This Week in Addiction Medicine from ASAM

Lead: Clinical Practice Guideline on the Management of Stimulant Use Disorder

Lead Story:
Clinical Practice Guideline on the Management of Stimulant Use Disorder 
American Society of Addiction Medicine and American Academy of Addiction Psychiatry
Overdose deaths involving stimulant drugs – including cocaine, methamphetamine, amphetamine, and prescription stimulants – have been rising precipitously over the past decade. In 2021, over fifty percent of overdose deaths in the US involved stimulant drugs. Beyond the mortality risk, stimulant use disorders (StUD) can also lead to long term health problems including infectious diseases, cardiac, pulmonary, psychiatric, dental, nutritional, skin, and cognitive issues.  The Clinical Practice Guideline on the Management of Stimulant Use Disorder, developed by the American Society of Addiction Medicine (ASAM) and the American Academy of Addiction Psychiatry (AAAP), provides information on evidence-based strategies and standards of care for the prevention and treatment of stimulant use disorders (StUD), stimulant intoxication, and stimulant withdrawal.
 
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Lead: Chronic pain, cannabis legalisation, and cannabis use disorder

Lead Story:
Chronic pain, cannabis legalisation, and cannabis use disorder among patients in the US Veterans Health Administration system, 2005 to 2019: a repeated, cross-sectional study
The Lancet Psychiatry
The prevalence of cannabis use disorder (CUD) in patients with chronic pain is increasing. This study considered the impact of both recreational (RCL) and medical cannabis laws (MCL) on the diagnosis of CUD using a VA population with chronic pain. Results demonstrate that MCL led to a 0.135% increase in the prevalence of CUD. Enacting RCL led to a 0.188% increase in its prevalence. The authors emphasize the importance of these findings and their public health implications, with a focus on clinician monitoring and patient education.
 
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Lead: Xylazine Adulteration of the Heroin–Fentanyl Drug Supply

Lead Story:
 
Xylazine Adulteration of the Heroin–Fentanyl Drug Supply
Annals of Internal Medicine
Since 2016, xylazine has appeared in the illicitly manufactured fentanyl supply and has increased in prevalence, due to its low cost, easy availability, and presumed synergistic psychoactive effect. It remains unclear whether a distinct xylazine withdrawal syndrome occurs. Xylazine may alter the findings and management of patients with fentanyl overdose and withdrawal. Inadequately treated opioid (and possibly xylazine) withdrawal contributes to the increase in self-directed discharges from treatment settings. Initiation of buprenorphine and perhaps methadone may be compounded by the concomitant use of xylazine. The presence of extensive wounds in people who use xylazine prevents them from accessing resources, including medically managed withdrawal treatment, leading to a cycle of continued and escalating use.
 
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Lead: Heterogeneous neuroimaging findings across substance use disorders localize to a common brain network

Lead Story:
 
Heterogeneous neuroimaging findings across substance use disorders localize to a common brain network 
Nature Mental Health
This study used network mapping approaches and a functional connectome from a large cohort of healthy participants (n = 1,000) to test whether neuroimaging abnormalities across substance use disorders map to a common brain network. Starting with coordinates of regional brain atrophy from 45 studies, researchers found that 91% of the neuroimaging findings mapped to a common brain network specific to substance use disorders compared to atrophy associated with normal aging and neurodegenerative disease. Coordinates of functional MRI abnormalities from 99 studies mapped to a similar brain network. Neuroimaging abnormalities across substance use disorders map to a common brain network that is similar across imaging modalities, substances, and lesion locations that cause remission from substance use disorders.
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Lead: The association between temperature and alcohol- and substance-related disorder hospital visits

Lead Story:
The association between temperature and alcohol- and substance-related disorder hospital visits in New York State 
Communications Medicine
Using New York State hospital data, this study investigated the link between daily temperature and hospital visits as a result of substance use from 1995-2014. An increase in temperature 0-6 days prior to seeking hospital care was associated with an increase in rates in care. Increase in visits was highest when opioids were involved, and lowest for sedatives. The 25-44 age group was primarily affected, and males made up the highest proportion of cases. These results indicate that the rise in SUD hospital visits is linked to continued rising temperatures related to climate change; healthcare and social interventions could potentially mitigate these harms.
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Lead: US tobacco companies selectively disseminated hyper-palatable foods into the US food system

Lead Story:
 
US tobacco companies selectively disseminated hyper-palatable foods into the US food system: Empirical evidence and current implications
Addiction
Hyper-palatable foods (HPF) contain fat and sodium, fat and simple sugars, and carbohydrate and sodium at specific thresholds to induce hyperpalatability, creating an artificially rewarding experience. This study compared tobacco companies who owned food companies to food companies not owned by tobacco companies, with regard to hyperpalatability between 1988 and 2001. Upon review of industry documents, this study found that tobacco companies “selectively disseminated” HPF into the US market. Tobacco-owned foods were 29% more likely to be classified as fat and sodium HPF and 80% more likely to be classified as carbohydrate and sodium HPF than foods that were not tobacco-owned. As late as 2018, market saturation of fat and sodium HPF was close to 60% and carbohydrate and sodium HPF was almost 20% regardless of tobacco ownership. Further research should consider the links between industries to appreciate potential impact on public health.
 
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Lead: America’s Opioid Ecosystem: How Leveraging System Interactions Can Help Curb Addiction, Overdose, and Other Harms

Lead Story:
America's Opioid Ecosystem: How Leveraging System Interactions Can Help Curb Addiction, Overdose, and Other Harms 
RAND Corporation
This ebook highlights that although opioids play an outsized role in US drug problems, they also play a critically important role in medicine. Thus, they deserve special attention. Illegally manufactured opioids are involved in a majority of US drug overdoses. Efforts to address problems related to opioids are insufficient and sometimes contradictory.  Components of the opioid ecosystem include substance use disorder treatment, harm reduction, medical care, the criminal legal system, illegal supply and supply control, first responders, the child welfare system, income support and homeless services, employment, and education. Leveraging the interactions of the opioid ecosystem can reduce addiction, overdose, suffering, and other harms.
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Lead: Naloxone Use in Novel Potent Opioid and Fentanyl Overdoses in Emergency Department Patients

Lead Story:
Naloxone Use in Novel Potent Opioid and Fentanyl Overdoses in Emergency Department Patients 
JAMA Network Open
In this cohort study of 537 patients, all patients with novel potent opioid (NPO) overdose presented with opioid overdose symptoms and received multiple doses of naloxone. Compared with fentanyl overdose, patients with NPO overdose had a higher number of naloxone doses administered in-hospital; metonitazene overdose was associated with cardiac arrest and more naloxone doses overall. These findings suggest that NPOs may have a higher potency than fentanyl due to the observed naloxone administration in the clinical setting of overdose.
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Lead: Examining sociodemographic correlates of opioid use, misuse, and use disorders in the All of Us Research Program

 
Lead Story:
Examining sociodemographic correlates of opioid use, misuse, and use disorders in the All of Us Research Program 🔓
PLOS ONE
This study aims to estimate the prevalence of opioid use and its association with sociodemographic characteristics from survey data and electronic health record (EHR). A total of 214,206 participants completed survey modules and shared EHR data. The lifetime prevalence of street opioids was 4%, and the nonmedical use of prescription opioids was 9%. Men had higher odds of lifetime opioid use but reduced odds of current nonmedical use of prescription opioids. Participants from other racial and ethnic groups were at reduced odds of lifetime use but increased odds of current use compared with non-Hispanic White participants. Foreign-born participants were at reduced risks of opioid use and diagnosis of opioid use disorders (OUD) compared with US-born participants. Men, younger, white, and US-born participants were more likely to have OUD.
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Lead: Prevalence of Cannabis Use Disorder and Reasons for Use Among Adults in a US

Lead Story:
Prevalence of Cannabis Use Disorder and Reasons for Use Among Adults in a US State Where Recreational Cannabis Use Is Legal
JAMA Network Open
This cross-sectional study investigated the prevalence of cannabis use disorder (CUD) among primary care patients in states with legal recreational cannabis. Patients were asked to report medical use, nonmedical use, or both, with 42.4% reporting medical use only, 25.1% nonmedical use only, and 32.5% reporting both. The prevalence of any CUD was 21.3%; for moderate to severe CUD prevalence was 6.5% overall, with 1.3% reporting medical use, 7.2% nonmedical use, and 7.5% reporting both. Those reporting medical use only tended to be older, female, and retired. Those reporting nonmedical use or both were more likely to disclose withdrawal; use in hazardous situations; use despite persistent or recurrent social or interpersonal problems; important social, occupational, or recreational activities given up or reduced; and use despite persistent or recurrent social or interpersonal problems. Hence, screening for CUD among patients who use cannabis is paramount.