The ‘fourth wave’ of the opioid epidemic is upon us

Plus: pot’s powerful link to addiction and psychosis, and sleep’s role in preventing relapse

By Mark Mravic

The apparent stabilization in the number of opioid-related deaths in recent months may have given rise to some optimism, but a new study from Northwestern University paints a much bleaker picture of the state of the opioid epidemic and his direction.

Also this week is a study that finds correlations between cannabis potency and serious mental health issues, and the importance of undisturbed REM sleep in preventing relapse.

From the Jama network:
“Explosive” growth in overdose deaths, everywhere

By studying geographic trends in opioid overdose deaths from 1999 to 2020, Northwestern researchers found that, for the first time, opioid-related death rates and the acceleration of those rates are converging at record numbers in all parts of the United States. The result, they say, is a “fourth wave” of overdose deaths that the study’s lead author says will be “worse than it’s ever been.”

Three previous waves of overlapping opioid-related deaths – the first caused by prescription painkillers from 2000, the second by an increase in heroin use from the late 2000s and the third by the influx synthetic opioids such as fentanyl in the mid-2010s – had distinct geographic profiles, the authors found. In the first wave, death rates were higher in urban counties but accelerated faster in rural areas. The second wave was concentrated in urban areas. The third wave affected both rural and urban areas, but in a non-linear way.

“Not only the mortality rate of [opioids] at an all-time high, but the acceleration in this death rate signals explosive exponential growth that is even greater than an already historic level.

—Lori Post, Northwestern University

The authors’ proposed “fourth wave,” which began with the onset of the COVID-19 pandemic, was made deadlier than previous waves by mixing potent synthetic opioids with stimulants such as cocaine and methamphetamine, complicating the treatment of overdoses. Most concerning is that, unlike previous waves, the number of deaths and rates of increase are on the rise in all types of communities in the United States.

“I am sounding the alarm because, for the first time, there is convergence and escalation in acceleration rates for every type of rural and urban county,” said corresponding author Lori Post, PhD, of the Feinberg School of Medicine at Northwestern. Release. “Not only the mortality rate of [opioids] at an all-time high, but the acceleration in this death rate signals explosive exponential growth that is even greater than an already historic level. That, Post said, “is going to mean mass death.”

The authors say policy makers need to look closely at available resources and treatment needs in different communities, especially because urban outreach and treatment approaches may not work in rural areas. “The only way forward,” Post said, “is to increase awareness to prevent opioid use disorder and provide drug treatment that is culturally appropriate and non-stigmatizing” in all communities.

Of The Lancet:
High potency cannabis linked to addiction and psychosis

As the acceptance of marijuana grows, it also gets stronger. This is a cause for significant concern, according to findings from the first systematic review of the research literature on the association of cannabis potency with mental health and addiction. Analyzing 20 studies on the subject, the review authors found that the higher the potency of a cannabis product – defined by the concentration of THC, the psychoactive compound that creates a high – the more likely it is to cause psychosis (characterized by a loss of contact with reality, such as hearing voices and having delusions) and cannabis use disorder (CUD).

The authors write: “The use of higher potency cannabis, relative to lower potency cannabis, is associated with an increased risk of psychosis, and this risk is higher in people who use cannabis daily. Higher potency cannabis use has also been associated with earlier onset of psychosis, more symptoms of psychosis, and increased risk of relapse. …use of more potent cannabis was also consistently associated with increased risk of CUD, recent problems with cannabis use, and severity of cannabis dependence.

“The results support recommendations to discourage the use of more potent cannabis products for low-risk use.”

—study in The Lancet

THC concentrations have been rising around the world in recent years, the authors note. In the United States and Europe, potency has more than doubled over the past decade, aided by the growth of the legal, mostly unregulated market, which has driven the development of new products such as concentrated extracts. And while legal marijuana sellers may provide information about the potency of their products, street weed usually doesn’t come with labels.

“The results support recommendations to discourage the use of more potent cannabis products for low-risk use,” the authors write. “This recommendation should be incorporated into educational tools and the management of cannabis use in clinical settings. Policymakers should carefully consider cannabis potency when regulating cannabis in legal markets, for example through limits or taxes based on THC concentration.

Of Biological psychiatry:
Links between sleep disorders and relapse

Yanhua Huang

Could a good night’s sleep be the key to avoiding relapses? A new study from the University of Pittsburgh provides insight into the interplay between rapid eye movement (REM) sleep and drug-seeking behavior and offers the potential for sleep therapies that reduce the risk of relapse. “Previously, there was a notion that poor sleep could worsen drug craving and relapse,” said lead author Yanhua Huang, PhD, “and we now offer a more granular view of specific sleep characteristics. to consider as potential biomarkers to predict relapse.”

Huang and his colleagues trained rats to self-administer cocaine and then withheld the drug, putting the rodents into withdrawal. When cocaine-associated cues were reintroduced, the rats developed “craving incubation” — an increased willingness to take the drug — and showed REM sleep disturbances. The researchers then warmed the rats’ beds to improve the continuity of their REM sleep and found a decrease in drug-seeking behavior. They also found that activating melanin-concentrating hormone (MCH)-producing neurons, which regulate REM sleep, decreased craving.

“The findings have important implications,” Huang said in a statement. “For example, when treating relapses, it is important to pay attention to improving REM sleep, complementary to current practice focused on non-REM sleep interventions. Moreover, we identified the important roles of MCH neurons in this regulation. This will provide the rationale for testing potential drugs in the future.

Photo: Matt Paul Catalano

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