This Week in the ASAM Weekly

Both the RAND Corporation and SAMHSA recently released reports providing broad perspectives on addiction in America. At over 600 pages, “America’s Opioid Ecosystem” (RAND) is a comprehensive review of the dynamic systems and issues underlying not only America’s opioid crisis but the entire addiction ecosystem. The report from SAMHSA provides a more focused view on resilience by putting forth several policy recommendations that support recovery. Both examine how the health of America's addiction problem is tied to its social fabric.

Woven in this fabric is the fourth wave of America’s opioid crisis, which has gone through a temporal, demographic, and geographic spread characterized by stimulant-fentanyl co-use and deaths (Addiction). This is a challenge that we must rapidly adapt to; buprenorphine doses need to be higher than FDA recommendations in order to be effective against fentanyl (JAMA Network Open), pharmacy-based methadone treatment will need to be utilized as it is in other countries (Substance Abuse Treatment, Prevention, and Policy), and contingency management programs will need to spread from California to the rest of the country (Preventive Medicine).

There is no singular approach to addressing addiction in America. As Oregon has experienced, decriminalization or legalization without adequate treatment utilization pretty much leads to continued substance use, but it doesn’t mean decriminalization failed (USA Today). Addiction treatment was never meant to fix the social fabric of America, but we do need to fix the social fabric to treat addiction.

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

America's Opioid Ecosystem: How Leveraging System Interactions Can Help Curb Addiction, Overdose, and Other Harms 🔓

RAND Corporation

This ebook highlights that although opioids play an outsized role in US drug problems, they also play a critically important role in medicine. Thus, they deserve special attention. Illegally manufactured opioids are involved in a majority of US drug overdoses. Efforts to address problems related to opioids are insufficient and sometimes contradictory. Components of the opioid ecosystem include substance use disorder treatment, harm reduction, medical care, the criminal legal system, illegal supply and supply control, first responders, the child welfare system, income support and homeless services, employment, and education. Leveraging the interactions of the opioid ecosystem can reduce addiction, overdose, suffering, and other harms.

Research and Science

Charting the fourth wave: Geographic, temporal, race/ethnicity and demographic trends in polysubstance fentanyl overdose deaths in the United States, 2010–2021 🔓

Addiction

This study uses the latest complete, finalized national data, with records through 2021, to provide a detailed characterization of emerging trends in polysubstance deaths. It focuses on fatal polysubstance overdose involving fentanyl and its analogues, as this has become the most common class of drugs involved in fatal overdose in the US and is understood to be the single most important driver of the current crisis. By 2021, stimulants were the most common drug class found in fentanyl-involved overdoses in every state in the US. The rise of deaths involving cocaine and methamphetamine must be understood in the context of a drug market dominated by illicit fentanyls which have made polysubstance use more sought-after and commonplace.

Buprenorphine Dose and Time to Discontinuation Among Patients With Opioid Use Disorder in the Era of Fentanyl 🔓

JAMA Network Open

The FDA set a target dose for buprenorphine of 16 mg, with an upper limit of 24 mg, during a period when fentanyl was not widely available. With fentanyl and other high potency opioids now driving overdose deaths, this cohort study considered whether higher doses of buprenorphine in the age of fentanyl were required to maintain treatment retention for patients using fentanyl vs. heroin. More than half of patients were prescribed 16 mg daily at the start of treatment. Each patient was followed for 180 days to assess for treatment retention, with discontinuation considered to be a treatment gap of 27 days or longer. Patients prescribed higher doses of buprenorphine were 20% more likely to stay in treatment. Hence, higher doses may be optimal for treatment retention.

Potential effect of antidepressants on remission from cocaine use disorder – A nationwide matched retrospective cohort study

Drug and Alcohol Dependence

This study extracted data from a large (100 million patients) EHR database to identify 161,544 patients with cocaine use disorder (CUD) and depression. This group was examined for association between the use of 13 antidepressants and remission of CUD. Bupropion was the only antidepressant with a statistically significant association with remission of CUD (HR 1.57). A similar analysis of patients with CUD and bupropion used for nicotine dependence also found a significant association with remission of CUD (HR 1.38). The authors note that of 22 genes associated with CUD, 4 are targeted by bupropion. They conclude that bupropion may have utility in treating patients with CUD and depression or nicotine dependence.

Association Between Alcohol Consumption and Ectopic Fat in the Multi‐Ethnic Study of Atherosclerosis 🔓

Journal of the American Heart Association

Alcohol is known to be associated with cardiovascular disease (CVD) and in this cross-sectional study researchers examine association between alcohol intake and ectopic fat, which may be a potential mechanism of that risk. Utilizing the Multi-Ethnic Study of Atherosclerosis, they assessed alcohol intake (lifetime abstinence, light (<1), moderate (1-2), heavy (>2), and binge (≥5) drinking) and fat distribution (pericardial, hepatic, visceral, intermuscular, and subcutaneous). The authors found a J-shaped association, with persons reporting heavy and/or binge drinking having higher ectopic fat. Additional research is needed to examine how ectopic fat distribution may mediate the association between alcohol and CVD and contribute to CVD.

Learn More

Recovery from Substance Use and Mental Health Problems Among Adults in the United States 🔓

SAMHSA

Utilizing data from the 2021 National Survey on Drug Use and Health (NSUDH), SAMHSA examined potential factors associated with self-report of recovery from substance use and mental health issues. Twenty-nine million adults reported a substance use issue with 20.9 (72.2%) million reporting being in recovery and 58.7 million reported a mental health problem with 38.8 (66.5%) reporting being in recovery. Low family income, use of government assistance, and lower level of education were all associated with a higher prevalence of recovery from substance use but a lower prevalence of recovery from mental health issues. In addition, having insurance, overall better health, and no history of legal involvement were associated with higher reports of recovery from mental health issues. Based on the findings, SAMHSA makes multiple policy recommendations to take advantage of potential protective factors.

Pharmacy-based methadone treatment in the US: views of pharmacists and opioid treatment program staff 🔓

Substance Abuse Treatment, Prevention, and Policy

This is a follow-up to a parent study that examined federal exemption allowing a physician at an OTP to electronically prescribe methadone to an independent pharmacy that dispensed the methadone to the patient. This study interviewed staff at the OTP (n=6) and the pharmacy (n=8) about their perspectives on this program. Staff at both the OTP and the pharmacy were supportive of the program. Benefits to patients included shorter travel distances and more flexible hours. Stable patients receiving services at pharmacies freed up resources for OTPs to accept additional new patients. Pharmacists enjoyed direct patient contact and seeing patients benefit from their efforts, along with additional revenue. The study notes that similar programs exist in Canada, UK, and Australia.

Recovery incentives program: California's contingency management benefit

Preventive Medicine

Currently, no medication is available to treat stimulant use disorder (StimUD). Contingency management (CM) is considered the most effective behavioral intervention to treat this disease. The state of California experienced more overdose deaths than any other state in 2021, with Black and American Indian and Alaska Native populations disproportionately affected. The Recovery Incentives Program: California's Contingency Management Benefit, launched in April 2023, is a protocol where participants can receive up to $599 over a six-month period, contingent upon 36 stimulant-negative UDS results. Implementation of this program could result in the widespread use of this modality nationally, with the opportunity to reduce deaths related to stimulant use.

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