This Week in the ASAM Weekly

This week we have a collection of recent publications from across the spectrum of medicine. From the New England Journal of Medicine, we have a sobering study on the use of psilocybin in treatment-resistant depression that separates itself from others through a rigorous design with less-than-enthusiastic but positive results. 

From Radiology there is a retrospective study identifying distinct CT findings of large and small airway damage that was more commonly found in marijuana smokers than cigarette smokers.  Frontiers in Endocrinology published a study demonstrating how methamphetamine exposure in mice leads to low birth weight through a dysfunction in fetal glucose metabolism. A research letter from the Journal of Internal Medicine informs us that although overall deaths from infective endocarditis have decreased over the past two decades, there has been an alarming increases in deaths among young adults - mostly a result of intravenous drug use.

And who doesn’t like a good prior-auth? Nobody. A study from JAMA Health Forum investigated Medicaid data and MOUD treatment coverage before initiation of the SUPPORT Act - legislation expected to address coverage inequities but not byzantine barriers such as prior-auths.

Thank you to the ASAM Weekly staff, Co-Editors, and readers for making this publication possible. Have a nice holiday.

Nicholas Athanasiou, MD, MBA, DFASAM
Editor in Chief

with Co-Editors: Brandon Aden, MD, Debra R. Newman, PA-C, MSPAS, MPH, Jack Woodside, MD, John A. Fromson, MD

Lead Story

Single-Dose Psilocybin for a Treatment-Resistant Episode of Major Depression

NEJM

Results of a phase II trial testing the psychedelic compound in magic mushrooms as a treatment for depression have found that the drug psilocybin is effective, but not to the extent that earlier, smaller studies had suggested. The proportion of participants in remission after treatment dropped over time, raising questions about its durability and whether additional doses would be helpful. Among adults with treatment-resistant depression, a single dose of 25 mg of psilocybin, but not 10 mg, reduced depression severity significantly more than a 1-mg dose at 3 weeks. The trial did not compare psilocybin with existing treatments for depression and persons who were judged to be at a clinically significant risk for suicide were excluded from the trial.

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 

Chest CT Findings in Marijuana Smokers 🔓

Radiology

This retrospective case-controlled study used chest CT to investigate the possible effects of marijuana smoking on the lung, comparing marijuana smokers, nonsmokers, and tobacco-only smokers. Emphysema rates were higher in age-matched marijuana smokers (93%) than in tobacco-only smokers (67%) (P = .009); emphysema was also more common in marijuana smokers than in nonsmokers (75% vs 5%, P < .001). Bronchial thickening, bronchiectasis, and mucoid impaction were higher in marijuana smokers than among all other groups. These findings may be related to specific inhalational techniques while smoking marijuana. Bronchodilatory and immunomodulatory properties of certain components of marijuana may also be involved.

Prenatal methamphetamine exposure causes dysfunction in glucose metabolism and low birthweight 🔓

Frontiers In Endocrinology

The mechanisms of prenatal exposure to methamphetamine are not fully understood. In this study, the authors investigated the effects of this exposure on low birthweight (LBW) and the fetal-placental relationship. Prenatal methamphetamine exposure induced fetal weight loss and an insulin production defect in the fetal pancreas. These results suggest that methamphetamine generates disturbances in glucose metabolism and promotes LBW in the prenatal period. 

Coverage and Prior Authorization Policies for Medications for Opioid Use Disorder in Medicaid Managed Care 

JAMA Health Forum

This study reviewed documents from the year 2018 for Medicaid plans to determine coverage for MOUD and the requirement for prior approval (PA). They note that PA is often used to reduce cost and when PA was removed from Medicare Part D plans, prescriptions for buprenorphine increased. A total of 266 managed care organization (MCO) plans and 39 fee-for-service (FFS) plans were included. Medicaid FFS plans were more likely to cover MOUD than MCO plans: for buprenorphine (100% v 98%), for methadone (82% v 70%), and for injectable naltrexone (95% v 71%). Coverage with a PA requirement under FFS plans versus MCO plans was: buprenorphine (64% v 42%), for methadone (31% v 36%), and for injectable naltrexone (46% v 30%). Overall, 53% of Medicaid beneficiaries were subject to PA. The authors suggest that PA for MOUD be removed from all Medicaid plans.

Assessing Clinically Significant Cognitive Impairment Using the NIH Toolbox in Individuals with Co-occurring Serious Mental Illness and Alcohol Use Disorder

Journal of Addiction Medicine

This study included 135 participants with AUD and serious mental illness (major depression, bipolar disorder, schizophrenia, or schizoaffective disorder). An NIH cognitive battery of tests assessed participants for clinically significant cognitive impairment (CSCI). CSCI was found in 41% of the sample, compared with the 15% in a normative sample. The most common impairment was in executive function. Multivariable regression found CSCI to be associated with head injury (OR 2.25, p=0.03), severity of AUD (OR 1.50, p=0.03), and psychiatric symptom severity (OR 1.63, p=0.03). The authors note that 45% of participants had a history of head injury. They conclude that head injury or severe AUD or psychiatric symptom severity may indicate formal neuropsychological assessment.

Learn More

Increasing mortality rates from infective endocarditis among young US residents

Journal of Internal Medicine

In this research letter, the authors analyzed US Center for Disease Control and Prevention Death Data to evaluate changes in death due to infective endocarditis (IE) between 1999 and 2020. While overall mortality due to IE decreased from 2.1 to 1.9 per 100,000, among young persons 15 to 44 years old it increased from 0.3 to 0.6 per 100,000. Further, among those aged 15 to 34 it increased from 0.1 to 0.3 per 100,000 in the same period. People who inject drugs (PWID) comprised an increasing percent of those who died, increasing from 10.2% to 19.5% among the young. The increase in deaths due to IE correlates with increases in overdose deaths due to opioids and of significant public health concern.

Annals for Hospitalists Inpatient Notes - Managing Alcohol Withdrawal Syndrome in the Hospital Setting—A Call for Research

Annals of Internal Medicine

A significant percent of patients admitted to the hospital have alcohol-related conditions and develop alcohol withdrawal syndrome (AWS). However, many are admitted for other medical issues, which may complicate the AWS treatment. While benzodiazepines are often the primary treatment for AWS, they have potential harms in hospitalized patients and most of the current evidence for their use is not from inpatient hospitalized settings. The author notes the Clinical Instrument Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) is also frequently not suited to this setting, often due to the comorbid medical issues. Given these gaps additional studies are needed in hospital settings to evaluate the best measures of AWS, medications (benzodiazepines versus phenobarbital), and dosing strategies. 

Trauma-focused treatment for comorbid post-traumatic stress and substance use disorder

Nature Reviews Psychology

Trauma-focused interventions using cognitive, emotional, or behavioral techniques are effective in treating post-traumatic stress disorder (PTSD) and comorbid substance use disorder (SUD). However, these treatments are underused. Further, this comorbidity remains difficult to treat, with smaller treatment effect sizes and higher dropout rates than for PTSD alone. This narrative Review found that psychosocial patient characteristics do not predict response or attendance consistently across studies, and patients’ baseline PTSD and SUD severity might be linked to treatment outcome in nuanced ways. Patients who present with more severe symptoms might show strong response to trauma-focused treatment, yet greater severity might be associated with worse attendance.

In The News

The global economics behind America's fentanyl problem

Quartz

CVS and Walgreens have agreed to $10 billion opioid settlement

NPR

Proposition 31 passes in California: flavored tobacco will be banned

NPR

FDA Announces Preliminary Assessment that Certain Naloxone Products Have the Potential to be Safe and Effective for Over-the-Counter Use

FDA

Fentanyl is making it harder to start addiction treatment

STAT News

The Opioid Epidemic Is Surging Among Black People because of Unequal Access to Treatment

Scientific American