Category: Addiction

Categories : AddictionTags :

Teens Have Triple the Risk of Developing Cannabis Addiction

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Cannabis plants
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Adolescents have more than three times the risk of developing a cannabis addiction than adults, although they may only have the same risk of other mental health problems related to the drug, according to a new study published in the Journal of Psychopharmacology.

The study, led by King’s College London and University College London, found that adolescent cannabis users had the same odds for higher levels of subclinical depression or anxiety than adults cannabis users, nor were they more vulnerable than adult users to cannabis’s associations with psychotic-like symptoms.

These findings build on a separate study by the same team that found adolescents were not more vulnerable to associations between chronic cannabis use and cognitive impairment.

Lead author Dr Will Lawn said: “There is a lot of concern about how the developing teenage brain might be more vulnerable to the long-term effects of cannabis, but we did not find evidence to support this general claim.

“Cannabis addiction is a real issue that teenagers should be aware of, as they appear to be much more vulnerable to it than adults.

“On the other hand, the impact that cannabis use has during adolescence on cognitive performance or on depression and anxiety may be weaker than hypothesised.

“But we also replicated previous work that if someone becomes addicted to cannabis, that may increase the severity of subclinical mental health symptoms. Given adolescents are also at a greater risk of experiencing difficulties with mental health than adults, they should be proactively discouraged from regular cannabis use.”

The findings in both papers come from the CannTeen study, which is comparing the effects of regular cannabis use among adolescents and adults, while also comparing to age-matched controls (non-users of cannabis), a completely novel design.

The study involved 274 participants, including 76 adolescents (aged 16–17) who used cannabis one to seven days per week, alongside similar numbers of adult (aged 26–29) users, and teenage and adult control (comparison) participants, who all reported their cannabis use over the last 12 weeks and responded to mental health questionnaires. The cannabis users in the study, on average, used it four times per week. The adolescent and adult users were also carefully matched on gender, ethnicity, and type and strength of cannabis.

The researchers found that adolescent cannabis users were three and a half times as likely to develop severe ‘cannabis use disorder’ (ie addiction) than adult users, a finding which is in line with previous studies. Cannabis use disorder is defined by symptoms such as cravings; cannabis use contributing to failures in school or work; heightened tolerance; withdrawal; interpersonal problems caused by or exacerbated by cannabis use; or intending to cut back without success. Oof the teenage cannabis users studied, 50% had six or more cannabis use disorder symptoms, qualifying as severe cannabis use disorder.

Among people of any age, previous studies have found that roughly 9–22% of people who try the drug develop cannabis use disorder, and that risk is higher for people who tried it at a younger age, a finding which has now been robustly replicated.

The researchers say that adolescents might be more vulnerable to cannabis addiction because of factors such as increased disruption to relationships with parents and teachers, a hyper-plastic (malleable) brain and developing endocannabinoid system (the part of the nervous system that THC in cannabis acts upon), and an evolving sense of identity and shifting social life.

Adolescent users had greater odds than adult users or adolescent non-users of developing psychotic-like symptoms, but analysis showed that this is because all adolescents, and all cannabis users, are more likely to newly develop psychotic-like symptoms, rather than a different effect of cannabis for teenagers than adults. Thus, there was no interaction between cannabis use and being an adolescent. The researchers say this fits in with prior evidence that cannabis use may increase the likelihood of developing a psychotic disorder such as schizophrenia, but they warn their study did not investigate the risk of clinical psychosis or schizophrenia.

The researchers found that neither teenage nor adult cannabis users were more likely to develop depressive or anxiety symptoms than non-users. Only the adolescents that have severe cannabis use disorder had worse mental health symptoms, but the researchers caution that the small sample size for this group limits their confidence in this finding.

The separate study found that cannabis users were no more likely to have impaired working memory or impulsivity. Cannabis users were more likely to have poor verbal memory (remembering things said to you); this effect was the same in adults and teenagers, so again there was no adolescent vulnerability. However, the researchers caution that cannabis use could impact school performance during a key developmental stage of life.

The researchers caution that these findings were cross-sectional (only looking at one time point), and that longitudinal analyses of how their participants changed over time are ongoing.

Senior author Professor Val Curran (UCL Clinical Psychopharmacology Unit, UCL Psychology & Language Sciences) said: “Our findings suggest that schools should be teaching pupils more about the risk of addiction to cannabis, which has been neglected in drugs education. Becoming addicted to cannabis is a serious problem in itself, but it can also increase the likelihood of other mental health problems. Teenagers should therefore be informed of their greater risk of addiction.”

Source: King’s College London

Categories : Addiction Metabolic DisordersTags :

Varenicline Effective in Helping Smokers with Diabetes to Quit

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Cigarette butts
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A new study published in JAMA Network has found that varenicline helps patients with type 2 diabetes to quit smoking.

Not only is cigarette smoking a major risk factor for cardiovascular disease, it is highly prevalent among patients with type 2 diabetes. Smoking worsens the effects of hyperglycaemia and other risk factors, accelerating vascular damage in patients with diabetes.

Compared with nonsmokers with diabetes, smokers have greater risks of mortality, coronary heart disease, stroke, and peripheral arterial disease. Quitting smoking has been associated with reduced mortality risk in patients with type 2 diabetes, as welling achieving better glycaemic control and lower cardiometabolic risk factors.

Smokers with type 2 diabetes are more reluctant quit than smokers without diabetes in part due to fear of weight gain. Weight gain needs to be controlled as part of any cessation intervention. The smoking cessation drug varenicline has been shown to help people without diabetes to quit, but considering the special behavioural and metabolic conditions of smokers with type 2 diabetes, its use and efficacy warranted investigation,

To this end, Cristina Russo, MD, and colleagues conducted a multicentre, double-blind, placebo-controlled randomised clinical trial with 300 participants. Patients with type 2 diabetes, average age 57.4 years who were smoking at least 10 cigarettes a day, and who intended to quit were randomised to either twice-daily varenicline 1mg or placebo treatment. Both groups received smoking cessation counselling. The trial consisted of a 12-week treatment phase followed by a 40-week follow-up, nontreatment phase. Intention-to-treat data analysis was performed from December 2020 to April 2021.

At weeks 9 to 24, continuous smoking abstinence was significantly higher for the varenicline than placebo group (24.0% vs 6.0%). At weeks 9 to 12 (31.3% vs 7.3%) and weeks 9 to 52 (18.7% vs 5.3%) were significantly higher for the varenicline vs placebo group. Adverse events in the varenicline group compared with the placebo group were nausea, insomnia, abnormal dreams, anxiety, and irritability. Serious adverse events were infrequent in both groups and not treatment-related.

The researchers concluded that using varenicline in a smoking cessation programme for people with type 2 diabetes is effective in achieving long-term abstinence without serious adverse events.

Categories : AddictionTags :

Fentanyl Induces Autism-like Behaviours in Young Mice

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Fentanyl is one of the most commonly used analgesics in the hospital and, in rodents, may have lasting sensorimotor and behavioural impacts. A study published in the British Journal of Anaesthesia has shown that fentanyl can induce changes similar to autism-like behaviours in young mice.

Fentanyl, a mu-opioid receptor agonist, is a potent synthetic opioid, which, similar to morphine, produces analgesia but is 50 to 100 times more potent. A dose of only 100 micrograms can produce equivalent analgesia to approximately 10mg of morphine. However, fentanyl exhibits vastly different properties and pharmacokinetics. Clinically, its most common use is as a sedative in intubated patients and severe cases of pain in patients with renal failure due to its primarily hepatic elimination. Fentanyl’s side effects are similar to those of heroin.

However, whether the use of fentanyl is associated with the development of autism is not known. An animal study led by investigators at Massachusetts General Hospital (MGH), Shanghai 10th People’s Hospital, and the University of Pennsylvania e. The findings are

Research by other groups has shown that N-methyl-D-aspartate receptor dysfunction contributes to autism. Variations in Grin2a and Grin2b, the genes encoding GluN2A and GluN2B subunits of N-methyl-D-aspartate receptor, are associated with autism. In addition, the anterior cingulate cortex of the brain is affected in autism.

In this current study, the research team reported that fentanyl induces autism-like behaviors in young male and female mice via activating the mu-opioid receptor in the anterior cingulate cortex. Further, these fentanyl-induced autism-like behaviors appear partially due to the hypermethylation-mediated reduction of Grin2b expression in the anterior cingulate cortex of mice.

“Because the anterior cingulate cortex is a hub for mediating social information, we focused on the expression of Grin2b in that area,” says Yuan Shen, MD, PhD, the paper’s senior author and a professor of Psychiatry at Shanghai 10th People’s Hospital. “We found fentanyl decreased expression of Grin2b in the anterior cingulate cortex. The overexpression of Grin2b prevents fentanyl-induced autism-like behavior in the mice. These findings suggest a potential mechanism to prevent or treat the autism-like behavior,” says Shen.

The group used an open field test (in which a mouse can walk inside a box) and an elevated plus-maze (in which a mouse can walk on an elevated platform) to observe the anxiety and stereotyped behaviours of mice. Using a three-chamber social preference test (where a mouse can interact with another mouse), they also assessed potential social deficits. “We used these tests because impaired social interaction, stereotyped behaviours, and anxiety are the key feature of autism-like behaviours in mice,” said Zhihao Sheng, co-first author of the paper. Sheng is a graduate student at Shanghai 10th People’s Hospital.

“However, the changes of mice in these behavioral tests do not equal autism in humans. These behavioral tests are only used to study the autism-like behaviors in mice because they can demonstrate certain features of behavior changes similar to the manifestation of autism,” said co-first author Qidong Liu, PhD, assistant professor at Shanghai 10th People’s Hospital.

Co-senior author Zhongcong Xie, MD, PhD, added: “There is no current evidence that fentanyl is associated with a similar effect in humans and the outcome of the animal study is not an indication to avoid fentanyl in clinical anesthesia. However, the outcome will promote further research, including clinical investigations, to determine the potential neurobehavioral influence of opioids on brain development.” 

Categories : Addiction Healthcare Politics and RegulationsTags :

Up in Smoke: The Tobacco Wars and Lessons for Vaccination Efforts

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Tobacco companies waged a massive disinformation campaign to keep people consuming their products. There are parallels with today’s antivaxx movement. Even before the 1964 US Surgeon General’s report on tobacco, the tobacco industry was deflecting health concerns by featuring doctors in their advertising and actively courting the medical industry. This advert is from 1930.

In a perspective piece published in the New England Journal of Medicine, authors find a parallel between the tactics used in the ‘tobacco wars’ and vaccination efforts. In a seeming repeat of history, anti-vaccination groups are using the same tactics the tobacco industry used to defend their products and undermine trust in science, but the successful anti-tobacco campaign holds important lessons for turning the tide against misinformation and normalising vaccination.

In late 2020 when the first COVID vaccines became available, the authors note that surveys indicated that about a third of US adults were keen to be vaccinated, 15% expressed strong resistance to vaccination (a proportion that has stayed fairly constant), and the remainder didn’t harbour strong ideological resistance. Now, about 27% of US adults now remain unvaccinated – and reaching this remainder is an important public health challenge.

The authors believe that the ‘tobacco wars’ can provide perspective. The tobacco industry fuelled preventable deaths by glamourising smoking, with almost 50% of US adults smoking cigarettes in the 1960s.

The current rate of about 12.5% is the result of decades of public health efforts to make tobacco use less socially acceptable. The first US Surgeon General’s report on smoking and health in 1964 was attacked by the tobacco industry. It was only until C. Everett Koop’s overwhelming report in 1986 that cemented tobacco use as a major preventable cause of cancer and death and highlighted the dangers of second-hand smoking.

Koop and others were vilified by the tobacco industry, which mounted a sustained campaign that cast doubts on the science, publicised misinformation, emphasised tobacco’s economic importance, and warned against restricting individual freedom. Industry leaders directly lied about knowing that nicotine was addictive and the lethal dangers of tobacco use. Indeed, from the 1920s to 1950s, in response to growing health concerns, the tobacco industry had actively courted doctors and influenced medical journals, widely reporting positive findings of studies that were deeply flawed. This may have only played into the hands of antivaxxers, creating a historical example of distrust in the medical system.

A 1940s advert showing how ‘doctors’ (probably actors) enjoyed Camel brand cigarettes. With the 1950 publication of studies showing the connection between cancer and tobacco, the public began to be suspicious and such campaigns featuring doctors ended by 1954.

While the focus of the debate was initially on smoking as an individual choice, two 1981 studies on nonsmoking wives of smokers vs nonsmokers revealed the dangers of secondhand smoke and shifted the discourse.

The US Congress has never enacted a federal smoking ban, but did grant the FDA limited authority to regulate tobacco in 2009, enabling restrictions on youth sales.

However, the broad-based effort from all levels of society that were important, discouraging smoking in public settings. This was supplemented by messaging from celebrities, taxation, and even a 1998 legal battle against the tobacco industry.

Efforts undertaken by the antivaccination movement, which is hardly new but is thriving during the COVID pandemic, bear many similarities to strategies used during the tobacco wars. Although not driven by a single industry but a collection of celebrities and social media groups, it sows mistrust in science and promotes conspiracy theories. Misinformation tactics are used that are strikingly similar to the tobacco industry’s, and this time Dr Antony Fauci is vilified instead of Koop.

There are big differences between tobacco control and vaccination; such as taking a long time for smoking interventions to reduce chronic diseases, whereas vaccinations usually reduce hospitalisations and severe illness within days or weeks.

The authors believe that success against antivaccination movement can draw on the tobacco wars’ lessons, illustrating COVID’s harm and the power of vaccines. Getting vaccinated and boosted should be the accepted social norm during a pandemic, they stress.

Drawing on similar efforts for anti-tobacco campaigns, vaccination campaigns using real patients in ICU who express regret over not being vaccinated. Unvaccinated people often assume they can be cared for if they get sick, so messages could also be included from healthcare works talking about the strain of the pandemic.

“There is an opportunity to mount a serious effort to provide accurate vaccination information using the same media channels on which people currently consume misinformation,” they wrote.

They also consider vaccine mandates which make being vaccinated a social norm such as wearing a seatbelt, and other regulations at the community and business level may be more effective.

They note that personal physicians play a key role, being the best way to transmit health information. But many people at risk of remaining unvaccinated have had negative experiences with health care, compounded by doctors spreading misinformation.

The authors note that the dangers of tobacco use were known to public health practitioners for years, but it took a well-funded concerted effort that emphasised the impact on others to achieve a change in behaviour. This is something that needs to be repeated for vaccinations.

“Freedom of choice remains; people can still smoke cigarettes and decline vaccinations. But the roadmap drawn by tobacco-control efforts shows that the public mindset can be tilted toward public health and social good. With vaccination, this work shouldn’t take decades; it needs to begin immediately.”

Source: New England Journal of Medicine

Categories : Addiction Medical IndustryTags :

How Supplier Pressure Unleashed the Opioid Crisis

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While the pandemic era has seen global supply chains strained and medicines running short even in the developed world, it was not the case with prescription opioids, namely oxycodone and hydrocodone in the early 2000s. In fact, the opposite was true, argues a study published in the Journal of Supply Chain Management: supply chains became so efficient that they produced a glut of opioids that helped spark the opioid crisis in the US that has since spread to other parts of the world.

This supply glut is partly due to the influence of supplier pool pressure on pharmacy participation in oversupply, according to research conducted by Ednilson Bernardes, professor at the West Virginia University John Chambers College of Business and Economics.

Simply put, pressure exerted by manufacturers and suppliers of opioids, particularly national corporations, influenced how pharmacies bought and distributed those prescriptions.

“We argued that when the pool of suppliers has cohesive expectations for how buyers should behave and sufficient power to dominate the supply relationship, then buyers are under pressure to act in line with those expectations,” Prof Bernardes said.

Prof Bernardes and co-author, Paul Skilton of Washington State University, analysed transactions involving oxycodone and hydrocodone between 2006 and 2012. They chose those two drugs, Prof Bernardes said, because they’re the most commonly abused, legally prescribed products and central to the American opioid epidemic.

The researchers tested a model using a dataset combining geographic, market and public health data. The model revealed that more than 90% of supply originated with three generics manufacturers that aggressively competed for shelf space in distributors and pharmacies.

Bernardes explained how several factors led to opioid oversupply, which occurs when ordinary production and distribution processes deliver products in excess of the safe needs of a market.

“First, even though pharmacists, suppliers and manufacturers knew the products were toxic, physicians were prescribing the products,” Bernardes said. “Second, although the DEA (US Drug Enforcement Agency) expected the companies selling opioids to report unusually large purchases, it put no controls to ensure that they did. Third, even if they had, individual transactions were typically small but made up very large totals.

“Under these conditions, the whole supply chain could produce far more of these products than were good for patients or society. While it is a system-level phenomenon, we theorize that it emerges from individual behaviours and that the actions of suppliers and competitors influence those behaviours in addition to demand from patients.”

In addition, Bernardes said market characteristics, such as demand, regulation and market population size, influenced pharmacy participation.

“Supplier pools can impose their expectations only if they have greater bargaining power than buyers or if buyers critically depend on them,” Bernardes said. “Pharmacies are critically dependent on the opioid supplier pool, which is regulated at the federal and state level, because opioids are an important contributor to supplier and pharmacy profitability.”

Bernardes and his colleague believe this study blazes a trail for further supply chain research as it develops a novel notion of oversupply, distinct from the traditional idea of excess inventory, and normal misconduct that explain how pressures within supply chains shape misconduct beyond the opioid context.

The research is also unique, Bernardes said, because previous studies focused primarily on firm-level consequences of behavior such as supplier sustainability risk and corrupt opportunism. The focus on firm-level outcomes leaves a gap in understanding systemic factors that normalize misconduct in supply chains.

“The phenomenon exposes supply chain behaviour that is widespread and persistent despite its negative consequences for society,” Bernardes said. “Examples include products that harm consumers and business models that degrade the environment, exploit labour or perpetuate social injustice.”

Source: West Virginia University

Categories : AddictionTags :

Single Pathway Controls Drug Withdrawal-induced Anxiety

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New research published today in Cell Reports finds that drug withdrawal-induced anxiety and return to drug seeking behaviours are controlled by a single pathway in the brain and are centred on dopamine cells, which are normally associated with reward behaviours.

Addiction occurs in phases: the initial drug exposures are rewarding, and then repeated administration leads to tolerance or sensitisation to the drug’s effects, with withdrawal leading to anxiety and a negative affective state, which, in turn, contributes to a return to drug taking or seeking.

“In order to prevent relapse among drug users, specifically cocaine users, we need to understand the factors in the brain that contribute to drug seeking behaviours and the vulnerability to relapse,” said Kevin Beier, PhD, assistant professor of physiology and biophysics from the University of California, Irvine. “In this study, we identified a brain circuit that is responsible for drug withdrawal-induced anxiety as well as relapse-related behaviour, along with the identification of a potential target for therapeutic interventions.”

The negative affective state induced by drug withdrawal is a critical factor in the relapse of drug users.

“Both the drug withdrawal-induced anxiety and reinstatement of drug seeking are controlled by a single pathway centred around dopamine cells in the ventral midbrain,” explained Dr Beier. “That a single pathway controls both sets of behavioural changes may help to explain many addiction-related behavioural phenomena. Importantly, it links them both directly to dopamine, which is more typically linked to reward-related behaviours.”

While midbrain dopamine circuits are central to motivated behaviours, just how experience modifies these circuits to facilitate subsequent behavioural adaptations is not well understood. This study demonstrates the selective role of a ventral tegmental area dopamine projection to the amygdala for cocaine induced anxiety, but not for cocaine reward or sensitisation. Silencing this projection prevents development of anxiety during protracted withdrawal after cocaine use.

According to the National Center for Drug Abuse Statistics, there are roughly 70 000 drug overdoses each year in the United States. In 2017, nearly one in five drug overdose deaths was cocaine-related, with the highest rate of cocaine-related overdoses and deaths occurring among non-Hispanic black populations. Between 2012 and 2018, the rate of cocaine-related overdose deaths increased from 1.4 to 4.5%. The American Addiction Centers state recent drug relapse statistics show that more than 85% of individuals relapse and return to drug use within a year following treatment.

Source: University of California – Irvine

Categories : Addiction Mental HealthTags :

Use of Electronic Devices Linked to Depression and Anxiety

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Photo by Tracy le Blanc from Pexels
Photo by Tracy le Blanc from Pexels

In a study published in Addiction Biology, researchers uncovered significant associations between use of electronic devices and signs of depression and anxiety, as well as cigarette smoking and alcohol drinking. The team also found certain genetic variants that were linked with these traits.

A review of studies on smartphone addiction found that anxiety and depression were commonly mediated mental health problems. A wide range of physical health sequelae was also associated with smartphone addiction. Furthermore, there was an association between smartphone addiction and neurological disorders.

The study included data on hundreds of thousands of individuals from the UK Biobank. Three indicators of use of electronic devices were included in the study: TV watching, computer using, and computer playing.

Their findings suggested that electronic devices use was associated with common mental traits and provided new clues for understanding genetic architecture of mental traits.

The authors wrote that the study’s findings suggest that reducing time spent using electronic devices may help reduce mental health burdens. 

Source: Wiley

Categories : AddictionTags :

Glutamate and Dopamine Interact in Addiction

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Image source: Pixabay

Drug addiction is a psychiatric disorder for which no pharmacological treatment with long-term efficacy currently exists: all addictive substances have in common the fact that they raise concentrations of the neurotransmitter dopamine within brain regions forming the neural reward circuit.

This increase in dopamine levels results in long-lasting alteration of signal transmission that is dependent on another neurotransmitter, glutamate, which causes addictive behaviours. Through a new study in mice and humans, an international team including scientists from the CNRS, INRAE, the CEA, Sorbonne University, Paris-Saclay University, the University of Bordeaux, and Université Côte d’Azur has uncovered, the molecular bases of this deleterious interplay between dopamine and glutamate.

The researchers’ findings demonstrate that the inhibition of interactions between dopamine and glutamate receptors prevents pathological behaviours provoked by cocaine in mice, without altering natural reward processing. Their findings, published in Science Advances, will help pave the way for the development of new therapeutic strategies to treat addiction, and a wider spectrum of psychiatric disorders.

Source: CNRS (Délégation Paris Michel-Ange)

Categories : Addiction GenderTags :

Despite Smoking Less, Women Find it Harder to Quit

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A large study has found that women smoke fewer cigarettes than men but are less likely to quit.

Study author Ms Ingrid Allagbe, PhD student at the University of Burgundy, said: “In our study, women who used smoking cessation services had higher rates of overweight or obesity, depression, and anxiety compared to men and kicked the habit less often. Our findings highlight the need to provide smoking cessation interventions tailored to the needs of women.”

This study, presented at ESC Congress 2021, compared characteristics and abstinence rates of men and women visiting smoking cessation services between 2001 and 2018 in France, obtained from a nationwide database. The participants were smokers with at least one additional risk factor for cardiovascular disease: overweight/obese (body mass index [BMI] 25 kg/m² or above); high cholesterol; diabetes; high blood pressure; history of stroke, heart attack or angina.

Participants were classified as having mild, moderate, or severe nicotine dependence. Smoking abstinence (at least 28 consecutive days) was self-reported and confirmed by measurement of exhaled carbon monoxide less than 10 parts per million (ppm).

Participant height, weight, age, education level, chronic conditions, and number of cigarettes smoked each day were recorded. Participants were classified as having anxiety and depression symptoms or not according to their medical history, use of anti-anxiety medication or antidepressants, and the Hospital Anxiety and Depression Scale (HADS).

A total of 37 949 smokers were included in the study, of whom 43.5% were women. The average age of women in the study was 48 years, while the average age of men was 51 years. More women (55%) reported a bachelor’s degree level of education or higher compared to men (45%).

Both men and women had a high burden of cardiovascular risk factors. High cholesterol was more common in men (33%) than women (30%), as was high blood pressure (26% vs 23%, respectively) and diabetes (13% vs 10%, respectively).

Women were more likely (27%) to be overweight or obese compared to men (20%), and more likely (37.5%) to have symptoms of anxiety or depression than men (26.5%). Chronic obstructive pulmonary disease was more common in women (24%) compared to men (21%) as was asthma (16% vs 9%, respectively).

However, women smoked fewer cigarettes per day (23) than men (27). Severe nicotine dependence was less common, 56% of women compared to 60% of men, and abstinence was less common in women (52%) than men (55%).

Ms Allagbe said: “The findings suggest that despite smoking fewer cigarettes and being less nicotine dependent than men, women find it more difficult to quit. Possible contributors could be the higher prevalence of anxiety, depression and overweight or obesity among women. It has previously been reported that women may face different barriers to smoking cessation related to fear of weight gain, sex hormones, and mood.”

She concluded: “The results indicate that comprehensive smoking cessation programmes are needed for women that offer a multidisciplinary approach involving a psychologist, dietitian, and physical activity specialist.”

Source: European Society of Cardiology

Categories : AddictionTags :

High-dose Buprenorphine in ED Could Improve Opioid Abuse Outcomes

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Photo by Mat Napo on Unsplash

High-dose buprenorphine therapy, provided under emergency department care, is safe and well tolerated in people with opioid use disorder experiencing opioid withdrawal symptoms, according to a study supported by the National Institutes of Health’s National Institute on Drug Abuse (NIDA).

Lower doses of buprenorphine, a medication approved by the US Food and Drug Administration to treat opioid use disorder, are the current standard of care. Higher doses, however, could extend the period of withdrawal relief for people after being discharged from the emergency department that could help them better seek care. 

“Emergency departments are at the front lines of treating people with opioid use disorder and helping them overcome barriers to recovery such as withdrawal,” said Nora D Volkow, MD, director of NIDA. “Providing buprenorphine in emergency departments presents an opportunity to expand access to treatment, especially for underserved populations, by supplementing urgent care with a bridge to outpatient services that may ultimately improve long-term outcomes.”

Presently, some emergency departments already administer higher buprenorphine doses to treat withdrawal and opioid use disorder. They do this as a response to the growing potency in illicit opioid drug supplies and delays in access to follow-up care, but this practice has not been evaluated previously.

Researchers used a retrospective chart review to analyse data from electronic health records documenting 579 emergency department visits at the Alameda Health System Highland Hospital in California, made by 391 adults with opioid use disorder in 2018. Many patients were from vulnerable populations, with 23% experiencing homelessness and 41% having a psychiatric disorder.

In 63% of cases, clinicians administered more than the standard upper limit of 12 mg of sublingual buprenorphine during emergency department induction, and in 23% of cases, patients were given 28 mg or more. Higher doses of buprenorphine were seen to be safe and tolerable, and there were no reports of respiratory problems or drowsiness among those given the higher doses. The few serious adverse events that occurred were determined to be unrelated to high-dose buprenorphine therapy.

Studies have shown that initiating buprenorphine in emergency departments improves engagement in treatment and is cost effective, but barriers to the medication’s use in the US persist, with restrictions on what training is required, how much can be administered and for how long. Recent changes to prescribing guidelines by the US Department of Health and Human Services now let some clinicians treating up to 30 patients to prescribe buprenorphine without the previous training and services criteria.

“Once discharged, many people have difficulty linking to follow-up medical care,” explained study leader Andrew A Herring, MD, of Highland Hospital Department of Emergency Medicine. “Adjusting the timing and dosage of buprenorphine in the emergency department, along with resources and counseling aimed at facilitating the transition to outpatient services, may provide the momentum needed to access continuing care.”

“This study enhances the evidence we know about emergency-department buprenorphine induction, and could be a gamechanger, particularly for vulnerable populations who would likely benefit from a rapid induction at the time of the visit,” said study author Gail D’Onofrio, MD, of Yale University. Dr D’Onofrio published the original studies on emergency department-initiated buprenorphine, as well as recent consensus recommendations on the emergency department treatment of opioid use disorder.
The researchers noted that their findings need confirmation in other emergency departments. Nevertheless, this study suggests that with proper support and training, emergency medicine providers may safely and effectively initiate high-dose buprenorphine therapy.

Source: NIH

Journal information: JAMA Network Open (2021). DOI: 10.1001/jamanetworkopen.2021.17128