This Week in the ASAM Weekly

This week we provide a range of publications touching upon the biologically human experience of opioid use disorder and its related impact on treatments and outcomes. Treatment gaps in OUD are unfortunately common, and results from a study on Medicare beneficiaries show that nonadherence to buprenorphine is associated with increased opioid overdose rates and total healthcare spending (JAMA Psychiatry). Similarly, while longer timeframes for MOUD maintenance better protect against relapse and overdose, retention in MOUD is unfortunately low and often driven by patient preference or life experiences. A better understanding of the characteristics and benefits of slow-tapering buprenorphine will help reduce harm when such tapers are initiated (JAMA Network Open). 

Innovations in delivering buprenorphine treatment at the patient level are necessary to address the challenges of today -- such as high-potency synthetic opioids- and tomorrow. In a JAM Commentary, Dr. Fiellin discusses the attributes of highly personalized, “precision medicine” and the importance of increasing the direction of knowledge flow from patients to clinicians and researchers. This is exemplified in a JAM Case Report demonstrating the successful transition from 100mg of methadone to buprenorphine via a microdosing approach. While impressive, the impetus behind this innovative intervention  -- the patient’s loss of transportation to pick up his methadone -- is just as meaningful.

People who use opioids can experience many difficult life events, particularly around bereavement and birth. In “I don’t go to funerals anymore…”, the authors bring focus to a critical gap in the literature about factors inhibiting bereavement in people who use opioids (Harm Reduction Journal). Similarly, perinatal women who use opioids experience a unique brand of stigma but there are interventions we can employ to empower the mother-newborn dyad (The American Journal of Drug and Alcohol Abuse). 

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

National Addiction Treatment Week

National Addiction Treatment Week begins this week! Listen to ASAM President Bill Haning's call for health care professionals to complete the certification process in addiction medicine. Dr. Haning's recording joins a series of videos from other ASAM members promoting this cause, which ASAM will share on social media channels throughout National Addiction Treatment Week. 

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 

Association Between Buprenorphine Treatment Gaps, Opioid Overdose, and Health Care Spending in US Medicare Beneficiaries With Opioid Use Disorder

JAMA Psychiatry

In this case-control study of 34,505 Medicare beneficiaries, patients had greater risk of experiencing an opioid overdose and higher health care expenditures in buprenorphine treatment gap months compared with treated months. Buprenorphine nonadherence is associated with an increased risk of opioid overdose and higher health care spending in Medicare.

Prescribing Characteristics Associated With Opioid Overdose Following Buprenorphine Taper 🔓

JAMA Network Open

This study collected information about tapering buprenorphine from health data in the province of Ontario Canada. In the six years, 2013-2018, 5774 individuals were identified as having undergone a taper of buprenorphine after at least 60 days of buprenorphine treatment and 349 experienced an opioid overdose. Those on buprenorphine over 1 year prior to taper had a lower incidence of overdose compared to less than one year (6.7 vs 10.4 overdoses/100 person-years (OD/100py)). Lower rates of taper had lower rates of overdose (<2mg/month 7.0 OD/100py, 2-4mg/mo 11.5 OD/100py, >4mg/mo 17.3 OD/100py). The authors conclude that starting taper after 1 year and a slower rate of taper were associated with lower rates of overdose.

Rates and correlates of cannabis-associated psychotic symptoms in over 230,000 people who use cannabis 🔓

Translational Psychiatry

Cannabis can trigger acute cannabis-associated psychotic symptoms (CAPS) in people who use cannabis (PWUC). To assess rates and correlates of CAPS requiring emergency medical treatment, this study analyzed data from an international sample of PWUC (n = 233,475).  It found that acute self-limiting psychotic symptoms in the context of cannabis use may occur in about 1 in 200 PWUC’s lifetime. Some individuals could be particularly sensitive to the adverse psychological effects of cannabis, such as young individuals or those with pre-existing mental health vulnerabilities. In light of the movements towards legalization of recreational cannabis, more research should focus on the potential harms related to cannabis use, to educate PWUC and the public about risks related to its use.

Supporting perinatal individuals with opioid use disorder and their newborns experiencing neonatal abstinence syndrome: impressions from patients and healthcare providers

The American Journal of Drug and Alcohol Abuse

Comprehensive educational strategies are needed to support perinatal individuals receiving opiate agonist therapy (OAT). This study examined how to best prepare these individuals to care for themselves and their newborns who may experience NAS during the perinatal period. Participants emphasized, through lived experience of caring for a newborn with NAS, the importance of self-advocacy while navigating healthcare and social systems. Providers from diverse professions and work settings emphasized the importance of communicating expectations to their patients. 

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Buprenorphine Initiation in the Era of High-Potency Synthetic Opioids: A Call for Community-Based Participatory Research to Help Learning Health Systems Provide Precision Medicine for Opioid Use Disorder

Journal of Addiction Medicine

Buprenorphine initiation challenges have resulted from high-potency synthetic opioids (HPSO) saturating the US opioid supply.. To improve treatment initiation, research should be conducted cooperatively with people who use drugs (PWUD). The following factors can help to inform treatment decision-making: detailed assessment/amount of substances used, time between last use and buprenorphine induction, withdrawal severity at time of induction, buprenorphine dose, etc.. Appropriate clinician training and experience is required now more than ever to address the needs of PWUD who are using HPSO.  

Transitioning From High-dose Methadone to Buprenorphine Using a Microdosing Approach: Unique Considerations at ASAM Level 3 Facilities

Journal of Addiction Medicine

In this case report, authors describe a protocol for transitioning a patient from high dose methadone (100 mg) to buprenorphine utilizing micro-dosing induction in an inpatient treatment center setting. The patient initially presents for alcohol withdrawal management, but then requests transition to buprenorphine. In the protocol, the patient is started on micro-dose of sublingual suboxone and titrated to 4 mg twice daily while continuing methadone over 6 days. The methadone is subsequently discontinued, and buprenorphine dose titration continues to the final dose of 12 mg twice daily. The patient is also provided adjunct medication for any withdrawal, but he has minimal symptoms during transition and is doing well at 26 days of follow-up. 

“I don’t go to funerals anymore”: how people who use opioids grieve drug-related death in the US overdose epidemic 🔓

Harm Reduction Journal

The authors note that the circumstances and stigma associated with overdose deaths can interfere with mourning. Individuals (n=30) were recruited at a syringe service program and interviewed about their experience with drug related deaths (DRD). Fatalism about DRD was common, feeling that it’s inevitable – “that’s the world I’m in.” For some the DRD prompted caution with their own opioid use but others increased their use to numb their grief. Many felt guilt about having used with the deceased. They often were blamed by others for the death, causing them to avoid funerals. One failed to recognize an overdose, thinking his friend was sleeping. The authors hope to draw attention to the unique needs of people grieving DRDs.

Stimulant misuse among youth 🔓

Current Problems in Pediatric and Adolescent Health Care

In this review, the authors describe the epidemiology of stimulant misuse, harms, potential treatments, and gaps in literature. Non-medical use of prescription stimulants is the most misused stimulant among youth (6.3-7.3%), but cocaine (4.3%) and methamphetamine (1.7%) use have also been on the rise. Methamphetamine use historically was more common in the Midwest and West but has increased across the country. Polysubstance use including stimulants and opioids is of particular concern as opioid overdoses involving stimulants increased 351% among adolescents between 2010 and 2018. Given the rise in misuse of stimulants, the authors note several areas in need of additional research, including disparities in misuse, pathways from prescription use to illicit misuse, polysubstance use, and treatment strategies (medications and behavioral interventions).