ASAM Weekly for November 8, 2022
This Week in the ASAM Weekly
We often present publications about initiating, engaging, and retaining individuals in addiction treatment — i.e., steps for successful outcomes. A brief report on street-based, low-barrier buprenorphine treatment is an example of how an adaptive model can be an initial approach to the unique needs of OUD and homelessness (Psychiatric Services). Telehealth in OUD treatment also provides an opportunity to expand access, but, as it matures, we are encouraged to redefine high-quality care and focus on fundamentals such as quality of life, disability, and treatment retention (Substance Abuse).
Engagement is crucial for retention. The HEDIS engagement quality measure can be used to predict 6-month retention in buprenorphine treatment, potentially enabling clinicians to develop individualized interventions that improve engagement and retention (American Journal of Psychiatry).
Treatment providers also have differing levels of engagement. A study on implementation facilitation for addiction treatment (tobacco, alcohol, and opioids) in HIV clinics found improvements in certain MAT outcomes, but, as the authors discuss, different levels of provider engagement are likely necessary due to varying treatment complexity (JAMA Network Open).
Ultimately, these steps lead us toward reducing the morbidity and mortality of addiction. The lead article this week estimated the excess mortality associated with cigarette use among various subgroups and demonstrated that smoking cessation was associated with a substantial risk reversal (JAMA Network Open). The accompanying editorial proposes a “quit by 35” campaign to motivate smokers and save lives.
Finally, we have wonderful ASAM news to share — David A. Fiellin, MD, FASAM, has been named the next editor in chief for the Journal of Addiction Medicine. Congratulations Dr. Fiellin and JAM! (YaleNews).
Thanks for reading,
Nicholas Athanasiou, MD, MBA, DFASAM
with Co-Editors: Brandon Aden, MD, Debra R. Newman, PA-C, MSPAS, MPH, Jack Woodside, MD, John A. Fromson, MD
JAMA Network Open
Using data from the U.S. National Health Interview Survey, this study looked at the association, by race, ethnicity, and sex, of cigarette smoking and cessation with all-cause/cause-specific mortality. Comparing those who quit smoking before age 45 years with never-smokers, all-cause mortality rate ratios (RRs) were noted in the following groups: 1.15 Hispanic, 1.16 non-Hispanic Black, 1.11 non-Hispanic White, and 1.17 other non-Hispanic persons. Current smoking was associated with substantial excess mortality in all groups. Quitting smoking before age 45 years was associated with close to 90% reduction in the excess mortality risk associated with continued smoking; quitting at ages 45-64 years was associated with a 66% risk reduction irrespective of race and ethnicity.
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
JAMA Network Open
In this randomized clinical trial of 3,647 patients with opioid, alcohol, or tobacco use disorder, during short term follow-up compared with the control period, implementation facilitation was not associated with a statistically significant increase in observed provision of medication for opioid use disorder (27% vs 28%) or alcohol use disorder (8% vs 13%). There was a significant increase in provision of medication for tobacco use disorder (33% vs 40%). These findings suggest that implementation facilitation can increase provision of medications for alcohol and tobacco use disorder in HIV clinics, although additional efforts may be needed to improve its impact, especially for medications for opioid use disorder.
The American Journal of Psychiatry
To investigate the predictive value of early treatment response on 6-month treatment retention, this study applied the Health Effectiveness and Data Information Set (HEDIS) engagement quality measure (NQF #0004) to patients in a multisite, multistate buprenorphine maintenance treatment program. Almost half of patients who successfully met HEDIS quality measures for substance use disorders were subsequently retained in care for a minimum of 6 months. The more striking finding was that only a nominal 2.9% of those who did not engage remained in care at 6 months. This finding is clinically meaningful and could guide intervention development to prioritize stabilization of high-risk patients early in treatment.
European Heart Journal
This study reported on the relation between atrial fibrillation (AF) and the use of four substances. ICD-9 and CPT codes were analyzed from over 23 million patients who had a hospital encounter between 2005 and 2015 in California. AF developed in 4.2% of this group. Methamphetamine use was associated with an increased incidence of AF with a hazard ratio (HR) of 1.86. Increased risk of AF was also associated with cocaine use (HR 1.61), opioid use (HR 1.74), and cannabis use (HR 1.35). Although cannabis had a weaker association it was similar to other known risk factors for AF such as diabetes mellitus (HR 1.24) and tobacco use (HR 1.32). Use of multiple substances and coding indicating increased severity of substance use each were associated with increased risk of AF.
This review article summarizes the neurobiology of psychedelics, including their chemistry, role of 5-HT2A serotonin receptors and downstream effects, and neuroimaging results. After reviewing current knowledge, the authors suggest some open questions and future research questions. Notably, there is a lack of studies explicitly testing if the 5-HT2A is the molecular basis for psychedelic therapeutic effects, especially given that many psychedelics also activate the 5-HT2C receptors. Additional research is also needed on the roles of the various cell types in psychedelics effects and linking the neurobiological action to its behavioral effects. One significant clinical question is can the potential therapeutic effects be separated from the subjective experience of these substances.
This article discusses both advantages and problems with telehealth for treatment of patients with OUD. Telehealth has been shown to provide similar outcomes to in-person treatment for other mental health conditions. They note that telehealth can address distance and transportation that can be barriers to initial access and retention in treatment. However, telehealth can present problems for the physical exam and toxicology testing. There is little evidence to show that these procedures improve patient outcomes, and they call for research to help define which components are essential to quality patient care. For example, frequent contact may be more important than in-person visits. They also caution that telehealth can provide opportunities for “bad actors” providing pill mills and exploitative cash-based practices.
The International Journal of Neuropsychopharmacology
The authors summarize the findings in 24 studies and present 3 potential models for psychedelics mode of action. The first model is the Relaxed Beliefs Under Psychedelics and Brain Entropy (REBUS) with primary effects via activation of 5-HT2A receptors, leading to increased brain entropy and attenuated top down-processing and associated with improved emotional regulation, feelings of self-transcendence, wellbeing, and decreased depression. The second model, Cortico-Straital-Thalmo-Cortical model (CSTC), postulated alteration in disinhibition of the thalamus, with increased sensory information input to the cortex. The final model, Cortico-Claustro-Cortical model (CCC), by activating receptors in the claustrum, leading to disruption in higher cortical networks. The authors note that additional research is needed to test various models and there are still legitimate questions about potential clinical benefits of the various neuropsychiatric conditions.
In 2016, the Connecticut Mental Health Center initiated street mental health outreach to care for the city’s estimated 673 unhoused individuals. From July 2019 to April 2021, the street team had 475 encounters. Providers noticed that patients with OUD who were motivated for treatment struggled with treatment access. The street team provided low-barrier buprenorphine treatment, and their success in prescribing, through street outreach, to individuals experiencing homelessness suggests that similar programs can be developed in other street-based mental health treatment settings.
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