ASAM Weekly for November 1, 2022
This Week in the ASAM Weekly
Not long ago we changed the ASAM Weekly section “Your Patients Are Reading” to “In the News,” mostly to acknowledge being part of a larger community that isn’t clearly separated by roles or titles. This week, our lead article explores how healthcare workers increasingly sought out mental health and substance use treatment during the COVID-19 pandemic, but the reasons behind this are not so clear-cut: increased access (telehealth), destigmatization, and systemic failures were all possible factors (JAMA Network Open).
Our perceptions in our roles can also affect how we treat others. Many healthcare workers know of an anecdote about the person who injects drugs through their PICC-line, and such anecdotal evidence can be more persuasive than a careful consideration of the risks, benefits, and patient’s stage of SUD illness (Open Forum Infectious Diseases). Similarly, will removing the educational requirement persuade more clinicians to get their x-waiver (JAMA Network Open)? Let’s be honest, the existence of the x-waiver allows too many clinicians to say, “I can’t” prescribe buprenorphine when what we really need is for them to feel like “I have to.”
Representation in research is important for developing successful treatments with real-world effectiveness. Analysis of three large comparative effectiveness trials for MOUD found poor representation for certain trial participants, most notably pregnant women, older adults, and middle-older-age adults (Drug and Alcohol Dependence Reports). This is particularly relevant for alcohol research in the age of the silver tsunami because knowledge gained from younger subjects cannot simply be extrapolated to older adults (Alcohol).
Ultimately, language helps communities feel connected and so the addiction community must continue to advocate for non-stigmatizing communication. Read more about it under “In the News” (STAT News).
Thanks for reading,
Nicholas Athanasiou, MD, MBA, DFASAM
with Co-Editors: Brandon Aden, MD, Debra R. Newman, PA-C, MSPAS, MPH, Jack Woodside, MD, John A. Fromson, MD
JAMA Network Open
With the emergence of the COVID-19 pandemic, physicians face specific occupational stressors, including a potentially greater risk of exposure to SARS-CoV-2, with consequent concerns over personal health and infecting family, friends, and colleagues; inadequate personal protective equipment; rapid practice changes including loss of income; and high, and at times overwhelming, workloads. In this population-based cohort study of 34,055 physicians in Ontario, Canada, the rate of outpatient visits for mental health and substance use increased on average by 13% per physician during the first 12 months of the pandemic compared with the prior 12 months. These findings suggest that the COVID-19 pandemic is associated with greater mental health services use among physicians.
Call for Reviewers
The Journal of Addiction Medicine is seeking to expand its cadre of manuscript reviewers. We are seeking reviewers with expertise in the following areas: Stimulants, Psychiatric epidemiology, Qualitative methodology, Genetics, Neurology, Emerging substances, Kratom, Novel Psychoactive Substances, Psychedelics, New pharmaceutical treatments, Toxicology, Criminal justice and addiction medicine, Machine Learning, Pain and Palliative Care, Adolescent Medicine, Maternal Child Health, and Behavioral Addictions. View the full opportunity here.
Research and Science
This Norwegian study explored smoking rates and cessation among patients receiving SUD outpatient or inpatient treatment. Patients receiving treatment in the outpatient setting reported opioids (78%) as their primary substance; the inpatient group reported stimulants (38%) and cannabis (28%). Both groups had a mean score on the lower side of self-reported physical health. There was a very high prevalence of smoking among patients entering treatment, and a low cessation rate one year after admission. Higher age and being in outpatient vs inpatient treatment was negatively associated with tobacco cessation.
In this study 165 long-term opioid users with chronic pain were randomly assigned to receive a series of mindfulness meditation (MM) sessions or supportive group psychotherapy (SG). MM resulted in significantly greater reductions in opioid misuse than SG through a 9-month follow-up. EEGs were obtained that showed significantly greater increases in frontal midline theta wave activity in the MM group compared to the SG group. MM also produced a significantly greater increase in self-transcendent experiences such as ego dissolution and affective bliss. The decrease in opioid misuse statistically correlated with the increase in theta activity. The authors conclude that the effect of MM on theta activity mediates the effect on opioid misuse.
Recent studies suggest that the gut microbiota may affect brain function and behavior. A 2021 study of patients with AUD and cirrhosis demonstrated that fecal microbiota transplants (FMT) could produce short-term reductions in alcohol craving and consumption. This study took pooled stool samples from the human study, pre and post FMT, and administered them to mice. They used a strain of mouse that voluntarily drinks alcohol. Mice administered stool from post-FMT AUD patients consumed less than half the amount of alcohol than mice administered stool pre-FMT from the patients. They found 843 genes expressed differently in the intestine of post-FMT mice compared to pre-FMT mice. These genes regulate the intestinal barrier, immune response, inflammation, and other functions. These results reflect the importance of the gut microbiota in AUD.
JAMA Network Open
Buprenorphine is associated with decreased mortality from opioid use disorder, but prescribing is limited in office-based settings to clinicians with federal waivers. To expand this workforce, in 2021, the US federal government eliminated educational requirements for waivers to prescribe buprenorphine to 30 or fewer patients. Modest growth in the nationwide number of clinicians with waivers was observed after this exemption. This cross-sectional study found that waiver growth during the first year after the federal education exemption was modest and concentrated among urban counties and counties with high baseline levels of clinicians with waivers. Although most growth occurred in urban areas, APN and PA waivers accounted for more than 70% of rural growth.
Drug and Alcohol Dependence Reports
In this study, the authors compare patient representation in 3 comparative effectiveness trials to patients in real-world treatment from the Treatment Episode Data Set: Admissions (TEDS-A). The study found that 10.7% of patient subgroups receiving MOUD were not represented in the trials. After excluding pregnancy, 8.3% were not represented. Older aged (≥65 years) and middle-to-older aged (50-64 years) individuals were largely underrepresented and many of the non-represented subgroups were women. While this study only examined 3 trials, it does identify potential gaps in research and targets for equity.
Aging may make the older brain more sensitive to some of the effects of alcohol; chronic alcohol use can also hijack the normal aging process. This literature search focused on research on alcohol use in older adults from 2020 to present in an effort to determine what the research community is doing to investigate the interplay of alcohol in older adults. What is known about alcohol and younger populations cannot be extrapolated to older adults who drink. Alcohol use is elevated among older adults, and in certain subsets of older adults rates are rising faster than expected.
Open Forum Infectious Diseases
People who inject drugs (PWID) are at increased risk of serious infections that often require longer periods of intravenous antibiotics through peripherally inserted central catheters (PICCs). In this study, the authors conducted qualitative interviews of both patients and clinicians to understand their opinions and potential concerns around use of PICCs. They identified 5 themes: 1) PICCs improved healthcare delivery, 2) Patients were concerned stigma impacted care including access to PICCs, 3) Patients recognized that PICCs were potentially risky for some PWID, 4) clinicians were very concerned about PWID having PICCs at discharge, and 5) patient-directed discharges were perceived to increase risk. Understanding these perspectives can inform care and support patient-centered care.
In The News
The White House