This Week in the ASAM Weekly

Preferring the use of buprenorphine over full agonist opioids in the management of chronic pain is a significant update to the VA/DoD clinical practice guideline. Add to it a more holistic behavioral perspective and we’re progressing similarly in our approaches to pain and addiction (Annals of Internal Medicine)

The White House has also advocated, with federal urgency, for the expansion of addiction treatment and harm-reduction services (JAMA Network). But implementation of this White House strategy will require an alignment of conflicting state and local policies around a single North Star of lives-saved (JAMA Network). Over-the-counter naloxone will be an important part of this (STAT News).

Even the Office of National Drug Control Policy (ONDCP) director, Dr. Rahul Gupta, has urged members of the American Medical Association to become part of the addiction medicine treatment system (Medpage Today). The American Academy of Emergency Medicine is also contributing to the addiction treatment system through a white paper on the treatment of alcohol use disorders in acute care settings (Journal of Emergency Medicine).

Finally, naltrexone is being re-acknowledged by mainstream media as a pre-party preventative measure (NY Times), and a large study from Korea challenges us to mind our U and J-curves when considering the risks of alcohol intake and dementia (JAMA Network).

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

The Use of Opioids in the Management of Chronic Pain: Synopsis of the 2022 Updated U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline 🔓

Annals of Internal Medicine

The VA, along with the Department of Defense, recently approved an updated guideline regarding the management of chronic pain with opioids (updated from the 2017 version). This includes considerations regarding initiation and continuation of therapy; dose, duration, and taper of opioids; screening, assessment, and evaluation; and risk mitigation. A new recommendation for patients receiving chronic opioid therapy is using buprenorphine in place of full agonists due to its lower risk of overdose and misuse. Other new recommendations suggest screening for additional psychiatric comorbidities that could increase risk and screening for pain catastrophizing.

2023 Addiction Medicine Research Priorities Listening Session

The National Institute on Alcohol Abuse and Alcoholism (NIAAA), National Institute on Drug Abuse (NIDA), and Agency for Healthcare Research and Quality (AHRQ) have requested input from addiction medicine specialists on how to improve the clinical relevance of their addiction medicine research portfolios.

Please provide input on their questions below and add any questions or comments you may have at the end of the form. We will also discuss these questions at the "Bridging the Gap between Science and Clinical Practice in Addiction Medicine" session during the ASAM 2023 Annual Conference.

If you have any questions, please email Ray Denny, PhD, Associate Director of Science, at rdenny@asam.org. Thank you!

Provide Input

Research and Science

Changes in Alcohol Consumption and Risk of Dementia in a Nationwide Cohort in South Korea 🔓

JAMA Network Open

In this cohort study of 3,933,382 individuals in Korea, maintaining mild to moderate alcohol consumption was associated with a decreased risk of dementia compared with sustained nondrinking, whereas sustained heavy drinking of alcohol was associated with an increased risk of dementia. Reduction of drinking from a heavy to a moderate level and initiation of mild drinking were associated with a decreased risk of dementia compared with a sustained level of drinking. These findings suggest that the threshold of alcohol consumption for dementia risk reduction is low.

Emergency Department Management of Patients with Alcohol Intoxication, Alcohol Withdrawal, and Alcohol Use Disorder: A White Paper Prepared for the American Academy of Emergency Medicine 🔓

The Journal of Emergency Medicine

This white paper discusses several issues facing Emergency Medicine clinicians who frequently see patients with alcohol use disorder (AUD) and the current evidence. Alcohol withdrawal syndrome (AWS) is of particular concern; the authors review the factors and screening tools that can help guide decisions, including managing patients as outpatient or inpatient, potential treatment before development of signs or symptoms of AWS, medications for mild to moderate AWS, and severe AWS. Benzodiazepines have traditionally been first-line treatment, but the authors discuss additional options, including carbamazepine, gabapentin, valproic acid, and phenobarbital. Also reviewed is the management of alcohol intoxication (AI), discharge medications for treatment of AUD, and other potential harm reduction strategies.

Are Dietary Supplements a Gateway to Doping? A Retrospective Survey of Athletes’ Substance Use 🔓

Substance Use and Misuse

The study used an online survey of 1,081 competitive athletes (at levels from club to international) to assess the use of dietary supplements (vitamins, protein shakes, creatine, etc.) and doping (anabolic steroids, testosterone, amphetamines, etc.). Most participants used supplements (71%) but few reported doping (4.4%). Users of dietary supplements were 11 times more likely to use doping substances. For most (77%), the use of dietary supplements preceded doping, by 4.5 years on average. Some (13%) began use at the same time and some (10%) began doping prior to supplement use.

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Clinical Presentations and Treatment of Phenibut Toxicity and Withdrawal: A Systematic Literature Review

Journal of Addiction Medicine

This study reviewed the literature concerning phenibut and identified 36 relevant articles. All were case reports of phenibut toxicity or withdrawal. Phenibut is a GABA agonist with sedative effects that is sold legally in the US as a dietary supplement. Patients with phenibut toxicity had altered mental status (90%), psychotic symptoms (18%), movement disorders (13%), and seizures (8%). There was one death, one case of neuroleptic malignant syndrome and half (49%) required intubation. Symptoms of withdrawal were anxiety (73%), psychotic symptoms (55%), and movement disorders (55%). Most withdrawals were managed with benzodiazepines, but antipsychotics, baclofen, phenobarbital, and gabapentin were also used. The study concludes that phenibut can lead to severe and potentially fatal consequences.

Trends in Stigmatizing Language about Addiction: A Longitudinal Analysis of Multiple Public Communication Channels

Drug and Alcohol Dependence

Stigma continues to be a barrier to care for persons with substance use disorders, including opioid use disorder. This paper examines trends in the use of stigmatizing language in media (news, blogs, twitter, reddit) utilizing National Institute of Drug Abuse (NIDA) recommendations for language reducing stigma. It found that between 2017 and 2021 use of stigmatizing language decreased in traditional media of news articles (-62.8%) and blogs (-33.6%) but increased or did not change in social media on twitter (+43.5%) and reddit (+3.1%). In addition, formal news organizations implemented language policies that may have led to the decrease in news articles, but as twitter is more reflective of the general public, the increase in use of stigmatizing language on that platform indicates more work is needed to educate the public.

One immune system plays many parts: The dynamic role of the immune system in chronic pain and opioid pharmacology

Neuropharmacology

This review highlights the need to understand the dynamic and adaptable characteristics of the immune system and their role in the transition, maintenance, and resolution of chronic pain. Neuroimmune interactions drive structural adaptations in neural circuits. Classical immune factors alter excitability of neurons via inflammatory independent mechanisms and inflammatory signaling plays a role in injury resolution. The complex multidimensional interplay of the immune system with multiple physiological systems may provide new transformative insight for novel targets for clinical management and treatment of chronic pain.

Implementing the White House’s Strategic Plan to Save Lives Amid the Opioid Crisis: Reaching for the “North Star” 🔓

JAMA Network

“Saving Lives is Our North Star” is the new initiative of the Biden administration for the treatment of opioid use disorders (OUD) in the U.S. This plan focuses on harm reduction practices, medications for opioid use disorder (MOUD), justice reform, long-term recovery, and thwarting drug trafficking. Specific measures include enhancing the reach of naloxone – without a prescription – and authorizing office-based methadone prescribing.

A 2023 Agenda for Substance Use Prevention and Treatment in the US 🔓

JAMA Network

Measures taken by the Biden-Harris administration are contributing to the flattening of the overdose death rate. By 2025, the National Drug Control Strategy has established a goal of reducing fatal drug overdoses by 13%, which means a reduction in the 12-month total to 81,000 or less. The Office of National Drug Control Policy (ONDCP) estimates if no actions were taken, number of fatal drug overdoses every year would be nearly 165,000. For the first time in years, flattening and possible reversal of long-standing fatal drug overdose trends seems to finally have taken place.