Plus: The effect of lowered barriers to buprenorphine, and how menthol drives youth smoking
By Mark Mravic
It’s easy to get overwhelmed by the sheer volume of data regarding the opioid crisis—prescription rates, misuse risks, illicit trafficking, outcome measures, overdose deaths. How to make sense of it all? A team of Boston-area researchers hopes their project, which pulls all of these elements and more into a new mathematical model of opioid use, can yield a big-picture account of where the crisis stands now, and where it’s headed.
Also this week, a study out of Philadelphia finds that the pandemic-driven easing of medication-assisted treatment (MAT) restrictions kept more people in treatment, and UC San Diego researchers offer more evidence to support a menthol ban.
A Data-Driven Model for the Evolving Opioid Epidemic
One of the thorniest issues in the opioid crisis is data—how to gather it, synthesize it and act on it. Scientists from Massachusetts General Hospital, Harvard, MIT and the Food and Drug Administration (FDA) hope to bring greater clarity and consistency to the vast waves of information surrounding opioid use in the U.S. through SOURCE (Simulation of Opioid Use, Response, Consequences, and Effects), a data-driven model meant to help stakeholders understand and address the crisis. As described in a recent study in the journal PNAS, SOURCE analyzes how a multitude of inputs (such as prescribing rates, overdose prevention measures and treatment availability) and feedback mechanisms (including the perception of risk and the spread of drug use through social exposure) influence the evolution of opioid use and overdose in the U.S.
For instance, SOURCE looked at two competing factors in the major shift in overdose deaths since the mid-2010s: the increasing penetration of illicit fentanyl into the heroin supply, and efforts to expand access to the overdose-reversal drug naloxone. While SOURCE calculates that the overdose risk in 2020 would have been 18% higher in the absence of naloxone efforts, illicit fentanyl’s influence was more than four times as powerful in the other direction—overdoses would have been 85% lower in the absence of illegal fentanyl. The model also explains why overdose deaths continue to soar even as rates of opioid misuse initiation have been on the decline—fentanyl is that deadly.
“SOURCE replicates how the risks of opioid misuse have evolved over time … providing a platform for projecting and analyzing potential policy impacts and solutions.”—Tse Yang Lim, MIT
There is a faint silver lining to SOURCE’s projections: After a few more years of rising opioid deaths, the model sees overdose numbers finally beginning to fall as the risks become more evident. Nevertheless, the study says total projected opioid overdose deaths will remain high, ranging from 543,000 from 2020 through 2032 in the optimistic scenario to 842,000 in the more pessimistic case.
Says MIT’s Tse Yang Lim, PhD, a co-author of the study, “Unlike other national models of the crisis, SOURCE replicates how the risks of opioid misuse have evolved over time in response to various behavioral and other factors, and how they may change in the future, providing a platform for projecting and analyzing potential policy impacts and solutions.”
SOURCE is now being beta-tested to project impacts of potential policy proposals and analyze intervention strategies. The authors say they’ve also made it available for use by nonprofits, researchers, government agencies and other stakeholders.
From Drug and Alcohol Dependence Reports:
Better Outcomes with Eased Buprenorphine Restrictions
In response to the COVID-19 pandemic, the federal government dramatically eased restrictions on MAT for opioid use disorder (OUD), lifting requirements for in-person visits and urine screening and allowing lengthier prescriptions and more time between appointments. How did that impact keeping people in treatment once they started?
To answer the question, researchers from Drexel University analyzed records for 506 patients who underwent buprenorphine treatment for OUD at Prevention Point Philadelphia, a harm reduction center, between 2018 and 2020. The cohort was divided into three groups. One, the control, ended treatment before March 13, 2020, when buprenorphine barriers were lowered. The other two groups began treatment under the new, relaxed guidelines—patients who had access to phones underwent full telemedicine treatment; while patients without phones would return to the center to access virtual appointments with an off-site provider.
The effect of the eased rules was notable: While the pre-COVID control group on average remained in treatment for about 23 days, the COVID group without phones was retained for an average of 78 days—and all of the patients in the fully telemedicine group remained in treatment (as defined by the study) throughout the six-month period analyzed.
“We treated the policy changes as a natural experiment and compared treatment outcomes before and after they took effect,” said lead author Kathleen Ward, MSPH, CHES, a doctoral research fellow at Drexel’s Urban Health Collaborative. “We found the lessened restrictions were associated with people remaining in care for a longer period of time. This is a really important finding in support of these policy changes.” Noting the disparity between the group with phones and the group without them, the authors also called for increased access to digital technology for vulnerable patients, such as those experiencing homelessness.
From JAMA Network:
Menthol Cigs and Kids
Add yet more evidence to support the growing movement to ban menthol flavoring in cigarettes. Researchers from the University of California San Diego analyzed data from the nationally representative Population Assessment of Tobacco and Health study to examine menthol use among young people. Their study found that 56%—a majority—of young people age 12 to 17 who smoked used menthol cigarettes over non-menthol products. In addition, youth who smoked menthol smoked more often (a mean of 12.8 days, compared to 9.4 for non-menthol smokers), were at greater risk of being “frequent” smokers and were more nicotine dependent.
“The ‘cooling’ sensation of menthol masks the harshness of tobacco, which can make cigarettes more palatable to youth,” said lead author Eric Leas, PhD, MPH. “Additionally, this cooling sensation can allow smoke to be inhaled deeper and held for longer, which can result in a greater absorption of nicotine per puff.” Added senior author John P. Pierce, PhD, “These results provide strong support for the FDA-proposed ban on menthol flavoring in cigarettes to protect our youth.”
Photo: Nicholas Cappello