Post-traumatic stress disorder and opioid use disorder: A narrative review of conceptual models

Posttraumatic stress disorder and its cross-generational familial relationship with drug use disorder and alcohol use disorder: an extended Swedish adoption study

Objective: Information on how parental risk for posttraumatic stress disorder (PTSD) relates to their children's risk for drug use disorder (DUD) and alcohol use disorder (AUD) is limited. This study is the first to utilize an extended adoption design which can address questions about the degree of, and sources of, cross-generational and cross-disorder transmission of PTSD and substance use disorders.Method: We examined diagnoses using Swedish National registries for parents and their adult offspring (n = 2,194,171, born 1960-1992) from six types of families (intact (1), not lived with biological father (2) or mother (3), step father (4), step mother (5), and adoptive (6)). Parent-child resemblance was assessed by tetrachoric correlation.Results: PTSD and DUD showed an approximately symmetrical cross-generational cross-disorder relationship. Conversely, AUD in parents was more related to the risk for PTSD in offspring compared to the reverse direction. The cross-disorder cross-generation transmission correlations for PTSD to DUD were higher than those for PTSD to AUD. Genetic and rearing correlations for PTSD-DUD were estimated at + .79 (CI: .66, .91) and + .49 (CI: .33, .65), significantly higher than those for PTSD-AUD + .59 (CI: .48, .71) and + .28 (CI: .12, .44).Conclusions: PTSD and the substance use disorders demonstrated cross-transmission, but more so for DUD. PTSD and DUD demonstrated highly correlated genetic effects, and moderately correlated rearing effects. Correlations of genetic and rearing effects between PTSD and AUD were lower than those for PTSD and DUD.

Childhood trauma is associated with developmental trajectories of EEG coherence, alcohol-related outcomes, and PTSD symptoms

BACKGROUND

Associations between childhood trauma, neurodevelopment, alcohol use disorder (AUD), and posttraumatic stress disorder (PTSD) are understudied during adolescence.

METHODS

Using 1652 participants (51.75% female, baseline Mage = 14.3) from the Collaborative Study of the Genetics of Alcoholism, we employed latent growth curve models to (1) examine associations of childhood physical, sexual, and non-assaultive trauma (CPAT, CSAT, and CNAT) with repeated measures of alpha band EEG coherence (EEGc), and (2) assess whether EEGc trajectories were associated with AUD and PTSD symptoms. Sex-specific models accommodated sex differences in trauma exposure, AUD prevalence, and neural development.

RESULTS

In females, CSAT was associated with higher mean levels of EEGc in left frontocentral (LFC, ß = 0.13, p = 0.01) and interhemispheric prefrontal (PFI, ß = 0.16, p < 0.01) regions, but diminished growth in LFC (ß = -0.07, p = 0.02) and PFI (ß = -0.07, p = 0.02). In males, CPAT was associated with lower mean levels (ß = -0.17, p = 0.01) and increased growth (ß = 0.11, p = 0.01) of LFC EEGc. Slope of LFC EEGc was inversely associated with AUD symptoms in females (ß = -1.81, p = 0.01). Intercept of right frontocentral and PFI EEGc were associated with AUD symptoms in males, but in opposite directions. Significant associations between EEGc and PTSD symptoms were also observed in trauma-exposed individuals.

CONCLUSIONS

Childhood assaultive trauma is associated with changes in frontal alpha EEGc and subsequent AUD and PTSD symptoms, though patterns differ by sex and trauma type. EEGc findings may inform emerging treatments for PTSD and AUD.

Assessing shared psychological constructs as risk factors in comorbid PTSD-AUD combat-exposed male veterans

PTSD and AUD are frequently comorbid post-trauma outcomes. Much remains unknown about shared risk factors as PTSD and AUD work tends to be conducted in isolation. We examined how self-report measures of distress tolerance (DT), experiential avoidance (EA), and drinking motives (DM) differed across diagnostic groups in white, male combat-exposed veterans (n = 77). A MANOVA indicated a significant difference in constructs by group, F (5, 210) = 4.7, p = <.001. Follow-up ANOVAs indicated DM subscales (Coping: F (3,82) = 21.3; Social: F (3,82) = 13.1; Enhancement: F (3,82) = 10.4; ps = <.001) and EA (F (3,73) = 7.8, p < .001) differed by groups but not DT. Post hoc comparisons indicated that mean scores of the comorbid and AUD-only groups were significantly higher than controls for all DM subscales (all ps < .01). EA scores were significantly higher for the comorbid as compared to control (p < .001) and PTS-only (p = .007) groups. Findings support shared psychological factors in a comorbid PTSD-AUD population.

Psychological profiles and prescription opioid misuse, craving, and withdrawal in people with chronic pain

BACKGROUND

The negative consequences of prescription opioid misuse and opioid use disorder make it relevant to identify factors associated with this problem in individuals with chronic pain. This cross-sectional study aimed at identifying subgroups of people with chronic pain based on their psychological profiles, prescription opioid misuse, craving, and withdrawal.

METHODS

The sample comprised 185 individuals with chronic pain. We performed hierarchical cluster analysis on impulsivity, anxiety sensitivity, pain acceptance, pain intensity, opioid misuse, craving, and withdrawal.

RESULTS

The four-cluster solution was the optimal one. Misuse, craving, and anxiety sensitivity were higher among people in the Severe-problems cluster than among people in the other three clusters. Withdrawal was the highest in the High-withdrawal cluster. Impulsivity was higher among people in the Severe-problems and High-withdrawal clusters than those in the Moderate-problems and Mild-problems clusters. Pain acceptance was higher among people in the Mild-problems cluster than among people in the other three clusters. Anxiety sensitivity and misuse were higher among people in the Moderate-problems cluster than among people in the Mild-problems cluster.

CONCLUSIONS

These results support that impulsivity, anxiety sensitivity, and pain acceptance are useful constructs to identify subgroups of people with chronic pain according to their level of prescription opioid misuse, craving, and withdrawal. The results of this study may help in selecting the early intervention most suitable for each of the identified profiles.

SIGNIFICANCE

The psychological profile of individuals with chronic pain, prescription opioid misuse, craving, and withdrawal is characterized by fearing anxiety-related symptoms due to the catastrophic interpretation of such symptoms and reacting impulsively to negative moods. In contrast, participants with high pain acceptance had less prescription opioid misuse, craving, and withdrawal. The profiles identified in this study could help clinicians select targets for intervention among profiles with similar needs and facilitate early interventions to prevent opioid misuse onset or aggravation.

Genetic and non-genetic predictors of risk for opioid dependence

BACKGROUND

Elucidation of the interaction of biological and psychosocial/environmental factors on opioid dependence (OD) risk can inform our understanding of the etiology of OD. We examined the role of psychosocial/environmental factors in moderating polygenic risk for opioid use disorder (OUD).

METHODS

Data from 1958 European ancestry adults who participated in the Yale-Penn 3 study were analyzed. Polygenic risk scores (PRS) were based on a large-scale multi-trait analysis of genome-wide association studies (MTAG) of OUD.

RESULTS

A total of 420 (21.1%) individuals had a lifetime diagnosis of OD. OUD PRS were positively associated with OD (odds ratio [OR] 1.42, 95% confidence interval [CI] 1.21-1.66). Household income and education were the strongest correlates of OD. Among individuals with higher OUD PRS, those with higher education level had lower odds of OD (OR 0.92, 95% CI 0.85-0.98); and those with posttraumatic stress disorder (PTSD) were more likely to have OD relative to those without PTSD (OR 1.56, 95% CI 1.04-2.35).

CONCLUSIONS

Results suggest an interplay between genetics and psychosocial environment in contributing to OD risk. While PRS alone do not yet have useful clinical predictive utility, psychosocial factors may help enhance prediction. These findings could inform more targeted clinical and policy interventions to help address this public health crisis.

The lived experiences and treatment needs of women with opioid use disorder and posttraumatic stress symptoms: A mixed methods study

INTRODUCTION

Women show a gender-specific risk for co-occurring opioid use disorder (OUD) and posttraumatic stress disorder (PTSD). Expert groups have called for the development of integrated treatments for women with OUD/PTSD, but there remains limited information on such interventions.

METHODS

This mixed-methods study interviewed and surveyed 10 women with current or past OUD and co-occurring posttraumatic stress symptoms (PTSS) and 16 providers who work with these women. Interviews and surveys queried patient participants' and providers' experiences of OUD/PTSS and how to best design an integrated, trauma-focused treatment for OUD/PTSD.

RESULTS

Patient participants (90 % white, 90 % mothers, Mage = 45.70) met criteria for severe, lifetime OUD and 40 % met a provisional diagnosis for PTSD. Four themes emerged for participants' experiences of OUD/PTSS: 1) numerous stressors; 2) shame; 3) multiple motivations to use opioids; and 4) a cycle of trauma and opioid use. Four themes emerged regarding patient participants' perceptions on the development of an OUD/PTSD treatment: 1) mixed attitudes towards medications for OUD; 2) barriers to treatment (e.g., insufficient treatments and contextual factors); 3) treatment facilitators (e.g., social support); and 4) preferences in treatment (e.g., trauma-focused, gender-focused, family content, ambivalence around group therapy). Providers (Mage = 38.94) were primarily white women (76.5 %). Two themes emerged from their experiences working with women with OUD/PTSS: 1) perceiving women to use opioids to regulate emotions and 2) gender differences in trauma types. Three themes emerged for providers' perceptions on the development of an OUD/PTSD treatment: 1) barriers to treatment (e.g., chaotic lives, contextual factors, family); 2) treatment facilitators (e.g., trust and external motivations); and 3) desired treatment modifications (e.g., stabilization, early skills in therapy, flexibility in therapy, social supports, safety guidelines, and assistance in identifying an index trauma). Most participants (90.0 %) and providers (93.5 %) preferred working on OUD/PTSD symptoms simultaneously rather than separately.

CONCLUSIONS

Findings demonstrate the need to modify integrated treatments to meet the preferences of providers and women with OUD/PTSS and OUD/PTSD. Treatments should consider therapeutic content, structure, contextual factors, social support, and PTSD severity to enhance uptake and reach.

Interpersonal trauma, shame, and substance use: A systematic review

BACKGROUND

Interpersonal trauma is a risk factor for a wide array of adverse mental health outcomes, including substance use. Research has begun investigating the role of shame in the intersection between substance use and interpersonal trauma. The current systematic review summarizes the existing literature documenting the relation among shame, substance use, and interpersonal trauma.

METHOD

Articles were collected using a Boolean search strategy of terms related to interpersonal trauma, substance use, and shame across six databases. Independent search and screening by three researchers led to a final review of 27 articles, 15 of which were qualitative studies.

RESULTS

Findings highlight robust associations among shame, interpersonal violence, and substance use across varied samples. Findings emphasize that increased shame is associated with greater substance use among survivors of interpersonal violence and elevated shame and greater interpersonal violence are present among individuals who use substances given the high prevalence rates. Burgeoning research suggests that shame mediates the relationship between interpersonal violence and substance use.

CONCLUSION

Results from our review suggest that shame may be an important treatment target for individuals presenting with substance use and a history of interpersonal violence. Future studies, with longitudinal designs, are needed to parse out the temporal relation among shame, substance use, and interpersonal violence.

Trauma-related shame predicts daily non-medical prescription opioid use among individuals with PTSD symptoms

Non-medical prescription opioid use (NMPOU) is the use of opioids without a prescription or in a way different from how they were prescribed and is the fourth most common type of drug use in the United States. Separate research has shown that trauma-related shame is linked to posttraumatic stress disorder (PTSD) and, respectively, opioid use. However, no study to date has empirically examined the association between trauma-related shame and NMPOU among individuals with PTSD symptoms. Forty adults with clinical or subclinical PTSD who reported engaging in NMPOU at least one day in the prior month before the study completed 28 days of daily surveys. Trauma-related shame was measured at baseline. NMPOU and underlying motives to engage in NMPOU were assessed once daily via a smartphone app. Twenty-four participants (60 %) reported NMPOU over the 28-day period. After controlling for PTSD symptoms and covariates, mixed models showed that higher trauma-related shame significantly predicted higher risk of daily NMPOU (B = 0.06, SE = 0.03, t = 2.14, p=.03). After controlling for false discovery rates, trauma-related shame also significantly predicted NMPOU due to the following motives (p's < 0.031): to manage depression/sadness, to manage anxiety, to manage other stress/worry, and to get high. Among individuals with PTSD, higher baseline trauma-related shame prospectively and positively predicted greater NMPOU over a four-week daily monitoring period. Findings suggest a need to attend to trauma-related shame and its impact on subsequent motivations to engage in NMPOU. Future research should examine how treatments may effectively target trauma-related shame to reduce NMPOU and more severe PTSD symptoms.

Is post-traumatic stress disorder a risk factor for development of opioid use disorder among individuals with chronic non-cancer pain? A systematic review

Introduction

There is emerging evidence that posttraumatic-stress disorder may have mediating effects in development of chronic-non-cancer-pain and opioid-use-disorder independently, but its impact on the development of opioid-use-disorder in people with chronic-non-cancer pain is still unclear.

Objectives

(i) Estimate the risk of opioid-use-disorder among individuals with chronic-non-cancer-pain and posttraumatic-stress disorder, relative to those with chronic-non-cancer-pain only, and (ii) identify potential correlates of opioid-use-disorder among people with chronic-non-cancer-pain and posttraumatic-stress disorder.

Methods

This systematic review was conducted as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Longitudinal, epidemiological, cohort, follow-up, retrospective, prospective and cross-sectional studies reporting measures of variance on the likelihood of developing opioid-use-disorder with posttraumatic-stress disorder among individuals with chronic-non-cancer-pain were identified from six-electronic databases (Medline, Embase, Evidence-based Medicine reviews, PsycINFO, Scopus and Web of Science) until December 2022.

Results

Three out of the four studies, which met the selection criteria for this analysis reported statistically significant positive association between risk of developing opioid-use-disorder with posttraumatic-stress disorder among chronic-non-cancer-pain cohort (unadjusted Relative-Risk range: 1.51-5.27) but this association was not evident in the fourth study (adjusted Relative-Risk: 0.96; statistically non-significant), when adjusted for sociodemographic variables. The increased risk was noted particularly with females and chronic musculoskeletal pain conditions.

Conclusions

Posttraumatic-stress disorder can increase the risk of development of opioid-use-disorder among people with chronic-non-cancer-pain and a better understanding of this relationship will help to predict and prevent the development of opioid-use-disorder and may also help in reducing the disability and burden associated with chronic-non-cancer-pain.

Perspective

This review quantifies the risk of developing opioid-use-disorder in the context of posttraumatic-stress disorder among individuals with chronic-non-cancer-pain. Awareness and subsequent practice change will reduce the increasing global burden associated with the chronic-non-cancer-pain.

The impact of exposure to physical and sexual violence on opioid consequences among trauma-exposed individuals recruited from the community who use opioids

Interpersonal violence and opioid use disorder are significant and intersecting public health concerns in the USA. The current study evaluated the consequences associated with opioid use (e.g., physical, social, interpersonal, intrapersonal, and impulse control) as a function of a history of exposure to interpersonal trauma, specifically physical and sexual violence. Participants were 84 trauma-exposed individuals recruited from the community who use opioids (M age = 43.5 50% men; 55% white). Whereas no significant differences emerged in the consequences of opioid use based on a history of physical violence, individuals with a history of sexual violence demonstrated higher levels of impulsive consequences of opioid use compared to individuals without a history of sexual violence. These data highlight the importance of considering the role of exposure to sexual violence in the context of opioid use disorder treatment.

“I'm putting a Band-Aid on a bullet hole the only way I know how:” a qualitative study of barriers and facilitators to opioid misuse and recovery in Nevada

Nevada, like the rest of the United States, is undergoing substantial challenges with opioid misuse and overdose deaths, further exacerbated by the COVID-19 pandemic. While much of the attention around opioid overdose prevention is centered on treatment and recovery, it is important to understand the factors that influence initiation of use, and the function opioids play in people’s everyday lives. We conducted qualitative semi-structured individual interviews using purposive and snowball sampling among 35 people across Nevada with a current or prior history of illegal opioid or nonmedical opioid use. Our study aimed to understand why people start to use drugs, why they continue to use, what motivates them to continue to use or to seek treatment, and why individuals maintain recovery or return to use. We found five significant themes as perceived by the participants: that trauma is a risk factor for drug misuse; that the function of opioids in everyday life is a source of temporary relief but highly disruptive in the longer term; that recovery is most often a complicated and nonlinear process; that there are many barriers to accessing services that are both logistical and psychosocial; and that compassion, hope, and having a sense of purpose are crucial to the recovery process. The experiences of the study participants portray opioid use as a rational choice to escape the emotional ramifications of trauma. However, due to the physiological dependence and physical risk of opioids, drug policies that criminalize addiction, societal stigma, and the barriers to timely access of harm reduction, treatment, and recovery services, opioid users often become trapped in a distressing and dangerous cycle. Lastly, respondents indicated that hope, value, belonging, and purpose are powerful factors in cultivating intrinsic motivation for making positive changes and fostering resilience in the recovery process. Opioid misuse services should help meet basic needs and incorporate holistic approaches to recovery that acknowledge past trauma and the complexity of the recovery process.

Examining the associations between PTSD symptom clusters and alcohol-related problems in a sample of low-SES treatment-seeking Black/African American adults

Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) often co-occur. This comorbidity negatively influences treatment outcomes, functioning, and quality of life. To better understand the relation between PTSD and AUD, research has begun to examine the influence of PTSD symptom clusters on alcohol-related problems. The current study is the first to analyze the associations between PTSD symptom clusters and alcohol consumption and AUD symptom severity in a treatment-seeking sample of Black/African American (AA) adults with co-occurring AUD and PTSD symptoms. Examination of these associations may help to facilitate greater recovery in this underserved population by identifying more precise targets for treatment. PTSD symptom clusters were identified from both the current 4-factor model identified in the DSM-5 and from a recently proposed 7-factor model. Participants were Black/AA adults (50.6% male) who endorsed trauma exposure and were seeking treatment for alcohol misuse. The majority (66%) were unemployed and almost half (45%) reported an income at or lower than $20,000. In the 4-factor model, results showed Cluster D symptoms of PTSD (i.e., negative alterations in cognitions and mood) were independently associated with alcohol consequences. Use of the 7-factor model, which divides Cluster D into symptoms of negative affect and anhedonia, further demonstrated that only anhedonic symptoms were independently associated with alcohol consequences. No symptom clusters were uniquely associated with alcohol consumption. Results suggest the absence of positive emotions, rather than the presence of negative emotions, are primarily associated with alcohol-related problems in a sample of trauma-exposed, Black/AA adults seeking treatment for alcohol misuse.

Traumatic Stress-Induced Vulnerability to Addiction: Critical Role of the Dynorphin/Kappa Opioid Receptor System

Substance use disorders (SUD) may emerge from an individual’s attempt to limit negative affective states and symptoms linked to stress. Indeed, SUD is highly comorbid with chronic stress, traumatic stress, or post-traumatic stress disorder (PTSD), and treatments approved for each pathology individually often failed to have a therapeutic efficiency in such comorbid patients. The kappa-opioid receptor (KOR) and its endogenous ligand dynorphin (DYN), seem to play a key role in the occurrence of this comorbidity. The DYN/KOR function is increased either in traumatic stress or during drug use, dependence acquisition and DYN is released during stress. The behavioural effects of stress related to the DYN/KOR system include anxiety, dissociative and depressive symptoms, as well as increased conditioned fear response. Furthermore, the DYN/KOR system is implicated in negative reinforcement after the euphoric effects of a drug of abuse ends. During chronic drug consumption DYN/KOR functions increase and facilitate tolerance and dependence. The drug-seeking behaviour induced by KOR activation can be retrieved either during the development of an addictive behaviour, or during relapse after withdrawal. DYN is known to be one of the most powerful negative modulators of dopamine signalling, notably in brain structures implicated in both reward and fear circuitries. KOR are also acting as inhibitory heteroreceptors on serotonin neurons. Moreover, the DYN/KOR system cross-regulate with corticotropin-releasing factor in the brain. The sexual dimorphism of the DYN/KOR system could be the cause of the gender differences observed in patients with SUD or/and traumatic stress-related pathologies. This review underlies experimental and clinical results emphasizing the DYN/KOR system as common mechanisms shared by SUD or/and traumatic stress-related pathologies, and suggests KOR antagonist as a new pharmacological strategy to treat this comorbidity.

[Comorbidity of posttraumatic stress disorder and addiction from a biopsychosocial perspective]

Posttraumatic stress disorder and substance use disorder often co-occur within the health care system. Their comorbidity is associated with more serious acute clinical symptomatology, more frequent hospital admissions in state of emergency and significantly lower chances of improvement by psychological and pharmacological treatment. Their comorbidity contributes to dramatically unfavourable courses of illness as regards all biopsychosocial levels. The survey presented will discuss empirical findings from various perspectives: general epidemiology, substance use disorder as risk factor of trauma and PTSD, trauma and PTSD as risk factor of SUD, neurobiological effects of SUD converging towards neurobiology of PTSD, shared common factors of genetics/epigenetics, personality traits, and early developmental stress and trauma. The main focus of analysis will be put on processes that are intrinsically linked to the development and course of both disorders.

Neurocircuitry basis of the opioid use disorder-post-traumatic stress disorder comorbid state: conceptual analyses using a dimensional framework

Understanding the interface between opioid use disorder (OUD) and post-traumatic stress disorder (PTSD) is challenging. By use of a dimensional framework, such as research domain criteria, convergent and targetable neurobiological processes in OUD-PTSD comorbidity can be identified. We hypothesise that, in OUD-PTSD, circuitry that is implicated in two research domain criteria systems (ie, negative valence and cognitive control) underpins dysregulation of incentive salience, negative emotionality, and executive function. We also propose that the OUD-PTSD state might be systematically investigated with approaches outlined within a neuroclinical assessment framework for addictions and PTSD. Our dimensional analysis of the OUD-PTSD state shows how first-line therapeutic approaches (ie, partial μ-type opioid receptor [MOR1] agonism) modulate overlapping neurobiological and clinical features and also provides mechanistic rationale for evaluating polytherapeutic strategies (ie, partial MOR1 agonism, κ-type opioid receptor [KOR1] antagonism, and α-2A adrenergic receptor [ADRA2A] agonism). A combination of these therapeutic mechanisms is projected to facilitate recovery in patients with OUD-PTSD by mitigating negative valence states and enhancing executive control.

Treatment outcomes in individuals diagnosed with comorbid opioid use disorder and Posttraumatic stress disorder: A review

OBJECTIVES

Opioid use disorder (OUD) is a public health emergency. Evidence suggests that posttraumatic stress disorder (PTSD) is common among individuals with OUD; however, few studies evaluate whether concurrent diagnoses affect treatment outcomes. This review examines the impact of concurrent diagnoses of OUD and PTSD on treatment outcomes.

METHODS

A search was performed using articles identified through June 30, 2020 in PubMed, PsycINFO, and EMBASE. Included peer-reviewed articles evaluated individuals with OUD and a PTSD diagnosis via standardized assessment and/or medical record diagnoses, and reported relationships between diagnosis and treatment outcomes and/or other psychiatric conditions.

RESULTS

Out of 412 articles, 17 studies met inclusion criteria for this review (from 13 databases). Articles included had a total of n = 2190 with OUD, with n = 79 non-OUD comparison participants. Studies examining individuals with OUD revealed comorbid PTSD was associated with more severe addiction, higher rates of depression, attempted suicide, and psychosocial problems.

CONCLUSIONS

Among individuals with OUD, presence of PTSD is associated with multiple mental health problems. The impact of PTSD on drug use is inconclusive. Although only 5 studies examined psychosocial PTSD treatment, all found PTSD-focused treatment to be effective for those with comorbid OUD. Overall, results suggest the need to better identify PTSD among those with OUD, and to develop and evaluate interventions that are brief, integrative, and easy to implement in clinical settings.

Effects of the glucocorticoid receptor antagonist PT150 on stress-induced fentanyl seeking in male and female rats

RATIONALE

Opioid use disorder (OUD) is highly comorbid with stress-related disorders, and stress can serve as a trigger for reinstatement of drug seeking. Glucocorticoid receptor (GR) antagonists such as mifepristone (RU-486) may be effective against stress-induced drug seeking. In the current study, PT150 (formerly ORG-34517), a more selective GR antagonist, was tested using two models of stress-induced drug seeking, namely footshock and yohimbine.

METHODS

Adult male and female Sprague-Dawley rats were trained to self-administer fentanyl (2.5 μg/kg/infusion, i.v.) in a model of escalation. Rats then received 7 days of abstinence, followed by extinction; PT150 (0, 50 or 100 mg/kg in Nutella®; p.o.) treatment started on the first day of extinction training and continued daily until the end of the study. Following 14 days of extinction, rats were tested for reinstatement following footshock and yohimbine (0, 1, or 2 mg/kg; i.p.), tested in counterbalanced order; PT150 or placebo treatment occurred prior to each extinction and reinstatement session.

RESULTS

Prior to initiation of PT150 treatment, females self-administered greater levels of fentanyl during 1-h sessions compared to males; however, when switched to 6-h sessions, males and females self-administered similar levels of fentanyl and showed a similar escalation of intake over time. PT150 had no effect on extinction of self-administration. While both footshock and yohimbine reinstated fentanyl seeking, only footshock-induced reinstatement was decreased by PT150 (50 and 100 mg/kg). The effect of PT150 on footshock-induced reinstatement was driven primarily by males.

CONCLUSION

The glucocorticoid antagonist PT150 reduces shock-induced fentanyl seeking, suggesting it may be effective against stress-induced relapse, although the sex difference in response may need further exploration.

Intraindividual association of PTSD symptoms with binge drinking among trauma-exposed students

People, particularly undergraduate students, who report elevated symptoms of posttraumatic stress disorder (PTSD) are at elevated risk of binge drinking. The present study used ecological momentary assessment to (a) evaluate whether PTSD severity, specifically, or psychological distress, generally, are associated with binge drinking and (b) examine the self-medication and susceptibility models of the comorbidity of PTSD with binge drinking while accounting for shared liability (i.e., the between-person association of PTSD symptom severity with binge drinking). Within a larger study of undergraduate student mental health, for 14 days, students who reported a potentially traumatic experience (N = 276) reported nightly on use of alcohol and psychoactive substances and thrice daily on current affect, internalizing symptoms, and PTSD symptoms. Daily binge drinking, per the NIAAA definition, was analyzed using multivariate mixed effects, multilevel logistic regression. Results support the self-medication model; participants were more likely to binge drink on days marked by elevated PTSD symptoms, OR = 2.82, p < .01. Binge drinking was also more likely on weekends, OR = 4.21, p < .0001, and days marked by elevated daily positive affect, OR = 1.60, p < .001. Binge drinking was not associated with concurrent depressive or general anxiety symptoms (p > .30). PTSD symptoms were not associated with use of cannabis or other substances (p > .06). Regarding the susceptibility model, following a binge drinking episode, participants reported elevated depressive symptoms, B = 0.34, p = .04, but no change in affect, PTSD symptoms, or general anxiety symptoms (p > .16). Results suggest that, beyond understanding who is at risk for binge drinking, fluctuations in PTSD severity clarify when students engage in binge drinking. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Association of opioid misuse with anxiety and depression: A systematic review of the literature

The opioid epidemic is a public health problem associated with a host of negative outcomes. Although clinicians recognize covariation between opioid misuse with anxiety and depressive symptoms and disorders, research on this topic has only recently accumulated. Progress in this domain is impeded by the lack of systematic and integrative research to better understand and treat these co-occurring problems. This paper represents the first attempt to systematically review the empirical literature examining relations between opioid use and misuse, and anxiety and depression. In the first section, we define key terms and describe the article selection strategy. In the second section, we review the prevalence of anxiety and depressive symptoms among individuals who use and misuse prescription and illicit opioids. In the third section, we review the magnitude of associations between anxiety and depressive symptoms and disorders with opioid misuse, as well as highlight studies examining the longitudinal and temporal sequence of the relations between these variables. In the fourth section, we focus on experimental therapeutics, reviewing what is known about individual difference and transdiagnostic vulnerability factors for anxiety and depression that might contribute to opioid misuse and its symptoms. Finally, we discuss current knowledge gaps and present a heuristic model to guide future research.

The Developmental Origins of Opioid Use Disorder and Its Comorbidities

Opioid use disorder (OUD) rarely presents as a unitary psychiatric condition, and the comorbid symptoms likely depend upon the diverse risk factors and mechanisms by which OUD can arise. These factors are heterogeneous and include genetic predisposition, exposure to prescription opioids, and environmental risks. Crucially, one key environmental risk factor for OUD is early life adversity (ELA). OUD and other substance use disorders are widely considered to derive in part from abnormal reward circuit function, which is likely also implicated in comorbid mental illnesses such as depression, bipolar disorder, and schizophrenia. ELA may disrupt reward circuit development and function in a manner predisposing to these disorders. Here, we describe new findings addressing the effects of ELA on reward circuitry that lead to OUD and comorbid disorders, potentially via shared neural mechanisms. We discuss some of these OUD-related problems in both humans and animals. We also highlight the increasingly apparent, crucial contribution of biological sex in mediating the range of ELA-induced disruptions of reward circuitry which may confer risk for the development of OUD and comorbid neuropsychiatric disorders.

Opioid overdose in the age of fentanyl: Risk factor differences among subpopulations of overdose survivors

BACKGROUND

Although fentanyl is the drug most frequently implicated in overdose deaths, the association between overdose risk and attitudes and behaviors surrounding fentanyl in opioid-using communities has remained understudied. Possible subpopulation differences in fentanyl-related overdose risk remain equally unexamined. This paper addresses these gaps by exploring the association between overdose and fentanyl-related attitudes/behaviors in three subpopulations of overdose survivors.

METHODS

In this cross-sectional study, we sampled 432 individuals who currently or recently used opioids from New Jersey methadone and acute residential detoxification programs. Using multinomial regression analysis, we compared overdose risk factors, including fentanyl-related attitudes/behaviors, of those who never overdosed with three subgroups of overdose survivors who experienced: 1. recent overdoses occurring after, but not before, fentanyl expansion; 2. past overdoses occurring before, but not after, fentanyl expansion; 3. persistent overdoses occurring before and after fentanyl expansion.

RESULTS

Forty percent of respondents had knowingly used fentanyl and 38% deliberately sought overdose-implicated drugs. Respondents with persistent overdoses represented under 10% of the sample but accounted for 44% of all lifetime overdoses (x̅ =8.03 vs. 1.71 for the full sample). This was also the only subgroup for whom PTSD (AOR=3.84; 95%CI=1.45-10.16; p=.01) and fentanyl-seeking (AOR=1.50; 95% CI=1.16-1.94; p=.01) were significant overdose risk factors. Those with recent overdoses engaged in frequent drug combining (AOR=2.28; 95% CI=1.19-6.98; p=.05), which could have led to inadvertent fentanyl use. Those with past overdoses were not at overdose risk from fentanyl-seeking or drug combining and had rates of methadone treatment comparable to rates of those with no overdoses.

CONCLUSION

Harm reduction strategies will need to address consumers' evolving drug preferences as fentanyl continues to saturate local drug markets. Targeting comprehensive interventions, including mental health treatment, to the small group of opioid users with longstanding overdose histories may reduce the burden of overdose in opioid-using communities.

A Systematic Review of the Self-Medication Hypothesis in the Context of Posttraumatic Stress Disorder and Comorbid Problematic Alcohol Use

Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) commonly co-occur and are associated with many negative public health outcomes. There are several etiological models that explain the overlap between PTSD and AUD, including shared genetic risk and phenotypic causality, but the predominant model of etiologic association is the drinking-to-cope self-medication model. Although the self-medication model is conceptually appealing and has been widely accepted within the literature examining alcohol use and anxiety (e.g., PTSD) phenotypes, the findings are inconsistent and there is a lack of rigorous empirical evidence in support of this model. This review, which was, to our knowledge, the first systematic review of the self-medication model in relation to PTSD to date, aimed to synthesize the current literature on the association between PTSD and problematic alcohol use within the context of the self-medication model. In total, 24 studies met the inclusion criteria for the review and assessed the self-medication hypothesis using a variety of measurement instruments and data analytic approaches, such as mediation, moderation, and regression. Overall, the included studies provide evidence for the self-medication hypothesis but are limited in rigor due to methodological limitations. These limitations, which include issues with the operationalization (or lack thereof) of trauma-related drinking to cope, are discussed, and directions for future research are presented.

Post-traumatic stress disorder and risk of prescription opioid use, over-use, and misuse among World Trade Center Health Registry enrollees, 2015-2016

BACKGROUND

Among veterans, post-traumatic stress disorder (PTSD) has been shown to be associated with the use and misuse of prescription opioids. Less is known about PTSD among the general population and PTSD resulting from non-combat related trauma. We sought to determine if PTSD following exposure to the World Trade Center (WTC) disaster is associated with the recent use, over use, or misuse of prescription opioids.

METHODS

This study, conducted in 2018, examined 26,840 individuals from the WTC Health Registry. PTSD symptoms were assessed on multiple surveys (2003-2016) using the PCL Checklist-17. Three categories of post-9/11 PTSD were derived: never, past, and current. Self-reported opioid use outcomes (past year, 2015-2016) were defined as (yes/no): recent use (use of a prescription opioid), over-use (use of a prescribed opioid in a manner other than prescribed) and misuse (use of a prescription opioid prescribed to someone else).

RESULTS

Opioid use, over-use, and misuse prevalence was highest among those with current PTSD (prevalence: 12.2 %-46.1 %) compared to past PTSD (prevalence: 6.7 %-35.8 %) and never PTSD (prevalence: 3.6 %-22.9 %). In adjusted models, individuals with past and current PTSD had a greater risk of all opioid outcomes compared to never PTSD.

CONCLUSIONS

Past and current 9/11-related PTSD is a risk factor for opioid use and misuse among the general population, findings which may assist in improving screening and surveillance measures.

Associations between Medication Assisted Therapy Services Delivery and Mortality in a National Cohort of Veterans with Posttraumatic Stress Disorder and Opioid Use Disorder

Objective: Opioid use disorder (OUD) is a notable concern in the United States (US) and strongly associated with mortality. There is a high prevalence of OUD in patients with posttraumatic stress disorder (PTSD) and the mortality associated with OUD may be exacerbated in patients with PTSD. Medication-assisted treatment (MAT) for OUD has become standard of care for OUD and has been shown to reduce mortality. However, there has been little study of MAT and mortality in patients with PTSD and OUD. Methods: We conducted a retrospective cohort study in U.S. veterans who had newly engaged in PTSD treatment, were diagnosed with OUD and were provided MAT for at least one day between 2004 and 2013. We assessed mortality for one year following the index diagnosis date. We calculated all-cause mortality as well as death by external cause, overdose plus suicide, overdose, and suicide rates per 100,000. We used hazard ratios (HR) and 95% confidence intervals (CI) to compare death rates between patients with high versus low adherence to MAT. We evaluated the impact of high versus low exposure to general substance abuse care. We considered a confidence interval that did not cross one to be significant. Results: A total of 5,901 patients met inclusion criteria. Most patients were men and the average age was 43.3 years (SD = 13.8). The all-cause mortality rate was 1,370 per 100,000 patients. High adherence to MAT resulted in a non-significant, decreased risk for death due to all-cause (HR = 0.73, 95% CI [0.47, 1.13]), external cause (HR = 0.71, 95% CI [0.38, 1.35]), and overdose or suicide (HR = 0.66, 95% CI [0.33, 1.35]). Patients with high exposure (≥ 60 days) to general substance abuse care were significantly less likely to die due to external cause (HR = 0.39, 95% CI [0.18, 0.85]) and overdose or suicide (HR = 0.31, 95% CI [0.12, 0.77]). Conclusions: In patients with PTSD and OUD, improved adherence to MAT and greater exposure to general substance abuse care may result in lower mortality. Studies with longer follow-up and larger sample sizes to assess the impact of MAT on suicide are needed to confirm our findings.

Anxiety sensitivity and opioid misuse and dependence among trauma-exposed adults with chronic pain

It is unclear if anxiety sensitivity may serve as mechanism underlying the relation between posttraumatic stress symptom severity and opioid misuse and dependence among trauma-exposed persons with chronic pain. Therefore, the current study evaluated the explanatory role of anxiety sensitivity in the relations between posttraumatic stress symptom severity and opioid misuse and dependence. Participants included 294 trauma-exposed adults with chronic pain (71.4% female, Mage = 37.79 years, SD = 10.85, Mpain rating = 7.32/10) that reported current moderate to severe chronic pain and prescription opioid use. Participants were recruited via an online national survey in the United States of America. There were statistically significant indirect effects of posttraumatic stress symptom severity via anxiety sensitivity in relation to opioid misuse and dependence. The indirect effects of the reverse models for opioid misuse and dependence also were significant and suggest the potential for bi-directional relations; however, the magnitude of the effect was smaller in the tests of specificity than in the original models. The present findings provide initial empirical evidence that greater posttraumatic stress symptom severity is related to anxiety sensitivity, which in turn, is associated with increased opioid misuse and dependence among trauma-exposed individuals with chronic pain.

Chronic pain, posttraumatic stress disorder, and opioid intake: A systematic review

BACKGROUND

The literature suggests that there is a high degree of co-occurrence between chronic pain and posttraumatic stress disorder (PTSD). An association has been found between PTSD and substance abuse. PTSD is a severe disorder that should be taken into account when opioids are prescribed. It has been found that the prevalence of opioid use disorder (OUD) in chronic pain patients is higher among those with PTSD than those without this disorder.

AIM

To perform a systematic review on the association between PTSD, chronic non-cancer pain (CNCP), and opioid intake (i.e., prescription, misuse, and abuse).

METHODS

We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The Patient, Intervention, Comparator, and Outcomes (PICOS) criteria were formulated a priori in the protocol of the systematic review. A search was conducted of the PROSPERO database. In March 2019, searches were also conducted of 5 other databases: PubMed, MEDLINE, PsycINFO, Web of Science, and PILOTS. The Scottish Intercollegiate Guidelines Network checklist for cohort studies was used to assess the selected studies for their methodological quality and risk of bias. Each study was evaluated according to its internal validity, participant sampling, confounding variables, and the statistical analysis.

RESULTS

A total of 151 potentially eligible studies were identified of which 17 were retained for analysis. Only 10 met the selection criteria. All the studies were published between 2008 and 2018 and were conducted in the United States. The eligible studies included a total of 1622785 unique participants. Of these, 196516 had comorbid CNCP and PTSD and were consuming opiates. The participants had a cross-study mean age of 35.2 years. The majority of participants were men (81.6%). The most common chronic pain condition was musculoskeletal pain: back pain (47.14% across studies; range: 16%-60.6%), arthritis and joint pain (31.1%; range: 18%-67.5%), and neck pain (28.7%; range: 3.6%-63%). In total, 42.4% of the participants across studies had a diagnosis of PTSD (range: 4.7%-95%). In relation to opioid intake, we identified 2 different outcomes: opioid prescription and OUD. All the studies reported evidence of a greater prevalence of PTSD in CNCP patients who were receiving prescribed opioids and that PTSD was associated with OUD in CNCP patients.

CONCLUSION

Opioid analgesic prescription as the treatment of choice for CNCP patients should include screening for baseline PTSD to ensure that these drugs are safely consumed.

A Biopsychosocial Overview of the Opioid Crisis: Considering Nutrition and Gastrointestinal Health

The opioid crisis has reached epidemic proportions in the United States with rising overdose death rates. Identifying the underlying factors that contribute to addiction vulnerability may lead to more effective prevention strategies. Supply side environmental factors are a major contributing component. Psychosocial factors such as stress, trauma, and adverse childhood experiences have been linked to emotional pain leading to self-medication. Genetic and epigenetic factors associated with brain reward pathways and impulsivity are known predictors of addiction vulnerability. This review attempts to present a biopsychosocial approach that connects various social and biological theories related to the addiction crisis. The emerging role of nutrition therapy with an emphasis on gastrointestinal health in the treatment of opioid use disorder is presented. The biopsychosocial model integrates concepts from several disciplines, emphasizing multicausality rather than a reductionist approach. Potential solutions at multiple levels are presented, considering individual as well as population health. This single cohesive framework is based on the interdependency of the entire system, identifying risk and protective factors that may influence substance-seeking behavior. Nutrition should be included as one facet of a multidisciplinary approach toward improved recovery outcomes. Cross-disciplinary collaborative efforts, new ideas, and fiscal resources will be critical to address the epidemic.

Polydrug use disorders in individuals with opioid use disorder

BACKGROUND

Understanding the association of polydrug use disorders (PUD) with psychosocial and clinical factors is essential for the treatment of individuals with opioid use disorder (OUD). The aim of this study is to examine whether there is an association between childhood maltreatment, mood disorders, anxiety disorders, personality disorders, or posttraumatic stress disorder (PTSD) and PUD in individuals with OUD.

METHODS

We used data from 356 individuals with OUD in the past 12 months from a nationally representative database in the United States. PUD patients were classified into two groups: a group with additional one substance disorder (OUD + 1) and that with two or more additional substance disorders (OUD + 2). We conducted multivariate logistic regression to predict the PUD status, after adjustment for confounders including childhood maltreatment.

RESULTS

Among all individuals, 57.3% were polydrug users (n = 204) and 42.7% were not (n = 152). There was a high prevalence of childhood maltreatment in both groups, ranging from 16.1% to 59.5%, but the difference was not statistically significant. After adjustment for confounders, we found an association between past-year PTSD and OUD + 2 (odds ratio: 3.98; 95% confidence interval: 1.15-13.72; p = 0.03) but not with OUD + 1.

CONCLUSION

PTSD is highly prevalent in individuals with OUD using multiple substances and could influence PUD. We recommend screening for PTSD in cases of PUD. Future studies should evaluate the effect of PTSD treatment on PUD.

Opioid Prescribing: A Retrospective Analysis of Opioid Prescription Requests in a Large, Multicenter Ambulatory Care Organization

Background: To date, Atrius Health has not assessed how often patients request additional pain medication after receiving an initial opioid for acute pain management. This assessment was requested to help justify prescribing patterns for opioids in the primary care setting. Objective: To assess the amount of requests for additional opioid prescriptions in patients who received a short-acting opioid for acute pain management. Methods: This was a retrospective chart review of a multicenter large ambulatory care organization in the Greater Boston Area. Atrius Health patients who received an initial prescription for a short-acting oral opioid indicated for acute pain management between May 1, 2016, and October 1, 2016, were included in the study. Results: The overall percentage of patients requesting additional medication for acute pain management was 13% (46/350). Of the 46 patients who requested additional medication, 15 patients received a second opioid prescription (33%, 15/46). For those patients who requested additional pain medication, there were no trends between the day supply that was prescribed and a patient receiving a second opioid prescription from a health care provider. Patients who received a 4- to 5-day supply of opioids were not more likely to call back requesting additional pain medication than patients who received a 1- to 3-day supply of opioids (odd ratio = 0.41; 95% confidence interval = 0.17-1.00). Conclusion: At Atrius Health, roughly 13% of patients are requesting additional pain medications after being prescribed a short-acting opioid for acute pain management. Other primary care and urgent care health systems may consider reducing the day supply of opioids prescribed for acute pain management.

Posttraumatic stress disorder and chronic pain are associated with opioid use disorder: Results from a 2012-2013 American nationally representative survey

BACKGROUND

Chronic pain conditions and posttraumatic stress disorder (PTSD) commonly co-occur and are associated with opioid use disorder (OUD). The aims of this paper were to identify prevalence estimates of OUD among individuals with and without PTSD and assess independent and combined contributions of PTSD and chronic pain conditions on OUD in a nationally representative sample.

METHODS

Data were extracted from 36,309 individuals from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions. Past-year PTSD and OUD were assessed using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-5 edition. Respondents reported physician-confirmed, past-year chronic pain conditions, categorized into musculoskeletal pain (e.g., arthritis), digestive pain (e.g., pancreatitis), and nerve pain (e.g., reflex sympathetic dystrophy). We examined the weighted prevalence of OUD among those with and without PTSD. Multiple logistic regressions examined the association between PTSD and chronic pain conditions on OUD.

RESULTS

The prevalence of OUD was higher among those with PTSD than those without. Comorbid PTSD/musculoskeletal pain and PTSD/nerve pain conditions were associated with increased odds of OUD, compared to those with neither PTSD nor chronic pain conditions. Digestive pain conditions were not associated with OUD. Comorbid PTSD/musculoskeletal pain conditions demonstrated an additive relationship on OUD compared to musculoskeletal pain conditions and PTSD alone.

CONCLUSIONS

Results reveal that musculoskeletal pain and nerve pain conditions are associated with increased odds of OUD, but only musculoskeletal pain conditions display an additive relationship on OUD when combined with PTSD. These findings have implications for opioid management and screening among those with comorbid conditions.

Association of childhood abuse and prescription opioid use in early adulthood

INTRODUCTION

Previous research has examined the association of childhood abuse with opioid misuse and dependence in adulthood. However, little research has focused specifically on prescription opioids, and no studies have examined associations with prescription opioid use, a potential pathway to later opioid misuse and dependence. The aim of the present study was to examine the association of childhood emotional, physical, and sexual abuse with prescription opioid use in early adulthood.

METHODS

We used data from Waves I (12-18years) and IV (24-32years) of the National Longitudinal Study of Adolescent to Adult Health. At Wave IV, respondents reported experiences of childhood abuse occurring prior to age 18years and prescription opioid use in the last four weeks. We conducted multivariable logistic regression to examine associations of childhood abuse with recent prescription opioid use.

RESULTS

In multivariable models adjusted for respondent sex, race/ethnicity, age, and socioeconomic status, childhood emotional abuse (OR=1.57, 95% CI 1.29, 1.90), physical abuse (OR=1.46, 95% CI 1.14, 1.87), and any childhood abuse (OR=1.51, 95% CI 1.24, 1.82) were significantly associated with recent prescription opioid use.

CONCLUSIONS

Given continued increases in prescription opioid use and opioid-related morbidity and mortality in the U.S., understanding upstream social and environmental factors associated with prescription opioid use is important to strengthening and expanding current prevention and intervention strategies. Future research is needed to examine factors potentially mediating the association between childhood abuse and prescription opioid use in order to provide additional insights for prevention and intervention efforts.