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The ASAM Weekly for April 23rd, 2024

This Week in the ASAM Weekly

Mortality is a critical concern with addiction. A study of over 1.47 million people across 8 countries demonstrates how mortality after prison release is really an international problem. Alcohol and other drug (AOD) poisonings -- along with suicides -- were the leading cause of death within the first two weeks post-release, but AOD poisonings continued to lead in all-cause mortality for the remaining 24 year time-period observed in the study (The Lancet).

Alcohol is recognized as an important factor in violence-related mortality also. A study analyzing US state-level policies found that one standard deviation in the Alcohol Policy Scale was associated with a 6% decline in homicide rates. The authors presented a model in which a shift from less to more restrictive policies could save 1200 lives annually (American Journal of Preventive Medicine). 

Addiction-related mortality is also a geo-political problem. A journalistic review of the Durango-Chicago Heroin Highway explores how economic modernization in Mexico is connected to the millions of lives lost in the opioid epidemic (The Conversation). A US House Panel is accusing the Chinese Communist Party of also contributing to American mortality by subsidizing and fueling the fentanyl crisis (Axios)

However, a number of interventions are associated with mortality reduction. Giving doses of buprenorphine that are above the FDA recommended 16mg within the first 30 days of treatment are associated with reductions in not only opioid overdose deaths, but all-cause deaths as well. The benefits can last up to 365 days (Journal of Addiction Medicine). A novel formulation of naloxone -- as a nasal swab -- absorbs more rapidly and with a higher concentration bringing the potential for many untrained bystanders to save countless lives (Drug and Alcohol Dependence). 

It goes without saying then, but is worth repeating -- treat addiction, save a lot of lives.

Thanks for reading,

Nicholas Athanasiou, MD, MBA, DFASAM
Editor in Chief

with Co-Editors: Brandon Aden, MD, MPH, FASAM, Jack Woodside, MD, John A. Fromson, MD

 

ASAM Clinical Algorithm Subcommittee

As a part of ASAM’s mission to define and promote evidence-based best practices in addiction prevention, treatment, remission, and recovery, the ASAM Clinical Algorithm Subcommittee will collaborate with ASAM staff in refining the 4th Edition clinical algorithms for ASAM Criteria based assessment tools.  

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Lead Story

Preventing deaths after prison release

The Lancet

Formerly incarcerated people have exceptionally poor health profiles and are at increased risk of preventable mortality when compared to their general population peers. This accompanying editorial discusses a study by Borschmann et al published in the same issue of The Lancet. Using administrative data from the multi-national Mortality After Release from Incarceration Consortium (MARIC) study, the authors examined mortality outcomes for 1,471,526 people released from incarceration in eight countries. 75,427 deaths were recorded. The markedly elevated rate of death in the first week post-release underscores an urgent need for investment in evidence-based, coordinated transitional healthcare, including treatment for mental illness and substance use disorders to prevent post-release deaths due to suicide and overdose. Temporal variations in rates and causes of death highlight the need for routine monitoring of post-release mortality.

Research and Science

A phenome-wide association and Mendelian randomisation study of alcohol use variants in a diverse cohort comprising over 3 million individuals ðŸ”“

eBioMedicine

Negative social and health outcomes may be direct consequences of drinking alcohol, or they may reflect common genetic factors that influence both alcohol consumption and other outcomes. This study performed exploratory phenome-wide association studies (PheWAS) of three of the best studied protective single nucleotide polymorphisms (SNPs) that have been consistently implicated by both candidate gene studies and genome-wide association studies of alcohol-related behaviors, but have not been investigated in detail for other relevant phenotypes in a hypothesis-free approach in such a large cohort of multiple ancestries. Results demonstrate that polymorphisms in the genes that encode alcohol metabolizing enzymes affect multiple domains of health beyond alcohol-related behaviors. Understanding the underlying mechanisms of these effects may have useful implications for treatments and preventative medicine.

Higher First 30-Day Dose of Buprenorphine for Opioid Use Disorder Treatment Is Associated With Decreased Mortality ðŸ”“

Journal of Addiction Medicine

This study compared the average daily dose of buprenorphine (transmucosal) during the first 30 days after initiation with mortality rates over the subsequent year. Data was obtained from Kentucky databases for 47,857 patients. The average daily dose was <8mg for 21% of patients, 8-16mg for 49%, and >16mg for 30%. During the follow-up year, 686 patients died -- 33% from opioid-involved overdoses. Compared to the group receiving <8mg, opioid overdoses were reduced by 55% for those receiving 8-16mg and by 64% for those receiving >16mg. The deaths from other causes (primarily overdoses from other drugs) and all-cause mortality was also reduced, though to a lesser degree. The authors conclude that higher first 30-day buprenorphine doses were associated with reduced mortality.

Bystander-application of a novel nasal swab optimized for drug delivery is safe and non-traumatic for the general population

Drug and Alcohol Dependence

Previous studies have shown that naloxone delivered by nasal swab resulted in more rapid absorption and higher blood concentrations at 2.5 minutes that naloxone nasal spray. These results are likely due to increased delivery to the inferior turbinate which has large surface area and rich blood supply. This study confirmed that non-medically trained personnel could use the swab in patients with abnormal nasal anatomy. Sixteen patients were divided into groups of four each: normal nasal anatomy, nasal obstruction/deviated septum, prior nasal surgery, and prior sinus surgery. Swabs soaked in fluorescein were administered by untrained personnel and then endoscopy determined the location of fluorescein staining and evidence of nasal trauma. There were only a few events of minor mucosal trauma and bleeding. The study found satisfactory delivery to the inferior turbinate in all patients, with somewhat improved delivery in those with normal anatomy and prior sinus surgery. 

ASAM PAM 7

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Relationships of State Alcohol Policy Environments with Homicides and Suicides ðŸ”“

American Journal of Preventive Medicine

This study examined the effect of changes in states’ alcohol policies on death rates. Each year from 2002 to 2018 was rated on the Alcohol Policy Scale (APS). The APS is associated in prior studies with binge drinking, drinking and driving, and cirrhosis mortality. An increase in the APS of one standard deviation was associated with a 6% decline in homicides overall and firearm homicides. The authors estimate that a nationwide increase in alcohol restrictions could result in 1,200 fewer homicide deaths annually. No association was found between changes in APS and deaths by suicide. The authors suggest that the lack of effect on suicides may be that many policy changes only affect drinking in public places (such as BAC limits and serving intoxicated persons) where fatal disputes are more likely to occur. The authors conclude that more restrictive alcohol policies could reduce homicides.

Efficacy and safety of psychedelics for the treatment of mental disorders: A systematic review and meta-analysis ðŸ”“

Psychiatry Research

In this systematic review, the authors examine clinical trials from 1960 onward that evaluate various psychedelics as monotherapy or adjunct therapy for mood disorders and other mental disorders. Included studies assessed four psychedelics for treatment of mood disorders. The review found an overall improvement in negative mood, with psilocybin showing the strongest effect. The authors also found that LSD was associated with improvement when treating alcohol use disorder, while MDMA-assisted psychotherapy was associated with reduced PTSD symptoms. The authors note these findings suggest psychedelic-assisted treatment may offer new opportunities, but many of the studies were a small sample size, leaving potential for adverse effects and abuse. 

Stepped Care for Patients to Optimize Whole Recovery (SC-POWR): An Effectiveness Trial Evaluating a Stepped Care Model for Individuals With Opioid Use Disorder and Chronic Pain

Substance Use and Addiction Journal

Chronic pain (CP) is more common among persons with opioid use disorder (OUD) and can have a negative impact among patients receiving medications for OUD (MOUD). Persons with CP receive MOUD may experience pain exacerbations, which can lead to nonmedical opioid use, leaving treatment, depression, or other substance use. The authors found some evidence that cognitive behavioral therapy (CBT) may help these patients with improved outcomes and decreased pain. This paper describes a randomized study evaluating MOUD, MOUD plus CBT, onsite exercise, and stress reduction over 24 weeks. The study assesses nonmedical opioid use and pain as its primary outcomes. In addition, it will evaluate retention in MOUD, depression, stress and alcohol use. 

What Risks Do Offspring of Parents With Alcohol Use Disorder Face? ðŸ”“

American Journal of Psychiatry

A study by Kendler et al. examined parent and offspring data from a large Swedish population sample to determine the relative magnitude of transmission of risk for five disorders -- alcohol use disorder [AUD], drug use disorders, attention deficit hyperactivity disorder [ADHD], major depression, and anxiety disorders -- from parents with AUD to their offspring. The study also evaluates differences between sons and daughters, examining whether the pattern of risk was similar when affected fathers were absent. The hazard ratio for offspring of a parent with AUD was highest for AUD, followed by drug use disorders and ADHD. The hazard ratios for sons and daughters were similar, but stronger if both parents were affected. The increased risk for drug use disorders was also elevated (1.7-fold higher); the effect was smaller for the other disorders. The risk for offspring of affected mothers and fathers was essentially identical.