Polydrug use patterns, risk behavior and unmet healthcare need in a community-based sample of women who use cocaine, heroin or methamphetamine

Are you thinking what I'm thinking? Defining what we mean by "polysubstance use."

The rise in drug overdoses and harms associated with the use of more than one substance has led to increased use of the term "polysubstance use" among researchers, clinicians, and public health officials. However, the term retains no consistent definition across contexts. The current authors convened from disciplines including sociology, epidemiology, neuroscience, and addiction psychiatry to propose a recommended definition of polysubstance use. An iterative process considered authors' formal and informal conversations, insights from relevant symposia, talks, and conferences, as well as their own research and clinical experiences to propose the current definition. Three key concepts were identified as necessary to define polysubstance use: (1) substances involved, (2) timing, and (3) intent. Substances involved include clarifying either (1) the number and type of substances used, (2) presence of more than one substance use disorder, or (3) primary and secondary substance use. The concept of timing is recommended to use clear terms such as simultaneous, sequential, and same-day polysubstance use to describe short-term behaviors (e.g., 30-day windows). Finally, the concept of intent refers to clarifying unintentional use or exposure when possible, and greater attention to motivations of polysubstance use. These three components should be clearly defined in research on polysubstance use to improve consistency across disciplines. Consistent definitions of polysubstance use can aid in the synthesis of evidence to better address an overdose crisis that increasingly involves multiple substances.

Understanding polysubstance use at the daily and event levels: protocol for a mixed-methods qualitative and ecological momentary assessment study in a community-based sample of people who use illicit drugs in Oakland, California, USA

INTRODUCTION

Polysubstance use is extremely common among people who use illicit opioids in the USA. It is associated with poor substance use treatment outcomes, infectious disease risk and alarming rates of drug overdose. Nearly all extant literature examines polysubstance use over broad time frames, such as 30 days or 6 months. However, both substance use and overdose risk are episodic. To build a stronger understanding of polysubstance use and overdose risk, we need to expand the knowledge base to include daily-level and event-level data that examine how substances are used together, in which combinations and in which contexts. The study described in this protocol will use qualitative and ecological momentary assessment (EMA) methods to examine polysubstance use and overdose risk on a daily and event level.

METHODS AND ANALYSIS

This is a mixed-methods observational study with three phases. The first phase is formative, consisting of qualitative interviews with people who use multiple substances (N=20), to inform the development of items for the EMA component. The second phase is EMA data collection with people who use multiple substances (N=120), three times daily for 28 days. The third phase consists of mixed-methods inquiries with a subset of participants (N=20), using participant-level EMA data and qualitative techniques to build a nuanced understanding of the motivations and contexts of polysubstance use in everyday life. Analytical induction methods will be used to interpret qualitative data. Hierarchical linear modelling methods will be used to analyse EMA data.

ETHICS AND DISSEMINATION

This research has been reviewed and approved by the Institutional Review Board at RTI International (#MOD00001782 for EMA procedures and #MOD00001241 for qualitative procedures). Participants engage in an informed consent procedure for each component of the study. Data will be managed and shared per the National Institutes of Health extramural data sharing policy.

Impact of Harm Reduction Treatment with or without Pharmacotherapy on Polysubstance Use among People Experiencing Homelessness and Alcohol Use Disorder

OBJECTIVES

A prior randomized controlled trial showed behavioral harm reduction treatment for alcohol use disorder (AUD), or HaRT-A, was effective in improving alcohol outcomes and quality of life for people experiencing homelessness and AUD when provided with or without pharmacotherapy (ie, extended-release naltrexone). Because nearly 80% of the sample also reported baseline polysubstance use, this secondary study tested whether HaRT-A also positively impacted other substance use.

METHODS

In the parent study, 308 adults with AUD and homelessness were randomized to receive HaRT-A plus intramuscular injections of 380-mg extended-release naltrexone (HaRT-A + extended-release naltrexone), HaRT-A plus placebo (HaRT-A + placebo), HaRT-A alone, or community-based services as usual (control). In this secondary study, we used random intercept models to detect changes in other substance use after exposure to any of the HaRT-A conditions. For less prevalent behaviors, outcomes included past-month use (cocaine, amphetamines/methamphetamines, opioids). For more prevalent behaviors (polysubstance, cannabis), outcomes were past-month use frequency.

RESULTS

Compared with controls, participants who received HaRT-A showed significantly reduced 30-day frequency of cannabis use (incident rate ratio = 0.59, 95% CI = 0.40-0.86, P = 0.006) and polysubstance use (incident rate ratio = 0.65, 95% CI = 0.43-0.98, P = 0.040). No other significant changes were detected.

CONCLUSIONS

Compared with services as usual, HaRT-A is associated with reduced cannabis and polysubstance use frequency. The benefits of HaRT-A may thus extend beyond its impact on alcohol and quality of life outcomes to positively reshape overall substance use patterns. A randomized controlled trial is needed to further investigate the efficacy of such combined pharmacobehavioral harm reduction treatment for polysubstance use.

HIV risk perception, pre-exposure prophylaxis (PrEP) awareness, and PrEP initiation intention among women who use drugs

INTRODUCTION

Women who use drugs (WWUD) are prime candidates for pre-exposure prophylaxis (PrEP) due to their elevated risk of acquiring HIV through biological, behavioral, and contextual factors. However, PrEP uptake among WWUD remains low. The relationship between unhealthy drug use and correlates of PrEP uptake in this vulnerable population is not well defined. The purpose of this study is to characterize the relationships between specific types and routes of drug use and several precursors of PrEP uptake among WWUD.

METHODS

The study collected data via a computer-based survey from 233 women living in New York City and Philadelphia who participated in a study designed to develop and pilot a women-focused intervention for PrEP uptake. The sample of cisgender, HIV-negative women were not currently taking PrEP but considered PrEP eligible. This analysis is focused on women's HIV risk perception, PrEP awareness, PrEP initiation intention, and any use of the following drugs: barbiturates, benzodiazepines, crack cocaine, powder cocaine, hallucinogens, heroin, methamphetamines, and prescription opioids.

RESULTS

Within the three months prior to study enrollment, 63.1 % of participants reported any drug use; 42 % reported polydrug use; 19.8 % had injected drugs; 75 % reported getting high or drunk before sex; and 44 % had been enrolled in drug treatment. Of our total sample, 41.2 % perceived themselves at risk for HIV infection, 41.6 % were aware of PrEP prior to the study, and 62.7 % intended to initiate PrEP after they were informed. When compared to other PrEP-eligible women, women who reported prescription opioid use and polydrug use perceived themselves at higher risk for HIV infection and had higher intention to start PrEP. However, they and women who reported injecting drugs also reported lower awareness of PrEP.

CONCLUSION

These findings have implications for increasing education about PrEP and the various modes of HIV exposure to support PrEP uptake in this vulnerable population.

Systems analysis and improvement approach to improve naloxone distribution within syringe service programs: study protocol of a randomized controlled trial

BACKGROUND

More than half a million Americans died of an opioid-related overdose between 1999 and 2020, the majority occurring between 2015 and 2020. The opioid overdose mortality epidemic disproportionately impacts Black, Indigenous, and people of color (BIPOC): since 2015, overdose mortality rates have increased substantially more among Black (114%) and Latinx (97%) populations compared with White populations (32%). This is in part due to disparities in access to naloxone, an opioid antagonist that can effectively reverse opioid overdose to prevent death. Our recent pilot work determined that many barriers to naloxone access can be identified and addressed by syringe service programs (SSPs) using the Systems Analysis and Improvement Approach to Naloxone distribution (SAIA-Naloxone). This randomized controlled trial will test SAIA-Naloxone's ability to improve naloxone distribution in general and among BIPOC specifically.

METHODS

We will conduct a trial with 32 SSPs across California, randomly assigning 16 to the SAIA-Naloxone arm and 16 to receive implementation as usual. SAIA-Naloxone is a multifaceted, multilevel implementation strategy through which trained facilitators work closely with SSPs to (1) assess organization-level barriers, (2) prioritize barriers for improvement, and (3) test solutions through iterative change cycles until achieving and sustaining improvements. SSPs receiving SAIA-Naloxone will work with a trained facilitator for a period of 12 months. We will test SAIA-Naloxone's ability to improve SSPs' naloxone distribution using an interrupted time series approach. Data collection will take place during a 3-month lead-in period, the 12-month active period, and for an additional 6 months afterward to determine whether impacts are sustained. We will use a structured approach to specify SAIA-Naloxone to ensure strategy activities are clearly defined and to assess SAIA-Naloxone fidelity to aid in interpreting study results. We will also assess the costs associated with SAIA-Naloxone and its cost-effectiveness.

DISCUSSION

This trial takes a novel approach to improving equitable distribution of naloxone amid the ongoing epidemic and associated racial disparities. If successful, SAIA-Naloxone represents an important organizational-level solution to the multifaceted and multilevel barriers to equitable naloxone distribution.

Tabernanthalog Reduces Motivation for Heroin and Alcohol in a Polydrug Use Model

Background

The potential use of psychedelic drugs as therapeutics for neuropsychiatric disorders has been limited by their hallucinogenic properties. To overcome this limitation, we developed and characterized tabernanthalog (TBG), a novel analogue of the indole alkaloids ibogaine and 5-methoxy-N,N-dimethyltryptamine with reduced cardiac arrhythmogenic risk and a lack of classical psychedelic drugs-induced sensory alterations. We previously demonstrated that TBG has therapeutic efficacy in a preclinical model of opioid use disorder (OUD) in rats and in a binge model of alcohol drinking in mice. Alcohol is commonly co-used in ∼35-50% of individuals with OUD, and yet, preclinical models that recapitulate this comorbidity are lacking.

Methodology

Here we employed a polydrug model of heroin and alcohol couse to screen the therapeutic efficacy of TBG on metrics of both opioid and alcohol seeking. We first exposed rats to alcohol (or control sucrose-fade solution) in the home-cage (HC), using a two-bottle binge protocol, over a period of 1 month. Rats were then split into two groups that underwent self-administration training for either intravenous heroin or oral alcohol, so that we could assess the impact of HC alcohol exposure on the self-administration of each substance separately. Thereafter, rats began self-administering both heroin and alcohol in the same sessions. Finally, we tested the effects of TBG on break points for heroin and alcohol in a progressive ratio test, where the number of lever presses required to obtain a single reward increased exponentially.

Results and Conclusion

TBG effectively reduced motivation for heroin and alcohol in this test, indicating its efficacy is preserved in animals with a history of heroin and alcohol polydrug use.

Health outcomes associated with patterns of substance use disorders among patients with type 2 diabetes and hypertension: Electronic health record findings

AIMS

To identify substance use disorder (SUD) patterns and their association with T2DM health outcomes among patients with type 2 diabetes and hypertension.

METHODS

We used latent class analysis on electronic health records from the MetroHealth System (Cleveland, Ohio) to obtain the target SUD groups: i) only tobacco (TUD), ii) tobacco and alcohol (TAUD), and iii) tobacco, alcohol, and at least one more substance (PSUD). A matching program with Mahalanobis distance within propensity score calipers created the matched control groups: no SUD (NSUD) for TUD and TUD for the other two SUD groups. The numbers of participants for the target-control groups were 8009 (TUD), 1672 (TAUD), and 642 (PSUD).

RESULTS

TUD was significantly associated with T2DM complications. Compared to TUD, the TAUD group showed a significantly higher likelihood for all-cause mortality (adjusted odds ratio (aOR) = 1.46) but not for any of the T2DM complications. Compared to TUD, the PSUD group experienced a significantly higher risk for cerebrovascular accident (CVA) (aOR = 2.19), diabetic neuropathy (aOR = 1.76), myocardial infarction (MI) (aOR = 1.76), and all-cause mortality (aOR = 1.66).

CONCLUSIONS

The findings of increased risk associated with PSUDs may provide insights for better management of patients with T2DM and hypertension co-occurrence.

Can cannabis kill? Characteristics of deaths following cannabis use in England (1998-2020)

BACKGROUND

Cannabis is the most widely used illegal drug but is rarely considered a causal factor in death.

AIMS

This study aimed to understand trends in deaths in England where cannabinoids were detected at post-mortem, and to evaluate the clinical utility of post-mortem cannabinoid concentrations in coronial investigations.

METHODS

Deaths with cannabinoid detections reported to the National Programme on Substance Abuse Deaths (NPSAD) were extracted and analysed.

RESULTS

From 1998 to 2011, on average 7% of all cases reported to NPSAD had a cannabinoid detected (n = 110 deaths per year), rising to 18% in 2020 (n = 350). Death following cannabis use alone was rare (4% of cases, n = 136/3455). Traumatic injury was the prevalent underlying cause in these cases (62%, n = 84/136), with cannabis toxicity cited in a single case. Polydrug use was evident in most cases (96%, n = 3319/3455), with acute drug toxicity the prevalent underlying cause (74%, n = 2458/3319). Cardiac complications were the most cited physiological underlying cause of death (4%, n = 144/3455). The median average Δ9-tetrahydrocannabinol post-mortem blood concentrations were several magnitudes lower than previously reported median blood concentrations in living users (cannabis alone: 4.3 µg/L; cannabis in combination with other drugs: 3.5 µg/L).

CONCLUSIONS

Risk of death due to cannabis toxicity is negligible. However, cannabis can prove fatal in circumstances with risk of traumatic physical injury, or in individuals with cardiac pathophysiologies. These indirect harms need careful consideration and further study to better elucidate the role cannabis plays in drug-related mortality. Furthermore, the relevance of cannabinoid quantifications in determining cause of death in coronial investigations is limited.

Substance use in the emergency department: Screening for risky drug use, using the ASSIST-Lite

INTRODUCTION

Substance use is a common contributing factor to emergency department (ED) presentations. While screening, brief intervention, and referral to treatment for alcohol and tobacco is common in ED settings, it is not routinely conducted for illicit substances. This study aimed to deploy the ASSIST-Lite to screen for risky use of alcohol and other drugs in the ED, to identify differences in risk based on between demographic characteristics.

METHOD

All ED attenders, aged 18 years or older, deemed well enough to participate were approached. Recruitment occurred at the Royal Adelaide Hospital ED between May and June 2017. Participants were asked to self-complete the ASSIST-Lite in the ED waiting room. Overall, 632 people were approached, of which 479 (75.8%) agreed to participate.

RESULTS

Alcohol (72.2%), tobacco (27.1%) and cannabis (15.2%) were most commonly reported. Eighty-nine participants reported moderate- or high-risk use of two substances, and a further 49 individuals reported moderate- or high-risk use of three or more substances. Across most substances, age, gender and employment status was associated with risky substance use, with higher likelihood of risk reported by males, unemployed and younger participants. Unemployment was also significantly associated with increased risk severity for both moderate and high-risk illicit use.

DISCUSSIONS AND CONCLUSIONS

The rate of risky illicit and polysubstance use found here highlight the need more focused research in ED settings. The findings also provide support for more routine screening, and early intervention approaches; and suggest the need for active referral pathways through an alcohol and other drug consultation liaison service.

Associations of Lifetime Nonmedical Opioid, Methamphetamine, and Kratom Use within a Nationally Representative US Sample

Co-use of non-medical opioids (NMO) and methamphetamine is increasing. So too is the use of the psychoactive botanical "kratom," including among people with NMO and methamphetamine use histories. We assessed characteristics associated with respondent groups who reported lifetime methamphetamine and/or kratom use within a nationally representative US sample using 2019 National Survey on Drug Use and Health data from respondents reporting lifetime NMO use (diverted prescription opioids, heroin). Weighted prevalence estimates for demographic, mental health, and substance use outcomes were determined. Logistic regression examined associations between group membership and outcomes. Among this sample of respondents with lifetime NMO use, 67.6% (95% CI = 65.6-69.4%) reported only NMO use; 4.6% (3.9-5.4%) reported NMO+Kratom; 24.7% (22.7-26.7%) reported NMO+Methamphetamine; and 3.2% (2.5-3.9%) reported NMO+Methamphetamine+Kratom. Compared to those in the NMO-only group, the NMO+Kratom group was more likely to report past-year serious mental illness (SMI; OR = 2.27), suicidality (OR = 1.89), and past-month psychological distress (OR = 1.88). The NMO+Methamphetamine+Kratom group was more likely to report past-year SMI (OR = 2.65), past-month psychological distress (OR = 2.06), and unmet mental health needs (OR = 2.03); increased odds for drug injection, opioid withdrawal, and perceived treatment need also emerged. Risk factors were observed for all groups but were greatest among those reporting use of all three substances.

Psychiatric symptoms, current use of tobacco, alcohol, illicit drug, and poly-substance among medical students in Eastern Turkey

The study aims to investigate the prevalence and patterns of substance use among medical students and to examine associated psychiatric symptoms. It has been observed that depression and psychoticism scores have a significant effect on smoking, and interpersonal sensitivity-hostility-paranoid ideation scores have a significant effect on drinking. It has been shown that interpersonal sensitivity and depression scores are more predictive of mono-and poly-substance use. Revealing the relationship between tobacco, alcohol, poly-substance use, and psychiatric symptoms in the medical school sample shows the importance of practices aimed at increasing students' awareness of their psychiatric symptoms and providing access to psychiatric services.

Prescription opioid misuse among university students: A systematic review

Misuse of prescription opioids has substantially increased in the past decade among the general population, including among university students. Relative to the literature concerning opioid misuse among the general population, little information is available regarding the college student population. Objective: The purpose of the present study was to conduct a systematic review of the literature concerning the prevalence of prescription opioid misuse among the university student population. Results: The lifetime estimate for prescription opioid misuse among general populations of students ranged from 4% to 19.7%, with higher estimates for special student populations. Students most at risk for misuse of prescription opioids are those who report higher rates of psychological distress, depression, and suicidal thoughts and behaviors, and white, male students who use alcohol and illicit drugs. Conclusions: Findings from this study underscore the need for opioid prevention and intervention programs on university campuses.

Bidirectional influence of heroin and cocaine escalation in persons with dual opioid and cocaine dependence diagnoses

Persons with dual severe opioid and cocaine use disorders are at risk of considerable morbidity, and the bidirectional relationship of escalation of mu-opioid agonists and cocaine use is not well understood. The aim of this study was to examine the bidirectional relationship between escalation of heroin and cocaine use in volunteers dually diagnosed with opioid and cocaine dependence (OD + CD). Volunteers from New York with OD + CD (total n = 295; male = 182, female = 113; age ≥ 18 years) were interviewed with the Structured Clinical Interview for the DSM-IV Axis I Disorders and Kreek-McHugh-Schluger-Kellogg scales for dimensional measures of drug exposure, which also collect ages of 1st use and onset of heaviest use. Time of escalation was defined as age of onset of heaviest use minus age of 1st use in whole years. Times of escalation of heroin and cocaine were positively correlated in both men (Spearman r = .34, 95% confidence interval [CI: .17, .48], p < .0001) and women (Spearman r = .51, [.27, .50], p < .0001) volunteers. After we adjusted for demographic variables, a Cox regression showed that time of cocaine escalation was a predictor of time of heroin escalation (hazard ratio [HR] = 0.97, 95% CI [0.95, 0.99], p = .003). Another Cox regression showed that this relationship is bidirectional, because time of heroin escalation was also a predictor of time of cocaine escalation (HR = 0.98, [0.96-0.99], p = .016). In these adjusted models, gender was not a significant predictor of time of escalation of either heroin or cocaine. Therefore, escalation did not differ robustly by gender when adjusting for demographics and other major variables. Overall, rapid escalation of cocaine use was a predictor of rapid escalation of heroin use, and vice versa, in persons with dual severe opioid and cocaine use disorders. These findings suggest a shared vulnerability to rapid escalation of these 2 drugs in persons with dual severe opioid and cocaine use disorders. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Client Characteristics Associated with Desire for Additional Services at Syringe Exchange Programs

Objectives

The objective of this study was to explore the relationship between client characteristics and desired services offered at syringe exchange program (SEP) sites among women who inject drugs (WWID). We investigated whether a desire for additional services varied as a function of these client characteristics.

Methods

A sample of 69 women who were syringe exchange clients participated in a survey about adding services to syringe exchange programs. Three Poisson regression analyses were run to examine if client age, education, housing status, polysubstance use, and previous pregnancies were associated with overall desire for services, desire for health-related services, and desire basic needs services.

Results

Participant characteristics of polysubstance use (IRR 1.62, 95% CI 1.34-1.96; p < .01) and greater number of previous pregnancies (IRR 1.14, 95% CI 1.08-1.22; p < .05), were predictive of a greater number of desired services. Engagement in polysubstance use was predictive of a greater number of desired basic need services (IRR 1.45, 95% CI 1.23-1.70; p < .05).

Conclusions

WWID desired services at SEP sites can inform policymakers to formulate policies to better promote utilization of health-related and basic need services among WWID and, in turn, facilitate improved outcomes for WWID.

Patterns of drug overdose deaths in Kuwait from 2014 to 2018

Background

Kuwait is an Arabian Gulf couFntry with a population of around 4.4 million as of 2020. In recent years, government based news agencies have commonly exposed drug smuggling plots that were foiled by local authorities. We attempted to study the patterns of drug overdose deaths in Kuwait, which we believe is a good method to address the effect of illicit drug use in the country.

Methodology

All cases that were signed out as drug overdose death were collected from the General department of criminal evidence. The relationship between demographic factors and drug types were analyzed using various statistical methodologies.

Results

344 victims were identified from 2014 to 2018. The majority of whom were Kuwaiti nationals (67%) and the average age of death was 38. Hawalli governorate had the highest number of cases, while Jahra governorate had the least. Morphine appeared to be the most common drug found in the victims post mortem (79.9%) followed by benzodiazepines (43%). Our study has an extremely low female number of victims (2.6%). Some substances that are commonly abused globally eg heroin and cocaine were rarely recovered in our study. The number of cases have had an increase over the study period with the highest number of cases in 2018.

Conclusion

The current study is the first of its kind in Kuwait and one of the first in the middle east region. It is evident that illicit drug use and subsequent drug overdose deaths are on a rise in Kuwait and government agencies need to put a strategic plan to address and reduce this problem.

Increased medical utilization and psychiatric comorbidity following a new diagnosis of methamphetamine use disorder

BACKGROUND

Evidence of patterns of medical utilization and distribution of comorbidities among individuals using methamphetamine remains limited.

OBJECTIVE

This study aims to investigate changes in medical utilization and comorbidities before and after a diagnosis of methamphetamine use disorder.

METHODS

A total of 3321 cases (79% were male) of methamphetamine use disorder between January 1, 1996, and December 31, 2012, were identified from Psychiatric Inpatient Medical Claims database in Taiwan. Information was collected on demographics, diagnoses, and medical utilizations. The date of newly diagnosed with methamphetamine use disorder was defined as the baseline. Mirror-image study design was used to compare changes in medical utilization and comorbidities between the pre-baseline period (within 1 year before diagnosis) and the post-baseline period (within 1 year after diagnosis). Conditional logistic regression was used to estimate changes in medical utilization and comorbidities.

RESULTS

Most cases (77%) were first identified in a psychiatric department. There is a significant increase (P < .001) in psychiatric admission (odds ratio[OR] = 2.19), psychiatric emergency visits (OR = 1.31), and psychiatric outpatient visits (OR = 1.15) after diagnosis. Multivariable analysis revealed significantly increased risks (P < .001) of non-methamphetamine drug induced mental disorders (adjusted OR[aOR] = 29.47), schizophrenia (aOR = 2.62), bipolar disorder (aOR = 2.14), organic mental disorder (aOR = 1.82), and upper respiratory tract infection (aOR = 2.03) after diagnosis.

CONCLUSIONS

We found significant increases of medical utilization and psychiatric comorbidities after diagnosed with methamphetamine use disorder. These findings may reflect the problem of delayed diagnosis and treatment. Enhancement of early identification of methamphetamine use disorder in general practice is required for early intervention and decreased subsequent morbidities.

Characteristics and health care events of patients admitted to treatment for both heroin and methamphetamine compared to patients admitted for heroin only

INTRODUCTION

Co-occurring heroin and methamphetamine use is a growing public health problem. This study assessed the characteristics of Medicaid patients admitted to substance use disorder (SUD) treatment programs for heroin and methamphetamine use compared with patients admitted for heroin only.

METHODS

The study identified patients who entered treatment for heroin and methamphetamine and those admitted for heroin only between 2014 and 2017 from the Oregon Treatment Episode Data Set linked with Medicaid enrollment, and medical and pharmacy claims. We used a cross-sectional design to compare demographics, type of treatment, and substance use characteristics between the two groups. We used logistic regression models to assess differences in the odds of opioid-related and all-cause adverse events.

RESULTS

Among the 3802 study sample, 2004 (53%) were admitted for both heroin and methamphetamine use. The heroin and methamphetamine group were more likely to be younger, female, White or American Indian/Alaska Native; and had more comorbidities than patients admitted for heroin only. Patients admitted for heroin and methamphetamine treatment were less likely to receive any medication for opioid use disorder (MOUD) (56% vs 75%, p < 0.001) and received fewer days of MOUD treatment (mean 188 vs. 265 days, p < 0.001) compared to the heroin only group. The heroin and methamphetamine group were more likely to receive buprenorphine (28.1% vs 24.2%) and less likely to receive methadone (39.9% vs 62.5%). The heroin and methamphetamine group began use at a younger age, used and injected more frequently than those admitted for heroin only. Patients treated for heroin and methamphetamine had 17% lower odds of OUD-related adverse events (aOR 0.83; 95% CI 0.70-0.99) and 52% higher odds of all-cause adverse events (aOR 1.52; 95% CI 1.14-2.03) relative to the heroin only group.

CONCLUSION

Patients admitted for both heroin and methamphetamine reported greater addiction severity (more frequent use, earlier onset of use, and injection use), yet less commonly received MOUD compared to those who were admitted for heroin only. These findings indicate substantial missed opportunities for MOUD treatment even among people who successfully engage with the SUD treatment system.

Dissociable neural substrates of opioid and cocaine use identified via connectome-based modelling

Opioid use disorder is a major public health crisis. While effective treatments are available, outcomes vary widely across individuals and relapse rates remain high. Understanding neural mechanisms of treatment response may facilitate the development of personalized and/or novel treatment approaches. Methadone-maintained, polysubstance-using individuals (n = 53) participated in fMRI scanning before and after substance-use treatment. Connectome-based predictive modeling (CPM)-a recently developed, whole-brain approach-was used to identify pretreatment connections associated with abstinence during the 3-month treatment. Follow-up analyses were conducted to determine the specificity of the identified opioid abstinence network across different brain states (cognitive vs. reward task vs. resting-state) and different substance use outcomes (opioid vs. cocaine abstinence). Posttreatment fMRI data were used to assess network changes over time and within-subject replication. To determine further clinical relevance, opioid abstinence network strength was compared with healthy subjects (n = 38). CPM identified an opioid abstinence network (p = 0.018), characterized by stronger within-network motor/sensory connectivity, and reduced connectivity between the motor/sensory network and medial frontal, default mode, and frontoparietal networks. This opioid abstinence network was anatomically distinct from a previously identified cocaine abstinence network. Relationships between abstinence and opioid and cocaine abstinence networks replicated across multiple brain states but did not generalize across substances. Network connectivity measured at posttreatment related to abstinence at 6-month follow-up (p < 0.009). Healthy comparison subjects displayed intermediate network strengths relative to treatment responders and nonresponders. These data indicate dissociable anatomical substrates of opioid vs. cocaine abstinence. Results may inform the development of novel opioid-specific treatment approaches to combat the opioid epidemic.

Understanding opioid overdose risk and response preparedness among people who use cocaine and other drugs: Mixed-methods findings from a large, multi-city study

BACKGROUND

Fatal overdoses involving cocaine (powdered or crack) and fentanyl have increased nationally and in Massachusetts. It is unclear how overdose risk and preparedness to respond to an overdose differs by patterns of cocaine and opioid use. Methods: From 2017 to 2019, we conducted a nine-community mixed-methods study of Massachusetts residents who use drugs. Using survey data from 465 participants with past-month cocaine and/or opioid use, we examined global differences (p < 0.05) in overdose risk and response preparedness by patterns of cocaine and opioid use. Qualitative interviews (n = 172) contextualized survey findings. Results: The majority of the sample (66%) used cocaine and opioids in the past month; 18.9% used opioids alone; 9.2% used cocaine and had no opioid use history; and 6.2% used cocaine and had an opioid use history. Relative to those with a current/past history of opioid use, significantly fewer of those with no opioid use history were aware of fentanyl in the drug supply, carried naloxone, and had received naloxone training. Qualitative interviews documented how people who use cocaine and have no history of opioid use are largely unprepared to recognize and respond to an overdose. Conclusions: Public health efforts are needed to increase fentanyl awareness and overdose prevention preparedness among people primarily using cocaine.

Nonmedical Prescription Opioid Use among a Sample of College Students: Prevalence and Predictors

Nonmedical use of prescription opioid medication (NMPO) in the United States is a public health crisis, resulting in high rates of emergency room visits, morbidity, and mortality. The purpose of this study was to explore prevalence estimates and correlates of NMPO among a convenience sample of college students in the northeast and southeast regions of the US to help generate directions for future research. Motivations for misuse, age of onset, access, concomitant substance use, and individual factors were investigated among a sample of undergraduate students from two universities. Participants (N = 847) completed a battery of various self-report measures. Findings revealed that 7.7% (Southeastern University) and 12.8% of students (Northeastern University) reported lifetime NMPO, whereas past-month NMPO was reported by 0.8% and 0.9% of participants, respectively. Lifetime history of regularly using alcohol, nonmedical use of benzodiazepine medication, nonmedical use of prescription stimulants, symptoms of depression and anxiety, and executive functioning (i.e., metacognition and behavioral regulation) were significantly related to lifetime history of NMPO in this college sample. These findings offer several potential subsequent lines of investigation regarding the associations between various demographic and psychological factors and NMPO. Future research is needed to help identify college students who are at risk of NMPO.

Perceived Healthcare Access among Persons with and without HIV Who Use Illicit Stimulants: The Role of Cumulative Risk

Background: Persons who use stimulant drugs have greater morbidity and mortality relative to non-users. HIV infection has the potential to contribute to even great disparity in health outcomes among persons who use stimulants. These health disparities likely result in part due to poorer access to healthcare. Our study used a cumulative risk model to examine the impact of multiple risk factors on healthcare access in a sample of persons with and without HIV who use stimulants. Method: Our sample included 453 persons who reported recent use of illicit stimulants (102 HIV+, 351 HIV-). Participants completed clinical interviews, questionnaires, and a rapid oral HIV test. We constructed an 8-item cumulative risk index that included factors related to socioeconomic status, homelessness, legal history, and substance use. Results: Participants with HIV (PHW) were older than participants without HIV and more likely to have health insurance. Participants with and without HIV reported similar prior treatment utilization, but PWH reported better healthcare access and lower cumulative risk scores. Regression analyses showed cumulative risk was a significant predictor of healthcare access (β = -0.20, p < 0.001) even after controlling for age, HIV status, and health insurance status. We did not observe an interaction of HIV status by cumulative risk. Conclusions: Access to care among persons who use stimulants, both with and without HIV, is negatively impacted by the accumulation of risk factors from a number of different domains. Understanding the cumulative effects of these factors is critical for developing interventions to facilitate access to care, thus reducing health disparities and improving health outcomes.

Association between discharges against medical advice and readmission in patients treated for drug injection-related skin and soft tissue infections

BACKGROUND

The prevalence of injection drug use (IDU)-related skin and soft tissue infections (SSTI) in Philadelphia has been steadily increasing since 2013. Patients seeking treatment for these infections are more likely to be discharged against medical advice (AMA), increasing the likelihood that they will end antibiotic treatment prematurely and require additional medical interventions.

METHODS

The research team performed a nested case-control study using the Pennsylvania Health Care Cost Containment Council database for Philadelphia residents hospitalized for SSTI and substance use-related diagnoses between 2013 and 2018. The primary outcome was readmission in the same or following quarter. The study examined the impact of discharge AMA on readmission along with clinical characteristics including diagnoses for anxiety, bipolar disorder, depression, schizophrenia, diabetes, and polydrug use.

RESULTS

There were 8265 hospitalizations for IDU-related SSTI and 316 (6%) were readmitted to the hospital at least once in the same or following quarter. In total, 23.4% of cases and 13% of controls left AMA. In the final multivariable regression model, AMA discharge (AOR 2.04, 95% CI 1.46-2.86), anxiety (AOR 1.44, 95% CI 1.01-2.05), diabetes (AOR 2.02, 95% CI 1.46-2.81), and polydrug use (AOR 2.11, 95% CI 1.52-2.92) were associated with higher odds of readmission.

CONCLUSIONS

Our study demonstrates that readmissions for IDU-related SSTI are associated with recent discharge AMA. As IDU-related SSTI and polydrug use continue to rise, premature antibiotic treatment completion will impact more people, leading to worse health outcomes and additional strain on the health care system.

Service Involvement Across Multiple Sectors Among People Who Use Opioids, Methamphetamine, or Both, United States-2015-2018

BACKGROUND

The fourth wave of the opioid crisis is characterized by increased use and co-use of methamphetamine. How opioid and methamphetamine co-use is associated with health care use, housing instability, social service use, and criminal justice involvement has not been studied and could inform future interventions and partnerships.

OBJECTIVES

To estimate service involvement across sectors among people who reported past year opioid and methamphetamine co-use, methamphetamine use, opioid use, or neither opioid nor methamphetamine use.

RESEARCH DESIGN

We examined 2015-2018 data from the National Survey on Drug Use and Health. We used multivariable negative binomial and logistic regression models and predictive margins, adjusted for sociodemographic and clinical characteristics.

SUBJECTS

Nonelderly US adults aged 18 or older.

MEASURES

Hospital days, emergency department visits, housing instability, social service use, and criminal justice involvement in the past year.

RESULTS

In adjusted analyses, adults who reported opioid and methamphetamine co-use had 99% more overnight hospital days, 46% more emergency department visits, 2.1 times more housing instability, 1.4 times more social service use, and 3.3 times more criminal justice involvement compared with people with opioid use only. People who used any methamphetamine, with opioids or alone, were significantly more likely be involved with services in 2 or more sectors compared with those who used opioids only (opioids only: 11.6%; methamphetamine only: 19.8%; opioids and methamphetamine: 27.6%).

CONCLUSIONS

Multisector service involvement is highest among those who use both opioids and methamphetamine, suggesting that partnerships between health care, housing, social service, and criminal justice agencies are needed to develop, test, and implement interventions to reduce methamphetamine-related morbidity.

Examining the neighborhood-level socioeconomic characteristics associated with fatal overdose by type of drug involved and overdose setting

BACKGROUND

Fatal drug overdose in the United States is a public health crisis fueled by increased opioid and polysubstance use. Few studies have compared the neighborhood-level socioeconomic characteristics associated with overdoses of various substance classes and, to our knowledge, no investigation has yet assessed these factors in relation to polysubstance overdoses. Further, no study has determined whether socioeconomic conditions predict other contextually relevant aspects of overdoses such as whether they occur at-home or out-of-home.

METHODS

Overdose data (2015-2018) were obtained from the Coroner/Medical Examiner's Office of Jefferson County, Alabama. The toxicology results of decedents with a known overdose locations (N = 768) were assessed for the presence of synthetic opioids, natural and semi-synthetic opioids, heroin, stimulants, benzodiazepines, and alcohol. Socioeconomic characteristics were obtained from the Unites States Census Bureau at the census tract level.

RESULTS

Stimulant overdoses occurred in neighborhoods with the highest rates of disadvantage relative to other substance and polysubstance overdose types. The majority of included overdoses occurred at-home (63.7%) and an index of socioeconomic disadvantage predicted overdose rates for both at-home and out-of-home overdoses. Heroin overdose deaths were more likely to occur at-home while polysubstance stimulant-heroin overdoses were more common out-of-home.

CONCLUSIONS

An index of socioeconomic disadvantage was generally predictive of overdose, regardless of the setting in which the overdose occurred (in-home vs. out-of-home). The associations between neighborhood-level socioeconomic characteristics and fatal overdose can be tailored by substance type to create targeted interventions. Overdose setting may be an important consideration for future policy efforts, as overdoses were nearly twice as likely to occur at-home.

A fentanyl test strip intervention to reduce overdose risk among female sex workers who use drugs in Baltimore: Results from a pilot study

BACKGROUND

In 2018, there were over 67,000 drug overdose deaths in the United States, with almost half involving illicit fentanyl and other synthetic opioids. While overall age-adjusted drug overdose deaths decreased by 4.6% from 2017 to 2018, synthetic opioid deaths increased 10.0%. This pilot study evaluates the impact of a brief fentanyl test strip (FTS) intervention to increase fentanyl awareness and reduce overdose risk.

METHODS

Female sex workers (FSW) reporting past month illicit opioid use were recruited between April 2018 through February 2019 in Baltimore City, Maryland. At baseline, they completed a baseline survey, and received tailored harm reduction messaging, 5 FTS and training, and a naloxone kit, then completed a survey after one month. McNemar's test was used to compare repeated measures.

RESULTS

Among N = 103, 54% were <40 years, 59% were white, and 24% had overdosed in the past year. Among 68 who completed follow-up, most (84%) used ≥1 FTS to test their drugs, 86% had ≥1 fentanyl-positive result, 57% were surprised by the result, and 69% engaged in harm reduction behaviors following the result (e.g., asked someone to check on them, did a tester shot, used a smaller amount). Significant pretest-posttest reductions in daily illicit opioid use (77% to 56%; p = 0.003), injection frequency (40% to 25%; p = 0.004), benzodiazepine use (22% to 7%; p = 0.008), and solitary drug use (96% vs. 68%; p < 0.001) were observed. No change in preferring drugs containing fentanyl was found. Some (18%) gave their FTS to others. All but three (96%) reported being likely to use FTS in the future.

CONCLUSIONS

We found high FTS acceptability and reductions in drug use frequency and solitary drug use following FTS use among FSW who use drugs in Baltimore. These findings demonstrate that FTS-based interventions hold potential in reducing overdose risk.

Changes in substance use in relation to opioid agonist therapy among people who use drugs in a Canadian setting

BACKGROUND

Although previous studies have shown that opioid agonist therapy (OAT) is linked to reductions in illicit opioid use, less is known about how OAT impacts the use of other psychoactive substances. We aimed to examine the changes in use of different substances by comparing patterns before and after initiating OAT.

METHODS

Data for this study was derived from three ongoing prospective cohorts involving people who use drugs in Vancouver, Canada from 1996 to 2018. We assessed use patterns for heroin, illicit prescription opioid, cocaine, crack cocaine, crystal methamphetamine, cannabis, daily alcohol use, and benzodiazepines. Segmented regression was conducted to compare the trends of substance use between pre-treatment and post-treatment periods.

RESULTS

The study included 1107 participants. After OAT engagement, we observed an immediate decline in the proportion as well as a decreasing trend for heroin (Adjusted Odds Ratio (AOR): 0.80, 95% confidence interval (CI): 0.77, 0.83), illicit prescription opioid (AOR: 0.87, 95% CI: 0.83, 0.90), and benzodiazepines (AOR: 0.73, 95 % CI: 0.67, 0.80). There was no significant difference comparing the pre-treatment and post-treatment trends for cocaine, crack cocaine, crystal methamphetamine, and cannabis. However, higher growth slope was noted during the post-treatment period for daily alcohol use (P = 0.016).

CONCLUSIONS

We observed significant reduction in illicit opioids use following OAT initiation, but not for stimulant and cannabis. The increasing problematic use of alcohol may pose challenges to the safety and effectiveness of OAT. Development of comprehensive and tailored treatment strategies is needed for poly-substance users accessing OAT.

One Is Not Enough: Understanding and Modeling Polysubstance Use

Substance use disorder (SUD) is a chronic, relapsing disease with a highly multifaceted pathology that includes (but is not limited to) sensitivity to drug-associated cues, negative affect, and motivation to maintain drug consumption. SUDs are highly prevalent, with 35 million people meeting criteria for SUD. While drug use and addiction are highly studied, most investigations of SUDs examine drug use in isolation, rather than in the more prevalent context of comorbid substance histories. Indeed, 11.3% of individuals diagnosed with a SUD have concurrent alcohol and illicit drug use disorders. Furthermore, having a SUD with one substance increases susceptibility to developing dependence on additional substances. For example, the increased risk of developing heroin dependence is twofold for alcohol misusers, threefold for cannabis users, 15-fold for cocaine users, and 40-fold for prescription misusers. Given the prevalence and risk associated with polysubstance use and current public health crises, examining these disorders through the lens of co-use is essential for translatability and improved treatment efficacy. The escalating economic and social costs and continued rise in drug use has spurred interest in developing preclinical models that effectively model this phenomenon. Here, we review the current state of the field in understanding the behavioral and neural circuitry in the context of co-use with common pairings of alcohol, nicotine, cannabis, and other addictive substances. Moreover, we outline key considerations when developing polysubstance models, including challenges to developing preclinical models to provide insights and improve treatment outcomes.

The impact of cocaine and heroin drug history on motivation and cue sensitivity in a rat model of polydrug abuse

RATIONALE

Comorbid use of heroin and cocaine is highly prevalent among drug users and can greatly increase addiction risk. Nonetheless, little is known regarding how a multi-drug history impacts motivation and cue responsivity to individual drugs.

OBJECTIVE

We used behavioral-economic procedures to examine motivation to maintain drug consumption and tests of drug-seeking to drug-associated cues to assess sensitivity to heroin and cocaine-associated cues in rats that had a self-administration history of heroin, cocaine, or both drugs.

RESULTS

Unexpectedly, we found that groups with a polydrug history of heroin and cocaine did not have higher levels of motivation or cue-induced reinstatement of drug-seeking for either cocaine or heroin compared to single drug groups. Nonetheless, we did find drug-specific differences in both economic price and cue sensitivity. Specifically, demand elasticity was lower for cocaine compared to heroin in animals with a single drug history, but not with polydrug groups. In addition, cocaine demand was predictive of the degree of cue-induced reinstatement of drug-seeking for cocaine following extinction, whereas heroin demand was predictive of the degree of reactivity to a heroin-associated cue. Furthermore, although cue reactivity following the initial self-administration phase did not differ across cues and drug history, reactivity to both heroin and cocaine cues was greater during subsequent heroin use compared to cocaine use, and this enhanced reactivity to heroin cues persisted during forced abstinence.

CONCLUSIONS

These results indicate that there is a greater motivation to maintain cocaine consumption, but higher sensitivity to drug-associated cues with a history of heroin use, suggesting that cocaine and heroin may drive continued drug use through different behavioral processes.

Escalation of drug use in persons dually diagnosed with opioid and cocaine dependence: Gender comparison and dimensional predictors

BACKGROUND

Persons dually diagnosed with opioid and cocaine dependence (OD + CD) present a clinical challenge and are at risk of morbidity and mortality. The time of escalation of heroin and cocaine exposure in persons with OD + CD remain understudied, and the influence of gender and other variables have not been examined. This observational study focused on the time of escalation of heroin and cocaine in volunteers with OD + CD, examining gender and exposure to other drugs (e.g., cannabis or alcohol) as predictors. Ages of first use and of onset of heaviest use of each drug were collected (in whole years). Time of escalation was defined as the interval between age of first use and onset of heaviest use.

VOLUNTEERS

sequentially ascertained adult volunteers recruited from the New York Metropolitan area, of which n = 297 were diagnosed with OD + CD.

METHODS

Instruments administered were the SCID-I diagnostic interview (DSM-IV criteria), BIS-11 impulsiveness scale, and KMSK scales, dimensional measures of maximal exposure to specific drugs.

RESULTS

In volunteers with OD + CD, ages of onset of heaviest use of cannabis (median age = 15) and alcohol (median age = 19) were in adolescence or emerging adulthood and preceded those for heroin and cocaine (median ages = 26 and 25, respectively). Maximal levels of cannabis and alcohol exposure were high, in volunteers with OD + CD. In adjusted Cox regressions, gender was not a significant predictor of time of heroin or cocaine escalation. However, more rapid time of alcohol escalation was a predictor of more rapid time of escalation of both heroin and cocaine, in volunteers with OD + CD.

Types of Polydrug Use Among Spanish Students in Health Sciences

Polydrug use among university students may be a predictor for established patterns of multiple substance use and potentially entail long-term health problems. This study examined the types of polydrug use among Spanish students in health sciences. Undergraduate students (n = 968), aged 18-38 years (M = 21.09 years, SD = 4.10), completed the survey. A percentage of 44.3% of the participants were classified as polydrug users. Type A users (alcohol and cigarettes) made up 17.8% of the participants surveyed, whereas 20.1% were Type B (cannabis with cigarettes and/or alcohol), and a further 5.7% were Type C (cannabis with cigarettes and/or alcohol, plus at least another kind of illegal drug). Type A was the most common type among women, whereas Type C was the most common among men. Type B use was higher among women 18-19 years old than among women 25-29 years old, whereas there were no female Type C users younger than 20 years old. Weekend consumption was higher, than weekday consumption, across all polydrug user types and substances. These results suggest that the prevalence of polydrug use among Spanish students in health sciences was similar to students in other disciplines, with Type B as the most prevalent among healthcare and nonhealthcare students. Taking into account the differences based on gender, age, and time of consumption, a specific approach to the different typologies of polydrug users might be a vital step in the successful development of preventive interventions tailored to the changing reality of psychoactive substance use.