News
The ASAM Weekly for February 5th, 2025
This Week in the ASAM Weekly
Viewing harm reduction as a therapeutic approach to heal maladaptive attachments is a thoughtful concept, but it’s not an easy one to convey (Psychology Today). Could we instead use a simpler message like “addiction is a relationship”?
For example, certain types of use represent “disordered relationships,” and with cannabis the harms of those relationships have shifted because of higher potency and diversified consumption methods (Addiction). In the opposite way, mutual help organizations can heal those disordered relationships by replacing them with healthy ones, eg, family, community, or religion (Drug and Alcohol Dependence). Could we also say that “healthy relationships heal addiction”?
The challenge of using a simple message is that it often lacks nuance. One can’t deny that low-dose initiation of buprenorphine sounds really great, but unfortunately evidence suggests it’s not ready for prime-time in the polysubstance/fentanyl era (JAMA Network Open). Should we instead reevaluate the messaging we’ve had about precipitated withdrawal and work on decreasing fear around it?
It’s not that easy. Even the seemingly simplest message must have space for complexity, but it also needs a little extra room for something else. Piggy-backing “Substance Use Disorder Treatment Month” onto “Dry January” could be an example of that “something else” and SAMHSA has gone all-in with guides, articles, and even virtual backgrounds (SAMHSA). Take a look.
Eventually though, when you combine enough messages you’ll have a narrative, and when someone can repeatedly and effectively deliver that (evidence-based) narrative while being adaptable, engaging, and attuned to the audience, then that person becomes a messenger (New York Times). Take a listen.
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
ASAM Criteria Fourth Edition Assessment Guide
The ASAM Criteria® Fourth Edition Level of Care Assessment Guide, developed by ASAM and pilot tested by UCLA Integrated Substance Use and Addiction Programs (ISAP), is a streamlined tool that helps clinical interviewers collect just enough information to make an appropriate level of care recommendation. The Guide promotes standardized decision-making by helping clinicians apply ASAM’s Dimensional Admission Criteria. It also supports identification of immediate needs and documentation for utilization review.
Lead Story
Outpatient Low-Dose Initiation of Buprenorphine for People Using Fentanyl🔓
JAMA Network Open
The accumulation of fentanyl in fat is likely responsible for the risk of precipitated withdrawal when buprenorphine is initiated. Low-dose initiation (LDI) of buprenorphine attempts to minimize this risk. This retrospective study included 126 individuals making 175 LDI attempts in an outpatient setting. Patients chose either a 4-day or 7-day LDI protocol with buprenorphine monoproduct. Both protocols begin with buprenorphine 0.5 mg, increasing to 8 mg tid. Overall, LDI was successful in 34% of attempts (with no difference between the protocols), and one-month retention on buprenorphine was 21%. Repeated LDI attempts were less likely to be successful (second attempt aOR 0.3). Unhoused people had lower odds of success (OR 0.4). The authors conclude that people with OUD using fentanyl attempting outpatient LDI of buprenorphine had low odds of success.
Research and Science
Drug and Alcohol Dependence
Celebrate Recovery (CR) is an explicitly Christian mutual help organization (MHO) founded in 1991 and reaching more than 7 million people worldwide. This study analyzed data from The National Recovery Study for individuals who reported attending an MHO. CR attendees were 5% of all MHO attendees. CR attendees were likely to attend other MHOs, with 70% attending AA and 65% attending NA. CR participants were slightly younger than other MHO participants (43 v. 49 years, p=0.01). Those with methamphetamine as their primary substance had 5 times the odds of attending CR, which may result from the younger age of CR attendees. There were few other differences between CR and non-CR MHO attendees. CR attendees had similar levels of quality of life, happiness, and self-esteem. These results suggest that CR may be an important recovery resource.
Addiction
Some cannabis consumption methods (eg, smoking, vaping, dabbing) are associated with more harms than others (eg, sublingual, transdermal). This cross-sectional study examined differences in the prevalence of cannabis consumption methods by people with medically recommended-only vs. nonmedical-only cannabis use. Among people with past-year medically recommended-only cannabis use in the US, three-fourths reported smoking cannabis and almost half reported vaping and eating/drinking cannabis. Cannabis vaping prevalence and dabbing prevalence were 1.3–1.5 times higher, respectively, among people with medically recommended-only use than people with nonmedical-only use.
International Journal of Drug Policy
Residential treatment for substance use disorders (SUD) is effective, but it is costly and not an unlimited resource. In this study, researchers used a generalized propensity-weighted dose-response curve to evaluate the optimal length of stay (LOS) in SUD residential treatment VA programs. They found a curvilinear dose-response relationship with accrual of benefits faster in earlier treatment and decreasing over time, and a range of optimal LOS between 35 and 49 days. Treatment outcomes were maximized with increasing benefits up to 35 days, before diminished returns on LOS began. Forty-nine-day LOS maximized average treatment outcomes, with limited improvement beyond that time.
Addiction
Sedative, hypnotic, or anxiolytic use disorders (SHA-UD) are defined by significant impairment or distress caused by recurrent sedative, hypnotic, or anxiolytic use. This annual, cross-sectional study aimed to measure trends in the prevalence of SHA-UD diagnoses in adolescent and young adult US Medicaid enrollees from 2001 to 2019. SHA-UD diagnoses increased 3- to 5-fold during this time for adolescent and young adult US Medicaid enrollees, with prevalence remaining low in adolescents. The increase over two decades may be attributed to changes in the availability, use, and misuse of sedative, hypnotic, and anxiolytic medications, and increased detection, awareness, and diagnosing of SHA-UD.
Learn More
International Journal of Drug Policy
There has been some suggestion that legalization of cannabis may be associated with a decrease in opioid misuse and opioid use disorder (OUD), potentially through substitution. In this study, using the National Survey on Drug Use and Health (NSDUH) between 2015 and 2019, researchers examined the association between medical cannabis legalization (MCL) and recreational cannabis legalization (RCL) and opioid misuse/OUD. Overall, they did not find any changes in opioid misuse or OUD associated with MCL or MCL+RCL. Researchers did find a decrease in odds of past-year opioid misuse (aOR 0.57) among those with past-year cannabis use with MCL adoption. The authors support ongoing research and continued evaluation as cannabis legal status evolves.
Nature Communications
Naloxone has a relatively short duration of action (DOA) with potential need for additional doses and observation needed after an opioid overdose. In this study, researchers tested a novel single-dose extended-release naloxone in animal models to potentially address this issue. The medication, given subcutaneously, was tested in rat models and monkeys. In the rat model, the medication was effective in preventing overdose mortality and worked prophylactically against fentanyl when given 6 hours after dose. The naloxone reached levels in monkeys that match effective doses in humans. One other benefit of this medication noted by the authors is that it does not require refrigeration. While additional research will be needed, the authors suggest multiple potential uses in the future.
Journal of Addiction Medicine
Despite positive initial evidence, prescribing rates of controlled prescription psychostimulants for stimulant use disorder (StUD) treatment remain low, possibly because some clinicians believe they are subject to the restrictions federal law imposes on medications for opioid use disorder. This is not the case. Rather, at the federal level, these medications are subject only to the general requirement that prescriptions be issued for a legitimate medical purpose within the usual course of professional practice, criteria that are buttressed by recent national guidelines that include controlled prescription psychostimulants as an option within a comprehensive treatment plan for StUD. This commentary reviews the federal legal landscape regarding the prescription of psychostimulants for StUD and recommends strategies for increasing the utilization of this promising approach.
In The News
The Interview: Digital Drugs Have Us Hooked. Dr. Anna Lembke Sees a Way Out.
The New York Times
Substance Use Disorder Treatment Month
Substance Abuse and Mental Health Services Administration (SAMHSA)
E-Cigarettes at the Supreme Court — Potential Implications for the FDA and Public Health
The New England Journal of Medicine
A Secure Base: Harm Reduction as Attachment Therapy
Psychology Today
Science Behind Approved OUD Risk Test Questioned
Medscape