Trends in comorbid opioid and stimulant use disorders among Veterans receiving care from the Veterans Health Administration, 2005-2019.

BACKGROUND: Identifying solutions to the continued rise in overdose deaths is a public health priority. However, there is evidence of change in recent substance type associated with morbidity and mortality. To better understand the continued rise in overdose deaths, in particular those attributed to opioid and stimulant use disorders, increased knowledge of patterns of use is needed. METHODS: Retrospective cohort study of Veterans diagnosed with an opioid or stimulant use disorder between 2005 and 2019. The outcome of interest was diagnosis of substance use disorders, specifically examining combinations of opioid and stimulant use disorders among this population. RESULTS: A total of 1932,188 Veterans were diagnosed with at least one substance use disorder (SUD) during the study period, 2005 through 2019. While the annual prevalence of opioid use disorder (OUD) diagnoses increased more than 155%, OUD diagnoses absent of any other SUD diagnosis increased by an average of 6.9% (95% CI, 6.4, 7.5) per year between 2005 and 2019. Between 2011 and 2019, diagnoses of co-morbid methamphetamine use disorder (MUD) and OUD increased at a higher rate than other SUD combinations. CONCLUSIONS: The prevalence of comorbid SUD, in particular co-occurring opioid and methamphetamine use disorder, increased at a higher rate than other combinations between 2005 and 2019. These findings underscore the urgent need to offer patients a combination of evidence-based treatments for each co-morbid SUD, such MOUD and contingency management for persons with comorbid opioid and methamphetamine use disorders.

Measurement-based care training curriculum in psychiatry residency programs: I: Description of the curriculum and demonstration of implementation.

BACKGROUND: Recent literature shows that most practicing psychiatrists do not receive training in measurement-based care (MBC). Among the primary barriers to MBC implementation are the lack of formal training and curriculums. We present the first comprehensive MBC curriculum for use in adult psychiatric practice, and describe how the curriculum is adapted and implemented in psychiatry residency training programs. METHODS: The Standard for Clinicians' Interview in Psychiatry (SCIP) was developed as a measurement-based care tool for clinicians' use. The SCIP is the only instrument that includes 18 reliable and validated clinician-rated scales covering most adult psychiatric disorders. The SCIP has simple, unified rules of measurement that apply to the 18 scales. The MBC curriculum includes 2 instruction manuals, 4 didactic lectures, and 12 videotaped interviews. We describe the annual learning and implementation of MBC curriculum in residency programs. RESULTS: The curriculum implementation at West Virginia University and Delaware Psychiatric Center began in 2019 and is ongoing. We present 3 case demonstrations of the implementation of MBC in clinical settings. CONCLUSIONS: Comprehensive implementation of MBC curriculum in residency programs has the potential to facilitate research and create a "culture" of MBC in future generations of psychiatrists.

Sublingual Buprenorphine/Naloxone and Multi-Modal Management for High-Risk Chronic Pain Patients.

Patients with chronic pain managed with opioid medications are at high risk for opioid overuse or misuse. West Virginia University (WVU) established a High-Risk Pain Clinic to use sublingual buprenorphine/naloxone (bup/nal) plus a multimodal approach to help chronic pain patients with history of Substance Use Disorder (SUD) or aberrant drug-related behavior. The objective of this study was to report overall retention rates and indicators of efficacy in pain control from approximately six years of High-Risk Pain Clinic data. A retrospective chart review was conducted for a total of 78 patients who enrolled in the High-Risk Pain Clinic between 2014 and 2020. Data gathered include psychiatric diagnoses, prescribed medications, pain score, buprenorphine/naloxone dosing, time in clinic, and reason for dismissal. A linear mixed effects model was used to assess the pain score from the Defense and Veterans Pain Rating Scale (DVPRS) and daily bup/nal dose across time. The overall retention of the High-Risk Pain Clinic was 41%. The mean pain score demonstrated a significant downward trend across treatment time (p < 0.001), while the opposite trend was seen with buprenorphine dose (p < 0.001). With the benefit of six years of observation, this study supports buprenorphine/naloxone as a safe and efficacious component of comprehensive chronic pain treatment in patients with SUD or high-risk of opioid overuse or misuse.

High prevalence of co-occurring substance use in individuals with opioid use disorder.

OBJECTIVE: Funding to address the current opioid epidemic has focused on treatment of opioid use disorder (OUD); however, rates of other substance use disorders (SUDs) remain high and non-opioid related overdoses account for nearly 30% of overdoses. This study assesses the prevalence of co-occurring substance use in West Virginia (WV) to inform treatment strategies. The objective of this study was to assess the prevalence of, and demographic and clinical characteristics (including age, gender, hepatitis C virus (HCV) status) associated with, co-occurring substance use among patients with OUD in WV. METHODS: This retrospective study utilized the West Virginia Clinical and Translation Science Institute Integrated Data Repository, comprised of Electronic Medical Record (EMR) data from West Virginia University Medicine. Deidentified data were extracted from inpatient psychiatric admissions and emergency department (ED) healthcare encounters between 2009 and 2018. Eligible patients were those with OUD who had a positive urine toxicology screen for opioids at the time of their initial encounter with the healthcare system. Extracted data included results of comprehensive urine toxicology testing during the study timeframe. RESULTS: 3,127 patients met the inclusion criteria of whom 72.8% had co-occurring substance use. Of those who were positive for opioids and at least one additional substance, benzodiazepines were the most common co-occurring substances (57.4% of patients yielded a positive urine toxicology screen for both substances), followed by cannabis (53.1%), cocaine (24.5%) and amphetamine (21.6%). Individuals who used co-occurring substances were younger than those who were positive for opioids alone (P < 0.001). There was a higher prevalence of individuals who used co-occurring substances that were HCV positive in comparison to those who used opioids alone (P < 0.001). There were limited gender differences noted between individuals who used co-occurring substances and those who used opioids alone. Among ED admissions who were positive for opioids, 264 were diagnosed with substance toxicity/overdose, 78.4% of whom had co-occurring substance use (benzodiazepines: 65.2%; cannabis: 44.4%; cocaine: 28.5%; amphetamine: 15.5%). Across the 10-year timespan, the greatest increase for the entire sample was in the rate of co-occurring amphetamine and opioid use (from 12.6% in 2014 to 47.8% in 2018). CONCLUSIONS: These data demonstrate that the current substance use epidemic extends well beyond opioids, suggesting that comprehensive SUD prevention and treatment strategies are needed, especially for those substances which do not yet have any evidence-based and/or medication treatments available.

Fentanyl Quality Assurance Project Prompted Change in Clinical Workflow and Test Configurations.

BACKGROUND: Deaths attributable to fentanyl (FEN, a synthetic opioid) are high in Appalachia and highest in West Virginia. The goal of the study was to determine FEN prevalence among specimens submitted for definitive opioid testing and monitor responses to provider notifications of unexpected FEN findings during Q1 2020. METHODS: All definitive opioid test data were reviewed daily for FEN signatures in Q1 2020. Unexpected FEN results were communicated to providers and monitored for 10 days to record actions taken. Prevalence data were categorized. Behavioral Medicine (BMED) leaders analyzed January data and implemented FEN screening in the clinic. BMED Q1 clinic visits and order volumes for drug screens were reviewed after Q1. RESULTS: FEN positivity was 11% in Q1; >60% of findings were unexpected. Actions were taken for 54% of notifications in January but only 18% in March. Notifications required 70 hours of combined laboratory effort each month. BMED providers ordered 44% of definitive opioid tests and 69% of definitive FEN tests. Data prompted the addition of FEN to routine drug screen panels in the laboratory, and a 10% random FEN screening rate in the BMED opioid use disorder clinics (COAT). CONCLUSIONS: Prevalence of FEN positivity was higher than initially expected, even for this region in Appalachia. Expanded presence of FEN screening should assist BMED providers with clinical efforts and help identify patients in need of intervention/therapy.

Transcranial magnetic stimulation, deep brain stimulation, and other forms of neuromodulation for substance use disorders: Review of modalities and implications for treatment.

Given the high prevalence of individuals diagnosed with substance use disorder, along with the elevated rate of relapse following treatment initiation, investigating novel approaches and new modalities for substance use disorder treatment is of vital importance. One such approach involves neuromodulation which has been used therapeutically for neurological and psychiatric disorders and has demonstrated positive preliminary findings for the treatment of substance use disorder. The following article provides a review of several forms of neuromodulation which warrant consideration as potential treatments for substance use disorder. PubMed, PsycINFO, Ovid MEDLINE, and Web of Science were used to identify published articles and clinicaltrials.gov was used to identify currently ongoing or planned studies. Search criteria for Brain Stimulation included the following terminology: transcranial direct current stimulation, transcranial magnetic stimulation, theta burst stimulation, deep brain stimulation, vagus nerve stimulation, trigeminal nerve stimulation, percutaneous nerve field stimulation, auricular nerve stimulation, and low intensity focused ultrasound. Search criteria for Addiction included the following terminology: addiction, substance use disorder, substance-related disorder, cocaine, methamphetamine, amphetamine, alcohol, nicotine, tobacco, smoking, marijuana, cannabis, heroin, opiates, opioids, and hallucinogens. Results revealed that there are currently several forms of neuromodulation, both invasive and non-invasive, which are being investigated for the treatment of substance use disorder. Preliminary findings have demonstrated the potential of these various neuromodulation techniques in improving substance treatment outcomes by reducing those risk factors (e.g. substance craving) associated with relapse. Specifically, transcranial magnetic stimulation has shown the most promise with several well-designed studies supporting the potential for reducing substance craving. Deep brain stimulation has also shown promise, though lacks well-controlled clinical trials to support its efficacy. Transcranial direct current stimulation has also demonstrated promising results though consistently designed, randomized trials are also needed. There are several other forms of neuromodulation which have not yet been investigated clinically but warrant further investigation given their mechanisms and potential efficacy based on findings from other studied indications. In summary, given promising findings in reducing substance use and craving, neuromodulation may provide a non-pharmacological option as a potential treatment and/or treatment augmentation for substance use disorder. Further research investigating neuromodulation, both alone and in combination with already established substance use disorder treatment (e.g. medication treatment), warrants consideration.

Something to despair: Gender differences in adverse childhood experiences among rural patients.

Existing research has demonstrated that patients in treatment for an opioid use disorder (OUD) have high rates of adverse childhood experiences (ACE) compared to community-based samples. While research has documented important gender differences in ACEs in patients with OUD receiving treatment in urban areas, research has not shown whether these findings would generalize to rural and Appalachian areas, which are known to have lower ACE scores. We conducted a secondary analysis of existing clinical data, utilizing intake assessment data from a rural Appalachian outpatient buprenorphine program. We restricted the sample to patients with an OUD who presented for treatment between June 2018 and June 2019 (n = 173). The clinical intake assessment included a modified 17-item ACE instrument that patients self-administered. More than half (54.3%) of patients reported having experienced 4+ categories of adverse childhood experiences. On average, females endorsed 4.5 categories of adverse experiences, whereas males endorsed 3.3 (p < 0.00); female patients were significantly more likely to have experienced sexual abuse (42.4% versus 10.6%, p < 0.00). Alarmingly, 25.9% of females and 8.2% of males reported being forced to have sex before age 18. Disproportionately high rates of childhood adversities, particularly among females, may partially explain despair in rural Appalachian areas. OUD treatment programs should conduct clinical assessments of trauma and integrate trauma-informed care into drug treatment, especially for female patients residing in rural Appalachia.

Long-term treatment retention in West Virginia's comprehensive opioid addiction treatment (COAT) program.

BACKGROUND: The United States continues to experience an opioid epidemic of unprecedented proportions despite FDA approval of life saving medications, such as buprenorphine. This paper describes a novel group-based buprenorphine treatment model and summarizes patient characteristics and treatment retention. This model, known as the Comprehensive Opioid Addiction Treatment (COAT) program, was developed in West Virginia, the epicenter of the opioid epidemic. METHODS: Data on 454 patients actively enrolled in the COAT program were extracted from an administrative clinical data set and electronic medical records and analyzed using descriptive and quantitative analysis to determine long-term retention in treatment using frequencies and means. RESULTS: The characteristics of the 454 patients are as follows: average age of 39, 53% female, predominantly white (94%) and Medicaid was the primary insurance provider (68%). Analysis of retention showed 37.8% of patents were retained less than one year and 14.7% were retained 10 or more years. Initiating treatment at a younger age was associated with long-term retention. CONCLUSION: Opioid use disorder is a chronic relapsing disease and treatment models that retain patients long-term have the greatest benefit. The COAT model has been successful in retaining patients long-term in a rural setting where barriers to treatment are many.

West Virginia's model of buprenorphine expansion: Preliminary results.

West Virginia (WV) is situated at the epicenter of the opioid epidemic with the highest rates of overdose deaths and some of the lowest rates of access to life saving evidence-based medication assisted treatment (MAT) for patients with opioid use disorder (OUD). WV used a modified hub-and-spoke model to build organizational capacity for facilities to use buprenorphine to treat patients with OUD and to provide ongoing case consultation. The purpose of this study is to 1) describe the group-base model of buprenorphine treatment and the model used to build organizational capacity, 2) to describe the preliminary results of buprenorphine expansion in WV and 3) to report preliminary data describing and comparing the characteristics of the patients served across five hubs. A single Coordinating Center uses video conferencing to train hubs and provide ongoing case consultation, as well as clinical support. Hubs were trained to deliver a buprenorphine treatment model that is multi-disciplinary and includes group-based medication management and psychosocial therapy. Five regional hubs independently treat patients and are leading MAT expansion in their local areas by training and mentoring spokes (n = 13). As a result of the WV STR funding, 14 health care facilities have started to use buprenorphine, 56 health professionals were trained and 196 patients with OUD have been treated. There were few sociodemographic characteristic differences across patients treated at the five hubs, while there were differences in self-reported alcohol and drug use in the 30 days prior to intake. Additional research is needed to determine whether the WV modified hub-and-spoke model resulted in statistically significant improvements in buprenorphine treatment capacity; there is a need to address MAT stigma and regulatory barriers in order to ensure the long-term sustainability of the buprenorphine expansion.

A case report illustrating the effects of repetitive transcranial magnetic stimulation on cue-induced craving in an individual with opioid and cocaine use disorder.

Nationally, it was estimated that 11.4 million people misused opioids in 2017 with more than 47,000 opioid-related deaths. Although medication-assisted treatment (MAT) has been effective in enhancing treatment retention and decreasing frequency of opioid use, relapse rates for opioids and other substances remain high, emphasizing the importance of investigating novel interventions to augment MAT. One potential treatment approach is repetitive transcranial magnetic stimulation (rTMS)-a noninvasive, electrophysiological method of neuromodulation. Recently published studies of rTMS in individuals with alcohol, nicotine, and cocaine use disorder have suggested that this treatment shows promise in reducing cravings and substance use. The literature specific to rTMS and opioid use disorder (OUD) is limited to a single published study in heroin users, which showed that a single session of rTMS to the left dorsolateral prefrontal cortex (DLPFC) reduced cue-induced craving, with a further reduction following 5 consecutive days of rTMS. The following case report involved a 25-year-old Caucasian male diagnosed with OUD and cocaine use disorder. This subject continued to demonstrate ongoing substance use despite participating in comprehensive MAT with buprenorphine/naloxone in combination with psychosocial interventions. He was administered 7 separate sessions of rTMS targeting the left DLPFC. Substance-related cues were presented prior to, during, and following these rTMS administration sessions and the subject rated his substance cravings via a 100-point Visual Analog Scale. When compared with his cue-induced craving ratings, there was a mean reduction in craving for heroin and cocaine by ∼60% to 82% following the 7 administration sessions. Although this is a single case, further investigation of rTMS as an augmentation strategy for OUD and polysubstance use is warranted. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Treating women with opioid use disorder during pregnancy in Appalachia: Initial neonatal outcomes following buprenorphine + naloxone exposure.

BACKGROUND AND OBJECTIVES: Rising concerns regarding diversion and misuse of mono-buprenorphine for treatment of pregnant women with opioid use disorders have sparked interest in the use of buprenorphine + naloxone to reduce misuse and diversion rates. Examined the relationship of prenatal buprenorphine + naloxone exposure to neonatal outcomes. METHODS: This is a retrospective chart review of 26 mother infant dyads in comprehensive medication-assisted treatment with buprenorphine + naloxone during pregnancy. RESULTS: All neonatal birth outcome parameters were within normal ranges, albeit on the lower side of normal for gestational age and birth weight. Only 19% of neonates required morphine pharmacology for NAS. CONCLUSIONS: Use of buprenorphine + naloxone shows relative safety in pregnancy. SCIENTIFIC SIGNIFICANCE: These findings can help better guide prescribing practices for pregnant patients at risk for misuse or diversion of buprenorphine. (Am J Addict 2018;27:92-96).

Amnesia Associated with Bilateral Hippocampal and Bilateral Basal Ganglia Lesions in Anoxia with Stimulant Use.

We report a case of a 55-year-old man with ischemic lesions of the bilateral hippocampus and bilateral basal ganglia following a myocardial infarction during an episode of multiple drug use with subsequent anoxia requiring resuscitation. He presented for a neuropsychological evaluation with an anterograde amnesia for both explicit and procedural memory. There are two main points to this case, the unique aspects of the bilateral multifocal lesions and the functional, cognitive impact of these lesions. We hypothesize that his rare focal bilateral lesions of both the hippocampus and basal ganglia are a result of anoxia acting in synergy with his stimulant drug use (cocaine and/or 3,4-methylenedioxy-methamphetamine). Second, his unique lesions produced an explicit and implicit/procedural anterograde amnesia.

Treatment Outcome Comparison Between Telepsychiatry and Face-to-face Buprenorphine Medication-assisted Treatment for Opioid Use Disorder: A 2-Year Retrospective Data Analysis.

OBJECTIVES: To retrospectively review clinic records to assess the difference between face-to-face and telepsychiatry buprenorphine medication-assisted treatment (MAT) programs for the treatment of opioid use disorder on 3 outcomes: additional substance use, average time to achieve 30 and 90 consecutive days of abstinence, and treatment retention rates at 90 and 365 days. METHODS: Medical records of patients (N = 100) who were participating in telepsychiatry and in face-to-face group-based outpatient buprenorphine MAT programs were reviewed and assessed using descriptive statistical analysis. RESULTS: In comparison with the telepsychiatry MAT group, the face-to-face MAT group showed no significant difference in terms of additional substance use, time to 30 days (P = 0.09) and 90 days of abstinence (P = 0.22), or retention rates at 90 and 365 days (P = 0.99). CONCLUSIONS: We did not find any significant statistical difference between telepsychiatry buprenorphine MAT intervention through videoconference and face-to-face MAT treatment in our Comprehensive Opioid Addiction Treatment model for individuals diagnosed with opioid use disorder in terms of additional substance use, average time to 30 and 90 days of abstinence, and treatment retention rates.

Guidelines for the Management of Pregnant Women With Substance Use Disorders.

BACKGROUND: Women of reproductive potential with substance use disorders, especially those who are pregnant, present many clinical challenges to healthcare providers, including comorbid psychiatric disorders, a history of trauma and abuse, avoidance of or poor access to prenatal care, fear of legal consequences, and countertransference reactions. METHODS: In November 2013, members of the Women's Mental Health Special Interest Group of the Academy of Psychosomatic Medicine presented a Workshop reviewing substance abuse in pregnancy, highlighting the specific contributions that psychosomatic medicine specialists can make in the care of these patients. The discussion focused on epidemiology; maternal and fetal risks; and screening and treatment considerations for tobacco, alcohol, cannabis, opioids, benzodiazepines, stimulants, and several other substances. OBJECTIVE: Our purpose in publishing this review is to provide clinicians and educators with the most up-to-date summary in this field to better engage these patients in care and break the intergenerational cycle of abuse and addiction.

Off-label use of transmucosal ketamine as a rapid-acting antidepressant: a retrospective chart review.

OBJECTIVE: This study evaluated the effectiveness and safety of subanesthetic doses of ketamine using an off-label, transmucosal administration route in patients with treatment-resistant depression. METHODS: A retrospective chart review was conducted to identify patients who met the inclusion criteria for treatment-resistant major depressive disorder. Seventeen such patients who received subanesthetic doses of ketamine were included. Patient demographics, efficacy (drug refill, clinician notes), side effects, and concurrent medications were assessed. RESULTS: Benefit from low-dose transmucosal ketamine was noted in 76% of subjects (average age 48 years, 88% female), with a dose duration lasting 7-14 days. No notable side effects were noted. The most common classes of concurrent medications to which ketamine was added were serotonin-norepinephrine reuptake inhibitors (59%), stimulants (47%), folate replacement (47%), and benzodiazepines (47%). CONCLUSION: Our results provide preliminary evidence of the effectiveness and safety of low-dose transmucosal ketamine in treatment-resistant patients. A controlled, prospective pilot study is warranted to validate these findings.

Rural healthcare disparities: challenges and solutions for the pregnant opioid-dependent population.

Substance abuse among pregnant women is a significant public health problem affecting both maternal and fetal health. Access to both obstetrical care and substance abuse treatment is a challenge for women in rural West Virginia. A multi-disciplinary collaborative treatment approach for this population is necessary to reach and retain women in treatment. Through such collaboration, a positive impact on access to treatment for women from rural communities and reduced barriers to both prenatal care and substance abuse treatment can be achieved in order to improve outcomes for both mother and infant.