Polydrug use disorders in individuals with opioid use disorder

Trends in comorbid opioid and stimulant use disorders among Veterans receiving care from the Veterans Health Administration, 2005-2019

BACKGROUND

Identifying solutions to the continued rise in overdose deaths is a public health priority. However, there is evidence of change in recent substance type associated with morbidity and mortality. To better understand the continued rise in overdose deaths, in particular those attributed to opioid and stimulant use disorders, increased knowledge of patterns of use is needed.

METHODS

Retrospective cohort study of Veterans diagnosed with an opioid or stimulant use disorder between 2005 and 2019. The outcome of interest was diagnosis of substance use disorders, specifically examining combinations of opioid and stimulant use disorders among this population.

RESULTS

A total of 1932,188 Veterans were diagnosed with at least one substance use disorder (SUD) during the study period, 2005 through 2019. While the annual prevalence of opioid use disorder (OUD) diagnoses increased more than 155%, OUD diagnoses absent of any other SUD diagnosis increased by an average of 6.9% (95% CI, 6.4, 7.5) per year between 2005 and 2019. Between 2011 and 2019, diagnoses of co-morbid methamphetamine use disorder (MUD) and OUD increased at a higher rate than other SUD combinations.

CONCLUSIONS

The prevalence of comorbid SUD, in particular co-occurring opioid and methamphetamine use disorder, increased at a higher rate than other combinations between 2005 and 2019. These findings underscore the urgent need to offer patients a combination of evidence-based treatments for each co-morbid SUD, such MOUD and contingency management for persons with comorbid opioid and methamphetamine use disorders.

Application of dose-addition analyses to characterize the abuse-related effects of drug mixtures

Polysubstance use makes up a majority of drug use, yet relatively few studies investigate the abuse-related effects of drug mixtures. Dose-addition analyses provide a rigorous and quantitative method to determine the nature of the interaction (i.e., supraadditive, additive, or subadditive) between two or more drugs. As briefly reviewed here, studies in rhesus monkeys have applied dose-addition analyses to group level data to characterize the nature of the interaction between the reinforcing effects of stimulants and opioids (e.g., mixtures of cocaine + heroin). Building upon these foundational studies, more recent work has applied dose-addition analyses to better understand the nature of the interaction between caffeine and illicit stimulants such as MDPV and methamphetamine in rats. In addition to utilizing a variety of operant procedures, including drug discrimination, drug self-administration, and drug-primed reinstatement, these studies have incorporated potency and effectiveness ratios as a method for both statistical analysis and visualization of departures from additivity at both the group and individual subject level. As such, dose-addition analyses represent a powerful and underutilized approach to quantify the nature of drug-drug interactions that can be applied to a variety of abuse-related endpoints in order to better understand the behavioral pharmacology of polysubstance use.

Polysubstance use poisoning deaths in Canada: an analysis of trends from 2014 to 2017 using mortality data

Background

Over the past decade, rates of drug poisoning deaths have increased dramatically in Canada. Current evidence suggests that the non-medical use of synthetic opioids, stimulants and patterns of polysubstance use are major factors contributing to this increase.

Methods

Counts of substance poisoning deaths involving alcohol, opioids, other central nervous system (CNS) depressants, cocaine, and CNS stimulants excluding cocaine, were acquired from the Canadian Vital Statistics Death Database (CVSD) for the years 2014 to 2017. We used joinpoint regression analysis and the Cochrane-Armitage trend test for proportions to examine changes over time in crude mortality rates and proportions of poisoning deaths involving more than one substance.

Results

Between 2014 and 2017, the rate of substance poisoning deaths in Canada almost doubled from 6.4 to 11.5 deaths per 100,000 population (Average Annual Percent Change, AAPC: 23%, p < 0.05). Our analysis shows this was due to increased unintentional poisoning deaths (AAPC: 26.6%, p < 0.05) and polysubstance deaths (AAPC: 23.0%, p < 0.05). The proportion of unintentional poisoning deaths involving polysubstance use increased significantly from 38% to 58% among males (p < 0.0001) and 40% to 55% among females (p < 0.0001). Polysubstance use poisonings involving opioids and CNS stimulants (excluding cocaine) increased substantially during the study period (males AAPC: 133.1%, p < 0.01; females AAPC: 118.1%, p < 0.05).

Conclusions

Increases in substance-related poisoning deaths between 2014 and 2017 were associated with polysubstance use. Increased co-use of stimulants with opioids is a key factor contributing to the epidemic of opioid deaths in Canada.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12678-z.

Addressing injecting related risks among people who inject both opioids and stimulants: Findings from an Australian survey of people who inject drugs

Background

Opioids and stimulants are the most commonly injected illicit drugs worldwide and in Australia. While some people who inject drugs (PWID) prefer either opioids or stimulants, others regularly use both opioids and stimulants. Limited available research indicates that those who use opioids and stimulants together, either in combination or alternating between the two, may engage in injection-related practices which potentially place them at greater health risk and could lead to poorer health outcomes.

Methods

Participants were recruited nationally through member organizations of the Australian Injecting and Illicit Drug Users League (AIVL); these organizations represent PWID in each Australian state and territory. This study compared a sample of PWID (N = 535) who reported past-month injection of opioids only (N = 173), stimulants only (N = 208), or both (N = 154) on a range of health and wellbeing outcomes. PWID completed a survey assessing drugs injected, frequency of injecting, receptive equipment sharing, psychological distress, self-reported hepatitis C (HCV) status, experienced and internalized stigma, drug use salience, and community attachment.

Results

People who injected both opioids and stimulants reported more frequent injecting, more experiences of stigma, and greater reported HCV diagnosis than people who injected stimulants or opioids alone. They also showed greater attachment to a community of PWID and greater salience of drug use to their identity.

Conclusions

The findings of increased injecting and broader harms associated with injecting both stimulants and opioids are important for tailoring harm reduction and intervention designs for people who use both opioid and stimulant drugs, including prioritizing peer-based approaches.

Synthetic cannabinoids use in a sample of opioid-use disorder patients

Cannabis is the most widely consumed illegal drug in the world and synthetic cannabinoids are increasingly gaining popularity and replacing traditional cannabis. These substances are a type of new psychoactive substance that mimics the cannabis effects but often are more severe. Since, people with opioids use disorder use widely cannabis, they are a population vulnerable to use synthetic cannabinoids. In addition, these substances are not detected by the standard test used in the clinical practice and drug-checking is more common in recreational settings. A cross-sectional study with samples of 301 opioid use disorder individuals was carried out at the addiction care services from Barcelona and Badalona. Urinalysis was performed by high-sensitivity gas chromatography-mass spectrometry (GC-MS) and ultra-high-performance liquid chromatography-high -resolution mass spectrometry (UHPLC-HRMS). Any synthetic cannabinoid was detected in 4.3% of the individuals and in 23% of these samples two or more synthetic cannabinoids were detected. Among the 8 different synthetic cannabinoids detected, most common were JWH-032 and JWH-122. Natural cannabis was detected in the 18.6% of the samples and only in the 0.7% of them THC was identified. Several different synthetic cannabinoids were detected and a non-negligible percentage of natural cannabis was detected among our sample. Our results suggest that the use of synthetic cannabinoids may be related to the avoidance of detection. In the absence of methods for the detection of these substances in clinical practice, there are insufficient data and knowledge making difficult to understand about this phenomenon among opioid use disorder population.

Exploring the genetic overlap of suicide-related behaviors and substance use disorders

Suicide-related behaviors are heterogeneous and transdiagnostic, and may demonstrate varying levels of genetic overlap with different substance use disorders (SUDs). We used linkage disequilibrium score regression, genomic structural equation models, and Mendelian randomization to examine the genetic relationships between several SUDs and suicide-related behaviors. Our analyses incorporated summary statistics from the largest genome-wide association studies (GWAS) of problematic alcohol use, the Fagerström test for nicotine dependence, cannabis use disorder, and opioid use disorder (Ns ranging from 46,213-435,563) and GWAS of ever self-harmed, suicide attempt, and suicide death (Ns ranging from 18,223-117,733). We also accounted for genetic liability to depression (N = 500,199) and risk tolerance (N = 315,894). Suicide-related behaviors were significantly genetically correlated with each other and each SUD, but there was little evidence of causal relationships between the traits. Simultaneously correlating a common SUD factor with each specific suicide indicator while controlling for depression and risk tolerance revealed significant, positive genetic correlations between the SUD factor and suicide-related behaviors (rg  = 0.26-0.45, SE = 0.08-0.09). In the model, depression's association with suicide death (β = 0.42, SE = 0.06) was weaker compared to ever-self harmed and suicide attempt (β = 0.58, SE = 0.05 and β = 0.50, SE = 0.06, respectively). We identify a general level of genetic overlap between SUDs and suicide-related behaviors, which is independent of depression and risk tolerance. Additionally, our findings suggest that genetic and behavioral contributions to suicide death may somewhat differ from nonlethal suicide-related behaviors.

Polydrug Use and Co-occurring Substance Use Disorders in a Respondent Driven Sampling of Cocaine Base Paste Users in Santiago, Chile

We characterized substance use patterns and co-occurring substance use disorders among active cocaine base paste (CBP) users in Santiago, Chile using data from respondent-driven sampling (RDS) in three areas of Metropolitan Santiago. Recruitment began with nine seeds, reaching 398 active CBP users (18% women; mean age 37.7 years), defined as persons consuming CBP at least twice per week in the last three months. Population proportions and uncertainty were estimated accounting for individuals' social network and homophily. The median CBP age of initiation was 21 years, and the median number of years using CBP was 7 for women and 15 for men. The median days of use in the past month was 25 days, with a median of 56 doses per week. The proportion of monthly income spent on CBP was 65%. The prevalence of substance use disorders (SUDs) were: 98% for CBP, 67% for alcohol, 60% for marijuana, and 41% for cocaine hydrochloride. Heavy polydrug use patterns and co-occurring SUDs are frequent among active CBP users in the metropolitan area of Santiago. Traditional surveillance strategies may have underestimated polysubstance use and co-occurring SUDs in active CBP users. RDS proved to be a feasible methodology that could be effectively used for substance use surveillance among hard-to-reach populations.

Interactions between opioids and stimulants: Behavioral pharmacology of abuse-related effects

Opioid abuse continues to be a significant public health challenge, with rates of opioid-related overdose deaths increasing continuously over the last two decades. There also has been a sharp increase in overdose deaths involving stimulant drugs, primarily cocaine and methamphetamine. Recent estimates indicate a high prevalence of co-use of opioids and stimulants, which is a particularly complex problem. Behavioral pharmacology research over the last few decades has characterized interactions between opioids and stimulants as well as evaluated potential treatments. This chapter describes interactions between opioids and stimulants, with a focus on pre-clinical studies of abuse-related behavioral effects using self-administration, reinstatement, drug discrimination, place conditioning, and intracranial self-stimulation paradigms in laboratory animals. In general, the literature provides substantial evidence of mutual enhancement between opioids and stimulants for abuse-related effects, although such results are not ubiquitous. Enhanced abuse-related effects could manifest in many ways including engaging in drug seeking and taking behaviors with greater persistence, effort, and motivation and/or increased likelihood of relapse. Moreover, studies on opioid/stimulant combinations set the stage for evaluating potential treatments for polysubstance use. Behavioral pharmacology research has proven invaluable for elucidating these relationships using rigorous experimental designs and quantitative analyses of pharmacological and behavioral data.

Use of methamphetamine and alcohol among people with opioid use disorder and HIV in Vietnam: a qualitative study

BACKGROUND

Heroin use continues to drive HIV transmission in Vietnam, but methamphetamine and alcohol use are growing rapidly and, as in other countries, polysubstance use is widespread. The objective of this study was to understand the interplay between heroin, methamphetamine, and alcohol use among people with opioid use disorder (OUD) and HIV in Vietnam.

METHODS

We conducted 44 in-depth, face-to-face qualitative interviews with people with OUD and HIV who participated in the BRAVO trial of buprenorphine versus methadone in five Vietnam HIV clinics. Interviews probed participants' experiences of heroin, methamphetamine, and alcohol use and their interplay with HIV/OUD treatment. Interviews were professionally transcribed and analyzed using a thematic analysis approach.

RESULTS

Of 44 participants interviewed 42 were male, on average 38.8 years of age, with 30 reporting a history of methamphetamine use and 33 reporting a history of alcohol use. Several themes emerged: 1) Methamphetamine and alcohol were perceived to have lower addiction potential than heroin 2) Social settings were key facilitators of alcohol and methamphetamine use 3) Some participants, but not all, used methamphetamine to help quit heroin 4) Consuming alcohol blunted the effects of heroin, while paradoxically serving as a catalyst for heroin use 5) Use of methamphetamine was perceived by many participants to be incompatible with treatment for HIV.

CONCLUSIONS

Participant experiences reflected a significant impact of polysubstance use on treatment of HIV and OUD. Patterns of polysubstance use are subject to common preconceptions of alcohol and methamphetamine as having a low addictive potential, and these substances are deeply enmeshed in the social life of many people with OUD in Vietnam. Interventions to address complex social norms and potential harms of polysubstance use are urgently needed as the population of people receiving medication for OUD (MOUD) increases in Vietnam and globally.

TRIAL REGISTRATION

BRAVO - NCT01936857 , September 2013.

Trends in drug poisoning deaths, by sex, in Ireland: a repeated cross-sectional study from 2004 to 2017

OBJECTIVE

To examine sex differences in age-standardised rates (ASR) of overall and drug-specific drug poisoning deaths in Ireland between 2004 and 2017.

DESIGN

Repeated cross-sectional study.

SETTING

Drug poisoning deaths in Ireland.

PARTICIPANTS

National Drug-Related Deaths Index and pharmacy claims database (Primary Care Reimbursement Service-General Medical Services) data from 2004 to 2017.

OUTCOME MEASURES

The primary outcome was trends in drug poisoning death rates by sex. The secondary outcomes were trends in drug poisoning death rates involving (1) any CNS (Central Nervous System) depressants, (2) ≥2 CNS depressants and (3) specific drugs/drug classes (eg, prescription opioids, benzodiazepines, antidepressants, alcohol, cocaine and heroin) by sex. Joinpoint regression was used to examine trends, stratified by sex, in the ASR of drug poisoning deaths (2004-2017), change points over time and average annual percentage changes (AAPCs) with 95% CI.

RESULTS

Increased ASR for all drug poisoning deaths from 6.86 (95% CI 6.01 to 7.72) per 100 000 in 2004 to 8.08 (95% CI 7.25 to 8.91) per 100 000 in 2017 was mainly driven by increasing deaths among men (AAPC 2.6%, 95% CI 0.2 to 5.1), with no significant change observed among women. Deaths involving ≥2 CNS depressants increased for both men (AAPC 5.6%, 95% CI 2.4 to 8.8) and women (AAPC 4.0%, 95% CI 1.1 to 6.9). Drugs with the highest significant AAPC increases for men were cocaine (7.7%, 95% CI 2.2 to 13.6), benzodiazepines (7.2%, 95% CI 2.9 to 11.6), antidepressants (6.1%, 95% CI 2.4 to 10.0) and prescription opioids (3.5%, 95% CI 1.6 to 5.5). For women, the highest AAPC was for antidepressants (4.2%, 95% CI 0.2 to 8.3), benzodiazepines (3.3%, 95% CI 0.1 to 6.5) and prescription opioids (3.0%, 95% CI 0.7 to 5.3).

CONCLUSION

Drugs implicated in drug poisoning deaths vary by sex. Policy response should include prescription monitoring programmes and practical harm reduction information on polydrug use, especially CNS depressant drugs.

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

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

Deep brain stimulation of the nucleus accumbens/ventral capsule for severe and intractable opioid and benzodiazepine use disorder

Given high relapse rates and the prevalence of overdose deaths, novel treatments for substance use disorder (SUD) are desperately needed for those who are treatment refractory. The objective of this study was to evaluate the safety of deep brain stimulation (DBS) for SUD and the effects of DBS on substance use, substance craving, emotional symptoms, and frontal/executive functions. DBS electrodes were implanted bilaterally within the Nucleus Accumbens/Ventral anterior internal capsule (NAc/VC) of a man in his early 30s with >10-year history of severe treatment refractory opioid and benzodiazepine use disorders. DBS of the NAc/VC was found to be safe with no serious adverse events noted and the participant remained abstinent and engaged in comprehensive treatment at the 12-week endpoint (and 12-month extended follow-up). Using a 0-100 visual analog scale, substance cravings decreased post-DBS implantation; most substantially in benzodiazepine craving following the final DBS titration (1.0 ± 2.2) compared to baseline (53.4 ± 29.5; p < .001). A trend toward improvement in frontal/executive function was observed on the balloon analog risk task performance following the final titration (217.7 ± 76.2) compared to baseline (131.3 ± 28.1, p = .066). FDG PET demonstrated an increase in glucose metabolism in the dorsolateral prefrontal and medial premotor cortices at the 12-week endpoint compared to post-surgery/pre-DBS titration. Heart Rate Variability (HRV) improved following the final titration (rMSSD = 56.0 ± 11.7) compared to baseline (19.2 ± 8.2; p < .001). In a participant with severe, treatment refractory opioid and benzodiazepine use disorder, DBS of the NAc/VC was safe, reduced substance use and craving, and improved frontal and executive functions. Confirmation of these findings with future studies is needed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Age-varying trends in alcohol and cannabis co-occurring use: Implications for prescription drug misuse

Background: Individuals who engage in alcohol and cannabis co-occurring use are at heightened risk for negative outcomes than individuals who only use alcohol or only use cannabis, but far less is known about implications of alcohol and cannabis co-occurring use for prescription drug misuse (PDM).Objectives: This study aimed to (1) identify whether co-occurring use was linked with greater risk for PDM across ages 18-60 and to determine ages at which this association was strongest, (2) determine whether associations remain after controlling for pain severity, and (3) test for gender differences.Methods: Cross-sectional data were from Wave 1 of the Population Assessment of Tobacco and Health (PATH) study. The analytic sample included 20,120 (50.6%_wt men) individuals aged 18-60 reporting past-year alcohol and/or cannabis use.Results: Time-varying effect models indicated that individuals reporting co-occurring use were at increased risk for PDM than individuals reporting single-substance use across all ages, with odds ratios peaking at >3 at age 34. After controlling for pain severity, associations were only slightly weakened. Associations were slightly stronger for men than women from ages 28 to 35.Conclusion: Co-occurring use was linked with heightened risk for PDM compared to individuals who used only one substance; co-occurring use may be important to target for PDM prevention. Identifying factors underlying study associations, beyond pain, and how these factors evolve with age are important avenues for prevention work.

High prevalence of co-occurring substance use in individuals with opioid use disorder

OBJECTIVE

Funding to address the current opioid epidemic has focused on treatment of opioid use disorder (OUD); however, rates of other substance use disorders (SUDs) remain high and non-opioid related overdoses account for nearly 30% of overdoses. This study assesses the prevalence of co-occurring substance use in West Virginia (WV) to inform treatment strategies. The objective of this study was to assess the prevalence of, and demographic and clinical characteristics (including age, gender, hepatitis C virus (HCV) status) associated with, co-occurring substance use among patients with OUD in WV.

METHODS

This retrospective study utilized the West Virginia Clinical and Translation Science Institute Integrated Data Repository, comprised of Electronic Medical Record (EMR) data from West Virginia University Medicine. Deidentified data were extracted from inpatient psychiatric admissions and emergency department (ED) healthcare encounters between 2009 and 2018. Eligible patients were those with OUD who had a positive urine toxicology screen for opioids at the time of their initial encounter with the healthcare system. Extracted data included results of comprehensive urine toxicology testing during the study timeframe.

RESULTS

3,127 patients met the inclusion criteria of whom 72.8% had co-occurring substance use. Of those who were positive for opioids and at least one additional substance, benzodiazepines were the most common co-occurring substances (57.4% of patients yielded a positive urine toxicology screen for both substances), followed by cannabis (53.1%), cocaine (24.5%) and amphetamine (21.6%). Individuals who used co-occurring substances were younger than those who were positive for opioids alone (P < 0.001). There was a higher prevalence of individuals who used co-occurring substances that were HCV positive in comparison to those who used opioids alone (P < 0.001). There were limited gender differences noted between individuals who used co-occurring substances and those who used opioids alone. Among ED admissions who were positive for opioids, 264 were diagnosed with substance toxicity/overdose, 78.4% of whom had co-occurring substance use (benzodiazepines: 65.2%; cannabis: 44.4%; cocaine: 28.5%; amphetamine: 15.5%). Across the 10-year timespan, the greatest increase for the entire sample was in the rate of co-occurring amphetamine and opioid use (from 12.6% in 2014 to 47.8% in 2018).

CONCLUSIONS

These data demonstrate that the current substance use epidemic extends well beyond opioids, suggesting that comprehensive SUD prevention and treatment strategies are needed, especially for those substances which do not yet have any evidence-based and/or medication treatments available.

Gender Differences in Patterns and Correlates of Continued Substance Use among Patients in Methadone Maintenance Treatment

BACKGROUND

Continued substance use is common during opioid use disorder (OUD) treatment. There are still inconsistencies in how continued substance use and concurrent patterns of substance use among patients with OUD varies by gender. There is still more to learn regarding how factors associated with continued and concurrent use might differ for men and women in methadone maintenance treatment (MMT). Methods: This cross-sectional study examined predictors of concurrent substance use subgroups among patients receiving MMT. The sample included 341 (n = 161 women) MMT patients aged 18 and older from opioid treatment programs in Southern New England and the Pacific Northwest. Patients completed a survey assessing sociodemographic and clinical characteristics including past-month substance use. Latent class analyses were conducted by gender to identify groups based on substance use and determine predictors of those classes. Results: Three-class solutions were the optimal fit for both men and women. For both genders, the first subgroup was characterized as Unlikely Users (59.8% women, 52.8% men). Classes 2 and 3 among women were Cannabis/Opioid Users (23.7%) and Stimulant/Opioid Users (13.0%). Among men, Classes 2 and 3 consisted of Alcohol/Cannabis Users (21.9%) and Cannabis/Stimulant/Opioid Users (25.3%). Ever using Suboxone (buprenorphine/naloxone) and depression/anxiety symptoms were significantly linked to substance use group among women, whereas homelessness and employment status were significantly associated with substance use group among men. Conclusions: This study furthers understanding of gender differences in factors associated with continued substance use and distinctive patterns of concurrent substance use that may guide tailored treatments among patients MMT.

Association of Opioid Use Disorder Treatment With Alcohol-Related Acute Events

IMPORTANCE

Persons with opioid use disorder (OUD) and co-occurring alcohol use disorder (AUD) are understudied and undertreated. It is unknown whether the use of medications to treat OUD is associated with reduced risk of alcohol-related morbidity.

OBJECTIVE

To determine whether the use of OUD medications is associated with decreased risk for alcohol-related falls, injuries, and poisonings in persons with OUD with and without co-occurring AUD.

DESIGN, SETTING, AND PARTICIPANTS

This recurrent-event, case-control, cohort study used prescription claims from IBM MarketScan insurance databases from January 1, 2006, to December 31, 2016. The sample included persons aged 12 to 64 years in the US with an OUD diagnosis and taking OUD medication who had at least 1 alcohol-related admission. The unit of observation was person-day. Data analysis was performed from June 26 through September 28, 2020.

EXPOSURES

Days of active OUD medication prescriptions, with either agonist (ie, buprenorphine or methadone) or antagonist (ie, oral or extended-release naltrexone) treatments compared with days without OUD prescriptions.

MAIN OUTCOMES AND MEASURES

The primary outcome was admission for any acute alcohol-related event defined by International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes. Conditional logistic regression was used to compare OUD medication use between days with and without an alcohol-related event. Stratified analyses were conducted between patients with OUD with and without a recent AUD diagnostic code.

RESULTS

There were 8 424 214 person-days of observation time among 13 335 participants who received OUD medications and experienced an alcohol-related admission (mean [SD] age, 33.1 [13.1] years; 5884 female participants [44.1%]). Agonist treatments (buprenorphine and methadone) were associated with reductions in the odds of any alcohol-related acute event compared with nontreatment days, with a 43% reduction for buprenorphine (odds ratio [OR], 0.57; 95% CI, 0.52-0.61) and a 66% reduction for methadone (OR, 0.34; 95% CI, 0.26-0.45). The antagonist treatment naltrexone was associated with reductions in alcohol-related acute events compared with nonmedication days, with a 37% reduction for extended-release naltrexone (OR, 0.63; 95% CI, 0.52-0.76) and a 16% reduction for oral naltrexone (OR, 0.84; 95% CI, 0.76-0.93). Naltrexone use was more prevalent among patients with OUD with recent AUD claims than their peers without AUD claims.

CONCLUSIONS AND RELEVANCE

These findings suggest that OUD medication is associated with fewer admissions for alcohol-related acute events in patients with OUD with co-occurring AUD.

Prevalence of childhood maltreatment among people with opioid use disorder: A systematic review and meta-analysis

BACKGROUND

Experience of childhood maltreatment (CM) is a risk factor for opioid use disorder (OUD). CM is also associated with comorbid mental disorders and poor treatment outcomes among people with OUD. To our knowledge, this is the first systematic review and meta-analysis to estimate the prevalence of CM among people with OUD.

METHODS

We searched MEDLINE, EMBASE, and PsycINFO to identify observational studies that evaluated CM among people with OUD from January 1990 to June 2020. Prevalence of each CM type, sample characteristics, and methodological factors were extracted from each eligible study. Random-effects meta-analyses were used to pool prevalence estimates. Stratified meta-analyses were used to assess heterogeneity.

RESULTS

Of the 6,438 publications identified, 113 studies reported quantitative CM data among people with OUD and 62 studies (k = 62; N = 21,871) were included in primary analyses. Among people with OUD, the estimated prevalence of sexual abuse was 41% (95% CI 36-47%; k = 38) among women and 16% (95% CI 12-20%; k = 25) among men. Among all people with OUD, prevalence estimates were 38% (95% CI 33-44%; k = 48) for physical abuse, 43% (95% CI 38-49%; k = 31) for emotional abuse, 38% (95% CI 30-46%; k = 17) for physical neglect, and 42% (95% CI 32-51%; k = 17) for emotional neglect. Sex, history of injecting drug use, recruitment methods, and method of assessing CM were associated with substantial heterogeneity.

CONCLUSIONS

People with OUD frequently report the experience of CM, supporting the need for trauma-informed interventions among this population. Future research should consider the impact of CM on OUD presentations and when assessment is appropriate, use of validated instruments.

The conundrum of polysubstance overdose

WHAT IS KNOWN AND OBJECTIVE

Treating an opioid overdose using an opioid receptor antagonist (such as naloxone) makes mechanistic sense and can be effective. Unfortunately, the majority of current drug overdose deaths involve polysubstance use (i.e., an opioid plus a non-opioid).

COMMENT

Respiratory depression induced by opioids results from excessive opioid molecules binding to opioid receptors. This effect can be reversed by an opioid receptor antagonist. However, the respiratory depression induced by non-opioid drugs is not due to action at opioid receptors; thus, an opioid receptor antagonist is ineffective in many of these cases. For respiratory depression induced by non-opioids, receptor antagonists are either not available (e.g., for propofol overdose) or there may be attendant risks with their use (e.g., seizures with flumazenil). This gives rise to a need for more effective ways to treat polysubstance overdose.

WHAT IS NEW AND CONCLUSION

A new approach to treating opioid-induced respiratory depression due to drug overdose focuses on agents that stimulate respiratory drive rather than competing for opioid receptors. Such an approach is "agnostic" to the cause of the respiratory depression, so might be a potential way to treat polysubstance overdose.

An Examination of the Feasibility of Detecting Cocaine Use Using Smartwatches

As digital technology increasingly informs clinical trials, novel ways to collect study data in the natural field setting have the potential to enhance the richness of research data. Cocaine use in clinical trials is usually collected via self-report and/or urine drug screen results, both of which have limitations. This article examines the feasibility of developing a wrist-worn device that can detect sufficient physiological data (i.e., heart rate and heart rate variability) to detect cocaine use. This study aimed to develop a wrist-worn device that can be used in the natural field setting among people who use cocaine to collect reliable data (determined by data yield, device wearability, and data quality) that is less obtrusive than chest-based devices used in prior research. The study also aimed to further develop a cocaine use detection algorithm used in previous research with an electrocardiogram on a chestband by adapting it to a photoplethysmography sensor on the wrist-worn device which is more prone to motion artifacts. Results indicate that wrist-based heart rate data collection is feasible and can provide higher data yield than chest-based sensors, as wrist-based devices were also more comfortable and affected participants' daily lives less often than chest-based sensors. When properly worn, wrist-based sensors produced similar quality of heart rate and heart rate variability features to chest-based sensors and matched their performance in automated detection of cocaine use events. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT02915341.

Trends in Poly Drug Use-associated Deaths based on Confirmed Analytical Toxicology Results in Tehran, Iran, in 2011-2016

BACKGROUND

Poly drug use is a public health threat causing morbidity and mortality all over the world. Combined use of licit and illicit drugs is among the possible causes of death. In this retrospective analytical study, we evaluated forensic toxicology analysis results from 2011 to 2016 in Tehran province, Iran.

METHODS

All deaths related to poly drug use and referred to the Legal Medicine Organization, Tehran during the 6-year study period were evaluated. Postmortem samples were analyzed to detect alcohols, and prescription and illicit drugs using headspace gas chromatography (HSGC), high performance liquid chromatography (HPLC), and gas chromatography/mass spectrometry (GC/MS) in a forensic toxicology laboratory. Manner of death, demographic characteristics, and different drug categories in postmortem samples were analyzed.

FINDINGS

A total of 1388 poly drug use-associated deaths were investigated during the 6-year study period. Overall, victims were mostly young men of 20-40 years of age (56.8%). The male to female ratio was 7:16. Methadone (n = 660; 47.6%) and amphetamine type stimulants (ATS) (n = 657; 47.3%) were in the highest category for poly drug use-associated deaths. Moreover, in some cases, opium (n = 458; 32.9%), tramadol (n = 389; 28.0%), and tricyclic antidepressants (n = 151; 10.9%) had been used with other drugs.

CONCLUSION

The present study provides information about poly drug use-associated deaths in Tehran and highlights the major role of substance abuse in death.

Polysubstance use in the U.S. opioid crisis

Interventions to address the U.S. opioid crisis primarily target opioid use, misuse, and addiction, but because the opioid crisis includes multiple substances, the opioid specificity of interventions may limit their ability to address the broader problem of polysubstance use. Overlap of opioids with other substances ranges from shifts among the substances used across the lifespan to simultaneous co-use of substances that span similar and disparate pharmacological categories. Evidence suggests that nonmedical opioid users quite commonly use other drugs, and this polysubstance use contributes to increasing morbidity and mortality. Reasons for adding other substances to opioids include enhancement of the high (additive or synergistic reward), compensation for undesired effects of one drug by taking another, compensation for negative internal states, or a common predisposition that is related to all substance consumption. But consumption of multiple substances may itself have unique effects. To achieve the maximum benefit, addressing the overlap of opioids with multiple other substances is needed across the spectrum of prevention and treatment interventions, overdose reversal, public health surveillance, and research. By addressing the multiple patterns of consumption and the reasons that people mix opioids with other substances, interventions and research may be enhanced.

Polysubstance use and association with opioid use disorder treatment in the US Veterans Health Administration

AIMS

To understand the role of comorbid substance use disorders (SUDs), or polysubstance use, in the treatment of opioid use disorder (OUD), this study compared patients with OUD only to those with additional SUDs and examined association with OUD treatment receipt.

DESIGN, SETTING AND PARTICIPANTS

Retrospective national cohort study of Veterans diagnosed with OUD (n = 65 741) receiving care from the US Veterans Health Administration (VHA) in fiscal year (FY) 2017.

MEASUREMENTS

Patient characteristics were compared among those diagnosed with OUD only versus those with one other SUD (OUD + 1 SUD) and with multiple SUDs (OUD + ≥ 2 SUDs). The study examined the relationship between comorbid SUDs and receipt of buprenorphine, methadone and SUD outpatient treatment during 1-year follow-up, adjusting for patient demographic characteristics and clinical conditions.

FINDINGS

Among the 65 741 Veterans with OUD in FY 2017, 41.2% had OUD only, 22.9% had OUD + 1 SUD and 35.9% had OUD + ≥ 2 SUDs. Common comorbid SUDs included alcohol use disorder (41.3%), cocaine/stimulant use disorder (30.0%) and cannabis use disorder (22.4%). Adjusting for patient characteristics, patients with OUD + 1 SUD [adjusted odds ratio (aOR) = 0.87, 95% confidence interval (CI) = 0.82-0.93] and patients with OUD +≥ 2 SUDs (aOR = 0.65, 95% CI = 0.61-0.69) had lower odds of receiving buprenorphine compared with OUD only patients. There were also lower odds of receiving methadone for patients with OUD + 1 SUD (aOR = 0.91, 95% CI = 0.86-0.97)and for those with OUD + ≥2 SUDs (aOR = 0.79, 95% CI = 0.74-0.84). Patients with OUD + 1 SUD (aOR = 1.85, 95% CI = 1.77-1.93) and patients with OUD + ≥2 SUDs (aOR = 3.25, 95% CI = 3.103.41) were much more likely to have a SUD clinic visit.

CONCLUSIONS

The majority of Veterans in the US Veterans Health Administration diagnosed with opioid use disorder appeared to have at least one comorbid substance use disorder and many have multiple substance use disorders. Despite the higher likelihood of a substance use disorder clinic visit, having a non-opioid substance use disorder is associated with lower likelihood of buprenorphine treatment, suggesting the importance of addressing polysubstance use within efforts to expand treatment for opioid use disorder.

Adults With Opioid and Methamphetamine Co-use Have Lower Odds of Completing Short-Term Residential Treatment Than Other Opioid Co-use Groups: A Retrospective Health Services Study

Objective: There is an increase in persons entering substance use treatment who co-use opioids and methamphetamines in recent years. Co-using these substances may negatively impact treatment retention in the residential setting. We explored predictors of adults completing short-term residential treatment among persons with primary opioid use disorder (OUD) who co-use either alcohol, benzodiazepines, cocaine, or methamphetamines. Methods: This study used the 2019 de-identified, publicly available Treatment Episode Dataset-Discharges. The sample included adults discharged from short-term residential treatment with primary OUD who co-used either alcohol, benzodiazepines, cocaine, or methamphetamines. The final sample size included 24,120 treatment episodes. Univariate statistics were used to describe the sample. Two logistic regression models were used to predict completing treatment. The first logistic regression model included the co-use groups as predictors and the second model added other demographic and treatment-relevant covariates. Results: A slight majority (51.4%) of the sample prematurely discharged from treatment. Compared to the other three co-use groups, the opioid and methamphetamine co-use group had the highest proportion of individuals who were women (45.0%), unemployed (62.5%), current injection drug use (76.0%), living in the Midwest (35.9%), living in the south (33.5%), and living in the west (15.5%). The opioid and methamphetamine co-use group also had the highest proportion of individuals not receiving medications for OUD (84.9%), not having a prior treatment episode (28.7%), and not completing treatment (57.4%). In the final logistic regression model, which included covariates, the opioid and alcohol (OR = 1.18, 95% CI = 1.080-1.287, p < 0.001), opioid and benzodiazepine (OR = 1.33, 95% CI = 1.213-1.455, p < 0.001), and opioid and cocaine (OR = 1.16, 95% CI = 1.075-1.240, p < 0.001) co-use groups had higher odds of completing treatment than the opioid and methamphetamine co-use group. Conclusions: Opioid and methamphetamine co-use may complicate short-term residential treatment retention. Future work should identify effective strategies to retain persons who co-use opioids and methamphetamines in treatment.

Transcranial magnetic stimulation, deep brain stimulation, and other forms of neuromodulation for substance use disorders: Review of modalities and implications for treatment

Given the high prevalence of individuals diagnosed with substance use disorder, along with the elevated rate of relapse following treatment initiation, investigating novel approaches and new modalities for substance use disorder treatment is of vital importance. One such approach involves neuromodulation which has been used therapeutically for neurological and psychiatric disorders and has demonstrated positive preliminary findings for the treatment of substance use disorder. The following article provides a review of several forms of neuromodulation which warrant consideration as potential treatments for substance use disorder. PubMed, PsycINFO, Ovid MEDLINE, and Web of Science were used to identify published articles and clinicaltrials.gov was used to identify currently ongoing or planned studies. Search criteria for Brain Stimulation included the following terminology: transcranial direct current stimulation, transcranial magnetic stimulation, theta burst stimulation, deep brain stimulation, vagus nerve stimulation, trigeminal nerve stimulation, percutaneous nerve field stimulation, auricular nerve stimulation, and low intensity focused ultrasound. Search criteria for Addiction included the following terminology: addiction, substance use disorder, substance-related disorder, cocaine, methamphetamine, amphetamine, alcohol, nicotine, tobacco, smoking, marijuana, cannabis, heroin, opiates, opioids, and hallucinogens. Results revealed that there are currently several forms of neuromodulation, both invasive and non-invasive, which are being investigated for the treatment of substance use disorder. Preliminary findings have demonstrated the potential of these various neuromodulation techniques in improving substance treatment outcomes by reducing those risk factors (e.g. substance craving) associated with relapse. Specifically, transcranial magnetic stimulation has shown the most promise with several well-designed studies supporting the potential for reducing substance craving. Deep brain stimulation has also shown promise, though lacks well-controlled clinical trials to support its efficacy. Transcranial direct current stimulation has also demonstrated promising results though consistently designed, randomized trials are also needed. There are several other forms of neuromodulation which have not yet been investigated clinically but warrant further investigation given their mechanisms and potential efficacy based on findings from other studied indications. In summary, given promising findings in reducing substance use and craving, neuromodulation may provide a non-pharmacological option as a potential treatment and/or treatment augmentation for substance use disorder. Further research investigating neuromodulation, both alone and in combination with already established substance use disorder treatment (e.g. medication treatment), warrants consideration.

The Influence of Co-Occurring Substance Use on the Effectiveness of Opiate Treatment Programs According to Intervention Type

This systematic review describes the influence of co-occurring substance use on the effectiveness of opiate treatment programs. MEDLINE/PubMed, Embase, PsychINFO, and the Cumulative Index to Nursing and Allied Health Literature were searched from database inception to November 28, 2018, to identify eligible opioid treatment studies in the United States that assessed the relationship between co-occurring substance use and treatment outcome (i.e., opioid abstinence and treatment retention). A total of 34 eligible studies were included. Overall, co-occurring substance use was associated with negative treatment outcomes regardless of intervention type. However, patterns varied by substance and intervention type. In particular, co-occurring use of cocaine or marijuana with opioids was associated with reduced treatment retention and opioid abstinence regardless of intervention type. Co-occurring use of amphetamines, compared with no use or reduced use of amphetamines, decreased treatment retention. Co-occurring use of alcohol was both positively and negatively associated with treatment outcomes. One study reported a significant positive association between sedative use and opioid abstinence. Generally, findings suggest that combined interventions reported better health outcomes compared with pharmacological or behavioral intervention studies alone. The findings of this review emphasize the need to comprehensively study and address co-occurring substance use to improve opiate treatment programs.

Interactions between opioids and cannabinoids: Economic demand for opioid/cannabinoid mixtures

BACKGROUND

Opioid abuse remains a significant public health challenge. With continuing emergence of novel psychoactive substances (e.g., synthetic cannabinoids found in "K2" or "spice" preparations), the co-administration of opioids and other novel drugs is likely to become more prevalent, which might increase the risk for abuse and other adverse effects. This study examined whether the synthetic cannabinoid receptor agonist JWH-018 alters the reinforcing effectiveness of the mu opioid receptor agonist remifentanil in rhesus monkeys (n = 4) using economic demand analyses.

METHODS

Lever presses delivered intravenous infusions of a drug or drug mixture according to a fixed-ratio schedule. For each condition, the ratio progressively increased in quarter-log unit steps across sessions yielding a demand curve: consumption (infusions obtained) was plotted as a function of price (fixed-ratio value).

RESULTS

When available alone, remifentanil (0.00032 mg/kg/infusion) occasioned the highest consumption at the lowest cost and highest essential value, while JWH-018 (0.0032 mg/kg/infusion) alone occasioned lower unconstrained demand and essential value. Unconstrained demand for a mixture of remifentanil and JWH-018 was lower than for remifentanil alone, but essential value of the mixture was not significantly different from that of remifentanil alone.

CONCLUSION

These data indicate that synthetic cannabinoids such as JWH-018 might alter some aspects of opioid self-administration (i.e., decreased consumption at the lowest price) but do not enhance reinforcing effectiveness as measured by sensitivity of consumption to increasing costs. Opioid/cannabinoid mixtures do not appear to have greater or lesser abuse potential compared with opioids alone.

Multiple drug use disorder diagnoses among drug-involved hospitalizations in the United States: Results from the 2016 National Inpatient Sample

BACKGROUND

Having more than one drug use disorders (DUDs) is an increasing public health concern, but it has been understudied. The goal of this study is to investigate the prevalence and patterns of coexisting DUD diagnoses among inpatient hospitalizations due to DUD in the United States.

METHODS

Data were from the 2016 National Inpatient Sample and included hospitalizations with a principal DUD diagnosis for patients aged ≥18 years (i.e., drug-involved hospitalizations, unweighted n = 31,707). The DUD diagnosis profile was categorized into three groups: single, two, and three or more DUD diagnoses. Generalized ordered logit models were used to examine correlates of DUD diagnosis groups.

RESULTS

Among drug-involved hospitalizations, approximately 50.1 % had multiple coexisting DUD diagnoses (2 DUD diagnoses, 32.1 %; ≥3 DUD diagnoses, 18.0 %). Particularly, opioid use disorder accounted for 58.6 % of drug-involved hospitalizations. Among specific opioid-involved hospitalizations, about 51.2 % had multiple DUD diagnoses. The most common secondary DUD diagnoses among opioid-involved hospitalizations included cocaine (21.7 %), cannabis (18.5 %), and sedatives (18.1 %). Adjusted analyses showed that being aged 18-25 years (vs. ≥ 26), living in areas with the lowest quartile of household income (vs. highest), and having a secondary diagnosis of mental disorders or tobacco/alcohol use disorder were associated with increased odds of having multiple DUD diagnoses in the total sample and in the opioid subsample.

CONCLUSIONS

Findings suggest that healthcare providers should increase the awareness of multiple DUDs while treating patients with DUD, especially those with opioid use disorder. More research is needed to better characterize treatment needs for patients with multiple DUDs.

From “Codeine Diet” to “Gutter Water”: polydrug use among Nigerian young adults

Purpose

The purpose of this paper is to explore polydrug use and the factors that motivate the use of multiple substances among selected young adults.

Design/methodology/approach

A total of 23 male and female participants (aged 23-29 years) who use illicit drugs and prescription pharmaceuticals for non-medical purposes were recruited through snowball sampling. Qualitative interviews were conducted, and the data were analysed thematically.

Findings

The use of drug “concoctions” and cocktails was widespread among the participants. Some used what they called Codeine Diet (codeine-based cough syrup mixed with a Coca-Cola® product or malt drink), while others took Gutter Water (a cocktail of cannabis, codeine, tramadol, vodka and juice or water). The use of Monkey Tail (a mixture of local gin, cannabis leaves, stems, roots and seeds) and petrol mixed with glue and La Casera® (carbonated soft drink) combined with Tom-Tom® (menthol-flavoured candy) was also revealed. Pleasure, better highs, the need to experience prolonged intoxication and the use of one drug to douse the effects of another substance motivated polysubstance use.

Social implications

The findings revealed that the reasons why codeine-based cough syrups are mixed with soft drinks (Codeine Diet) include avoiding social discrimination and evading law enforcement agencies. Results suggest that these drug use practices require specifically tailored public health interventions. Social stigmatization against substance users and the use of extra-legal measures by the police should be discouraged to facilitate harm reduction.

Originality/value

This study represents the first qualitative research to explore polydrug use among an understudied Nigerian population.

Assessment of Co-Occurring Substance Use During Opiate Treatment Programs in the United States

The effectiveness of opiate treatment programs (OTPs) can be significantly influenced by co-occurring substance use, yet there are no standardized guidelines for assessing the influence of co-occurring substance use on treatment outcomes. In this review, we aim to provide an overview on the status of the assessment of co-occurring substance use during participation in OTPs in the United States. We searched 4 databases-MEDLINE/PubMed, EMBASE, PsychINFO, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL)-from database inception to November 2018 to select relevant publications on OTPs that assessed participants' co-occurring substance use. We used a standardized protocol to extract study, intervention, and co-occurring substance use characteristics. Methodological quality was assessed using the Quality in Prognosis Studies tool. Of the 3,219 titles screened, 614 abstracts and 191 full-text original publications were assessed, leaving 85 eligible articles. Co-occurring substance use was most often assessed during opioid treatments using combined (pharmacological and behavioral) (n = 57 studies) and pharmacological (n = 25 studies) interventions. Cocaine, alcohol, marijuana, and benzodiazepines were frequently measured, while amphetamines and tobacco were rarely assessed. Great variation existed between studies in the timing and measurement of co-occurring substance use, as well as definitions for substances and polysubstance/polydrug use. Inconsistencies in the investigation of co-occurring substance use make comparison of results across studies challenging. Standardized measures and consensus on research on co-occurring substance use is needed to produce the evidence required to develop personalized treatment programs for persons using multiple substances and to inform best-practice guidelines for addressing polydrug use during participation in OTPs.

The Role of Attachment in Poly-Drug Use Disorder: An Overview of the Literature, Recent Findings and Clinical Implications

Background: Substance use disorders (SUDs) represent a worldwide epidemic with extensive costs to the individual and to society. Occasionally described as an attachment disorder, they have been linked to various impairments in self-regulation and social functioning. However, while there have been significant advances in the development and validation of treatment strategies for SUD in recent years, the components of these treatment approaches have yet to be fully explored. The characteristics of polydrug use disorder (PUD) especially need to be addressed in more detail, as this diagnosis is highly common in individuals seeking treatment, while simultaneously being associated with poor treatment success. Aim and Scope: This review aims at further exploring the relevance of attachment in PUD and its treatment. To this end, this review provides a concise summary of relevant theories on the development and treatment of SUD in general, including related parameters of attachment, emotion regulation, and neuroscience. Furthermore, several studies focused specifically on PUD are described in more detail. These studies explored the connections between attachment, personality structure, primary and higher emotions (including spirituality), as well as structural and functional neural parameters in inpatients with PUD as well as in healthy controls. Most notably, the described studies highlight that insecure attachment and impairments in personality structure are present in inpatients with PUD. In addition, these characteristics are paralleled by extensive impairments in white matter integrity, especially in tracts connected to facets of emotion regulation. Conclusions: Based on our findings, we emphasize conceptualization of PUD as an Attachment Disorder, on a behavioral as well as on a neural level. Furthermore, we point out the importance of an integrated bio-psycho-social approach in this research area. Consequently, future studies might more closely focus on the influence of attachment-based interventions on emotion regulation abilities as well as a potentially related neuroplasticity. Neuroplastic changes, which are still rather unexplored, might represent important parameters for the assessment of treatment outcomes especially in long-term SUD treatment.