In this study, the ORT-OUD was translated into Arabic and validated in this language in the general population (Sample 1); its criterion validity was also confirmed in a clinical sample of participants with OUD (Sample 2). The construct validity led to the distribution of items on four factors with a rational explanation, appropriate sampling adequacy, anti-image correlations, and communalities. The four factors were a history of substance abuse, a history of alcohol abuse, a history of illegal drug use, and psychological factors. The initial validation of the ORT-OUD was performed by determining the discriminant predictive validity and the receiver operating characteristic (ROC) curve in two samples of chronic nonmalignant pain patients taking long-term opioid therapy; the first sample of patients developed OUD after starting opioid therapy, while the other one displayed no evidence of OUD. However, no factor analysis was done for validation in the original paper, which impedes comparison with our results. Additionally, to the best of our knowledge, no previous research has translated and validated the ORT-OUD. In this study, Cronbach’s alpha was valued at 0.648, suggesting acceptable reliability (34). Nevertheless, the average value of ICC between the test and the retest indicated good reliability (33).
The ORT-OUD score converged well with the ASSIST subscales of sedatives/hypnotics and alcoholic beverages, confirming the known role of risks related to other substance use disorders. Firstly, the ORT-OUD score correlated positively with the sedatives and hypnotics subscales of the ASSIST tool, consistent with previous findings showing that 70% of OUD patients reported lifetime use of nonmedical sedatives and tranquilizers and 11.3% had a sedative/tranquilizer use disorder (30). Several studies among OUD patients correlated sociodemographic characteristics, such as female gender, younger age, and opioid use severity indicators, with the use of nonmedical sedatives and tranquilizers (35)(36)(37). Moreover, OUD patients who used nonmedical sedatives and tranquilizers had higher rates of other substance use and overall polysubstance use (38)(39). Consumption of opioids and sedatives such as benzodiazepines is at risk of deleterious drug-drug interactions, which may lead to fatal opioid overdoses (40). Secondly, the ORT-OUD score also correlated with the ASSIST-alcohol subscale in the general population, in line with findings from the United States showing that nonmedical prescription opioid use and OUD increase the risk of concurrent AUD in adults (41). Another study among OUD patients revealed that 23.4% of the sample had a co-diagnosis of AUD (42). In addition to the correlations of the ORT-OUD with both sedatives and alcoholic beverages of the ASSIST tool, the opioid subscale also correlated with both other subscales, demonstrating that the Arabic version of the ORT-OUD has good convergent validity and allows the identification of the same association as the ASSIST scale.
Using both scales, the prevalence of OUD was estimated at 14.5% (Arabic ORT-OUD scale) and 6.54% (ASSIST-Opioid subscale). The difference between the two scales might be due to the fact that ORT-OUD evaluates the risk of developing OUD using questions about well-known risk factors such as age, family, personal history of substance abuse, and mental health conditions, while ASSIST looks more at an individual’s current substance use habits, thus leading to a lower calculated prevalence (16,18).
Other studies using the ORT tool reported a risk prevalence of developing OUD from 9 to 11.6% (43)(44). Interestingly, one of these studies evaluated the association between hurricane exposure and the risk of opioid-abusive behavior and concluded that exposure to a natural disaster, particularly personal exposure, was associated with an increased risk of opioid-abusive behavior (approximately 9% of participants were classified as having a high risk of developing an OUD) (44). Our study was conducted in a backdrop of multiple crises, i.e., the COVID-19 pandemic, an economic collapse described as one of the worst crises in the last century (8,45), and the Beirut port massive explosion in August 2020 considered one of the largest non-nuclear blasts ever recorded in history, with more than 200 deaths, 7000 injured, and 300000 displaced Lebanese (7,8,46). Nevertheless, and since data related to OUD before the current crisis lack, no conclusions can be drawn as to whether these crises might have potentially affected the high prevalence values reported in this paper; more robust, larger-size epidemiological studies would allow for a better understanding of prevalence trends over time.
Another valuable factor is the significant number of healthcare practitioners who are not thoroughly evaluating patients for potential risk factors before prescribing opioids in Lebanon. Additionally, many practitioners do not follow patients adequately after prescribing opioids and do not explain or screen for potential adverse effects. This lack of proper evaluation and follow-up can contribute to the emergence of an opioid epidemic by increasing the number of people who develop OUD (10).
This study also aimed to explore the association between sociodemographic and clinical data and the risk of OUD in the Lebanese population. The results showed that a family and a personal history of illegal/prescription drug use predisposes a person to develop OUD. A family history of substance use disorder is a well-established risk factor for OUD in patients with chronic nonmalignant pain (47)(48)(49)(50)(51). Evidence from the literature showed that teenagers with a family history of alcohol or drug abuse and a lack of pro-social skills might quickly switch from transient use to severe patterns of abuse or dependence (52). Thus, understanding these factors helps elucidate the etiopathology and trajectory of addictive behaviors. Finally, social risk factors, including connection with deviant peers, popularity, bullying, and gang affiliation, help shape positive beliefs and attitudes toward drug use. Therefore, friends and family provide immediate access to substances and are also role models of behavior and drug use (53)(54).
When exploring sleep patterns, a positive and significant correlation was noted between the risk of developing OUD and sleep disorders, as evaluated by the ISI. The association between illegal psychoactive substance use and sleep problems appears to be bidirectional (55). Sleep problems increase the risk of developing substance use disorders (56)(57)(58), which, in turn, might lead to sleep problems (57) (59) (60) (61). There is considerable evidence that chronic use of some illicit substances results in chronic sleep alterations, distinct from the acute effects of these substances (62). A recent study exploring the bidirectional relationship between lack of sleep and the need to use opioids found that opioid craving/use and sleep deficiency share common circuits linked via the activation of stress-regulatory systems, such as the sympathetic nervous system, the hypothalamic-pituitary-adrenal axis, and inflammatory processes (63). Another study has even shown that suvorexant, an orexin-blocking sleep medication approved for the treatment of insomnia, can also decrease opioid-induced cravings (64).
Our study is the first to assess the relationship between chronotype and the risk of OUD in the Lebanese population. While no significant results could be demonstrated with the Composite Scale used to evaluate chronotype, other studies found a connection between circadian preferences (i.e., eveningness) and substance use disorder in young adults and adolescents (65)(66).
The evaluation of mood and other psychiatric disorders with OUD revealed that subjects with high anxiety scores (auto-evaluated by the HADS-A) and those with psychiatric illnesses were more likely to develop OUD. A strong association exists between opioid- and anxiety-related symptoms and disorders (67), which are more common and more strongly associated with the use of prescribed opioids than other substances (67–69). Furthermore, the genetic predisposition for OUD increases the risk of anxiety, stress-related disorders, and major depressive disorder (70). According to the literature, common mental health disorders and problematic drug use are associated with the initiation and use of prescribed opioids in the general population (71). Therefore, it is essential to evaluate and identify psychiatric disorders correctly before starting an opioid treatment in pain management (72).
Finally, our study revealed that participants who consumed more waterpipes had a lower risk of developing OUD. This result is consistent with the fact that the high levels of nicotine in waterpipe smoke may help reduce anxiety (73), and thus decrease the need for individuals to seek drugs, including opioids. Additionally, anxious individuals may find it hard to self-regulate during stressful situations and may turn to external methods, such as tobacco use, to cope with stress (74).
Limitations and strengths
This study has several limitations. Other scales could have been used to compare the results obtained with the ORT-OUD, such as the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP®-R) (75) or the Diagnosis, Intractability, Risk, Efficacy (DIRE) scale (19), as the ASSIST-opioids subscale might not be the best tool to evaluate the risk of developing OUD. However, it was selected because it is the only scale with a good validity and reliability in Arabic (76). Other limitations are related to the demographic characteristics of the general population (Sample 1) since more than 60% of participants were female, young, with a university level of education and good computer literacy. Thus, our results may not be generalized to the entire population.
Despite all these limitations, this study is the first to validate a questionnaire related to OUD in the Lebanese population. This validated tool can now be use in any Arabic-speaking country to detect OUD risks before initiating an opioid therapy. Moreover, our study is the first nationwide and regional investigation of OUD and potential risk factors, such as sleep disorders, chronotype, and mood disorders.