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ASAM Weekly for January 17, 2023

This Week in the ASAM Weekly

Pain and addiction have a close relationship. For example, research has shown that three days of opioids prescribed for acute postoperative pain can increase the chances of chronic opioid use. However, a study from JAMA Oncology has shown that a protocol limiting opioid prescriptions to three days upon discharge could reduce the association with chronic opioid use without compromising recovery in most postsurgical patients. Even individuals with chronic pain are trying to reduce their use of opioids and other pain medications, but in states with medical cannabis laws, reducing opioid use may be leading to a substitution with cannabis and possibly a reduction in effective, non-pharmacologic treatments (JAMA Network Open). Interestingly, the increasing use of cannabis and its relationship to pain (among other things) has prompted the American Society of Regional Anesthesia and Pain Medicine to publish a consensus guideline on the safe management of surgical patients using cannabinoids, which includes a recommendation for universal, and rather thorough, screening (Regional Anesthesia).

Non-physical pain and addiction also have a close relationship, likely adding to the intrigue of psychedelic medicine. The rapid antidepressant effect of psilocybin-assisted therapy should be further studied for dose-response and longer-term follow-up, but the potential transdiagnostic anxiolytic properties of psilocybin are intriguing (eClinical Medicine). A study on the associations of stigma, substance use, and depression demonstrates a process in which depression can create an awareness and acceptance of self-stigma which causes further psychological distress in individuals with substance use disorders (BMC Psychiatry). Evidently, insight can also be painful. 

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Thanks for reading,

Nicholas Athanasiou, MD, MBA, DFASAM
Editor in Chief

with Co-Editors: Brandon Aden, MD, Debra R. Newman, PA-C, MSPAS, MPH, Jack Woodside, MD, John A. Fromson, MD

 

Lead 

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 < .001), a 45% drop. Patients in the post-ROPP group also requested fewer refills compared to the pre-ROPP group. These results indicate that such a protocol is achievable for most patients, with the potential for reduced opioid use.

 

Research and Science

Single-dose psilocybin-assisted therapy in major depressive disorder: A placebo-controlled, double-blind, randomised clinical trial 🔓

eClinical Medicine

In this randomized, double-blind clinical trial, participants received either a single dose (0.215 mg/kg) of psilocybin, a preferential serotonin 1A/2A receptor agonist, or placebo for the treatment of major depressive disorder (MDD). Both groups also received psychological support. Mean differences two weeks post-treatment were −13.0 points on the Montgomery-Åsberg Depression Rating Scale (MADRS) and −10.5 points on the Beck Depression Inventory (BDI). This suggests that this single dose of psilocybin yields antidepressant effects in patients with MDD. Further trials with larger study populations and longer follow-up periods are needed.

 

ASRA Pain Medicine consensus guidelines on the management of the perioperative patient on cannabis and cannabinoids 🔓

Regional Anesthesia & Pain Medicine

In this article, the authors asked nine questions to develop consensus guidelines for management of cannabis use perioperatively. They provided grades along with the guidelines based on the level of evidence available. Among those recommendations with good evidence are universal screening for cannabinoids prior to surgery, counseling about potential risk if used perioperatively, including potentially worsening perioperative pain if used regularly, and counseling about potential risk of maternal cannabis use to fetus/neonate. Most of the other recommendations were advised to be used selectively based on professional judgment and patient needs. The authors also provided a negative recommendation against universal toxicology screenings. 

 

Use of Cannabis and Other Pain Treatments Among Adults With Chronic Pain in US States With Medical Cannabis Programs 🔓

JAMA Network Open

This cross-sectional study seeks to arrive at an accurate estimate of cannabis use or its substitution in place of pain treatments among adults with chronic noncancer pain.  Among adults with chronic pain in states with medical cannabis laws, 3 in 10 persons reported using cannabis to manage their pain. Most persons who used cannabis as a treatment for chronic pain reported substituting cannabis in place of other pain medications including prescription opioids. The high degree of substitution of cannabis for both opioid and nonopioid treatment emphasizes the importance of research to clarify the effectiveness and potential adverse consequences of cannabis.

 

Association Between Alcohol Use Disorder and Receipt of Direct-Acting Antiviral Hepatitis C Virus Treatment 🔓

JAMA Network Open

​​This study included 133,753 patients in the Veterans Health Administration between 2014 and 2017 who tested positive for hepatitis C virus (HCV) and had alcohol screening (AUDIT-C). In 2014, highly effective direct acting antiviral (DAA) treatment for HCV became available. Patients' alcohol use was current AUD (38%), abstinent with history of AUD (12%), at-risk drinking (14%), lower-risk drinking (6%), and abstinent with no history of AUD (30%). Patients were less likely to receive DAA treatment if they had current AUD (HR=0.75, 95%CI 0.70-0.81) or were abstinent with a history of AUD (HR=0.76, 95%CI 0.68-0.86), compared to patients with lower-risk drinking. Despite guidelines that recommend DAA treatment without consideration of alcohol use, even patients abstinent with a history of AUD were less likely to receive DAA treatment.

 

Learn More

Temporal associations between depressive features and self-stigma in people with substance use disorders related to heroin, amphetamine, and alcohol use: a cross-lagged analysis 🔓

BMC Psychiatry

More than two-thirds of people with depression have co-occurring drug use disorders. This study examined the cross-sectional and longitudinal relationships between features of depression and self-stigma in people with substance use disorders. Positive associations between depressive features and self-stigma were found in people with substance use disorders. Although these associations may be bidirectional longitudinally, the directions from depressive features to self-stigma may be stronger than the reverse directions, suggesting treatment of depression in earlier stages may prevent self-stigmatization and subsequent poor outcomes in people with substance use disorders.

 

Alcohol-Associated Hepatitis

New England Journal of Medicine

In this review article the authors summarize the current data around alcohol-associated liver disease (ALD), including predisposing factors, pathogenesis, diagnosis, prognosis, and management. Pathogenesis occurs both through direct damage from the acetaldehyde and from inflammation in response to increased pathogenic bacteria due to increased gut permeability. The main factor predicting long-term prognosis is prolonged alcohol abstinence, with episodes of alcohol-associated hepatitis associated with significant mortality. The authors also review treatments of alcohol use disorder in the context of ALD, including potential contraindications from advanced liver disease or kidney disease. In addition, while the authors discuss some of the emerging therapies, they do note additional research is needed to understand determinants of ALD, including severe forms, and for development of new therapies. 

 

Outpatient Rapid Microinduction of Sublingual Buprenorphine in 3 Days From Methadone for Opioid Use Disorder 🔓

Primary Care Companion CNS Disorders

This case report describes a patient transitioned from methadone to buprenorphine over 3 days in an outpatient setting. The patient continued to receive methadone 72mg during the 3-day transition. On day 1, buprenorphine was administered in divided doses totaling 2mg. On day 2, buprenorphine 4mg was administered in divided doses. On day 2, the patient experienced withdrawal symptoms described as mild (COWS 7) and treated with clonidine 0.1mg, ondansetron 4mg, and trazodone 50mg hs. On day 3, buprenorphine 8mg in divided doses produced minimal withdrawal (COWS 2). No methadone was administered on day 4 and buprenorphine was continued. The authors note that this 3-day protocol is shorter than the 4-10 days typically described.