Katherine A. McDermott

Long-term outcomes from the National Drug Abuse Treatment Clinical Trials Network Prescription Opioid Addiction Treatment Study

BACKGROUND Despite the growing prevalence of prescription opioid dependence, longitudinal studies have not examined long-term treatment response. The current study examined outcomes over 42 months in the Prescription Opioid Addiction Treatment Study (POATS). METHODS POATS was a multi-site clinical trial lasting up to 9 months, examining different durations of buprenorphine-naloxone plus standard medical management for prescription opioid dependence, with participants randomized to receive or not receive additional opioid drug counseling. A subset of participants (N=375 of 653) enrolled in a follow-up study. Telephone interviews were administered approximately 18, 30, and 42 months after main-trial enrollment. Comparison of baseline characteristics by follow-up participation suggested few differences. RESULTS At Month 42, much improvement was seen: 31.7% were abstinent from opioids and not on agonist therapy; 29.4% were receiving opioid agonist therapy, but met no symptom criteria for current opioid dependence; 7.5% were using illicit opioids while on agonist therapy; and the remaining 31.4% were using opioids without agonist therapy. Participants reporting a lifetime history of heroin use at baseline were more likely to meet DSM-IV criteria for opioid dependence at Month 42 (OR=4.56, 95% CI=1.29-16.04, p<.05). Engagement in agonist therapy was associated with a greater likelihood of illicit-opioid abstinence. Eight percent (n=27/338) used heroin for the first time during follow-up; 10.1% reported first-time injection heroin use. CONCLUSIONS Long-term outcomes for those dependent on prescription opioids demonstrated clear improvement from baseline. However, a subset exhibited a worsening course, by initiating heroin use and/or injection opioid use.

Identifying Patients With Problematic Drug Use in the Emergency Department: Results of a Multisite Study

STUDY OBJECTIVE Drug-related emergency department (ED) visits have steadily increased, with substance users relying heavily on the ED for medical care. The present study aims to identify clinical correlates of problematic drug use that would facilitate identification of ED patients in need of substance use treatment. METHODS Using previously validated tests, 15,224 adult ED patients across 6 academic institutions were prescreened for drug use as part of a large randomized prospective trial. Data for 3,240 participants who reported drug use in the past 30 days were included. Self-reported variables related to demographics, substance use, and ED visit were examined to determine their correlative value for problematic drug use. RESULTS Of the 3,240 patients, 2,084 (64.3%) met criteria for problematic drug use (Drug Abuse Screening Test score ≥ 3). Age greater than or equal to 30 years, tobacco smoking, daily or binge alcohol drinking, daily drug use, primary noncannabis drug use, resource-intense ED triage level, and perceived drug-relatedness of ED visit were highly correlated with problematic drug use. Among primary cannabis users, correlates of problematic drug use were age younger than 30 years, tobacco smoking, binge drinking, daily drug use, and perceived relatedness of the ED visit to drug use. CONCLUSION Clinical correlates of drug use problems may assist the identification of ED patients who would benefit from comprehensive screening, intervention, and referral to treatment. A clinical decision rule is proposed. The correlation between problematic drug use and resource-intense ED triage levels suggests that ED-based efforts to reduce the unmet need for substance use treatment may help decrease overall health care costs.

Longitudinal association between pain severity and subsequent opioid use in prescription opioid dependent patients with chronic pain

BACKGROUND Patients with prescription opioid use disorder commonly report relief of chronic pain as the chief reason for first opioid use; indeed, the prevalence of chronic pain is high in this population. Understanding the association between pain severity and subsequent opioid use is crucial for understanding how to manage these conditions simultaneously and has not been examined in this population. The aim of this analysis was to examine the proximal effect of pain severity on opioid use during 12 weeks of buprenorphine-naloxone therapy for patients with chronic pain and prescription opioid use disorder. METHODS This study is a secondary analysis of a national, randomized, controlled trial of buprenorphine-naloxone plus counseling for prescription opioid dependent patients. The association between past-week pain severity and opioid use in the subsequent week was examined in 148 patients presenting with chronic pain at baseline. RESULTS Results from a multivariable logistic regression model showed that greater pain severity in a given week was significantly associated with increased odds of opioid use in the following week over the 12-week treatment, even after adjusting for covariates associated with opioid use (aOR=1.15, p<0.001). CONCLUSIONS Despite previous reports of no association between baseline pain and subsequent opioid use, our findings suggest that patients who experience flare-ups of pain during treatment are prone to relapse to opioid use. Future studies may identify those who are at risk to use opioids by carefully monitoring patterns of their pain intensity over time.

Initial response as a predictor of 12-week buprenorphine-naloxone treatment response in a prescription opioid-dependent population.

OBJECTIVE Initial medication response has been shown to predict treatment outcome across a variety of substance use disorders, but no studies have examined the predictive power of initial response to buprenorphine-naloxone in the treatment of prescription opioid dependence. We therefore conducted a secondary analysis of data from the Prescription Opioid Addiction Treatment Study to determine whether initial response to buprenorphine-naloxone predicted 12-week treatment outcome in a prescription opioid-dependent population. METHOD Using data from a multisite, randomized controlled trial of buprenorphine-naloxone plus counseling for DSM-IV prescription opioid dependence (June 2006-July 2009), we conducted a secondary analysis to investigate the relationship between initial medication response and 12-week treatment outcome to establish how soon the efficacy of buprenorphine-naloxone could be predicted (N = 360). Outcomes were determined from the Substance Use Report, a self-report measure of substance use, and confirmatory urinalysis. Predictive values were calculated to determine the importance of abstinence versus use at various time points within the first month of treatment (week 1, weeks 1-2, 1-3, or 1-4) in predicting successful versus unsuccessful treatment outcome (based on abstinence or near-abstinence from opioids) in the last 4 weeks of buprenorphine-naloxone treatment (weeks 9-12). RESULTS Outcome was best predicted by medication response after 2 weeks of treatment. Two weeks of initial abstinence was moderately predictive of treatment success (positive predictive value = 71%), while opioid use in both of the first 2 weeks was strongly predictive of unsuccessful treatment outcome (negative predictive value [NPV] = 84%), especially when successful outcome was defined as total abstinence from opioids in weeks 9-12 (NPV = 94%). CONCLUSIONS Evaluating prescription opioid-dependent patients after 2 weeks of buprenorphine-naloxone treatment may help determine the likelihood of successful outcome at completion of the current treatment regimen. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00316277.

Denial of urinalysis-confirmed opioid use in prescription opioid dependence

Although research has generally supported the validity of substance use self-reports, some patients deny urine-verified substance use. We examined the prevalence and patterns of denying urinalysis-confirmed opioid use in a sample of prescription opioid dependent patients. We also identified characteristics associated with denial in this population of increasing public health concern. Opioid use self-reports were compared with weekly urinalysis results in a 12-week multi-site treatment study for prescription opioid dependence. Among those who used opioids during the trial (n=246/360), 44.3% (n=109) denied urinalysis-confirmed opioid use, although usually only once (78%). Overall, 22.9% of opioid-positive urine tests (149/650) were denied on self-report. Multivariable analysis found that initially using opioids to relieve pain was associated with denying opioid use. These findings support the use of both self-reports and urine testing in treating prescription opioid dependence.

Prevalence of restless legs syndrome during detoxification from alcohol and opioids

BACKGROUND AND AIMS Restless legs syndrome (RLS) is a movement disorder associated with adverse health outcomes and decreased quality of life. Small case series suggest that symptoms of RLS occur during opioid withdrawal. However, the prevalence is unknown. METHODS We conducted an observational study to determine the prevalence of RLS among inpatients patients receiving buprenorphine detoxification from opioids. To assess the specificity of RLS to opioid detoxification, we also evaluated patients receiving detoxification from alcohol as a comparison group. The diagnosis of RLS was established using a validated questionnaire. RESULTS The sample consisted of 124 adults with primary opioid use disorder and 180 with primary alcohol use disorder. In the total sample, 33.6% met a likely RLS diagnosis: 50.8% of those with opioid use disorder and 21.7% of those with alcohol use disorder (χ2 = 27.96[1,304] p < .001). In the logistic regression analysis controlling for socio-demographic and clinical variables, diagnosis of opioid use disorder was associated with more than twice the likelihood of RLS diagnosis (OR=2.05, 95% CI 1.09-3.88) relative to diagnosis of alcohol use disorder. CONCLUSIONS Approximately half of patients undergoing inpatient opioid detoxification exhibited the symptoms characteristic of RLS. We believe that these data support the existence of a secondary form of RLS associated with opioid withdrawal.

Grit in patients with substance use disorders

BACKGROUND AND OBJECTIVES Grit is an emerging concept in positive psychology, defined as the ability to be persistent and focused in pursuit of long-term goals. This concept has received a great deal of interest recently because of its robust ability to predict success and well-being across a wide variety of domains. The study aim was to examine the clinical relevance of the construct of grit among patients with substance use disorders. METHODS Inpatients on a detoxification unit were enrolled from September 2013 to August 2015 (N = 673). Psychometric properties of the Short Grit Scale (Grit-S) were reported. We then examined sociodemographic and clinical variables that might be associated with grit in this population. RESULTS In this sample of patients with substance use disorders, the total Grit-S demonstrated strong psychometric properties. Grit-S scores were higher among older patients and those who were employed; scores were lower among those never married, diagnosed with a co-occurring psychiatric disorder, or who had used heroin during the past month, according to bivariate analyses. Grit-S scores remained associated with age, employment, and presence of a co-occurring psychiatric disorder in adjusted analysis. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE This study provides initial support for the utility of the Grit-S among those with substance use disorders; this novel measure has not been previously reported in clinical populations. Research examining grit prospectively is needed to determine whether the links between grit and outcomes observed in other populations apply to patients with substance use disorders. (Am J Addict 2016;25:652-658).

Distress Intolerance Moderation of Attention to Emotion: An Eye-Tracking Study

Distress intolerance (DI) is an important individual difference reflective of the inability to endure aversive affective states and is relevant to multiple clinical populations, but underlying emotional processing mechanisms remain unclear. The current study used eye-tracking to examine biased attention towards emotional stimuli at baseline and in the context of acute stress in a non-clinical sample (N = 165). We hypothesized that DI would incrementally predict greater stressor-elicited increases in sustained/delayed disengagement, but not initial orientation/facilitated engagement negative (i.e., threat, dysphoric) attention biases, and that DI’s association with maladaptive stress regulation would depend on these increases. Partially consistent with predictions, DI was only independently associated with stressor-elicited increases in sustained negative bias and, unexpectedly, decreases in sustained positive bias. Further, DI and change in sustained threat bias marginally interacted to predict cardiovascular but not subjective anxious mood recovery. Theoretical implications are discussed.

“Not just right” experiences account for unique variance in eating pathology

ABSTRACT “Not just right” experiences (NJREs) are uncomfortable sensations of incompleteness linked to obsessive–compulsive disorder; however, NJREs may be transdiagnostic and play a role in eating pathology. The current study examined relations between NJREs and eating pathology in undergraduate students. Participants (n = 248) completed self-report and behavioral assessments. Controlling for obsessive–compulsive symptoms, negative affect, and perfectionism, NJRE frequency was associated with greater drive for thinness, body dissatisfaction, and bulimic symptoms. Discomfort in response to a visual in vivo NJRE task was positively associated with drive for thinness and body dissatisfaction. The present study provides initial evidence for NJREs in eating pathology. Theoretical implications are discussed.

Pain interference and alcohol, nicotine, and cannabis use disorder in a national sample of substance users.

BACKGROUND Pain interference is associated with substance use, but has yet to be considered as a potential indicator of SUDs among substance users. We sought to examine whether moderate and high pain interference would confer risk for SUDs in ever and weekly users. METHODS Using data from the National Epidemiologic Survey on Alcohol and Related Conditions, logistic regression analyses were conducted to examine the association between pain interference and concurrent and prospective alcohol and nicotine dependence, as well as concurrent cannabis use disorder. Those with no/low pain were used as the reference group. Gender was examined as a moderator. RESULTS Controlling for relevant covariates, moderate pain interference was associated with past year alcohol (odds ratio [OR] = 1.33, 95% CI, 1.16-1.52, p < .001) and nicotine (OR = 1.41, 95% CI 1.27-1.56, p < .001) dependence among ever users. In prospective analyses, moderate pain interference predicted the development of alcohol (Moderate: OR = 1.56, 95% CI, 1.39-1.75, p < .001) and nicotine (OR = 1.37, 95% CI, 1.14-1.65, p < .001) dependence. Similar results were found with high pain and for weekly users. Both moderate and high pain interference were associated with past-year occurrence of cannabis use disorder for women but not men. High pain predicted the development of nicotine dependence exclusively among males. CONCLUSION Pain interference may confer risk for the occurrence of cannabis use disorder among female cannabis users and the occurrence and development of alcohol and nicotine dependence among users of both genders. Pain interference may be an important factor to monitor in these populations.