Trajectories of Opioid Use Following First Opioid Prescription in Opioid-Naive Youths and Young Adults

Journal: JAMA Network Open, 2021, doi:10.1001/jamanetworkopen.2021.4552

Authors: J. Deanna Wilson, M.D., M.P.H.; Kaleab Z. Abebe, Ph.D.; Kevin Kraemer, M.D., M.Sc.; Jane Liebschutz, M.D., M.P.H.; Jessica Merlin, M.D., Ph.D., M.B.A.; Elizabeth Miller, M.D., Ph.D.; David Kelley, M.D.; & Julie Donohue, Ph.D.

Importance: Although prescription opioids are the most common way adolescents and young adults initiate opioid use, many studies examine population-level risks following the first opioid prescription. There is currently a lack of understanding regarding how patterns of opioid prescribing following the first opioid exposure may be associated with long-term risks.

Objective: To identify distinct patterns of opioid prescribing following the first prescription using group-based trajectory modeling and examine the patient-, clinician-, and prescription-level factors that may be associated with trajectory membership during the first year.

Design, Setting, and Participants: This cohort study examined Pennsylvania Medicaid enrollees’ claims data from 2010 through 2016. Participants were aged 10 to 21 years at time of first opioid prescription. Data analysis was performed in March 2020.

Main Outcomes and Measures: This study used group-based trajectory modeling and defined trajectory status by opioid fill.

Results: Among the 189 477 youths who received an initial opioid prescription, 107 562 were female (56.8%), 81 915 were non-Latinx White (59.6%), and the median age was 16.9 (interquartile range [IQR], 14.6-18.8) years. During the subsequent year, 47 477 (25.1%) received at least one additional prescription. Among the models considered, the 2-group trajectory model had the best fit. Of those in the high-risk trajectory, 65.3% (n = 901) filled opioid prescriptions at month 12, in contrast to 13.1% (n = 6031) in the low-risk trajectory. Median age among the high-risk trajectory was 19.0 years (IQR, 17.1-20.0 years) compared with the low-risk trajectory (17.8 years [IQR, 15.8-19.4 years]). The high-risk trajectory received more potent prescriptions compared with the low-risk trajectory (median dosage of the index month for high-risk trajectory group: 10.0 MME/d [IQR, 5.0-21.2 MME/d] vs the low-risk trajectory group: 4.7 MME/d [IQR, 2.5-7.8 MME/d]; P < .001). The trajectories showed persistent differences with more youths in the high-risk trajectory going on to receive a diagnosis of opioid use disorder (30.0%; n = 412) compared with the low-risk group (10.1%; n = 4638) (P < .001).

Conclusions and Relevance: This study’s results identified 2 trajectories associated with elevated risk for persistent opioid receipt within 12 months following first opioid prescription. The high-risk trajectory was characterized by older age at time of first prescription, and longer and more potent first prescriptions. These findings suggest even short and low-dose opioid prescriptions can be associated with risks of persistent use for youths.

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Management of adolescents with OUD: A simulation case for subspecialty trainees in Addiction Medicine and Addiction Psychiatr

Journal: MedEdPORTAL, 2021, doi: 10.15766/mep_2374-8265.11147.

Authors: Gabriela Garcia-Vassallo, Ellen Lockard Edens, Brady Heward, Marc A. Auerbach, Ambrose H. Wong, & Deepa Camenga

Introduction: The opioid epidemic impacts all ages, yet few published medical education curricula exist to train physicians on how to care for opioid use disorder (OUD) in adolescents, a developmental stage where confidentiality protection is appropriate and contributes to quality health care. We developed a simulation-based educational intervention to increase addiction medicine and addiction psychiatry trainees’ confidence in managing adolescents with OUD.

Methods: Trainees completed a confidence survey and viewed an educational video covering state-specific confidentiality laws pertinent to treating adolescents with OUD. One week later, trainees participated in a simulated encounter where they described the scope of confidentiality to a trained actor, used the Clinical Opiate Withdrawal Scale to assess symptoms of opioid withdrawal, and explained adolescent-specific OUD medication treatment options. Immediately afterward, trainees completed a self-reflection and satisfaction survey and participated in a debriefing session with a faculty member where they identified learning goals. One month later, they completed the confidence survey to quantify changes in confidence.

Results: Thirty-five fellows (21 male, 14 female) completed the simulation-based educational intervention between 2016 and 2019. When asked to answer yes or no, 96% of participants described the exercise as effective and 100% (n = 26) would recommend it to peers. In addition, learners identified future learning goals, including researching specific topics and seeking out additional opportunities to evaluate adolescents with OUD.

Discussion: Based on our participants’ report, this simulation-based educational intervention is an effective teaching method for increasing trainee confidence in managing adolescents with OUD.

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Who, me? Optimism bias about US teenagers' ability to quit vaping

Journal: Addiction, 2021, doi: 10.1111/add.15525.

Authors: Kiersten Strombotne, Jody Sindelar & John Buckell

Background and aims: The vaping rate among US teenagers has doubled in the last 2 years, which may be explained in part by teenagers’ optimism that they would have relatively little trouble in quitting. The aim of this study was to estimate the extent to which teenagers exhibited optimism bias, what characteristics are associated with optimism bias, and which factors are related to respondents’ perceptions of how hard it would be for them to quit.

Design: a national, online, cross‐sectional survey in 2018 using quota sampling.

Setting: USA

Participants: Respondents were n=1,610 teenagers aged 14‐18 who had ever tried or heard of JUULs or e‐cigarettes generally.

Measurements: Optimism bias was defined as respondents’ perceptions of their own difficulty quitting vaping compared with that of an average US person of their own age. Linear regression was used to examine associations between respondents’ characteristics with both optimism bias and their own perceived difficulty quitting vaping.

Findings: Over 60% of teenagers were optimistically biased about their ability to quit vaping. Smoking (b=‐0.69, p<0.01) and JUULing (b=‐0.62, p<0.01) were negatively associated with optimism bias but reduced‐price school lunch eligibility (0.24, p=0.02) and school satisfaction were positively associated (b=0.05, p=0.02). Smoking (b=0.84, p<0.01) was associated with an increased perception of the difficulty of quitting. That association was negative for Black respondents (b=‐0.81, p=0.01) and those eligible for reduced‐priced lunches (b=‐0.48, p=0.01), and positive for Hispanic respondents (b=0.47, p=.04).

Conclusions: On average, US teenagers appear to show optimism bias about their ability to quit vaping, which decreases with smoking and vaping and increases with eligibility for reduced‐price school lunches.

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Individual associations of adolescent alcohol use disorder versus cannabis use disorder symptoms in neural prediction error signaling and the response to novelty

Journal: Developmental Cognitive Neuroscience, 2021, doi: 10.1016/j.dcn.2021.100944.

Authors: Joseph Aloia, Kathleen I. Crum, Karina S. Blair, Ru Zhang, Johannah Bashford-Largo, Sahil Bajaj, Amanda Schwartz, ErinCarollo, Soonjo Hwang, Emily Leiker, Francesca M. Filbey, Bruno B. Averbeck, Matthew Dobbertin, & R. James R. Blair

Abstract: Two of the most commonly used illegal substances by adolescents are alcohol and cannabis. Alcohol use disorder (AUD) and cannabis use disorder (CUD) are associated with poorer decision-making in adolescents. In adolescents, level of AUD symptomatology has been negatively associated with striatal reward responsivity. However, little work has explored the relationship with striatal reward prediction error (RPE) representation and the extent to which any augmentation of RPE by novel stimuli is impacted. One-hundred fifty-one adolescents participated in the Novelty Task while undergoing functional magnetic resonance imaging (fMRI). In this task, participants learn to choose novel or non-novel stimuli to gain monetary reward. Level of AUD symptomatology was negatively associated with both optimal decision-making and BOLD response modulation by RPE within striatum and regions of prefrontal cortex. The neural alterations in RPE representation were particularly pronounced when participants were exploring novel stimuli. Level of CUD symptomatology moderated the relationship between novelty propensity and RPE representation within inferior parietal lobule and dorsomedial prefrontal cortex. These data expand on an emerging literature investigating individual associations of AUD symptomatology levels versus CUD symptomatology levels and RPE representation during reinforcement processing and provide insight on the role of neuro-computational processes underlying reinforcement learning/decision-making in adolescents.

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Child Maltreatment and Substance Use in Emerging Adulthood: Internalizing and Externalizing Behaviors at the Transition to Adolescence as Indirect Pathways.

Journal: Child Maltreatment, 2021, doi:10.1177/10775595211010965

Authors: Anneke E. Olson, Chad E. Shenk & Jennie G. Noll

Abstract: One well-established outcome of child maltreatment is an increased likelihood of substance use in emerging adulthood. However, research identifying the indirect pathways that explain this relation is lacking, thereby limiting substance use prevention efforts for the child maltreatment population. The present study helped address this gap by accessing data from The Longitudinal Studies on Child Abuse and Neglect (LONGSCAN; n = 1,136), a prospective cohort study of child maltreatment from birth through age eighteen. Internalizing and externalizing problems at age twelve were examined as indirect effects of the relation between child maltreatment prior to age four and substance use at age eighteen. A multiple mediator model tested the total and specific indirect effects of internalizing and externalizing concerns while controlling for demographic risk factors. Results demonstrated that the total indirect effect for internalizing and externalizing behaviors was statistically significant, Standardized Point Estimate = 0.01, 95% CI: 0.00-0.02. Examination of the specific indirect effects revealed that only externalizing behaviors constituted an indirect pathway, Standardized Point Estimate = 0.01, 95% CI: 0.00-0.03. These results suggest that externalizing behaviors at the transition to adolescence are important intervention targets for reducing the risk for substance use in emerging adulthood in the child maltreatment population.

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