Is Abstinence from Alcohol and Smoking Associated with Less Anxiety and Depressive Symptoms Among People with HIV?

Achieving abstinence from alcohol, tobacco, or both may improve mental health, but is understudied in people with HIV (PWH). The St PETER HIV randomized clinical trial compared varenicline, cytisine, and nicotine replacement therapy on alcohol and smoking behavior among 400 PWH in Russia. The primary exposure was thirty-day point prevalence abstinence (PPA) from (1) alcohol, (2) smoking, (3) both, or (4) neither and was assessed at 1, 3, 6 and 12-months as were the study outcomes of anxiety (GAD-7) and depressive (CES-D) symptoms. The primary aim was to examine the association between smoking and/or alcohol abstinence and subsequent symptoms of depression and anxiety. Primary analysis used repeated measures generalized linear modeling to relate PPA with mental health scores across time. In secondary analyses, Kruskal-Wallis tests related PPA with mental health scores at each timepoint. Primary analyses did not identify significant differences in anxiety or depressive symptoms between exposure groups over time. Secondary analyses found CES-D scores across PPA categories were similar at 1-month (11, 10, 11, 11) and 6-months (10, 10, 11, 11) but differed at 3-months (9, 11, 10, 12; p = 0.035) and 12-months (10, 6, 11, 10; p = 0.019). GAD-7 scores did not vary across PPA categories at any time point. While abstinence was associated with fewer depressive symptoms at times, findings were not consistent during follow-up, perhaps reflecting intermittent relapse. PWH with polysubstance use and mental health comorbidity are complex, and larger samples with sustained abstinence would further elucidate effects of abstinence on mental health.

Interventions to increase naloxone access for undergraduate students: A systematic review of the literature.

OBJECTIVE: To identify and describe interventions that increase access to naloxone for undergraduate students. METHODS: A systematic review across 4 databases identified interventions that expand access to naloxone at colleges in the United States from 2015-2023. Three reviewers extracted the following data to create a narrative synthesis and summary of program elements: setting, rationale for intervention, timeline, intervention components, study size, collaboration, sustainability, outcomes and results. RESULTS: Seven articles met inclusion criteria. Institutions' implemented naloxone interventions due to concerns for student safety and/or student overdose fatalities. Three universities collaborated with their School of Pharmacy for program design and/or dissemination, while two partnered with state-based naloxone distribution programs. Most programs combined opioid-overdose/naloxone training; four distributed naloxone kits. Three studies included pre/post-outcomes, and all reported increases in participant knowledge, attitudes, and/or ability to respond to an overdose. CONCLUSIONS: Our results indicates an opportunity for wide-scale implementation of undergraduate naloxone programs within US colleges. However, more rigorous implementation research is needed to identify barriers and facilitators to program feasibility, acceptability, and participation.

Healthcare Utilization Among Persons with HIV and Unhealthy Alcohol Use in St. Petersburg, Russia.

Few studies have examined the association between healthcare utilization and heavy alcohol use in Russia among persons with HIV (PWH), a group with high healthcare needs. This study analyzed the association between unhealthy alcohol use (defined as AUDIT score ≥ 8) and healthcare utilization among PWH with heavy alcohol use and daily smoking in St. Petersburg, Russia. This secondary analysis used data from a randomized controlled trial addressing alcohol use. The primary outcome was seeing an infectionist for HIV care in the past year. Outcomes were measured at baseline, 6 months, and 12 months. We assessed the association between unhealthy alcohol use and healthcare utilization outcomes with a repeated measures logistic regression model, controlling for relevant covariates. Nearly all (96.0%) participants had unhealthy alcohol use at baseline, and 90.0% had seen an infectionist for HIV care in the past year. In adjusted analyses, unhealthy alcohol use was associated with a 36% decrease in seeing an infectionist for HIV care (aOR = 0.64, 95% CI 0.43-0.95). Participants reported low levels of emergency department visits and hospitalizations. Understanding how to engage this population in alcohol use disorder treatment and HIV care is an important next step for improving health outcomes for this population.

Gender differences among persons entering medication treatment for opioid use disorder in the community.

BACKGROUND AND OBJECTIVES: We evaluated gender differences among persons initiating medications for opioid use disorder (MOUD). METHODS: Analyses of baseline assessments for a study evaluating the impact of MOUD on outcomes included: demographics, DSM-5 diagnoses, depression severity, quality of life (QoL), and medication history (N = 125). RESULTS: When compared to men, women had a greater prevalence of generalized anxiety and posttraumatic stress disorders; and worse psychological QoL. Women were less likely to be prescribed psychiatric medications. DISCUSSION AND CONCLUSIONS: Women may benefit from tailored multidisciplinary programs with MOUD. SCIENTIFIC SIGNIFICANCE: This study identified that women with OUD seeking MOUD in the community had greater sedative hypnotic nonprescribed medication use and psychiatric comorbidity than men, all of which can contribute to poorer retention on MOUD and higher risk of morbidity and mortality. Thus, concurrent psychiatric disorder screening and treatment integrated with MOUD may improve retention on MOUD, opioid relapse and overdose for women.

Factors associated with retention on medications for opioid use disorder among a cohort of adults seeking treatment in the community.

BACKGROUND: Medication treatment for opioid use disorder (OUD) (MOUD; buprenorphine and methadone) reduces opioid use and overdose. Discontinuation of MOUD can quickly lead to relapse, overdose and death. Few persons who initiate MOUD are retained on treatment, thus it is critical to identify factors associated with retention. METHODS: Evaluated data was from an ongoing prospective cohort study of adults aged 18 or older with DSM-5 moderate to severe OUD seeking MOUD in the community and followed for 6 months. Participants were considered retained on MOUD through 6 months if they reported taking MOUD at every study interview without discontinuation. A high dose of MOUD was defined as a methadone dose > 85 mg or buprenorphine dose ≥ 16 mg. Multivariable logistic regression was conducted to assess factors associated with 6-month MOUD retention. RESULTS: A total of 118 participants (73% male, 58% white, 36% with HIV) were included. Buprenorphine was initiated by 58% and 42% started methadone. MOUD retention was 49% and 58% among buprenorphine and methadone, respectively, at 6-months. In adjusted models, a high MOUD dose (OR = 4.71, 95% CI 2.05-10.84) and higher pain interference (OR = 1.59, 95% CI 1.15-2.19) was associated with MOUD retention. CONCLUSIONS: Adequate dosing of MOUD leads to improved retention on MOUD. Further, persons with high pain interference at baseline had higher odds of retention on MOUD. Both methadone and buprenorphine have analgesic effects, thus those with high pain interference could have dual benefits of MOUD for treating OUD and pain. Interventions should be tailored to improve adequate MOUD dosing to improve retention on MOUD.

Sex Differences in Injection Drug Risk Behaviors Among Hospitalized Persons.

OBJECTIVES: As opioid use increases, it remains important to assess factors that contribute to injection drug risk behaviors, as sharing needles and other drug use equipment contributes to the spread of human immunodeficiency virus and hepatitis C virus. Such risks may differ by sex and injecting with others. The current study examined factors that contribute to increased injection drug risk separately for men and women. METHODS: People who inject drugs were recruited at an academic safety-net hospital that reported recent injection drug use. Two main injection outcomes were assessed: (1) human immunodeficiency virus drug risk behaviors as assessed by the Risk Assessment Battery and (2) the number of times participants injected drugs with a needle used by someone else. For each outcome, different models for women and men were conducted to detect differences by sex. RESULTS: Both men and women were more likely to inject with a needle used by someone else if they used drugs within a sexual relationship (incidence rate ratio (IRR) = 14.61, P < 0.01; IRR = 7.17, P < 0.05). Being employed was associated with lower risk assessment battery scores among men, and lower mean rates of using a needle used by someone else among women (IRR = 0.22, P < 0.05). Women with post-traumatic stress disorder (PTSD) and men with higher depression scores had higher rates of injecting with a needle used by someone else. CONCLUSIONS: People who inject drugs who are in intimate relationships report higher injection drug risk behaviors. We found benefits to employment among both men and women. Identifying factors associated with increased injection risk behaviors can be useful for creating interventions tailored by sex.

A Systematic Review and Meta-Analysis of Studies Evaluating the Effect of Medication Treatment for Opioid Use Disorder on Infectious Disease Outcomes.

The opioid epidemic has fueled infectious disease epidemics. We determined the impact of medications for opioid use disorder (MOUD) on treatment outcomes of opioid use disorder (OUD)-associated infectious diseases: antiretroviral therapy (ART) adherence, human immunodeficiency virus (HIV) viral suppression, hepatitis C virus (HCV) sustained virologic response, HCV reinfection, new hepatitis B virus infections, and infectious endocarditis-related outcomes. Manuscripts reporting on these infectious disease outcomes in adults with OUD receiving MOUD compared with those with OUD "not" receiving MOUD were included. Initial search yielded 8169 papers; 9 were included in the final review. The meta-analysis revealed that MOUD was associated with greater ART adherence (odds ratio [OR] = 1.55; 95% confidence interval [CI] = 1.12-2.15) and HIV viral suppression (OR = 2.19; 95% CI = 1.88-2.56). One study suggested a positive association between MOUD and HCV sustained virologic response. There is significant support for integrating MOUD with HIV treatment to improve viral suppression among persons with HIV (PWH) and OUD. Treatment of OUD among PWH should be a priority to combat the opioid and HIV epidemics.

Gender differences among criminal justice-involved persons living with HIV interested in extended-release naltrexone treatment.

Background: Previous research has shown gender differences with respect to entry into medication treatment of substance use disorders (SUDs), yet few have examined gender differences among participants consented to be treated with extended-release naltrexone (XR-NTX). Understanding gender differences is critical to developing interventions to overcome barriers to initiation of and retention on medication treatment for SUDs. Methods: Data from two double-blind placebo-controlled trials of XR-NTX among persons with HIV and alcohol or opioid use disorders leaving the criminal justice system (CJS) were analyzed for gender differences among clinical characteristics, mental health, drug use severity, and other domains. The study that recruited persons with alcohol use disorder (AUD) was conducted from September 2010-February 2016 at two sites in Connecticut (CT), and the opioid use disorder (OUD) study was conducted from September 2010-March 2016 at three sites in CT and one site in Massachusetts. Results: Baseline data were analyzed from 193 participants consented to be randomized to XR-NTX or placebo; 40 women and 153 men. Women were younger, had worse mental health severity, and were more likely to be diagnosed with cocaine use disorder. There were no statistical differences between men and women in the prescription of antiretroviral therapy (ART) or ART adherence. Conclusions: Women had greater mental health severity and a higher prevalence of cocaine use as compared to men, both of which are known to be barriers to engagement and retention on medication treatment for alcohol and opioid use disorders. For women with CJS involvement and living with HIV and SUDs, understanding factors that may affect initiation and retention on medication treatment of SUDs are necessary to improve treatment outcomes in women.

Design and implementation of a prospective cohort study of persons living with and without HIV infection who are initiating medication treatment for opioid use disorder.

BACKGROUND: Opioid use disorder (OUD) negatively impacts the HIV continuum of care for persons living with HIV. Medication treatment for OUD (MOUD) may have differential biological effects in individuals with HIV and OUD. To address the question of modulation of immune responses by MOUDs, we describe state of the art systems biology approaches to carry out the first prospective, longitudinal study of persons with and without HIV infection with OUD initiating MOUD. METHODS: A prospective cohort study of persons with DSM-5 diagnosed OUD who are living with and without HIV infection and initiating treatment with methadone or buprenorphine is underway to assess biological effects of these medications on immunobiological outcomes. RESULTS: We describe the recruitment, laboratory, and statistical methods of this study as well as the protocol details. Of those screened for enrollment into the study, 468 (36%) were eligible and 135 were enrolled thus far. Retention through month 6 has been high at 80%. CONCLUSIONS: This study will use state of the art systems biology approaches to carry out the first prospective, longitudinal studies of persons living with and without HIV with DSM-5 OUD initiating treatment with MOUD.

A systematic review of patients' and providers' perspectives of medications for treatment of opioid use disorder.

BACKGROUND: The opioid epidemic is a public health crisis. Medications for opioid use disorder (MOUD) include: 1) buprenorphine, 2) methadone, and 3) extended-release naltrexone (XR-NTX). Research should investigate patients' and providers' perspectives of MOUD since they can influence prescription, retention, and recovery. METHODS: This systematic review focused on patients' and providers' perceptions of MOUD. The review eligibility criteria included inclusion of the outcome of interest, in English, and involving persons ≥18 years. A PubMed database search yielded 1692 results; we included 152 articles in the final review. RESULTS: There were 63 articles about buprenorphine, 115 articles about methadone, and 16 about naltrexone. Misinformation and stigma associated with MOUD were common patient themes. Providers reported lack of training and resources as barriers to MOUD. CONCLUSION: This review suggests that patients have significant misinformation regarding MOUD. Due to the severity of the opioid epidemic, research must consider the effects of patients' and providers' perspectives on treatment for OUD, including the effects on the type of MOUD prescribed, patient retention and adherence, and ultimately the number of patients treated for OUD, which will aid in curbing the opioid epidemic.

A Literature Review Examining Primary Outcomes of Medication Treatment Studies for Opioid Use Disorder: What Outcome Should Be Used to Measure Opioid Treatment Success?

BACKGROUND AND OBJECTIVES: Medications for opioid use disorder (MOUD) reduce opioid use and overdose; however, MOUD clinical trials have used varying primary outcomes to document treatment success. We conducted a literature review to assess and critically examine the methodologies used in MOUD treatment studies. METHODS: Published studies in English that examined MOUD (buprenorphine, methadone, or extended-release naltrexone) were included (N = 20). The methods and frequencies of measuring primary opioid outcomes, including urine drug tests (UDTs) and self-report of opioid use were compared among studies. RESULTS: A total of 20 studies fit the inclusion criteria. Each study assessed opioid use; only 12 had opioid use as a primary outcome. Other primary outcomes included retention in treatment (N = 6), and two had other primary outcomes (death and opioid withdrawal symptoms). Opioid use was assessed through both self-report and UDTs in 15 studies. Two studies did not use UDTs. Differences were found in the methods used for how opioid use, retention in treatment, self-report of opioid use, and UDTs were measured. DISCUSSION AND CONCLUSIONS: The different primary outcomes used and operational definitions in each study make comparisons between studies difficult. The use of both self-report and UDTs for opioid use has several advantages, and if possible, researchers should use both measures. SCIENTIFIC SIGNIFICANCE: This is the first review critically examining outcome measures from MOUD treatment studies. Creating a standard for opioid treatment outcomes in MOUD studies will allow for generalizable results that can inform both researchers and clinicians to better care for those with OUD. (Am J Addict 2020;00:00-00).

A Call to Action to Combat the Opioid Epidemic Among Women.

: Acknowledging the needs and challenges of women with opioid use disorder is an essential step to reduce the opioid epidemic in the United States. Efforts that can help women include increasing psychosocial services to address trauma, increasing access to medication treatment for opioid use disorder, reducing barriers and stigma that impede access to and retention on treatment, and addressing structural and policy barriers. This commentary discusses the reasons why women-focused treatment for opioid use disorder is necessary and makes specific recommendations for interventions, treatment, services, and policies that can reduce barriers to care and improve treatment and retention among women.

Reduced Sexual Risk Behaviors Among Persons With HIV After Release From the Criminal Justice System.

BACKGROUND: HIV prevalence is 3 times greater for those in the criminal justice system than the general population, with an assumed increase in sexual risk behaviors (SRBs) postrelease. HIV viral suppression impacts HIV transmission; however, studies of SRBs among persons with HIV leaving the criminal justice system are limited, and no studies have examined viral suppression in relation to SRBs in persons leaving the criminal justice system. METHODS: Data were examined from 2 double-blind placebo-controlled trials of extended-release naltrexone among persons with HIV and alcohol use or opioid use disorder. Participants self-reported sexual activity, including number of sexual partners, sex type, and condom use. HIV viral suppression was evaluated prerelease and at 6 months. RESULTS: Thirty days before incarceration, 60% reported having sex compared with 41% and 46%, respectively, at months 1 and 6 postrelease. The number of sex partners and sexual intercourse events decreased from pre-incarceration to months 1 and 6 postrelease. Condom use increased but was not statistically significant. Of the 11 (9.7%) who reported having sex without a condom 1 month postrelease, only 2 did not have viral suppression (VS; HIV VL <200 copies/mL), whereas the 7 (6.5%) who reported SRBs at 6 months all had VS. CONCLUSIONS: After release, SRBs decreased, and among those who reported SRBs, most were virally suppressed, and thus risk of transmitting HIV was low.

Extended-Release Naltrexone Improves Viral Suppression Among Incarcerated Persons Living With HIV With Opioid Use Disorders Transitioning to the Community: Results of a Double-Blind, Placebo-Controlled Randomized Trial.

OBJECTIVE: To determine whether extended-release naltrexone (XR-NTX) would improve or maintain viral suppression (VS) among prisoners or jail detainees with HIV and opioid use disorder (OUD) transitioning to the community. DESIGN: A 4-site, prospective randomized double-blind, placebo-controlled trial was conducted among prison and jail inmates with HIV and OUD transitioning to the community from September 2010 through March 2016. METHODS: Eligible participants (N = 93) were randomized 2:1 to receive 6 monthly injections of XR-NTX (n = 66) or placebo (n = 27) starting at release and observed for 6 months. The primary outcome was the proportion that maintained or improved VS (<50 copies/mL) from baseline to 6 months. RESULTS: Participants allocated to XR-NTX significantly improved to VS (<50 copies/mL) from baseline (37.9%) to 6 months (60.6%) (P = 0.002), whereas the placebo group did not (55.6% at baseline to 40.7% at 6 months P = 0.294). There was, however, no statistical significant difference in VS levels at 6 months between XR-NTX (60.6%) vs. placebo (40.7%) (P = 0.087). After controlling for other factors, only allocation to XR-NTX (adjusted odds ratio = 2.90; 95% confidence interval = 1.04 to 8.14, P = 0.043) was associated with the primary outcome. Trajectories in VS from baseline to 6 months differed significantly (P = 0.017) between treatment groups, and the differences in the discordant values were significantly different as well (P = 0.041): the XR-NTX group was more likely than the placebo group to improve VS (30.3% vs. 18.5%), maintain VS (30.3% vs. 27.3), and less likely to lose VS (7.6% vs. 33.3%) by 6 months. CONCLUSIONS: XR-NTX improves or maintains VS after release to the community for incarcerated people living with HIV with OUD.