ASAM Weekly for October 10, 2023
This Week in the ASAM Weekly
A study from New York has found that increasing temperatures are associated with increased hospital visits related to alcohol and substance use (Communications Medicine). Although the reasons for this will need to be further studied, a profile of agricultural workers in India provides another perspective. Many turn to nicotine and alcohol to cope with climate stress because of the economic instability created by floods, droughts, and harvest loss (WIRED).
More locally, schools are not in agreement about having naloxone on campus. The stigma of “acknowledging there’s a drug problem” still worries many districts, but the students are advocating for access to this low-cost, life-saving intervention (KFF Health News). Many of these same students are also part of Generation Z, which is making rock concerts tame and the word “teetotaler” relevant again (WSJ).
The FDA is under criticism from lawmakers for recommending a particular research method (enriched enrollment randomized withdrawal) for studying long-acting opioids in pain treatment. Experts warn this method will lead to biased results (STAT News). The FDA is also providing guidance to industry, academics, and the public about future steps in developing treatments for stimulant use disorders (StUD). Unfortunately, there are curretly no FDA-approved medications for stimulant use disorder (FDA).
Most importantly -- but unofficially until today -- the DEA will be extending telemedicine exceptions related to controlled medications. We have until the end of 2024 to figure this all out (Federal Register).
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
Using New York State hospital data, this study investigated the link between daily temperature and hospital visits as a result of substance use from 1995-2014. An increase in temperature 0-6 days prior to seeking hospital care was associated with an increase in rates in care. Increase in visits was highest when opioids were involved, and lowest for sedatives. The 25-44 age group was primarily affected, and males made up the highest proportion of cases. These results indicate that the rise in SUD hospital visits is linked to continued rising temperatures related to climate change; healthcare and social interventions could potentially mitigate these harms.
Research and Science
The American Journal of Psychiatry
This study investigated the frequency and determinants of long-term use and risk of dose escalation of benzodiazepines and benzodiazepine-related drugs (benzodiazepine receptor agonists, or BZRAs). Researchers identified 950,767 incident BZRA users, of whom 15% and 3% became long-term users for more than 1 or 7 years, respectively. These percentages were highest for individuals who initiated Z-drugs (17.8% and 4%). Among the 5% of BZRA users who had at least 3 years of continuous use, there was no indication of dose escalation, as the median dose remained relatively stable. However, 7% of BZRA users escalated to doses above the recommended level. Psychiatric comorbidity, especially substance use disorder, was associated with higher risk of long-term use and dose escalation. This study does not, under the current regulations, support the belief that BZRA use frequently results in long-term use or dose escalation.
There have been multiple reports of an acute amnestic syndrome associated with opioid use and overdose. The syndrome is characterized by anterograde amnesia that can last for several months. This study measured hippocampal volume on MRI scans of 49 patients with OUD. A history of overdose was present in 17 of the patients and the remaining 23 had no overdose history. The hippocampal volume was significantly less in those with a history of overdose compared to those without overdose (p=0.041). The hippocampus lies at the border of two vascular distributions making it particularly susceptible to hypoxic injury. The authors suggest that this hippocampal injury underlies the opioid overdose amnestic syndrome.
Journal of Addiction Medicine
This study used a global database of electronic medical records (TriNetX) to identify a cohort of patients with alcohol use disorder (AUD). Patients with AUD and a laboratory confirmed diagnosis of COVID (n=45,842) were matched with AUD patients without a history of COVID. The measured outcome was major cardiovascular events (MACE) during the year following COVID diagnosis. In patients with AUD, a COVID diagnosis significantly increased the risk of MACE (HR=2.0). Specifically, COVID increased the risk of myocardial infarction (HR=3.8), ischemic stroke (HR=1.8), hemorrhagic stroke (HR=2.7), and myocarditis (HR=6.0). In patients with AUD, a COVID infection is associated with a significant increased risk of multiple cardiovascular events.
Drug and Alcohol Dependence
Persons who receive Medicare disability benefits are at higher risk of developing opioid use disorder (OUD), but also frequently have difficulty accessing medical services. In this study, researchers look at Medicare disability beneficiaries (MDB) with OUD access to buprenorphine and racial disparities. Overall, only 6.15 of MDB received buprenorphine within 180 days of an OUD diagnosis. Black (aHR 0.50), Asian/Pacific Islander (aHR=0.54), and Hispanic/LatinX (aHR=0.81) persons were all less likely to receive buprenorphine than white beneficiaries within 180 days. Efforts are needed to improve access to treatment for all beneficiaries, including removing barriers and expanding telehealth, but these efforts also need to specifically address the significant racial/ethnic disparities in access.
Substance Use & Misuse
Efforts to reduce prison populations and drug court policies to divert persons convicted of drug related crimes to community treatment programs have coincided with the opioid epidemic. This study interviewed persons on probation and parole and compared their substance use and health risks to the general population. The authors found that rates of opioid use were 4 times higher among those on parole (17%) compared to the general population (3.8%). In addition, those on parole with opioid use had much higher rates of other health risks, including other substance use (tobacco, alcohol, cocaine), significant mental health issues, and involvement in crime. The authors note that interventions and treatment for this group need to address polysubstance use and policies to keep persons out of jail should also provide for investments in treatment.
Using U.S. Poison Control Center data, this study explored trends in ADHD medication errors over a 22-year period. Close to 150,000 errors were reported, with a whopping annual increase of nearly 300%. Results reveal that some 2.3% of children were admitted to a healthcare facility, 4.2% with an untoward outcome, predominantly affecting those under 6 years of age.Errors included dosing medication twice, taking another person’s medication, or the wrong medication administered or taken by the child. The authors suggest that increased prescribing of these medications is a contributor. Consideration to safer packaging and caregiver education is warranted.
Significant trauma histories and post-traumatic stress disorder (PTSD) are common in persons with substance use disorders (SUD) and often associate with increased SUD severity and poorer response to SUD treatment. This study employed supervised machine learning algorithms and neurocognitive tasks demonstrating that within a population of individuals with SUD, aberrations in tolerating and regulating aversive internal experiences may also characterize those with significant trauma histories, akin to findings in persons with anxiety without SUD. The results also highlight the need for further research on PTSD-SUD comorbidity that includes additional comparison groups (i.e., persons with only PTSD), captures additional comorbid diagnoses that may influence the PTSD-SUD relationship, examines additional types of SUDs (e.g., alcohol use disorder), and differentiates between subtypes of PTSD.
In The News
MSN/The Wall Street Journal
KFF Health News