The ASAM Weekly for September 24th, 2024

This Week in the ASAM Weekly

The US drug overdose death rate dropped for the first time in decades. CDC data show a 10% reduction nationally, but some areas are seeing even bigger declines of 20-30% (NPR). This is truly exciting news and evidence that many of our efforts have been working. Now the important question - which ones?

For example, how effective is harm reduction and prevention? In order to increase naloxone availability, an editorial in Pediatrics urges pediatricians to provide naloxone education as part of their regular safety and prevention discussions with families. Pediatricians are also as likely to talk with youth about e-cigarettes, which in effect means competing with social media that often does not comply with FDA-required health warnings (JAMA Network Open).

What about the impact of current addiction treatments? Telemedicine has helped improve access to MOUD, but it can also improve initiation of medications for alcohol use disorder (JAMA Network Open). We have a number of treatments for tobacco cessation, and a review of Cochrane Reviews confirms their efficacy (Addiction). Even treatments under development look promising, like enzymes that break down cocaine before entering the brain or monoclonal antibodies that target multiple drugs simultaneously (Drug Discovery News).

The above questions are just a few examples of the current crisis whose answers will apply to future crises. But the most important question we need to answer now is, why did some groups experience reductions in overdose deaths while others did not?

Thanks for reading,

Nicholas Athanasiou, MD, MBA, DFASAM
Editor in Chief

with Co-Editors: Brandon Aden, MD, MPH, FASAM, Jack Woodside, MD, John A. Fromson, MD

Lead Story 

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.

Impact on beer sales of removing the pint serving size: An A-B-A reversal trial in pubs, bars, and restaurants in England 🔓 

PLOS Medicine

In England, the largest serving size of draught beer is one pint. This study determined the effect of reducing the largest size on the total amount of alcohol sold. Licensed premises (n=12) in 6 geographic regions of England had their sales recorded for 4 weeks, followed by 4 weeks during which the largest size was 2/3 pint, and then 4 weeks during which the largest size was again 1 pint (A-B-A design). The reduction to 2/3 pint reduced beer sales by 2,769 ml/day, or 9.7% (p<0.001). An unexpected effect was an increase in wine sales during the intervention by 232 ml/day, or 7.2% (p=0.035). Revenue decreased by 5% (p=0.038). The reduction in beer sales was equivalent to 13 units of alcohol, and the increase in wine sales was equivalent to 3 units, resulting in an overall decrease of 10 units of alcohol sold. The authors conclude that reducing the amount of the largest size of beer sold has the potential to reduce alcohol consumption.

Improving Estimates of the Prevalence of Opioid Use Disorder in the United States: Revising Keyes et al

Journal of Addiction Medicine

In 2022, Keyes et al published an estimate of the prevalence of OUD in the US in 2019 to be 6-7 million. This paper attempts to adjust that estimate by A) using mortality estimates for synthetic opioids, B) using the prevalence of fentanyl, C) using opioid-involved ODs rather than all drug ODs, and D) adjusting for underreporting of opioid involvement. The paper describes the mathematics involved in making these adjustments. Adjustments A and B resulted in an OUD prevalence in 2019 of 7.6 million, which the researchers feel is an upper bound. Using adjustments A-D resulted in an OUD prevalence in 2019 of 3.8 million, which they feel is a lower bound. Both methods show a significant decline in OUD prevalence between 2016 and 2019, whereas Keyes’ estimate shows only a slight decline. The authors suggest further adjustments could include hospital data on OUD complications and data on OUD admissions to treatment centers.

Effects of interventions to combat tobacco addiction: Cochrane update of 2021 to 2023 reviews 🔓

Addiction 

This summary updated Cochrane Reviews between 2021 and 2023 examining interventions for tobacco use, including behavioral interventions, e-cigarettes (EC), and pharmacotherapies. The authors found that varenicline, cytisine, bupropion, and nicotine replacement therapy (NRT), particularly patches in combination with gum or other fast-acting forms, were effective for smoking cessation. In addition, behavioral interventions, including financial incentives, and EC were also effective. Varenicline, cytisine, and nicotine EC appeared to be most effective. The authors also make several recommendations for further research, including various behavioral interventions, long-term safety of EC, and interventions to help people stop EC use. 

Pediatricians’ Role in Overdose Prevention: A Call for Universal Naloxone Dispensing

Pediatrics

In this commentary, the authors address a paper by Terranella et al that estimates naloxone distribution among youth. The overdose crisis has affected the pediatric population, with deaths from fentanyl increasing more than 30-fold in the last 10 years. While naloxone dispensing increased by 669%, pediatricians account for only 5.6% of naloxone prescribers, and overdose deaths continue to rise. In this context and the culture of safety and prevention in pediatrics, the authors suggest that pediatricians consider prescribing naloxone universally at health maintenance visits. This practice could remove stigma and perhaps provide families with more comfort in discussing any issues or concerns.

Discussing the concept of substance-induced psychosis (SIP) 🔓

Psychological Medicine

In this narrative review, the authors argue against the use of substance-induced psychosis (SIP) as a diagnosis, suggesting that it places too much attention on the substance use as assumption of cause and misses other potential risk factors resulting in suboptimal treatment. Approximately 1 in 4 patients with SIP will go on to have a diagnosis of schizophrenia, and while there are clear guidelines for treatment for first-episode psychosis (FEP) that can have long-term impacts on schizophrenia, the population diagnosed with SIP do not receive these interventions. Those presenting with SIP are typically referred for substance use treatment with primary focus on substance abstinence, but the authors argue that patients presenting with SIP should in addition be receiving treatment closer to the guidelines for those with FEP.

Telemedicine for Initiation of Alcohol Use Disorder Medications 🔓

JAMA Network Open

While medications for alcohol use disorder (MAUD) are efficacious and can be prescribed in primary care or specialty behavioral health settings, only 2.2% of individuals with alcohol use disorder (AUD) in 2022 received MAUD in the past year. This case-control study examined telemedicine initiation of MAUD and compared the characteristics of US adults who initiate via telemedicine vs in-person care. While most MAUD initiations occur in person, telemedicine may play an important role in the initiation of these efficacious medications. Greater telemedicine use in higher-income areas supports concerns about how the “digital divide” may decrease access to care. Study limitations include findings that may not be generalizable to other populations, lack of race and ethnicity information, and an inability to observe initiations for people who pay fully out of pocket for outpatient AUD visits.

In The News

Developing new drugs to treat addiction

Drug Discovery News

Deep Links Between Alcohol and Cancer Are Described in New Report

The New York Times

Quitting Drinking Was Easy. Learning How to Be Myself Around Friends Was Hard.

The New York Times

Update on the DEA's efforts to reschedule cannabis: what you need to know

Reuters

U.S. sees a sudden and unexpected drop in fatal overdoses

National Public Radio (NPR)

New Treatments Address Addiction alongside Trauma

Scientific American