Summer 2021 | Issue 47
By: David Lott, MD
In order to keep our readership informed, I want to give several updates relating to substance use disorders. At the top of the list is opioids, with a continuing rise in overdose deaths, worsened further by the COVID-19 pandemic. For instance, Illinois saw a 36% increase in overdose deaths in Jan-Sep 2020 compared to the same time period in 2019 (1).
Fentanyl analogues and other illicit synthetic opioids continue to fuel the rise in opioid use and deaths, though other factors also play a role. As in many other areas, the increase in Illinois is disproportionately affecting Black and Hispanic people, one more example of the vast racial inequities we face. Identifying and combating structural racism is a key part of addressing this crisis.
There are several highly effective treatments for opioid use disorder – particularly buprenorphine, methadone, and naltrexone (collectively known as MOUD - medications for opioid use disorder), but they are underutilized. Often people with OUD are ready to make a change but cannot get help, and limited availability of MOUD is one of the major barriers for patients who are seeking treatment. ASAM and other groups have recently tried to improve MOUD access by advocating for elimination of the X-waiver required for buprenorphine prescribing. In response, in late April, the U.S. Department of Health and Human Services (HHS) issued an exemption which now allows providers to prescribe buprenorphine for up to 30 patients without an X-waiver.
Another important recent development in Illinois is recreational cannabis, which became available in 2020. It is too soon to know what the impact of this will be on rates of cannabis use, cannabis use disorder, and related psychiatric symptoms. Illinois rates of cannabis use were already increasing for over a decade before this (per NSDUH annual survey past year cannabis use data), and we do not know yet whether the availability of recreational cannabis will impact this further. Another unknown is the impact on side effects such as psychosis. If use rates continue to increase, and products continue to increase in potency, then there is a good possibility that this will translate into higher rates of psychosis. In fact, recent studies have demonstrated a dose-response relationship with psychosis (2,3).
There are many other trends worth mentioning – telemedicine, rising stimulant use, ketamine and hallucinogens as treatments, vaping, and more – but I want to spend the last portion of this article on alcohol. Rates of alcohol use have increased steadily for several years now, a trend that appears to have continued during the pandemic (4,5,6). Unfortunately, this increase in alcohol use is happening at the same time as studies are showing more negative health effects of alcohol use. For instance, a recent study from Oxford, though not yet peer-reviewed, received widespread media coverage in May after showing negative effects on brain fMRI measures with even modest amounts of alcohol consumption (7). Other possible negative effects linked to alcohol include dementia, some cardiovascular diseases, and a variety of cancers (8,9,10).
Another harmful effect of alcohol is on the developing fetus. With increasing alcohol use rates, there is also an expected increase in alcohol exposure during pregnancy. Growing awareness of the negative effects of prenatal alcohol exposure is reflected in the use of the term Fetal Alcohol Spectrum Disorders (FASD) and other similar constructs that identify alcohol effects not meeting full criteria for Fetal Alcohol Syndrome (FAS). In addition, DSM-5 included Neurobehavioral Disorder associated with Prenatal Alcohol Exposure (ND-PAE) as a condition requiring further study (11). These and other similar diagnostic terms are notable for the ongoing significant developmental and neurobehavioral deficits in affected children (12). Considering the long-term impact of such cognitive and behavioral problems on individuals, families, and communities, it is clear these effects will persist for many years to come.
These substance-related problems and trends are pressing issues for all of us, and I hope each of you will continue to keep updated on them. One good way to stay informed is the Providers Clinical Support System or PCSS (https://pcssnow.org), where you can find up-to-date information, free CME content, and even sign up for a newsletter. This is a group funded by SAMHSA and led by AAAP (American Academy of Addiction Psychiatry), which is the subspecialty professional group for Addiction Psychiatry. AAAP itself also provides many educational opportunities for interested providers, as does the American Society of Addiction Medicine (ASAM). I encourage each of you to use some of these resources to stay informed on all these important issues.
1.Illinois Department of Public Health. (2021). Illinois opioid overdose epidemic during the COVID-19 pandemic. http://www.dph.illinois.gov/sites/default/files/publications/il-opioid- overdoses-and-covid-pandemic-04012021.pdf
2. Arianna Marconi, Marta Di Forti, Cathryn M. Lewis, Robin M. Murray, Evangelos Vassos, Meta-analysis of the Association Between the Level of Cannabis Use and Risk of Psychosis, Schizophrenia Bulletin, Volume 42, Issue 5, September 2016, Pages 1262–1269, https://doi-org.proxy.cc.uic.edu/10.1093/schbul/sbw003
3. Di Forti, M., Quattrone, D., Freeman, T. P., Tripoli, G., Gayer-Anderson, C., Quigley, H., Rodriguez, V., et al. (2019). The contribution of cannabis use to variation in the incidence of psychotic disorder across Europe (EU-GEI): a multicentre case-control study.. The lancet. Psychiatry, 6 (5), 427-436. https://doi.org/10.1016/s2215-0366(19)30048-3
4. Grant BF, Chou SP, Saha TD, Pickering RP, Kerridge BT, Ruan WJ, Huang B, Jung J, Zhang H, Fan A, Hasin DS. Prevalence of 12-Month Alcohol Use, High-Risk Drinking, and DSM-IV Alcohol Use Disorder in the United States, 2001-2002 to 2012-2013: Results From the National Epidemiologic Survey on Alcohol and Related Conditions. JAMA Psychiatry. 2017 Sep 1;74(9):911-923. doi: 10.1001/jamapsychiatry.2017.2161. PMID: 28793133; PMCID: PMC5710229
5. Barbosa C, Cowell AJ, Dowd WN. Alcohol Consumption in Response to the COVID-19 Pandemic in the United States. J Addict Med. 2020 Oct 23. doi: 10.1097/ADM.0000000000000767. Epub ahead of print. PMID: 33105169
6. Grossman ER, Benjamin-Neelon SE, Sonnenschein S. Alcohol Consumption during the COVID-19 Pandemic: A Cross-Sectional Survey of US Adults. Int J Environ Res Public Health. 2020 Dec 9;17(24):9189. doi: 10.3390/ijerph17249189. PMID: 33316978; PMCID: PMC7763183
8. Lao Y, Hou L, Li J, Hui X, Yan P, Yang K. Association between alcohol intake, mild cognitive impairment and progression to dementia: a dose-response meta-analysis. Aging Clin Exp Res. 2021 May;33(5):1175-1185. doi: 10.1007/s40520-020-01605-0. Epub 2020 Jun 1. PMID: 32488474
9. Stătescu C, Clement A, Șerban IL, Sascău R. Consensus and Controversy in the Debate over the Biphasic Impact of Alcohol Consumption on the Cardiovascular System. Nutrients. 2021 Mar 25;13(4):1076. doi: 10.3390/nu13041076. PMID: 33806249; PMCID: PMC8066508
10. Rehm J, Shield KD, Weiderpass E. Alcohol consumption. A leading risk factor for cancer. Chem Biol Interact. 2020 Nov 1;331:109280. doi: 10.1016/j.cbi.2020.109280. Epub 2020 Oct 1. PMID: 33010221
11. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013
12. Mattson SN, Bernes GA, Doyle LR. Fetal Alcohol Spectrum Disorders: A Review of the Neurobehavioral Deficits Associated With Prenatal Alcohol Exposure. Alcohol Clin Exp Res. 2019 Jun;43(6):1046-1062. doi: 10.1111/acer.14040. Epub 2019 May 2. PMID: 30964197; PMCID: PMC6551289