This Week in Addiction Medicine from ASAM

Lead: Human brain effects of DMT assessed via EEG-fMRI

Lead Story:
Human brain effects of DMT assessed via EEG-fMRI 
PNAS
Interest in psychedelics as potential treatment for depression has increased. In this study, researchers examine the effects of N,N-Dimethyltryptamine (DMT) on brain function using electroencephalography (EEG) and functional MRI (fMRI). The study found a dysregulating effect on activity in the transmodal association pole (TOP) an area with high expression of serotonin 2A receptors (5-HT2AR). The authors also found increased communication between TOP and the rest of the brain, which may be evidence of increased information processing and hyperassociative cognition. They were able to correlate their findings through simultaneous EEG, fMRI, and symptom reports from participants. 
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Lead: Characteristics of Fatal Poisonings Among Infants and Young Children in the United States

Characteristics of Fatal Poisonings Among Infants and Young Children in the United States 
Pediatrics
Child death reviews present an opportunity to improve understanding of fatal poisonings. This study employed the National Fatality Review-Case Reporting System (NFR-CRS), a national standardized reporting tool, to describe the demographics of childhood deaths by poisoning, identify associated factors, and characterize those deaths attributable to opioids. Opioids were the most common substance (47.3%) contributing to death in young children, followed by OTC pain, cold, and allergy medications (14.8%). There was a substantial rise in these opioid-involved deaths over time, from 24.1% of the substances contributing to deaths in 2005 compared with 52.2% in 2018, illustrating the impact of the opioid epidemic on young children. Opportunities for naloxone education are paramount.
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Synthesising evidence of the effects of Lead: COVID-19 regulatory changes on methadone treatment for opioid use disorder: implications for policy

Synthesising evidence of the effects of COVID-19 regulatory changes on methadone treatment for opioid use disorder: implications for policy 
The Lancet Public Health
In this review article, methadone take-home dosing considerations during the COVID-19 pandemic were examined. A search of published research on the flexibility of these practices, patient-provider experience, health outcomes, and how these findings might influence updated regulations was performed. The review found no evidence of increased methadone overdose risk as a result of greater pandemic flexibility. Benefits of such policy include potentially improved treatment retention and impressive improvements in patient quality of life. This is key for SAMHSA as it ponders the steps to make these flexibilities permanent.
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Not all vaping is the same: differential pulmonary effects of vaping cannabidiol versus nicotine

Not all vaping is the same: differential pulmonary effects of vaping cannabidiol versus nicotine 
Thorax
This in vivo inhalation study in mice and in vitro cytotoxicity experiments with human cells assessed the pulmonary damage-inducing effects of cannabidiol (CBD) or nicotine aerosols emitted from vaping devices. Inhalation of CBD aerosol resulted in greater inflammatory changes, more severe lung damage, and higher oxidative stress compared with nicotine. CBD aerosol also showed higher toxicity to human cells compared with nicotine.
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Lead: The Howard Street Method: A Community Pharmacy-Led Low Dose Overlap Buprenorphine Initiation Protocol for Individuals Using Fentanyl

The Howard Street Method: A Community Pharmacy-Led Low Dose Overlap Buprenorphine Initiation Protocol for Individuals Using Fentanyl
Journal of Addiction Medicine
Concerns about precipitated withdrawal can be a barrier for patients initiating buprenorphine. This case series examined the implementation of buprenorphine low dose overlap initiation (LDOI) utilizing a community pharmacy. A blister pack was provided with a 7-day titration schedule increasing from 0.5 mg to 4 mg daily. Of the twenty-six patients who started treatment, fourteen completed the protocol with 79% reporting no withdrawal symptoms and 21% reporting only mild symptoms. At thirty days of follow-up, 71% were still receiving buprenorphine, and at 180 days 43% were retained in care but only 14% were still receiving buprenorphine. The study suggests that this community-based pharmacy approach is novel and may offer a new way to initiate buprenorphine in high-risk populations.
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Lead: The Use of Opioids in the Management of Chronic Pain

The Use of Opioids in the Management of Chronic Pain: Synopsis of the 2022 Updated U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline 
Annals of Internal Medicine 
The VA, along with the Department of Defense, recently approved an updated guideline regarding the management of chronic pain with opioids (updated from the 2017 version). This includes considerations regarding initiation and continuation of therapy; dose, duration, and taper of opioids; screening, assessment, and evaluation; and risk mitigation. A new recommendation for patients receiving chronic opioid therapy is using buprenorphine in place of full agonists due to its lower risk of overdose and misuse. Other new recommendations suggest screening for additional psychiatric comorbidities that could increase risk and screening for pain catastrophizing.
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Lead: State Cannabis Legalization and Psychosis-Related Health Care Utilization

State Cannabis Legalization and Psychosis-Related Health Care Utilization 
JAMA Network
Psychosis has long been considered a potential consequence of cannabis use. In this retrospective cohort study, the association of state cannabis legalization with psychosis-related health care claims among some 63,680,589 privately insured individuals were investigated. There were 7,503,907 psychosis-related diagnoses and 20,799,285 prescriptions filled for antipsychotics over the study period. State medical and recreational cannabis policies were not found to be associated with a statistically significant increase in rates of psychosis-related health outcomes.
 
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Lead: Buprenorphine Dispensing Among Youth Aged ≤19 Years in the United States

Buprenorphine Dispensing Among Youth Aged ≤19 Years in the United States: 2015–2020
Pediatrics
Opioid related overdose among adolescents and young adults in the United States is rising. Medications for opioid use disorder (MOUD), including buprenorphine, can reduce the risk of overdose; however, they are underutilized.  Given rates of opioid use disorder (OUD) among youth, these findings suggest that many young people who could benefit from MOUD are not receiving it. Pediatricians could play a role in expanding access to MOUD for this high-risk population. Efforts to expand access to MOUD for adolescents could include improving pediatrician training in OUD treatment and encouraging all clinicians who care for adolescents and young adults to prescribe buprenorphine for MOUD.
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Lead Story: Trends and Characteristics of Buprenorphine-Involved Overdose Deaths Prior to and During the COVID-19 Pandemic

Trends and Characteristics of Buprenorphine-Involved Overdose Deaths Prior to and During the COVID-19 Pandemic 
JAMA Network Open
Questions remain about emergency authorizations permitting telehealth services for buprenorphine, and whether these measures resulted in overdose deaths involving buprenorphine. This cross-sectional study examined 74,474 opioid-involved overdose deaths in 46 states and the District of Columbia prior to and during COVID-19. From July 2019-June 2021 there was a total of 89,111 total overdose deaths and 74,474 opioid-involved overdose deaths; buprenorphine was involved in 1,955 deaths, 2.2% of all drug overdose deaths and 2.6% of opioid-involved overdose deaths.  Of these, a higher proportion were female, non-Hispanic White, and lived in rural areas. While opioid-involved overdose deaths increased during this period, those involving buprenorphine did not increase.
 
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Lead Story: Availability of best practices for opioid use disorder in jails and related training and resource needs

Availability of best practices for opioid use disorder in jails and related training and resource needs: findings from a national interview study of jails in heavily impacted counties in the U.S. 
Health & Justice
This study investigated OUD best practices in US jails in those counties heavily impacted by overdose. Core best practice domains included screening, clinical assessment by qualified treatment provider, medically managed withdrawal, medication for opioid use disorder (MOUD) administration, services for pregnant women, counseling/wrap-around services, collaboration with community MOUD providers, assistance with Medicaid/insurance coverage, re-entry services, and overdose prevention. Some 92% reported some MOUD availability, but only 20% provided it to persons assessed with OUD. Best practices were more common in counties with larger populations, a higher percentage of Hispanic residents, fewer people living below the poverty line, and fewer jail admissions. A number of challenges including MOUD funding, training, and addressing stigma were reported. This study highlights the impact of lost opportunities for reducing disease, death, and recidivism that result from the lack of greater MOUD availability and accessibility.
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