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ASAM Weekly for April 11th, 2023

This Week in the ASAM Weekly

Challenges that arise in addiction are opportunities for effective interventions. A research letter from JAMA Psychiatry found that overdose in older Americans, although uncommon, has quadrupled over the last 20 years indicating that Medicare parity is an important policy focus. Stimulants are driving a fourth wave of the overdose crisis, so it is time for a thoughtful approach to deploy contingency management across the US (Johns Hopkins). 

Mothers with substance use disorders often face a Catch-22 barrier with addiction treatment and deserve changes in health care delivery and child custody laws (Medpage Today). Black girls involved with youth punishment systems often experience significant trauma on individual and structural levels yet interventions have often focused on the behavioral manifestations. Instead, interventions should be focusing on the underlying traumas (Addictive Behaviors).

Robust results can come from sound interventions. Over three decades of the California Tobacco Control Program prevented over 9.5 million person-years of smoking and 15.7 billion packs of cigarette consumption with a return-on-investment of $231 per $1 spent (PLOS One). These outcomes should be at the forefront as as we discuss cannabis policy, including exploring a standardized measurement of dose and minimum unit pricing (Addiction). Unfortunately, the existence of an illicit cannabis market makes it difficult to predict whether policies effective for tobacco and alcohol will work with cannabis.    

Lastly, researchers made an important finding about emergency department-initiated buprenorphine treatment in the fentanyl era. A study across 28 diverse ED’s found the incidence of precipitated withdrawal was less than 1% -- rates similar to what we’ve seen with heroin and prescription opioid use (JAMA Network Open). 

Enjoy the conference and 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 

Shared genetic liability for alcohol consumption, alcohol problems, and suicide attempt: Evaluating the role of impulsivity ðŸ”“

Translational Psychiatry

This study investigated the extent to which shared liability for alcohol consumption and problems (ACP) and suicide attempt (SA) is genetically related to five dimensions of impulsivity. Common genetic liability to ACP and SA was significantly correlated with all five impulsive personality traits examined, and the largest correlation was with lack of premeditation, though supplementary analyses suggested that these findings were potentially more strongly influenced by ACP than SA. These analyses have potential implications for screening and prevention: Impulsivity can be comprehensively assessed in childhood, whereas heavy drinking and suicide attempt are quite rare prior to adolescence. Features of impulsivity may serve as early indicators of genetic risk for alcohol problems and suicidality.

Research and Science

Patient Perceptions of Integrating Meditation-based Interventions in Office-based Opioid Treatment with Buprenorphine: A Mixed-methods Survey 

Journal of Addiction Medicine

This study surveyed 72 patients receiving buprenorphine for OUD in a primary care clinic about meditation practices. A majority of patients reported having ever used a variety of meditation practices, and only 10% reported never having practiced meditation. They felt that meditation reduced stress, anxiety, or depression (70%), pain (63%), substance use (61%), craving (58%), risk of relapse (55%), and opioid withdrawal (52%). Encounters with clinicians was the most commonly cited reason for initiating meditation. Daily practice was reported by 40%, and 42% practiced at least weekly. The authors note the high acceptance of meditation in patients receiving MOUD and suggest increasing its availability.

 

Smoking and healthcare expenditure reductions associated with the California Tobacco Control Program, 1989 to 2019: A predictive validation ðŸ”“

PLOS One

In this study, the authors update an evaluation of the impact of the California Tobacco Control Program (CCTP) from 2008 to assess impact of the program on prevalence of smoking and packs of cigarettes consumed. In addition, they model the health care cost saving attributed to the program. The updated model highly correlated with the previous model and estimated that for each dollar spent on the program there was a reduction in prevalence of 0.05% and consumption by 2.23 packs. Between 1989 and 2019, the program was estimated to prevent 9.5 million person-years of smoking and have saved between $544 and $816 billion in health care expenditures. Given a cost of $3.5 billion, the program return on investment was $231 for every $1 dollar spent, supporting that the program not only had health impact, but also significant financial return. 

ASAM REMS
 

Exploring substance misuse behaviors among black girls in detention: Intersections of trauma, sex, and age ðŸ”“

Addictive Behaviors

This study investigated the degree to which a history of abuse, trauma, gang involvement, and risky sex correlate with substance misuse among Black girls in the Atlanta detention system. Of the nearly 200 girls who participated, some 56% reported using drugs while having sex in the last 30 days; 15% self-reported a problem with drugs. Nearly 50% of girls with an SUD reported a history of moderate or severe physical abuse, or sexual abuse. Younger girls were more likely to have a higher prevalence of having a problem with substances than older girls at baseline. The need remains to focus on individual and macrostructural inequalities that impact the health and well-being of this population.  


Learn More

Incidence of Precipitated Withdrawal During a Multisite Emergency Department–Initiated Buprenorphine Clinical Trial in the Era of Fentanyl ðŸ”“

JAMA Network Open

Emergency departments (EDs) are an important setting in which to initiate buprenorphine for patients with opioid use disorder, but there may be concerns about precipitated withdrawal (PW) among persons using fentanyl, given its potency. In this cohort study, the authors examine data from a randomized trial initiating sublingual buprenorphine (BUP) versus extended-release buprenorphine (XR-BUP). Among 1200 enrolled patients, who were all positive for fentanyl, only 9 developed PW (5 who received BUP and 4 who received XR-BUP). Given these findings across 28 geographically diverse EDs, the authors conclude that even with increase in fentanyl use, buprenorphine remains safe and continued access in EDs is essential. 

 

Twenty-Year Trends in Drug Overdose Fatalities Among Older Adults in the US

JAMA Psychiatry

US opioid overdose deaths have been concentrated in the working-age population, but older adults may be at increasing risk as the baby boom generation ages. This study calculated the annual overdose death rate from 2002 to 2021 for all US adults 65 years or older and contribution of overdose to all-cause mortality. The rate of fatal drug overdoses among people 65 years and older quadrupled in 2002, with highest rates among non-Hispanic African American individuals. Concurrently, mortality from alcohol poisoning rose from 10 deaths in 2002 to 279 in 2021. The share of all-cause mortality attributable to drug overdose increased 359% during this period. By 2021, 1 in 370 deaths among those 65 years and older was caused by an overdose.

 

Using the standard THC unit to regulate THC content in legal cannabis markets ðŸ”“

Addiction

This commentary cites evidence that consumption of higher potency cannabis products is associated with worse health outcomes. The authors discuss various approaches to regulating THC content. They suggest that labeling %THC or mgTHC can be confusing when comparing products such as flowers, extracts, or edibles. They also point to the regulation of alcohol content by the international development of a standard alcohol unit. Setting a minimum price per alcohol unit in Scotland resulted in a prompt decrease in alcohol consumption. A standard THC unit of 5mg is a low dose similar to the standard alcohol unit. Products would then be labeled by the number of standard THC units they contained.
 

Prenatal nicotine exposure alters gene expression profiles of neurons in the sub-regions of the VTA during early postnatal development ðŸ”“

Scientific Reports

Nicotine exposure during early development results in sensory and cognitive processing problems in adults. This animal study investigated the influence of perinatal nicotine exposure on gene expressions of neurons within the following sub-regions of the ventral tegmental area (VTA): the parabrachial pigmented nucleus (PBP), parainterfascicular (PIF), and paranigral nucleus (PN). The dopamine marker tyrosine hydroxylase demonstrated consistently increased significance in PN compared to PIF and PBP, indicating that following perinatal nicotine exposure, VTA dopamine neurons (especially within the PN) are significantly activated from birth.