The ASAM Weekly for December 26, 2023
This Week in the ASAM Weekly
Dear readers,
Please enjoy the following most-read publications from 2023.
Happy Holidays,
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
Top Publication of 2023
Journal of Addiction Medicine
This clinical considerations document is based on a narrative literature review and expert consensus and addresses considerations for changes to the clinical practice of treatment of opioid use disorder (OUD) with buprenorphine for individuals using high-potency synthetic opioids (HPSOs). Broadly, it suggests that individualized strategies for buprenorphine initiation may be needed. The experience of opioid withdrawal negatively impacts the success of buprenorphine treatment, and attention to withdrawal management before and during buprenorphine initiation should be proactively addressed. Buprenorphine dose and dosing frequency should be individualized based on patients’ treatment needs, the possibility of novel components in the drug supply should be considered during OUD treatment, and all forms of opioid agonist treatment should be offered and considered for patients.
Most Read Publication of 2023
Association Between Daily Alcohol Intake and Risk of All-Cause Mortality 🔓
JAMA Network Open
This updated systematic review and meta-analysis investigated the association between alcohol use and all-cause mortality. Among occasional (>0 to <1.3 g of ethanol/day) or low-volume drinkers (1.3-24.0 g of ethanol/day) there was no significantly reduced risk of all-cause mortality compared with lifetime nondrinkers. There was an increased risk of all-cause mortality for drinkers who drank 25 grams or more and a significantly increased risk when drinking 45 grams or more daily. Additionally, a larger risk of all-cause mortality was found for women compared to men when drinking 25 grams or more per day.
Increasing overdose deaths among Black Americans: a review of the literature
The Lancet Psychiatry
This scoping review analyzed the many and varied factors contributing to the recent rise in opioid overdose death rates among Black Americans. Differences in structural and social determinants of health; unequal access, use, and continuity of SUD and harm reduction services; variability in fentanyl exposure and risk; and changes in social and economic conditions were all found to play a role. Black Americans historically are less likely to have access to treatment services than White Americans. Work to reform the criminal legal system, expand access, address provider bias, and fund equity-improving programs need to happen to affect change.
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.
Journal of Addiction Medicine
Concerns about precipitated withdrawal can be a barrier for patients initiating buprenorphine. This case series examined the implementation of buprenorphine low dose overlap initiation (LDOI) utilizing a community pharmacy. A blister pack was provided with a 7-day titration schedule increasing from 0.5 mg to 4 mg daily. Of the twenty-six patients who started treatment, fourteen completed the protocol with 79% reporting no withdrawal symptoms and 21% reporting only mild symptoms. At thirty days of follow-up, 71% were still receiving buprenorphine, and at 180 days 43% were retained in care but only 14% were still receiving buprenorphine. The study suggests that this community-based pharmacy approach is novel and may offer a new way to initiate buprenorphine in high-risk populations.
Drug Overdose Mortality by Usual Occupation and Industry: 46 U.S. States and New York City, 2020 🔓
National Vital Statistics Reports
This report describes deaths from drug overdoses in 2020 in US residents in 46 states and New York City by usual occupation and industry. Workers in the construction and extraction occupation group and construction industry group had the highest drug overdose death rates. The highest group-level drug overdose proportionate mortality ratios (PMRs) were observed in decedents in the construction and extraction occupation group and the construction industry group. Differences in drug overdose PMRs by usual occupation and industry group were observed within each sex, within each race and Hispanic origin group, by drug type, and by drug overdose intent. Among individual occupations and industries, the highest drug overdose PMRs were observed in decedents who worked as fishers and related fishing occupations and in fishing, hunting, and trapping industries.
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.
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.
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.
Psychedelics reopen the social reward learning critical period 🔓
Nature
Psychedelics have been used for millennia in both spiritual and medicinal contexts, and a number of recent clinical successes have spurred a renewed interest in developing psychedelic therapies. This study demonstrates in mice that the ability to reopen the social reward learning critical period is a shared property across psychedelic drugs. Notably, the time course of critical period reopening is proportional to the duration of acute subjective effects reported in humans. Furthermore, the ability to reinstate social reward learning in adulthood is paralleled by metaplastic restoration of oxytocin-mediated long-term depression in the nucleus accumbens. Finally, identification of differentially expressed genes in the ‘open state’ versus the ‘closed state’ provides evidence that reorganization of the extracellular matrix is a common downstream mechanism underlying psychedelic drug-mediated critical period reopening.