This Week in Addiction Medicine from ASAM

Lead: Associations of semaglutide with incidence and recurrence of alcohol use disorder in real-world population

Associations of semaglutide with incidence and recurrence of alcohol use disorder in real-world population
Nature Communications
In this retrospective cohort study of patients receiving medication for treatment of obesity, the authors evaluated the association of semaglutide with incidence of and recurrence of alcohol use disorder (AUD). In the cohort patients received semaglutide or non-GLP1RA medications, including naltrexone and topiramate. In matched cohort analysis, patients who received semaglutide had much lower rates of incident AUD (HR=0.5) compared to those receiving non-GLP1RA medications and in sub-analysis comparing semaglutide to naltrexone/topiramate the also had lower incident AUD (HR=0.44). Among those with a history of AUD, semaglutide was also associated with lower recurrence of AUD (HR=0.44) overall and in sub-analysis (HR=0.25). These findings support potential benefit of semaglutide for AUD in a real-world population and need for randomized clinical trials.
 
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Lead: Innovation and adaptation: The rise of a fentanyl smoking culture in San Francisco

Innovation and adaptation: The rise of a fentanyl smoking culture in San Francisco
Plos One
This is a qualitative study describing the growing practice in the San Francisco area of smoking rather than injecting fentanyl. Fentanyl salts are stable up to 350°C making heating and inhalation more effective than for heroin. Some of the increase in smoking is driven by users’ difficulty finding accessible veins. There is also the perception that smoking presents less of a risk of overdose compared to injection. It is unclear if smoking is safer and overdose deaths continue to rise in San Francisco. Over time a brown residue accumulates that contains a high concentration of drug. The smoking equipment is often used for both methamphetamine and fentanyl so this residue contains an unknown mixture of the history of the drugs consumed. The residue is valued for potency but presents a new overdose risk due to the unknown amounts of drugs it contains.
 
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Lead: Rapid Initiation of Injection Naltrexone for Opioid Use Disorder

Rapid Initiation of Injection Naltrexone for Opioid Use Disorder
JAMA Network
Standard initiation procedures (SP) for extended-release (XR)-naltrexone can be a barrier to initiation for patients. In this stepped-wedge cluster-randomized trial, they compared SP initiation (3-5 days buprenorphine taper, 7-10 days opioid-free) to a rapid procedure (RP) initiation (1 day buprenorphine, 1 day opioid free, 3-4 days ascending dose of oral naltrexone). Patients in the RP group (62.7%) were more likely to receive the initial XR-naltrexone dose (OR 3.6, P<0.001) than the SP group (35.8%). There was not a statistically significant difference between the groups in rate of 2nd and 3rd doses. The study demonstrates that RP for initiation of XR-naltrexone is non-inferior to SP and may lead to shorter in-patient stay.
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Lead: Burden of Mental Disorders and Suicide Attributable to Childhood Maltreatment

Burden of Mental Disorders and Suicide Attributable to Childhood Maltreatment
JAMA Psychiatry
Studies have demonstrated that childhood maltreatment is strongly associated with mental health conditions, but this study uses a quasi-experimental design and meta-analysis to assess proportion of various mental health issues that are attributed to childhood maltreatment. The authors found that approximately 25% of mental health disorders (anxiety, depression, alcohol use disorder (AUD), substance use disorders (SUD), self-harm, and suicide) could be attributed to childhood mistreatment, accounting for approximately 1.8 million cases in Australia. Approximately 27% of AUD and 32% of SUD were attributed to childhood maltreatment. The findings strongly support the importance of efforts to prevent childhood maltreatment. 
 
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Lead: Associations of cannabis use, use frequency, and cannabis use disorder with violent behavior among young adults in the United States

Associations of cannabis use, use frequency, and cannabis use disorder with violent behavior among young adults in the United States
International Journal of Drug Policy
An association between cannabis use and violent behavior has previously been reported, so the authors used the 2015-2019 National Survey on Drug Use and Health to better explore this association. In adjusted models, the authors found an increased prevalence of violent behavior among males reporting daily cannabis use with and without cannabis use disorder (CUD) versus no cannabis use. However, there was no increase among males reporting non-daily cannabis use with or without CUD. Researchers found an increase in violent behavior among females reporting non-daily use with or without CUD and daily use with or without CUD. While additional research is needed to better understand this relationship and the sex differences, these findings support the importance of early screening and treatment for CUD. 
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Lead: Biomarkers of metal exposure in adolescent e-cigarette users

Lead Story
Biomarkers of metal exposure in adolescent e-cigarette users: correlations with vaping frequency and flavouring 
Tobacco Control
Various metals have been identified in e-cigarettes and, as their use among youth has increased in the last decade, this is of public health concern. In this study, researchers utilized a national sample of youth who use e-cigarettes and associated between lead, cadmium, and uranium levels and use patterns. Youth who reported intermittent or frequent use had higher levels of lead than occasional users, and frequent users also had higher levels of uranium. In addition, when evaluating by flavor types, sweet flavor e-cigarette use was associated with higher uranium levels than menthol/mint flavors. Given the potential deleterious health effects of these metals, particularly in youth, these findings support the need for regulations and public health interventions to target youth populations and minimize e-cigarette use.
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Lead: Association of regular opioid use with incident dementia and neuroimaging markers of brain health in chronic pain patients

Association of regular opioid use with incident dementia and neuroimaging markers of brain health in chronic pain patients: analysis of UK Biobank
The American Journal of Geriatric Psychiatry
In this cohort study, researchers examine the association between regular opioid use in patients with chronic pain and development of dementia over 15 years of follow-up. Regular opioid use versus non-opioid analgesic use in this population was associated with increased risk of incident dementia (HR=1.18 CL,1.08-1.30). In addition, there appeared a dose-dependent response with those receiving more prescriptions being more likely to develop dementia: 1-5 prescriptions OR=1.21, 6-20 prescriptions OR=1.27, and >20 prescriptions OR=1.43. Finally, in brain imaging, those with regular opioid use exhibited lower total gray matter and higher white matter hyperintensities. While additional research may be needed to support causality, the authors suggest these findings support caution in regular use of opioids for chronic pain. 
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Lead: Preventing deaths after prison release

Preventing deaths after prison release
The Lancet
Formerly incarcerated people have exceptionally poor health profiles and are at increased risk of preventable mortality when compared to their general population peers. This accompanying editorial discusses a study by Borschmann et al published in the same issue of The Lancet. Using administrative data from the multi-national Mortality After Release from Incarceration Consortium (MARIC) study, the authors examined mortality outcomes for 1,471,526 people released from incarceration in eight countries. 75,427 deaths were recorded. The markedly elevated rate of death in the first week post-release underscores an urgent need for investment in evidence-based, coordinated transitional healthcare, including treatment for mental illness and substance use disorders to prevent post-release deaths due to suicide and overdose. Temporal variations in rates and causes of death highlight the need for routine monitoring of post-release mortality.
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Lead: Telling the story of the opioid crisis

Lead Story:
Telling the story of the opioid crisis: A narrative analysis of the TV series Dopesick 
PLOS One
Dopesick (2021) is the first TV series whose plot deals exclusively with the opioid crisis in the United States. The current study uses narrative analysis and framing theory to explore this series, discussing its portrayal of the people and themes involved in the opioid crisis. This analysis found that although Dopesick attempts to portray multiple dimensions of the opioid crisis, its narrative oversimplifies the story in attributing the cause of the problem almost exclusively to Purdue Pharma and its director Richard Sackler, while downplaying other factors that contributed to the opioid crisis. Thus, the narrative in this TV series tends to offer simple explanations to a complex problem for which simple solutions are likely to be inadequate.
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Lead: Impact of jail-based methadone or buprenorphine treatment on non-fatal opioid overdose after incarceration

Lead Story:
Impact of jail-based methadone or buprenorphine treatment on non-fatal opioid overdose after incarceration
Drug and Alcohol Dependence
The authors studied the effect of receiving MOUD during incarceration in New York City jails on non-fatal overdose events during the year after discharge. Data were analyzed for patients with OUD incarcerated between 2011-2017 who either received MOUD during the 3 days before release (n=8660) or did not receive MOUD just prior to release (n=10,163). After controlling for covariates, those receiving MOUD had a significant reduction in non-fatal overdoses during the 14 days after release (adjusted HR: 0.49; 95% CI = 0.33-0.74). However, there was no reduction in non-fatal overdoses during the remainder of the 1 year after release. The authors speculate that this lack of benefit beyond 14 days may be due to failure to transition to outpatient MOUD after release. They conclude that MOUD in jail could be lifesaving and that it is important to ensure MOUD continues after release.
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