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ASAM Weekly for April 25th, 2023

This Week in the ASAM Weekly

Overdose and suicide are known relatives. A recent study looking at population-level data found a positive association between reductions in opioid prescribing and suicide deaths, which may lead some to question prior cohort studies about opioid tapering and mental health crisis (American Journal of Psychiatry). But could the findings actually be complimentary?

Firearm possession is a well-known risk factor for suicide. A study demonstrating a dose-response curve in the alcohol-firearm-suicide connection highlights the benefit of targeting alcohol use in reducing gun deaths (JAMA Network Open). Somewhat relative to this is loneliness, or more specifically living alone, which may also be demonstrating itself as a risk factor in overdose deaths (JAMA Psychiatry). 

Even homelessness, or rather our response to it, can increase drug-related morbidity and mortality while driving up associated costs (JAMA). Modeling studies touch upon the cost-savings of prevention which can be improved when researchers and funders collaborate to develop services that are scalable and sustainable ( Psychiatric Services). 

Looking forward, Dr. Volkow is setting a bold trajectory for neuromodulation in addiction treatment (Milken Institute) and the future of psychedelic medicine almost feels inevitable (Nature). For people suffering from long covid, the psychedelic hope of symptom relief is not at all unreasonable (TIME). 

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 

Opioid Prescribing and Suicide Risk in the United States

The American Journal of Psychiatry

Approximately 40% of overdose suicide deaths in the United States involve opioids. Because of their respiratory depression effects and narrow therapeutic window, opioids pose a greater risk than any other drug class of an intentional overdose proving to be lethal.  In this retrospective study of US commuting zone–level opioid prescriptions and mortality, regional decreases in opioid prescriptions were consistently associated with declines in total suicide deaths, including suicide overdose deaths involving opioids. For some opioid prescribing measures, negative associations were observed with unintentional overdose deaths involving opioids among younger people. Individual-level inferences are limited by the ecological nature of the analysis.

Research and Science

Association Between Acute Alcohol Use and Firearm-Involved Suicide in the United States ?

JAMA Network Open

This cross-sectional study investigated the association between amount of alcohol consumed and probability of using a firearm as the method of suicide. Using mortality data from the US National Violent Death Reporting System (NVDRS), the probability of using a firearm as the method of suicide when alcohol was consumed was found to be higher for male decedents; this started at just below a BAC level of 0.50 and increased to approximately 0.75. For female decedents, the numbers were at just above 0.30 to just below 0.55. Hence, increasing amounts of alcohol consumed increases the probability of suicide to a certain BAC level. One prevention strategy may be to address alcohol use among individuals at risk of suicide.

 

Use of residential opioid use disorder treatment among Medicaid enrollees in nine states

Journal of Substance Abuse and Addiction Treatment

This study explored the use of residential treatment for OUD in the Medicaid program of 9 states. Federal law prohibits Medicaid reimbursement for residential facilities with >16 beds. Since 2015, states could request waivers allowing funding of residential treatment. Claims data for 491,071 Medicaid enrollees were analyzed. Overall 7.5% of enrollees had residential treatment with a range of 0.3% to 14.6% among states. Those receiving residential care were more likely to be younger (55% <35 yo vs. 41%, p<0.001) and male (58% vs 45%, p<0.001). Those in residential treatment were more likely to have co-occurring SUDs (91% vs 57%, p<0.001). The authors note considerable heterogeneity in residential treatment among states.

ASAM Review Course
 

Epidemiology of injecting drug use, prevalence of injecting-related harm, and exposure to behavioural and environmental risks among people who inject drugs: a systematic review ?

The Lancet Global Health

This literature review compiled worldwide data on injection drug use from 190 countries representing 99.4% of the world’s population aged 15 to 64 years. Reports from 2017-2022 were added to the previous review published in 2017. Worldwide, 0.29% injected drugs, ranging from 0.10% in the Middle East to 1.38% in North America. More than four times as many men injected (0.49%) as women (0.11%). Among people injecting drugs, 15% had HIV, 39% had HCV and 32% had a recent skin or soft tissue infection. Opioids were the primary drug injected for 80%. In addition, 25% experienced recent homelessness, 58% had a lifetime history of incarceration and 15% had recently engaged in sex work. Since the 2017, study there have not been substantial reductions in HIV, HCV or HBV, suggesting that harm reduction has yet to have a notable impact globally.

 

Population-Level Health Effects of Involuntary Displacement of People Experiencing Unsheltered Homelessness Who Inject Drugs in US Cities

JAMA

Of the half million people in the US experiencing homelessness, more than 30% have a substance use disorder (SUD). This study sought to investigate the long-term effects of involuntary displacement of this population in 23 cities across the country. Outcomes included overdose mortality, serious injection–related infections and mortality related to these infections, hospitalizations, and life-years lived over a 10-year period. Using a closed-cohort microsimulation model, a substantial increase was found in drug-related morbidity and mortality compared to unhoused persons who were not displaced. These results have implications for the practice of involuntary displacement, including access to housing and supportive services.

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Living Alone and Drug Overdose Deaths in the US

JAMA Psychiatry

This nationally representative cohort study compared risk of fatal overdose among adults who were living alone or with others. From 2008-2019, the overall drug overdose death rate was 10.56 per 100 000 person-years -- 11.84 for adults who lived alone and 10.37 for adults who lived with others. There was a 42% increased risk of overdose death for persons living alone after adjusting for age, sex, and race and ethnicity. The adjusted hazard ratio (aHR) between living alone and overdose death varied; the largest aHRs were among unemployed adults aged 65 years or older, other non-Hispanic racial and ethnic groups, adults with incomes above $125,000, and Hispanic adults. Among adults 18-29 years of age, being separated or divorced, never married, and with incomes of $40,001-$75,000, living alone was associated with a lower aHR. These results suggest that people who live alone are likely an at-risk population for overdose death.

 

From Prevention Science to Services: Identifying Paths to Sustainable Evidence-Based Preventive Interventions 

Psychiatric Services

This article notes that even when research demonstrates the efficacy of mental health prevention programs, they may not be implemented due to lack of funding. Three sources of funding are discussed. The Affordable Care Act requires payors to cover preventive services with an A or B grade from the US Preventive Services Task Force. Interventions for illicit drug use are graded I, insufficient evidence to assess. The authors call for research designed specifically to advance the grade to A or B. The 2018 Family First Prevention Services Act can fund prevention services that prevent youth’s entry into foster care. Research needs to be tailored to meet the Act’s definition of evidence-based. States have funds from SAMHSA block grants that can be used for preventive services but states need to have uniform criteria that could be targeted by research. Preventive service research needs to be designed with criteria of funders in mind.

 

The traps of adaptation: Addiction as maladaptive referent-dependent evaluation ?

Cognitive, Affective, and Behavioral Neuroscience

In the US, it is estimated that addiction accounts for up to 20% of deaths each year and for one-third of inpatient hospital costs. Referent-dependent evaluation theories propose that the ongoing context influences how the brain attributes value to stimuli. This paper casts addiction as a form of maladaptive referent-dependent evaluation. Specifically, addiction is proposed to arise from the establishment of an excessive reference point following repeated drug consumption. This formulation has important analogies with classical accounts of addiction, such as set point theories and associative learning theories, as well as the pattern of striatal dopaminergic activity observed in addiction, a key neural signature of the disorder.