This Week in the ASAM Weekly

It’s been more than a decade since the MOTHER trial introduced many of us to the benefits of buprenorphine treatment in pregnancy. A larger, updated study has further supported its findings — buprenorphine exposure in neonates results in more favorable outcomes than methadone (NEJM). The significance is underscored by another study making headlines — drug overdose deaths in pregnant and postpartum persons jumped during the pandemic (NBC). 

Synthetic opioids, like fentanyl, represent a common thread and have also led to  an increase in overdose deaths among older Americans (CDC). As Dr. Edwin Salsitz presented at a recent conference, there are several unique considerations about fentanyl to keep in mind, such as “wooden chest syndrome” and its ability to overcome other opioid treatments (MDedge). The latter is a somewhat sobering consideration as we anticipate FDA approval for over-the-counter naloxone (The Hill), but it should not distract us from appreciating the progress made in treating addiction and saving lives (HHS). 

A new law will expand our ability to research cannabis (Senate.gov), but its tone towards medical benefits is interesting after reading a creative study from JAMA Network Open which found that the commercialization of cannabis may be influencing a collective placebo response that could intrude on the “best-of” clinical trial designs. A less sophisticated but still effective process is convenience — prenatal cannabis use was more common among individuals living near cannabis retail shops (JAMA Network Open).   

Thanks for reading,

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

Buprenorphine versus Methadone for Opioid Use Disorder in Pregnancy 🔓

The New England Journal of Medicine

This cohort study involving pregnant persons in the US from 2000-2018 found that buprenorphine treatment for opioid use disorder during pregnancy was associated with more favorable neonatal outcomes than methadone treatment. Neonatal abstinence syndrome occurred in 69% of the infants exposed to methadone as compared with 52% of those exposed to buprenorphine in the 30 days before delivery. An inverse association was also observed between buprenorphine exposure (as compared with methadone exposure) and preterm birth, regardless of whether exposure occurred in early or late pregnancy in both the unadjusted and adjusted analyses. Inverse associations were also observed between buprenorphine exposure (as compared with methadone exposure) and small size for gestational age and low birth weight.

Research and Science 

Placebo Response and Media Attention in Randomized Clinical Trials Assessing Cannabis-Based Therapies for Pain: A Systematic Review and Meta-analysis 🔓

JAMA Network Open

This meta-analysis included 20 randomized placebo-controlled trials of cannabis-based treatment of pain with a total of 1459 individuals. Both placebo and active cannabinoids had a large effect size on pain; however, the difference between the groups was not statistically significant. They also assessed mass media attention to these studies. The media attention was high and reflected a positive bias that was not associated with the clinical outcome. The authors suspect that positive media attention creates an expectation of cannabis pain relief that results in an increased placebo response. They “suggest that placebo responses contribute significantly to pain reduction in cannabinoid clinical trials.”

Geographic Accessibility of Retail Cannabis in Northern California and Prenatal Cannabis Use During the COVID-19 Pandemic 🔓

JAMA Network Open

It is known that prenatal cannabis use increases health risks for mothers and their children. This cross-sectional study investigated use of prenatal cannabis via urine toxicology before (January 2019 to March 2020) and during (April 2020 to December 2020) the COVID-19 pandemic in a population of Kaiser Permanente Northern California patients. Over 50% of patients lived within a 10-minute drive of a retailer, and the study found a greater increase in use in these individuals. Residing near a cannabis retailer may increase the risk for increased prenatal cannabis use during periods of heightened distress, such as the COVID-19 pandemic.

Association of polysubstance use disorder with treatment quality among Medicaid beneficiaries with opioid use disorder

Journal of Substance Abuse Treatment

The authors examine medication for opioid use disorder (MOUD) initiation and retention in treatment among persons with opioid use disorder (OUD) and co-occurring substance use disorders (SUD) utilizing Medicaid data across 4 states. Overall, 52.7% of persons with OUD had co-occurring SUD, with alcohol, cocaine, amphetamines, and cannabis being most prevalent with some variability across states. When compared to persons with OUD alone, persons with co-occurring alcohol and cannabis use disorders were less likely to receive MOUD and persons with any co-occurring SUD were less likely to continue in treatment. The authors found significant variability in MOUD initiation among persons with co-occurring amphetamine use disorder. The authors note that efforts to increase access to and retention in MOUD should also focus on persons with co-occurring SUD.

Learn More

Methamphetamine-associated heart failure: a systematic review of observational studies

Heart

This paper reviewed 21 studies concerning methamphetamine-associated heart failure (MethHF) between 1997 and 2020. In one study of ER patients, 10% of those with methamphetamine use (MU) had an elevated BNP compared to 7% of the rest (p<0.0001). Among patients with MU, 5% have LVEF<50% and 25% had elevated pulmonary artery pressure. One study reported a 585% increase in MethHF hospitalizations between 2008 and 2018. MU resulted in an increased risk of readmission for heart failure (OR=1.58). Methamphetamine cessation led to LV remodeling and improved functional status. The authors note the dramatic increase in MethHF and believe many cases go unrecognized due to lack of awareness.

The genetic aetiology of cannabis use: from twin models to genome-wide association studies and beyond 🔓

Translational Psychiatry

This review discusses the genetic literature on cannabis use. Twin studies have shown that cannabis use is moderately heritable, with higher heritability estimates for more severe phases of use. Linkage and candidate-gene studies have been largely unsuccessful, while genome-wide association studies (GWASs) so far only explain a small portion of the heritability. Dozens of genetic variants predictive of cannabis use have been identified, located in genes such as CADM2, FOXP2, and CHRNA2. Studies that applied multivariate methods indicate considerable genetic overlap between cannabis use and other traits (especially other substances and externalizing disorders) and some evidence for causal relationships, most convincingly for schizophrenia.

Adverse effects of ayahuasca: Results from the Global Ayahuasca Survey 🔓

PLOS Global Public Health

Ayahuasca use globally has increased and while the side effects are generally well known, less is known about the side effects' frequency, severity and persistence. In this study, the authors surveyed participants in the Global Ayahuasca Project about physical and mental health effects. Overall, 69.9% reported at least one adverse physical effect and 55.4% reported at least one adverse mental health effect. The most common symptoms were vomiting/nausea (62%), hearing or seeing things (28.5%), and feeling disconnected (21%), with adverse effects generally lasting less than a week. Adverse events were associated with increased lifetime use, comorbid physical health conditions, anxiety disorder, and greater age of initial use. Notably, the context in which ayahuasca was used was also associated with adverse effects. 

Drug Overdose Deaths in Adults Aged 65 and Over: United States, 2000–2020 🔓

CDC

This CDC report presents trends in drug overdose death rates for adults aged 65 and over for the period 2000–2020. Age-adjusted rates of drug overdose deaths increased from 2.4 deaths per 100,000 to 8.8 deaths per 100,000 during the reporting period.  Rates increased for men by 14% and more than doubled between 2014-2020; likewise, rates doubled for women between 2000-2009. Deaths involving synthetic opioids other than methadone increased by 53% from 2019 to 2020. 

Alcohol-induced Deaths in Adults Aged 65 and Over: United States, 2019 and 2020 🔓

CDC

This CDC report presents data on alcohol-induced deaths for adults aged 65 and over during 2019 and 2020. Rates were higher for men than women in 2020: 3.4 times higher for those 65–74 years and 4.1 times higher for those 75 years and over. Rates were highest for non-Hispanic American Indian or Alaska Natives (55.1 deaths per 100,000), followed by Hispanic, non-Hispanic White, non-Hispanic Black, and non-Hispanic Asian adults.

New Articles Available for CME in ASAM's eLearning Center

Supporting Self-isolation for COVID-19 With ‘‘Risk Mitigation’’ Prescribing and Housing Supports for People Who Use Drugs

Use of a Telemedicine Bridge Clinic to Engage Patients in Opioid Use Disorder Treatment

In The News

Drug deaths among pregnant women hit a record high

NBC News

The chase is on: Regulators are slowly cracking down on vapes aimed at teens

NPR

How one artist took on the Sacklers and shook their reputation in the art world

NPR

FACT SHEET: One Year After Releasing its Groundbreaking Overdose Prevention Strategy, HHS Announces New Data Showing Nation Has Expanded its Ability to Treat Addiction and Save Lives

HHS.gov

Higher potency of fentanyl affects addiction treatment, screening

MDedge

President Signs Schatz Bill To Expand Marijuana Research Into Law 

Senate.gov

Narcan maker says over-the-counter nasal spray fast-tracked by FDA

The Hill