The ASAM Weekly for October 17, 2023
This Week in the ASAM Weekly
There’s something remarkable about identifying a common brain network underlying substance use disorders (Nature Mental Health). This commonality was not a given -- the results could have gone the other way -- but its existence is reassuring for how it unifies the disorders of addiction.
In a similar fashion, early abstinence acts as a universal predictor for return to opioid use across multiple settings with different treatments - methadone, buprenorphine, or ER-naltrexone. This finding, based on predictive modeling, confirms many of our anecdotal experiences and assumptions (JAMA Psychiatry). Anecdotal evidence may also lead many of us to assume that contamination of stimulants with fentanyl is so common that it’s almost universal. But is it (Drug and Alcohol Dependence)?
When the evidence doesn’t reinforce broadly held assumptions it can be a bit disconcerting. Governor Newsom seemed to acknowledge this when he vetoed a bill decriminalizing plant-based hallucinogens, citing the need for better evidence (WIRED). But when there isn’t overwhelming evidence to follow, then common sense may be the next best thing. Only time (and evidence) will tell whether California’s courts can successfully address addiction, mental illness, and homelessness (AP). Fingers crossed.
Lastly, NPR presents a news story about New Zealand, tobacco, and the Māori community that explores discrimination and addiction- a theme not bound by geography. If one changes the place, substance, or people, this underlying commonality becomes remarkably clear.
Before you go, --we all share the common cause of treating addiction, and this week is National Addiction Treatment Week. So please check out the website to find out how you can get involved and help bring more people from addiction to recovery.
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
Nature Mental Health
This study used network mapping approaches and a functional connectome from a large cohort of healthy participants (n = 1,000) to test whether neuroimaging abnormalities across substance use disorders map to a common brain network. Starting with coordinates of regional brain atrophy from 45 studies, researchers found that 91% of the neuroimaging findings mapped to a common brain network specific to substance use disorders compared to atrophy associated with normal aging and neurodegenerative disease. Coordinates of functional MRI abnormalities from 99 studies mapped to a similar brain network. Neuroimaging abnormalities across substance use disorders map to a common brain network that is similar across imaging modalities, substances, and lesion locations that cause remission from substance use disorders.
Research and Science
Individual-level risk prediction is a useful tool in the management of several chronic conditions, but such a tool does not exist for the treatment of opioid use disorder (OUD). Such a tool could assist clinicians in determining at medication initiation the risk of return to use early in treatment. The purpose of this study was to formulate such a prediction tool for return to use by week 12 using data from three large clinical trials. One score, the OUD Return-to-Use Risk Score, afforded quality clinical risk stratification: patients with weekly UDS results negative for opioids in the 3 weeks after treatment initiation had a 13% risk of return to use, while those with UDS results that were positive or missing UDS had an 85% risk of return to use.
Academic Emergency Medicine
Alcohol use disorder (AUD) is prevalent in North America, with rates estimated between 13.8% and 18.1%, and with many encountering the health system in Emergency Departments (ED). While Screening, Brief Intervention, and Treatment Referral (SBIRT) has been implemented in many EDs, the authors wanted to evaluate the evidence for initiation of pharmacological treatments- specifically naltrexone, acamprosate, and gabapentin- in EDs for persons with AUD. Conducting a systematic review, they identified 6 articles for inclusion, 3 clinical trials, and 3 case reports; none included acamprosate or gabapentin as interventions. Two clinical trials included naltrexone and one disulfiram as interventions, and only one provided some evidence of positive impact on alcohol consumption after naltrexone initiation. Overall, the authors found there is a paucity of data and suggest research is needed.
Drug and Alcohol Dependence
This study investigated the extent to which cocaine and methamphetamine also contained fentanyl. Data were acquired from a drug checking service which analyzed samples submitted by drug users, health departments, medical clinics, and others. Samples of stimulants (n=718) came from 25 states, mostly in 2022 and 2023. Overall, 13.5% of stimulant samples contained fentanyl: 8.9% of methamphetamine samples and 21.5% of cocaine samples. Less than 1% of crystal methamphetamine samples contained fentanyl compared to 14.8% for powder cocaine. Xylazine was present in 5% of stimulant samples and the presence of xylazine reduced donors’ ability to identify fentanyl from 92% to 42%. The authors conclude that crystalline forms of the stimulants were significantly less likely to contain fentanyl than powder forms.
This study suggests that some tobacco products marketed in California and Massachusetts after a ban on menthol cigarettes contained a synthetic cooling agent, WS-3. WS-3 was restricted to non-menthol brands (Newport, Camel) marketed by R.J. Reynolds. These cigarettes can generate strong cooling sensations. Presence of WS-3 in non-menthol cigarettes raises concerns because WS-3 has documented organ toxicity in rodent studies. Crushable filter capsules in Camel Crush Oasis non-menthol varieties contained sweet vanilla, floral, and coconut flavorants, product characteristics known to be popular among youth. Regulators should consider including synthetic coolants in flavor bans because they can mimic menthol’s actions, making tobacco products more appealing and less irritating, and review whether capsule flavorants represent a nonpermitted characterizing flavor.
Western Journal of Emergency Medicine
EMS records from a North Carolina County with over 300,000 people included 2,327 dispatches for opioid overdose between 2016 and 2019. The actual EMS response time was compared to the estimated response time for a drone delivering naloxone based at an EMS/fire station. Calculation of drone response times was similar to a 2017 study modeling drone delivery of AEDs in Toronto, Canada. The average EMS response time was approximately 11 minutes. Using a configuration of 4 drone bases, response time was reduced by 4 minutes 38 seconds. Although this conserved resources, these 4 bases were located in urban regions of the county in order to cover most of the population but left rural areas to EMS. If drones were located at EMS/fire stations throughout the county, average response time would be approximately 3 minutes. This study’s model estimates that drones could deliver naloxone to an opioid overdose in a fraction of the EMS response time.
Journal of Addiction Medicine
As opioid settlement funds are dispersed to state and local jurisdictions, the authors of this commentary provide suggestions about how addiction medicine specialists can affect the way monies are utilized and help ensure they have a significant impact on the opioid epidemic. Suggestions include direct involvement in advisory committees that make or influence funding decisions, or more indirectly, providing expert recommendations to those committees or participating in policy reviews or evaluations of interventions. Over the next few years, we can influence the process to ensure the money is used equitably to save lives, based on scientific evidence.,
Canadian Medical Association Journal
This article considers whether the objectives of recreational cannabis legislation in Canada in 2018 have been met. Such objectives include improvement in cannabis-related public health and safety, less youth access, as well as reduction in cannabis-related crime. Five years out, a reduction in cannabis-related enforcement and significantly reduced arrests have been noted. At the same time, there has been an increase in emergency department visits and admissions. Data on cannabis use disorders and its treatment, and the degree to which legalization may have substituted for use of other substances, are lacking.
In The News
The Washington Post