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A podcast source for news briefings on the top stories in the field of addiction medicine.
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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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