The primary purpose of this study is to determine the occurrence of drug therapy adjustment in people with substance use disorder receiving medication-assisted treatment when admitted to an acute care facility for a comorbid condition. The secondary purpose is to understand the correlation between the presence of adjustment of therapy for substance use disorder and influence on recovery from comorbid conditions. A literature review exploring drug therapy for addicted individuals during hospitalization was performed using various databases, search terms included *substance use disorder or *substance abuse or *illicit drug use or *drug abuse or *MAT or *maintenance therapy, combined with *inpatient or *hospital or *acute care or *admission. The data was conformed into tables that synthesized the relationship between drug therapy adjustment for individuals with substance use disorder during an acute care admission. Initial review of the articles revealed 78 articles relative to the topic, 16 of those articles met inclusion criteria and were selected for a detailed analysis. Studies suggest the need for provider education and guidelines for treating individuals receiving MAT in an acute care facility. While individuals with substance use disorder often use acute care services, their medication-assisted treatment is rarely acknowledged or adjusted. Many studies focus on individuals with substance use disorder, yet, addressing medication-assisted therapy is still inconsistent, and lacks official guidelines.

Drug use is considered in many countries the plague of today's society. Researchers from medical, psychological and sociological fields, as well as lawmakers, are interested in finding more answers to this widespread phenomenon. All over the world there are known conflicts related to drug producing, transportation routes and distribution, that harm the economy and social standing of the involved communities or countries. Policies towards drug use vary from country to country, but this research focuses on how stigma affects the lives of individuals suffering from substance use disorder (SUD) in Albania. Substance use disorder is not often considered a disease, and more often individuals suffering from this disorder are stigmatized and not given the right care from their families, societies, or healthcare providers. Drug usage in Albania is closely linked to the country's geopolitics and its communism and dictatorship past history. This phenomenon has influenced the Albanian societal perceptions. Even though Albania became a democratic country in the 1990s, there are still old mentalities to be changed, with social stigma towards drugs being one of them. The purpose of this pilot research is to understand the connection between social stigma and the treatment that individuals with substance use disorder receive from their families, society, and medical institutions. This pilot study was based on interviews conducted in a small sampling of 18 individuals. The qualitative information collected through interviews falls into four categories: Medical professionals and psychologists, family members or people who have loved ones with substance use disorder, current users of cocaine or synthetic drugs who are in denial regarding their addiction and everything it entails, and heroin users currently in treatment programs. There are also different types of stigma associated with different types of drugs. These types of stigma are herein categorized based on the collected information which supports the premise of how social stigma affects these individuals' lives. This study is the first known research for this subject matter in the country of Albania, therefore, it intends to open the path for further research that is inclusive of more groups/individuals.

Posttraumatic stress disorder (PTSD) and substance use disorder (SUD) frequently co-occur. Comorbid PTSD+SUD confers heightened risk of other mental health concerns, suicidality, mortality, and functional impairment. Current treatments for comorbid PTSD+SUD show inconsistent results, highlighting the need for a more comprehensive understanding of the associations between PTSD and SUD symptoms. The current dissertation aimed to characterize the associations between PTSD and SUD using structural equation modelling among three different samples with differing clinical severity and presentation: (1) concurrent disorders sample with a high prevalence of PTSD; (2) an in-patient sample seeking treatment for PTSD; and (3) a subclinical sample of healthcare workers and public safety personnel. Data were extracted from multiple clinical databases across different studies to evaluate the associations between PTSD symptoms and alcohol/cannabis/substance use-related problems. Furthermore, the role of underlying mechanisms such as dissociation and emotion dysregulation, which are associated with both PTSD and SUD, were analyzed. All analyses used a structural equation modelling framework to represent the complex clinical presentation of comorbid PTSD+SUD analytically. A relatively consistent pattern of results was observed across the three samples. Global PTSD symptoms were significantly associated with cannabis-related problems, alcohol-related problems, and other illicit substance-related problems. Among PTSD symptoms, the reactivity symptom cluster (characterized by symptoms of hypervigilance, irritability, reckless behaviour, problems with concentration and sleep disturbances) was significantly associated with alcohol/cannabis/substance-related v problems across among the three samples. Furthermore, underlying mechanisms such as dissociation and emotion dysregulation significantly mediated the relations between PTSD symptoms and alcohol/cannabis/substance-related problems. Overall, the current results contribute to the limited literature examining the associations between PTSD and SUD symptoms. Lastly, the current results have important clinical implications for identifying efficacious treatment targets for comorbid PTSD+SUD. / Dissertation / Doctor of Philosophy (PhD) / Psychological distress following a traumatic event, known as traumatic stress, is often associated with problematic alcohol and/or substance use. The co-occurrence of these two confers a heightened risk of other mental health problems. As such, studying how these phenomena are associated with one another and what about each thing is more important to the association is important to understand. The purpose was to examine the connection between these phenomena among three different groups of people: two treatment-seeking groups and non-treatment seeking group one group. Traumatic stress was associated with problematic substance use in all three groups. In addition, other factors like mentally escaping from your body and having difficulties with regulating your emotions explained how traumatic stress and problematic substance use were connected to each other. These findings can help clinicians hone their treatment programs to better help individuals struggling with traumatic stress and problematic substance use.

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Bakgrund: Substansbrukssyndrom drabbar människor över hela världen. Tidigare forskning har visat att hälso- och sjukvårdspersonal upplevde att de hade en negativ inställning till patienter med substansbrukssyndrom. Hälso-och sjukvårdspersonal har också rapporterats ha fördomar mot denna patientgrupp. Det har även visats att patienter med substansbrukssyndrom behandlades annorlunda än andra patienter. Patienter med substansbrukssyndrom vårdas på många olika avdelningar, vilket gör att den grundutbildade sjuksköterskan kan möta dessa patienter inom olika vårdinstanser. Syfte: Syftet med litteraturstudien var att belysa vilka erfarenheter patienter med substansbrukssyndrom hade av mötet med hälso- och sjukvårdspersonal. Metod: En litteraturstudie baserad på tolv vetenskapliga artiklar med kvalitativ studiedesign. Artiklarna hämtades från databaserna Cinahl, Pubmed och Psychinfo. Artiklarna analyserades enligt metod beskriven av Friberg (2017). Resultat: Två teman identifierades: Positiva upplevelser samt Negativa upplevelser. Utifrån dessa genererades fyra subteman: Professionellt bemötande, Terapeutisk allians, Oprofessionellt bemötande och Inadekvat vård. Konklusion: Patienterna hade både positiva och negativa erfarenheter av möten med hälso- och sjukvårdspersonal. Vid positiva upplevelser beskrevs ett fördomsfritt och accepterande bemötande samt att hälso- och sjukvårdspersonal skapade en anknytning till patienten och gjorde patienten delaktig i vården. Vid negativa erfarenheter skildrades bemötandet som fördomsfullt, dömande och stigmatiserande. Hälso- och sjukvårdspersonal upplevdes ofta ha bristande kunskaper inom beroendemedicin. Patienter med substansbrukssyndrom upplevde att de fick sämre vård än patienter utan substansbrukssyndrom. Hälso- och sjukvårdspersonal behöver ha kunskap inom beroendemedicin samt ett professionellt och fördomsfritt bemötande för att kunna ge patienter med substansbrukssyndrom en god och likvärdig vård som andra patienter. / Background: Substance use disorder affects people all over the world. Previous research showed that health care professionals had a negative attitude towards patients with substance use disorder. They also had prejudices against this patient group. Patients with substance use disorder were treated differently than other patients. They are cared for in many different wards, which means that the undergraduate nurse can meet these patients in different care institutions. Aim: The purpose of the literature study was to illustrate the experiences of patients with substance use disorder meeting health care professionals. Method: A literature study based on twelve scientific articles with qualitative study design. The articles were retrieved from the databases Cinahl, Pubmed and Psychinfo and were analyzed according to Friberg (2017). Result: Two themes were identified: Positive experiences and Negative experiences. Based on these, four subthemes were generated: Professional attitude, Therapeutic alliance, Unprofessional attitude and Inadequate care. Conclusion: Patients had both positive and negative experiences of meetings with health care professionals. In positive experiences, an open-minded and accepting attitude was described and health care professionals created a connection to the patient and involved patients in the care. In negative experiences, the attitude was portrayed as prejudiced, judgmental and stigmatizing. Healthcare professionals often had a lack of knowledge in addiction medicine. Patients with substance use disorder experienced that they received inferior care than patients without substance use disorder. Healthcare professionals need to have knowledge in addiction medicine as well as a professional and open-minded attitude to be able to give patients with substance use disorder a good and equivalent care as other patients.

Inledning: Sjuksköterskan möter individer med substansbrukssyndrom i många sammanhang i den psykiatriska kontexten. Det finns en önskan hos individerna om en helhetssyn, sjuksköterskans möte kan ha betydelse för en vård där hela patientens hälsa beaktas. Författarna vill därför sammanställa den befintliga kunskapen om mötet utifrån sjuksköterskans perspektiv.  Syfte: Att sammanställa kvalitativ och kvantitativ forskning avseende sjuksköterskans möte med individer som har substansbrukssyndrom.  Metod: Aktuell studie är en integrativ litteraturstudie. Den integrativa metoden är genomförd enligt Whittemore och Knafl (2005).  Resultat: your de meningsbärande enheterna växte en huvudkategori; Sjuksköterskans anpassning av rollen samt fyra underkategorier fram; den auktoritära rollen, den praktiska utföraren, den medmänskliga terapeutiska rollen och den reflekterande vaksamma rollen. Slutsats: De fyra rollerna som framkom your analysen belyser hur flexibel och medveten sjuksköterskan behöver vara i omvårdnaden, både med hänsyn till helhetssynen av individen samt beträffande var i sjukdomsprocessen individen befinner sig. Sjuksköterskan stödjer individen i att återta kontrollen i sitt eget liv.

Introduction: Substance abuse syndrome is common in society. According to the Patient Act, each individual is always entitled to adapted care, according to maturity, age, experience, ethnicity and other individual aspects. Previous studies have shown that healthcare professionals feel insecure meeting patients with substance abuse syndrome, so it will be interesting to investigate how patients experience the response from healthcare professionals and what consequences leads to. Aim: The aim was to compile current research on how people with previous or ongoing substance use syndrome experience the treatment from healthcare professionals. As well as their views on the significance of the treatment for the impact on the care they receive. Method: The method used is a literature review with a qualitative approach. The data collection was done via the database PubMed, where 11 scientific studies were found and reviewed via SBU's review template. Results: Three main categories were identified and followed by subcategories. The main categories that were used were treatment, stigma and pain treatment. It demonstrated a need for healthcare professionals to become aware of the stigma and differences in power that arise at healthcare meetings with patients. This review of the literature showed that patients did not experience a satisfactory treatment, it also emerged that the patients experienced a better treatment from specialist trained staff in the subject of substance use syndrome. The consequences for the patients when the treatment from the care staff was not perceived as satisfactory was an inadequate pain relief, delayed care, premature discharge, self-medication and the patients completely refraining from seeking care. In the long run, the consequences became a longer and more difficult suffering for the patient. Conclusion: The nurse's previous experience and competence were decisive for how the patient experienced the treatment in the care search. A non-judgmental attitude created an increased sense of security for patients, to dare to open up and not use strategies to hide their substance use syndrome. Keywords: “substance use disorder”, “experience”, “nurses”, “stigmatization”, “patient experience”and “substance dependence”. / Introduktion: Substansbrukssyndrom är vanligt förekommande i samhället. Enligt patientlagen har alltid varje enskild individ rätt till en anpassad vård, efter mognad, ålder, erfarenhet, etnicitet och andra individuella aspekter. Tidigare studier har visat att sjukvårdspersonal känner sig osäkra inför mötet med patienter med substansbrukssyndrom, därför blir det intressant att undersöka hur patienterna upplever bemötandet från sjukvårdspersonalen och vad det kan ha för upplevda konsekvenser.  Syfte: Syftet var att sammanställa aktuell forskning om hur personer med tidigare eller pågående substansbrukssyndrom upplever bemötandet från vårdpersonal. Samt deras åsikter om bemötandets betydelse för inverkan på den vård de får.  Metod: Metoden som använts är en litteraturöversikt med kvalitativ ansats. Datainsamlingen gjordes via databasen PubMed, där 11 vetenskapliga studier hittades och granskades via SBU:s granskningsmall.  Resultat: Tre Huvudkategorier identifierades och följdes av underkategorier. Huvudkategorierna som togs fram var bemötande, stigmatisering och smärtbehandling. Det påvisade ett behov hos vårdpersonal att bli medvetna om stigmatisering och maktskillnader som uppstår vid vårdmötet med patienterna. Denna litteraturöversikt visade att patienter inte upplevde ett tillfredsställande bemötande, det framkom även att patienterna upplevde ett bättre bemötande från specialistutbildad personal inom ämnet substansbrukssyndrom. Konsekvenserna för patienterna när bemötandet från vårdpersonalen inte upplevdes som tillfredsställande var en icke adekvat smärtlindring, försenat vårdförlopp, för tidiga utskrivningar, självmedicinering och att patienterna helt avstod från att söka vård. I förlängningen blev konsekvenserna ett längre och svårare lidande för patienten.  Slutsats: Sjuksköterskans tidigare erfarenhet och kompetens var avgörande för hur patienten upplevde bemötandet i vårdsökandet. En icke dömande attityd skapade en ökad trygghetskänsla för patienterna, att våga öppna upp och inte använda strategier för att dölja sitt substansbrukssyndrom.  2 Nyckelord: missbruksrelaterade sjukdomar, upplevelser, sjuksköterskor, stigmatisering, patientens upplevelse, substansberoende

Posttraumatic stress disorder (PTSD) co-occurs with substance use disorders at high rates, but the neurobiological basis of this relationship remains largely unknown. Identifying mechanisms that underlie this association is necessary, and recognizing pathologies shared by these disorders may provide pertinent information in understanding their functional relationship. Separate lines of evidence suggest that PTSD and drug addiction may share a common feature, that is, dysregulation of the brain's reward circuitry. We hypothesize that PTSD results in reduced dopaminergic neurotransmission which may contribute to deficient reward function and vulnerability to drug-seeking behavior. To address this hypothesis, we combined single-prolonged stress (SPS), a rodent model of PTSD, with a series of behavioral and neuropharmacological assays to assess dopaminergic reward function and cocaine intake. The results of the studies presented herein extend our understanding of the effects of severe stress on drug reinforcement and consumption, and establish a potential mechanism by which PTSD produces deficient reward function through alterations in the dopamine system. A modified SPS procedure consisting of 2 hours of restraint, 20 minutes of group swimming, isoflurane exposure until loss consciousness, and 7 days of isolation was used to induce severe stress in our studies. Initial studies were conducted to examine the effect of SPS on cocaine-conditioned reward and anhedonia-like behavior in adult male Sprague-Dawley rats. Using a biased conditioned place preference paradigm, unstressed controls demonstrated a significant preference for the cocaine-paired context following four pairings with cocaine (5-20 mg/kg, i.p.). Preference for the cocaine-paired side was significantly lower in rats exposed to SPS, suggesting a deficit in the rewarding properties of cocaine following exposure to severe stress. Anhedonia-like behavior was assessed by a two-bottle choice sucrose preference test. Robust consumption of sucrose solution (0.25-1%) was observed in rats that underwent control handling, however, SPS significantly reduced sucrose intake compared to controls. These results suggest an increase in anhedonia-like behavior or a reduction in the rewarding effects of sucrose as a non-drug reinforcer. Finally, basal behavioral activity in SPS rats was compared to unstressed controls in a 24-hour test. Results indicate a significant reduction in spontaneous nocturnal activity following SPS versus control handling. In contrast, hyperlocomotion induced by an acute cocaine injection (5-20 mg/kg, i.p.) was unaltered between rats that underwent SPS or control handling. These data suggest that deficient behavioral activity may be specific to voluntary movements or behavior, and support an increase in anhedonia following exposure to SPS. Intravenous cocaine self-administration was conducted to examine the effect of SPS on the acquisition, motivation, and escalation of cocaine intake. Acquisition of cocaine self-administration was studied using an escalating dose regimen in which rats had sequential access to 0.1875, 0.375, and 0.75 mg/kg/infusion on a fixed-ratio 1 schedule of reinforcement. Rats exposed to SPS did not significantly differ from control handled animals in the latency to meet acquisition criteria (consumption of 6.75 mg/kg/day for 3 consecutive days) or the general pattern and level of cocaine intake at each dose. A subsequent study assessing the breakpoint for cocaine self-administration using a progressive-ratio schedule of reinforcement determined a dose-dependent increase in motivation to work for cocaine (0-1.5 mg/kg/infusion) across both experimental groups. However, motivation to obtain cocaine was similar between SPS and unstressed rats, as there was no significant difference in breakpoint for cocaine self-administration at any dose of cocaine tested. To evaluate potential differences in the transition to escalated cocaine intake, self-administration was measured using an extended-access procedure in which unlimited cocaine (0.375 mg/kg/infusion) was available for six hours daily. Upon extended-access to cocaine, SPS significantly attenuated cocaine intake compared to control handling over 14 sessions. Despite a significant reduction in cocaine intake, rats exposed to SPS still significantly escalated their cocaine intake over the course of 14 days. These results suggest that escalation of cocaine intake occurred in the presence of lower total doses of cocaine in the SPS exposed animals compared to controls. In addition, SPS rats demonstrated a greater percent increase in cocaine consumption compared to controls. This finding suggests that rats exposed to SPS compensated for a decrease in cocaine reinforcement by escalating their intake to a greater magnitude than controls. These studies indicate that SPS may not alter the acquisition of cocaine self-administration or motivation for cocaine. However, the finding of reduced cocaine intake upon extended-access in SPS rats is consistent with a deficit in cocaine-induced reward. The ability of SPS rats to escalate cocaine intake in the presence of less cocaine, or a greater magnitude of escalated cocaine intake than controls, may reflect mechanisms leading to enhanced vulnerability to cocaine abuse. To understand the mechanisms of reduced reward and behavior in the SPS model of PTSD, a series of neurochemical assays was used to assess the ability of SPS to induce dysfunction of dopaminergic neurotransmission. Using high performance liquid chromatography, tissue levels of dopamine and the dopamine metabolites DOPAC and HVA were measured immediately and one week following SPS or control handling. Tissue obtained from SPS rats demonstrated significant decreases in dopamine, DOPAC, and HVA content in both the nucleus accumbens and caudate putamen immediately following SPS and one week later, suggesting a potential deficit in dopaminergic tone. Quantitative autoradiography was used measure the density of dopamine transporters and dopamine D1 and D2 receptors. [3H]WIN35428 binding to dopamine transporters was higher in the nucleus accumbens of SPS rats compared to controls, suggesting an increase in dopamine transporter density following severe stress. The level of [3H]WIN35428 binding in the caudate putamen was not different between groups. [3H]Raclopride binding to D2 receptors was significantly reduced in both the nucleus accumbens and caudate putamen following SPS versus control handling. These results suggest a decrease in the density of striatal D2 receptors. D1 receptor expression was not significantly altered by SPS, as no significant difference in [3H]SCH23390 binding was detected in SPS rats compared to controls. A preliminary functional assessment of dopamine transporters revealed a significant increase in dopamine uptake in the nucleus accumbens of SPS rats compared to controls, whereas uptake in the caudate putamen was unaltered between groups. Enhanced dopamine uptake following SPS is consistent with the increase in dopamine transporter density observed in the nucleus accumbens of SPS rats. Activation of D1 receptors and G-protein mediated transduction was assessed using an adenylyl cyclase assay with the D1 agonist SKF82958. In the caudate putamen, a significant decrease in D1 receptor-stimulated cAMP production was revealed in SPS rats compared to controls, whereas SKF82958-induced cAMP was unchanged in the nucleus accumbens. Finally, the function of D2 dopamine receptors was assessed by D2 receptor-stimulated [35S]GTPγS binding using quinpirole. In the caudate putamen, [35S]GTPγS binding following stimulation of D2 receptors was enhanced by SPS compared to control handling, whereas no difference was observed between groups in the nucleus accumbens. These results indicate increased D2 receptor-mediated activation of G-proteins in the caudate putamen following SPS. In summary, the studies described herein tested the hypothesis that reduced dopaminergic function may be a mechanism for deficient reward and heightened susceptibility to drug use in PTSD. Results demonstrated a significant reduction in cocaine-conditioned reward, as well as attenuated sucrose preference and spontaneous activity in rats exposed to SPS. These findings are consistent with the presence of a dysfunctional reward system which may contribute to anhedonia-like behavior in PTSD. Furthermore, reward deficits may promote altered patterns of cocaine taking behavior and vulnerability to substance abuse. Results demonstrated significant escalation of drug intake following exposure to SPS, which occurred in the presence of less cocaine than controls. A greater increase in cocaine intake was observed in SPS rats over the course of escalation, which may reflect a mechanism for enhanced vulnerability to the development of a substance use disorder in PTSD. Dopaminergic dysfunction may contribute to deficient reward capacity and an altered pattern of cocaine intake in SPS. SPS-induced alterations in dopamine function included a reduction in striatal dopamine content alongside enhanced dopamine transporter levels and function. Mild alterations in D2 receptor density and the function of D1 and D2 receptors were also observed. These findings support the hypothesis that PTSD results in reduced dopaminergic neurotransmission, which may contribute to deficient reward function and altered drug-seeking behavior. Identifying the pathology of PTSD, such as altered dopamine neurotransmission, may lead to enhanced treatment strategies and interventions to prevent substance abuse in persons with PTSD. / Pharmacology

Thesis advisor: Stephen J. Pope / This dissertation attends to the crisis of addiction in the United States. The increasing number in annual overdoses and the inadequacy of national responses to curtail these preventable deaths demands an immediate moral response. In the last year, deaths caused by overdose increased by nearly 29 percent, and 20.8 million people in the United States are currently living with substance use disorders. The number of families affected by addiction presents a striking testimony to the scope of the problem. Nevertheless, there is still enormous disagreement over the nature of addiction and therefore how to best treat it. This dissertation will therefore offer a theological approach to addiction in order to advocate for a social response to this crisis.This dissertation proceeds in five chapters. In the first chapter, I evaluate the medical and moral models of addiction. This first chapter engages research in neurobiology and psychology and argues that these models are premised upon a false dichotomy between determinism and freedom of the will. The second chapter explores disagreements in bioethics over the meanings of health, disease, and illness. These different definitions contribute to the chasm between the medical and moral models of addiction. This chapter proposes a holistic account of health for understanding addiction and healing. The third chapter grounds this holistic account of health in Karl Rahner’s transcendental anthropology in order to uphold the fundamental relationality of human persons and to move past the false dichotomy presented in chapter one between determinism and freedom of the will. This chapter then offers a theological examination of sin as a power or force that preconditions freedom. It concludes by proposing a theological and relational account of autonomy. The fourth chapter engages philosophy of the mind in order to argue for a nonreductive approach to mentality that appreciates the ways in which human persons are co-constituted by bottom up and top down causality. A nonreductive approach to mentality offers a way to understand addiction as an interacting set of processes and patterns. This fourth chapter concludes by considering the possibility for responsibility by examining narrativity, vulnerability, and imagination. It argues that there is a moral responsibility to imagine a better world for people living with addictions, and to bring that world about. Finally, the fifth chapter draws upon the theological virtue of solidarity and the principle of the preferential option for the poor in order to articulate a preferential option for people living with addictions. I argue here that Church institutions can stand in solidarity with people who suffer from addiction by acting as providers, educators, and lobbyers. / Thesis (PhD) — Boston College, 2022. / Submitted to: Boston College. Graduate School of Arts and Sciences. / Discipline: Theology.