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The ASAM Weekly for June 25th, 2024

Jun 27, 2024

This Week in the ASAM Weekly

The HEALing Communities Study brought 617 evidence-based practices for reducing opioid-related overdose deaths to 67 communities across four states making it the largest addiction prevention and treatment implementation study ever conducted. Unfortunately, it did not result in a reduction in opioid-related overdose deaths, but it did demonstrate how to successfully implement an ambitious, complex, and comprehensive prevention strategy just before a global pandemic and during the rise of a fentanyl crisis- all within 10 months (NEJM).

There is always more to learn and gain from implementing evidence-based strategies. MOUD reduces the risk of an opioid overdose, but not nearly enough Americans receive MOUD or naloxone after a non-fatal drug overdose (JAMA Internal Medicine). Some Canadian politicians are pushing back against safer supply programs expecting immediate results from harm-reduction efforts even though many spent decades waiting for the war on drugs to fail (Medscape). Evan a case report about the effectiveness of injectable buprenorphine in a seventeen-year-old illustrates some of the barriers to adolescent care in the US (Journal of Adolescent Health).

Furthermore, France can teach us something about reducing overdose deaths. An analysis of their approach to methadone access demonstrates how policies and practices that emphasize engagement rather than abstinence can be successfully implemented across the entire healthcare continuum (International Journal of Drug Policy).

But when it comes to methadone access, France is just one example of many, and there is overwhelming scientific evidence showing that America’s policies need to change (Lexington Herald Leader). In fact, there’s enough scientific evidence on this that it’s more than just evidence-based, it’s common sense.

Nicholas Athanasiou, MD, MBA, DFASAM
Editor in Chief

with Co-Editors: Brandon Aden, MD, MPH, FASAM, Jack Woodside, MD, John A. Fromson, MD

Invitation to Review: ASAM Draft Clinical Practice Guideline on Benzodiazepine Tapering

Through July 19th, the American Society of Addiction Medicine (ASAM) has made available for public comment a draft of its Clinical Practice Guideline on Benzodiazepine Tapering. For more information and instructions to review, please click here.

Lead Story

Community-Based Cluster-Randomized Trial to Reduce Opioid Overdose Deaths

The New England Journal of Medicine

HEALing (Helping to End Addiction Long-term Initiative) Communities Study (HCS) investigators examined the potential of the community-engaged, data-driven Communities That HEAL (CTH) intervention to reduce the rate of opioid-related overdose deaths in highly affected communities. Intervention communities implemented hundreds of strategies to expand opioid overdose education and naloxone distribution, the use of medications for opioid use disorder, and safety measures for prescription opioid use, as well as communication campaigns to support these efforts. Although there were no significant between-group differences in the rate of opioid-related overdose deaths, the trial showed that the CTH community-engaged intervention, with its leveraging of community coalitions and a data-driven approach, can bring about meaningful progress in implementing evidence-based practices.

ASAM Clinical Algorithm Subcommittee
CALL FOR APPLICATIONS!

The ASAM Clinical Algorithm Subcommittee is looking for members to collaborate on refining the 4^th Edition clinical algorithms for ASAM Criteria-based assessment tools! Click the link below to learn more and apply.

Applications Deadline Extension: June 30, 2024

Apply Here

Research and Science

Overdose, Behavioral Health Services, and Medications for Opioid Use Disorder After a Nonfatal Overdose

JAMA Internal Medicine

In this cohort study of 136,762 Medicare beneficiaries with an index nonfatal drug overdose, subsequent nonfatal and fatal drug overdoses were observed. Subsequent nonfatal drug overdose and an opioid use disorder diagnostic code were associated with increased risk for fatal drug overdose, whereas receipt of a naloxone prescription, methadone, or buprenorphine treatment for opioid use disorder as well as behavioral health services were associated with decreased risk. Findings of this study suggest the need to improve access to behavioral health services; medications for opioid use disorder (MOUD); and overdose-prevention strategies, such as prescribing naloxone and linking individuals to community-based health care settings for ongoing care.

Electronic Cigarettes vs Varenicline for Smoking Cessation in Adults

JAMA Internal Medicine

This study explored the relative effectiveness of nicotine-containing electronic cigarettes (ECs) and varenicline as smoking cessation aids. Using a randomized, double-blinded, double-dummy, placebo-controlled trial that included 458 adults with moderate to heavy dependence on nicotine who were motivated to quit smoking traditional cigarettes, nicotine-containing ECs and varenicline were both effective in helping participants to stop smoking for up to 6 months. The results of this randomized clinical trial indicated that nicotine-containing ECs seem to be an effective option as smoking cessation treatment for adults who smoke traditional cigarettes.

Evaluation of a Digital Tool for Detecting Stress and Craving in SUD Recovery: An Observational Trial of Accuracy and Engagement

Drug and Alcohol Dependence

This study recorded physiologic data to assess stress and craving in patients in treatment for SUDs. Fifty patients were recruited and asked to wear a commercially available smartwatch for 30 days and to log episodes of stress and craving. The smartwatch transmitted accelerometer data, heart rate, and heart rate variability to a smartphone application that recorded the data and was used by participants to log self-reported episodes of stress and craving. Only 30 (60%) of patients completed the 30-day trial. The physiologic data were analyzed with a machine learning tool that was able to predict 76% of episodes of stress and 69% of episodes of craving. There were also false positive predictions 33% and 28% of the time, respectively. A majority of participants (75%) felt the app was helpful in their recovery. The goal is that detection of stress or craving episodes could trigger real-time interventions to support patients.

Insomnia symptoms and neurofunctional correlates among adults receiving buprenorphine for opioid use disorder 🔓

PLOS One

This study investigated the role of insomnia in the recovery of patients with OUD treated with buprenorphine. Participants receiving outpatient treatment with buprenorphine for an average of 2.5 years (n=129) completed assessments of insomnia severity and 6 neurofunctional domains. Sixty percent had clinically significant insomnia symptoms. Insomnia was associated with depression, anxiety, stress intolerance, post-traumatic stress, and poor frustration tolerance. The patients also believed that poor sleep was interfering with their OUD treatment. The authors contend that these neurofunctional features associated with insomnia are not conducive to OUD recovery.

**CO*RE REMS/ASAM Striking a Balance: Podcast Series**

This free series consists of three 45-minute podcasts designed to empower clinicians to confidently manage opioid analgesics, from patient assessment and therapy initiation to modification, discontinuation, and patient counseling.

Learn More

Learn More

Comparing methadone policy and practice in France and the US: Implications for US policy reform

International Journal of Drug Policy

While methadone is known to be an effective treatment for opioid use disorder (OUD) access is still very limited in the United States, largely due to policies and regulation. Relative to the US, France has widespread access and high rates of OUD treatment with methadone. The authors compare policies in the US and France as efforts are underway in the US to change policy and increase access to methadone. In France, methadone is regulated like other medications and can be dispensed in any pharmacy. Treatment is initiated in treatment programs and hospitals and then can be continued by any primary care provider. There are no legal restrictions on dosing or in-person visit requirements, and there are multiple dosing formulations. Given the relative success in France, the authors note there are significant lessons to be gleaned from their model for practice in the US.

Early Remission of Opioid Use Disorder in an Adolescent Using Buprenorphine Extended – Release Subcutaneous Injection: A Case Report 🔓

Journal of Adolescent Health

Opioid overdoses and opioid use disorder (OUD) have increased significantly among adolescents and young adults (AYA), but many in these populations do not receive evidence-based treatment with buprenorphine. While sublingual and transdermal formulations of buprenorphine are approved for AYA, extended-release injectable buprenorphine (XR-BUP) has not been FDA-approved for those under 18. In this case study, the authors report on a case of a 17-year-old with moderate OUD who initiated treatment on sublingual buprenorphine and then transitioned to XR-BUP. The patient did well with the XR-BUP: the authors contend additional research is needed and XR-BUP may be a valuable additional treatment option for this population.

Association between cannabis potency and mental health in adolescence 🔓

Drug and Alcohol Dependence

Studies in adults have shown that high-potency cannabis is associated with an increased risk of psychosis. This study, including 6,612 participants, randomly distributed a questionnaire in schools in England and Wales. The average respondent age was 14 years. Cannabis potency was assessed by asking what type of cannabis was used (such as herbal, hashish, or cannabis concentrate): photographs were used to assist in identification. Of those using cannabis, 82% were using high-potency cannabis. Participants using high-potency cannabis had three times the risk of depression, anxiety, and auditory hallucinations (p<0.001). They conclude that more attention should be paid to cannabis potency.

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