Kratom Use Disorder

Nearly a third of people who use the herbal supplement kratom develop symptoms of withdrawal and tolerance that could be signs of kratom use disorder (KUD), according to a small survey by the National Institute on Drug Abuse. Withdrawal symptoms included gastrointestinal upset, restlessness, anxiety, irritability and fatigue.

Kratom comes from the leaves of a tree that grows in Southeast Asia, where it has been used for centuries as a natural stimulant and pain reliever. An estimated two million Americans use kratom to self-treat their pain, depression, anxiety and addiction.

NIDA researchers recruited 129 past and current kratom users in the U.S. to participate in the online survey, asking them about their symptoms and demographic information.

The study findings, recently published in the Journal of Addiction Medicine, found that over half of kratom users showed no signs of addiction. But 29.5% met the diagnostic criteria for KUD, such as increased use, tolerance, withdrawal, unsuccessful attempts to quit, and craving. Most reported KUD symptoms that were mild or moderate, with about one in four with KUD having severe symptoms.  

Nearly 10% of participants also reported “psychosocial impairments,” such as decreases in social, occupational, or recreational activities because of their kratom use.

“As assessed here, tolerance and withdrawal are primary KUD features rather than psychosocial impairments. As kratom is often used among persons with a myriad of health conditions, clinicians should be aware of and assess for kratom use and withdrawal,” wrote lead author Kirsten Smith, PhD, who heads much of the kratom research at NIDA.

Federal health officials have long taken a dim view of kratom and made unsuccessful attempts to ban it. In 2018, former FDA Commissioner Scott Gottlieb, MD, claimed that kratom was an opioid, addictive, and should not be used to treat any medical condition.

“Kratom use disorder” is a relatively new diagnosis and does not appear often in medical literature.  One of the first references to it is in a 2019 study that called kratom an “emerging public health threat.” Researchers said healthcare providers need to be aware that kratom use was “typically accompanied by increasing tolerance and dependence making it highly problematic.”

A kratom advocate said the new NIDA study shows the risk of kratom addiction is low and that symptoms are often mild. 

“I thought the results of this research were particularly interesting because of the growing number of addiction recovery centers expanded their service-for-hire to include kratom use disorder (KUD) and characterizes this condition as mirroring opioid use disorder (OUD) that requires intensive drug interventions of different substances,” said Mac Haddow, a lobbyist and Senior Fellow for the American Kratom Association, which represents kratom vendors and consumers.  

“Importantly, the study concludes that tolerance of kratom over time, and withdrawal from that level of dependence are the primary outcomes rather than psychosocial impairments that are largely debilitating among drug addictions. The study also recognizes that kratom continues to be a harm reduction alternative for those suffering from polydrug use addiction issues and that accounts for its increasing use as the drug overdose crisis deepens in the U.S.” 

Kratom is often used as a treatment for addiction. A 2016 PNN survey of over 6,400 kratom users found that nearly 12% used it to reduce their cravings for alcohol or opioids. Nine out of ten said kratom was “very effective” at treating their substance use disorder. And over 98% of all respondents don’t believe kratom is harmful or dangerous.

Majority of adolescents with severe substance use
disorder don’t grow out of it

While it’s estimated that 1 in 3 Americans will develop a substance use disorder in their lifetime, experts know little about the long-term outcomes for people with substance use disorder symptoms from adolescence through adulthood.
New University of Michigan research findings on the topic are grim: The majority of 18-year-olds with severe substance use disorder symptoms who were followed in a longitudinal study over 32 years still had multiple substance use disorder symptoms as adults, according to a new study from
the U-M School of Nursing.

An estimated 12% of 18-year-olds had severe substance use disorder, or SUD, symptoms.
U.S. adolescents with severe SUD symptoms were significantly more likely to report prescription drug misuse in adulthood.
The relationship between severe SUD symptoms and later SUD symptoms also held for adolescents with severe alcohol, cannabis and other drug use disorder symptoms.
Most adults in the study prescribed opioids, benzodiazepines or other sedatives/tranquilizers had multiple SUD symptoms during adolescence.
“This is a major wake-up call,” said lead author Sean Esteban McCabe, professor at the U-M School of Nursing and director of the Center for the Study of Drugs, Alcohol, Smoking, and Health. “The majority of middle-age adults being prescribed these medications had multiple substance use
disorder symptoms at age 18, raising serious concerns about the safety of prescribing controlled substances to these individuals.
“Some of the disorders and conditions we treat with these same medications are also associated with an increased risk for substance use disorder, such as anxiety disorders, sleep disorders and pain.
“We must rethink how we screen and prescribe to individuals who have multiple substance use disorder symptoms in their past, because they might need additional help to take their medication safely. For example, some people in long-term recovery from substance use disorders use ‘gatekeepers’ to help dispense and dispose of medications, and lockboxes to reduce access to only
the gatekeepers.”
Most of the people in the study did not seek treatment, and the findings suggest the need to find ways of offering treatment over long periods of time even if the person isn’t ready for help, McCabe said. Better screening, prevention and education through adulthood would also help. “Screening that accounts for polysubstance use and substance use disorder symptom severity
during adolescence can identify individuals at the greatest risk for prescription drug misuse and substance use disorder in adulthood,” McCabe said.
Additionally, insurers can assist by helping cover the time it takes for wraparound services, and counties and states can use the opioid settlement funds to invest in evidence based treatment efforts he said.

McCabe and colleagues sought to understand the association between an adolescent’s substance use disorder symptom severity and later medical use of prescription drugs, prescription drug misuse and substance use disorder symptoms at ages 35-50.
Eleven cohorts of 12th graders were followed from age 18 to age 50 in the Monitoring the Future study, one of the nation’s most relied upon sources of information on emerging trends in illicit drug, alcohol and tobacco use among American adolescents, college students and young and middle aged adults.
Subsequent studies will examine the role of stimulant and nonstimulant medication to treat ADHD and the later misuse of stimulants and other drugs

Overdose Deaths Exceed 100,000 this year for the First Time

NEW YORK (AP) — An estimated 100,000 Americans died of drug overdoses in one year, a never-before-seen milestone that health officials say is tied to the COVID-19 pandemic and a more dangerous drug supply.

Overdose deaths have been rising for more than two decades, accelerated in the past two years and, according to new data posted Wednesday, jumped nearly 30% in the latest year.

President Joe Biden called it “a tragic milestone” in a statement, as administration officials pressed Congress to devote billions of dollars more to address the problem.

“This is unacceptable and it requites an unprecedented response,” said Dr. Rahul Gupta, director of National Drug Control Policy.

Experts believe the top drivers of overdose deaths are the growing prevalence of deadly fentanyl in the illicit drug supply and the COVID-19 pandemic, which left many drug users socially isolated and unable to get treatment or other support.

The number is “devastating,” said Katherine Keyes, a Columbia University expert on drug abuse issues. “It’s a magnitude of overdose death that we haven’t seen in this country.”

Drug overdoses now surpass deaths from car crashes, guns and even flu and pneumonia. The total is close to that for diabetes, the nation’s No. 7 cause of death.

Drawing from the latest available death certificate data, the Centers for Disease Control and Prevention estimated that 100,300 Americans died of drug overdoses from May 2020 to April 2021. It’s not an official count. It can take many months for death investigations involving drug fatalities to become final, so the agency made the estimate based on 98,000 reports it has received so far.

The CDC previously reported there were about 93,000 overdose deaths in 2020, the highest number recorded in a calendar year. Robert Anderson, the CDC’s chief of mortality statistics, said the 2021 tally is likely to surpass 100,000.

“2021 is going to be terrible,” agreed Dr. Daniel Ciccarone, a drug policy expert at the University of California, San Francisco.

The new data shows many of the deaths involve illicit fentanyl, a highly lethal opioid that five years ago surpassed heroin as the type of drug involved in the most overdose deaths. Dealers have mixed fentanyl with other drugs — one reason that deaths from methamphetamines and cocaine also are rising.

Drug cartels in Mexico are using chemicals from China to mass produce and distribute fentanyl and meth across America, said Anne Milgram, administrator of the Drug Enforcement Administration.

This year, the DEA has seized 12,000 pounds of fentanyl, a record amount, Milgram said. But public health experts and even police officials say that law enforcement measures will not stop the epidemic, and more needs to be done to dampen demand and prevent deaths.

The CDC has not yet calculated racial and ethnic breakdowns of the overdose victims.

It found the estimated death toll rose in all but four states — Delaware, New Hampshire, New Jersey and South Dakota — compared with the same period a year earlier. The states with largest increases were Vermont (70%), West Virginia (62%) and Kentucky (55%).

Minnesota saw an increase of about 39%, with estimated overdose deaths rising to 1,188 in May 2020 through April 2021 from 858 in the previous 12-month period.

The area around the city of Mankato has seen its count of overdose deaths rise from two in 2019, to six last year to 16 so far this year, said police Lt. Jeff Wersal, who leads a regional drug task force.

“I honestly don’t see it getting better, not soon,” he said.

Alcoholics Anonymous: The Evidence is In !

An Updated review shows it performs better than some other common treatments and is less expensive.

For a long time, medical researchers were unsure whether Alcoholics Anonymous worked better than other approaches to treating people
with alcohol use disorder. In 2006, a review of the evidence concluded we didn’t have enough evidence to judge.
That has changed.
An updated systematic review published Wednesday by the Cochrane Collaboration found that A.A. leads to increased rates and lengths of
abstinence compared with other common treatments
. On other measures, like drinks per day, it performs as well as approaches provided
by individual therapists or doctors who don’t rely on A.A.’s peer connections.
What changed? In short, the latest review incorporates more and better evidence. The research is based on an analysis of 27 studies
involving 10,565 participants.
The 2006 Cochrane Collaboration review was based on just eight studies, and ended with a call for more research to assess the program’s
efficacy. In the intervening years, researchers answered the call. The newer review also applied standards that weeded out some weaker
studies that drove earlier findings.
In the last decade or so, researchers have published a number of very high-quality randomized trials and quasi-experiments. Of the 27
studies in the new review, 21 have randomized designs. Together, these flip the conclusion.
“These results demonstrate A.A.’s effectiveness in helping people not only initiate but sustain abstinence and remission over the long
term,” said the review’s lead author, John F. Kelly, a professor of psychiatry at Harvard Medical School and director of the Recovery
Research Institute at Massachusetts General Hospital. “The fact that A.A. is free and so widely available is also good news.
“It’s the closest thing in public health we have to a free lunch.”
Studies generally show that other treatments might result in about 15 percent to 25 percent of people who remain abstinent. With A.A., it’s
somewhere between 22 percent and 37 percent (specific findings vary by study). Although A.A. may be better for many people, other
approaches can work, too. And, as with any treatment, it doesn’t work perfectly all the time.
Rigorous study of programs like Alcoholics Anonymous is challenging because people self-select into them. Those who do so may be more
motivated to abstain from drinking than those who don’t.
Unless a study is carefully designed, its results can be driven by who participates, not by what the program does. Even randomized trials
can succumb to bias from self-selection if people assigned to A.A. don’t attend, and if people assigned to the control group do. (It may go
without saying, but we’ll say it: It would be unethical to prevent people in a control group from attending Alcoholics Anonymous if they
wanted to.)
Despite these challenges, some high-quality randomized trials of Alcoholics Anonymous have been conducted in recent years. One,
published in the journal Addiction, found that those who were randomly assigned to a 12-step-based directive A.A. approach, and were
supported in their participation, attended more meetings and exhibited a greater degree of abstinence, compared with those in the other
treatment groups. Likewise, other randomized studies found that greater Alcoholics Anonymous participation is associated with greater
alcohol abstinence.

Alcoholics Anonymous is often paired with other kinds of treatment that encourage engagement with it. “For people already in treatment,
if they add A.A. to it, their outcomes are superior than those who just get treatment without A.A.,” said Keith Humphreys, a Stanford
University professor and co-author of the new Cochrane review.
Alcoholics Anonymous not only produced higher rates of abstinence and remission, but it also did so at a lower cost, the Cochrane review
found. A.A. meetings are free to attend. Other treatments, especially those that use the health care system, are more expensive.
One study found that compared with Alcoholics Anonymous participants, those who received cognitive behavioral treatments had about
twice as many outpatient visits — as well as more inpatient care — that cost just over $7,000 per year more in 2018 dollars. (Cognitive
behavioral treatments help people analyze, understand and modify their drinking behavior and its context.)
Another study found that for each additional A.A. meeting attended, health care costs fell by almost 5 percent, mostly a result of fewer
days spent in the hospital and fewer psychiatric visits.
A.A. meetings are ubiquitous and frequent, with no appointment needed — you just show up. The bonds formed from the shared challenge
of addiction — building trust and confidence in a group setting — may be a key ingredient to help people stay on the road to recovery.
Worldwide, alcohol misuse and dependence are responsible for 3.3 million deaths per year, 10 times the number of fatalities from all illicit
drugs combined.
In the United States, alcohol is a larger killer than other drugs; accounts for the majority of all addiction treatment cases; and is
responsible for at least $250 billion per year in lost productivity and costs related to crime, incarceration and health care. Moreover,
American deaths related to alcohol more than doubled between 1999 and 2017.
Reducing the human and financial burdens of alcohol is an often overlooked public health priority, and the new evidence suggests that on
balance one of the oldest solutions — Alcoholics Anonymous has been around almost 85 years — is still the better one.

Austin Frakt is director of the Partnered Evidence-Based Policy Resource Center at the V.A. Boston Healthcare System; associate professor with Boston University’s School of
Public Health; and a senior research scientist with the Harvard T.H. Chan School of Public Health. He blogs at The Incidental Economist, and you can follow him on Twitter @afrakt
Aaron E. Carroll is a professor of pediatrics at Indiana University School of Medicine and the Regenstrief Institute who blogs on health research and policy at The Incidental
Economist and makes videos at Healthcare Triage. He is the author of “The Bad Food Bible: How and Why to Eat Sinfully.” @aaronecarrol

Predisposition to addiction may be genetic, study finds

People who have a high sensation-seeking personality trait may be more likely to develop an addiction to cocaine, according to a Rutgers study.

Although many people try illicit drugs like cocaine or heroin, only a small proportion develop an addiction,” said lead author Morgan James, a member of the Rutgers Brain Health Institute and an assistant professor in the department of psychiatry at Rutgers Robert Wood Johnson Medical School. “The interaction found between sensation-seeking traits and the drug-taking experience show that predisposition to addiction has a genetic basis, and that this interacts with environmental factors such as patterns of drug use. The sensation-seeking trait was predictive of rats’ likelihood to exhibit stronger motivation for drugs when we gave them the opportunity to take cocaine.”

The findings, published in the journal Neuropharmacology, shed light on what predisposes people to addiction and may help with substance use screening and treatment.

The lab study found that high sensation-seeking rats — those with a strong desire for new experiences and a willingness to take risks to be stimulated — were more prone to developing behavior that reflects human addiction. The findings suggest that high sensation-seeking people have a greater risk of losing control over their drug intake, which makes them more vulnerable to drug addiction.

A major goal of addiction research is to identify behavioral biomarkers that predict addiction vulnerability. Future studies can build on these findings to determine what is different in the brains of those who are high sensation-seeking to see what predisposes them to addiction.

Alcohol Related Deaths Increasing in the United States

An analysis of U.S. death certificate data by researchers at the National Institute on Alcohol Abuse and Alcoholism (NIAAA), part of the National Institutes of Health, found that nearly 1 million people died from alcohol-related causes between 1999 and 2017. The number of death certificates mentioning alcohol more than doubled from 35,914 in 1999 to 72,558 in 2017, the year in which alcohol played a role in 2.6% of all deaths in the United States. The increase in alcohol-related deaths is consistent with reports of increases in alcohol consumption and alcohol-involved emergency department visits and hospitalizations during the same period. The new findings are reported online in the journal Alcoholism: Clinical and Experimental Research. “Alcohol is not a benign substance and there are many ways it can contribute to mortality,” said NIAAA Director Dr. George F. Koob. “The current findings suggest that alcohol-related deaths involving injuries, overdoses, and chronic diseases are increasing across a wide swath of the population. The report is a wakeup call to the growing threat alcohol poses to public health.”

Two illustrations of the human liver. left: a healthy liver; right: a liver showing signs of cirrhosis

 In the new study, Aaron White, Ph.D., senior scientific advisor to the NIAAA director, and colleagues analyzed data from all U.S. death certificates filed from 1999 to 2017.  A death was identified as alcohol-related if an alcohol-induced cause was listed as the underlying cause or as a contributing cause of death.  The researchers found that, in 2017, nearly half of alcohol-related deaths resulted from liver disease (31%; 22,245) or overdoses on alcohol alone or with other drugs (18%; 12,954). People aged 45-74 had the highest rates of deaths related to alcohol, but the biggest increases over time were among people age 25-34. High rates among middle-aged adults are consistent with recent reports of increases in “deaths of despair,” generally defined as deaths related to overdoses, alcohol-associated liver cirrhosis, and suicides, primarily among non-Hispanic whites. However, the authors report that, by the end of the study period, alcohol-related deaths were increasing among people in almost all age and racial and ethnic group. As with increases in alcohol consumption and related medical emergencies, rates of death involving alcohol increased more for women (85%) than men (35%) over the study period, further narrowing once large differences in alcohol use and harms between males and females. The findings come at a time of growing evidence that even one drink per day of alcohol can contribute to an increase in the risk of breast cancer for women. Women also appear to be at a greater risk than men for alcohol-related cardiovascular diseases, liver disease, alcohol use disorder, and other consequences. “Alcohol is a growing women’s health issue,” said Dr. Koob. “The rapid increase in deaths involving alcohol among women is troubling and parallels the increases in alcohol consumption among women over the past few decades.” The authors note that previous studies have shown that the role of alcohol in deaths is vastly underreported. Since the present study examined death certificates only, the actual number of alcohol-related deaths in 2017 may far exceed the 72,558 determined by the authors.     “Taken together,” said Dr. Koob, “the findings of this study and others suggests that alcohol-related harms are increasing at multiple levels – from ED visits and hospitalizations to deaths. We know that the contribution of alcohol often fails to make it onto death certificates. Better surveillance of alcohol involvement in mortality is essential in order to better understand and address the impact of alcohol on public health.” Reference: Aaron White, PhD, I-Jen P. Castle, PhD, Ralph Hingson, ScD, Patricia Powell, PhD. Using death certificates to explore changes in alcohol-related mortality in the United States, 1999–2017 Alcoholism: Clinical and Experimental Research. Published online January 8, 2020