This Week in Addiction Medicine from ASAM: Recent Episodes
American Society of Addiction Medicine
2025 National Survey on Drug Use and Health (NSDUH)
SAMHSA
The 2025 National Survey on Drug Use and Health (NSDUH) shows encouraging trends among adolescents and young adults with broad declines across past-month nicotine, alcohol, and marijuana use, and binge drinking, as well as reduced rates of substance use disorders, major depressive episodes, and suicidality.
Conversely, troubling overall increases occurred in past-month nicotine vaping and marijuana use, past-year use of marijuana and hallucinogens, and past-year marijuana use disorder. Interestingly, it is important to point out that these increases are driven by use among adults aged 26 or older. For each of these indicators, use among adults 26 or older all increased whereas use among youth 12 to 17 and young adults aged 18 to 25 either declined or remained stable.
Furthermore, while youth mental health improved, suicide indicators among adults aged 26-49 and 50+ rose between 2021 and 2025. These findings highlight the importance of ensuring a lifespan approach to suicide prevention and mental health promotion and treatment initiatives, including incorporating age-related changes in physical abilities and social environments into prevention strategies.
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Association between GLP-1 receptor agonists and alcohol-related hospitalisations among adults with alcohol use disorder: Multi-target trial emulation study
BMJ Open
This retrospective cohort study using target trial emulation evaluated the association between use of newer glucagon-like peptide-1 receptor agonists (GLP-1 RAs; semaglutide, tirzepatide) and alcohol-related hospitalizations among adults with alcohol use disorder (AUD) and type 2 diabetes (T2D) or obesity. The authors found that among adults with AUD and T2D or obesity, initiation of newer GLP-1 RAs was associated with a lower observed risk of alcohol-related hospitalization.
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Trends in alcohol-related deaths in the United States over 55 years: 1968-2023
Alcohol, Clinical and Experimental Research
This study of alcohol-related mortality trends since 1968 used primarily death certificate data from the CDC WONDER database. Between 1998 and 2023 there were 1.3 million alcohol-related deaths. Overall age-adjusted mortality rates (AAMR) per 100,000 increased from 13 to 19. Rates increased from 1968 to 1980, declined from 1980 to 2000, and began an accelerating increase from 2000 to 2023, with a peak during COVID. AAMRs were higher for males (increasing from 20 to 28) than for females (increasing from 7 to 11). AAMR declined by 50% for Black individuals (from 28 to 14) and nearly doubled for Whites (increasing from 11 to 21) resulting in a dramatic racial inversion. Among age groups, the highest mortality was for 65+, attributed to baby boomer heavy drinking plus frailty of age. The largest increases were seen in the Midwest with the Northeast remaining stable.
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Comparison of buprenorphine treatment by virtual-only vs. traditional clinicians
Journal of Substance Use and Addiction Treatment
Few patients with opioid use disorder (OUD) receive medications for OUD (MOUD), such as buprenorphine. Given that many patients, particularly those in rural communities, do not live near a clinician who prescribes MOUD, telemedicine could increase MOUD access. However, clinicians and policymakers are concerned about the quality of the virtual-only model. This study compared the care provided by virtual-only versus traditional clinicians. The authors found few substantive differences in who used virtual-only care. For example, patients initiating buprenorphine with virtual-only versus traditional clinicians were equally likely to live in urban areas. Patients initiating buprenorphine with virtual-only clinicians had more visits in the 6 months after the initiation and were more likely to be on buprenorphine at 6 months, but had fewer days of continuous buprenorphine treatment. These results can inform ongoing debates about the strengths and weaknesses of virtual-only OUD care.
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Adjunctive psychosocial interventions and opioid abstinence among patients receiving buprenorphine: A randomized clinical trial
JAMA Network Open
This randomized clinical trial of 340 adults with opioid use disorder (OUD) taking buprenorphine examined the comparative effectiveness of 2 psychosocial treatments—cognitive- behavioral therapy (CBT) and peer recovery support (PRS)—on opioid abstinence when used as adjunctive therapy to office-based buprenorphine treatment in adults with OUD. Researchers found that neither PRS, CBT, nor a combination of these psychosocial interventions yielded differential effects on opioid abstinence. These results suggest that adjunctive psychosocial interventions may not enhance buprenorphine treatment outcomes in the early stages of treatment.
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Alcohol intake and health study: No protective effect at low levels, with mortality increasing to 1 in 25 at 14 Drinks per week
Journal of Studies on Alcohol and Drugs
This study used a cause-specific modeling approach to estimate the lifetime risk of alcohol-attributable mortality and morbidity in the United States based on a person’s average lifetime weekly alcohol consumption to assess the impact of per-occasion alcohol consumption on health. Researchers found that alcohol consumption, including at what may be perceived as “moderate” levels, is associated with increased mortality and morbidity risks. These results support tightening alcohol use guidance in the United States, for both males and females, to no more than 1 drink per day.
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Social media use trajectories and substance use experimentation: A prospective cohort study
The American Journal of Psychiatry
An analysis of data from more than 7,000 adolescents over 5 years found significant associations between rising social media use trajectories and substance use. Four distinct social media use trajectories were identified, with greater social media use over time throughout early adolescence being proportionally associated with an elevated likelihood of substance use.
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Benzodiazepine tapering: Evidence limitations and research recommendations
Journal of Addiction Medicine
This systematic review of publications (2000-2023) concerning tapering benzodiazepines (BZDs) was used to inform the Joint Clinical Practice Guideline on Benzodiazepine Tapering, published in 2025. Rates of taper were often faster than recommended, such as 25%-50% reduction in the initial 1-2 weeks. There was little information on long-term outcomes such as protracted withdrawal and quality of life, and some studies had high rates of attrition. Patients were often switched from short- to long-acting BZDs; however, there are no data on the effect on withdrawal severity or outcomes. There is little information about adverse events such as mortality and suicidality, despite insurance data associating discontinuing BZDs and mortality. The authors conclude the evidence base for tapering BZDs is deficient and list 10 areas for future research.
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Tobacco industry contributions to the development of ultraprocessed food in the United States, 1985–2007: A case study of Lunchables
American Journal of Public Health
Tobacco firms began acquiring US food companies in the 1960s-1990s to increase revenues and leverage research and development across holdings in tobacco, alcohol, and ultra-processed foods (UPF) subsidiaries. In this case study, the authors examine the development of Lunchables® following Phillip Morris (PMC) acquisition of Kraft and General Foods (KGF). PMC applied a “consumer-driven product development” strategy, previously used for tobacco, in the development process to maximize consumer appeal. PMC also used technologies from KGF to make lower-nicotine cigarettes and then low-fat versions of Lunchables®, in a “better-for-you” strategy to preserve market share in the face of health concerns about both products. The authors suggest public health strategies and policies used to address tobacco could be expanded to UPFs to reduce harm to children.
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A retrospective comparison of two state-funded smartphone-based contingency management programs with different incentives
Drug and Alcohol Dependence
This retrospective study compared outcomes for patients with stimulant use disorder enrolled in a smartphone-based contingency management program based on the amount of total incentives possible, either $75 (“low-value”) or $599 (“moderate-value”). The low-value program was based in New Jersey, funded through SAMHSA (which limited reimbursement to $75/patient at the time of implementation, which has since been increased), and rewarded completing drug testing, attending counseling visits, and completing CBT modules rather than abstinence over 16 weeks. The moderate-value program was funded by West Virginia’s Medicaid managed care organizations, lasted up to 26 weeks, and largely rewarded negative drug screening results, with additional rewards for counseling and CBT modules. Patients in the moderate-value program submitted significantly higher rates of negative substance tests (36%, with an average of 3.2 negative tests) compared to those in the low-value group (24.7%, with an average of 24.8 negative tests).
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Methamphetamine use among adult patients presenting with acute coronary syndrome: A single‐center retrospective cohort study🔓
Journal of the American Heart Association
This study included 1,309 patients treated for an acute myocardial infarct (MI) at a California health system between 2012 and 2022. A total of 194 patients (15%) were methamphetamine users. The Meth-MI group had less diabetes than the No-Meth-MI group (38% vs 51%, p=.001) but many more smokers (72% vs 28%, p<.001). Nonobstructive coronary disease (eg, vasospasm) was more common in the Meth-MI group (24% vs 11%, p<.001), which consequently had lower rates of revascularization, aspirin, and statin therapy. The Meth-MI group had double the mortality (HR, 2.1, p<.001), and methamphetamine use was the strongest predictor of mortality, greater than diabetes. The Meth-MI group was more likely to have a subsequent MI (42% vs 27%, p<.001). The risk of MI with methamphetamine use is 19% higher than the risk with cocaine use (this study excluded cocaine users). The authors believe presentations with methamphetamine use and angina, without MI, is even more common.
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Best practices for hospital-based initiation of medications for opioid use disorder: A consensus statement
JAMA Network Open
This survey study used a 2-round Delphi process to develop expert consensus on best practices for hospital-based MOUD initiation for patients with OUD, with a goal to provide guidance on changing inpatient addiction treatment in response to increased synthetic opioids in the unregulated drug supply. A total of 42 expert clinicians participated; clinicians were considered a national expert if they had cared for at least 100 hospitalized patients with OUD in the last two years. There was consensus that buprenorphine and methadone initiation in the hospital setting were appropriate, with less support for hospital-based naltrexone initiation. Consensus was also reached to support rapid methadone initiation; high- and low-dose buprenorphine initiation; and provision of non-MOUD full agonist opioids for treatment of opioid withdrawal during methadone initiation, as a bridge to buprenorphine initiation, and for those declining MOUD.
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Access to Medications for Opioid Use Disorder Among Veterans With Homeless Experience in Permanent Supportive Housing
JAMA Network Open
This cohort study assessed 10,110 US veterans with homeless experience and opioid use disorder (OUD) residing in permanent supportive housing (PSH), in terms of what factors are associated with receipt of medications for opioid use disorder (MOUD). Only 17% received MOUD within 12 months. Greater behavioral health engagement was associated with MOUD receipt, while older age, race minority status, and prior inpatient hospitalization were associated with lower odds. These results suggest that MOUD access in supportive housing should be expanding, which could require embedding addiction care into PSH teams, leveraging behavioral health touchpoints, and addressing persistent disparities.
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Medicaid Managed Care Plan Alignment With State Substance Use Disorder Treatment Coverage Requirements
The Milbank Quarterly
Medicaid managed plan coverage for medications for alcohol use disorders (AUD) and opioid use disorder (OUD) varies across states but is generally lower in Republican-leaning states. Researchers conducted a national survey to evaluate if these differences in coverage were due to variation in state policy or variations in Medicaid managed plan alignment with state policy. Researchers found that while Republican-leaning states were generally a little less likely to require coverage of most or all medications for AUD and OUD and place limits on prior authorization, managed plans in Republican-leaning states were much less likely to follow state requirements. Given these findings, efforts to increase access to medications for AUD and OUD will need to address misalignment between managed care plans and state policy, and not just focus on making changes to state policy.
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Outpatient Direct Initiation of Injectable Buprenorphine in a Harm Reduction Agency and Primary Care Clinic: A Retrospective Case Series
Journal of Addiction Medicine
Initiating weekly long-acting injectable buprenorphine (LAIB) without prior sublingual buprenorphine (“direct-to-inject” or DTI) may reduce buprenorphine initiation barriers. In this case series, outpatient DTI outcomes are described. Of the 23 patients with available data, 19 (83%) had no withdrawal symptoms pre-DTI. Of the 20 patients with documented post-DTI withdrawal symptoms, 3 (15%) had no withdrawal, 12 (60%) had mild, 4 (20%) had moderate, and one (5%) patient had severe withdrawal. Thirty days post-DTI, 14 (58%) patients were retained on any buprenorphine formulation, and 11 (46%) patients were retained at 90 days. The median post-DTI buprenorphine treatment days were 77 (range: 9–90). The majority of patients had no pre-DTI withdrawal symptoms, no or mild withdrawal symptoms post-DTI, and were retained on buprenorphine at 30 days post-DTI, with nearly half retained at 90 days. DTI is a promising buprenorphine initiation strategy, but further research is warranted.
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A µ-opioid receptor superagonist analgesic with minimal adverse effects
Nature
This study identifies a novel µ-opioid receptor (MOR) agonist with supramaximal intrinsic efficacy and a unique pharmacological profile that produced effective analgesia in rodents with minimal adverse effects. N-desethyl-fluornitrazene (DFNZ) was derived from a class of synthetic benzimidazole opioids called nitazenes. DFNZ has impaired brain penetrance, a unique spatiotemporal MOR cellular signaling profile, and diminished efficacy at the MOR–galanin 1 receptor (GAL1) heteromer. DFNZ does not induce respiratory depression, tolerance, or MOR downregulation after repeated exposure. Compared with other MOR agonists, DFNZ has limited effects on dopamine neurotransmission in the nucleus accumbens and weaker reinforcing effects in the drug self-administration procedure. These results provide novel insights about MOR and nitazene pharmacology, have important implications for pain and addiction treatment, and challenge the prevailing dogma that high-efficacy MOR agonists cannot constitute safe and effective therapeutic agents.
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Methadone Dose and Patient-Directed Discharge in Hospitalized Patients with Opioid Use Disorder
JAMA Network
This retrospective observational cohort study of 554 individuals examined rates of patient-directed discharge (PDD) among hospitalized patients with opioid use disorder who received methadone during the first 72 hours of hospitalization from July 2019 to June 2022. Higher doses of methadone were associated with a decreased rate of PDD. For each additional 10 mg of methadone received in the first 24 hours, there was a decrease in odds of PDD at 48 hours (adjusted OR 0.71). This study highlights the importance of adequate treatment of opioid withdrawal to reduce the risk of PDD.
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Do US Adults View Drug and Alcohol Addiction as a Health Condition?
Journal of Addiction Medicine
Participants (n=5250), part of Gallup’s random sample of US households, completed a web-based survey that explored their beliefs about addiction. Asked if addiction is a health condition 77% of US adults agree, 16% disagree, and 6% don’t know. Men are more likely to disagree (20%) than women (15%). Those who have struggled with addiction but not in recovery were more likely to disagree (22%) than those in recovery (13%) or with no personal addiction experience (16%). Those with less education and income were more likely to disagree. Those who disagree that addiction is a health condition are less likely to believe it is treatable by doctors (OR=0.3), believe that medications are effective treatments (OR=0.4), or help friends or family with addiction (OR=0.5).
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Cannabis cessation and neurocognitive recovery: Patterns, predictors, and clinical implications—a systematic review
The American Journal on Addictions
Researchers conducted a literature review of the neurocognitive effects of cannabis use and recovery from those effects. They found a range of neurocognitive effects including neuroreceptor adaptation, decrease in memory, processing speeds, and attention. Deficits increased with higher frequency and amount of use, but recovery can occur. Receptor normalization can occur within weeks of abstinence while cognitive recovery can take months and years. Adolescent-onset users have more severe and persistent deficits, suggesting effects to neurodevelopment beyond reversible neuroadaptation. The authors suggest treatment for cannabis use disorder should focus on both the disorder and its neurocognitive effects.
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Cost-effectiveness of contingency management for methamphetamine use disorder: A model-based analysis
Addiction
This study used a microsimulation model of methamphetamine use behavior among individuals with methamphetamine use disorder (MethUD) to assess the cost-effectiveness of contingency management (CM) for MethUD. Both 12-week and 24-week CM programs were modeled, using a maximum incentive of $750/patient, per SAMHSA guidelines. The model simulation was run for a cohort of 10,000 individuals with MethUD and looked at lifetime cost. Compared to no treatment, the model predicted an estimated net gain of 0.70 QALYs per person at a cost of $6850/QALY for a 12-week program, with an incremental cost-effectiveness ratio (ICER) of $9830/QALY. For a 24-week program, the benefit was 0.81 QALYs at a cost of $10,000, yielding an ICER of $12,312/QALY. This suggests that both durations of CM for MethUD are highly cost-effective, even at the maximum level of incentives.
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Glucagon-like peptide-1 receptor agonists and risk of substance use disorders among US veterans with type 2 diabetes: cohort study
The BMJ
This study investigated whether initiation of glucagon-like peptide-1 (GLP-1) receptor agonists is associated with both reduced risks of incident alcohol, cannabis, cocaine, nicotine, opioid, and other substance use disorders (SUDs) in people with no history of SUDs (protocol 1) and with reduced risk of SUD-related adverse clinical outcomes among people with a pre-existing SUDs (protocol 2). Researchers found that use of GLP-1 receptor agonists was consistently associated with reduced risks of developing various incident SUDs, suggesting a broad preventive effect across multiple substance types. Use was also associated with reduced risks of adverse clinical outcomes in people with pre-existing SUDs. These observational data suggest a potential role for GLP-1 receptor agonists in both the prevention and treatment of various SUDs, warranting further evaluation.
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Does the total consumption model apply to cannabis use?
Addiction
This repeated cross-sectional study based on annual surveys tested whether the total consumption model and its extension, the theory of collectivity, apply to adolescent cannabis use in Sweden. Frequency of cannabis use was measured by a question on how many occasions the respondent has used hashish or marijuana. The seven response alternatives ranged from 0 to 50 times or more. Increases in mean frequency use were associated with a higher prevalence of high-frequency users. Adolescent cannabis use in Sweden appears to conform to key predictions of the total consumption model and its extension, the theory of collectivity.
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Spirituality and Harmful or Hazardous Alcohol and Other Drug Use
JAMA Psychiatry
This meta-analysis of 55 rigorous studies on spirituality and harmful or hazardous drug use (alcohol, tobacco, marijuana, or illicit drugs) examined the association between spiritual exposures and related drug use outcomes. It documented a significant protective association of 13% related to both prevention and recovery. The risk reduction, which extended across all 4 drug categories, reached 18% for individuals with greater than weekly religious service attendance. These results have implications for clinicians and communities regarding future strategies to address harmful or hazardous alcohol or other drug use.
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Emergency Department–Initiated Buprenorphine for Opioid Use Disorder
JAMA Network
This multicenter randomized study examined if 7-day extended-release injectable buprenorphine compared with sublingual buprenorphine to improve treatment engagement at 7 days. It included 1,994 adult patients presenting to the emergency department with untreated opioid use disorder and a Clinical Opiate Withdrawal Scale (COWS) score of 4 or higher. In treatment at 7 days, 40.5% were in the extended-release group and 38.5% were in the sublingual buprenorphine group, demonstrating no significant difference between groups. The study concluded that a 7-day extended-release injectable preparation of buprenorphine does not improve treatment engagement.
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Use of gabapentin with or without a prescription in substance use treatment settings: A national analysis of urine drug testing data, 2016–2023
Drug and Alcohol Dependence
Gabapentin prescriptions have increased due to off-label use, including managing withdrawal/comorbidities in substance use disorder (SUD) treatment, despite gaps in evidence bases and corresponding increases in nonmedical use. This retrospective, serial cross-sectional study sought to identify trends in gabapentin use with and without a prescription in SUD treatment settings. Researchers found that gabapentin prescribing significantly increased in SUD treatment settings despite a lack of strong evidence bases for its utility. While rates of gabapentin use outside a prescription were nearly double that for prescribed use, this appears to be decreasing over time. Polysubstance use and potential gaps in multimorbidity care may contribute to the use of gabapentin without a prescription.
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Association of alcohol intake over the lifetime with colorectal adenoma and colorectal cancer risk in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial
Cancer
This study analyzed data from the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial to look for an association between alcohol intake and colorectal cancer (CRC) or colorectal adenoma. Participants' lifetime pattern of alcohol intake was determined from a dietary history recorded as part of the PLCO trial. Current drinkers with a lifetime average of over 14 drinks per week had a higher CRC risk than those with under 1 drink per week (HR 1.25, p = .003) and an even higher risk of rectal cancer (HR 1.95). There was no consistent association between alcohol intake and colorectal adenoma risk, however results suggested that former drinkers may have a reduced risk of adenoma. They discussed potential mechanisms such as acetaldehyde, a known carcinogen and product of alcohol metabolism, and effects of alcohol on gut microbiome. They conclude that heavy alcohol intake increases CRC risk and that alcohol cessation may lower adenoma risk.
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Medication Availability for Alcohol Use Disorder in Substance Use Disorder Treatment Facilities
JAMA Network Open
This study examined the availability of medications for alcohol use disorder (MAUD) in SUD treatment facilities (SUDTF) from 2017 to 2023. Data was obtained from SAMSA’s Mental Health and Addiction Treatment Tracking Repository. The percentage of counties with a SUDTF offering MAUD increased from 34% in 2017 to 50% in 2021. This increase leveled out between 2021 and 2023 perhaps related to the pandemic. Counties with a MAUD-offering facility were more likely to be metropolitan (57% vs 25%, p<.001) with substantially more population (mean 220,100 vs 26,650, p<.001), and fewer uninsured residents (8.5% vs 10.7, p<.001). They call for policies supporting MAUD-offering facilities, particularly in underserved counties.
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Public Views About Opioid Overdose and People With Opioid Use Disorder
JAMA Network Open
This study completed a national web-based survey of 1552 adults in the United States in April 2025 to assess perceptions of opioid overdose deaths and opinions of people who use opioids. Those who responded to the survey primarily identified as female (60.5%) and aged 30-44 (33.7%). Political views varied, with 28.9% conservatives, 39.6% moderates, and 31.5% liberals. Most respondents viewed opioid overdose deaths as serious (88.2%). Respondents felt that people who use opioids (81%) and pharmaceutical companies (72.7%) were most responsible for reducing overdose deaths, with more liberals identifying pharmaceutical companies as responsible while moderates and conservatives more often identified individuals as responsible. 38.3% of respondents reported they were unwilling to have a person with OUD as a neighbor and 58.4% were unwilling to have a person with OUD marry into their family, with higher percentages of conservatives than liberals endorsing these beliefs.
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Did the illicit fentanyl trade experience a supply shock?
Science
In the United States overdose deaths (ODDs) from synthetic opioids peaked in mid-2023 and then began a sharp decline decreasing by over one third by the end of 2024. One possible explanation is a decrease in fentanyl supply. The purity of fentanyl powder rose in 2022, cresting at 25% in early 2023, but by the end of 2024 purity had fallen to 11%. From 2019 to 2024 the rate of ODDs correlated with the purity of fentanyl in both powder and pills. Drug seizures also peaked in early 2023 and then decreased by 37% in 2024. Analysis of Reddit posts by drug users found increased mentions of “drought” in 2023 that remained high at the end of 2024. All these indicators suggest a reduction in fentanyl supply beginning in 2023. In 2023 China took aggressive action against suppliers of synthetic opioid precursor chemicals, likely a result of meetings between Presidents Biden and Xi. This suggests international cooperation can help reduce ODDs.
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Barriers to Buprenorphine Initiation in Patients Using Fentanyl
JAMA Network Open
This is a survey study of 396 buprenorphine-prescribing clinicians in the US to determine if they faced problems initiating buprenorphine among patients using fentanyl, and whether their practice had changed as a result. Participants were selected from a stratified random sample of X-waivered clinicians registered with the DEA who had prescribed buprenorphine in 2022, with representation across all regions nationally. 72.8% of participants reported difficulty with buprenorphine initiation (either precipitated and/or prolonged withdrawal). Clinicians with waivers to treat larger numbers of patients, those reporting fentanyl use by their patients, and those in outpatient settings were more likely to report challenges with buprenorphine initiation. 67.3% of participants reported they had modified their standard buprenorphine treatment protocols for patients using fentanyl.
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Productivity Losses From Substance Use Disorder in the U.S. in 2023
American Journal of Preventive Medicine
Information on morbidity-related productivity losses attributable to substance use disorder is limited. This study estimates morbidity-related productivity losses attributable to substance use disorder among U.S. adults aged ≥18 years in 2023. It found that total morbidity-related productivity losses attributable to substance use disorder in the U.S. are substantial, amounting to $92.65 billion in 2023. Inability to work cost accounted for $45.25 billion, followed by absenteeism cost of $25.65 billion, presenteeism cost of $12.06 billion, and cost of household productivity loss of $9.68 billion. Given that these estimates depend on the prevalence of substance use disorder and the amount of lost productive time, evidence-based prevention efforts and policies addressing them can help reduce these losses.
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Expanding Access to Buprenorphine and Methadone: Global Perspectives and Policy Recommendations
Substance Use and Addiction Journal
This is a narrative review of methadone and buprenorphine regulations, prescriber eligibility, dispensing models, and coverage across eight countries: the United States, Canada, the United Kingdom, Russia, France, Iran, Australia, and Portugal. The study identified several key barriers to MOUD: requirements for daily supervised dosing, restricted community prescribing, and stigmatizing drug scheduling. The authors highlight policies that improved MOUD access without compromising safety such as: 1) community pharmacy dispensing supports in the U.K. and Australia, 2) liberal buprenorphine prescribing in primary care in France, and 3) decriminalization and expansion of low-threshold public health models in Portugal and Iran.
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Very Low Nicotine Content Cigarettes for Smoking Cessation: Examining a Facilitated Extinction Approach and Dosing Schedule
Drug and Alcohol Dependence
Very low nicotine cigarettes (VLNC, 0.4 mg nicotine/g tobacco) have been shown to reduce smoking behavior when compared to normal nicotine cigarettes (NNC,17 mg nicotine/g tobacco). Participants (n=208) were randomly assigned to 4 experimental groups, immediate versus gradual (over 5 weeks) transition to VLNC, and standard counseling versus facilitated extinction counseling (weekly for 5 weeks). Facilitated extinction had participants smoke only in relevant contexts (e.g., places, affects, triggers). The immediate nicotine reduction group reported less smoking satisfaction and lower completion rates (72% immediate reduction versus 88% gradual reduction, p=.02). Abstinence (biochemically verified) at 2 months post study was 29%. There were no significant differences between the 4 study groups. VLNC were beneficial in smoking cessation.
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Fatal Opioid Overdoses by Historical and Contemporary Neighborhood-Level Structural Racism🔓
JAMA Health Forum
This cross-sectional study of 796 census tracts prior to the COVID-19 pandemic (2017-2019) and 792 census tracts during the COVID-19 pandemic (2020-2022) in Chicago, Illinois, assessed the extent to which there is a spatial association between neighborhood-level structural racism and opioid-involved overdose deaths. Researchers found that neighborhoods exposed to high levels of structural racism in the past (historical redlining) and present (contemporary segregation) had the highest fatal overdose incidence rates before the COVID-19 pandemic (2017-2019). Neighborhoods that experienced high levels of contemporary racism had the highest fatal overdose incidence rates during the pandemic (2020-2022).
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State Laws Banning Prior Authorization For Medications For Opioid Use Disorder Increased Substantially, 2015–23
Health Affairs
While medications for opioid use disorder (MOUD) is effective treatment, most patients with OUD don’t receive it and prior authorization (PA) has been a barrier to access. Researchers looked at state policies trying to address this barrier, specifically for private health insurance, between 2015 and 2022. Some states adopted “full prohibitions” against PAs while others adopted “partial prohibitions” that allowed PA under some circumstances. Overall, the number of states with at least some prohibition increased from 2 in 2015 to 22 in 2023. In addition, 7 states adopted “full prohibitions” initially, while 15 adopted “partial prohibitions”, with 4 of those 15 transitioning to “full prohibitions” later. Additional research will be needed to assess the impact of these prohibitions, but this study elucidates the current landscape of policy.
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Rapid vs Standard Induction to Injectable Extended-Release Buprenorphine
JAMA Network
This industry-sponsored, multicenter, open-label randomized clinical trial with 729 participants, assessed if rapid induction (RI) for initiating extended-release buprenorphine is as safe and effective as standard induction (SI) in individuals who inject opioids or use fentanyl. RI was well tolerated and had higher retention than SI at extended-release buprenorphine injection 2 overall and in fentanyl positive participants. Administering the second extended-release buprenorphine injection 1 week after the first was well tolerated in both the RI arm and SI arm. These findings suggest support RI for extended-release buprenorphine induction in high-risk patients and demonstrate the feasibility of administering the first 2 doses at least 1 week apart.
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States With Substantial Increases In Buprenorphine Uptake Did So With Increased Medicaid Prescribing, 2018–24
Health Affairs
Multiple federal policy changes since 2018 intended to increase buprenorphine prescribing in response to a persistent treatment gap for opioid use disorder (OUD) in the US. Anticipated national increases did not occur, but highly variable state-level trends provide important insights. This study used IQVIA data to examine all-payer and per payer prescribing across states during the period 2018–24. Researchers found that highly disparate state-level changes suggest that federal policy impacts were mediated by state-specific factors. Medicaid’s key role in driving overall prescribing highlights the public health urgency of maintaining expansions and sustaining enrollment for the single adult population.
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Ultra-processed food addiction in a nationally representative sample of older adults in the USA
Addiction
Using a cross-sectional online and telephone survey of a nationally representative sample of older adults (aged 50–80 years) in the US, this study examined the prevalence of ultra-processed food addiction (UPFA) in older US adults and its association with various health domains. It found that ultra-processed food addiction appears to be prevalent among older adults in the US, particularly among women who were in adolescence and early adulthood when the nutrient quality of the US food supply worsened. Addictive patterns of UPF intake appear to be associated with poorer physical health, mental health, and social well-being.
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Alcohol Consumption Per Capita and Suicide: A Meta-Analysis
JAMA Network Open
This meta-analysis that included 13 studies assessed if alcohol consumption per capita is associated with suicide mortality and, if so, does the association differ by sex. Researchers found that a 1-L increase in alcohol consumption per capita was associated with a 3.59% increase in the suicide mortality rate. There was no evidence of a sex difference in this association. These findings suggest alcohol consumption per capita may be a useful target to consider within comprehensive national suicide prevention strategies.
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Measures of General Intelligence and Risk for Alcohol Use Disorder
JAMA Psychiatry
This male Swedish cohort study that included 573,855 participants assessed if there is an association between IQ and risk for alcohol use disorder, and if so, what is the nature of this association. It found that IQ at age 18 years was associated with subsequent alcohol use disorder risk. Mendelian randomization analyses suggest a causal association, albeit with context-dependent differences; genetic liability for cognitive performance also predicted alcohol use disorder in a US-based sample. Results suggest that there was a clear impact of genetic liability for cognitive performance on alcohol disorder risk, but the association varies based on the sociocultural context.
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Medications for Opioid Use Disorder Playbook
Agency for Healthcare Research and Quality (AHRQ)
The AHRQ Integration Academy developed the Medications for Opioid Use Disorder Playbook as a practical guide for providing medications for opioid use disorder (MOUD) and immediate care for patients with OUD in primary care and other ambulatory care settings. It is interactive, web-based, and has the latest guidance, tools, resources, and examples that address key aspects of MOUD implementation. The MOUD Quick Start Guide covers the essentials of low-threshold care, while the balance of the Playbook offers more in-depth resources and guidance for those practices interested in working toward more comprehensive, whole-person care. The low-threshold approach ensures immediate access to MOUD, eliminating barriers for both patients and providers.
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Cannabis Use During Pregnancy and Lactation
American College of Obstetricians & Gynecologists
Cannabis is the most commonly used illicit drug under U.S. federal law. With increasing social acceptability, accessibility, and legalization in many states, the prevalence of cannabis use among pregnant and lactating individuals has increased significantly. Substance use in pregnancy, including cannabis use, has been associated with adverse outcomes such as spontaneous preterm birth, low birth weight, and developmental delay. Clinicians should be aware of the possibility of pregnant and lactating patients' use of cannabis and be prepared to counsel and screen all patients and use evidence-based strategies to reduce cannabis use. These include supportive home visits, psycho-behavioral strategies, or brief electronic or text messaging interventions to reduce cannabis use in pregnancy and the postpartum period to promote parental and newborn health.
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Contingency Management for Stimulant Use Disorder and Association With Mortality: A Cohort Study
American Journal of Psychiatry
This national retrospective cohort study found that veterans with stimulant use disorder who received contingency management (CM) were 41% less likely to die in the year following treatment initiation relative to matched comparison subjects. These findings provide the strongest real-world evidence to date that CM is associated with reduced all-cause mortality, underscoring its potential as a life-saving intervention in routine care. Results support expanding access to CM across healthcare systems and public health settings.
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Machine learning– and multilayer molecular network–assisted screening hunts fentanyl compounds
Science Advances
Fentanyl and its analogs are a global concern, making their accurate identification essential for public health. This article introduces Fentanyl-Hunter, a screening platform that uses a machine learning classifier and multilayer molecular network that covers more than 87% of known fentanyls to select and annotate fentanyl compounds using mass spectrometry (MS). Fentanyl-Hunter identified fentanyl members in biological and environmental samples. During biotransformation, 35 metabolites from four widely consumed fentanyl derivatives were identified. Norfentanyl was the major fentanyl compound in wastewater. Retrospective screening of these biomarkers across more than 605,000 MS files in public datasets revealed fentanyl, sufentanil, norfentanyl, or remifentanil acid in more than 250 samples from eight major countries, indicating the potential widespread presence of fentanyl.
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Evaluation of a Novel Patient-Centered Methadone Restart Protocol 🔓
JAMA Network Open
Restarting methadone for patients who have had a gap in treatment is often a frustratingly slow process for both the patient and provider. This cohort study of individuals examined outcomes for patients of a public, safety-net opioid treatment program before (n=786 patients) and after (n=780 patients) implementation of a 2022 clinical protocol focused on individualized methadone restart doses based on opioid tolerance. Preimplementation restart doses were 32.8% lower than the last prior methadone dose, whereas postimplementation restart doses were only 3.4% lower than the last prior methadone dose. There was no significant change in patient safety (emergency department visits within 7 days after restart and all-cause mortality within 7 and 90 days after restart) or 90-day retention in care.
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Recommendations for Addressing In-Hospital Substance Use From a National Delphi Consensus Process
JAMA Network Open
This survey study utilized a 3-round Delphi consensus process to identify best practices for addressing in-hospital substance use. A panel of 38 addiction experts developed 84 consensus-based and patient-centered recommendations which can inform local responses, including policies, to address in-hospital substance use.
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Injectable-Only Overlapping Buprenorphine Starting Protocol in a Low-Threshold Setting
JAMA Network Open
Injectable-only buprenorphine protocols are an exciting new strategy for buprenorphine initiation, particularly in the fentanyl era. This is a cohort study of 95 patients with moderate to severe opioid use disorder who received care in a low-threshold setting in Seattle. 79% of patients included in the study were experiencing homelessness or living in permanent supportive housing. Patients selected a long-acting injectable (LAI) buprenorphine initiation protocol which included three escalating doses of LAI buprenorphine over three days, with no sublingual buprenorphine and without cessation of fentanyl/opioid use. 75% of the patients completed the protocol, and 64% received a second monthly dose of LAI buprenorphine.
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Association between housing status and mental health and substance use severity among individuals with opioid use disorder and co-occurring depression and/or PTSD
BMC Primary Care
This is a cross-sectional analysis of associations between housing status and mental health and substance use severity among primary care patients with co-occurring disorders. The study is a sub-analysis using data from the Collaboration Leading to Addiction Treatment and Recovery from other Stresses randomized controlled trial, which tested the Collaborative Care Model for primary care patients with OUD and co-occurring depression and/or PTSD. Of 797 patients in the study, 13% were currently unhoused, 24% were unstably housed, and 63% were stably housed. Those who were unhoused were on average younger and had not used prescribed MOUD in the past 30 days. The analysis found that being unhoused or unstably housed was significantly associated with higher PTSD symptom severity, depression symptom severity, opioid use severity, and opioid overdose risk behaviors compared to those who were stably housed.
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Oral methadone versus sublingual buprenorphine for the treatment of acute opioid withdrawal: A triple-blind, double-dummy, randomized control trial
Drug and Alcohol Dependence
Researchers compared oral methadone to sublingual buprenorphine for the management of acute opioid withdrawal. Patients at an inpatient drug treatment center in India were randomly assigned to receive either methadone or buprenorphine titrated over days 1-3 to control opioid withdrawal symptoms. Over days 4-10 medications were tapered and stopped by day 11. Completion of treatment was similar in both groups (83% methadone, 82% buprenorphine). Both subjective (SOWS) and objective (COWS) withdrawal symptoms decreased during the treatment, however the buprenorphine group had significantly greater withdrawal symptoms than the methadone group (p=0.009) at the end of treatment (day 10). Opioid craving also decreased in both groups with no significant difference between groups. Authors conclude that methadone is a safe and effective alternative to buprenorphine for management of opioid withdrawal.
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Implementation Gaps in US Syringe Service Programs, 2022
JAMA
This study performed a cross-sectional analysis of the Syringe Services Programs in the US (SSPUS) dataset to determine implementation gaps. 613 syringe service programs (SSPs) included in the dataset were geocoded to county boundaries, which were then analyzed for urbanicity and SSP need (based on HCV mortality, HIV incidence, and drug overdose mortality). The study found that most high need counties did not have an SSP: 81.2% of high HCV need counties, 69.5% of high HIV need counties, and 75.7% of high overdose need counties did not have an SSP. SSPs were more commonly located in urban counties than suburban or rural counties. The study is limited in that not all SSPs are represented within the SSPUS database; however it highlights important implementation gaps.
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Co-involvement of stimulants with opioids in North America: A 'silent epidemic’
Plos Mental Health
The opioid epidemic unfolded in three distinct waves, with the latest being deaths attributed to illegally manufactured synthetic opioids. Using U.S. and Canadian data, this study reviews evidence for a 'silent epidemic' alongside the opioid epidemic that is characterized by the co-ingestion of stimulants including methamphetamine and cocaine leading to an increasing number of deaths. Trends for stimulant and opioid use were analyzed using Joinpoint regression and public interest in the substances was assessed via Google Trends. While stimulant use and its role in deaths are rising, public interest in stimulants has declined since its peak in 2004-05. Co-use leads to more deaths than either drug alone. Urgent strategies are needed to reduce harm and raise awareness among health professionals, policymakers, and the public about the dangers of stimulant-opioid co-use.
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Did alcohol facilitate the evolution of complex societies?
Humanities and Social Sciences Communications
This study tested the “drunk” hypothesis, which claims that alcohol promoted social bonding and cooperation, aiding the rise of complex societies. Using data from 186 non-industrial societies, they found a modest positive link between indigenous alcoholic beverages and political complexity, even after controlling for ancestry, environment, and agriculture. Results suggest traditional fermented alcohols provided social benefits that helped societal evolution. However, other factors like agriculture and religion were likely more effective drivers.
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Disparities in Treatment and Referral After an Opioid Overdose Among Emergency Department Patients
JAMA Network Open
This cohort study of 1,683 patients assessed if there are racial and ethnic disparities in treatment referral rates among patients in the emergency department (ED) with opioid overdose. It found a statistically significant difference in the proportion of Black patients who received an outpatient treatment referral (5.7%) compared with White patients (9.6%). These findings suggest that Black patients presenting to the ED with opioid overdose may be less likely to receive outpatient treatment referrals, underscoring the need for targeted intervention and enhanced referral processes.
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Prescriber-Level Changes in Buprenorphine Dispensing in the USA Before and After Federal Policy Changes Aimed at Increasing Prescribing
Journal of General Internal Medicine
This study used interrupted-time-series analysis to model prescriber-level trends in buprenorphine prescriptions after recent federal policy changes. It found that the elimination of the waiver requirement to prescribe buprenorphine in December 2022 was associated with a significant increase in the number of buprenorphine prescribers, but a decrease in the mean number of patients and the mean number of prescriptions per prescriber. Changes in telehealth flexibilities and relaxed training requirements were largely not associated with prescribing changes. This study expands on prior research by providing further insight as to why waiver elimination has not increased the number of patients receiving buprenorphine, as expected.
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Joint Clinical Practice Guideline on Benzodiazepine Tapering: Considerations When Risks Outweigh Benefits
Journal of General Internal Medicine
The American Society of Addiction Medicine (ASAM), in collaboration with nine other medical societies and professional associations, developed evidence-based guidelines for tapering benzodiazepine (BZD) medications across various clinical settings. These guidelines were created using a modified GRADE methodology and a clinical consensus process, which included a systematic literature review and several targeted supplemental searches. The guidelines were also revised based on feedback from external stakeholders. Key recommendations include that clinicians should continually assess the risks and benefits of BZD use and tapering. They should engage in shared decision-making with patients and avoid abrupt discontinuation in individuals who may be physically dependent or at risk of withdrawal. Tapering strategies should be personalized and adjusted based on the patient’s response. Additionally, clinicians are encouraged to provide psychosocial support to help patients successfully taper off BZDs.
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Receipt of addiction treatment after nonfatal opioid overdose and risk of subsequent overdose: A retrospective cohort study
Drug and Alcohol Dependence
People who experience a nonfatal opioid overdose are at increased risk of subsequent overdose but is also a potential moment to intervene. In this cohort study, they used statewide data from Connecticut to assess differences in overdose outcomes in the year following a nonfatal overdose by treatment type received. Overall, 56% of patients received no treatment, while 35% received medication for opioid use disorder (MOUD) (25% buprenorphine and 11% methadone) and 21% received inpatient treatment (detox and/or extended inpatient). Both methadone (aHR=0.41) and buprenorphine (aHR=072) were associated with decrease in subsequent overdose, whereas neither detox nor prolonged inpatient treatment were associated with decreased overdose. These findings further support the importance of MOUD and the need to increase access to treatment in this high-risk population.
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Bitter sensing protects Drosophila from developing experience-dependent cocaine consumption preference
The Journal of Neuroscience
Cocaine use disorder (CUD) is a highly heritable condition for which there are no effective treatments. Testing the many human genetic variants linked to CUD requires a cost-effective, genetically tractable model. This study showed that bitter-sensing neurons prevent cocaine self-administration in Drosophila. Disrupting Drosophila bitter perception enables a model for experience-dependent cocaine preference. The findings underscore the potential of Drosophila as a crucial tool for identifying the genetic mechanisms underlying CUD, aiding in the discovery of new therapeutic targets, and contributing to the development of effective treatments for this highly heritable disease.
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Memory function in patients with opioid dependence treated with buprenorphine and methadone in comparison with healthy persons
Scientific Reports
This study compared memory performance in patients treated with methadone or buprenorphine for drug abuse to healthy controls using the Wechsler Memory Scale. Healthy controls performed better than both treatment groups in mental control. Methadone patients scored higher than controls in personal and general information, while buprenorphine patients scored lower in associate learning. Longer buprenorphine treatment was linked to better overall memory scores, and patients on methadone for over two years showed better awareness of place and time compared to long-term buprenorphine users. Overall, neither medication showed major negative effects on memory except for mental control, which was impaired in both groups. Buprenorphine appeared to better preserve memory function over time than methadone.
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Medicaid Unwinding and Changes in Buprenorphine Dispensing
JAMA Network Open
Among Medicaid-insured adults with buprenorphine use, this cross-sectional study examined if changes in buprenorphine dispensing were greater among those residing in states with the highest vs lowest decreases in Medicaid enrollment after “Medicaid unwinding” began in April 2023. Researchers used 2017-2023 data from a national prescription dispensing database that included 754,675 person-years from 569,069 patients. They found that patients in states with the highest decreases in Medicaid enrollment were more likely to decrease buprenorphine use, discontinue buprenorphine therapy, and use private insurance or cash to pay for buprenorphine prescriptions. The finding that Medicaid unwinding was associated with disruptions in buprenorphine therapy raises concerns about the potential for increased opioid-related morbidity and mortality.
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Loneliness Among US Veterans With Problematic Substance Use: Results From the National Health and Resilience in Veterans Study
Journal of Addiction Medicine
Loneliness is a major public health concern, especially among individuals with problematic substance use (PSU), but little research has focused on vulnerable groups like US military veterans. This study, using data from the National Health and Resilience in Veterans Study, found that nearly half of veterans with PSU (47.4%) experience clinically significant loneliness. Factors contributing to loneliness included being unmarried, higher psychological distress (depression and PTSD), a history of suicide attempts, physical disability, smaller social networks, and lower purpose in life and optimism. The analysis highlighted that depressive and PTSD symptoms had the strongest impact on loneliness, followed by social network size and sense of purpose. Furthermore, veterans with depressive symptoms who had a strong sense of purpose were less likely to feel lonely. The study underscores the need for strategies targeting psychological distress, fostering social connections, and enhancing purpose to help alleviate loneliness in this population.
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The IARC Perspective on the Effects of Policies on Reducing Alcohol Consumption
New England Journal of Medicine
In 2020, alcohol use was responsible for over 740,000 new cancer cases worldwide. In response, The International Agency for Research on Cancer (IARC) released a two-part handbook assessing the effectiveness of public policy measures in reducing alcohol-related cancer risk. The report found that reducing or stopping alcohol consumption lowers the risk of certain cancers and that several policy interventions, such as increasing alcohol taxes; setting minimum pricing; restricting sales by time, place, and age; implementing total sales bans; and enacting strong marketing restrictions, effectively reduce alcohol consumption. Government-run alcohol monopolies and coordinated national strategies were also associated with decreased use. However, bans on alcohol discounts produced inconsistent results. These findings align with the WHO’s Global Alcohol Action Plan and SAFER initiative, highlighting the importance of targeted, enforceable strategies to reduce alcohol-related harm globally.
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Building Multidisciplinary Consensus on Inpatient Xylazine Management through Clinical Protocols
Substance Use and Addiction Journal
Xylazine in the unregulated drug supply produces significant morbidity and this paper describes utilizing a multidisciplinary team to develop protocols for inpatient setting to manage patients with xylazine exposure. Protocols developed included use of scheduled clonidine or tizanidine to manage withdrawal with hold parameters. As there is no FDA approved immunoassay screen, they recommended assuming xylazine exposure in areas with high prevalence and limited testing. The team also developed guidelines for cases in which surgical interventions would be considered, when to culture wounds, antibiotic usage, and consistent wound care based on size and clinical characteristics. In addition, they developed standardized discharge instructions, including referral to substance use disorder treatment, harm reduction and education around xylazine test strip use.
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Varenicline for Youth Nicotine Vaping Cessation: A Randomized Clinical Trial
Journal of the American Medical Association
This 12-week randomized clinical trial in 261 treatment-seeking youth aged 16 to 25 years assessed if varenicline, when added to brief, remotely delivered behavioral support, was efficacious and well tolerated for nicotine vaping cessation in youth. Researchers found that continuous abstinence rates were higher in the varenicline group than in the placebo group in the last month of treatment (51% vs 14%) and at 6-month follow-up (28% vs 7%). Treatment-emergent adverse events did not differ significantly between groups. Varenicline, when added to brief cessation counseling, is well tolerated and promotes nicotine vaping cessation compared with placebo in youth with addiction to vaped nicotine.
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Comprehensive drug policies increase trust in local government: an analysis of authorities’ and residents’ perspectives in rural US Appalachian and Midwestern counties 🔓
Harm Reduction Journal
Implementation of harm reduction intervention policies by local governments may be met with caution because of concern about potential backlash from communities and erosion of public trust. The authors conducted two studies to assess the influence of perceptions of government support for comprehensive drug policies (including harm reduction) on public trust in local government. In both a field study and an experimental study, the authors found that public trust was positively associated with increased perception of government support for comprehensive drug policies. The authors note residents recognized harm reduction policies as a step to address the issue of drug use, and these findings may ease some concerns about public pushback for local government officials when considering these policies.
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Hospital Addiction Consultation Service and Opioid Use Disorder Treatment
JAMA Internal Medicine
While medication for opioid use disorder (MOUD) is effective, many patients with OUD do not receive it, particularly in hospitalized settings. In this randomized trial they evaluated the Substance Use Treatment and Recovery Team (START) model, a team of an addiction medicine provider and a care manager, and provided motivational interviewing, discharge planning and telephone follow-up for one month. Patients who received the START intervention were more likely to receive MOUD (aRR=2.10) and connect to OUD care after discharge (aRR=1.49). In addition, these patients were more likely to have an OUD-focused discharge plan (aRR=1.8), initiate or continue MOUD post discharge (aRR=1.71), and see a clinician for OUD post discharge (aRR=1.89). These findings support use of hospital-based addiction consult services to address this healthcare gap.
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Averted lung cancer deaths due to reductions in cigarette smoking in the United States, 1970–2022
Cancer
Smoking prevalence peaked in the 50s and 60s but has declined following the US Surgeon General’s report in 1964 on its health risk. As 85% of lung cancer is attributable to smoking, the authors evaluated this impact by assessing lung cancer deaths averted, and person-years of life (PYL) gained between 1970 and 2022 using cancer mortality data from the CDC. The authors estimated 3,856,240 lung cancer deaths were averted and 76,275,550 PYL were gained during the study period (average of 19.8 PYL gained per death averted). The deaths averted were higher in men (2,246,610), but average PYL gained per death averted was higher in women (22.4 years). Lung cancer deaths averted accounted for 51.4% of the estimated decrease in overall cancer deaths. The findings highlight the importance of tobacco controls and interventions and need for ongoing efforts to decrease tobacco use.
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Prescription Stimulant Use, Misuse, and Use Disorder Among US Adults Aged 18 to 64 Years
JAMA Psychiatry
This study examined the prevalence of prescription stimulant use, prescription stimulant misuse, and prescription stimulant use disorder (PSUD) among adults aged 18 to 64 years in the US. Researchers found that 25.3% of adults in the study reported misuse, and 9.0% had PSUD. Among those with PSUD, 72.9% solely used their own prescribed stimulants, 87.1% used amphetamines, 42.5% reported no misuse, and 63.6% had mild PSUD. The prevalence of misuse was 3.1 times higher and the prevalence of PSUD was 2.2 times higher among those using prescription amphetamines than among those using methylphenidate. Regardless of prescription stimulant misuse status, screening for and treating PSUD is needed for US adults aged 18 to 64 years using prescription stimulants, especially those receiving prescription amphetamines.
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Alcohol Use Disorder Medication Coverage and Utilization Management in Medicaid Managed Care Plans
JAMA Network Open
This cross-sectional study examined how Medicaid managed care plans (MCPs) cover and manage medications for alcohol use disorder (AUD). A content analysis of publicly available data from all 241 comprehensive Medicaid MCPs in 2021 revealed that 103 plans (42.7%) covered all approved medications (acamprosate, naltrexone, and disulfiram) for AUD. Prior authorization and quantity limits were used rarely, except for injectable naltrexone. This study suggests that expanding medication use for AUD and providing patient-centered care may be undermined by insurance coverage limitations.
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Association Between Telehealth Initiation Of Stimulant Therapy And New Substance Use Disorder Diagnoses
Health Affairs
During the COVID-19 pandemic, the Drug Enforcement Administration (DEA) temporarily allowed for prescribing of controlled substances via telehealth and extended the policy through the end of 2025. With concern about potential adverse outcomes with this policy, there is debate about making it permanent. The authors utilized commercial and Medicaid claims data to assess newly diagnosed substance use disorders (SUD) after initiation of stimulants via telehealth versus in-person visits to inform this policy decision. In unadjusted analysis, patients initiated on stimulants via telehealth visits had higher rates of non-ADHD psychiatric comorbidities and new diagnoses of SUD in the year following initiation. In the adjusted analysis, controlling for psychiatric comorbidities, they did not find a difference in SUD outcomes. The authors suggest additional research to inform policy decisions.
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The association between buprenorphine doses above 16 milligrams and treatment retention in a multi-payer national sample in the United States, 2014 to 2021
Addiction
Buprenorphine labeling identifies 16 mg as the “target dose,” supported by prior evidence that higher doses (≥16 mg) were associated with increased retention in treatment. Studies comparing doses above 16 mg to 16 mg, particularly in the era of fentanyl, have been very limited. The authors conducted a cohort study to look at retention for those receiving 24, 32, and 40 mg compared to 16 mg. Overall, higher doses were associated with increased retention, as follows: 1) 24 mg was more effective than 16 mg at 1 (aOR=1.52) and 18 months (aOR=1.17), 2) 32 mg was more effective than 24 mg at 6 (aOR=1.06), 12 (aOR=1.09), and 18 months (aOR=1.12), and 3) 40 mg was more effective than 24 mg at 12 (aOR=1.10) and 18 months (aOR=1.18). The authors suggest updates to label language and recommendations are prudent, while also supporting more research on long-term treatment with these higher doses.
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Illicit Substance Use and Treatment Access Among Adults Experiencing Homelessness
Journal of the American Medical Association
Utilizing a multistaged probability-based survey, this study assessed the prevalence of illicit substance use, treatment, nonfatal overdose, and naloxone possession among 3,200 adults experiencing homelessness in California from October 2021 to November 2022. An estimated 37% of respondents reported using any illicit substance regularly (≥ 3 times per week) in the last 6 months; methamphetamine use (33%) was the most common. Of those who reported regular use, an estimated 21% wanted but were unable to receive treatment. Approximately 20% of participants reported a nonfatal overdose, and 25% reported being in possession of naloxone. Substance use and nonfatal overdose were common among people experiencing homelessness in California. There was a high unmet need for substance use treatment and naloxone.
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Once-Weekly Semaglutide in Adults With Alcohol Use Disorder
JAMA Psychiatry
This randomized clinical trial explored if glucagon-like peptide 1 (GLP-1) receptor agonist semaglutide reduces alcohol consumption and craving in adults with alcohol use disorder (AUD). Relative to placebo, low-dose semaglutide reduced the amount of alcohol consumed during a posttreatment laboratory self-administration procedure. Over the course of nine weeks of treatment, semaglutide led to reductions in some but not all measures of weekly consumption, significantly reduced weekly alcohol craving relative to placebo, and led to greater relative reductions in cigarettes per day in a subgroup of participants with current cigarette use. These results justify larger clinical trials of incretin therapies for AUD.
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Cannabis Use Disorder Emergency Department Visits and Hospitalizations and 5-Year Mortality
JAMA Network Open
This cohort study of 11.6 million people who were studied for a median of five years investigated if individuals who have hospital-based (emergency department or hospitalization) care for a cannabis use disorder (CUD) were at increased risk of death. Researchers found that individuals with incident hospital-based care for a CUD were at a 2.8-fold increased risk of death within five years relative to the general population. These results suggest that individuals who require hospital-based care for a CUD may be at increased risk of premature death.
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Real-Time Assessment of Alcohol Reward, Stimulation, and Negative Affect in Individuals With and Without Alcohol Use Disorder and Depressive Disorders
American Journal of Psychiatry
A commonly held model of addiction posits that as addictions develop, there is progression from positive reinforcement to negative reinforcement to ameliorate withdrawal symptoms. In this study, researchers examined the subjective response to alcohol among persons with and without alcohol use disorder (AUD) and with or without comorbid depression. Regardless of the presence of comorbid depression, persons with AUD reported pleasurable effects, including stimulation and hedonic reward, after consumption of alcohol. In contrast, among those without AUD, the positive effects were less substantial. Participants did report reduction in negative affect, but the effects were relatively small. These findings suggest that positive reinforcement is sustained in the progression of AUD and the reward-sensitive stage may exist along with negative reinforcement.
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Outpatient Low-Dose Initiation of Buprenorphine for People Using Fentanyl
JAMA Network Open
The accumulation of fentanyl in fat is likely responsible for the risk of precipitated withdrawal when buprenorphine is initiated. Low dose initiation (LDI) of buprenorphine attempts to minimize this risk. This retrospective study included 126 individuals making 175 LDI attempts in an outpatient setting. Patients chose either a 4 day or 7 day LDI protocol with buprenorphine monoproduct. Both protocols begin with buprenorphine 0.5mg, increasing to 8mg tid. Overall LDI was successful in 34% of attempts (with no difference between the protocols) and one month retention on buprenorphine was 21%. Repeated LDI attempts were less likely to be successful (second attempt aOR 0.3). Unhoused people had lower odds of success (OR 0.4). The authors conclude that people with OUD using fentanyl attempting outpatient LDI of buprenorphine had low odds of success.
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Association of State Cannabis Legalization With Cannabis Use Disorder and Cannabis Poisoning
JAMA Psychiatry
This longitudinal cohort study examined the association of state-level medical and recreational cannabis laws with cannabis use disorder (CUD) and cannabis poisonings in the adult population with employer-sponsored health insurance. The study showed that from 2011 to 2021, states with legalized medical cannabis experienced 42.7% and 88.6% increases in CUD and cannabis poisoning, respectively, compared to states without legalized medical cannabis. States with legalized recreational cannabis experienced a 31.6% increase in cannabis poisoning compared to states without legalized recreational cannabis. Thus, state medical cannabis legalization was associated with increased CUD and cannabis poisonings, and state recreational cannabis legalization was associated with increased cannabis poisoning in the adult population with employer-sponsored health insurance.
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Current Advances in Behavioral Addictions: From Fundamental Research to Clinical Practice
American Journal of Psychiatry
This narrative review discusses five clinically relevant and prevalent behavioral addictions that are common and often co-occur with psychiatric disorders such as depression and anxiety. Gambling disorder is the only behavioral addiction recognized as a clinical disorder in DSM-5, and Internet gaming disorder is included as a condition requiring further research. ICD-11 categorizes gambling and gaming disorders as disorders due to addictive behaviors. Additional behavioral addictions may include compulsive sexual behavior disorder, compulsive buying-shopping disorder, and problematic use of social media. Validated diagnostic instruments exist, with empirical support varying across conditions. No medications have approved indications from regulatory bodies for behavioral addictions, and cognitive-behavioral therapy has the most empirical support for efficacious treatment. Treatment optimization involving pharmacotherapy, psychotherapy, neuromodulation, and their combination warrants additional investigation.
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Host Dr. Nick Athanasiou is joined by Dr. David Fiellin and Dr. Eric Strain to discuss the concept of Treatment Refractory Addiction. Why does the field of addiction medicine need this term, how is it defined and how the current treatment system aligns with the idea? Listen to the full interview to learn more!
Treatment Failure Versus Failed Treatments: The Risks of Embracing Treatment Refractory Addiction [Dr. David Fiellin]
The Concept of Treatment-Refractory Addiction: A Call to the Field [Dr. Eric Strain]
The Concept of Treatment-Refractory Addiction: Implications for Addiction Treatment Systems and Research [Dr. Edward Nunes & Dr. Thomas McLellan]
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Review of Evidence on Alcohol and Health
National Academies of Sciences, Engineering, and Medicine
To inform the next edition of the Dietary Guidelines for Americans (DGA), Congress tasked the National Academies with convening an expert committee to independently review the evidence on the relationship between moderate alcohol consumption and eight health outcomes including obesity, cancer, and cardiovascular disease. This controversial report found that a pattern of moderate drinking was associated with 18 percent fewer cardiovascular disease deaths, a 16 percent lower risk of all-cause mortality, and a 10 percent heightened risk of breast cancer for women.
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The impact of schizophrenia genetic load and heavy cannabis use on the risk of psychotic disorder in the EU-GEI case-control and UK Biobank studies
Psychological Medicine
Using data from the EU-GEI case-control study and UK Biobank, researchers examined the independent and combined effect of heavy cannabis use and schizophrenia polygenic risk score (PRS), on risk for psychosis. Schizophrenia PRS and cannabis use independently increased risk of psychosis. Schizophrenia PRS was not associated with patterns of cannabis use. It was associated with lifetime and daily cannabis use without psychosis, but the effect was substantially reduced when cannabis use disorder (CUD) PRS was included in the model. Regular users of high-potency cannabis had the highest odds of being a case independently of schizophrenia PRS. Regular use of high-potency cannabis remains a strong predictor of psychotic disorder, independent of schizophrenia PRS. Schizophrenia PRS does not seem to be associated with heavy cannabis use. These are important findings, at a time of increasing use and potency of cannabis worldwide.
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Prevalence of pharmacotherapy for attention-deficit/hyperactivity disorder and prescription stimulant misuse: A national study of US college students
Addiction
This is an observational study using cross-sectional data from the American College Health Association–National College Health Assessment III. It measured the association between university-level prevalence of attention deficit/hyperactivity disorder (ADHD) medication treatment and prevalence of prescription stimulant misuse (PSM) among college students. Among university students in the United States, there appears to be a positive association between attending universities with a greater prevalence of ADHD medication treatment and risk of prescription stimulant misuse (PSM). This study provides further support for the possibility that ADHD medication treatment prevalence is a risk factor for PSM.
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Xylazine Pharmacokinetics in Patients Testing Positive for Fentanyl and Xylazine
Clinical Chemistry
This study of xylazine pharmacokinetics used plasma samples from 28 patients who had urine screens positive for xylazine and fentanyl. The patients were being treated for skin lesions, most commonly, then shortness of breath or opioid overdose. At least two subsequent plasma samples were analyzed for xylazine and xylazine metabolites by LC-MS/MS. The median terminal half-life for xylazine in plasma was 12 hours (range 6-21 hours). Animal studies show xylazine to be extensively metabolized, with little unchanged xylazine eliminated in urine. The two most abundant metabolites were oxo-x and sulfone-x, which did not have a window of detection longer than xylazine. Researchers had no information as to the timing or route of xylazine ingestion or if additional xylazine was consumed during the study period. These factors could affect the accuracy of the results.
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Suicide in people prescribed opioid-agonist therapy in Scotland, United Kingdom, 2011–2020: A national retrospective cohort study 🔓
Addiction
This retrospective cohort study aimed to determine if opioid agonist therapy (OAT) in Scotland is protective against suicide, and measure trends in suicide rates in those with opioid dependence over time. The study included 46,453 individuals who received at least one prescription for OAT between 2011 and 2020 with over 304,000 person-years (pys) of follow-up. Results suggested that people with opioid dependence in Scotland have a greater risk of suicide than the general population. Treatment is protective, with rates of suicide lower among those on opioid agonist therapy. Suicide rates have decreased over time, during a period in which drug-related death rates in Scotland have risen to globally high levels.
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Links between adolescent binge drinking and midlife alcohol use behaviors by age, sex, and race/ethnicity 🔓
Alcohol Clinical and Experimental Research
Using data from the Monitoring the Future study, which enrolled cohorts of high school seniors annually starting in 1976, this analysis evaluated alcohol drinking patterns in adults 35-60 and potential association with their drinking patterns at age 18. Overall, the reported mean number of drinks at a time ranged from 1.7 to 1.4, and the mean maximum number of drinks ranged from 3.2 to 2.3. The reported number of drinks was generally lower at older ages. Those who reported binge drinking at 18 versus those who did not report a significantly higher mean (2.3 vs. 1.3) and maximum (4.0 vs. 2.3) number of drinks as adults. Additionally, they were more likely to report binge drinking (39.5% vs 19.1%) and high-intensity drinking (10.5% vs 4.4%) as adults. Further, this association was even stronger in older age groups, suggesting adolescent binge drinking is a risk factor across the lifespan.
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Buprenorphine/Naloxone vs Methadone for the Treatment of Opioid Use Disorder
JAMA Network
This population-based retrospective cohort study assessed whether the use of buprenorphine/naloxone is associated with lower risk of treatment discontinuation and mortality compared with methadone. It included 30,891 individuals initiating treatment for the first time during the study period and found that the risk of treatment discontinuation was higher among recipients of buprenorphine/naloxone compared with methadone (88.8% vs 81.5% within 24 months). The risk of mortality was low while in either form of treatment (0.08% vs 0.13%). Individuals receiving methadone had a lower risk of treatment discontinuation compared with those who received buprenorphine/naloxone. The risk of mortality while receiving treatment was similar between medications.
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Association of Daily Doses of Buprenorphine With Urgent Health Care Utilization 🔓
JAMA Network Open
This cross-sectional study using health care claims data from 35,451 US adults with an opioid use disorder diagnosis assessed whether buprenorphine treatment using doses higher than Food and Drug Administration recommendations is associated with subsequent acute health care utilization. Those receiving higher maximum doses of buprenorphine (i.e., doses above 16 mg and 24 mg) had significantly lower rates of acute care utilization than their peers receiving FDA-recommended doses (between 8 mg and 16 mg). These results suggest that higher doses of buprenorphine are associated with lower acute care utilization and could provide benefits to patients, particularly those using fentanyl who might need these higher doses.
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Facilitators of and barriers to buprenorphine initiation in the emergency department: a scoping review
The Lancet Regional Health Americas
In the context of the opioid overdose epidemic, great efforts have been made to increase access to medication for opioid use disorder (MOUD), specifically buprenorphine. Initiation of buprenorphine in emergency departments (ED) has been a focus of these efforts. While initiation has been increasing, only 3-15% of persons treated in EDs fill a prescription. In this summary literature review, authors examined potential barriers and facilitators to initiation. Having care-coordination with streamlined and easy connection to outpatient treatment was associated with increased initiation. Conversely, the absence of care-coordination was associated with decreased uptake. Additionally, provider training and comfort increased uptake as did flexibility in induction strategies.
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Cannabis Policy Impacts Public Health and Health Equity
National Academy of Sciences Engineering Medicine
This report from the National Academies of Sciences, Engineering, and Medicine urges the federal government to provide policy guidance to states that have legalized cannabis, close regulatory loopholes on intoxicating products derived from hemp, and create a public health campaign aimed at parents and vulnerable populations, among other measures that would protect public health and reduce the harms of rising cannabis use. Federal action includes closing regulatory loopholes for hemp-derived cannabinoids, a cannabis public health campaign, best practices for cannabis policy, and improved cannabis public health data and allowing research. State action includes required training for cannabis retail staff, automatically expunging criminal records, a model for state cannabis policy, and setting product standards.
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In this episode recorded live at ASAM's 55th Annual Conference in Fort Worth, TX, host Dr. Nick Athanasiou sat down with Dr. Shannon Miller to discuss his work on PAM-7, and his path to addiction medicine.
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Risk of Incident Psychosis and Mania With Prescription Amphetamines
The American Journal of Psychiatry
This case-control study used electronic health records to examine the impact of dose levels of prescription amphetamines on the risk of incident psychosis and mania with prescription amphetamines. Among 1,374 case subjects and 2,748 control subjects, the odds of psychosis and mania were increased for individuals with past-month prescription amphetamine use compared with no use. A dose-response relationship was observed; high doses of amphetamines (>30 mg dextroamphetamine equivalents) were associated with 5.28-fold increased odds of psychosis or mania. Past-month methylphenidate use was not associated with increased odds of psychosis or mania compared with no use. Caution should be exercised when prescribing high doses of amphetamines, with regular screening for symptoms of psychosis or mania.
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Cannabis Laws and Utilization of Medications for the Treatment of Mental Health Disorders 🔓
JAMA Network Open
This cross-sectional study of 9,438,716 commercially insured patients examined if access to cannabis, via medical or recreational legalization, is associated with changes in the dispensing of prescription medications to treat mental health disorders. Researchers found statistically significant reductions in benzodiazepine dispensing after increases in both medical and recreational cannabis access. However, evidence suggests increases in other types of psychotropic dispensing. The study suggests that cannabis laws may be significantly associated with the population-level use of prescription drugs to treat mental health disorders, although the associations vary by drug class and state.
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State-level racial and ethnic disparities in buprenorphine treatment duration in the United States
The American Journal on Addictions
National trends reveal a concerning escalation in racial and ethnic disparities in buprenorphine treatment duration for opioid use disorder. This study examined such disparities at the state level. Analyzing 9,040,620 buprenorphine prescriptions dispensed between January 2011 and December 2020 from IQVIA Longitudinal Prescription data, the study revealed substantial statewide variations in racial and ethnic disparities. Specifically, 21 states showed longer treatment durations for White people across all episodes, and 8 states displayed similar trends among episodes lasting ≥180 days. Longer treatment durations for White people in both overall and long-term episodes were exhibited in 5 states, and 15 states showed no racial and ethnic disparities.
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Virtual reality-based Mindfulness-Oriented Recovery Enhancement (MORE-VR) as an adjunct to medications for opioid use disorder: a Phase 1 trial 🔓
Annals of Medicine
Mindfulness-Oriented Recovery Enhancement (MORE) uses mindfulness training to address dysregulation in brain reward systems. MORE has been shown to reduce drug cue reactivity and in an RCT reduced opioid misuse 45% at 9 months. Face-to-face MORE requires significant time of trained clinicians, and this study explored the feasibility of delivering MORE by virtual reality (VR). Treatment consisted of 8 weekly, one-hour MORE-VR sessions. Patients could choose the VR setting for their meditation (beach, forest, waterfall) and interact with virtual drugs and paraphernalia during session 5, which was devoted to examining and managing craving. Of 38 patients, 68% completed 4 or more sessions and 50% completed all sessions. Opioid use decreased significantly (p =.04), as well as craving (p<.001), and results showed a significant increase in positive affect (p<.001).
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The Lancet Psychiatry Commission on youth mental health🔓
The Lancet Psychiatry
Mental ill health, which has been the leading health and social issue impacting the lives and futures of young people for decades, has entered a dangerous phase. Accumulating research evidence indicates that in many countries, the mental health of emerging adults has been declining steadily over the past two decades, with a major surge of mental ill health driven by the COVID-19 pandemic, the measures taken to contain it, and its aftermath. This alarming trend signals a warning that global megatrends (major, long-lasting societal changes such as environmental, social, economic, political, or technological changes) and changes in many societies around the world in the past two decades have harmed the mental health of young people and increased mental ill health among them.
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Alcohol Consumption Patterns and Mortality Among Older Adults With Health-Related or Socioeconomic Risk Factors
JAMA Network Open
This British study included 135,103 older (median age 64) adults and compared drinking patterns with mortality during a median follow-up of 12 years. Compared to occasional drinkers, low-risk drinkers had higher cancer mortality (HR, 1.11), moderate-risk drinkers had higher all-cause and cancer mortality (HRs, 1.10 and 1.15), and high-risk drinking had higher all-cause, cancer, and cardiovascular mortality (HRs, 1.33, 1.39, and 1.21). These results contrast with earlier studies showing protective effects of low- to moderate-risk drinking. Researchers used occasional drinkers as the control group, where previous studies used abstainers including former drinkers with residual health effects. There was a small protective effect of drinking only with meals and drinking wine. In conclusion, the authors failed to find a protective effect of low-risk drinking on mortality.
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Physician Reluctance to Intervene in Addiction: A Systematic Review
JAMA Network Open
This systematic review of 283 articles explored the reasons physicians give for not addressing substance use and addiction in their clinical practice. The institutional environment (81.2% of articles) was the most common reason given for physicians not intervening in addiction, followed by lack of skill (73.9%), cognitive capacity (73.5%), and knowledge (71.9%). These findings suggest that efforts should be directed at creating institutional environments that facilitate the delivery of evidence-based addiction care while improving access to education and training opportunities for physicians to practice the necessary skills.
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Host Dr. Nick Athanasiou sat down with Drs. Matisyahu Shulman and Adam Bisaga to discuss the study they recently authored titled Rapid Initiation of Injection Naltrexone for Opioid Use Disorder: A Stepped-Wedge Cluster Randomized Trial. The doctors share their findings and the impact and implications of the study.
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Rapid Initiation of Injection Naltrexone for Opioid Use Disorder: A Stepped-Wedge Cluster Randomized Clinical Trial
This project has been funded as a whole or in part with Federal funds from the National Institute on Drug Abuse, National Institutes of Health, Department of Health and Human Services, under Contract No. 75N95020C00028.
Social Vulnerability and Prevalence and Treatment for Mental Health and Substance Use Disorders
JAMA Psychiatry
This is a survey study of 4,674 participants from US households that examined the association between social vulnerability and mental health and substance use disorders and related treatment in the US noninstitutionalized population of adults aged 18 years and older. Large increases in several mental health and substance use disorders and corresponding decreases in treatment were found in the most socially vulnerable communities. The findings suggest that routine measurement of social vulnerability might assist in developing more comprehensive care models that integrate medical and social care for mental health and substance use disorders.
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Psilocybin desynchronizes the human brain
Nature
To assess how human brain network changes relate to the subjective and lasting effects of psychedelics, this study tracked individual-specific brain changes with longitudinal precision functional mapping (roughly 18 magnetic resonance imaging visits per participant). Psilocybin massively disrupted functional connectivity (FC) in the cortex and subcortex, acutely causing more than threefold greater change than methylphenidate. These FC changes were driven by brain desynchronization across spatial scales (areal, global), which dissolved network distinctions by reducing correlations within and anticorrelations between networks. Persistent reduction of hippocampal-default mode network connectivity may represent a neuroanatomical and correlate of the proplasticity and therapeutic effects of psychedelics.
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Secondhand Nicotine Absorption From E-Cigarette Vapor vs Tobacco Smoke in Children
JAMA Network Open
This cross-sectional study of 1,777 US children aged 3 to 11 years examined how children’s nicotine absorption, as indexed by serum cotinine level, differ among those exposed to (1) secondhand tobacco smoke only, (2) secondhand e-cigarette vapor only, or (3) neither. Compared with children exposed to secondhand smoke only, nicotine absorption was 83.6% lower in those exposed to secondhand vapor only and 96.7% lower in those exposed to neither. These findings suggest that children absorb much more nicotine from secondhand smoke than from secondhand vapor; switching from smoking to vaping indoors may substantially reduce children’s secondhand exposure to nicotine and other noxious substances, but both smoke and vapor increase children’s absorption vs no exposure.
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Benzodiazepine use in relation to long-term dementia risk and imaging markers of neurodegeneration: a population-based study 🔓
BMC Medicine
This study examined the relationship between benzodiazepine (BZD) use and dementia, using data from the population-based Rotterdam (Netherlands) study started in 1990. For 5,443 participants, BZD use during the 15 years from 1990 to 2005 was compared to dementia screens performed through 2020. Half of the participants had used BZD at some time during the 15-year baseline, and 13% developed dementia. Overall, there was no association between BZD use and dementia risk. However, the use of BZD as an anxiolytic in higher doses was associated with dementia risk (HR=1.3). The authors note that BZD with longer half-life are used as anxiolytics, whereas short half-life BZD are used as sedative-hypnotics. A reduction in hippocampal volume on MRI was also associated with BZD use. Overall, there was no association of BZD use with dementia risk, however, some associations were observed that deserve further study.
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Extended-release ketamine tablets for treatment-resistant depression: a randomized placebo-controlled phase 2 trial
Nature Medicine
The safety and tolerability of racemic ketamine may be improved if given orally, as an extended-release tablet (R-107), compared with other routes of administration. In this phase 2 multicenter clinical trial, male and female adult patients with treatment-resistant major depression (TRD) and Montgomery–Asberg Depression Rating Scale (MADRS) scores ≥20 received open-label R-107 tablets 120 mg per day for 5 days and were assessed on day 8 (enrichment phase). On day 8, responders (MADRS scores ≤12 and reduction ≥50%) were randomized to receive double-blind R-107 doses of 30, 60, 120, or 180 mg, or placebo, twice weekly for 12 weeks. Nonresponders on day 8 exited the study. Tolerability was excellent, with no changes in blood pressure, minimal reports of sedation, and minimal dissociation. The most common adverse events were headache, dizziness, and anxiety. R-107 tablets were effective, safe, and well tolerated in patients with TRD, enriched for initial response to R-107 tablets.
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Global status report on alcohol and health and treatment of substance use disorders
World Health Organization
This report utilizes data from the WHO member states to summarize alcohol consumption, its health consequences, and alcohol policies around the world. Overall, there was a decrease in alcohol consumption between 2010 and 2019, but alcohol-related deaths still accounted for 4.7% of all deaths in 2019. Despite the burden, there are still significant gaps in access to and types of treatment available worldwide, with the percentage of patients with substance use disorder receiving care ranging from 1% to 30% in countries that gather that data. The report makes several recommendations to address the concern, including a global advocacy campaign, increased training for health professionals at all levels, international knowledge transfers, and resource mobilization.
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Community-Based Cluster-Randomized Trial to Reduce Opioid Overdose Deaths
The New England Journal of Medicine
HEALing (Helping to End Addiction Long-term Initiative) Communities Study (HCS) investigators examined the potential of the community-engaged, data-driven Communities That HEAL (CTH) intervention to reduce the rate of opioid-related overdose deaths in highly affected communities. Intervention communities implemented hundreds of strategies to expand opioid overdose education and naloxone distribution, the use of medications for opioid use disorder, and safety measures for prescription opioid use, as well as communication campaigns to support these efforts. Although there were no significant between-group differences in the rate of opioid-related overdose deaths, the trial showed that the CTH community-engaged intervention, with its leveraging of community coalitions and a data-driven approach, can bring about meaningful progress in implementing evidence-based practices.
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Piloting a Hospital-Based Rapid Methadone Initiation Protocol for Fentanyl
Journal of Addiction Medicine
The epidemic of fentanyl has led to increased opioid tolerance and made traditional dosing for methadone initiation insufficient. In this study, the authors examine an inpatient rapid titration of methadone initiation among patients with opioid use disorder (OUD). The protocol recommended dosing of 60 mg on day 1, 70 mg day 2, 80 mg day 3 and 100 mg day 4-7. After patients with significant underlying medical conditions, benzodiazepine or alcohol use and age >65 were excluded, 25 patients underwent the rapid initiation. No patients in the study experienced an adverse event and while additional research is needed, the study demonstrated the feasibility of rapid initiation of methadone for OUD in select patients in an inpatient setting.
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Associations of semaglutide with incidence and recurrence of alcohol use disorder in real-world population
Nature Communications
In this retrospective cohort study of patients receiving medication for treatment of obesity, the authors evaluated the association of semaglutide with incidence of and recurrence of alcohol use disorder (AUD). In the cohort patients received semaglutide or non-GLP1RA medications, including naltrexone and topiramate. In matched cohort analysis, patients who received semaglutide had much lower rates of incident AUD (HR=0.5) compared to those receiving non-GLP1RA medications and in sub-analysis comparing semaglutide to naltrexone/topiramate the also had lower incident AUD (HR=0.44). Among those with a history of AUD, semaglutide was also associated with lower recurrence of AUD (HR=0.44) overall and in sub-analysis (HR=0.25). These findings support potential benefit of semaglutide for AUD in a real-world population and need for randomized clinical trials.
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Innovation and adaptation: The rise of a fentanyl smoking culture in San Francisco
Plos One
This is a qualitative study describing the growing practice in the San Francisco area of smoking rather than injecting fentanyl. Fentanyl salts are stable up to 350°C making heating and inhalation more effective than for heroin. Some of the increase in smoking is driven by users’ difficulty finding accessible veins. There is also the perception that smoking presents less of a risk of overdose compared to injection. It is unclear if smoking is safer and overdose deaths continue to rise in San Francisco. Over time a brown residue accumulates that contains a high concentration of drug. The smoking equipment is often used for both methamphetamine and fentanyl so this residue contains an unknown mixture of the history of the drugs consumed. The residue is valued for potency but presents a new overdose risk due to the unknown amounts of drugs it contains.
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Rapid Initiation of Injection Naltrexone for Opioid Use Disorder
JAMA Network
Standard initiation procedures (SP) for extended-release (XR)-naltrexone can be a barrier to initiation for patients. In this stepped-wedge cluster-randomized trial, they compared SP initiation (3-5 days buprenorphine taper, 7-10 days opioid-free) to a rapid procedure (RP) initiation (1 day buprenorphine, 1 day opioid free, 3-4 days ascending dose of oral naltrexone). Patients in the RP group (62.7%) were more likely to receive the initial XR-naltrexone dose (OR 3.6, P<0.001) than the SP group (35.8%). There was not a statistically significant difference between the groups in rate of 2nd and 3rd doses. The study demonstrates that RP for initiation of XR-naltrexone is non-inferior to SP and may lead to shorter in-patient stay.
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Estimated Number of Children Who Lost a Parent to Drug Overdose in the US From 2011 to 2021
JAMA Psychiatry
Children who lose parents can face significant short- and long-term negative outcomes related to substance use, mental and physical health issues, and housing and financial insecurity. This study estimated the number of children who lost a parent due to overdose between 2011 and 2021, including trends and demographics. The authors estimated 321,566 children lost a parent during the study period, with the number per 100,000 increasing annually from 27 in 2011 to 63.1 in 2021. They also found significant disparities by race, with rates particularly high among non-Hispanic American Indian and Alaska Native people. The authors suggest programs to address the opioid epidemic and overdose crisis should also consider the burden placed on children who lose parents.
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Associations of cannabis use, use frequency, and cannabis use disorder with violent behavior among young adults in the United States
International Journal of Drug Policy
An association between cannabis use and violent behavior has previously been reported, so the authors used the 2015-2019 National Survey on Drug Use and Health to better explore this association. In adjusted models, the authors found an increased prevalence of violent behavior among males reporting daily cannabis use with and without cannabis use disorder (CUD) versus no cannabis use. However, there was no increase among males reporting non-daily cannabis use with or without CUD. Researchers found an increase in violent behavior among females reporting non-daily use with or without CUD and daily use with or without CUD. While additional research is needed to better understand this relationship and the sex differences, these findings support the importance of early screening and treatment for CUD.
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Lead Story
Biomarkers of metal exposure in adolescent e-cigarette users: correlations with vaping frequency and flavouring
Tobacco Control
Various metals have been identified in e-cigarettes and, as their use among youth has increased in the last decade, this is of public health concern. In this study, researchers utilized a national sample of youth who use e-cigarettes and associated between lead, cadmium, and uranium levels and use patterns. Youth who reported intermittent or frequent use had higher levels of lead than occasional users, and frequent users also had higher levels of uranium. In addition, when evaluating by flavor types, sweet flavor e-cigarette use was associated with higher uranium levels than menthol/mint flavors. Given the potential deleterious health effects of these metals, particularly in youth, these findings support the need for regulations and public health interventions to target youth populations and minimize e-cigarette use.
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Association of regular opioid use with incident dementia and neuroimaging markers of brain health in chronic pain patients: analysis of UK Biobank
The American Journal of Geriatric Psychiatry
In this cohort study, researchers examine the association between regular opioid use in patients with chronic pain and development of dementia over 15 years of follow-up. Regular opioid use versus non-opioid analgesic use in this population was associated with increased risk of incident dementia (HR=1.18 CL,1.08-1.30). In addition, there appeared a dose-dependent response with those receiving more prescriptions being more likely to develop dementia: 1-5 prescriptions OR=1.21, 6-20 prescriptions OR=1.27, and >20 prescriptions OR=1.43. Finally, in brain imaging, those with regular opioid use exhibited lower total gray matter and higher white matter hyperintensities. While additional research may be needed to support causality, the authors suggest these findings support caution in regular use of opioids for chronic pain.
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Preventing deaths after prison release
The Lancet
Formerly incarcerated people have exceptionally poor health profiles and are at increased risk of preventable mortality when compared to their general population peers. This accompanying editorial discusses a study by Borschmann et al published in the same issue of The Lancet. Using administrative data from the multi-national Mortality After Release from Incarceration Consortium (MARIC) study, the authors examined mortality outcomes for 1,471,526 people released from incarceration in eight countries. 75,427 deaths were recorded. The markedly elevated rate of death in the first week post-release underscores an urgent need for investment in evidence-based, coordinated transitional healthcare, including treatment for mental illness and substance use disorders to prevent post-release deaths due to suicide and overdose. Temporal variations in rates and causes of death highlight the need for routine monitoring of post-release mortality.
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Lead Story:
Telling the story of the opioid crisis: A narrative analysis of the TV series Dopesick
PLOS One
Dopesick (2021) is the first TV series whose plot deals exclusively with the opioid crisis in the United States. The current study uses narrative analysis and framing theory to explore this series, discussing its portrayal of the people and themes involved in the opioid crisis. This analysis found that although Dopesick attempts to portray multiple dimensions of the opioid crisis, its narrative oversimplifies the story in attributing the cause of the problem almost exclusively to Purdue Pharma and its director Richard Sackler, while downplaying other factors that contributed to the opioid crisis. Thus, the narrative in this TV series tends to offer simple explanations to a complex problem for which simple solutions are likely to be inadequate.
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Lead Story:
Impact of jail-based methadone or buprenorphine treatment on non-fatal opioid overdose after incarceration
Drug and Alcohol Dependence
The authors studied the effect of receiving MOUD during incarceration in New York City jails on non-fatal overdose events during the year after discharge. Data were analyzed for patients with OUD incarcerated between 2011-2017 who either received MOUD during the 3 days before release (n=8660) or did not receive MOUD just prior to release (n=10,163). After controlling for covariates, those receiving MOUD had a significant reduction in non-fatal overdoses during the 14 days after release (adjusted HR: 0.49; 95% CI = 0.33-0.74). However, there was no reduction in non-fatal overdoses during the remainder of the 1 year after release. The authors speculate that this lack of benefit beyond 14 days may be due to failure to transition to outpatient MOUD after release. They conclude that MOUD in jail could be lifesaving and that it is important to ensure MOUD continues after release.
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Lead Story:
Epigenome-wide association study on methamphetamine dependence
Addiction Biology
The authors of this study postulate that some of the biologic changes resulting from methamphetamine use may be associated with epigenetic changes from DNA methylation. Such associations have been seen in schizophrenia, mood disorder, obsessive-compulsive disorder, and Parkinson’s disease. Subjects with methamphetamine dependence (n=24) as well as age and sex matched controls had an epigenome-wide analysis of DNA methylation and identification of sites where methylation differed between subjects with methamphetamine dependence and controls. Thirteen regions with differential methylation were found. Of particular interest was hypomethylation of the CNOT1 and PUM1 genes leading to alterations in mRNA metabolism similar to those seen in bipolar disorder and schizophrenia. These changes relate to symptoms in common such as psychosis. The authors conclude that symptoms seen in methamphetamine dependency may result from genetic changes similar to those in other psychiatric disorders.
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Disposable E-Cigarette Use and Subsequent Use Patterns in Adolescents and Young Adults
Pediatrics
Utilizing sequential surveys in adolescents and young adults, the study evaluated the association between disposable e-cigarette (E-cig) use versus non-disposable E-cig and subsequent E-cig use. Those reporting the use of disposable e-cigs at baseline reported greater number of use days in past 30-days. In the follow-up survey, while controlling for demographics and baseline e-cig use patterns, disposable e-cig use was associated with continued e-cig use (OR=1.92) and greater number of times used daily (IRR=1.29). The authors note that disposable E-cigs are generally inexpensive, relatively easy to hide, and sold in various flavors (not regulated compared to non-disposable forms) and thus recommend comprehensive policies to regulate all forms of nicotine products.
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Lead Story:
Adolescent Δ8-THC and Marijuana Use in the US 🔓
JAMA
D8-THC is synthesized from legal hemp plants (with low D9-THC) and has intoxicating effects similar to D9-THC. D8-THC is available in smoking, vaping, and edible products and is marketed as federally legal. To investigate the extent of D8-THC use by adolescents, data were extracted from the 2023 Monitoring the Future study in which a random selection of 12th grade students were asked about D8-THC use (n=2186). Prevalence of D8-THC use over the past 12 months was 11.4%, and for marijuana use was 30.4%. D8-THC use was lower in western states (5%) than southern states (14.4%), states where D8-THC was regulated (5.7% v. 14.4%), and states where marijuana was legal (8.0% v. 14.0%). The authors conclude that D8-THC use among adolescents is significant and deserves further attention.
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Lead Story:
Association of Cannabis Use With Cardiovascular Outcomes Among US Adults
Journal of the American Heart Association
Cannabis use has increased in the US and perceived harmfulness has decreased, but there is evidence to suggest that cannabis use may increase risk of cardiovascular disease. In this study, the authors utilized the Brief Risk Factor Surveillance System survey to assess association between cannabis use and cardiovascular disease. In a multivariate analysis, they found an association between daily cannabis use and myocardial infarction (MI) (aOR=1.25) and stroke (aOR=1.42). Among adults who had never smoked cigarettes, the association was even greater for MI (aOR=1.49) and stroke (aOR=2.16). While additional research is needed, these findings suggest cannabis may be a risk for cardiovascular disease, independent of cigarette use.
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Lead Story:
Racial and Ethnic Disparities in Geographic Availability of Buprenorphine
Journal of Addiction Medicine
To identify whether buprenorphine availability equitably meets the needs of diverse populations, this study examined the differential geographic availability of buprenorphine in areas with greater concentrations of racial and ethnic minority groups. There were 45% to 55% fewer prescribers in urban areas and 62% to 79% fewer prescribers in rural areas as minority composition increased. Differences in dispensed buprenorphine per capita were similar but larger in magnitude. Achieving more equitable buprenorphine access requires not only increasing the number of buprenorphine-prescribing clinicians; in urban areas with higher racial and ethnic minority group populations, it also requires efforts to promote greater buprenorphine prescribing among already prescribing clinicians.
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Lead Story
Smoking changes adaptive immunity with persistent effects
Nature
There is significant variability in immune response across the population, some of which is related to age, sex, and genetics, but this study examines other factors that may be related to immune response. Notably, the authors found that smoking affected both innate and adaptive immune response, and that the associations were consistent across number of years smoking and number of cigarettes. The effect on innate immune response was short-term, with immune response returning to levels comparable to non-smokers after quitting. The effect on adaptive immunity, however, was long-term and persisted even after quitting — the result of DNA methylation changes. These findings have clinical implications regarding risk of infection, cancer, and autoimmune disease in persons who smoke.
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Lead Story:
Overdose mortality incidence and supervised consumption services in Toronto, Canada: an ecological study and spatial analysis
The Lancet Public Health
The objective of this study was to measure the effect of safe consumption sites (SCS) on overdose mortality. Between 2017 and 2019, nine SCS were implemented in Toronto, Canada. During this period there were 787 overdose deaths. In the 15 neighborhoods within 500 meters of an SCS, overdose deaths decreased by 67% (p=0.037) after SCS were implemented. There was no decrease in other neighborhoods. Researchers were surprised to observe some decrease in overdose deaths up to 5000m from SCS. They note that in addition to onsite overdose reversal, SCS also distribute naloxone and offer referrals to low-barrier MOUD. They speculate that these other services could explain the effects at greater distances. The authors conclude that SCS result in significant reductions in overdose deaths in surrounding neighborhoods.
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Lead Story:
Safety of e-cigarettes and nicotine patches as stop-smoking aids in pregnancy: Secondary analysis of the Pregnancy Trial of E-cigarettes and Patches (PREP) randomized controlled trial
Addiction
It is not clear to what extent nicotine is responsible for adverse outcomes of smoking during pregnancy. This study examined outcomes of e-cigarette (EC) and nicotine replacement therapy (NRT) use in pregnancy. Pregnant smokers were randomly assigned to EC or NRT. ECs were more than twice as likely to be used regularly compared to NRT. Those abstaining from cigarettes had higher birth weights (3.3 Kg) than smokers (3.1 Kg), and the use of EC or NRT did not affect birth weight in abstainers. In the entire group (abstainers and smokers), use of EC and/or NRT was not associated with an increase in adverse events. Those using EC had less cough and phlegm than those using NRT. Other studies have confirmed the same, possibly resulting from antibacterial effects of additives to the EC liquid. The authors found no risks to pregnancy from EC or NRT use.
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Polysubstance mortality trends in White and Black Americans during the opioid epidemic, 1999–2018
BMC Public Health
The CDC characterizes the opioid epidemic in three waves: first, prescription opioids (1999-2010); second, heroin (2011-2013); and third, synthetic opioids (2013-present). The authors examine the epidemic, looking at trends in multiple substances involved in overdoses and differences by race. Psychostimulant and benzodiazepine involvement were more common among White persons, while cocaine-related deaths were higher among Black persons. Overdose deaths have increased faster among Black persons since 2013. Overall, overdose deaths frequently involve multiple substances and can’t simply be attributed to opioids. The authors give three policy implications for their findings: 1) polysubstance use should be considered the norm, 2) addressing racial disparities requires interventions across primary, secondary, and tertiary prevention, and 3) the importance of measures to address fentanyl specifically.
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Lead Story:
First Trimester Use of Buprenorphine or Methadone and the Risk of Congenital Malformations 🔓
JAMA Internal Medicine
In this cohort study of 9,514 pregnancies with first-trimester buprenorphine exposure and 3,846 with methadone exposure, the prevalence of congenital malformations overall and several malformation subtypes was lower among pregnant individuals treated with buprenorphine compared with methadone, except for gastrointestinal malformations. There was an 18% relative risk reduction for malformations overall, which translates to 1 less event per 100 patients treated with buprenorphine vs methadone. When determining optimal treatment for pregnant individuals with opioid use disorder, considerations should include the relative risk reduction for malformations overall with buprenorphine vs methadone, as well as treatment access, previous success on a particular treatment, and the likelihood of retention in treatment.
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Trends in hallucinogen-associated emergency department visits and hospitalizations in California, USA, from 2016 to 2022 🔓
Addiction
There has been growing interest in recent years around hallucinogens as potential therapeutics, and use among young adults has increased significantly. With limited data, the mounting perception is that hallucinogens are safe. In this context, the authors examined emergency department (ED) visits and hospitalizations due to hallucinogens versus alcohol and cannabis in California between 2016 and 2022. Hallucinogen-associated ED visits increased by 54% (2260 visits to 3476 visits), while alcohol-associated visits decreased by 20% and cannabis-associated visits increased by 15%. Additionally, hallucinogen-associated hospital admissions increased by 55% (2556 to 3965) with no significant changes in alcohol- and cannabis-associated hospitalizations. Additional research is needed to assess hallucinogen-associated potential harms.
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Lead Story:
Adolescent Residential Addiction Treatment In The US: Uneven Access, Waitlists, And High Costs
Health Affairs
Residential treatment facilities are one treatment option for adolescents with substance use disorders, yet little is known about their accessibility or cost. This study identified 160 residential addiction treatment facilities that treated adolescents with opioid use disorder as of December 2022. Eighty-seven facilities (54.4 percent) had a bed immediately available. Among sites with a waitlist, the mean wait time for a bed was 28.4 days. Of facilities providing cost information, the mean cost of treatment per day was $878. Daily costs among for-profit facilities were triple those of nonprofit facilities. Half of facilities required up-front payment by self-pay patients. The mean up-front cost was $28,731. The authors were unable to identify any facilities for adolescents in ten states or Washington, D.C. Access to adolescent residential addiction treatment centers in the United States is limited and costly.
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Lead Story:
Benzodiazepine Discontinuation and Mortality Among Patients Receiving Long-Term Benzodiazepine Therapy
JAMA Network Open
In this comparative effectiveness study among 353,576 patients receiving stable long-term treatment with benzodiazepines, discontinuation was associated with small absolute increases in mortality and other potential harms, including nonfatal overdose, suicide attempt, suicidal ideation, and emergency department visits. These results suggest benzodiazepine discontinuation among patients prescribed for stable long-term treatment may be associated with unanticipated harms, and that efforts to promote discontinuation should carefully consider the potential risks of discontinuation relative to continuation.
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Top Publication of 2023:ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder for Individuals Using High-potency Synthetic Opioids 🔓
Journal of Addiction Medicine
This clinical considerations document is based on a narrative literature review and expert consensus and addresses considerations for changes to the clinical practice of treatment of opioid use disorder (OUD) with buprenorphine for individuals using high-potency synthetic opioids (HPSOs). Broadly, it suggests that individualized strategies for buprenorphine initiation may be needed. The experience of opioid withdrawal negatively impacts the success of buprenorphine treatment, and attention to withdrawal management before and during buprenorphine initiation should be proactively addressed. Buprenorphine dose and dosing frequency should be individualized based on patients’ treatment needs, the possibility of novel components in the drug supply should be considered during OUD treatment, and all forms of opioid agonist treatment should be offered and considered for patients.
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Lead Story:
Examining the benefit of a higher maintenance dose of extended-release buprenorphine in opioid-injecting participants treated for opioid use disorder
Harm Reduction Journal
This is a secondary analysis of a randomized, double-blind study comparing 100 mg and 300 mg maintenance doses of extended-release buprenorphine (BUP-XR). All patients (n=311) received 2 monthly induction doses of 300 mg BUP-XR followed by 4 monthly maintenance doses of either 100 mg or 300 mg BUP-XR. For patients who had not been using opioids by injection, there was no difference in weekly abstinence or treatment retention comparing the two maintenance doses. However, for patients with a history of injecting opioids, the 300 mg maintenance dose resulted in significantly higher percentages of weeks abstinent as well as improved treatment retention. The authors speculated that opioid injecting patients may have had higher levels of tolerance that required a higher maintenance dose.
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Lead Story:
Relationship between alcohol use and firearm-involved suicide: Findings from the National Violent Death Reporting System, 2003-2020
American Journal of Preventive Medicine
This study evaluated the sex- and age group-specific relationship between alcohol intoxication and firearm-involved suicide. Among males of all ages and young and middle-aged females, alcohol intoxication was associated with increased risk of suicide by firearm, an extremely lethal method that accounts for a majority of suicides in the US, compared to their non-intoxicated counterparts. Interventions targeting excessive alcohol consumption may be effective in reducing suicide mortality rates
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Lead Story:
Pregnancy and Postpartum Drug Overdose Deaths in the US Before and During the COVID-19 Pandemic
JAMA Psychiatry
This cross-sectional exploratory study examined knowledge gaps in overdose deaths among pregnant and postpartum persons from 2018-2021 as compared to nonpregnant overdose deaths and obstetrical deaths. Overdose deaths among pregnant and postpartum women consistently increased among those aged 10 to 44 years, and more than tripled among those aged 35 to 44 years, from 4.9 per 100,000 from January-June 2018 to 15.8 from July-December 2021. These deaths differed from nonpregnant overdose deaths and obstetrical deaths in sociodemographic characteristics and place of death. Among overdose deaths in total (pregnant and nonpregnant), nearly 75% occurred outside of health care settings. Clearly more work needs to be done to treat SUDs in this population.
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Lead Story:
2022 National Survey on Drug Use and Health (NSDUH)
SAMHSA
Key findings include that in 2022, 70.3 million people aged 12 or older (or 24.9%) used illicit drugs in the past year. Marijuana was the most used illicit drug, with 22.0% of people aged 12 or older (or 61.9 million people) using it in the past year. In 2022, 48.7 million people aged 12 or older (or 17.3%) had a substance use disorder (SUD) in the past year, including 29.5 million who had an alcohol use disorder (AUD), 27.2 million who had a drug use disorder (DUD), and 8.0 million people who had both an AUD and a DUD. Almost 1 in 4 adults aged 18 or older had any mental illness (AMI) in the past year (59.3 million or 23.1%) and among adolescents aged 12 to 17 in 2022, 19.5% (or 4.8 million people) had a past year major depressive episode (MDE).
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Lead Story:
Neural circuit selective for fast but not slow dopamine increases in drug reward🔓
Nature Communications
The authors note that rapid delivery to the brain when drugs are injected or smoked results in more severe substance use disorders. They used functional MRI and PET scans to monitor dopamine increases while subjects (n=20) received methylphenidate either orally or intravenously. Intravenous methylphenidate caused a more rapid increase in dopamine than oral. Activity in the medial prefrontal cortex decreased in both groups but was more pronounced with intravenous methylphenidate. However, only intravenous methylphenidate produced increased activity in the dorsal anterior cingulate cortex and insula that was reflected in the subjective rating of “high.” This brain region was activated only by intravenous methylphenidate and the associated rapid increase in dopamine.
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Lead Story:
Public health approaches to gambling: a global review of legislative trends
The Lancet Public Health
Authors of this article systematically reviewed legislation of jurisdictions that introduced major gambling legislation change (i.e., restricting or extending gambling provision) between Jan 1, 2018, and Dec 31, 2021. More than 80% of countries worldwide now legally permit gambling. Harmful gambling was recognized as a health and wellbeing issue in most of the analyzed jurisdictions, but near-exclusive focus was given to individual-level harms rather than to wider social and economic harms or harms to others. Most of the proposed prevention measures focused on individual responsibility. Gambling policies worldwide are changing, but addressing gambling as a public health issue has not yet translated into comprehensive policy action across jurisdictions.
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Lead Story:
Clinical Practice Guideline on the Management of Stimulant Use Disorder
American Society of Addiction Medicine and American Academy of Addiction Psychiatry
Overdose deaths involving stimulant drugs – including cocaine, methamphetamine, amphetamine, and prescription stimulants – have been rising precipitously over the past decade. In 2021, over fifty percent of overdose deaths in the US involved stimulant drugs. Beyond the mortality risk, stimulant use disorders (StUD) can also lead to long term health problems including infectious diseases, cardiac, pulmonary, psychiatric, dental, nutritional, skin, and cognitive issues. The Clinical Practice Guideline on the Management of Stimulant Use Disorder, developed by the American Society of Addiction Medicine (ASAM) and the American Academy of Addiction Psychiatry (AAAP), provides information on evidence-based strategies and standards of care for the prevention and treatment of stimulant use disorders (StUD), stimulant intoxication, and stimulant withdrawal.
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Lead Story:
Chronic pain, cannabis legalisation, and cannabis use disorder among patients in the US Veterans Health Administration system, 2005 to 2019: a repeated, cross-sectional study
The Lancet Psychiatry
The prevalence of cannabis use disorder (CUD) in patients with chronic pain is increasing. This study considered the impact of both recreational (RCL) and medical cannabis laws (MCL) on the diagnosis of CUD using a VA population with chronic pain. Results demonstrate that MCL led to a 0.135% increase in the prevalence of CUD. Enacting RCL led to a 0.188% increase in its prevalence. The authors emphasize the importance of these findings and their public health implications, with a focus on clinician monitoring and patient education.
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Lead Story:
Xylazine Adulteration of the Heroin–Fentanyl Drug Supply
Annals of Internal Medicine
Since 2016, xylazine has appeared in the illicitly manufactured fentanyl supply and has increased in prevalence, due to its low cost, easy availability, and presumed synergistic psychoactive effect. It remains unclear whether a distinct xylazine withdrawal syndrome occurs. Xylazine may alter the findings and management of patients with fentanyl overdose and withdrawal. Inadequately treated opioid (and possibly xylazine) withdrawal contributes to the increase in self-directed discharges from treatment settings. Initiation of buprenorphine and perhaps methadone may be compounded by the concomitant use of xylazine. The presence of extensive wounds in people who use xylazine prevents them from accessing resources, including medically managed withdrawal treatment, leading to a cycle of continued and escalating use.
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Lead Story:
Heterogeneous neuroimaging findings across substance use disorders localize to a common brain network
Nature Mental Health
This study used network mapping approaches and a functional connectome from a large cohort of healthy participants (n = 1,000) to test whether neuroimaging abnormalities across substance use disorders map to a common brain network. Starting with coordinates of regional brain atrophy from 45 studies, researchers found that 91% of the neuroimaging findings mapped to a common brain network specific to substance use disorders compared to atrophy associated with normal aging and neurodegenerative disease. Coordinates of functional MRI abnormalities from 99 studies mapped to a similar brain network. Neuroimaging abnormalities across substance use disorders map to a common brain network that is similar across imaging modalities, substances, and lesion locations that cause remission from substance use disorders.
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Lead Story:
The association between temperature and alcohol- and substance-related disorder hospital visits in New York State
Communications Medicine
Using New York State hospital data, this study investigated the link between daily temperature and hospital visits as a result of substance use from 1995-2014. An increase in temperature 0-6 days prior to seeking hospital care was associated with an increase in rates in care. Increase in visits was highest when opioids were involved, and lowest for sedatives. The 25-44 age group was primarily affected, and males made up the highest proportion of cases. These results indicate that the rise in SUD hospital visits is linked to continued rising temperatures related to climate change; healthcare and social interventions could potentially mitigate these harms.
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Lead Story:
US tobacco companies selectively disseminated hyper-palatable foods into the US food system: Empirical evidence and current implications
Addiction
Hyper-palatable foods (HPF) contain fat and sodium, fat and simple sugars, and carbohydrate and sodium at specific thresholds to induce hyperpalatability, creating an artificially rewarding experience. This study compared tobacco companies who owned food companies to food companies not owned by tobacco companies, with regard to hyperpalatability between 1988 and 2001. Upon review of industry documents, this study found that tobacco companies “selectively disseminated” HPF into the US market. Tobacco-owned foods were 29% more likely to be classified as fat and sodium HPF and 80% more likely to be classified as carbohydrate and sodium HPF than foods that were not tobacco-owned. As late as 2018, market saturation of fat and sodium HPF was close to 60% and carbohydrate and sodium HPF was almost 20% regardless of tobacco ownership. Further research should consider the links between industries to appreciate potential impact on public health.
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Lead Story:
America's Opioid Ecosystem: How Leveraging System Interactions Can Help Curb Addiction, Overdose, and Other Harms
RAND Corporation
This ebook highlights that although opioids play an outsized role in US drug problems, they also play a critically important role in medicine. Thus, they deserve special attention. Illegally manufactured opioids are involved in a majority of US drug overdoses. Efforts to address problems related to opioids are insufficient and sometimes contradictory. Components of the opioid ecosystem include substance use disorder treatment, harm reduction, medical care, the criminal legal system, illegal supply and supply control, first responders, the child welfare system, income support and homeless services, employment, and education. Leveraging the interactions of the opioid ecosystem can reduce addiction, overdose, suffering, and other harms.
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Lead Story:
Naloxone Use in Novel Potent Opioid and Fentanyl Overdoses in Emergency Department Patients
JAMA Network Open
In this cohort study of 537 patients, all patients with novel potent opioid (NPO) overdose presented with opioid overdose symptoms and received multiple doses of naloxone. Compared with fentanyl overdose, patients with NPO overdose had a higher number of naloxone doses administered in-hospital; metonitazene overdose was associated with cardiac arrest and more naloxone doses overall. These findings suggest that NPOs may have a higher potency than fentanyl due to the observed naloxone administration in the clinical setting of overdose.
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ASAM Weekly for September 12, 2023
Prevalence of Cannabis Use Disorder and Reasons for Use Among Adults in US
Our news stories this week show how there’s usually another layer to consider with addiction and government. California has a history of counterculture movements but it's the modern-day focus on wellness that may actually be leading the state toward decriminalizing psychedelics (Los Angeles Times). This could be a positive step but needs to be built on a framework of prevention. The Biden administration announced almost $450 million going towards addiction treatments and prevention (UPI) which is welcomed news but we need to build infrastructure that will be sustainable beyond the opioid crisis. An article from the NY Times reveals a dynamic between governments and cartels in Mexico that has more to do with funding and protection than it does with corruption -- or was it the other way around?
Washington state was early to cannabis legalization so it may or may not be surprising that cannabis use disorder is actually quite common (21%) in primary care patients who use cannabis in the state (JAMA Network Open). But what’s even more interesting is how much we are learning about the endocannabinoid system during this era of legalization. For example, endogenous cannabinoids can regulate stress in a way that affects motivational processes in addiction reward (PNAS) as well as alcohol consumption (Translational Psychiatry).
A study from Vancouver demonstrates how population-level testing of opioid samples could act as an early warning system for overdose risks and potentially save lives (AJPM). Communities also need tools to rapidly diagnose OUD and StUD; the Rapid Opioid Use Disorder Assessment (ROUDA) and the Rapid Stimulant Use Disorder Assessment (RSUDA) could help both clinicians and non-clinicians alike (Psychiatric Research and Clinical Practice). These assessments also remind us that although substance use is not a course specifier for remission (DSM-5), its utility in diagnostic tools and research outcomes continues.
Lead:
Prevalence of Cannabis Use Disorder and Reasons for Use Among Adults in a US State Where Recreational Cannabis Use Is Legal
JAMA Network Open
This cross-sectional study investigated the prevalence of cannabis use disorder (CUD) among primary care patients in states with legal recreational cannabis. Patients were asked to report medical use, nonmedical use, or both, with 42.4% reporting medical use only, 25.1% nonmedical use only, and 32.5% reporting both. The prevalence of any CUD was 21.3%; for moderate to severe CUD prevalence was 6.5% overall, with 1.3% reporting medical use, 7.2% nonmedical use, and 7.5% reporting both. Those reporting medical use only tended to be older, female, and retired. Those reporting nonmedical use or both were more likely to disclose withdrawal; use in hazardous situations; use despite persistent or recurrent social or interpersonal problems; important social, occupational, or recreational activities given up or reduced; and use despite persistent or recurrent social or interpersonal problems. Hence, screening for CUD among patients who use cannabis is paramount.
Research and Science
Synaptic and cellular endocannabinoid signaling mechanisms regulate stress-induced plasticity of nucleus accumbens somatostatin neurons
PNAS
How stress affects neuronal plasticity within brain reward circuits is important to understand given the link between stress and mood disorders and addiction. While endogenous cannabinoids (eCBs) are well known to regulate synaptic plasticity onto NAc medium spiny neurons and modulate nucleus accumbens (NAc) function at the behavioral level, how eCBs regulate NAc interneuron function is less well understood. This study shows that endogenous cannabinoids regulate the balance of excitatory drive to the nucleus accumbens in mice and are required for stress to shift excitatory drive to this key reward center. These cannabinoid-mediated shifts in balance of excitatory drive could reveal how stress affects motivational processes and provide insight into the neural basis of cannabis reward.
Validation of Two Diagnostic Assessments for Opioid and Stimulant Use Disorder for Use by Non‐Clinicians
Psychiatric Research and Clinical Practice
This cross-sectional study tested the validity of two DSM-5 diagnostic assessment tools for opioid use disorder and stimulant use disorder by non-clinicians. The study updates the Rapid Opioid Dependence Screen (RODS) to the Rapid Opioid Use Disorder Assessment (ROUDA) and includes fentanyl. The Rapid Stimulant Use Disorder Assessment (RSUDA) was also tested. The ROUDA demonstrated a sensitivity of 82.5% (95% CI) and a specificity of 100% (95% CI). Likewise, the RSUDA demonstrated similarly high sensitivity. Non-clinician diagnosis of these disorders affords an opportunity for rapid education, treatment, and implementation of harm reduction measures in community settings.
Fentanyl concentration in drug checking samples and risk of overdose death in Vancouver, Canada
American Journal of Preventive Medicine
Fentanyl and its analogs are the known major drivers of the opioid overdose epidemic in the last few years and in response community drug checking services have expanded, which allow persons who use drugs to test their supply. These programs test for the presence and concentration of fentanyl. Utilizing the fentanyl concentration data from these services in Vancouver, Canada, the authors found a strong association between median monthly fentanyl concentration and illicit drug toxicity death rates between January 2019 and October 2020. There was a notable increase in both the fentanyl concentration and overdose death rate starting in March 2020. The authors suggest that data from these types of services can be used as a tool to monitor evolving drug supply and fentanyl concentrations which can inform real-time public health responses.
N-oleoyl glycine and N-oleoyl alanine attenuate alcohol self-administration and preference in mice
Translational Psychiatry
It is hypothesized that drug-induced elevation in endocannabinoids (eCBs) and/or eCB-like molecules (eCB-Ls) may represent a protective mechanism against drug insult, and boosting their levels exogenously may strengthen their neuroprotective effects. This study determined the involvement of ECS in alcohol addiction. Systemic administration of N-oleoyl glycine (OlGly) or N-oleoyl alanine (OlAla) during intermittent alcohol consumption significantly reduced alcohol intake and preference without affecting the hedonic state. These findings suggest that the endocannabinoid system (ECS) negatively regulates alcohol consumption and boosting selective eCBs exogenously has beneficial effects against alcohol consumption and potentially in preventing relapse.
Learn More
Racial inequities and addiction research
Drug and Alcohol Dependence
There is a significant need for research on the racial and ethnic inequities for substance use disorders, but there are also disparities present among those who conduct the research. The authors describe some of the efforts by NIDA to address the disparities among researchers, citing several programs including Diversity Scholars Network, Summer Research Internship Programs, Diversity supplement Awards, and other funding opportunities. While some progress has been made in the demographic trends in funding over the last decade, the absolute number of applicants among racial and ethnic minorities remains low. One significant barrier may be relatively low salaries for post-doctoral positions that may prevent persons from lower socio-economic backgrounds from entering research careers. The authors suggest grantee institutions could offer additional support to address this barrier.
Epigenetic alterations identify a confluence of genetic vulnerabilities tied to opioid overdose
Neuropsychopharmacology
Neurons were obtained from the dorsolateral prefrontal cortex of 51 opioid overdose cases and 51 sudden death controls and studied for epigenetic changes. While the specific epigenetic changes varied in the overdose cases, they all converged on 5 genes known to be linked to OUD. The authors state that these studies increase understanding of the role of genetic influences in opioid overdose.
Preliminary Evidence of the Association between Time on Buprenorphine and Cognitive Performance among Individuals with Opioid Use Disorder Maintained on Buprenorphine: A Pilot Study
International Journal of Environmental Research and Public Health
Participants (n=16) had been on buprenorphine maintenance treatment (BMT) for at least 30 days and had used an illicit drug in the past 30 days and were compared to matched healthy controls (n=23). The cognitive tests assessed response inhibition and attention by showing participants words, colors, and letters on a screen and asking participants to respond when specific patterns appeared. The BMT participants had more errors and slower reaction times than the controls. The BMT participants had an average of 315 days on buprenorphine and the length of time on buprenorphine was associated with fewer errors and faster reaction times. There was no correlation between illicit drug use or craving and errors or reaction time.
In the News
In Mexico, Drug Trade Flourished With the Help of the State
The New York Times
California moves to decriminalize use of magic mushrooms, other psychedelics
Los Angeles Times
Few pregnant women, babies in New Mexico in need of medication for opioid addiction receive it
Santa Fe New Mexican
What patients – and doctors – should know about ‘benzo’ withdrawal
Yahoo!News
White House announces $450 million to strengthen drug abuse recovery efforts
UPI
As teen fentanyl deaths rise, schools grapple with their role
NPR
Fentanyl is killing kids. State lawmakers are searching for answers.
POLITICO
This Week in the ASAM Weekly
This week, the titles tell much of the story. All of Us(not to be confused This is Us)is an engaging (almost heartwarming) name for an expansive research program tasked with better understanding our diverse populations. It can improve upon data from other sources like NSDUHand NESARC by capturing groups that may be underrepresented in national surveys (PLOS ONE).
Also in the titles, the emerging fentanyl-xylazine syndemic in the US has its challenges while its future direction sees remnants of the past (The Lancet). There are increasing numbers and shifting demographics for adolescents presenting to emergency departments with OUD but outpatient capacity still remains underdeveloped (American Journal of Emergency Medicine). Both are part of a unifying problem: substance use disorder treatment falls short of the need (NEJM Catalyst).
Of course, there is much more to the story than can be conveyed in a title. A case study on the involuntary use of extended-release buprenorphine in a patient with schizophrenia is brief but full of ethical and legal considerations (JAM). Unintentional pediatric ingestion of cannabis is as much about copycats and counterfeits in the cannabis market as it is about the harms toward children (JAMA Pediatrics).
We’ll end with a title from The New York Times. Its wording could cause some to assume it’s a story about a progressive state being too progressive or maybe the use of “tries” implies “fails” because what else should a lay reader assume about “drug users.”
But it’s just a title. The actual story is about contingency management and the brave steps California has taken to provide an effective treatment for stimulant use disorders.
Thanks for reading,
Nicholas Athanasiou, MD, MBA, DFASAM
Editor in Chief
with Co-Editors: Brandon Aden, MD, MPH, FASAM, Debra R. Newman, PA-C, MSPAS, MPH, Jack Woodside, MD, John A. Fromson, MD
Lead Examining sociodemographic correlates of opioid use, misuse, and use disorders in the All of Us Research Program 🔓
PLOS ONE
This study aims to estimate the prevalence of opioid use and its association with sociodemographic characteristics from survey data and electronic health record (EHR). A total of 214,206 participants completed survey modules and shared EHR data. The lifetime prevalence of street opioids was 4%, and the nonmedical use of prescription opioids was 9%. Men had higher odds of lifetime opioid use but reduced odds of current nonmedical use of prescription opioids. Participants from other racial and ethnic groups were at reduced odds of lifetime use but increased odds of current use compared with non-Hispanic White participants. Foreign-born participants were at reduced risks of opioid use and diagnosis of opioid use disorders (OUD) compared with US-born participants. Men, younger, white, and US-born participants Prevalence and impact of recreational drug use in patients with acute cardiovascular events
Heart
This prospective observational study investigated the prevalence of recreational substance use in patients admitted for an acute cardiovascular event in France. Of all patients screened, over 10% had a positive urine toxicology screen, and close to 30% of these used multiple substances. One-third of those under 40 years of age had a positive screen. Those patients who used substances experienced a greater proportion of in-hospital major adverse events (MAE) than those who did not (13% vs. 3%). After adjusting for comorbidities, cannabis, cocaine, and MDMA were independently associated with higher risk of MAE. Those using multiple substances demonstrated a doubling of risk of MAE as well.
Duration and Timing of In Utero Opioid Exposure and Incidence of Neonatal Withdrawal Syndrome🔓
Obstetrics and Gynecology
This study examines the association of neonatal opioid withdrawal syndrome (NOWS) and prenatal exposure to prescription opioids (excluding MOUD). They counted the number of days of exposure to opioids during pregnancy and timing of that exposure in early or late pregnancy. Data were obtained from Wisconsin administrative records between 2011 and 2019. Exposure to opioids late in pregnancy (adjusted for duration of exposure) was associated with an increased odds of NOWS (aOR 1.57, p<0.001). Longer duration of exposure (adjusting for the timing of exposure during pregnancy) was associated with increased odds of NOWS: 7-29 days – aOR=1.58, 30-89 days – aOR=3.29, and >90 days – aOR=6.21. The risk of NOWS increases with a longer duration of opioid exposure and with exposure in the third trimester.
Changes to opioid overdose deaths and community naloxone access among Black, Hispanic and White people from 2016 to 2021 with the onset of the COVID-19 pandemic: An interrupted time-series analysis in Massachusetts, USA
Addiction
The authors evaluated opioid overdose deaths (OODs), community-based naloxone distribution, and the naloxone availability (naloxone distribution/OODs) in Massachusetts from 2016-2021 (pre- and post-COVID-Increasing number and shifting demographics of adolescent opioid use disorder presentations to the emergency department
The American Journal of Emergency Medicine
In this study, the authors examine opioid related emergency department (ED) visits among adolescents ages 12-21 in a hospital system between 2014 and 2022. In the study period, they found a drastic increase in visits occurred post-COVID, with over half (63.2%) of all visits occurring in the last 2 years. Among those ages 13-17, there was a 1700% increase in ED visits post-COVID versus pre-COVID. They also found the most significant increases among the Hispanic population in this hospital system. The authors note that linkage to care from EDs for adolescents is limited or not available, particularly medication for opioid use disorder; however, given the dramatic increase in adolescent opioid-related visits to Eds, pathways to care for this population are needed.
Learn MoreThe emerging fentanyl–xylazine syndemic in the USA: challenges and future directions 🔓The LancetThis commentary notes the increasing involvement of the sedative analgesic xylazine in opioid overdoses and describes it as a syndemic. This past July, the Office of National Drug Control Policy identified fentanyl adulterated with xylazine as an emerging threat. The authors propose three responses. First, increased checking of the drug supply and addition of xylazine to toxicology screens to serve as an early warning system. Second, education of health-care providers regarding xylazine, including management of skin ulcers and polysubstance withdrawal, along with efforts to reduce the stigma associated with xylazine among providers. Third, expand naloxone distribution and education. There is no approved reversal agent for xylazine, so naloxone use needs to include measures such as airway management and oxygen.
Initiation of Extended-release Depot Buprenorphine in a Patient Subject to a Community Treatment Order for Both Antipsychotic and Opioid Agonist TreatmentsJournal of Addiction MedicineOpioid use disorder (OUD) and schizophrenia are commonly comorbid, and patient outcomes are improved when these conditions are managed concurrently. Extended-release depot buprenorphine is an emerging option for the treatment of moderate-to-severe OUD, and it may provide certain benefits in patients with concurrent OUD and psychosis. This is a case study of a 32-year-old man with schizophrenia, traumatic brain injury, and OUD with a history of multiple opioid-related overdoses, followed by an assertive community treatment team, and subject to a community treatment order for both his primary psychotic disorder and OUD treatments. The role of extended-release depot buprenorphine in this unique patient population and the ethical considerations of involuntary treatment of OUD in patients lacking capacity to consent to treatment are explored.
Unintentional Pediatric Ingestion of Cannabis—Addressing a Growing Public Health RiskJAMA PediatricsSome 37 states now permit some degree of cannabis use. Unintentional THC exposure in children has increased as more cannabis products become more widely available. In this Viewpoint, the authors address the risks posed by copycat THC products, products packaged to look like well-known consumer brands. National poison control centers report more than 10,000 cases of unintentional exposure to edible THC products from January 2021 to May 2022. In spite of state laws prohibiting products Substance Use Disorder Treatment Falls Short of the NeedNEJM Catalyst
California Tries Paying Drug Users to Stay Sober
The New York Times
Drug Overdose Deaths with Evidence of Counterfeit Pill Use — United States, July 2019–December 2021
Morbidity & Mortality Weekly Report
People in red states where pot is illegal can buy other hemp products
NPR
Like Bradley Cooper, I hit rock bottom with drink – and I have one request…
The Independent
We Need Comprehensive Illicit Drug Analysis Now to Stop Overdose Deaths
Scientific American
Native American substance abuse Medicaid scam Phoenix Arizona Navajo Nation
NPR
Special Guest:
Melissa Weimer, DO, MCR, FASAM
Article Referenced:
ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder for Individuals Using High-potency Synthetic Opioids
ASAM Resources:
ASAM Clinical Guidelines
2020 National Practice Guideline for the Treatment of Opioid Use Disorder
ASAM's Treatment of Opioid Use Disorder Virtual Course
ASAM's Moving Beyond the Barriers of Treating Opioid Use Disorder Live Course
OUD Treatment Education
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Lead Story:
Marijuana and hallucinogen use, binge drinking reached historic highs among adults 35 to 50
NIDA News
According to data from the Monitoring the Future (MTF) study, use of marijuana and hallucinogens reached their highest levels ever for people 35-50 years of age in 2022. Binge drinking among this age group also reached peak levels. For those 19-30 years of age, marijuana and vaping reached their highest levels since reporting MTF data. Past year use of other substances including sedatives, cigarettes, and non-prescribed opioids, however, revealed a 10-year decline for both age groups. According to NIDA director Dr. Nora Volkow, “Understanding these trends is a first step, and it is crucial that research continues to illuminate how substance use and related health impacts may change over time.”
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Perceptions of Safety of Daily Cannabis vs Tobacco Smoking and Secondhand Smoke Exposure, 2017-2021
JAMA Network Open
This study investigated perceived safety of cannabis vs. tobacco from 2017-2021 via daily smoking or secondhand exposure. The study found a significant shift in beliefs about the safety of daily smoking of cannabis vs. tobacco, with more than one-third reporting cannabis was safer than tobacco, and these numbers increased over time. Results were similar regarding secondhand cannabis smoke, with over 40% reporting it safer than secondhand tobacco smoke. Younger people and those who were unmarried were more likely to view cannabis as safer. A public health and regulatory response is therefore imperative to inform people of the known health risks associated with both daily cannabis smoking as well as secondhand exposure.
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Alcohol Intake and Blood Pressure Levels: A Dose-Response Meta-Analysis of Nonexperimental Cohort Studies 🔓
Hypertension
Employing a systematic search of longitudinal studies, the authors investigated links between blood pressure and alcohol intake. A considerable linear positive association was found between baseline alcohol intake and changes over time in both systolic blood pressure (SBP) and diastolic blood pressure (DBP). Average SBP was 1.25 and 4.90 mm Hg higher for 12 or 48 grams of alcohol compared with no drinking. The differences were for DBP were 1.14 and 3.10 mm Hg. There was no evidence of a threshold for this connection.
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Special Guest:
David E. Smith, MD, DFASAM
Editorial Referenced:
The Future of Psychedelic Therapy and Addiction Treatment ASAM Resources:
ASAM Clinical Guidelines
On-Demand Session: Psychedelics for Substance Use Disorders: Preparing for the Impending Paradigm Shift
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Lead Story
ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder for Individuals Using High-potency Synthetic Opioids 🔓
Journal of Addiction Medicine
This clinical considerations document is based on a narrative literature review and expert consensus and addresses considerations for changes to the clinical practice of treatment of opioid use disorder (OUD) with buprenorphine for individuals using high-potency synthetic opioids (HPSOs). Broadly, it suggests that individualized strategies for buprenorphine initiation may be needed. The experience of opioid withdrawal negatively impacts the success of buprenorphine treatment, and attention to withdrawal management before and during buprenorphine initiation should be proactively addressed. Buprenorphine dose and dosing frequency should be individualized based on patients’ treatment needs, the possibility of novel components in the drug supply should be considered during OUD treatment, and all forms of opioid agonist treatment should be offered and considered for patients.
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Lead Story:
Recommendations for Reducing the Risk of Cannabis Use-Related Adverse Psychosis Outcomes: A Public Mental Health-Oriented Evidence Review 🔓
Journal of Dual Diagnosis
As legal controls liberalize around cannabis, the authors reviewed the literature about links between cannabis use and psychosis to make recommendations for consumers, health professionals, and policy makers to decrease risk of developing psychosis symptoms. The authors provide 11 recommendations and the level of evidence for each. Recommendations based on the most substantial evidence of linkage to psychosis include: 1) avoid use in adolescence (<16), 2) avoid cannabis with high tetrahydrocannabinol (THC) concentration, 3) limit frequency of use, 4) avoid use if experiencing psychosis symptoms or receiving treatment, and 5) avoid use if one has other risk factors for developing psychosis.
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Why do we focus on the exception and not the rule? Examining the prevalence of mono- versus polysubstance use in the general population.
Addiction
Most literature on substance use disorders (SUD) is focused on single drug classifications and does not typically include polysubstance use (PSU), particularly in treatment studies where persons with PSU are often excluded. Using the National Survey on Drug Use and Health (NSDUH) from 2015 to 2019 this study assesses the prevalence of PSU versus mono-use patterns. They found that among those who reported use of at least one substance in the last year, the majority (64%) reported mono-use, primarily alcohol use (90%). However, among those with 2 or more diagnostic criteria for SUD, mono-use was much less frequent (26%) and even less frequent among those who sought care for SUD (22%). Given these findings the authors contend research should include those with PSU whenever possible and consideration of PSU should be part of clinical evaluations and treatment.
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Lead Story:
Questioning the Right to Pain Relief and Its Role in the Opioid Epidemic
Mayo Clinic Proceedings
The Harrison Act of 1914 helped establish opioids as specific painkillers that had a distinct capacity to induce addiction. This understanding of opioids as having distinct and separable analgesic and addictive potential was challenged by the 1970s discovery of an endogenous opioid system, which integrates pain and reward functions to support survival. Modern pain neurophysiology places the patient with pain in a passive position from which it makes sense to assert a right to pain relief. To prevent future opioid epidemics, the authors advocate for the abandonment of clinical outpatient use of pain intensity scores. They redefine the medical necessity of pain treatment as less about the reduction of pain intensity and more about the capacity to pursue personally valued activities.
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Xylazine effects on opioid-induced brain hypoxia
Psychopharmacology
Xylazine has emerged in recent years as an adulterant in an increasing number of opioid-positive overdose deaths in the United States. Although its exact role in opioid-induced overdose deaths is largely unknown, xylazine is known to depress vital functions and cause hypotension, bradycardia, hypothermia, and respiratory depression. This study examined the brain-specific hypothermic and hypoxic effects of xylazine and its mixtures with fentanyl and heroin in freely moving rats. It found that xylazine exacerbates the life-threatening effects of opioids, proposing worsened brain hypoxia as the mechanism contributing to xylazine-positive opioid-overdose deaths.
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Lead Story:
Psychedelics reopen the social reward learning critical period
Nature
Psychedelics have been used for millennia in both spiritual and medicinal contexts, and a number of recent clinical successes have spurred a renewed interest in developing psychedelic therapies. This study demonstrates in mice that the ability to reopen the social reward learning critical period is a shared property across psychedelic drugs. Notably, the time course of critical period reopening is proportional to the duration of acute subjective effects reported in humans. Furthermore, the ability to reinstate social reward learning in adulthood is paralleled by metaplastic restoration of oxytocin-mediated long-term depression in the nucleus accumbens. Finally, identification of differentially expressed genes in the ‘open state’ versus the ‘closed state’ provides evidence that reorganization of the extracellular matrix is a common downstream mechanism underlying psychedelic drug-mediated critical period reopening.
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Lead Story:
Reduced Stress-Related Neural Network Activity Mediates the Effect of Alcohol on Cardiovascular Risk
Journal of the American College of Cardiology
Chronic stress is associated with major adverse cardiovascular events (MACE) via increased stress-related neural network activity (SNA). Light/moderate alcohol consumption (ACl/m) has been linked to lower MACE risk, but the mechanisms are unclear. This study evaluated whether the association between ACl/m and MACE is mediated by decreased SNA. Individuals enrolled in the Mass General Brigham Biobank who completed a health behavior survey were studied. A subset underwent 18F-fluorodeoxyglucose positron emission tomography, enabling assessment of SNA. Alcohol consumption was classified as none/minimal, light/moderate, or high (14 drinks/week, respectively). ACl/m associates with reduced MACE risk, in part, by lowering the activity of a stress-related brain network known for its association with cardiovascular disease. Given alcohol’s potential health detriments, new interventions with similar effects on SNA are needed.
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Lead Story
Signaling-specific inhibition of the CB1 receptor for cannabis use disorder: phase 1 and phase 2a randomized trials
Nature Medicine
Cannabis use disorder (CUD) is widespread, and there is no pharmacotherapy to facilitate its treatment. AEF0117, the first of a new pharmacological class, is a signaling-specific inhibitor of the cannabinoid receptor 1 (CB1-SSi). AEF0117 selectively inhibits a subset of intracellular effects resulting from Δ9-tetrahydrocannabinol (THC) binding without modifying behavior per se. In mice and non-human primates, AEF0117 decreased cannabinoid self-administration and THC-related behavioral impairment without producing significant adverse effects. In healthy human volunteers with CUD, AEF0117 was well tolerated and did not precipitate cannabis withdrawal. These data suggest that AEF0117 is a safe and potentially efficacious treatment for CUD.
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Lead Story:
Ketamine versus ECT for Nonpsychotic Treatment-Resistant Major Depression
The New England Journal of Medicine
While electroconvulsive therapy (ECT) has been used for several years for treatment-resistant major depression, ketamine has been relatively recently approved. The authors conducted an open label, randomized, noninferiority trial with 403 patients to compare the effectiveness of ketamine to ECT. The ketamine was found to be noninferior to ECT for treatment response as reported by decrease in depressive symptoms. Further, both were associated with improved quality of life, but the ECT group did have a greater decline in memory performance. Of note, this trial excluded patients with major depression with psychosis, and previous studies have found that ketamine is inferior to ECT among those patients.
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Special Guests:
Ashish P. Thakrar and Jarratt D. Pytell
Article Referenced:
Ashish P. Thakrar, Jarratt D. Pytell, Kenneth B. Stoller, Vickie Walters, Roger D. Weiss, Geetanjali Chander, Transitioning off methadone: A qualitative study exploring why patients discontinue methadone treatment for opioid use disorder, Journal of Substance Use and Addiction Treatment, Volume 150, 2023, 209055, ISSN 2949-8759.
ASAM Resources:
2020 National Practice Guideline for the Treatment of Opioid Use Disorder
OUD Treatment Education
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Lead Story
Increasing overdose deaths among Black Americans: a review of the literature
The Lancet Psychiatry
This scoping review analyzed the many and varied factors contributing to the recent rise in opioid overdose death rates among Black Americans. Differences in structural and social determinants of health; unequal access, use, and continuity of SUD and harm reduction services; variability in fentanyl exposure and risk; and changes in social and economic conditions were all found to play a role. Black Americans historically are less likely to have access to treatment services than White Americans. Work to reform the criminal legal system, expand access, address provider bias, and fund equity-improving programs need to happen to affect change.
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Lead Story
The glucagon-like peptide-1 (GLP-1) analogue semaglutide reduces alcohol drinking and modulates central GABA neurotransmission
JCI Insight
Evidence suggests that the glucagon-like-peptide-1 (GLP-1) system may be involved in the neurobiology of addiction. The authors studied the impact of semaglutide, a long acting GLP-1 analogue, on alcohol use in mice and rat models and found a decrease in binge-like alcohol drinking in both mice and rats. They also found reduced alcohol intake in rates with dependence. The proposed mechanism for this effect is modulation of central GABA neurotransmission and supports the potential role of the GLP-1 system as a potential pharmacotherapeutic target for alcohol use disorder.
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Lead Story
Racial Inequality in Receipt of Medications for Opioid Use Disorder
The New England Journal of Medicine
Opioid overdose mortality has increased over the last ten years, but disproportionately among Black persons. The authors examine racial disparities in receipt of buprenorphine and naloxone after opioid use disorder (OUD) related events using Medicare data from 2016-2019. They found that Black persons were less likely to receive buprenorphine (12.7 vs 23.3%) and naloxone (14.4% vs 22.9%) than White persons within six months after the event. Further, Black persons received lower day supply of buprenorphine and were less likely to be retained on treatment. Of note, Black and White persons had similar rates of ambulatory visits in the 6 months after the event, indicating patient and provider-level barriers to access.
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Lead Story:
Eat, Sleep, Console Approach or Usual Care for Neonatal Opioid Withdrawal
The New England Journal of Medicine
This multicenter randomized controlled trial was undertaken to evaluate the the Eat, Sleep, Console Care Tool vs usual care for neonatal opioid withdrawal with the primary outcome being medically ready for hospital discharge. The Eat, Sleep, Console Care Tool relies on an assessment of withdrawal severity focused on an infant’s ability to eat, sleep, and be consoled, along with the use of nonpharmacologic interventions as first line of treatment. The Eat, Sleep, Console care approach decreased the time until infants with opioid withdrawal were medically ready for discharge by a mean of 6.7 days, and the proportion of infants receiving pharmacologic treatment by 32.5%. Hence, this approach facilitates more judicious use of medication for these infants.
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Article Referenced:
Noel, Marnie PharmD, BCPP; et all. The Howard Street Method: A Community Pharmacy-Led Low Dose Overlap Buprenorphine Initiation Protocol for Individuals Using Fentanyl. Journal of Addiction Medicine.
ASAM Resources:
2020 National Practice Guideline for the Treatment of Opioid Use Disorder
OUD Treatment Education
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Lead Story
Subtypes in addiction and their neurobehavioral profiles across three functional domains
Translational Psychiatry
Over two-thirds of the 40.3 million people in the U.S. who have a substance use disorder (SUD) return to use within weeks to months of initiating treatment, and up to 85% of individuals return to substance use within one year of treatment completion. This study hypothesized that considerable individual differences exist in the three functional domains underlying addiction — approach-related behavior, executive function, and negative emotionality. Results support functionally derived subtypes, demonstrating considerable individual heterogeneity in the multi-dimensional impairments in addiction. This confirms the need for mechanism-based subtyping to inform the development of personalized addiction medicine approaches.
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Lead Story:
The conserved endocannabinoid anandamide modulates olfactory sensitivity to induce hedonic feeding in C. elegans
Current Biology
Laboratory worm Caenorhabditis elegans apparently gets the ‘munchies’ when exposed to cannabis. After soaking in an endocannabinoid bath, worms preferred to eat nutrient-rich, rather than nutrient-poor, bacteria. They fed for longer than worms not exposed to endocannabinoid or worms without working endocannabinoid receptors. This shared trait points to the deep evolutionary origin of cannabinoid receptors and behaviors influenced by the molecules.
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Opioid Prescribing and Suicide Risk in the United States
The American Journal of Psychiatry
Approximately 40% of overdose suicide deaths in the United States involve opioids. Because of their respiratory depression effects and narrow therapeutic window, opioids pose a greater risk than any other drug class of an intentional overdose proving to be lethal. In this retrospective study of US commuting zone–level opioid prescriptions and mortality, regional decreases in opioid prescriptions were consistently associated with declines in total suicide deaths, including suicide overdose deaths involving opioids. For some opioid prescribing measures, negative associations were observed with unintentional overdose deaths involving opioids among younger people. Individual-level inferences are limited by the ecological nature of the analysis.
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Lead Story
Association Between Daily Alcohol Intake and Risk of All-Cause Mortality
JAMA Network Open
This updated systematic review and meta-analysis investigated the association between alcohol use and all-cause mortality. Among occasional (>0 to
Lead Story:
Shared genetic liability for alcohol consumption, alcohol problems, and suicide attempt: Evaluating the role of impulsivity
Translational Psychiatry
This study investigated the extent to which shared liability for alcohol consumption and problems (ACP) and suicide attempt (SA) is genetically related to five dimensions of impulsivity. Common genetic liability to ACP and SA was significantly correlated with all five impulsive personality traits examined, and the largest correlation was with lack of premeditation, though supplementary analyses suggested that these findings were potentially more strongly influenced by ACP than SA. These analyses have potential implications for screening and prevention: Impulsivity can be comprehensively assessed in childhood, whereas heavy drinking and suicide attempt are quite rare prior to adolescence. Features of impulsivity may serve as early indicators of genetic risk for alcohol problems and suicidality.
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Lead Story:
Multivariate genome-wide association meta-analysis of over 1 million subjects identifies loci underlying multiple substance use disorders
Nature Mental Health
Recent large-scale genome-wide association studies (GWASs) show that the genetic architecture of substance use disorders (SUDs) is characterized by a high degree of commonality, i.e., a general addiction genetic factor likely conveys vulnerability to multiple SUDs. Genetic liability to substance use disorders can be parsed into loci that confer general or substance-specific addiction risk. This is a multivariate genome-wide association meta-analysis that disaggregates general and substance-specific loci from published summary statistics of SUDs. Findings provide insight into genetic risk loci for substance use disorders that could be leveraged as treatment targets.
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Special Guest:
Lewis S. Nelson, MD
Article Referenced:
R.J. Strayer et al., EMERGENCY DEPARTMENT MANAGEMENT OF PATIENTS WITH ALCOHOL INTOXICATION, ALCOHOL WITHDRAWAL, AND ALCOHOL USE DISORDER: A WHITE PAPER PREPARED FOR THE AMERICAN ACADEMY OF EMERGENCY MEDICINE, Journal of Emergency Medicine, https://doi.org/10.1016/j.jemermed.2023.01.010
ASAM Resources:
The ASAM Clinical Practical Guideline on Alcohol Withdrawal Management
Alcohol Withdrawal Management Pocket Guide
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Lead Story:
Human brain effects of DMT assessed via EEG-fMRI
PNAS
Interest in psychedelics as potential treatment for depression has increased. In this study, researchers examine the effects of N,N-Dimethyltryptamine (DMT) on brain function using electroencephalography (EEG) and functional MRI (fMRI). The study found a dysregulating effect on activity in the transmodal association pole (TOP) an area with high expression of serotonin 2A receptors (5-HT2AR). The authors also found increased communication between TOP and the rest of the brain, which may be evidence of increased information processing and hyperassociative cognition. They were able to correlate their findings through simultaneous EEG, fMRI, and symptom reports from participants.
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Characteristics of Fatal Poisonings Among Infants and Young Children in the United States
Pediatrics
Child death reviews present an opportunity to improve understanding of fatal poisonings. This study employed the National Fatality Review-Case Reporting System (NFR-CRS), a national standardized reporting tool, to describe the demographics of childhood deaths by poisoning, identify associated factors, and characterize those deaths attributable to opioids. Opioids were the most common substance (47.3%) contributing to death in young children, followed by OTC pain, cold, and allergy medications (14.8%). There was a substantial rise in these opioid-involved deaths over time, from 24.1% of the substances contributing to deaths in 2005 compared with 52.2% in 2018, illustrating the impact of the opioid epidemic on young children. Opportunities for naloxone education are paramount.
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Synthesising evidence of the effects of COVID-19 regulatory changes on methadone treatment for opioid use disorder: implications for policy
The Lancet Public Health
In this review article, methadone take-home dosing considerations during the COVID-19 pandemic were examined. A search of published research on the flexibility of these practices, patient-provider experience, health outcomes, and how these findings might influence updated regulations was performed. The review found no evidence of increased methadone overdose risk as a result of greater pandemic flexibility. Benefits of such policy include potentially improved treatment retention and impressive improvements in patient quality of life. This is key for SAMHSA as it ponders the steps to make these flexibilities permanent.
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Not all vaping is the same: differential pulmonary effects of vaping cannabidiol versus nicotine
Thorax
This in vivo inhalation study in mice and in vitro cytotoxicity experiments with human cells assessed the pulmonary damage-inducing effects of cannabidiol (CBD) or nicotine aerosols emitted from vaping devices. Inhalation of CBD aerosol resulted in greater inflammatory changes, more severe lung damage, and higher oxidative stress compared with nicotine. CBD aerosol also showed higher toxicity to human cells compared with nicotine.
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The Howard Street Method: A Community Pharmacy-Led Low Dose Overlap Buprenorphine Initiation Protocol for Individuals Using Fentanyl
Journal of Addiction Medicine
Concerns about precipitated withdrawal can be a barrier for patients initiating buprenorphine. This case series examined the implementation of buprenorphine low dose overlap initiation (LDOI) utilizing a community pharmacy. A blister pack was provided with a 7-day titration schedule increasing from 0.5 mg to 4 mg daily. Of the twenty-six patients who started treatment, fourteen completed the protocol with 79% reporting no withdrawal symptoms and 21% reporting only mild symptoms. At thirty days of follow-up, 71% were still receiving buprenorphine, and at 180 days 43% were retained in care but only 14% were still receiving buprenorphine. The study suggests that this community-based pharmacy approach is novel and may offer a new way to initiate buprenorphine in high-risk populations.
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The Use of Opioids in the Management of Chronic Pain: Synopsis of the 2022 Updated U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline
Annals of Internal Medicine
The VA, along with the Department of Defense, recently approved an updated guideline regarding the management of chronic pain with opioids (updated from the 2017 version). This includes considerations regarding initiation and continuation of therapy; dose, duration, and taper of opioids; screening, assessment, and evaluation; and risk mitigation. A new recommendation for patients receiving chronic opioid therapy is using buprenorphine in place of full agonists due to its lower risk of overdose and misuse. Other new recommendations suggest screening for additional psychiatric comorbidities that could increase risk and screening for pain catastrophizing.
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State Cannabis Legalization and Psychosis-Related Health Care Utilization
JAMA Network
Psychosis has long been considered a potential consequence of cannabis use. In this retrospective cohort study, the association of state cannabis legalization with psychosis-related health care claims among some 63,680,589 privately insured individuals were investigated. There were 7,503,907 psychosis-related diagnoses and 20,799,285 prescriptions filled for antipsychotics over the study period. State medical and recreational cannabis policies were not found to be associated with a statistically significant increase in rates of psychosis-related health outcomes.
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Buprenorphine Dispensing Among Youth Aged ≤19 Years in the United States: 2015–2020
Pediatrics
Opioid related overdose among adolescents and young adults in the United States is rising. Medications for opioid use disorder (MOUD), including buprenorphine, can reduce the risk of overdose; however, they are underutilized. Given rates of opioid use disorder (OUD) among youth, these findings suggest that many young people who could benefit from MOUD are not receiving it. Pediatricians could play a role in expanding access to MOUD for this high-risk population. Efforts to expand access to MOUD for adolescents could include improving pediatrician training in OUD treatment and encouraging all clinicians who care for adolescents and young adults to prescribe buprenorphine for MOUD.
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Trends and Characteristics of Buprenorphine-Involved Overdose Deaths Prior to and During the COVID-19 Pandemic
JAMA Network Open
Questions remain about emergency authorizations permitting telehealth services for buprenorphine, and whether these measures resulted in overdose deaths involving buprenorphine. This cross-sectional study examined 74,474 opioid-involved overdose deaths in 46 states and the District of Columbia prior to and during COVID-19. From July 2019-June 2021 there was a total of 89,111 total overdose deaths and 74,474 opioid-involved overdose deaths; buprenorphine was involved in 1,955 deaths, 2.2% of all drug overdose deaths and 2.6% of opioid-involved overdose deaths. Of these, a higher proportion were female, non-Hispanic White, and lived in rural areas. While opioid-involved overdose deaths increased during this period, those involving buprenorphine did not increase.
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Availability of best practices for opioid use disorder in jails and related training and resource needs: findings from a national interview study of jails in heavily impacted counties in the U.S.
Health & Justice
This study investigated OUD best practices in US jails in those counties heavily impacted by overdose. Core best practice domains included screening, clinical assessment by qualified treatment provider, medically managed withdrawal, medication for opioid use disorder (MOUD) administration, services for pregnant women, counseling/wrap-around services, collaboration with community MOUD providers, assistance with Medicaid/insurance coverage, re-entry services, and overdose prevention. Some 92% reported some MOUD availability, but only 20% provided it to persons assessed with OUD. Best practices were more common in counties with larger populations, a higher percentage of Hispanic residents, fewer people living below the poverty line, and fewer jail admissions. A number of challenges including MOUD funding, training, and addressing stigma were reported. This study highlights the impact of lost opportunities for reducing disease, death, and recidivism that result from the lack of greater MOUD availability and accessibility.
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Postoperative Restrictive Opioid Protocols and Durable Changes in Opioid Prescribing and Chronic Opioid Use
JAMA Oncology
This prospective cohort study investigated whether postsurgical acute pain using a restrictive opioid prescription protocol (ROPP) of 3 days or less after discharge would result in reduced opioid use. Mean opioid prescribing days decreased from a mean (SD) of 3.9 (4.5) days in the pre-ROPP group to 1.9 (3.6) days in the post-ROPP group (P
A neuromarker for drug and food craving distinguishes drug users from non-users
Nature Neuroscience
Functional MRI images were obtained while subjects were exposed to visual cues for drugs and palatable foods and asked to rate their level of craving. Subjects were individuals who use drugs (cigarette users=21, alcohol users=17, and cocaine users n=21) and matched controls (n=40). Machine learning was used to identify a pattern of neural activation associated with craving, the Neurobiological Craving Signature (NCS), that extended throughout the brain including areas such as the parietal and temporal areas and cerebellum, not usually associated with craving. The same NCS was found for food and drugs indicating the similarity of these cravings. NCS response to drug cues was able to identify individuals who use drugs with an 82% accuracy. The authors suggest that the NCS has promise for diagnosing SUD as well as measuring responses to treatment.
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The ASAM Weekly's most read news items from 2022 were as follows:
On ‘Last Week Tonight,’ John Oliver Takes on the Nation’s Dumbest Drug Myth
Rolling Stone
High-dose drug treats fentanyl overdose, if you can get it
New Haven Register
A man who lost 80 pounds on a 'game changer' weight-loss drug also lost his desire to drink alcohol. Experts say the drug could be a treatment for addiction.
MSN/Insider
The Next Big Addiction Treatment
The New York Times
What Is Delta-8, and Why Is It So Popular?
The New York Times
Can a monthly injection be the key to curbing addiction? These experts say yes
Los Angeles Times
They Call It ‘Tranq’ — And It’s Making Street Drugs Even More Dangerous
KHN
Medication for Drinking Addiction May Thwart Liver Disease
MedPage Today
The Most Important Question About Addiction
The New York Times
Gabapentin's link to fatal drug overdoses draws concern
UPI News
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Defining Recovery From Alcohol Use Disorder: Development of an NIAAA Research Definition
The American Journal of Psychiatry
The authors present a newly developed National Institute on Alcohol Abuse and Alcoholism (NIAAA) definition of recovery from the DSM-5 diagnosis of alcohol use disorder (AUD). This definition views recovery as a process of behavioral change and an outcome, incorporating two key components of recovery: remission from DSM-5 AUD and cessation from heavy drinking, a non-abstinent recovery outcome. It also emphasizes the importance of biopsychosocial functioning and quality of life in enhancing outcomes. By adopting a uniform definition, researchers and health care professionals can more precisely operationalize and measure recovery-related processes.
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Genetic diversity fuels gene discovery for tobacco and alcohol use
Nature
This study leverages global genetic diversity across 3.4 million individuals from four major clines of global ancestry to power the discovery and fine-mapping of genomic loci associated with tobacco and alcohol use, to inform function of these loci via ancestry-aware transcriptome-wide association studies, and to evaluate the genetic architecture and predictive power of polygenic risk within and across populations. The authors found that increases in sample size and genetic diversity improved locus identification and fine-mapping resolution, and that a large majority of the associated variants showed consistent effect sizes across ancestry dimensions. However, polygenic risk scores developed in one ancestry performed poorly in others, highlighting the continued need to increase sample sizes of diverse ancestries to realize any potential benefit of polygenic prediction.
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Buprenorphine versus Methadone for Opioid Use Disorder in Pregnancy
The New England Journal of Medicine
This cohort study involving pregnant persons in the US from 2000-2018 found that buprenorphine treatment for opioid use disorder during pregnancy was associated with more favorable neonatal outcomes than methadone treatment. Neonatal abstinence syndrome occurred in 69% of the infants exposed to methadone as compared with 52% of those exposed to buprenorphine in the 30 days before delivery. An inverse association was also observed between buprenorphine exposure (as compared with methadone exposure) and preterm birth, regardless of whether exposure occurred in early or late pregnancy in both the unadjusted and adjusted analyses. Inverse associations were also observed between buprenorphine exposure (as compared with methadone exposure) and small size for gestational age and low birth weight.
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Increased vulnerability to atrial and ventricular arrhythmias caused by different types of inhaled tobacco or marijuana products
Heart Rhythm
This study investigated the cardiovascular effects of exposure to tobacco smoke, vape aerosol, heated tobacco products, marijuana smoke, THC free marijuana, or air (placebo control). Rats were exposed to a single 5 minute session 5 days a week for 2 months. This exposure was judged to be similar to a single smoking or vaping session a day. Left ventricular dilation and reduction in LV ejection fraction was seen in all non-air groups along with reduction in heart rate variability. Both atrial fibrillation and ventricular tachycardia were more easily induced in all non-air groups. Decrease in microvessel density and severe interstitial fibrosis was seen on histology from all non-air groups. The authors conclude that all tobacco products (including vaping) and marijuana carry substantial risk of cardiac disease.
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Concurrent use of opioids and stimulants and risk of fatal overdose: A cohort study
BMC Public Health
The authors note a dramatic increase in the use of methamphetamine in people with OUD and an increased presence of a stimulant in opioid toxicity deaths. A random sample of 20% of persons in the overdose registry of the Province of British Columbia, Canada, was selected for years 2010 to 2018. Persons who used opioids, stimulants, or both (n=7460) were identified by ICD codes and fatal overdose events determined from coroners’ data. People using both opioids and stimulants had twice the risk of fatal overdose compared to those using opioids only (HR=2.02, p
Single-Dose Psilocybin for a Treatment-Resistant Episode of Major Depression
NEJM
Results of a phase II trial testing the psychedelic compound in magic mushrooms as a treatment for depression have found that the drug psilocybin is effective, but not to the extent that earlier, smaller studies had suggested. The proportion of participants in remission after treatment dropped over time, raising questions about its durability and whether additional doses would be helpful. Among adults with treatment-resistant depression, a single dose of 25 mg of psilocybin, but not 10 mg, reduced depression severity significantly more than a 1-mg dose at 3 weeks. The trial did not compare psilocybin with existing treatments for depression and persons who were judged to be at a clinically significant risk for suicide were excluded from the trial.
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Estimated Deaths Attributable to Excessive Alcohol Use Among US Adults Aged 20 to 64 Years, 2015 to 2019
JAMA Network Open
This cross-sectional study sought to estimate the mean annual number of deaths from excessive alcohol use relative to total deaths among adults 20 to 64 years of age. Alcohol-attributable deaths accounted for an estimated 20.3% of total deaths among adults 20 to 49 years of age. By state, alcohol-attributable deaths ranged from 9.3% of total deaths in Mississippi to a high of 21.7% in New Mexico. Findings suggest that alcohol-attributable deaths were responsible for 1 in 8 deaths among adults 20 to 64 years of age, and 1 in 5 deaths among adults 20 to 49 years of age. The authors suggest that these death rates could be reduced with increased implementation of evidence-based policies, such as increasing alcohol taxes or regulating alcohol outlet density.
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Association Between Smoking, Smoking Cessation, and Mortality by Race, Ethnicity, and Sex Among US Adults
JAMA Network Open
Using data from the U.S. National Health Interview Survey, this study looked at the association, by race, ethnicity, and sex, of cigarette smoking and cessation with all-cause/cause-specific mortality. Comparing those who quit smoking before age 45 years with never-smokers, all-cause mortality rate ratios (RRs) were noted in the following groups: 1.15 Hispanic, 1.16 non-Hispanic Black, 1.11 non-Hispanic White, and 1.17 other non-Hispanic persons. Current smoking was associated with substantial excess mortality in all groups. Quitting smoking before age 45 years was associated with close to 90% reduction in the excess mortality risk associated with continued smoking; quitting at ages 45-64 years was associated with a 66% risk reduction irrespective of race and ethnicity.
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Physician Health Care Visits for Mental Health and Substance Use During the COVID-19 Pandemic in Ontario, Canada
JAMA Network Open
With the emergence of the COVID-19 pandemic, physicians face specific occupational stressors, including a potentially greater risk of exposure to SARS-CoV-2, with consequent concerns over personal health and infecting family, friends, and colleagues; inadequate personal protective equipment; rapid practice changes including loss of income; and high, and at times overwhelming, workloads. In this population-based cohort study of 34,055 physicians in Ontario, Canada, the rate of outpatient visits for mental health and substance use increased on average by 13% per physician during the first 12 months of the pandemic compared with the prior 12 months. These findings suggest that the COVID-19 pandemic is associated with greater mental health services use among physicians.
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National trends of suicidal ideation and mental health services use among US adults with opioid use disorder, 2009–2020
eClinicalMedicine
National Survey on Drug Use and Health (NSDUH) data were used to examine trends in suicidal ideation (SI) between 2009 and 2020 among adults aged 18 or older with OUD. From 2009 to 2020, the prevalence of individuals with OUD who reported SI increased significantly from 22.8% to 29.8%. The subgroups with the most significant changes included young adults, females, non-Hispanic whites, working full-time, individuals with Medicaid, living in a large metropolitan areas, and having another SUD. Among those with past-year OUD, over half with SI reported needing mental health treatment in the past year but not receiving it.
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Association Between Buprenorphine Treatment Gaps, Opioid Overdose, and Health Care Spending in US Medicare Beneficiaries With Opioid Use Disorder
JAMA Psychiatry
In this case-control study of 34,505 Medicare beneficiaries, patients had greater risk of experiencing an opioid overdose and higher health care expenditures in buprenorphine treatment gap months compared with treated months. Buprenorphine nonadherence is associated with an increased risk of opioid overdose and higher health care spending in Medicare.
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Impact of Administering Buprenorphine to Overdose Survivors Using Emergency Medical Services
Annals of Emergency Medicine
Initiation of buprenorphine in emergency departments (EDs) after opioid overdose is increasing, but many patients seen by emergency medical services (EMS) in the field refuse transport to the ED or leave the ED prior to evaluation. This study evaluated a program in which EMS was able to provide buprenorphine to patients in the field after opioid overdose, along with a same or next-day appointment in a substance use disorder clinic. Patients evaluated by EMS units with buprenorphine were significantly more likely to engage in treatment within 30 days (OR 5.62) than those evaluated by non-buprenorphine units. In addition, those evaluated by EMS units with buprenorphine who received buprenorphine were significantly more likely to engage in treatment (OR 12.83) than those who did not. There were no significant differences in subsequent opioid overdoses between groups.
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Estimating the Prevalence of Substance Use Disorders in the US Using the Benchmark Multiplier Method
JAMA Psychiatry
In this cross-sectional study, using the benchmark multiplier method and Medicaid administrative data in combination with data from the National Survey on Drug Use and Health for 2018 and 2019, the 12-month prevalence estimates of alcohol use disorder, cannabis use disorder, opioid use disorder, and stimulant use disorder were higher than estimates from the National Survey on Drug Use and Health. The findings suggest that the prevalence of substance use disorders may be considerably higher than National Survey on Drug Use and Health estimates indicate.
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Association of State Child Abuse Policies and Mandated Reporting Policies With Prenatal and Postpartum Care Among Women Who Engaged in Substance Use During Pregnancy
JAMA Pediatrics
Certain states have enacted policies that consider substance use during pregnancy as child abuse. In this cross-sectional study of 4,155 pregnant women who engaged in substance use during pregnancy, 33.9% delivered in states with a child abuse policy only, 16.4% in states with a mandated reporting policy only, 32.9% in states with both policies, and 16.8% in states with neither policy. Women who delivered in states with a child abuse policy only, mandated reporting policy only, or both policies initiated prenatal care later, with a reduced chance for adequate prenatal and postnatal care compared with women who delivered in states without these policies. Such policies may deter pregnant people who engage in substance use from receiving the essential care and treatment they deserve.
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Association of Mental Health Burden With Prenatal Cannabis Exposure From Childhood to Early Adolescence
JAMA Pediatrics
In this study, the authors credit longitudinal data from the Adolescent Brain Cognitive Development (ABCD) study and investigate whether associations with psychopathology last into early adolescence and past middle childhood. Prenatal Cannabis Exposure (PCE) was found to be associated with lasting vulnerability to psychopathology throughout early adolescence, and this did not change with age. Evidence that the impact of PCE on psychopathology does not improve as children enter adolescence is further warning against the use of this substance in pregnancy.
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Thirty Years of The ASAM Criteria: A Report Card
Psychiatric Clinics of North America
The ASAM Criteria® – the sophisticated system for organizing treatment services and settings with patient care decision rules – defined the infrastructure of addiction care, the types and intensity of treatment, staffing, and service provision for each level of care. For more than 30 years, this led to a national standard in addiction treatment and a leadership role in behavioral health. Beyond the ASAM Criteria, there is ASAM CONTINUUMTM software and the ASAM–CARF Level of Care (LOC) Certification Program, affording a common language and process for improving care. The authors have constructed a report card given the history of the Criteria, with plans for improvement.
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Receipt of Telehealth Services, Receipt and Retention of Medications for Opioid Use Disorder, and Medically Treated Overdose Among Medicare Beneficiaries Before and During the COVID-19 Pandemic
JAMA Psychiatry
During the COVID-19 pandemic, emergency authority allowed expanded telehealth services for MOUD as well as increased take home doses of methadone at OTPs. This study used data from the US Centers for Medicare & Medicaid Services regarding telehealth services for OUD, retention in treatment, and medically treated overdoses. Telehealth services for OUD increased significantly during the pandemic to 20% of beneficiaries compared to 0.6% prepandemic. Receipt of telehealth services was associated with increased MOUD retention (aOR 1.27) and reduced medically treated overdose (aOR 0.67). MOUD (mostly methadone) from an OTP increased during the pandemic to 4.0% from 1.4% prepandemic. The authors conclude that the improved retention and decrease in overdoses associated with telehealth support making these emergency changes permanent.
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Marijuana and hallucinogen use among young adults reached all time-high in 2021
NIDA
2021 MONITORING THE FUTURE PANEL STUDY ANNUAL REPORT
Monitoring the Future
Since 1975, the Monitoring the Future study has annually surveyed substance use behaviors and attitudes among a nationally representative sample of teens. As reported by young adults, marijuana and hallucinogen use in the past year increased significantly in 2021, reaching historic highs in this age group since 1988. Rates of past-month nicotine vaping also continued their general upward trend in 2021, despite leveling off in 2020. Past-month marijuana vaping rebounded to pre-pandemic levels in 2021. Alcohol remains the most used substance among adults in the study. Binge drinking (five or more drinks in a row in the past two weeks) rebounded in 2021 from a historic low in 2020, during the early stages of COVID-19 pandemic. In 2021, high-intensity drinking (having 10 or more drinks in a row in the past two weeks) reached its highest level ever recorded since first measured in 2005.
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Longitudinal Assessments of Neurocognitive Performance and Brain Structure Associated With Initiation of Tobacco Use in Children, 2016 to 2021
JAMA Network Open
Data from the Adolescent Brain and Cognitive Development (ABCD) study was analyzed to assess impact of early initiation (
Adolescent Use of Flavored Non-Tobacco Oral Nicotine Products
Pediatrics
Prevalence of non-tobacco oral nicotine product use among adolescents is unknown. This study calculated prevalence of ever and past 6-month use of nicotine pouches, other non-tobacco oral nicotine products, e-cigarettes, cigarettes, hookah or waterpipe, cigars, cigarillos, and snus among high school students in Southern California between September and December 2021. Generalized linear mixed models tested associations of sociodemographic factors and tobacco-product use with use of any non-tobacco oral nicotine product. Flavored non-tobacco oral nicotine products were the second most prevalent nicotine product used by adolescents in Southern California. They were disproportionately used by certain racial and ethnic, sexual, or gender minority groups and those with a history of nicotine use.
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Impact of COVID-19 Telehealth Policy Changes on Buprenorphine Treatment for Opioid Use Disorder
American Journal of Psychiatry
This was a national retrospective cohort study with interrupted time-series analyses that examined the impact of policy changes in March 2020 on buprenorphine treatment for OUD in the Veterans Health Administration, during the year before the start and during the first year of the COVID-19 pandemic. Also examined were trends in the use of telephone, video, and in-person visits for buprenorphine treatment and a comparison of patient demographic characteristics and retention in buprenorphine treatment across the two periods. The number of patients receiving buprenorphine continued to increase after the COVID-19 policy changes, but the delivery of care shifted to telehealth visits, suggesting that any reversal of COVID-19 policies must be carefully considered.
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Associations of cannabis potency with mental ill health and addiction: a systemic review
The Lancet Psychiatry
Cannabis potency, defined as the concentration of Δ9-tetrahydrocannabinol (THC), has increased internationally, which could increase the risk of adverse health outcomes for cannabis users. This is the first systematic review of the association of cannabis potency with mental health and addiction. Overall, use of higher potency cannabis, relative to lower potency cannabis, was associated with an increased risk of psychosis and Cannabis Use Disorder (CUD). Evidence varied for depression and anxiety. The association of cannabis potency with CUD and psychosis highlights its relevance in health-care settings and for public health guidelines and policies on cannabis sales. Standardization of exposure measures and longitudinal designs are needed to strengthen the evidence of this association.
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Drug Overdose Deaths, by Selected Sociodemographic and Social Determinants of Health Characteristics — 25 States and the District of Columbia, 2019–2020 🔓
CDC Morbidity and Mortality Weekly Report
This CDC report shows that as overdose deaths exploded during the pandemic, racial disparities widened. Specifically, while overall overdose deaths increased by 30% from 2019 to 2020, rates spiked much more among Black, American Indian, and Alaska Native populations than among white, Asian/Pacific Islander, and Hispanic people. Overdose deaths had been rising for decades before the pandemic, and they continued to climb into 2021, reaching more than 107,000 that year. Disparities were emerging in the pre-pandemic years and are expected to keep growing without concentrated efforts to stem them. Not surprisingly, the deaths were broadly driven by illicit fentanyl, though deaths attributed to other drug types, including stimulants like methamphetamine, have also been rising in recent years. The vast majority of people who died did not have evidence of past treatment for substance use disorder. White people who died appeared to have higher rates of treatment than people of other races and ethnicities.
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Preaddiction—A Missing Concept for Treating Substance Use Disorders
JAMA Psychiatry
This opinion piece calls for intervention with mild to moderate SUD (as defined by DSM V) to interrupt the progression to severe SUD. They suggest the term preaddiction, similar to the concept of prediabetes. Engaging the public in screening and intervening with prediabetes has succeeded in halting progression. For SUD, existing interventions, such as screening and brief intervention and computerized cognitive behavioral therapy could be used. However, they expect a range of medications and social support services will also be needed. It will be necessary for medical and nursing schools to teach recognition and management of SUDs and for there to be adequate reimbursement for these interventions. The example of prediabetes demonstrates that an early intervention program can be effective.
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Laws for expanding access to medications for opioid use disorder: a legal analysis of 16 states & Washington D.C
The American Journal of Drug and Alcohol Abuse
This qualitative analysis identified and categorized state MOUD-related statutes and regulations in a random sample of four geographic locations covering 16 states and Washington D.C. The policies that appear to expand MOUD access fall within six policy domains: 1) expanding the availability of waivered buprenorphine providers, 2) expanding MOUD awareness, 3) criminal justice, 4) licensed SUD facilities, 5) insurers, and 6) hospitals. Some states appear to have taken more substantial policy efforts than others toward MOUD expansion, rather than conducting needs assessments or expanding educational opportunities for patients/providers. The authors identified several frontiers where laws are changing in ways that could potentially translate to better access to care.
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Reducing opioid use disorder and overdose deaths in the United States: A dynamic modeling analysis
Science Advances
Since 1999, nearly 650,000 Americans have died of an opioid overdose. More than half of these deaths have occurred since 2016 due to increasing misuse of prescription opioids, followed by heroin, and now synthetic opioids such as illicitly manufactured fentanyl. This study used a system dynamics simulation model of the US opioid-using population age 12 and older to explore the impacts of 11 strategies on the prevalence of opioid use disorder (OUD) and fatal opioid overdoses from 2022 to 2032. By 2032, three strategies saved the most lives: (i) reducing the risk of opioid overdose involving fentanyl use, which may be achieved through fentanyl-focused harm reduction services; (ii) increasing naloxone distribution to people who use opioids; and (iii) recovery support for people in remission, which reduced deaths by reducing OUD.
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Long-term Risk of Overdose or Mental Health Crisis After Opioid Dose Tapering 🔓
JAMA Network Open
In this cohort study, 19,377 patients experienced opioid dose tapering from 2008 to 2017; this, after a 12-month baseline period of stable daily dosing of 50 morphine milligram equivalents or higher. The authors hypothesized that tapered patients would have reduced rates of study outcomes during the postinduction period. However, rates of withdrawal, overdose, and mental health crises each increased significantly in the postinduction period. These findings suggest that elevated risks of overdose and mental health crisis may persist for up to 2 years after taper initiation. Patients prescribed higher doses may benefit from more intensive support and monitoring, particularly for depression and suicidality.
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Brain lesions disrupting addiction map to a common human brain circuit 🔓
Nature Medicine
In rare cases, regional brain damage can lead to addiction remission. These cases may be used to identify therapeutic targets for neuromodulation. This study analyzed two cohorts of patients addicted to smoking at the time of focal brain damage. Associations with addiction remission were identified. Lesions disrupting smoking addiction occurred in many different brain locations but were characterized by a specific pattern of brain connectivity. This pattern involved positive connectivity to the dorsal cingulate, lateral prefrontal cortex, and insula and negative connectivity to the medial prefrontal and temporal cortex. This circuit was reproducible across independent lesion cohorts, associated with reduced alcohol addiction risk, and specific to addiction metrics. Hubs in this circuit provide testable targets for therapeutic neuromodulation.
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Lead Story: Modeling the Evolution of the US Opioid Crisis for National Policy Development 🔓
From: Proceedings of the National Academy of Sciences
Delays between enaction of policy and data about the impact of the policy on drug-use behavior, as well as the complexity of other factors that influence drug-use behaviors, can make policy decision making difficult. To assist policy makers, the authors created a model utilizing data between 1999 and 2020 to understand historical use patterns and to project future scenarios. In testing, the model was able to closely replicate historical trajectories and had good model fit for various scenarios. While the model has some limitations -- notably it does not address co-occurring stimulant use -- it does potentially provide a resource for policy makers in projecting future use patterns and policy analysis.
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Show Notes for Tuesday, June 7, 2022
Lead Story: Daily E-cigarette Use and the Surge in JUUL Sales: 2017–2019 🔓
From: Pediatrics
This study identified how the 2017 rapid surge in sales of JUUL e-cigarettes affected usage among US youth and young adults. For 5 age groups, it compared 2-year incidence of first tobacco use and of new-onset daily tobacco use by product, and report levels of dependence. Sociodemographic variables and rates of experimentation with any tobacco product were similar between cohorts. About 600 000 Americans aged
Getting to the Heart of Cannabis Health Risks
Cell Press
Cannabis has deleterious effects on cardiovascular physiology. Wei et al. (Cell 185, May 12, 2022) confirm that important inflammatory markers increase transiently after a single marijuana joint and prove a mechanistic link between THC induced vascular inflammation, endothelial dysfunction, cellular oxidative stress, and atherosclerosis using cell-based and mouse models of atherosclerosis. They provide a pharmacological model in which THC-mediated activation of CB1 receptor signaling pathways converge on MAP kinase, TNFa, and NF-kB outputs to create a proinflammatory and atherogenic environment in endothelial cells. That genistein can antagonize the negative effects of THC with minimal central effects is exciting because genistein is a common component of soy and is already a widely consumed dietary product.
Electronic Cigarettes Versus Nicotine Patches for Smoking Cessation in Pregnancy: A Randomized Controlled Trial
Nature Medicine
Pregnant smokers were randomized to use either nicotine replacement therapy with patches (NRT, n=571) or e-cigarettes (n=569) for smoking cessation. For the primary outcome, validated prolonged quit rates at the end of pregnancy, the results were 4.4% for NRT and 6.8% for e-cigarettes (P=0.08). However, 25 participants in the NRT arm who reported abstinence also used e-cigarettes. When these participants were excluded from data analysis the quit rates were 3.6% for NRT and 6.8% for e-cigarettes (P=0.02). Low birthweight was less common in the e-cigarette arm, 9.6% versus 14.8% for NRT (P=0.01). The authors conclude that “e-cigarettes were markedly more effective than patches” and do not pose more risk.
Daily Cannabis Use, Cannabis Use Disorder, and Any Medical Cannabis Use Among US Adults: Associations Within Racial, Ethnic, and Sexual Minoritized Identities in a Changing Policy Context
Preventive Medicine Reports
Cannabis use has steadily increased in the United States, with daily and medical use associated with cannabis use disorder (CUD) and the negative consequences more frequent among marginalized groups. In this study, the authors use the National Survey on Drug Use and Health (NSDUH) to examine medical and daily use and CUD across the intersections of racial, ethnic, and sexual minorities. They found that sexual minorities were more likely to have medical and daily use and CUD than their heterosexual counterparts within each racial and ethnic group. However, when examining the intersection of race, ethnicity and sexual identity, there was more heterogeneity across these groups. In addition, they found that in states with medical cannabis laws (MCL) daily cannabis use was higher across all intersectional groups.
Effect of AXS-05 (Dextromethorphan-Bupropion) in Major Depressive Disorder: A Randomized Double-Blind Controlled Trial
AJP Psychiatry
Altered glutamatergic neurotransmission is implicated in the pathogenesis of major depressive disorder. AXS-05 (dextromethorphan-bupropion) is an oral NMDA receptor antagonist and sigma-1 receptor agonist, which utilizes inhibition of CYP2D6 to increase its bioavailability. This phase 2 trial assessed the efficacy and safety of dextromethorphan-bupropion in the treatment of major depressive disorder. In patients with major depression, dextromethorphan-bupropion (AXS-05) significantly improved depressive symptoms compared with bupropion and was generally well tolerated. The most common adverse events were dizziness, nausea, dry mouth, decreased appetite, and anxiety. Dextromethorphan-bupropion was not associated with psychotomimetic effects, weight gain, or sexual dysfunction.
Mental Health and Substance Use Among Homeless Adolescents in the US
JAMA Network
This study evaluated mental health and substance use outcomes among homeless and non-homeless adolescents in 2019. Alcohol, cigarette, marijuana, and binge drinking during the prior 30 days was assessed, along with lifetime use of cocaine, methamphetamine, heroin, ecstasy, and injection drugs or prescription opioid misuse. Results found current substance use ranging from cigarettes to alcohol were higher among homeless adolescents. Lifetime cocaine use was significantly higher among homeless adolescents, as were methamphetamine, heroin, ecstasy, and injection drug use. Homeless adolescents experience worse mental health outcomes, including depression and suicidality, and struggle with more SUDs than their counterparts.
The Importance of Federal Action Supporting Overdose-Prevention Centers
NEJM
In this prospective piece, the authors discuss the need for new approaches to harm reduction and substance use disorder treatment in the face of substantially increasing overdose deaths, particularly since the start of the COVID-19 pandemic. One such strategy they discuss is overdose-prevention centers, which operate in other countries and are associated with significant reductions in opioid-overdose morbidity and mortality. However, under Section 856 of the Controlled Substances Act, such facilities may be subject to federal legal sanctions. The authors recommend that the Biden administration declare they will not interfere with such public health interventions or declare that section 856 does not apply to legally sanctioned centers. Further, Congress should modify the Controlled Substance Act to exempt overdose-prevention centers.
Complex Persistent Benzodiazepine Dependence—When Benzodiazepine Deprescribing Goes Awry
JAMA Psychiatry
Benzodiazepines remain popular medications among patients due to rapid symptom relief and reinforcing effects. As clinicians and patients become more aware of potential risks, and clinical guidelines increasingly urge caution in prescribing, guidance for benzodiazepine deprescribing is needed. The authors propose a new clinical concept for patients experiencing significant psychological or functional decline during or after a benzodiazepine taper—complex
persistent benzodiazepine dependence (CPBD). CPBD can be described as symptomatic or functional decompensation with or without the development of aberrant medication behaviors in the setting of benzodiazepine deprescribing–in the absence of a benzodiazepine use disorder. Further research is needed to validate this concept.
What is Success in Treatment for Opioid Use Disorder? Perspectives of Physicians and Patients in Primary Care Settings
JSAT
Opioid abstinence and treatment retention are typically used as measures of success of MOUD treatment. This study sought to identify other important treatment outcomes and patient-centered measures of success. Qualitative, structured interviews were conducted with physicians (n=14) and patients (n=18) in 2 family medicine residency programs. The physicians (7 faculty and 7 residents) were experienced buprenorphine prescribers. Both patients and physicians identified 5 themes: staying sober, and improvement in physical health, mental health, relationships, and role functioning. Patients, but not physicians, identified 2 additional themes: tapering off buprenorphine, and decreased stigma and shame. The authors conclude that “clinicians and researchers need to consider a broader scope of success indicators.”
Comparative Effectiveness Associated With Buprenorphine and Naltrexone in Opioid Use Disorder and Cooccurring Polysubstance Use 🔓
JAMA Network Open
This comparative effectiveness study evaluated 179 280 individuals with opioid use disorder (OUD) using insurance claims. Individuals with OUD and co-occurring substance use disorders (SUDs) were less likely to receive buprenorphine and more likely to receive extended-release naltrexone than peers without polysubstance use; buprenorphine and extended-release naltrexone were comparable in their protective associations with drug- related poisonings in both populations. These findings suggest that individuals with co-occurring SUDs were less likely to receive buprenorphine despite buprenorphine’s association with protecting against overdose in this population.
Perceived effectiveness of objective elements of vaping prevention messages among adolescents 🔓
Tobacco Control
To date, no comprehensive analysis of vaping prevention message elements has been conducted. This study examined how objective features of vaping prevention messages predict adolescents’ perceptions of those messages. Items such as addiction, chemicals, and negative health symptoms/effects were associated with higher perceived message effectiveness (PME); the word ‘addiction’ was associated with higher PME only for non-users. Referencing lung effects increased PME for current users but not for non-users. Items such as industry targeting, environmental impact, and flavor themes were associated with lower PME, along with first-person language or the word ‘teen.’ Prevention messages that even moderately improve vaping-related outcomes have the potential to improve vaping prevention.
Survey of Barriers and Facilitators to Prescribing Buprenorphine and Clinician Perceptions on the Drug Addiction Treatment Act of 2000 Waiver 🔓
JAMA Network Open
As opioid-related deaths increase, methods to reduce barriers to prescribing buprenorphine are needed. What is unclear is whether removal of the X-waiver requirement for prescribing buprenorphine will be enough to increase access. This study was conducted to better understand key barriers/facilitators to prescribing beyond those related to the X-waiver process. A survey of Texas clinicians who received waiver training between March 2019 and February 2020 was distributed, with a follow-up survey later in the year assessing nine barriers to treatment. Complexity of X-waiver process, perceived lack of professional support and referral network, and getting started were found to be barriers to prescribing; supportive professional networks were a key facilitator.
Prevalence and Correlates of Driving under the Influence of Stimulants: Evidence from a National Sample
Addictive Behaviors
This study notes an increase in cocaine use over the last decade and even greater increase in the use of methamphetamine. Data on stimulant use and driving under the influence of stimulants (DUIS) was obtained from four years of the National Survey on Drug Use and Health (2016-2019). Among adults reporting stimulant use in the past year 28% reported DUIS and 56% for those who met DSM IV criteria for stimulant abuse/dependence. Odds of DUIS was lower among women (AOR 0.78). A majority of those reporting DUIS also reported driving under the influence of alcohol (53%) or cannabis (59%).
Does it come from tobacco? Young adults’ interpretations of the term “tobacco-free nicotine” in a cross-sectional national survey sample 🔓
PLOS One
“Tobacco-free” nicotine (TFN) products are relatively new to the market. Although as of March 2022 they fall under FDA regulation as tobacco products, there is still concern about public understanding of these products and potential impact on nicotine product use, particularly among adolescents and young adults. In this study, the authors surveyed those 18-25 years of age to assess knowledge about tobacco products in general and TFN products in particular. Overall, young adults lack knowledge about nicotine-containing products, frequently incorrectly identifying the nicotine source for cigarettes (38.1%), smokeless tobacco (47.9%), e-cigarettes (53.4%) nicotine pouches (74.4%), and TFN (42.2%). Of particular concern, 17.1% of respondents believed TFN products did not contain nicotine or tobacco. FDA regulation around marketing of TFN products may be needed.
Prevention, treatment and care of substance use disorders in times of COVID-19 🔓
World Psychiatry
In this editorial, The United Nations Office on Drugs and Crime (UNODC) – World Health Organization Informal Scientific Network (ISN) provides multiple recommendations for care of substance use disorders (SUDs). During the COVID-19 pandemic, persons with SUDs have fared worse than the general population, both in terms of risk of infection and worse outcomes with infection. One of the key public health principles is providing services to populations with increased vulnerabilities; this also benefits the entire population. Among the recommendations from the ISN are inclusion of mental health and SUD experts in COVID-19 task forces and development of strategies to ensure SUDs are treated like any other chronic medical condition during the pandemic and beyond.
Can slogans prevent gambling harm?
The Lancet Public Health
This is a commentary on a study assessing the efficacy of a slogan used in a safer gambling campaign in the UK. The slogan “When the fun stops, stop” did not have the intended effect in this study of experienced gamblers. The author observes that a safer gambling campaign implies that there is a safe level of gambling which may not exist, for example with electronic gambling machines. A parallel is drawn with responsible drinking campaigns that have little impact on actual alcohol consumption. They also focus responsibility on the individual rather than providers and regulators. The author notes that experience with alcohol and tobacco has shown that advertising emphasizing the harms of use can discourage harmful use.
The stigma of alcohol-related liver disease and its impact on healthcare
Journal of Hepatology
This review summarizes the evidence on alcohol related liver disease (ALD) stigma in healthcare and its implications for people with ALD. Public stigma, self-stigma and structural stigma all contribute to increased illness burden of ALD, failure to or delay of seeking help, inferior healthcare, and negative health outcomes. Stigma can be experienced, but also anticipated and avoided, which all negatively impacts ALD healthcare. Blaming people with ALD for their condition is central to ALD stigma. Stigma affects ALD healthcare at all stages, from prevention, early detection and intervention, to allocation of scarce resources in liver transplantation. People with lived experience need to be empowered to lead action against the stigma of ALD.
Opioid and Naloxone Prescribing Following Insertion of Prompts in the Electronic Health Record to Encourage Compliance With California State Opioid Law [OPEN ACCESS]
JAMA Network Open
In 2018, California passed Assembly Bill (AB) 2760, mandating coprescription of naloxone and opioids for patients with high overdose risk. The current study assessed whether electronic prompts were associated with increased naloxone orders and reduced opioid prescribing when integrated into the practitioner workflow. Naloxone order rate increased from 2% in December 2018 to 13.2% in January 2019 and then continued to increase to 27.1% in December 2019. Outpatient opioid prescribing rates decreased by 15.1% per prescriber-month and total MMEs per prescriber-month decreased by 7.8%, along with other improvements in safe opioid prescribing. Adding decision support prompts to the practitioner workflow encourages safe prescribing habits and can mitigate opioid overdose risks.
Epidemiological trends in opioid-only and opioid/polysubstance-related death rates among American Indian/Alaska Native populations from 1999 to 2019: a retrospective longitudinal ecological study [OPEN ACCESS]
BMJ Open
Deaths due to overdoses have been increasing in the United States over the last 2 decades, but little is known about the epidemic among American Indian/Alaskan Native (AI/AN) populations. In this study the authors use the National Center for Health Statistics Mortality database to examine overdose deaths between 1999 and 2019. Overdose deaths related to opioids increased significantly over the observation period, including deaths involving other substances, notably alcohol and methamphetamines. Overall overdose mortality rates, and specifically those related to opioids in combination with alcohol or methamphetamines, have been higher among AI/AN than in other racial and ethnic groups. This study highlights inequities in access to treatment for AI/AN populations, including lack of access to medication assisted treatment for opioid use disorder.
Effects of Buprenorphine Dose and Therapeutic Engagement on Illicit Opiate Use in Opioid Use Disorder Treatment Trials [OPEN ACCESS]
International Journal of Environmental Research and Public Health
The authors identified 6 randomized clinical trials of buprenorphine efficacy and/or safety and performed a secondary analysis with lapse to substance use as the outcome variable. They developed a mathematical model to adjust for the effects of dose changes or missed doses during the study period (time-weighted dose). The 6 trials included 3022 participants. The mean (and median) dose was 12mg and ranged up to 32mg. Increased dose was found to be the most protective factor in preventing lapse to drug use. Also of benefit were increased interaction with clinicians and treatment center staff. The authors conclude that doses greater than that needed to prevent withdrawal are needed for maintenance treatment.
Association Between Receipt of Antidepressants and Retention in Buprenorphine Treatment for Opioid Use Disorder: A Population-Based Retrospective Cohort Study
The Journal of Clinical Psychiatry
This study examined the association between receiving antidepressants and retention in buprenorphine treatment. Receipt of antidepressants during buprenorphine treatment was significantly associated with reduced risk of treatment discontinuation, even after accounting for demographics, buprenorphine dosage, receipt of other psychotropic medications, co-occurring SUDs, psychiatric disorders, and pain conditions. Receiving antidepressants only prior to buprenorphine initiation was associated with an increased risk of treatment discontinuation. Using antidepressants concurrently during buprenorphine treatment is associated with improved treatment retention and highlights the importance of screening for and treating mental health disorders.
Delivering Remote Measurement-Based Care in Community Addiction Treatment: Engagement and Usability Over a 6-Month Clinical Pilot [OPEN ACCESS]
Frontiers in Psychiatry
Measurement-based care (MBC) is an evidence-based practice where patients routinely complete standardized measures throughout treatment to monitor clinical progress and inform clinical decision-making. This pilot study evaluated the feasibility of incorporating a digital and remotely delivered MBC system into substance use disorder (SUD) treatment within a community setting. Patient and clinician ratings of usability and clinical utility were favorable: most patients agreed with statements that the weekly check-in was easy to navigate and aided self-reflection. All clinicians who completed usability questionnaires agreed with statements indicating that the dashboard was easy to navigate and that it provided meaningful information for SUD treatment.
Evaluation of Trends in Alcohol Use Disorder–Related Mortality in the US Before and During the COVID-19 Pandemic
JAMA Network Open
Alcohol sales and use have increased during the COVID-19 pandemic and in this cross-sectional study utilizing the National Vital Statistic System, the authors examine alcohol use disorder (AUD)-related mortality changes. The study looks at AUD-related mortality trends between 2012 and 2019 to project expected mortality in 2020 and 2021, which were then compared to the observed rates. The authors found a significant increase in mortality rates across all ages in 2020 (30.74%) and 2021 (28.7%) compared to projected rates. In addition, the study found the increase was most profound among those aged 25-44 (40.47% and 33.95% increases). Interventions to address the increase in AUD-related mortality should consider changes in use related to the pandemic.
Wait No Longer: Reducing Medication Wait-Times for Individuals with Co-Occurring Disorders
Journal of Dual Diagnosis
Community addiction treatment agencies have utilized Network for the Improvement of Addiction Treatment (NIATx) to reduce appointment wait-times. This exploratory analysis evaluated the impact of the NIATx implementation strategies on reduced wait-times to addiction, psychotropic, or both medications for individuals with co-occurring disorders (COD). NIATx implementation strategies reduced medication encounter wait-times but timing of agency improvements varied. Despite a significant improvement, a three-week wait-time to receive pharmacological interventions is suboptimal for those with a COD in need of immediate intervention. Community addiction treatment agencies should improve medication access so that their patients “wait no longer” to receive integrated treatment for their COD.
Prehospital Buprenorphine Treatment for Opioid Use Disorder by Paramedics: First Year Results of the EMS Buprenorphine Use Pilot [OPEN ACCESS]
Prehospital Emergency Care
This study describes a program allowing EMS personnel to administer buprenorphine in the field to patients experiencing withdrawal (COWS>7) under the supervision of an Emergency Physician. Initial doses of 16 mg were administered and an additional 8mg were provided if needed. Substance use navigators facilitated connection with treatment and followed patient outcomes. Over the one-year trial period, 36 patients received buprenorphine. Treatment retention at seven days was 50% and 36% at 30 days. The authors conclude that EMS administered buprenorphine is feasible, safe, and has significant treatment retention at 30 days.
Association of co-prescribing of opioid and benzodiazepine substitutes with incident falls and fractures among older adults: a cohort study [Open Access]
BMJ Open
This study extracted data from Medicare records of 47,964 enrollees who were diagnosed with chronic pain and anxiety and prescribed some combination of the studied medications (opioids, benzodiazepines, gabapentinoids (GABA), or antidepressants (SSRI/SNRI)). The outcome measure was falls or fractures. The authors note that prior research has shown opioids+benzodiazepines to be associated with high rates of falls, fractures, and deaths. These data show that opioids+GABA was associated with a greater risk of falls and fractures than opioids+benzodiazepines. An even greater risk of falls was associated with use of three or more of these medications. The authors conclude that clinicians may be underestimating the sedating effects of gabapentinoids.
Stimulant-related incident surveillance using emergency medical service records in Massachusetts, 2013–2020
Drug and Alcohol Dependence
Rates of stimulant use and stimulant use disorder (StUD) have been steadily increasing, as have overdoses with stimulant use involvement. The authors examine emergency responses involving stimulants between 2013 and 2020 in Massachusetts. They categorize calls in 3 classes: class 1 – any stimulant use, class 2 – problematic stimulant use in which stimulant use was associated with acute medical or behavioral issue, and class 3 – acute stimulant-related incidents in which stimulant use was the primary issue for the call. Over the study period, calls in all 3 categories steadily increased, were more likely to be among younger adults, and the callers were more frequently male. While race/ethnicity data were frequently missing, when the data were present, Hispanic/Latinx and Black non-Hispanic patients appeared to be overrepresented among stimulant-related calls.
Trends in Prevalence of Cigarette Smoking Among US Adults With Major Depression or Substance Use Disorders, 2006-2019
JAMA
This cross-sectional study assessed trends in past-month prevalence of cigarette smoking among adults with vs. without past-year major depressive episode (MDE), substance use disorders (SUDs), or both. Using data from the 2006-2019 US National Surveys on Drug Use and Health, past-month self-reported cigarette smoking prevalence declined significantly among adults with MDE from 37.3% to 24.2% (average annual percent change: −3.2), adults with SUD from 46.5% to 35.8% (average annual percent change: −1.7), and adults with co-occurring MDE and SUD from 50.7% to 37.0% (annual average annual percent change of −2.1). Prevalence declined significantly for each examined subgroup but not for American Indian or Alaskan Native with either MDE or SUDs.
Emerging Agents of Substance Use/Misuse
Emergency Medicine Clinics of North America
In the last decade, there has been a rise in the use of novel psychoactive substances (NPS) for recreational purposes. Many of these synthetic psychoactive substances are derived or based on older substances of abuse, but because of their novel structures, they are not easily detectable by routine immunoassay urine drug screens. Clinical effects encountered in patients using these substances depend on the substance’s structure but can be unpredictable due to the effects on various receptors at varying doses. It is important for clinicians to be aware that these novel substances exist because the diagnosis is often clinical and not based on UDS. Treatment for these substances is generally supportive and aimed at the presenting signs and symptoms.
Dopamine Supersensitivity: A Novel Hypothesis of Opioid-Induced Neurobiological Mechanisms Underlying Opioid-Stimulant Co-use and Opioid Relapse [Open Access]
Frontiers in Psychiatry
Stimulants are uniquely reinforcing to persons with opioid physical dependence, contribute to the acute opioid withdrawal syndrome, and could manifest as craving and/or motivation to use, prompting opioid relapse during acute and protracted withdrawal. Current research demonstrates that changes in the dopamine system occur once physical dependence to opioids develops, the chronicity of opioid exposure is associated with a severity of changes, and dopamine deficits persist long after signs of opioid withdrawal appear to have resolved. This review discusses how dopamine supersensitivity develops soon after opioid abstinence and results in increased response to dopamine agonists that increases in magnitude as the abstinence period continues and is evident several weeks into protracted withdrawal.
Psychological online interventions for problem gambling and gambling disorder – A meta-analytic approach
Journal of Psychiatric Research
In the context of the Covid-19 pandemic, this systematic review and meta-analysis investigated the effectiveness of psychological online interventions on problem gambling and gambling disorder (PGGD). Results indicate that psychological online interventions have moderate effects on PGGD in the short term. There was no indication that guided vs. unguided forms of online interventions affect the outcome. However, there is a clear trend toward unguided and even autonomous interventions which have the potential to complement or even substitute a therapist in person. Recent reviews indicate the superiority of online CBT formats compared to interventions with other theoretical backgrounds.
Toward Risk-Benefit Assessments in Psychedelic- and MDMA-Assisted Therapies | Research, Methods, Statistics
JAMA Psychiatry
There has been considerable attention to the evidence showing the benefits of psychedelic- and MDMA-assisted therapy. Less is known about the associated risks, primarily psychiatric, such as mood and thought disorders that sometimes outlast the acute effects of the drug and may provoke suicidal behavior. It will be important to identify patients at higher risk, for example patients with a family history of schizophrenia or bipolar disorder; however, such patients have been excluded from most clinical trials. One consideration is the implementation of risk evaluation and management strategies (REMS) but MDMA and psilocybin are already in the public domain so alternate strategies may be needed.
Implementation of a Standardized Clinical Definition of Opioid Withdrawal in the Neonate Challenges and Opportunities
JAMA
A standard clinical definition for neonatal abstinence syndrome (NAS) has been lacking for more than 45 years. The new definition of opioid withdrawal in the neonate includes 2 specific elements: in utero exposure to opioids with or without exposure to other psychotropic substances and the presence of 2 of 5 of the most common clinical signs of opioid withdrawal. A consistent clinical definition is essential in informing treatment protocols, administrative coding, surveillance, research criteria, and the spectrum of care for the mother-infant dyad. This could provide a significant shift in the way mothers and neonates with prenatal opioid exposure are identified, and represents a promising path forward for pregnant people and neonates with prenatal opioid exposure to improve their health and well-being
Adolescents’ and young adults’ perceptions of risks and benefits differ by type of cannabis products
Addictive Behaviors
Cannabis use patterns among adolescents and young adults (AYAs) have changed recently, with increasing use of non-combustible cannabis products. This survey of 433 California AYAs compared a variety of perceived risks and benefits corresponding to short-term and long-term use of combustible, blunt, vaporized, and edible cannabis, and between "ever" and "never" users. Combustible cannabis and blunts were perceived to have greater risks and benefits than vaporized/edible cannabis. The most common perceived risks were “get into trouble” and “become addicted.” The most common benefits were “feel high or buzzed” and “feel less anxious.” Ever cannabis users perceived less risks and greater benefits than never users.
Electronic cigarette use among adults in 14 countries: A cross-sectional study
eClinicalMedicine
Using 2015-2018 Global Adult Tobacco Survey (GATS) data, prevalence of e-cigarette use and variations by sociodemographic characteristics was examined in 14 countries. Given the progress towards a tobacco-free generation, continued surveillance of e-cigarette use is essential to developing, sustaining, and strengthening tobacco control at the country level. Approximately 18.3 million adults used e-cigarettes across these countries; higher use was observed in certain countries among men, young adults, urban residents, adults with higher education levels, and higher wealth index. Continued monitoring of e-cigarette use is critical for developing interventions and policies to prevent tobacco initiation and enhance cessation support.
Assessment of Community-Level Vulnerability and Access to Medications for Opioid Use Disorder
JAMA Network Open
This cross-sectional study examined the association of community vulnerability to disasters and pandemics with geographic access to each of the three Medications for Opioid Use Disorder (MOUDs) and whether this association differs by urban, suburban, or rural classification. All zip code tabulation areas (ZCTAs) within the continental U.S. were included. Median drive time to the nearest treatment location was greatest for methadone (35 [16-60] minutes) and shortest for buprenorphine (16 [0-30] minutes; P
Show Notes:
Defining Recovery From Alcohol Use Disorder: Development of an NIAAA Research Definition
The American Journal of Psychiatry
The authors present a newly developed National Institute on Alcohol Abuse and Alcoholism (NIAAA) definition of recovery from the DSM-5 diagnosis of alcohol use disorder (AUD). This definition views recovery as a process of behavioral change and an outcome, incorporating two key components of recovery: remission from DSM-5 AUD and cessation from heavy drinking, a non-abstinent recovery outcome. It also emphasizes the importance of biopsychosocial functioning and quality of life in enhancing outcomes. By adopting a uniform definition, researchers and health care professionals can more precisely operationalize and measure recovery-related processes.
Benzodiazepine-Involved Overdose Deaths in the USA: 2000–2019
Journal of General Internal Medicine
Overdose deaths involving benzodiazepines and opioids are well studied and characterized. In this study, the authors examine all benzodiazepine-involved overdose deaths to better understand the pattern of use and overdoses between 2010 and 2019. While opioids were involved in 83.5% of all benzodiazepine related overdoses, antidepressants (18.8%), alcohol (16.3%), cocaine (13.4%) and psychostimulants (7.3%) were also frequently involved. Only 9% of benzodiazepine overdose deaths did not co-involve another substance. In addition, a larger proportion of deaths with benzodiazepine alone were due to suicide (36.2%) compared to those involving opioids (8.5%). Any interventions to reduce overdose deaths involving benzodiazepines need to consider co-involved substances and the role of suicide.
Differences in clinical features associated with cannabis intoxication in presentations to European emergency departments according to patient age and sex
Clinical Toxicology
Using presentations in the Euro-DEN Plus dataset from 2014 to 2019, this study investigated whether clinical features associated with acute cannabis intoxication in patients presenting to Emergency Departments for medical assistance differ according to patient age and sex. The most frequent clinical features in patients younger than 20 years were vomiting, reduced consciousness, and headache; and less frequently acute psychosis. Patients older than 49 years more often had hypotension and less frequently vomiting, anxiety, agitation, and reduced consciousness. Males more frequently presented with hypertension, psychosis, chest pain, and seizures.
Increased global integration in the brain after psilocybin therapy for depression
Nature Medicine
Two clinical trials assessed the subacute impact of psilocybin on brain function in treatment resistant depression. In both trials, the antidepressant response to psilocybin was rapid, sustained, and correlated with decreases in fMRI brain network modularity, implying that psilocybin’s antidepressant action may depend on a global increase in brain network integration. Network cartography analyses indicated that 5-HT2A receptor-rich higher-order functional networks became more functionally interconnected and flexible after psilocybin treatment. Consistent efficacy-related brain changes, correlating with robust antidepressant effects across two studies, suggest an antidepressant mechanism for psilocybin therapy: global increases in brain network integration.
Non–prescribed buprenorphine preceding treatment intake and clinical outcomes for opioid use disorder
Journal of Substance Abuse Treatment
In this study, data were obtained from a large, multi-site, multi-state office-based opioid treatment (OBOT) network. Individuals (n=971) were randomly selected from a pool of 18,513 initiating buprenorphine care. At treatment entry, 60% tested positive for buprenorphine (TPB), and 73% of these were taking non-prescribed buprenorphine. The TPB group was less likely to test positive for opiates at treatment entry (25% vs. 53%) and continued to be less likely to test positive for opiates during the first several months of treatment. The TPB group was less likely to discontinue treatment (hazard ratio 0.52). There were no significant differences comparing those prescribed with non-prescribed use, in the TPB group. They suggest that use of “diverted” buprenorphine is a marker of patient motivation for treatment and conclude that “concerns regarding buprenorphine diversion due to misuse may be misplaced.”
What are the implications of the steady 40 year rise in US fatal overdoses?: Introduction to a special section
International Journal of Drug Policy
While overdose deaths due to opioids is understood to be the driver of current increase in overdose deaths and a well-recognized epidemic, in a series of recent studies it was demonstrated that overdose deaths have been steadily increasing over the last 40 years. In this editorial, the authors discuss various commentaries responding to these studies and highlight various perspectives on these data. While much of the focus in recent years has been on opioid overdose deaths and access to medication assisted treatment, interventions may be needed to address broader factors associated with substance use, including both supply and demand side factors. In addition, data at more local levels may be useful in predicting substance use epidemics at more local levels for intervention.
The Effectiveness of Exercise as an Adjunct Intervention to Improve Quality of Life and Mood in Substance Use Disorder: A Systematic Review
Substance Use and Misuse
This review examined 42 papers (2531 individuals) regarding the effect of exercise on quality of life, depression, and anxiety during treatment of substance use disorder. The majority, 22 studies, took place in an inpatient rehabilitation setting. They examined a broad range of exercise modalities: aerobic, resistance, flexibility, tai chi, yoga, high intensity interval training, and increasing step count. The results support a beneficial impact of exercise on quality of life, depression, and anxiety. There was a dose response effect with greater benefit with increased number of sessions per week and over 12 weeks of program duration, however, some improvement was seen following a single session. The modality of exercise was less important and simply increasing daily step count was beneficial.
Addressing the substance use treatment gap in Africa using digital screening and brief interventions
The Lancet Psychiatry
Services and staffing for substance use treatment and prevention are scarce throughout many parts of Africa. One treatment option is a self-administered digital substance use screening and brief intervention (SBI). This literature search noted a paucity of research investigating the feasibility of SBIs in Africa. Such an SBI has the potential to increase access to care and decrease intervention delivery costs. Given the rapid increase in internet penetration rates, and smartphone usage across the continent, as well as limited access to treatment, there is an urgent need to explore the utility of this treatment tool across the continent.
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Association of Medication Treatment for Opioid Use Disorder With Suicide Mortality
The American Journal of Psychiatry
This study evaluated whether medications for opioid use disorders (MOUD) are associated with reduced risk of suicide mortality and compared different agents. Data were collected for 61,633 veterans (93% male) receiving MOUD. Approximately half received buprenorphine and a quarter received methadone or naltrexone (oral or extended-release). The hazard ratio (HR) for suicide mortality while on MOUD was 0.45 and for all-cause mortality, it was 0.34. Stopping MOUD increased the risk for suicide (HR = 1.47) and all-cause mortality (HR = 1.14). Buprenorphine reduced suicide mortality (HR = 0.34) whereas naltrexone did not (HR = 1.28). Buprenorphine reduced all-cause mortality (HR = 0.27) to a greater extent than naltrexone (HR = 0.64), while results with methadone were less clear. Overall, MOUD produced dramatic reductions in both suicide and all-cause mortality with the effect most pronounced for buprenorphine. Naltrexone, however, did not reduce suicide mortality.
Research and Science
Fetal Exposure to Cannabis and Childhood Metabolic Outcomes: The Healthy Start Study
The Journal of Clinical Endocrinology & Metabolism
This study investigated whether fetal exposure to cannabis is associated with increased adiposity and markers of impaired glucose homeostasis in early childhood. Approximately 15% of mothers had detectable levels of any cannabinoid at ~27 weeks’ gestation, indicating fetal exposure to cannabis. Fetal exposure to cannabis was associated with increased adiposity and fasting glucose in early childhood. This study further supports discouraging women from using any cannabis while pregnant or breastfeeding to minimize adverse health effects on the offspring.
Trends in seizures of powders and pills containing illicit fentanyl in the United States, 2018 through 2021
Drug and Alcohol Dependence
Fentanyl continues to be a leading cause of overdose in the United States and is increasingly found in counterfeit prescription pills. This study examines trends in pills containing fentanyl using the national seizure data from High Intensity Drug Trafficking Areas between January 2018 and December 2021. There was a significant increase in both fentanyl-containing powder seizures (424 to 1539) and pill seizures (68 to 635) during the study period. In addition, the proportion of seizures that were pills increased (13.8% to 29.2%) and the number of pills seized increased (42,202 to 2,089,186). While the presence of fentanyl in heroin supply is more widely known, its presence in pills poses a potential risk that is not as widely disseminated, resulting in the need for public education.
Beliefs and Characteristics Associated With Believing Nicotine Causes Cancer: A Descriptive Analysis to Inform Corrective Message Content and Priority Audiences
Nicotine and Tobacco Research
In this study, authors examine cigarette smokers’ perceptions about harm from tobacco, specifically nicotine as the source of harm. The authors found that a significant proportion of smokers (61.2%) believed that nicotine was the source of cancer risk or were not sure. This belief was more common among non-Hispanic Black and Hispanic smokers as well as those with low incomes. Smokers with high school or higher education were less likely to believe nicotine was the source of the risk. In addition, those who had used a non-combustible tobacco product, including electronic cigarettes, were less likely to have this perception. The misperception about the risk of nicotine may impact smokers’ behavior, and switching to less harmful products and education is needed to correct this commonly held belief.
Effect of Medical Marijuana Card Ownership on Pain, Insomnia, and Affective Disorder Symptoms in Adults
JAMA Network Open
This randomized clinical trial involving 186 participants examined the risks and benefits of obtaining a medical marijuana card for adults who seek medical marijuana for pain, insomnia, and anxiety or depressive symptoms. Immediate acquisition of a medical marijuana card increased the incidence and severity of cannabis use disorder (CUD) and resulted in no significant improvement in pain, anxiety, or depressive symptoms, but improved self-reported sleep quality. Findings suggest the need for further investigation into the benefits of medical marijuana card ownership for insomnia symptoms and the risk of CUD, particularly for those with anxiety or depressive symptoms.
Learn More Burst Suppression Electroencephalography (EEG) Pattern with Coma and Loss of Brain Stem Reflexes Following a Baclofen Overdose with Subsequent Full Recovery
American Journal of Case Reports
Baclofen toxicity can present both clinically and with EEG abnormalities consistent with anoxic brain injury, suggesting an inevitable progression to brain death. This is a case report of a middle-aged woman found unresponsive who presented with apnea, loss of rudimentary neurologic findings on physical exam, burst suppression EEG findings, and a prolonged comatose state for nearly 48 h, followed by rapid resolution of symptoms secondary to a supratherapeutic baclofen ingestion. When provided with appropriate supportive care and prolonged observation, improvement with full neurologic recovery is often seen despite the initial grim clinical picture.
Against Our Instincts: Decriminalization of Buprenorphine
Journal of the American Board of Family Medicine
In this commentary the authors make a case for the decriminalization of the possession of buprenorphine. The authors cite the dramatic reduction in mortality (by 2/3 in one meta-analysis) with buprenorphine treatment. According to data from Tennessee, buprenorphine has little risk of overdose when used alone. A meta-analysis indicated that diverted buprenorphine was used for therapeutic rather than recreational purposes. Many have difficulty accessing buprenorphine due to a lack of providers and economic barriers, and the authors note that when a Vermont county decided not to prosecute possession of buprenorphine (along with other measures to increase access) the overdose rate reduced by 50% while increasing in the rest of the state. The authors conclude that the benefits of decriminalizing buprenorphine possession outweigh the risks.