ASAM Weekly for October 31, 2023
This Week in the ASAM Weekly
If you haven’t recently explored the ASAM website, this week’s publications may be a good motivation to do so. Our lead study evaluates the relationship between cannabis legalization, use, and chronic pain in US Veterans (The Lancet Psychiatry) while another demonstrates an association between CUD and suicide risk (moderated by depression) in hospitalized adolescents (PLOS One). Both demonstrate the harms of cannabis for the young and the old. ASAM’s Public Policy Statement on Cannabis helps lay the groundwork for understanding this as well as other implications of cannabis use.
Two more studies explore technology and buprenorphine treatment. One analyzes a novel technology-assisted buprenorphine treatment strategy that increases abstinence rates (JAMA Network Open) while another reaffirms the benefits of telehealth, especially in rural areas (JAMA Network Open). ASAM has been an influential advocate for the use of telehealth in addiction treatment. You can learn more about ASAM's position in Optimizing Telehealth Access to Addiction Care.
The momentum around methadone treatment for OUD is building (STAT News) and ASAM has both a public policy statement and a comprehensive guide with resources for policymakers and clinicians. The first-ever Canadian guideline on AUD was recently published and may diverge slightly from its American counterparts on the recommendation of when to use SSRI's (CMAJ). Given the importance of clinical guidelines, you can find a full list of ASAM’s Clinical Guidelines here.
One thing the ASAM website doesn’t have but could use is a guide for non-stigmatizing, addiction-themed Halloween costumes. For example, what’s the scariest thing an addiction specialist could be on Halloween night?
A Zombie X-Waiver of course, because no one wants to see that thing come back from the dead.
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
The Lancet Psychiatry
The prevalence of cannabis use disorder (CUD) in patients with chronic pain is increasing. This study considered the impact of both recreational (RCL) and medical cannabis laws (MCL) on the diagnosis of CUD using a VA population with chronic pain. Results demonstrate that MCL led to a 0.135% increase in the prevalence of CUD. Enacting RCL led to a 0.188% increase in its prevalence. The authors emphasize the importance of these findings and their public health implications, with a focus on clinician monitoring and patient education.
Research and Science
This study used data from The Nationwide Inpatient Sample, administered by The Agency for Healthcare Research and Quality. Researchers obtained diagnoses for all hospital admissions of adolescents (10-19 years) for the years 2016-2019 (n= 807,105). They found that those with a diagnosis of cannabis use disorder (CUD) were more likely to have a diagnosis of suicide attempt than those without CUD (2.8% v. 0.9%, p<0.001). CUD was also associated with other mental health disorders such as depression (44% v. 17%, p<0.001), anxiety (32% v. 13%, p<0.001), and ADHD (16.3% v. 9.1%, p<0.001). CUD was also associated with other SUDs, for example, alcohol use disorder (11.9% v. 0.8%, p<0.001) and nicotine use disorder (31.1% v. 4.1%, p<0.001). The authors conclude that CUD is associated with suicide attempts and depression and call for efforts to prevent cannabis use among adolescents.
JAMA Network Open
The COVID-19 pandemic disrupted health care delivery in the US, which may have contributed to sharp increases in drug overdose mortality. In Kentucky and Ohio, restrictions limiting access to medical care disproportionately affected individuals with opioid use disorder (OUD), who already faced significant barriers accessing care. Decreases in the delivery of in-person care were partially offset by an increase in telemedicine services. In this cohort study using Medicaid data on 91,914 individuals from 2020, enrollees who initiated buprenorphine treatment via telemedicine had higher odds of retention in treatment but no change in the odds of opioid-related nonfatal overdose. This study suggests that patients may benefit from the use of telemedicine during buprenorphine initiation.
Journal of Studies on Alcohol and Drugs
Although each US state has passed legislation to expand access to naloxone, preventable deaths still occur daily because of failures to administer the medication. This study assesses whether online patient education materials for naloxone meet national readability guidelines. It further compares the readability of naloxone materials to that of cardiopulmonary resuscitation (CPR) materials, given that the latter is an established and widespread life-saving procedure. The average readability of naloxone/Narcan websites was grade 11.2 ± 2.3, and none of the websites met the recommended sixth-grade reading level for patient education materials such as those used for CPR. Online information about naloxone should be simplified to broaden educational access to this life-saving medication.
Harm Reduction Journal
With the loosening of restrictions on buprenorphine prescribing, there has been some concern about increases in diversion and potential negative outcomes. The authors conducted an agent-based modeling study to compare 3 scenarios: status quo, controlled prescribing with no diversion, and increased diversion scenario. They specifically looked at opioid overdoses and overdose deaths in all 3 scenarios and found that overdoses were highest in the controlled scenario, likely due to buprenorphine used as substitution for heroin/fentanyl when diverted. Even after conducting sensitivity analysis with higher rates of diversion and diversion among opioid naïve persons, the overdose rates were not higher. These data support ongoing efforts to liberalize buprenorphine prescribing and increase access.
Canadian Medical Association Journal
This study helped inform a national practice guideline for the Canadian Research Initiative in Substance Misuse for the clinical management of alcohol use disorder (AUD). The guideline contains 15 recommendations for screening, diagnosis, and treatment, as well as psychosocial treatment interventions. Underutilized interventions were highlighted, as well as information on practices that are not evidence-based, with the potential to worsen outcomes. Principles of care include social determinants of health, patient-centered care, trauma and violence-informed practice, harm reduction, and comprehensive health management. The intent is to provide a framework so evidence-based practices are embraced.
Frontiers in Psychiatry
The authors discuss current studies addressing the use of psychedelics, including ketamine, for treatment of substance use disorders (SUD). Though existing studies are limited and frequently small, there are studies looking at treatment for depression or anxiety in persons with SUDs, alcohol use disorder, cannabis use disorder, and methamphetamine use disorder. There are also limited studies examining the potential mechanisms for psychedelic effects including neuroplasticity. The authors note that given the significant need for novel therapies for SUDs and the potential for psychedelics as treatment, much additional research is needed and that research needs to be equitable to ensure high risk populations benefit.
JAMA Network Open
This study collected outcome data on patients receiving technology-assisted buprenorphine (TAB) treatment. The TAB consisted of 4 components: 1) buprenorphine induction followed by 2 week supplies of take-home doses, 2) Nightly calls from a voice response system asking about drug use and craving, 3) twice monthly random calls for urinalysis, and 4) HIV, HCV, and overdose education administered by tablet computer. The control group was informed about community resources, did not receive medication, and received the same urinalysis schedule as the TAB patients. Data collection continued for 6 months. Trial 1 consisted of 50 patients treated at the research clinic where the TAB patients achieved 85% abstinence compared to 24% in the controls (p<0.001). Trial 2 consisted of 50 patients treated in a rural setting where the TAB patients achieved 88% abstinence compared to 21% in the controls (p<0.001). This demonstrates the efficacy of TAB treatment.
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