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BACKGROUND: Patients presenting for treatment of substance use disorders (SUDs) often exhibit medical comorbidities that affect functional health status and healthcare costs. Providing primary care within addictions clinics (onsite care) may improve medical and SUD treatment outcomes in this population. OBJECTIVE: The objective of this study was to compare outcomes among Veterans' Administration (VA) patients who receive medical care within the SUD clinic and those referred to a general medicine clinic at the same facility. METHODS: Veterans entering SUD treatment with a chronic medical condition and no current primary care were randomized to receive primary medical care: 1) onsite in the VA SUD clinic (n = 358), or 2) in the VA general internal medicine clinic (n = 362). Subjects were assessed at baseline and at 3, 6, and 12 months postrandomization. Intention-to-treat analyses used random-effects regression. MEASURES: Measures included SF-36 Physical and Mental Component Summaries (PCS, MCS), VA service utilization, SUD treatment retention, Addiction Severity Index (ASI) scores, 30-day abstinence, and total VA healthcare costs. RESULTS: Over the study year, patients assigned to onsite care were more likely to attend primary care (adjusted odds ratio [OR] = 2.20; 95% confidence interval [CI] = 1.53-3.15) and to remain engaged in SUD treatment at 3 months (adjusted OR = 1.36; 1.00-1.84). Overall, outcomes on the MCS (but not the PCS) and the ASI improved significantly over time but did not differ by treatment condition. Total VA healthcare costs did not differ reliably across conditions. CONCLUSIONS: Compared with referral care, providing primary care within a VA addiction clinic increased primary care access and initial SUD treatment retention but showed no effect on overall health status or costs. [ABSTRACT FROM AUTHOR]

Abstract: In the United States, cannabis is increasingly used to manage chronic pain. Veterans Health Administration (VHA) patients are disproportionately affected by pain and may use cannabis for symptom management. Because cannabis use increases the risk of cannabis use disorders (CUDs), we examined time trends in CUD among VHA patients with and without chronic pain, and whether these trends differed by age. From VHA electronic health records from 2005 to 2019 (∼4.3-5.6 million patients yearly), we extracted diagnoses of CUD and chronic pain conditions ( International Classification of Diseases [ ICD ]- 9-CM , 2005-2014; ICD-10-CM , 2016-2019). Differential trends in CUD prevalence overall and age-stratified (<35, 35-64, or ≥65) were assessed by any chronic pain and number of pain conditions (0, 1, or ≥2). From 2005 to 2014, the prevalence of CUD among patients with any chronic pain increased significantly more (1.11%-2.56%) than those without pain (0.70%-1.26%). Cannabis use disorder prevalence increased significantly more among patients with chronic pain across all age groups and was highest among those with ≥2 pain conditions. From 2016 to 2019, CUD prevalence among patients age ≥65 with chronic pain increased significantly more (0.63%-1.01%) than those without chronic pain (0.28%-0.47%) and was highest among those with ≥2 pain conditions. Over time, CUD prevalence has increased more among VHA patients with chronic pain than other VHA patients, with the highest increase among those age ≥65. Clinicians should monitor symptoms of CUD among VHA patients and others with chronic pain who use cannabis, and consider noncannabis therapies, particularly because the effectiveness of cannabis for chronic pain management remains inconclusive., (Copyright © 2023 International Association for the Study of Pain.)

Abstract: Chronic pain is associated with mental and physical health difficulties and is prevalent among veterans. Cannabis has been put forth as a treatment for chronic pain, and changes in laws, attitudes, and use patterns have occurred over the past 2 decades. Differences in prevalence of nonmedical cannabis use and cannabis use disorder (CUD) were examined across 2 groups: veterans or nonveterans and those reporting or not reporting recent pain. Data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (2012-2013; n = 36,309) were analyzed using logistic regression. Prevalence differences (PDs) for 3 cannabis outcomes (1) past-year nonmedical cannabis use, (2) frequent (≥3 times a week) nonmedical use, and (3) DSM-5 CUD were estimated for those reporting recent moderate to severe pain (veterans or nonveterans) and veterans reporting or not reporting recent pain. Difference in differences was calculated to investigate PDs on outcomes associated with residence in a state with medical cannabis laws (MCLs). Associations between physical and mental health and cannabis variables were tested. The results indicated that the prevalence of recent pain was greater among veterans (PD = 7.25%, 95% confidence interval (CI) [4.90-9.60]). Among veterans, the prevalence of frequent cannabis use was greater among those with pain (PD = 1.92%, 98% CI [0.21-3.63]), and among veterans residing in a state with MCLs, the prevalence of CUD was greater among those reporting recent pain (PD = 3.88%, 98% CI [0.36-7.39]). Findings failed to support the hypothesis that cannabis use improves mental or physical health for veterans with pain. Providers treating veterans with pain in MCL states should monitor such patients closely for CUD., (Copyright © 2021 International Association for the Study of Pain.)

Purpose of Review: Cocaine is a highly addictive substance with serious medical and mental health consequences. Despite these concerns, there are no Food and Drug Administration-approved medications for the treatment of cocaine use disorder (CUD). Although many medication-assisted treatments (MATs) have been investigated, no clear guidelines exist for clinicians treating patients with CUDs., Recent Findings: There are a limited number of recent data examining MATs for CUD. Multiple high-quality reviews of existing literature have been performed with psychostimulants, modafinil, bupropion, topiramate and disulfiram showing the most promise. Evidence is limited by heterogeneity of studies, small sample sizes and inconsistent results., Summary: The current literature does not strongly support any individual MAT for CUD. Psychosocial interventions, namely contingency management, have the most evidence for treatment of CUD, but it is worth seriously considering MAT for patients who do not respond well to psychosocial interventions alone given limitations in access to care, relatively low risks associated with MAT and significant morbidity associated with CUD. Further research into MAT for CUD is necessary, as the combination of MAT and psychosocial interventions may be better than either alone.

Background: Over the past decade, overdoses involving opioids and benzodiazepines have risen at alarming rates, making reductions in coprescribing of these medications a priority, particularly among patients who may be susceptible to adverse events due to high-risk conditions., Objectives: This quality improvement project evaluated the effectiveness of a medication alert designed to reduce opioid and benzodiazepine coprescribing among Veterans with known high-risk conditions (substance use, sleep apnea, suicide-risk, age 65 and above) at 1 Veterans Affairs (VA) health care system., Methods: Prescribers were exposed to the point-of-prescribing alert for 12 months. For each high-risk cohort we used interrupted time series design to examine population trends in coprescribing 12 months after alert launch adjusting for coprescribing 12 months before launch, demographics and clinical covariates. Trends at the alert site were compared with those of a similar VA health care system without the alert. Secondary analyses examined population trends in opioid and benzodiazepine prescribing separately., Results: Over 12 months, the alert activated for 1332 patients. Proportions of patients with concurrent prescriptions decreased significantly postalert launch among substance use [adjusted odds ratio (AOR)=0.97; 95% confidence interval (CI)=0.96-0.99; 12-month decrease=25.0%], sleep apnea (AOR=0.97, 95% CI=0.95-0.98, 12-month decrease=38.5%), and suicide-risk (AOR=0.94, 95% CI=0.91-0.98, 12-month decrease=61.5%) cohorts at the alert site. Decreases in coprescribing were significantly different from the comparison site among suicide-risk (AOR=0.92, 95% CI=0.86-0.97) and sleep apnea (AOR=0.98, 95% CI=0.96-1.00) cohorts. Significant decreases in benzodiazepine prescribing trends were observed at the alert site only., Conclusions: Medication alerts hold promise as a means of reducing opioid and benzodiazepine coprescribing among certain high-risk groups.

Objective: The completion of the human genome sequence has spurred investigation of the genetic contribution to substance dependence. In this article some of the recent scientific evidence for genetic determinants of opioid and cocaine dependence is reviewed., Method: An electronic search of the medical literature was conducted to locate published studies relevant to the genetics of opioid and cocaine dependence. The collected information judged to be most pertinent is described and discussed., Results: Genetic epidemiologic studies support a high degree of heritable vulnerability for both opioid and cocaine dependence. Polymorphisms in the genes coding for dopamine receptors and transporter, opioid receptors, endogenous opioid peptides, cannabinoid receptors, and serotonin receptors and transporter all appear to be associated with the phenotypic expression of this vulnerability once opioids or cocaine are consumed., Conclusions: Despite this initial progress, identification of specific genes and quantification of associated risk for the expression of each gene remain to be elucidated. While alteration of an individual's genome to change the phenotype seems remote, future interventions for treatment of opioid and cocaine dependence may include precise medications targeted to block the effects of proteins that have been identified through genetic research.

Methamphetamine (MA) abuse is increasing to epidemic proportions, both nationally and globally. Chronic MA use has been linked to significant impairments in different arenas of neuropsychological function. To better understand this issue, a computerized literature search (PubMed, 1964-2004) was used to collect research studies examining the neurobiological and neuropsychiatric consequences of chronic MA use. Availability of MA has markedly increased in the United States due to recent technological improvements in both mass production and clandestine synthesis, leading to significant public health, legal, and environmental problems. MA intoxication has been associated with significant psychiatric and medical comorbidity. Research in animal models and human subjects reveals complicated mechanisms of neurotoxicity by which chronic MA use affects catecholamine neurotransmission. This pathology may underlie the characteristic cognitive deficits that plague chronic MA users, who experience impairments in memory and learning, psychomotor speed, and information processing. These impairments have the potential to compromise, in turn, the ability of MA abusers to engage in, and benefit from, psychosocially based chemical-dependency treatment. Development of pharmacological interventions to improve these cognitive impairments in this population may significantly improve the degree to which they may be able to participate in treatment. Atypical antipsychotics may have some promise in this regard.

Little normative data exist about the frequency and variety of sexual behavior of injection drug users. Sexual behaviors of a group of 313 injection drug users (225 men and 88 women) were assessed by a structured interview at the start of an acquired immune deficiency syndrome prevention project. Celibacy was reported by 12.3% of men and 26.9% of women in the year before the initial interview. Male injection drug users who had been sexually active reported a mean number of 4.61 (median, 2.0) female sexual partners in the previous year; sexually active women reported a mean number of 5.28 (median, 1.0) male sexual partners. Sexually active men and women reported median condom use frequency at 0% of vaginal intercourse events (mean for men, 10.31%; mean for women, 14.48%). Male injection drug users who reported using drugs to help them relax for sex, to enhance sexual performance, or to meet sexual partners reported greater frequency of anal intercourse, fellatio, and cunnilingus, less relative frequency of vaginal intercourse, more sexual partners, and greater involvement in being paid for sex and paying for sex than did men who did not report using drugs to enhance sex. Men who used drugs to enhance sex also reported higher frequency of use of a number of different drug classes than men who did not use drugs to enhance sex. For women, using drugs to enhance sex was related to greater frequency of anal intercourse and having more sexual partners. Implications for treatment of drug abusers and future research are discussed.

Objective: To determine whether injection drug users (IDU) maintained sexual behavior risk reduction over an 18-month period that had been noted previously over a 4-month period., Design: A repeated measures design was utilized with IDU assessed initially at study enrollment and again 18 months later., Methods: Sexual behaviors of a group of 220 IDU (148 men and 72 women) were assessed by a structured interview at the start of an AIDS prevention project and again 18 months later., Results: Having multiple sex partners during the 12 months before initial assessment was reported by 42.6% of the men and 35.7% of the women. Significantly fewer had multiple sex partners during the 10 months before follow-up assessment (men, 20.9%; women, 14.3%). Condom use for vaginal intercourse increased from a mean of 11.9% initially to 27.8% at follow-up for men. The increase in condom use was greater for those with multiple sex partners. Women did not report significant increases in condom use. Continued involvement in unsafe sexual behaviors was associated with exchanging sex for money or drugs, using drugs to help meet sexual needs, alcohol use and drug use., Conclusions: Risk reductions noted previously were maintained over 18 months for the majority of the sample. Drug-use treatment and interventions that closely examine the interplay between drug use and sexuality for individual IDU are recommended as strategies to further reduce the sexual risk of HIV transmission among IDU.

The urinalysis practices of 324 methadone maintenance clinics were surveyed using a brief self-report questionnaire. Results indicate that there is wide variability in collection practices and clinic responses to positive findings. Virtually all clinics provide counseling and revocation of take-home methadone doses as a response to positive urinalysis results. However, increase in urine screening frequency, methadone dose adjustments, contingency contracting, group therapy, and eventual discharge are interventions also used. The implementation of different interventions varied as a function of clinic size, city size, region of the country, and program funding source.

Needle-use practices of intravenous drug users (IVDUs) were examined in a region (Seattle, King Country, Washington State, USA) where needle purchase is legal. IVDUs in treatment (n = 313) were administered extensive structured interviews concerning drug and injection equipment-use practices. Of the 80.2% reporting intravenous drug use in the previous year, 78.3% reported sharing needles. Of the 47.7% reporting intravenous use in the previous 30 days, only 40.5% shared needles, with 59.3% sharing with only one other person. Most needle-sharing partners were very well known (63%) or well known (17%) to the subjects. The most frequent method for obtaining needles was 'buying in a drug store', ranked first by 65% of the sample. Subjects whose primary source was 'buying in a drug store' shared equipment less frequently during drug-use events in the previous year (mean: 16.2%) than those with other primary sources (mean: 28.5%). Compared with findings from other regions where needle purchase and possession are illegal without a prescription, fewer subjects in the current investigation shared needles, and those who did shared with a smaller number of people. The apparent association between legalized injection equipment and reduced sharing of equipment among IVDUs should be further examined in longitudinal studies of needle-sharing before and after legalization is instituted.