This Week in Addiction Medicine from ASAM

Lead: Virtual reality-based Mindfulness-Oriented Recovery Enhancement (MORE-VR) as an adjunct to medications for opioid use disorder: a Phase 1 trial

Virtual reality-based Mindfulness-Oriented Recovery Enhancement (MORE-VR) as an adjunct to medications for opioid use disorder: a Phase 1 trial 🔓
Annals of Medicine
Mindfulness-Oriented Recovery Enhancement (MORE) uses mindfulness training to address dysregulation in brain reward systems. MORE has been shown to reduce drug cue reactivity and in an RCT reduced opioid misuse 45% at 9 months. Face-to-face MORE requires significant time of trained clinicians, and this study explored the feasibility of delivering MORE by virtual reality (VR). Treatment consisted of 8 weekly, one-hour MORE-VR sessions. Patients could choose the VR setting for their meditation (beach, forest, waterfall) and interact with virtual drugs and paraphernalia during session 5, which was devoted to examining and managing craving. Of 38 patients, 68% completed 4 or more sessions and 50% completed all sessions. Opioid use decreased significantly (p =.04), as well as craving (p<.001), and results showed a significant increase in positive affect (p<.001).
 
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Lead: The Lancet Psychiatry Commission on youth mental health

The Lancet Psychiatry Commission on youth mental health🔓
The Lancet Psychiatry
Mental ill health, which has been the leading health and social issue impacting the lives and futures of young people for decades, has entered a dangerous phase. Accumulating research evidence indicates that in many countries, the mental health of emerging adults has been declining steadily over the past two decades, with a major surge of mental ill health driven by the COVID-19 pandemic, the measures taken to contain it, and its aftermath. This alarming trend signals a warning that global megatrends (major, long-lasting societal changes such as environmental, social, economic, political, or technological changes) and changes in many societies around the world in the past two decades have harmed the mental health of young people and increased mental ill health among them.
 
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Lead: Alcohol Consumption Patterns and Mortality Among Older Adults With Health-Related or Socioeconomic Risk Factors

Alcohol Consumption Patterns and Mortality Among Older Adults With Health-Related or Socioeconomic Risk Factors 
JAMA Network Open 
This British study included 135,103 older (median age 64) adults and compared drinking patterns with mortality during a median follow-up of 12 years. Compared to occasional drinkers, low-risk drinkers had higher cancer mortality (HR, 1.11), moderate-risk drinkers had higher all-cause and cancer mortality (HRs, 1.10 and 1.15), and high-risk drinking had higher all-cause, cancer, and cardiovascular mortality (HRs, 1.33, 1.39, and 1.21). These results contrast with earlier studies showing protective effects of low- to moderate-risk drinking. Researchers used occasional drinkers as the control group, where previous studies used abstainers including former drinkers with residual health effects. There was a small protective effect of drinking only with meals and drinking wine. In conclusion, the authors failed to find a protective effect of low-risk drinking on mortality.
 
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Lead: Physician Reluctance to Intervene in Addiction: A Systematic Review

Physician Reluctance to Intervene in Addiction: A Systematic Review
JAMA Network Open
This systematic review of 283 articles explored the reasons physicians give for not addressing substance use and addiction in their clinical practice. The institutional environment (81.2% of articles) was the most common reason given for physicians not intervening in addiction, followed by lack of skill (73.9%), cognitive capacity (73.5%), and knowledge (71.9%). These findings suggest that efforts should be directed at creating institutional environments that facilitate the delivery of evidence-based addiction care while improving access to education and training opportunities for physicians to practice the necessary skills.
 
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ASAM Weekly Special Episode: Rapid Initiation of Injection Naltrexone for OUD | Dr. Matisyahu Shulman & Dr. Adam Bisaga

Host Dr. Nick Athanasiou sat down with Drs. Matisyahu Shulman and Adam Bisaga to discuss the study they recently authored titled Rapid Initiation of Injection Naltrexone for Opioid Use Disorder: A Stepped-Wedge Cluster Randomized Trial. The doctors share their findings and the impact and implications of the study. 
 
Subscribe to The ASAM Weekly to read the guest editorial: 
Guest Editorial: Rapid Initiation of Injectable Extended-Release Naltrexone for Opioid Use Disorder: A Time for Paradigm Shift in Treatment Protocols
 
This project has been funded as a whole or in part with Federal funds from the National Institute on Drug Abuse, National Institutes of Health, Department of Health and Human Services, under Contract No. 75N95020C00028.

Lead: Social Vulnerability and Prevalence and Treatment for Mental Health and Substance Use Disorders

Social Vulnerability and Prevalence and Treatment for Mental Health and Substance Use Disorders
JAMA Psychiatry
This is a survey study of 4,674 participants from US households that examined the association between social vulnerability and mental health and substance use disorders and related treatment in the US noninstitutionalized population of adults aged 18 years and older. Large increases in several mental health and substance use disorders and corresponding decreases in treatment were found in the most socially vulnerable communities. The findings suggest that routine measurement of social vulnerability might assist in developing more comprehensive care models that integrate medical and social care for mental health and substance use disorders.
 
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Lead: Psilocybin desynchronizes the human brain

Psilocybin desynchronizes the human brain 
Nature
To assess how human brain network changes relate to the subjective and lasting effects of psychedelics, this study tracked individual-specific brain changes with longitudinal precision functional mapping (roughly 18 magnetic resonance imaging visits per participant). Psilocybin massively disrupted functional connectivity (FC) in the cortex and subcortex, acutely causing more than threefold greater change than methylphenidate. These FC changes were driven by brain desynchronization across spatial scales (areal, global), which dissolved network distinctions by reducing correlations within and anticorrelations between networks. Persistent reduction of hippocampal-default mode network connectivity may represent a neuroanatomical and correlate of the proplasticity and therapeutic effects of psychedelics.
 
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Lead: Secondhand Nicotine Absorption From E-Cigarette Vapor vs Tobacco Smoke in Children

Secondhand Nicotine Absorption From E-Cigarette Vapor vs Tobacco Smoke in Children 
JAMA Network Open
This cross-sectional study of 1,777 US children aged 3 to 11 years examined how children’s nicotine absorption, as indexed by serum cotinine level, differ among those exposed to (1) secondhand tobacco smoke only, (2) secondhand e-cigarette vapor only, or (3) neither. Compared with children exposed to secondhand smoke only, nicotine absorption was 83.6% lower in those exposed to secondhand vapor only and 96.7% lower in those exposed to neither. These findings suggest that children absorb much more nicotine from secondhand smoke than from secondhand vapor; switching from smoking to vaping indoors may substantially reduce children’s secondhand exposure to nicotine and other noxious substances, but both smoke and vapor increase children’s absorption vs no exposure.
 
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Lead: Benzodiazepine use in relation to long-term dementia risk and imaging markers of neurodegeneration: a population-based study

Benzodiazepine use in relation to long-term dementia risk and imaging markers of neurodegeneration: a population-based study 🔓
BMC Medicine
This study examined the relationship between benzodiazepine (BZD) use and dementia, using data from the population-based Rotterdam (Netherlands) study started in 1990. For 5,443 participants, BZD use during the 15 years from 1990 to 2005 was compared to dementia screens performed through 2020. Half of the participants had used BZD at some time during the 15-year baseline, and 13% developed dementia. Overall, there was no association between BZD use and dementia risk. However, the use of BZD as an anxiolytic in higher doses was associated with dementia risk (HR=1.3). The authors note that BZD with longer half-life are used as anxiolytics, whereas short half-life BZD are used as sedative-hypnotics. A reduction in hippocampal volume on MRI was also associated with BZD use. Overall, there was no association of BZD use with dementia risk, however, some associations were observed that deserve further study.
 
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Lead: Extended-release ketamine tablets for treatment-resistant depression: a randomized placebo-controlled phase 2 trial

Extended-release ketamine tablets for treatment-resistant depression: a randomized placebo-controlled phase 2 trial 
Nature Medicine
The safety and tolerability of racemic ketamine may be improved if given orally, as an extended-release tablet (R-107), compared with other routes of administration. In this phase 2 multicenter clinical trial, male and female adult patients with treatment-resistant major depression (TRD) and Montgomery–Asberg Depression Rating Scale (MADRS) scores ≥20 received open-label R-107 tablets 120 mg per day for 5 days and were assessed on day 8 (enrichment phase). On day 8, responders (MADRS scores ≤12 and reduction ≥50%) were randomized to receive double-blind R-107 doses of 30, 60, 120, or 180 mg, or placebo, twice weekly for 12 weeks. Nonresponders on day 8 exited the study. Tolerability was excellent, with no changes in blood pressure, minimal reports of sedation, and minimal dissociation. The most common adverse events were headache, dizziness, and anxiety. R-107 tablets were effective, safe, and well tolerated in patients with TRD, enriched for initial response to R-107 tablets.
 
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