The ASAM Weekly for October 22nd, 2024

This Week in the ASAM Weekly

Higher doses of buprenorphine are better. This according to a NIDA-funded study (and others) demonstrating that buprenorphine doses of 16-24 mg and beyond are dose-dependently associated with less behavioral health emergencies than doses below 16 mg (JAMA Network Open).

MunichBREW will not be on tap at Oktoberfest. That’s because it’s actually a study demonstrating how binge drinking in healthy, young adults is associated with an array of irregular heart rhythms, both during and after drinking episodes. Known as “holiday heart syndrome," it apparently lacks a German translation - according to Google AI (European Heart Journal).

Snus should be seen as a “key element in tobacco harm reduction." Lars M. Ramstrom, who has published prolifically on the topic, makes the case based on Sweden’s low level of smoking-related mortality (Harm Reduction Journal). 

We need a reliable marker for alcohol intake. It’s too bad phosphatidylethanol has its limitations because it seems to work as a cut-off for hazardous drinking when paired with self-report (Alcohol and Alcoholism). 

In case you missed it, the DEA is warning about illicitly contaminated “medications” being sold through online pharmacies (The Atlanta Journal - Constitution). Emergency departments are adjusting to the withdrawal challenges of “tranq dope” and improving retention (The Conversation). San Francisco is taking OUD telehealth to the 2.0 level with a night navigation team providing tele-care until midnight (San Francisco Examiner). 

All this information about helping people and saving lives, in less than a two-minute read!

Thanks for reading,

Nicholas Athanasiou, MD, MBA, DFASAM
Editor in Chief

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

Lead Story 

Association of Daily Doses of Buprenorphine With Urgent Health Care Utilization 🔓

JAMA Network Open 
(30 SEC READ)

This cross-sectional study using health care claims data from 35,451 US adults with an opioid use disorder diagnosis assessed whether buprenorphine treatment using doses higher than Food and Drug Administration recommendations is associated with subsequent acute health care utilization. Those receiving higher maximum doses of buprenorphine (i.e., doses above 16 mg and 24 mg) had significantly lower rates of acute care utilization than their peers receiving FDA-recommended doses (between 8 mg and 16 mg). These results suggest that higher doses of buprenorphine are associated with lower acute care utilization and could provide benefits to patients, particularly those using fentanyl who might need these higher doses. 

Research and Science 

Acute Alcohol Consumption and Arrhythmias in Young Adults: The MunichBREW II Study 🔓

European Heart Journal
(30 SEC READ)

Excessive acute alcohol intake (binge-drinking) has been associated with cardiac arrythmias (“holiday heart syndrome”) in prior case series and observational studies. In this prospective study, researchers monitored volunteers who were planning to consume alcohol using 48-hour Holter ECGs to assess effects on heart rhythms. They found an increase in heart rate and episodes of atrial tachycardias associated with increasing alcohol intake. They also observed clinically relevant supraventricular and ventricular arrhythmias in the ‘recovery period’ (6-19 hours, period after intake). The findings support the understanding that alcohol modulates the autonomic nervous system, with increased sympathetic activation during and post alcohol consumption.

Systematic review: The relationship between gabapentinoids, etizolam, and drug related deaths in Scotland 🔓 

PLOS ONE
(30 SEC READ)

The authors note that Scotland has a high number of drug related deaths (DRD) compared to other European countries. They suggest this could result from an increase in polydrug use, particularly involving gabapentinoids and the designer benzodiazepine etizolam. The authors performed a literature review, identifying 18 relevant articles, and summarized the findings. Etizolam was the most common substance in seized drug samples, present in 23% of tablets labeled as diazepam, and the second most common benzodiazepine in DRDs. Prescriptions for gabapentinoids quadrupled between 2006 and 2016, with a 12-fold increase in gabapentinoid related deaths. Among people who use drugs, 20% reported gabapentinoid misuse. The authors conclude that the high number of DRDs in Scotland is likely related to polydrug use of etizolam and/or gabapentinoids, particularly with opioids.

Learn More 

If there had been no snus in Sweden: the impact of snus on mortality attributable to smoking 🔓 

Harm Reduction Journal
(30 SEC READ)

The prevalence of smoking among males in Sweden is lower than in the rest of European Union (EU) countries. This may be related to the use of snus, the Swedish kind of low-toxicity oral tobacco. Snus use is related to decreased initiation of smoking and increased cessation. In this study, researchers compared smoking related mortality in Sweden to other similar EU countries without snus and hypothetical models in Sweden to estimate smoking related mortality prevented due to availability of snus. In both analyses, an estimated 3000 deaths due to smoking per year are prevented due to availability and use of snus. The authors suggest snus can be an important factor to reduce harms of tobacco, and governments should support its availability. 

The intersection of substance use stigma and anti-Black racial stigma: A scoping review 🔓 

International Journal of Drug Policy
(30 SEC READ)

Stigma can be a significant barrier to accessing care for substance use disorders (SUD), and the intersection between various stigma in impacting access is not well understood. In this scoping review, the authors examined the literature to try to better understand the intersection between SUD stigma and anti-Black stigma. They noted contradictory findings, with some studies suggesting Black persons experience less SUD related stigma than white persons, while other studies found that stigma more negatively impacted treatment and recovery in Black populations. There was a lack of attention to evaluation of structural stigma in all the studies reviewed. Given the clear disparities in treatment access and outcomes, the authors suggest additional research is needed to examine in-group and out-group experiences to better understand the impact of stigma. 

Phosphatidylethanol as an outcome measure in treatment aimed at controlled drinking 🔓 

Alcohol and Alcoholism
(30 SEC READ)

This Swedish study examined the relationship between phosphatidylethanol (PEth) levels and self-reported alcohol consumption in the previous 14 days. The goal was to identify a PEth level that indicated hazardous alcohol consumption (³10 units/week). Data from patients (n=181) were obtained from a previous study of treatments for AUD. Researchers found that the correlation between PEth and self-reported drinking was “relatively weak.” This could be explained by a prior study finding 3-fold variation in PEth formation/elimination between individuals. They identified a cutoff of ³0.22 mmol/l as indicating hazardous drinking with sensitivity of 88% and specificity of 71%. The authors concluded that PEth can be a useful outcome measure.

Receptor and metabolic insights on the ability of caffeine to prevent alcohol-induced stimulation of mesolimbic dopamine transmission 🔓

Translational Psychiatry 
(45 SEC READ)

This study showed that caffeine, via antagonistic activity on A2A adenosine receptors (A2AR), prevents alcohol-dependent activation of mesolimbic DA function as assessed, in-vivo, by brain microdialysis of nucleus accumbens shell (AcbSh) DA and, in-vitro, by electrophysiological recordings of posterior ventral tegmental area (pVTA) DA neuronal firing. Caffeine also prevents direct salsolinol- and morphine-stimulated DA function, suggesting that it can exert these inhibitory effects also independently from affecting alcohol-induced salsolinol formation or bioavailability. Finally, untargeted metabolomics of the pVTA showcases that caffeine antagonizes alcohol-mediated effects on molecules involved in lipid signaling and energy metabolism, which could represent an additional salsolinol-independent mechanism of caffeine in impairing alcohol-mediated stimulation of mesolimbic DA transmission. The outcomes of this study strengthen the potential of caffeine, as well as of A2AR antagonists, for future development of preventive/therapeutic strategies for alcohol use disorder.

In The News 

DEA warns Americans to watch out for online pharmacies

The Atlanta Journal-Constitution

Oregon is spending a record $13.7M on addiction prevention for youth

KATU2/ABC

SF overdose deaths fall year over year in 6th straight month

San Francisco Examiner

Teen opioid treatment options still limited despite profound loss

NBC News4 Washington

Recovery from Helene and addiction, how treatment centers are keeping clients connected

USA Today

Philly hospitals test new strategy for ‘tranq dope’ withdrawal – and it keeps patients from walking out before their treatment is done

The Conversation