Neurocognitive Impulsivity in Opiate Users at Different Lengths of Abstinence

The aim of the current study was to examine the effects of length of abstinence on decision making (impulsive choice) and response inhibition (impulsive action) in former opiate users (OU). Participants included 45 OU in early remission [0−12 months of abstinence], 68 OU in sustained remission [>12 months of abstinence], and 68 control participants. Decision making was assessed with the Iowa Gambling Task (IGT), the Cambridge Gambling Task (CGT), and the Monetary Choice Questionnaire (MCQ). Response inhibition was examined with the Stop Signal Task (SST), and the Go/No-Go Task (GNG). Results revealed group differences in decision making under risk (CGT) and ambiguity (IGT), where control participants displayed better decision making compared to OU in early remission. Both groups of former OU were also characterized by higher discounting of delayed rewards (MCQ). Regression analyses revealed minimal effects of length of abstinence on performance on decision-making tasks and no effects on delay discounting. In addition, both OU groups showed reduced action inhibition (GNG) relative to controls and there were no group differences in action cancellation (SST). Length of abstinence had no effect on response inhibition. Overall, our findings suggest that neurocognitive function may not fully recover even with protracted abstinence, which should be addressed by relapse prevention and cognitive remediation programs for OU.

Hepatitis C Treatment in Persons Who Inject Drugs in a Medication Assisted Treatment Program: A Retrospective Review of an Integrated Model

BACKGROUND

Hepatitis C virus (HCV) infection is common among persons who inject drugs (PWID), mostly due to needle sharing. The number of new cases in PWID are steadily increasing despite the availability of effective treatments. The objective of this model is to increase uptake and compliance with HCV treatment. We developed a model to treat HCV and opioid use disorder simultaneously in a methadone maintenance program.

METHODS

Patients were screened on site for HCV at admission and then annually. Once HCV was positive, the genotypes and fibrosis scores were identified. Patients were enrolled into the treatment program after obtaining written consent. Patients either self-administered the medications at home or utilized a directly observed treatment (DOT). The sustained virologic response (SVR) was tested at 12 weeks posttreatment. We conducted a retrospective review of patients who received treatment and reviewed the demographic data, co-infections, medication administration, and SVR results at the end of study period.

RESULTS

One hundred ninety patients were identified as Hepatitis C positive. 88.9% (169 patients) received HCV treatment during the study period. 62.7% (106 patients) were male and 37.3% were female (63 patients). 62.7% of them (106 patients) completed HCV treatment by the end of study period. Out of them, 96.2% (102 patients) achieved SVR. 68.9% (73 patients) utilized DOT for medication administration.

CONCLUSIONS

Our model successfully treated HCV in our patient population, who are otherwise deprived of resources and access to health care. Replicating this model is a potential strategy to reduce the disease burden and break the transmission cycle of HCV.

Does An ERAS Protocol Reduce Postoperative Opiate Prescribing in Plastic Surgery?

Background

Enhanced recovery after surgery (ERAS) protocols are effective at reducing inpatient opiate use. There is a paucity of studies on the effects of an ERAS protocol on outpatient opiate prescriptions. The aim of this study was to determine whether an ERAS protocol for plastic and reconstructive surgery would reduce opiate use in the outpatient postoperative setting.

Methods

A statewide (Massachusetts, USA) controlled substance prescription monitoring database was retrospectively reviewed to assess the prescribing patterns of a single academic plastic surgeon performing common plastic surgical outpatient operations. The time period prior to implementation of the ERAS protocol was then compared with the time period following protocol implementation. An additional three months of post-implementation data were then compared with those of each of the previous time periods to investigate whether the results were sustained.

Results

A comparison of opiate prescriptions in pre-ERAS, immediate post-ERAS procedures, and follow-up ERAS implementation procedures revealed a statistically significant decrease in opiate prescriptions after ERAS protocol implementation. This decrease in the quantity of opiates prescribed was sustained over time.

Conclusions

ERAS protocols are effective at reducing outpatient opiate prescriptions after a variety of plastic surgery operations. Appropriate patient and physician education is paramount for success.

Predictors of Opiate Utilization in the Treatment of Headache and Impact on Three-Month Outcomes Following Subarachnoid Hemorrhage

Despite multiple investigational drugs, headache due to subarachnoid hemorrhage (SAH) remains inadequately controlled and requires high opiate utilization. This study investigates the factors associated with increased opiate usage for the management of headache in SAH in the first 14 days of admission, the association between opiate usage and hospital length of stay, and the incidence of opiate consumption during the outpatient follow up.

This is a single-center cross-sectional study. A total of 138 patients admitted between January 1, 2017, and May 31, 2019, with a diagnosis of SAH, were identified through a neurocritical care dashboard. Outpatient electronic medical records were evaluated at three months. Statistical analysis included descriptive statistics, Mann-Whitney U test, stepwise regression, and multiple regression analysis.

We found that of 138 patients, the majority (90%) were prescribed opiates during their hospitalization, and the mean daily morphine equivalent dosage was 18.74 mg. Steroid usage was associated with an increase in 14-day opiate usage (r = 0.4, p = 0.0001); however, the cerebral spinal fluid profile did not show a statistically significant correlation. Over 14 days, smokers significantly used more opiates compared to nonsmokers (353 mg vs. 184 mg, p = 0.01). In addition, peri-mesencephalic SAH required less morphine compared to aneurysmal SAH (195 mg vs. 283 mg, p = 0.004). Aneurysm clipping was associated with less opiate usage compared to aneurysm coiling (186 vs. 320, p = 0.08).

Only the high Hunt and Hess scale score predicted opiate usage, and the high modified Fisher scale score, aneurysmal SAH, and more opiate usage predicted hospital length of stay. A total of 48 patients (42%) suffered from headaches during their outpatient follow-up within three months of discharge; however, only six (5%) were still on opiates. There was a significant association between the amount of opiate used in the first 14 days of admission and the rate of post-discharge headache.

In summary, even though patients admitted with SAH require a large amount of opiate for headache management, this did not lead to more opiate consumption in the outpatient setting. However, patients continued to suffer from headaches at three months follow-up. This high opiate consumption is associated with increased hospital length of stay. Studies are needed to identify opiate sparing analgesics that target the pathogenesis of headaches in this patient population.

A Multi-Modal Curriculum Teaching Opioid Use Disorder Management in Young Adult Populations

BACKGROUND

The use of both prescription and illicit opioids among adolescents and young adults (AYA) is increasing. Barriers to effective treatment of opioid use disorders among AYA range from patients leaving against medical advice to decreased knowledge and experience of providers caring for those with opioid dependence. No formal curricula for residents on AYA opioid use disorder and management have been implemented despite rapidly increasing use in this population.

OBJECTIVE

To develop a brief curriculum for trainees who encounter AYA that will increase knowledge and skills to treat opioid use in the AYA population.  Methods: Twenty-six pediatric and family medicine interns participated in this pilot study. The multimodal curriculum included standardized patient encounters, case-based learning sessions, didactics, and high-fidelity simulations. The curriculum encompasses five individual sessions, each with a different theme: motivational interviewing, naloxone administration, opioid withdrawal medications, complex overdoses, and infectious complications of intravenous drug use. A pre-survey was administered prior to the curriculum and a post-survey was administered at the conclusion to assess its effectiveness in improving knowledge for this specific population and increasing comfort levels providing medical interventions in AYA patients with opioid use disorders.

RESULTS

Trainee comfort levels increased significantly in all four domains as measured by the average Likert scale, including interviewing AYA about opioid use (2.5 (standard deviation (SD) 1.2) to 4 (SD 0.9), p<0.0001)), prescribing medication for opioid use disorder (1.3 (SD 0.5) to 2.8 (SD 1.3), p<0.0001)), treating acute opioid overdose (1.5 (SD 0.8) to 3.7 (SD 0.9), p<0.0001)), and treating infectious complications of intravenous drug use (1.7 (SD 0.8) to 3 (SD 1.1), p <0.0001)). The Chi-square test showed similarly significant increases in comfort levels.

CONCLUSIONS

Early trainees who provide care to young adults benefit from opioid education specific to this population. Participants described increased knowledge and comfort in interviewing and treating this vulnerable patient group.

A Demographic and Regional Comparison of Opioid-Related Hospital Visits within Community Type in the United States

BACKGROUND

The opioid epidemic is a complex national crisis in the United States with a 400% increase in related deaths over the past two decades with no signs of slowing. The purpose of this study was to assess the incidence of opioid use, based on the geographic and population characteristics.

METHODS

The opioid-related hospital inpatient stays and emergency department visits obtained from the 2010 to 2018 Healthcare Cost and Utilization Project and demographic confounders, including age, race, education, and income gathered from US Census data were analyzed through generalized linear mixed models and reported by community size and region.

RESULTS

Opioid use varies among population center sizes and the region analyzed. In general, opioid visits in the southwest region were greatest across the majority of population center sizes. Rural usage was greatest in the northeast, southeast, and southwest. Unemployment and diverse ethnicities were commonly associated with opioid use in the metro areas studied but these associations were not seen in rural areas.

CONCLUSION

Opioid use remains significant among diverse populations across the United States. Understanding the unique dynamics associated with opioid usage in populations within the regions studied is important in guiding future interventions to fight this crisis.

Effectiveness of a Mobile eHealth App in Guiding Patients in Pain Control and Opiate Use After Total Knee Replacement: Randomized Controlled Trial

Background

Little is known about pain and opiate use at home directly after total knee replacement (TKR). Due to adverse effects, low opiate use is desired. An electronic health app (PainCoach) was developed to guide patients in pain control and opiate use.

Objective

The aim of this paper was to investigate the effects of the PainCoach app on pain control and opiate use in patients who underwent TKR during the first 2 weeks at home after surgery.

Methods

In an unblinded randomized controlled trial, patients scheduled for TKR were offline recruited and randomized to a PainCoach group or control group. In the PainCoach group, the PainCoach app was downloaded on each patient’s smartphone or tablet. In response to the patient’s input of the pain experienced, the PainCoach app gave advice on pain medication use, exercises/rest, and when to call the clinic. This advice was the same as that received during usual care. The control group received usual care. The primary outcomes were opiate use and visual analog scale (VAS) pain scores at rest, during activity, and at night during the first 2 weeks at home after surgery, which were collected daily from day 1 until 14 postoperatively by online questionnaires. The actual amount of app use was recorded, and active use was defined as ≥12 total app uses.

Results

The pain scores did not differ between the groups. The PainCoach group (n=38) used 23.2% less opiates (95% CI −38.3 to −4.4; P=.02) and 14.6% more acetaminophen (95% CI 8.2-21.3; P<.001) when compared with the findings in the control group (n=33). The PainCoach app was used 12 (IQR 4.5-22.0) times per patient. In the active PainCoach subgroup (n=19), the following were noted when compared with the findings in the control group: 4.1 times faster reduction of the VAS pain score during activity (95% CI −7.5 to −0.8; P=.02), 6.3 times faster reduction of the VAS pain score at night (95% CI −10.1 to −2.6; P=.001), 44.3% less opiate use (95% CI −59.4 to −23.5; P<.001), 76.3% less gabapentin use (95% CI −86.0 to −59.8; P<.001), and 21.0% more acetaminophen use (95% CI 12.6-30.0; P<.001).

Conclusions

The use of the PainCoach app contributes to reduced opiate use in the initial period at home after TKR. Active use of this app leads to a further reduction in opiate use and improved pain control.

Trial Registration

ClinicalTrials.gov NCT03961152; https://clinicaltrials.gov/ct2/show/NCT03961152

Preoperative and Postoperative Opiate Use by the Arthroplasty Patient

BACKGROUND

As opioid use increases nationally, the arthroplasty surgeon is likely to see more patients taking opioid analgesics on initial presentation. The purpose of this study was to investigate the use of opiate medication in the preoperative and postoperative patient undergoing primary total joint arthroplasty.

METHODS

From October 2010 to November 2011, data on 367 consecutive patients who underwent primary total joint arthroplasty were reviewed. Using the Michigan Automated Prescription System database, data were collected on opiate use from 3 months preop to 12 months postop. Patients were grouped by preoperative opiate use. Patients with ≥2 opiate prescriptions filled per 6-week period before surgery were considered chronic opiate users.

RESULTS

Three hundred fifteen patients fit our inclusion/exclusion criteria. There were 158 primary total knee and 157 primary total hip arthroplasty patients. At 1 year after operation, 64% of chronic opiate users were still being prescribed opiates compared with 22% of the control group (P < .001). Thirty-one percent of the chronic opiate users were discharged to an extended care facility compared to 21% of the control group (P = .123). Of all the opiate prescriptions, 77% were written by a practitioner other than the surgeon.

CONCLUSIONS

Opiates are frequently prescribed by providers other than the surgeon preoperatively and postoperatively. The use of opiates that were presumably prescribed to treat joint pain was continued for more than 1 year postoperatively in 64% of cases. Patients taking multiple opiates or more potent opiates preoperatively filled more prescriptions postoperatively. Chronic use of opiates negatively influenced the discharge disposition.

Emerging Drug Use Trends in Kelantan, Malaysia

The primarily rural and agrarian Kelantan province of Malaysia has high rates of drug use and is characterized by unique sociocultural factors. Combining qualitative and ethnographic methods, we investigated drug use and treatment needs of people who use drugs (PWUD) in rural areas of Kelantan. In February 2014, field visits, participant observation, and focus group discussions (FGDs) with 27 active PWUD were conducted in rural areas surrounding the capital city of Kelantan. The findings indicate a high prevalence of opiate and amphetamine type stimulants (ATS) use in these areas. FGD participants reported initiating drug use at early ages due to peer influences, to relieve boredom, to cope with problems, and a high saturation of villages with other PWUD was reported as a major contributor to their own continued drug use. They reported a trend of drug use initiation at younger ages and increased drug use among females. Participants were interested in treatment; however, their limited knowledge about treatment options and perceived limited availability of services were barriers to treatment seeking. Easy access to drugs, primarily from Thailand and facilitated by the use of mobile phones, resulted in an expanding prevalence of drug use that underscores the need to bolster education and prevention efforts and accessibility of treatment services in Kelantan.

Characteristics and Outcomes of Young Adult Opiate Users Receiving Residential Substance Abuse Treatment

Opiate use patterns, user characteristics, and treatment response among young adults are of interest due to current high use prevalence and historical low levels of treatment engagement relative to older populations. Prior research in this population suggests that overall, young adults present at treatment with different issues. In this study the authors investigated potential differences between young adult (18-25 years of age) and older adult (26 and older) opiate users and the impact of differences relative to treatment motivation, length and outcomes. Data for this study was drawn from 760 individuals who entered voluntary, private, residential treatment. Study measures included the Addiction Severity Index (ASI), the Treatment Service Review (TSR), and University of Rhode Island Change Assessment (URICA). Interviews were conducted at program intake and 6-month post-discharge. Results indicate that older adults with a history of opiate use present at treatment with higher levels of severity for alcohol, medical, and psychological problems and young adults present at treatment with greater drug use and more legal issues. Significant improvement for both groups was noted at 6 months post treatment; there were also fewer differences between the two age groups of opiate users. Results suggest different strategies within treatment programs may provide benefit in targeting the disparate needs of younger opiate users. Overall, however, results suggest that individualized treatment within a standard, abstinence-based, residential treatment model can be effective across opiate users at different ages and with different issues, levels of severity, and impairment at intake.

Emergency room use after being released from incarceration

Background

This study investigates opiate use in mediating the impact of history of incarceration on emergency department (ED) use.

Method

Data were collected from 1,341 clients who underwent HIV and STI screening in an outpatient care center in Long Beach, California. The Risk Behavior Assessment (RBA, baseline) and Risk Behavior Follow-Up Assessment (RBFA, follow-up) were administered to each client with at least a three months interval between assessments.

Results

Of 1341 participants in the study, 931 (69.43%) reported previous incarceration. Having a history of incarceration was significantly associated with emergency room use as well as a history of sexually transmitted infections (STIs), injection drug use, opiate use, and survival sex trading, defined as sex for money or drugs. The relationship between previous incarceration and ED use was mediated by opiate use for men but not for women. The findings suggested that the effect of history of incarceration on ED use was exacerbated when the individuals were male and opiate users.

Conclusions

Targeted interventions in treatment and rehabilitation programs could help prevent unnecessary ED use and reduce the use of EDs through drug treatment during incarceration and after release.

Electronic supplementary material

The online version of this article (doi:10.1186/2194-7899-2-5) contains supplementary material, which is available to authorized users.

Sexual transmissibility of HIV among opiate users with concurrent sexual partnerships: an egocentric network study in Yunnan, China

AIMS

To investigate the patterns of concurrent sexual partnerships among young opiate users and sexual transmissibility of human immunodeficiency virus (HIV) in concurrent sexual partnerships in drug-use and sexual networks.

DESIGN

Cross-sectional design.

PARTICIPANTS

A total of 426 young opiate users in Yunnan, China.

SETTING

Young opiate users recruited from their network ties.

MEASUREMENT

Respondent-driven sampling (RDS) was used to recruit participants. Multiple logistic regressions were performed to analyze the relationships of concurrent sexual partnerships with egocentric social network components, risky sexual behavior for HIV and drug-use practices.

FINDINGS

The RDS-adjusted prevalence of concurrent sexual partners was 42.9% among opiate users. Opiate users with concurrent sexual partnerships were more likely to engage in risky HIV-related sexual behavior, compared to those without. Specifically, they were more likely to report having had four or more sexual partners (26.3% versus 2.0%), having had a spouse or boy/girlfriends who also had concurrent sexual partnerships (28.1% versus 8.2%), having exchanged drug for sex (12.4% versus 3.8%), having had sexual partners who were non-injection drug users (22.6% versus 10.1%), having had sexual partners who were injection drug users (25.3% versus 13.5%) and having used club drugs (26.3% versus 13.5%). There were no significant differences in consistent condom use between opiate users with sexual concurrency and those without. The same proportion (25.8%) of opiate users in the two groups reported having consistently used condoms when having sex with regular partners, and 46.3% of opiate users with sexual concurrency and 36.4% of those without such concurrency consistently used condoms with non-regular partners.

CONCLUSION

The expansion of the human immunodeficiency virus epidemic from high-risk populations to the general population in China may be driven by concurrent sexual partnerships. Behavioral interventions targeting safer sex should be integrated into harm reduction programmes.

The effects of opiate use and hepatitis C virus infection on risk of diabetes mellitus in the Women's Interagency HIV Study

BACKGROUND

Opiate use is common in HIV-infected and hepatitis C virus (HCV)-infected individuals, however, its contribution to the risk of diabetes mellitus is not well understood.

METHODS

Prospective study of 1713 HIV-infected and 652 HIV-uninfected participants from the Women's Interagency HIV Study between October 2000 and March 2006. Diabetes defined as fasting glucose > or =126 mg/dL, self report of diabetes medication use, or confirmed diabetes diagnosis. Opiate use determined using an interviewer-administered questionnaire. Detectable plasma HCV RNA confirmed HCV infection.

RESULTS

Current opiate users had a higher prevalence of diabetes (15%) than nonusers (10%, P = 0.03), and a higher risk of incident diabetes (adjusted relative hazard: 1.58, 95% confidence interval: 1.01 to 2.46), after controlling for HCV infection, HIV/antiretroviral therapy status, and diabetes risk factors including age, race/ethnicity, family history of diabetes, and body mass index. HCV infection was also an independent risk factor for diabetes (adjusted relative hazard: 1.61, 95% confidence interval: 1.02 to 2.52). HCV-infected women reporting current opiate use had the highest diabetes incidence (4.83 cases per 100 person-years).

CONCLUSIONS

Among women with or at-risk for HIV, opiate use is associated with increased diabetes risk independently of HCV infection. Diabetic screening should be part of care for opiate users and those infected with HCV.

Abnormal glucose metabolism among older men with or at risk of HIV infection

OBJECTIVES

To determine factors associated with diabetes, insulin resistance, and abnormal glucose tolerance in older men with or at risk of HIV infection.

METHODS

Diabetes was assessed by self-report in 643 men >or=49 years old with or at risk of HIV infection. In a subset of 216 men without previously diagnosed diabetes [including 90 HIV-uninfected men, 28 HIV-infected, antiretroviral-naive men, 28 HIV-infected men taking non-protease inhibitor (PI)-containing highly active antiretroviral therapy (HAART), and 70 HIV-infected men taking PI-containing HAART], an oral glucose tolerance test with insulin levels was performed. HIV serology, CD4 cell count, weight, height and waist circumference were measured. Antiretroviral use, drug use, family history of diabetes, physical activity and sociodemographic data were obtained using standardized interviews.

RESULTS

Of 643 participants, 116 (18%) had previously diagnosed diabetes. With the oral glucose tolerance test, 15 of 216 men (7%) were found to have undiagnosed diabetes and 40 (18%) impaired glucose tolerance. Factors independently associated with previously diagnosed diabetes included use of non-PI-containing HAART, methadone treatment, positive CAGE test for alcoholism, obesity and family history of diabetes. Factors independently associated with greater insulin resistance included waist circumference and heroin use. Factors independently associated with abnormal glucose tolerance (impaired glucose tolerance or diabetes) included age >or=55 years and Hispanic ethnicity.

CONCLUSIONS

HIV-infected men with diabetes risk factors should undergo screening for diabetes regardless of HAART use. Interventions targeting modifiable risk factors, including overweight and physical inactivity, are warranted. The potential impact of opiate and alcohol abuse on glucose metabolism should be recognized in clinical care, and addressed in future research studies of HIV-infected persons.