Addiction Medicine

Aggression is an underappreciated mental health issue, and biological mechanisms might help explain more extreme forms like intermittent explosive disorder (IED), which is characterized by episodes of sudden impulses and inappropriate aggression, violence, or even verbal outbursts. IED can lead to road rage, domestic abuse, in addition to throwing objects and engaging in other destructive behaviors.

Despite those consequences, aggression hasn’t gained the same level of attention as other psychiatric conditions, according to Emil F. Coccaro, MD, who spoke about the topic at a virtual meeting presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.

“People seem to think that aggressive behavior is bad behavior, and therefore people just need an attitude adjustment. So there’s this sort of stigma, and there are no advocacy groups for it. There are no poster children for it. But there’s a whole lot of biology and neuroscience behind it,” said Dr. Coccaro, in an interview. He is a professor and vice chair of research in psychiatry and behavioral health at Ohio State University, Columbus.

IED is also more common than people generally suspect, with an estimated 4% lifetime incidence, according to Dr. Coccaro, who spoke at the meeting presented by MedscapeLive. MedscapeLive and this news organization are owned by the same parent company.

There is a general view that psychiatric conditions may lead to increased aggression, but there is little evidence of that. “As a general statement, having a psychological [illness] in and of itself does not really increase the risk of being aggressive. What does is being aggressive in general, and substance use disorder. And the thing with [people who have] substance use disorders is that they only get aggressive when they are aggressive to begin with,” said Dr. Coccaro, noting that the strongest case for the relationship surrounds alcohol abuse.

The DSM-5 criteria for IED include: verbal or physical aggression without destruction, at least twice per week, or three or more episodes of assault or physical destruction within a year. The behavior must be out of proportion to the provocation, cause distress or impairment, and not be accountable by other diagnoses. “If they’re blowing up twice a week, for a few months, and usually they’re doing it for a long time, then that’s different than just blowing up very occasionally. Healthy people, nonaggressive people, maybe they blow up once a year, or even less frequently than that,” Dr. Coccaro said.

Functional magnetic resonance imaging and other imaging studies consistently show differences associated with aggression.

“The IEDs really do distinguish themselves from the psychiatric controls. They also have other stuff going on with them; they have a hostile attribution. And they’re kind of irritable at baseline. They’re not walking around irritable all the time, but the people around them may be walking on eggshells,” Dr. Coccaro said.

The results from these sorts of studies aren’t fully conclusive and can’t be used for diagnosis, in part because of a lack of power. “It’s hard to do these MRI studies and lots and lots of subjects, because they’re kind of expensive,” Dr. Coccaro said. “We’re just not there yet.”

Other, less expensive imaging techniques like near-infrared spectroscopy may improve matters. “That might be something down the road that could lead to something (diagnostic). Right now, most imaging studies are being done to really understand mechanisms,” said Dr. Coccaro.

Those mechanistic studies suggest that the culprit for IED may be a combination of too much drive from subcortical structures like the amygdala and insufficient inhibitor function in the frontal part of the brain. The frontal cortex may suffer a loss of gray matter, according to Dr. Coccaro, and there may be insufficient connectivity, which could weaken signals coming from the frontal areas that might otherwise inhibit lower centers of the brain.

Treatment for IED could be aimed at improving that connectivity and signaling. Ketamine and other anesthetic agents like nitrous oxide may increase connectivity to nerve cells by increasing branching at synaptic dendrites.

Selective serotonin reuptake inhibitors have the potential to treat IED, but their utility is limited because they bind to the presynaptic transporter for serotonin, and more aggressive people have fewer of those transporters. “You only get so much bang for your buck,” Dr. Coccaro said.

Cognitive-behavioral therapy that focuses on anger management and relaxation shows promise. “CBT does help people deal with what’s coming at them. So it’s like, ‘oh, I’m getting angry, I better start doing those relaxation (techniques).’ It teaches them to rethink things.”

During the Q&A session following the presentation, Henry A. Nasrallah, MD, who moderated the session, pointed out that misattribution can occur, leading an affected individual to misread someone’s facial expression and react aggressively, which is a problem also seen in psychosis.

“There are studies showing [that if] you show them a series of faces with different affects, many times paranoid patients read a normal facial expression as threatening. So it may be that it’s the same thing with aggression,” said Dr. Nasrallah, who is a professor of psychiatry, neurology, and neuroscience at the University of Cincinnati.

In the midst of the ongoing COVID-19 pandemic, it’s also possible that mask-wearing could improve or worsen such misunderstandings. “There is expression in the eyes that you can see, but you miss a lot,” Dr. Coccaro said.

For now, the effects of masks remain largely unknown. But that will change. “Sooner or later we will have a bunch of papers coming out about how masks have changed a lot of behaviors,” Dr. Nasrallah said.

Dr. Coccaro has consulted for Avanir, Azevan, and Brackett. Dr. Nasrallah has consulted for Acadia, Alkermes, Allergan Janssen, Otsuka, Indivior, IntraCellular, Neurocrine, Sunovion, Teva, and Boehringer-Ingelheim. Dr. Nasrallah has been on a speaker’s bureau for Acadia, Alkermes, Allergan, Janssen, Otsuka, Indivior, Intracellular, Neurocrine, Noven, Sunovion, and Teva.
 

Aggression is an underappreciated mental health issue, and biological mechanisms might help explain more extreme forms like intermittent explosive disorder (IED), which is characterized by episodes of sudden impulses and inappropriate aggression, violence, or even verbal outbursts. IED can lead to road rage, domestic abuse, in addition to throwing objects and engaging in other destructive behaviors.

Despite those consequences, aggression hasn’t gained the same level of attention as other psychiatric conditions, according to Emil F. Coccaro, MD, who spoke about the topic at a virtual meeting presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.

“People seem to think that aggressive behavior is bad behavior, and therefore people just need an attitude adjustment. So there’s this sort of stigma, and there are no advocacy groups for it. There are no poster children for it. But there’s a whole lot of biology and neuroscience behind it,” said Dr. Coccaro, in an interview. He is a professor and vice chair of research in psychiatry and behavioral health at Ohio State University, Columbus.

IED is also more common than people generally suspect, with an estimated 4% lifetime incidence, according to Dr. Coccaro, who spoke at the meeting presented by MedscapeLive. MedscapeLive and this news organization are owned by the same parent company.

There is a general view that psychiatric conditions may lead to increased aggression, but there is little evidence of that. “As a general statement, having a psychological [illness] in and of itself does not really increase the risk of being aggressive. What does is being aggressive in general, and substance use disorder. And the thing with [people who have] substance use disorders is that they only get aggressive when they are aggressive to begin with,” said Dr. Coccaro, noting that the strongest case for the relationship surrounds alcohol abuse.

The DSM-5 criteria for IED include: verbal or physical aggression without destruction, at least twice per week, or three or more episodes of assault or physical destruction within a year. The behavior must be out of proportion to the provocation, cause distress or impairment, and not be accountable by other diagnoses. “If they’re blowing up twice a week, for a few months, and usually they’re doing it for a long time, then that’s different than just blowing up very occasionally. Healthy people, nonaggressive people, maybe they blow up once a year, or even less frequently than that,” Dr. Coccaro said.

Functional magnetic resonance imaging and other imaging studies consistently show differences associated with aggression.

“The IEDs really do distinguish themselves from the psychiatric controls. They also have other stuff going on with them; they have a hostile attribution. And they’re kind of irritable at baseline. They’re not walking around irritable all the time, but the people around them may be walking on eggshells,” Dr. Coccaro said.

The results from these sorts of studies aren’t fully conclusive and can’t be used for diagnosis, in part because of a lack of power. “It’s hard to do these MRI studies and lots and lots of subjects, because they’re kind of expensive,” Dr. Coccaro said. “We’re just not there yet.”

Other, less expensive imaging techniques like near-infrared spectroscopy may improve matters. “That might be something down the road that could lead to something (diagnostic). Right now, most imaging studies are being done to really understand mechanisms,” said Dr. Coccaro.

Those mechanistic studies suggest that the culprit for IED may be a combination of too much drive from subcortical structures like the amygdala and insufficient inhibitor function in the frontal part of the brain. The frontal cortex may suffer a loss of gray matter, according to Dr. Coccaro, and there may be insufficient connectivity, which could weaken signals coming from the frontal areas that might otherwise inhibit lower centers of the brain.

Treatment for IED could be aimed at improving that connectivity and signaling. Ketamine and other anesthetic agents like nitrous oxide may increase connectivity to nerve cells by increasing branching at synaptic dendrites.

Selective serotonin reuptake inhibitors have the potential to treat IED, but their utility is limited because they bind to the presynaptic transporter for serotonin, and more aggressive people have fewer of those transporters. “You only get so much bang for your buck,” Dr. Coccaro said.

Cognitive-behavioral therapy that focuses on anger management and relaxation shows promise. “CBT does help people deal with what’s coming at them. So it’s like, ‘oh, I’m getting angry, I better start doing those relaxation (techniques).’ It teaches them to rethink things.”

During the Q&A session following the presentation, Henry A. Nasrallah, MD, who moderated the session, pointed out that misattribution can occur, leading an affected individual to misread someone’s facial expression and react aggressively, which is a problem also seen in psychosis.

“There are studies showing [that if] you show them a series of faces with different affects, many times paranoid patients read a normal facial expression as threatening. So it may be that it’s the same thing with aggression,” said Dr. Nasrallah, who is a professor of psychiatry, neurology, and neuroscience at the University of Cincinnati.

In the midst of the ongoing COVID-19 pandemic, it’s also possible that mask-wearing could improve or worsen such misunderstandings. “There is expression in the eyes that you can see, but you miss a lot,” Dr. Coccaro said.

For now, the effects of masks remain largely unknown. But that will change. “Sooner or later we will have a bunch of papers coming out about how masks have changed a lot of behaviors,” Dr. Nasrallah said.

Dr. Coccaro has consulted for Avanir, Azevan, and Brackett. Dr. Nasrallah has consulted for Acadia, Alkermes, Allergan Janssen, Otsuka, Indivior, IntraCellular, Neurocrine, Sunovion, Teva, and Boehringer-Ingelheim. Dr. Nasrallah has been on a speaker’s bureau for Acadia, Alkermes, Allergan, Janssen, Otsuka, Indivior, Intracellular, Neurocrine, Noven, Sunovion, and Teva.
 

Aggression is an underappreciated mental health issue, and biological mechanisms might help explain more extreme forms like intermittent explosive disorder (IED), which is characterized by episodes of sudden impulses and inappropriate aggression, violence, or even verbal outbursts. IED can lead to road rage, domestic abuse, in addition to throwing objects and engaging in other destructive behaviors.

Despite those consequences, aggression hasn’t gained the same level of attention as other psychiatric conditions, according to Emil F. Coccaro, MD, who spoke about the topic at a virtual meeting presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.

“People seem to think that aggressive behavior is bad behavior, and therefore people just need an attitude adjustment. So there’s this sort of stigma, and there are no advocacy groups for it. There are no poster children for it. But there’s a whole lot of biology and neuroscience behind it,” said Dr. Coccaro, in an interview. He is a professor and vice chair of research in psychiatry and behavioral health at Ohio State University, Columbus.

IED is also more common than people generally suspect, with an estimated 4% lifetime incidence, according to Dr. Coccaro, who spoke at the meeting presented by MedscapeLive. MedscapeLive and this news organization are owned by the same parent company.

There is a general view that psychiatric conditions may lead to increased aggression, but there is little evidence of that. “As a general statement, having a psychological [illness] in and of itself does not really increase the risk of being aggressive. What does is being aggressive in general, and substance use disorder. And the thing with [people who have] substance use disorders is that they only get aggressive when they are aggressive to begin with,” said Dr. Coccaro, noting that the strongest case for the relationship surrounds alcohol abuse.

The DSM-5 criteria for IED include: verbal or physical aggression without destruction, at least twice per week, or three or more episodes of assault or physical destruction within a year. The behavior must be out of proportion to the provocation, cause distress or impairment, and not be accountable by other diagnoses. “If they’re blowing up twice a week, for a few months, and usually they’re doing it for a long time, then that’s different than just blowing up very occasionally. Healthy people, nonaggressive people, maybe they blow up once a year, or even less frequently than that,” Dr. Coccaro said.

Functional magnetic resonance imaging and other imaging studies consistently show differences associated with aggression.

“The IEDs really do distinguish themselves from the psychiatric controls. They also have other stuff going on with them; they have a hostile attribution. And they’re kind of irritable at baseline. They’re not walking around irritable all the time, but the people around them may be walking on eggshells,” Dr. Coccaro said.

The results from these sorts of studies aren’t fully conclusive and can’t be used for diagnosis, in part because of a lack of power. “It’s hard to do these MRI studies and lots and lots of subjects, because they’re kind of expensive,” Dr. Coccaro said. “We’re just not there yet.”

Other, less expensive imaging techniques like near-infrared spectroscopy may improve matters. “That might be something down the road that could lead to something (diagnostic). Right now, most imaging studies are being done to really understand mechanisms,” said Dr. Coccaro.

Those mechanistic studies suggest that the culprit for IED may be a combination of too much drive from subcortical structures like the amygdala and insufficient inhibitor function in the frontal part of the brain. The frontal cortex may suffer a loss of gray matter, according to Dr. Coccaro, and there may be insufficient connectivity, which could weaken signals coming from the frontal areas that might otherwise inhibit lower centers of the brain.

Treatment for IED could be aimed at improving that connectivity and signaling. Ketamine and other anesthetic agents like nitrous oxide may increase connectivity to nerve cells by increasing branching at synaptic dendrites.

Selective serotonin reuptake inhibitors have the potential to treat IED, but their utility is limited because they bind to the presynaptic transporter for serotonin, and more aggressive people have fewer of those transporters. “You only get so much bang for your buck,” Dr. Coccaro said.

Cognitive-behavioral therapy that focuses on anger management and relaxation shows promise. “CBT does help people deal with what’s coming at them. So it’s like, ‘oh, I’m getting angry, I better start doing those relaxation (techniques).’ It teaches them to rethink things.”

During the Q&A session following the presentation, Henry A. Nasrallah, MD, who moderated the session, pointed out that misattribution can occur, leading an affected individual to misread someone’s facial expression and react aggressively, which is a problem also seen in psychosis.

“There are studies showing [that if] you show them a series of faces with different affects, many times paranoid patients read a normal facial expression as threatening. So it may be that it’s the same thing with aggression,” said Dr. Nasrallah, who is a professor of psychiatry, neurology, and neuroscience at the University of Cincinnati.

In the midst of the ongoing COVID-19 pandemic, it’s also possible that mask-wearing could improve or worsen such misunderstandings. “There is expression in the eyes that you can see, but you miss a lot,” Dr. Coccaro said.

For now, the effects of masks remain largely unknown. But that will change. “Sooner or later we will have a bunch of papers coming out about how masks have changed a lot of behaviors,” Dr. Nasrallah said.

Dr. Coccaro has consulted for Avanir, Azevan, and Brackett. Dr. Nasrallah has consulted for Acadia, Alkermes, Allergan Janssen, Otsuka, Indivior, IntraCellular, Neurocrine, Sunovion, Teva, and Boehringer-Ingelheim. Dr. Nasrallah has been on a speaker’s bureau for Acadia, Alkermes, Allergan, Janssen, Otsuka, Indivior, Intracellular, Neurocrine, Noven, Sunovion, and Teva.
 

Pfizer has recalled four more lots of the smoking cessation drug varenicline (Chantix), according to an Aug. 16 update on the U.S. Food and Drug Administration website.

In a new FDA MedWatch, the agency notes that these 0.5 mg/1 mg tablets are being recalled because of the presence of N-nitroso-varenicline, a nitrosamine impurity, at a level higher than Pfizer’s acceptable intake limit.

On July 2, the FDA reported that Pfizer had voluntarily recalled nine lots of the drug for this reason. As reported by this news organization, the company added three more lots to the recall a few weeks later. The new recall now brings to 16 the number of lots that have been recalled.

In the update, the FDA noted that, although long-term ingestion of the impurity “may be associated with a theoretical potential increased cancer risk in humans,” there is no immediate risk in taking this medication. The agency added that no related adverse events (AEs) have been reported.

The four additional lots included in the newest recall are as follows:

• 00018522 (expiration date: August 2021).
• 00018523 (expiration date: August 2021).
• 00018739 (expiration date: August 2021).
• 00018740 (expiration date: August 2021).

The recalled lots were distributed in the United States and Puerto Rico from June 2019 to June 2021.

As before, the FDA noted that the benefits of stopping smoking “outweigh the theoretical potential cancer risk” from varenicline’s impurity.

It added that, although the impurities may increase risk for cancer if a high level of exposure continues over a long period, the drug is intended as a short-term treatment to aid in smoking cessation.

For now, clinicians should report any AEs from varenicline to the FDA’s MedWatch program, and patients taking this treatment should consult with their health care practitioner or pharmacy, the update notes.

A version of this article first appeared on Medscape.com.

Pfizer has recalled four more lots of the smoking cessation drug varenicline (Chantix), according to an Aug. 16 update on the U.S. Food and Drug Administration website.

In a new FDA MedWatch, the agency notes that these 0.5 mg/1 mg tablets are being recalled because of the presence of N-nitroso-varenicline, a nitrosamine impurity, at a level higher than Pfizer’s acceptable intake limit.

On July 2, the FDA reported that Pfizer had voluntarily recalled nine lots of the drug for this reason. As reported by this news organization, the company added three more lots to the recall a few weeks later. The new recall now brings to 16 the number of lots that have been recalled.

In the update, the FDA noted that, although long-term ingestion of the impurity “may be associated with a theoretical potential increased cancer risk in humans,” there is no immediate risk in taking this medication. The agency added that no related adverse events (AEs) have been reported.

The four additional lots included in the newest recall are as follows:

• 00018522 (expiration date: August 2021).
• 00018523 (expiration date: August 2021).
• 00018739 (expiration date: August 2021).
• 00018740 (expiration date: August 2021).

The recalled lots were distributed in the United States and Puerto Rico from June 2019 to June 2021.

As before, the FDA noted that the benefits of stopping smoking “outweigh the theoretical potential cancer risk” from varenicline’s impurity.

It added that, although the impurities may increase risk for cancer if a high level of exposure continues over a long period, the drug is intended as a short-term treatment to aid in smoking cessation.

For now, clinicians should report any AEs from varenicline to the FDA’s MedWatch program, and patients taking this treatment should consult with their health care practitioner or pharmacy, the update notes.

A version of this article first appeared on Medscape.com.

Pfizer has recalled four more lots of the smoking cessation drug varenicline (Chantix), according to an Aug. 16 update on the U.S. Food and Drug Administration website.

In a new FDA MedWatch, the agency notes that these 0.5 mg/1 mg tablets are being recalled because of the presence of N-nitroso-varenicline, a nitrosamine impurity, at a level higher than Pfizer’s acceptable intake limit.

On July 2, the FDA reported that Pfizer had voluntarily recalled nine lots of the drug for this reason. As reported by this news organization, the company added three more lots to the recall a few weeks later. The new recall now brings to 16 the number of lots that have been recalled.

In the update, the FDA noted that, although long-term ingestion of the impurity “may be associated with a theoretical potential increased cancer risk in humans,” there is no immediate risk in taking this medication. The agency added that no related adverse events (AEs) have been reported.

The four additional lots included in the newest recall are as follows:

• 00018522 (expiration date: August 2021).
• 00018523 (expiration date: August 2021).
• 00018739 (expiration date: August 2021).
• 00018740 (expiration date: August 2021).

The recalled lots were distributed in the United States and Puerto Rico from June 2019 to June 2021.

As before, the FDA noted that the benefits of stopping smoking “outweigh the theoretical potential cancer risk” from varenicline’s impurity.

It added that, although the impurities may increase risk for cancer if a high level of exposure continues over a long period, the drug is intended as a short-term treatment to aid in smoking cessation.

For now, clinicians should report any AEs from varenicline to the FDA’s MedWatch program, and patients taking this treatment should consult with their health care practitioner or pharmacy, the update notes.

A version of this article first appeared on Medscape.com.

State laws capping initial opioid prescriptions to 7 days or less have led to a reduction in opioid prescribing, a new analysis of Medicare data shows.

While overall opioid prescribing has decreased, the reduction in states with legislation restricting opioid prescribing was “significantly greater than in states without such legislation,” study investigator Michael Brenner, MD, University of Michigan, Ann Arbor, said in an interview.

The study was published online August 9 in JAMA Internal Medicine.
 

Significant but limited effect

Because of rising concern around the opioid crisis, 23 states representing 43% of the U.S. population passed laws from 2016 through 2018 limiting initial opioid prescription to 7 days or less.

Using Medicare data from 2013 through 2018, Dr. Brenner and colleagues conducted a before-and-after study to assess the effect of these laws.

They found that on average, the number of days an opioid was prescribed for each Medicare beneficiary decreased by 11.6 days (from 44.2 days in 2013 to 32.7 days in 2018) in states that imposed duration limits, compared with 10.1 days in states without these laws (from 43.4 days in 2013 to 33.3 days in 2018).

Prior to the start of duration limits in 2016, days an opioid was prescribed were comparable among states.

After adjusting for state-level differences in race, urbanization, median income, tobacco and alcohol use, serious mental illness, and other factors, state laws limiting opioid prescriptions to 7 days or less were associated with a reduction in prescribing of 1.7 days per enrollee, “suggesting a significant but limited outcome” for these laws, the researchers note.

The largest decrease in opioid prescribing occurred in primary care, but this was not significantly different in states with limit laws versus those without. However, state laws limiting duration led to a significant reduction in days of opioid prescribed among surgeons, dentists, pain specialists, and other specialists.
 

Inadequate pain control?

The researchers note the study was limited to Medicare beneficiaries; however, excess opioid prescribing is prevalent across all patient populations.

In addition, it’s not possible to tell from the data whether acute pain was adequately controlled with fewer pills.

“The question of adequacy of pain control is a crucial one that has been investigated extensively in prior work but was not possible to evaluate in this particular study,” said Dr. Brenner.

However, “ample evidence supports a role for reducing opioid prescribing and that such reduction can be achieved while ensuring that pain is adequately controlled with fewer pills,” he noted.

“A persistent misconception is that opioids are uniquely powerful and effective for controlling pain. Patients may perceive that effective analgesia is being withheld when opioids are not included in a regimen,” Dr. Brenner added.

“Yet, the evidence from meta-analyses derived from large numbers of randomized clinical trials finds that [nonsteroidal anti-inflammatory drugs] NSAIDS combined with acetaminophen provide similar or improved acute pain when compared to commonly prescribed opioid regimens, based on number-needed-to-treat analyses,” he added.

In a related editorial, Deborah Grady, MD, MPH, with University of California, San Francisco, and Mitchell H. Katz, MD, president and CEO of NYC Health + Hospitals, say the decrease in opioid prescribing with duration limits was “small but probably meaningful.” 

Restricting initial prescriptions to seven or fewer days is “reasonable because patients with new onset of pain should be re-evaluated in a week if the pain continues,” they write. 

However, Dr. Grady and Dr. Katz “worry” that restricting initial prescriptions to shorter periods, such as 3 or 5 days, as has occurred in six states, “may result in patients with acute pain going untreated or having to go to extraordinary effort to obtain adequate pain relief.”

In their view, the data from this study suggest that limiting initial prescriptions to seven or fewer days is “helpful, but we would not restrict any further given that we do not know how it affected patients with acute pain.”

The study had no specific funding. Dr. Brenner, Dr. Grady, and Dr. Katz have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

State laws capping initial opioid prescriptions to 7 days or less have led to a reduction in opioid prescribing, a new analysis of Medicare data shows.

While overall opioid prescribing has decreased, the reduction in states with legislation restricting opioid prescribing was “significantly greater than in states without such legislation,” study investigator Michael Brenner, MD, University of Michigan, Ann Arbor, said in an interview.

The study was published online August 9 in JAMA Internal Medicine.
 

Significant but limited effect

Because of rising concern around the opioid crisis, 23 states representing 43% of the U.S. population passed laws from 2016 through 2018 limiting initial opioid prescription to 7 days or less.

Using Medicare data from 2013 through 2018, Dr. Brenner and colleagues conducted a before-and-after study to assess the effect of these laws.

They found that on average, the number of days an opioid was prescribed for each Medicare beneficiary decreased by 11.6 days (from 44.2 days in 2013 to 32.7 days in 2018) in states that imposed duration limits, compared with 10.1 days in states without these laws (from 43.4 days in 2013 to 33.3 days in 2018).

Prior to the start of duration limits in 2016, days an opioid was prescribed were comparable among states.

After adjusting for state-level differences in race, urbanization, median income, tobacco and alcohol use, serious mental illness, and other factors, state laws limiting opioid prescriptions to 7 days or less were associated with a reduction in prescribing of 1.7 days per enrollee, “suggesting a significant but limited outcome” for these laws, the researchers note.

The largest decrease in opioid prescribing occurred in primary care, but this was not significantly different in states with limit laws versus those without. However, state laws limiting duration led to a significant reduction in days of opioid prescribed among surgeons, dentists, pain specialists, and other specialists.
 

Inadequate pain control?

The researchers note the study was limited to Medicare beneficiaries; however, excess opioid prescribing is prevalent across all patient populations.

In addition, it’s not possible to tell from the data whether acute pain was adequately controlled with fewer pills.

“The question of adequacy of pain control is a crucial one that has been investigated extensively in prior work but was not possible to evaluate in this particular study,” said Dr. Brenner.

However, “ample evidence supports a role for reducing opioid prescribing and that such reduction can be achieved while ensuring that pain is adequately controlled with fewer pills,” he noted.

“A persistent misconception is that opioids are uniquely powerful and effective for controlling pain. Patients may perceive that effective analgesia is being withheld when opioids are not included in a regimen,” Dr. Brenner added.

“Yet, the evidence from meta-analyses derived from large numbers of randomized clinical trials finds that [nonsteroidal anti-inflammatory drugs] NSAIDS combined with acetaminophen provide similar or improved acute pain when compared to commonly prescribed opioid regimens, based on number-needed-to-treat analyses,” he added.

In a related editorial, Deborah Grady, MD, MPH, with University of California, San Francisco, and Mitchell H. Katz, MD, president and CEO of NYC Health + Hospitals, say the decrease in opioid prescribing with duration limits was “small but probably meaningful.” 

Restricting initial prescriptions to seven or fewer days is “reasonable because patients with new onset of pain should be re-evaluated in a week if the pain continues,” they write. 

However, Dr. Grady and Dr. Katz “worry” that restricting initial prescriptions to shorter periods, such as 3 or 5 days, as has occurred in six states, “may result in patients with acute pain going untreated or having to go to extraordinary effort to obtain adequate pain relief.”

In their view, the data from this study suggest that limiting initial prescriptions to seven or fewer days is “helpful, but we would not restrict any further given that we do not know how it affected patients with acute pain.”

The study had no specific funding. Dr. Brenner, Dr. Grady, and Dr. Katz have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

State laws capping initial opioid prescriptions to 7 days or less have led to a reduction in opioid prescribing, a new analysis of Medicare data shows.

While overall opioid prescribing has decreased, the reduction in states with legislation restricting opioid prescribing was “significantly greater than in states without such legislation,” study investigator Michael Brenner, MD, University of Michigan, Ann Arbor, said in an interview.

The study was published online August 9 in JAMA Internal Medicine.
 

Significant but limited effect

Because of rising concern around the opioid crisis, 23 states representing 43% of the U.S. population passed laws from 2016 through 2018 limiting initial opioid prescription to 7 days or less.

Using Medicare data from 2013 through 2018, Dr. Brenner and colleagues conducted a before-and-after study to assess the effect of these laws.

They found that on average, the number of days an opioid was prescribed for each Medicare beneficiary decreased by 11.6 days (from 44.2 days in 2013 to 32.7 days in 2018) in states that imposed duration limits, compared with 10.1 days in states without these laws (from 43.4 days in 2013 to 33.3 days in 2018).

Prior to the start of duration limits in 2016, days an opioid was prescribed were comparable among states.

After adjusting for state-level differences in race, urbanization, median income, tobacco and alcohol use, serious mental illness, and other factors, state laws limiting opioid prescriptions to 7 days or less were associated with a reduction in prescribing of 1.7 days per enrollee, “suggesting a significant but limited outcome” for these laws, the researchers note.

The largest decrease in opioid prescribing occurred in primary care, but this was not significantly different in states with limit laws versus those without. However, state laws limiting duration led to a significant reduction in days of opioid prescribed among surgeons, dentists, pain specialists, and other specialists.
 

Inadequate pain control?

The researchers note the study was limited to Medicare beneficiaries; however, excess opioid prescribing is prevalent across all patient populations.

In addition, it’s not possible to tell from the data whether acute pain was adequately controlled with fewer pills.

“The question of adequacy of pain control is a crucial one that has been investigated extensively in prior work but was not possible to evaluate in this particular study,” said Dr. Brenner.

However, “ample evidence supports a role for reducing opioid prescribing and that such reduction can be achieved while ensuring that pain is adequately controlled with fewer pills,” he noted.

“A persistent misconception is that opioids are uniquely powerful and effective for controlling pain. Patients may perceive that effective analgesia is being withheld when opioids are not included in a regimen,” Dr. Brenner added.

“Yet, the evidence from meta-analyses derived from large numbers of randomized clinical trials finds that [nonsteroidal anti-inflammatory drugs] NSAIDS combined with acetaminophen provide similar or improved acute pain when compared to commonly prescribed opioid regimens, based on number-needed-to-treat analyses,” he added.

In a related editorial, Deborah Grady, MD, MPH, with University of California, San Francisco, and Mitchell H. Katz, MD, president and CEO of NYC Health + Hospitals, say the decrease in opioid prescribing with duration limits was “small but probably meaningful.” 

Restricting initial prescriptions to seven or fewer days is “reasonable because patients with new onset of pain should be re-evaluated in a week if the pain continues,” they write. 

However, Dr. Grady and Dr. Katz “worry” that restricting initial prescriptions to shorter periods, such as 3 or 5 days, as has occurred in six states, “may result in patients with acute pain going untreated or having to go to extraordinary effort to obtain adequate pain relief.”

In their view, the data from this study suggest that limiting initial prescriptions to seven or fewer days is “helpful, but we would not restrict any further given that we do not know how it affected patients with acute pain.”

The study had no specific funding. Dr. Brenner, Dr. Grady, and Dr. Katz have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The long-observed association between cannabis use and schizophrenia is likely partially causal in nature, new research shows.

Investigators found a clear increase in the proportion of schizophrenia cases linked to cannabis use disorder over the past 25 years.

“In my view, the association is most likely causative, at least to a large extent,” first author Carsten Hjorthøj, PhD, from the Copenhagen Research Center for Mental Health, Copenhagen University Hospital, told this news organization.

“It is, of course, nearly impossible to use epidemiological studies to actually prove causation, but all the numbers behave exactly in the way that would be expected under the theory of causation,” said Dr. Hjorthøj.

The study was published online July 21 in JAMA Psychiatry.
 

Far from harmless

The findings are based on Danish national health registry data. The study sample included all people in Denmark born before Dec. 31, 2000 who were aged 16 years or older at some point from Jan. 1, 1972 to Dec. 31, 2016. The data analysis was conducted from August 2020 to April 2021.

Despite some fluctuation, there was a general increase in the population-attributable risk fraction (PARF) for cannabis use disorder with regard to schizophrenia over time, the researchers report. The PARF increased from about 2% in 1995 to about 4% in 2000 and has hovered from 6% to 8% since 2010.

“Although not in itself proof of causality, our study provides evidence of the theory of cannabis being a component cause of schizophrenia,” the investigators write.

The findings are “particularly important with the increasing legalization of cannabis for both medicinal and recreational uses seeming to lead to an increase in the perception of cannabis as relatively harmless and possibly in the uptake of cannabis use, especially among youth,” they add.

“Although psychosis is not the only outcome of interest in terms of cannabis use, our study clearly indicates that cannabis should not be considered harmless,” they conclude.
 

Cases linked to cannabis underestimated?

In an accompanying editorial, Tyler VanderWeele, PhD, Harvard School of Public Health, Boston, notes that estimates in this study could be conservative as a result of underdiagnosis of cannabis use disorder and because it only examined cannabis use disorder.

“Cannabis use disorder is not responsible for most schizophrenia cases, but it is responsible for a nonnegligible and increasing proportion. This should be considered in discussions regarding legalization and regulation of the use of cannabis,” Dr. VanderWeele writes.

Experts with the Science Media Center, a U.K. nonprofit organization, also weighed in on the results.

Terrie Moffitt, PhD, with King’s College London, said the study “adds important evidence that patients with diagnosed cannabis use disorder are more at risk for psychosis now than they used to be.”

“A study weakness that readers will spot right away is that the study reported on patients who had a clinical diagnosis of cannabis dependence. However, most cannabis users, even those who are dependent on it, never come in to clinics for treatment. Also, it is known that people who seek treatment tend to have multiple mental health problems, not solely cannabis problems,” Dr. Moffitt commented.

Emir Englund, PhD, also from King’s College London, said the study “strengthens an already well-established association between the two. However, it is unable to shed additional light on whether cannabis causes schizophrenia or not, due to the observational nature of the study.”

“In my opinion, the current scientific view of cannabis use as a ‘component cause’ which interacts with other risk factors to cause schizophrenia but is neither necessary nor sufficient to do so on its own still stands,” Dr. Englund said.

The study was supported by a grant from Lundbeckfonden. The authors have disclosed no relevant financial relationships. Dr. VanderWeele has received grants from the National Cancer Institute and the John Templeton Foundation. Dr. Moffitt and Dr. Englund have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The long-observed association between cannabis use and schizophrenia is likely partially causal in nature, new research shows.

Investigators found a clear increase in the proportion of schizophrenia cases linked to cannabis use disorder over the past 25 years.

“In my view, the association is most likely causative, at least to a large extent,” first author Carsten Hjorthøj, PhD, from the Copenhagen Research Center for Mental Health, Copenhagen University Hospital, told this news organization.

“It is, of course, nearly impossible to use epidemiological studies to actually prove causation, but all the numbers behave exactly in the way that would be expected under the theory of causation,” said Dr. Hjorthøj.

The study was published online July 21 in JAMA Psychiatry.
 

Far from harmless

The findings are based on Danish national health registry data. The study sample included all people in Denmark born before Dec. 31, 2000 who were aged 16 years or older at some point from Jan. 1, 1972 to Dec. 31, 2016. The data analysis was conducted from August 2020 to April 2021.

Despite some fluctuation, there was a general increase in the population-attributable risk fraction (PARF) for cannabis use disorder with regard to schizophrenia over time, the researchers report. The PARF increased from about 2% in 1995 to about 4% in 2000 and has hovered from 6% to 8% since 2010.

“Although not in itself proof of causality, our study provides evidence of the theory of cannabis being a component cause of schizophrenia,” the investigators write.

The findings are “particularly important with the increasing legalization of cannabis for both medicinal and recreational uses seeming to lead to an increase in the perception of cannabis as relatively harmless and possibly in the uptake of cannabis use, especially among youth,” they add.

“Although psychosis is not the only outcome of interest in terms of cannabis use, our study clearly indicates that cannabis should not be considered harmless,” they conclude.
 

Cases linked to cannabis underestimated?

In an accompanying editorial, Tyler VanderWeele, PhD, Harvard School of Public Health, Boston, notes that estimates in this study could be conservative as a result of underdiagnosis of cannabis use disorder and because it only examined cannabis use disorder.

“Cannabis use disorder is not responsible for most schizophrenia cases, but it is responsible for a nonnegligible and increasing proportion. This should be considered in discussions regarding legalization and regulation of the use of cannabis,” Dr. VanderWeele writes.

Experts with the Science Media Center, a U.K. nonprofit organization, also weighed in on the results.

Terrie Moffitt, PhD, with King’s College London, said the study “adds important evidence that patients with diagnosed cannabis use disorder are more at risk for psychosis now than they used to be.”

“A study weakness that readers will spot right away is that the study reported on patients who had a clinical diagnosis of cannabis dependence. However, most cannabis users, even those who are dependent on it, never come in to clinics for treatment. Also, it is known that people who seek treatment tend to have multiple mental health problems, not solely cannabis problems,” Dr. Moffitt commented.

Emir Englund, PhD, also from King’s College London, said the study “strengthens an already well-established association between the two. However, it is unable to shed additional light on whether cannabis causes schizophrenia or not, due to the observational nature of the study.”

“In my opinion, the current scientific view of cannabis use as a ‘component cause’ which interacts with other risk factors to cause schizophrenia but is neither necessary nor sufficient to do so on its own still stands,” Dr. Englund said.

The study was supported by a grant from Lundbeckfonden. The authors have disclosed no relevant financial relationships. Dr. VanderWeele has received grants from the National Cancer Institute and the John Templeton Foundation. Dr. Moffitt and Dr. Englund have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The long-observed association between cannabis use and schizophrenia is likely partially causal in nature, new research shows.

Investigators found a clear increase in the proportion of schizophrenia cases linked to cannabis use disorder over the past 25 years.

“In my view, the association is most likely causative, at least to a large extent,” first author Carsten Hjorthøj, PhD, from the Copenhagen Research Center for Mental Health, Copenhagen University Hospital, told this news organization.

“It is, of course, nearly impossible to use epidemiological studies to actually prove causation, but all the numbers behave exactly in the way that would be expected under the theory of causation,” said Dr. Hjorthøj.

The study was published online July 21 in JAMA Psychiatry.
 

Far from harmless

The findings are based on Danish national health registry data. The study sample included all people in Denmark born before Dec. 31, 2000 who were aged 16 years or older at some point from Jan. 1, 1972 to Dec. 31, 2016. The data analysis was conducted from August 2020 to April 2021.

Despite some fluctuation, there was a general increase in the population-attributable risk fraction (PARF) for cannabis use disorder with regard to schizophrenia over time, the researchers report. The PARF increased from about 2% in 1995 to about 4% in 2000 and has hovered from 6% to 8% since 2010.

“Although not in itself proof of causality, our study provides evidence of the theory of cannabis being a component cause of schizophrenia,” the investigators write.

The findings are “particularly important with the increasing legalization of cannabis for both medicinal and recreational uses seeming to lead to an increase in the perception of cannabis as relatively harmless and possibly in the uptake of cannabis use, especially among youth,” they add.

“Although psychosis is not the only outcome of interest in terms of cannabis use, our study clearly indicates that cannabis should not be considered harmless,” they conclude.
 

Cases linked to cannabis underestimated?

In an accompanying editorial, Tyler VanderWeele, PhD, Harvard School of Public Health, Boston, notes that estimates in this study could be conservative as a result of underdiagnosis of cannabis use disorder and because it only examined cannabis use disorder.

“Cannabis use disorder is not responsible for most schizophrenia cases, but it is responsible for a nonnegligible and increasing proportion. This should be considered in discussions regarding legalization and regulation of the use of cannabis,” Dr. VanderWeele writes.

Experts with the Science Media Center, a U.K. nonprofit organization, also weighed in on the results.

Terrie Moffitt, PhD, with King’s College London, said the study “adds important evidence that patients with diagnosed cannabis use disorder are more at risk for psychosis now than they used to be.”

“A study weakness that readers will spot right away is that the study reported on patients who had a clinical diagnosis of cannabis dependence. However, most cannabis users, even those who are dependent on it, never come in to clinics for treatment. Also, it is known that people who seek treatment tend to have multiple mental health problems, not solely cannabis problems,” Dr. Moffitt commented.

Emir Englund, PhD, also from King’s College London, said the study “strengthens an already well-established association between the two. However, it is unable to shed additional light on whether cannabis causes schizophrenia or not, due to the observational nature of the study.”

“In my opinion, the current scientific view of cannabis use as a ‘component cause’ which interacts with other risk factors to cause schizophrenia but is neither necessary nor sufficient to do so on its own still stands,” Dr. Englund said.

The study was supported by a grant from Lundbeckfonden. The authors have disclosed no relevant financial relationships. Dr. VanderWeele has received grants from the National Cancer Institute and the John Templeton Foundation. Dr. Moffitt and Dr. Englund have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Rates of heart failure (HF) caused by methamphetamine abuse are climbing quickly in the western United States, at great financial and societal cost, suggests an analysis that documents the trends in California over a recent decade.

In the new study, methamphetamine-associated HF (meth-HF) admissions in the state rose by 585% between 2008 and 2018, and charges related those hospitalizations jumped 840%. Cases of HF unrelated to meth fell by 6% during the same period.

The recent explosion in meth-HF hospitalizations has also been costly for society in general, because most cases are younger adults in their most productive, prime earning years, Susan X. Zhao, MD, Santa Clara Valley Medical Center, San Jose, Calif., said in an interview.

“Over the past 11 years, especially since 2018, it has really started to take off, with a pretty dramatic rise. And it happened without much attention, because when we think about drugs, we think about acute overdose and not so much about the chronic, smoldering, long-term effects,” said Dr. Zhao, who is lead author on the study published July 13, 2021, in Circulation: Cardiovascular Quality and Outcomes.

“It’s really affecting a section of the population that is not supposed to be having heart failure problems. I think it is going to continue for the next decade until we put a stop to the parent problem, which is methamphetamine,” Dr. Zhao said. “We’re at the beginning, even though the rise has been pretty dramatic. The worst is yet to come.”
 

Under the radar

Methamphetamine-associated HF has been a growing problem for many years but has largely been “flying under the radar” because HF hospitalization data focus on Medicare-age patients, not the overwhelmingly younger meth-HF population, the report notes.

“We have to get this message out. Many of my patients with meth heart failure had no idea this would happen to them. They didn’t know,” Dr. Zhao said. “Once I tell them that this is what methamphetamines will do to you after years and years of use, they say they wish someone had told them.”

Dr. Zhao and colleagues looked at HF admission data collected by California’s Health and Human Services Agency to assess meth-HF trends and disease burden. They identified 1,033,076 HF hospitalizations during the decade, of which 42,565 (4.12%) were for meth-HF.

Patients hospitalized with meth-HF had a mean age of 49.6 years, compared with 72.2 for the other patients admitted with HF (P < .001). Virtually all of the patients hospitalized for meth-HF were younger than 65 years: 94.5%, compared with 30% for the other HF patients (P < .001).

Hospitalized patients with meth-HF were mostly men, their prevalence of 80% contrasting with 52.4% for patients with non–meth-related HF (P < .001).

Rates of hospitalization for meth-HF steadily increased during the study period. The age-adjusted rate of meth-HF hospitalization per 100,000 rose from 4.1 in 2008 to 28.1 in 2018. The rate of hospitalization for HF unrelated to meth actually declined, going from 342.3 in 2008 to 321.6 in 2018.

Charges for hospitalizations related to meth-HF shot up more than eight times, from $41.5 million in 2008 to $390.2 million in 2018. In contrast, charges for other HF hospitalizations rose by only 82%, from $3.5 billion to $6.3 billion.
 

Multiple layers of prevention

Dr. Zhao proposed ways that clinicians can communicate with their patients who are using or considering to use meth. “There are multiple layers of prevention. For people who are thinking of using meth, they need to get the message that something really bad can happen to them years down the road. They’re not going to die from it overnight, but it will damage the heart slowly,” she said.

The next layer of prevention can potentially help meth users who have not yet developed heart problems, Dr. Zhao said. “This would be the time to say, ‘you’re so lucky, your heart is still good. It’s time to stop because people like you, a few years from now are going to die prematurely from a very horrible, very suffering kind of death’.”

Importantly, in meth users who have already developed HF, even then it may not be too late to reverse the cardiomyopathy and symptoms. For up to a third of people with established meth-HF, “if they stop using meth, if they take good cardiac medications, and if the heart failure is in an early enough course, their heart can entirely revert to normal,” Dr. Zhao said, citing an earlier work from her and her colleagues.

Currently, methamphetamine abuse has taken especially strong root in rural areas in California and the Midwest. But Dr. Zhao predicts it will soon become prevalent throughout the United States.
 

Spotlight on an ‘epidemic’

The rapid growth of the methamphetamine “epidemic” has been well-documented in the United States and around the world, observed an accompanying editorial from Pavan Reddy, MD, Icahn School of Medicine at Mount Sinai Morningside, New York, and Uri Elkayam, MD, University of Southern California, Los Angeles.

They contend that more attention has been given to opioid overdose deaths; meth abuse does not seem to command the same attention, likely because meth is not as strongly associated with acute overdose.

But meth, wrote Dr. Reddy and Dr. Elkayam, “is a different drug with its own M.O., equally dangerous and costly to society but more insidious in nature, its effects potentially causing decades of mental and physical debilitation before ending in premature death.”

The current study “has turned a spotlight on a public health crisis that has grown unfettered for over 2 decades,” and is a call for the “medical community to recognize and manage cases of meth-HF with a comprehensive approach that addresses both mental and physical illness,” they concluded. “Only then can we hope to properly help these patients and with that, reduce the socioeconomic burden of meth-HF.”
 

A quietly building crisis

The sharp rise in meth-HF hospitalizations is an expected reflection of the methamphetamine crisis, which has been quietly building over the last few years, addiction psychiatrist Corneliu N. Stanciu, MD, Dartmouth-Hitchcock Medical Center, Lebanon, N.H., said in an interview.

“This new version of methamphetamines looks like ice and is more potent and toxic than former versions traditionally made in home-built labs,” he said. Lately the vast majority of methamphetamines in the United States have come from Mexico, are less expensive with higher purity, “and can be manufactured in greater quantities.”

Some patients with opioid use disorder (OUD) also inject methamphetamines, which can make OUD treatment clinics good places to screen for meth abuse and educate about its cardiovascular implications, Dr. Stanciu said.

“Just as addiction treatment centers present an opportunity to implement cardiac screening and referrals,” he said, “cardiology visits and hospitalizations such as those for meth-HF also present a golden opportunity for involvement of substance use disorder interventions and referrals to get patients into treatment and prevent further damage through ongoing use.”

Dr. Zhao, Dr. Reddy, Dr. Eklayam, and Dr. Stanciu report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Rates of heart failure (HF) caused by methamphetamine abuse are climbing quickly in the western United States, at great financial and societal cost, suggests an analysis that documents the trends in California over a recent decade.

In the new study, methamphetamine-associated HF (meth-HF) admissions in the state rose by 585% between 2008 and 2018, and charges related those hospitalizations jumped 840%. Cases of HF unrelated to meth fell by 6% during the same period.

The recent explosion in meth-HF hospitalizations has also been costly for society in general, because most cases are younger adults in their most productive, prime earning years, Susan X. Zhao, MD, Santa Clara Valley Medical Center, San Jose, Calif., said in an interview.

“Over the past 11 years, especially since 2018, it has really started to take off, with a pretty dramatic rise. And it happened without much attention, because when we think about drugs, we think about acute overdose and not so much about the chronic, smoldering, long-term effects,” said Dr. Zhao, who is lead author on the study published July 13, 2021, in Circulation: Cardiovascular Quality and Outcomes.

“It’s really affecting a section of the population that is not supposed to be having heart failure problems. I think it is going to continue for the next decade until we put a stop to the parent problem, which is methamphetamine,” Dr. Zhao said. “We’re at the beginning, even though the rise has been pretty dramatic. The worst is yet to come.”
 

Under the radar

Methamphetamine-associated HF has been a growing problem for many years but has largely been “flying under the radar” because HF hospitalization data focus on Medicare-age patients, not the overwhelmingly younger meth-HF population, the report notes.

“We have to get this message out. Many of my patients with meth heart failure had no idea this would happen to them. They didn’t know,” Dr. Zhao said. “Once I tell them that this is what methamphetamines will do to you after years and years of use, they say they wish someone had told them.”

Dr. Zhao and colleagues looked at HF admission data collected by California’s Health and Human Services Agency to assess meth-HF trends and disease burden. They identified 1,033,076 HF hospitalizations during the decade, of which 42,565 (4.12%) were for meth-HF.

Patients hospitalized with meth-HF had a mean age of 49.6 years, compared with 72.2 for the other patients admitted with HF (P < .001). Virtually all of the patients hospitalized for meth-HF were younger than 65 years: 94.5%, compared with 30% for the other HF patients (P < .001).

Hospitalized patients with meth-HF were mostly men, their prevalence of 80% contrasting with 52.4% for patients with non–meth-related HF (P < .001).

Rates of hospitalization for meth-HF steadily increased during the study period. The age-adjusted rate of meth-HF hospitalization per 100,000 rose from 4.1 in 2008 to 28.1 in 2018. The rate of hospitalization for HF unrelated to meth actually declined, going from 342.3 in 2008 to 321.6 in 2018.

Charges for hospitalizations related to meth-HF shot up more than eight times, from $41.5 million in 2008 to $390.2 million in 2018. In contrast, charges for other HF hospitalizations rose by only 82%, from $3.5 billion to $6.3 billion.
 

Multiple layers of prevention

Dr. Zhao proposed ways that clinicians can communicate with their patients who are using or considering to use meth. “There are multiple layers of prevention. For people who are thinking of using meth, they need to get the message that something really bad can happen to them years down the road. They’re not going to die from it overnight, but it will damage the heart slowly,” she said.

The next layer of prevention can potentially help meth users who have not yet developed heart problems, Dr. Zhao said. “This would be the time to say, ‘you’re so lucky, your heart is still good. It’s time to stop because people like you, a few years from now are going to die prematurely from a very horrible, very suffering kind of death’.”

Importantly, in meth users who have already developed HF, even then it may not be too late to reverse the cardiomyopathy and symptoms. For up to a third of people with established meth-HF, “if they stop using meth, if they take good cardiac medications, and if the heart failure is in an early enough course, their heart can entirely revert to normal,” Dr. Zhao said, citing an earlier work from her and her colleagues.

Currently, methamphetamine abuse has taken especially strong root in rural areas in California and the Midwest. But Dr. Zhao predicts it will soon become prevalent throughout the United States.
 

Spotlight on an ‘epidemic’

The rapid growth of the methamphetamine “epidemic” has been well-documented in the United States and around the world, observed an accompanying editorial from Pavan Reddy, MD, Icahn School of Medicine at Mount Sinai Morningside, New York, and Uri Elkayam, MD, University of Southern California, Los Angeles.

They contend that more attention has been given to opioid overdose deaths; meth abuse does not seem to command the same attention, likely because meth is not as strongly associated with acute overdose.

But meth, wrote Dr. Reddy and Dr. Elkayam, “is a different drug with its own M.O., equally dangerous and costly to society but more insidious in nature, its effects potentially causing decades of mental and physical debilitation before ending in premature death.”

The current study “has turned a spotlight on a public health crisis that has grown unfettered for over 2 decades,” and is a call for the “medical community to recognize and manage cases of meth-HF with a comprehensive approach that addresses both mental and physical illness,” they concluded. “Only then can we hope to properly help these patients and with that, reduce the socioeconomic burden of meth-HF.”
 

A quietly building crisis

The sharp rise in meth-HF hospitalizations is an expected reflection of the methamphetamine crisis, which has been quietly building over the last few years, addiction psychiatrist Corneliu N. Stanciu, MD, Dartmouth-Hitchcock Medical Center, Lebanon, N.H., said in an interview.

“This new version of methamphetamines looks like ice and is more potent and toxic than former versions traditionally made in home-built labs,” he said. Lately the vast majority of methamphetamines in the United States have come from Mexico, are less expensive with higher purity, “and can be manufactured in greater quantities.”

Some patients with opioid use disorder (OUD) also inject methamphetamines, which can make OUD treatment clinics good places to screen for meth abuse and educate about its cardiovascular implications, Dr. Stanciu said.

“Just as addiction treatment centers present an opportunity to implement cardiac screening and referrals,” he said, “cardiology visits and hospitalizations such as those for meth-HF also present a golden opportunity for involvement of substance use disorder interventions and referrals to get patients into treatment and prevent further damage through ongoing use.”

Dr. Zhao, Dr. Reddy, Dr. Eklayam, and Dr. Stanciu report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Rates of heart failure (HF) caused by methamphetamine abuse are climbing quickly in the western United States, at great financial and societal cost, suggests an analysis that documents the trends in California over a recent decade.

In the new study, methamphetamine-associated HF (meth-HF) admissions in the state rose by 585% between 2008 and 2018, and charges related those hospitalizations jumped 840%. Cases of HF unrelated to meth fell by 6% during the same period.

The recent explosion in meth-HF hospitalizations has also been costly for society in general, because most cases are younger adults in their most productive, prime earning years, Susan X. Zhao, MD, Santa Clara Valley Medical Center, San Jose, Calif., said in an interview.

“Over the past 11 years, especially since 2018, it has really started to take off, with a pretty dramatic rise. And it happened without much attention, because when we think about drugs, we think about acute overdose and not so much about the chronic, smoldering, long-term effects,” said Dr. Zhao, who is lead author on the study published July 13, 2021, in Circulation: Cardiovascular Quality and Outcomes.

“It’s really affecting a section of the population that is not supposed to be having heart failure problems. I think it is going to continue for the next decade until we put a stop to the parent problem, which is methamphetamine,” Dr. Zhao said. “We’re at the beginning, even though the rise has been pretty dramatic. The worst is yet to come.”
 

Under the radar

Methamphetamine-associated HF has been a growing problem for many years but has largely been “flying under the radar” because HF hospitalization data focus on Medicare-age patients, not the overwhelmingly younger meth-HF population, the report notes.

“We have to get this message out. Many of my patients with meth heart failure had no idea this would happen to them. They didn’t know,” Dr. Zhao said. “Once I tell them that this is what methamphetamines will do to you after years and years of use, they say they wish someone had told them.”

Dr. Zhao and colleagues looked at HF admission data collected by California’s Health and Human Services Agency to assess meth-HF trends and disease burden. They identified 1,033,076 HF hospitalizations during the decade, of which 42,565 (4.12%) were for meth-HF.

Patients hospitalized with meth-HF had a mean age of 49.6 years, compared with 72.2 for the other patients admitted with HF (P < .001). Virtually all of the patients hospitalized for meth-HF were younger than 65 years: 94.5%, compared with 30% for the other HF patients (P < .001).

Hospitalized patients with meth-HF were mostly men, their prevalence of 80% contrasting with 52.4% for patients with non–meth-related HF (P < .001).

Rates of hospitalization for meth-HF steadily increased during the study period. The age-adjusted rate of meth-HF hospitalization per 100,000 rose from 4.1 in 2008 to 28.1 in 2018. The rate of hospitalization for HF unrelated to meth actually declined, going from 342.3 in 2008 to 321.6 in 2018.

Charges for hospitalizations related to meth-HF shot up more than eight times, from $41.5 million in 2008 to $390.2 million in 2018. In contrast, charges for other HF hospitalizations rose by only 82%, from $3.5 billion to $6.3 billion.
 

Multiple layers of prevention

Dr. Zhao proposed ways that clinicians can communicate with their patients who are using or considering to use meth. “There are multiple layers of prevention. For people who are thinking of using meth, they need to get the message that something really bad can happen to them years down the road. They’re not going to die from it overnight, but it will damage the heart slowly,” she said.

The next layer of prevention can potentially help meth users who have not yet developed heart problems, Dr. Zhao said. “This would be the time to say, ‘you’re so lucky, your heart is still good. It’s time to stop because people like you, a few years from now are going to die prematurely from a very horrible, very suffering kind of death’.”

Importantly, in meth users who have already developed HF, even then it may not be too late to reverse the cardiomyopathy and symptoms. For up to a third of people with established meth-HF, “if they stop using meth, if they take good cardiac medications, and if the heart failure is in an early enough course, their heart can entirely revert to normal,” Dr. Zhao said, citing an earlier work from her and her colleagues.

Currently, methamphetamine abuse has taken especially strong root in rural areas in California and the Midwest. But Dr. Zhao predicts it will soon become prevalent throughout the United States.
 

Spotlight on an ‘epidemic’

The rapid growth of the methamphetamine “epidemic” has been well-documented in the United States and around the world, observed an accompanying editorial from Pavan Reddy, MD, Icahn School of Medicine at Mount Sinai Morningside, New York, and Uri Elkayam, MD, University of Southern California, Los Angeles.

They contend that more attention has been given to opioid overdose deaths; meth abuse does not seem to command the same attention, likely because meth is not as strongly associated with acute overdose.

But meth, wrote Dr. Reddy and Dr. Elkayam, “is a different drug with its own M.O., equally dangerous and costly to society but more insidious in nature, its effects potentially causing decades of mental and physical debilitation before ending in premature death.”

The current study “has turned a spotlight on a public health crisis that has grown unfettered for over 2 decades,” and is a call for the “medical community to recognize and manage cases of meth-HF with a comprehensive approach that addresses both mental and physical illness,” they concluded. “Only then can we hope to properly help these patients and with that, reduce the socioeconomic burden of meth-HF.”
 

A quietly building crisis

The sharp rise in meth-HF hospitalizations is an expected reflection of the methamphetamine crisis, which has been quietly building over the last few years, addiction psychiatrist Corneliu N. Stanciu, MD, Dartmouth-Hitchcock Medical Center, Lebanon, N.H., said in an interview.

“This new version of methamphetamines looks like ice and is more potent and toxic than former versions traditionally made in home-built labs,” he said. Lately the vast majority of methamphetamines in the United States have come from Mexico, are less expensive with higher purity, “and can be manufactured in greater quantities.”

Some patients with opioid use disorder (OUD) also inject methamphetamines, which can make OUD treatment clinics good places to screen for meth abuse and educate about its cardiovascular implications, Dr. Stanciu said.

“Just as addiction treatment centers present an opportunity to implement cardiac screening and referrals,” he said, “cardiology visits and hospitalizations such as those for meth-HF also present a golden opportunity for involvement of substance use disorder interventions and referrals to get patients into treatment and prevent further damage through ongoing use.”

Dr. Zhao, Dr. Reddy, Dr. Eklayam, and Dr. Stanciu report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

In combing the genome, scientists can use genetic clues to determine a person’s risk for psychiatric disease and even identify new drug targets. But the benefits of these discoveries will be limited to people of European descent.

Nearly 90% of participants in genome-wide association studies (GWASs), which search for gene variants linked to disease, are of European ancestry. This Eurocentric focus threatens to widen existing disparities in racial and ethnic mental health.

The significant downsides of genomics’ one-track mind

One obstacle hindering therapeutic advances in psychiatry is a shallow understanding of the mechanisms of disorders. “The biggest problem in terms of advancing research for mental health conditions is that we don’t understand the underlying biology,” says Laramie Duncan, PhD, assistant professor of psychiatry and behavioral sciences at Stanford (Calif.) University. “Genetics is one of the best ways to systematically look for new clues about the underlying biology.”

At the advent of genomic research, scientists thought it best to study DNA from people of a single ancestry from one continent. “Researchers for a long time held the idea that it was going to be too complicated to include multiple ancestries in the first rounds of genetic analyses,” says Dr. Duncan.

Studying DNA from someone with ancestors from multiple parts of the world wasn’t compatible with methods used in the early days of GWASs. “Individual parts of a person’s DNA can be linked back to one region of the world or another, and most of our methods essentially assume that all of a person’s DNA came from one region of the world,” says Dr. Duncan.

Because many genes are usually involved in psychiatric disorders, scientists need large numbers of participants to detect uncommon, influential variants. Early research was concentrated in North America and Europe so that scientists could readily collect samples from people of European ancestry.

“It then went out of hand because it became routine practice to use only this one group, essentially White, European ancestry people,” says Karoline Kuchenbaecker, PhD, associate professor of psychiatry at University College London.

Yet findings from one population won’t necessarily translate to others. “And that’s exactly what has been shown,” says Dr. Teferra. Polygenic risk scores developed for schizophrenia from European samples, for example, perform poorly among people of African ancestry, although among Europeans, they are strongly effective at differentiating European individuals with and those without schizophrenia. Moreover, drugs that target a gene identified from studies in European populations may be harmful to other groups.

Studies drawn from a diverse pool of participants would benefit a wider swath of humanity. They would also allow scientists to discover small areas of overlap in genomes of different populations, which would help them close in on the true biology of diseases and ensure that “we’re all benefiting from more diverse data in genetics and psychiatric genetics,” says Dr. Kuchenbaecker.
 

New efforts aim at filling the gaps

Genomic studies are featuring more people of non-European ancestry, but most of that improvement comes from populations of Asian ancestry, not African, Latin American, or Indigenous ancestry.

Efforts to increase representation of persons of African ancestry have largely focused on African Americans; fewer efforts have extended to the African continent, home to the most genetically diverse populations. Even fewer have focused on mental health. “The little that was being done was on a very small scale,” says Karestan Koenen, PhD, a professor at Harvard School of Public Health, Boston.

With this in mind, researchers from institutions in Kenya, Uganda, South Africa, and Ethiopia partnered with researchers at the Broad Institute of the Massachusetts Institute of Technology and Harvard to conduct the largest GWAS of psychiatric disorders in Africa. Dr. Koenen leads the project, Neuropsychiatric Genetics of African Populations–Psychosis (NeuroGAP-Psychosis), which will analyze DNA from over 35,000 people of African ancestry in each of these four countries. Investigators will compare the half of participants who have no history of psychosis with the half with schizophrenia or bipolar disorder in the hopes of identifying the genetic determinants of psychosis.

“Then any potential intervention or therapeutics that will be developed will also be useful for Africans,” says Dr. Teferra, a NeuroGAP principal investigator. Because of the tremendous degree of genetic diversity among people on the continent, however, findings still might not translate to all African populations.

But correcting equity problems in genomics isn’t as simple as recruiting people with non-European backgrounds, especially if those people are unfamiliar with research or have been subject to scientific exploitation. “Special care needs to be taken to, first of all, provide information that’s appropriate [to participants], but also motivate people to take part and then find ways to keep these communities involved and understand what they’re interested in,” says Dr. Kuchenbaecker, who is not involved with NeuroGAP.

For NeuroGAP, the team needed to work with ethical committees at all of the institutions involved, ensure research materials were appropriate for each community’s cultural context, and gain the trust of local communities.

“One of the biggest criticisms within the scientific world is that people from more endowed countries just fly in, bully everyone, collect the data, and leave, with no credit to the local scientists or communities,” says NeuroGAP principal investigator Lukoye Atwoli, MMed, PhD, professor of psychiatry and dean of the Medical College, East Africa, at the Aga Khan University, Nairobi, Kenya. “That is one of the biggest pitfalls we had to grapple with.”

To address that concern, NeuroGAP is training local researchers and is providing them with requested resources so they can carry out similar studies in the future. “We will be looking to address a real need in the academic community and in clinical service delivery,” says Dr. Atwoli.

Dr. Kuchenbaecker says that NeuroGAP demonstrates features necessary for projects seeking to improve equity in psychiatric genomics. “What they’re doing right is recruiting really large numbers, recruiting from different African countries, and involving African investigators,” she says.

In the Americas, Janitza Montalvo-Ortiz, PhD, assistant professor in the Division of Genetics, department of psychiatry, Yale University, New Haven, Conn., and her colleagues are expanding psychiatric genomics projects in Latin America. She co-founded the Latin American Genomics Consortium in 2019, a network of scientists supporting psychiatric genomic research in the region. The consortium also involves the Neuropsychiatric Genetics in Mexican Populations project, which is similar to NeuroGAP and is also led by Dr. Koenan.

The study of Latin American populations is complicated, because genes in these populations reflect Indigenous American, European, and African ancestries. Even when investigators sampled DNA from Latin American individuals, that data often went unused. “Now with new methods emerging to allow us to properly analyze admixed populations in GWAS studies, we’re making efforts to compile different datasets scattered across different large-scale cohorts,” says Dr. Montalvo-Ortiz. “Our ultimate goal is to conduct the first large-scale LatinX GWAS of psychiatry,” she says.

With these projects, researchers hope that new psychiatric research will produce clinical advances for people historically left on the sidelines of genomic studies. By involving their communities in genomic research, “whatever is going to be developed will also benefit our community,” says Dr. Teferra. “We will not be left out.”

A version of this article first appeared on Medscape.com.

In combing the genome, scientists can use genetic clues to determine a person’s risk for psychiatric disease and even identify new drug targets. But the benefits of these discoveries will be limited to people of European descent.

Nearly 90% of participants in genome-wide association studies (GWASs), which search for gene variants linked to disease, are of European ancestry. This Eurocentric focus threatens to widen existing disparities in racial and ethnic mental health.

The significant downsides of genomics’ one-track mind

One obstacle hindering therapeutic advances in psychiatry is a shallow understanding of the mechanisms of disorders. “The biggest problem in terms of advancing research for mental health conditions is that we don’t understand the underlying biology,” says Laramie Duncan, PhD, assistant professor of psychiatry and behavioral sciences at Stanford (Calif.) University. “Genetics is one of the best ways to systematically look for new clues about the underlying biology.”

At the advent of genomic research, scientists thought it best to study DNA from people of a single ancestry from one continent. “Researchers for a long time held the idea that it was going to be too complicated to include multiple ancestries in the first rounds of genetic analyses,” says Dr. Duncan.

Studying DNA from someone with ancestors from multiple parts of the world wasn’t compatible with methods used in the early days of GWASs. “Individual parts of a person’s DNA can be linked back to one region of the world or another, and most of our methods essentially assume that all of a person’s DNA came from one region of the world,” says Dr. Duncan.

Because many genes are usually involved in psychiatric disorders, scientists need large numbers of participants to detect uncommon, influential variants. Early research was concentrated in North America and Europe so that scientists could readily collect samples from people of European ancestry.

“It then went out of hand because it became routine practice to use only this one group, essentially White, European ancestry people,” says Karoline Kuchenbaecker, PhD, associate professor of psychiatry at University College London.

Yet findings from one population won’t necessarily translate to others. “And that’s exactly what has been shown,” says Dr. Teferra. Polygenic risk scores developed for schizophrenia from European samples, for example, perform poorly among people of African ancestry, although among Europeans, they are strongly effective at differentiating European individuals with and those without schizophrenia. Moreover, drugs that target a gene identified from studies in European populations may be harmful to other groups.

Studies drawn from a diverse pool of participants would benefit a wider swath of humanity. They would also allow scientists to discover small areas of overlap in genomes of different populations, which would help them close in on the true biology of diseases and ensure that “we’re all benefiting from more diverse data in genetics and psychiatric genetics,” says Dr. Kuchenbaecker.
 

New efforts aim at filling the gaps

Genomic studies are featuring more people of non-European ancestry, but most of that improvement comes from populations of Asian ancestry, not African, Latin American, or Indigenous ancestry.

Efforts to increase representation of persons of African ancestry have largely focused on African Americans; fewer efforts have extended to the African continent, home to the most genetically diverse populations. Even fewer have focused on mental health. “The little that was being done was on a very small scale,” says Karestan Koenen, PhD, a professor at Harvard School of Public Health, Boston.

With this in mind, researchers from institutions in Kenya, Uganda, South Africa, and Ethiopia partnered with researchers at the Broad Institute of the Massachusetts Institute of Technology and Harvard to conduct the largest GWAS of psychiatric disorders in Africa. Dr. Koenen leads the project, Neuropsychiatric Genetics of African Populations–Psychosis (NeuroGAP-Psychosis), which will analyze DNA from over 35,000 people of African ancestry in each of these four countries. Investigators will compare the half of participants who have no history of psychosis with the half with schizophrenia or bipolar disorder in the hopes of identifying the genetic determinants of psychosis.

“Then any potential intervention or therapeutics that will be developed will also be useful for Africans,” says Dr. Teferra, a NeuroGAP principal investigator. Because of the tremendous degree of genetic diversity among people on the continent, however, findings still might not translate to all African populations.

But correcting equity problems in genomics isn’t as simple as recruiting people with non-European backgrounds, especially if those people are unfamiliar with research or have been subject to scientific exploitation. “Special care needs to be taken to, first of all, provide information that’s appropriate [to participants], but also motivate people to take part and then find ways to keep these communities involved and understand what they’re interested in,” says Dr. Kuchenbaecker, who is not involved with NeuroGAP.

For NeuroGAP, the team needed to work with ethical committees at all of the institutions involved, ensure research materials were appropriate for each community’s cultural context, and gain the trust of local communities.

“One of the biggest criticisms within the scientific world is that people from more endowed countries just fly in, bully everyone, collect the data, and leave, with no credit to the local scientists or communities,” says NeuroGAP principal investigator Lukoye Atwoli, MMed, PhD, professor of psychiatry and dean of the Medical College, East Africa, at the Aga Khan University, Nairobi, Kenya. “That is one of the biggest pitfalls we had to grapple with.”

To address that concern, NeuroGAP is training local researchers and is providing them with requested resources so they can carry out similar studies in the future. “We will be looking to address a real need in the academic community and in clinical service delivery,” says Dr. Atwoli.

Dr. Kuchenbaecker says that NeuroGAP demonstrates features necessary for projects seeking to improve equity in psychiatric genomics. “What they’re doing right is recruiting really large numbers, recruiting from different African countries, and involving African investigators,” she says.

In the Americas, Janitza Montalvo-Ortiz, PhD, assistant professor in the Division of Genetics, department of psychiatry, Yale University, New Haven, Conn., and her colleagues are expanding psychiatric genomics projects in Latin America. She co-founded the Latin American Genomics Consortium in 2019, a network of scientists supporting psychiatric genomic research in the region. The consortium also involves the Neuropsychiatric Genetics in Mexican Populations project, which is similar to NeuroGAP and is also led by Dr. Koenan.

The study of Latin American populations is complicated, because genes in these populations reflect Indigenous American, European, and African ancestries. Even when investigators sampled DNA from Latin American individuals, that data often went unused. “Now with new methods emerging to allow us to properly analyze admixed populations in GWAS studies, we’re making efforts to compile different datasets scattered across different large-scale cohorts,” says Dr. Montalvo-Ortiz. “Our ultimate goal is to conduct the first large-scale LatinX GWAS of psychiatry,” she says.

With these projects, researchers hope that new psychiatric research will produce clinical advances for people historically left on the sidelines of genomic studies. By involving their communities in genomic research, “whatever is going to be developed will also benefit our community,” says Dr. Teferra. “We will not be left out.”

A version of this article first appeared on Medscape.com.

In combing the genome, scientists can use genetic clues to determine a person’s risk for psychiatric disease and even identify new drug targets. But the benefits of these discoveries will be limited to people of European descent.

Nearly 90% of participants in genome-wide association studies (GWASs), which search for gene variants linked to disease, are of European ancestry. This Eurocentric focus threatens to widen existing disparities in racial and ethnic mental health.

The significant downsides of genomics’ one-track mind

One obstacle hindering therapeutic advances in psychiatry is a shallow understanding of the mechanisms of disorders. “The biggest problem in terms of advancing research for mental health conditions is that we don’t understand the underlying biology,” says Laramie Duncan, PhD, assistant professor of psychiatry and behavioral sciences at Stanford (Calif.) University. “Genetics is one of the best ways to systematically look for new clues about the underlying biology.”

At the advent of genomic research, scientists thought it best to study DNA from people of a single ancestry from one continent. “Researchers for a long time held the idea that it was going to be too complicated to include multiple ancestries in the first rounds of genetic analyses,” says Dr. Duncan.

Studying DNA from someone with ancestors from multiple parts of the world wasn’t compatible with methods used in the early days of GWASs. “Individual parts of a person’s DNA can be linked back to one region of the world or another, and most of our methods essentially assume that all of a person’s DNA came from one region of the world,” says Dr. Duncan.

Because many genes are usually involved in psychiatric disorders, scientists need large numbers of participants to detect uncommon, influential variants. Early research was concentrated in North America and Europe so that scientists could readily collect samples from people of European ancestry.

“It then went out of hand because it became routine practice to use only this one group, essentially White, European ancestry people,” says Karoline Kuchenbaecker, PhD, associate professor of psychiatry at University College London.

Yet findings from one population won’t necessarily translate to others. “And that’s exactly what has been shown,” says Dr. Teferra. Polygenic risk scores developed for schizophrenia from European samples, for example, perform poorly among people of African ancestry, although among Europeans, they are strongly effective at differentiating European individuals with and those without schizophrenia. Moreover, drugs that target a gene identified from studies in European populations may be harmful to other groups.

Studies drawn from a diverse pool of participants would benefit a wider swath of humanity. They would also allow scientists to discover small areas of overlap in genomes of different populations, which would help them close in on the true biology of diseases and ensure that “we’re all benefiting from more diverse data in genetics and psychiatric genetics,” says Dr. Kuchenbaecker.
 

New efforts aim at filling the gaps

Genomic studies are featuring more people of non-European ancestry, but most of that improvement comes from populations of Asian ancestry, not African, Latin American, or Indigenous ancestry.

Efforts to increase representation of persons of African ancestry have largely focused on African Americans; fewer efforts have extended to the African continent, home to the most genetically diverse populations. Even fewer have focused on mental health. “The little that was being done was on a very small scale,” says Karestan Koenen, PhD, a professor at Harvard School of Public Health, Boston.

With this in mind, researchers from institutions in Kenya, Uganda, South Africa, and Ethiopia partnered with researchers at the Broad Institute of the Massachusetts Institute of Technology and Harvard to conduct the largest GWAS of psychiatric disorders in Africa. Dr. Koenen leads the project, Neuropsychiatric Genetics of African Populations–Psychosis (NeuroGAP-Psychosis), which will analyze DNA from over 35,000 people of African ancestry in each of these four countries. Investigators will compare the half of participants who have no history of psychosis with the half with schizophrenia or bipolar disorder in the hopes of identifying the genetic determinants of psychosis.

“Then any potential intervention or therapeutics that will be developed will also be useful for Africans,” says Dr. Teferra, a NeuroGAP principal investigator. Because of the tremendous degree of genetic diversity among people on the continent, however, findings still might not translate to all African populations.

But correcting equity problems in genomics isn’t as simple as recruiting people with non-European backgrounds, especially if those people are unfamiliar with research or have been subject to scientific exploitation. “Special care needs to be taken to, first of all, provide information that’s appropriate [to participants], but also motivate people to take part and then find ways to keep these communities involved and understand what they’re interested in,” says Dr. Kuchenbaecker, who is not involved with NeuroGAP.

For NeuroGAP, the team needed to work with ethical committees at all of the institutions involved, ensure research materials were appropriate for each community’s cultural context, and gain the trust of local communities.

“One of the biggest criticisms within the scientific world is that people from more endowed countries just fly in, bully everyone, collect the data, and leave, with no credit to the local scientists or communities,” says NeuroGAP principal investigator Lukoye Atwoli, MMed, PhD, professor of psychiatry and dean of the Medical College, East Africa, at the Aga Khan University, Nairobi, Kenya. “That is one of the biggest pitfalls we had to grapple with.”

To address that concern, NeuroGAP is training local researchers and is providing them with requested resources so they can carry out similar studies in the future. “We will be looking to address a real need in the academic community and in clinical service delivery,” says Dr. Atwoli.

Dr. Kuchenbaecker says that NeuroGAP demonstrates features necessary for projects seeking to improve equity in psychiatric genomics. “What they’re doing right is recruiting really large numbers, recruiting from different African countries, and involving African investigators,” she says.

In the Americas, Janitza Montalvo-Ortiz, PhD, assistant professor in the Division of Genetics, department of psychiatry, Yale University, New Haven, Conn., and her colleagues are expanding psychiatric genomics projects in Latin America. She co-founded the Latin American Genomics Consortium in 2019, a network of scientists supporting psychiatric genomic research in the region. The consortium also involves the Neuropsychiatric Genetics in Mexican Populations project, which is similar to NeuroGAP and is also led by Dr. Koenan.

The study of Latin American populations is complicated, because genes in these populations reflect Indigenous American, European, and African ancestries. Even when investigators sampled DNA from Latin American individuals, that data often went unused. “Now with new methods emerging to allow us to properly analyze admixed populations in GWAS studies, we’re making efforts to compile different datasets scattered across different large-scale cohorts,” says Dr. Montalvo-Ortiz. “Our ultimate goal is to conduct the first large-scale LatinX GWAS of psychiatry,” she says.

With these projects, researchers hope that new psychiatric research will produce clinical advances for people historically left on the sidelines of genomic studies. By involving their communities in genomic research, “whatever is going to be developed will also benefit our community,” says Dr. Teferra. “We will not be left out.”

A version of this article first appeared on Medscape.com.

State laws permitting recreational marijuana use have not led to an increase in opioid-related emergency department visits, as many had feared.

On the contrary, states that legalize recreational marijuana may see a short-term decrease in opioid-related ED visits in the first 6 months, after which rates may return to prelegalization levels, new research suggests.

Previous research suggests that individuals may reduce the use of opioids when they have an alternative and that cannabis can provide pain relief.

“At the same time, we often hear claims from politicians that we should not legalize cannabis because it may act as a ‘gateway drug’ that leads to use of other drugs,” lead researcher Coleman Drake, PhD, Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, told this news organization.

“Our findings indicate that cannabis legalization does not effect any increase in opioid-related ED visits, contradicting the gateway drug explanation,” Dr. Drake said.

The study was published online July 12 in Health Economics.
 

Significant reduction

So far, 19 states have legalized recreational cannabis, meaning that nearly half of the U.S. population lives in a state that allows recreational cannabis use.

The investigators analyzed data on opioid-related ED visits from 29 states between 2011 and 2017. Four states – California, Maine, Massachusetts, and Nevada – legalized recreational marijuana during the study period; the remaining 25 states did not.

The four states with recreational cannabis laws experienced a 7.6% reduction in opioid-related ED visits for 6 months after the law went into effect in comparison with the states that did not legalize recreational marijuana.

“This isn’t trivial – a decline in opioid-related emergency department visits, even if only for 6 months, is a welcome public health development,” Dr. Drake said in a statement.

Not surprisingly, these effects are driven by men and adults aged 25 to 44 years. “These are populations that are more likely to use cannabis, and the reduction in opioid-related ED visits that we find is concentrated among them,” Dr. Drake told this news organization.

However, the downturn in opioid-related ED visits after making marijuana legal was only temporary.

“The effect dissipates after the first 6 months, perhaps because cannabis ultimately is not a treatment for opioid use disorder,” Dr. Drake said.

Encouragingly, he said, the data show that opioid-related ED visits don’t increase above baseline after recreational marijuana laws are adopted.

“We conclude that cannabis legalization likely is not a panacea for the opioid epidemic, but there are some helpful effects,” Dr. Drake said in an interview.

The study was supported by the National Institute on Drug Abuse. The authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

State laws permitting recreational marijuana use have not led to an increase in opioid-related emergency department visits, as many had feared.

On the contrary, states that legalize recreational marijuana may see a short-term decrease in opioid-related ED visits in the first 6 months, after which rates may return to prelegalization levels, new research suggests.

Previous research suggests that individuals may reduce the use of opioids when they have an alternative and that cannabis can provide pain relief.

“At the same time, we often hear claims from politicians that we should not legalize cannabis because it may act as a ‘gateway drug’ that leads to use of other drugs,” lead researcher Coleman Drake, PhD, Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, told this news organization.

“Our findings indicate that cannabis legalization does not effect any increase in opioid-related ED visits, contradicting the gateway drug explanation,” Dr. Drake said.

The study was published online July 12 in Health Economics.
 

Significant reduction

So far, 19 states have legalized recreational cannabis, meaning that nearly half of the U.S. population lives in a state that allows recreational cannabis use.

The investigators analyzed data on opioid-related ED visits from 29 states between 2011 and 2017. Four states – California, Maine, Massachusetts, and Nevada – legalized recreational marijuana during the study period; the remaining 25 states did not.

The four states with recreational cannabis laws experienced a 7.6% reduction in opioid-related ED visits for 6 months after the law went into effect in comparison with the states that did not legalize recreational marijuana.

“This isn’t trivial – a decline in opioid-related emergency department visits, even if only for 6 months, is a welcome public health development,” Dr. Drake said in a statement.

Not surprisingly, these effects are driven by men and adults aged 25 to 44 years. “These are populations that are more likely to use cannabis, and the reduction in opioid-related ED visits that we find is concentrated among them,” Dr. Drake told this news organization.

However, the downturn in opioid-related ED visits after making marijuana legal was only temporary.

“The effect dissipates after the first 6 months, perhaps because cannabis ultimately is not a treatment for opioid use disorder,” Dr. Drake said.

Encouragingly, he said, the data show that opioid-related ED visits don’t increase above baseline after recreational marijuana laws are adopted.

“We conclude that cannabis legalization likely is not a panacea for the opioid epidemic, but there are some helpful effects,” Dr. Drake said in an interview.

The study was supported by the National Institute on Drug Abuse. The authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

State laws permitting recreational marijuana use have not led to an increase in opioid-related emergency department visits, as many had feared.

On the contrary, states that legalize recreational marijuana may see a short-term decrease in opioid-related ED visits in the first 6 months, after which rates may return to prelegalization levels, new research suggests.

Previous research suggests that individuals may reduce the use of opioids when they have an alternative and that cannabis can provide pain relief.

“At the same time, we often hear claims from politicians that we should not legalize cannabis because it may act as a ‘gateway drug’ that leads to use of other drugs,” lead researcher Coleman Drake, PhD, Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, told this news organization.

“Our findings indicate that cannabis legalization does not effect any increase in opioid-related ED visits, contradicting the gateway drug explanation,” Dr. Drake said.

The study was published online July 12 in Health Economics.
 

Significant reduction

So far, 19 states have legalized recreational cannabis, meaning that nearly half of the U.S. population lives in a state that allows recreational cannabis use.

The investigators analyzed data on opioid-related ED visits from 29 states between 2011 and 2017. Four states – California, Maine, Massachusetts, and Nevada – legalized recreational marijuana during the study period; the remaining 25 states did not.

The four states with recreational cannabis laws experienced a 7.6% reduction in opioid-related ED visits for 6 months after the law went into effect in comparison with the states that did not legalize recreational marijuana.

“This isn’t trivial – a decline in opioid-related emergency department visits, even if only for 6 months, is a welcome public health development,” Dr. Drake said in a statement.

Not surprisingly, these effects are driven by men and adults aged 25 to 44 years. “These are populations that are more likely to use cannabis, and the reduction in opioid-related ED visits that we find is concentrated among them,” Dr. Drake told this news organization.

However, the downturn in opioid-related ED visits after making marijuana legal was only temporary.

“The effect dissipates after the first 6 months, perhaps because cannabis ultimately is not a treatment for opioid use disorder,” Dr. Drake said.

Encouragingly, he said, the data show that opioid-related ED visits don’t increase above baseline after recreational marijuana laws are adopted.

“We conclude that cannabis legalization likely is not a panacea for the opioid epidemic, but there are some helpful effects,” Dr. Drake said in an interview.

The study was supported by the National Institute on Drug Abuse. The authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

More Americans died from drug overdoses in 2020 than in any other year, the CDC said July 14.

Fatal overdoses rose by nearly 30% last year to a total of more than 93,000 deaths, according to the provisional data the National Center for Health Statistics reported.

The spikes are largely attributed to the rise in use of fentanyl and other synthetic opioids.

The Washington Post reported that more than 69,000 overdose deaths involved opioids, up from 50,963 in 2019.

Amid the crush of overdoses, the White House announced that President Joe Biden has nominated Rahul Gupta, MD, to lead the White House Office of National Drug Control Policy.

Dr. Gupta is a former health commissioner of West Virginia, and is chief medical and health officer for the March of Dimes.

“Dr. Gupta led efforts in West Virginia to address the opioid crisis, gaining national prominence as a leader in tackling this issue,” March of Dimes President and CEO Stacey Stewart said in a statement. “At March of Dimes, he has advocated for policies and programs to prevent and treat substance use, with a focus on the safety and care of pregnant women and infants.”

Healthday contributed to this report. A version of this article first appeared on WebMD.com.

More Americans died from drug overdoses in 2020 than in any other year, the CDC said July 14.

Fatal overdoses rose by nearly 30% last year to a total of more than 93,000 deaths, according to the provisional data the National Center for Health Statistics reported.

The spikes are largely attributed to the rise in use of fentanyl and other synthetic opioids.

The Washington Post reported that more than 69,000 overdose deaths involved opioids, up from 50,963 in 2019.

Amid the crush of overdoses, the White House announced that President Joe Biden has nominated Rahul Gupta, MD, to lead the White House Office of National Drug Control Policy.

Dr. Gupta is a former health commissioner of West Virginia, and is chief medical and health officer for the March of Dimes.

“Dr. Gupta led efforts in West Virginia to address the opioid crisis, gaining national prominence as a leader in tackling this issue,” March of Dimes President and CEO Stacey Stewart said in a statement. “At March of Dimes, he has advocated for policies and programs to prevent and treat substance use, with a focus on the safety and care of pregnant women and infants.”

Healthday contributed to this report. A version of this article first appeared on WebMD.com.

More Americans died from drug overdoses in 2020 than in any other year, the CDC said July 14.

Fatal overdoses rose by nearly 30% last year to a total of more than 93,000 deaths, according to the provisional data the National Center for Health Statistics reported.

The spikes are largely attributed to the rise in use of fentanyl and other synthetic opioids.

The Washington Post reported that more than 69,000 overdose deaths involved opioids, up from 50,963 in 2019.

Amid the crush of overdoses, the White House announced that President Joe Biden has nominated Rahul Gupta, MD, to lead the White House Office of National Drug Control Policy.

Dr. Gupta is a former health commissioner of West Virginia, and is chief medical and health officer for the March of Dimes.

“Dr. Gupta led efforts in West Virginia to address the opioid crisis, gaining national prominence as a leader in tackling this issue,” March of Dimes President and CEO Stacey Stewart said in a statement. “At March of Dimes, he has advocated for policies and programs to prevent and treat substance use, with a focus on the safety and care of pregnant women and infants.”

Healthday contributed to this report. A version of this article first appeared on WebMD.com.

The impact of the COVID-19 pandemic on the well-being of youth has been significant. Its possible effects range from boredom, depression, anxiety, and suicidal ideation to potential increased rates of internet gaming disorder (IGD), which may have worsened during a nationwide shutdown and extended period of limited social interactions. Presently, there is a paucity of research on the impact of internet gaming on children and adolescents’ mental health and well-being during COVID-19. This article aims to bring awareness to the possible rising impact of the COVID-19 pandemic on IGD and mental health in youth.

Gaming offers benefits—and risks

The gaming industry has grown immensely over the past several years. While many businesses were impacted negatively during the pandemic, the gaming industry grew. It was estimated to be worth $159.3 billion in 2020, an increase of 9.3% from 2019.¹

Stay-at-home orders and quarantine protocols during the COVID-19 pandemic have significantly disrupted normal activities, resulting in increased time for digital entertainment, including online gaming and related activities. Internet gaming offers some benefits for children and adolescents, including socialization and connection with peers, which was especially important for avoiding isolation during the pandemic. Empirical evidence of the positive effects of internet gaming can be seen in studies of youth undergoing chemotherapy, those receiving psychotherapy for anxiety or depression, and those having emotional and behavioral problems.² Internet gaming also provides participants with a platform to communicate with the outside world while maintaining social distancing, and might reduce anxiety, and in some cases, depression.³

Despite these benefits, for some youth, excessive internet gaming can have adverse effects. Due to its addictive properties, internet gaming can be dangerous for vulnerable individuals and lead to unhealthy habits, such as disturbed sleep patterns and increased anxiety.⁴ In a cross-sectional study conducted in China, Yu et al⁵ examined the association between IGD and suicidal ideation. They concluded that IGD was positively associated with insomnia and then depression, which in turn contributed to suicide ideation.⁵ A study based on a survey conducted in Iran from May to August 2020 in individuals age 13 to 18 years found that depression, anxiety, and stress were significant mediators in the association between IGD and self-reported quality of life.²

Internet gaming disorder is included in DSM-5 as a “condition for further study” and in ICD-11.⁶ Before the COVID-19 pandemic, a study of 1,178 American youth age 8 to 18 years revealed that 8.5% of gamers met the criteria for IGD.⁷ In a meta-analysis that included 16 studies, the pooled prevalence of IGD among adolescents was 4.6%.⁸ Some countries, including China and South Korea, have developed treatment plans for IGD,⁶ but in the United States treatment guidelines have not been established due to insufficient evidence.⁹

The COVID-19 pandemic has likely led to an increased number of children and adolescents with IGD and its adverse effects on their mental health and well-being. It remains to be seen whether these youth will improve as the pandemic resolves and they resume normal activities, or if impairments will persist.

In conclusion, while internet gaming during the COVID-19 pandemic has provided benefits for many children and adolescents, the negative impact for those who develop IGD may be significant. We should be prepared to detect and address the needs of these youth and their families. Additional research is needed on the post-pandemic prevalence of IGD, its impact on youth mental health, and treatment strategies.

The impact of the COVID-19 pandemic on the well-being of youth has been significant. Its possible effects range from boredom, depression, anxiety, and suicidal ideation to potential increased rates of internet gaming disorder (IGD), which may have worsened during a nationwide shutdown and extended period of limited social interactions. Presently, there is a paucity of research on the impact of internet gaming on children and adolescents’ mental health and well-being during COVID-19. This article aims to bring awareness to the possible rising impact of the COVID-19 pandemic on IGD and mental health in youth.

Gaming offers benefits—and risks

The gaming industry has grown immensely over the past several years. While many businesses were impacted negatively during the pandemic, the gaming industry grew. It was estimated to be worth $159.3 billion in 2020, an increase of 9.3% from 2019.¹

Stay-at-home orders and quarantine protocols during the COVID-19 pandemic have significantly disrupted normal activities, resulting in increased time for digital entertainment, including online gaming and related activities. Internet gaming offers some benefits for children and adolescents, including socialization and connection with peers, which was especially important for avoiding isolation during the pandemic. Empirical evidence of the positive effects of internet gaming can be seen in studies of youth undergoing chemotherapy, those receiving psychotherapy for anxiety or depression, and those having emotional and behavioral problems.² Internet gaming also provides participants with a platform to communicate with the outside world while maintaining social distancing, and might reduce anxiety, and in some cases, depression.³

Despite these benefits, for some youth, excessive internet gaming can have adverse effects. Due to its addictive properties, internet gaming can be dangerous for vulnerable individuals and lead to unhealthy habits, such as disturbed sleep patterns and increased anxiety.⁴ In a cross-sectional study conducted in China, Yu et al⁵ examined the association between IGD and suicidal ideation. They concluded that IGD was positively associated with insomnia and then depression, which in turn contributed to suicide ideation.⁵ A study based on a survey conducted in Iran from May to August 2020 in individuals age 13 to 18 years found that depression, anxiety, and stress were significant mediators in the association between IGD and self-reported quality of life.²

Internet gaming disorder is included in DSM-5 as a “condition for further study” and in ICD-11.⁶ Before the COVID-19 pandemic, a study of 1,178 American youth age 8 to 18 years revealed that 8.5% of gamers met the criteria for IGD.⁷ In a meta-analysis that included 16 studies, the pooled prevalence of IGD among adolescents was 4.6%.⁸ Some countries, including China and South Korea, have developed treatment plans for IGD,⁶ but in the United States treatment guidelines have not been established due to insufficient evidence.⁹

The COVID-19 pandemic has likely led to an increased number of children and adolescents with IGD and its adverse effects on their mental health and well-being. It remains to be seen whether these youth will improve as the pandemic resolves and they resume normal activities, or if impairments will persist.

In conclusion, while internet gaming during the COVID-19 pandemic has provided benefits for many children and adolescents, the negative impact for those who develop IGD may be significant. We should be prepared to detect and address the needs of these youth and their families. Additional research is needed on the post-pandemic prevalence of IGD, its impact on youth mental health, and treatment strategies.

The impact of the COVID-19 pandemic on the well-being of youth has been significant. Its possible effects range from boredom, depression, anxiety, and suicidal ideation to potential increased rates of internet gaming disorder (IGD), which may have worsened during a nationwide shutdown and extended period of limited social interactions. Presently, there is a paucity of research on the impact of internet gaming on children and adolescents’ mental health and well-being during COVID-19. This article aims to bring awareness to the possible rising impact of the COVID-19 pandemic on IGD and mental health in youth.

Gaming offers benefits—and risks

The gaming industry has grown immensely over the past several years. While many businesses were impacted negatively during the pandemic, the gaming industry grew. It was estimated to be worth $159.3 billion in 2020, an increase of 9.3% from 2019.¹

Stay-at-home orders and quarantine protocols during the COVID-19 pandemic have significantly disrupted normal activities, resulting in increased time for digital entertainment, including online gaming and related activities. Internet gaming offers some benefits for children and adolescents, including socialization and connection with peers, which was especially important for avoiding isolation during the pandemic. Empirical evidence of the positive effects of internet gaming can be seen in studies of youth undergoing chemotherapy, those receiving psychotherapy for anxiety or depression, and those having emotional and behavioral problems.² Internet gaming also provides participants with a platform to communicate with the outside world while maintaining social distancing, and might reduce anxiety, and in some cases, depression.³

Despite these benefits, for some youth, excessive internet gaming can have adverse effects. Due to its addictive properties, internet gaming can be dangerous for vulnerable individuals and lead to unhealthy habits, such as disturbed sleep patterns and increased anxiety.⁴ In a cross-sectional study conducted in China, Yu et al⁵ examined the association between IGD and suicidal ideation. They concluded that IGD was positively associated with insomnia and then depression, which in turn contributed to suicide ideation.⁵ A study based on a survey conducted in Iran from May to August 2020 in individuals age 13 to 18 years found that depression, anxiety, and stress were significant mediators in the association between IGD and self-reported quality of life.²

Internet gaming disorder is included in DSM-5 as a “condition for further study” and in ICD-11.⁶ Before the COVID-19 pandemic, a study of 1,178 American youth age 8 to 18 years revealed that 8.5% of gamers met the criteria for IGD.⁷ In a meta-analysis that included 16 studies, the pooled prevalence of IGD among adolescents was 4.6%.⁸ Some countries, including China and South Korea, have developed treatment plans for IGD,⁶ but in the United States treatment guidelines have not been established due to insufficient evidence.⁹

The COVID-19 pandemic has likely led to an increased number of children and adolescents with IGD and its adverse effects on their mental health and well-being. It remains to be seen whether these youth will improve as the pandemic resolves and they resume normal activities, or if impairments will persist.

In conclusion, while internet gaming during the COVID-19 pandemic has provided benefits for many children and adolescents, the negative impact for those who develop IGD may be significant. We should be prepared to detect and address the needs of these youth and their families. Additional research is needed on the post-pandemic prevalence of IGD, its impact on youth mental health, and treatment strategies.

The opioid prescription rates have significantly decreased for children, teens, and younger adults between 2006 and 2018, according to new research.

“What’s important about this new study is that it documented that these improvements were also occurring for children and young adults specifically,” said Kao-Ping Chua, MD, PhD, primary care physician and assistant professor of pediatrics at the University of Michigan, Ann Arbor, who was not involved in the study. “The reason that’s important is that changes in medical practice for adults aren’t always reflected in pediatrics.”

The study, published in JAMA Pediatrics, found that dispensed opioid prescriptions for this population have decreased by 15% annually since 2013. However, the study also examined specific prescribing variables, such as duration of opioid prescription and high-dosage prescriptions. Researchers found reduced rates of high-dosage and long-duration prescriptions for adolescents and younger adults. However, these types of prescription practices increased in children aged 0-5 years.

“I think [the findings are] promising, suggesting that opiate prescribing practices may be improving,” study author Madeline Renny, MD, pediatric emergency medicine doctor at New York University Langone Health, said in an interview. “But we did find that there were increases in the young children for the practice variables, which we didn’t expect. I think that was kind of one of the findings that we were a bit surprised about and want to explore further.”

Previous studies have linked prescription opioid use in children and teens to an increased risk of future opioid misuse. A 2015 study published in Pediatrics found that using prescribed opioids before the 12th grade is associated with a 33% increase in the risk of future opioid misuse by the age of 23. The study also found that for those with a low predicted risk of future opioid misuse, an opioid prescription increases the risk for misuse after high school threefold.

Furthermore, a 2018 study published in JAMA Network Open found that, between 1999 and 2016, the annual estimated mortality rate for all children and adolescents from prescription and illicit opioid use rose 268.2%.

In the new study, Dr. Renny and colleagues examined data from 2006 to 2018 from IQVIA Longitudinal Prescription Data, which captured 74%-92% of U.S. retail outpatient opioid prescriptions dispensed to people up to the age of 24. Researchers also examined prescribing practice variables, which included opioid dispensing rates, average amount of opioid dispensed per prescription, duration of opioid prescription, high-dosage opioid prescription for individuals, and the rate in which extended-release or long-acting opioids are prescribed.

Researchers found that between 2006 and 2018, the total U.S. annual opioid prescriptions dispensed to patients younger than 25 years was highest in 2007 at 15,689,779 prescriptions, and since 2012 has steadily decreased to 6,705,478 in 2018.

“Our study did show that there were declines, but opioids remain readily dispensed,” Dr. Renny said. “And I think it’s good that rates have gone down, but I think opioids are still commonly dispensed to children and adolescents and young adults and all of our age groups.”

Dr. Chua said that the study was important, but when it came to younger children, it didn’t account for the fact that “the underlying population of patients who were getting opioids changed because it’s not the same group of children.”

“Maybe at the beginning there were more surgical patients who are getting shorter duration, lower dosage opioids,” he added. “Now some of those surgical exceptions kind of went away and who’s left in the population of people who get opioids is a sicker population.”

“Who are the 0 to 5-year-olds who are getting opioids now?” Dr. Chua asked. “Well, some of them are going to be cancer or surgical patients. If you think about it, over time their surgeons may be more judicious and they stop prescribing opioids for some things like circumcision or something like that. So that means that who’s left in the population of children who get opiate prescriptions are the cancer patients. Cancer patients’ opioid dosages are going to be higher because they have chronic pain.”

Dr. Chua said it is important to remember that the number of children who are affected by those high-risk prescriptions are lower because the overall number of opioid prescriptions has gone down. He added that the key piece of missing information is the absolute number of prescriptions that were high risk.

Researchers of the current study suggested that, because of the differences between pediatric and adult pain and indications for opioid prescribing, there should be national guidelines on general opioid prescribing for children and adolescents.

Experts did not disclose relevant financial relationships.

The opioid prescription rates have significantly decreased for children, teens, and younger adults between 2006 and 2018, according to new research.

“What’s important about this new study is that it documented that these improvements were also occurring for children and young adults specifically,” said Kao-Ping Chua, MD, PhD, primary care physician and assistant professor of pediatrics at the University of Michigan, Ann Arbor, who was not involved in the study. “The reason that’s important is that changes in medical practice for adults aren’t always reflected in pediatrics.”

The study, published in JAMA Pediatrics, found that dispensed opioid prescriptions for this population have decreased by 15% annually since 2013. However, the study also examined specific prescribing variables, such as duration of opioid prescription and high-dosage prescriptions. Researchers found reduced rates of high-dosage and long-duration prescriptions for adolescents and younger adults. However, these types of prescription practices increased in children aged 0-5 years.

“I think [the findings are] promising, suggesting that opiate prescribing practices may be improving,” study author Madeline Renny, MD, pediatric emergency medicine doctor at New York University Langone Health, said in an interview. “But we did find that there were increases in the young children for the practice variables, which we didn’t expect. I think that was kind of one of the findings that we were a bit surprised about and want to explore further.”

Previous studies have linked prescription opioid use in children and teens to an increased risk of future opioid misuse. A 2015 study published in Pediatrics found that using prescribed opioids before the 12th grade is associated with a 33% increase in the risk of future opioid misuse by the age of 23. The study also found that for those with a low predicted risk of future opioid misuse, an opioid prescription increases the risk for misuse after high school threefold.

Furthermore, a 2018 study published in JAMA Network Open found that, between 1999 and 2016, the annual estimated mortality rate for all children and adolescents from prescription and illicit opioid use rose 268.2%.

In the new study, Dr. Renny and colleagues examined data from 2006 to 2018 from IQVIA Longitudinal Prescription Data, which captured 74%-92% of U.S. retail outpatient opioid prescriptions dispensed to people up to the age of 24. Researchers also examined prescribing practice variables, which included opioid dispensing rates, average amount of opioid dispensed per prescription, duration of opioid prescription, high-dosage opioid prescription for individuals, and the rate in which extended-release or long-acting opioids are prescribed.

Researchers found that between 2006 and 2018, the total U.S. annual opioid prescriptions dispensed to patients younger than 25 years was highest in 2007 at 15,689,779 prescriptions, and since 2012 has steadily decreased to 6,705,478 in 2018.

“Our study did show that there were declines, but opioids remain readily dispensed,” Dr. Renny said. “And I think it’s good that rates have gone down, but I think opioids are still commonly dispensed to children and adolescents and young adults and all of our age groups.”

Dr. Chua said that the study was important, but when it came to younger children, it didn’t account for the fact that “the underlying population of patients who were getting opioids changed because it’s not the same group of children.”

“Maybe at the beginning there were more surgical patients who are getting shorter duration, lower dosage opioids,” he added. “Now some of those surgical exceptions kind of went away and who’s left in the population of people who get opioids is a sicker population.”

“Who are the 0 to 5-year-olds who are getting opioids now?” Dr. Chua asked. “Well, some of them are going to be cancer or surgical patients. If you think about it, over time their surgeons may be more judicious and they stop prescribing opioids for some things like circumcision or something like that. So that means that who’s left in the population of children who get opiate prescriptions are the cancer patients. Cancer patients’ opioid dosages are going to be higher because they have chronic pain.”

Dr. Chua said it is important to remember that the number of children who are affected by those high-risk prescriptions are lower because the overall number of opioid prescriptions has gone down. He added that the key piece of missing information is the absolute number of prescriptions that were high risk.

Researchers of the current study suggested that, because of the differences between pediatric and adult pain and indications for opioid prescribing, there should be national guidelines on general opioid prescribing for children and adolescents.

Experts did not disclose relevant financial relationships.

The opioid prescription rates have significantly decreased for children, teens, and younger adults between 2006 and 2018, according to new research.

“What’s important about this new study is that it documented that these improvements were also occurring for children and young adults specifically,” said Kao-Ping Chua, MD, PhD, primary care physician and assistant professor of pediatrics at the University of Michigan, Ann Arbor, who was not involved in the study. “The reason that’s important is that changes in medical practice for adults aren’t always reflected in pediatrics.”

The study, published in JAMA Pediatrics, found that dispensed opioid prescriptions for this population have decreased by 15% annually since 2013. However, the study also examined specific prescribing variables, such as duration of opioid prescription and high-dosage prescriptions. Researchers found reduced rates of high-dosage and long-duration prescriptions for adolescents and younger adults. However, these types of prescription practices increased in children aged 0-5 years.

“I think [the findings are] promising, suggesting that opiate prescribing practices may be improving,” study author Madeline Renny, MD, pediatric emergency medicine doctor at New York University Langone Health, said in an interview. “But we did find that there were increases in the young children for the practice variables, which we didn’t expect. I think that was kind of one of the findings that we were a bit surprised about and want to explore further.”

Previous studies have linked prescription opioid use in children and teens to an increased risk of future opioid misuse. A 2015 study published in Pediatrics found that using prescribed opioids before the 12th grade is associated with a 33% increase in the risk of future opioid misuse by the age of 23. The study also found that for those with a low predicted risk of future opioid misuse, an opioid prescription increases the risk for misuse after high school threefold.

Furthermore, a 2018 study published in JAMA Network Open found that, between 1999 and 2016, the annual estimated mortality rate for all children and adolescents from prescription and illicit opioid use rose 268.2%.

In the new study, Dr. Renny and colleagues examined data from 2006 to 2018 from IQVIA Longitudinal Prescription Data, which captured 74%-92% of U.S. retail outpatient opioid prescriptions dispensed to people up to the age of 24. Researchers also examined prescribing practice variables, which included opioid dispensing rates, average amount of opioid dispensed per prescription, duration of opioid prescription, high-dosage opioid prescription for individuals, and the rate in which extended-release or long-acting opioids are prescribed.

Researchers found that between 2006 and 2018, the total U.S. annual opioid prescriptions dispensed to patients younger than 25 years was highest in 2007 at 15,689,779 prescriptions, and since 2012 has steadily decreased to 6,705,478 in 2018.

“Our study did show that there were declines, but opioids remain readily dispensed,” Dr. Renny said. “And I think it’s good that rates have gone down, but I think opioids are still commonly dispensed to children and adolescents and young adults and all of our age groups.”

Dr. Chua said that the study was important, but when it came to younger children, it didn’t account for the fact that “the underlying population of patients who were getting opioids changed because it’s not the same group of children.”

“Maybe at the beginning there were more surgical patients who are getting shorter duration, lower dosage opioids,” he added. “Now some of those surgical exceptions kind of went away and who’s left in the population of people who get opioids is a sicker population.”

“Who are the 0 to 5-year-olds who are getting opioids now?” Dr. Chua asked. “Well, some of them are going to be cancer or surgical patients. If you think about it, over time their surgeons may be more judicious and they stop prescribing opioids for some things like circumcision or something like that. So that means that who’s left in the population of children who get opiate prescriptions are the cancer patients. Cancer patients’ opioid dosages are going to be higher because they have chronic pain.”

Dr. Chua said it is important to remember that the number of children who are affected by those high-risk prescriptions are lower because the overall number of opioid prescriptions has gone down. He added that the key piece of missing information is the absolute number of prescriptions that were high risk.

Researchers of the current study suggested that, because of the differences between pediatric and adult pain and indications for opioid prescribing, there should be national guidelines on general opioid prescribing for children and adolescents.

Experts did not disclose relevant financial relationships.