This Week in the ASAM Weekly

For some reason(s), buprenorphine treatment has been declining in recent years among youth in the US, even though opioid-associated mortality hasn’t. Comparing recent buprenorphine dispensing data across age-groups highlights a striking contrast: 45% decline in youth vs. a 47% increase in adults (Pediatrics). Medicare beneficiaries also encounter significant imbalances in the opioid use disorder (OUD) treatment gap but for different reasons. The cost-savings from improving their treatment access (not to mention lives saved) could reach almost $5 billion (Drug and Alcohol Dependence).

Understanding the puzzle of events leading to an overdose death is an important challenge of the opioid crisis. One study analyzed individual prescription data (opioids and benzodiazepines) with post-mortem toxicology and found the two were often not concordant but still tragically linked (Drug and Alcohol Dependence). Another investigation found that over 30% of unintentional opioid-overdose deaths in Illinois involved alcohol (JAMA Network Open). Both underscore the growing challenge of polysubstance use in the current crisis.

Bridging data from different perspectives will often lead us to harm reduction and the creative craft of public health messaging. How do we convey the risks of family history and high-intensity drinking to an 11th grader? (JAMA Pediatrics). Was it serendipitous that “Yes We nar-Can” fits on a bumper sticker? (NBC Philadelphia). What can we do to improve the distribution of fentanyl test strips through local pharmacies where it is legal? (Harm Reduction Journal)

Obviously, borrowed slogans like “Got fentanyl test strips?” or “Just Test It.” wouldn’t do the trick -- or would they?

Thanks for reading,

Nicholas Athanasiou, MD, MBA, DFASAM
Editor in Chief

with Co-Editors: Brandon Aden, MD, Debra R. Newman, PA-C, MSPAS, MPH, Jack Woodside, MD, John A. Fromson, MD

Lead

Buprenorphine Dispensing Among Youth Aged ≤19 Years in the United States: 2015–2020

Pediatrics

Opioid related overdose among adolescents and young adults in the United States is rising. Medications for opioid use disorder (MOUD), including buprenorphine, can reduce the risk of overdose; however, they are underutilized. Given rates of opioid use disorder (OUD) among youth, these findings suggest that many young people who could benefit from MOUD are not receiving it. Pediatricians could play a role in expanding access to MOUD for this high-risk population. Efforts to expand access to MOUD for adolescents could include improving pediatrician training in OUD treatment and encouraging all clinicians who care for adolescents and young adults to prescribe buprenorphine for MOUD.

Call for Reviewers

The Journal of Addiction Medicine is seeking to expand its cadre of manuscript reviewers. We are seeking reviewers with expertise in the following areas: Stimulants, Psychiatric epidemiology, Qualitative methodology, Genetics, Neurology, Emerging substances, Kratom, Novel Psychoactive Substances, Psychedelics, New pharmaceutical treatments, Toxicology, Criminal justice and addiction medicine, Machine Learning, Pain and Palliative Care, Adolescent Medicine, Maternal Child Health, and Behavioral Addictions. View the full opportunity here.

Research and Science

The cost of opioid use disorder-related conditions in Medicare

Drug and Alcohol Dependence

Approximately 1 million Medicare beneficiaries have opioid use disorder (OUD), and this number is increasing. However, Medicare does not cover all substance use disorder (SUD) treatments, and in 2020 only 16% received medications for OUD (MOUD). In this study, the authors examine the potential cost savings of expanding Medicare coverage for OUD. The authors conducted attributable cost analysis for comorbid conditions associated with OUD and estimated $1.8 billion for those beneficiaries below age 65 and $2.9 billion for those 65 and older. The potential cost offsets for expanding OUD treatment were $3.0-4.7 billion depending on assumptions about elimination of comorbid conditions with treatment. Of note, this analysis does assume that if coverage was expanded all members would have access to treatment, but the cost savings would be less depending on the percentage who received care.

Concordance Between Controlled Substance Receipt and Post-mortem Toxicology in Opioid-detected Overdose Deaths: A Statewide Analysis

Drug and Alcohol Dependence

This study identified 1412 deaths in Connecticut in 2016-2017 where an opioid was detected. The authors consulted the prescription monitoring database to see if an opioid and/or benzodiazepine had been prescribed in the 90 days before death. The study found that of these deaths, 47% received a prescription for an opioid and/or benzodiazepine (36% opioid, 27% benzodiazepine). However, only 17% of the prescribed opioids and 21% of the prescribed benzodiazepines appeared on post-mortem toxicology (PMT). A non-pharmaceutical opioid (heroin or fentanyl) was detected on PMT in 85% of the opioid deaths. A benzodiazepine was detected on PMT in 37% of the opioid deaths. The authors conclude that a prescribed opioid and/or benzodiazepine may have contributed to a substantial number (although an overall minority) of opioid deaths, highlighting the importance of safe opioid and benzodiazepine prescribing.

Initiation of and Escalation to High-Intensity Drinking in Young Adults

JAMA Pediatrics

Survey data from participants who reported alcohol use within the past 30 days were analyzed using the 2018 12^th grade Monitoring the Future study followed by the Young Adult Life study. Measures included year drinking began, first binge (≥5 drinks), and high intensity drinking (HID, intake ≥10 drinks). Later, at age 20, measures included weekly alcohol consumption, HID frequency, and Alcohol Use Disorders Identification Test (AUDIT) scores. Family history was associated with earlier HID initiation; earlier HID initiation was in turn associated with higher alcohol consumption, more frequent HID, and symptoms of alcohol use disorder at age 20. These factors may assist with appropriate screening for adolescents and young adults.

Racial and Ethnic Disparities in Emergency Department‐Initiated Buprenorphine Across 5 Healthcare Systems

Academic Emergency Medicine

Emergency departments (ED) offer an important opportunity for intervention and initiation of treatment for patients with opioid use disorder (OUD). In this study, the authors conducted a secondary analysis of a prior study to evaluate racial and ethnic differences in initiation of buprenorphine (BUP) for patients presenting with an OUD-related ED visit. Overall, 12.2% of patients received BUP, but Black patients (8.9%) were less likely (OR 0.64, p<0.05) to receive BUP than White patients (13.1%). Hispanic patients were more likely (OR 1.41, p-=0.01) to receive BUP than non-Hispanic patients. However, these differences were attenuated when controlling for OUD discharge diagnosis. The study’s findings are consistent with other studies and support additional focus on disparities in ED treatment and diagnosis of OUD.

Learn More

Five ways ‘health scholars’ are complicit in upholding health inequities, and how to stop 🔓

International Journal for Equity in Health

The commentary identifies five mental models that perpetuate the status quo and contribute to the inequities in research institutions. 1) Euphemisms are indirect words or expressions that allow for understating root causes of inequity and perpetuating those systems. 2) Middle ground refers to the tendency to avoid conflict and remaining neutral or “hearing all sides” which limits progress. 3) Distraction is continuously moving the goal post, with demands for additional data, committees, etc., without making any real change. 4) Mystery involves not being able to comprehend or articulate the problem (e.g., it is “too complex”) and thus not addressing the problem. 5) Capacity is the narrative that equity is beyond our capabilities and forgetting our skills when it comes to addressing racism. Interrupting these models could open us to engaging in actions leading to real and sustained changes.

North Carolina pharmacists’ willingness to sell fentanyl test strips: a survey study 🔓

Harm Reduction Journal

An email invitation was sent to the 4644 community pharmacists in North Carolina inviting them to complete a survey about providing fentanyl test strips (FTS). Surveys were completed by 592 (13%). Most pharmacists were willing to refer patients to harm reduction organizations (87%), sell FTS (79%), and advertise FTS for sale (63%). Only 36% felt comfortable initiating a conversation about FTS. Reducing overdose deaths was the most commonly perceived benefit (81%). Perceived barriers included not knowing where to order FTS (50%), lack of time to educate about FTS (46%), and not wanting to attract individuals with substance use disorder to the pharmacy (42%). The authors conclude pharmacists “could be an incredible resource to reduce harm.”

Prevalence of Alcohol in Unintentional Opioid Overdose Deaths, 2017-2020 🔓

JAMA Network Open

This study investigated the prevalence of alcohol in opioid overdose deaths (OODs) from July 1, 2017, to December 31, 2020, in Illinois. Over 30% of unintentional OODs involved alcohol. The prevalence of alcohol use in OODs was higher for men than women, for non-Hispanic Black and Hispanic decedents than White decedents, and for decedents aged 55 years or older than decedents younger than 55 years. There were no significant changes associated with COVID-19 policy changes. This suggests that alcohol may be viewed differently than illicit substances by individuals who use opioids and by treating clinicians and given alcohol’s detrimental effect on the liver and the high rates of hepatitis C among individuals who inject drugs.

Inpatient Low-dose Transitions From Full Agonist Opioids Including Methadone Onto Long-acting Depot Buprenorphine: Case Series From a Multicenter Clinical Trial

Journal of Addiction Medicine

The inpatient setting is a unique and underutilized environment to concomitantly treat infections related to injection drug use and start medications for opioid use disorder (MOUD). The COMMIT Trial (Coordinated Medical Treatment of Opioid Use Disorder and Infectious Disease) tests this model of care, where OUD and its related infections are managed by infection disease specialists and hospitalists using long-acting buprenorphine (LAB). In the present study, a case series of participants from this trial underwent transition from full agonist opioids, including methadone, to LAB via low-dose transition. Low-dose transitions onto LAB for patients with serious comorbidities were found to be safe and well tolerated and accelerated treatment.