Multiple Substance Use Disorders and Self-Reported Cognitive Function in U.S. Adults: Associations and Sex-Differences in a Nationally Representative Sample

Polysubstance use is a growing public health concern that has been associated with poor clinical outcomes. Compared to single-drug users, this population suffers greater deficits in cognitive function, which hinder treatment success and recovery. Despite its high prevalence and poor prognosis, epidemiological research on polysubstance use and accompanying cognitive profile is lacking. We investigated associations between numbers of past-year co-occurring substance use disorders (SUDs) and self-reported cognitive function using data from the National Epidemiologic Survey for Alcohol and Related Conditions III (NESARC-III). Regression analyses revealed a significant negative association between cognitive scores and numbers of past-year SUDs, which was moderated by sex. After adjusting for confounding variables, greater numbers of SUDs were associated with declining self-reported cognitive function, and this relationship was stronger among females. Our findings expand on current literature on cognitive impairments among polysubstance users and provide a novel, nuanced description of this relationship among the general population. We highlight the need for targeted and individualized treatment approaches in order to improve outcomes in this population.

Novel Opipramol-Baclofen Combination Alleviates Depression and Craving and Facilitates Recovery From Substance Use Disorder—An Animal Model and a Human Study

Substance use disorders (SUDs) are associated with depression and anxiety, with the latter being one of the major factors in substance-seeking and relapse. Due to dose-dependent sedative side effects there is limited efficacy of baclofen treatment for SUDs. Here we suggest the use of a novel combination of opipramol and baclofen (O/B) which is known to attenuate anxiety and depression, for the facilitation of recovery from SUDs. Since both opipramol and baclofen have a common downstream signal transduction, their individual doses could be reduced while still maintaining the benefits of the combination. We tested the O/B combination in both animals and patients. Rats treated with O/B showed significant attenuation in craving behavior and in relapse rate during withdrawal from cocaine. In a double-blind, placebo-controlled pilot study, conducted in a residential detoxification center, 14 males and 3 females, aged 28–60 years were assigned to a study (n = 6) and a placebo (n = 11) group (placebo group: 40 ± 10.5 years; O/B group 40 ± 10.8 years). The participants completed scales measuring depression, anxiety and craving symptoms and provided saliva samples for stress hormone examination [cortisol and dehydroepiandrosterone-sulfate (DHEA-S)]. Participants with polysubstance use disorder (PsUD) treated with O/B showed a reduction in cravings and depression and an increase in DHEA-S and in the DHEA-S/cortisol ratio. Our findings indicate a beneficial effect of O/B treatment. This study suggests a novel candidate for pharmacological treatment of patients with SUD and comorbid mood/anxiety disorders that may facilitate their rehabilitation.

Chronic Pain among Individuals Experiencing Homelessness and Its Interdependence with Opioid and Other Substance Use and Mental Illness

Chronic pain and substance use disorders are serious conditions that are prevalent among homeless populations. The aim of this study was to examine the association between chronic pain and substance use among individuals experiencing homelessness and mental illness. We analyzed cross-sectional data from two sites of the At Home/Chez Soi study (Vancouver and Toronto) using bivariate statistics and multivariate logistic regression. Substance use and chronic pain parameters were assessed with the Maudsley Addiction Profile and purpose-designed short instruments. The sample comprised 828 participants. Mean age was 42.4 years and 54% reported chronic pain. In bivariate analysis, chronic pain was significantly associated with use of opioids and stimulants, daily substance use, polysubstance use and injecting as route of administration. In multivariate analysis, only daily substance use (OR: 1.46, 95% CI: 1.02–2.09) and injecting (OR: 1.81, 95% CI: 1.08–3.05) remained as significant associated factors, whereas neither use of opioids nor use of stimulants specifically were significantly associated with chronic pain. Among participants with chronic pain, daily substance users (50% vs. 22%, p < 0.001) and injectors (66% vs. 24%, p < 0.001) were more likely to use non-prescribed medication for pain. Participants with daily substance use were less likely to receive professional treatment (52% vs. 64%, p = 0.017) and prescribed pain medication (42% vs. 54%, p = 0.023). Our findings suggest an association of chronic pain with patterns related to severity of substance use rather than to specific substance use in homeless persons with mental illness. Interventions aiming at prevention and treatment of chronic pain in this population should consider severity of substance use and associated risk behavior over use of specific substances.

Shifting Pathways of Stimulant Use Among Individuals With Opioid Use Disorder: A Retrospective Analysis of the Last Thirty Years

Background: Stimulant use among individuals with opioid use disorder has recently increased, driven by changes in drug distribution channels. However, our understanding of polysubstance use is often limited by a need to provide targeted treatment to a primary drug of addiction. Yet there is a crucial need to better understand pathways to addiction, and how the use of multiple substances may differ between populations, as well as time periods.Methods: Using a national opioid surveillance system, we analyzed survey data from new entrants to 124 opioid use disorder treatment centers from 2017 to 2020. Age of first use was collected for prescription opioids, illicit opioids, prescription stimulants, crack/cocaine, and methamphetamines. Year of initial use of an opioid or stimulant was calculated and grouped by 5 year blocs, inclusive of initial use starting from 1991 and ending in 2020 (n = 6,048).Results: Lifetime exposure to stimulants was 82.5% among individuals with opioid use disorder. Mean age of initiation increased for all drugs in 2016–2020, in particular prescription opioids (22.3 to 31.8). Stimulants were initiating drugs for a substantial proportion of individuals with opioid use throughout the analyzed time period. Those initiating opioid/stimulant use from 1991 to 1995 had a mean average of 6.8 years between first and second drug exposure, which steadily decreased to 1.5 years between exposures in 2016–2020. Sankey plots depict significantly more drug transitions in those initiating use from 1991 to 2000 (65.1% had at least two drug transitions) compared to 2010–2020 (16.0%). Opioid-stimulant use increased over time among racial/ethnic minorities, sexual minorities, and those with an educational attainment of high school or less.Conclusion: These data highlight not only the substantial prevalence of stimulant use among individuals who develop opioid use disorder, but also the variability through which pathways of use occur. Prevention and intervention efforts need to take into account increasing ages of initial drug exposures, demographic shifts in stimulant-using populations, and more rapid drug transitions between opioid and stimulants. But at a broader level, prevention, harm reduction ideology, and addiction medicine needs to take into account the ubiquity of polysubstance use among individuals with substance use disorders.

Acute pain and self-directed discharge among hospitalized patients with opioid-related diagnoses: a cohort study

Background Patients with substance use disorders are more likely than those without to have a self-directed hospital discharge, putting them at risk for poor health outcomes including progressing illness, readmissions, and death. Inadequate pain management has been identified as a potential motivator of self-directed discharge in this patient population. The objective of this study was to describe the association between acute pain and self-directed discharges among persons with opioid-related conditions; the presence of chronic pain in self-directed discharges was likewise considered. Methods We employed a large database of all hospitalizations at acute care hospitals during 2017 in the city of Philadelphia to identify adults with opioid-related conditions and compare the characteristics of admissions ending with routine discharge versus those ending in self-directed discharge. We examined all adult discharges with an ICD-10 diagnoses related to opioid use or poisoning and inspected the diagnostic data to systematically identify acute pain for the listed primary diagnosis and explore patterning in chronic pain diagnoses with respect to discharge outcomes. Results Sixteen percent of the 7972 admissions involving opioid-related conditions culminated in self-directed discharge, which was more than five times higher than in the general population. Self-directed discharge rates were positively associated with polysubstance use, nicotine dependence, depression, and homelessness. Among the 955 patients with at least one self-directed discharge, 15.4% had up to 16 additional self-directed discharges during the 12-month observation period. Those admitted with an acutely painful diagnosis were almost twice as likely to complete a self-directed discharge, and for patients with multiple admissions, rates of acutely painful diagnoses increased with each admission coinciding with a cascading pattern of worsening infectious morbidity over time. Chronic pain diagnoses were inconsistent for those patients with multiple admissions, appearing, for the same patient, in one admission but not others; those with inconsistent documentation of chronic pain were substantially more likely to self-discharge. Conclusions These findings underscore the importance of pain care in disrupting a process of self-directed discharge, intensifying harm, and preventable financial cost and suffering. Each admission represents a potential opportunity to provide harm reduction and treatment interventions addressing both substance use and pain.

Exploring the Potential of Implementing Managed Alcohol Programmes to Reduce Risk of COVID-19 Infection and Transmission, and Wider Harms, for People Experiencing Alcohol Dependency and Homelessness in Scotland

People who experience homelessness and alcohol dependency are more vulnerable than the general population to risks/harms relating to COVID-19. This mixed methods study explored stakeholder perspectives concerning the impact of COVID-19 and the potential utility of introducing managed alcohol programmes (MAPs) in Scotland as part of a wider health/social care response for this group. Data sources included: 12 case record reviews; 40 semi-structured qualitative interviews; and meeting notes from a practitioner-researcher group exploring implementation of MAPs within a third sector/not-for-profit organisation. A series of paintings were curated as a novel part of the research process to support knowledge translation. The case note review highlighted the complexity of health problems experienced, in addition to alcohol dependency, including polysubstance use, challenges related to alcohol access/use during lockdown, and complying with stay-at-home rules. Qualitative analysis generated five subthemes under the theme of ‘MAPs as a response to COVID-19′: changes to alcohol supply/use including polysubstance use; COVID-19-related changes to substance use/homelessness services; negative changes to services for people with alcohol problems; the potential for MAPs in the context of COVID-19; and fears and concerns about providing MAPs as a COVID-19 response. We conclude that MAPs have the potential to reduce a range of harms for this group, including COVID-19-related harms.