American Society of Addiciton Medicine

The ASAM Weekly for February 27, 2024

by ASAM Weekly Editors

This Week in the ASAM Weekly

Are Headlines, Crises, and the Innocence of Youth Distracting Us from the Realities of Addiction Later in Life?

Bethea (Annie) Kleykamp, PhD, MA
Assistant Professor, University of Maryland School of Medicine, Psychiatry
Director, Research and Evaluation, Maryland Addiction Consultation Service

The question was simple: Do people still smoke cigarettes?

They asked because none of their friends or family smoked, they didn’t see people do it in public, and they hadn’t seen a cigarette butt since the 90s.

They also asked because they had heard alarming news stories about nicotine vaping alongside warnings from public health agencies, including a congressional testimonial from FDA leadership on the youth vaping “epidemic” and a 295-page Surgeon General’s report on e-cigarette use among young people (my thoughts on the low quality of the latter are published in Nicotine and Tobacco Research).

Vaping was the new smoking, and youth were its victims, right?

The epidemics and crises related to youth addiction don’t stop at tobacco. Just out in the New England Journal of Medicine is an article highlighting the “The Overdose Crisis among U.S. Adolescents.” Other headline stories on the state and national level add to growing concerns about opioid use among youth.

The sense of responsibility to protect young people impacted by the harms of tobacco, fentanyl, and other drugs is compelling. But isn’t that what we have been doing and, by many measures, succeeding?

Read the full editorial.

Lead Story

Smoking changes adaptive immunity with persistent effects 🔓

Nature

There is significant variability in immune response across the population, some of which is related to age, sex, and genetics, but this study examines other factors that may be related to immune response. Notably, the authors found that smoking affected both innate and adaptive immune response, and that the associations were consistent across number of years smoking and number of cigarettes. The effect on innate immune response was short-term, with immune response returning to levels comparable to non-smokers after quitting. The effect on adaptive immunity, however, was long-term and persisted even after quitting — the result of DNA methylation changes. These findings have clinical implications regarding risk of infection, cancer, and autoimmune disease in persons who smoke. 

Research and Science

Smoking Cessation and Short- and Longer-Term Mortality

NEJM Evidence

Smoking cessation reduces mortality and morbidity. However, the extent and rapidity at which cessation reduces contemporary death rates from smoking-related illnesses remain uncertain. This study pooled current or former versus never cigarette smoker hazard ratios from four national cohorts with linkage to death registries in the United States, United Kingdom, Norway, and Canada among adults 20 to 79 years of age from 1974 to 2018. It calculated excess risk differences and survival, comparing current or never smokers with age-specific cessation and cessation fewer than 3, 3 to 9, or 10 or more years earlier. Quitting smoking at any age, but particularly in younger years, was associated with lower excess mortality overall and from vascular, respiratory, and neoplastic diseases. Beneficial associations were evident as early as 3 years after cessation.

Electronic Nicotine-Delivery Systems for Smoking Cessation

The New England Journal of Medicine

In this open-label, randomized controlled trial, researchers evaluated e-cigarettes as a smoking-cessation aid. Patients were randomized to receive either smoking-cessation counseling or counseling plus e-cigarettes. Both groups could also access nicotine replacement therapy and smoking-cessation medications. The group provided e-cigarettes had higher rates of tobacco abstinence at 6 months (28.9% vs 16.3%, RR 1.77), validated by biochemical markers. The e-cigarette group did have higher rates of continued nicotine use (33.7% vs 20.1%). The authors note that e-cigarettes added to standard counseling may be beneficial to patients who wish to abstain from tobacco, though not as useful if they wish to abstain from all nicotine. 

Comparative analysis between CDT in serum and Ethyl glucuronide in hair to define the best reliable tool for the diagnosis of alcohol abuse 

Drug and Alcohol Dependence

This study was conducted in Italy where individuals driving under the influence must have a negative laboratory test for alcohol use prior to reinstatement of their driving license. This study compared the performance of carbohydrate-deficient transferrin (CDT) in blood with ethyl glucuronide in hair (EtG). Subjects seeking license reinstatement (n=336) had peripheral blood analyzed for CDT as well as a hair sample analyzed for EtG. Positive CDT was found in 1.5% of samples and positive EtG was found in 16.4%. The authors note that CDT has a half-life in blood of 7-10 days whereas EtG in hair reflects alcohol use over the past 3 months. Although detecting alcohol use via CDT is less expensive, they conclude that EtG in hair has greater reliability.

Learn More

Routes of Drug Use Among Drug Overdose Deaths — United States, 2020–2022 🔓

Morbidity and Mortality Weekly Report

Overdose deaths in the US have been increasing due to synthetic opioids, primarily illegally manufactured fentanyl (IMF). In this report, the authors examine those trends and changes in route of drug use between January 2020 and December 2022. During this time, overdose deaths increased 20.2% with the percentage of those deaths due to IMFs increasing from 71.4% to 77.4%. The routes of use also changed; deaths with evidence of smoking increased from 13.3% to 23.1% and snorting increased from 13.6% to 16.2%, while deaths with injection decreased from 22.7% to 16.1%. Given changes in routes of use, the authors state the possible effects of public health messaging to highlight the risk of overdose from non-injection routes, in addition to ongoing syringe services programs and harm reduction services. 

Expanding access to medication treatment for opioid use disorders: Findings from the Washington State hub and spoke effort 

Drug and Alcohol Dependence

Between 2010 and 2019 Washington State increased MOUD use by 200%, compared to 106% nationally. In 2017 Washington State implemented a hub and spoke (HS) network to support MOUD initiation. Six hubs consisting of MOUD-experienced providers connected to over 50 spokes comprised of community-based providers. This study collected Medicaid claims data between 2016 and 2019 for 115,911 persons with OUD. After HS began persons connected to the HS network had a 50% increase in MOUD use compared to a 10% increase in the non-HS group. These increases were primarily due to buprenorphine. Prior to HS implementation the groups were comparable with similar rates of MOUD growth. The authors conclude that the HS network is associated with an increased use of buprenorphine.

Federal Policy Changes Must Occur To Provide A Lifesaving Stimulant Drug Intervention 🔓

Health Affairs Forefront

At the present time, there is a drug poisoning crisis in the US, and half of these fatalities involved the use of cocaine or methamphetamine alone or in combination with fentanyl or other drugs. A behavioral intervention called contingency management (CM) is the only treatment that is consistently associated with reductions in stimulant use, but the federal government has created obstacles to using this approach. One obstacle, the $75 limit on federal funds, is tantamount to having an effective medication for a fatal condition but only allowing clinicians to use the medication at a dose far below what is needed to be effective. Obstacles to the effective use of CM using evidence-based parameters are contributing to the current failure to prevent drug-related deaths in the US. CM should be available to all people with a stimulant use disorder in the US.