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ASAM Weekly for May 30th, 2023

This Week in the ASAM Weekly

As treatment providers we are working to adjust our clinical approach to illicitly manufactured fentanyl and its unique challenges, such as secondary peaking, non-linear withdrawal, and peripheral tissue accumulation (JAM). 

Fentanyl has also caused us to refocus our attention on the more favorable retention rates of methadone maintenance, but head-to-head comparisons with buprenorphine shouldn’t dissuade us from the clear and practical needs of what is a “first-line treatment” (Lancet Psychiatry). Unlike methadone (thus far), buprenorphine has the capacity to expand, and over the last several years Advanced Practice Practitioners have done an incredible job of this, taking a lead in the number of buprenorphine prescriptions provided (Drug and Alcohol Dependence). 

In a similar way, our understanding of obesity and addiction is also becoming more pragmatic. The food-drug competition hypothesis may explain a relationship between obesity, tobacco use, and reduced addiction (Drug and Alcohol Dependence Reports), while semaglutide may reduce alcohol and caloric intake through a general reduction of both appetite and thirst (JCI Insight). Practically speaking, both addiction and obesity are diseases of consumption.

Thanks for reading,

Nicholas Athanasiou, MD, MBA, DFASAM
Editor in Chief

with Co-Editors: Brandon Aden, MD, MPH, FASAM, Debra R. Newman, PA-C, MSPAS, MPH, Jack Woodside, MD, John A. Fromson, MD

Lead 

The glucagon-like peptide-1 (GLP-1) analogue semaglutide reduces alcohol drinking and modulates central GABA neurotransmission 🔓

JCI Insight

Evidence suggests that the glucagon-like-peptide-1 (GLP-1) system may be involved in the neurobiology of addiction. The authors studied the impact of semaglutide, a long acting GLP-1 analogue, on alcohol use in mice and rat models and found a decrease in binge-like alcohol drinking in both mice and rats. They also found reduced alcohol intake in rates with dependence. The proposed mechanism for this effect is modulation of central GABA neurotransmission and supports the potential role of the GLP-1 system as a potential pharmacotherapeutic target for alcohol use disorder.

Stimulant Use Disorder Guideline: Public Comment Open

Public comment closes tomorrow for the American Society of Addiction Medicine (ASAM) and American Academy of Addiction Psychiatry (AAAP)’s jointly developed Clinical Practice Guideline on the Management of Stimulant Use Disorder.

Please click here to view the draft guideline and provide your feedback by May 31, 2023.

 

Research and Science

Change in opioid and buprenorphine prescribers and prescriptions by specialty, 2016-2021

Drug and Alcohol Dependence

This study obtained data from a national database including 92% of retail prescriptions in the US. Researchers analyzed data on opioid analgesic and buprenorphine prescriptions during the period 2016 to 2021. During that period, the number of opioid analgesic prescriptions decreased by 32% while the number of buprenorphine prescriptions increased 36%. The number of prescribers of opioid analgesics decreased by 7% whereas the number of buprenorphine prescribers increased by 86% to 59,090. Despite increases in training programs, addiction specialists wrote only 3% of buprenorphine prescriptions. Primary Care clinicians and Advanced Practice Practitioners accounted for 37% and 35%, respectively, of buprenorphine prescriptions.

Effects of Abstinence From Opioid on Neuropsychological Performance in Men With Opioid Use Disorder: A Longitudinal Study

Journal of Addiction Medicine

This study measured neuropsychological performance of 50 male patients with OUD during their first 8 weeks of abstinence. The tests measured executive function, attention and concentration, verbal memory, and nonverbal memory. They were administered at baseline, after 2 weeks, and then at 8 weeks of abstinence. At 2 weeks, improvement was seen in attention, concentration, verbal memory, and nonverbal memory (all p<0.01). However, executive function did not show significant improvement until 8 weeks of abstinence (p<0.01). Duration of opioid use, severity of dependence, and frequency of use were all associated with worse scores on some of the tests at baseline. The authors suggest future studies include female patients and have a longer period of follow-up.

ASAM Review Course

Examining the relationship of concurrent obesity and tobacco use disorder on the development of substance use disorders and psychiatric conditions: Findings from the NESARC-III 🔓

Drug and Alcohol Dependence Reports

There has been some evidence that obesity is associated with lower rates of substance use disorders (SUD). In this study, the authors examine the associations between obesity, tobacco use disorder (TUD), and SUD and psychiatric illness. Persons with obesity were associated with lower odds of SUD than persons without TUD or obesity; persons with obesity and TUD were associated with lower odds of SUD than those with TUD alone. While additional research is needed to examine the relationship between obesity and SUD, the authors note both conditions may share similar neurobiological pathways and hypothesize they may have a competitive relationship for rewards.

Patient-Concerned Other Dyads’ 12-Step Involvement and Patients’ Substance Use: A Latent Class Growth Model Analysis

Journal of Studies on Alcohol and Drugs

This study aimed to inform clinical practice by identifying subgroups of patient-Concerned Other (CO) dyads. Patients with alcohol use disorders (AUDs) were characterized on Alcoholics Anonymous (AA) involvement and substance use together with COs’ Al-Anon involvement. Predictors and recovery maintenance outcomes of subgroup membership were examined. Among patients treated for AUD, AA involvement was related to better outcomes, and to COs’ lessened concern about the patients’ drinking. COs’ Al-Anon involvement was associated with having a more positive view of their relationship with the patient. That more than one-third of dyads had low 12-step group involvement suggests that treatment programs may need to facilitate involvement in non-12-step mutual-help groups.

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Fentanyl Absorption, Distribution, Metabolism, and Excretion: Narrative Review and Clinical Significance Related to Illicitly Manufactured Fentanyl 

Journal of Addiction Medicine

This narrative review summarizes literature on pharmaceutical fentanyl's absorption, distribution, metabolism, and excretion patterns to inform research on illicitly manufactured fentanyl (IMF). It highlights research gaps due to differences in medicinal fentanyl studies and IMF use patterns, including that medicinal fentanyl studies are largely conducted with persons who were opioid-naive, anesthetized, or had severe chronic pain and that IMF use is characterized by supratherapeutic doses and frequent and sustained administration patterns, as well as adulteration with other substances and/or fentanyl analogs. In persons who use drugs, peripheral accumulation of fentanyl may be leading to prolonged exposure. More focused research on the pharmacology of fentanyl in persons using IMF is warranted.

Buprenorphine versus methadone for the treatment of opioid dependence: a systematic review and meta-analysis of randomised and observational studies 🔓

The Lancet Psychiatry

This systematic review and meta-analysis sought to compare buprenorphine vs methadone across a wide range of primary and secondary outcomes. Primary outcomes included retention in treatment up to 24 months, treatment adherence, or other prescribed/illicit opioid use. Secondary outcomes included use of other substances, withdrawal, craving, criminal activity, overdose, mental and physical health, global functioning, and suicidality. Treatment retention was better for methadone vs buprenorphine, but there was no difference in adherence to treatment between these two forms of MOUD. Evidence on the other outcomes explored demonstrated few statistically significant differences, and for the most part was based on small numbers of studies. 

Changing approaches to treating opioid withdrawal in the USA

The Lancet Psychiatry

In this commentary, the authors address the poor responsiveness to the treatment of opioid withdrawal in EDs, noting without a change in approach, deaths will continue to mount. They list ways to reduce opioid deaths and emphasize that continued stigma, criminalization, and social and health inequities are factors that require attention. The authors conclude that appropriate management of OUD puts the human rights and dignity of people who use drugs upfront, helps in establishing compassionate, therapeutic relationships with patients, and improves outcomes.