The influence of drug class on reward in substance use disorders

In the United States, the societal costs associated with drug use surpass $500 billion annually. The rewarding and reinforcing properties that drive the use of these addictive substances are typically examined concerning the neurobiological effects responsible for their abuse potential. In this review, terms such as "abuse potential," "drug," and "addictive properties" are used due to their relevance to the methodological, theoretical, and conceptual framework for understanding the phenomenon of drug-taking behavior and the associated body of preclinical and clinical literature. The use of these terms is not intended to cast aspersions on individuals with substance use disorders (SUD). Understanding what motivates substance use has been a focus of SUD research for decades. Much of this corpus of work has focused on the shared effects of each drug class to increase dopaminergic transmission within the central reward pathways of the brain, or the "reward center." However, the precise influence of each drug class on dopamine signaling, and the extent thereof, differs considerably. Furthermore, the aforementioned substances have effects on several neurobiological targets that mediate and modulate their addictive properties. The current manuscript sought to review the influence of drug class on the rewarding effects of each of the major pharmacological classes of addictive drugs (i.e., psychostimulants, opioids, nicotine, alcohol, and cannabinoids). Our review suggests that even subtle differences in drug effects can result in significant variability in the subjective experience of the drug, altering rewarding and other reinforcing effects. Additionally, this review will argue that reward (i.e., the attractive and motivational property of a stimulus) alone is not sufficient to explain the abuse liability of these substances. Instead, abuse potential is best examined as a function of both positive and negative reinforcing drug effects (i.e., stimuli that the subject will work to attain and stimuli that the subject will work to end or avoid, respectively). Though reward is central to drug use, the factors that motivate and maintain drug taking are varied and complex, with much to be elucidated.

Learning curve of ultrasound-guided surgeon-administered transversus abdominis plane (UGSA-TAP) block on a porcine model

Background

Surgeons commonly perform ultrasound-guided Transversus Abdominis Plane blocks to manage acute pain following abdominal surgeries. There is no consensus on whether surgeons should undergo basic hands-on training to perform TAP blocks or if video-based learning is sufficient. We theorized that simulation-based learning is superior to video-based learning. In the present study, we present the analysis of technical skills of UGSA-TAP block performance on a live porcine model by general surgery trainees after undergoing video or simulation-based learning.

Methods

We performed a prospective, double-blinded, randomized study. Ten surgery residents and two surgery critical-care fellows (n = 12) without prior experience in performing the TAP block were recruited. The participants were randomized either into a video-based or simulation-based training group. After that, all participants performed a TAP block on a live anesthetized pig, which was recorded and scored by three blinded anesthesiologists. All participants completed a post-performance survey to assess their confidence in gaining competency in the UGSA-TAP block. Statistical analyses were performed to assess the differences between the two groups. P < 0.05 was considered statistically significant.

Results

All simulation-based learning participants successfully performed a survey scan, identified the three muscular layers of the abdominal wall, and identified the transversus abdominis plane compared to 50 %, 50 %, and 33 % video-based learning group participants for the respective parameters (p < 0.05). While some performance metrics showed no statistically significant differences between the groups, substantial effect sizes (Cohen's ℎ up to 1.07) highlighted notable differences in participants' performance. Both groups exhibited confidence in core competencies, with varied rates of satisfactory skill execution. Performance assessed using a global rating scale revealed a higher passing rate for the simulation group (83 % vs. 33 %). Participant feedback via the Likert scale reflected confidence post-training. Inter-rater reliability (0.83-1) confirmed the robustness of study evaluations.

Conclusion

The UGSA-TAP block curriculum should be introduced into the surgical residency programs with an emphasis on simulation-based learning to enhance the procedural skills of the trainees before transitioning to surgical patients.

Availability of substance use disorder treatment in Spanish: Associations with state-level proportions of Spanish speakers and treatment facility characteristics in the United States

BACKGROUND AND OBJECTIVES

Spanish is the second most spoken language in the United States. Not all substance use disorder (SUD) treatment facilities provide treatment in Spanish. This study examined factors associated with SUD treatment facilities having counselors that provide treatment in Spanish.

METHODS

State-level estimates of Spanish-speaking individuals were derived from the American Community Survey 2019. SUD treatment facility characteristics were captured from the National Survey of Substance Abuse Treatment Services 2020. We examined a sample of 15,246 facilities which included 12,798 outpatient, 3554 nonhospital residential, and 1106 with both outpatient and residential programs. Binary logistic regression models were used to observe state-level proportions of Spanish speakers and facility-level characteristics as factors associated with a facility having counselors that provide treatment in Spanish.

RESULTS

Approximately 23.3% of facilities had counselors able to provide treatment in Spanish. Among outpatient or nonhospital residential SUD facilities, those in a state with a larger proportion of Spanish-speaking individuals, facilities with pay assistance, facilities that accept Medicaid, and facilities that engage in community outreach had higher odds of having counselors that provide treatment in Spanish.

CONCLUSIONS

Considering that less than a quarter of facilities provide treatment in Spanish, increasing the availability of linguistically appropriate and culturally responsive services for SUD is imperative.

SCIENTIFIC SIGNIFICANCE

This national study is the first of its kind to examine associations between estimates of Spanish speakers and treatment facility characteristics associated with counselors that provide treatment in Spanish in outpatient and nonhospital residential SUD treatment.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Toward Precision Medicine in Atopic Dermatitis Using Molecular-Based Approaches

Atopic dermatitis is the most common chronic inflammatory skin disorder, affecting up to 20% of children and 10% of adults in developed countries. The pathophysiology of atopic dermatitis is complex and involves a strong genetic predisposition and T-cell driven inflammation. Although our understanding of the pathology and drivers of this disease has improved in recent years, there are still knowledge gaps in the immune pathways involved. Therefore, advances in new omics technologies in atopic dermatitis will play a key role in understanding the pathogenesis of this burden disease and could develop preventive strategies and personalized treatment strategies. In this review, we discuss the latest developments in genetics, transcriptomics, epigenomics, proteomics, and metagenomics and understand how integrating multiple omics datasets will identify potential biomarkers and uncover nets of associations between several molecular levels.

Toward Precision Medicine in Atopic Dermatitis Using Molecular-Based Approaches

Atopic dermatitis is the most common chronic inflammatory skin disorder, affecting up to 20% of children and 10% of adults in developed countries. The pathophysiology of atopic dermatitis is complex and involves a strong genetic predisposition and T-cell driven inflammation. Although our understanding of the pathology and drivers of this disease has improved in recent years, there are still knowledge gaps in the immune pathways involved. Therefore, advances in new omics technologies in atopic dermatitis will play a key role in understanding the pathogenesis of this burden disease and could develop preventive strategies and personalized treatment strategies. In this review, we discuss the latest developments in genetics, transcriptomics, epigenomics, proteomics, and metagenomics and understand how integrating multiple omics datasets will identify potential biomarkers and uncover nets of associations between several molecular levels.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

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.

Resilience Phenotypes and Psychological Functioning among Individuals with Opioid Use Disorder

BACKGROUND

Opioid use disorder (OUD) is a heterogeneous disorder. However, there is a lack of deep phenotyping investigations focusing on important psychological constructs such as resilience that may impact OUD. The present study aimed to investigate the relationship between trait resilience and the five-factor model of personality (FFM) among individuals with opioid use disorder (OUD). We also explored whether the FFM and trait resilience form specific phenotypes associated with psychological functioning.

METHODS

This secondary analysis of an epigenetic study included participants of African ancestry (n = 72), an understudied population, who met DSM-5 criteria for OUD. Participants completed measures to assess personality traits, trait resilience, current and previous drug use, and psychological functioning (depression, anxiety, and stress).

RESULTS

Linear regression revealed a significant relationship between resilience (CD-RISC-25 score) and the FFM, R2 = 0.56, F(5,62) = 15.7, p<.001. Further, a two-cluster classification emerged as the optimal solution from the cluster analysis. Cluster 1 (n = 33, 45.8% of the sample) showed lower resilience (CD-RISC-25 score: M = 58.6, SD = 11.2) compared to Cluster 2 (n = 35, 48.6%; CD-RISC-25 score: M = 76.1, SD = 11.9). The "High-Resilience Cluster" (Cluster 2) was characterized by higher FFM traits of: Extraversion, Openness, Agreeableness, and Conscientiousness, and lower Neuroticism versus Cluster 1. Multivariate analysis of variance revealed statistically significant differences between the two resilience clusters concerning other psychological symptoms, Λ = 0.732, F(4, 50) = 7.05, p < 0.003.

CONCLUSIONS

These findings suggest associations between the FFM and trait resilience among individuals with OUD. Two distinct "resilience phenotypes" emerged, with high-resilience individuals displaying less stress, anxiety, and depressive symptoms. Results highlight the clinical importance of resilience as a potential target for intervention in people with OUD.

Development and Validation of a Protective Behavioral Strategies Scale for Individuals who use Opioids: Preliminary Findings and Future Directions

Background

Protective Behavioral Strategies (PBS) are individually implemented harm reduction (HR) strategies to reduce the frequency or severity of risks associated with drug use. Existing scales measuring PBS for alcohol and cannabis suggest PBS are associated with reductions in associated problems. Despite many HR strategies related to opioid use, no PBS scale has been developed in the context of opioid use. To address this gap, this study aimed to test and validate a PBS scale for individuals using opioids (PBSO).

Methods

An online survey utilized a 32-item PBS scale for individuals endorsing recent opioid use, and measured opioid use frequency, HR service use, and experience of opioid overdose. PBSO items were rated on a Likert scale ranging from "never" (0) to "always" (6), and an exploratory factor analysis (EFA) examined factor structure.

Results

In the current sample (n=499; 32% female), EFA suggested a 3-factor structure among the 28 items retained, accounting for 51% of total variance. Factor 1 reflected health-service seeking, Factor 2 reflected individually-implemented and dose-reduction strategies, Factor 3 reflected social strategies, and Factor 4 reflected strategies related to injection drug use. Endorsement of PBSO items were slightly above "occasional" (3). PBSO use appeared positively related to past-month HR service utilization and negatively related to opioid use frequency.

Conclusions

Findings provide preliminary support for the PBSO scale as a valid and reliable measure. Further work is needed to test this scale in larger samples, and future work should explore the association between PBSO and relevant health outcomes, and whether factor scores differentially impact these outcomes.

A pilot study examining the relationship between chronic heroin use and telomere length among individuals of African ancestry

BACKGROUND

Prior research has suggested a possible link between heroin use and shortened telomere length (TL), a marker of cellular aging and genomic stability. We sought to replicate these findings by examining the relationship between TL and heroin use among individuals of African ancestry.

METHODS

This cross-sectional study examined TL among 57 participants [17.5 % female; mean age 48.0 (±6.80) years] of African ancestry with Opioid Use Disorder (OUD) and a mean heroin use duration of 18.2 (±10.7) years. Quantitative polymerase chain reaction (qPCR) was used to calculate TL as the ratio between telomere repeat copy number (T) and a single-copy gene, copy number (S). The primary dependent variable was TL (T/S Ratio) measured in kilobase pairs. Covariates included heroin use years and personality traits. Using a hybrid approach, multiple linear regression and Bayesian linear regression examined the association of chronological age, heroin use years and personality traits with TL.

RESULTS

The multiple linear regression model fit the data well, R2 = 0.265, F(7,49) = 2.53, p < .026. Chronological age (β = -0.36, p = .017), neuroticism (β = 0.46, p = .044), and conscientiousness (β = 0.52, p = .040) were significant predictors of TL. Bayesian linear regression provided moderate support for the alternate hypothesis that chronological age and TL are associated, BF10 = 5.77, R2 = 0.120. The posterior summary of the coefficient was M = 0.719 (SD = 0.278, 95 % credible interval [-1.28, -0.163]).

CONCLUSIONS

Contrary to prior studies, these findings suggest that heroin use duration may not be significantly associated with TL among individuals of African ancestry, highlighting the need for more rigorous research to elucidate the complexity of this relationship.

No evidence of accelerated epigenetic aging among black heroin users: A case vs control analysis

This study sought to assess the association between illicit opioid use and accelerated epigenetic aging (A.K.A. DNAm Age) among people of African ancestry who use heroin. DNA was obtained from participants with opioid use disorder (OUD) who confirmed heroin as their primary drug of choice. Clinical inventories of drug use included: the Addiction Severity Index (ASI) Drug-Composite Score (range: 0-1), and Drug Abuse Screening Test (DAST-10; range: 0-10). A control group of participants of African ancestry who did not use heroin was recruited and matched to heroin users on sex, age, socioeconomic level, and smoking status. Methylation data were assessed in an epigenetic clock to determined and compare Epigenetic Age to Chronological Age (i.e., age acceleration or deceleration). Data were obtained from 32 controls [mean age 36.3 (±7.5) years] and 64 heroin users [mean age 48.1 (±6.6) years]. The experimental group used heroin for an average of 18.1 (±10.6) years, reported use of 6.4 (±6.1) bags of heroin/day, with a mean DAST-10 score of 7.0 (±2.6) and ASI Score of 0.33 (±0.19). Mean age acceleration for heroin users [+0.56 (± 9.5) years] was significantly (p< 0.05) lower than controls [+5.19 (± 9.1) years]. This study did not find evidence that heroin use causes epigenetic age acceleration.

Immunotherapeutic strategies for treating opioid use disorder and overdose

INTRODUCTION

Development and implementation of effective treatments for opioid use disorder (OUD) and prevention of overdose are urgent public health needs. Though existing medications for OUD (MOUD) are effective, barriers to initiation and retention in treatment persist. Therefore, development of novel treatments, especially those may complement existing treatments, is needed.

AREAS COVERED

This review provides an overview of vaccines for substance use disorders (SUD) and mechanisms underlying their function and efficacy. Next, we focus on existing preclinical and clinical trials of SUD vaccines. We focus briefly on related strategies before providing an expert opinion on prior, current, and future work on vaccines for OUD. We included published findings from preclinical and clinical trials found on PubMed and ScienceDirect as well as ongoing or initiated trials listed on ClinicalTrials.gov.

EXPERT OPINION

The present opioid overdose and OUD crises necessitate urgent development and implementation of effective treatments, especially those that offer protection from overdose and can serve as adjuvants to existing medications. Promising preclinical trial results paired with careful efforts to develop vaccines that account for prior SUD vaccine shortcomings offer hope for current and future clinical trials of opioid vaccines. Clinical advantages of opioid vaccines appear to outnumber disadvantages, which may result in improved treatment options.

The subjective experience of heroin effects among individuals with chronic opioid use: Revisiting reinforcement in an exploratory study

Aims

Consistent with the opponent process theory individuals with chronic opioid use should predominantly endorse the avoidance of aversive negative emotional and/or physiological states as the motivation for continued opioid use (source of reinforcement: reductions in negative states). The primary aim of this study was to explore whether this view is supported by the subjective effects of heroin reported by individuals with opioid use disorder (OUD).

Methods

Responses during in-person interviews of participants to the question "What do you like about heroin? " were categorized as positive, negative, or mixed (positive and negative) reinforcement. In addition, we examined differences between these "reinforcement groups" in sociodemographic and clinical variables.

Results

Participants (N = 307) with OUD were predominantly male (78.1%), with chronic heroin use (M = 15.8 years, SD = 11.5), and 46.1% currently used heroin and were not enrolled in treatment. Agreement between two raters concerning the categorization of participant-reported effects of heroin into reinforcement categories was high, κ= 0.924, p < .0005. Approximately half (49.8%) of participant-reported effects of heroin were categorized as attributable to positive reinforcement. About one-fourth (22.8%) were categorized as negative reinforcement and 9.0% as "mixed ". There were no statistically significant differences between the three reinforcement groups in any of the socio-demographic variables, duration of heroin use, or treatment status/interest.

Conclusions

The results of this study indicate marked heterogeneity of heroin effects experienced by individuals with OUD and their source of reinforcement, respectively. Better integration of how individuals construe their drug use is important to understand the psychological-and neurobiological-processes in the development and maintenance of OUD.

A randomized clinical trial of the effects of brief versus extended opioid overdose education on naloxone utilization outcomes by individuals with opioid use disorder

BACKGROUND

Overdose education and naloxone distribution (OEND) trains people who use opioids (PWUO) in how to intervene in cases of opioid overdose but best practices have not been assessed empirically.

METHODS

PWUO along with a significant other (SO) were randomized to one of three training conditions. In the Treatment-as-Usual (TAU) condition, participants were randomized to receive minimal overdose-related education. In the extended training (ET) condition, PWUO received an extended training, while their SO received no overdose training. In the final condition, both the participant and SO received the extended overdose training (ETwSO). Outcome measures were naloxone use and overdose knowledge and competency assessed immediately before and after training, and at 1-, 3-, 6-, and 12-month timepoints following training.

RESULTS

Three hundred and twenty-one PWUO (w/ a SO) were randomized. All intensities of OD training were associated with sustained increases in OD knowledge/ competency (versus pre-training baseline p's < 0.01). PWUO intervened in 166 ODs. The 12-month incidence of naloxone use did not significantly differ between groups. Extended training (ET + ETwSO) compared to TAU resulted in significantly greater naloxone utilization by: 30 days (10.1% vs 4.1%, p = 0.041), 60 days (16.4% vs 5.2%, p<0.001) and 90 days (17.9% vs 9.5%, p = 0.039).

CONCLUSIONS

All intensities of OD training were associated with sustained increases in OD knowledge and competency, and equivalent rates of successful naloxone use. More extensive training increased naloxone utilization during the first 3 months. However, the benefits of more comprehensive training should be balanced against feasibility.

The effects of acute oral naltrexone pretreatment on the abuse potential of intranasal methamphetamine, and the relationship between reward/punishment sensitivity and methamphetamine's effects

One potential medication for treating methamphetamine use disorder is the opioid antagonist naltrexone (NLTX). Despite encouraging preclinical findings, the results of clinical studies have been mixed. The primary aim of the current trial was to examine the effects of acute NLTX pretreatment on the subjective and reinforcing effects of intranasal methamphetamine. Nonmedical psychostimulant users completed outpatient testing sessions in which they received oral placebo (0 mg) or NLTX (50 mg) before intranasal methamphetamine (30 mg/70 kg). Primary outcome measures were peak positive subjective effects (e.g. drug 'Liking') assessed on a visual analog scale (0-100), and methamphetamine self-administration using an operant self-administration task. Participants also completed a probabilistic categorization task to assess reward and punishment learning sensitivity. Complete data were available from 13 male and 1 transgender (male-to-female) participant (age: 33.4 ± 7.6 years). Intranasal methamphetamine significantly increased subjective ratings of drug 'Liking', 'Good Effect' and 'High' from baseline (P's < 0.01), but did not significantly vary as a function of placebo or NLTX pretreatment. Similarly, methamphetamine self-administration did not vary between the placebo and NLTX pretreatment conditions. This sample did not demonstrate a significant 'bias' in learning from positive and negative outcomes (i.e. reward and punishment sensitivity), and reward/punishment sensitivity was not correlated with the effects of methamphetamine or the effects of NLTX on methamphetamine. The current study argues against the use of NLTX as a stand-alone medication for treating methamphetamine use disorder.

Patient Engagement With a Game-Based Digital Therapeutic for the Treatment of Opioid Use Disorder: Protocol for a Randomized Controlled Open-Label, Decentralized Trial

BACKGROUND

Prescription digital therapeutics are software-based disease treatments that are regulated by the US Food and Drug Administration; the reSET-O prescription digital therapeutic was authorized in 2018 and delivers behavioral treatment for individuals receiving buprenorphine for opioid use disorder. Although reSET-O improves outcomes for individuals with opioid use disorder, most of the therapeutic content is delivered as narrative text. PEAR-008 is an investigational device based on reSET-O that uses an interactive, game-based platform to deliver similar therapeutic content designed to enhance patient engagement, which may further improve treatment outcomes.

OBJECTIVE

We aim to investigate how participants interact with the prescription digital therapeutic's new content delivery format. Secondary objectives include evaluating treatment success, symptoms of co-occurring mental health disorders, recovery capital, and skill development.

METHODS

Due to the COVID-19 pandemic, this study was redesigned using a decentralized model because it was not possible to conduct medication initiation and study visits in person, as initially intended. A decentralized, randomized controlled trial design will be utilized to compare patient engagement with PEAR-008 and that with reSET-O using both subjective and objective assessments. The study population will consist of approximately 130 individuals with opioid use disorder (based on Diagnostic and Statistical Manual of Mental Disorders 5 criteria) who have recently started buprenorphine treatment for opioid use disorder. Participants will be virtually recruited and randomly assigned to receive either PEAR-008 or reSET-O. All study sessions will be virtual, and the duration of the study is 12 weeks. The primary outcome measure of engagement is operationalized as the number of active sessions per week with either PEAR-008 or reSET-O. (An active session is any session that contains some active participation in the app, such as navigating to a different screen, engaging with a learning module, or responding to a notification.) Subjective dimensions of engagement will be assessed with participant surveys. The hypothesis is that PEAR-008 will have significantly greater participant engagement than reSET-O.

RESULTS

As of February 2021, participant enrollment is ongoing.

CONCLUSIONS

This randomized controlled trial will investigate if changing the delivery format and enhancing the content of a prescription digital therapeutic for opioid use disorder will affect how participants use and interact with the prescription digital therapeutic. The study design may serve as a useful model for conducting decentralized studies in this patient population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04542642; https://clinicaltrials.gov/ct2/show/NCT04542642.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/32759.

Multi-informant Implementation and Intervention Outcomes of Opioid Overdose Education and Naloxone Distribution in New York City

Overdose Education and Naloxone Distribution (OEND) is an effective public health intervention to reduce opioid overdose fatalities (McDonald and Strang, Addiction 111:1177-1187, 2016). However, we know little about OEND implementation outcomes (i.e., indicators of implementation success), specifically the fidelity of training delivery, and how these may relate to intervention outcomes (i.e., indicators of the success or effectiveness of an intervention), such as overdose knowledge and attitudes. This study evaluated 16 OEND trainings conducted at different Opioid Overdose Prevention Programs in New York City. Trainees (N = 75) completed the Opioid Overdose Knowledge and Attitude Scales before and after training (intervention outcomes). Implementation outcomes were fidelity (competence and adherence of the trainer, N = 10; modified Fidelity Checklist) and acceptability of OEND (Acceptability of Intervention Measure), assessed from multiple perspectives (trainees, trainers, and an independent observer). Trainees' overdose knowledge, t(71) = - 8.12, p < 0.001, 95% CI [- 6.54, - 3.96], and attitudes, t(65) = - 6.85, p < 0.001, 95% CI [- 0.59, - 0.33], improved significantly from pre- to post-training. Stepwise multiple regression models indicated that adherence of the trainer rated from the observer perspective added significantly to the prediction of changes in overdose knowledge, F(1, 67) = 9.81, p = 0.003, and explained 13% of the variance in outcome. However, fidelity measures from the perspective of trainees or trainers and acceptability of OEND were not associated with changes in trainees' overdose knowledge or attitudes. OEND implementation outcomes and their relationship with intervention outcomes differed depending on the role of the fidelity rater in relation to the intervention. Specifically, our findings indicate that fidelity should be measured from an independent perspective (i.e., an individual who is experienced with fidelity rating but not directly involved in the intervention).

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43477-021-00021-4.

Emotional reactions of trained overdose responders who use opioids following intervention in an overdose event

Background: Our aim was to explore emotional reactions to intervening in an overdose event from the perspective of individuals who use opioids (peer responders). In addition, we were interested in the impact this experience may have on peer responders' feelings about helping in an overdose situation in the future. Methods: For this qualitative sub-study of a randomized controlled trial (RCT), data from 61 interviews were analyzed thematically using an inductive approach. Results: Peer responders had diverse emotional reactions to the overdose event. These ranged from a sense of pride and other positive feelings associated with their ability to help to ambivalence about being involved in situations perceived as challenging and burdensome. There were few reports of the overdose event as an exclusively negative experience. Many peer responders perceived it as their duty to use naloxone again if required. However, some had ambivalent feelings toward this responsibility, which may be related to negative experiences with previous intervention efforts. Conclusions: The capacity of people who use opioids to help reduce the harms associated with opioid overdose is experienced as empowering by some. Nonetheless, engaging peer responders in strategies to reduce opioid-related mortality should be coupled with appropriate resources to process their experiences and emotional responses.

AB0275 TOFACITINIB EFFECTIVENESS IN PATIENTS WITH RHEUMATOID ARTHRITIS AFTER CONVENTIONAL OR BIOLOGICAL THERAPY - IT REAL ROLE IN DIFFERENT LINES OF TREATMENT

Background:

rheumatoid arthritis (RA) is a chronic and disabling autoimmune disease, with a high clinical and economic burden. This implies the need to investigate therapies that maximize clinical results. Tofacitinib is recommended as a different alternative to biologic therapy when a patient remains with moderate or high disease activity after conventional DMARDs use, or as an option after failure to biologic therapy.

Objectives:

to evaluate the effectiveness of Tofacitinib in RA as first-line (after conventional DMARDs failure) or second-line treatment (after biologic therapy failure) in a real-life cohort of RA patients and its differences.

Methods:

this is a descriptive retrospective cohort study conducted at a specialized center for RA in Bogota, Colombia; databases from 2017 to 2019 were used to select and study patients with indication of Tofacitinib, regardless of their previous treatment or disease status. The indication and initiation of Tofacitinib (5 mg BID or 11 mg once daily) was an independent medical decision made as part of the individualized management of every patient. Effectiveness was evaluated in those patients who met the high adherence criteria (at least three visits with a rheumatologist per year), with no change or addition of other conventional DMARDs. Frequencies and proportions in baseline characteristics, differences in disease activity were calculated between the first and second line tofacitinib treatment. Comparisons of continuous variables data between the two patient groups were made using the t-test; the chi-square test and Fisher’s exact test were used for statistical analysis of categorical variables. Logistic regressions were performed to analyze related factors with therapeutic response outcomes.

Results:

we included 152 RA patients who received tofacitinib: first-line (T1) (n= 85, 55.9%) or second-line (T2) (n= 67, 44.1%). T1 first-line group was younger than the T2 second-line patients (53±12.8 years and 59±11.4 years, p-value 0.01) and they had a shorter disease duration than T2 patients (11.8 vs. 12.8 years, p-value 0.01). Comparative analysis of response to treatment showed a reduction in DAS28 at 3, 6 and 12 months in both study groups. The response in disease activity at 3 months was a major factor related to 6-month response (OR 13.4, 95% CI 4.5-39.4, p value 0.000), while non-response at 3 months were associated with no response at 6 months of follow-up. Baseline DAS28 was significantly associated with response at 12 months (OR 1.9, 95% CI 1.11-3.25, p-value 0.028). At 12 months of treatment, both groups showed disease response and control according to the DAS28 from baseline, but a higher proportion of T1 patients achieved remission (45% vs 23%). A subgroup analysis to evaluate T2 second-line Tofacitinib therapy showed no statistically significant differences in any response criteria according to the number of previously received biologicals.

Table 1.

Regression analysis (risk of response of the disease at 6 and 12 months of treatment with Tofacitinib)

FactorResponse at Month 6Response at Month 12*ORIC95%P valueORIC95%P valueAge1.000.97-1.030.7881.020.98-1.060.211Male1.820.65-5.080.2510.810.27-2.380.709Duration of RA0.990.94-1.040.9081.020.96-1.080.444Positive Rheumatoid Factor0.81026-2.560.7300.630.17-2.260.485Positive Anti-CCP0.340.068-1.60.189Initial DAS281.611.04-2.490.0331.91.11-3.250.018First line0.440.19-1.010.0541.470.56-3.830.423Treatment period1.120.80-1.550.4921.10.75-1.610.607Dose: 11 mg.0.950.42-2.130.9040.750.258-1.90.565Response at Month 313.424.57-39.40.0002.320.87-6.180.091

*Positive Anti-CCP at month 12 was omitted because of collinearity

Conclusion:

Tofacitinib is an effective treatment option for patients with RA after conventional DMARDs and in patients after biologic therapy failure, but maybe is better used it as a T1 first-line of treatment. Further studies are required to determine the real role of tofacitinib in different lines of RA treatment.

Disclosure of Interests:

Wilberto Rivero: None declared, Linda Ibata: None declared, Susan Martinez: None declared, Adriana Rojas-Villarraga: None declared, Pedro Santos-Moreno Speakers bureau: Pedro Santos-Moreno has received fees for conferences from: Abbvie, Biopas-UCB, Bristol, Janssen, Pfizer, Sanofi., Consultant of: Pedro Santos-Moreno has received fees for counseling and advisory boards from: Abbvie, Abbott, Biopas-UCB, Bristol, Janssen, Pfizer, Roche, Sanofi., Grant/research support from: Pedro Santos-Moreno has received research grants from: Abbvie, Abbott, Biopas-UCB, Bristol, Janssen, Pfizer, Roche, Sanofi.

AB0242 CERTOLIZUMAB IN MONOTHERAPY AS EFFECTIVE THAN IN COMBINATION IN RHEUMATOID ARTHRITIS PATIENTS

Background:

Tumour necrosis factor-a (TNFa) inhibitors are one of the most used biological therapy for rheumatoid arthritis (RA) patients without response to conventional disease-modifying antirheumatic drugs (cDMARDs). There is scarce information about biological DMARDs (bDMARDs) effectiveness as monotherapy in real life.

Objectives:

To assess the effectiveness of Certolizumab pegol in real-life clinical practice in a cohort of patients with RA and previous failure to cDMARDs who received certolizumab as monotherapy, combined with Methotrexate (MTX), combined with leflunomide (LFN), or both MTX and LFN.

Methods:

A retrospective cohort study was conducted at a specialized center for RA management in Colombia. Patients treated with Certolizumab as monotherapy or in combination with MTX, or LFN, or both MTX plus LFN, (2012 – 2020) were included. The indication of certolizumab was a independent decision based on disease activity. Patients could be taking adjuvant medications for pain and/or corticosteroids. Certolizumab was administered 400 mg SC monthly after three induction doses at weeks 0, 2 y 4, as monotherapy or in combination with MTX (until 25 mg/week), LFN (20 mg/day) or both as a first-line treatment after failure with cDMARDs or as a second-line treatment after failure with one or more bDMARDs. Effectiveness was assessed at three, six, and twelve months according to the change in DAS28. Exploratory comparisons of numeric variable data between groups were done (ANOVA). Chi-square test and Fisher’s exact test were used for categorical variables. Multivariate analyses (logistic regressions) were performed to analyse factors related to the response at 6 and 12 months.

Results:

Of 181 enrolled patients, 24 received certolizumab as monotherapy, 62 combined with MTX, 47 in combination with LFN and 48 in combination with MTX and LFN. 55.2% of patients were first-line treatment, without significant differences between groups. Mean age of subjects included was 57.87 ± 12.33 with a mean age of around 60 years in patients treated with CERTO+MTX and CERTO+LFN (p=0,014). Women predominated in all groups (84% of the total) (p=0,275). The duration of arthritis on average was 8.27 ± 8.73 years, without significant differences between treatment groups (p=0,871). In terms of disease activity, 78.5% of patients were in moderate or high disease activity, according to DAS28, without significant differences between the groups (p=0,787). Differences in the number of biologicals and corticoid use were observed, patients in the combination groups had used in a higher proportion two or more biological (p=0,046) than in the monotherapy group and had used corticosteroids (p=0,042) more frequently. Overall, there were decreased disease activity, at 3 and 6 months with no significant differences between groups (p=0,08). At 12 months of treatment, there was a higher maintenance in mild activity/remission response in monotherapy group compared to the others (p=0,01). In the multivariate analysis, no differences were observed in the response at 6 and 12 months between the treatment groups. The response at three months was the only variable associated with the 6-month response (OR 5.46; CI 95% 2.08 – 14.32). The response at three months (OR 4.04; CI 95% 1.28-12.69) and positive anti-CCP (OR 3.83; CI 95% 1.11-13.21) were associated with 12-month response.

Conclusion:

These exploratory results show a clear trend of Certolizumab being effective as monotherapy in patients previously treated with cDMARDs and even after being treated with one bDMARD. Although results are not statistically different, it seems that certolizumab in monotherapy could be as least as effective as combination therapy. Prospective studies with larger sample size and with a structured follow-up are needed to confirm these findings.

Disclosure of Interests:

Paola Osorio: None declared, Laura Villarreal: None declared, Wilberto Rivero: None declared, Linda Ibata: None declared, Susan Martinez: None declared, Adriana Rojas-Villarraga: None declared, Pedro Santos-Moreno Speakers bureau: has received fees for conferences from: Abbvie, Abbott, Biopas-UCB, Bristol, Janssen, Pfizer, Roche, Sanofi, Consultant of: has received fees for counseling, advisory boards from: Abbvie, Abbott, Biopas-UCB, Bristol, Janssen, Pfizer, Roche, Sanofi, Grant/research support from: has received fees for research grants from: Abbvie, Abbott, Biopas-UCB, Bristol, Janssen, Pfizer, Roche, Sanofi

Factor structure and psychometric properties of the Connor-Davidson resilience scale (CD-RISC) in individuals with opioid use disorder

AIMS

Resilience is defined as the capacity for an individual to maintain normal functioning and resist the development of psychiatric disorders in response to stress and trauma. Although previous investigators have acknowledged the important role of resilience in those with substance use disorders, this is the first study to investigate the reliability, validity, and factor structure of the Connor-Davidson Resilience Scale (CD-RISC-25) in a sample of individuals with opioid use disorder (OUD). Additionally, we explored the relationship between trait resilience and the severity of drug-related problems.

METHODS

Four hundred and three participants (22 % female) with OUD completed the CD-RISC-25, Beck Depression Inventory (BDI-II), and the self-report Addiction Severity Index (ASI). Confirmatory factor analysis (CFA) tested the originally proposed 5-factor solution of the CD-RISC-25.

RESULTS

CFA results indicated that a 5-factor model of the CD-RISC-25 performed somewhat better than the 1-factor solution. Pearson correlation revealed a negative association between CD-RISC-25 (M = 75.82, SD = 15.78) and ASI drug-use composite score (M = .25, SD=-0.16), r=-0.148, p<.01, and between CD-RISC-25 and BDI-II (M = 11.33, SD = 10.58), r=-.237, p<.001.

CONCLUSIONS

Albeit providing only limited support for the original 5-factor structure, our results indicate that the scale may be useful for screening individuals with OUD who have a vulnerability to stress. Consistent with prior studies, higher resilience was associated with lower depression symptoms and addiction severity, further demonstrating the CD-RISC-25 ability to predict psychiatric stability. To inform the development of more targeted interventions, future studies should examine resilience longitudinally, in addition to exploring more comprehensive approaches to measuring resilience.

"Optimization of Surgical Resident Safety and Education During the COVID-19 Pandemic - Lessons Learned"

The COVID-19 pandemic has engendered rapid and significant changes in patient care. Within the realm of surgical training, the resultant reduction in clinical exposure and case volume jeopardizes the quality of surgical training. Thus, our general surgery residency program proceeded to develop a tailored approach to training that mitigates impact on resident surgical education and optimizes clinical exposure without compromising safety. Residents were engaged directly in planning efforts to craft a response to the pandemic. Following the elimination of elective cases, the in-house resident complement was effectively decreased to reduce unnecessary exposure, with a back-up pool to address unanticipated absences and needs. Personal protective equipment availability and supply, the greatest concern to residents, has remained adequate, while being utilized according to current guidelines. Interested residents were given the opportunity to work in designated COVID ICUs on a volunteer basis. With the decrease in operative volume and clinical duties, we shifted our educational focus to an intensive didactic schedule using a teleconferencing platform and targeted areas of weakness on prior in-service exams. We also highlighted critical COVID-19 literature in a weekly journal club to better understand this novel disease and its effect on surgical practice. The long-term impact of the COVID-19 pandemic on resident education remains to be seen. Success may be achieved with commitment to constant needs assessment in the changing landscape of healthcare with the goal of producing a skilled surgical workforce for public service.

The Increasing Prevalence of Fentanyl: A Urinalysis-Based Study Among Individuals With Opioid Use Disorder in New York City

BACKGROUND AND OBJECTIVES

Opioid-related overdose deaths in North America have increased drastically, partially due to the increased prevalence of illicitly manufactured fentanyl. The current study sought to assess the prevalence and intentionality of fentanyl use among individuals with opioid use disorder (OUD).

METHODS

For this secondary analysis (study 1) we screened a total of 1118 urine samples from 316 participants with OUD from 2016 to 2019. Fentanyl knowledge and intentionality of use were assessed in a separate OUD sample (study 2; N = 33).

RESULTS

In study 1, 34.6% of all urine samples tested positive for fentanyl. Overall, 149 (47.2%) participants provided more than or equal to one urine sample that tested fentanyl-positive, and 93 (29.4%) provided more than or equal to two fentanyl-positive samples. The number of fentanyl-positive samples, relative to the number of samples tested each year, increased by 330% from year 1 to 3. Study 2 found all participants had pre-existing knowledge that drugs may be adulterated with fentanyl, yet 67% were surprised by their own fentanyl-positive test result.

DISCUSSION AND CONCLUSIONS

Like previous studies, our data indicate the high prevalence of fentanyl exposure and low perception of fentanyl-related risk among individuals with OUD, respectively, suggesting that opioid overdose harm reduction efforts may need to focus more on drug users' understanding of risks related to fentanyl use and adulteration of drugs.

SCIENTIFIC SIGNIFICANCE

The current studies provide longitudinal data on fentanyl exposure prevalence and risk perception that is uniquely granular by assessing OUD treatment status, and by identifying potential associations between fentanyl exposure with the presence of other drug use and nonfatal overdose. (Am J Addict 2021;30:65-71).

Comparative ecotoxicity of single and binary mixtures exposures of cadmium and nickel on growth and biomarkers of Lemna gibba

The aim of the present study was to investigate the toxicity effects of cadmium-nickel (Cd-Ni) after single and mixtures exposures over the macrophyte Lemna gibba. Effects were assessed on growth, as frond number and fresh weight and biochemical parameters, such as total protein content and activity of antioxidant enzymes. Plants were exposed to single Cd and Ni in concentrations that ranged between 0.13-33 mg/L and 0.18 and 11.82 mg/L, respectively. For binary mixtures, individual metal IC50 values were used for selection of the evaluated concentrations. The experimental design consisted in three different ratios based on the concept of toxic units (TU), each ratio was evaluated by five different concentrations. Both single and mixture treatments were performed for 7 days following the conditions according to OECD (2006). Single and mixture exposures affected plant growth and the biomarkers of the antioxidant response. Growth parameters showed a differential sensitivity after individual metal exposures. Cd was more toxic for L. gibba plants when fresh weight was considered, but on the contrary, considering frond number, Ni was the most toxic metal. IC50-7d, based on growth rate calculated on frond number were 17.8 and 2.47 mg/L, and on fresh weight were 1.08 and 3.89 mg/L, for Cd and Ni respectively. LOEC values for Cd were obtained at 2.06 and 1.03 mg/L, for frond number and fresh weight, respectively; while for Ni, these values were 0.92 and 11.82 mg/L. The three evaluated ratios for binary mixtures resulted in a high toxicity considering the same response variables in single metal exposures. Ratio 1 (2/3 TU Cd-1/3 TU Ni) was the most toxic considering both frond number and fresh weight, showing percentage inhibition of growth rates of 96 and 90%, respectively for the highest concentration. A modification of the protein content was observed in single, but especially in the mixture treatments. The activity of catalase (CAT; EC 1.11.1.6), ascorbate peroxidase (APOX; EC 1.11.1.11) and guaiacol peroxidase (GPOX; EC 1.11.1.7) was also affected in single and mixtures assays. APOX and GPOX showed a higher increase of its activities respect the controls after mixture treatments than for single metal treatments. Such optimization of the antioxidant system could be one of the causes of the antagonistic toxicity observed in mixture exposures. Concentration addition (CA) reference model, based on frond number, in Cd-Ni mixtures was not a good predictor to evaluate toxicity from dissolved metal concentration since the results showed that toxicity was less than additive, with an average of ΣTU = 2.17. The observed antagonisms resulted to be stronger in mixtures with higher metal concentrations.

The acute and repeated effects of cigarette smoking and smoking-related cues on impulsivity

INTRODUCTION AND AIMS

Impulsivity may be a risk factor that increases vulnerability to nicotine dependence. However, nicotine exposure itself may directly increase impulsivity. This is a secondary analysis of the first study in a controlled laboratory setting, which assessed the effects of nicotine administration (acute and repeated) and exposure to smoking cues on behavioural impulsivity in humans (ClinicalTrials.gov Identifier: NCT01395797).

DESIGN AND METHODS

Twenty-seven smokers completed three tasks to assess behavioural impulsivity (the Immediate Memory Task and the Delayed Memory Task assessing response initiation, and the GoStop Task assessing response inhibition) following: (i) 4 days of cigarette smoking (nicotinised or denicotinised cigarette); (ii) acute cigarette smoking (nicotinised); and (iii) exposure to smoking-related cues.

RESULTS

Four days of nicotinised cigarette smoking (vs. denicotinised) did not significantly increase Immediate Memory Task, Delayed Memory Task and GoStop scores. However, acute cigarette smoking increased GoStop impulsivity, but only following 4 days of smoking nicotinised cigarettes (P < 0.05). Exposure to smoking-related cues had no statistically significant effect on impulsivity.

DISCUSSION AND CONCLUSIONS

Our results suggest that repeated nicotine exposure may sensitise subsequent acute nicotine effects on behavioural impulsivity in heavy smokers.

Photodynamic therapy (PDT) in non-surgical treatment of periodontitis

Periodontitis represents a major problem for patients, since it is not possible to eliminate the bacteria that are responsible for this pathology with a pharmacological treatment. The present study included forty-four patients with periodontitis, who had undergone disinfection via photodynamic therapy (PDT) using a laser source having a 635 nm wavelength associated with a photoactivable substance (methylene blue). Clinical assessment of plaque index (PI), bleeding on probing (BOP), probing depth (PD), calculus index (CI), gingival recession (REC) and clinical attachment level (CAL) were recorded at base line, 1 month (4 weeks) after treatment and again 3 months (12 weeks) after treatment, while site radiography (RX) and microbiological test (MT) were recorded at base line and 3 months (12 weeks) after treatment. The outcomes show a good efficacy of the PDT in the elimination of the periodontal pathogenic microflora and in the improvement of the clinical parameters considered: from the base line to the final check after 12 weeks it has been observed a reduction in REC of about 16.9%, a reduction of CAL of about 17.85%, a reduction of the BoP of about 93.3%, a reduction of the PD of about 17%, a reduction of the CI of about 66.3%, a reduction of PI of about 44%, and microbiologically a reduction of the total amount of bacteria with proven parodontopathic properties (red complex bacteria) of about 58.74%. Within the limits of the present study, PDT can be reasonably considered as a good carrier that leads to significant improvements in the parameters (clinical and microbiological) considered.

Comparative ecotoxicity of single and binary mixtures exposures of cadmium and zinc on growth and biomarkers of Lemna gibba

In the present study, single and mixture effects of cadmium (Cd) and zinc (Zn) on Lemna gibba were analyzed and compared using growth parameters, based on frond number and fresh weight, and biochemical parameters, such as pigment, protein content and activity of antioxidant enzymes. Plants were exposed for 7 days to these metals in nutrient solution. Single and mixture exposures affected plant growth and the biomarkers of the antioxidant response. Considering the growth parameters, Cd was found to be much more toxic than Zn. IC50-7d, based on growth rate calculated on frond number, were 17.8 and 76.73 mg/L, and on fresh weight were 1.08 and 76.93 mg/L, for Cd and Zn respectively. For Cd, LOEC values were obtained at 2.06 and 1.03 mg/L, for frond number and fresh weight respectively; while for Zn, at 20.1 and 74.6 mg/L. A high toxicity effect, considering the same response variables, was observed in plants exposed to the mixtures. Three fixed ratios, based on toxic units (TU) were assayed, ratio 1: 2/3 Cd-1/3 Zn, ratio 2: 1/2 Cd-1/2 Zn and ratio 3: 1/3 Cd-2/3 Zn. Ratio 3 (where Zn was added in higher proportion) was the less toxic. All concentrations of Ratio 1 and 2 significantly inhibited plant growth, showing a 100% inhibition of growth rate at the highest concentrations when based on frond number. Catalase (CAT; EC 1.11.1.6), ascorbate peroxidase (APOX; EC 1.11.1.11) and guaiacol peroxidase (GPOX; EC 1.11.1.7) activities in single metals assays were higher than controls. In mixture tests, the activity of APOX and GPOX was significantly stimulated in plants exposed to all evaluated combinations, while CAT was mainly stimulated in Ratio 3. It was observed that the activity of the enzymes was increased in the mixtures compared with similar concentrations evaluated individually. APOX activity was observed to fit the CA model and following a concentration-response pattern. The response of this antioxidant enzyme could serve as a sensitive stressor biomarker for Cd-Zn interactions. Frond number in Cd-Zn mixtures was not well predicted from dissolved metal concentration in solution using concentration addition (CA) as reference model, as results showed that toxicity was more than additive, with an average of ΣTU = 0.75. This synergistic effect was observed up to 50 mg Zn/L in the mixture, but when it was present in higher concentrations a less than additive effect was observed, indicating a protective effect of Zn. A synergistic and dose-ratio deviations from CA model were also observed.

A randomized, double-blind, placebo-controlled study of the kappa opioid receptor antagonist, CERC-501, in a human laboratory model of smoking behavior

Preclinical data indicate that selective kappa opioid receptor antagonists reduce nicotine self-administration and withdrawal symptoms. The aim of the current study was to determine whether treatment with CERC-501, an orally available, potent, and selective kappa opioid receptor antagonist, could alleviate nicotine withdrawal and craving and mitigate mood alterations associated with nicotine withdrawal in humans. Healthy, adult cigarette smokers were enrolled into this randomized, multisite, double-blind, placebo-controlled, crossover study. Participants completed two 8-day treatment phases during which they received either CERC-501 (15 mg, p.o., once daily) or placebo. On the seventh day of each dosing phase, participants were admitted as inpatients for an 18-hour cigarette abstinence period followed by experimental testing. The primary outcome measures were (a) performance on the McKee Smoking Lapse test (ie, latency to smoke in exchange for money) and (b) number of cigarettes self-administered during a 60-minute ad lib smoking period. Other outcomes included measures of craving, mood, anxiety, nicotine withdrawal, and subjective effects of cigarette smoking. A total of 71 participants who smoked an average of approximately 23 cigarettes per day were enrolled, and 56 subjects completed the study. CERC-501 was well tolerated, but it did not significantly alter the latency to start smoking (CERC-501: 16.5 min vs placebo: 17.7 min) or the number of cigarettes smoked (CERC-501: 3.3 cigarettes vs placebo: 3.1 cigarettes). Compared with placebo, CERC-501 also did not affect cigarette craving, mood, anxiety, nicotine withdrawal, or subjective effects of smoking. These findings do not support a role for CERC-501 in the treatment of nicotine use disorder.

0683 CPAP Adherence Relative To Sleep Duration And Sleep Period In Different Study Populations

Introduction

CPAP is intended for use during sleep to alleviate disordered breathing. Most patients who use CPAP do so for only a portion of their sleep period, although anecdotally it is known that some also use CPAP while awake. We compared the unusually high levels of CPAP adherence found in a recent study of patients with Overlap Syndrome to a VA clinical population and to participants from the APPLES study.

Methods

CPAP adherence levels were taken from three sources: (1) The O2VERLAP Study, a large comparative effectiveness trial that used two different methods of providing information and support to current CPAP users diagnosed with both OSA and COPD. (2) Combined data from the four most recent clinical CPAP trials conducted at VA San Diego Healthcare System. (3) The APPLES study. Total sample sizes were 332, 957, and 405, respectively. Total sleep time (TST) and total sleep period (TSP) were assessed via the Pittsburgh Sleep Quality Index (PSQI) for (1) and (2) and via polysomnography for (3).

Results

Mean CPAP use, TST, and TSP for each source were: (1) 6.7, 6.8, & 8.1; (2) 4.0, 6.1, & 7.5; (3) 4.5, 6.6, & 8.0. We examined the ratios of adherence over either TST or TSP, and the ratios for each source were: (1) 98% & 83%; (2) 66% & 55%; (3) 68% & 56%.

Conclusion

This comparison demonstrates that unlike many CPAP users who tend to use therapy for only a fraction of time spent asleep, patients with COPD and OSA exhibit higher levels of adherence which often exceed sleep time and may be obtaining additional benefits from CPAP use during non-sleep periods. More research is needed both to improve CPAP delivery and support for patients who are using CPAP sub optimally and to understand the factors that account for the heightened levels of CPAP adherence in COPD.

Support

PPRND #1507-31666; IIR 02-275; IIR 07-163; IIR 12-069; PULM-028-12F.

0995 Nightcap For School-nights: Association Between Milk Intake And Sleep Duration In First-graders

Introduction

Insufficient sleep has been identified as an obesity risk factor due to mechanistic pathways contributing to higher carbohydrate intake, including in children. Dietary intake of macronutrients, such as fats and protein found in milk, may serve as a modifiable risk factor for adequate sleep. We hypothesize that milk intake among a sample of urban first-graders may be associated with sleep duration.

Methods

Cross-sectional analysis of parent reports of an adapted version of the Child Sleep Health Questionnaire (CSHQ) and Block Dietary Data Systems Food Frequency Questionnaire (FFQ) were analyzed among a sample of 837 Black children in Brooklyn, New York. Summary scores were created for milk type. Milk intake was classified by fat content: whole milk and 2% categorized as high-fat, and 1% and skim as low-fat. Independent t-test, correlations and regression analysis to identify associations between parent reports of child’s sleep duration and milk intake were conducted.

Results

On average, children were 7.3 + 0.6 years old and 52% female. Nearly 57% of parents were immigrants. Children’s mean BMI was 17.27, approximately at the 85th BMI percentile according to CDC index-for-age percentiles. On average, FFQ data reported children consumed high-fat milk 6 days a week. Linear variable regression analysis between high-fat milk intake and sufficient sleep were significant (β =, 0.090, p &lt; 0.05). BMI was significantly associated with high-fat milk intake (β= 0.17, p&lt;0.05). However, high-fat milk intake was not significantly associated with (in)sufficient sleep, after controlling for BMI, sex and age. No difference was reported between immigrant parents and U.S. born parents.

Conclusion

Plausibly, high-fat milk is contributing to satiety and longer sleep duration. Future studies should include more comprehensive measurement of milk consumption (i.e. time of day and volume) to consider possible effects on children’s sleep. Actigraphy measures and sleep diaries should also be considered.

Support

Bezos Grant and Community Service Plan grant.

0238 Campus Food Pantry Assistance is Related to Better Physical And Mental Health Through Adequate Sleep Among College Students in a Public University System

Introduction

Food insecurity is an issue among students in higher education and has been linked to insufficient sleep, and poor mental and general health. College campuses have quickly responded by establishing campus food pantries. However, the extent to which campus food pantries are ameliorating the impacts of food insecurity is unknown.

Methods

Online survey data were collected from a cross-sectional sample of 1,855 students who were food pantry users in the 10-campus UC system. Students were asked to report their number of visits to a food pantry in the past month, and to rate their general health, depressive symptoms, and number of days of enough sleep (in a week) before and after food pantry access. Changes in days of enough sleep, depressive symptoms and general health were computed. Demographic characteristics were obtained from institutional data. Path analysis was used to examine direct and indirect pathways from food pantry use to depressive symptoms and general health through enough sleep days, controlling for workstudy receipt, Pell grant receipt and family income.

Results

Students on average were 21.7 years old (SD= 3.5), and had more days of adequate sleep (25%), and improved depressive symptoms (43%) and general health (31%) after obtaining services from a campus food pantry. An increase in monthly food pantry use was directly related to a decrease in depressive symptoms (β= 0.08, p&lt;0.001) and an increase in general health (β= 0.07, p=0.001). Additionally, an increase in food pantry use related to an increase in getting more days of enough sleep (β=0.07, p=0.001), which in turn positively related to a decrease in depressive symptoms (β=0.18, p&lt;0.001) and improved general health (β=0.24, p&lt;0.001).

Conclusion

Food pantry use had a positive relationship with student health outcomes, and enough sleep days played an important mediating role. Findings suggest that emergency food access may have a positive impact on student health outcomes.

Support

This study was funded by the UC Campus Basic Needs Committees.

0696 The O2VERLAP Study: High Cpap Use Levels Found In Overlap Syndrome (OSA And COPD) Patients

Introduction

CPAP therapy is prescribed to help manage disordered breathing during sleep time periods. Most users, especially those with non-severe obstructive sleep apnea (OSA), use it only for some portion of their sleep period. Patients with Overlap Syndrome have both OSA and chronic obstructive pulmonary disease (COPD). While there has been some research on CPAP use levels in this patient population, there has been little indication that they use CPAP any differently than those with OSA only.

Methods

The O2VERLAP Study was a large comparative effectiveness trial enrolling people with COPD and OSA and using two different methods of providing information and support to current users of CPAP therapy. The study utilized an electronic national recruitment strategy and 332 participants were enrolled. CPAP data from the 12-week study period was analyzed. The Pittsburgh Sleep Quality Index was used to determine both estimated total sleep period (TSP) and total sleep time (TST). Because participants were all current users of CPAP, data from the total sample was combined and used. The percentage of TST and TSP that CPAP was used was calculated as CPAP use divided by either TST or TSP.

Results

The mean TST was 6.8 hours, TSP was 8.1 hours, and CPAP use was 6.7 hours. CPAP was used during 98.5% of the TST and during 82.7% of the TSP. Over 35% of the sample used CPAP at a level that was equal to or greater than their total sleep period.

Conclusion

Most OSA study populations use CPAP for some fraction of their night’s sleep. This COPD/OSA study population used CPAP to a markedly high level, including over one-third of the sample (n=~100) who used CPAP more than their self-reported sleep period. Further research on the extent and reasons for non-sleep period (i.e., daytime) CPAP use in COPD patients is warranted.

Support

PPRND #1507-31666.

Combustion Method for Determination of Crude Protein in Meat and Meat Products: Collaborative Study

Twelve laboratories participated in a collaborative study to compare a combustion method with the AOAC mercury catalyst Kjeldahl method (928.08) for the determination of crude protein in meat and meat products. Three different combustion instruments were used; consequently, the combustion method for this study is written in generic terms describing the principle, the apparatus specifications, and the performance requirements needed. Fifteen sample pairs were used for the study; each pair consisted of the same commercial meat product from each of 2 different manufacturers. Protein content of all samples ranged from about 10 to 20%. In addition, nicotinic acid and lysine monohydrochloride were used as standards to assess combustion equipment performance. All laboratories and all instruments performed the combustion method satisfactorily on the basis of results for the standards. For the meat samples, repeatability standard deviations (sr) ranged from 0.11 to 0.40 for the Kjeldahl method and from 0.12 to 0.41 for the combustion method; the repeatability relative standard deviations (RSDr) ranged from 0.82 to 2.41% and from 0.60 to 2.23% for the Kjeldahl and combustion methods, respectively. Reproducibility standard deviations (SR) ranged from 0.20 to 0.49 for the Kjeldahl method and from 0.18 to 0.46 for the combustion method, whereas the reproducibility relative standard deviations (RSDR) ranged from 1.59 to 2.84% for the Kjeldahl method and from 1.32 to 3.35% for the combustion method. Overall grand means were 15.59% protein for the Kjeldahl method and 15.75% protein for the combustion method. The combustion method was adopted first action by AOAC International.

Naloxone-Induced Withdrawal in Individuals With and Without Fentanyl-Positive Urine Samples

BACKGROUND AND OBJECTIVE

This retrospective analysis of data from heroin users screening for clinical research, sought to determine if more naloxone is needed to precipitate opioid withdrawal among those who regularly use heroin with fentanyl, as opposed to those who use heroin without fentanyl.

METHODS

Over the course of three to five screening visits, participants completed assessments of drug use, along with urine toxicology tests at each visit. To test for opioid dependence, 29 participants completed a modified Wang test (score: 0-150) during which an intramuscular dose of naloxone (0.2-0.4 mg) was administered and the severity of withdrawal was quantified.

RESULTS

The severity of opioid withdrawal was compared between individuals whose urine toxicology regularly tested positive for fentanyl (N = 15), and those only positive for other opioids (N = 14). No significant differences were found in demographic or drug use between the fentanyl-positive (mean: age 41.1 years, 9.1 bags heroin/d) and fentanyl-negative (42.0 years, 10.0 bags heroin/d) groups. Intramuscular naloxone-precipitated robust withdrawal in both samples (P < .01) with no significant difference (P = .8) in the severity (fentanyl positive [100.6 ± 13.4]; fentanyl negative [82.7 ± 9.6]).

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

These data suggest that a standard naloxone dose can be equally effective at precipitating withdrawal in individuals using heroin with fentanyl compared to heroin without fentanyl. These data contribute to our understanding of how naloxone antagonizes the effects of fentanyl and may have significant implications for the clinical laboratory and opioid overdose. A prospective clinical laboratory study with the proper opioid maintenance controls is needed to provide a more definitive finding. (Am J Addict 2019;00:00-00).

Assessing the contribution of opioid- and dopamine-related genetic polymorphisms to the abuse liability of oxycodone

BACKGROUND

Attempts to identify opioid users at increased risk of escalating to opioid use disorder have had limited success. Data from a variety of sources suggest that genetic variation may mediate the subjective response to opioid drugs, and therefore contribute to their abuse potential. The goal of the current study was to observe the relationship between select genetic polymorphisms and the subjective effects of oxycodone under controlled clinical laboratory conditions.

METHODS

Non-dependent, volunteers with some history of prescription opioid exposure (N = 36) provided a blood sample for analyses of variations in the genes that encode for the μ-, κ- and δ-opioid receptors, and the dopamine metabolizing enzyme, catechol-O-methyltransferase (COMT). Participants then completed a single laboratory test session to evaluate the subjective and analgesic effects of oral oxycodone (0, 10, and 20 mg, cumulative dose = 30 mg).

RESULTS

Oxycodone produced typical μ-opioid receptor agonist effects, such as miosis, and decreased pain perception. Oxycodone also produced dose-dependent increases in positive subjective responses such as: drug "Liking" and "Good Effect." Genetic variants in the μ- (rs6848893) and δ-opioid receptor (rs581111) influenced the responses to oxycodone administration. Additionally, self-reported "Stimulated" effects of oxycodone varied significantly as a function of COMT rs4680 genotype.

DISCUSSION

The current study shows that the euphoric and stimulating effects of oxycodone can vary as a function of genetic variation. Though the relationship between the stimulating effects of opioids and their abuse liability is not well established, we know that the ability of opioids to provide intense feelings of pleasure is a significant motivator for continued use. If replicated, specific genetic variants may be useful in predicting who is at increased risk of developing maladaptive patterns of use following medical exposure to opioid analgesics.

Hypoxia-Induced Caveolin-1 Expression Promotes Migration and Invasion of Tumor Cells

BACKGROUND

Exacerbated proliferation of cancer cells in nascent tumors leads to the genesis of a hypoxic microenvironment, which is associated with poor patient prognosis, because these stress conditions enhance migratory, invasive and metastatic capacities of tumor cells. These changes are associated with the induction of the hypoxia-inducible factors (HIFs, mainly HIF1α) and increased expression of target genes, including Caveolin-1 (CAV1). Results from our group have shown that CAV1 expression in metastatic cancer cells promotes cell migration/invasion in vitro and metastasis in vivo in a manner dependent on tyrosine-14 phosphorylation by src family kinases. Here, we evaluated whether hypoxia-induced expression of CAV1 was required for hypoxia-dependent migration and invasion in cancer cells.

METHODS

B16-F10 murine melanoma and HT29(US) colon adenocarcinoma cells were exposed to hypoxia (1% O2). CAV1 expression was evaluated by western blotting. Endogenous CAV1 and HIF1α were knocked-down using different shRNA constructs. Cell migration and invasion were evaluated in Boyden Chamber and Matrigel assays, respectively.

RESULTS

We observed that hypoxia increased CAV1 protein levels in a HIF1 α- dependent manner, in B16-F10 and HT29(US) cells. Importantly, hypoxia-dependent migration of both tumor cell lines was blocked upon CAV1 knock-down. Likewise, pharmacological inhibition of HIF prevented hypoxia-induced migration and invasion in B16-F10 cells. Finally, hypoxia-induced migration was also blocked by the src-family kinase inhibitor 4-amino-5-(4-chloro-phenyl)-7-(t-butyl) pyrazolo3,4-dpyrimidine (PP2), an inhibitor of CAV1 phosphorylation.

CONCLUSION

Hypoxia induced migration and invasion of metastatic cancer cells require HIF1α-dependent induction of CAV1 expression and src family kinase activation.

Origin and composition of cell-free DNA in spent medium from human embryo culture during preimplantation development

STUDY QUESTION

What is the origin and composition of cell-free DNA in human embryo spent culture media?

SUMMARY ANSWER

Cell-free DNA from human embryo spent culture media represents a mix of maternal and embryonic DNA, and the mixture can be more complex for mosaic embryos.

WHAT IS KNOWN ALREADY

In 2016, ~300 000 human embryos were chromosomally and/or genetically analyzed using preimplantation genetic testing for aneuploidies (PGT-A) or monogenic disorders (PGT-M) before transfer into the uterus. While progress in genetic techniques has enabled analysis of the full karyotype in a single cell with high sensitivity and specificity, these approaches still require an embryo biopsy. Thus, non-invasive techniques are sought as an alternative.

STUDY DESIGN, SIZE, DURATION

This study was based on a total of 113 human embryos undergoing trophectoderm biopsy as part of PGT-A analysis. For each embryo, the spent culture media used between Day 3 and Day 5 of development were collected for cell-free DNA analysis. In addition to the 113 spent culture media samples, 28 media drops without embryo contact were cultured in parallel under the same conditions to use as controls. In total, 141 media samples were collected and divided into two groups: one for direct DNA quantification (53 spent culture media and 17 controls), the other for whole-genome amplification (60 spent culture media and 11 controls) and subsequent quantification. Some samples with amplified DNA (N = 56) were used for aneuploidy testing by next-generation sequencing; of those, 35 samples underwent single-nucleotide polymorphism (SNP) sequencing to detect maternal contamination. Finally, from the 35 spent culture media analyzed by SNP sequencing, 12 whole blastocysts were analyzed by fluorescence in situ hybridization (FISH) to determine the level of mosaicism in each embryo, as a possible origin for discordance between sample types.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Trophectoderm biopsies and culture media samples (20 μl) underwent whole-genome amplification, then libraries were generated and sequenced for an aneuploidy study. For SNP sequencing, triads including trophectoderm DNA, cell-free DNA, and follicular fluid DNA were analyzed. In total, 124 SNPs were included with 90 SNPs distributed among all autosomes and 34 SNPs located on chromosome Y. Finally, 12 whole blastocysts were fixed and individual cells were analyzed by FISH using telomeric/centromeric probes for the affected chromosomes.

MAIN RESULTS AND THE ROLE OF CHANCE

We found a higher quantity of cell-free DNA in spent culture media co-cultured with embryos versus control media samples (P ≤ 0.001). The presence of cell-free DNA in the spent culture media enabled a chromosomal diagnosis, although results differed from those of trophectoderm biopsy analysis in most cases (67%). Discordant results were mainly attributable to a high percentage of maternal DNA in the spent culture media, with a median percentage of embryonic DNA estimated at 8%. Finally, from the discordant cases, 91.7% of whole blastocysts analyzed by FISH were mosaic and 75% of the analyzed chromosomes were concordant with the trophectoderm DNA diagnosis instead of the cell-free DNA result.

LIMITATIONS, REASONS FOR CAUTION

This study was limited by the sample size and the number of cells analyzed by FISH.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first study to combine chromosomal analysis of cell-free DNA, SNP sequencing to identify maternal contamination, and whole-blastocyst analysis for detecting mosaicism. Our results provide a better understanding of the origin of cell-free DNA in spent culture media, offering an important step toward developing future non-invasive karyotyping that must rely on the specific identification of DNA released from human embryos.

STUDY FUNDING/ COMPETING INTEREST

This work was funded by Igenomix S.L. There are no competing interests.