ÂÒÂ×ÊÓƵ Weekly for June 13th, 2023
This Week in the ÂÒÂ×ÊÓƵ Weekly
THE FUTURE OF PSYCHEDELIC THERAPY AND ADDICTION TREATMENT
By David E. Smith, MD, DFÂÒÂ×ÊÓƵ
(editorial and research assistance provided by Amanda J. Lee)
With the resurgence of scientific interest into the healing properties of psychedelics, current studies are investigating potential therapeutic breakthroughs in the treatment of substance use and mental health disorders. The landscape of addiction treatment faces new challenges, as evidenced during the Covid pandemic. With dual-diagnoses on the rise, promising new treatment modalities are needed more than ever.
Psychedelics include plant-based hallucinogens such as ayahuasca (a South American psychoactive brewed drink used both socially, ceremonially, or as shamanic spiritual medicine among the indigenous peoples of the Amazon basin), psilocybin (more commonly known as “magic” mushrooms) and mescaline (present in certain cacti), as well synthetics such as MDMA, ketamine and LSD (lysergic acid diethylamide, made from a substance found in ergot, a fungus that infects rye grain).
Lead
The New England Journal of Medicine
While electroconvulsive therapy (ECT) has been used for several years for treatment-resistant major depression, ketamine has been relatively recently approved. The authors conducted an open label, randomized, noninferiority trial with 403 patients to compare the effectiveness of ketamine to ECT. The ketamine was found to be noninferior to ECT for treatment response as reported by decrease in depressive symptoms. Further, both were associated with improved quality of life, but the ECT group did have a greater decline in memory performance. Of note, this trial excluded patients with major depression with psychosis, and previous studies have found that ketamine is inferior to ECT among those patients.
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Research and Science
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JAMA Health Forum
This study looked at the effect of 6 laws enacted by some states, related to the amount of buprenorphine prescribed, measured as buprenorphine treatment months per 1000 residents (BTMPR). Nationally BTMPR increased from 1.5 in 2006 to 22.8 in 2018. States that required education of buprenorphine prescribers beyond the X waiver requirements showed an increase of 14.4 BTMPR after 5 years. Requiring CME on SUD showed an increase of 11.4 BTMPR after five years. No increase was seen with Medicaid coverage of buprenorphine, Medicaid expansion, pain clinic regulations, and mandatory checking of the PDMP. The authors conclude that the additional education increased clinicians’ confidence in their ability to prescribe buprenorphine. It may increase awareness of the efficacy of MOUD thereby increasing willingness to refer patients for MOUD.
Psychology of Addictive Behaviors
This qualitative study demonstrated the importance of psychological factors that influence outcomes in psilocybin-assisted therapy for alcohol use disorder (AUD). The findings suggest that psilocybin treatment prompted meaningful and enduring improvements in self-compassion and affect regulation. These psychological processes may help individuals with AUD cope with difficult emotions and stress and prevent relapse by encouraging adaptive coping responses.
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BMC Health Services Research
This study took place in a clinic in British Columbia, Canada where 110 clients receive injectable opioid agonist treatment (iOAT) with diacetylmorphine or hydromorphone. The short half-life requires clients to come to the clinic 2 or 3 times a day for supervised injections. This study allowed 11 clients with 3-6 months of stable iOAT to attend the clinic once daily and receive 2 take-home doses. The greater freedom allowed clients to attend to daily activities such as shopping, laundry, childcare, employment, and recreation (go to the beach). They had greater autonomy in the amount dosed and the timing. Clients did not divert doses (“…because I need it") or feel unsafe about transporting or storing the doses. Clients expressed a desire for more doses and pick-up at pharmacies which would permit trips out of town. The authors conclude that this program enhanced person-centered care.
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World Psychiatry
This very comprehensive update on SUDs by Dr. Nora Volkow covers topics such as classification and prevalence, neurobiology, risk factors, clinical aspects, treatment, prevention, and special populations. Strategies for prevention, especially if adopted in childhood and adolescence, can decrease SUD risk along with that of other mental illnesses. Evidence of clinically significant benefit exists for medications, behavioral therapies and neuromodulation (specifically in the treatment of nicotine use disorder). The authors discussed the importance of treatment within the context of a Chronic Care Model, with interventions targeted to the severity of the disorder and concomitant treatment of physical and mental health conditions.
The American Journal of Psychiatry
The opioid overdose epidemic, which has been markedly exacerbated by fentanyl, highlights the urgency for psychiatrists to be well versed on the proper screening and management of opioid use disorder (OUD). This overview provides a brief review of opioid pharmacology, the neurobiology of opioid addiction (corresponding to moderate and severe OUD), and treatments and promising interventions, and outlines some knowledge gaps and research needs, particularly in relation to fentanyl.
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Maternal and Child Health Journal
Mothers who use opioids during pregnancy are often referred to child protective services (CPS), but in some states, including Massachusetts, mandatory reporting is required even for mothers taking medications for opioid use disorder (MOUD). The authors conducted interviews of mothers with OUD (24 taking MOUD, one stopped MOUD prior to delivery, one taking non-prescribed opioid) about the impact of this policy. The mothers reported three main themes: 1) they perceived the mandate as discriminatory, unjust and stigmatizing; 2) mandated reporting caused stress and negatively impacted family health and wellbeing; and 3) mandated reporting policies influenced medical decisions about accessing MOUD during pregnancy. The authors note that while this policy may be designed to identify infants at risk, it causes harm to families and potential negative impact on uptake of MOUD during pregnancy.
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The Consortium for Risk-Based Firearm Policy & the Center for Gun Violence Solutions at the Johns Hopkins Bloomberg School of Public Health
Together, the Consortium for Risk-Based Firearm Policy and the Johns Hopkins Center for Gun Violence Solutions developed this comprehensive report with alcohol and gun policy recommendations. Its aim is to highlight research to inform policy. Despite alcohol being a significant risk factor for gun violence, few attempts have been made to address the interplay between them. Summarized are the connections between alcohol and firearm use, existing state laws, and a core set of recommendations for addressing the problem.
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