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The ASAM Weekly for January 23, 2024

Jan 23, 2024

This Week in the ASAM Weekly

History Repeats Itself: Psychedelics Are Promoted Today the Way Opioids Were Promoted in the Early 2000s
Anna Lembke, MD, FASAM

Anna Lembke, MD, FASAM is a professor of psychiatry at Stanford University School of Medicine, program director of the Stanford Addiction Medicine Fellowship, and author of Dopamine Nation: Finding Balance in the Age of Indulgence.

After more than two decades as a practicing psychiatrist, I’ll be the first to admit that we need new and innovative treatments to treat depression, anxiety, and other psychiatric disorders. Psychedelics like LSD, psilocybin, and MDMA (Ecstasy) are being researched and promoted as ground-breaking advances for combatting mental illness. Multiple jurisdictions have already relaxed laws or policies related to these substances, often with an eye toward therapeutic use.

But the evidence to support the therapeutic use of psychedelics is not yet robust enough to justify liberalized access, especially for unsupervised use. Even more concerning, I see eerie similarities between the promotion of medicinal psychedelics today and medicinal opioids beginning in the 1990s, based on unsubstantiated claims of high benefit and low risk. Full disclosure, I have been retained as a medical expert witness in opioid litigation against Purdue Pharma and others.

The unsubstantiated claims about opioids are the following: (1) Opioids are the safest and best treatment for chronic pain; (2) opioids are the answer to our epidemic of pain; (3) opioids are ‘rarely’ addictive when prescribed by a doctor for a patient with pain.

In fact, the evidence shows that opioids are no better than Tylenol in the treatment of chronic pain and incur more medication-related adverse events. The increase in opioid prescribing did not decrease the population pain burden and was instead a major contributor to today’s opioid epidemic of addiction and overdose death. Far from being ‘rare,’ getting addicted to opioids through a doctor’s prescription is tragically common.

Read the full editorial here.

Lead Story

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.

Research and Science

Effect of Risk Mitigation Guidance opioid and stimulant dispensations on mortality and acute care visits during dual public health emergencies: retrospective cohort study 🔓

The BMJ

Utilizing population level administrative data, this cohort study evaluated the impact of Risk Mitigation Guidance (RMG) dispensations for persons with opioid use disorder and stimulant use disorder. RMG, developed in British Columbia in 2020, provides guidance for prescribing opioids (hydromorphone, oral morphine) and stimulants (dextroamphetamine) as a safer alternative to the illegal drug supply. The authors found that one or more days of RMG opioid dispensation was associated with lower all-cause mortality (HR=0.39) and overdose related mortality (HR=0.45), but not with changes in acute care visits. Further, RMG opioid dispensation was associated with even lower all-cause mortality (HR=0.09) and overdose related mortality (HR=0.11). RMG stimulant dispensation was not associated with changes in mortality but was associated with a decrease in odds of acute care visits.

Medicaid Managed Care Prior Authorization For Buprenorphine Tied To State Partisanship And Health Plan Profit Status, 2018

Health Affairs

Requiring prior authorization has been identified as an important barrier to buprenorphine access. However, the practice remains widespread in Medicaid — the largest insurer of Americans with opioid use disorder. This study examined how prior authorization for buprenorphine is related to plan structure and state political environment, using data on all 266 comprehensive Medicaid managed care plans active in 2018. Researchers found substantial variation in prior authorization use across states, with all plans requiring prior authorization in eleven states and no plans requiring prior authorization in thirteen other states. For-profit plans and those located in Republican states were more likely to impose prior authorization policies.

Regional Cortical Brain Volumes at Treatment Entry Relates to Post Treatment WHO Risk Drinking Levels in Those with Alcohol Use Disorder

Drug and Alcohol Dependence

This study compared cerebral cortex volumes with outcomes of treatment for alcohol use disorder (AUD). Patients with AUD (n=75) had MRI scans at entry to outpatient treatment. Cortex volume of 68 brain regions was measured and compared to healthy controls (51 light or non-drinkers (LN)). Outcomes 6 months post-treatment were classified as abstainer (AB), return to light drinking (RL), or return to heavy drinking (RH). Compared to LN, AB had reduced volume in 18 of 68 regions (26%), LN in 24/68 (35%), and RH in 34/68 (60%). RH had the greatest magnitude of volume loss. RH and RL had more depression post-treatment than AB and magnitude of symptoms correlated with number of daily drinks post-treatment. This degree of pretreatment volume losses, in regions involving executive function and the salience network, predicted treatment outcome. The authors speculate that these losses of function may impair the ability to benefit from treatment.

Childhood Trauma, Emotional Awareness, and Neural Correlates of Long-Term Nicotine Smoking 🔓

JAMA Network Open

In this cross-sectional study of 102 individuals who smoked nicotine long term matched with 102 healthy controls, individuals who smoked nicotine spent more time in the frontoinsular default mode brain network. Alexithymia mediated the association between childhood trauma and time spent in the frontoinsular default mode network only in individuals who smoked nicotine. The findings suggest that distinct neurobiological profiles noted in those who smoke nicotine are associated with childhood trauma–related alexithymia.

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The impact of cannabis on non-medical opioid use among individuals receiving pharmacotherapies for opioid use disorder: a systematic review and meta-analysis of longitudinal studies🔓

The American Journal of Drug and Alcohol Abuse

Some states have included opioid use disorder as an indication for the medical use of cannabis. This systematic literature review and meta-analysis assessed the effect of cannabis use on the use of non-medical opioids during medications for opioid use disorder (MOUD) treatment. A total of 19 studies were identified, of which 10 produced data suitable for the meta-analysis. The meta-analysis found no association between cannabis use and the non-medical use of opioids during MOUD (OR 1.00, CI 0,97-1,04). Three of the 9 studies not in the meta-analysis found cannabis use increased the non-medical use of opioids; however, the other 6 found no relationship. The authors conclude there is no association between cannabis use during MOUD and non-medical opioid use and that programs that require cannabis abstinence reconsider these policies.

Broken Both Ways

The New England Journal of Medicine

This is a physician's poignant account of a young woman with endocarditis resulting from injection drug use. Stella’s drug use began with opiates to control headaches after a head injury and progressed to heroin and methamphetamine. Stella is refused surgery until she can “get clean.” Her predicament is contrasted with those needing treatment because of smoking or the diabetic who ignores their diet. Is Stella receiving a medical decision or moral judgment? During clinic visits, the author comes to know the Stella whose Olympic training was ended by the head injury, who lost a boyfriend (“my heart is broken both ways”), and who digs clams at the seashore. When Stella suffers heart failure, he wonders if the treatment team will only see an illicit drug user who resumed use after treatment “and not the woman I’ve come to know.”

“Tobacco-free nicotine” electronic cigarette perceptions and use among adolescents and adults in five New England states 🔓

Addictive Behaviors Reports

Tobacco-free nicotine (TFN) has become more prevalent in e-cigarettes and is often marketed as “additive-free” or a pure alternative to tobacco-derived nicotine (TDN), which may impact perceptions about harms and addictiveness of TFN e-cigarettes. In this survey of adolescents and adults, researchers found that approximately one-third had heard of TFN e-cigarettes, and 8.9% of adolescents and 21.1% of adults had ever used TFN e-cigarettes. In addition, those who were aware were significantly more likely to have used them than those who were not aware, and aware adolescents reported they were more likely to use TFN than TDN e-cigarettes, though they also perceived TFN e-cigarettes as more addictive than TDN e-cigarettes. The authors suggest education is needed about potential harms of TFN and support regulation to ban the use of “tobacco-free nicotine” in marketing and packaging.

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