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ASAM Weekly for September 5th, 2023

Sep 6, 2023

This Week in the ASAM Weekly

This week, the titles tell much of the story. All of Us (not to be confused with the hit TV drama-series 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 NSDUH and 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 were more likely to have OUD.

Research and Science

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-19 pandemic). Overall, the OOD rate did not change pre- and post-pandemic, while naloxone distribution rates increased with the trend continuing post-pandemic. However, in stratified analysis by race and ethnic groups (non-Hispanic White, non-Hispanic Black, Hispanic, and other) they found significant differences. In particular, the OOD rate among the non-Hispanic Black population increased significantly post-pandemic, while remaining relatively stable among other groups. While naloxone distribution rates did increase among all groups, it did not increase among the non-Hispanic Black population in proportion to the increase in OODs. These findings highlight the need to consider race and ethnicity in evaluation and tailoring interventions to address disparities.

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 More

The emerging fentanyl–xylazine syndemic in the USA: challenges and future directions 🔓

The Lancet

This 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 healthcare 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 Treatments

Journal of Addiction Medicine

Opioid 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 Risk

JAMA Pediatrics

Some 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 being attractive to children, enforcement faces challenges due to law enforcement authority. Providers must do more to educate consumers about the inherent dangers of these unregulated and unlicensed products.

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