Improving Medical Student Knowledge and Reducing Stigmatizing Attitudes Toward Treating Patients With Opioid Use Disorder.

Objectives: Stigma and lack of knowledge are barriers to clinicians when caring for individuals with opioid use disorder (OUD). In 2018, only about 15 out of 180 American medical schools had comprehensive addiction programs. The AAMC reports that institutions are increasingly incorporating competencies to address the OUD and opioid epidemic. There have been few evaluated curriculums focused on reducing stigmatizing attitudes. This study evaluated whether a 4-hour case-based curriculum focused on improving stigmatizing attitudes toward patients with OUD could reduce medical student perceptions around viewing addiction as a punitive condition and other substitution-based misconceptions around opioid agonist-based medication. Methods: Medical students completed a 4-hour curricular workshop which included learning objectives focusing on barriers to healthcare/stigmatizing attitudes, effective behavioral therapy options, and appropriate use of opioid medications. We measured changes in knowledge and attitudes using validated scales on stigma. Non-parametric repeated measure tests determined statistically significant differences between pre and post assessments between OUD related perceptions and a control condition (diabetes). Results: Of 135 eligible participants, 99 (76%) students completed both pre- and post-surveys. Mean scores across knowledge questions improved (60%-81%, P < .001) and stigmatizing attitudes regarding perceived violence of people with OUD decreased (2.04-1.82, P = .016). There was significant improvement in mean scores for OUD-related opinions including desire to work with and effectively treat patients with OUD (3.58-3.88, P < .001) while no significant concurrent change was observed in mean opinion scores of a non-OUD comparator, diabetes (3.88-3.97, P = .201). Conclusions: Results indicate that the workshop was associated with measurable changes in knowledge and attitudinal forms of OUD stigma. With recent policy changes eliminating the X-waiver, healthcare institutions are eager to design curriculum around OUD management and treatment. This study provides a blueprint for an effective curriculum that improves clinician knowledge and reduces stigmatizing attitudes.

Psychostimulant Misuse Among American Indian, Alaskan Native, or Native Hawaiian College Students in the U.S. From 2015 to 2019.

Introduction: This study examines factors associated with psychostimulant misuse, including polysubstance use and social factors, among the understudied American Indian/Alaska Native/Native Hawaiian (AI/AN/NH) college student population. Methods: Data were from the 2015 to 2019 American College Health Association-National College Health Assessment IIc (ACHA-NCHA IIc) survey. Multivariable logistic regression models and odds ratios were used to estimate associations between psychostimulant misuse and potential risk and protective factors among AI/AN/NH college students, including licit and illicit substance use, social support, relationship factors, exposure to violence or abuse, mental health symptoms, drug and alcohol education, and sample demographics. Results: Opioid misuse among AI/AN/NH college students significantly increased the odds of using psychostimulants. Specifically, for cocaine use, the adjusted odds ratio (aOR) was 3.17 with a 95% confidence interval (C.I.) of 2.17 to 4.63; for methamphetamine use, the aOR was 38.87 (95% C.I. 19.24-78.52). For amphetamine misuse among non-Tobacco users, the aOR was 5.47 (95% C.I. 3.49-8.55), while among Tobacco users, the aOR was 2.65 (95% C.I. 2.07-3.41). For cocaine and other stimulant misuse, the aOR was 3.64 (95% C.I. 2.30-5.67). Additionally, the use of other types of licit and illicit substances was associated with greater odds of psychostimulant use and misuse. Conversely, factors such as age, living on campus, and residing in parental/guardian housing were linked with lower odds of psychostimulant use and misuse. Conclusion: Substance use prevention and treatment interventions targeting AI/AN/NH college students should address polysubstance use, including the combined use of opioids and psychostimulants. Substance use interventions should not be siloed to focus narrowly on single substances but rather should leverage potential protective factors against substance use, such as promoting supportive campus and family living conditions and other social support networks, in broad efforts to reduce multiple forms of substance use among AI/AN/NH students.

Exploring the Association Between Opioid Use Disorder and Alzheimer's Disease and Dementia Among a National Sample of the U.S. Population.

BACKGROUND: Past research suggests associations between heavy alcohol use and later life dementia. However, little is known about whether opioid use disorder (OUD) and dementia share this association, especially among age groups younger than 65 years old. OBJECTIVE: Examine the association between OUD and Alzheimer's disease (AD) and dementia. METHODS: Electronic health records between 2000 and 2021 for patients age 12 or older were identified in the Cerner Real-World database™. Patients with a prior diagnosis of dementia were excluded. Patients were followed for 1-10 years (grouped by one, three, five, and ten-year follow-up periods) in a matched retrospective cohort study. Cox proportional hazards regressions were used to estimate adjusted hazard ratios (aHRs) of incident AD/dementia stratified by age and follow-up group. RESULTS: A sample of 627,810 individuals with OUD were compared to 646,340 without OUD. Individuals with OUD exhibited 88% higher risk for developing AD/dementia compared to those without OUD (aHR = 1.88, 95% CI 1.74, 2.03) within 1 year follow-up and 211% (aHR = 3.11, 95% CI 2.63, 3.69) within 10 years follow-up. When stratifying by age, younger patients (age 12-44) had a greater disparity in odds of AD/dementia between OUD and non-OUD groups compared with patients older than 65 years. CONCLUSIONS: Additional research is needed to understand why an association exists between OUD and AD/dementia, especially among younger populations. The results suggest that cognitive functioning screening programs for younger people diagnosed with OUD may be useful for targeting early identification and intervention for AD/dementia in particularly high risk and marginalized populations.

Risk of Feeding Problems Among Infants With Neonatal Abstinence Syndrome: A Retrospective Cohort Study.

BACKGROUND: The rate of infants born with neonatal abstinence syndrome (NAS) increased by more than 500% between 2004 and 2016. Although feeding problems among infants diagnosed with NAS have been documented, the risk of feeding problems among infants diagnosed with NAS has not been estimated. PURPOSE: This study evaluates the extent to which feeding problems among infants diagnosed with NAS differ from thise in infants without an NAS diagnosis. METHODS/SEARCH STRATEGY: A matched retrospective cohort study (2008-2017) of infants diagnosed with NAS in the United States was conducted using hospital admission data from the Cerner Health Facts Database. Multivariable logistic regressions controlling for confounders were used to assess whether an NAS diagnosis is associated with hospital admission due to feeding problems. FINDINGS/RESULTS: Infants with NAS were nearly 3 times as likely (OR = 2.81; 95% CI, 2.68-2.95) to have feeding problems compared with infants without NAS after adjusting for infant and hospital characteristics. Lower birth weight, higher infant age, Hispanic ethnicity, and hospital location in the Midwest region were also associated with higher odds of feeding problems. Infants diagnosed with NAS who had feeding problems had slightly lower odds of being offered lactation services than infants without NAS who had feeding problems. IMPLICATIONS FOR PRACTICE: These findings suggest the need for targeted feeding interventions. IMPLICATIONS FOR RESEARCH: Future research on infants with NAS may build on these findings by assessing the role of maternal factors such as nutrition and substance use to understand how parental characteristics also influence the risk for hospitalization.

The long tail of COVID and the tale of long COVID: Diagnostic construction and the management of ignorance.

We bring together insights from the sociology of diagnosis and the sociology of ignorance to examine the early diagnostic unfolding of 'Long COVID' (LC). Originally described by patient activists, researchers set out to ponder its unwieldy clinical boundaries. Using a scoping review method in tandem with qualitative content analytic techniques, we analyse medicine's initial struggles to construct a LC diagnosis. Paying attention to the dynamics of ignorance, we highlight three consequential conceptual manoeuvres in the early classifications of LC: causal agnosticism concerning the relationship between COVID-19 and LC, evasion of lumping LC with similar conditions; and the predictable splitting off of medically explainable cases from the LC designation. These manoeuvres are not maleficent, inept or unreasonable. They are practical but impactful responses to the classificatory dilemmas present in the construction of diagnoses amidst ignorance. Although there are unique aspects to LC, we suggest that its early fate is nevertheless emblematic of medicine's diagnostic standardisation processes more generally. To varying degrees, diagnoses are ignorance management strategies; they create a pathway through the uncertainty at the core of disease realities. However, while diagnoses circumscribe some types of ignorance, they produce others through the creation of blind spots and paths not taken.

Sexuality and Gender Identity Inequities in Substance Use Disorder and Its Treatment among American Indian, Alaska Native, and Native Hawaiian College Students.

BACKGROUND: The aim of this study was to investigate inequities in substance use disorder (SUD) diagnosis, opioid misuse, marijuana misuse, SUD treatment utilization, and utilization of university mental health services among sexual and gender minority (SGM) American Indian, Alaska Native, and Native Hawaiian (AI/AN/NH) college students. METHODS: Data consisting of 8,103 AI/AN/NH students' responses to the American College Health Association's National College Health Assessment survey from fall 2015 through spring 2019 were utilized for this study. Multivariable logistic regression models were used to compare the odds of SUD diagnosis, opioid misuse, and marijuana misuse in SGM AI/AN/NH students to cisgender, heterosexual peers. Unadjusted odds of SUD treatment utilization and utilization of university mental health services were also evaluated. RESULTS: Compared to cisgender females, transgender (aOR = 4.43, 95% CI = 2.67-7.34) and gender diverse (aOR = 2.86, 95% CI = 1.61-5.07) students had significantly higher odds of SUD diagnosis. Similarly, significantly higher odds of SUD diagnosis were observed among sexual minorities, including gay/lesbian (aOR = 2.95, 95% CI = 1.71-5.09) and bisexual (aOR = 1.97, 95% CI = 1.30-2.99) students compared to heterosexual peers. Sexual minority students had significantly higher odds of utilizing university mental health services (uOR = 2.43, 95% CI = 1.22-4.84) than heterosexual peers. Odds of opioid misuse and marijuana misuse were also significantly increased among sexual minority students. CONCLUSIONS: AI/AN/NH college students who identify as SGM have higher odds of SUD diagnosis, opioid misuse, and marijuana misuse than their cisgender, heterosexual peers. These findings highlight the need to consider tailored programming for SGM AI/AN/NH students in substance use prevention and intervention efforts in U.S. college settings.

Associations between discrimination and adverse mental health symptoms and disorder diagnoses among college students in the United States.

BACKGROUND: Mental health disorders are prevalent among college students in the US. Perceived discrimination is a known risk factor for adverse mental health and is widespread on college campuses. METHODS: We estimated the association between perceived discrimination and mental health among US college students using the American College Health Association-National College Health Assessment (ACHA-NCHA), a large national cross-sectional survey of college students. RESULTS: 7.9% of students reported experiences of discrimination, and that discrimination was more common among minority students. Perceived discrimination was associated with 86 excess cases of students reporting being too depressed to function per 1000 students, and 27 excess cases of students reporting seriously considering suicide per 1000 students. Students who experienced discrimination had a 37% increase in the number of mental health symptoms (IRR 1.37 [95% CI 1.35, 1.39], P < .0001) compared to non-discriminated students, and a 94% increase in the number of mental health diagnoses (IRR 1.94 [95% CI 1.89, 1.99], P < .0001). Discrimination was positively associated with all mental health symptoms and diagnoses. This pattern was largely held across sub-analyses by race/ethnicity, gender, and sexual orientation, but with varying magnitudes. LIMITATIONS: Inability to distinguish between the forms of discrimination experienced, whether involving gender, sexual orientation, or race/ethnicity. CONCLUSIONS: Consequences of perceived discrimination are of clinical relevance for healthcare providers in general and mental health providers in particular. This study confirms the association between perceived discrimination and adverse mental health in college students. Efforts to reduce discrimination and bias in college campuses may improve the mental health of students.

Epidemiological trends in opioid-only and opioid/polysubstance-related death rates among American Indian/Alaska Native populations from 1999 to 2019: a retrospective longitudinal ecological study.

OBJECTIVES: The rate of drug overdose deaths in the USA has more than tripled since the turn of the century, and rates are disproportionately high among the American Indian/Alaska Native (AI/AN) population. Little is known about the overall historical trends in AI/AN opioid-only and opioid/polysubstance-related mortality. This study will address this gap. DESIGN: This is a retrospective longitudinal ecological study. SETTING: US death records from 1999 to 2019 using the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research. PARTICIPANTS: US non-Hispanic AI/AN people age 12 years and older. MEASURES: The primary outcomes, identified via the 10th revision of the International Statistical Classification of Diseases and Related Health Problems codes, included overdose deaths due to (1) opioids only, opioids in combination with any other substance, all-opioid related overdoses; (2) combinations of opioids and alcohol, opioids and methamphetamine, opioids and cocaine, opioids and benzodiazepines; and (3) specific types of opioids. RESULTS: From 1999 to 2019, opioid-only mortality rates increased from 2.8 to 15.8 per 100 000 (p<0.001) for AI/AN women and 4.6 to 25.6 per 100 000 (p<0.001) for AI/AN men. All opioid-related mortality rates increased significantly (p<0.001) from 5.2 to 33.9 per 100 000 AI/AN persons, 3.9 to 26.1 for women and 6.5 to 42.1 for men. AI/AN also exhibited significant increases in mortality rates due to opioids and alcohol, opioids and benzodiazepines, opioids and methamphetamine, and AI/AN men experienced substantial increases in mortality due to opioids and cocaine. Mortality rates by individual opioid types increased significantly over time for heroin, natural and semi-synthetic (prescription), and synthetic opioids (fentanyl/fentanyl analogues) other than methadone. CONCLUSIONS: These findings highlight magnification over time in opioid-related deaths and may point to broader systemic factors that may disproportionately affect members of AI/AN communities and drive inequities.

Associations between discrimination and substance use among college students in the United States from 2015 to 2019.

Discrimination has been associated with adverse health behaviors and outcomes, including substance use. Higher rates of substance use are reported among some marginalized groups, such as lesbian, gay, and bisexual populations, and have been partially attributed to discrimination. This study uses 2015-2019 National College Health Assessment data to determine whether college students reporting discrimination due to sexual orientation, race/ethnicity, gender, or age report greater substance use than their peers who do not report such experiences. Additionally, we assess exploratory questions regarding whether substance choices differ among students who reported facing discrimination. Over time, about 8.0% of students reported experiencing discrimination in the past year. After applying inverse probability treatment weights (IPTWs), exposure to discrimination was associated with an excess of 44 cases of marijuana use per 1000 students, an excess of 39 cases of alcohol use per 1000 students, and an excess of 11 cases of prescription painkiller use per 1000 students. Multivariable logistic regression models with IPTW demonstrated that students who experienced discrimination were more than twice as likely to use inhalants and methamphetamine. These students were also significantly more likely to use other drugs, including opiates, non-prescribed painkillers, marijuana, alcohol, hallucinogens, cocaine, and cigarettes; however, the differences with peers were smaller in magnitude. Students who experienced discrimination did not differ from peers who reported non-prescribed antidepressants use and were significantly less likely to use e-cigarettes and smokeless tobacco. Associations between discrimination and substance use vary by race, gender, sexual orientation, and age. These findings indicate that discrimination has significant associations with many kinds of substance use; however, the magnitude varies by substance type. More institutional efforts to address sources of discrimination affecting college students are needed.

Trends in the Use of Naltrexone for Addiction Treatment among Alcohol Use Disorder Admissions in U.S. Substance Use Treatment Facilities.

BACKGROUND: Naltrexone, a medication for addiction treatment (MAT), is an FDA-approved medication recommended for the treatment of alcohol use disorder (AUD). Despite the high prevalence of AUD and efficacy of naltrexone, only a small percentage of individuals with AUD receive treatment. OBJECTIVES: To identify trends for the prescription of naltrexone in AUD admissions in substance use treatment centers across the U.S. METHODS: Data from the 2000-2018 U.S. Treatment Episode Data Set: Admissions (TEDS-A) were used in temporal trend analysis of naltrexone prescription in admissions that only used alcohol. Data from the 2019 National Survey of Substance Abuse Treatment Services (N-SSATS) were also used to characterize medication use among AUD clients across different treatment service settings. RESULTS: Treatment of AUD with naltrexone was 0.49% in 2000 and tripled from 0.53% in 2015 to 1.64% in 2018 in AUD admissions (p < 0.0001 for the Cochran-Armitage trend test). Women, middle-aged adults, and admissions for clients living in the Northeast U.S. were more likely to be prescribed naltrexone than their respective counterparts, as were admissions with prior treatment episodes and referrals through alcohol/drug use care providers, who paid for treatment primarily through private insurance, used alcohol daily in the month prior to admission, and waited 1-7 days to enter treatment. Naltrexone was more commonly prescribed by AUD admissions compared to acamprosate and disulfiram and was more frequently prescribed in residential and outpatient services as opposed to hospital inpatient services. CONCLUSIONS: Naltrexone remains underutilized for AUD, and factors that influence prescription of medication are multifaceted. This study may contribute to the creation of effective interventions aimed at reducing naltrexone disparities for AUD.

Associations between opioid misuse and social relationship factors among American Indian, Alaska Native, and Native Hawaiian college students in the U.S.

BACKGROUND: Despite declining overall rates of opioid misuse among college students, racial and ethnic differences in percentage and correlates of opioid misuse among student populations remains unclear. This study seeks to estimate percentages of opioid misuse among American Indian, Alaska Native, and Native Hawaiian (AI/AN/NH) college students and determine whether problems in social bonds affect AI/AN/NH opioid misuse. METHODS: Guided by social relationship factors associated with substance use in the Social Development Model, we used 2015-2019 data from the American College Health Association-National College Health Assessment survey in multivariable logistic regression models to examine the role of social bonds with peers and family in opioid misuse (prescription and non-prescription) among AI/AN/NH college students across the U.S. RESULTS: The percentage of opioid misuse was highest among AI/AN/NH college students (7.12 %) relative to other race/ethnicity groups. AI/AN/NH college students who reported experiencing loneliness (aOR: 1.68; 95 % CI 1.33-2.12; P < .0001), difficult social relationships (aOR: 1.27; 95 % CI 1.04-1.55; P = 0.0196), family problems (aOR: 1.32; 95 % CI 1.07-1.63; P = 0.0097), and intimate partner violence (aOR: 1.92; 95 % CI 1.56-2.36; P < .0001) were significantly more likely to misuse opioids than students who did not report experiencing these relationship problems. CONCLUSIONS: Relationship problems with peers and family increase AI/AN/NH college student risk for opioid misuse, indicating opportunities for colleges to support programs addressing healthy social relationships as a means to reduce opioid misuse among AI/AN/NH students.