Lead Story: Association of Co-Prescribing of Opioid and Benzodiazepine Substitutes With Incident Falls and Fracture

Association of co-prescribing of opioid and benzodiazepine substitutes with incident falls and fractures among older adults: a cohort study [Open Access]

BMJ Open 

This study extracted data from Medicare records of 47,964 enrollees who were diagnosed with chronic pain and anxiety and prescribed some combination of the studied medications (opioids, benzodiazepines, gabapentinoids (GABA), or antidepressants  (SSRI/SNRI)). The outcome measure was falls or fractures. The authors note that prior research has shown opioids+benzodiazepines to be associated with high rates of falls, fractures, and deaths. These data show that opioids+GABA was associated with a greater risk of falls and fractures than opioids+benzodiazepines. An even greater risk of falls was associated with use of three or more of these medications. The authors conclude that clinicians may be underestimating the sedating effects of gabapentinoids.  

 

Stimulant-related incident surveillance using emergency medical service records in Massachusetts, 2013–2020

Drug and Alcohol Dependence

Rates of stimulant use and stimulant use disorder (StUD) have been steadily increasing, as have overdoses with stimulant use involvement. The authors examine emergency responses involving stimulants between 2013 and 2020 in Massachusetts. They categorize calls in 3 classes: class 1 – any stimulant use, class 2 – problematic stimulant use in which stimulant use was associated with acute medical or behavioral issue, and class 3 – acute stimulant-related incidents in which stimulant use was the primary issue for the call. Over the study period, calls in all 3 categories steadily increased, were more likely to be among younger adults, and the callers were more frequently male. While race/ethnicity data were frequently missing, when the data were present, Hispanic/Latinx and Black non-Hispanic patients appeared to be overrepresented among stimulant-related calls. 

 

Trends in Prevalence of Cigarette Smoking Among US Adults With Major Depression or Substance Use Disorders, 2006-2019

JAMA

This cross-sectional study assessed trends in past-month prevalence of cigarette smoking among adults with vs. without past-year major depressive episode (MDE), substance use disorders (SUDs), or both. Using data from the 2006-2019 US National Surveys on Drug Use and Health, past-month self-reported cigarette smoking prevalence declined significantly among adults with MDE from 37.3% to 24.2% (average annual percent change: −3.2), adults with SUD from 46.5% to 35.8% (average annual percent change: −1.7), and adults with co-occurring MDE and SUD from 50.7% to 37.0% (annual average annual percent change of −2.1). Prevalence declined significantly for each examined subgroup but not for American Indian or Alaskan Native with either MDE or SUDs.

 

Emerging Agents of Substance Use/Misuse

Emergency Medicine Clinics of North America

In the last decade, there has been a rise in the use of novel psychoactive substances (NPS) for recreational purposes. Many of these synthetic psychoactive substances are derived or based on older substances of abuse, but because of their novel structures, they are not easily detectable by routine immunoassay urine drug screens. Clinical effects encountered in patients using these substances depend on the substance’s structure but can be unpredictable due to the effects on various receptors at varying doses. It is important for clinicians to be aware that these novel substances exist because the diagnosis is often clinical and not based on UDS. Treatment for these substances is generally supportive and aimed at the presenting signs and symptoms.

 

Dopamine Supersensitivity: A Novel Hypothesis of Opioid-Induced Neurobiological Mechanisms Underlying Opioid-Stimulant Co-use and Opioid Relapse  [Open Access]

Frontiers in Psychiatry

Stimulants are uniquely reinforcing to persons with opioid physical dependence, contribute to the acute opioid withdrawal syndrome, and could manifest as craving and/or motivation to use, prompting opioid relapse during acute and protracted withdrawal. Current research demonstrates that changes in the dopamine system occur once physical dependence to opioids develops, the chronicity of opioid exposure is associated with a severity of changes, and dopamine deficits persist long after signs of opioid withdrawal appear to have resolved.  This review discusses how dopamine supersensitivity develops soon after opioid abstinence and results in increased response to dopamine agonists that increases in magnitude as the abstinence period continues and is evident several weeks into protracted withdrawal.  

 

Psychological online interventions for problem gambling and gambling disorder – A meta-analytic approach

Journal of Psychiatric Research

In the context of the Covid-19 pandemic, this systematic review and meta-analysis investigated the effectiveness of psychological online interventions on problem gambling and gambling disorder (PGGD). Results indicate that psychological online interventions have moderate effects on PGGD in the short term. There was no indication that guided vs. unguided forms of online interventions affect the outcome. However, there is a clear trend toward unguided and even autonomous interventions which have the potential to complement or even substitute a therapist in person. Recent reviews indicate the superiority of online CBT formats compared to interventions with other theoretical backgrounds.
 

Toward Risk-Benefit Assessments in Psychedelic- and MDMA-Assisted Therapies | Research, Methods, Statistics

JAMA Psychiatry

There has been considerable attention to the evidence showing the benefits of psychedelic- and MDMA-assisted therapy. Less is known about the associated risks, primarily psychiatric, such as mood and thought disorders that sometimes outlast the acute effects of the drug and may provoke suicidal behavior. It will be important to identify patients at higher risk, for example patients with a family history of schizophrenia or bipolar disorder; however, such patients have been excluded from most clinical trials. One consideration is the implementation of risk evaluation and management strategies (REMS) but MDMA and psilocybin are already in the public domain so alternate strategies may be needed. 

 

Implementation of a Standardized Clinical Definition of Opioid Withdrawal in the Neonate Challenges and Opportunities

JAMA

A standard clinical definition for neonatal abstinence syndrome (NAS) has been lacking for more than 45 years. The new definition of opioid withdrawal in the neonate includes 2 specific elements: in utero exposure to opioids with or without exposure to other psychotropic substances and the presence of 2 of 5 of the most common clinical signs of opioid withdrawal. A consistent clinical definition is essential in informing treatment protocols, administrative coding, surveillance, research criteria, and the spectrum of care for the mother-infant dyad. This could provide a significant shift in the way mothers and neonates with prenatal opioid exposure are identified, and represents a promising path forward for pregnant people and neonates with prenatal opioid exposure to improve their health and well-being