The ASAM Weekly for December 19, 2023
This Week in The ASAM Weekly
As we start wrapping up 2023, the next two issues of The ASAM Weekly will contain the best of publications in both news and science. We do this each year to allow our readers an opportunity to catch up on things they may have missed, reflect on things that might have changed, or find out if they’re reading what their colleagues are reading (sort of like personalized normative feedback mentioned in the study from Alcohol Clinical and Experimental Research).
It’s also an opportunity to allow the ASAM Weekly editorial team a few weeks off from the newsroom grind of publishing a weekly newsletter (thank you team for an amazing year). So with that, here is a brief commentary to introduce the final summaries of 2023.
Included are several studies evaluating affinities for opioid receptors. One finds that higher maintenance doses of buprenorphine-XR are likely needed for individuals who inject opioids (Harm Reduction Journal), while higher doses of buprenorphine likely have a protective effect on overdose death (Journal of Substance Use and Addiction Treatment). Nalmafene has a higher affinity for opioid receptors and longer duration of action, but two leading organizations in toxicology are advising to continue use of naloxone until further evidence on nalmafene is available (Clinical Toxicology). The toxicology report of Matthew Perry is unfortunately making headlines (PBS).
We have a brief announcement from the National Academies. The institution is examining the challenges of accessing behavioral health care through Medicare and Medicaid and is asking providers for their input, but you need to act soon.
Lastly, we can’t end 2023 without heartfelt recognition. This is the last issue of The ASAM Weekly that will include the amazing work of Co-Editor Debbie Newman. She has decided to step down from The ASAM Weekly in order to focus her time on several new endeavors in 2024. Since bribes and guilttrips didn’t work, all we have left is a big thank you. It has been great to work with you, Debbie, and we all wish you the best.
Thank you and Happy Holidays,
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
Harm Reduction Journal
This is a secondary analysis of a randomized, double-blind study comparing 100 mg and 300 mg maintenance doses of extended-release buprenorphine (BUP-XR). All patients (n=311) received 2 monthly induction doses of 300 mg BUP-XR followed by 4 monthly maintenance doses of either 100 mg or 300 mg BUP-XR. For patients who had not been using opioids by injection, there was no difference in weekly abstinence or treatment retention comparing the two maintenance doses. However, for patients with a history of injecting opioids, the 300 mg maintenance dose resulted in significantly higher percentages of weeks abstinent as well as improved treatment retention. The authors speculated that opioid injecting patients may have had higher levels of tolerance that required a higher maintenance dose.
Research and Science
Journal of Substance Use and Addiction Treatment
This study examined all unintentional deaths involving fentanyl in West Virginia between 2011 and 2020 (n=3036). In 168 of these deaths, buprenorphine was present. The presence of the metabolite norbuprenorphine suggests that for about 90% of these deaths the buprenorphine was a chronic medication rather than a component of the acute overdose event. When buprenorphine was present, the median fentanyl concentration was 65% higher. These results suggest that buprenorphine had a protective effect for fentanyl overdose in that higher doses of fentanyl are required for a fatality. Also, the presence of alcohol was associated with a 21% lower fentanyl concentration suggesting alcohol facilitated the overdose.
This randomized control trial considered the efficacy of single-dose psilocybin for the management of treatment-resistant bipolar II disorder. Some 15 participants were enrolled and administered a single 25 mg dose two weeks after psychotropic medications were discontinued. Results demonstrate at the study endpoint (12 weeks) that 12 participants achieved response and remission criteria on the Montgomery-Åsberg Depression Rating Scale, supporting further investigation of this therapy for this population.
Journal of Studies on Alcohol and Drugs
Alcohol delivery and to-go sales may contribute to changes in drinking patterns, including where and what people drink. This study tested whether home delivery and to-go alcohol purchases were associated with context- and beverage-specific consumption volumes during the first year of the COVID-19 pandemic after adjusting for pre-pandemic consumption volumes. On average, respondents who had alcohol delivered (vs. not) reported consuming larger volumes overall. People who bought alcohol to go (vs. not) reported larger volumes of wine, at home and in bars. People who had alcohol delivered reported drinking smaller volumes in bars. Thus, during the first year of the pandemic, adults who had alcohol delivered or bought it to go reported larger volumes for several locations and beverage types.
Methamphetamine (MA), a psychostimulant, is the second most frequently used illegal substance worldwide. This study reported on the immunological profiles of MA use, MA dependency, or MA-induced psychosis (MAP). Long-term MA use and dependency severely undermine immune homeostasis, whereas MAP may be the consequence of increased IL-1α – CCL5 signaling superimposed on strongly depleted CIRS and Th-1 functions. The widespread immunosuppression established in longstanding MA use may increase the likelihood of infectious and immune illness or exacerbate disorders such as hepatitis and AIDS. Furthermore, elevated levels of CCL5, CCL11, CCL27, IL-1α, and/or IL-12p70 may play a role in the peripheral (atherosclerosis, cutaneous inflammation, immune aberrations, hypospermatogenesis) and central (neuroinflammation, neurotoxic, neurodegenerative, depression, anxiety, and psychosis) side effects of MA use.
Alcohol Clinical and Experimental Research
Alcohol use is prevalent in young adulthood, an important time when alcohol use habits form with potential long-term consequences. In addition, beliefs about peer attitudes and behavior strongly influence young adults’ decisions about alcohol use, and they frequently overestimate their peers’ use. Providing personalized normative feedback (PNF), providing referent group actual norms, and correcting misperceptions, has been shown to decrease alcohol use. In this pilot, researchers conducted PNF utilizing dynamic norms, which are temporal trends and projected trends in norms, and found reductions in perceived drinking use behavior at follow-up. The authors support further research based on this preliminary data.
American College of Medical Toxicology and the American Academy of Clinical Toxicology position statement: nalmefene should not replace naloxone as the primary opioid antidote at this time (OPEN ACCESS)
In this position piece, the authors discuss the status of nalmefene and recommend against utilizing it in place of naloxone for opioid overdose reversal at this time. Nalmefene was initially approved in 1995 as an injectable opioid agonist but was removed from the market due to market forces. Intranasal nalmefene was recently approved and marketed as advantageous for synthetic opioid overdoses. Nalmefene does have higher affinity for opioid receptors than naloxone and longer duration of action, however the authors note there is sparse clinical data on intranasal nalmefene reversal of synthetic opioids or potential harm such as longer-lasting precipitated withdrawal. The authors thus recommend continued use of naloxone until additional clinical studies with nalmefene are conducted.
Journal of Addiction Medicine
This commentary considers two current studies that address structural and interpersonal bias as it relates to pregnant and postpartum women who struggle with substance use disorders. Patients report their distress in terms of the intensive monitoring of their newborns; feelings of being judged were also expressed in terms of parenting. This created an atmosphere of low self-worth, and mistrust of the health care system. Clearly more needs to be done to embrace this population and alleviate these concerns.
In The News
The New York Times
San Francisco Chronicle