The Convergent Neuroscience of Affective Pain and Substance Use Disorder

When Addiction Co-Occurs With Traumatic Brain Injury

Adolescent versus adult onset and the development of substance use disorders in males

Back to table of contents Previous article Next article Education & TrainingFull AccessResource Document Calls for Improved Residency Training on SUDsMark MoranMark MoranSearch for more papers by this authorPublished Online:26 Apr 2021https://doi.org/10.1176/appi.pn.2021.5.23AbstractTrainees need to see patients in a wide variety of settings, over time, with supervisory training that focuses on a patient’s addiction.When trainees are exposed to patients who recover from a substance use disorder, it is humanizing, destigmatizing, and unforgettable, said Shelly F. Greenfield, M.D., M.P.H., a member of APA’s Council on Addiction Psychiatry, at the virtual meeting of the American Association of Directors of Psychiatric Residency Training (AADPRT).“When trainees have that opportunity to work with a patient with a substance use disorder over time and see the patient get better in a real-world setting, it is incredibly gratifying,” says Shelly F. Greenfield, M.D., M.P.H.Residents and fellows need more of those experiences. Greenfield cited data from surveys of program directors and from an October 2020 APA Resource Document on Education and Training for Substance Use Disorders (see section below) indicating that trainees generally do not receive sufficient training in the treatment of substance use disorders (SUDs), including faculty supervision focused specifically on treatment of SUD patients over time. Additionally, too few residents receive training in prescribing buprenorphine and other medications approved for treating SUDs.“When trainees graduate as early career psychiatrists—no matter where they practice—they will see a very high proportion of patients with an SUD either alone or co-occurring with another psychiatric disorder,” Greenfield said. “Yet they have very little training in their four years overall. There have been some positive changes in addiction training in residency, but most studies and the APA resource document demonstrate that training for diagnosing and treating patients with substance use disorders is inadequate for graduating residents in 2021.”She noted that the requirement of the Accreditation Council for Graduate Medical Education for just four weeks of dedicated training in addiction has not been changed since 2001. A 2012 survey of 104 program directors supported by the APA Council on Addiction Psychiatry found that only 19% of program directors reported that trainees were paired with supervisors for addiction, and 68% said patients with SUDs were sent elsewhere for treatment. Most did not provide opportunity for long-term treatment for patients with SUDs.In comments to Psychiatric News after the meeting, Greenfield emphasized four areas in which training in addiction falls short:Lack of supervision that is specifically focused on treatment of patients with SUD. Greenfield cited a 2018 survey of 84 program directors by the Addiction Task Force of AADPRT that found that in many programs addiction training takes place only on general psychiatry units in which co-occurring disorders are evaluated and treated, but the extent to which addiction-trained supervisors are available or addiction is the focus of the training is unclear. In that survey, 41.6% of program directors indicated there was a limited number of faculty with expertise in co-occurring conditions to provide trainee supervision.Greenfield said one approach for programs that lack faculty expertise in addiction is collaboration with other programs, an opportunity made possible by the widespread use of video technology in medicine and psychiatry during the pandemic.Failure to see patients over time. Trainees need to see the progress and recovery of patients with SUD over time. “Longitudinal experience with patients having SUD usually happens in outpatient settings where the trainee can treat patients with SUD, receive supervision, and be able to follow them beyond just a four-week experience on an inpatient unit,” Greenfield said.Lack of training in using buprenorphine and other medications approved for addiction and SUD. “If residents have eight-hour waiver training in buprenorphine, they learn a lot about the medication and about opioid use disorder,” Greenfield said. “Data show that if you get just eight hours of training in residency, you are much more likely to prescribe this medication in your practice after residency. And yet we don’t have a requirement to complete that training.”The tendency of residents to see patients with SUD only in the emergency department. “If you mostly expose trainees to patients who present to the emergency department with SUD, this can contribute to stigma and therapeutic nihilism—the belief that this condition never gets better,” Greenfield told Psychiatric News. “Most patients with SUDs are never seen in emergency departments.”Psychiatrists should learn how to care for patients presenting in the emergency department with acute withdrawal or intoxication, she said, but most will graduate to practice in other settings—outpatient practices, community health settings, inpatient services, and residential and partial hospital settings. “Psychiatrists will routinely encounter patients in these settings who have substance use disorders including those with co-occurring psychiatric disorders, and it is imperative that they feel competent in providing that care.”In addition to the APA resource document, Greenfield cited a number of resources for trainees and training programs. They include the Opioid Response Network and the Providers Clinical Support System, of which APA is a partner. This program offers training and mentoring in evidence-based prevention and treatment of opioid use disorders and treatment of chronic pain.When trainees are expose to patients who recover from an SUD, it can be an experience the trainee will never forget.“We have an apprentice system of learning in graduate medical education—as a resident you have a supervisor, but you are treating the patient yourself,” she said. “What we know is that when trainees have that opportunity to work with a patient with a substance use disorder over time and see the patient get better in a real-world setting—it’s incredibly gratifying.” ■The APA Resource Document on Education and Training for Substance Use Disorders is posted here.APA Resource Document Offers Recommendations for Medical Students, Residents, and Lifelong Learners“Medical schools, physician training (residency) programs, and continuing education programs for physicians in practice provide limited training in the treatment of SUDs,” according to the APA Resource Document on Education and Training in Substance Use Disorders. “The scope of training on SUDs is disproportionate to the population health need to address these problems, and many with SUDs go undiagnosed and untreated.”The resource document is a product of APA’s Council on Addiction Psychiatry, the Council on Medical Education and Lifelong Learning, and the Council on Healthcare Systems and Financing. The document offers recommendations for medical schools, residencies, and continuing medical education for physicians in practice, as well as strategies for change.Recommendations for medical student rotations and residency programs include the following:Addiction and co-occurring disorders should be incorporated into all aspects of psychiatry residency training since patients with SUD are seen at all levels of care.Supervision and discussion of SUD cases should occur at inpatient and outpatient levels of care and should include an addiction psychiatrist.Programs should ensure they have access to resources to help them incorporate enhanced training in SUD with the goal of bolstering resident competencies in assessing and treating patients for these conditions.All psychiatry residents should complete the buprenorphine waiver training or its equivalent.Residents should be trained to treat patients with alcohol use disorder, stimulant use disorder, opioid use disorder, sedative/hypnotic use disorder, cannabis use disorder, tobacco use disorder, and other substances.Training experience should include various levels of patient acuity and corresponding care including outpatient and residential treatment.Residents should receive training in the use of FDA-approved medications for opioid, alcohol, and tobacco use disorder (and others as developed and approved by the FDA).Training on SUD treatments should include knowledge of the range of evidence-based behavioral therapies and competency to practice at least one. This might include, but is not limited to, the ability to integrate motivational interviewing concepts and techniques into patient assessments and sessions. ISSUES NewArchived

PACAP-PAC1 receptor inhibition is effective in opioid induced hyperalgesia and medication overuse headache models

To understand the role of comorbid substance use disorders (SUDs), or polysubstance use, in the treatment of opioid use disorder (OUD), this study compared patients with OUD only to those with additional SUDs and examined association with OUD treatment receipt. Retrospective national cohort study of Veterans diagnosed with OUD (n=65 741) receiving care from the US Veterans Health Administration (VHA) in fiscal year (FY) 2017. Patient characteristics were compared among those diagnosed with OUD only versus those with one other SUD (OUD+1 SUD) and with multiple SUDs (OUD+≥2 SUDs). The study examined the relationship between comorbid SUDs and receipt of buprenorphine, methadone and SUD outpatient treatment during 1-year follow-up, adjusting for patient demographic characteristics and clinical conditions. Among the 65 741 Veterans with OUD in FY 2017, 41.2% had OUD only, 22.9% had OUD+1 SUD and 35.9% had OUD+≥2 SUDs. Common comorbid SUDs included alcohol use disorder (41.3%), cocaine/stimulant use disorder (30.0%) and cannabis use disorder (22.4%). Adjusting for patient characteristics, patients with OUD+1 SUD [adjusted odds ratio (aOR)=0.87, 95% confidence interval (CI)=0.82-0.93] and patients with OUD+≥2SUDs (aOR=0.65, 95% CI=0.61-0.69) had lower odds of receiving buprenorphine compared with OUD only patients. There were also lower odds of receiving methadone for patients with OUD+1 SUD (aOR=0.91, 95% CI=0.86-0.97)and for those with OUD+≥2SUDs (aOR=0.79, 95% CI=0.74-0.84). Patients with OUD+1 SUD (aOR=1.85, 95% CI=1.77-1.93) and patients with OUD+≥2SUDs (aOR=3.25, 95% CI=3.103.41) were much more likely to have a SUD clinic visit. The majority of Veterans in the US Veterans Health Administration diagnosed with opioid use disorder appeared to have at least one comorbid substance use disorder and many have multiple substance use disorders. Despite the higher likelihood of a substance use disorder clinic visit, having a non-opioid substance use disorder is associated with lower likelihood of buprenorphine treatment, suggesting the importance of addressing polysubstance use within efforts to expand treatment for opioid use disorder.

To investigate whether initiation of glucagon-like peptide-1 (GLP-1) receptor agonists is associated with both reduced risks of incident alcohol, cannabis, cocaine, nicotine, opioid, and other substance use disorders (SUDs) in people with no history of SUDs (protocol 1) and with reduced risk of SUD related adverse clinical outcomes among people with a pre-existing SUD (protocol 2). Emulation of eight parallel, new user, active comparator target trials using electronic health records: seven trials for each incident SUD outcome (protocol 1) and one trial for adverse outcomes in people with pre-existing SUD (protocol 2). US Department of Veterans Affairs. From a base population of 606 434 US veterans with type 2 diabetes, participants were assigned to one of the two protocols and followed for up to three years. Trial 1 (primary trial) of protocol 1 included 524 817 initiators of GLP-1 receptor agonists (n=124 001) or sodium-glucose cotransporter-2 (SGLT-2) inhibitors (n=400 816). Protocol 2 included 81 617 initiators of GLP-1 receptor agonists (n=16 768) and SGLT-2 inhibitors (n=64 849). Incident outcomes were alcohol, cannabis, cocaine, nicotine, opioid, other SUDs, and a composite of these outcomes. Adverse outcomes among participants with pre-existing SUDs included SUD related emergency department visits, SUD related hospital admissions, and SUD related mortality, and drug overdose and suicidal ideation or attempt. Hazard ratios and net three year risk difference (NRD) per 1000 people were reported based on inverse probability weighted (standardised mortality ratio weighted) cause specific Cox survival models. Compared with initiation of SGLT-2 inhibitors, initiation of GLP-1 receptor agonists was associated with reduced risk of disorders related to alcohol use (hazard ratio 0.82 (95% confidence interval (CI) 0.78 to 0.85); NRD per 1000 people -5.57 (-6.61 to -4.53)), cannabis use (0.86 (0.81 to 0.90), NRD -2.25 (-3.00 to -1.50)), cocaine use (0.80 (0.72 to 0.88), NRD -0.97 (-1.37 to -0.57)), nicotine use (0.80 (0.74 to 0.87), NRD -1.64 (-2.19 to -1.09)), and opioid use (0.75 (0.67 to 0.85), NRD -0.86 (-1.19 to -0.52)), and other SUDs (0.87 (0.81 to 0.94), NRD -1.12 (-1.68 to -0.55)) and composite outcome of all incident SUDs (0.86 (0.83 to 0.88), NRD -6.61 (-7.95 to -5.26)). Among people with pre-existing SUDs, initiation of GLP-1 receptor agonists was associated with reduced risk of SUD related emergency department visits (0.69 (0.61 to 0.78), NRD -8.92 (-11.59 to -6.25)), SUD related hospital admissions (0.74 (0.65 to 0.85), NRD -6.23 (-8.73 to -3.74)), and SUD related mortality (0.50 (0.32 to 0.79), NRD -1.52 (-2.32 to -0.72)), and drug overdose (0.61 (0.42 to 0.88), NRD -1.49 (-2.43 to -0.55)) and suicidal ideation or attempt (0.75 (0.67 to 0.83), NRD -9.95 (-13.14 to -6.77)). Analyses of treatment adherence showed directionally consistent results with analyses of treatment initiation for both incident SUDs and adverse outcomes among participants with pre-existing SUDs. Use of GLP-1 receptor agonists was consistently associated with reduced risks of developing various incident SUDs, suggesting a broad preventive effect across multiple substance types. Use was also associated with reduced risks of adverse clinical outcomes in people with pre-existing SUDs. These observational data suggest a potential role for GLP-1 receptor agonists in both the prevention and the treatment of various SUDs, warranting further evaluation.

The relationship between man and substances that have abuse potentials, and whose use has been associated with the development or progression of substance use disorders has continued to evolve in terms of geography, economic implications, and time. History shows that local plants with psychoactive constituents can get exported worldwide through global travel, commerce, or even conquest. Time and globalization also change people’s relationship with substances of abuse; hence, an area that was initially alien to certain substances might evolve to becoming a trafficking hub, and then a destination. A case in point is Africa where a rapidly increasing prevalence of substance use/abuse and substance use disorder among adolescents and young adults is putting enormous strain on the economy, healthcare system, and society at large. However, there appears to be a paucity of scientific literature and data on the epidemiology, risk assessment, and contributing factors to substance use and the development of substance use disorders across Africa. In this narrative review, we examine extant literature (PubMed, Google scholar, Medline) for information on the prevalence, trends, and influencers of substance use and the development of substance use disorders. This is with a view of understanding the determinants of substance use and factors that influence the development of substance use disorders in the region, and how this information can be channeled towards developing a comprehensive intervention and treatment program.

Familial transmission of derived phenotypes for molecular genetic studies of substance use disorders

BackgroundJustice-impacted persons aged 40 and up with substance use disorders (SUD) demonstrate increased health risks and health disparities relative to general population peers. Persons with SUD are less likely to age out of criminal behavior, appearing on criminal dockets, in jails, prisons, and under community supervision throughout the life course, with greater community-level cost burdens as they age. Justice system involvement presents health risks that compound with SUD to undermine well-being, which is amplified as people age and experience age-related health decline. Propensity for premature mortality from overdose is startlingly high for this population, highlighting demand for targeted policies to better meet the needs of this vulnerable group. To better understand justice-impacted older adults in treatment for SUD and inform policy, we examined opioid use outcomes among 357 low-income justice-impacted adults in SUD treatment in the Midwest, USA, including a natural oversampling of Black and American Indian or Alaska Native (AIAN) persons. We explored patterns among persons in their 40s, 50s, and 60s, relative to those under 40, conceptualizing life-course risk factors and using logistic regression to assess overdose, opioid use, and opioid agonist medication use.ResultsSignificant differences in opioid use by age were observed, with older persons less likely to report opioid prescription misuse or illicit opioid use. Differences were not significant once controlling for user preferences, race/ethnicity, gender, family, childhood, and life course experiences. Overdose history was also significantly less likely for the 40 and older SUD patient, though this was no longer significant when controlling for demographic covariates. Opioid agonist medication use did not significantly differ by age.ConclusionsJustice-involved patients aged 40 and up in SUD treatment were less likely to have experienced overdose or report opioid use, relative to their younger peers, but this variation dissipated when considering demographic, family and/or life course factors. Targeted treatment services for gender and racial minorities may be beneficial for patients 40 and up. We identify preference for one substance, versus two, as protective against overdose and opioid use among older persons who use drugs.

Background: Traumatic brain injury (TBI) imposes a substantial public health burden through long-term physical, cognitive, and psychiatric effects. This includes substance use disorders (SUDs) for which TBI is a demonstrated risk factor; however, prior studies have not comprehensively compared relative incidences of SUD subtypes post-TBI or differences between intracranial hemorrhage (ICH) and non-ICH TBI in patients without prior SUD history. This global retrospective analysis using the TriNetX database aims to quantify new-onset SUD incidence post-TBI in the largest cohort of patients evaluated to date, with cohorts stratified by SUD subtype and ICH versus non-ICH TBI, to highlight opportunities for post-injury care models to mitigate SUD risk. Methods: De-identified data from the TriNetX Research Network were used to select patients with TBI (n = 1,889,112) and define distinct cohorts based upon the presence (n = 420,868) or absence (n = 1,471,592) of ICH. Patients with previously diagnosed SUD before the date of TBI were excluded. Patient demographics and medical comorbidities were calculated for each group. The incidence of new SUD diagnosis over the lifetime and at 1-, 3-, and 5-years post-TBI were calculated and compared. Subtypes of SUD were defined and calculated based on the specific substance used. Propensity scores were calculated to create balanced matched ICH and non-ICH cohorts (n = 331,812 each) were used for comparisons of 5-year SUD incidence. Results: In the full TBI cohort, 5-year new SUD incidence was 4.2% overall, with nicotine (2.4%) and alcohol (1.1%) predominating, followed by cannabis (0.9%) and opioids (0.4%). Rates of SUDs increased over time, but attenuated beyond 5 years, with approximately 50% of those who would ultimately be diagnosed with SUD manifesting (lifetime) by 3 years post-TBI. After propensity matching, non-ICH TBI showed higher 5-year risk for any SUD (4.2% vs. 3.6%; risk difference −0.65%, p < 0.0001) and all subtypes (p < 0.05) except inhalants (p = 0.53). Conclusions: This largest-to-date analysis of new-onset SUD post-TBI demonstrates significantly higher rates of SUD in TBI patients; rates of nicotine, alcohol, cannabis, and opioid use disorders were most common. Non-ICH TBI patients demonstrated greater rates of SUD after injury than patients with ICH-associated TBI. Of patients suffering from TBI without ICH who would eventually be diagnosed with SUD, approximately 50% had obtained that diagnosis within 3 years of the injury. Taken together, these findings demonstrate the clinical need for routine SUD screening in post-TBI care, especially for 3 years post-injury. Such an intervention has the potential to significantly alleviate the public health burden and associated cost of care for TBI-associated substance use disorder patients.

A Scoping Review of the Prevalence and Correlates of Sexual Dysfunction in Adults With Substance use Disorders

appears neither logical nor beneficial to patients.

IntroductionAbout 2.7 million U.S. households face an eviction filing each year. The effect of eviction policy on substance use disorder (SUD) treatment is uncertain.MethodsWe used IQVIA all-payer claims, Jan 2020–Dec 2021, in a difference-in-differences design. Phase 1 compared states where moratoria expired March–August 2020 with states that kept protections. Phase 2 examined the August 2021 end of the federal moratorium, contrasting states with ongoing state moratoria vs none. The population was people with a mental health or SUD diagnosis. Outcomes were state-week counts of unique patients with outpatient SUD visits, inpatient SUD stays, medications for opioid or alcohol use disorder, and opioid use disorder (OUD)-specific outpatient and inpatient care.ResultsEnding moratoria was associated with more patients receiving outpatient SUD care: +3.3% (95% CI −0.5% to 7.2%; P = 0.09) in Phase 1 and +4.9% (95% CI 1.8% to 8.0%; P = 0.002) in Phase 2. We observed no change in inpatient SUD care. In Phase 2, medication treatment increased by 2.5% (95% CI 0.3% to 4.7%; P = 0.03). OUD-specific results were similar.ConclusionThe return of eviction risk coincided with greater use of clinic-based SUD services but not hospital care. Housing policy may shift where and how people seek SUD treatment.

Back to table of contents Previous article Next article Education & TrainingFull AccessThe Fight Against OUD Needs Academic MedicineTerri D'ArrigoTerri D'ArrigoSearch for more papers by this authorPublished Online:27 Sep 2021https://doi.org/10.1176/appi.pn.2021.10.3AbstractDecades of research has produced a plethora of treatments for diagnosing and treating opioid use disorder and overdose, but those interventions are worthless if health care professionals are not taught when and how to use them.Opioid overdoses resulted in more than 24 million hospitalizations and have claimed the lives of more than 360,000 Americans in the last decade. Yet only about two-thirds of medical schools include lectures about opioids and addiction medicine in their curricula, representing a dearth of education that may leave physicians and trainees with a poor understanding of how to screen for and treat opioid use disorder (OUD) with evidence-based interventions. If the nation is ever to get a handle on the crisis and rein it in, academic medicine must step up and be more proactive, experts in addiction medicine wrote in a commentary in Academic Medicine.The growing awareness of health disparities and social justice issues may build support for giving substance use disorders more attention in medical and nursing schools, say Nora Volkow, M.D., and colleagues.NIH“This is where academic medicine can be most influential in addressing this public health problem: by enhancing the preparedness of the current and future clinical workforce to treat substance use disorders (SUDs), including opioid use disorder (OUD), through increased attention to addiction medicine in medical and nursing schools and in residency training programs,” wrote Nora Volkow, M.D., the director of the National Institute on Drug Abuse, and colleagues.The authors wrote that the growing awareness of health disparities, social justice issues, and the needs of vulnerable populations can build support for increased attention to SUDs in medical and nursing schools, and added that more training in addiction medicine is part of a larger shift toward recognizing that behavioral health in general is key to the prevention, management, and treatment of many illnesses and conditions.“By offering more training in behavioral health, medical and nursing schools will not only better equip current students to meet the needs of the communities they will serve but also attract premedical and prenursing students who are more interested in and motivated to address these concerns,” they wrote.Amber Frank, M.D., an instructor in psychiatry and director of the Cambridge Health Alliance adult psychiatry residency program at Harvard Medical School, who was not an author on the commentary, told Psychiatric News that medical schools can help equip all students for working patients with SUD by teaching them the following core skills:Didactic learning in medical school about substance use disorders should be coupled with clinical experience, says Amber Frank, M.D.Harvard UniversityThe ability to obtain a comprehensive substance history with respect and empathy.A basic knowledge of screening tools, diagnostic criteria, and evidence-based pharmacological and psychosocial treatments for SUD, including OUD.The ability to recognize SUD-related emergencies such as overdose or dangerous intoxication.A basic familiarity with levels of care from community supports through inpatient settings.The ability to conduct motivational interviewing.“This may sound like a lot, but it is in alignment with what we would expect medical students to master for other medical and surgical conditions, and it is doable,” said Frank, chair of the American Association of Directors of Psychiatric Residency Training’s Addictions Committee. “At the same time, these didactic-based learning experiences should be coupled with actual clinical experience. We wouldn’t expect our medical students to learn endocrinology only from preclinical coursework without associated clinical exposure. Similarly, we need to move toward addictions education that is robust in both classroom and clinical learning venues.”Frank said that patients with SUDs can be found across clinical settings.“[They] are everywhere: in our primary care clinics, our medical specialty services, the OR and ED, in OB/GYN. It is essential that we train our future primary care physicians, surgeons, and other specialists to recognize and treat substance use disorders, as relying only on subspecialty-trained addictions experts will be insufficient to meet the health needs of the population,” she said. “The responsibility for care of individuals with SUD is one we all share, whether we are in academic medicine and researching new treatments or training the next generation, or if we are in community practice and refining our own clinical skills.” ■“How Academic Medicine Can Help Confront the Opioid Crisis” is posted here. ISSUES NewArchived

Background and Aims:Substance use disorder (SUD) commonly associates with alcohol use disorder (AUD), and certain substances have independently been shown to drive liver injury. In this work, we sought to determine if co-existing SUD in patients with AUD associated with the presence of alcohol-associated liver disease (ALD).Methods:We performed a cross-sectional analysis using the Mass General Brigham Biobank to identify patients based on ICD-10 codes. We performed multivariate analyses accounting for a wide range of demographic and clinical variables to evaluate the association between SUD and ALD. We subsequently used the same method to evaluate the association between SUD and hepatic decompensation.Results:We identified 2848 patients with a diagnosis of AUD, 9.0% of which had ALD. 25.2% had a history of SUD. In multivariate analyses, patients with SUD were more frequently diagnosed with ALD compared to those without SUD (OR = 1.95, P = 0.001). Furthermore, the number of concurrent SUDs was positively associated with the diagnosis of ALD (OR: 1.33, P < 0.001). Independent of the presence of other SUDs, opioid use disorder in patients with AUD was associated with ALD (OR = 1.902, P = 0.02). In subsequent analyses, we found that sedative use disorder was associated with hepatic decompensation (OR: 2.068, P = 0.03).Conclusions:In patients with AUD, SUD, and in particular opioid use disorder, was independently associated with the diagnosis of ALD.