Substance use patterns, sociodemographics, and health profiles of harm reduction service recipients in Burlington, Vermont.

BACKGROUND: Understanding current substance use practices is critical to reduce and prevent overdose deaths among individuals at increased risk including persons who use and inject drugs. Because individuals participating in harm reduction and syringe service programs are actively using drugs and vary in treatment participation, information on their current drug use and preferred drugs provides a unique window into the drug use ecology of communities that can inform future intervention services and treatment provision. METHODS: Between March and June 2023, 150 participants in a harm reduction program in Burlington, Vermont completed a survey examining sociodemographics; treatment and medication for opioid use disorder (MOUD) status; substance use; injection information; overdose information; and mental health, medical, and health information. Descriptive analyses assessed overall findings. Comparisons between primary drug subgroups (stimulants, opioids, stimulants-opioids) of past-three-month drug use and treatment participation were analyzed using chi-square and Fisher's exact test. RESULTS: Most participants reported being unhoused or unstable housing (80.7%) and unemployed (64.0%) or on disability (21.3%). The drug with the greatest proportion of participants reporting past three-month use was crack cocaine (83.3%). Fentanyl use was reported by 69.3% of participants and xylazine by 38.0% of participants. High rates of stimulant use were reported across all participants independent of whether stimulants were a participant's primary drug. Fentanyl, heroin, and xylazine use was less common in the stimulants subgroup compared to opioid-containing subgroups (p < .001). Current- and past-year MOUD treatment was reported by 58.0% and 77.3% of participants. Emergency rooms were the most common past-year medical treatment location (48.7%; M = 2.72 visits). CONCLUSIONS: Findings indicate high rates of polysubstance use and the underrecognized effects of stimulant use among people who use drugs-including its notable and increasing role in drug-overdose deaths. Crack cocaine was the most used stimulant, a geographical difference from much of the US where methamphetamine is most common. With the increasing prevalence of fentanyl-adulterated stimulants and differences in opioid use observed between subgroups, these findings highlight the importance and necessity of harm reduction interventions (e.g., drug checking services, fentanyl test strips) and effective treatment for individuals using stimulants alongside MOUD treatment.

A call to action: Contingency management to improve post-release treatment engagement among people with opioid use disorder who are incarcerated.

People with opioid use disorder (OUD) are overrepresented in US correctional facilities and experience disproportionately high risk for illicit opioid use and overdose after release. A growing number of correctional facilities offer medication for OUD (MOUD), which is effective in reducing these risks. However, a recent evaluation found that <50% of those prescribed MOUD during incarceration continued MOUD within 30 days after release, demonstrating a need to improve post-release continuity of care. We describe available evidence on contingency management (CM), an intervention wherein patients receive incentives contingent on behavior change, to achieve this goal. A prior systematic review reported strong evidence in support of CM for increasing treatment adherence in MOUD programs, but the trials reviewed did not include incarcerated participants. Research on CM to increase treatment adherence among participants in the criminal justice system is limited with mixed findings. However, in comparison to the trials that supported CM's efficacy in the community, CM trials in the criminal justice system provided smaller rewards with greater delays in the delivery of rewards to patients, which likely contributed to null findings. Indeed, a prior meta-analysis demonstrates a dose-response relationship between the magnitude and immediacy of reward and CM effectiveness. Thus, CM involving larger and more immediately delivered rewards are likely necessary to improve MOUD adherence during the critical period following release from incarceration. Future research on the effectiveness and implementation of CM to improve MOUD retention after release from incarceration is warranted.

The fourth wave of the overdose crisis: Examining the prominent role of psychomotor stimulants with and without fentanyl.

The current overdose and broader public health crisis involving illicit drug use is often referred to as the "opioid" or "fentanyl" crisis. Clearly there is extensive data on the profound damage done by opioids over the past 20 years and specifically by fentanyl in the past 5 years. However, there is an extensive array of data that suggests there is more to the current crisis than opioids/fentanyl. Much recent evidence indicates that methamphetamine and cocaine are playing a substantial and increasing role in the illicit drug crisis in the US-the 4th wave. This paper reviews data that illustrate the role of psychomotor stimulants in fatal overdoses, nonfatal overdoses, and emergency department visits. Despite the major detrimental role that stimulants are having on the public health in the US in 2023, there is virtually no evidence-based treatment available in practice for people with stimulant use disorder (StimUD). Although there are no medications with FDA-approval for the treatment of StimUD, there is a behavioral treatment, contingency management (CM), with over 3 decades of robust research supporting its efficacy for individuals with StimUD. Despite the overwhelming evidence supporting CM, it is not being widely used in routine treatment outside the VA healthcare system. This paper reviews some of the (a) evidence for CM, (b) CM protocol design elements that require consideration, (c) current obstacles to the widespread implementation of CM, and (d) strategies for addressing these obstacles. Overcoming these obstacles is a priority to allow routine use of CM as a treatment for StimUD.

Recovery incentives program: California's contingency management benefit.

OBJECTIVE: The role of methamphetamine and cocaine use in California's drug poisoning (overdose) crisis has dramatically increased in the past five (5) years and has disproportionately affected American Indian, Alaska Native, and Black Californians. No FDA-approved medications currently exist for the treatment of individuals with stimulant use disorder (StimUD). Outside the Veteran's Administration, the Recovery Incentives Program: California's Contingency Management Benefit is the first large scale implementation of contingency management (CM). CM is the behavioral treatment with the most evidence and largest effect sizes for StimUD. METHODS: The Program uses a CM protocol where participants can receive a maximum of $599 over a six-month period, contingent upon 36 stimulant-negative urine test results. Urine tests are conducted using a set of approved, CLIA-waived, point-of-care urine drug tests (UDTs). To ensure fidelity to the CM protocol and to prevent fraud, waste, and abuse, all aspects of incentive accounting and distribution are managed electronically via a custom-developed software system. Incentive distribution utilizes electronic gift cards. A significant innovation of the project is the conceptualization of the CM Coordinator, a designated and highly trained and supervised individual responsible for all aspects of CM operation in a specific site. RESULTS AND CONCLUSIONS: The California Department of Health Care Services contracted with UCLA to develop and implement a robust evaluation of the Program; goals include evaluating the effectiveness of real-world implementation and facilitating quality improvement. The project will likely significantly impact the use of CM for StimUD nationally and may well reduce stimulant-related drug poisoning deaths.

US state laws relevant to incentives for health behavior: A qualitative analysis.

Contingency management (CM) involves provision of incentives for positive health behaviors via a well-defined protocol and is among the most effective treatments for patients with substance use disorders (SUDs). An understanding of laws affecting incentives for health behaviors and outcomes, including contexts in which incentives are already permitted, could inform efforts to disseminate CM. We conducted a systematic NexisUni legal database review of state statutes and regulations effective during 2022 to identify (a) laws that explicitly permit or prohibit delivery of incentives to patients, employees, or insurance beneficiaries for SUD-specific behaviors or outcomes, and (b) laws that explicitly permit delivery of incentives for any health behaviors or outcomes. We identified 27 laws across 17 jurisdictions that explicitly permit delivery of incentives for SUD-related behaviors or outcomes, with most occurring in the context of wellness programs. No state laws were identified that explicitly prohibit SUD-specific incentives. More broadly, we identified 57 laws across 29 jurisdictions permitting incentives for any health outcomes (both SUD- and non-SUD-related). These laws occurred in the contexts of wellness programs, K-12/early childhood education, government public health promotion, and SUD treatment provider licensing. Considering the urgent need to expand evidence-based SUD treatment in rural and underserved areas throughout the US, these findings could inform efforts to develop laws explicitly permitting provision of incentives in SUD care and enhance efforts to disseminate CM more broadly.

The urgent need for contingency management among Tribal communities in the United States: Considerations for implementation, policy, and sovereignty.

In two randomized controlled trials, culturally adapted contingency management (i.e., incentives provided for substance-negative urine samples) was associated with reduced alcohol and drug use among geographically diverse American Indian and Alaska Native (AI/AN) adults. In response to interest in contingency management from other Tribal and AI/AN communities, our research team in collaboration with AI/AN behavioral health experts, translated the research into practice with new AI/AN community partners. Tenets of community-based participatory research were applied to develop, pilot, and refine contingency management training and implementation tools, and identify implementation challenges. In partnership with the AI/AN communities, four members of the university team developed tools and identified implementation and policy strategies to increase the successful uptake of contingency management in each location. Through our collaborative work, we identified policy barriers including inadequate federal funding of contingency management incentives and a need for further clarity regarding federal anti-kickback regulations. Adoption of contingency management is feasible and can strengthen Tribal communities' capacity to deliver evidence-based substance use disorder treatments to AI/AN people. Unfortunately, non-evidence-based limits to the use of federal funding for contingency management incentives discriminate against AI/AN communities. We recommend specific federal policy reforms, as well as other practical solutions for Tribal communities interested in contingency management.

Prescription opioid misuse in relation to addiction susceptibility among women at a Saudi university.

Objectives: The trends of prescription opioid misuse are understudied in Arab populations, let alone among university students. Additionally, little is known about the psychological traits that increase susceptibility for such behaviors in this region. Thus, this study aimed to assess the prevalence of prescription opioid misuse and its association with addiction susceptibility, as measured by the Substance Abuse Risk Profile Scale (SURPS). Methods: We sampled university students from King Saud University's women's campus. Data on prescription opioid misuse, SURPS traits, and demographic characteristics were collected using an electronic self-administered survey. Results: Lifetime prescription opioid misuse was 48.5%, while past-month misuse was 28.9%. On average, SURPS subscale scores for impulsivity (mean = 11.6; SD = 2.8) hopelessness (mean = 12.3; SD = 3.5), sensation seeking (mean = 16.4; SD = 3.8), and anxiety sensitivity (mean = 14.6; SD = 2.6). Anxiety sensitivity composite scores significantly differed between students reporting misuse and those who did not. Moreover, the odds for prescription opioid misuse increased by 7% for every 1 unit increase in anxiety sensitivity (AOR = 1.07; 95% CI = 1.00, 1.14), when controlling for other SURPS measures and student characteristics. Conclusion: The prevalence of prescription opioid misuse in our study is higher than what is reported in global student populations. This may reflect unmonitored availability of controlled substances and unsupervised medical prescriptions. Additionally, high levels of anxiety sensitivity may be driving such misuse. Further surveillance of prescription drug misuse among university students and motivators for such behavior is needed for planning prevention and control interventions.

Patient perceptions of treatment with medication treatment for opioid use disorder (MOUD) in the Vermont hub-and-spoke system.

In 2013, Vermont leaders implemented the "hub-and-spoke" (H & S) system to increase access to medication treatment for opioid use disorder (MOUD). "Hubs" are licensed specialty opioid treatment programs (OTPs) with the authority to dispense buprenorphine/naloxone and methadone. "Spokes" are primary care practices that provide office-based opioid treatment, primarily with buprenorphine/naloxone. This report describes the qualitative component of an evaluation of the H&S system, conducted in 2016. The qualitative data collection assessed patient perspectives about the positive and negative aspects of treatment in the H & S system. The data collected included 80 responses to five open-ended questions and 24 in-depth interviews. Five open-ended questions were completed with hub (n = 40) and spoke (n = 40) participants. In-depth qualitative interviews were conducted with different hub (n =12) and spoke (n =12) participants. Findings from both data collection approaches suggest positive perceptions about treatment overall by patients treated in both settings. Participants treated in spokes reported a positive treatment environment, minimal stigma, and few obstacles to treatment and a strong positive relationship with their prescriber. Hub patients valued the MOUD and expressed gratitude for having access to MOUD, but reported the treatment environment was somewhat challenging, with long lines and drug talk in the clinic, high staff turnover and "cookie cutter" treatment. There appear to be some differences in patient perceptions of MOUD treatment between patients treated in primary care settings and specialized OTP settings.

Cost-Effectiveness of Publicly Funded Treatment of Opioid Use Disorder in California.

Background: Only 1 in 5 of the nearly 2.4 million Americans with an opioid use disorder received treatment in 2015. Fewer than half of Californians who received treatment in 2014 received opioid agonist treatment (OAT), and regulations for admission to OAT in California are more stringent than federal regulations. Objective: To determine the cost-effectiveness of OAT for all treatment recipients compared with the observed standard of care for patients presenting with opioid use disorder to California's publicly funded treatment facilities. Design: Model-based cost-effectiveness analysis. Data Sources: Linked population-level administrative databases capturing treatment and criminal justice records for California (2006 to 2010); published literature. Target Population: Persons initially presenting for publicly funded treatment of opioid use disorder. Time Horizon: Lifetime. Perspective: Societal. Intervention: Immediate access to OAT with methadone for all treatment recipients compared with the observed standard of care (54.3% initiate opioid use disorder treatment with medically managed withdrawal). Outcome Measures: Discounted quality-adjusted life-years (QALYs) and discounted costs. Results of Base-Case Analysis: Immediate access to OAT for all treatment recipients costs less (by $78 257), with patients accumulating more QALYs (by 0.42) than with the observed standard of care. In a hypothetical scenario where all Californians starting treatment of opioid use disorder in 2014 had immediate access to OAT, total lifetime savings for this cohort could be as high as $3.8 billion. Results of Sensitivity Analysis: 99.6% of the 2000 simulations resulted in lower costs and more QALYs. Limitation: Nonrandomized delivery of OAT or medically managed withdrawal. Conclusion: The value of publicly funded treatment of opioid use disorder in California is maximized when OAT is delivered to all patients presenting for treatment, providing greater health benefits and cost savings than the observed standard of care. Primary Funding Source: National Institute on Drug Abuse.

Trends in Tramadol: Pharmacology, Metabolism, and Misuse.

Tramadol is a unique analgesic medication, available in variety of formulations, with both monoaminergic reuptake inhibitory and opioid receptor agonist activity increasingly prescribed worldwide as an alternative for high-affinity opioid medication in the treatment of acute and chronic pain. It is a prodrug that is metabolized by cytochrome P450 (CYP) enzymes CYP2D6 and CYP3A4 to its more potent opioid analgesic metabolites, particularly the O-demethylation product M1. The opioid analgesic potency of a given dose of tramadol is influenced by an individual's CYP genetics, with poor metabolizers experiencing little conversion to the active M1 opioid metabolite and individuals with a high metabolic profile, or ultra-metabolizers, experiencing the greatest opioid analgesic effects. The importance of the CYP metabolism has led to the adoption of computer clinical decision support with pharmacogenomics tools guiding tramadol treatment in major medical centers. Tramadol's simultaneous opioid agonist action and serotonin (5-HT) and norepinephrine reuptake inhibitory effects result in a unique side effect profile and important drug interactions that must be considered. Abrupt cessation of tramadol increases the risk for both opioid and serotonin-norepinephrine reuptake inhibitor withdrawal syndromes. This review provides updated important information on the pharmacology, pharmacokinetics, CYP genetic polymorphisms, drug interactions, toxicity, withdrawal, and illicit use of tramadol.

Interventions for the management of substance use disorders: an overview.

For the past 50 years, there has been a systematic effort to expand and improve treatment services for individuals with substance use disorders by developing an evidence base to guide practice. This policy brief aims to review the available interventions for the management of substance use disorders, examine the evidence base for these interventions, including the WHO Mental Health Gap Action Programme intervention guide, and make recommendations related to the treatment of substance use disorders. In the development of this policy brief, numerous documents were reviewed. The WHO Mental Health Gap Action Programme intervention guide offers the most well synthesized summary of interventions that have evidence of support, clinical acceptance, extensive implementation and expert consensus. The recommendations within this policy brief incorporate the core recommendations on substance use disorder elements included in the mhGAP intervention guide.

National Rehabilitation Center programme performance measures in the United Arab Emirates, 2013.

The aim of this study was to measure the performance of the National Rehabilitation Center (NRC) programme and the services it provides. A 6-point tool was developed based on international standards with appropriate performance measures. The elements of the tool were applied to the electronic data files for 2013. The results showed that there were some operational, quality and data system issues. Some items were easily accessible, e.g. capacity, waiting time, family involvement. Others were difficult to sort and find and some were not available in the electronic system and had to be retrieved from other sources, e.g. programme effectiveness. There was a high no-show rate for appointments (46%) and readmission rate (52%) and most families did not attend family sessions (72%). This was a valuable exercise which identified gaps in operations and records. The findings were shared with the different teams to help improve the quality of data and services and the tool will be used for annual performance evaluations.

A demonstration project implementing extended-release naltrexone in Los Angeles County.

BACKGROUND: Extended-released naltrexone (XR-NTX) is a Food and Drug Administration (FDA)-approved medication associated with higher rates of abstinence, reduced cravings, and delayed relapse to use. However, there is a dearth of literature on real-world implementation of XR-NTX. The Los Angeles County Department of Public Health, in collaboration with UCLA Integrated Substance Abuse Programs, developed a demonstration project to increase access to XR-NTX. This article describes that project, along with data on the expansion of XR-NTX service delivery and patient uptake. METHODS: A secondary descriptive data analysis of demographics, substance use history, current substance use behaviors, health-related variables, and dosing records was conducted on 609 patients who received XR-NTX from Los Angeles County substance use disorder (SUD) treatment facilities from April 2010 through July 2013. A geographic information system approach mapped the distribution of XR-NTX-referring agencies across Los Angeles County. RESULTS: Of the 609 records analyzed, a majority of patients (64%) obtained more than 1 dose of XR-NTX. Most XR-NTX patients reported alcohol use disorder (71.9%; n = 438). Compared with the general Los Angeles County substance use disorder patients, XR-NTX recipients reported more severe substance use histories. Finally, XR-NTX was accessed by providers in 6 of the 8 Service Planning Areas of Los Angeles County. CONCLUSIONS: These findings reflect a higher XR-NTX cessation rate and a lower average number of doses, in contrast to similar demonstration projects in community settings with patients on parole or probation. However, this study shows that it is feasible to engage treatment providers in the use XR-NTX among their patients with alcohol or opioid use disorders. Several implications for future research and implementation are discussed.

Predictors of depression outcomes among abstinent methamphetamine-dependent individuals exposed to an exercise intervention.

BACKGROUND AND OBJECTIVES: This paper expands on a study investigating depression outcomes in response to an 8-week exercise intervention among methamphetamine (MA) dependent individuals in early recovery. METHODS: A total of 135 MA-dependent individuals enrolled in residential treatment were randomly assigned to either a structured exercise intervention or a structured health education control group. Both groups were similar in format: 60-minute sessions, offered three times a week over an 8-week study period. RESULTS: Results showed that at the 8-week trial endpoint, participants randomized to the exercise intervention showed significantly greater reduction in depression symptom scores than participants randomized to the health education group, and that participants who attended the greatest number of exercise sessions derived the greatest benefit. This paper further analyzes study data to uncover individual predictors of depression response to exercise and finds that among participants randomized to exercise treatment, individuals with the most severe medical, psychiatric, and addiction disease burden at baseline showed the most significant improvement in depressive symptoms by study endpoint. CONCLUSIONS: Our findings suggest that exercise in moderate dose is effective at treating depressive symptoms in individuals in early recovery from addiction, and furthermore, that treatment with exercise appears to be particularly beneficial to individuals who suffer from severe medical, psychiatric, and addictive disorders.

Drug and alcohol use in Iraq: findings of the inaugural Iraqi Community Epidemiological Workgroup.

BACKGROUND: Reports suggest increased use of alcohol, prescription drugs, and illicit drugs in Iraq in the past decade, which may portend an increase in substance use disorders (SUDs) and, thus, an increased need for treatments. OBJECTIVES/METHODS: To develop better information on the nature and extent of drug and alcohol use in Iraq, the Iraqi Ministry of Health, with support from the US government and technical assistance from US researchers, held an initial Iraqi Community Epidemiology Work Group meeting in May 2012 in Baghdad. Drug seizure data were the primary data source, provided by Iraqi law enforcement and customs officials. Ministry of Health officials presented data from hospitals (medical and psychiatric), outpatient clinics, and health centers, as well as from surveys of medical patients, pharmacy patients, and prisoners. RESULTS: The data suggest that the most commonly used substances are alcohol, hashish, and prescription drugs. New drugs in Iraq's drug use scene include the amphetamine-type substances "Captagon" and crystal methamphetamine, and the painkiller tramadol. Seizures of Captagon, methamphetamine, Afghan opium, teriac (a crude form of opium), and heroin at border crossings may indicate that these substances are becoming more popular. A plan for an ongoing program of CEWG meetings was developed. CONCLUSIONS: Drug and alcohol use in Iraq is increasing and new drugs are appearing in the country. An ongoing program for monitoring drug use trends and informing Iraqi policy makers is important for public health planning, including the development of strategies to identify citizens with SUDs and provide them treatment.

Should contingency management protocols and dissemination practices be modified to accommodate rising stimulant use and harm reduction frameworks?

BACKGROUND: Stimulant-related overdoses have increased dramatically, with almost 50% of overdoses in the United States now involving stimulants. Additionally, harm-reduction approaches are increasingly seen as key to reducing the negative impact of substance use. Contingency management (CM), the provision of financial incentives for abstinence, is the most effective treatment for stimulant use disorder, but historically has not been widely implemented. Many recent, large-scale implementation efforts have relied upon foundational CM protocols that may not sufficiently account for recent increases in the prevalence and lethality of stimulant use nor the growing preference for harm reduction versus abstinence-only frameworks. ARGUMENT: We argue the need to (1) consider whether and how CM protocols might be modified to address rising stimulant use and harm reduction frameworks and (2) make CM widely accessible so that it can reduce population-level stimulant use while ensuring that it is delivered with fidelity to its basic principles. Proposed changes include changing CM reinforcement schedules to emphasize treatment engagement and reductions in use in addition to abstinence, changing guidelines on the duration of and re-engagement in CM, investing in research on virtual CM, incentivizing providers and health systems to deliver CM, making it easier to purchase and use point-of-care drug screens, using direct-to-consumer marketing to increase demand for CM and adapting CM to the community in which it is being implemented. CONCLUSIONS: Our proposed modifications to contingency management (CM) protocols and accessibility may more effectively address rising stimulant use and align CM more closely with harm-reduction frameworks. Given the urgent need to reduce overdose deaths, developing and testing modified CM protocols may need to rely upon methods other than randomized controlled trials. Efforts to disseminate CM widely to reduce population-level stimulant use must be balanced with the need to maintain fidelity to CM's basic principles.

An analysis of relapse prevention factors and their ability to predict sustained abstinence following treatment completion.

BACKGROUND & OBJECTIVES: This study assessed the role of 14 specific relapse-prevention activities and their underlying factors in maintaining abstinence among subjects (N = 302) completing outpatient treatment for stimulant dependence. METHODS: We examined what broader dimensions might subsume the 14 items constituting the Drug Avoidance Activities checklist (Farabee et al. J Subst Abuse Treat 2002;23:343-350), and how well these derived factors predicted concurrent drug use at baseline and again 3 and 12 months later. RESULTS: Although four factors were identified consistently for the three time points, only avoidance strategies had sufficient internal consistency to be retained for further analysis. Controlling for age, gender, and ethnicity, the avoidance subscale was a significant predictor of UA results at all time periods: a one-point increase in the avoidance strategies scale was associated with an 86% increase in odds of a negative UA at baseline (OR = 1.86, 95% CI = 1.37-2.53, p < .001), a 77% increase at 3-month follow-up (OR = 1.77, CI = 1.37-2.29, p < .001), and a 37% increase at 12-month follow-up (OR = 1.37, CI = 1.04-1.81, p = .026). CONCLUSIONS: Although correlations of individual items with UA results showed statistically significant (p < .05) results for 8 of 14 items at one or more observation points, avoidance-related behaviors showed the strongest associations with sustained abstinence.

Dissemination and implementation of cognitive behavioral therapy for stimulant dependence: a randomized trial comparison of 3 approaches.

BACKGROUND: This study evaluated the effectiveness of 3 approaches to transferring cognitive behavioral therapy (CBT) to addiction clinicians in the Republic of South Africa (RSA). METHODS: Clinicians (N = 143) were assigned to 3 training conditions: ( 1 ) an in vivo (IV) approach in which clinicians received in-person training and coaching; ( 2 ) a distance learning (DL) approach providing training via videoconference and coaching through teleconferencing; and ( 3 ) a control condition (C) providing a manual and 2-hour orientation. RESULTS: Frequency of use of CBT skills increased significantly with the IV and DL approaches compared with the C approach, and the IV approach facilitated greater use of CBT skills than the DL approach. During the active phase of the study, skill quality declined significantly for clinicians trained in the C condition, whereas those in the DL approach maintained skill quality and those in the IV approach improved skill quality. After coaching was discontinued, clinicians in the IV and DL approaches declined in skill quality. However, those in the IV approach maintained a higher level of skill quality compared with the other approaches. Cost of the IV condition was double that of the DL condition and 10 times greater than the C condition. CONCLUSIONS: In vivo supervision and distance learning methods appear to be effective dissemination and implementation strategies, and distance learning has significant potential to be less costly.

Does Posttraumatic Stress Disorder (PTSD) Affect Post-Treatment Methamphetamine Use?

OBJECTIVE: Although trauma is a well-established risk factor for substance use disorders, little is known about the association between posttraumatic stress disorder (PTSD) and treatment outcomes among methamphetamine users. In the present study, we examine the relationship between PTSD and post-treatment methamphetamine use outcomes, hospitalizations, and overall psychiatric impairment. METHODS: Using data from 526 adults in the largest psychosocial clinical trial of methamphetamine users conducted to date, this study examined: (1) treatment outcomes of methamphetamine users with concomitant PTSD three years after psychosocial treatment for methamphetamine dependence; and (2) PTSD symptom clusters as risk factors for post-treatment relapse to methamphetamine use. RESULTS: PTSD was associated with poorer methamphetamine use outcomes; methamphetamine use frequency throughout the 3-year follow-up was significantly greater among individuals with a PTSD diagnosis, and those with PTSD had more than five times the odds of reporting methamphetamine use in the 30 days prior to the follow-up interview, OR= 5.2, 95% CI [2.0-13.3]. Additionally, higher levels of other Axis I psychopathology were observed among methamphetamine users with PTSD. Avoidance and arousal symptoms predicted post-treatment methamphetamine use. CONCLUSIONS: Addressing these high risk PTSD symptoms and syndromes in methamphetamine users may be helpful as a means of improving treatment outcomes in this population.

Stimulant use among patients in opioid treatment settings: Provider perspectives.

INTRODUCTION: Methadone maintenance therapy (MMT) has been a pillar of opioid addiction treatment. Opioid treatment programs (OTPs) have been faced with an escalating threat of stimulant use and related overdose deaths among patients. We know little about how providers currently address stimulant use while maintaining treatment for opioid use disorder. METHODS: We conducted 5 focus groups with 36 providers (n = 11 prescribers; 25 behavioral health staff), and collected an additional 46 surveys (n = 7 prescribers; 12 administrators; 27 behavioral health staff). Questions focused on perceptions of patient stimulant use and interventions. We applied inductive analysis to identify themes relevant to identification of stimulant use, use trends, intervention approaches, and perceived needs to improve care. RESULTS: Providers indicated a trend of rising stimulant use among patients, especially those experiencing homelessness or comorbid health conditions. They reported a range of approaches to patient screening and intervention, including medication and harm reduction, improving treatment engagement, increasing level of care, and providing incentives. Providers expressed less agreement as to which of these interventions were effective, and though providers saw stimulant use as a common and severe problem, they reported little problem recognition and interest in treatment from their patients. A particular concern of providers was the prevalence and danger of synthetic opioids, such as fentanyl. They sought more research and resources to identify effective interventions and medications to address these issues. Also notable was an interest in contingency management (CM) and use of reinforcements/rewards to encourage stimulant use reduction. CONCLUSION: Providers face challenges in treating patients who use both opioids and stimulants. Although methadone is available to treat opioid use, no such "silver bullet" exists for stimulant use disorder. The rise in stimulant and synthetic opioid (e.g., fentanyl) combination products is presenting an extraordinary challenge for providers whose patients are at unprecedented risk for overdose. Providing OTPs with more resources to address polysubstance use is critical. Existing research indicates strong support for CM in OTPs, but providers reported regulatory and financial barriers to implementation. Further research should develop effective interventions that are accessible to providers in OTPs.