ASAM Weekly for November 7, 2023
This Week in the ASAM Weekly
As we presented last week, ASAM provides expert guidance for the field of addiction medicine. Today, the American Society of Addiction Medicine (ASAM) and the American Academy of Addiction Psychiatry (AAAP) published the Clinical Practice Guideline on the Management of Stimulant Use Disorder.
This is a timely publication as the opioid crisis evolves into a dual crisis with psychostimulants. It’s important to note the significance placed on contingency management as well as the considerations for pharmacotherapies, including prescribed psychostimulants. Further research is welcome regarding the efficacy of prescribed psychostimulants for StUD, especially at supratherapeutic doses. More on this can be found in a recent meta-analysis from the journal Addiction.
The US Agency for Healthcare Research and Quality has published a topic brief on the role of low-threshold OUD treatment in primary care settings. It’s incredibly user-friendly and comprehensive but also liberating because high-threshold addiction treatment is not only bad for the patient but also for the provider (AHRQ). Another concept moving us forward in addiction treatment is point-of-care (POC) testing. We still face several challenges with POC testing for fentanyl, but we’re making progress, and hopefully in time for xylazine (NEJM).
A safe-for-work review on the withdrawal-like symptoms of problematic pornography use conceptualizes it as an addiction while identifying the moderating (partial agonist?) effects of masturbation (JAM). Similarly, alcohol withdrawal symptoms such as headaches can often drive individuals back to problematic use, but scientists identified the mechanism for these headaches and thus a potential target for future therapeutics (Neuron).
As the news media over-speculate about the death of Matthew Perry, many individuals share their gratitude for how his addiction story helped them (The Independent). Celebrities have often played a significant role in reducing stigma..
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
American Society of Addiction Medicine and American Academy of Addiction Psychiatry
Overdose deaths involving stimulant drugs – including cocaine, methamphetamine, amphetamine, and prescription stimulants – have been rising precipitously over the past decade. In 2021, over fifty percent of overdose deaths in the US involved stimulant drugs. Beyond the mortality risk, stimulant use disorders (StUD) can also lead to long term health problems including infectious diseases, cardiac, pulmonary, psychiatric, dental, nutritional, skin, and cognitive issues. The Clinical Practice Guideline on the Management of Stimulant Use Disorder, developed by the American Society of Addiction Medicine (ASAM) and the American Academy of Addiction Psychiatry (AAAP), provides information on evidence-based strategies and standards of care for the prevention and treatment of stimulant use disorders (StUD), stimulant intoxication, and stimulant withdrawal.
Research and Science
This systematic review with meta-analysis pooled results from randomized placebo-controlled trials to evaluate efficacy and safety of prescription psychostimulants (PPs) for amphetamine-type stimulant (ATS) use disorder (ATSUD). The results suggest that relatively potent PP agonists, especially when used in high doses, may be more effective than placebo in diminishing ATS use, increasing retention in treatment and decreasing craving among individuals with ATSUD. Such use of PPs would be coherent with an agonist therapy approach, where doses that compensate for the use of ATS are required to have an impact upon outcomes.
Abstinence from alcohol for those with alcohol use disorder (AUD) can be threatened because of withdrawal symptoms, which are often relieved with resumption of alcohol intake. In this study, the authors specifically look at the mechanisms involved in headache during withdrawal. In a mouse model, they identified the Mas-related G-protein-coupled receptor B2 (MrgprB2), expressed in mast cells and mediates neurogenic inflammation, induces headache behavior in mice. When the receptor was blocked in this model, it moderated the headache response. The authors suggest the MrgprB2 may be a novel new therapeutic target for treating alcohol withdrawal and AUD.
Drug and Alcohol Dependence
This study used the National Vital Statistics System to obtain information about all US drug overdose deaths between 2016 and 2021. The last two years were during the COVID pandemic while the first 4 years were before the pandemic. The overdose mortality rate (ODMR) for males with high school education or less had the largest increase during COVID, from 60 to 149 deaths/100 thousand. For females with high school or less the increase was 36 to 73 deaths/100 thousand. For males with a bachelor’s degree, the ODMR and the increase were dramatically less, 7.5 to 11.5 deaths/100 thousand. For females with a bachelor’s degree, the ODMR was the lowest with little increase, 5.0 to 5.6 deaths/100 thousand. The ODMR was significantly higher for those with less education and for males. These disparities increased dramatically during the COVID pandemic.
This study extracted data from the National Emergency Medical Services Information System (all EMS cases in the US) for 2017 to 2021 involving motor vehicle crash injuries for people aged 65 years and older. Injuries were classified as low acuity (67%), emergent (25%), critical (6%), and fatal (1%). Substance use was identified in 3% of the study group. The presence of substance use was associated with 36% increased odds of worse severity injury. Researchers also found increased injury severity in rural as compared to urban areas. The authors call for increased awareness of the risk of substance use in older road users.
Agency for Healthcare Research and Quality
Changes in regulation have reduced barriers to prescribing buprenorphine in primary care settings, yet patients with opioid use disorder (OUD) frequently do not access treatment. This brief argues for low-threshold treatment in primary care settings, citing the evidence that already exists and making recommendations to improve access and patient engagement. First, just start prescribing buprenorphine and encourage your team to prescribe. By treating OUD like any other chronic disease and incorporating buprenorphine into your practice, you will improve access, patient engagement, and outcomes. Additional measures include addressing patients’ other medical needs and mental health, making your practice welcoming and non-stigmatizing, and providing care in non-traditional settings, such as telehealth or needle exchange programs.
New England Journal of Medicine
In this perspective, the authors discuss the struggles associated with current fentanyl testing. Adapting toxicology screening practices when fentanyl is the primary driver of overdose deaths needs attention. Lack of scaled up testing, cost, and proper interpretation of results remain challenges. Another challenge involves payors not covering OUD residential treatment for clients using fentanyl in the setting of a negative opioid screen. This reinforces the critical importance of all clinicians not only testing for fentanyl but working to shorten waiting times on results. The latter issue impacts the increased risk of patients growing weary of waiting for these results, and so foregoing treatment. Improvements in fentanyl testing are therefore required in informing decision-making for clinicians.
Journal of Addiction Medicine
Significant concern with the use of pornography has been referred to as problematic pornography use (PPU). In this scoping review, the authors investigated whether PPU can be classified as an addictive disorder. Cravings were a particular concern given their intensity with resulting return to PPU. Studies revealed the presence of “withdrawal-like symptoms” including mental, sexual, and physical symptoms; these occurred in close to 75% of subjects. In several studies, these symptoms, when particularly pronounced, led to consideration of treatment.
In The News
Los Angeles Times
San Francisco Chronicle