ASAM Weekly for November 28, 2023
This Week in the ASAM Weekly
SAMHSA recently released results from the 2022 National Survey on Drug Use and Health (NSDUH). While further analysis of the data is expected to follow, many of our featured publications this week provide important context for the numbers.
Marijuana continues to be the most commonly used illicit substance in the US, bringing with it unique public health concerns. Researchers from the largest genetic study of cannabis use disorders (CUD) found a potential link between CUD and lung cancer and expanded upon our understanding of psychopathology and cannabis use (Nature Genetics). The CDC published an important yet unfortunate case report on the death of an employee from cannabis-related occupational asthma, and also found evidence of symptoms in other co-workers (MMWR).
Nearly 9 million Americans (12 and older) misused opioids in the past year, but estimating the misuse of illegally made fentanyl (IMF) complicates treatment implications. An industry-sponsored study conducted in England found that extended-release buprenorphine (BUP-XR or BUP-ER) was clinically superior to standard treatments (oral buprenorphine and methadone) but only cost-effective in the most severe OUD cases (eClinicalMedicine). Importantly, the findings may not generalize well to real-world settings with a higher prevalence of IMF, as manufacturer-recommended dosing of BUP-ER can be inadequate in such cases (Drug and Alcohol Dependence).
Expanding access to buprenorphine treatment may not be sufficient for the problems of IMF potency. Therefore, expanding access to methadone is crucial. Although concerns about safety have been raised some in the industry (Medpage Today), many leaders in the field, including ASAM, strongly support the passage of the Modernizing Opioid Treatment Access Act (MOTAA).
Ultimately, data from the 2022 NSDUH survey help us make important decisions about addiction treatment, but sometimes the stories of individuals can help us connect the dots. Addiction treatment is a part of harm reduction, not the other way around (NPR).
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
Journal of Addiction Medicine Call for Papers: “Research funded through the HEAL Initiative”
The Journal of Addiction Medicine is soliciting papers funded through the Helping to End Addiction Long-Term (HEAL) initiative. Papers should present results of HEAL-funded research, although narrative and systematic review articles conducted as part of HEAL-funded research will also be considered. To be considered for this special collection, potential authors of reviews should submit an outline to the editorial office for approval before submitting a manuscript. The outline can be sent to JAMReviewOutline@gmail.com. Please copy email@example.com. The editors will provide feedback on the outline and a recommendation regarding whether to write and submit a manuscript.
Key findings include that in 2022, 70.3 million people aged 12 or older (or 24.9%) used illicit drugs in the past year. Marijuana was the most used illicit drug, with 22.0% of people aged 12 or older (or 61.9 million people) using it in the past year. In 2022, 48.7 million people aged 12 or older (or 17.3%) had a substance use disorder (SUD) in the past year, including 29.5 million who had an alcohol use disorder (AUD), 27.2 million who had a drug use disorder (DUD), and 8.0 million people who had both an AUD and a DUD. Almost 1 in 4 adults aged 18 or older had any mental illness (AMI) in the past year (59.3 million or 23.1%) and among adolescents aged 12 to 17 in 2022, 19.5% (or 4.8 million people) had a past year major depressive episode (MDE).
Research and Science
As recreational use of cannabis is being decriminalized in many places and medical use widely sanctioned, there are growing concerns about increases in cannabis use disorder (CanUD), which is associated with numerous medical comorbidities. Researchers performed a genome-wide association study of CanUD followed by meta-analysis in 1,054,365 individuals, finding a statistically significant single nucleotide polymorphism-based heritability for CanUD in all but the smallest population (East Asian). A genetically informed causal relationship analysis indicated a possible effect of genetic liability for CanUD on lung cancer risk, suggesting potential unanticipated future medical and psychiatric public health consequences that require further study to disentangle from other known risk factors such as cigarette smoking.
Journal of Studies on Alcohol and Drugs
This study of sober living houses (SLH) examined the effect of house characteristics and neighborhood environment on percentage of days abstinent (PDA) and number of psychiatric symptoms (PS). The SLHs (n=48) were in Los Angeles County, and 557 participants were recruited at the time they entered the SLH. PDA and PS were measured at baseline and after 12 months. Over this time, PDA increased (71% to 84%) and PS decreased (28 to 15 symptoms). Number of self-help groups within 1 mile was associated with higher PDA, whereas number of alcohol outlets within 1 mile was associated with lower PDA. SLH maintenance was associated with fewer psychiatric symptoms, but no features of the SLH were associated with PDA. Researchers conclude that SLHs located in neighborhoods with more self-help groups and fewer alcohol outlets were associated with improved abstinence.
Superiority and cost-effectiveness of monthly extended-release buprenorphine versus daily standard of care medication: a pragmatic, parallel-group, open-label, multicentre, randomized, controlled, phase 3 trial 🔓
In this superiority randomized controlled trial in the United Kingdom, researchers assess if extended-release buprenorphine (BUP-XR) was superior to the standard of care (SoC) of methadone or sublingual buprenorphine for treatment of opioid use disorder (OUD). Patients were randomized to SoC or BUP-XR with an evaluation end point of abstinence out to 24-weeks. The mean number of days for abstinence was greater for the BUP-XR (123.4 days) group versus SoC (104.37 days) group (IRR 1.18, p-value=0.004). In cost-effectiveness analysis, using £30,000 per QALY, BUP-XR was not found to be cost-effective overall, but in sub-group analysis it was cost-effective for those with severe OUD.
International Journal of Mental Health and Addiction
The evidence for association between medical cannabis laws (MCL) and decreases in opioid overdoses and non-medical prescription opioid (NMPO) use is inconsistent. In this study, researchers examined the association between state-level MCLs and occasional, regular, and frequent NMPO use and found a statistically significant increase in occasional use (2.1%) but decreases in regular (-0.6%) and frequent (-1.5%) NMPO use after MCL implementation. After performing stratified analysis, they found the greatest change among those with cannabis use disorder. While additional studies are needed, the authors note these findings suggest MCLs may reduce opioid-related morbidity and mortality, but tradeoffs of MCLs should also be considered.
Drug and Alcohol Dependence
Details of use of extended-release buprenorphine (BUP-ER) were extracted from databases maintained by the health system in Ontario, Canada. There was a steady increase in the use of BUP-ER during the 2-year study period (2020-2022), finally reaching 5.8% of opioid agonist therapy initiations. A total of 2366 cases of BUP-ER initiation were analyzed. BUP-ER was discontinued by 1554 (66%) after a median of 183 days, and 502 of these (32%) later re-initiated BUP-ER. Over half (52%) continued to use buprenorphine/naloxone after BUP-ER initiation. After the two 300mg loading doses, 19% continued a dose of 300mg. Of those reduced to the 100mg maintenance dose, 39% later increased to 300mg. The authors conclude that BUP-ER retention is relatively low and that continued use of the 300mg dose and supplementation with buprenorphine/naloxone suggest that dosing recommendations are not adequate.
JAMA Network Open
This cross-sectional study of over 400,000 individuals looked at patterns of e-cigarette use during the COVID-19 pandemic. In the 2021 Behavioral Risk Factor Surveillance System survey, nearly 20% of young adults between the ages of 18 to 24 reported using e-cigarettes. Upon further scrutiny of this age group, almost 75% of those between 18 and 20 years of age used e-cigarettes, with this group having no history of using combustible cigarettes. The age-standardized prevalence of current and daily e-cigarette use was 6.9%, with half of those reporting daily use. Continued monitoring of these patterns is imperative to inform policy and regulation.
Morbidity and Mortality Weekly Report
Occupational respiratory hazards related to the US cannabis cultivation and production industry have been reported. The first fatality occurred at a Massachusetts cannabis cultivation and processing facility in January 2022, with the employee experiencing progressively worsening work-associated respiratory symptoms, which resulted in death. This report provides the findings of an OSHA investigation at the Massachusetts facility. This report is critical to preventing workplace exposure, with the implementation of surveillance monitoring, medical oversight, and employee training throughout the industry. It speaks to the importance of prompt evaluation of industry employees with new-onset or worsening asthma.
In The News
The New York Times