The current study found that a HIV+ status was associated with membership in the decreaser, increaser and chronic high marijuana trajectory groups, a finding that suggests that overall HIV+ MSM in the MACS were more likely to use marijuana as compared to HIV− MSM. This finding is consistent with a number of studies reporting higher rates of marijuana use among HIV+ individuals as compared to HIV-uninfected populations. HIV+ individuals report using marijuana to alleviate symptoms related to HIV-infection as well as side effects of ART, although a substantial proportion of HIV+ individuals use marijuana recreationally. This pattern of decreasing substance use over time was recently observed in a study of trajectories of stimulant use among MACS participants. The authors also found that the men who decreased stimulant drug use reported significant reduction in risky sexual practices over time. Among the HIV+ MSM in this study, having a detectable HIV RNA over time was associated with increasing marijuana use among individuals in the increaser group, but not among the men in the decreaser or chronic high groups. Accordingly, we found that ART use over time was associated with decreasing marijuana use in the abstainer/infrequent and increaser groups. It is important to note that the assessment procedures used in this study make it difficult to ascertain that ART use preceded marijuana use.
However, these findings provide some reassurance that there may not be an urgent need to intervene; however, there is a need to continue to study the long term effects of marijuana use on other health outcomes both in HIV+ and HIV− individuals. In the data presented here,cannabis grow system among the entire sample as well as HIV+ individuals, younger age was associated with membership in all marijuana trajectory groups and being non-Hispanic, black was associated with membership in the decreaser and increaser groups. In addition, alcohol use, cigarette smoking, stimulants/recreational drug use, and depressive symptoms over time served to increase marijuana use within nearly all marijuana trajectory groups. This finding is consistent with previous studies that found substantial overlap between several types of drug use and other psychosocial health problems. Accordingly, any prevention approaches to mitigate these behaviors should not focus on one of these behaviors or conditions but must consider these co-occurring conditions holistically. Our study has some limitations which we highlight in order for some caution to be exercised in the interpretation of our study findings. We restricted our analysis to MACS participants who had at least 25 % or more study visits in order to estimate stable trajectory models. However, at baseline, those included in the study differed from those not included on a number of sociodemographic, clinical characteristics as well as use of substances including marijuana . Therefore, it is possible that different trajectories of marijuana use may have emerged if these participants had been included in our study. Furthermore, in the MACS, data on substance use was obtained via Audio Computer- Assisted Self-Interview .
Although this method has demonstrated good accuracy in obtaining sensitive information such as drug use in studies of HIV+ individuals as well as the MSM samples, the data reported here related to substance use may be subject to social desirability bias and most likely an under reporting with a potential underestimation of the true trajectories of marijuana use. Related to this issue is the effect of other biases related to participation in a large ongoing cohort study such as the MACS, along with participant attrition due to drop outs and mortality, which may result in an underestimation of long-term marijuana use. Indeed, in the current study, we found that men who increased their marijuana use and those with chronic high use over time were significantly more likely to die or to drop out during follow-up as compared to the abstainer/infrequent group. What this suggests is that the attrition in these groups may have precluded us from identifying what their patterns of marijuana use would have been if they had remained in the study. Also, participants in the MACS represent a highly cooperative cohort of MSM who have been retained in an ongoing cohort study; thus, our findings may not be generalizable to the larger MSM population. Finally, the semi-parametric group based modeling approach used in this study has been criticized for its tendency to over identify trajectory groups. Accordingly, Nagin and Tremblay caution that groups extracted from the group-based trajectory models should be thought of as approximations of the more complex underlying reality of individual-level trajectories of a behavior; thus, reification of trajectory groups should be done with caution. In summary we used data from a large sample, with a long follow-up period, and utilized frequency measures of marijuana use to describe the natural history of marijuana use among HIV+ and HIV− MSM.
Our study revealed different trajectories of use over time: with approximately 1 in 10 of the men emerging as chronic heavy users or increasing their use over time. Future investigations are needed determine whether long-term patterns of heavy use are associated with adverse consequences especially among HIV+ persons. Opioid use disorder is a public health concern in the United States, with an estimated 2.0 million Americans age 12 or older having this disorder in 2018 . Emergency department visits for suspected opioid overdose increased 30 % from July 2016 to September 2017 , and almost 50,000 people died from an opioid-involved overdose in 2019 . Effective OUD pharmacotherapy include the opioid agonist methadone, the partial opioid agonist buprenorphine, and the opioid antagonist naltrexone , all of which may be delivered with adjunctive behavioral treatments. Literature has reported a higher rate of comorbid psychiatric disorders among adults with OUD than those in the general population . National reports on treatment-seeking patients with OUD indicate that 37.9 % have a current comorbid psychiatric diagnosis . The most common psychiatric disorders among patients with OUD include major depression, anxiety, and bipolar disorder . Research findings are mixed regarding the impacts of psychiatric disorders on treatment outcomes and psychosocial functioning in populations with OUD. Some studies have reported that psychiatric comorbidity in patients with OUD is associated with worse treatment outcomes, such as higher risks for a return to opioid use and non-adherence to pharmacotherapy treatment, poorer psychosocial or physical health status, and lower quality of life . Conversely, other studies have found that individuals with comorbid opioid and psychiatric disorders have equivalent or better treatment outcomes, such as improved negative urine drug assays, longer treatment engagement, and better medication adherence .
These conflicting findings indicate treatment outcomes may be different by type of psychiatric condition and influenced by the duration of observation,cannabis grow lights which underscores the need for additional evidence on the impact of psychiatric comorbidities on treatment outcomes among patients with OUD. We aimed to address this gap in knowledge by examining a longitudinal cohort study of patients with OUD to assess different types of psychiatric disorders in relation to treatment experiences.We conducted a secondary analysis of data provided by the Starting Treatment with Agonist Replacement Therapies study , which was conducted at nine federally licensed opioid treatment program sites with 1269 participants randomized to buprenorphine or methadone from 2006 to 2009 . All participants were tapered off their assigned study medications by 32 weeks post-randomization. Any OUD pharmacotherapy received during the follow-up interval was arranged by the participants themselves independent of the study and could change over time. Analyses also included data from a follow-up study of all randomized participants conducted from 2011 to 2016, nearly 2–8 years after randomization, performing three assessments 1 year apart . After participants provided written informed consent, face-to-face interviews and urine samples were collected at the first follow-ups at each site . The second and third follow-ups were conducted by research staff via phone interviews. Participants were compensated for each visit according to local site policies for study testing and assessments . The parent study and the follow-up study were funded by the National Institute on Drug Abuse Clinical Trials Network . The studies were approved by the Institutional Review Boards at each site, the State of California, and UCLA. A federal Certificate of Confidentiality was also obtained to protect participants’ information further. At the outset of the follow-up study, two sites were dropped, accounting for 189 participants due to small sample sizes and difficulties with conducting follow-ups. Hence, 1080 study participants were ultimately targeted for the three follow-up visits. At the first follow-up interview , conducted August 2011–April 2014, 965 participants were located, and 797 were interviewed .
At the second follow-up interview , conducted August 2012-June 2016, 723 participants from the group who completed Visit 1 were administered the Mini-International Neuropsychiatric Interview ; of these, 597 were again interviewed , from December 2013–June 2016, as the final followup interview . We omitted patients with eating disorders and psychotic disorders for the present paper, yielding a final analysis sample of 593 participants who completed all assessments. The mean length of the follow-up period among 593 participants was 6.5 years . The study flowchart provides additional details . The MINI was used at Visit 2 to assess psychiatric disorders according to DSM-IV criteria. The MINI includes modules on current diagnosis of different types of psychiatric disorders. We used indicators of current diagnoses to construct four mutually exclusive groups: 1) bipolar disorder , 2) major depressive disorder , 3) anxiety disorders , and 4) no mental disorder . Some participants had several mental health conditions . Thus, drawing on prior research , we used the following hierarchy to categorize participants into one group based on diagnostic severity. First, those with any current BPD diagnosis were assigned to the BPD group, regardless of other non-SUD mental health diagnoses and the presence of psychotic features. The MDD and AXD groups were then similarly constructed. The remaining participants did not have any current non-SUD mental disorders and therefore were categorized to the NMD group. It is important to note that post-traumatic stress disorder was included as an anxiety disorder in this study, consistent with DSM-IV classification, given that the data collection was initiated before the publication of the DSM-5, at which time PTSD was recategorized.This study aimed to characterize psychiatric disorders and their association with long-term treatment outcomes among individuals initially treated with methadone or buprenorphine for OUD in the START study. In our follow-up study, we found that the participants without mental disorders had the lowest proportion of females, injection drug use, and history of psychiatric disorders at baseline. During follow-up visits, those with MDD had a higher proportion of follow-up months with OUD pharmacotherapy than those without mental disorders. At the end of the follow-up, participants with BPD had significantly more days of using heroin and all opioids in the past 30 days. Furthermore, those with comorbid psychiatric disorders showed more severe substance-related conditions, psychosocial functioning, and psychiatric symptoms at the end of follow-up. It has been well-established by previous studies that women are more likely than men to be diagnosed with a mental health condition . We also found that the prevalence of injection drug use at baseline was higher among patients with OUD and comorbid psychiatric disorders. Other studies have reported that psychiatric and substance abuse comorbidity is highly prevalent among people who inject drugs . Taken together, these findings replicate prior evidence and highlight the need to design treatments and other interventions that are sensitive to gender and infectious disease risk behaviors. We also found that over 5 or more years of observation, patients with co-occurring opioid and major depressive disorders engaged with OUD pharmacotherapy for more months during follow-up than those without mental disorders. The continued high utilization of pharmacotherapy among patients with OUD and comorbid psychiatric disorders compared to those without mental disorders is notable and may have several explanations. Findings from the literature on the association between psychiatric comorbidity and treatment engagement have been inconsistent . Possible reasons for inconsistent results include different outcome variables, multiple types of medication used, and different diagnostic criteria for psychiatric disorders. However, MDD diagnosis has been associated with improved opioid treatment outcomes in prior research, possibly related to greater engagement in treatment , and that depression symptoms are associated with higher motivation to change opioid use . In the current study, we found higher utilization of methadone than buprenorphine by participants, which may be explained by methadone clinic procedures.