Stress in the daily lives of cocaine and heroin users: relationship to mood, craving, relapse triggers, and cocaine use

Effectiveness of transcranial alternating current stimulation (tACS) and cognitive bias modification (CBM) in treating anxiety, depression, attentional bias, and drug craving in opioid-dependent patients

INTRODUCTION

Substance Use Disorders (SUDs) pose significant challenges globally, with opiate addiction being particularly prevalent. This study investigates the impact of transcranial alternating current stimulation (tACS) at 10 Hz and individual alpha frequencies (IAF), along with cognitive bias modification (CBM), on drug craving, anxiety, depression, and attention bias in individuals with SUDs.

METHODS

Participants (N = 72) were allocated to control, tACS 10 Hz, tACS IAF, Sham, CBM, and CBM + tACS groups (n = 12 each). Measures included demographic questionnaires, dot probe tasks, Desires for Drug Questionnaires (DDQ), DASS-21 assessments, and Visual Analog Scale (VAS) for craving. Mixed repeated measures ANOVA were conducted, revealing significant interactions (TIME*GROUP), indicating differential treatment effects over time.

FINDINGS

The study involved 72 substance abusers divided into six groups: control, tACS.10 Hz, tACS Real, Sham, CBM, and CBM + tACS. Demographic variables were similar among groups. Mixed ANOVA showed significant TIME*GROUP interactions for all assessments. Significant differences were found in anxiety, drug dependence, and visual analog scale measures.

CONCLUSION

In brief, although using tACS and CBM separately didn't lead to significant decreases in substance-related issues, employing them together demonstrated potential. This research underscores how the brain can adapt to electrical stimulation and emphasizes the importance of delving deeper into treating SUDs. However, limitations such as limited participant availability and the reliance on verbal craving induction indicate the necessity for more comprehensive study designs and varied assessment methods in future investigations.

Daily profiles of nondrug reward and their association with daily outcomes for people in recovery from opioid use disorder: An application of latent profile analysis applied to intensive longitudinal data

INTRODUCTION

Daily rewarding experiences not involving drugs are complex and may differentially support recovery from addiction. Rarely has nondrug reward, and its multiple facets (i.e. anticipation, meaning etc.), been examined in daily life-this could uncover the acute benefits of different components of nondrug reward on daily recovery outcomes.

METHODS

153 adults in recovery from OUD receiving opioid agonist treatment (M age=41.1, SD=9.5; 57 % women; 84 % white) completed daily diaries for three weeks (2067 person-days), answering 7 continuous items about appraisals of nondrug rewards (e.g., meaning, reward, and anticipation). Item responses were used as indicators in a latent profile analysis. Daily latent profiles of nondrug reward were tested for their association with recovery outcomes (quality of life, mood, craving and use) using robust standard errors to adjust for the multilevel data structure.

RESULTS

The selected model had four latent profiles (% of days): Highly Anticipated-Rewarding (35 %), Moderately Rewarding (31 %), Minimally Rewarding-Unplanned (22 %), and Highly Rewarding-Unplanned profile (12 %). Relative to the Moderately Rewarding profile, Highly Anticipated-Rewarding was associated with greater positive mood and quality of life and lower negative mood and low-arousal moods. People with more days in the Highly Anticipated-Rewarding Profile (vs. Moderately Rewarding) were less likely to use or crave opioids.

CONCLUSION

Greater meaning, reward, and anticipation (including planning) across indicators within profiles were associated with the best recovery outcomes. Latent profile analysis applied to intensive longitudinal data offers an innovative methodological approach for simultaneously assessing multiple daily protective factors that together may differentially promote recovery.

Delineating anticipatory arousal from reward consumption: evaluating fixed-intervals in cocaine seeking-taking response chains

RATIONALE

Anticipation is a critical antecedent to drug use, in which the prospect of imminent drug availability can potently motivate instrumental actions directed to procure it. Models that capture the behavioral dynamics that precede drug access may allow for the dissociation of key neural mechanisms underlying appetitive or consummatory processes in drug self-administration.

OBJECTIVES

We aimed to isolate measurements attributed to the procurement and consumption of a reward by defining distinct actions for each using a chain-schedule of reinforcement.

METHODS

Male Long-Evans rats were trained to self-administer cocaine or saccharin under a chained schedule of reinforcement (FI-FR) in order to dissociate appetitive ('seeking') from consummatory ('taking') behaviors. Completion of a fixed-interval (5 min) was followed by 5 min of continuously reinforced responding (FR1) on another lever.

RESULTS

The FI-FR chain procedure appears to provide sensitive and dissociable dimensions of cocaine self-administration within a single experimental session. Importantly, we demonstrate that responding during the FI (i.e., seeking) link tracks with the incentive value of anticipated reward access - whereby response rates corresponded to expected reward magnitude, degree of reward-specific satiety, and general motivational state.

CONCLUSIONS

The FI component is a sensitive and reliable index of motivational changes induced by either the extrinsic incentive value of reinforcement (i.e., anticipated dose) or intrinsic motive states (i.e., satiety or deprivation). This procedure provides a valuable tool for interrogating the neural dynamics of drug-seeking and -taking behavior, in isolation.

Fos expression in the periaqueductal gray, but not the ventromedial hypothalamus, is correlated with psychosocial stress-induced cocaine-seeking behavior in rats

Psychosocial stressors are known to promote cocaine craving and relapse in humans but are infrequently employed in preclinical relapse models. Consequently, the underlying neural circuitry by which these stressors drive cocaine seeking has not been thoroughly explored. Using Fos expression analyses, we sought to examine whether the ventromedial hypothalamus (VMH) or periaqueductal gray (PAG), two critical components of the brain's hypothalamic defense system, are activated during psychosocial stress-induced cocaine seeking. Adult male and female rats self-administered cocaine (0.5 mg/kg/inf IV, fixed-ratio 1 schedule, 2 h/session) over 20 sessions. On sessions 11, 14, 17, and 20, a tactile cue was present in the operant chamber that signaled impending social defeat stress (n=16, 8/sex), footshock stress (n=12, 6/sex), or a no-stress control condition (n=12, 6/sex) immediately after the session's conclusion. Responding was subsequently extinguished, and rats were tested for reinstatement of cocaine seeking during re-exposure to the tactile cue that signaled their impending stress/no-stress post-session event. All experimental groups displayed significant reinstatement of cocaine seeking, but Fos analyses indicated that neural activity within the rostrolateral PAG (rPAGl) was selectively correlated with cocaine-seeking magnitude in the socially-defeated rats. rPAGl activation was also associated with active-defense coping behaviors during social defeat encounters and with Fos expression in prelimbic prefrontal cortex and orexin-negative cells of the lateral hypothalamus/perifornical area in males, but not females. These findings suggest a potentially novel role for the rPAGl in psychosocial stress-induced cocaine seeking, perhaps in a sex-dependent manner.

Evaluation of a digital tool for detecting stress and craving in SUD recovery: An observational trial of accuracy and engagement

BACKGROUND

Digital health interventions offer opportunities to expand access to substance use disorder (SUD) treatment, collect objective real-time data, and deliver just-in-time interventions: however implementation has been limited. RAE (Realize, Analyze, Engage) Health is a digital tool which uses continuous physiologic data to detect high risk behavioral states (stress and craving) during SUD recovery.

METHODS

This was an observational study to evaluate the digital stress and craving detection during outpatient SUD treatment. Participants were asked to use the RAE Health app, wear a commercial-grade wrist sensor over a 30-day period. They were asked to self-report stress and craving, at which time were offered brief in-app de-escalation tools. Supervised machine learning algorithms were applied retrospectively to wearable sensor data obtained to develop group-based digital biomarkers for stress and craving. Engagement was assessed by number of days of utilization, and number of hours in a given day of connection.

RESULTS

Sixty percent of participants (N=30) completed the 30-day protocol. The model detected stress and craving correctly 76 % and 69 % of the time, respectively, but with false positive rates of 33 % and 28 % respectively. All models performed close to previously validated models from a research grade sensor. Participants used the app for a mean of 14.2 days (SD 10.1) and 11.7 h per day (SD 8.2). Anxiety disorders were associated with higher mean hours per day connected, and return to drug use events were associated with lower mean hours per day connected.

CONCLUSIONS

Future work should explore the effect of similar digital health systems on treatment outcomes and the optimal dose of digital interventions needed to make a clinically significant impact.

Dynamic alterations in gene co-expression networks and gene-transcript associations characterize co-morbidities in cocaine use disorder

Background-

Individuals with cocaine use disorder (CUD) who attempt abstinence experience craving and relapse, which poses challenges in treatment. Longitudinal studies linking behavioral manifestations in CUD to the blood transcriptome in living individuals are limited. Therefore, we investigated the connection between drug use behaviors during abstinence with blood transcriptomics.

Methods-

We conducted a comprehensive longitudinal study involving 12 subjects (9 males, 3 females) with CUD and RNA sequencing on blood collected at a drug-free baseline, and 3, 6 & 9 months thereafter. We categorized subjects into 2 responder groups (high-low) based on scores of drug use variables, and 3 responder groups (low-intermediate-high) on days of abstinence. We investigated differential expression and gene-transcript associations across responder groups at each time point. Lastly, we examined genes that are both co-expressed and showed dynamic expression with time.

Results-

Genes with significant transcript associations between high and. intermediate days of abstinence at 9 months were notably enriched for cannabis use disorder, drinks weekly, and coronary artery disease risk genes. Time-specific gene co-expression analysis prioritized transcripts related to immune processes, cell cycle, RNA-protein synthesis, and second messenger signaling for days of abstinence.

Conclusion-

We demonstrate that abstinence reflects robust changes in drug use behaviors and the blood transcriptome in CUD. We also highlight the importance of longitudinal studies to capture complex biological processes during abstinence in CUD.

Serum brain-derived neurotrophic factor in relation to craving and duration of abstinence in patients with heroin dependence-A case-control study

BACKGROUND AND OBJECTIVES

Addiction is a chronic disorder that comes with emotional and financial burdens. Several neurobiological factors were correlated to opiate-use disorder which is brain-derived neurotrophic factor (BDNF). BDNF has been found to be involved in long-term potentiation of synaptic strength, a mechanism that is thought to motivate both natural adaption mechanisms as well as the development of addictive behavior. In this study, we aimed to address the relation between BDNF serum level and heroin craving and the effect of duration of abstinence on them.

METHODS

A case study was conducted on 80 subjects from Kasr Al-Ainy Psychiatry and Addiction Treatment Hospital with a history of heroin dependence and were divided into two groups: Group A had 40 active heroin-dependent subjects while in Group B, 40 subjects with 1-year heroin abstinence. Severity of addiction was assessed by the addiction severity index, heroin craving was measured by Brief Substance Craving Scale and serum BDNF level was investigated using an enzyme-linked immunosorbent assay.

RESULTS

The findings show that active heroin users had significantly higher serum BDNF which is associated with high heroin craving in comparison to the abstinent group.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

This study revealed a significant positive correlation between serum BDNF levels and craving in active heroin users versus 1-year abstinent subjects. It is the first study to address the relationship between craving and serum BDNF level in a 1-year abstinent participants. These findings help to determine the brain alterations associated with illness and recovery in heroin dependence.

Discriminating cocaine use from other sympathomimetics using wearable electrocardiographic (ECG) sensors

BACKGROUND

Our group has established the feasibility of using on-body electrocardiographic (ECG) sensors to detect cocaine use in the human laboratory. The purpose of the current study was to test whether ECG sensors and features are capable of discriminating cocaine use from other non-cocaine sympathomimetics.

METHODS

Eleven subjects with cocaine use disorder wore the Zephyr BioHarness™ 3 chest band under six experimental (drug and non-drug) conditions, including 1) laboratory, intravenous cocaine self-administration, 2) after a single oral dose of methylphenidate, 3) during aerobic exercise, 4) during tobacco use (N=7 who smoked tobacco), and 5) during routine activities of daily inpatient living (unit activity). Three ECG-derived feature sets served as primary outcome measures, including 1) the RR interval (i.e., heart rate), 2) a group of ECG interval proxies (i.e., PR, QS, QT and QTc intervals), and 3) the full ECG waveform. Discriminatory power between cocaine and non-cocaine conditions for each of the three outcomes measures was expressed as the area under the receiver operating characteristics (AUROC) curve.

RESULTS

All three outcomes successfully discriminated cocaine use from unit activity, exercise, tobacco, and methylphenidate conditions with a mean AUROC values ranging from 0.66 to 0.99 and with least squares means values all statistically different/higher than 0.5 among all subjects [F(3, 99) = 3.38, p =0.02] and among those with tobacco use [F(4, 84) = 5.39, p = 0.0007].

CONCLUSIONS

These preliminary results support discriminatory power of wearable ECG sensors for detecting cocaine use.

Role of mesolimbic cannabinoid receptor 1 in stress-driven increases in cocaine self-administration in male rats

Stress is prevalent in the lives of those with substance use disorders (SUDs) and influences SUD outcomes. Understanding the neurobiological mechanisms through which stress promotes drug use is important for the development of effective SUD interventions. We have developed a model wherein exposure to a stressor, uncontrollable electric footshock, daily at the time of cocaine self-administration escalates intake in male rats. Here we test the hypothesis that stress-induced escalation of cocaine self-administration requires the CB1 cannabinoid receptor. Male Sprague-Dawley rats self-administered cocaine (0.5 mg/kg/inf, i.v.) during 2-h sessions comprised of four 30-min self-administration components separated by 5-min shock sequences or 5-min shock-free periods for 14 days. Footshock produced an escalation of cocaine self-administration that persisted following shock removal. Systemic administration of the cannabinoid receptor type 1 (CB1R) antagonist/inverse agonist, AM251, attenuated cocaine intake only in rats with a history of stress. This effect was localized to the mesolimbic system, as intra-nucleus accumbens (NAc) shell and intra-ventral tegmental area (VTA) micro-infusions of AM251 attenuated cocaine intake only in stress-escalated rats. Cocaine self-administration, regardless of stress history, increased CB1R binding site density in the VTA, but not NAc shell. Following extinction, cocaine-primed reinstatement (10 mg/kg, ip) was increased in rats with prior footshock during self-administration. AM251 attenuated reinstatement only in rats with a stress history. Altogether, these data demonstrate that mesolimbic CB1Rs are required to escalate intake and heighten relapse susceptibility and suggest that repeated stress at the time of cocaine use regulates mesolimbic CB1R activity through a currently unknown mechanism.

Health Outcomes by Neighborhood (HON): Effects of Neighborhood, Social Instability, and Health Factors on 12-Month Trajectories of Substance-Use Disorder Symptoms

BACKGROUND

Previous studies have shown that environment and health can influence drug use trajectories and the effects of substance use disorder (SUD) treatments. We hypothesized that trajectories of drug use-related problems, based on changes in DSM-5 symptoms, would vary by type(s) of drugs used, health factors, and neighborhood characteristics.

METHODS

We assessed mental and physical health, stress, social instability, neighborhood characteristics (disorderliness and home value), and DSM-5 symptom counts at two study visits, 12 months apart, in a community sample (baseline N = 735) in Baltimore, MD. Three prominent categories of drug-use trajectory were identified with K-means cluster analysis of symptom counts: Persistent (4 or more symptoms at both visits or at Visit 2), Improved (decrease from 4 or more symptoms at Visit 1 to 3 or fewer symptoms at Visit 2), and Low-Stable (3 or fewer symptoms at both visits). Baseline health and neighborhood measures were tested as predictors of trajectory in mediation and moderation models.

RESULTS

Among people with current opioid- and/or stimulant-use, odds of an Improved trajectory were (1) decreased with neighborhood disorder and social instability, or (2) increased with home value and social instability. Odds of a Low-Stable trajectory were decreased by social instability and stress but increased in those who were older or self-identified as white.

CONCLUSIONS

Trajectories of drug use-related problems are influenced by sociodemographic variables, neighborhood factors, and health. Assessing DSM-5 symptom counts as an outcome measure may be valuable in monitoring or predicting long-term trajectories and treatment effectiveness.

Intentional use of both opioids and cocaine in the United States

The combination of opioids and cocaine has been increasingly implicated in overdose fatalities, but it is unknown how much is intentional vs. fentanyl-adulterated drug supply. 2017-2019 data from the nationally representative National Survey on Drug Use and Health (NSDUH) was used. Variables included sociodemographics, health, and 30-day drug use. Opioid use captured heroin, and prescription pain reliever use not according to own doctor. Modified Poisson regressions were used to estimate prevalence ratios (PRs) for variables associated with opioid and cocaine use. Among the 167,444 responders, 817(0.49%) reported use of opioids on a regular or daily basis. Of these, 28% used cocaine ≥1 of prior 30 days, 11% >1 day. Of 332(0.20%) who used cocaine on a regular/daily basis, 48% used opioids ≥1 of prior 30 days, 25% >1 day. People with serious psychological distress were >6 times as likely to use both opioids and cocaine regularly/daily (PR = 6.48; 95% CI = [2.82-14.90]) and people who have never been married were 4 times as likely (PR = 4.17; 95% CI = [1.18-14.75]). Compared to those living in a small metropolitan region, people living in a large metropolitan region were >3 times as likely (PR = 3.29; 95% CI = [1.43-7.58]) and the unemployed were twice as likely (PR = 1.96; 95% CI = [1.03-3.73]). People with post-high school education were 53% less likely to use opioids and cocaine at least occasionally (PR = 0.47; 95% CI = [0.26-0.86]). People who use opioids or cocaine commonly choose to use the other. Knowing the characteristics of those most likely to use both should guide interventions for prevention and harm reduction.

Sex differences in cocaine self-administration by Wistar rats after predator odor exposure

Traumatic stress disorders are defined in part by persistent avoidance of trauma-related contexts. Our lab uses a preclinical model of traumatic stress using predator odor (i.e., bobcat urine) in which some but not all rats exhibit persistent avoidance of odor-paired stimuli, similar to what is seen in humans. Bobcat urine exposure increases alcohol consumption in male Avoider rats, but it has not been tested for its effects on intake of other drugs. Here, we tested the effect of bobcat urine exposure on cocaine self-administration in adult male and female Wistar rats. We did not observe any effect of bobcat urine exposure on cocaine self-administration in male or female rats. We observed that (1) female rats with long access (6 hours) to cocaine self-administer more cocaine than long-access males, (2) long-access males and females exhibit escalation of cocaine intake over time, (3) stressed rats gain less weight than unstressed rats following acute predator odor exposure, (4) baseline cocaine self-administration is predictive of subsequent cocaine self-administration. The results of this study may inform future work on predator odor effects on cocaine self-administration.

Characteristics of Stress Sensitivity in Heroin Use Disorder Patients during Their Opioid Agonist Treatment

In the present study, performed on a sample of Heroin Use Disorder (HUD) patients undergoing Opioid Agonist Treatment (OAT), we attempted to explore the relationships between stress sensitivity and heroin addiction-related clinical aspects. HUD patients' stress sensitivity was evaluated with the Heroin/PTSD-Spectrum questionnaire (H/PSTD-S). The Drug Addiction History Questionnaire (DAH-Q), the Symptomatological Check List-90 (SCL-90), and The Behavioural Covariate of Heroin Craving inventory (CRAV-HERO) were all used, as were the Deltito Subjective Wellness Scale (D-SWS), a self-report scale evaluating subjective well-being; the Cocaine Problem Severity Index (CPSI), a questionnaire determining the extent of a cocaine problem; and the Marijuana Craving Questionnaire (MC-Q), an instrument assessing craving for cannabinoids. We checked correlations between stress sensitivity and the extent of HUD clinical features and compared patients with and without problematic stress sensitivity. H/PTSD-S was positively correlated with patients' income, altered mental status, legal problems, the lifetime different treatments index, the current treatment load index, and all SCL-90 indexes and factors. Regarding subjective well-being, stress sensitivity negatively correlated with the contrast best week (last five years) index. Patients with high-stress sensitivity were females with a low income. They exhibited a more severe mental status at treatment entry, greater difficulty in working adaptation, and legal problems during treatment. Additionally, these patients showed a higher level of psychopathology, more impairment in well-being, and more risky behaviours during treatment. Stress sensitivity, as H/PTSD-S, must be considered an outcome of HUD. HUD's addiction history and clinical features are significant risk factors for H/PTSD-S. Therefore, social and behavioural impairment in HUD patients could be considered the clinical expression of the H/PTSD spectrum. In summary, the long-term outcome of HUD is not represented by drug-taking behaviours. Rather, the inability to cope with the contingent environmental conditions is the key feature of such a disorder. H/PTSD-S, therefore, should be seen as a syndrome caused by an acquired inability (increased salience) concerning regular (daily) life events.

Using ecological momentary assessments of negative affect and craving during residential opioid use disorder treatment to predict patients' relapse to substance use

BACKGROUND

Negative affect (NA) and craving are often independently examined as precipitators of relapse among individuals with substance use disorders, including opioid use disorder (OUD). Recent ecological momentary assessment (EMA) research has revealed that NA and craving frequently co-occur within individuals. Yet we know little about the general patterns of, and variability in, within-person associations between NA and craving, as well as whether the nature and degree of within-person NA-craving coupling predicts post-treatment time-to-relapse.

METHODS

Seventy-three patients (77 % male, Mage = 30.10, Range = 19-61) in residential treatment for OUD took part in a 12-day, 4× daily smartphone-based EMA study. Linear mixed-effects models tested within-person, day-level associations between self-reported NA and craving during treatment. The study used Person-specific slopes (i.e., average within-person NA-craving coupling for each participant) estimated from the mixed-effects model in survival analyses with Cox proportional hazards regression models to determine if between-person differences in the within-person coupling predicted post-treatment time-to-relapse (operationalized as the return to problematic use of any substance except tobacco), and whether this prediction was similar across patients' average levels of NA and craving intensity. The study monitored relapse through a combination of hair samples and reports from patients or alternative contacts via a voice response system twice a month for up to 120 days or more following discharge.

RESULTS

Among the 61 participants with time-to-relapse data, those with stronger positive within-person NA-craving coupling on average during residential OUD treatment had a lower hazard of relapsing (slower time to relapse) post-treatment than participants with weaker NA-craving slopes. The significant association held after controlling for interindividual differences in age, sex, and average levels of NA and craving intensity. Average NA and craving intensity did not moderate the association between NA-craving coupling and time-to-relapse.

CONCLUSIONS

Interindividual differences in average within-person, day-level NA-craving coupling during residential treatment predict OUD patients' post-treatment time-to-relapse.

Sex differences in cocaine self-administration by Wistar rats after predator odor exposure

Traumatic stress disorders are defined in part by persistent avoidance of trauma-related contexts. Our lab uses a preclinical model of traumatic stress using predator odor (i.e., bobcat urine) in which some but not all rats exhibit persistent avoidance of odor-paired stimuli, similar to what is seen in humans. Bobcat urine exposure increases alcohol consumption in male Avoider rats, but it has not been tested for its effects on intake of other drugs. Here, we tested the effect of bobcat urine exposure on cocaine self-administration in adult male and female Wistar rats. We did not observe any effect of bobcat urine exposure on cocaine self-administration in male or female rats. We observed that (1) female rats with long access (6 hours) to cocaine self-administer more cocaine than long-access males, (2) long-access males and females exhibit escalation of cocaine intake over time, (3) stressed rats gain less weight than unstressed rats following acute predator odor exposure, (4) baseline cocaine self-administration is predictive of subsequent cocaine self-administration. The results of this study may inform future work on predator odor effects on cocaine self-administration.

Therapeutics for Substance-Using Women: The Need to Elucidate Sex-Specific Targets for Better-Tailored Treatments

In the last decade, alcohol consumption in the US has risen by 84% in women compared with 35% in men. Furthermore, research has shown that sex- and gender-related differences may disadvantage women in terms of developing a range of psychological, cognitive, and medical problems considerably earlier in their drinking history than men, and despite consuming a similar quantity of substances. While this "telescoping" process has been acknowledged in the literature, a concomitant understanding of the underlying biobehavioral mechanisms, and an increase in the development of specific treatments tailored to women, has not occurred. In the current chapter we focus on understanding why the need for personalized, sex-specific medications is imperative, and highlight some of the potential sex-specific gonadal and stress-related adaptations underpinning the accelerated progress from controlled to compulsive drug and alcohol seeking in women. We additionally discuss the efficacy of these mechanisms as novel targets for medications development, using exogenous progesterone and guanfacine as examples. Finally, we assess some of the challenges faced and progress made in terms of developing innovative medications in women. We suggest that agents such as exogenous progesterone and adrenergic medications, such as guanfacine, may provide some efficacy in terms of attenuating stress-induced craving for several substances, as well as improving the ability to emotionally regulate in the face of stress, preferentially in women. However, to fully leverage the potential of these therapeutics in substance-using women, greater focus needs to the placed on reducing barriers to treatment and research by encouraging women into clinical trials.

Corticotropin releasing factor and drug seeking in substance use disorders: Preclinical evidence and translational limitations

The neuropeptide, corticotropin releasing factor (CRF), has been an enigmatic target for the development of medications aimed at treating stress-related disorders. Despite a large body of evidence from preclinical studies in rodents demonstrating that CRF receptor antagonists prevent stressor-induced drug seeking, medications targeting the CRF-R1 have failed in clinical trials. Here, we provide an overview of the abundant findings from preclinical rodent studies suggesting that CRF signaling is involved in stressor-induced relapse. The scientific literature that has defined the receptors, mechanisms and neurocircuits through which CRF contributes to stressor-induced reinstatement of drug seeking following self-administration and conditioned place preference in rodents is reviewed. Evidence that CRF signaling is recruited with repeated drug use in a manner that heightens susceptibility to stressor-induced drug seeking in rodents is presented. Factors that may determine the influence of CRF signaling in substance use disorders, including developmental windows, biological sex, and genetics are examined. Finally, we discuss the translational failure of medications targeting CRF signaling as interventions for substance use disorders and other stress-related conditions. We conclude that new perspectives and research directions are needed to unravel the mysterious role of CRF in substance use disorders.

Real-time momentary mood as a predictor of college students' prescription drug misuse in daily life: Direct links and the moderating role of background mental health

The present study addressed calls for research to identify real-time predictors of prescription drug misuse (Schepis et al., 2020) by testing young adults' momentary reports of their negative mood and positive mood as predictors of event-level misuse in daily life. We implemented a 28-day ecological momentary assessment (EMA) procedure that collected individuals' mood and other contextual experiences in moments preceding prescription drug misuse. Consistent with models of problematic substance use as a means to reduce negativity (Khantzian, 1997), results from hierarchical generalized linear modeling (HGLM) indicated within-person links between higher than usual negative mood and greater likelihood of prescription misuse in daily life. Contrary to the hypothesis, misuse was also more likely when preceded by elevated positive mood. We found consistent support for the hypothesized between-person effects, with prescription misuse in daily life associated with higher average levels of negative mood, and lower average levels of positive mood, across the reporting period. We further predicted that individuals reporting greater levels of social anxiety, depression, and externalizing symptoms would evidence stronger links between their momentary negative mood and prescription misuse. Partial support for this moderation hypothesis was found, with the positive within-person link between negative mood and prescription misuse significantly stronger among individuals higher (vs. lower) on social anxiety and depression. Results provide support for intricate connections between young adults' momentary mood, mental health symptoms, and prescription drug misuse. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Family members' experiences of caring for a relative with substance-induced psychosis disorder

BACKGROUND

 When there is a lack of resources in the community to support deinstitutionalisation, family members of a relative diagnosed with substance-induced psychosis disorder (SIPD) are the most affected and vulnerable. Nevertheless, family members' care is still largely unacknowledged in the mental health sector in low- and middle-income countries. Furthermore, no prior research could be found on family members' experiences caring for a relative with SIPD in Giyani, Limpopo province, South Africa.

OBJECTIVES

 To explore and describe family members' experiences caring for a relative with SIPD.

METHOD

 The study employed a qualitative research design using interpretative phenomenological analysis as the research method. Telephonic interviews were conducted and analysed. Eight family members were selected to participate in the study using a purposive sampling technique.

RESULTS

 The analysis of data led to the emergence of the following themes: family members experienced caring for a relative with SIPD as a destabilising responsibility; they experienced acceptance and support from significant others and the community and solace in prayer. Participants also expressed they experienced a need for support from government structures in order to care for a relative with SIPD.

CONCLUSION

 The study's findings highlighted the family members' experiences of caring for a relative with SIPD and the role of the family, community and government structures in caring for an individual with SIPD. It is evident from the challenges experienced that the family members need external interventions to develop healthy coping strategies.Contribution: This study adds knowledge to nursing practice, nursing education and nursing research by promoting effective coping amongst family members caring for a relative with SIPD.

Prefrontal cortical response to natural rewards and self-reported anhedonia are associated with greater craving among recently withdrawn patients in residential treatment for opioid use disorder

Both anhedonia and craving are common among patients with opioid use disorder (OUD), and are associated with vulnerability to relapse. Although these constructs are theoretically linked relatively few studies have examined them together. In the current study, recently withdrawn patients (N = 71) in residential treatment for prescription OUD underwent a cue reactivity paradigm while being monitored with functional near-infrared spectroscopy (fNIRS). Patients also self-reported symptoms of anhedonia via the Snaith-Hamilton Pleasure Scale (SHAPS), while smartphone-based ecological momentary assessments (EMA) were used to measure craving levels. On average, lower right prefrontal cortex (PFC) activity in response to positive social stimuli was associated with higher craving (β = - 2.87; S.E. = 1.23; p = 0.02). Self-reported anhedonia moderated the association between PFC activity and craving (β = - 1.02; S.E. = 0.48; p = 0.04), such that patients with two or more anhedonic symptoms had a significant and stronger negative association between PFC activation to hedonically positive images and craving, compared to patients with fewer than two anhedonic symptoms, among whom the association was not significant. This finding provides evidence that higher levels of anhedonia among patients in residential treatment for OUD are associated with a stronger link between lower PFC response to positive social experiences and higher levels of craving, potentially increasing overall vulnerability to relapse.

Cue-induced cocaine craving enhances psychosocial stress and vice versa in chronic cocaine users

Stress and craving, it has been found, contribute to the development and maintenance of and relapse in cocaine use disorder. Chronic cocaine users (CU), previous research has shown, display altered physiological responses to psychosocial stress and increased vegetative responding to substance-related cues. However, how psychosocial stress and cue-induced craving interact in relation to the CU's physiological responses remains largely unknown. We thus investigated the interaction between acute psychosocial stress and cocaine-cue-related reactivity in 47 CU and 38 controls. In a crossed and balanced design, the participants were randomly exposed to a video-based cocaine-cue paradigm and the Trier Social Stress Test (TSST) or vice versa to investigate possible mutually augmenting effects of both stressors on physiological stress responses. Over the course of the experimental procedure, plasma cortisol, ACTH, noradrenaline, subjective stress, and craving were assessed repeatedly. To estimate the responses during the cocaine-cue paradigm and TSST, growth models and discontinuous growth models were used. Overall, though both groups did not differ in their endocrinological responses to the TSST, CU displayed lower ACTH levels at baseline. The TSST did not elevate craving in CU, but when the cocaine-cue video was shown first, CU displayed an enhanced cortisol response to the subsequent TSST. In CU, cocaine-cues robustly evoked craving but no physiological stress response, while cue-induced craving was intensified after the TSST. Taken together, though CU did not show an altered acute stress response during the TSST, stress and craving together seemed to have mutually augmenting effects on their stress response.

Academic factors associated with college students' prescription stimulant misuse in daily life: An ecological analysis of multiple levels

ObjectiveTo identify academic factors pertaining to college students, calendar timing, and particular moments that are uniquely associated with elevated likelihood of prescription stimulant misuse (intentions and actual behavior) in daily life. Participants: Participants were 297 freshmen and sophomores at a large public university in the United States in 2017-2019. Methods: Participants completed survey measures during lab visits and ecological momentary assessment procedures in daily life. Hypotheses were tested using multilevel models that accounted for the nested data and demographic covariates. Results: Student, calendar-based, and momentary academic factors were uniquely associated with stimulant misuse intentions in daily life. Real-time academic events, beyond the proportion of academic events experienced, emerged as a robust predictor of misuse behavior. Within-person links between real-time momentary predictors and misuse behavior were moderated by finals week timing. Conclusions: Findings offer implications for prevention and intervention strategies for college students at risk for prescription drug misuse.

Intra-individual variability and stability of affect and craving among individuals receiving medication treatment for opioid use disorder

Affect and craving are dynamic processes that are clinically relevant in opioid use disorder (OUD) treatment, and can be quantified in terms of intra-individual variability and stability. The purpose of the present analysis was to explore associations between opioid use and variability and stability of affect and craving among individuals receiving medication treatment for OUD (MOUD). Adults (N = 224) with OUD in outpatient methadone or buprenorphine treatment completed ecological momentary assessment (EMA) prompts assessing positive affect, negative affect, opioid craving, and opioid use. Dynamic structural equation modeling (DSEM) was used to quantify person-level indices of magnitude and stability of change. Beta regression was used to examine associations between intra-individual variability and stability and proportion of opioid-use days, when controlling for overall intensity of affect and craving. Results suggested that greater magnitude of craving variability was associated with opioid use on a greater proportion of days, particularly among individuals with lower average craving. Low average positive affect was also associated with higher proportion of days of use. Individuals who experience substantial craving variability in the context of lower average craving may be particularly vulnerable to opioid use during treatment. Ongoing assessment of craving may be useful in identifying treatment needs. Examining correlates of intra-individual variability and stability in MOUD treatment remains a relevant direction for future work.

Examining Within- and Between-Person Facets of Negative Affect and Associations with Daily Craving Among Young Adults in Substance Use Disorder Recovery

The role of negative affect in precipitating drug craving and relapse among young adults in recovery from substance use disorder (SUD) is well documented. However, most studies focus on negative affect as a trait-level congregate of multiple negative emotion states. The present study examined the associations between specific facets of negative affect, college stressors, and craving among young adult college students in SUD recovery. Data were drawn from a three-week daily diary study of 50 students participating in a collegiate recovery community at a U.S. university (M age = 21.42, 76% males). At the within-person level, craving was higher on days when young adults experienced higher than usual anger, fear, and sadness, but not guilt. At the between-person level, individuals higher in agitation reported greater levels of craving on average. Moderation analyses further showed that college stressors heightened the within-person association between anger and craving. Findings demonstrate that negative affect is not monolithic and that its different aspects are uniquely associated with craving at both between- and within-person levels. Findings from this study could guide collegiate SUD recovery programs that wish to provide greater support to their members by helping them identify both individual- and time-specific relapse risks, such as generally high levels of agitation or days when anger, fear, or sadness are higher than usual for a particular individual. Our findings also suggest that future research should consider distinct features and implications of affective structures at between- and within-person levels, and how these may be uniquely associated with craving.

A neuroeconomic signature of opioid craving: How fluctuations in craving bias drug-related and nondrug-related value

How does craving bias decisions to pursue drugs over other valuable, and healthier, alternatives in addiction? To address this question, we measured the in-the-moment economic decisions of people with opioid use disorder as they experienced craving, shortly after receiving their scheduled opioid maintenance medication and ~24 h later. We found that higher cravers had higher drug-related valuation, and that moments of higher craving within-person also led to higher drug-related valuation. When experiencing increased opioid craving, participants were willing to pay more for personalized consumer items and foods more closely related to their drug use, but not for alternative "nondrug-related" but equally desirable options. This selective increase in value with craving was greater when the drug-related options were offered in higher quantities and was separable from the effects of other fluctuating psychological states like negative mood. These findings suggest that craving narrows and focuses economic motivation toward the object of craving by selectively and multiplicatively amplifying perceived value along a "drug relatedness" dimension.

Determinantes intermedios de la salud en personas institucionalizadas reincidentes en el consumo de sustancias psicoactivas

Objetivo Caracterizar los determinantes intermedios de la salud en consumidores de sustancias psicoactivas (SPA) reincidentes que están siendo atendidos en un centro de rehabilitación (UNIPSSAM IPS) de la ciudad de Valledupar, Colombia, durante 2021. Métodos Investigación descriptiva de corte transversal. La muestra estuvo constituida por 21 personas reincidentes en el consumo de sustancias psicoactivas que asisten a un centro de rehabilitación de Valledupar, quienes, previo consentimiento informado, diligenciaron el instrumento de recolección de datos. La información fue procesada en SPSS y resumida en tablas uni y bivariadas. Resultados Se evidencian historias de consumo progresivo asociado a determinantes intermedios de salud, en especial circunstancias materiales de vida y comportamentales, mientras que las socioambientales, sobre todo derechos e inclusión social, parecen no afectar la reincidencia. Conclusiones Es necesario realizar intervenciones y programas, orientados a la comunidad, familia e individuo, las cuales tengan un enfoque promocional de la salud y preventivo de la reincidencia en el consumo de psicoactivos, al tiempo que se fortalezca la investigación en este campo.

Coronavirus Disease 2019 and the Impact on Substance Use Disorder Treatments

Coronavirus disease 2019 (COVID-19)-related stressors and restrictions, in the absence of social and institutional support, have led many individuals to either increase their substance consumption or relapse. Consequently, treatment programs for substance use disorders (SUDs) made a transition from in-person to remote care delivery. This review discusses the following evidence regarding changes prompted by the COVID pandemic to the clinical care of individuals with SUDs: (1) reduction in availability of care, (2) increase in demand for care, (3) transition to telemedicine use, (4) telemedicine for treatment of opioid use disorders, and (5) considerations for use of telemedicine in treating SUDs.

A Proof-of-Concept Ecological Momentary Assessment Study of Day-Level Dynamics in Value-Based Decision-Making in Opioid Addiction

BACKGROUND

Drug addiction is thought to be characterized by risky and impulsive behavior despite harmful consequences. Whether these aspects of value-based decision-making in people with addiction are stable and trait-like, and the degree to which they vary within-person and are sensitive to changes in psychological state, remains unknown. In this pilot study, we examined the feasibility of distinguishing these state- vs. trait-like components by probing day-level dynamics of risk and time preferences in patients with opioid use disorder (OUD) as they engaged with their natural environment.

METHODS

Twenty-three individuals with OUD receiving outpatient treatment (40% female; M = 45.67 [SD = 13.16] years of age) and twenty-one matched healthy community controls (47% female; M = 49.67 [SD = 14.38] years of age) participated in a 28-day smartphone-based ecological momentary assessment study (1085 person days; M = 24.66, SD = 5.84). Random prompts administered daily assessed subjects' psychological state (e.g., mood) and economic preferences for real delayed and risky monetary rewards.

RESULTS

Subjects demonstrated dynamic decision-making preferences, with 40-53% of the variation in known risk and ambiguity tolerance, and 67% in discounting, attributable to between-person vs. within-person (day-to-day) differences. We found that changes in psychological state were related to changes in risk preferences, with patients preferring riskier offers on days they reported being in a better mood but no differences between groups in aggregate level behavior. By contrast, temporal discounting was increased overall in patients compared to controls and was unrelated to global mood. The study was well-tolerated, but compliance rates were moderate and lower in patients.

CONCLUSION

Our data support the idea that decision-making preferences in drug addiction exhibit substantial within-person variability and that this variability can be well-captured using remote data collection methods. Preliminary findings suggested that aspects of decision-making related to consideration of risk may be more sensitive to within-person change in global psychological state while those related to consideration of delay to reward, despite also being somewhat variable, stably differ from healthy levels. Identifying the cognitive factors that contribute to opioid use risk in a "real-world" setting may be important for identifying unique, time-sensitive targets for intervention.

Associations between relationship quality and treatment-related stress among couples receiving methadone for opioid use disorder

BACKGROUND

Social relationships may buffer or exacerbate stress among patients receiving methadone treatment for opioid use disorder (OUD). Little is known, however, about how relationship quality is linked to treatment-related stress among couples in which both partners receive methadone. We considered the links between relationship quality and treatment-related stress among couples in methadone treatment for OUD.

METHODS

Participants for this cross-sectional observational study included 60 heterosexual married or cohabiting couples aged 18 and older drawn from two opioid treatment programs in Rhode Island and Massachusetts. Both partners completed a self-administered survey which assessed their sociodemographic information, relationship and treatment characteristics, and perceived treatment-related stress. We estimated actor-partner interdependence models to evaluate the links between each partner's perceptions of relationship quality (with their partner and their closest family member or friend) and treatment-related stress.

RESULTS

When their partners reported a more positive partner relationship, women had lower treatment-related stress. When women reported a more positive relationship with their own closest family member or friend, both women and their partners had lower treatment-related stress. When men perceived a more positive relationship with their closest family member or friend, their partners reported greater treatment-related stress. Negative relationship quality was not significantly linked to treatment-related stress.

CONCLUSIONS

This study highlights the importance of considering how social relationship quality might impact the experiences of couples receiving methadone for OUD. In particular, women's close relationships may help to mitigate treatment-related stress.

Prospective Prediction of Lapses in Opioid Use Disorder: Protocol for a Personal Sensing Study

BACKGROUND

Successful long-term recovery from opioid use disorder (OUD) requires continuous lapse risk monitoring and appropriate use and adaptation of recovery-supportive behaviors as lapse risk changes. Available treatments often fail to support long-term recovery by failing to account for the dynamic nature of long-term recovery.

OBJECTIVE

The aim of this protocol paper is to describe research that aims to develop a highly contextualized lapse risk prediction model that forecasts the ongoing probability of lapse.

METHODS

The participants will include 480 US adults in their first year of recovery from OUD. Participants will report lapses and provide data relevant to lapse risk for a year with a digital therapeutic smartphone app through both self-report and passive personal sensing methods (eg, cellular communications and geolocation). The lapse risk prediction model will be developed using contemporary rigorous machine learning methods that optimize prediction in new data.

RESULTS

The National Institute of Drug Abuse funded this project (R01DA047315) on July 18, 2019 with a funding period from August 1, 2019 to June 30, 2024. The University of Wisconsin-Madison Health Sciences Institutional Review Board approved this project on July 9, 2019. Pilot enrollment began on April 16, 2021. Full enrollment began in September 2021.

CONCLUSIONS

The model that will be developed in this project could support long-term recovery from OUD-for example, by enabling just-in-time interventions within digital therapeutics.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/29563.

Cannabidiol as a treatment for craving and relapse in individuals with cocaine use disorder: a randomized placebo-controlled trial

BACKGROUND AND AIMS

Cocaine use disorder (CUD) is a significant public health concern for which no efficacious pharmacological interventions are available. Cannabidiol (CBD) has attracted considerable interest as a promising treatment for addiction. This study tested CBD efficacy for reducing craving and preventing relapse in people with CUD.

DESIGN

Single-site double-blind randomized controlled superiority trial comparing CBD with placebo.

SETTING AND PARTICIPANTS

Centre Hospitalier de l'Université de Montréal, Canada. Seventy-eight adults (14 women) with moderate to severe CUD participated.

INTERVENTION

Participants were randomly assigned (1 : 1) by stratified blocks to daily 800 mg CBD (n = 40) or placebo (n = 38). They first underwent an inpatient detoxification phase lasting 10 days. Those who completed this phase entered a 12-week outpatient follow-up.

MEASUREMENTS

Primary outcomes were drug-cue-induced craving during detoxication and time-to-cocaine relapse during subsequent outpatient treatment.

FINDINGS

During drug-cue exposure, craving scores [mean ± standard deviation (SD)] increased from baseline by 4.69 (2.89) versus 3.21 (2.78) points, respectively, in CBD (n = 36) and placebo (n = 28) participants [confidence interval (CI) = -0.33 to 3.04; P = 0.069; Bayes factor = 0.498]. All but three participants relapsed to cocaine by week 12 with similar risk for CBD (n = 34) and placebo (n = 27) participants (hazard ratio = 1.20, CI = 0.65-2.20, P = 0.51; Bayes factor = 0.152). CBD treatment was well tolerated and associated mainly with diarrhoea.

CONCLUSIONS

CBD did not reduce cocaine craving or relapse among people being treated for CUD.

Longitudinal patterns of momentary stress during outpatient opioid agonist treatment: A growth-mixture-model approach to classifying patients

BACKGROUND

We previously showed, in people starting treatment for opioid use disorder (OUD), that stress is neither necessary nor sufficient for lapses to drug use to occur, despite an association between the two. Both theoretical clarity and case-by-case prediction accuracy may require initial differentiation among patients.

AIM

To examine: (a) evidence for distinct overall trajectories of momentary stress during OUD treatment, (b) relationships between stress trajectory and treatment response, and (c) relationships between stress trajectory and momentary changes in stress and craving prior to lapses.

METHODS

We used ecological momentary assessment (EMA) to collect ratings of stress and craving 3x/day for up to 16 weeks in 211 outpatients during agonist treatment for OUD. With growth mixture models, we identified trajectories of stress. We used mixed effect models to examine trajectory-group differences in the dynamics of stress and craving just before lapses to any drug use.

RESULTS

We identified four trajectories of stress: Increasing (13.7 %); Moderate and Stable (23.7 %); Declining and Increasing (18 %); and Low (44.6 %). Overall drug use and opioid craving were lowest in the Low Stress group. Overall drug use was highest in the Moderate and Stable group. Alcohol use and opioid craving were highest in the Increasing Stress group. Opioid craving increased before lapse for most groups, but stress increased before lapses for only the Moderate and Stable group.

CONCLUSION

There are natural groupings of participants with distinct patterns of stress severity during OUD treatment. Momentary stress/craving/lapse associations may be better characterized when these groupings are considered first.

Sleep moderates the relationship between stress and craving in individuals with opioid use disorder

Opioid use disorder (OUD) is a national public health concern. Craving, stress, and exposure to conditioned drug cues are implicated in risk of relapse to opioids. Although impaired sleep has been implicated in risk of relapse to other substances of misuse, little research to date has examined the relationship between sleep and craving in individuals with OUD. The present study examined sleep as a moderator of the relationship between craving and stress in a randomized controlled human laboratory study. Individuals with current OUD (N = 39) completed a 1-night hospital stay to control for factors that may affect craving, stress, and sleep. Sleep was monitored via an actigraphy watch and the Pittsburgh Sleep Quality Index. The next morning, participants were randomized to a 15-min laboratory stress task or a no-stress condition. All participants were then exposed to a 15-min opioid cue paradigm, and craving was measured via self-report. Moderation models were conducted to evaluate whether the sleep indices moderated the relationship between stress condition (independent variable) and craving (dependent variable). Average self-reported nightly sleep duration moderated the relationship between stress condition and craving for participants in the no-stress condition (b = 0.95, p < .05). Specifically, participants in the no-stress condition with lower average nightly sleep duration exhibited significantly greater craving following the opioid cue paradigm. Although preliminary, the findings add to the literature on craving, stress, and sleep among individuals with OUD. Sleep impairment may be an important target of a comprehensive, long-term treatment plan for some patients with OUD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Craving mediates the association between momentary pain and illicit opioid use during treatment for opioid-use disorder: an ecological momentary assessment study

AIM

To assess the role of momentary pain on opioid craving and illicit opioid use among individuals receiving opioid agonist treatment.

DESIGN

Observational study using ecological momentary assessment.

SETTING

The National Institute of Drug Abuse Intramural Research Program in the United States.

PARTICIPANTS

Fifty-six adults who qualified for opioid agonist treatment.

MEASUREMENTS

Participants completed randomly prompted assessments of pain severity, stress, negative mood, opioid craving and illicit opioid use for a mean of 66 days [standard deviation (SD) = 27]. Urine samples were collected two to three times/week throughout.

FINDINGS

Almost 70% of participants reported moderate average pain severity in the past 24 hours at intake and 35% of participants reported chronic pain. There were no significant differences in percent of opioid-positive urine samples (P = 0.73) and average level of opioid craving during the study period (P = 0.91) among opioid agonist treatment only patients versus opioid agonist treatment patients with chronic pain. However, momentary pain severity significantly predicted concurrent opioid craving [B = 0.02, 95% confidence interval (CI) = 0.01, 0.04], over and above stress and negative mood. Momentary opioid craving, in turn, significantly predicted illicit opioid use that was assessed in the next moment [odds ratio (OR) = 1.72, 95% CI = 1.12, 2.64), while controlling for autocorrelation and the effects of pain, negative mood and stress. Momentary opioid craving significantly mediated the prospective association between momentary pain and illicit opioid use (95% CI = 0.003, 0.032). Exploratory analysis revealed that momentary pain severity also significantly moderated the momentary association between stress and opioid craving (B = 0.02, 95% CI = 0.00, 0.04), such that when momentary pain severity increased, the association between the two intensified.

CONCLUSIONS

Among people receiving opioid agonist treatment, momentary pain appears to be indirectly associated with illicit opioid use via momentary opioid craving.

Neurochemical mechanisms and neurocircuitry underlying the contribution of stress to cocaine seeking

In individuals with substance use disorders, stress is a critical determinant of relapse susceptibility. In some cases, stressors directly trigger cocaine use. In others, stressors interact with other stimuli to promote drug seeking, thereby setting the stage for relapse. Here, we review the mechanisms and neurocircuitry that mediate stress-triggered and stress-potentiated cocaine seeking. Stressors trigger cocaine seeking by activating noradrenergic projections originating in the lateral tegmentum that innervate the bed nucleus of the stria terminalis to produce beta adrenergic receptor-dependent regulation of neurons that release corticotropin releasing factor (CRF) into the ventral tegmental area (VTA). CRF promotes the activation of VTA dopamine neurons that innervate the prelimbic prefrontal cortex resulting in D1 receptor-dependent excitation of a pathway to the nucleus accumbens core that mediates cocaine seeking. The stage-setting effects of stress require glucocorticoids, which exert rapid non-canonical effects at several sites within the mesocorticolimbic system. In the nucleus accumbens, corticosterone attenuates dopamine clearance via the organic cation transporter 3 to promote dopamine signaling. In the prelimbic cortex, corticosterone mobilizes the endocannabinoid, 2-arachidonoylglycerol (2-AG), which produces CB1 receptor-dependent reductions in inhibitory transmission, thereby increasing excitability of neurons which comprise output pathways responsible for cocaine seeking. Factors that influence the role of stress in cocaine seeking, including prior history of drug use, biological sex, chronic stress/co-morbid stress-related disorders, adolescence, social variables, and genetics are discussed. Better understanding when and how stress contributes to drug seeking should guide the development of more effective interventions, particularly for those whose drug use is stress related.

Beyond abstinence and relapse II: momentary relationships between stress, craving, and lapse within clusters of patients with similar patterns of drug use

RATIONALE

Given that many patients being treated for opioid-use disorder continue to use drugs, identifying clusters of patients who share similar patterns of use might provide insight into the disorder, the processes that affect it, and ways that treatment can be personalized.

OBJECTIVES AND METHODS

We applied hierarchical clustering to identify patterns of opioid and cocaine use in 309 participants being treated with methadone or buprenorphine (in a buprenorphine-naloxone formulation) for up to 16 weeks. A smartphone app was used to assess stress and craving at three random times per day over the course of the study.

RESULTS

Five basic patterns of use were identified: frequent opioid use, frequent cocaine use, frequent dual use (opioids and cocaine), sporadic use, and infrequent use. These patterns were differentially associated with medication (methadone vs. buprenorphine), race, age, drug-use history, drug-related problems prior to the study, stress-coping strategies, specific triggers of use events, and levels of cue exposure, craving, and negative mood. Craving tended to increase before use in all except those who used sporadically. Craving was sharply higher during the 90 min following moderate-to-severe stress in those with frequent use, but only moderately higher in those with infrequent or sporadic use.

CONCLUSIONS

People who share similar patterns of drug-use during treatment also tend to share similarities with respect to psychological processes that surround instances of use, such as stress-induced craving. Cluster analysis combined with smartphone-based experience sampling provides an effective strategy for studying how drug use is related to personal and environmental factors.

Functional evaluation of NK1 antagonism on cue reactivity in opiate dependence; An fMRI study

BACKGROUND

Opiate addiction is a major health challenge with substantial societal cost. Though harm minimisation strategies have been effective, there is a growing need for new treatments for detoxification and relapse prevention. Preclinical research has found neurokinin 1 (NK1) receptors have prominent effects on opiate reward and reinforcement, and human studies have found NK1 antagonism led to reductions in craving and withdrawal. However, its effect on brain mechanisms in opiate addiction has not yet been examined.

METHODS

This study aims to assess the impact of NK1 antagonist aprepitant on heroin cue-elicited changes in blood-oxygenation level dependent (BOLD) signal in opiate dependent individuals undergoing detoxification. Participants will attend two scanning sessions and receive a single dose of aprepitant (320 mg) and a placebo in a randomised, cross-over design. During functional magnetic resonance imaging participants will undergo two runs of a cue reactivity task, which consists of passive viewing of drug cues or neutral cues in a block design fashion. We hypothesise that NK1 antagonism will attenuate the BOLD response to drug cues in the caudate nucleus and amygdala. Regions of interest were selected based on NK1 receptor density and their role in cue reactivity and craving.

Realize, Analyze, Engage (RAE): A Digital Tool to Support Recovery from Substance Use Disorder

Background:

Substance use disorders are a highly prevalent group of chronic diseases with devastating individual and public health consequences. Current treatment strategies suffer from high rates of relapse, or return to drug use, and novel solutions are desperately needed. Realize Analyze Engage (RAE) is a digital, mHealth intervention that focusses on real time, objective detection of high-risk events (stress and drug craving) to deploy just-in-time supportive interventions. The present study aims to (1) evaluate the accuracy and usability of the RAE system and (2) evaluate the impact of RAE on patient centered outcomes.

Methods:

The first phase of the study will be an observational trial of N = 50 participants in outpatient treatment for SUD using the RAE system for 30 days. Accuracy of craving and stress detection algorithms will be evaluated, and usability of RAE will be explored via semi-structured interviews with participants and focus groups with SUD treatment clinicians. The second phase of the study will be a randomized controlled trial of RAE vs usual care to evaluate rates of return to use, retention in treatment, and quality of life.

Anticipated findings and future directions:

The RAE platform is a potentially powerful tool to de-escalate stress and craving outside of the clinical milieu, and to connect with a support system needed most. RAE also aims to provide clinicians with actionable insight to understand patients’ level of risk, and contextual clues for their triggers in order to provide more personalized recovery support.

Hyperfunction of the stress response system and novelty-induced hyperactivity correlate with enhanced cocaine-induced conditioned place preference in NCAM-deficient mice

Several studies in humans and rodents suggest an association between impulsivity and activity of the stress response on the one hand and addiction vulnerability on the other. The neural cell adhesion molecule (NCAM) has been related to several neuropsychiatric disorders in humans. Constitutively NCAM-deficient (-/-) mice display enhanced novelty-induced behavior and hyperfunction of the hypothalamic-pituitary-adrenal axis. Here we hypothesize that NCAM deficiency causes an altered response to cocaine. Cocaine-induced behaviors of NCAM-/- mice and wild-type (+/+) littermates were analyzed in the conditioned place preference (CPP) test. c-fos mRNA levels were investigated by quantitative polymerase chain reaction (qPCR) to measure neural activation after exposure to the cocaine-associated context. NCAM-/- mice showed an elevated cocaine-induced sensitization, enhanced CPP, impaired extinction, and potentiated cocaine-induced hyperlocomotion and CPP after extinction. NCAM-/- showed no potentiated CPP as compared with NCAM+/+ littermates when a natural rewarding stimulus (ie, an unfamiliar female) was used, suggesting that the behavioral alterations of NCAM-/- mice observed in the CPP test are specific to the effects of cocaine. Activation of the prefrontal cortex and nucleus accumbens induced by the cocaine-associated context was enhanced in NCAM-/- compared with NCAM+/+ mice. Finally, cocaine-induced behavior correlated positively with novelty-induced behavior and plasma corticosterone levels in NCAM-/- mice and negatively with NCAM mRNA levels in the hippocampus and nucleus accumbens in wild-type mice. Our findings indicate that NCAM deficiency affects cocaine-induced CPP in mice and support the view that hyperfunction of the stress response system and reactivity to novelty predict the behavioral responses to cocaine.

Integrated substance use and prenatal care delivery in the era of COVID-19

The COVID-19 pandemic has directly impacted integrated substance use and prenatal care delivery in the United States and has driven a rapid transformation from in-person prenatal care to a hybrid telemedicine care model. Additionally, changes in regulations for take home dosing for methadone treatment for opioid use disorder due to COVID-19 have impacted pregnant and postpartum women. We review the literature on prenatal care models and discuss our experience with integrated substance use and prenatal care delivery during COVID-19 at New England's largest safety net hospital and national leader in substance use care. In our patient-centered medical home for pregnant and postpartum patients with substance use disorder, patients' early responses to these changes have been overwhelmingly positive. Should clinicians continue to use these models, thoughtful planning and further research will be necessary to ensure equitable access to the benefits of telemedicine and take home dosing for all pregnant and postpartum patients with substance use disorder.

Ambulatory Assessment Methods to Examine Momentary State-Based Predictors of Opioid Use Behaviors

PURPOSE OF REVIEW

Addiction scientists have begun using ambulatory assessment methods-including ecological momentary assessment (EMA), experience sampling, and daily diaries-to collect real-time or near-real-time reports of participants' internal states in their natural environments. The goal of this short review is to synthesize EMA findings from our research group, which has studied several hundred outpatients during treatment for opioid-use disorder (OUD). (We cite pertinent findings from other groups, but have not tried to be comprehensive.) One of our main goals in using EMA is to examine momentary changes in internal states that proximally predict, or concurrently mark, events such as lapses to opioid use.

RECENT FINDINGS

We summarize findings evaluating several classes of momentary markers or predictors (craving, stress, negative and positive moods, and physical pain/discomfort) of lapses and other states/behaviors. Craving and some negatively valenced mood states are concurrently and prospectively associated with lapses to opioid use during treatment. Craving is also concurrently and prospectively associated with momentary changes in stress and mood. Convincing evidence has not yet emerged for stress as a robust redictor of lapse to opioid use; it appears to be contributory, but neither necessary nor sufficient.

SUMMARY

Ambulatory assessment can capture changes in internal states and drug-related behaviors in situ and at high temporal resolution. We recommend research strategies that may increase the clinical and prognostic utility of ambulatory assessment, including denser sampling (i.e., more assessments per day) and more attention to heterogeneity across people and across populations.

Choosing the right drug: status and future of endocannabinoid research for the prevention of drug-seeking reinstatement

Prolonged exposure to drugs of abuse leads to severe alterations in mesocorticolimbic dopamine circuitry deeply implicated in substance use disorders. Despite considerable efforts, few medications to reduce relapse rates are currently available. To solve this issue, researchers are uncovering therapeutic opportunities offered by the endocannabinoid system. The cannabinoid receptor type 1 (CB₁R), and its endogenous ligands, participate in orchestration of cue-triggered and stress-triggered responses leading to obtain natural and drug rewards. Here, we review the evidence supporting the use of CB₁R neutral antagonists, allosteric modulators, indirect agonists, as well as multi-target compounds, as improved alternatives compared to classical CB₁R antagonists. The promising therapeutic value of other substrates participating in endocannabinoid signaling, like peroxisome proliferator-activated receptors, is also covered. Overall, a wide body of pre-clinical evidence avails novel pharmacological strategies interacting with the endocannabinoid system as clinically amenable candidates able to counteract drug-induced dopamine maladaptations contributing to increased risk of relapse.

Development and Acceptability of a Method to Investigate Prescription Drug Misuse in Daily Life: Ecological Momentary Assessment Study

Background

Prescription drug misuse and abuse is an established public health challenge, and young adults are particularly affected. There is a striking lack of real-time, naturalistic data collection assessing intentions to misuse and other precipitating factors at the time of actual misuse, leaving the conditions under which individuals are most likely to misuse prescription medications unknown. Ecological momentary assessment (EMA) apps and protocols designed to capture this information would accelerate and expand the knowledge base and could directly contribute to prevention and treatment efforts.

Objective

The objectives of this study are to describe the development and administration of a mobile app and the EMA protocol designed to collect real-time factors associated with college students’ prescription drug misuse intentions and behaviors in daily life; present completion rates, compliance, acceptability, and reactivity associated with the EMA protocol for participants who endorsed recent prescription drug misuse at screening (ie, risk group; n=300) and those who did not (ie, nonrisk group; n=55); and establish initial construct validity by linking the reports of misuse behaviors in daily life collected via the EMA app to prescription drug misuse reported on a standard survey.

Methods

An EMA data collection app and protocol were designed specifically to capture hypothesized contextual factors along with prescription drug misuse intentions and behaviors in daily life. Using this protocol, young adult college students (N=352) completed signal- and event-contingent reports over a 28-day period. When the intention to misuse a prescription drug was endorsed, a brief follow-up prompt was sent 15 min later to collect participants’ indications of whether or not misuse had occurred.

Results

Risk-group participants were significantly more likely than nonrisk counterparts to endorse any prescription drug misuse intentions in daily life (P<.001), to complete one or more follow-up reports (P<.001), and to endorse any prescription drug misuse behavior in daily life on the follow-ups (P<.001). Overall, participants demonstrated consistent engagement with the EMA procedures and returned an average of 74.5 (SD 23.82; range 10-122) reports. Participants in the risk and nonrisk groups did not differ in the number of reports they completed (P=.12), the number of their reporting days (P=.32), or their average completion rates (P=.14). The results indicated some evidence of reactivity to the momentary reporting procedure. Participants reported uniformly positive experiences and remained highly engaged throughout the reporting protocol and broader study.

Conclusions

The novel EMA app and protocol provide an effective way to assess real-time factors associated with prescription drug misuse intentions and behaviors in daily life. The resulting investigations offer the potential to provide highly translatable information for research and prevention efforts.

Real-time associations between young adults' momentary pain and prescription opioid misuse intentions in daily life

Managing pain has been identified (mainly through retrospective reports) as a robust motivator for individuals engaging in prescription opioid misuse. However, surprisingly little work has directly examined whether momentary pain experiences are associated with prescription opioid misuse in daily life. Participants included 297 young-adult college students recruited on the basis of recent prescription drug misuse. Ecological momentary assessment over a 28-day period was utilized to collect participants' pain experiences and prescription opioid misuse intention and behavior. Hierarchical generalized linear modeling and binary logistic regression tested hypotheses. Findings revealed that higher in-the-moment pain was positively associated with intentions to engage in prescription opioid misuse, accounting for report timing and participant sex and background substance use. Also, the between-person result indicated that participants who reported higher levels of pain across the reporting period were more likely to intend to misuse prescription opioids in daily life. There was a similar reliable association between higher pain ratings across the reporting period and greater likelihood of engaging in misuse behavior, although actual misuse frequency was low. Reliable moderation was observed: As hypothesized, the within-person association between momentary pain and misuse intentions was stronger for females compared with males. Also, the within-person link between pain and misuse intentions was stronger for those who reported lower (vs. higher) levels of problematic alcohol use; this was not consistent with the hypothesized direction. Understanding the role of college students' pain in their intentions to engage in prescription opioid misuse is important for informing future research and prevention efforts. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

(-)-Stepholidine blocks expression, but not development, of cocaine conditioned place preference in rats

The purpose of this study was to investigate the effects of (-)-stepholidine (SPD), a compound with dopamine D1 partial agonist and D2/D3 antagonist properties, on the development and expression of cocaine conditioned place preference (CPP). Subjects (N = 65; male Long Evans rats) were tested using a CPP procedure consisting of 3 phases: (1) a 15-min pre-exposure session where animals could explore each compartment freely, (2) eight 30-min conditioning sessions where animals were restricted to one side or the other with cocaine (10 mg/kg) or saline, respectively, on alternating days and (3) a 15-minute preference test session where animals could explore each compartment freely. To test the effects of SPD on expression of cocaine CPP, rats were administered vehicle (distilled water with 20 % DMSO), 10, 15 or 20 mg/kg SPD (intraperitoneally) 30 min prior to the test session. We found that 20 mg/kg of SPD significantly blocked the expression of cocaine CPP. To test the effects of SPD on the development of CPP, 0 (vehicle), 10, 15 or 20mg/kg SPD were administered 30 min prior to each cocaine conditioning session and vehicle before each saline conditioning session; no treatment was given prior to the test session. A preference test showed that each SPD group maintained a CPP similar to the vehicle group. These data indicate that SPD can block the expression of a cocaine CPP but has no effect on its development, suggesting that it inhibits the effects of cocaine cues on cocaine incentive motivated behavior. These results suggest that SPD may be a potential treatment for cue-driven aspects of cocaine use disorder.

COVID-19 and persons with substance use disorders: Inequities and mitigation strategies

The COVID-19 pandemic disproportionately disrupts the daily lives of marginalized populations. Persons with substance use disorders are a particularly vulnerable population because of their unique social and health care needs. They face significant harm from both the pandemic itself and its social and economic consequences, including marginalization in health care and social systems. Hence, we discuss: (1) why persons with substance use disorders are at increased risk for infection with COVID-19 and a severe illness course; (2) anticipated adverse consequences of COVID-19 in persons with substance use disorders; (3) challenges to health care delivery and substance use treatment programs during and after the COVID-19 pandemic; and (4) the potential impact on clinical research in substance use disorders. We offer recommendations for clinical, public health, and social policies to mitigate these challenges and to prevent negative outcomes.

Computational Markers of Risky Decision-making for Identification of Temporal Windows of Vulnerability to Opioid Use in a Real-world Clinical Setting

IMPORTANCE

Opioid addiction is a major public health problem. Despite availability of evidence-based treatments, relapse and dropout are common outcomes. Efforts aimed at identifying reuse risk and gaining more precise understanding of the mechanisms conferring reuse vulnerability are needed.

OBJECTIVE

To use tools from computational psychiatry and decision neuroscience to identify changes in decision-making processes preceding opioid reuse.

DESIGN, SETTING, AND PARTICIPANTS

A cohort of individuals with opioid use disorder were studied longitudinally at a community-based treatment setting for up to 7 months (1-15 sessions per person). At each session, patients completed a risky decision-making task amenable to computational modeling and standard clinical assessments. Time-lagged mixed-effects logistic regression analyses were used to assess the likelihood of opioid use between sessions (t to t + 1; within the subsequent 1-4 weeks) from data acquired at the current session (t). A cohort of control participants completed similar procedures (1-5 sessions per person), serving both as a baseline comparison group and an independent sample in which to assess measurement test-retest reliability. Data were analyzed between January 1, 2018, and September 5, 2019.

MAIN OUTCOMES AND MEASURES

Two individual model-based behavioral markers were derived from the task completed at each session, capturing a participant's current tolerance of known risks and ambiguity (partially unknown risks). Current anxiety, craving, withdrawal, and nonadherence were assessed via interview and clinic records. Opioid use was ascertained from random urine toxicology tests and self-reports.

RESULTS

Seventy patients (mean [SE] age, 44.7 [1.3] years; 12 women and 58 men [82.9% male]) and 55 control participants (mean [SE] age, 42.4 [1.5] years; 13 women and 42 men [76.4% male]) were included. Of the 552 sessions completed with patients (mean [SE], 7.89 [0.59] sessions per person), 252 (45.7%) directly preceded opioid use events (mean [SE], 3.60 [0.44] sessions per person). From the task parameters, only ambiguity tolerance was significantly associated with increased odds of prospective opioid use (adjusted odds ratio, 1.37 [95% CI, 1.07-1.76]), indicating patients were more tolerant specifically of ambiguous risks prior to these use events. The association of ambiguity tolerance with prospective use was independent of established clinical factors (adjusted odds ratio, 1.29 [95% CI, 1.01-1.65]; P = .04), such that a model combining these factors explained more variance in reuse risk. No significant differences in ambiguity tolerance were observed between patients and control participants, who completed 197 sessions (mean [SE], 3.58 [0.21] sessions per person); however, patients were more tolerant of known risks (B = 0.56 [95% CI, 0.05-1.07]).

CONCLUSIONS AND RELEVANCE

Computational approaches can provide mechanistic insights about the cognitive factors underlying opioid reuse vulnerability and may hold promise for clinical use.

Wearable sensor-based detection of stress and craving in patients during treatment for substance use disorder: A mixed methods pilot study

AIMS

To determine the accuracy of a wearable sensor to detect and differentiate episodes of self-reported craving and stress in individuals with substance use disorders, and to assess acceptability, barriers, and facilitators to sensor-based monitoring in this population.

METHODS

This was an observational mixed methods pilot study. Adults enrolled in an outpatient treatment program for a substance use disorder wore a non-invasive wrist-mounted sensor for four days and self-reported episodes of stress and craving. Continuous physiologic data (accelerometry, skin conductance, skin temperature, and heart rate) were extracted from the sensors and analyzed via various machine learning algorithms. Semi-structured interviews were conducted upon study completion, and thematic analysis was conducted on qualitative data from semi-structured interviews.

RESULTS

Thirty individuals completed the protocol, and 43 % (N = 13) were female. A total of 41 craving and 104 stress events were analyzed. The differentiation accuracies of the top performing models were as follows: stress vs. non-stress states 74.5 % (AUC 0.82), craving vs. no-craving 75.7 % (AUC 0.82), and craving vs. stress 76.8 % (AUC 0.8). Overall participant perception was positive, and acceptability was high. Emergent themes from the exit interviews included a perception of connectedness and increased mindfulness related to wearing the sensor, both of which were reported as helpful to recovery. Barriers to engagement included interference with other daily wear items, and perceived stigma.

CONCLUSIONS

Wearable sensors can be used to objectively differentiate episodes of craving and stress, and individuals in recovery from substance use disorder are accepting of continuous monitoring with these devices.