Publications by authors named "John Strang"

276 Publications

Abuse-deterrent extended-release oxycodone and risk of opioid-related harm.

Addiction 2021 Sep 22. Epub 2021 Sep 22.

Department of Psychiatry, Oxford University, UK.

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http://dx.doi.org/10.1111/add.15667DOI Listing
September 2021

Emotional reactions of trained overdose responders who use opioids following intervention in an overdose event.

Subst Abus 2021 Sep 14:1-11. Epub 2021 Sep 14.

Division on Substance Use Disorders, New York State Psychiatric Institute & Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, USA.

Background: Our aim was to explore emotional reactions to intervening in an overdose event from the perspective of individuals who use opioids (peer responders). In addition, we were interested in the impact this experience may have on peer responders' feelings about helping in an overdose situation in the future. For this qualitative sub-study of a randomized controlled trial (RCT), data from 61 interviews were analyzed thematically using an inductive approach. Peer responders had diverse emotional reactions to the overdose event. These ranged from a sense of pride and other positive feelings associated with their ability to help to ambivalence about being involved in situations perceived as challenging and burdensome. There were few reports of the overdose event as an exclusively negative experience. Many peer responders perceived it as their duty to use naloxone again if required. However, some had ambivalent feelings toward this responsibility, which may be related to negative experiences with previous intervention efforts. The capacity of people who use opioids to help reduce the harms associated with opioid overdose is experienced as empowering by some. Nonetheless, engaging peer responders in strategies to reduce opioid-related mortality should be coupled with appropriate resources to process their experiences and emotional responses.
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http://dx.doi.org/10.1080/08897077.2021.1975870DOI Listing
September 2021

Testosterone treatment, internalizing symptoms, and body image dissatisfaction in transgender boys.

Psychoneuroendocrinology 2021 Jul 17;132:105358. Epub 2021 Jul 17.

Center for Biobehavioral Health, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA; Department of Pediatrics, Ohio State University Wexner College of Medicine, Columbus, OH, USA.

Objective: Many transgender adolescents experience clinically elevated anxiety and depression. Testosterone (T), used as a gender affirming treatment, may reduce symptoms of anxiety and depression. We assessed the effect of gender affirming T treatment on internalizing symptoms, body image dissatisfaction, and activation patterns within the amygdala-prefrontal cortex circuit in transgender adolescent boys.

Method: Symptoms of generalized anxiety, social anxiety, depression, suicidality and body image dissatisfaction were measured by self-report and brain activation was measured during a face processing task with functional MRI in a group of 19 adolescent transgender boys receiving T treatment and 23 not receiving gonadal hormone treatment (UT).

Results: Severity of anxiety and depression was significantly lower in the T treated group relative to the UT group, along with a trend of lower suicidality. The T group also reported less distress with body features and exhibited stronger connectivity within the amygdala-prefrontal cortex circuit compared to the UT group. Finally, group differences on depression and suicidality were directly associated with body image dissatisfaction, and anxiety symptoms were moderated by amygdala-prefrontal cortex connectivity differences between groups.

Conclusion: T treatment is associated with lower levels of internalizing symptoms among transgender adolescent boys. T is also associated with greater body satisfaction and greater connectivity in a neural circuit associated with anxiety and depression. Satisfaction with body image was found to overlap with the association between T and both depression and suicidality, and amygdala-prefrontal co-activation moderated the role of T on anxiety.
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http://dx.doi.org/10.1016/j.psyneuen.2021.105358DOI Listing
July 2021

Adding the missing voice: How self-report of autistic youth self-report on an executive functioning rating scale compares to parent report and that of youth with attention deficit hyperactivity disorder or neurotypical development.

Autism 2021 Jul 9:13623613211029117. Epub 2021 Jul 9.

The George Washington University, USA.

Lay Abstract: Executive functions are often impaired in autistic people and relate to important outcomes such as mental health, success in school and work, and quality of life. Evaluating executive functions helps autistic people, clinicians, and families identify targets for external supports and skill building. Youth self-report of executive function has not been studied, yet we know that self-report from autistic youth is key to understanding other cognitive/behavioral phenomena in autism such as anxiety, obsessions/compulsions, sensory sensitivities, and repetitive behaviors. We investigated self- and parent-report of executive function problems in 197 autistic youth without intellectual disability (ages 11-18 years), including the magnitude and profiles of executive function problems autistic youth report across subdomains of executive function. We compared autistic self-report with that of 114 youth with attention deficit hyperactivity disorder without intellectual disability and 197 neurotypical youth. We found that autistic youth report significant executive function problems compared to neurotypical youth and a distinctive profile of challenges in comparison to attention deficit hyperactivity disorder youth. Parents and their autistic children diverged regarding the magnitude of the youth's executive function difficulties, but both identify inflexibility as the most impaired executive function subdomain. Autistic youth and their parents were somewhat more concordant in their report of executive function problems than youth with attention deficit hyperactivity disorder and their parents, but only showed moderate concordance at best. These findings elevate the importance of asking autistic youth directly about their executive functioning when engaging them in assessment and intervention, or researching executive functions in autism.
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http://dx.doi.org/10.1177/13623613211029117DOI Listing
July 2021

Using a pragmatically adapted, low-cost contingency management intervention to promote heroin abstinence in individuals undergoing treatment for heroin use disorder in UK drug services (PRAISE): a cluster randomised trial.

BMJ Open 2021 07 1;11(7):e046371. Epub 2021 Jul 1.

Drug and Alcohol Services, Avon and Wiltshire Mental Health Partnership NHS Trust, Bath, UK.

Introduction: Most individuals treated for heroin use disorder receive opioid agonist treatment (OAT)(methadone or buprenorphine). However, OAT is associated with high attrition and persistent, occasional heroin use. There is some evidence for the effectiveness of contingency management (CM), a behavioural intervention involving modest financial incentives, in encouraging drug abstinence when applied adjunctively with OAT. UK drug services have a minimal track record of applying CM and limited resources to implement it. We assessed a CM intervention pragmatically adapted for ease of implementation in UK drug services to promote heroin abstinence among individuals receiving OAT.

Design: Cluster randomised controlled trial.

Setting And Participants: 552 adults with heroin use disorder (target 660) enrolled from 34 clusters (drug treatment clinics) in England between November 2012 and October 2015.

Interventions: Clusters were randomly allocated 1:1:1 to OAT plus 12× weekly appointments with: (1) CM targeted at opiate abstinence at appointments (CM Abstinence); (2) CM targeted at on-time attendance at appointments (CM Attendance); or (3) no CM (treatment as usual; TAU). Modifications included monitoring behaviour weekly and fixed incentives schedule.

Measurements: Primary outcome: heroin abstinence measured by heroin-free urines (weeks 9-12).

Secondary Outcomes: heroin abstinence 12 weeks after discontinuation of CM (weeks 21-24); attendance; self-reported drug use, physical and mental health.

Results: CM Attendance was superior to TAU in encouraging heroin abstinence. Odds of a heroin-negative urine in weeks 9-12 was statistically significantly greater in CM Attendance compared with TAU (OR=2.1; 95% CI 1.1 to 3.9; p=0.030). CM Abstinence was not superior to TAU (OR=1.6; 95% CI 0.9 to 3.0; p=0.146) or CM Attendance (OR=1.3; 95% CI 0.7 to 2.4; p=0.438) (not statistically significant differences). Reductions in heroin use were not sustained at 21-24 weeks. No differences between groups in self-reported heroin use.

Conclusions: A pragmatically adapted CM intervention for routine use in UK drug services was moderately effective in encouraging heroin abstinence compared with no CM only when targeted at attendance. CM targeted at abstinence was not effective.

Trial Registration Number: ISRCTN 01591254.
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http://dx.doi.org/10.1136/bmjopen-2020-046371DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8252884PMC
July 2021

Transgender Youth Executive Functioning: Relationships with Anxiety Symptoms, Autism Spectrum Disorder, and Gender-Affirming Medical Treatment Status.

Child Psychiatry Hum Dev 2021 Jun 19. Epub 2021 Jun 19.

Center for Neuroscience, Children's National Hospital, Washington, DC, USA.

Executive function (EF) underlies broad health and adaptive outcomes. For transgender youth, navigating gender discernment and gender affirmation demand EF. Yet, factors associated with transgender youth EF are unknown. We investigate hypothesized predictors of EF: over-represented conditions among transgender youth (anxiety and depression symptoms, autism spectrum disorder [ASD]) and gender-affirming care. One-hundred twenty-four transgender 11-21-year-olds participated. Parents/caregivers completed EF and mental health report measures. ASD diagnostics and gender-affirming medication histories were collected. 21 % of non-autistic and 69 % of autistic transgender youth had clinically elevated EF problems. Membership in the gender-affirming hormone treatment group was associated with better EF. ASD, anxiety symptoms, and membership in the long-duration pubertal suppression group were associated with poorer EF. Given the importance of EF skills for multiple outcomes, and the unique and additional EF demands specific to transgender youths' experiences, EF skill monitoring-and when appropriate, supports-should be considered for transgender youth.
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http://dx.doi.org/10.1007/s10578-021-01195-6DOI Listing
June 2021

In Addition to Stigma: Cognitive and Autism-Related Predictors of Mental Health in Transgender Adolescents.

J Clin Child Adolesc Psychol 2021 Jun 14:1-18. Epub 2021 Jun 14.

Center for Autism Spectrum Disorders, Division of Neuropsychology, Children's National Hospital.

: Autism spectrum disorder (ASD) is significantly over-represented among transgender adolescents. Independently, ASD and gender diversity are associated with increased mental health risks. Yet, mental health in autistic-transgender adolescents is poorly understood. This study investigates mental health in the largest matched sample to date of autistic-transgender, non-autistic (allistic) transgender, and autistic-cisgender adolescents diagnosed using gold-standard ASD diagnostic procedures. In accordance with advancing understanding of sex/gender-related autism phenotypes, slightly subthreshold autistic diagnostic presentations (common in autistic girls/women) are modeled.: This study includes 93 adolescents aged 13-21, evenly divided between autistic-transgender, autistic-cisgender, and allistic-transgender groups; 13 transgender adolescents were at the margin of ASD diagnosis and included within a larger "broad-ASD" grouping. Psychological and neuropsychological evaluation included assessment of mental health, IQ, LGBT stigma, ASD-related social symptoms, executive functioning (EF), and EF-related barriers to achieving gender-related needs.: Autistic-transgender adolescents experienced significantly greater internalizing symptoms compared to allistic-transgender and autistic-cisgender groups. In addition to stigma-related associations with mental health, ASD-related cognitive/neurodevelopmental factors (i.e., poorer EF and greater social symptoms) were associated with worse mental health: specifically, social symptoms and EF gender barriers with greater internalizing and EF problems and EF gender barriers with greater suicidality. Comparing across all ASD and gender-related groups, female gender identity was associated with greater suicidality.: Parsing the heterogeneity of mental health risks among transgender youth is critical for developing targeted assessments and interventions. This study identifies ASD diagnosis, ASD phenotypic characteristics, and EF-related gender barriers as potential risks for poorer mental health in transgender adolescents.
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http://dx.doi.org/10.1080/15374416.2021.1916940DOI Listing
June 2021

Gambling and COVID-19: Initial Findings from a UK Sample.

Int J Ment Health Addict 2021 Jun 4:1-12. Epub 2021 Jun 4.

Addictions Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 4 Windsor Walk, Camberwell, London, SE5 8AF UK.

In response to the COVID-19 pandemic, the UK Government placed society on 'lockdown', altering the gambling landscape. This study sought to capture the immediate lockdown-enforced changes in gambling behaviour. UK adults ( = 1028) were recruited online. Gambling behaviour (frequency and weekly expenditure, perceived increase/decrease) was measured using a survey-specific questionnaire. Analyses compared gambling behaviour as a function of pre-lockdown gambling status, measured by the Brief Problem Gambling Scale. In the whole sample, gambling participation decreased between pre- and during-lockdown. Both gambling frequency and weekly expenditure decreased during the first month of lockdown overall, but, the most engaged gamblers did not show a change in gambling behaviour, despite the decrease in opportunity and availability. Individuals whose financial circumstances were negatively affected by lockdown were more likely to perceive an increase in gambling than those whose financial circumstances were not negatively affected. Findings reflect short-term behaviour change; it will be crucial to examine, at future release of lockdown, if behaviour returns to pre-lockdown patterns, or whether new behavioural patterns persist.
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http://dx.doi.org/10.1007/s11469-021-00545-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8176872PMC
June 2021

The hospital admission profile of people presenting to specialist addiction services with problematic use of alcohol or opioids: A national retrospective cohort study in England.

Lancet Reg Health Eur 2021 Apr;3:100036

National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London and South London and the Maudsley NHS Foundation Trust, United Kingdom.

Background: Over the past decade in England the rate of alcohol and opioid-related hospitalisation has increased alongside a simultaneous reduction in people accessing specialist addiction treatment. We aimed to determine the hospitalisation patterns of people presenting to addiction treatment with problematic use of alcohol or opioids, and estimate how individual sociodemographic characteristics and hospital admission diagnoses are associated with the rate of hospitalisation, death and successful completion of addiction treatment.

Methods: A national record linkage between Hospital Episode Statistics (HES) and the National Drug Treatment Monitoring System (NDTMS) captured lifetime hospital admission profiles of people presenting to addiction services in England in 2018/19. Latent class analysis assigned individuals to clusters based on the ICD-10 diagnosis coded as primary reason for admission. Negative binomial, and multilevel logistic regression models determined if outcomes differed due to sociodemographic characteristics or assigned diagnostic clusters.

Findings: Inpatient data were available for 64,840 alcohol patients, and 107,296 opioid patients. The most common reasons for admission were alcohol withdrawal ( = 20,024 (5.3% of alcohol-cohort admissions)), and unspecified illness ( = 11,387 (2.1% of opioid-cohort admissions)). Seven diagnostic clusters were identified for each substance cohort. People with admissions predominantly relating to mental and behavioural disorders, and injuries or poisonings had significantly higher hospitalisation rates (adjusted IRR 7.06 (95%CI 6.72-7.42); < 0.001), higher odds of death during addiction treatment (adjusted OR 2.71 (95%CI 2.29-3.20); < 0.001) and lower odds of successful treatment completion (adjusted OR 0.72 (95%CI 0.68-0.76); < 0.001).

Interpretation: This is the first study to interrogate national hospitalisation patterns within people presenting to addiction services with problematic use of alcohol or opioids. Having identified high-risk, high-cost individuals with increased hospital usage, and increased odds of death, future work should focus on targeting appropriate interventions, to improve their health outcomes and prevent unnecessary hospital readmission.

Funding: The work was funded by the Medical Research Council (MRC).
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http://dx.doi.org/10.1016/j.lanepe.2021.100036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8080891PMC
April 2021

Factors associated with crack-cocaine early initiation: a Brazilian multicenter study.

BMC Public Health 2021 04 23;21(1):781. Epub 2021 Apr 23.

Department of Psychiatry, Federal University of São Paulo (UNIFESP), São Paulo, Brazil, Rua Major Maragliano, 241, SP, 04017030, São Paulo, Brazil.

Background: Crack-cocaine dependence is a serious public health issue, related to several psychiatric and psychosocial problems. Crack-cocaine users are usually embedded in a context of great social vulnerability, often associated with violence, poverty, family conflict and easy and early access to alcohol, tobacco and other drugs.

Methods: This cross-sectional study enrolled a consecutive sample of 577 patients admitted to 20 therapeutic communities located in Southern Brazil, between September 2012 and September 2013. A structured interview assessed life-time exposure to risk and protective factors for drug use, such as parental monitoring in childhood, deviant behaviors and peer pressure.

Results: Presence of family conflict (p = 0.002), maltreatment (p = 0.016), and deviant behavior prior to age 15 in a bivariate analysis predicted an earlier age of crack-cocaine initiation, whereas adolescents experiencing parental monitoring during adolescence started use later (p < 0.001). In the multivariate model, perceptions related to ease of access of illicit drugs (marijuana: p = 0.028, 95% CI = - 3.81, - 0.22; crack-cocaine: p < 0.001, 95% CI = - 7.40, - 4.90), and deviant behavior (threatening someone with a gun: p = 0.028, 95% CI = - 2.57, - 0.14) remained independent predictors of early age of crack-cocaine initiation.

Conclusions: Early onset of crack-cocaine use seems to be associated with exposure to family conflict, easy access to drugs and deviant behavior. Treatment and preventive programs should take these factors into account when designing and implementing community interventions.
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http://dx.doi.org/10.1186/s12889-021-10769-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8063477PMC
April 2021

Rethinking 'carriage' of take-home naloxone.

Int J Drug Policy 2021 Apr 10;95:103253. Epub 2021 Apr 10.

National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; South London and Maudsley NHS Foundation Trust, London, UK. Electronic address:

Take-home naloxone (THN) provision to people who use drugs, their family/friends, and non-medical personnel is considered a public health strategy to improve community-based naloxone access and reduce the time to antidote treatment for opioid overdose in order to prevent fatal outcome. THN programs typically report up to three performance indicators: the volume of THN kits distributed, the rate of requests for re-supply of THN kits (e.g., following naloxone use for overdose reversal), and - increasingly - THN "carriage". In this Research Methods piece, we discuss the current shortcomings in the latter measurement of THN carriage from a mixed-methods perspective and describe possible implications for public health related research and improved data analyses. We present an argument for the need to improve research methods in the case of THN "carriage" and propose a multidimensional measurement structure that takes into account: 1) the location of the THN kit relative to its owner, 2) the owner's immediate access to the kit in an emergency, 3) the type of THN device, and 4) the purpose of THN ownership (i.e., for use in self or known/unknown other/s).
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http://dx.doi.org/10.1016/j.drugpo.2021.103253DOI Listing
April 2021

Association of Symptoms of Attention Deficit and Hyperactivity with Problematic Internet Use among University Students in Wuhan, China During the COVID-19 Pandemic.

J Affect Disord 2021 05 5;286:220-227. Epub 2021 Mar 5.

National Institute on Drug Dependence and Beijing Key Laboratory of Drug Dependence, Peking University, Beijing 100191, China. Electronic address:

Background: COVID-19 is still spreading worldwide and posing a threat to individuals' physical and mental health including problematic internet use (PIU). A potentially high-risk group for PIU are those with symptoms of attention deficit and hyperactivity (ADHD symptoms), because of restrictions in their physical activity levels and engagement in computer diversions requiring only short attention spans.

Methods: We used convenience sampling in a cross-sectional survey of university students from 30 universities in Wuhan, Hubei Province, China. We assessed PIU using the Internet Addiction Test and ADHD symptoms using the WHO Adult ADHD Self-Report Screening Scale. Using logistic regression and linear regression analyses we adjusted for demographic, epidemic-related and psychological covariates in models of the association between ADHD symptoms and PIU.

Results: Among 11,254 participants, we found a 28.4% (95% CI, 27.5%-29.2%) prevalence of PIU, relatively higher than before the pandemic. In our final logistic regression model, participants with ADHD symptoms had approximately two times the risk for PIU (OR: 2.31, 95% CI: 1.89-2.83). Similarly, individuals with depression, anxiety, insomnia, PTSD symptoms and feeling stress during the pandemic had a higher risk of PIU, while those exercising regularly during the pandemic had a lower risk.

Limitations: The cross-sectional design and reliance on internet based self-reports for ADHD symptoms and PIU assessments, without direct structured interviews for validation, are limitations.

Conclusions: The prevalence of PIU was high during COVID-19, and those people with ADHD symptoms and other mental illness symptoms appear to be at higher risk of PIU. Regular exercise may reduce that PIU risk and hence should be recommended during the COVID-19 pandemic.
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http://dx.doi.org/10.1016/j.jad.2021.02.078DOI Listing
May 2021

Internet Addiction Increases in the General Population During COVID-19: Evidence From China.

Am J Addict 2021 07 19;30(4):389-397. Epub 2021 Mar 19.

Beijing Key Laboratory of Drug Dependence, National Institute on Drug Dependence, Peking University, Beijing, China.

Background And Objectives: COVID-19-related quarantine and stress have likely escalated the crisis of Internet addiction. This study aimed to determine the impact of the COVID-19 pandemic on Internet use and related risk factors among the general public in China.

Methods: A large-sample cross-sectional online survey was conducted from March 24 to April 30, 2020, in China, and 20,472 participants completed the survey. We investigated the prevalence and severity of Internet addiction based on the Internet Addiction Test (IAT), and explored the risk factors related to increases in time spent on Internet use and severity of Internet addiction, as well as severe Internet addiction.

Results: The overall prevalence of Internet addiction was 36.7% among the general population during the pandemic, and that of severe Internet addiction was 2.8%, according to IAT scores. Time spent on recreational Internet use had significantly increased during the pandemic, and almost half of participants reported increases in the severity of Internet addiction. Risk factors for increases in time spent on Internet use and severity of Internet addiction and severe Internet addiction included having fewer social supporters, perceiving pressure and impact on mental health status due to COVID-19, and being over-engaged in playing videogames.

Discussion And Conclusions: The COVID-19 pandemic adversely impacted Internet use and increased the prevalence and severity of Internet addiction among the general population in China, especially in vulnerable populations.

Scientific Significance: This study provides evidence for policymakers to refine public health policies to control the pandemic and make efforts to provide population-specific prevention and interventions for people at risk of developing Internet addiction. (Am J Addict 2021;00:00-00).
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http://dx.doi.org/10.1111/ajad.13156DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8251395PMC
July 2021

Gambling in COVID-19 Lockdown in the UK: Depression, Stress, and Anxiety.

Front Psychiatry 2021 25;12:621497. Epub 2021 Jan 25.

National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, United Kingdom.

To combat the spread of COVID-19, the UK Government implemented a range of "lockdown" measures. Lockdown has necessarily changed the gambling habits of gamblers in the UK, and the impact of these measures on the mental health of gamblers is unknown. To understand the impact of lockdown on gamblers, in April 2020, after ~6 weeks of lockdown, participants ( = 1,028, 72% female) completed an online questionnaire. Gambling engagement data was collected for pre-lockdown via the Brief Problem Gambling Screen (BPGS) allowing participants to be classified as Non-Gamblers (NG), Non-Problem Gamblers (NPG) or Potential Problem Gamblers (PPG). The Depression, Stress, and Anxiety Scale (DASS21) was used to measure depression, stress, and anxiety scores both pre- and during-lockdown. Results indicate that depression, stress and anxiety has increased across the whole sample. Participants classified in the PPG group reported higher scores on each sub scale at both baseline and during lockdown. Increases were observed on each DASS21 subscale, for each gambler group, however despite variable significance and effect sizes, the magnitude of increases did not differ between groups. Lockdown has had a significant impact on mental health of participants; whilst depression stress and anxiety remain highest in potential problem gamblers, pre-lockdown gambler status did not affect changes in DASS21 scores.
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http://dx.doi.org/10.3389/fpsyt.2021.621497DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7868396PMC
January 2021

Brief interventions to prevent excessive alcohol use in adolescents at low-risk presenting to Emergency Departments: Three-arm, randomised trial of effectiveness and cost-effectiveness.

Int J Drug Policy 2021 07 22;93:103113. Epub 2021 Jan 22.

Institute of Psychiatry, Psychology & Neuroscience, King's College London, London UK.

Background: Alcohol consumption and related harm increase rapidly from the age of 12 years. We evaluated whether alcohol screening and brief intervention is effective and cost-effective in delaying hazardous or harmful drinking amongst low-risk or abstaining adolescents attending Emergency Departments (EDs).

Methods: This ten-centre, three-arm, parallel-group, single-blind, pragmatic, individually randomised trial screened ED attenders aged between 14 and 17 years for alcohol consumption. We sampled at random one third of those scoring at most 2 on AUDIT-C who had access to the internet and, if aged under 16, were Gillick competent or had informed consent from parent or guardian. We randomised them between: screening only (control intervention); one session of face-to-face Personalised Feedback and Brief Advice (PFBA); and PFBA plus an electronic brief intervention (eBI) on smartphone or web. We conducted follow-up after six and 12 months. The principal outcomes were alcohol consumed over the 3 months before 12-month follow up, measured by AUDIT-C; and quality-adjusted life-years.

Findings: Between October 2014 and May 2015, we approached 5,016 eligible patients of whom 3,326 consented to be screened and participate in the trial; 2,571 of these were low-risk drinkers or abstainers, consuming an average 0.14 units per week. We randomised: 304 to screening only; 285 to PFBA; and 294 to PFBA and eBI. We found no significant difference between groups, notably in weekly alcohol consumption: those receiving screening only drank 0.10 units (95% confidence interval 0.05 to 0.18); PFBA 0.12 (0.06 to 0.21); PFBA and eBI 0.10 (0.05 to 0.19).

Interpretation: While drinking levels remained low in this population, this trial found no evidence that PFBA with or without eBI was more effective than screening alone in reducing or delaying alcohol consumption.
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http://dx.doi.org/10.1016/j.drugpo.2021.103113DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8261826PMC
July 2021

Abuse-deterrent extended-release oxycodone and risk of opioid-related harm.

Addiction 2021 09 18;116(9):2409-2415. Epub 2021 Jan 18.

Department of Psychiatry, Oxford University, UK.

Aim: To establish and quantify the association between abuse-deterrent formulation (ADF) oxycodone and 1-year risk of opioid-related harm.

Design: Propensity score-matched cohort study of electronic medical records for years 2014-18, with patients followed up for 1 year after their index health-care visit.

Setting: More than 70 million patients from 56 US health-care organizations.

Participants: Patients aged 18-64 years at index health-care visit with any indication for an oral opioid analgesic, with no past 12-month history of oral oxycodone use or substance use disorder, and who were alive at the end of the 1-year follow-up (new episode of prescription oral ADF oxycodone [OxyContin], n = 45 045; new episode of non-ADF oxycodone opioid preparation, n = 1 377 359).

Measurements: International Classification of Diseases diagnoses of any opioid-related disorder or non-fatal opioid poisoning within 1 year of the index health-care visit. Pooled odds ratios (OR) with 95% confidence intervals (95% CI).

Findings: After propensity score matching, 89 802 patients with a mean age of 44 [standard deviation (SD) = 11] years (62% women, 68% white) were included. During 1-year follow-up, 1445 diagnoses of opioid use disorder or opioid poisoning occurred in the ADF oxycodone cohort (34.8/1000 person-years) and 765 occurred in the non-ADF oxycodone cohort (18.2/1000 person-years). The odds of opioid-related adverse outcomes were increased in the ADF oxycodone cohort compared with the non-ADF oxycodone opioid cohort, including for opioid use disorders (OR = 2.02; 95% CI = 1.83, 2.23) and opioid poisoning (OR = 1.64 95% CI = 1.35, 1.99).

Conclusions: Patients with a new prescription of abuse-deterrent formulation oxycodone may be at increased risk of opioid-related harm.
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http://dx.doi.org/10.1111/add.15392DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8363193PMC
September 2021

Consensus Parameter: Research Methodologies to Evaluate Neurodevelopmental Effects of Pubertal Suppression in Transgender Youth.

Transgend Health 2020 11;5(4):246-257. Epub 2020 Dec 11.

Center for Biobehavioral Health, The Research Institute, Nationwide Children's Hospital, Columbus, Ohio, USA.

Pubertal suppression is standard of care for early pubertal transgender youth to prevent the development of undesired and distressing secondary sex characteristics incongruent with gender identity. Preliminary evidence suggests pubertal suppression improves mental health functioning. Given the widespread changes in brain and cognition that occur during puberty, a critical question is whether this treatment impacts neurodevelopment. A Delphi consensus procedure engaged 24 international experts in neurodevelopment, gender development, puberty/adolescence, neuroendocrinology, and statistics/psychometrics to identify priority research methodologies to address the empirical question: is pubertal suppression treatment associated with real-world neurocognitive sequelae? Recommended study approaches reaching 80% consensus were included in the consensus parameter. The Delphi procedure identified 160 initial expert recommendations, 44 of which ultimately achieved consensus. Consensus study design elements include the following: a minimum of three measurement time points, pubertal staging at baseline, statistical modeling of sex in analyses, use of analytic approaches that account for heterogeneity, and use of multiple comparison groups to minimize the limitations of any one group. Consensus study comparison groups include untreated transgender youth matched on pubertal stage, cisgender (i.e., gender congruent) youth matched on pubertal stage, and an independent sample from a large-scale youth development database. The consensus domains for assessment includes: mental health, executive function/cognitive control, and social awareness/functioning. An international interdisciplinary team of experts achieved consensus around primary methods and domains for assessing neurodevelopmental effects (i.e., benefits and/or difficulties) of pubertal suppression treatment in transgender youth.
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http://dx.doi.org/10.1089/trgh.2020.0006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7759272PMC
December 2020

Contingency management for tobacco smoking during opioid addiction treatment: Implementation challenges.

Drug Alcohol Rev 2021 May 24;40(4):658-661. Epub 2020 Nov 24.

Addictions Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.

Introduction And Aims: Tobacco smoking prevalence in opioid addiction patients is approximately six times that of the general population, highlighting the need for novel interventions. A pilot/feasibility study was conducted to investigate whether a contingency management (CM) intervention could be added to UK standard smoking cessation treatment. The aim of this report is to describe the challenges experienced during the implementation of this CM intervention.

Design And Methods: A two-armed, randomised, pilot/feasibility study of a 5-week escalating with reset CM intervention, conducted as an adjunct to smoking cessation treatment in an outpatient drug and alcohol treatment centre.

Results: Forty participants were recruited, but only 19 attended the baseline session. Ten participants attended all treatment sessions (25% retention), with only one contactable at 6-month follow-up. While smoking cessation clinic engagement was higher than previously, implementation issues included limited operating hours of the smoking treatment clinic, ineffective biochemical verification of abstinence and overly restrictive inclusion criteria.

Discussion And Conclusions: This study highlighted not only the difficulty of integrating CM interventions into standard smoking cessation treatment for this population, but also the potential of CM to engage this group with smoking cessation treatment. Future research in this area should consider increasing the availability and flexibility of smoking cessation treatment, and relaxing inclusion criteria to be more reflective of the opioid-treatment-seeking population. This study is registered on ClinicalTrials.gov (NCT03015597, https://clinicaltrials.gov/ct2/show/NCT03015597).
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http://dx.doi.org/10.1111/dar.13216DOI Listing
May 2021

A qualitative study of repeat naloxone administrations during opioid overdose intervention by people who use opioids in New York City.

Int J Drug Policy 2021 01 20;87:102968. Epub 2020 Oct 20.

Division on Substance Use Disorders, Columbia University Irving Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 120, New York, NY 10032, United States.

Background: Take-home naloxone (THN) kits have been designed to provide community members (including people who use drugs, their families and/or significant others) with the necessary resources to address out-of-hospital opioid overdose events. Kits typically include two doses of naloxone. This 'twin-pack' format means that lay responders need information on how to use each dose. Advice given tends to be based on dosage algorithms used by medical personnel. However, little is currently known about how and why people who use drugs, acting as lay responders, decide to administer the second dose contained within single THN kits. The aim of this article is to explore this issue.

Methods: Data were generated from a qualitative semi-structured interview study that was embedded within a randomised controlled trial examining the risks and benefits of Overdose Education and Naloxone Distribution (OEND) training in New York City (NYC). Analysis for this article focuses upon the experiences of 22 people who use(d) opioids and who provided repeat naloxone administrations (RNA) during 24 separate overdose events. The framework method of analysis was used to compare the time participants believed had passed between each naloxone dose administered ('subjective response interval') with the 'recommended response interval' (2-4 minutes) given during OEND training. Framework analysis also charted the various reasons and rationale for providing RNA during overdose interventions.

Results: When participants' subjective response intervals were compared with the recommended response interval for naloxone dosing, three different time periods were reported for the 24 overdose events: i. 'two doses administered in under 2 minutes' (n = 10); ii. 'two doses administered within 2-4 minutes' (n = 7), and iii. 'two doses administered more than 4 minutes apart' (n = 7). A variety of reasons were identified for providing RNA within each of the three categories of response interval. Collectively, reasons for RNA included panic, recognition of urgency, delays in retrieving naloxone kit, perceptions of recipients' responsiveness/non-responsiveness to naloxone, and avoidance of Emergency Response Teams (ERT).

Conclusion: Findings suggest that decision-making processes by people who use opioids regarding how and when to provide RNA are influenced by factors that relate to the emergency event. In addition, the majority of RNA (17/24) occurred outside of the recommended response interval taught during OEND training. These findings are discussed in terms of evidence-based intervention and 'evidence-making intervention' with suggestions for how RNA guidance may be developed and included within future/existing models of OEND training.
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http://dx.doi.org/10.1016/j.drugpo.2020.102968DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7940548PMC
January 2021

Lack of evidence for the effectiveness or safety of over-the-counter cannabidiol products.

Ther Adv Psychopharmacol 2020 9;10:2045125320954992. Epub 2020 Sep 9.

Addictions Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Over the past 5 years, public interest in the potential health benefits of cannabidiol (CBD) has increased exponentially, and a wide range of over-the-counter (OTC) preparations of CBD are now available. A substantial proportion of the population appears to have used these products, yet the extent to which they are effective or safe is unclear. We reviewed the evidence for whether CBD has significant pharmacological and symptomatic effects at the doses typically found in OTC preparations. We found that most of the evidence for beneficial effects is derived from studies of pure, pharmaceutical grade CBD at relatively high doses. Relatively few studies have examined the effect of OTC CBD preparations, or of CBD at low doses. Thus, at present, there is little evidence that OTC CBD products have health benefits, and their safety has not been investigated. Controlled trials of OTC and low-dose CBD preparations are needed to resolve these issues.
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http://dx.doi.org/10.1177/2045125320954992DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7491225PMC
September 2020

Parent-Child Concordance on the Pubertal Development Scale in Typically Developing and Autistic Youth.

Res Autism Spectr Disord 2020 Sep 7;77. Epub 2020 Jul 7.

Department of Neurology, University of Virginia School of Medicine.

Background: Characterizing puberty in autism spectrum disorder (ASD) is critical given the direct impacts of pubertal progression on neural, cognitive, and physical maturation. Limited information is available about the utility and parent-child concordance of the self-report and parent-report Pubertal Development Scale (PDS) in ASD, an economical and easily administered measure.

Method: The primary aim of this study was to examine the concordance between self-report and parent-report PDS ratings in autistic males and females ages 8-17y compared to typically developing (TD) youth, including using the PDS to derive informant-based estimates of adrenal and gonadal development. We hypothesized that there would be greater parent-youth discrepancies in pubertal ratings among autistic males. Our second aim was exploratory; we examined whether individual characteristics impact PDS concordance and hypothesized that lower intellectual and adaptive skills, higher autistic traits, and reduced self-awareness/monitoring would correlate with lower concordance.

Results: There were no significant diagnostic group differences in parent-youth concordance for overall PDS scores among males and females. Autistic males had significantly lower inter-item agreement with their parents than TD males and had lower agreement for both adrenal and gonadal aspects of pubertal maturation (adrenal κ=.48; gonadal κ=.55).

Conclusions: The PDS is a feasible measure in ASD. Greater parent-youth discrepancies in autistic males may be due to reduced parental awareness or reduced insight into pubertal maturation among autistic males. Future research is needed to further elucidate individual and/or environmental characteristics that influence youth- and parent-reported PDS scores, including differences in self-perception and insight.
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http://dx.doi.org/10.1016/j.rasd.2020.101610DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7449027PMC
September 2020

Modifying and Evaluating the Opioid Overdose Knowledge Scale for Prescription Opioids: A Pilot Study of the Rx-OOKS.

Pain Med 2020 10;21(10):2244-2252

Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado.

Objective: To develop a validated instrument that measures knowledge about prescription opioid overdose.

Methods: Within an integrated health care system, we adapted, piloted, and tested the reliability and predictive validity of a modified Opioid Overdose Knowledge Scale (OOKS) instrument specific to prescription opioids (Rx-OOKS) with a patient population prescribed long-term opioid therapy and potentially at risk of opioid overdose. We used an interdisciplinary team approach and patient interviews to adapt the instrument. We then piloted the survey on a patient sample and assessed it using Cronbach's alpha and logistic regression.

Results: Rx-OOKS (N = 56) resulted in a three-construct, 25-item instrument. Internal consistency was acceptable for the following constructs: "signs of an overdose" (10 items) at α = 0.851, "action to take with opioid overdose" (seven items) at α = 0.692, and "naloxone use knowledge" (eight items) at α = 0.729. One construct, "risks of an overdose" (three items), had an α of 0.365 and was subsequently eliminated from analysis due to poor performance. We conducted logistic regression to determine if any of the constructs was strongly associated with future naloxone receipt. Higher scores on "actions to take in an overdose" had nine times the odds of receiving naloxone (odds ratio [OR] = 9.00, 95% confidence interval [CI] = 1.42-57.12); higher "naloxone use knowledge" scores were 15.8 times more likely to receive naloxone than those with lower scores (OR = 15.83, 95% CI = 1.68-149.17).

Conclusions: The Rx-OOKS survey instrument can reliably measure knowledge about prescription opioid overdose recognition and naloxone use. Further, knowledge about actions to take during an opioid overdose and naloxone use were associated with future receipt of naloxone.
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http://dx.doi.org/10.1093/pm/pnaa190DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7593800PMC
October 2020

Factors associated with withdrawal symptoms and anger among people resuscitated from an opioid overdose by take-home naloxone: Exploratory mixed methods analysis.

J Subst Abuse Treat 2020 10 5;117:108099. Epub 2020 Aug 5.

Division on Substance Use Disorders, Columbia University Irving Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 120, New York, NY 10032, United States. Electronic address:

Introduction: Take-home naloxone (THN) is a clinically effective and cost-effective means of reducing opioid overdose fatality. Nonetheless, naloxone administration that successfully saves a person's life can still produce undesirable and harmful effects.

Aim: To better understand factors associated with two widely reported adverse outcomes following naloxone administration; namely the person resuscitated displays: i. withdrawal symptoms and ii. anger.

Methods: A mixed methods study combining a randomized controlled trial of overdose education and naloxone prescribing to people with opioid use disorder and semi-structured qualitative interviews with trial participants who had responded to an overdose whilst in the trial. All data were collected in New York City (2014-2019). A dataset (comprising demographic, pharmacological, situational, interpersonal, and overdose training related variables) was generated by transforming qualitative interview data from 47 overdose events into dichotomous variables and then combining these with quantitative demographic and overdose training related data from the main trial. Associations between variables within the dataset and reports of: i. withdrawal symptoms and ii. anger were explored using chi-squared tests, t-tests, and logistic regressions.

Results: A multivariate logistic regression found that people who had overdosed were significantly more likely to display anger if the person resuscitating them criticized, berated or chastised them during resuscitation (adjusted OR = 27 [95% CI = 4.0-295]). In contrast, they were significantly less likely to display anger if the person resuscitating them communicated positively with them (OR = 0.10 [95% CI = 0.01-0.78]). Both positive and negative communication styles were independently associated with anger, and communication was associated with 59% of the variance in anger. There was no evidence that people who displayed withdrawal symptoms were more likely to display anger than those not displaying withdrawal symptoms, and neither displaying withdrawal symptoms nor displaying anger were associated with using more drugs after resuscitation.

Conclusions: Contrary to common assumptions, withdrawal symptoms and anger following naloxone administration may be unrelated phenomena. Findings are consistent with previous research that has suggested that a lay responder's positive or reassuring communication style may lessen anger post overdose. Implications for improving THN programmes and naloxone administration are discussed.
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http://dx.doi.org/10.1016/j.jsat.2020.108099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7491601PMC
October 2020

Addiction stigma and the production of impediments to take-home naloxone uptake.

Health (London) 2020 Jun 12:1363459320925863. Epub 2020 Jun 12.

King's College London, UK.

Opioid overdose deaths are a major health issue in Australia and around the world. Programmes to provide opioid consumers with 'take-home' naloxone to reverse overdose exist internationally, but uptake by mainstream health services and consumers remains inconsistent. Researchers have identified a range of important educational, training and logistical impediments to take-home naloxone uptake and distribution, yet they have focused less on the social dynamics that can enhance or limit access, such as stigma. In this article, we also explore impediments to uptake, drawing on qualitative interview data gathered for an Australian research project on take-home naloxone. Mobilising a performative approach to stigma, we argue that overdose and prevention are shaped by the social dynamics of stigma and, as such, responsibility for dealing with overdose, as with take-home naloxone, should also be considered social (i.e. shared among peers, the public, communities and governments). Our interview data illuminate the various ways in which addiction stigma limits the possibilities and capacities of take-home naloxone and overdose prevention. First, we focus on how stigma may impede professional information provision about take-home naloxone by limiting the extent to which it is presented as a matter of interest for opioid consumers, not just those who consume opioids illicitly. Second, we explore how stigma may limit the scale-up and expansion of programmes and access points. From here, we focus on how stigma co-constitutes the politics of overdose and prevention, rendering take-home naloxone ill-suited to many social settings of overdose. In closing, we point out that stigma is not just a post hoc impediment to access to and use of take-home naloxone but is central to opioid overdose production itself, and to effective prevention. While take-home naloxone is an excellent life-saving initiative, uncritically valorising it may divert attention from broader goals, such as the de-stigmatisation of drug consumption through decriminalisation, and other ambitious attempts to reduce overdose.
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http://dx.doi.org/10.1177/1363459320925863DOI Listing
June 2020

Brief Report: Increased Addictive Internet and Substance Use Behavior During the COVID-19 Pandemic in China.

Am J Addict 2020 07 4;29(4):268-270. Epub 2020 Jun 4.

National Institute on Drug Dependence, Peking University, Beijing, China.

Background And Objectives: The COVID-19 pandemic and control measures may have increased the risk of abusing addictive substances as well as addictive behaviors.

Methods: We present an initial online survey in 6416 Chinese about the relation between the COVID-19 pandemic and addictive behavior in China.

Results: During the COVID-19 pandemic, 46.8% of the subjects reported increased dependence on internet use, and 16.6% had longer hours of internet use. The prevalence (4.3%) of severe internet dependence rose up to 23% than that (3.5%) before the COVID-19 pandemic occurred, and their dependence degree rose 20 times more often than being declined (60% vs 3%). Relapses to abuse from alcohol and smoking abstinence were relatively common at 19% and 25%, respectively. Similarly, 32% of regular alcohol drinkers and 20% of regular smokers increased their usage amount during the pandemic.

Conclusion And Scientific Significance: These three coping behaviors (internet, alcohol, and smoking) during this COVID-19-related crisis appear to have increased the risk for substance use disorders and internet addiction. (Am J Addict 2020;00:00-00).
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http://dx.doi.org/10.1111/ajad.13066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7300868PMC
July 2020

A study protocol to assess the feasibility of conducting an evaluation trial of the ADVANCE integrated intervention to address both substance use and intimate partner abuse perpetration to men in substance use treatment.

Pilot Feasibility Stud 2020 11;6:62. Epub 2020 May 11.

9School of Health in Social Science, University of Edinburgh, 8-9 Hope Park Square, Edinburgh, 8HQ 9NW UK.

Background: Strong evidence exists that substance use is a contributory risk factor for intimate partner abuse (IPA) perpetration. Men in substance use treatment are more likely to perpetrate IPA than men from the general population. Despite this, referral pathways are lacking for this group. This trial will assess the feasibility of conducting an evaluation trial of a tailored integrated intervention to address substance use and IPA perpetration to men in substance use treatment.

Methods/design: ADVANCE is a multicentre, parallel-group individually randomised controlled feasibility trial, with a nested formative evaluation, comparing an integrated intervention to reduce IPA + substance use treatment as usual (TAU) to TAU only. One hundred and eight men who have perpetrated IPA in the past 12 months from community substance use treatment in London, the West Midlands, and the South West will be recruited. ADVANCE is a manualised intervention comprising 2-4 individual sessions (2 compulsory) with a keyworker to set goals, develop a personal safety plan and increase motivation and readiness, followed by a 12-session weekly group intervention delivered in substance use services. Men will be randomly allocated (ratio 1:1) to receive the ADVANCE intervention + TAU or TAU only. Men's female (ex) partners will be invited to provide outcome data and offered support from integrated safety services (ISS). Regular case management meetings between substance use and ISS will manage risk. Outcome measures will be obtained at the end of the intervention (approximately 4 months post-randomisation) for all male and female participants. The main objective of this feasibility trial is to estimate parameters required for planning a definitive trial including rates of consent, recruitment, and follow-up by site and group allocation. Nested formative evaluation including focus groups and in-depth interviews will explore the intervention's acceptability to participants, group facilitators, keyworkers and ISS workers. Secondary outcomes include substance use, IPA, mental health, self-management, health and social care service use, criminal justice contacts, and quality of life.

Discussion: Findings from this feasibility trial will inform the design of a multicentre randomised controlled trial evaluating the efficacy and cost-effectiveness of the ADVANCE intervention for reducing IPA and improving the well-being of female (ex)partners.

Trial Registration: ISRCTN79435190.
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http://dx.doi.org/10.1186/s40814-020-00580-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7212681PMC
May 2020

Incidence and treatment costs of severe bacterial infections among people who inject heroin: A cohort study in South London, England.

Drug Alcohol Depend 2020 07 6;212:108057. Epub 2020 May 6.

National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, 4 Windsor Walk, Camberwell, London SE5 8AF, UK; South London and Maudsley NHS Foundation Trust, Monks Orchard Road Beckenham, London BR3 3BX, UK; Centre for Epidemiology and Biostatistics, Melbourne School of Global and Population Health, Level 3, 207 Bouverie Street, The University of Melbourne Victoria 3010 Australia; RAND Europe, Westbrook Centre, Milton Road, Cambridge CB4 1YG, UK.

Background: People who inject drugs often get bacterial infections. Few longitudinal studies have reported the incidence and treatment costs of these infections.

Methods: For a cohort of 2335 people who inject heroin entering treatment for drug dependence between 2006 and 2017 in London, England, we reported the rates of hospitalisation or death with primary causes of cutaneous abscess, cellulitis, phlebitis, septicaemia, osteomyelitis, septic arthritis, endocarditis, or necrotising fasciitis. We compared these rates to the general population. We also used NHS reference costs to calculate the cost of admissions.

Results: During a median of 8.0 years of follow-up, 24 % of patients (570/2335) had a severe bacterial infection, most commonly presenting with cutaneous abscesses or cellulitis. Bacterial infections accounted for 13 % of all hospital admissions. The rate was 73 per 1000 person-years (95 % CI 69-77); 50 times the general population, and the rate remained high throughout follow-up. The rate of severe bacterial infections for women was 1.50 (95 % CI 1.32-1.69) times the rate for men. The mean cost per admission was £4980, and we estimate that the annual cost of hospital treatment for people who inject heroin in London is £4.5 million.

Conclusions: People who inject heroin have extreme and long-term risk of severe bacterial infections.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108057DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7301433PMC
July 2020

A Clinical Program for Transgender and Gender-Diverse Neurodiverse/Autistic Adolescents Developed through Community-Based Participatory Design.

J Clin Child Adolesc Psychol 2020 May 6:1-16. Epub 2020 May 6.

Gender and Autism Program, Division of Neuropsychology, Children's National Health System.

Objective: A series of studies report elevated rates of autism and autistic characteristics among gender-diverse youth seeking gender services. Although youth with the co-occurrence present with complex care needs, existing studies have focused on co-occurrence rates. Further, clinical commentaries have emphasized provider-centered interpretations of clinical needs rather than key stakeholder-driven clinical approaches. This study aimed to employ community-based participatory research methodologies to develop a key stakeholder-driven clinical group program.

Method: Autistic/neurodiverse gender-diverse (A/ND-GD) youth ( = 31), parents of A/ND-GD youth ( = 46), A/ND-GD self-advocates ( = 10), and expert clinical providers ( = 10) participated in a multi-stage community-based participatory procedure. Needs assessment data were collected repeatedly over time from A/ND-GD youth and their parents as the youth interacted with one another through ongoing clinical groups, the curriculum of which was developed progressively through the iterative needs assessments.

Results: Separate adolescent and parent needs assessments revealed key priorities for youth (e.g., the importance of connecting with other A/ND-GD youth and the benefit of experiencing a range of gender-diverse role models to make gender exploration and/or gender affirmation more concrete) and parents (e.g., the need for A/ND-related supports for their children as well as provision of an A/ND-friendly environment that fosters exploration of a range of gender expressions/options). Integration and translation of youth and parent priorities resulted in 11 novel clinical techniques for this population.

Conclusions: With generally high acceptability ratings for each component of the group program, this study presents a community-driven clinical model to support broad care needs and preferences of A/ND-GD adolescents.
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http://dx.doi.org/10.1080/15374416.2020.1731817DOI Listing
May 2020

Opioid overdose reversals using naloxone in New York City by people who use opioids: Implications for public health and overdose harm reduction approaches from a qualitative study.

Int J Drug Policy 2020 Apr 15;79:102751. Epub 2020 Apr 15.

Division on Substance Use Disorders, Columbia University Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 20, New York, NY 10032, United States.

Background: Adverse reactions to naloxone, such as withdrawal symptoms and aggression, are widely recognised in the literature by pharmaceutical manufacturers and clinical practitioners as standard reactions of individuals who are physically dependent upon opioid drugs following the reversal of potentially fatal opioid overdose. This paper seeks to provide a differentiated view on reactions to naloxone that may have important implications for public health and harm reduction approaches.

Methods: Analyses from a qualitative investigation embedded within a 5-year Randomised Controlled Trial (RCT) examined the risks and benefits of Overdose Education and Naloxone Distribution (OEND) training models (brief or extended training) in various populations of people who use opioids in New York City. The qualitative experiences (obtained through semi-structured interviews) of 46 people who use opioids and who were each involved in the delivery of naloxone, during 56 separate overdose events that occurred throughout 2016-2018, were studied. Situational analysis and inductive content analysis of interview data focused upon overdose reversals in an attempt to provide understandings of the various adverse effects associated with naloxone from their perspective. These analyses were supplemented by data sessions within the research team during which the findings obtained from situational analysis and inductive content analysis were reviewed and complemented by deductive (clinical) appraisals of the various physical and psychological effects associated with the overdose reversals.

Results: People who use opioids recognise three distinct and interconnected outcomes that may follow a successful opioid overdose reversal after intramuscular or intranasal administration of naloxone. These outcomes are here termed, (i) 'rage' (describing a wide range of angry, hostile and/or aggressive outbursts), (ii) 'withdrawal symptoms,' and (iii) 'not rage, not withdrawal' (i.e., a wide range of short-lived, 'harmless' conditions (such as temporary amnesia, mild emotional outbursts, or physical discomfort) that do not include rage or withdrawal symptoms).

Conclusion: Physical and psychological reactions to naloxone should not be understood exclusively as a consequence of acute, opioid-related, withdrawal symptoms. The three distinct and interconnected reversal outcomes identified in this study are considered from a harm reduction policy perspective and are further framed by concepts associated with 'mediated toxicity' (i.e., harm triggered by medicine). The overall conclusion is that harm reduction training programmes that are aligned to the policy and practice of take home naloxone may be strengthened by including awareness and training in how to best respond to 'rage' associated with overdose reversal following naloxone administration by people who use opioids and other laypersons.
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http://dx.doi.org/10.1016/j.drugpo.2020.102751DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7572435PMC
April 2020
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