This Week in Addiction Medicine from ASAM

Lead: Genetic Liability for Alcohol Consumption, Alcohol Problems and Suicide Attempts

Lead Story: 
Shared genetic liability for alcohol consumption, alcohol problems, and suicide attempt: Evaluating the role of impulsivity 
Translational Psychiatry
This study investigated the extent to which shared liability for alcohol consumption and problems (ACP) and suicide attempt (SA) is genetically related to five dimensions of impulsivity. Common genetic liability to ACP and SA was significantly correlated with all five impulsive personality traits examined, and the largest correlation was with lack of premeditation, though supplementary analyses suggested that these findings were potentially more strongly influenced by ACP than SA. These analyses have potential implications for screening and prevention: Impulsivity can be comprehensively assessed in childhood, whereas heavy drinking and suicide attempt are quite rare prior to adolescence. Features of impulsivity may serve as early indicators of genetic risk for alcohol problems and suicidality.
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Lead: Genome-wide association study identifies loci underlying multiple substance use disorders

Lead Story: 
Multivariate genome-wide association meta-analysis of over 1 million subjects identifies loci underlying multiple substance use disorders 
Nature Mental Health
Recent large-scale genome-wide association studies (GWASs) show that the genetic architecture of substance use disorders (SUDs) is characterized by a high degree of commonality, i.e., a general addiction genetic factor likely conveys vulnerability to multiple SUDs. Genetic liability to substance use disorders can be parsed into loci that confer general or substance-specific addiction risk. This is a multivariate genome-wide association meta-analysis that disaggregates general and substance-specific loci from published summary statistics of SUDs. Findings provide insight into genetic risk loci for substance use disorders that could be leveraged as treatment targets.
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Special Episode: Emergency Room Treatment of AUD

Special Guest:
Lewis S. Nelson, MD, MBA, DFASAM
 
Article Referenced:  
R.J. Strayer et al., EMERGENCY DEPARTMENT MANAGEMENT OF PATIENTS WITH ALCOHOL INTOXICATION, ALCOHOL WITHDRAWAL, AND ALCOHOL USE DISORDER: A WHITE PAPER PREPARED FOR THE AMERICAN ACADEMY OF EMERGENCY MEDICINE, Journal of Emergency Medicine, https://doi.org/10.1016/j.jemermed.2023.01.010  
 
ASAM Resources: 
The ASAM Clinical Practical Guideline on Alcohol Withdrawal Management
Alcohol Withdrawal Management Pocket Guide
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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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Lead: Synthesising evidence of the effects of 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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