Addressing opioid overdose deaths: The vision for the HEALing communities study.

The United States is facing two devastating public health crises- the opioid epidemic and the COVID-19 pandemic. Within this context, one of the most ambitious implementation studies in addiction research is moving forward. Launched in May 2019, the HEALing Communities Study (HCS) was developed by the National Institutes of Health (NIH) and the Substance Abuse and Mental Health Services Administration (SAMHSA) as part of the Helping to End Addiction Long-termSM Initiative (National Institutes of Health, 2020). The goal for this research was to reduce opioid overdose deaths by 40 % in three years by enhancing and integrating the delivery of multiple evidence-based practices (EBPs) with proven effectiveness in reducing opioid overdose deaths across health care, justice, and community settings. This paper describes the initial vision, goals, and objectives of this initiative; the impact of COVID-19; and the potential for knowledge to be generated from HCS at the intersection of an unrelenting epidemic of opioid misuse and overdoses and the ravishing COVID-19 pandemic.

Adolescent treatment admissions for marijuana following recreational legalization in Colorado and Washington.

INTRODUCTION: There is concern that recreational marijuana legalization (RML) may lead to increased cannabis use disorder (CUD) among youth due to increased marijuana use. This study investigates whether adolescent substance use disorder treatment admissions for marijuana use increased in Colorado and Washington following RML. METHODS: Annual data on 2008-2017 treatment admissions for marijuana use from the SAMHSA TEDS-A dataset for adolescents age 12-17 were used to model state treatment admissions trends. Difference-in-differences models were used to investigate whether treatment admissions increased following RML in Colorado/Washington compared to non-RML states, after adjusting for socioeconomic characteristics and treatment availability. RESULTS: Over all states in the analysis, the rate of adolescent treatment admissions for marijuana use declined significantly over the study period (ß=-3.375, 95 % CI=-4.842, -1.907), with the mean rate falling nearly in half. The decline in admissions rate was greater in Colorado and Washington compared to non-RML states following RML, though this difference was not significant (ß=-7.671, 95 % CI=-38.798, 23.456). CONCLUSION: Adolescent treatment admissions for marijuana use did not increase in Colorado and Washington following RML. This may be because youth marijuana use did not increase, CUD did not increase (even if use did increase), or treatment seeking behaviors changed due to shifts in attitudes and perceptions of risk towards marijuana use.

Cognitive and Behavioral Impact on Children Exposed to Opioids During Pregnancy.

The developmental impact of opioid use during pregnancy is a subject of ongoing debate. Short-term neonatal outcomes, such as lower birth weight and neonatal abstinence syndrome, are the most well-recognized outcomes. However, knowledge gaps exist regarding longer-term neurocognitive and mental health outcomes. In this article, we summarize an expert panel discussion that was held in April 2018 by the Substance Abuse and Mental Health Services Administration and attended by national experts in the field of perinatal opioid exposure and its impact on child development. Despite the challenges with research in this area, there is emerging literature revealing an association between neonates exposed to opioids in utero and longer-term adverse neurocognitive, behavioral, and developmental outcomes. Although adverse sequalae may not be apparent in the neonatal period, they may become more salient as children develop and reach preschool and school age. Multiple variables (genetic, environmental, and biological) result in a highly complex picture. The next steps and strategies to support families impacted by opioid use disorder are explored. Model programs are also considered, including integrated care for the child and mother, parenting supports, and augmentations to home visiting.

Prescription drug use, misuse and related substance use disorder symptoms vary by educational status and attainment in U.S. adolescents and young adults.

BACKGROUND: Prescription drug misuse (PDM) rates are highest in adolescents and young adults. Little research in these high-risk groups has examined PDM differences by educational status or attainment. This investigation attempted to further our understanding of adolescent and young adult prescription drug use and misuse through examining PDM type (i.e., nonmedical misuse, medical misuse and mixed misuse) and substance use disorder (SUD) symptoms from PDM by educational status/attainment. METHODS: Data were from the 2015 National Survey on Drug Use and Health, with 13,585 adolescent and 14,553 young adult respondents. Participants were categorized by educational status separately in adolescents and young adults. Outcomes were rates of past-year prescription drug use, PDM, PDM type, and SUD symptoms, with analyses performed separately by age group and for opioids, stimulants and sedatives/tranquilizers. Analyses used logistic regression and controlled for age, race/ethnicity and sex. RESULTS: In adolescents and across medication classes, the highest rates of any use, PDM, medical misuse, nonmedical misuse and presence of two or more SUD symptoms were seen in those with poor school adjustment or not in school. In young adults, opioid-PDM and related outcomes were more prevalent in those not in school, especially high school dropouts. For stimulants, rates were highest in full-time college students and college graduates. CONCLUSIONS: These results further suggest the importance of assessing educational status in adolescent and educational attainment in young adult PDM investigations. Adolescents poorly engaged in school or not in school appear especially in need of interventions to limit PDM and associated SUD symptoms.

Internet searches for opioids predict future emergency department heroin admissions.

BACKGROUND: For a number of fiscal and practical reasons, data on heroin use have been of poor quality, which has hampered the ability to halt the growing epidemic. Internet search data, such as those made available by Google Trends, have been used as a low-cost, real-time data source for monitoring and predicting a variety of public health outcomes. We aimed to determine whether data on opioid-related internet searches might predict future heroin-related admissions to emergency departments (ED). METHODS: Across nine metropolitan statistical areas (MSAs) in the United States, we obtained data on Google searches for prescription and non-prescription opioids, as well as Substance Abuse and Mental Health Services Administration (SAMHSA) data on heroin-related ED visits from 2004 to 2011. A linear mixed model assessed the relationship between opioid-related Internet searches and following year heroin-related visits, controlling for MSA GINI index and total number of ED visits. RESULTS: The best-fitting model explained 72% of the variance in heroin-related ED visits. The final model included the search keywords "Avinza," "Brown Sugar," "China White," "Codeine," "Kadian," "Methadone," and "Oxymorphone." We found regional differences in where and how people searched for opioid-related information. CONCLUSIONS: Internet search-based modeling should be explored as a new source of insights for predicting heroin-related admissions. In geographic regions where no current heroin-related data exist, Internet search modeling might be a particularly valuable and inexpensive tool for estimating changing heroin use trends. We discuss the immediate implications for using this approach to assist in managing opioid-related morbidity and mortality in the United States.

Health insurance, alcohol and tobacco use among pregnant and non-pregnant women of reproductive age.

BACKGROUND: Understanding the relationship between health insurance coverage and tobacco and alcohol use among reproductive age women can provide important insight into the role of access to care in preventing tobacco and alcohol use among pregnant women and women planning to become pregnant. METHODS: We examined the association between health insurance coverage and both past month alcohol use and past month tobacco use in a nationally representative sample of women age 12-44 years old, by pregnancy status. The women (n=97,788) were participants in the National Survey of Drug Use and Health (NSDUH) in 2010-2013. Logistic regression models assessed the association between health insurance (insured versus uninsured), past month tobacco and alcohol use, and whether this was modified by pregnancy status. RESULTS: Pregnancy status significantly moderated the relationship between health insurance and tobacco use (p-value≤0.01) and alcohol use (p-value≤0.01). Among pregnant women, being insured was associated with lower odds of alcohol use (adjusted odds ratio [AOR]=0.47; 95% confidence interval [CI]=0.27-0.82), but not associated with tobacco use (AOR=1.14; 95% CI=0.73-1.76). Among non-pregnant women, being insured was associated with lower odds of tobacco use (AOR=0.67; 95% CI=0.63-0.72), but higher odds of alcohol use (AOR=1.23; 95% CI=1.15-1.32). CONCLUSION: Access to health care, via health insurance coverage is a promising method to help reduce alcohol use during pregnancy. However, despite health insurance coverage, tobacco use persists during pregnancy, suggesting missed opportunities for prevention during prenatal visits.

The Relationship Between Client Characteristics and Wraparound Services in Substance Use Disorder Treatment Centers.

OBJECTIVE: The National Institute on Drug Abuse (NIDA) recommends a comprehensive treatment program for individuals with substance use disorder (SUD) in order to treat needs they often have in addition to their SUD. Specifically, NIDA suggests providing services related to the following issues: medical care, mental health care, HIV/AIDS, child care, educational, vocational, family counseling, housing, transportation, financial, and legal. By providing a comprehensive model that combines core and wraparound services, treatment centers can deliver a higher quality of treatment. In this article, we assessed the relationship between client characteristics and the availability of wraparound services in SUD treatment centers. METHOD: We combined two nationally representative samples of treatment centers and used a negative binomial regression and a series of logistic regressions to analyze the relationship between client characteristics and wraparound services. RESULTS: On average, centers offered fewer than half of the wraparound services endorsed by NIDA. Our results indicated that client characteristics were significantly related to the provision of wraparound services. Most notably, the proportion of adolescent clients was positively related to educational services, the proportion of female clients was positively related to child care, but the proportion of clients referred from the criminal justice system was negatively associated with the provision of multiple wraparound services. CONCLUSIONS: Our findings have important implications for SUD clients and suggest that, although centers are somewhat responsive to their clients' ancillary needs, most centers do not offer the majority of wraparound services.

Converging Patterns of Alcohol Use and Related Outcomes Among Females and Males in the United States, 2002 to 2012.

BACKGROUND: Females in the United States consume less alcohol and cause and experience fewer alcohol-related harms than males. However, recent research suggests such gaps might be narrowing. The purpose of this study was to explore changes in alcohol use and associated outcomes among females and males in the United States between 2002 and 2012. METHODS: Data from the National Survey on Drug Use and Health were used to assess the prevalence and trends for females and males aged 12+ in lifetime abstinence, age of onset, current drinking, binge drinking, drinking and driving, reaching DSM-IV criteria for an alcohol use disorder, combining alcohol with other drugs such as marijuana, and other variables. Of particular interest was whether differences between females and males narrowed during the decade under study. RESULTS: Differences in the drinking patterns of females and males aged 12+ narrowed between 2002 and 2012 for current drinking, number of drinking days per month, past year DSM-IV alcohol abuse, and past-year driving under the influence of alcohol. In addition, convergence was noted in 1 or more age subgroups for the prevalence of binge drinking and DSM-IV alcohol dependence and mean age at drinking onset. Divergence in drinking habits did not occur for any measure in any age subgroups with the exception of a greater increase in the prevalence of combining alcohol with marijuana among young adult male drinkers than female drinkers aged 18 to 25. CONCLUSIONS: Between 2002 and 2012, differences in alcohol consumption and related outcomes narrowed for females and males. Reasons for converging patterns of alcohol use are unclear and do not appear to be easily explainable by recent trends in employment status, pregnancy status, or marital status. More research is needed to identify the psychosocial and environmental contributors to these changes and to assess implications for prevention and treatment efforts.

Dissemination, adoption, and implementation of acamprosate for treating alcohol use disorders.

OBJECTIVE: Acamprosate has been available in the United States for treating alcohol use disorders (AUDs) for nearly a decade, yet few studies have examined its use within AUD treatment organizations. In addition to describing dissemination and adoption of acamprosate, this study provides novel data regarding organizational processes that underlie its implementation within adopting programs. METHOD: Data were drawn from interviews with leaders of a nationally representative sample of 307 organizations delivering AUD treatment. Quantitative indicators of organizational characteristics, dissemination, adoption, and implementation of acamprosate, as well as qualitative measures of implementation processes, were measured during face-to-face interviews. RESULTS: Only 18.0% (n = 55) of sampled organizations had adopted acamprosate for treating AUDs, and adoption was positively associated with accreditation, having a physician on staff, receiving information about acamprosate via pharmaceutical representatives, and learning about this medication from other treatment providers. Within adopting programs, an average of 6.0% of AUD patients were currently receiving acamprosate. Numerous implementation challenges were identified, including appropriate patient selection, patient reluctance to be prescribed acamprosate, suboptimal adherence, its costs, and limited counselor training. CONCLUSIONS: The limited adoption and implementation of acamprosate likely limits the potential public health impact of this adjunct to AUD treatment. Research integrating the perspectives of organizational leaders, medical professionals, and patients is needed to determine whether specific strategies can address the implementation challenges identified in the current study and increase use of acamprosate in specialty AUD treatment settings.

How the states stack up: disparities in substance abuse outpatient treatment completion rates for minorities.

BACKGROUND: This study was an exploratory investigation of state-level minority disparities in successfully completing outpatient treatment, a major objective for attending substance abuse treatment and a known process outcome measure. METHOD: This was a retrospective analysis of state discharge and admission data from the 2006 to 2008 Treatment Episode Datasets-Discharge (TEDS-D). Data were included representing all discharges from outpatient substance abuse treatment centers across the United States. All first treatment episode clients with admission/discharge records meeting inclusion criteria who could be classified as White, Latino, or Black/African American were used (n=940,058). RESULTS: States demonstrated racial and ethnic disparities in their crude and adjusted completion rates, which also varied considerably among the states. Minorities typically showed a disadvantage. A few states showed significantly higher completion rates for Blacks or Latinos. CONCLUSIONS: Realistically, a variety of factors likely cause the state race/ethnic differences in successful completion rates. States should investigate their delivery systems to reduce completion disparities.

Trends in substance abuse treatment 1998-2008: increasing older adult first-time admissions for illicit drugs.

OBJECTIVES: To see whether the percentage of older adults entering substance abuse treatment for their first time was increasing and whether there were changes in the use patterns leading to the treatment episode, particularly an increase in illicit drugs. SETTING: The Treatment Episode Data Sets publicly available from the Substance Abuse Mental Health Services Administration from 1998 to 2008. PARTICIPANTS: Young adults age 30-54 years as a comparison group (N = 3,547,733) and those age 55 years or older (N = 258,542) with a first-time admission for a publicly funded substance abuse treatment. MEASUREMENTS: Demographic and substance use history variables at admission. RESULT: The proportion of older adults going for substance abuse treatment for the first time is increasing relative to younger adults. The pattern of drug use is also changing, with an increasing illicit drug involvement (cocaine and heroin) in older adult admissions. CONCLUSIONS: We know little of these long-time users, their current medical state, cognitive abilities, and psychiatric symptoms after such a long exposure time. Previous studies on heroin and cocaine exposure focused on individuals identified much earlier in life, and the aging long-term users might represent a relatively large but unknown population.