Such models also demonstrate that HIV infection can alter the metabolism of alcohol, which has direct consequences for alcohol-induced expression of genes that affect neurotransmission . Combined, these data, collected at multiple levels of analysis, suggest that HIV infection has a direct impact on learning and memory and that it may also increase vulnerability to the effects of alcohol consumption on memory functioning. Consideration of the impact of problematic alcohol use on memory functioning may therefore further enrich our understanding of health outcomes among individuals with HIV. The current study is characterized by several strengths including examination of varying levels of alcohol use, comprehensive interview-based assessment of medication adherence, psychiatric illness, and co-occurring substance use, as well as evaluation of patient-perceived everyday memory functioning. However the current study is not without limitations. First, although the presented mediational results represent an important first step, without a prospective design our findings have limited interpretability. Future studies should longitudinally examine the influence of perceived memory functioning and problematic alcohol use on HIV symptom severity to confirm directionality of observed effects. Second, HIV symptom severity is a subjective self-report measure and represents only one index of HIV health. Future research should use a multi-method approach to determine how problematic alcohol use and self-reported memory functioning impact objective measures of adherence ,greenhouse tables engagement with care and biological markers of HIV disease severity . Third, we did not simultaneously employ laboratory based measures of neuropsychological performance traditionally used to establish cognitive impairment in clinical populations.

Indeed discordance between self-reported cognitive functioning and objective indices of neuropsychological performance has been documented among HIV infected individuals. However, other research has found increased cognitive complaints to predict poorerneuropsychological test performance and thus supports a relation between self-reported cognitive complaints and neuropsychological skills among HIV-infected individuals. Further, the majority of observed cognitive impairment among HIV-infected individuals in the post-ART era is mild, variable, and may go undetected . As such, it is possible that neuropsychological assessment measures, which possess somewhat less obvious face validity for real world impairment, are less sensitive to mild and fluctuating difficulties in everyday memory functioning. Hence, our reliance on patient’s self-report of memory dysfunction offers a unique understanding of how HIV symptom severity and problematic alcohol use can affect subjective experience. Nevertheless, future studies should employ a multi-modal assessment of cognitive functioning that includes both self-report and neuropsychological assessment tools. In addition, although the EMQ has been used with cognitively compromised clinical samples and is sensitive to differential use of alcohol, it has not been employed in previous studies with HIV-infected samples. Of note though, other studies have included similar measures of meta-memory to assess perceived memory difficulties in HIV-infected samples. Fourth, counter to expectations, our analyses did not reveal an association between self-reported medication adherence and HIV symptom severity. It is possible that memory problems may have impacted accuracy of self-reported adherence . Another potential reason for the lack of association could have been the differing time frames in which HIV symptom severity and medication adherence were assessed. It is possible that recent non-adherence may not yet have rendered increases in symptom severity. Accordingly, the shorter 2-week window in which medication adherence was assessed is a limitation of this study.

Future studies should aim to match assessment time periods for medication adherence and HIV symptom severity. In addition, given that some of the named symptoms included affective disturbance, medication adherence alone may not have been sufficient to reduce such symptoms. HIV infection is associated with a wide range of symptoms, and future research should examine the extent which problematic alcohol use and perceived memory functioning impact specific facets of HIV symptoms . Fifth, although our hypotheses were supported above and beyond the effects of sample stratification by cannabis use status, researchers should also examine associations between problematic alcohol use, memory functioning and HIV symptom severity in an a priori study. Last, the current study did not employ an objective measure of adherence and observed self-reported estimates may have been overinflated. Other studies with HIV-infected substance users have reported significantly lower adherence ratings with objective measures . In summary, problematic alcohol use, more so than medication non-adherence, current depression, or cannabis or tobacco use, was associated with greater perceived memory dysfunction in this HIV-infected sample. Additionally, perceived memory dysfunction emerged as a factor that may explain why individuals with problematic alcohol use experience increased HIV symptom severity. Accordingly, memory functioning may represent a high yield trans-disease target for interventions among individuals with co-occurring HIV and substance use disorders . Further, the current findings, in conjunction with previous work, suggest that assessment of cognitive functioning should precede symptom-focused empirically-supported interventions in order to bolster outcomes for HIV-infected individuals with problematic alcohol and substance use. Identification of cognitive deficits prior to treatment would afford clinicians the opportunity to modify intervention delivery and preemptively recruit organizational and community resources.

Finally, our results highlight the importance of integrated care for this high-risk population that includes cross training initiatives across health disciplines , co-location of services, enhanced provider communication, monitoring of drug interactions and side effects, and a united, multidisciplinary team approach to combating the serious social and economic consequences that typify HIV infection and substance use.That same year, with these high rates of prescribing, an average of 3.6% of Americans 12 and older self-reported prescription opioid abuse, resulting in 41 deaths per day.A major push to curtail opioid prescriptions has been initiated nationwide, yielding volumes of research and effective strategies to limit prescriptions. Opioid prescriptions in the emergency department have been identified as a possible gateway for drug overuse or addiction. In a recent study of 53 patients who reported using heroin or nonmedical opioids, 59% of patients were first exposed to opioids by prescription, 29% of whom were first prescribed opioids in the ED.Furthermore, 12% of patients with acute pain who are prescribed opioids for the first time in the ED will continue to refill them after one year.The decision to prescribe opioids, and the quantity of opioids, can be subjective and may be influenced by the provider’s explicit and implicit biases. Studies have found that opioid prescription rates are dependent on the facility, physician, geographic location, and situational or workload factors.Other more implicit factors that have been identified may include a patient’s age, race, ethnicity, socioeconomic status, gender, insurance, clinical presentation, and physician’s judgment as to whether a patient may display drug-seeking behaviors.Physicians are often wary of prescribing opioids to patients who have a history of drug abuse or are taking illicit drugs that may cause an accidental overdose. However, this situation is further complicated when patients require opioids due to a major injury. Literature is sparse regarding guidelines on prescribing controlled medications to patients with suspected or confirmed illicit drug use.Previous literature has identified that individuals with alcohol, marijuana, hallucinogen, cocaine, stimulant, heroin, and sedative use disorders, as well as those with nicotine dependence, had a higher prevalence of prescription opioid use disorders.These individuals were also found to have used prescription opioids non-medically more often than those without substance use disorders, with an incidence rate ratio between 1.46 to 1.96. Conversely, individuals misusing prescription opioids had much higher odds of using illicit drugs, including heroin, crystal methamphetamine, and cocaine.Given that nearly two-thirds of prescription opioid deaths co-occurred with cocaine, methamphetamine, or benzodiazepines, this presents a challenge to physicians who are prescribing opioids to patients with evidence of illicit substance use.Furthermore,vertical farming supplier a population-based cohort study of adolescents determined that illicit drug use is a risk factor for future opioid misuse in that population.24 In light of this evidence, it would be prudent for physicians to adjust their opioid prescribing habits, or coprescribe an overdose-reversing agent such as naloxone to patients who require opioids but present with evidence of prior illicit substance use. With the recent legalization and increase in the use of cannabis and cannabinoid products including tetrahydrocannabinol and cannabidiol in many states, it is important to consider the implications for opioid prescriptions. The most psychoactive component in the majority of cannabis products is THC, and it has been identified as playing a principal role in the analgesic effects of cannabis.To date, research bridging the years before and after medicinal and recreational cannabis legalization has demonstrated that the introduction of cannabis has either had no effect or decreased the quantity and dosage of opioid prescriptions.However, pre-clinical evidence is mixed regarding the opioid-sparing effects of THC. High quality clinical trials in humans are lacking, and results from the trials that have been conducted are mixed.Given the general lack of literature on opioid prescribing guidelines for patients with substance use disorder, we aimed to explore how a physician’s behavior and opioid-prescribing habits may be altered by knowledge of the patient’s concomitant use of psychotropic compounds as evidenced on urine and serum toxicology screens. Additionally, our goal was to elucidate which patient populations are more likely to receive naloxone, and whether knowledge of recreational drug use through toxicology screens is associated with higher rates of naloxone prescriptions.Patients 18 years of age and older who were discharged from the ED with a diagnosis of fracture, dislocation, or amputation and received an opioid prescription upon discharge were included in the study.

We excluded from the analysis patients who were admitted to the hospital, transferred to another hospital, or not discharged with an opioid prescription. The study was reviewed and approved by the university’s institutional review board as an exempt category . Patient informed consent was not applicable.We obtained our data from the hospital’s health records database. We extracted the following information for each patient: age; gender; diagnosis ; urine and serum toxicology results; prescription medication ; and quantity . For each patient we calculated a total prescribed milligram morphine equivalent by multiplying the prescribed amount by potency of prescribed medication. The data collection was performed by a single abstractor, a pharmacist trained in using structured query language and the Observational Medical Outcomes Partnership. The abstractor was blinded to the study hypothesis.We divided the study population into five subgroups: patients with negative urine and serum toxicology screen; those who tested positive for depressants; stimulants; mixed; and no toxicology screens. A basic urine drug screen was used without confirmation testing. The drugs identified on the urine drug screen were amphetamines, barbiturates, cocaine, benzodiazepines, methadone, opiates, phencyclidine, THC, propoxyphene, and MDMA . Alcohol was a quantitative test tested through serum. Depressants included patients who tested positive for alcohol, opiates, benzodiazepines, or methadone. The mixed subgroup contained urine or serum toxicology components from both the depressant and stimulant classes, as described above. Given that THC has a complex pharmacology and its effects can vary from having depressant or stimulant properties depending on the dose, type, and individual user, any patient found to be THC positive was categorized as “mixed.” Because opiates and benzodiazepines are often used in the ED to treat painful conditions or for conscious sedation for fracture or dislocation reductions, patients with urine toxicology screens obtained after the ED administration of opiates or benzodiazepines were presumed negative for the substance, and the data was analyzed accordingly. Nine cases were presumed negative due to the patients having received an opioid or benzodiazepine prior to obtaining a urine sample for drug screen analysis: seven patients were presumed negative for opioids and recategorized from the depressant group to the negative group; one patient was presumed negative due to both benzodiazepine and opioid administration and recategorized from the depressant group to the negative group; and one patient was presumed negative for opioids and recategorized from the mixed group to the stimulant group. Of 103 patients who had a urine toxicology screen, eight had opioids that could not be explained by a prior opioid prescription or ED administration of an opioid. None of the patients in the stimulants group had active prescriptions for amphetamine containing products such as dextroamphetamine for attention deficit hyperactivity disorder. All opioids and benzodiazepines identified to have been administered to these nine patients were confirmed by the institution’s lab to have been administered medications that are typically detected by the urine toxicology screen. Furthermore, for trauma activations, the trauma service was actively involved in the care of patients including decisions on imaging, inpatient analgesics, and disposition.