The ASAM Weekly for August 6th, 2024
This Week in the ASAM Weekly
Rapid Initiation of Injectable Extended-Release Naltrexone for Opioid Use Disorder: A Time for Paradigm Shift in Treatment Protocols
Matisyahu Shulman, MD
Edward V. Nunes, MD
Adam Bisaga, MD
The opioid crisis remains a critical public health issue in the United States, contributing to over 80,000 opioid overdose deaths in 2023 alone. Addressing this problem necessitates effective treatment options for individuals with opioid use disorder (OUD) that reduce the risk of relapse and overdose. Injectable extended-release (XR)-naltrexone is an FDA-approved treatment for OUD, particularly for populations less inclined towards agonist-based therapies such as methadone or buprenorphine, and otherwise attempting to remain abstinent without the help of medications. However, the conventional approach to initiate XR-naltrexone poses a significant hurdle due to the necessity of an extended opioid-free period to avoid precipitated withdrawal. This approach is often not practical and has a low rate of success, leading to discouragement among both providers and patients from trying this treatment option.
A recent evaluated an alternative, rapid procedure (RP) for initiating XR-naltrexone, comparing it to the standard procedure (SP) in a stepped-wedge cluster randomized trial across six community-based inpatient addiction treatment units. We would like to explore the implications of these findings, which suggest that the RP could significantly enhance the accessibility and effectiveness of XR-naltrexone, despite certain limitations.
Lead Story
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.
Research and Science
馃敁
JAMA Network Open
Serious injection-related infections (SIRIs) have doubled in recent years and provide an opportunity to initiate medications for opioid use disorder (MOUD). In this retrospective study, the authors examine MOUD initiation after hospitalization for SIRI between 2014 and 2020. In the 12 months after hospitalization, only 49.1% of patients received any MOUD and among them, less than half were retained in treatment over the following year. Factors associated with MOUD initiation include: MOUD receipt in the 6 months prior to hospitalization, homelessness, having Medicaid, and having anxiety or depression. Notably, non-Hispanic Black patients were less likely to receive MOUD. Additional efforts are needed to target this population to both initiate MOUD and retain individuals in treatment.
Preventive Medicine
Scaling overdose education and naloxone distribution (OEND) and medications for opioid use disorder (MOUD) are important interventions to address the opioid epidemic. The Communities That HEAL (CTH) intervention utilized community engagement in four states to increase support for MOUD and OEND. This study evaluated the impact of the CTH intervention on perceived barriers to the expansion of MOUD and OEND. There was a significant reduction in perceived barriers to scaling OEND in healthcare/behavioral health settings, and other/non-traditional settings. In addition, there was a decrease in perceived barriers to scaling MOUD to other/non-traditional venues. There was a reduction for expansion in criminal-legal settings for Kentucky only, where specific strategies were targeted at this sector. These findings support the importance of community engagement in expanding access to these services.
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Journal of Addiction Medicine
This is a case report of a 35-year-old man presenting to the ER with psychotic symptoms (visual hallucinations and paranoid delusions) after using methamphetamine and cocaine. He was successfully treated with haloperidol and lorazepam and discharged home where he resumed use of methamphetamine. He returned to the ER with psychotic symptoms and was again treated with haloperidol and diazepam. The following morning, he was catatonic (unresponsive with posturing and rigidity) with a BP of 170/155 and a pulse of 132. He was diagnosed with malignant catatonia (catatonia with autonomic instability), often lethal. He was treated with lorazepam and was discharged after 5 days. The authors review proposed mechanisms for malignant catatonia and suggest haloperidol may have precipitated the event by dopamine blockade in the basal ganglia. They advise cautious use of antipsychotics in psychostimulant intoxication.
Drug and Alcohol Dependence
This study analyzed data on psychiatric admissions throughout the US between 2015 and 2019. During this period, there were 963,202 total psychiatric admissions and most (84%) did not involve substances. Admissions involving substances other than methamphetamine (11%) exceeded those involving methamphetamine with or without other substances (5%). Over the study period, admissions involving methamphetamine with or without other substances increased by 68% and admissions involving methamphetamine alone increased by 79%. During the same period, admissions involving opioids and/or cocaine (without methamphetamine) decreased 22%. The authors conclude that methamphetamine-involved psychiatric admissions significantly increased while opioid-involved admissions decreased.
In The News
The Conversation
Substance Abuse and Mental Health Services Administration (SAMSHA)
National Public Radio (NPR)
STAT
British Broadcasting Corporation (BBC)
US Centers for Disease Control and Prevention (CDC)