Impact of the COVID-19 Pandemic on Functions of Nursing Professionals in the Care of Opioid Use Disorder: Systematic Review.

BACKGROUND: Nursing professionals are vitally involved in the cascade of care for opioid use disorders (OUDs). The global spread of COVID-19 has had complex effects on public health aspects of major diseases, including OUDs. There are limited data on the major ways in which the COVID-19 pandemic has affected the functions of nursing professionals in the care of OUDs. METHOD: This systematic review followed Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines and examined published data for trends in OUD care during the first 2 years of the COVID-19 pandemic, focusing on nursing functions. The National Library of Medicine PubMed database and the EMBASE database were examined for peer-reviewed studies with primary data published between January 1, 2020, and December 31, 2021. REVIEW FINDINGS AND CONCLUSIONS: Rapid changes were observed in numerous aspects of OUDs during the early pandemic stage, as well as its care by nursing and other health professionals. These changes include increased overdoses (primarily from synthetic opioids such as fentanyl) and emergency department visits. These trends varied considerably across U.S. jurisdictions, underscoring the importance of region-specific examinations for public health policy and intervention. Out of necessity, healthcare systems and nursing professionals adapted to the challenges of OUD care in the pandemic. These adaptations included increases in telehealth services, increases in take-home doses of methadone or buprenorphine/naloxone, and expansion of layperson training in the use of naloxone for overdose reversal. It is likely that some of these adaptations will result in long-term changes in standards of care practices for OUDs by nursing professionals.

Has the United States Reached a Plateau in Overdoses Caused by Synthetic Opioids After the Onset of the COVID-19 Pandemic? Examination of Centers for Disease Control and Prevention Data to November 2021.

Background: Overdoses caused by synthetic mu-opioid receptor (MOR) agonists such as fentanyl are causing increasing mortality in the United States. The COVID-19 pandemic continues to have complex effects on public health, including opioid use disorders (OUD). It is unclear whether recent increases in mortality caused by synthetic opioids have reached a plateau (i.e., a stable period), after the onset of the COVID-19 pandemic. Method: This study examined provisional overdose mortality data from the Centers for Disease Control and Prevention, for synthetic opioids excluding methadone (code T40.4; monthly data available from 39 States, plus New York City and Washington DC), for June 2019-November 2021. Data were first examined as crude mortality rates. The presence of a maximum plateau was analyzed for the last 4 months of available data. For authorities in which a plateau in mortality was detected, sigmoidal Boltzmann equations were used to model parameters of this phenomenon (e.g., level of the plateau). Results: At the end of the study period, all but one authority (New Hampshire) reported increases in mortality rates for synthetic opioids, compared to the baseline month of June 2019 (range: 111-745% of baseline). A plateau was observed over the last 4 months of the study period (Aug 2021-Nov 2021) in 29 of the authorities. Ten other authorities had not reached a stable plateau at the end of the study period. For the authorities where a plateau was detected, a sigmoidal Boltzmann model revealed a fitted maximum of 262% rise in mortality over the study period, from the baseline month. The midpoint in the rise in mortality was fitted in September 2020. After separation of data into census regions, the highest plateau was observed in the West region, followed by South, Midwest, and Northeast (fitted plateau values were 409, 262, 204, and 149% of baseline, respectively). Discussion: There were increases in overdose mortality due to synthetic opioids across most states, ranging considerably in magnitude. A plateau in overdose mortality was detected at the end of the study period in most of these authorities. The reasons for these plateaus should be explored, in order to develop optimized public health interventions.

Bidirectional influence of heroin and cocaine escalation in persons with dual opioid and cocaine dependence diagnoses.

Persons with dual severe opioid and cocaine use disorders are at risk of considerable morbidity, and the bidirectional relationship of escalation of mu-opioid agonists and cocaine use is not well understood. The aim of this study was to examine the bidirectional relationship between escalation of heroin and cocaine use in volunteers dually diagnosed with opioid and cocaine dependence (OD + CD). Volunteers from New York with OD + CD (total n = 295; male = 182, female = 113; age ≥ 18 years) were interviewed with the Structured Clinical Interview for the DSM-IV Axis I Disorders and Kreek-McHugh-Schluger-Kellogg scales for dimensional measures of drug exposure, which also collect ages of 1st use and onset of heaviest use. Time of escalation was defined as age of onset of heaviest use minus age of 1st use in whole years. Times of escalation of heroin and cocaine were positively correlated in both men (Spearman r = .34, 95% confidence interval [CI: .17, .48], p < .0001) and women (Spearman r = .51, [.27, .50], p < .0001) volunteers. After we adjusted for demographic variables, a Cox regression showed that time of cocaine escalation was a predictor of time of heroin escalation (hazard ratio [HR] = 0.97, 95% CI [0.95, 0.99], p = .003). Another Cox regression showed that this relationship is bidirectional, because time of heroin escalation was also a predictor of time of cocaine escalation (HR = 0.98, [0.96-0.99], p = .016). In these adjusted models, gender was not a significant predictor of time of escalation of either heroin or cocaine. Therefore, escalation did not differ robustly by gender when adjusting for demographics and other major variables. Overall, rapid escalation of cocaine use was a predictor of rapid escalation of heroin use, and vice versa, in persons with dual severe opioid and cocaine use disorders. These findings suggest a shared vulnerability to rapid escalation of these 2 drugs in persons with dual severe opioid and cocaine use disorders. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Age of onset of heaviest use of cannabis or alcohol in persons with severe opioid or cocaine use disorders.

BACKGROUND: Persons with severe opioid or cocaine use disorders are particularly vulnerable to morbidity and mortality. Heaviest use of mu-opioid receptor agonists and cocaine typically commences in early adulthood and is preceded by substantial adolescent exposure to cannabis and/or alcohol. Little information exists on the age trajectories of exposure to cannabis or alcohol in persons diagnosed with severe opioid or cocaine use disorders, compared to persons diagnosed with other substance use disorders (unrelated to opioids or cocaine). METHOD: This observational study had n = 854 volunteers (male = 581, female = 273; ≥18 years of age at the time of interview) and examined the ages of onset of heaviest use of cannabis and alcohol in persons diagnosed by DSM-IV criteria with opioid dependence (OD), both opioid and cocaine dependence (OD + CD) and cocaine dependence (CD). These age trajectory measures were compared to persons with other substance use disorders (primarily cannabis and alcohol use disorders, termed "Any Other Diagnoses"). RESULTS: Unadjusted survival analyses showed persons diagnosed with either OD + CD or CD had earlier onset of heaviest use of cannabis (mean ages of 16.2 and 17.8, respectively) compared to the "Any Other Diagnoses" reference group (mean age = 19.5). A multivariate logistic regression showed that later onset of heaviest use of cannabis was associated with lower odds of being in the OD + CD or CD groups, when compared to the reference group. CONCLUSIONS: Persons diagnosed with severe cocaine use disorders or dual opioid and cocaine use disorders exhibit a pattern of heavy and especially early adolescent exposure to cannabis, compared to persons with other substance use disorders.

Are trait impulsivity and exposure to cannabis or alcohol associated with the age of trajectory of cocaine use? A gender-specific dimensional analysis in humans with cocaine dependence diagnosis.

Cocaine use disorders (CUD) cause major morbidity and optimized prevention efforts are critical. It is unclear if trait impulsivity and exposure to cannabis or alcohol are associated with age trajectory of cocaine use (e.g., age of onset of heaviest use, or time of escalation), or with vulnerability to develop a CUD. This is an observational study with volunteers (≥ 18 years old), from a metropolitan area. The sample (n = 1,010) included: n = 360 normal volunteers, n = 438 with cocaine dependence (CD) diagnoses, and n = 212 with other addictive diseases. Trait impulsivity was examined with BIS-11 scores. Maximal self-exposure to cannabis, alcohol, and cocaine were characterized dimensionally with Kreek-McHugh-Schluger-Kellogg (KMSK) scales. Time of escalation was defined as the interval between age of first use and age of onset of heaviest use. Onset of maximal use of cannabis (median age = 17) and alcohol (median age = 21) preceded that of cocaine (median age = 27), in volunteers with CD. Multivariate Cox regressions in volunteers with CD show that increasing self-exposure to cannabis was a predictor of earlier onset of heaviest use of cocaine. Also, more rapid time of escalation of alcohol was a predictor of more rapid time of escalation of cocaine. A multiple logistic regression shows that increasing self-exposure to cannabis or alcohol was a positive predictor of odds of CD diagnosis. Trait impulsivity and gender were not significant predictors in these multivariate analyses. This study shows that aspects of adolescent exposure to nonmedical cannabis and alcohol are predictors of early onset of CUD, and may be potentially targeted for prevention efforts. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Escalation of drug use in persons dually diagnosed with opioid and cocaine dependence: Gender comparison and dimensional predictors.

BACKGROUND: Persons dually diagnosed with opioid and cocaine dependence (OD + CD) present a clinical challenge and are at risk of morbidity and mortality. The time of escalation of heroin and cocaine exposure in persons with OD + CD remain understudied, and the influence of gender and other variables have not been examined. This observational study focused on the time of escalation of heroin and cocaine in volunteers with OD + CD, examining gender and exposure to other drugs (e.g., cannabis or alcohol) as predictors. Ages of first use and of onset of heaviest use of each drug were collected (in whole years). Time of escalation was defined as the interval between age of first use and onset of heaviest use. VOLUNTEERS: sequentially ascertained adult volunteers recruited from the New York Metropolitan area, of which n = 297 were diagnosed with OD + CD. METHODS: Instruments administered were the SCID-I diagnostic interview (DSM-IV criteria), BIS-11 impulsiveness scale, and KMSK scales, dimensional measures of maximal exposure to specific drugs. RESULTS: In volunteers with OD + CD, ages of onset of heaviest use of cannabis (median age = 15) and alcohol (median age = 19) were in adolescence or emerging adulthood and preceded those for heroin and cocaine (median ages = 26 and 25, respectively). Maximal levels of cannabis and alcohol exposure were high, in volunteers with OD + CD. In adjusted Cox regressions, gender was not a significant predictor of time of heroin or cocaine escalation. However, more rapid time of alcohol escalation was a predictor of more rapid time of escalation of both heroin and cocaine, in volunteers with OD + CD.

Re-evaluation of the KMSK scales, rapid dimensional measures of self-exposure to specific drugs: Gender-specific features.

BACKGROUND: The Kreek-McHugh-Schluger-Kellogg (KMSK) scales provide a rapid assessment of maximal self-exposure to specific drugs and can be used as a dimensional instrument. This study provides a re-evaluation of the KMSK scales for cannabis, alcohol, cocaine, and heroin in a relatively large multi-ethnic cohort, and also the first systematic comparison of gender-specific profiles of drug exposure with this scale. METHODS: This was an observational study of n = 1,133 consecutively ascertained adult volunteers. The main instruments used were the SCID-I interview (DSM-IV criteria) and KMSK scales for cannabis, alcohol, cocaine, and heroin. RESULTS: Participants were 852 volunteers (297 female) with specific DSM-IV abuse or dependence diagnoses, and 281 volunteers without any drug diagnoses (154 female). Receiver operating characteristic (ROC) curves were calculated for concurrent validity of KMSK scores with the respective DSM-IV dependence diagnoses. The areas under the ROC curves for men and women combined were 99.5% for heroin, 97% for cocaine, 93% for alcohol, and 85% for cannabis. Newly determined optimal KMSK "cutpoint" scores were identical for men and women for cocaine and heroin dependence diagnoses, but were higher in men than in women, for cannabis and alcohol dependence diagnoses. CONCLUSIONS: This study confirms the scales' effectiveness in performing rapid dimensional analyses for cannabis, alcohol, cocaine, and heroin exposure, in a cohort larger than previously reported, with "cutpoints" changed from initial determinations, based on this larger sample. The KMSK scales also detected gender differences in self-exposure to alcohol and cannabis that are associated with the respective dependence diagnoses.

Non-medical Cannabis Self-Exposure as a Dimensional Predictor of Opioid Dependence Diagnosis: A Propensity Score Matched Analysis.

Background: The impact of increasing non-medical cannabis use on vulnerability to develop opioid use disorders has received considerable attention, with contrasting findings. A dimensional analysis of self-exposure to cannabis and other drugs, in individuals with and without opioid dependence (OD) diagnoses, may clarify this issue. Objective: To examine the age of onset of maximal self-exposure to cannabis, alcohol, cocaine, and heroin, in volunteers diagnosed with OD, using a rapidly administered instrument (the KMSK scales). To then determine whether maximal self-exposure to cannabis, alcohol, and cocaine is a dimensional predictor of odds of OD diagnoses. Methods: This outpatient observational study examined maximal self-exposure to these drugs, in volunteers diagnosed with DSM-IV OD or other drug diagnoses, and normal volunteers. In order to focus more directly on opioid dependence diagnosis as the outcome, volunteers who had cocaine dependence diagnoses were excluded. Male and female adults of diverse ethnicity were consecutively ascertained from the community, and from local drug treatment programs, in 2002-2013 (n = 574, of whom n = 94 had OD diagnoses). The age of onset of maximal self-exposure of these drugs was examined. After propensity score matching for age at ascertainment, gender, and ethnicity, a multiple logistic regression examined how increasing self-exposure to non-medical cannabis, alcohol and cocaine affected odds of OD diagnoses. Results: Volunteers with OD diagnoses had the onset of heaviest use of cannabis in the approximate transition between adolescence and adulthood (mean age = 18.9 years), and onset of heaviest use of alcohol soon thereafter (mean age = 20.1 years). Onset of heaviest use of heroin and cocaine was detected later in the lifespan (mean ages = 24.7 and 25.3 years, respectively). After propensity score matching for demographic variables, we found that the maximal self-exposure to cannabis and cocaine, but not to alcohol, was greater in volunteers with OD diagnoses, than in those without this diagnosis. Also, a multiple logistic regression detected that increasing self-exposure to cannabis and cocaine, but not alcohol, was a positive predictor of OD diagnosis. Conclusions/Importance: Increasing self-exposure to non-medical cannabis, as measured with a rapid dimensional instrument, was a predictor of greater odds of opioid dependence diagnosis, in propensity score-matched samples.