Concurrent Stimulant Use Research Articles

Assessment of harm reduction receipt and infectious diseases outcomes in United States Veterans with opioid use disorder and history of injection drug use

BackgroundInjection drug use (IDU) may lead to negative health outcomes and increased healthcare utilization. In US Veterans (USV) with opioid use disorder (OUD), there is sparse information about healthcare utilization, harm reduction prescription, and outcomes associated with IDU, including severe injection-related infections (SIRI). We assessed psychosocial factors, clinical outcomes, and harm reduction receipt in a cohort of USV with OUD, specifically focusing on persons who inject drugs (PWID).MethodsA retrospective cohort study was performed of USV aged ≥ 18 years with a diagnosis of OUD who presented to the Northport Veterans Affairs Medical Center (Long Island, NY) between 2012 and 2022. Demographics, psychosocial factors, history of human immunodeficiency virus (HIV), hepatitis C virus (HCV) infection, and healthcare utilization were compared by IDU status. Prescription of medications for opioid use disorder, naloxone and pre-exposure prophylaxis (PrEP) for HIV were also compared by IDU status. SIRI episodes and associated sequelae were characterized in USV with IDU.ResultsA total of 502 USV with OUD were included and 216 (43%) were PWID. Mean age was 52.6 years. PWID were more likely to use multiple stimulants (14.4% PWID vs. 7.3% non-PWID, p < 0.011), be hospitalized with an infection (26.4% PWID vs. 12.2% non-PWID, p < 0.001) and had more frequent inpatient admissions (n = 5.5 PWID vs. n = 3.51 non-PWID, p = 0.003). Among PWID, 134 (62%) had a history of HCV infection, 9 (4.2%) had HIV, and 35 (16.2%) had at least one SIRI episode. PWID had a higher frequency of current (51.9% PWID vs. 38.5% non-PWID, p = 0.003) or previous MOUD use (45.8% PWID vs. 31.1% non-PWID, p < 0.001). Overall PrEP receipt in our cohort (0.46% PWID vs. 1.4% non-PWID, p = 0.4) was low.ConclusionsUSV with OUD and a history of IDU had a high prevalence of concurrent stimulant use, HCV, SIRI episodes, and were more likely to be hospitalized than USV with OUD and no history of IDU. Harm reduction strategies such as MOUD or PrEP, can help decrease the risk of infectious diseases, yet PrEP was underutilized in our population regardless of IDU status. USV with OUD would benefit from improved integration of OUD treatment, infectious diseases clinical care and harm reduction interventions.

Impact of baseline methamphetamine/amphetamine use on discontinuation of methadone and buprenorphine/naloxone among people with prescription-type opioid use disorder in Canada.

Although concurrent stimulant use is common among people with opioid use disorder (OUD), there is little evidence on its impacts on opioid agonist therapy (OAT) outcomes. This study sought to determine the impact of baseline methamphetamine/amphetamine use on discontinuation of OAT among individuals with prescription-type OUD (POUD) initiating methadone or buprenorphine/naloxone as part of a pragmatic randomized trial in Canada. Secondary analysis of a pan-Canadian pragmatic trial conducted between 2017 and 2020 comparing supervised methadone versus flexible take-home dosing buprenorphine/naloxone models of care. Cox proportional hazard models were used to evaluate the effect of baseline methamphetamine/amphetamine use (measured by urine drug test [UDT]) on two discontinuation outcomes (i.e., assigned OAT discontinuation, any OAT discontinuation). Two hundred nine (n = 209) participants initiated OAT, of which 96 (45.9%) had positive baseline methamphetamine/amphetamine UDT. Baseline methamphetamine/amphetamine use was associated with shorter median times in assigned OAT (21 vs. 168 days, hazard ratio [aHR] = 2.45, 95% confidence interval [CI] = 1.60-3.76) and any OAT (25 days vs. 168 days, aHR = 2.06, CI = 1.32-3.24). No interaction between methamphetamine/amphetamine and assigned OAT was observed for either outcome (p > .05). This study offers novel insights on the impact of methamphetamine/amphetamine use on OAT outcomes among people with POUD. Methamphetamine/amphetamine use was common and was associated with increased risk of OAT discontinuation. Supplementary interventions, including treatment for stimulant use, are needed to improve retention in OAT and optimize treatment outcomes in this population.

Changes in real-world dispensing of ADHD stimulants in youth from 2019 to 2021 in California.

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common pediatric neurobehavioral disorders in the U.S. Stimulants, classified as controlled substances, are commonly used for ADHD management. We conducted an analysis of real-world stimulants dispensing data to evaluate the pandemic's impact on young patients (≤ 26 years) in California. Annual prevalence of patients on stimulants per capita across various California counties from 2019 and 2021 were analyzed and further compared across different years, sexes, and age groups. New patients initiating simulants therapy were also examined. A case study was conducted to determine the impact of socioeconomic status on patient prevalence within different quintiles in Los Angeles County using patient zip codes. Logistic regression analysis using R Project was employed to determine demographic factors associated with concurrent use of stimulants with other controlled substances. There was a notable reduction in prevalence of patients ≤26 years old on stimulants during and after the pandemic per 100,000 people (777 in 2019; 743 in 2020; 751 in 2021). These decreases were more evident among the elementary and adolescent age groups. The most prevalent age group on stimulants were adolescents (12-17 years) irrespective of the pandemic. A significant rise in the number of female patients using stimulants was observed, increasing from 107,957 (35.2%) in 2019 to 121,241 (41.1%) in 2021. New patients initiating stimulants rose from 102,754 in 2020 to 106,660 in 2021, with 33.2% being young adults. In Los Angeles County, there was an increasing trend in patient prevalence from Q1 to Q5 income quintiles among patients ≥6 years. Consistently each year, the highest average income quintile exhibited the highest per capita prevalence. Age was associated with higher risk of concurrent use of benzodiazepines (OR, 1.198 [95% CI, 1.195-1.201], p < 0.0001) and opioids (OR, 1.132 [95% CI, 1.130-1.134], p < 0.0001) with stimulants. Our study provides real-world information on dispensing of ADHD stimulants in California youth from 2019 to 2021. The results underscore the importance of optimizing evidence-based ADHD management in pediatric patients and young adults to mitigate disparities in the use of stimulants.

Extended-release Buprenorphine Administered at Discharge in Hospitalized Persons With Opioid Use Disorder: A Case Series.

Monthly subcutaneous injectable buprenorphine (XR-Bup) is an option for treatment of opioid use disorder (OUD) that addresses some sublingual buprenorphine adherence barriers and is infrequently offered to hospitalized patients with OUD. A retrospective case series was performed for patients receiving XR-Bup upon discharge from 1 academic medical center. Demographic information, diagnoses, follow-up, and documented factors informing the selection of XR-Bup were extracted from the electronic health record. In 1 year, 37 hospitalized patients with OUD received XR-Bup at discharge. The average age was 37.6 years, and patients were primarily Medicaid insured with an injection-related infection. The most common documented factors informing the selection of XR-Bup were as follows: previous sublingual buprenorphine adherence barriers, concurrent stimulant use disorder, and patient preference. Sixty-four percent of patients scheduled for follow-up attended appointments, and 55% received a second dose of XR-Bup. Subcutaneous injectable buprenorphine is an option for OUD treatment among hospitalized patients providing 30 or more days of buprenorphine coverage in the postdischarge period.

Correlates of Stimulant Use among People Who Use Heroin Undergoing Treatment in Out-Patient Facilities in France, 2010–2020

Background: Polydrug use has been implicated in driving a “fourth wave” of the overdose crisis in North America, specifically through concurrent use of stimulants and opioids, especially fentanyl. In France, however, heroin has historically been and remains the easiest-to-access opioid, accounting for most drug treatment demand. Whether similar polydrug use is increasing in Western Europe remains understudied, despite severe health implications and potential inadequate public health responses. Methods: We take advantage of a nation-wide dataset containing information on all patients serviced in treatment centers in France from 2010 to 2020. We conduct Poisson regression to determine the main predictors of stimulant use among people who use heroin (PWUH) and opioids (PWUO) generally. Results: Heroin remains the primary opioid within drug treatment in France. A decreasing number of out-patients seeking treatment for heroin use has been accompanied by an increasing trend of stimulant use over time, most commonly with powder cocaine. Our results suggest a significant increase of crack cocaine use among the most vulnerable PWUH. Concurrent use of stimulants among PWUH was positively associated with use of alcohol, cannabis, unprescribed psychotropics and hallucinogens, and negatively with tobacco. Similar results were found for all in-treatment PWUO. Conclusions: Our results uncover heterogeneity in the profiles of PWUH that should be fully acknowledged to ensure better efficiency in substance use clinical practices and policy, while simultaneously drawing attention to trends in concurrent opioid-stimulant use outside North America. We advocate for an extension of the generalized risk framework and its implementation in prevention programs.

Stimulant use disorder diagnosis and opioid agonist treatment dispensation following release from prison: a cohort study

BackgroundConcurrent opioid and stimulant use is on the rise in North America. This increasing trend of use has been observed in the general population, and among people released from prison in British Columbia (BC), who face an elevated risk of overdose post-release. Opioid agonist treatment is an effective treatment for opioid use disorder and reduces risk of overdose mortality. In the context of rising concurrent stimulant use among people with opioid use disorder, this study aims to investigate the impact of stimulant use disorder on opioid agonist treatment dispensation following release from prison in BC.MethodsLinked health and corrections records were retrieved for releases between January 1st 2015 and December 29th 2018 (N = 13,380). Hospital and primary-care administrative health records were used to identify opioid and stimulant use disorder and mental illness. Age, sex, and health region were derived from BC’s Client Roster. Incarceration data were retrieved from provincial prison records. Opioid agonist treatment data was retrieved from BC’s provincial drug dispensation database. A generalized estimating equation produced estimates for the relationship of stimulant use disorder and opioid agonist treatment dispensation within two days post-release.ResultsCases of release among people with an opioid use disorder were identified (N = 13,380). Approximately 25% (N = 3,328) of releases ended in opioid agonist treatment dispensation within two days post-release. A statistically significant interaction of stimulant use disorder and mental illness was identified. Stratified odds ratios (ORs) found that in the presence of mental illness, stimulant use disorder was associated with lower odds of obtaining OAT [(OR) = 0.73, 95% confidence interval (CI) = 0.64–0.84)] while in the absence of mental illness, this relationship did not hold [OR = 0.89, 95% CI = 0.70–1.13].ConclusionsPeople with mental illness and stimulant use disorder diagnoses have a lower odds of being dispensed agonist treatment post-release compared to people with mental illness alone. There is a critical need to scale up and adapt opioid agonist treatment and ancillary harm reduction, and treatment services to reach people released from prison who have concurrent stimulant use disorder and mental illness diagnoses.

Methadone Maintenance Treatment Discontinuation Among Young People who use Opioids in Vancouver, Canada.

Retaining adolescents and young adults (AYA) in medications for opioid use disorder (MOUD), like methadone maintenance treatment (MMT), is critical to reducing toxic drug fatalities. This analysis sought to identify factors associated with MMT discontinuation among AYA. Data were derived from the At-Risk Youth Study, a prospective cohort study of street-involved AYA in Vancouver, Canada, between December 2005 and June 2018. Multivariable extended Cox regression identified factors associated with time to MMT discontinuation among AYA who recently initiated MMT. In subanalysis, multivariable extended Cox regression analysis identified factors associated with time to "actionable" MMT discontinuation, which could be addressed through policy changes. A total of 308 participants reported recent MMT during the study period. Participants were excluded if they reported MMT in the past 6 months at baseline and were retained in MMT (n = 94, 30.5%); were missing MMT status data (n = 43, 14.0%); or completed an MMT taper (n = 11, 3.6%). Of the remaining 160 participants who initiated MMT over the study period, 102 (63.8%) discontinued MMT accounting for 119 unique discontinuation events. In multivariable extended Cox regression, MMT discontinuation was positively associated with recent weekly crystal methamphetamine use (adjusted hazard ratio [AHR] = 1.67, 95% confidence interval [CI]: 1.19 to 2.35), but negatively associated with age of first "hard" drug use (per year older) (AHR = 0.95, 95% CI: 0.90 to 1.00) and female sex (AHR = 0.66, 95% CI: 0.44 to 0.99). In subanalysis, recent weekly crystal methamphetamine use (AHR = 4.61, 95% CI: 1.78 to 11.9) and weekly heroin or fentanyl use (AHR = 3.37, 95% CI: 1.21 to 9.38) were positively associated with "actionable" MMT discontinuation, while older age (AHR = 0.87, 95% CI: 0.76 to 0.99) was negatively associated. Efforts to revise MMT programming; provide access to a range of MOUD, harm reduction, and treatments; and explore coprescribing stimulants to AYA with concurrent stimulant use may improve treatment retention and reduce toxic drug fatalities.

Patterns of attention deficit hyperactivity disorder medicine use in the era of new non-stimulant medicines: A population-based study among Australian children and adults (2013-2020).

New therapeutic options such as lisdexamfetamine and guanfacine have recently become available for the treatment of attention deficit hyperactivity disorder. We described contemporary patterns of attention deficit hyperactivity disorder medicine use among children, adolescents and adults in Australia. This population-based study used dispensing data for a 10% random sample of Australian residents between July 2012 and December 2020. We estimated the annual prevalence and incidence of attention deficit hyperactivity disorder medicines, second-line guanfacine use and examined concurrent medicine use of both stimulants and non-stimulants. We followed incident users for up to 5 years and analysed treatment persistence using a novel proportion of people covered method. Analyses were stratified by attention deficit hyperactivity disorder medicine, sex and age group; young children (0-5 years), children (6-12 years), adolescents (13-17 years), young adults (18-24 years) and adults (⩾25 years). We observed a twofold increase in the overall prevalence of attention deficit hyperactivity disorder medicine use between 2013 and 2020, from 4.9 to 9.7 per 1000 persons. Incident use also increased across all age groups and both sexes, with the most pronounced increases among adolescent females (from 1.4 to 5.3 per 1000 persons). Stimulant treatment persistence after 5 years was highest among those initiating treatment as young children (64%) and children (69%) and lowest among those initiating treatment in adolescence (19%). Concurrent use of stimulants and non-stimulants was more common among males and younger age groups. Most children (87%) initiating guanfacine had prior dispensings of attention deficit hyperactivity disorder medicines. We observed increasing attention deficit hyperactivity disorder medicine use in Australia, especially among young females. Nevertheless, treatment rates remain lower than the estimated prevalence of attention deficit hyperactivity disorder across all subpopulations. Poor long-term treatment persistence in adolescence may warrant improved clinical monitoring of attention deficit hyperactivity disorder in patients transitioning from paediatric to adult care. Reassuringly, use of newly approved guanfacine appeared to be in accordance with guidelines among children.

Feasibility, Acceptability, and Preliminary Efficacy of a Smartphone-Based Contingency Management Intervention for Buprenorphine Adherence.

Buprenorphine is an important medication for treating opioid use disorder, but medication adherence and treatment retention are key issues that can limit its impact, especially when patients have concurrent stimulant use. Contingency management is efficacious in promoting medication adherence and drug abstinence. Delivering contingency management via smartphones addresses practical barriers to its adoption and improves patient access. A single-group (n = 20) nonexperimental study was conducted to evaluate the feasibility of smartphone-based contingency management to promote adherence to buprenorphine treatment in people with opioid use disorder. Participants were recruited from outpatient treatment clinics. Over 12 weeks participants had access to a smartphone app that provided contingency management supported with peer recovery coaching. Adherence was confirmed daily either by GPS monitoring of clinic medication visits or self-recorded video, and salivary toxicology was conducted weekly. The overall rate of confirmed buprenorphine adherence was 76%, and visual inspection of individual participant outcomes shows consistent medication use for a large majority of participants. All participants were able to successfully use all app features and spend earnings. Participants rated the app and intervention highly on measures of likability, ease of use, and helpfulness. All participants (100%) were retained in buprenorphine treatment throughout the study period. Direct methods for confirming adherence appear superior to confirmation via salivary toxicology. This study shows that smartphone-based contingency management is a feasible means of promoting buprenorphine adherence. The potential efficacy of smartphone-based contingency management as a means of promoting buprenorphine adherence warrants evaluation in a randomized controlled trial.

Correlates of concurrent use of stimulants and opioids among people who access harm reduction services in British Columbia, Canada: Findings from the 2019 Harm Reduction Client Survey.

During a public health overdose emergency driven by fentanyl in British Columbia (BC), Canada, a parallel increase in concurrent use of methamphetamines may be contributing to the risk of overdose. Concurrent use refers to the use of stimulants and opioids one after the other, or together. Describing substance use practices and elucidating correlates of concurrent use can inform harm reduction service provision and prevent overdose events. This cross-sectional study analyzed the 2019 Harm Reduction Client Survey administered at 22 harm reduction sites across BC and sampled individuals aged 19 and older. Bivariable and multivariable logistic regression models identified correlates of concurrent use of stimulants and opioids in the last three days. The study sample was composed of 574 individuals who used stimulants and/or opioids, among whom 307 (53.5%) reported concurrent use. Compared with individuals who used stimulants and/or opioids separately, the odds of concurrent use were significantly increased (OR=2.74, 95%CI 1.71-4.51) while the adjusted odds were increased (aOR=1.79, 95%CI 0.98-3.34) among individuals who experienced an opioid overdose. Further, the adjusted odds of concurrent use decreased with every one-year increase in age (aOR=0.97, 95%CI 0.95-0.99), among individuals with paid work (aOR=0.58, 95%CI 0.33-0.99), and stable housing (aOR=0.61, 95%CI 0.37-1.02). The adjusted odds of concurrent use increased among individuals who used drugs daily (aOR=3.78, 95%CI 2.28-6.40), used tobacco (aOR=2.03, 95%CI 1.09-3.87), used benzodiazepines (aOR=3.72, 95%CI 1.76-8.41), owned a naloxone kit (aOR=1.94, 95%CI 1.15-3.31), used observed consumption sites (aOR=2.51, 95%CI 1.57-4.07), and were prescribed opioid agonist therapy (aOR=2.92, 95%CI 1.81-4.77). Individuals who used stimulants and opioids concurrently tend to be younger, without paid work or housing. They were engaged in harm reduction and treatment services, yet used illicit drugs with unknown concentration daily. Improving access to age-appropriate services and expanding the availability of both legal and regulated stimulants and opioids may further reduce harms of concurrent use.

Modeling Stimulant and Opioid Co-use in Rats Provided Concurrent Access to Methamphetamine and Fentanyl.

Concurrent use of stimulants (e.g., methamphetamine) and opioids (e.g., fentanyl) has become increasingly common in recent years and continues to pose an enormous health burden, worldwide. Despite the prevalence, relatively little is known about interactions between the reinforcing effects of stimulants and opioids in this pattern of polysubstance use. The goals of the current study were to evaluate the relative reinforcing and relapse-related effects of methamphetamine and fentanyl using a concurrent access, drug-vs.-drug choice procedure. Male Sprague-Dawley rats were first allowed to acquire self-administration for either 0.1 mg/kg/infusion methamphetamine or 0.0032 mg/kg/infusion fentanyl, independently, after which concurrent access to both drugs was provided. When training doses of methamphetamine and fentanyl were concurrently available, a subset of rats self-administered both drugs, either within a session or alternating across sessions, whereas the remaining rats responded exclusively for one drug. When the cost of the preferred drug was increased (i.e., unit dose reduced), or the cost of the non-preferred drug was decreased (i.e., unit dose increased), choice was largely allocated toward the cheaper alternative. Following extinction of responding, methamphetamine- and fentanyl-paired cues reinstated responding on both levers. Responding reinstated by a priming injection of methamphetamine or fentanyl allocated more responding to the lever previously reinforced by the priming drug. The current studies suggest that choice of methamphetamine and fentanyl is largely allocated to the cheaper alternative, although more co-use was observed than would be expected for economic substitutes. Moreover, they lay the groundwork for more fully evaluating interactions between commonly co-abused drugs (e.g., stimulants and opioids) in order to better understand the determinants of polysubstance use and develop effective treatment strategies for individuals suffering from a polysubstance use disorder.

A Smartphone-Smartcard Platform for Implementing Contingency Management in Buprenorphine Maintenance Patients With Concurrent Stimulant Use Disorder.

Background and Objectives: Opioid agonist pharmacotherapies are effective in the treatment of opioid use disorder (OUD) but concurrent stimulant use is common and can lead to relapse and treatment drop out. Contingency management in combination with opioid agonist pharmacotherapy has broad beneficial effects in polysubstance users, including promoting drug abstinence and treatment retention, but clinic-based implementation can be burdensome. The present study was conducted to evaluate a contingency management intervention delivered via a smartphone-smartcard platform in OUD patients who had concurrent stimulant use disorder.Methods: Retrospective comparison of (n = 124) patients; half received the contingency management intervention and half were matched controls. Drug use and clinic attendance outcomes over four consecutive 30-day periods were analyzed with regression.Results: The intervention group showed consistently higher rates of drug abstinence and clinic attendance which were significant at the latter two timepoints.Discussion: Smartphone-smartcard platforms can facilitate dissemination of contingency management by surmounting or obviating key barriers to adoption. They appear to be convenient for all stakeholders, are easy to use, and facilitate high-fidelity implementation. Delivering contingency management via a smartphone-smartcard platform produces effects consistent with those observed when the intervention is delivered with substantially costlier and more burdensome in-person procedures.

Exploring the effectiveness of dextroamphetamine for the treatment of stimulant use disorder:\xa0a qualitative study\xa0with patients receiving injectable opioid agonist treatment

BackgroundA high proportion of people receiving both oral and injectable opioid agonist treatment report concurrent use of stimulants (i.e. cocaine and or amphetamines), which has been associated with higher rates of continued illicit opioid use and treatment dropout. A recent randomized controlled trial demonstrated the effectiveness of dextroamphetamine (a prescribed stimulant) at reducing craving for and use of cocaine among patients receiving injectable opioid agonist treatment. Following this evidence, dextroamphetamine has been prescribed to patients with stimulant use disorder at a clinic in Vancouver. This study investigates perceptions of the effectiveness of dextroamphetamine from the perspective of these patients.MethodsData were collected using small focus groups and one-on-one interviews with patients who were currently or formerly receiving dextroamphetamine (n = 20). Thematic analysis was conducted using an iterative approach, moving between data collection and analysis to search for patterns in the data across transcripts. This process led to the defining and naming of three central themes responding to the research question.ResultsParticipants reported a range of stimulant use types, including cocaine (n = 8), methamphetamine (n = 8), or both (n = 4). Three central themes were identified as relating to participants’ perceptions of the effectiveness of the medication: 1) achieving a substitution effect (i.e. extent to which dextroamphetamine provided a substitution for the effect they received from use of illicit stimulants); 2) Reaching a preferred dose (i.e. speed of titration and effect of the dose received); and 3) Ease of medication access (i.e. preference for take home doses (i.e. carries) vs. medication integrated into care at the clinic).ConclusionIn the context of continued investigation of pharmacological treatments for stimulant use disorder, the present study has highlighted how the study of clinical outcomes could be extended to account for factors that contribute to perceptions of effectiveness from the perspective of patients. In practice, elements of treatment delivery (e.g. dosing and dispensation protocols) can be adjusted to allow for various scenarios (e.g. on site vs. take home dosing) by which dextroamphetamine and other pharmacological stimulants could be implemented to provide “effective” treatment for people with a wide range of treatment goals and needs.

Self-managing illicit stimulant use: A qualitative study with patients receiving injectable opioid agonist treatment.

Illicit stimulant use is prevalent among patients receiving injectable opioid agonist treatment (iOAT) and has been associated with early treatment discontinuation and illicit opioid use. Despite these concerns, little is known about the use of illicit stimulants in this population. As such, this study aimed to explore the processes by which patients receiving iOAT engage in the use of illicit stimulants. One-on-one in-depth qualitative interviews were conducted. Data collection and analysis followed an iterative approach of coding, searching for meaning, and returning to data collection to saturate categories and explicate relationships between them. Participants were patients receiving iOAT in Vancouver, Canada that reported the use of illicit stimulants (n = 31). The process of 'self-managing illicit stimulant use' was constructed from the data. This process was made up of three interrelated categories reflecting participants' engagement in illicit stimulant use: (i) distancing from the street environment; (ii) taking control of use; and (iii) mobilising support (clinical and social). For patients with opioid use disorder and concurrent stimulant use disorder, access to iOAT can promote the self-management of illicit stimulant use. Daily visits to the clinic for opioid agonist treatment present an important opportunity to offer services and supports for patients who use illicit stimulants. Interventions can be guided by patients, recognising them as experts in the management of their stimulant use.

Motives and Correlates of Anabolic-Androgenic Steroid Use With Stimulant Polypharmacy

Individuals who use anabolic-androgenic steroids (AAS) may engage in concurrent psychoactive drug use recreationally and/or as an additional training aid. Aside from cannabis, individuals who use AAS most commonly report concurrent use of stimulants such as amphetamines and cocaine. In this study, we examine demographic characteristics, frequency of heavy drinking, and nightclubbing in a sample of 993 men from the Global Drug Survey 2015 who reported both AAS and psychoactive drug use before exploring the relationship between motivation for AAS use and the propensity to concurrently engage with stimulant-type substances. Results of a logistic regression analysis suggest that the propensity for concurrent use of AAS and stimulants is greater when AAS use is motivated by weight loss goals, while performance goals are associated with reduced odds of concurrent stimulant use. Identifying individuals who are at risk of polydrug use and associated harms can inform targeted harm reduction strategies.

Understanding concurrent stimulant use among people on methadone: A qualitative study.

Opioid-related overdoses are an epidemic in North America, prompting a greater use of medications for opioid use disorder, such as methadone. Although many people work toward overall drug abstinence while on methadone, a sub-population of people with and without histories of polysubstance use engage in stimulant use while on methadone treatment. This study explores motivations for concurrent stimulant and methadone use in a street-involved drug-using population. Semi-structured qualitative interviews were conducted with 39 people on methadone in Vancouver, Canada. Participants were recruited from among the participants in two community-based prospective cohort studies consisting of HIV-positive and HIV-negative people who use drugs. Interview transcripts were analysed using an inductive and iterative approach. Our analysis identified three primary themes. First, participants articulated how stimulants were used to counter the sedating effects of methadone and enable them to engage in daily and survival activities (e.g. income generation). Second, participants described increased stimulant use to compensate for reduced stimulant intoxication while taking methadone. Finally, participants described the desire to achieve intoxication on stimulants once stable on methadone, as their substance use treatment goals did not involve drug abstinence. Among a street-involved drug-using population in which people do not have abstinence-based treatment goals, there are several functional reasons to use stimulants concurrently while on methadone. A deeper and more nuanced understanding of substance use motivators may contribute to further research and inform policy and guideline changes that support low threshold and harm reduction-focused methadone treatment programs and other interventions to reduce drug-related harms.

Concurrent Amphetamine and Methamphetamine Use Among Clients of Opioid Maintenance Treatment Programs in Golestan, Iran

Background: Concurrent use of stimulants during opioid maintenance treatments (OMTs) negatively impacts the treatment outcomes. Objectives: The aim of this study is to evaluate the prevalence and correlation of amphetamine and methamphetamine use among OMT clients in Golestan province-Northeast of Iran. Methods: In a cross-sectional study, 750 OMT clients were recruited through a two-stage cluster sampling. Face-to-face interviews were conducted to complete the study questionnaire. Urine samples were also taken to perform rapid drug testing for morphine, amphetamine, methamphetamine, tramadol, cannabis, and benzodiazepines. Survey analysis command in STATA was used to estimate the prevalence of drug use among the target population. Results: In this study, 8.1% (95% CI: 3.6 to 12.6) of the participants had positive urine sample for amphetamine or methamphetamine. Also, 41.8% (95% CI: 34.4 to 49.1) of the clients had positive samples for morphine. The urine positivity rate of morphine was significantly higher among those who had positive urine sample for amphetamines (68.3%; 95% CI: 51.7 to 84.9 versus 39.4% 95% CI: 31.3 to 47.6). In multivariate analysis, lifetime alcohol consumption (adjusted OR: 2.8, 95% CI 1.5 to 5.5) and history of imprisonment (adjusted OR: 2.2, 95% CI: 1.0 to 4.6) were associated with positive urine sample for amphetamines. Conclusions: Simultaneous use of amphetamines among clients of OMTs was considerable. It is recommended to regularly test all OMT clients for concurrent use of stimulants. This is particularly important for clients with past history of alcohol consumption or imprisonment.

Prevalence of and Factors Associated With Long-term Concurrent Use of Stimulants and Opioids Among Adults With Attention-Deficit/Hyperactivity Disorder

There exist limited data on the long-term concurrent use of stimulants and opioids among adults with attention-deficit/hyperactivity disorder (ADHD), a population at risk for prescription drug abuse. To assess the prevalence and secular trends of and the factors associated with long-term concurrent use of stimulants and opioids among adults with ADHD. This cross-sectional study assessed Medicaid Analytic eXtract data from 29 states between 1999 and 2010. Medicaid fee-for-service enrollees aged 20 to 64 years with ADHD who were continuously enrolled for more than 12 months after receiving an ADHD diagnosis were included. One 12-month continuous enrollment period was randomly selected as an observation unit for each enrollee. Multivariable regression models were used to determine secular trends in the prevalence of and the potential risk factors associated with long-term concurrent stimulant-opioid use. Analyses were conducted between January 1 and December 31, 2017. Risk factors measured during the first half of the 12-month observation unit. Prevalence of long-term use of stimulants and opioids overlapping for at least 30 consecutive days was measured during the second half of the randomly selected 12-month observation unit. Of the 66 406 Medicaid-enrolled adults with ADHD who were identified as eligible, 35 670 (53.7%) were 20 to 30 years old, 37 155 (56.0%) were women, and 52 551 (79.1%) were non-Hispanic white individuals. Of these 66 406 adults with ADHD, 21 723 (32.7%) used stimulants, and 3590 (5.4%) were long-term users of stimulants and opioids. Long-term opioid use was more common among adults with ADHD who used stimulants (3590 of 21 723 [16.5%]) than among those with ADHD who did not use stimulants (5826 of 44 683 [13.0%]). Long-term concurrent stimulant-opioid use increased between 1999 and 2010 (adjusted prevalence relative ratio [PRR], 1.12; 95% CI, 1.10-1.14). Compared with patients aged 20 to 30 years, the prevalence of long-term concurrent stimulant-opioid use was higher among patients in their 30s (PRR, 1.07; 95% CI, 1.07-1.08) and was further increased among patients in their 40s (PRR, 1.14; 95% CI, 1.12-1.15) and 50s (PRR, 1.17; 95% CI, 1.16-1.19). Other strongly associated risk factors included being non-Hispanic white (black PRR, 0.93; 95% CI, 0.92-0.93; other PRR, 0.97; 95% CI, 0.97-0.98; vs white), living in the southern United States (Midwest PRR, 0.98; 95% CI, 0.97-0.98; Northeast PRR, 0.94; 95% CI, 0.93-0.94; West PRR, 0.95; 95% CI, 0.94-0.96; vs South), and receiving a diagnosis of substance abuse disorder (PRR, 1.04; 95% CI, 1.03-1.05), depression (PRR, 1.02; 95% CI, 1.01-1.03), anxiety disorder (PRR, 1.05; 95% CI, 1.04-1.07), chronic pain (PRR, 1.10; 95% CI, 1.07-1.13), chronic obstructive pulmonary disease (PRR, 1.05; 95% CI, 1.04-1.07), or cardiovascular disease (PRR, 1.02; 95% CI, 1.01-1.03). Long-term concurrent use of stimulants and opioids among adults with ADHD is common. This study suggests that clinical and research priorities should be made toward understanding the benefits and risks of long-term coadministration of stimulants and opioids in the management of ADHD and co-occurring pain conditions.

A randomized controlled efficacy trial of behavioral activation for concurrent stimulant use and sexual risk for HIV acquisition among MSM: project IMPACT study protocol

BackgroundIn the United States, problematic stimulant use is a prevalent and difficult to treat problem among men who have sex with men (MSM), as well as a major driver of HIV transmission through the large number of sexual partners and concomitant condomless anal sex (CAS). Evidence-based behavioral studies that address problematic stimulant use in MSM at risk for HIV infection are also lacking. In this paper, we describe the design of a behavioral intervention trial to reduce sexual risk behavior and stimulant use in HIV-uninfected MSM.MethodsThis study, funded by the National Institute on Drug Abuse (NIDA), is a randomized controlled trial (RCT) testing an integrated HIV risk reduction and behavioral activation counseling intervention (IMPACT) for HIV-uninfected, stimulant using MSM in Boston, MA, and Miami, FL. Participants are randomized (2:2:1) to either (1) the IMPACT intervention; (2) a relaxation condition, an active therapy time- and intensity-matched control; or (3) a standard of care risk reduction counseling comparison. At enrollment, all participants receive an HIV test and pre- and post-test counseling. The primary outcome is the difference in the rate of change in the number of self-reported condomless anal sex acts without the protection of consistent Pre-Exposure Prophylaxis (PrEP) use, as well as reductions in stimulant use during the prior 4-months. Major assessments are conducted at baseline, 4-, 8-, and 12-month follow-up visits.DiscussionEffective and sustainable behavioral interventions are sorely needed to reduce HIV acquisition in stimulant using MSM at risk for HIV infection. In this study, we will evaluate the evidence of efficacy of the IMPACT intervention to reduce HIV acquisition in HIV-uninfected, stimulant-using MSM. If found effective, the intervention tested here holds promise for being readily integrated into real-world clinical settings.Trial registrationClinicalTrials.gov number NCT03175159, registered June 5, 2017.

Management of Sea Sickness in Susceptible Flight Crews.

Sea sickness may greatly impact the readiness of Service personnel deployed aboard naval vessels. Medications used in the treatment of sea sickness may have adverse effects, limiting their use as flight crew. Although the prevalence of sea sickness in flight crews remains unclear, individual susceptibility and high sea states are established risk factors. Literature review can guide optimized management strategies for this population. The first author conducted a PubMed search using the terms "sea sickness" "flight crew" "scopolamine," "hyoscine," and "cinnarizine," identifying 15 articles of 350 matches, which addressed potential impact to flight performance. Analysis also included two historic reports about motion sickness maintained within the U.K. Army Aviation Centre's aeromedical archives in Middle Wallop, Hampshire. Both authors reviewed aeromedical policy for the International Civil Aviation Organization, U.K. Civil Aviation Authority, U.S. Federal Aviation Authority, the National Aeronautics Space Administration, U.S. Army, U.S. Navy, and U.S. Air Force. Scopolamine, also known as hyoscine, has fewer operationally relevant side effects than cinnarizine or first-generation antihistamines. Although no aeromedical authorities endorse the unsupervised use of scopolamine, many will consider authorizing its temporary use following an initial assessment on the ground. Evidence supports the concomitant use of stimulant medication for augmenting antinausea effects and countering the potential sedative effects of scopolamine. Scopolamine should be considered as a first-line medication for flight crews at risk of sea sickness but such use must be guided by the appropriate aeromedical authority, ideally in conjunction with a ground trial to evaluate individual response. The limited evidence to support concurrent use of stimulants must be weighed against the challenges of maintaining accountability of controlled substances in the operational environment.