Patterns of polysubstance use and clinical comorbidity among persons seeking substance use treatment: An observational study.

INTRODUCTION: Polysubstance use is common among individuals seeking treatment for substance use disorders (SUD). However, we know less about patterns and correlates of polysubstance use among treatment-seeking populations. The current study aimed to identify latent patterns of polysubstance use and associated risk factors in persons entering SUD treatment. METHODS: Patients (N = 28,526) being admitted for substance use treatment reported on their use of thirteen substances (e.g., alcohol, cannabis, cocaine, amphetamines, methamphetamines, other stimulants, heroin, other opioids, benzodiazepines, inhalants, synthetics, hallucinogens, and club drugs) in the month before treatment and prior to the month before treatment. Latent class analysis (LCA) determined the relationship between class membership and gender, age, employment status, unstable housing, self-harm, overdose, past treatment, depression, generalized anxiety disorder, and/or post-traumatic stress disorder (PTSD). RESULTS: Identified classes included: 1) Alcohol primary, 2) Moderate probability of past-month alcohol, cannabis, and/or opioid use; 3) Alcohol primary, Lifetime cannabis and cocaine use; 4) Opioid primary, Lifetime use of alcohol, cannabis, hallucinogens, club drugs, amphetamines, and cocaine; 5) Moderate probability of past-month alcohol, cannabis, and/or opioid use, Lifetime use of various substances; 6) Alcohol and cannabis primary, Lifetime use of various substances; and 7) High past-month polysubstance use. Individuals who engaged in past-month polysubstance use attended to face elevated risk of screening positive for recent unstable housing, unemployment, depression, anxiety, PTSD, self-harm, and overdose. CONCLUSIONS: Current polysubstance use is associated with significant clinical complexity. Tailored treatments that reduce harms resulting from polysubstance use and related psychiatric comorbidity may improve treatment outcomes in this population.

Recreational drug toxicity with severe hyperthermia: Rapid onsite treatment and clinical course.

Electronic dance music festivals have gained notoriety in the critical care and emergency medicine fields due to an alarming incidence of hospitalizations and deaths related to the high prevalence of recreational drug use. Recreational drug use toxicity, in part related to sympathomimetic toxidromes, may cause hyponatremia, seizures, rhabdomyolysis, hyperkalemia, acidosis, coagulopathy, circulatory shock, multi-organ failure, and even death. This wide-ranging syndrome has been referred to as psychostimulant drug-induced toxicity. Rapid onsite diagnosis and treatment, with attention to the A-B-C's of clinical emergencies, is essential to preserve life. We describe a patient presenting with the highest recorded core temperature in a survivor of psychostimulant drug-induced toxicity, and emphasize management principles of this life-threatening and increasingly prevalent condition.

Prevalence, beliefs and impact of drug-drug interactions between antiretroviral therapy and illicit drugs among people living with HIV in Spain.

Drug use implies important challenges related to HIV management, particularly due to an increased risk of potential interactions between antiretroviral therapy (ART) and illicit drugs (pDDIs). This study analyses the prevalence and severity of pDDIs among people living with HIV (PLHIV). It also explores their awareness of pDDIs and their beliefs about the toxicity that they may cause, as well as the impact of pDDIs on selected health variables. We conducted an on-line cross-sectional survey across 33 Spanish hospitals and NGOs to collect demographics and clinical data. pDDIs were checked against the Interaction Checker developed by Liverpool University. The sample of the present study was composed of 694 PLHIV who used illicit drugs. They represented 49.5% of the 1,401 PLHIV that participated in the survey. After excluding 38 participants due to lack of information on their ART or illicit drug use, 335 (51.1%) participants consuming drugs presented with some potentially significant pDDIs between their ART and illicit drugs, with a mean of 2.1±1.7 (1-10) pDDIs per patient. The drugs most frequently involved in pDDIs were cocaine, cannabis, MDMA and nitrates ("poppers"). The prevalence of pDDIs across ART regimens was: protease inhibitors (41.7%); integrase inhibitor-boosted regimens (32.1%), and non-nucleoside reverse transcriptase inhibitors (26.3%). An awareness of pDDIs and beliefs about their potential toxicity correlated positively with intentional non-adherence (p<0.0001). Participants with pDDIs exhibited a higher prevalence of intentional non-adherence (2.19±1.04 vs. 1.93±0.94; p = 0.001). The presence of pDDIs was not associated with poorer results in the clinical variables analysed. A significant proportion of PLHIV who use drugs experience pDDIs, thereby requiring close monitoring. pDDIs should be considered in the clinical management of HIV patients. Adequate information about pDDIs and indicators about how to manage ART when PLHIV use drugs could improve ART non-adherence.

High prevalence of recreational and illicit drug use in German people living with HIV with a potential for drug-drug interactions with antiretroviral therapy.

Recreational drug use is higher in people living with HIV (PLHIV) than in the general population in Europe. This use increases the risk for drug-drug interactions (DDIs) and adverse events. We assessed the prevalence and clinical consequences of substance abuse among PLHIV. BESIDE was a cross-sectional, multi-center study in 2016/18, evaluating comorbidities, polypharmacy and recreational/illicit drug use in PLHIV on antiretroviral therapy (ART) in Germany. Legal and illicit drug use was recorded using two anonymous patient questionnaires one year apart (Q1 and Q2). The BESIDE study population consisted of 453 PLHIV (22% female, median age 46 years). Recreational drug use was reported by the majority (Q1: ever used 73%, within previous 6 months 56%): nitrite inhalants ("poppers"), cannabis and PDE-5 inhibitors were common across all age groups; ecstasy, (meth-)amphetamine and gamma-hydroxybutyrate/gamma-butyrolactone were predominantly reported by younger PLHIV. Based on Q2, two-thirds of PLHIV (67%) had been informed about potential risks of drug abuse by their doctors, whereas one-third (33%) had talked to their doctors on their own initiative with only 7% considering drug use in combination with ART a problem. Strikingly, 44% and 42% had undergone medical treatment or had been hospitalized due to drug use. These data emphasize the high clinical relevance of recreational drug use in PLHIV and the need for treating physicians to pro-actively communicate the potential risks.

An update on drug-drug interactions between antiretroviral therapies and drugs of abuse in HIV systems.

INTRODUCTION: While considerable progress has been made in the fight against HIV/AIDS, to date there has not been a cure, and millions of people around the world are currently living with HIV/AIDS. People living with HIV/AIDS have substance abuse disorders at higher rates than non-infected individuals, which puts them at an increased risk of drug-drug interactions. AREAS COVERED: Potential drug-drug interactions are reviewed for a variety of potential drugs of abuse, both licit and illicit. These drugs include alcohol, cigarettes or other nicotine delivery systems, methamphetamine, cocaine, opioids, and marijuana. Potential interactions include decreased adherence, modulation of drug transporters, or modulation of metabolic enzymes. We also review the relative incidence of the use of these drugs of abuse in People living with HIV/AIDS. EXPERT OPINION: Despite considerable improvements in outcomes, disparities in outcomes between PLWHA who use drugs of abuse, vs those who do not still exist. It is of critical necessity to improve outcomes in these patients and to work with them to stop abusing drugs of abuse.

Prevalence of Vitamin D Deficiency in a Large Newborn Cohort from Northern United States and Effect of Intrauterine Drug Exposure.

Vitamin D is not only a vital element in bone health but is also a prohormone. Data regarding distribution of vitamin D status among preterm and term neonates in the United States are limited. There are no data on the effect of intrauterine drug exposure on vitamin D status. Our objective was to determine the distribution of vitamin D levels among preterm and term neonates and the effect of intrauterine illicit drug exposure. We did a retrospective chart review of neonates admitted from 2009 to 2016 to our neonatal intensive care unit with serum 25-hydroxycholecalciferol (25[OH]D) levels measured during the hospital stay. Of 1517 neonates, the median 25[OH]D level was 19 ng/mL with 31% deficient and 49% insufficient, even though 75% of mothers took prenatal vitamins. In pregnant women, 38% were vitamin-D-deficient and 44% were vitamin-D-insufficient. Four hundred seventy-one neonates had intrauterine drug exposure, with a median 25[OH]D level of 22.9 ng/mL versus 17.8 ng/mL in nonexposed neonates (p = 0.001). Despite maternal prenatal vitamin intake, neonates are at risk of vitamin D deficiency. Maternal illicit drug use was not related to lower 25[OH]D levels in neonates.

Longitudinal patterns of illicit drug use, antiretroviral therapy exposure and plasma HIV-1 RNA viral load among HIV-positive people who use illicit drugs.

OBJECTIVES: HIV-positive people who use illicit drugs (PWUD) experience elevated rates of HIV-associated morbidity and mortality compared with members of other key affected populations. Although suboptimal levels of access and adherence to antiretroviral therapy (ART) are common among HIV-positive PWUD, there is a need for studies investigating the possible biological impacts of noninjection illicit drug use among people living with HIV in real-world settings. METHODS: We accessed data from the ACCESS study, an ongoing prospective cohort of illicit drug users with systematic HIV viral load monitoring in a setting with universal care and ART dispensation records. We used multivariable generalized linear mixed models to estimate the longitudinal associations between noninjection use of crack cocaine, powder cocaine, opioids, methamphetamine, cannabis and alcohol on plasma HIV-1 RNA viral load, adjusted for ART exposure and relevant confounders. RESULTS: Between 2005 and 2018, 843 individuals from the ACCESS cohort were included and contributed to 8698 interviews. At baseline, the mean age was 43 years, 566 (67%) reported male sex and 659 (78%) used crack cocaine in the previous 6 months. In multivariable models adjusted for ART exposure, only crack cocaine use in the last 6 months was found to be significantly associated with higher HIV viral load. CONCLUSION: We observed significantly higher HIV viral load during periods of crack cocaine use independent of ART exposure. Our findings support further research to investigate the possible biological mechanisms of this effect.

Drug use and antiretroviral therapy (ART) interactions: a qualitative study to explore the knowledge, beliefs, adherence, and quality of life of people living with HIV taking ART and illicit drugs.

BACKGROUND: To explore the use of illicit drugs by people living with HIV (PLHIV) taking antiretroviral therapy (ART) and their relationship with variables relevant to the management of HIV infection, such as knowledge and beliefs about drug-drug interactions (DDIs), ART adherence, quality of life (QoL), and use of health-care resources. METHODS: 21 PLHIV in Spain who concomitantly took illicit drugs and ART participated in this qualitative study. Eight experts collaborated in the design of the semi-structured interview guide which explored the following topics: illicit drug use, knowledge and beliefs about DDIs and their impact on ART adherence, the effects of using illicit drugs on health, QoL, and use of health-care resources. Four of those experts, who were PLHIV and members of the executive boards of non-government organizations (NGOs) from four Spanish regions, recruited the participants through their NGOs and carried out the face-to-face interviews. Content analysis of the qualitative data was conducted with the support of the MAXQDA 12 program. RESULTS: Participants were mainly men (85.7%) and only 14.3% of them were heterosexual. Content analysis showed that the most frequently consumed illicit drugs were poppers, cocaine, and cannabis. Participants were polydrug users and this was, in many cases, prior to HIV diagnosis. Most participants presented theoretical potential moderate DDIs that would require monitoring. More than three quarters of them were not aware of these DDIs. Participants reported interactive toxicity beliefs that lead to intentional nonadherence behaviors. In most cases (n = 17), the participant's doctor knew about their drug use, however only six of them had had an open dialogue with their physician about it. Illicit drug use led to some health-related problems, mainly sexually transmitted infections. A positive QoL's self-perception was found among several participants that used recreational illicit drugs. CONCLUSIONS: Adequate information about DDIs and clues about how to manage ART when PLHIV are using illicit drugs could reduce the negative effects of such interactions and improve ART adherence and QoL.

Skin hyperpigmentation: a rare presenting symptom of nitrous oxide abuse.

Context: Recreational nitrogen oxide (N2O) abuse can cause nervous system damage. There was a sharp increase in the number of patients with neurological disorders associated with recreational N2O use in China, as recreational N2O use became popular in young people nationwide. Among cases with neurological disorders caused by N2O abuse, a few showed skin hyperpigmentation, which has rarely been reported. We explored the characteristics of hyperpigmentation in N2O abusers to draw the attention of clinicians to this rare cutaneous symptom related to N2O abuse.Methods: We retrospectively collected data of patients with neurological disorders related to recreational N2O abuse in Shengjing Hospital of China Medical University from January 2014 to June 2019. Detailed clinical data were gathered from patients who manifested skin pigmentation, including the history of N2O abuse and characteristics of neurological lesions and skin pigmentation.Results: In total, 66 patients (average age: 22.7 ± 4.5 years, 36 males) with neurological disorders due to N2O abuse were included; four of them (17-23 years old, 1 male) manifested skin hyperpigmentation. The duration of N2O abuse of the four patients ranged from 2 to 24 months, and they all had peripheral neuropathy; the two patients also had subacute combined degeneration of the spinal cord. One patient exhibited significant hyperpigmentation throughout the body (trunk, limbs, and face), with no abnormalities in cortisol and other biochemical tests. One patient presented with punctuate pigmentation throughout the trunk. Two patients presented with finger skin pigmentation, especially in the distal phalanxes. Pigmentation after N2O use remitted slowly with vitamin B12 supplementation.Conclusion: Skin hyperpigmentation is a rare symptom in N2O abusers, which can distribute locally in hands or diffusely throughout the body. Therefore, attention should be paid to a history of N2O abuse and serum vitamin B12 level should be tested.

Treatment for Individuals With Severe Mental Illness Who Use Illicit Drugs While Maintained on Methadone: Mindfulness and Modification Therapy.

Substantial research has noted the serious consequences of 1) co-occurring severe mental illness (SMI) and substance use disorders, and 2) use of illicit drugs while maintained on methadone for opioid dependence. However, treatment needs of individuals who meet both of the above criteria remain largely unmet. This pilot study investigated the feasibility and acceptability of a 12-week, transdiagnostic group therapy (mindfulness and modification therapy [MMT]) tailored for opioid-dependent individuals (N = 6) with SMI and illicit drug use. Retention was 83%. At posttreatment and 2-month follow-up, participants rated the treatment as highly helpful (9 of 10; 8.67 of 10, respectively), reported routinely practicing the guided-mindfulness exercises, and reported high confidence that they would continue to practice. Assessments revealed clinically meaningful decreases in reported days of illicit drug use at posttreatment and follow-up, with large effect sizes. Preliminary evidence suggests that MMT may be a feasible and acceptable therapy that may improve treatment engagement in this underserved population.

Drug treatment presentations at a treatment centre in southern Nigeria (2015-2018): Findings and implications for policy and practice.

INTRODUCTION: Recent evidence suggests that rates of drug use and abuse in Nigeria exceed the global average. There is a strong treatment demand for psychoactive drug use disorders in Nigeria; however, it is not known whether available treatment facilities are attending to the array of treatment needs. This audit compares the pattern of presentations at a tertiary facility with a community-based survey. METHODS: A review of cases (n = 212) seen at a regional drug treatment facility over a 4-year period, using local data retrieved from the Nigerian Epidemiological Network of Drug Use (NENDU) and comparison with data from the recently published national drug use survey. RESULTS: Nine out of ten clients seen were male (93.4%). About half (49.5%) of the clients used psychoactive substances for the first time between ages 10 and 19 years. Cannabis was the primary drug of use overall and also among males, while females were more likely to present with opiate abuse. Over half had a co-occurring physical or mental disorder, and a minority had received testing for hepatitis C in the past 12 months. CONCLUSION: Although patterns of drug abuse presentations were consistent with findings from a national community-based survey, there was an under-representation of females in treatment. Implications for policy development and practice are discussed.

Characteristics of deaths associated with kratom use.

BACKGROUND: Kratom (Mitragyna speciosa Korth) use has increased in Western countries, with a rising number of associated deaths. There is growing debate about the involvement of kratom in these events. AIMS: This study details the characteristics of such fatalities and provides a 'state-of-the-art' review. METHODS: UK cases were identified from mortality registers by searching with the terms 'kratom', 'mitragynine', etc. Databases and online media were searched using these terms and 'death', 'fatal*', 'overdose', 'poisoning', etc. to identify additional cases; details were obtained from relevant officials. Case characteristics were extracted into an Excel spreadsheet, and analysed employing descriptive statistics and thematic analysis. RESULTS: Typical case characteristics (n = 156): male (80%), mean age 32.3 years, White (100%), drug abuse history (95%); reasons for use included self-medication, recreation, relaxation, bodybuilding, and avoiding positive drug tests. Mitragynine alone was identified/implicated in 23% of cases. Poly substance use was common (87%), typically controlled/recreational drugs, therapeutic drugs, and alcohol. Death cause(s) included toxic effects of kratom ± other substances; underlying health issues. CONCLUSIONS: These findings add substantially to the knowledge base on kratom-associated deaths; these need systematic, accurate recording. Kratom's safety profile remains only partially understood; toxic and fatal levels require quantification.

Nitrous oxide myelopathy with functional vitamin B 12 deficiency.

Recreational use of nitrous oxide as a 'legal high' is increasing in the UK. Physicians should be 'street wise' to this increasing prevalence and aware of the potential neurological complications which may result from misuse. We describe a 17-year-old male patient who presented to neurology with a severe myelopathy following prolonged recreational use of nitrous oxide. MRI demonstrated characteristic changes affecting the dorsal columns and blood tests demonstrated a 'functional' B12 deficiency. Clinical and radiological improvement was noted following initiation of vitamin B12 replacement.

Racial disparities in discontinuation of long-term opioid therapy following illicit drug use among black and white patients.

BACKGROUND: Among patients prescribed long-term opioid therapy (LTOT) for chronic pain, no study has yet examined how clinicians respond to evidence of illicit drug use and whether the decision to discontinue opioids is influenced by a patient's race. METHODS: Among outpatients of black and white race initiating LTOT through the VA between 2000 and 2010, we reviewed electronic medical records to determine whether opioids were discontinued within 60 days of a positive urine drug test. Logistic regression was used to examine differences by race. RESULTS: Among 15,366 patients of black (48.1%) or white (51.9%) race initiating LTOT from 2000 to 2010, 20.5% (25.5% of blacks vs. 15.8% of whites, P <. 001) received a urine drug test within the first 6 months of treatment; 13.8% tested positive for cannabis and 17.4% for cocaine. LTOT was discontinued in 11.4% of patients who tested positive for cannabis and in 13.1% of those who tested positive for cocaine. Among patients testing positive for cannabis, blacks were 2.1 times more likely than whites to have LTOT discontinued (adjusted odds ratio [AOR] 2.06, 95% confidence interval [CI] 1.04-4.08). Among patients testing positive for cocaine, blacks were 3.3 times more likely than whites to have LTOT discontinued (AOR 3.30, CI 1.28-8.53). CONCLUSIONS: Among patients testing positive for illicit drug use while receiving LTOT, clinicians are substantially more likely to discontinue opioids when the patient is black. A more universal approach to administering and responding to urine drug testing is urgently needed.

Phantom menace: novel psychoactive substances and the UK Armed Forces.

Novel psychoactive substances (NPS) encompass a large group of synthesised compounds specifically designed to mimic traditional recreational drugs. Current UK Armed Forces compulsory drug testing does not screen for these substances, making them tempting to the small proportion of UK Armed Forces personnel who indulge in recreational drug use. The acute and chronic sequelae of NPS misuse are widely variable and associated with high morbidity. In this paper, we discuss NPS pharmacology and clinical presentation. We describe toxidromes and management of patients who have misused NPS.Finally, we reflect on the legal, ethical and military consequences of NPS misuse for both the service person misusing NPS and the Military Physician providing their care.

Peripheral Neuropathy Due to Recreational Use of Nitrous Oxide Presenting After an Ankle Sprain With Foot Drop.

A 22-year-old man was referred for orthopedic follow-up after an ankle injury. Initial evaluation in urgent care included radiographs with negative findings. After a delayed presentation, a course of functional treatment was recommended. Subsequently, he developed a deep venous thrombosis and pulmonary emboli. He was found to be factor V Leiden deficient and was fully anticoagulated on warfarin. Later reevaluation revealed a steppage gait and foot drop. Electrodiagnostic studies (ie, electromyography and nerve conduction studies) revealed a severe peripheral polyneuropathy. The patient admitted to engaging in high-volume recreational use of nitrous oxide. Neurological evaluation confirmed vitamin B12 deficiency consistent with the toxic effects of nitrous oxide. The patient's condition improved with vitamin B supplementation, bracing, and avoidance of nitrous oxide and similar neurotoxins. He participated in a 3-month physical rehabilitation program, and he displayed partial recovery at most recent follow-up. [Orthopedics. 2018; 41(3):e432-e433.].

Intended and unintended use of cathinone mixtures.

INTRODUCTION: Cathinones are one of the most popular categories of new psychoactive substances (NPS) consumed. Cathinones have different pharmacological activities and receptor selectivity for monoamine transporters based on their chemical structures. They are incorporated into NPS mixtures and used with other NPS or 'traditional' drugs. Cathinone use represents significant health risks to individuals and is a public health burden. METHODS: Evidence of poly-NPS use with cathinones, seizure information, and literature analyses results on NPS mixtures was systematically gathered from online database sources, including Google Scholar, Scopus, Bluelight, and Drugs-Forum. RESULTS AND DISCUSSION: Results highlight the prevalence of NPS with low purity, incorporation of cathinones into NPS mixtures since 2008, and multiple members of the cathinone family being present in individual UK-seized samples. Cathinones were identified as adulterants in NPS marketed as being pure NPS, drugs of abuse, branded products, herbal blends, and products labelled "not for human consumption." Toxicity resulting from cathinone mixtures is unpredictable because key attributes remain largely unknown. Symptoms of intoxication include neuro-psychological, psychiatric, and metabolic symptoms. Proposed treatment includes holistic approaches involving psychosocial, psychiatric and pharmacological interventions. CONCLUSION: Raising awareness of NPS, education, and training of health care professionals are paramount in reducing harms related to cathinone use.

Recreational stimulants, herbal, and spice cannabis: The core psychobiological processes that underlie their damaging effects.

AIMS: Recreational drugs are taken for their positive mood effects, yet their regular usage damages well-being. The psychobiological mechanisms underlying these damaging effects will be debated. METHODS: The empirical literature on recreational cannabinoids and stimulant drugs is reviewed. A theoretical explanation for how they cause similar types of damage is outlined. RESULTS: All psychoactive drugs cause moods and psychological states to fluctuate. The acute mood gains underlie their recreational usage, while the mood deficits on withdrawal explain their addictiveness. Cyclical mood changes are found with every central nervous system stimulant and also occur with cannabis. These mood state changes provide a surface index for more profound psychobiological fluctuations. Homeostatic balance is altered, with repetitive disturbances of the hypothalamic-pituitary-adrenal axis, and disrupted cortisol-neurohormonal secretions. Hence, these drugs cause increased stress, disturbed sleep, neurocognitive impairments, altered brain activity, and psychiatric vulnerability. Equivalent deficits occur with novel psychoactive stimulants such as mephedrone and artificial "spice" cannabinoids. These psychobiological fluctuations underlie drug dependency and make cessation difficult. Psychobiological stability and homeostatic balance are optimally restored by quitting psychoactive drugs. CONCLUSIONS: Recreational stimulants such as cocaine or MDMA (3.4-methylenedioxymethamphetamine) and sedative drugs such as cannabis damage human homeostasis and well-being through similar core psychobiological mechanisms.

Health and Public Policy to Facilitate Effective Prevention and Treatment of Substance Use Disorders Involving Illicit and Prescription Drugs: An American College of Physicians Position Paper.

Substance use disorders involving illicit and prescription drugs are a serious public health issue. In the United States, millions of individuals need treatment for substance use disorders but few receive it. The rising number of drug overdose deaths and the changing legal status of marijuana pose new challenges. In this position paper, the American College of Physicians maintains that substance use disorder is a treatable chronic medical condition and offers recommendations on expanding treatment options, the legal status of marijuana, addressing the opioid epidemic, insurance coverage of substance use disorders treatment, education and workforce, and public health interventions.