ASAM Weekly for July 11th, 2023
This Week in the ASAM Weekly
Attention to xylazine is coalescing because of the combined harms that come with fentanyl. A new study in rats shows how the alpha-2 agonist may contribute to opioid deaths by eliminating a compensatory mechanism for opioid-induced brain hypoxia, leading to a stronger and more prolonged hypoxic state (Psychopharmacology). How this works in humans is important as the rate of xylazine detected in fentanyl-involved overdose deaths jumped 276% in recent years (MMWR) with men accounting for the majority (73%) of all xylazine-detected overdose deaths (NVSS).
The clinical images of xylazine-associated skin injury speak volumes and have caught national attention (NEJM). Delaware is piloting a single test strip that detects xylazine and fentanyl adulterants to protect against unintentional use (Philadelphia Inquirer) but intentional use is also a concern. More broadly, the discussion around harm reduction and decriminalization involves tensions between human rights, social norms, and treatment funding. Portugal’s experience exemplifies this fragile balance (Washington Post).
All this encourages us to recognize the significance of implementation- equally if it is driven by popular sentiment or scientific consensus. For example, the world’s first placebo-controlled trial of opioids in acute lowback and neck pain has confirmed what we’ve learned in hindsight -- that opioids should not be recommended in such situations (The Lancet). Researchers also hypothesized that medical cannabis laws would lead to a reduction in opioid prescribing, but it does not appear to have panned out that way (Annals of Internal Medicine). With such lessons-learned, many will be paying attention to Australia as it becomes a first in implementing treatments with psilocybin and MDMA (Nature).
While we have your attention, we’d like to share some important news from ASAM:
The Journal of Addiction Medicine continues to lead with yet another jump in its impact factor (5.5).
Experts in adolescent addiction are encouraged to apply to serve on writing committees for the 4th Edition of The ASAM Criteria®, Adolescent Volume.
ASAM reiterates its commitment to advancing access to high-quality addiction care (see below).
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
ASAM’s Commitment to Advancing Access to High-Quality Addiction Medicine Care
ASAM is a champion of addiction medicine access for all and is committed to increasing public awareness of the disease of addiction and the benefits of high-quality addiction care. With respect to policies that may limit access to addiction medicine services and educational opportunities, ASAM is reiterating our public policy that healthcare systems should act with the understanding that there are structural implications to who accesses addiction medicine services and that increasing diversity within the healthcare workforce is critical to improving addiction care. All clinicians and healthcare systems should consider and address social determinants of health, including housing, education, transportation, employment, racism, sexism, and discrimination against people identifying as LGBT+, as part of a patient’s comprehensive treatment and recovery.
Lead
Xylazine effects on opioid-induced brain hypoxia 🔓
Psychopharmacology
Xylazine has emerged in recent years as an adulterant in an increasing number of opioid-positive overdose deaths in the United States. Although its exact role in opioid-induced overdose deaths is largely unknown, xylazine is known to depress vital functions and cause hypotension, bradycardia, hypothermia, and respiratory depression. This study examined the brain-specific hypothermic and hypoxic effects of xylazine and its mixtures with fentanyl and heroin in freely moving rats. It found that xylazine exacerbates the life-threatening effects of opioids, proposing worsened brain hypoxia as the mechanism contributing to xylazine-positive opioid-overdose deaths.
Call for Applications: 4th Edition Adolescent Writing Committees
ASAM is seeking experts in specific topic areas to serve on writing committees for the 4th Edition of The ASAM Criteria®, Adolescent Volume. These writing groups will be chaired by Lead Editors who report to the Editor in Chief. ASAM members and non-members are encouraged to apply, as are all members of the addiction medicine care team. Applications will be accepted through July 21, 2023.
Research and Science
Effects of U.S. State Medical Cannabis Laws on Treatment of Chronic Noncancer Pain
Annals of Internal Medicine
State medical cannabis laws may lead patients with chronic noncancer pain to substitute cannabis in place of prescription opioid or clinical guideline–concordant nonopioid prescription pain medications or procedures. Using data from 12 states that implemented medical cannabis laws and 17 comparison states, augmented synthetic control analyses estimated laws’ effects on receipt of chronic noncancer pain treatment, relative to predicted treatment receipt in the absence of the law. This study did not identify important effects of medical cannabis laws on receipt of opioid or nonopioid pain treatment among patients with chronic noncancer pain.
The Lancet
In this triple-blinded, placebo-controlled, randomized trial, the safety and efficacy of a short course of opioids for the treatment of low back and neck pain were examined. Guideline recommended care plus oxycodone-naloxone vs. that care and a placebo was employed for a six-week period. Mean pain score at six weeks was 2.78 (on a 1-10 scale) for those on opioids, and 2.25 for the placebo-controlled group. These findings support a change in current prescribing habits -- that opioids are not recommended for these conditions.
The Lancet
With intervention, early diagnosis of alcohol-related liver disease (ARLD) can support cessation efforts. This randomized control trial assessed the efficacy of transient elastography-based advice and alcohol recovery video stories (ARVS) in changing harmful drinking patterns. Capturing recruitment at community alcohol services, those randomized to the intervention group plus usual care had liver stiffness measured by transient elastography (TE), followed by scripted feedback based on these results. In those asymptomatic but high-risk, 20% had an elevated liver stiffness measure, close to 15% nearing cirrhosis. Non-invasive testing for liver disease hence enables early disease detection in an otherwise high-risk asymptomatic population.
JAMA Psychiatry
Smoking tobacco is a significant cause of morbidity and mortality in persons with serious mental illness (SMI), but these patients are frequently not offered smoking cessation treatments. People with SMI also have higher rates of obesity which could be exacerbated by weight gain with smoking cessation. In this randomized control trial, patients were randomized to an 18-month program offering pharmacotherapy, behavioral support for smoking cessation, and weight management versus a control group that received referral to a quit line, quarterly health newsletters, and list of exercise resources. 26.4% of participants in the study group quit smoking versus 5.7% in the control group (OR 5.9, p-value < 0.01). In addition, there was no significantly greater weight gain in the intervention group, supporting use of smoking cessation interventions in this population.
Learn More
Drug Overdose Deaths Involving Xylazine: United States, 2018–2021 🔓
National Vital Statistics System
In this study, trends in overdose deaths involving xylazine between 2018 and 2021 were examined. The age-adjusted rate of overdose deaths involving xylazine increased from 0.03 to 1.06 per 100,000. Rates among males were more than double those of females. Rates also increased across all race and ethnicity groups and were highest among non-Hispanic Black individuals; they increased the most among Hispanic individuals. The eastern US was impacted more than the middle and western US. While fentanyl was the most common co-involved drug, co-involvement with methamphetamines increased, becoming the second most common co-involved drug. These findings highlight the growing involvement of xylazine in the ongoing overdose epidemic in the US.
Harm Reduction Journal
Virtual overdose monitoring services (VOMS) are an alternative for those unable or unwilling to use safe consumption sites. Interviews were conducted with people who use substances (PWUS) regarding their experiences and beliefs about VOMS. PWUS were optimistic about VOMS for harm reduction and noted that “spotting” already exists (telephone contact with a spotter while using). Some VOMS provided telephone peer-to-peer contact which was warm and not judgmental and a source of referral to health and social services. Other VOMS were digital where a timer had to be reset to prevent a call to EMS. Privacy was a concern with fear of legal consequences (arrest and loss of child custody). Others were concerned that rural areas may have unreliable cell signals and slow EMS response times. Many felt the need for increased awareness of VOMS.
Drug and Alcohol Dependence
This study compared the accuracy of oral fluid drug testing (OFDT) compared to urine drug testing. Comparison was also made between in-person versus remote (over video) OFDT. Remote OFDT has the potential to allow contingency management to be conducted via telehealth. Sensitivity of OFDT was varied; results from most to least sensitive were methadone (.85-.93), oxycodone (.71-1.00), cocaine (.63), amphetamine (.33), opiates (.21), and cannabis (.07-.23). The “validity of oral fluids testing was similar for samples collected in-person and remotely.” At times the lines on the OFDT device were difficult to see on video and the device had to be monitored continuously on the video for the 10-minute test period to avoid tampering. OFDT lacks adequate sensitivity to be reliable.
In The News
Xylazine-Associated Skin Injury
The New England Journal of Medicine
New test strips that can detect "tranq" and fentanyl in drugs distributed in Delaware
The Philadelphia Inquirer
San Francisco Will Use Opioid Settlement to Also Expand Treatment for Meth, Cocaine Use
KQED
Portugal's drug decriminalization faces opposition as addiction multiplies
The Washington Post
Australia to prescribe MDMA and psilocybin for PTSD and depression in world first
Nature
CDC
Psychedelics group wrestles with new pharma identity
STAT
Why Isn't Buprenorphine Available at All Pharmacies?
MedPage Today
United States Department of Justice