Opioid use disorder (OUD) is a chronic relapsing disorder that, whilst initially driven by activation of brain reward neurocircuits, increasingly engages anti-reward neurocircuits that drive adverse emotional states and relapse. However, successful recovery is possible with appropriate treatment, although with a persisting propensity to relapse. The individual and public health burdens of OUD are immense; 26.8 million people were estimated to be living with OUD globally in 2016, with >100,000 opioid overdose deaths annually, including >47,000 in the USA in 2017. Well-conducted trials have demonstrated that long-term opioid agonist therapy with methadone and buprenorphine have great efficacy for OUD treatment and can save lives. New forms of the opioid receptor antagonist naltrexone are also being studied. Some frequently used approaches have less scientifically robust evidence but are nevertheless considered important, including community preventive strategies, harm reduction interventions to reduce adverse sequelae from ongoing use and mutual aid groups. Other commonly used approaches, such as detoxification alone, lack scientific evidence. Delivery of effective prevention and treatment responses is often complicated by coexisting comorbidities and inadequate support, as well as by conflicting public and political opinions. Science has a crucial role to play in informing public attitudes and developing fuller evidence to understand OUD and its associated harms, as well as in obtaining the evidence today that will improve the prevention and treatment interventions of tomorrow. The ongoing epidemic of opioid use disorder includes, in addition to increasing global use of illicitly manufactured heroin and other opioids, a public health crisis aggravated by the over-prescribing of opioid pain medications, in North America particularly. This Primer by Strang, Volkow and colleagues discusses the risk factors of opioid use disorder, together with its epidemiology, mechanisms, diagnosis and treatment.

Opioid use disorder.

Substance use was considered to be primarily a male problem, and many substance abuse studies are conducted with a predominance of male participants. However, recent substance abuse research indicates significant gender differences in the substance-related epidemiology, social factors and characteristics, biological responses, progressions to dependence, medical consequences, co-occurring psychiatric disorders, and barriers to treatment entry, retention, and completion. The epidemiology of women's drug use presents challenges separate from those raised by men's drug use. A convergence of evidence suggests that women with substance use disorders are more likely than men to face multiple barriers affecting access and entry to substance abuse treatment. Gender-specific medical problems as a result of the interplay of gender-specific drug use patterns and sex-related risk behaviors create an environment in which women are more vulnerable than men to human immunodeficiency virus. Individual characteristics and treatment approaches can differentially affect outcomes by gender. All of these differences have important clinical, treatment, and research implications.

Women and Addiction: The Importance of Gender Issues in Substance Abuse Research

Prior efforts to estimate U.S. prevalence of substance use disorders (SUDs) in HIV care have been undermined by caveats common to single-site trials. The current work reports on a cohort of 10,652 HIV-positive adults linked to care at seven sites, with available patient data including geography, demography, and risk factor indices, and with substance-specific SUDs identified via self-report instruments with validated diagnostic thresholds. Generalized estimating equations also tested patient indices as SUD predictors. Findings were: (1) a 48 % SUD prevalence rate (between-site range of 21–71 %), with 20 % of the sample evidencing polysubstance use disorder; (2) substance-specific SUD rates of 31 % for marijuana, 19 % alcohol, 13 % methamphetamine, 11 % cocaine, and 4 % opiate; and (3) emergence of younger age and male gender as robust SUD predictors. Findings suggest high rates at which SUDs occur among patients at these urban HIV care sites, detail substance-specific SUD rates, and identify at-risk patient subgroups.

/pdf/prevalence-and-predictors-of-substance-use-disorders-among-2s2549ohjg.pdf

Prevalence and Predictors of Substance Use Disorders Among HIV Care Enrollees in the United States

Information on the direct and indirect effects of buprenorphine (BUP) on the fetus is essential for determining its potential for treatment of the pregnant opiate addict. The goal of this investigation is to determine the transplacental transfer of BUP to the fetal circulation, its metabolism, and effects on the tissue. The technique of dual perfusion of placental lobule is used. The range of BUP concentrations investigated included its peak plasma levels (10 ng/ml) in patients under treatment. A biphasic decline in concentration of the drug in the maternal circulation was observed, initially rapid then slow. During the initial (60 min), the tissue sequestered most of BUP resulting in a low (<10%) transplacental transfer of the drug to the fetal circulation. The concentration ratios of the drug in tissue/maternal and tissue/fetal were 13 ± 6.5 and 27.4 ± 0.4. The drug sequestered did not have any adverse effects on placental tissue viability and functional parameters. Less than 5% of the perfused BUP was metabolized to norbuprenorphine during the 4 h of perfusion and the metabolite was distributed between the tissue, maternal, and fetal circulations. Taken together, these data suggest that the therapeutic levels of BUP in the maternal circulation may have no indirect effects (via the placenta) on the fetus. The observed low transplacental transfer of BUP to the fetal circuit may explain the moderate/absence of neonatal withdrawal in the limited number of reports on mothers treated with the drug during pregnancy.

* BUP
 : buprenorphine
 CYP
 : cytochrome P450
 hCG
 : human chorionic gonadotropin
 AP
 : antipyrine
 AUC
 : area under the concentration-time curve
 norBUP
 : norbuprenorphine
 HPLC
 : high-performance liquid chromatography

Transplacental Transfer and Metabolism of Buprenorphine

The presence of depression in alcohol-dependent persons is likely to influence treatment process and outcomes Identification of depression is important though not every depressed alcohol-dependent person requires treatment with antidepressants Understanding the association between depression and alcohol dependence is essential for proper management of alcohol dependence Objectives To determine the prevalence of depression among alcohol-dependent persons before and after alcohol detoxification and rehabilitation Design Clinical trial with pre-/postmeasurements Method The CIDI and WHO-ASSIST were administered to 188 alcohol-dependent persons at intake and after six months A researcher-designed sociodemographic questionnaire was also administered at intake Results The prevalence of depression among alcohol-dependent persons is high (638%) with a significant association between depression and the mean AUDIT score At posttest, depressed participants had a statistically significant craving for alcohol Conclusion Alcohol dependence is associated with major depression

https://downloads.hindawi.com/archive/2012/482802.pdf

The Association between Alcohol Dependence and Depression before and after Treatment for Alcohol Dependence

NIDA Guide Details Research-Based Principles of Drug Addiction Treatment

Heroin Snorters Risk Transition To Injection Drug Use And Infectious Disease

NIDA Clinical Trials Network Begins First Multisite Tests of New Science-Based Drug Abuse Treatments

"Ecstasy" Damages the Brain and Impairs Memory in Humans

substances also suffer from posttraumatic stress disorder (PTSD) related to life-threatening or other traumatic events they have experienced or witnessed. Individuals with PTSD suffer recurring flashbacks, anxiety, and other symptoms that can impede substance abuse treatment. Similarly, substance abuse can make PTSD symptoms worse. Thus, integrated treatment is recommended as the way to treat patients with both disorders. Yet until recently, the most effective nonpharmacological treatment for PTSD, known as exposure therapy, was considered too risky to use with cocaine-dependent patients. The therapy seeks to desensitize patients to the distressing emotional effects of the trauma that triggered their PTSD by requiring them to repeatedly and graphically describe it. “Researchers and clinicians have been reluctant to use exposure therapy with cocaine-dependent patients,” says Dr. Kathleen Brady of the Medical University of South Carolina in Charleston. “Drug abuse patients were thought to be likely to turn to alcohol and drugs to cope with the emotional demands placed on them by recounting the fear-inducing experience.”

http://www.ntakd.lt/files/informacine_medzega/4-NIDA_informacine_medziaga/4-NIDA_zinios/18-1.pdf

Joint Treatment of PTSD and Cocaine Abuse May reduce Severity of Both Disorders

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