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ASAM Weekly for April 18th, 2023

This Week in the ASAM Weekly

If you follow Altmetric scores, this week’s lead publication is getting a lot of attention. A meta-analysis of over 100 studies, it found that low-moderate daily alcohol intake does not protect against all-cause mortality. In fact, just a few to several drinks per day -- with differences based on gender -- can significantly increase these risks (JAMA Network Open).

Many people in the addiction field are also paying attention to the pending changes around COVID telehealth rules, especially regarding OUD treatment. Not only has receipt of medications for OUD (MOUD) via telehealth been associated with a reduction in nonfatal overdose, but a follow-up study has demonstrated reduced odds of fatal drug overdoses as well (JAMA Psychiatry). Instead of placing restrictions on MOUD access, authorities should be promoting equity in OUD treatment (Drug and Alcohol Dependence) and telehealth could be a part of this.   

Xylazine has many worried about its presence in the drug overdose crisis (NBC News). Interestingly, a large, multicenter study of emergency department patients found xylazine was associated with lower odds of cardiac arrests or coma in opioid overdose. As the authors consider, the elusive reasons may have to do with concentration (Clinical Toxicology). 

Broadening addiction education is always an important topic. Empathy-based nursing education could help reduce stigma in newer-to-practice nurses as an older generation gets ready to retire (American Journal of Nursing). And for those clinicians who have not already fulfilled the requirements, the new DEA license renewal requirement for addiction training will be coming soon (MedPage Today).

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 

Association Between Daily Alcohol Intake and Risk of All-Cause Mortality ðŸ”“

JAMA Network Open

This updated systematic review and meta-analysis investigated the association between alcohol use and all-cause mortality. Among occasional (>0 to <1.3 g of ethanol/day) or low-volume drinkers (1.3-24.0 g of ethanol/day) there was no significantly reduced risk of all-cause mortality compared with lifetime nondrinkers. There was an increased risk of all-cause mortality for drinkers who drank 25 grams or more and a significantly increased risk when drinking 45 grams or more daily. Additionally, a larger risk of all-cause mortality was found for women compared to men when drinking 25 grams or more per day.

Research and Science

Association of Receipt of Opioid Use Disorder–Related Telehealth Services and Medications for Opioid Use Disorder With Fatal Drug Overdoses Among Medicare Beneficiaries Before and During the COVID-19 Pandemic ðŸ”“

JAMA Psychiatry

In this cohort study of a prepandemic cohort comprising 105,162 beneficiaries and a pandemic cohort comprising 70,479 beneficiaries, receipt of opioid use disorder (OUD)-related telehealth services and receipt of medications for opioid use disorder (MOUD) during the pandemic were associated with reduced odds for fatal drug overdose. This study found that emergency authorized telehealth expansion and MOUD provision during the COVID-19 pandemic were associated with lower odds of fatal drug overdose, demonstrating the potential benefits of continuing these services.

Development of Mobile Contingency Management for Cannabis Use Reduction 

Behavior Therapy

In this pilot study, the authors conducted a sequential cohort study to evaluate a mobile contingency management program for cannabis use. The study involved 3 sequential cohorts, with changes to the program implemented between cohorts based on feedback from each group. The overall goal of this contingency program was a reduction in cannabis use, not abstinence. In each cohort, the authors found statistically significant decreases in both days of use (48.33%, 55.29% and 48.9% reductions) and grams used (60.8%, 67.36%, and 56.03% reductions). A subsequent trial is planned to evaluate potential effects of reduction in cannabis use on functional and mental health. 

ASAM REMS
 

Interaction between maternal immune activation and peripubertal stress in rats: impact on cocaine addiction-like behaviour, morphofunctional brain parameters and striatal transcriptome ðŸ”“

Translational Psychiatry

Substance use disorders are more prevalent in schizophrenia. Maternal immune activation (MIA) is associated with schizophrenia which may be triggered by stressful experiences during adolescence. This study used a double-hit rat model, combining MIA and peripubertal stress (PUS), to study cocaine addiction and the underlying neurobehavioural alterations. MIA facilitated the acquisition of cocaine self-administration and increased the motivation for the drug; however, PUS reduced cocaine intake, an effect that was reversed in MIA + PUS rats. On its own, PUS reduced hippocampal volume and hyperactivated the dorsal subiculum, also having a profound effect on the dorsal striatal transcriptome. However, these effects were obliterated when PUS occurred in animals with MIA experience. These results describe an unprecedented interplay between MIA and stress on neurodevelopment and the susceptibility to cocaine addiction.

 

Opioid overdoses involving xylazine in emergency department patients: a multicenter study

Clinical Toxicology

The authors examine clinical outcomes in this multicenter prospective cohort study among suspected non-fatal opioid overdoses that do versus do not involve the adulterant xylazine, a central alpha-2 adrenergic agonist. Out of 321 patients included, 28% tested positive for xylazine and 82.6% received naloxone. While cardiovascular-related outcomes were uncommon, xylazine-negative patients were more likely to have the events (14.3% vs 4.4%, p-0.013). In multivariate logistic regression models, xylazine exposure was associated with lower odds of coma within 4 hours (OR=0.52) and cardiac arrest (OR=0.30). The authors hypothesize that the lower odds of these outcomes in xylazine-positive patients may be due to lower opioid concentrations in xylazine-adulterated drugs. They suggest future studies evaluate the serum concentration of opioids and xylazine.

Learn More

Nitrous oxide misuse: a clue not to be missed in young patients with venous thromboembolism ðŸ”“

Clinical Medicine

A 2021 drug use survey in the UK found 10% of participants had used nitrous oxide in the past year. This paper from London, UK, reports on 2 cases of thrombosis as a result of nitrous oxide misuse. The first case is a 27-year-old man with a swollen leg and venous thrombosis extending from the inferior vena cava to the popliteal vein. He also had sensory loss due to vitamin B12 deficiency. The second case is a 21-year-old woman with headache due to cerebral venous sinus thrombosis. Both reported daily nitrous oxide misuse. Thrombosis, venous and arterial, associated with nitrous oxide was reported in 2017 and is believed to result from homocysteine accumulation resulting from altered B12 function. The authors note that nitrous oxide is often perceived as harmless and suggest public education about the risks of nitrous oxide misuse.

 

Duration of medication for opioid use disorder during pregnancy and postpartum by race/ethnicity: Results from 6 state Medicaid programs

Drug and Alcohol Dependence

This descriptive study of Medicaid-enrolled women with OUD compared receipt, duration, and type of MOUD during pregnancy and the first 12 months postpartum. In six state Medicaid programs, racial and ethnic inequities were found in receipt and duration of MOUD during these periods. A higher percentage of White non-Hispanic women had any MOUD during this time. Racial and ethnic disparities in provision of MOUD exist in this population of women with OUD.

 

Original Research: Nurses' Self-Assessed Knowledge, Attitudes, and Educational Needs Regarding Patients with Substance Use Disorder ðŸ”“

American Journal of Nursing

This study used Facebook to recruit nurses providing direct patient care in a hospital setting. The nurses completed an online survey that included the 20 item Drug and Drug Problems Questionnaire to assess knowledge and attitudes towards people who use drugs. A total of 691 nurses completed the surveys and met inclusion criteria. The findings show that, in general, hospital nurses have negative attitudes towards patients with SUD. Nurses working in mental health units had significantly more positive attitudes (p<0.001). Also, older nurses had significantly more positive attitudes (26-42 yrs. v. 55-73 yrs., p=0.02). Many nurses saw SUD as an intentional choice rather than a chronic illness. The authors conclude that there is a need for “empathy-based nursing education.”