Brief report: The influence of childhood trauma on the effects of delta-9-tetrahydrocannabinol in persons with opioid use disorder

BACKGROUND AND OBJECTIVES

Childhood trauma (CT) increases addiction vulnerability. We examined CT's impact on delta-9-tetrahydrocannabinol (THC) effects.

METHODS

This is a post-hoc analysis of a randomized, placebo-controlled, crossover trial investigating the effects of oral THC (10, 20 mg) among 25 persons receiving methadone for opioid use disorder (OUD).

RESULTS

Greater CT was associated with lower aversive effects from higher THC doses (20 mg) (p = .006).

DISCUSSION AND CONCLUSIONS

CT may reduce the subjective aversive effects of THC, potentially leading to greater cannabis use in individuals with OUD.

SCIENTIFIC SIGNIFICANCE

These findings offer insights into THC's risks versus benefits in OUD subgroups and emphasize assessing CT in OUD treatment and research.

Efficacy of Integrating the Management of Pain and Addiction via Collaborative Treatment (IMPACT) in Individuals With Chronic Pain and Opioid Use Disorder: Protocol for a Randomized Clinical Trial of a Digital Cognitive Behavioral Treatment

BACKGROUND

Chronic pain is common among individuals with opioid use disorder (OUD) who are maintained on medications for OUD (MOUD; eg, buprenorphine or methadone). Chronic pain is associated with worse retention and higher levels of substance use. Treatment of individuals with chronic pain receiving MOUD can be challenging due to their increased clinical complexity. Given the acute and growing nature of the opioid crisis, MOUD is increasingly offered in a wide range of settings, where high-quality, clinician-delivered, empirically validated behavioral treatment for chronic pain may not be available. Therefore, digital treatments that support patient self-management of chronic pain and OUD have the potential for wider implementation to fill this gap.

OBJECTIVE

This study aims to evaluate the efficacy of Integrating the Management of Pain and Addiction via Collaborative Treatment (IMPACT), an interactive digital treatment program with asynchronous coach feedback, compared to treatment as usual (TAU) in individuals with chronic pain and OUD receiving MOUD.

METHODS

Adult participants (n=160) receiving MOUD and reporting bothersome or high-impact chronic pain will be recruited from outpatient opioid treatment programs in Connecticut (United States) and randomized 1:1 to either IMPACT+TAU or TAU only. Participants randomized to IMPACT+TAU will complete an interactive digital treatment that includes 9 modules promoting training in pain and addiction coping skills and a progressive walking program. The program is augmented with a weekly personalized voice message from a trained coach based on daily participant-reported pain intensity and interference, craving to use opioids, sleep quality, daily steps, pain self-efficacy, MOUD adherence, and engagement with IMPACT collected through digital surveys. Outcomes will be assessed at 3, 6, and 9 months post randomization. The primary outcome is MOUD retention at 3 months post randomization (ie, post treatment). Secondary outcomes include pain interference, physical functioning, MOUD adherence, substance use, craving, pain intensity, sleep disturbance, pain catastrophizing, and pain self-efficacy. Semistructured qualitative interviews with study participants (n=34) randomized to IMPACT (completers and noncompleters) will be conducted to evaluate the usability and quality of the program and its outcomes.

RESULTS

The study has received institutional review board approval and began recruitment at 1 site in July 2022. Recruitment at a second site started in January 2023, with a third and final site anticipated to begin recruitment in January 2024. Data collection is expected to continue through June 2025.

CONCLUSIONS

Establishing efficacy for a digital treatment for addiction and chronic pain that can be integrated into MOUD clinics will provide options for individuals with OUD, which reduce barriers to behavioral treatment. Participant feedback on the intervention will inform updates or modifications to improve engagement and efficacy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05204576; https://clinicaltrials.gov/ct2/show/NCT05204576.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54342.

The relationship of pain intensity and opioid craving with delayed methadone dose: A preliminary study of individuals with opioid use disorder

AIMS

Despite a strong theoretical link between opioid craving and pain, little is known about the temporal relationship between pain and craving and the acute experience of pain in the context of methadone treatment. Using a cross-over design, the current study evaluated the time course of pain and craving and objective experience of pain as a function of the last methadone dose.

METHODS

Participants (n = 20) presented for the study in the morning and either received methadone dose as scheduled or delayed dose until the afternoon. During the 4-h study visit, participants completed a series of tasks, including repeated assessment of pain and craving at 0, +40, +70, +130, +160 and +240 min and a cold pressor test (CPT) at +15 and +220 min.

RESULTS

Separate mixed model results demonstrated no effect of dosing condition on craving; however, there was a significant dosing condition by time interaction (F(5,209) = 3.38, P = .006) such that pain increased over time in the delayed methadone condition but decreased in time in the scheduled methadone condition. A mixed model predicting self-reported pain revealed a three-way interaction between dosing condition, craving and time (F(5,197) = 2.39, P = .039) explained by a positive association between craving and pain at each time point (except 240 min) in delayed condition (P-range = .004-.0001). A separate mixed model on CPT data indicated a significant condition by time interaction such that pain threshold decreased in the delayed, but not scheduled, condition (F(1,57) = 4.01, P = .050).

CONCLUSIONS

These preliminary findings highlight the potential for increased risks after even a short delay in receiving a methadone dose.

Associations Between Childhood Trauma and Tobacco Use Outcomes in Adults after Overnight Abstinence

INTRODUCTION

Childhood trauma is known to be associated with nicotine dependence, yet limited smoking outcomes have been examined and few studies have assessed associations between specific trauma subscales and smoking. Additionally, sex differences in trauma-smoking relations are understudied. This study examined associations between childhood trauma and several smoking-related outcomes in adults who smoke after overnight abstinence.

AIMS AND METHODS

People who smoke (N = 205) completed self-report and biochemical assessments evaluating childhood trauma, affect, nicotine dependence, smoking urges, withdrawal, and plasma cortisol and cotinine levels. Smoking outcomes were compared between those with and without a history of moderate to severe childhood trauma among the total sample and by sex.

RESULTS

Relative to those with no to minimal abuse, those with moderate to severe abuse had higher negative affect, withdrawal severity, and plasma cotinine levels. Exploratory analyses revealed that women were more likely than men to have urges to smoke for negative reinforcement and have higher withdrawal severity, but no interactions between abuse group and sex were observed. Examining specific trauma subscales, the moderate to severe emotional abuse group had more severe nicotine dependence, negative affect, and withdrawal compared to the no to minimal group. The moderate to severe sexual abuse group had more severe nicotine dependence and withdrawal compared to the no to minimal group.

CONCLUSIONS

Exposure to childhood trauma is associated with more severe nicotine dependence, negative affect, withdrawal, and higher plasma cotinine levels. Findings also indicate that different types of trauma may differentially affect smoking behaviors.

IMPLICATIONS

This study of adults who smoke finds that childhood trauma history may be a marker for smoking susceptibility and suggests that individuals with experiences of emotional and sexual abuse may require targeted forms of smoking cessation interventions. Moreover, findings suggest that smoking risks may differ for men and women. Findings inform public health interventions intended to reduce cigarette use in individuals with exposure to childhood trauma.

Delta-9-tetrahydrocannabinol modulates pain sensitivity among persons receiving opioid agonist therapy for opioid use disorder: A within-subject, randomized, placebo-controlled laboratory study

The opioid and cannabinoid receptor systems are inextricably linked-overlapping at the anatomical, functional and behavioural levels. Preclinical studies have reported that cannabinoid and opioid agonists produce synergistic antinociceptive effects. Still, there are no experimental data on the effects of cannabinoid agonists among humans who receive opioid agonist therapies for opioid use disorder (OUD). We conducted an experimental study to investigate the acute effects of the delta-9-tetrahydrocannabinol (THC) among persons receiving methadone therapy for OUD. Using a within-subject, crossover, human laboratory design, 25 persons on methadone therapy for OUD (24% women) were randomly assigned to receive single oral doses of THC (10 or 20 mg, administered as dronabinol) or placebo, during three separate 5-h test sessions. Measures of experimental and self-reported pain sensitivity, abuse potential, cognitive performance and physiological effects were collected. Mixed-effects models examined the main effects of THC dose and interactions between THC (10 and 20 mg) and methadone doses (low-dose methadone defined as <90 mg/day; high dose defined as >90 mg/day). Results demonstrated that, for self-reported rather than experimental pain sensitivity measures, 10 mg THC provided greater relief than 20 mg THC, with no substantial evidence of abuse potential, and inconsistent dose-dependent cognitive adverse effects. There was no indication of any interaction between THC and methadone doses. Collectively, these results provide valuable insights for future studies aiming to evaluate the risk-benefit profile of cannabinoids to relieve pain among individuals receiving opioid agonist therapy for OUD, a timely endeavour amidst the opioid crisis.

Developing non-opioid therapeutics to alleviate pain among persons with opioid use disorder: a review of the human evidence

The opioid crisis remains a major public health concern, causing significant morbidity and mortality worldwide. Pain is frequently observed among individuals with opioid use disorder (OUD), and the current opioid agonist therapies (OAT) have limited efficacy in addressing the pain needs of this population. We reviewed the most promising non-opioid analgesic therapies for opioid-dependent individuals synthesising data from randomised controlled trials in the Medline database from December 2022 to March 2023. Ketamine, gabapentin, serotoninergic antidepressants, and GABAergic drugs were found to be the most extensively studied non-opioid analgesics with positive results. Additionally, we explored the potential of cannabinoids, glial activation inhibitors, psychedelics, cholecystokinin antagonists, alpha-2 adrenergic agonists, and cholinergic drugs. Methodological improvements are required to advance the development of novel analgesic strategies and establish their safety profile for opioid-dependent populations. We highlight the need for greater integration of experimental pain methods and abuse liability assessments, more granular assessments of prior opioid exposure, greater uniformity of pain types within study samples, and a particular focus on individuals with OUD receiving OAT. Finally, future research should investigate pharmacokinetic interactions between OAT and various non-opioid analgesics and perform reverse translation basic experiments, particularly with methadone and buprenorphine, which remain the standard OUD treatment.

Examining racial differences in smoking outcomes among smokers enrolled in an intravenous nicotine infusion study

INTRODUCTION

Large racial disparities exist in the prevention and treatment of smoking-related diseases, and minoritized populations carry a heavier burden of smoking-related morbidity and mortality. To date, most studies investigating smoking-related illnesses have been conducted in samples in which the majority, or totality, self-identified as White or Caucasian. While Black individuals who smoke tend to have a lower rate of nicotine clearance, in part due to the use of mentholated cigarettes, less is known about how slower clearance affects their acute subjective and physiologic responses in response to either overnight abstinence or subsequent nicotine administration. This study aimed to investigate differences between the experiences of Black and White individuals who smoke across these outcomes after a period of short-term abstinence and after IV nicotine infusion.

METHODS

The study included 206 smokers (N = 103 Black, N = 103 White, by self-report). The study investigated self-report, physiological, and biochemical smoking-related outcomes following confirmed overnight abstinence followed by IV nicotine infusion. The outcome measures were separately analyzed with repeated-measures mixed-models.

RESULTS

Black individuals had lower rates of nicotine clearance and were more likely to smoke mentholated cigarettes than White individuals. Despite these differences, no differences in withdrawal, cravings, or physiological outcomes were observed between the two groups. There were some trends toward differences in subjective experiences, in that an interaction with trend level significance between race and dose was observed for negative subjective drug effects, with White smokers trending towards endorsing higher levels of negative affect after abstinence and nicotine infusion. We also observed that Black individuals trended towards experiencing more negative drug effects in response to initial nicotine delivery than to saline, whereas White individuals had no differences in negative drug effects across saline or nicotine doses.

CONCLUSIONS

Despite slower nicotine clearance, Black participants exhibited withdrawal and urges to smoke as severe as White participants, and did not have blunted physiological responses to overnight abstinence or administration of nicotine, which were contrary to our hypotheses. Our findings suggest minimal differences across races in the acute pharmacologic effects of nicotine. We observed trend-level differences in subjective and affective responses to nicotine. Greater insight into these differences may lead to improved prevention and treatment strategies for smoking-related illnesses for Black individuals who smoke.

Integrating cognitive bias modification for pain and opioid cues into medication for opioid use disorder clinical care: Feasibility, acceptability, and preliminary results

BACKGROUND

Despite high co-occurrence, chronic pain is often unaddressed in treatment for opioid use disorder (OUD) and little is known about mechanisms that may underlie associations between pain and opioid use. Using an attentional bias (AB) task with both pain and opioid cues, we evaluated a cognitive bias modification (CBM) task administered during regularly scheduled medications for OUD (mOUD) dosing visits. The current study evaluated the feasibility, acceptability, and preliminary efficacy of the CBM task. Outcomes for AB tasks used traditional mean-based score and trial-level bias scores (TLBS).

METHODS

In a double-blind, randomized controlled trial, 28 individuals with OUD and chronic pain engaged in mOUD were randomized to either CBM or an AB control condition and completed up to three tasks per week for four weeks. Standard AB task was completed at baseline and post-treatment. Participants completed feasibility and acceptability measures, and preliminary efficacy (i.e., change in AB) was assessed using ANOVA models.

RESULTS

Participants attended 83.3% of scheduled sessions and generally reported the task was enjoyable, credible, and easy to complete. Preliminary results demonstrated a condition by time interaction highlighting a reduction in AB in the CBM group but not the control group in opioid TLBS variability (F[1,26]=5.01, p = .034) and pain TLBS towards (F[1,26]=6.42, p = .018) and pain TLBS variability (F[1,26]=5.24, p = .03).

CONCLUSIONS

The current study supports integrating brief, computer-based tasks designed to reduce AB into mOUD clinical care. The preliminary results suggest that TLBS outcomes may be more sensitive to capture changes in AB; however, larger studies are required.

Opioid use disorder with chronic pain increases disease burden and service use

To address the ongoing opioid epidemic, there has been an increased focus on the treatment and evaluation of opioid use disorder (OUD). OUD and chronic pain (CP) frequently co-occur; however, little is known about the additional comorbidities that present when they occur together as compared to when either condition presents alone. Using data from Fiscal Year 2012 Veteran's Health Administration, all veterans diagnosed with both OUD + CP were compared to those diagnosed with OUD or CP alone on socioenvironmental characteristics, medical and mental health diagnoses, and Veterans Affairs (VA) clinical service use. Veterans with OUD + CP (n = 33,166), compared to those with OUD only (n = 12,517), had higher numbers of medical conditions. Compared to those with CP only (n = 2,015,368), veterans with OUD + CP had higher rates of homelessness and substance use diagnoses. Most mental health diagnoses, numbers of psychotropic medication fills, opioid prescriptions, and use of all other services were higher in the OUD + CP group than in either single disorder group. Multinomial regression analysis revealed stronger effects for medical disorders and medical-surgical outpatient service use in the comparison of OUD + CP with OUD only and stronger effects for substance use and mental health disorders and use of prescription opiates in the comparison with CP only. These findings suggest that concurrent OUD + CP imposes exceptional disease and clinical service burdens that likely require the development of simultaneous, integrated approaches to treatment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Threshold for the pleasurable effects of nicotine are lower than its reinforcing effects during self-administration

A recent study demonstrated that during a single sampling period, 0.1 mg of intravenous (IV) nicotine (vs. placebo) was found to be the threshold for subjective and physiological drug effects. The present study is a secondary analysis evaluating whether the threshold for subjective and physiological effects is similar when the subject has repeated opportunities to choose blinded doses of nicotine versus placebo. We also examined whether cigarette craving, withdrawal, and rate of nicotine metabolism affected nicotine reinforcement, defined by a greater number of nicotine choices than placebo. Young adult (n = 34; 68% male), daily smokers had five laboratory sessions after overnight abstinence. After sampling an IV dose of nicotine (0.0125, 0.025, 0.05, 0.1, or 0.2 mg/70 kg) versus saline (placebo), participants completed a nicotine self-administration (NSA) procedure that included 10 opportunities to self-administer IV dose of nicotine or placebo. The threshold for subjective positive effects of nicotine during the NSA was equal to or lower than the sampling period, 0.05-0.1 mg versus 0.1 mg. The threshold for nicotine-induced heart rate increase was higher during the NSA than during the sampling period (0.2 mg vs. 0.1 mg). Higher baseline craving and nicotine metabolite ratio (NMR) were associated with nicotine reinforcement at 0.2 mg and 0.1 mg doses, respectively (p < .05). The results suggest that subjective effects during NSA are reported at doses lower than the sampling period. Taken together, tobacco products thought to be subthreshold for reinforcement should be carefully evaluated for their subjective effects, including their discriminative stimulus effects. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A systematic review evaluating PTSD treatment effects on intermediate phenotypes of PTSD

OBJECTIVE

Although the efficacy of evidence-based treatments for posttraumatic stress disorder (PTSD) has been well established, high rates of treatment dropout and/or nonresponse or under-response to treatment suggest a need to explore novel treatment approaches. Most current research has focused on DSM-based categorical outcomes as primary indicators of treatment response, which may obscure the phenotypic heterogeneity of PTSD and limit the ability to map symptoms to underlying neurobiology. This systematic review aimed to identify intermediate phenotypes (IPs) of PTSD and evaluate IP sensitivity to PTSD treatments.

METHOD

Five databases were searched for empirical studies published in English between January 1, 2010 and August 1, 2022 examining behavioral and pharmacological PTSD treatment effects on biobehavioral PTSD outcomes.

RESULTS

Twenty-two studies met the inclusion criteria. Most studies evaluated behavioral treatment outcomes (n = 20), while only two studies evaluated pharmacological interventions. Five PTSD IPs were identified, including "impairments in working memory," "alterations in cognitive control," "unstable threat processing," "heightened fear or startle response," and "disturbances in sleep and wakefulness." This review offers preliminary support to suggest the utility of IP measures in assessing treatment efficacy; however, risk of bias and methodological limitations constrain the validity and generalizability of the results.

CONCLUSIONS

The paucity of research combined with the heterogeneity of study methodologies and significant study limitations makes it difficult to draw strong conclusions regarding IP sensitivity to treatment. However, the existing body of research incorporating this framework shows potential for the IP approach to improve the translation of treatment efficacy from clinical trials to clinical settings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Catechol-O-Methyltransferase Effects on Smoking: A Review and Proof of Concept of Sex-Sensitive Effects

Purpose of Review

This article reviews recent research on how catechol-O-methyltransferase (COMT) may impact cigarette smoking behavior, and how effects may be sex-sensitive. Preliminary data are presented on sex-sensitive effects of COMT on response to short-term abstinence in individuals who smoke.

Recent Findings

Although research is mixed, functional variants in the COMT gene have been linked with smoking behavior, cessation outcomes and nicotine abstinence-related symptoms. Our proof-of-concept preliminary data from a human laboratory study of individuals who smoke cigarettes found that those with the high COMT enzyme activity genotype (Val/Val) reported more severe smoking urges and withdrawal symptoms following overnight abstinence than Met carriers. These effects were present in women, but not in men and were abstinent-dependent, in that they dissipated following nicotine administration.

Summary

The preliminary data showing sex-sensitive pharmacogenetic effects may shed light on mechanisms contributing to sex differences in barriers to smoking cessation or potential sex-specific treatment options.

Alleviation of opioid withdrawal by cannabis and delta-9-tetrahydrocannabinol: A systematic review of observational and experimental human studies

BACKGROUND

While six U.S. states have already officially authorized cannabinoids to substitute opioids and treat opioid use disorder, the therapeutic benefits of cannabinoids remain unclear, especially when weighted against their adverse effects.

METHODS

We conducted a systematic review of studies examining the association between opioid withdrawal and cannabis use or delta-9-tetrahydrocannabinol (THC) administration. We searched multiple databases from inception to July 30, 2022, and assessed study quality.

RESULTS

Eleven studies were identified, with a total of 5330 participants, of whom 64 % were male. Nine observational studies examined the association between cannabis use and opioid withdrawal. Two randomized, placebo-controlled clinical trials (RCTs) investigated the withdrawal-alleviating effects of dronabinol, a synthetic form of THC. Four observational studies found an association between cannabis use and the alleviation of opioid withdrawal; one reported exacerbation of opioid withdrawal symptoms; and four reported no association. RCTs reported that THC alleviated opioid withdrawal, albeit with dose-dependent increases in measures of abuse liability, dysphoria, and tachycardia. There was high heterogeneity in measurements of opioid withdrawal and the type and dose of opioid at baseline.

CONCLUSIONS

Although there is preliminary evidence that cannabis and its main psychoactive constituent, THC, may alleviate opioid withdrawal, these effects are likely to have a narrow therapeutic window. Further, the potential of cannabinoids to alleviate opioid withdrawal is determined by complex interactions between patient characteristics and pharmacological factors. Collectively, these findings have clinical, methodological, and mechanistic implications for treating opioid withdrawal during cannabinoid use, and for efforts to alleviate opioid withdrawal using non-opioid therapeutics.

Progesterone Increases Nicotine Withdrawal and Anxiety in Male but Not Female Smokers During Brief Abstinence

INTRODUCTION

Although exogenous progesterone may hold promise as a treatment for nicotine use disorders, it is unclear whether it is similarly effective in males and females. This study examined the effects of progesterone on nicotine use disorder comprehensively using behavioral, psychological, and neural measures in male and female smokers exposed to brief abstinence.

AIMS AND METHODS

Thirty-three male and 33 female non-treatment-seeking smokers participated in a double-blind, randomized, placebo-controlled crossover study of 200 mg of progesterone or placebo daily over a four-day abstinence period. Smoking behavior and subjective effects of nicotine were assessed at baseline and after final drug administration. Nicotine withdrawal, smoking urges, mood states, and neural response to smoking cues were measured at baseline, after the first drug administration, and after the final drug administration.

RESULTS

No main effect of drug (progesterone vs. placebo) emerged for any outcome. Significant sex by drug interactions emerged for nicotine withdrawal (p = .020), perceived strength of nicotine (p = .040), and perceived bad effects of nicotine (p = .029). Males receiving progesterone reported worse nicotine withdrawal (p = .046) and a trend towards decreased bad effects of nicotine (p = .070). Males on progesterone also reported greater tension and anxiety relative to placebo (p = .021). Females on progesterone perceived nicotine's effects as being stronger relative to placebo (p = .046).

CONCLUSIONS

Progesterone causes sex-dependent effects on smoking-related outcomes during brief abstinence. Specifically, progesterone in males may increase rather than decrease nicotine withdrawal and negative affect during abstinence, potentially hindering efforts to quit smoking.

IMPLICATIONS

In male and female smokers undergoing a brief period of abstinence, we examined the effects of progesterone on smoking outcomes. While progesterone had limited effects in female smokers, in males, it worsened nicotine withdrawal and negative affect. Our findings emphasize the importance of analyzing sex differences in future studies examining progesterone as a potential treatment and suggest that progesterone in males could potentially exacerbate aspects of nicotine dependence.

CLINICALTRIALS.GOV REGISTRATION

NCT01954966. https://clinicaltrials.gov/ct2/show/NCT01954966.

Effect of progesterone administration in male and female smokers on nicotine withdrawal and neural response to smoking cues: role of progesterone conversion to allopregnanolone

BACKGROUND

Progesterone administration has therapeutic effects in tobacco use disorder (TUD), with females benefiting more than males. Conversion of progesterone to the neurosteroid allopregnanolone is hypothesized to partly underlie the therapeutic effects of progesterone; however, this has not been investigated clinically.

METHODS

Smokers (n = 18 males, n = 21 females) participated in a randomized, double-blind, placebo-controlled crossover study of 200 mg progesterone daily across 4 days of abstinence. The ratio of allopregnanolone:progesterone was analyzed in relationship to nicotine withdrawal, smoking urges, mood states, subjective nicotine effects, and neural response to smoking cues.

RESULTS

Allopregnanolone:progesterone ratio interacted with sex to predict withdrawal symptoms (p = 0.047), such that females with higher allopregnanolone:progesterone ratios reported lower withdrawal severity (b = - 0.98 [- 1.95, - 0.01]; p = 0.048). In addition, allopregnanolone:progesterone ratio interacted with sex to predict confusion (p = 0.014) and fatigue (p = 0.034), such that females with higher allopregnanolone:progesterone ratios reported less confusion (b = - 0.45 [- 0.78, - 0.12]; p = 0.008) and marginally lower fatigue (b = - 0.50 [- 1.03, 0.02]; p = 0.062. Irrespective of sex, higher ratios of allopregnanolone:progesterone were associated with stronger "good effects" of nicotine (b = 8.39 [2.58, 14.20]); p = 0.005) and weaker "bad effects" of nicotine (b = - 7.13 [- 13.53, - 0.73]; p = 0.029).

CONCLUSIONS

Conversion of progesterone to allopregnanolone correlated with smoking-related outcomes in both sex-dependent and sex-independent ways. Sex-dependent effects suggest that conversion of progesterone to allopregnanolone may contribute to greater therapeutic benefits in females but not males with TUD. Trial registration Clinicaltrials.gov registration, retrospectively registered: NCT01954966; https://clinicaltrials.gov/ct2/show/NCT01954966 \.

Cocaine Use Disorder (CUD): Current Clinical Perspectives

Cocaine use disorder (CUD) is a devastating disorder, impacting both individuals and society. Individuals with CUD face many barriers in accessing treatment for CUD, and most individuals with CUD never receive treatment. In this review, we provide an overview of CUD, including risk factors for CUD, common co-occurring disorders, acute and chronic effects of cocaine use, and currently available pharmacological and behavioral treatments. There are no FDA-approved pharmacological treatments for CUD. Future studies with larger sample sizes and testing treatment combinations are warranted. However, individuals with CUD and co-occurring disorders (eg, a mood or anxiety disorder) may benefit from medication treatments. There are behavioral interventions that have demonstrated efficacy in treating CUD – contingency management (CM) and cognitive-behavioral therapy for substance use disorders (CBT-SUD) in particular – however many barriers remain in delivering these treatments to patients. Following the discussion of current treatments, we highlight some promising emerging treatments, as well as offer a framework that can be used in building a treatment plan for individuals with CUD.

Plasma Menthol Glucuronide as a Biomarker for the Behavioral Effects of Menthol and Nicotine in Humans

This secondary analysis sought to determine if plasma menthol glucuronide (MG) concentrations predict changes in three outcomes, subjective drug effects, urges to smoke, and heart rate, following concurrent inhaled menthol and intravenous nicotine. A total of 45 menthol and non-menthol cigarettes smokers (36 male, nine female, 20 Black, and 23 White) were included in this double-blind, placebo-controlled study. Across three test sessions, participants were assigned to a different flavor condition for each session: 0% (no menthol), 0.5%, or 3.2% menthol. In each test session, participants received in a random order one intravenous delivery of saline and two intravenous deliveries of nicotine (0.25 mg/70 kg and 0.5 mg/70 kg), each 1 h apart, concurrent with menthol delivery by e-cigarettes. The main outcomes were subjective drug effects, urges to smoke, and heart rate. The results showed that following e-cigarette inhalation, changes in plasma MG concentrations or “menthol boost” increased proportionally to the menthol concentration in the e-liquids. While changes in plasma MG concentrations were not predictive of increases in heart rate or subjective drug effects that are reflective of acute effects from nicotine (i.e., feel good effects, stimulated, aversive effects), they were predictive of cooling effect, a typical effect of menthol, but only in menthol smokers in the absence of concurrent active nicotine infusion. These findings demonstrate the utility of plasma MG as a biomarker both for acute menthol exposure by e-cigarette inhalation and for the examination of the concentration-dependent behavioral and physiological effects of menthol in humans.

Impact of delivery rate on the acute response to intravenous nicotine: A human laboratory study with implications for regulatory science

Faster delivery rate enhances the abuse potential of drugs of abuse, yet systematic studies on the impact of delivery rate on the acute effects of nicotine in humans are lacking. Using an intravenous (IV) nicotine infusion procedure that allows precise control of rate of delivery, we examined the impact of nicotine delivery rate on the positive subjective drug effects, smoking urges, withdrawal, heart rate, blood pressure and attention function in smokers. Twenty-four male and female (ages 21-35) dependent smokers attended five experimental sessions, following overnight abstinence from smoking. Using a crossover design, participants attended five sessions, where they were assigned to a random sequence of saline infusion or 1 mg nicotine delivered over 1, 2.5, 5 or 10 min at rates of 1, 0.4, 0.2 or 0.1 mg/min, respectively. The positive subjective effects of nicotine were most robust under the two faster delivery rate conditions, 1- and 0.4-mg nicotine/min. In contrast, all nicotine delivery rates were equally more effective than saline in alleviating urges to smoke. Likewise, nicotine-induced heart rate increases did not vary with the rate of nicotine delivery. Lastly, the cognitive enhancing effects of nicotine were observed only under the two slowest delivery rate conditions-0.1- and 0.2-mg nicotine/min. Collectively, these findings support the critical role of delivery rate in optimizing nicotine's abuse potential versus potential therapeutic effects and have timely implications for developing novel therapeutics for nicotine dependence, as well as for tobacco regulatory science.

Modafinil Does Not Reduce Cocaine Use in Methadone-Maintained Individuals

Introduction

There are no approved medications for the treatment of cocaine use disorder (CUD). Modafinil, a cognitive-enhancer with weak stimulant-like effects, has shown promise in initial studies as a treatment for CUD. Its potential efficacy has not been examined in individuals dually dependent on cocaine and opioids.

Methods

This study examined the efficacy of modafinil, in combination with contingency management (CM), for reducing cocaine and opioid use and improving cognitive function in methadone-stabilized individuals with opioid and cocaine dependence. We conducted a 17-week, double-blind, randomized controlled trial in which participants were randomized to one of four conditions: 1) modafinil + CM; 2) modafinil + yoked-control (YC); 3) placebo +CM; or 4) placebo + YC. Additionally, all subjects received platform treatments of cognitive behavioral therapy (CBT) and methadone. While the original planned sample size was N=160, a total of 91 participants were randomized. The two primary cocaine use outcomes were percentage of urine specimens positive for cocaine and percent of days of self-reported abstinence from cocaine during treatment. Cognitive function, opioid use, and secondary cocaine use outcomes were also considered.

Results

Modafinil was well-tolerated with minimal reports of adverse effects. Modafinil was no more effective than placebo in reducing cocaine or opioid use or improving cognitive performance.

Conclusions

In the context of a trial with robust control conditions and platform treatments, findings did not provide support for the efficacy of modafinil treatment for the treatment of CUD in methadone-stabilized individuals with dual opioid and cocaine dependence.

Reappraising Choice in Addiction: Novel Conceptualizations and Treatments for Tobacco Use Disorder

The introduction of alternative nicotine and tobacco products (such as e-cigarettes, heat-not-burn devices, nicotine pouches) warrants an updated framework from which to conceptualize tobacco use disorder (TUD). The following review provides considerations for TUD within the context of novel products. Historically, the tobacco industry falsely claimed that cigarettes were not addictive or harmful and that those who smoked simply chose to do so. This generated an inaccurate lay perception that smoking is a free or informed choice. Research on nicotine pharmacology demonstrates the powerful addictive potential of nicotine, which is shaped by dose, speed of delivery, and other constituents generated. In addition, non-pharmacologic reinforcers motivate and maintain tobacco use behaviors for both traditional cigarettes and novel products. The negative consequences of combustible tobacco use are well known; however, these outcomes may differ for alternative products. Strategies used for combustible product cessation may be adapted for novel products, and treatment recommendations for TUD should be made within the context of a harm reduction framework wherein alternative product use may be the desired outcome. Providers must therefore be willing to modify their perceptions of products and treatment recommendations accordingly. Better public health outcomes are accomplished through promotion of abstinence from combustible smoking. For those who cannot wean from nicotine entirely, switching to less risky modes of delivery might be a secondary goal, with an eventual aim of stopping use of the alternative product. Implications: Given the advent of novel, alternative tobacco products, tobacco use disorder (TUD) must be conceptualized within a contemporary framework that includes harm reduction and alternative outcomes. The unique contributions of nicotine pharmacology, non-pharmacologic reinforcers, and consequences of use can be used to inform treatments for TUD with the ultimate goal of improving the health of individuals who use tobacco.

Pilot examination of stress, heart rate variability, and alcohol craving and use among female veterans

Rates of alcohol use disorder (AUD) are increasing among civilian and veteran populations of women in the United States, and stress pathophysiology (i.e., abnormal acute and long-term change in physiological responses to stress) is central to the maintenance of alcohol misuse within this population. Heart rate variability (HRV) is one measure of stress regulation that may help to explain the association of stress with alcohol misuse among women. In the current analysis of pilot data, 20 women veterans attended an in-person laboratory session and completed 35 daily assessments of their alcohol use and craving. During the lab session, the effects of a stress induction procedure on self-reported alcohol craving and HRV were assessed. HRV was continuously measured and indexed in the time domain, using the root mean square of successive differences between normal heartbeats (RMSSD). Alcohol craving and use during the longitudinal 35-day study period were measured via self-report questionnaires sent to participants' phones. Results indicated that resting HRV in the lab was positively associated with odds of daily craving. Moreover, HRV during the stressor, as measured in lab, was positively associated with (1) overall alcohol craving in the lab (i.e., with resting and post-stress craving), and (2) number of daily drinks during the 35-day study period. This pilot study suggests the potential role of HRV in response to stressors in predicting alcohol craving and use among female veterans. It provides pilot data for research on stress-reactive HRV as a biomarker for alcohol misuse among women, and discusses directions for future research.

The effects of inhaled flavors on intravenous nicotine

Menthol is the only available flavor in combusted tobacco cigarettes; however, e-cigarettes are available in thousands of flavors. Research on flavors and rewarding properties of nicotine is limited. The present study sought to examine the acute rewarding effects of flavors inhaled from an e-cigarette, in combination with intravenous (IV) nicotine among cigarette smokers. In the present study, 24 menthol-preferring young adult (aged 18 to 30) cigarette smokers were tested under 3 different e-cigarette flavor conditions (menthol, green apple, or menthol + green apple) in a within-subject cross-over design. During each test session, each participant received 3 IV infusions (saline, 0.25 mg/70 kg nicotine, 0.5 mg/70 kg nicotine) administered 1 hr apart. The main outcome measures assessed cardiovascular, subjective, and cognitive domains. Compared with green apple or green apple + menthol, menthol produced higher ratings of "cooling" (ps < 0.01). Craving was rated higher following administration of green apple and the combined menthol + apple flavor compared to menthol alone (ps < 0.05). As expected, IV-nicotine dose-dependently increased the ratings of subjective liking/disliking and peak heart rate, improved cognitive performance, and reduced smoking urges (all ps < 0.05). These subjective, cognitive, and physiological effects of nicotine were not affected by any flavor condition. The present findings did not support an interaction between IV-nicotine dose and inhaled flavor for acute effects of nicotine. Green apple flavor, alone or in combination with menthol, could result in higher craving or insufficiently alleviate craving, relative to menthol flavor alone. Additional research is warranted to examine extended exposure to inhaled flavors on the rewarding and addictive effects of nicotine. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Acute effects of inhaled menthol on cognitive effects of intravenous nicotine among young adult cigarette smokers

Basic science studies indicate that menthol can enhance the cognitive effects of nicotine to increase nicotine dependence; however, the effect of menthol and nicotine on cognitive functioning among humans has been understudied. This double-blind, placebo-controlled study examined the dose-dependent effects of inhaled menthol flavoring and intravenous nicotine on cognitive task performance. Twenty menthol (MS) and 18 non-menthol (NMS) cigarette preferring, young-adult smokers (21% female; 7.9% Hispanic, 44.7% Non-Hispanic/White, 47.4% Non-Hispanic/Black) completed three sessions with randomized order of menthol flavoring (between-sessions: 0.0%/tobacco control, 0.5%/low, 3.2%/high) and intravenous nicotine (within-session: 0.0 mg/saline control, 0.25 mg/low, 0.5 mg/high). After each administration, participants completed three cognitive tasks: Continuous Performance Task (CPT), Mathematical Processing Task (MPT), and Stroop Task. Mixed effects models were used to examine interactive effects of cigarette type preference and menthol and nicotine doses. MS vs. NMS had decreased accuracy on CPT and MPT and efficiency during Stroop. No significant effects of cigarette type preference by menthol or nicotine were found for any task. Significant effects of nicotine by menthol were found during Stroop, where participants had greater accuracy for high nicotine compared to saline during the low menthol session. Significant effects of menthol by timepoint were seen during Stroop, where participants improved across timepoints during the low menthol session. Findings did not support significant effects of inhaled menthol, alone or with nicotine, on cognitive performance. Further research clarifying the impact of varying menthol and nicotine levels in nicotine products may help to elucidate menthol's role in smoking sustainment.

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.

Opioid-induced analgesia among persons with opioid use disorder receiving methadone or buprenorphine: A systematic review of experimental pain studies

BACKGROUND

Treating acute pain among persons with opioid use disorder (OUD) on opioid agonist therapy (OAT) is complex, and the therapeutic benefits of opioids remain unclear when weighted against their abuse potential and respiratory depressant effects.

METHODS

We conducted a systematic review of experimental pain studies examining opioid-induced analgesia among persons with OUD on OAT. We searched multiple databases from inception to July 30, 2021. Study quality was assessed by previously established validity measures.

RESULTS

Nine studies were identified, with a total of 225 participants, of whom 63% were male, and 37% were female. Six studies included methadone-maintained persons with OUD; four studies included buprenorphine-maintained persons with OUD; and three studies included healthy persons as comparison groups. Either additional doses of OAT or other opioids - morphine, oxycodone, hydromorphone, or remifentanil - were administered. In seven studies, persons with OUD on OAT did not experience analgesia, despite receiving opioid doses up to 20 times greater than those clinically used to treat severe pain among the opioid naïve. Conversely, in two studies, high-potency opioids did produce analgesia, albeit with greater abuse potential. Notably, persons with OUD on OAT remained vulnerable to respiratory depression.

CONCLUSIONS

Although persons with OUD on OAT can derive analgesic effects from opioids, high-potency compounds may be required to achieve clinically significant pain relief. Further, persons with OUD on OAT may remain vulnerable to opioid-induced abuse potential and respiratory depression. Together, these finding have clinical, methodological, and mechanistic implications for the treatment of acute pain in the context of OAT.

Threshold dose for intravenous nicotine self-administration in young adult non-dependent smokers

RATIONALE

Reducing nicotine content of inhaled tobacco products may prevent nicotine addiction, but the threshold for nicotine reinforcement has not been systematically evaluated in controlled human laboratory studies.

OBJECTIVES

The current study uses a novel double-blind placebo-controlled intravenous (IV) nicotine self-administration (NSA) model to determine threshold for subjective effects of nicotine and nicotine reinforcement using a forced choice self-administration procedure.

METHODS

Young adults (n = 34) had 5 laboratory sessions after overnight nicotine abstinence. In each session, participants sampled and rated the subjective effects of an IV dose of nicotine (0.0125, 0.025, 0.05, 0.1, or 0.2 mg nicotine/70 kg bodyweight) versus saline (placebo), then were given a total of 10 opportunities to self-administer either the IV dose of nicotine or placebo.

RESULTS

Mixed effect models revealed a significant effect of nicotine dose for positive (i.e., "stimulatory" and "pleasurable"; p < .0001) effects, but not "aversive" effects during sampling period. Post hoc comparisons showed that higher doses (i.e., 0.1 and 0.2 mg) were associated with greater stimulatory, pleasurable, and physiological effects than placebo and lower doses. Mixed effect models revealed that only the highest dose (i.e., 0.2 mg) was consistently preferred over placebo. Sex differences were generally weak (p = .03-.05).

CONCLUSIONS

Using our IV nicotine NSA model, the threshold for detecting positive effects of nicotine in young adult smokers is about 0.1 mg, but a higher dose of nicotine, 0.2 mg, is required to produce a consistent nicotine reinforcement. Regarding the regulatory impact, our findings further support the value of nicotine reinforcement threshold as a tobacco regulatory target.

Baseline executive functions and receiving cognitive rehabilitation can predict treatment response in people with opioid use disorder

BACKGROUND

Impaired cognitive functions, particularly executive function, predicts poor treatment success in people with substance use disorders. The current study investigated the effect of receiving adjunct cognitive rehabilitation and baseline executive function (EF) measures on treatment response among people with opioid use disorder (OUD).

METHOD

The analysis sample consisted of 113 participants with OUD who were discharged from a compulsory court-mandated methadone maintenance treatment (MMT) and followed for 3 months. We used the Backward digit span/Auditory verbal learning, Stroop, and Trail making tests to assess the three measures of EF, including working memory, inhibition, and shifting, respectively. Treatment response was operationalized as (1) treatment retention and (2) the number of positive urine tests for morphine during 3-month follow-up periods. The study used Cox's proportional hazards model and linear mixed model to identify predictive factors.

RESULTS

Lower Stroop interference scores predicted increased length of stay in treatment (χ² = 33.15, P < 0.001). The linear mixed model showed that scores on auditory verbal learning test and group intervention predicted the number of positive urine tests during a 3-month follow-up.

CONCLUSION

Working memory and inhibitory control, as well as receiving cognitive rehabilitation, could be potentially considered as predictors of treatment response for newly MMT admitted patients with OUD. Assessment of EF before treatment initiation may inform treatment providers about patient's cognitive deficits that may interfere with therapeutic interventions.

Pharmacological treatment of pain among persons with opioid addiction: A systematic review and meta-analysis with implications for drug development

The clinical features and neurobiology of pain and opioid use disorder (OUD) are inextricably linked. Despite emerging evidence supporting the negative impact of ongoing pain in the treatment of OUD, the pharmacological management of pain in the presence of OUD has received limited attention. We sought to systematically review the studies investigating pharmacotherapies for pain among persons with OUD. Eligible studies had participants with OUD and outcomes including evoked or spontaneous pain. We searched Scopus, Cochrane Database of Systematic Reviews, Medline, and Embase. Out of 1,097 studies that met the search criteria, 12 studies provided data relevant to the research question-five laboratory studies and seven clinical trials. Random effects pooled estimates suggested no significant difference between groups at baseline but a response favoring the active treatment group over placebo, with nonsignificant heterogeneity between studies. Findings from these studies provide preliminary evidence for analgesic and antihyperalgesic effects of gabapentin, GABA agonists, and NMDA antagonists among persons with OUD. To establish the tradeoffs between the analgesic effects and abuse liability of these compounds, further well-controlled clinical trials are required among persons with OUD. This review also underscores the need for methodological enhancement in drug development for pain in OUD. Future research should address the clinical and neurobiological overlap between pain- and addiction-related phenomena. Transdisciplinary approaches may identify biomarkers of these shared phenomena and their neural substrates. The development of novel therapeutics for pain in OUD may be accelerated by such integration of pain and addiction research.

The Pharmacology of Buprenorphine Microinduction for Opioid Use Disorder

Although expanding the availability of buprenorphine—a first-line pharmacotherapy for opioid-use disorder (OUD)—has increased the capacity of healthcare systems to offer treatment, starting this medication is fraught with significant barriers. Standard induction regimens require persons with OUD to taper and discontinue full opioid agonists and experience opioid withdrawal prior to the first dose of buprenorphine. Further, emerging evidence indicates that precipitated withdrawal during induction may impact long-term treatment outcomes. Microinduction is a novel approach that, by harnessing buprenorphine’s unique pharmacological profile, may allow circumventing the needed for prolonged opioid tapers, and reduce the risk of precipitated withdrawal—holding promise to enhance treatment access. In this review, we examine the pharmacological basis for microinduction and appraise the evidence of this approach to improve clinical outcomes among persons with OUD. First, we highlight the potential dose-dependent effects of buprenorphine on two key neuroadaptations at the mu-opioid receptor (MOR)—resensitization and upregulation. We then focus on how microinduction may reverse these chronic MOR neuroadaptations, allowing the maintenance of an adequate opioid tone, and thereby potentially circumventing opioid withdrawal. Second, we describe the clinical evidence available, derived from observational reports and open-label studies, examining the potential efficacy of microinduction. Despite significant heterogeneity—exemplified by variable buprenorphine formulations, daily doses, and schedules of administration—these data provide preliminary support for the feasibility of microinduction. Finally, we provide new mechanistic, methodological, and clinical insights to guide future translational research, as well as randomized, placebo-controlled clinical trials in this compelling agenda of pharmacotherapy development.

Sex Differences in Opioid Use Disorder Prevalence and Multimorbidity Nationally in the Veterans Health Administration

Opioid use disorder (OUD) is a significant problem among US veterans with increasing rates of OUD and overdose, and thus has substantial importance for service delivery within the Veterans Health Administration (VHA). Among individuals with OUD, several sex- specific differences have begun to emerge regarding co-occurring medical, psychiatric and pain-related diagnoses. The rates of such multimorbidities are likely to vary between men and women with OUD and may have important implications for treatment within the VHA but have not yet been studied. Methods: The present study utilized a data set that included all veterans receiving VHA health care during Fiscal Year (FY) 2012 (October 1, 2011 through September 30, 2012), who were diagnosed during the year with opioid dependence or abuse. VHA patients diagnosed with OUD nationwide in FY 2012 were compared by sex on proportions with OUD, and among those with OUD, on sociodemographic characteristics, medical, psychiatric and pain-related diagnoses, as well as on service use, and psychotropic and opioid agonist prescription fills. Results: During FY 2012, 48,408 veterans were diagnosed with OUD, 5.77% of whom were women. Among those veterans with OUD, few sociodemographic differences were observed between sexes. Female veterans had a higher rate of psychiatric diagnoses, notably mood, anxiety and personality disorders, as well as higher rates of pain-related diagnoses, such as headaches and fibromyalgia, while male veterans were more likely to have concurrent, severe medical co-morbidities, including hepatic disease, HIV, cancers, peripheral vascular disease, diabetes and related complications, and renal disease. There were few differences in health service utilization, with women reporting greater receipt of prescriptions for anxiolytic/sedative/hypnotics, stimulants and lithium. Men and women did not differ in receipt of opioid agonist medications or mental health/substance use treatments. Conclusions: There are substantial sex-specific differences in patterns of multimorbidity among veterans with OUD, spanning medical, psychiatric and pain-related diagnoses. These results illustrate the need to view OUD as a multimorbid condition and design interventions to target such multimorbidities. The present study highlights the potential benefits of sex-specific treatment and prevention efforts among female veterans with OUD and related co-occurring disorders.

Modulation of "Protective" Nicotine Perception and Use Profile by Flavorants: Preliminary Findings in E-cigarettes

INTRODUCTION

Characterizing flavors are widely available in e-cigarettes and motivate initiation and continued use. Flavors may enhance appeal and facilitate development of addiction to tobacco products through modulation of tobacco products' reinforcing or aversive actions. Palatable flavors (eg, fruit) may increase appeal through primary reinforcing properties. Menthol's cooling and anesthetic effects may increase appeal by counteracting nicotine's aversive effects. Genetics provide a method for modeling individual differences in sensitivity to nicotine's effects. A common polymorphism, rs16969968, encoded in the α5 nicotinic acetylcholine receptor subunit gene (CHRNA5), is a well-recognized marker for smoking risk and reduces sensitivity to nicotine aversiveness.

METHODS

This pilot study tested how flavors impacted e-cigarette appeal and self-administration. In a single testing day, cigarette smokers (N = 32; 94% menthol-smokers) self-administered e-cigarettes containing e-liquids differing in nicotine level (0 mg/mL, 24 mg/mL) and flavor (unflavored, menthol, fruit-flavored) within directed and ad libitum e-cigarette paradigms. Subjective drug effects, number of puffs, rs16969968 genotype, plasma nicotine, and menthol glucuronide levels were collected.

RESULTS

Menthol partially ameliorated nicotine aversiveness; fruit did not. In nicotine's absence, fruit flavor increased self-reported preference and ad libitum use relative to menthol-containing or unflavored e-liquids. Individuals with high-smoking-risk rs16969968 genotype (N = 7) reported greater craving alleviation following directed administration of nicotine-containing e-liquids, showed a trend rating nicotine-containing e-liquids as less harsh, and self-administered more nicotine during ad libitum compared to individuals with low-smoking-risk genotype (N = 23).

CONCLUSIONS

While menthol countered aversiveness of nicotine-containing e-liquids, fruit flavor increased appeal of nicotine-free e-liquids. These preliminary findings suggest menthol and fruit flavor increase e-cigarettes' appeal through distinct mechanisms.

IMPLICATIONS

This study provides a detailed characterization of the effects of flavors (unflavored, menthol, fruit), nicotine (0 mg/mL, 24 mg/mL) and their interactions on the subjective drug effects and ad libitum self-administration of e-cigarettes. Genetics were used to assess these effects in higher-smoking-risk (diminished sensitivity to nicotine aversiveness) and lower-risk groups. Findings could inform impact of regulation of flavors or nicotine in e-cigarettes, and their impacts on vulnerable sub-populations.

Impact of cannabis on non-medical opioid use and symptoms of posttraumatic stress disorder: a nationwide longitudinal VA study

BACKGROUND

Multiple states have authorized cannabis as an opioid substitution agent and as a treatment for posttraumatic stress disorder (PTSD).

OBJECTIVES

This study sought to investigate the relationship between cannabis use, non-medical opioid use, and PTSD symptoms among U.S. veterans.

METHODS

From 1992-2011, veterans admitted to specialized intensive PTSD treatment participated in a national evaluation with assessments at intake and four months after discharge. Participants with non-medical opioid use ≥ 7 days during the 30 days preceding admission were divided into two groups: those with cannabis use ≥ 7 days, and those without cannabis use. These two groups were compared on measures of substance use and PTSD symptoms at baseline and 4-months outpatient follow-up. We hypothesized that, at both assessments, the group with baseline cannabis use would show less non-medical opioid use and less severe PTSD symptoms.

RESULTS

Of 1,413 veterans with current non-medical opioid use, 438 (30.3%) also used cannabis, and 985 (69.7%) did not. At baseline, veterans with concurrent non-medical opioid and cannabis use had slightly fewer days of non-medical opioid use (p < .005; d = -0.16), greater use of other substances (p < .0001) and more PTSD symptoms (p = .003; d = 0.16), compared to veterans who used non-medical opioids but not cannabis. At follow-up, substance use or PTSD symptoms did not significantly differ.

CONCLUSION

Cannabis use was not associated with a substantial reduction of non-medical opioid use, or either improvement or worsening of PTSD symptoms in this population. Hence, these data do not encourage cannabis use to treat either non-medical opioid use or PTSD.

Systematic Review of Pain Severity and Opioid Craving in Chronic Pain and Opioid Use Disorder

OBJECTIVE

To evaluate measurement and associations between pain severity and opioid craving in individuals with chronic pain on long-term opioid therapy and/or with opioid use disorder.

STUDY DESIGN

. Systematic review of randomized controlled trials and observational studies.

METHODS

. The PubMed, EMBASE, and PsycINFO databases were searched in October 2018. Eligible studies evaluated pain severity and opioid craving in individuals with chronic pain on long-term opioid therapy and/or with opioid use disorder. Two reviewers independently screened eligible studies, assessed risk of bias, and extracted data.

RESULTS

Of 625 studies, 16 fulfilled the inclusion/exclusion criteria of this review and were grouped by diagnostic focus (i.e., chronic pain on long-term opioid therapy, opioid use disorder, or both). Methods of assessment varied considerably across studies, especially with respect to opioid craving in chronic pain populations. Mean levels of pain were at what is considered moderate to severe in individuals with chronic pain and/or opioid use disorder. There was a modest positive relationship between pain and opioid craving that was more pronounced in studies of individuals with opioid use disorder compared with those with chronic pain on long-term opioid therapy.

CONCLUSIONS

Pain severity and opioid craving are likely related, but inconsistencies in measurement limit confidence. The overall quality of evidence is moderate, and careful consideration of how pain and craving are assessed in both chronic pain and opioid use disorder patients is warranted.

Stress and opioid use disorder: A systematic review

Medication assisted treatment (MAT) is highly effective in reducing illicit opioid use and preventing overdose in individuals with opioid use disorder (OUD); however, treatment retention of patients engaged in MAT is a significant clinical concern. The experience of stress may contribute to a decision to drop out of treatment. The current study is a systematic review conducted across multiple databases of empirical studies on primary appraisal of stress and its relationship to opioid craving, opioid use, and OUD treatment outcomes. Primary appraisal of stress is defined as an explicit inquiry into individual perception of feeling stressed using a self-report measure administered in laboratory, clinical, or naturalistic environment. A total of 21 included studies were organized into three categories: observed stress, experimentally-induced stress, and stress-focused interventions. Appraised stress was generally associated with greater craving, but associations with opioid use and treatment retention were mixed. All but one study included MAT samples and every study sample included some form of drug counseling. These findings suggest that individuals experience considerable stress in spite of receiving standard treatment for OUD. Psychopharmacological interventions targeting stress were promising, but no behavioral interventions specific to stress management were found. The preliminary results with clonidine and lofexidine targeting stress in individuals with OUD warrant further studies. To better understand the impact of stress in OUD, future research should consider using repeated assessment of stress in the context of daily life. Utilization of behavioral treatments specifically targeting stress could have benefits in improving OUD outcomes.

Minocycline does not affect experimental pain or addiction-related outcomes in opioid maintained patients

RATIONALE

Minocycline, a tetracycline antibiotic, inhibits activation of microglia. In preclinical studies, minocycline prevented development of opioid tolerance and opioid-induced hyperalgesia (OIH). The goal of this study was to determine if minocycline changes pain threshold and tolerance in individuals with opioid use disorder who are maintained on agonist treatment.

METHODS

In this double-blind, randomized human laboratory study, 20 participants were randomized to either minocycline (200 mg/day) or placebo treatment for 15 days. The study had three test sessions (days 1, 8, and 15 of treatment) and one follow-up visit 1 week after the end of treatment. In each test session, participants were assessed on several subjective and cognitive measures, followed by assessment of pain sensitivity using the Cold Pressor Test (CPT). Daily surveys and cognitive measures using Ecological Momentary Assessment (EMA) were also collected four times a day on days 8 through 14 of treatment, and proinflammatory serum cytokines were assessed before and on the last day of treatment.

RESULTS

Minocycline treatment did not change pain threshold or tolerance on the CPT. Similarly, minocycline did not change severity of pain, opioid craving, withdrawal, or serum cytokines. Minocycline treatment increased accuracy on a Go/No-Go task.

CONCLUSIONS

While these findings do not support minocycline's effects on OIH, minocycline may have a potential use as a cognitive enhancer for individuals with opioid use disorder, a finding that warrants further systematic studies.

Anhedonia as a key clinical feature in the maintenance and treatment of opioid use disorder

There is a critical need for research on clinical features that may influence response to treatment for opioid use disorder (OUD). Given its neurobiology and relevance to opioid use, anhedonia may be one such promising clinical feature. We identified and reviewed 11 studies that measured anhedonia in humans with OUD to characterize the current state of evidence and highlight potential implications for treatment. The majority of studies were cross-sectional, indicating higher anhedonia scores in opioid-dependent samples compared to healthy controls. Rates of participants with clinically significant anhedonia ranged from 21% to 48%. Anhedonia scores were correlated with opioid craving and use, however there are significant knowledge gaps regarding its time course and impact on treatment adherence and outcomes. Repeated assessment of anhedonia early in treatment for OUD is recommended, as it may be a unique predictor of dropout or non-response, and a potential target for behavioral and/or pharmacological intervention.

Gender differences among Veterans with alcohol use disorder nationally in the Veterans Health Administration

Alcohol use among women is increasing relative to men but no study has compared rates and characteristics of women with alcohol use disorder (AUD) to men among Veterans Health Administration (VHA) service users. To compare male and female VHA service users on rates of AUD, and among those with AUD, on sociodemographic characteristics, medical and physical comorbidities, and service and medication use national VHA data from fiscal year (FY) 2012 were used to identify Veterans diagnosed with AUD. Bivariate analyses evaluate gender differences in: sociodemographic characteristics; comorbid medical and psychiatric diagnoses; service use and psychotropic prescription fills. Multivariate stepwise logistic regression was used to identify a parsimonious set of differences. About 13,797 of all 349,430 women served by VHA in FY 2012 (3.94%) were diagnosed with AUD as compared to 331,407 of 5,102,877 men (6.50%) for a risk ratio of 0.608 for AUD among women. Women were younger, more likely to have served in recent Middle East conflicts and had more comorbid psychiatric and substance use diagnoses than men. They filled fewer psychotropic prescriptions (after taking greater number of psychiatric diagnoses in to account), but were more likely to fill a prescription for naltrexone than men. Women had fewer comorbid medical diagnoses than men. Women Veterans with an AUD have higher rates of psychiatric comorbidities than men, highlighting the need for better integration of treatment for AUD and comorbid psychiatric conditions, and suggesting different pathways and potential interventions for AUD in women.

Randomized placebo-controlled trial of galantamine in individuals with cocaine use disorder

No pharmacotherapies are approved for the treatment of cocaine use disorder (CUD). Galantamine, a cholinesterase inhibitor, has shown initial promise for cocaine use reduction in methadone-maintained individuals with CUD and cognitive improvement in abstinent individuals with past CUD. However, galantamine has not previously tested in individuals with current CUD and no comorbid opioid use disorder or methadone maintenance. The goal of this 13-week, double-blind, placebo-controlled, randomized controlled trial was to test the efficacy of galantamine (8 mg or 16 mg/day; extended release (ER)) for reducing cocaine use and improving cognitive function in individuals with cocaine use disorder (CUD). Ninety-three treatment-seeking cocaine users were randomized to placebo (n = 32), 8 mg/day galantamine (n = 31) or 16 mg/day galantamine (n = 30). The medication was well-tolerated with minimal reports of side-effects. However, there were no significant treatment group differences in cocaine use outcomes (as measured by self-report or urines). The 16 mg galantamine group had a greater improvement in working memory capacity (Backwards Digit Span), but there were no other significant treatment group differences on key cognitive outcomes. These findings did not provide support for the efficacy of galantamine as a treatment for cocaine use in this sample of individuals with CUD.

Galantamine and Computerized Cognitive Behavioral Therapy for Cocaine Dependence: A Randomized Clinical Trial

OBJECTIVE

To examine whether galantamine, a cognitive-enhancing medication that is both acetylcholinesterase inhibitor and agonist at nicotinic acetylcholine receptors, is effective at improving cocaine use outcomes and cognitive functioning, alone and in combination with computerized cognitive behavioral therapy (CBT).

METHOD

A 12-week, randomized 2 × 2, factorial trial was conducted to evaluate galantamine versus placebo (double-blind) and computerized CBT plus standard methadone treatment versus standard methadone treatment alone in a community-based methadone maintenance program (September 2009-April 2015). One hundred twenty individuals diagnosed with DSM-IV cocaine use disorder were randomly assigned to the following conditions: (1) galantamine (8 mg/d) plus standard methadone maintenance treatment (treatment as usual [TAU]), (2) placebo plus TAU, (3) galantamine plus computerized CBT plus TAU, or (4) placebo plus computerized CBT plus TAU; medication administration was supervised at the time of daily methadone dosing. The primary cocaine use outcome was change in percent days of abstinence over time. Number of cocaine-negative urine toxicology screens submitted and cognitive function were secondary outcomes.

RESULTS

Random effect regression analysis indicated significant reductions in frequency of cocaine use over time, with significant treatment-by-time effects for both galantamine over placebo (F = 5.3, P = .02, d = 0.34) and computerized CBT over standard methadone treatment (F = 4.2, P = .04, d = 0.30) but no evidence of significant benefit of the combination over either treatment alone. Pretreatment to posttreatment comparisons of multiple indices of cognitive functioning, including sustained attention, indicated no benefit of galantamine over placebo.

CONCLUSIONS

Findings suggest benefits of galantamine and computerized CBT for reducing cocaine use in this sample. Although galantamine did not improve measures of cognitive function in this sample, multiple measures of cognitive function were associated with cocaine use outcomes, underlining the significance of cognitive function in cocaine treatment outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00809835.

Adverse Consequences of Co-Occurring Opioid Use Disorder and Cannabis Use Disorder Compared to Opioid Use Disorder Only

Background: While there is growing interest in the possibility that cannabis may be a partial substitute for opioids, studies have yet to examine whether individuals with co-occurring opioid and cannabis use disorders (OUD and CUD) have less risk of negative outcomes than those with OUD only. Objective: This study sought to compare the sociodemographic and clinical characteristics of patients diagnosed with co-occurring OUD and CUD to patients with OUD only, CUD only, and patients with any other drug use disorders. We hypothesized that co-occurring OUD and CUD would be associated with lower risk of inpatient admissions and emergency department (ED) visits, lower rates of homelessness, and fewer opioid prescriptions. Methods: Comparisons were based on bivariate analyses, logistic and linear multiple regression models of National Veterans Health Administration (VHA) data from Fiscal Year 2012. Results: Of the 234,181 (94% male) patients diagnosed with drug use disorders, 8.6% were diagnosed with co-occurring OUD and CUD; 33.3% with OUD only; 26.5% with CUD only; and 31.6% with other drug use disorders. Compared to the OUD only group (Mean = 4.8 (SD = 8.84)), the group with co-occurring OUD and CUD was associated with a lower number of opioid prescriptions (Mean = 3.79 (SD = 8.22)) (d = -0.16), but higher likelihood of inpatient psychiatric admission (RR = 1.95) and homelessness (RR = 1.52), and no significant difference in ED visits. Conclusions: These data highlight the need to further investigate whether the complex effects of cannabis use on patients with OUD are counterbalanced by potential benefits of reduced in opioid prescribing.

E-cigarettes, alcohol use, and mental health: Use and perceptions of e-cigarettes among college students, by alcohol use and mental health status

INTRODUCTION

Electronic cigarettes (e-cigarettes) are popular among college students, who display risky alcohol use patterns. However, little is known about patterns of co-use of e-cigarettes and alcohol. Further, relationships between e-cigarette use and mental illness among college students are unclear.

METHODS

College student participants (N = 631) at a northeastern U.S. university were invited via email to participate in a survey about e-cigarettes and alcohol use. Mental health was self-reported diagnosis of psychiatric (depression, bipolar disorder, schizophrenia, PTSD, anxiety disorder, personality disorder), and substance (alcohol and other drug) use disorders. Current use of e-cigarette, combustible cigarette, and other tobacco products were assessed via self-reported past 30-day use frequency. Alcohol consumption was assessed via number of self-reported standard alcoholic beverages consumed during a typical drinking episode. Participants also reported regarding co-use of alcohol, e-cigarettes and/or combustible cigarettes. Participants were categorized as non-drinkers, moderate drinkers or binge drinkers, and associations between e-cigarette use, drinking patterns and mental health diagnoses were examined.

RESULTS

E-cigarette use was associated with drinking alcohol χ2 = 18.62, p < .001, and binge drinking (vs. moderate drinking) χ2 = 12.20, p < .001. Students who had tried e-cigarettes reported drinking more alcohol per episode (χ2 = 15.94, p < .001). E-cigarette use was more prevalent among those with psychiatric and substance use disorders χ2 = 11.65, p < .001.

CONCLUSIONS

Drinking college students (especially binge drinkers) and those with mental illness may have heightened risks for e-cigarette use. More research is needed to elucidate relationships between risky alcohol and/or nicotine use and mental illness, and to guide appropriate prevention and intervention efforts for vulnerable college students.

Pharmacological and Behavioral Treatment of Opioid Use Disorder

Objective:

Opioid use disorder (OUD) in the United States has surged, with an estimated 2.5 million needing treatment. The aim of this article is to provide a clinical overview of the key pharmacological and behavioral treatments for OUD.

Methods:

A nonsystematic review of the literature was conducted to investigate OUD treatments, including their mechanism of action, efficacy, clinical guidelines in the United States, and consideration of frequently occurring comorbid conditions.

Results:

Food and Drug Administration (FDA)–approved pharmacotherapies for OUD include methadone, buprenorphine, and naltrexone, each of which has different actions on opioid receptors. Although these medications all show efficacy in some dosages and formulations, barriers to accessibility may be most pronounced for methadone, whereas treatment retention poses greater challenges for naltrexone and, to a lesser extent, buprenorphine. Lofexidine, an α₂‐adrenergic agonist, has recently been approved by the FDA for treatment of opioid withdrawal symptoms. OUD is commonly treated with medication‐assisted treatment (MAT), which offers pharmacotherapy in the context of counseling and/or behavioral treatments. Behavioral therapies, rarely offered as stand‐alone treatments for OUD, are generally used in the context of MAT, in structured settings or to prevent relapse after detoxification and stabilization. The aim of behavioral interventions is to improve medication compliance and target problems not addressed with medication alone. Individuals with OUD commonly have other comorbid psychiatric and substance use conditions, which are not exclusionary for initiating MAT but should be carefully evaluated and monitored because they may reduce treatment effectiveness.

Conclusions:

MAT is the first‐line treatment for patients with OUD and should be provided in combination with behavioral interventions. Treatment retention remains challenging in this population. Future studies should focus on approaches that will serve the complex needs of patients with OUD, including those with comorbid psychiatric and substance use conditions.

Accounting for the uncounted: Physical and affective distress in individuals dropping out of oral naltrexone treatment for opioid use disorder

BACKGROUND

The theoretical benefits of naltrexone as a treatment for opioid use disorder (e.g., safety, non-addictive, low risk of diversion) stand in sharp contrast to its disappointing record on retention in most samples. The relationship of uncomfortable physical and dysphoric symptoms to retention on naltrexone is a controversial and under-studied issue.

METHODS

Using data from a randomized controlled trial of voucher-based contingency management and support from a significant other to enhance retention on oral naltrexone, we compared self-reported somatic and dysphoric symptoms, measured weekly, for individuals who were retained on naltrexone through the 12-week trial (n = 50) versus those who dropped out (n = 70).

RESULTS

There were no differences between participants who completed treatment and those who dropped out on multiple baseline characteristics, including somatic or affective symptoms prior to treatment. However, whether analyzed cross-sectionally or over time, participants who dropped out consistently reported higher rates of somatic symptoms, particularly difficulty sleeping, as well as affective symptoms, including multiple indicators of depression, anxiety, and anhedonia.

CONCLUSIONS

Although the smaller group of participants who were retained on oral naltrexone for 12 weeks reported decreasing physical and affective discomfort over time, there was substantial evidence that those who dropped out experienced continued and significant levels of distress. Individuals who report physical or affective distress while taking naltrexone may be at higher risk of dropout.