Further, poorer sleep quality among PWH with comorbid lifetime MA use disorder was associated with a number of neurobehavioral functional outcomes, including decreased physical and mental life quality, IADL dependence, unemployment and clinician-rated functional disability. As expected, lifetime MA use disorder was negatively associated with sleep quality; however, this finding was isolated to PWH and independent of recent MA use. In addition, MA use characteristics did not differ by HIV serostatus, suggesting sleep among PWH may be specifically related to the effects of nonrecent MA use. Prior studies have demonstrated detrimental effects of MA on neurobehavioral health specific to PWH, including neurocognitive impairment and associated everyday life consequences such as unemployment and difficulties performing activities of daily living . It is possible that disrupted sleep may mediate the link between MA and functional outcomes, although longitudinal studies are needed to determine causality. Depressive symptoms in the HIV+/MA+ group are also consistent with prior research . While depressive symptoms were also associated with global PSQI scores, as expected, this did not attenuate the relationship between MA and global PSQI scores in PWH, suggesting additional mechanisms underlying MA-related sleep disturbance independent of mood. One explanation for our findings is the combined, long-term CNS effects of excessive MA use and HIV on brain structures and/or pathways responsible for sleep regulation. While MA’s major mechanism of action is through increased activity of the mesolimbic dopamine system , emerging evidence supports that GABA-ergic dysfunction results from abuse of amphetamines . Projection systems of GABA include the reticular nucleus of the thalamus to the rostral brainstem reticular formation, a structure critical for sleep regulation. Further, GABA also promotes sleep via hypothalamic projections that inhibit serotonergic, noradrenergic, histaminergic,vertical grow racks and cholinergic arousal systems . Future studies linking GABA to MA use and sleep quality are necessary to establish this theoretical mechanism of action. Also, while the lack of evidence of sleep disturbance in the very small HIV−/MA+ group would not support long-term effects of MA use on CNS mechanisms important for sleep, a much larger subject sample would be needed to draw any confident conclusions about HIV−/MA+ individuals.

Prior literature on the prevalence of sleep disturbance in PWH is variable and comparisons between demographically matched, HIV serostaus groups on sleep quality is lacking. In a meta-analysis of self-reported sleep disturbance in PWH, the overall prevalence was 58% . No comparisons have been made with HIV-uninfected individuals from the same population to determine whether this prevalence is higher than in this type of comparison group. The current findings suggest HIV status alone may not elicit poor perception of sleep, however, fragmented sleep has been identified in chronic health conditions even without the patient’s perception of poor sleep . Consistent with prior literature , detectable HIV RNA was associated with poorer perceived sleep quality in our multiple regression analyses, but the specific mechanism for this association could not be established. Other literature has suggested that HIV infection is linked to objective sleep measurements, including reduced slow wave sleep and reduced rapid eye movement latency . However, studies have failed to detect similar associations between HIV disease severity and objective sleep measurements , highlighting the uncertainty to which HIV infection, by itself, may contribute to reductions in sleep quality. The study has several limitations. First, the data are cross-sectional and cannot determine causality. Lifetime MA use disorder is suspected to precede self-reported poor sleep within the last 30 days, however, such self-reported sleep disturbances may be longstanding and could even have served as a precursor to problematic substance use . Thus, future longitudinal evaluations or with increased sample size, the use of structural equation modeling, would be helpful in better determining the timing, duration, and directionality of associations between MA use disorders and sleep. This goes alongside our report of neurobehavioral outcomes associated with problematic sleep within PWH with a history of MA use disorder. While theoretically, sleep should have some influence on function, it is also possible that there is some unique third variable quality within the HIV+/MA+ group that leads to both poor sleep and poor neurobehavioral outcomes. Again, a longitudinal research design or a larger sample size may help in teasing out the directionality of our findings. Second, the small sample size of the HIV−/MA+ group hinders our ability to detect statistically significant associations between MA use and other findings with the HIV− participants.

For example, the difference between HIV+/MA+ and HIV−/MA+ groups on global PSQI was not statistically significant , yet the effect size suggests a nontrivial difference . While our sample did not demonstrate an interaction between HIV and MA possibily due to this limitation, this relationship may exist. Further, while lifetime MA use disorder independently contributed to sleep quality in PWH, we did not observe a recent MA use effect on sleep. We should note that this too may be due to low power, with very few participants reporting use in the last 30 days. It is also important to highlight the complexity of poly substance use in the context of a cross-sectional, retrospective study. Despite this, lifetime MA use disorder was retained in the multiple regression model, while the other substances did not. Due to limited data on participants who met criteria for a current substance use disorder or other measurements of current substance use parameters, our finding cannot speak to other potential factors associated with poly substance use that may explain differences in sleep between MA+ and MA− groups. Future studies to formally investigate poly substance use in more detail is needed to futher confirm our findings. In addition, we did not find associations between age, sex, or sexual orientation on sleep quality, which is contrary to well established literature on these topics . We suspect that the presence of other clinical risk factors for poor sleep, including those identified in this study , may be masking the detection of these variables traditionally known to impact sleep quality. There also remains the possibility that other unmeasured factors such as homelessness and/or SES may account for the observed relationship that MA was related to sleep in PWH that should be explored further in future studies. Lastly, the PSQI questionnaire is based on self-report, which is subject to recall and reporting bias. While there is merit in characterizing perceived sleep quality in vulnerable populations, as even the perception of poor sleep can influence mood and physical health , subjective measurements are just one facet of sleep quality and the inclusion of objective measurements such as actigraphy would enhance understanding of sleep in PWH and substance using populations. Importantly, the global PSQI score demonstrates strong sensitivity and specificity in distinguishing good from poor sleepers among the general population . While the sensitivity in detecting an insomnia diagnosis in PWH remains high , the specificity drops considerably . This suggests that the PSQI may not just be capturing sleep quality in PWH and raises the question as to whether items such as “trouble staying awake during the day” or “trouble keeping enthusiasm” are purely a function of poor sleep or a result of HIV-infection, prescribed medications, and/or associated psychosocial factors. Studies investigating the quality of the PSQI sub-components in capturing sleep quality within PWH using factor analyses may be a natural next step for future research. For people with substance use disorders,vertical grow rack system denial of untoward consequences from their actions is common and can affect commitment to treatment. In 2019, 96% of untreated individuals with a substance use disorder in the previous year denied needing treatment.

Psychodynamic approaches toward addiction encourage accountability and minimizing denial; and 12-step programs, such as Alcoholics Anonymous, target denial by encouraging clients to acknowledge that they have lost control over addictive behavior, with a focus on accountability-centered goals. Among participants who had polysubstance misuse and attended Alcoholics Anonymous or Narcotics Anonymous, the number of days in attendance was associated with decreased self-deception measured in a followup assessment.The transtheoretical model of behavior change likewise posits that changing addictive behavior relies on a transition from lack of recognition that a problem exists to increased awareness and motivation to change.The rostral anterior cingulate cortex , which participates in self-related processing, including self-awareness, has been implicated in personal relevance of drug-related stimuli, as is the ventromedial prefrontal cortex, which contributes to decision making.In an fMRI study, denial of methamphetamine-related problems was negatively related to resting-state connectivity between the rACC and precuneus.Among participants who met diagnostic criteria for Methamphetamine Dependence ,denial of methamphetamine-related problems correlated negatively with overall cognitive function and with rACC connectivity to frontal lobe regions, including the precentral gyri, left ventromedial prefrontal cortex, and left orbitofrontal cortex.These data implicate the rACC and its connections in a person’s ability to acknowledge problematic aspects of their substance use. One of the most important clinical measurements, the diagnosis of a substance use disorder, involves clinical judgment, but self-reports are very important. Structured diagnostic interviews, such as the Structured Clinical Interview for DSM-IV or Mini-International Neuropsychiatric Interview , query self-reports of symptoms indicating craving, tolerance, withdrawal, and interference with activities of daily living. Although interview guidelines encourage the use of referral notes, records, and observations of friends and family,diagnosis often relies on interview with the client alone. In these interviews, denial of problems related to substance use is common and can alter diagnosis. This study sought to clarify how a diagnostic measure of Methamphetamine Dependence that relies on self-report is related to a participant’s denial of his or her addiction problem. Participants comprised a sample of 69 individuals who acknowledged enough symptoms on the SCID to meet criteria for the diagnosis of Methamphetamine Dependence. They also completed the University Rhode Island Change Assessment Scale , which assesses motivation for change by providing scores on 4 stages of change: Precontemplation, Contemplation, Action and Maintenance. The Precontemplation score measures the respondent’s denial that their drug problem warrants change and is based on a transtheoretical model of addiction.In a prior study, the Precontemplation score was positively related to years of heavy methamphetamine use and arrests for drug offenses, supporting the notion that high scores reflect denial rather than the absence of problems. We hypothesized the Precontemplation score would correlate negatively with symptom severity, confounding the diagnosis.A quasi-experimental, non-intervention design was employed using secondary data analysis. Other studies of the parent dataset have been published.Participants, recruited using internet and local newspaper advertisements, provided written informed consent, following the guidelines of the UCLA Office for Protection of Research Subjects. This analysis included data from 69 participants. Detailed inclusion/exclusion criteria are published.In brief, participants were fluent in English, met criteria for Methamphetamine Dependence but not diagnoses related to drugs other than methamphetamine, cannabis, or tobacco; or for any Axis-I psychiatric disorders other than those related to drug abuse . They had a positive urine test for methamphetamine at screening but were not seeking treatment and were otherwise healthy. Participants received monetary payment for their time.The opioid crisis has had a substantial effect on women who are pregnant and parenting, focusing both public health and policymaker attention on opioids and on other substance use in pregnancy and postpartum. The number of pregnant women with an opioid use disorder diagnosis at delivery quadrupled from 1999 to 2014,1 and the incidence of neonatal opioid withdrawal syndrome increased nearly seven-fold from 2000 to 2014. Alcohol use remains common, with 1 of 9 pregnant women endorsing past 30 day use, one third of whom reported binge drinking.Cannabis use is increasing, with daily or near-daily cannabis use in pregnancy increasing from <1% in 2002 to nearly 3.5% in 2017.Stimulant use, specifically methamphetamine, doubled in pregnancy from 2008 to 2015.These trends have contributed to an increase in drug-related deaths among women in general and during pregnancy and postpartum in particular, with overdose among the leading causes of maternal death in the US today.Furthermore, the child welfare system response to substance use in pregnancy is straining already-limited resources. From 2011 to 2017, the number of infants entering the U.S. foster care system grew by almost 10,000, and at least half of infant placements are associated with parental substance use.Below, we review the change over time in state-level policy environments around substance use in pregnancy and contrast the policy response with the principles and guidance from professional societies and federal agencies.