This Week in the ASAM Weekly

Many of us may not be aware that the prevalence rate of in-hospital substance use among people with substance use disorders is as high as it is (30-44%), and even more of us likely don’t know whether our hospital has a policy to address it. But, importantly, we have a consensus, based on a Delphi process involving clinicians and people with lived experience, that will shape system-level approaches going forward (JAMA Network Open). 

A similar sense of consensus guided our response to the opioid crisis. Even though the US accounted for more than half of all global drug-related deaths over the past 20+ years (PLOS One), we built a response that helped turn the tide. But we may soon learn if or how that consensus holds once Medicaid cuts take effect (The New York Times). 

Some are already pointing to progressive cities as evidence that cracks are forming. San Francisco is embracing “recovery first,” Philadelphia stopped funding syringe service programs, and there’s a worry that “drug-free sidewalks” means that harm reduction is done (The New York Times). It’s hard to know what this all means—there never was a consensus around harm reduction that included drug-free sidewalks.  

It's difficult to build consensus around issues that are not singularly defined. This can be seen with high-potency cannabis—most of us know it can’t be good for the brain, but the research doesn’t state this clearly, so we can’t say there’s consensus (Annals of Internal Medicine). And until we can, people will form their own opinions in an attempt to make their own decisions—whether they be patients, parents (Journal of Addiction Medicine), people with lived experience, politicians, the public… and even professionals. 

Thanks for reading,

Nicholas Athanasiou, MD, MBA, DFASAM
Editor in Chief

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

Lead Story 

Recommendations for Addressing In-Hospital Substance Use From a National Delphi Consensus Process🔓

JAMA Network Open

This survey study utilized a 3-round Delphi consensus process to identify best practices for addressing in-hospital substance use. A panel of 38 addiction experts developed 84 consensus-based and patient-centered recommendations which can inform local responses, including policies, to address in-hospital substance use. 

Research and Science

Hospital-Wide Implementation, Clinical Outcomes, and Safety of Phenobarbital for Alcohol Withdrawal 🔓 

JAMA Network Open 

This is a quality improvement study comparing outcomes before and after implementation of a phenobarbital electronic health record order set for the treatment of alcohol withdrawal syndrome (AWS) in a community hospital in Seattle. Notably, the study was conducted in a hospital where the majority of hospitalists had no prior experience using phenobarbital for AWS. Researchers compared outcomes for 154 patients before implementation of the order set to 100 patients afterwards. Main findings included faster symptom resolution (based on a 4.2 to 5.0 point maximum CIWA-Ar score reduction from 24-96 hours), reduced AWS treatment duration (by 30.1 hours), and decreased length of hospital stay (by 2.2 days). There was no increase in adverse events (including use of physical restraints, intubation, and in-hospital mortality). 

Time from waking to first cigarette, accelerated biological aging, and risk of premature mortality 

Drug and Alcohol Dependence

Time from waking to first cigarette (TWFC) has been used as a measure of nicotine dependence. For this study, which used data from the UK Biobank, researchers calculated biological age using two validated methods (Klemera-Doubal and PhenoAge) that use a panel of laboratory values to estimate biological age. A shorter TWFC was associated with increased premature mortality. Compared to never smokers the premature mortality hazard ratio for TWFC > 2 hours was 1.45 and for TWFC < 5 minutes was 2.54. TWFC was also associated with accelerated biological aging which the authors estimate mediated 10-25% of the association of TWFC and premature mortality.

High-Concentration Delta-9-Tetrahydrocannabinol Cannabis Products and Mental Health Outcomes: A Systematic Review

Annals of Internal Medicine

Changes in legal status of cannabis has been associated with an increase in high-concentration THC cannabis products. In this systematic review researchers included 99 studies to evaluate association between high-concentration THC and anxiety, depression, psychosis or schizophrenia, and cannabis use disorder (CUD). Overall, the authors found a consistent unfavorable association between these products and psychosis or schizophrenia and CUD. The association between these products and anxiety and depression was more mixed between favorable and unfavorable outcomes with limited evidence of therapeutic benefits. 

The effects of psychostimulant prescription on opioid use disorder among people with co-occurring ADHD

Journal of Substance Use and Addiction Treatment 

This retrospective cohort study utilized commercial claims data to assess outcomes for patients with concurrent attention-deficit/hyperactivity disorder (ADHD) and opioid use disorder (OUD) diagnoses. The sample included 10,712 individuals (ages 12 to 64, with a mean age of 31.7) with both ADHD and OUD who initiated treatment with buprenorphine between 2011 and 2021. Of this group, 5,190 also received psychostimulant prescriptions while 5,522 did not. The study found that individuals who received psychostimulants had lower odds of buprenorphine discontinuation (OR=0.669) and opioid-related hospitalization (OR=0.493). Additionally, increased fill count of psychostimulant prescriptions was associated with a lower rate of opioid-related hospitalization.

Learn More

Global burden of disease due to opioid, amphetamine, cocaine, and cannabis use disorders, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021🔓

PLOS One 

This paper reports on the global burden of disease due to drug use disorders (DUD) in 2021 and trends since 1990. Over this period the overall incidence rate of DUD decreased by 8.1% to 169 per 100,000 in 2021. However, the number of deaths from DUD increased by 122% since 1990; the greatest increase was for cocaine (+255%) followed by opioids (+140%) and amphetamines (+104%). Opioids were responsible for the highest number of deaths. North America had a DUD mortality rate (18 per 100,000) that was 11 times the global mortality rate, and in 2019 the United States accounted for more than half of the global DUD mortality. These results show rising mortality due to DUD despite a modest decrease in incidence. 

Discontinuation of treatment for alcohol use disorder during pregnancy and postpartum in the United States 

Alcohol Clinical and Experimental Research

Using combined commercial and Medicaid claims data, researchers examined alcohol use disorder (AUD) treatment during pregnancy and postpartum. The researchers compared women with AUD receiving medication for AUD (MAUD) or psychosocial interventions (PSY) who became pregnant to a matched group of nonpregnant women. Findings showed a significant decrease in MAUD during pregnancy from 12.1% preconception to 0.3% during the 3rd trimester. Further, few of the women restarted MAUD in the postpartum period (1.9%). In an adjusted model, pregnant women were much more likely to discontinue MAUD than nonpregnant peers (HR=2.11), but not PSY. These findings highlight that this population may need targeted intervention to be retained in AUD treatment and to potentially resume MAUD in the postpartum period.

Parental Literacy on Adolescent Substance Use: A Crucial Yet Overlooked Factor

Journal of Addiction Medicine

This commentary explores the importance of parental substance use (SU) literacy, the obstacles impeding it, and possible strategies to enhance parental awareness. Many parents encounter difficulties in recognizing symptoms, often misjudge the risks associated with occasional substance use or compulsive behaviors, and are unsure about where to seek reliable support. In addition, stigma, misinformation, and a lack of accessible resources further hinder parents’ ability to take timely action. Strategies to enhance parental SU literacy are discussed, aiming not only to promote early detection and intervention but also to reduce the long-term societal burden of adolescent SU. 

In the News

Audrey Tanksley: A hurricane damages people, and people are harder to heal than property 🔓

Pittsburgh Post-Gazette

Cities Move Away From Strategies That Make Drug Use Safer

The New York Times

The intersection of drugs and homelessness is complicated. A Portland addiction doctor weighs in

The Oregonian/OregonLive

NA beer and mocktails can help people stay sober or drink less 🔓

The Associated Press

Opinion | America Was Making Progress on Opioid Addiction. That’s Now at Risk

The New York Times

Cigarette filters do nothing for smokers’ health and just create plastic pollution – they should be banned 🔓

The Conversation