasons for opioid use during treatment

Background

Opioid use is a cause of concern in many parts of the world. About 2.1% Indians use opioids. Opioids are also the most common drugs used by injection drug users in India. Despite various treatment strategies used to manage opioid use disorders (OUDs), relapse is common. A good treatment program would make efforts to address lapses and prevent relapse. Hence, there is a need to understand the factors associated with relapse in OUD.

Method

One hundred and twenty patients completed a baseline assessment that included socio-demographic details and the Maudsley Addiction Profile (MAP). They were followed up for three months and assessed using telephonic interview for opioid use. All those who relapsed were assessed using the Reasons for Relapse Questionnaire (RRQ). The patients who relapsed were compared with the patients who were abstinent. Relapse was defined as any use of opioid during follow-up.

Results

Forty participants relapsed during the 90 days of the study period. Relapsed patients had a greater number of conflict days with family members, used a higher amount of heroin and cannabis at baseline, were less likely to be discharged on buprenorphine, and were more likely to drop out. Participants cited mood and social reasons more often than cue/craving and unwell domains of RRQ.

Conclusion

Baseline treatment and prospective factors are associated with relapse in OUD. Addressing these factors can help in reducing relapse in OUD patients.

A protocol of a systematic review on deep brain stimulation surgery and its efficacy in addressing substance abuse addiction

Background

Pharmacotherapy and psychotherapeutic approaches are still the mainstay first line of treatment for substance use disorder. However, the path to rehabilitation and cessation of dependence often proves uncertain and laborious, with risks of relapse being considerable despite exposure to current therapeutic modalities. For cases of treatment-refractory addiction, deep brain stimulation (DBS) interventions can prove a more effective long term therapeutic solution for the patient.

Objectives

The aim of the study will be to systematically assess whether attempts at correcting substance use disorder via DBS neurosurgical interventions have been successful in inducing remission or ameliorating relapse rates.

Methods

The current study will analyze available literature from database inception up to 15th April 2023, reviewing all publications documenting results achieved with human patients undergoing DBS for substance use disorder in PubMed, Ovid, Cochrane, and Web of Science. The electronic database search will exclude animal studies in the field and focus solely on the application of DBS for the purposes of addressing addiction disorders.

Results

The expectation is for a reduced number of trial results to have been reported, namely due to the relatively recent application of DBS to address severe addiction. Nonetheless, numbers should be in sufficient amount to inform about the efficacy of the intervention.

Conclusion

This study will attempt to demonstrate the viability of DBS as a solution for tackling treatment-refractory substance use disorder, proposing it as a valid therapeutic option that can deliver robust results and help combat an expanding societal plague that is drug dependence.

Subtypes in addiction and their neurobehavioral profiles across three functional domains

Rates of return to use in addiction treatment remain high. We argue that the development of improved treatment options will require advanced understanding of individual heterogeneity in Substance Use Disorders (SUDs). We hypothesized that considerable individual differences exist in the three functional domains underlying addiction-approach-related behavior, executive function, and negative emotionality. We included N = 593 participants from the enhanced Nathan Kline Institute-Rockland Sample community sample (ages 18-59, 67% female) that included N = 420 Controls and N = 173 with past SUDs [54% female; N = 75 Alcohol Use Disorder (AUD) only, N = 30 Cannabis Use Disorder (CUD) only, and N = 68 Multiple SUDs]. To test our a priori hypothesis that distinct neuro-behavioral subtypes exist within individuals with past SUDs, we conducted a latent profile analysis with all available phenotypic data as input (74 subscales from 18 measures), and then characterized resting-state brain function for each discovered subtype. Three subtypes with distinct neurobehavioral profiles were recovered (p < 0.05, Cohen's D: 0.4-2.8): a "Reward type" with higher approach-related behavior (N = 69); a "Cognitive type" with lower executive function (N = 70); and a "Relief type" with high negative emotionality (N = 34). For those in the Reward type, substance use mapped onto resting-state connectivity in the Value/Reward, Ventral-Frontoparietal and Salience networks; for the Cognitive type in the Auditory, Parietal Association, Frontoparietal and Salience networks; and for the Relief type in the Parietal Association, Higher Visual and Salience networks (pFDR < 0.05). Subtypes were equally distributed amongst individuals with different primary SUDs (χ2 = 4.71, p = 0.32) and gender (χ2 = 3.44, p = 0.18). Results support functionally derived subtypes, demonstrating considerable individual heterogeneity in the multi-dimensional impairments in addiction. This confirms the need for mechanism-based subtyping to inform the development of personalized addiction medicine approaches.

Psychosocial Factors Affecting Drug Relapse among Youth in Punjab, Pakistan

The present study was intended to examine the effect of psychosocial factors on the stigma of mental illness among people addicted to drugs who have relapsed in Punjab, Pakistan. A sample composed of 116 people addicted to drugs and who have relapsed was collected through the purposive sampling technique. Certain self-report measures were used to assess the pertinent study variables. The results elucidated that self-efficacy, social support, and conscientiousness were found to be negative predictors and neuroticism a positive predictor of stigma. The results also confirmed social support as being a significant moderator in the relationship between self-efficacy and stigma, and self-efficacy as being a significant moderator in the relationship between social support and stigma. It was safe to conclude that psychosocial factors such as self-efficacy, social support, personality traits and stigma have a significant role in causing addiction relapse. The conclusions made have been discussed thoroughly.

Habits and Routines of Adults in Early Recovery From Substance Use Disorder: Clinical and Research Implications From a Mixed Methodology Exploratory Study

The purpose of this exploratory, non-experimental mixed methods study was to analyze the habits and routines of adults in early recovery (>3 months) from substance use disorder (SUD). Participants (N = 14) were recruited from an intensive outpatient treatment (IOP) program for substance use disorders. Data collection consisted of a demographic survey, a researcher developed Daily Occupational Questionnaire (DOQ), and follow-up semi-structured interviews with 5 randomly selected participants. Quantitative results indicate rest as the most frequently engaged in activity on the most busy (31.0%) and least busy day (36.6%). There was no significant difference, t(13) = 0.117, P = .909, between newly established activities on the most busy and least busy day. Qualitative themes included 1. The most difficult time of day is often related to patterns of unused time. 2. When there is a lack of structure or unoccupied time, they return to their previously established positive supports. 3. There is a need for consistency and structure for developing anticipated/perceived routines. Implications for all healthcare and clinical providers working with this population, as well as research suggestions, are outlined.

Effects of neuromodulation on cognitive and emotional responses to psychosocial stressors in healthy humans

Physiological and psychological stressors can exert wide-ranging effects on the human brain and behavior. Research has improved understanding of how the sympatho-adreno-medullary (SAM) and hypothalamic-pituitary-adrenocortical (HPA) axes respond to stressors and the differential responses that occur depending on stressor type. Although the physiological function of SAM and HPA responses is to promote survival and safety, exaggerated psychobiological reactivity can occur in psychiatric disorders. Exaggerated reactivity may occur more for certain types of stressors, specifically, psychosocial stressors. Understanding stressor effects and how the body regulates these responses can provide insight into ways that psychobiological reactivity can be modulated. Non-invasive neuromodulation is one way that responding to stressors may be altered; research into these interventions may provide further insights into the brain circuits that modulate stress reactivity. This review focuses on the effects of acute psychosocial stressors and how neuromodulation might be effective in altering stress reactivity. Although considerable research into stress interventions focuses on treating pathology, it is imperative to first understand these mechanisms in non-clinical populations; therefore, this review will emphasize populations with no known pathology and consider how these results may translate to those with psychiatric pathologies.

A comparison of risk factors for relapse in opiate-related and stimulant-related substance use disorders: A cross-sectional multicenter study

INTRODUCTION

Recognizing the specific factors in relapse disorders related to each substance can help improve treatment methods and adopt more effective preventive strategies. This study aimed to compare the situational factors associated with relapse in opiate-related disorders with stimulant-related disorders (SRDs) of those referred to substance misuse treatment centers.

DESIGN

This study was a cross-section type.

METHODS

The study participants were 150 clients with SRDs and 150 with opiate-related disorders. Samples were selected using two stages random sampling method. Data were collected through a demographic questionnaire and the Inventory of Drug-Taking Situations (IDTS).

RESULTS

The mean score of IDTS in the two groups was significantly different (X̄₁  = 45.93 ± 11.12 vs. X̄₂  = 48.34 ± 15.07; t = 3.32, p < 0.01). The mean scores of 'unpleasant emotions,' 'physical discomfort,' 'conflict with others,' and 'social pressure to use and urge/temptations' subscales were significantly higher in the stimulant group than in the opiate group (p < 0.05). However, the mean of the testing' personal control' subscale was higher in the opiate group than in the stimulant group (p < 0.05).

CONCLUSION

This study reveals that despite some similarities, relapse-related situational factors in opiates and stimulants differ. Some situational factors, such as social pressure and coping with unpleasant emotions, play a more critical role in relapse to both stimulant and opiate groups.

The role of repetitive transcranial magnetic stimulation in reduction of opioid craving: a single-blinded randomized sham-controlled clinical trial

Background

Opioid use disorder (OUD) poses a great concern due to problems associated with their abuse as well as fatal and non-fatal overdose consequences. Craving has a complex relationship with opioid use and relapse. Developing new, effective treatments for substance use disorders (SUDs), including opioid use disorders is crucial. This study aimed to assess the effect of 18 sessions of high-frequency (HF) repetitive transcranial magnetic stimulation (rTMS) over the left dorsolateral prefrontal cortex (DLPFC) on opioid craving in 26 OUD male patients compared to sham rTMS in 26 OUD patients, during early abstinence, with craving assessment using brief substance craving scale (BSCS) for tramadol and morphine and heroin craving questionnaire (HCQ) for heroin craving.

Results

There was a statistically significant reduction in craving scores in the group of OUD patients receiving real rTMS compared to those receiving sham rTMS for both BSCS (p value = 0.044) and HCQ (p value=0.002). A statistically significant positive correlation was revealed between the number of hospital admissions and the mean scores of post-rTMS HCQ scores (r=0.05, p value= 0.040).

Conclusions

A high frequency of 10-Hz rTMS over the left DLPFC for 18 treatment sessions reduced craving OUD patients during early abstinence. These preliminary results suggest that 10-Hz rTMS of the left DLPFC may be used in the treatment of OUD, so our study recommends that the use of rTMS in the reduction of opioid craving in early abstinence.

Trial registration

Unique identification number PACTR202206487514449 in the Pan African Clinical Trial Registry retrospectively (www.pactr.org) registered on 10 June 2022.

A Glitch in the Matrix: The Role of Extracellular Matrix Remodeling in Opioid Use Disorder

Opioid use disorder (OUD) and deaths from drug overdoses have reached unprecedented levels. Given the enormous impact of the opioid crisis on public health, a more thorough, in-depth understanding of the consequences of opioids on the brain is required to develop novel interventions and pharmacological therapeutics. In the brain, the effects of opioids are far reaching, from genes to cells, synapses, circuits, and ultimately behavior. Accumulating evidence implicates a primary role for the extracellular matrix (ECM) in opioid-induced plasticity of synapses and circuits, and the development of dependence and addiction to opioids. As a network of proteins and polysaccharides, including cell adhesion molecules, proteases, and perineuronal nets, the ECM is intimately involved in both the formation and structural support of synapses. In the human brain, recent findings support an association between altered ECM signaling and OUD, particularly within the cortical and striatal circuits involved in cognition, reward, and craving. Furthermore, the ECM signaling proteins, including matrix metalloproteinases and proteoglycans, are directly involved in opioid seeking, craving, and relapse behaviors in rodent opioid models. Both the impact of opioids on the ECM and the role of ECM signaling proteins in opioid use disorder, may, in part, depend on biological sex. Here, we highlight the current evidence supporting sex-specific roles for ECM signaling proteins in the brain and their associations with OUD. We emphasize knowledge gaps and future directions to further investigate the potential of the ECM as a therapeutic target for the treatment of OUD.

Comparison of Recovery Capital in Patients with Alcohol and Opioid Dependence - An Exploratory Study

Background

Recovery capital helps in the assessment of the personal strengths and challenges that exist in an individual with substance use which may have an impact on recovery process. This study aims at finding out the factors which help such individuals to sustain their recovery and how these factors differ across the two groups of people suffering from Alcohol Dependence Syndrome and Opioid Dependence Syndrome.

Methods

A cross-sectional observational was designed where sociodemographic and clinical variables, the recovery capital ARC (Assessment of Recovery Capital) Scale and Severity of substance use SDS (Severity of Dependence) Scale of patients diagnosed with Alcohol Dependence Syndrome (ADS group) and those with Opioid Dependence Syndrome (ODS group) were assessed among patients not reporting withdrawal symptoms.

Findings

A total of 49 subjects in the ODS group and 30 subjects in the ADS group were enrolled. The majority of the subjects in both groups were married, belonged to urban areas, practiced Hinduism, and were living in nuclear families. There was a significant difference between the educational status (p<0.001), religion practiced (p<0.001), age of onset of dependence (p<0.001), severity of dependence (p=0.11), and duration of abstinence (p<0.001) between the ADS and ODS groups. The mean scores on ARC Scale were 45.9 (S.D. =3.5) in the ODS group and 47.4 (S.D. =4.3) in the ADS group. ADS group had higher scores in Social Support Domain (p=0.034) and Housing and Safety domain (p=0.025). Other domains like global health, citizenship, meaningful activities, risk-taking, coping, and recovery experience did not significantly differ between the groups.

Conclusion

This study aims at comparing the recovery capital of ADS patients with ODS patients. It also suggests that tailored treatment plans for people with ADS and ODS especially in housing and social support and common treatment approach in other domains of recovery will help them sustain the state for a longer term.

Changes in craving following acute aerobic exercise in adults with alcohol use disorder

AIMS

Exercise is increasingly being studied as treatment for alcohol use disorder (AUD). We examined the effects of an acute bout of exercise on alcohol craving, heterogeneity of response, and factors associated with reductions in craving.

METHODS

Within the context of a randomized controlled trial, we conducted an exploratory, single-arm study. In total, 117 adults with AUD (52.7 years; SD = 12.3; 68.4% female) and indications of alcohol craving (Desire for Alcohol Questionnaire, DAQ-short version total score >8) were included. The intervention was a 12-min sub-maximal fitness test performed on a cycle ergometer. We examined changes in participant's self-rated desire for alcohol immediately before and after exercise. Personal, clinical, and exercise-related factors associated with reductions (≥0.5 SD) in craving were identified using hierarchical logistic regression.

RESULTS

In the total sample craving reduced from pre-to post-exercise (p < 0.001, g = 0.60 [0.40-0.79]). Three groups were observed: those whose craving decreased (70.1%; p < 0.001, g = 1.12 [0.85-1.40]), increased (16.2%; p < 0.001, g = 1.08 [0.51-1.64]), or did not change (13.7%). Forty percent experienced clinically meaningful reductions in craving (≥0.5 SD). In fully adjusted models, two factors were associated with these reductions: higher pre-exercise cravings (OR = 1.15 [1.07-1.23], p < 0.001) and lower cardiorespiratory fitness (OR = 0.88 [0.79-1.00], p = 0.043).

CONCLUSIONS

In most adults with AUD, short bouts of moderately intense aerobic exercise helps reduce cravings for alcohol. Those with higher cravings and lower cardiorespiratory fitness are most likely to benefit.

When Triggers Become Tigers: Taming the Autonomic Nervous System via Sensory Support System Modulation

Personalized recovery technologies may enable individuals with Substance Use Disorder (SUD) to monitor and manage acute craving and drug use urges in ways that improve drug-seeking decisions in real-time. Direct and indirect regulation of the autonomic nervous system through sensory input monitoring and modulation may enhance control over behavioral decisions and prevent relapse. A personalized sensory support system that monitors neurophysiological reactivity and offers non-pharmacological point-in-time personalized digital interventions may increase awareness of and control over craving reactivity. It is critical to be able to detect these warning signs and intervene early and effectively. The use of wearable technologies that assess point-in-time neurophysiological escalation and shape behavioral response through personalized interventions could be transformative in allowing individuals to better manage their recovery as they transition out of institutions and move back into community settings.

Change in normative eating self-efficacy is associated with six-month weight restoration following inpatient treatment for anorexia nervosa

Anorexia nervosa (AN) is a disorder characterized by rigid and restrictive eating behaviors, resulting in significantly low body weight. While specialized behavioral intensive treatment programs can reliably support individuals with AN to normalize eating and weight control behaviors and achieve weight restoration, prognostic factors predicting relapse following treatment are unclear. We examined whether changes in (i) normative eating self-efficacy, (ii) body image self-efficacy, (iii) drive for thinness, and (iv) body dissatisfaction from inpatient admission to six-month follow-up were associated with weight restoration status at program discharge and at six-month follow-up. The sample comprised 146 participants with AN admitted to a meal-based inpatient-partial hospitalization program. Participants completed questionnaires at inpatient admission and six months following program discharge. Additionally, at follow-up, participants reported the frequency of engaging in normalized eating behaviors since discharge (e.g. eating with others and preparing a balanced meal). The majority (73.3%) of participants attained a BMI > 19 at discharge and 59.6% were weight restored at six-month follow-up. Change in normative eating self-efficacy was significantly associated with weight restoration at follow-up, whereas change in body image self-efficacy, drive for thinness, and body dissatisfaction were not. For each one unit increase in normative eating self-efficacy, patients were 4.65 times more likely to be weight restored at follow-up (p = .002). Additionally, individuals reporting a higher frequency of normalized eating behaviors at follow-up were more likely to be weight restored. Normative eating self-efficacy and normalized eating behaviors may represent vital treatment targets for relapse prevention interventions for this high-risk population.

Apathy is associated with poorer abstinence self-efficacy in individuals with methamphetamine dependence

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Used an apathy composite T-score approach validated in methamphetamine-dependence.

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Apathy, above other factors, associated with poorer drug abstinence self-efficacy.

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Methamphetamine use characteristics unrelated to drug abstinence self-efficacy.

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Social peer pressure was riskiest situation for potential methamphetamine relapse.

Background

Confidence in one’s ability to achieve and maintain drug abstinence (i.e., abstinence self-efficacy) is a strong predictor of substance use treatment outcomes. Neurobehavioral factors that may interfere with abstinence self-efficacy are less well established, particularly in methamphetamine (METH). This study investigated whether apathy, which is highly prevalent during active METH use and periods of abstinence, influences abstinence self-efficacy among METH dependent individuals.

Methods

Sixty-six participants with lifetime METH dependence and METH abuse/METH dependence diagnoses within the last 18 months (mean age [SD] = 39.5 years [10.7]), and no severe psychiatric or neurological diseases, completed the Methamphetamine Self-Efficacy Scale (MSES), alongside a comprehensive neurobehavioral evaluation. The MSES presents six situations that may lead to relapse and collects self-report ratings for two subscales: “Confidence” (i.e., confidence in one’s ability to abstain from using METH, or METH abstinence self-efficacy) and “Temptation” (i.e., how tempted one is to use METH) with regard to each situation. Apathy was measured using a composite T-score comprised of items and scales from three well-validated, self-report assessments.

Results

Multivariable linear regression found that higher Apathy T-scores were significantly associated with lower Confidence ratings (i.e., poorer METH abstinence self-efficacy; p < .05), independent of potentially relevant factors (e.g., Temptation to use METH, comorbid HIV disease, and neurocognitive impairment).

Conclusions

Elevated apathy may adversely impact one’s confidence to abstain from METH use. Findings highlight the importance of addressing apathy in order to improve METH abstinence self-efficacy, which may subsequently increase the likelihood of successful METH treatment outcomes.

Synthesis of a deuterated 6-AmHap internal standard for the determination of hapten density in a heroin vaccine drug product

A deuterated hapten was designed and synthesized that will be essential for a future study of residual hapten and stability of a hapten-protein conjugate. This hapten, 6-AmHap, was chosen for a heroin vaccine that is now slated for a Phase 1 clinical trial. A maleimide-thiol bioconjugation strategy was successfully applied to our heroin vaccine to connect the hapten 6-AmHap with an immunogenic carrier protein (tetanus toxoid, TT) through a trityl-protected 3-mercaptopropanamide linker. The antibodies induced by the vaccine have been found to have activity against several opioids, including heroin and its metabolites, and, importantly, leave alternate pain treatment medications such as methadone untouched. To the best of our knowledge, no other hapten for a heroin vaccine has been deuterated, yet this tool may prove to be of great importance in the study of residual hapten during product release and the long-term stability program of a hapten-protein conjugate as part of FDA regulatory requirements. Hydrocodone was the starting material for the synthesis of the deuterated 6-AmHap, with a stable amide at C6 and a 3-mercaptopropanamide linker attached at C3. The desired deuterated product was prepared as the disulfide, 3,3'-disulfanediylbis(N-((7S,7aR,12bS)-7-acetamido-3-[2 H3 ]methyl)-2,3,4,4a,5,6,7,7a-octahydro-1H-4,12-methanobenzofuro[3,2-e]isoquinolin-9-yl)propanamide), that could be easily reduced to form the needed hapten, N-((4aR,7S,7aR,12bS)-7-acetamido-3-[2 H3 ]methyl]-2,3,4,4a,5,6,7,7a-octahydro-1H-4,12-methanobenzofuro[3,2-e]isoquinolin-9-yl)-3-mercaptopropanamide.

Daily associations among craving, affect, and social interactions in the lives of patients during residential opioid use disorder treatment

OBJECTIVE

This study captured the interrelationships among craving, negative affect, and positive and negative social exchanges in the daily lives of patients in residential treatment for opioid use disorders (OUDs).

METHOD

Participants were 73 patients (77% male), age 19 to 61 (Mage = 30.10, SDage = 10.13) in residential treatment for OUD. Participants completed a smartphone-based survey 4 times per day for 12 consecutive days that measured positive and negative social exchanges (Test of Negative Social Exchange), negative affect (PA-NA scales), and craving (frequency and intensity). Within-person, day-level associations among daily positive and negative social exchanges, negative affect, and craving were examined using multilevel modeling.

RESULTS

Daily negative social exchanges (M = 1.44, SD = 2.27) were much less frequent than positive social exchanges (M = 6.59, SD = 4.00) during residential treatment. Whereas negative social exchanges had a direct association with same-day craving (β = 0.08; 95% CI = 0.01, 0.16, ΔR2 = 0.01), positive social exchanges related to craving indirectly via moderation of the within-person negative affect-craving link (β = -0.01; 95% CI = -0.01, -0.001, ΔR2 = 0.002). Positive social exchanges decoupled the same-day linkage between negative affect and craving on days when individuals had at least four more positive social exchanges than usual.

CONCLUSIONS

These results indicate that both negative affect and negative social exchanges are uniquely related to craving on a daily basis, and that extra positive social interactions can reduce the intraindividual coupling of negative affect and craving during residential treatment for OUD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Stressful life events, social support, and risk for relapse in relapsed harmful alcohol users in South India: a comparative study between psychiatry and gastroenterology patients

Background: Previous studies have identified risk factors for relapse in patients with alcohol use disorders in deaddiction or community settings. There are limited studies comparing the stressful life events, social support, and risk of relapse in relapsed harmful alcohol users between psychiatry and gastroenterology departments.Objective: To compare the stressful life events, social support, and risk of relapse in relapsed harmful alcohol users between psychiatry and gastroenterology departments.Methods: Comparative, cross-sectional study design was used in males with harmful alcohol use as defined by AUDIT and with at least one relapse. Presumptive Stressful Life Events Scale, Multidimensional Perceived Social Support Scale, and Alcohol Relapse Risk Scale were used.Results: Severity of alcohol harmful use was significantly higher in psychiatry patients than gastroenterology. Increased number of gastroenterology patients reported "change in their sleeping habits" as an important factor for relapse than psychiatry, which was not significant. Only stimulus-induced vulnerability was significantly increased in psychiatry patients compared to gastroenterology. Social support significantly correlated with the alcohol relapse risk scores in the psychiatry group, while in the gastroenterology, the severity of alcohol harmful use scores significantly correlated with total alcohol relapse risk scores.Conclusions: The individual stressors and the risk for relapse were different between the two groups. There was no difference in social support between the two groups. These findings can have implications for using these factors in relapse prevention strategies by focusing on the factors specifically found in each group. However, these findings have to be studied in a larger community sample.

Relapse to substance use: A concept analysis

The concept of relapse is ubiquitous in the health literature related to addiction. Nevertheless, relapse is-and has been-described and measured under various definitions, which precipitates confusion, inconsistency, and stigma. This study aimed to (a) clarify the meaning of relapse and (b) present a comprehensive definition of relapse vis-à-vis substance use. Walker and Avant's method of concept analysis was followed to analyze the relapse using CINAHL, PsychINFO, and PubMed databases. Three key attributes of relapse were identified: (a) interruption of abstinence, (b) vulnerability to uncontrollable substance-related behavior and/or cues, (c) a transition to potential progression or regression. Antecedents and consequences of attributes were identified, followed by the construction of the model and additional cases. Relapse is defined conceptually as either a transition to regression or a progression in the process of recovery, prompted by a return to the previous behavior of substance use, despite the intention to stay abstinent. A standardized definition and understanding of relapse not only minimize confusion, inconsistency, and social and self-stigma associated with the term but also helps provide relapse-sensitive care with accurate methods of assessment and evaluation.

Relationships Between Alexithymia and Psychopathy in Heroin Dependent Individuals

BACKGROUND

Psychopathy and substance use disorders are highly co-morbid and their co-occurrence is associated with higher severity of addictive behavior and increased risk of violent offending. Both substance use disorders and psychopathy are related to prominent impairments in emotion processing, which are also central features of alexithymia. The nature of the relationship between psychopathy and alexithymia is not well-understood and has been particularly understudied among substance dependent individuals.

AIM

Our goal was to evaluate the levels of psychopathy and alexithymia in a relatively homogeneous sample of heroin dependent individuals (HDIs) and healthy controls and to examine group differences in the pattern of associations between these constructs.

METHODS

We examined 62 participants (31 heroin dependent individuals and 31 healthy controls) with the Psychopathy Checklist: Screening version (PCL:SV, Hart et al., 1995) and the Toronto Alexithymia Scale-20 (TAS-20, Bagby et al., 1994).

RESULTS

Heroin dependent individuals were characterized by higher levels of both psychopathy and alexithymia as compared to the control group. In addition, HDIs with higher levels of psychopathy reported more difficulties in identifying and verbalizing emotional states. In the heroin group, alexithymia was more strongly associated with the impulsive/antisocial characteristics (impulsivity, irresponsibility, antisocial behavior) than with the interpersonal/affective features of psychopathy (grandiosity, manipulativeness, lack of empathy, and remorse).

CONCLUSION

Our findings suggest that alexithymia may be one potential mechanism linking psychopathy with opioid use disorders. The development of interventions targeting alexithymia could have significant applications in relapse prevention programs and psychotherapy of substance use disorders with concurrent psychopathy.

A Biopsychosocial Overview of the Opioid Crisis: Considering Nutrition and Gastrointestinal Health

The opioid crisis has reached epidemic proportions in the United States with rising overdose death rates. Identifying the underlying factors that contribute to addiction vulnerability may lead to more effective prevention strategies. Supply side environmental factors are a major contributing component. Psychosocial factors such as stress, trauma, and adverse childhood experiences have been linked to emotional pain leading to self-medication. Genetic and epigenetic factors associated with brain reward pathways and impulsivity are known predictors of addiction vulnerability. This review attempts to present a biopsychosocial approach that connects various social and biological theories related to the addiction crisis. The emerging role of nutrition therapy with an emphasis on gastrointestinal health in the treatment of opioid use disorder is presented. The biopsychosocial model integrates concepts from several disciplines, emphasizing multicausality rather than a reductionist approach. Potential solutions at multiple levels are presented, considering individual as well as population health. This single cohesive framework is based on the interdependency of the entire system, identifying risk and protective factors that may influence substance-seeking behavior. Nutrition should be included as one facet of a multidisciplinary approach toward improved recovery outcomes. Cross-disciplinary collaborative efforts, new ideas, and fiscal resources will be critical to address the epidemic.