This Week in the ASAM Weekly

Remove Arbitrary Barrier to Evidence-based Treatment for Stimulant Use Disorder

Richard Rawson, PhD

Although the current overdose crisis in the US is almost universally referred to as the “opioid” or “fentanyl crisis” the overdose death rate associated with psychomotor stimulants including methamphetamine and cocaine has also dramatically increased in recent years. A recent report using CDC data documented a “50-fold increase in the methamphetamine mortality rate” from 1999-2021. Of the 32,353 total methamphetamine-associated deaths in 2021, 61.2% included fentanyl, meaning that that, 38.2% -- or 12, 617 deaths -- did not involve fentanyl. Other CDC data also indicated a tripling of cocaine-related deaths, with and without fentanyl. Thus, it would be a misrepresentation of the 2023 overdose crisis to be viewed as exclusively an opioid or fentanyl crisis.

Read the full editorial here.

Lead

Why do we focus on the exception and not the rule? Examining the prevalence of mono- versus polysubstance use in the general population.

Addiction

Most literature on substance use disorders (SUD) is focused on single drug classifications and does not typically include polysubstance use (PSU), particularly in treatment studies where persons with PSU are often excluded. Using the National Survey on Drug Use and Health (NSDUH) from 2015 to 2019 this study assesses the prevalence of PSU versus mono-use patterns. They found that among those who reported use of at least one substance in the last year, the majority (64%) reported mono-use, primarily alcohol use (90%). However, among those with 2 or more diagnostic criteria for SUD, mono-use was much less frequent (26%) and even less frequent among those who sought care for SUD (22%). Given these findings the authors contend research should include those with PSU whenever possible and consideration of PSU should be part of clinical evaluations and treatment.

Research and Science

The motives and methods of methamphetamine and ‘heroin’ co-use in West Virginia 🔓

Harm Reduction Journal

In southwestern West Virginia, 30 people who inject opioids and also use methamphetamine were interviewed about their co-use. Three patterns of use emerged. Simultaneous injection was mostly to enhance, synergistically, the effects of the two drugs. Of interest, this practice, referred to as a “speedball”, was uncommon prior to 2015. Others used the two drugs at different times of the day according to which effect was desired. Some used methamphetamine to manage opioid withdrawal. Others believed that methamphetamine could prevent or treat an opioid overdose. Other studies suggest that co-use increases the risk of overdose. Some used methamphetamine only because it was available, cheap or being offered by friends but didn’t find the effects desirable.

Cytisinicline for Smoking Cessation A Randomized Clinical Trial

JAMA

Cytisinicline, also known as cystisine, is an alkaloid found in plants that, like varenicline, is a partial agonist at the a2b4 nicotinic acetylcholine receptor. It is used as a OTC smoking cessation aid in Europe. This study is a randomized, double-blind, phase 3 trial of cystisinicline’s efficacy and tolerability for smoking cessation. Individuals (n=810) were randomized to 3 groups, 6 weeks of cytisinicline, 12 weeks of cytisinicline, or placebo. Tobacco abstinence was verified by exhaled carbon monoxide. Continuous abstinence through 6 months was achieved by 9% treated for 6 weeks (OR 3.7), and by 21% treated for 12 weeks (OR 5.3), both p<0.001. Among adverse events, only abnormal dreams and insomnia were significantly different from placebo. Two other studies comparing cytisinicline with varenicline found significantly fewer adverse events with cytisinicline.

Lessons learned from statewide contingency management rollouts addressing stimulant use in the Northwestern United States

Preventive Medicine

This paper describes the training and technical assistance (TTA) efforts and lessons learned for two state-wide stimulant-focused contingency management (CM) implementation projects in the Northwestern United States (Montana and Washington). Site-specific implementation barriers such as logistical fit precluded implementation in more than 50% of the trained sites; however, strategies tailoring details of the intervention to fit the site aided in implementation, resulting in successful implementation in a diverse cross-section of service sites across the states. The lessons learned add to the body of literature describing CM implementation barriers and solutions.

Leveraging existing provider networks in Europe to eliminate barriers to accessing opioid agonist maintenance therapies for Ukrainian refugees 🔓

PLOS Global Public Health

Ukraine has one of the highest prevalence rates of Opioid use disorder (OUD) in Europe and with the Russian invasion many refugees with OUD who were in treatment were displaced and at risk for continued care. In this qualitative study, they examine barriers to treatment for these refugees and potential lessons learned. The barriers included capacity in the existing programs, language barriers, financial, and geographic constraints. Many of these barriers are frequent barriers to access OUD care in general but were particularly problematic for the refugee population. In interviews with providers, they found that there were some formal and informal networks of providers in various countries, but they were not well utilized. The authors suggest such networks could be better used in this crisis and developed to address potential future similar crises.

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Development of a neural network model to predict the presence of fentanyl in community drug samples 🔓

PLOS One

Increasingly, Fourier-transform infrared (FTIR) spectroscopy is being used as a harm reduction tool to provide people who use drugs real-time information about the contents of their substances. However, FTIR spectroscopy has been shown to have a high detection limit for fentanyl and interpretation of results by a technician can be subjective. This poses concern, given that some synthetic opioids can produce serious toxicity at sub-detectable levels. The objective of this study was to develop a neural network model to identify fentanyl and related analogues more accurately in drug samples compared to traditional analysis by technicians. It found that neural network models can accurately predict the presence of fentanyl and related analogues using FTIR data, including samples with low fentanyl concentrations. Integrating this tool within drug checking services utilizing FTIR spectroscopy has the potential to improve decision making to reduce the risk of overdose and other negative health outcomes.

Involvement of the Opioid Peptide Family in Cancer Progression 🔓

Biomedicines

Opioids can exert an antitumoral effect or promote tumor growth and metastasis. No clinical studies have been performed concerning the antitumor action of opioid peptides/opioid-peptide receptor antagonists. This review updates findings related to opioid peptides (enkephalins, endorphins, and dynorphins) and their role in cancer development. Methionine-enkephalin (MET) is the most common opioid peptide studied in cancer. The authors determined that a systematic study on the role of these opioid peptides and their receptors in many types of cancers is urgently needed. This would include their role in tumor progression, the tumor microenvironment, and as tumor agents. Knowledge of which opioid receptors and signaling pathways are involved in cancer progression can better establish strategies for the future.

E-Cigarettes and Stroke Risk—Present Uncertainties and Future Directions

JAMA Neurology

There are multiple toxins in e-cigarettes that could impact risk for stroke. However evidence about the role e-cigarettes play in stroke is lacking. Studies are needed that consider smoking status (current, former, never smokers), duration/frequency of use, and age. Additives and other toxins present also need consideration. This will help in evaluating the effects of these devices on subsequent stroke. Clearly a need exists for funding research able to address these and other concerns.

In The News

E-Cigarettes and Stroke Risk—Present Uncertainties and Future Directions

JAMA Neurology