This Week in the ASAM Weekly

It might help if we think about harm reduction and prevention like we do infrastructure. A study of safe consumption sites in Toronto found that in surrounding neighborhoods, overdose deaths decreased by up to 67%. The spill-over effect demonstrates how sites can act as hubs of harm reduction: increasing naloxone and test strips in the community, providing sterile drug use equipment, and engaging individuals toward treatment (The Lancet Public Health).

Funding infrastructure can be incredibly cost-effective, but fiscal shortsightedness often overshadows the financing and billing structures of substance use prevention. The Northwest Center for Family Support details how prevention is most effective when it is holistic and seamless throughout the care system (Health Affairs).

It is also important to recognize that broader, population-level initiatives can increasingly improve the lives of specific groups. For example, policies singling out pregnant people who use alcohol are often ineffective (or worse) in reducing infant morbidities but policies limiting alcohol availability in general can help (American Journal of Preventive Medicine). Banning menthol in cigarettes can save lives, but as two former surgeons general advocate, banning menthol can significantly save Black lives (STAT News).

However, when broad provisions don’t benefit all groups equally, targeted improvements are necessary. The Veterans Health Association (VHA) launched an initiative to increase buprenorphine treatment in primary care, which found uptake in general was low, but structural disparities particularly persisted for Black veterans (Journal of Addiction Medicine). Efforts to increase naloxone availability for all are needed but out-of-pocket costs disproportionately affect individuals over 65, who saw the highest relative increase in overdose deaths in recent years (JAMA).

So, it is reassuring when political leaders respond to a crisis by investing in infrastructure. Bipartisan senators in Florida are putting forward a bill that provides $114 million in capital investment toward expanding education in behavioral health and addiction (WUSF/Health News Florida).

One last important announcement -- the 7th edition of the ASAM Principles of Addiction Medicine is available for pre-order. You can even download a special free preview chapter today!

Thanks for reading,

Nicholas Athanasiou, MD, MBA, DFASAM
Editor in Chief

with Co-Editors: Brandon Aden, MD, MPH, FASAM, Jack Woodside, MD, John A. Fromson, MD

Lead Story

Overdose mortality incidence and supervised consumption services in Toronto, Canada: an ecological study and spatial analysis 🔓

The Lancet Public Health

The objective of this study was to measure the effect of safe consumption sites (SCS) on overdose mortality. Between 2017 and 2019, nine SCS were implemented in Toronto, Canada. During this period there were 787 overdose deaths. In the 15 neighborhoods within 500 meters of an SCS, overdose deaths decreased by 67% (p=0.037) after SCS were implemented. There was no decrease in other neighborhoods. Researchers were surprised to observe some decrease in overdose deaths up to 5000m from SCS. They note that in addition to onsite overdose reversal, SCS also distribute naloxone and offer referrals to low-barrier MOUD. They speculate that these other services could explain the effects at greater distances. The authors conclude that SCS result in significant reductions in overdose deaths in surrounding neighborhoods.

Research and Science

National and regional trends in seizures of shrooms (psilocybin) in the United States, 2017–2022

Drug and Alcohol Dependence

In recent years, with media coverage and increased awareness of potential therapeutic uses for hallucinogens, there is potential for an increase in non-medical use of psilocybin (“shrooms”). There are limited data about personally-reported use of psilocybin, so the authors looked at trends in law enforcement seizures as a marker for availability and demand. There was a 368.9% increase in number of seizures and a 2749.7% increase in weight of “shrooms” seized between 2017 and 2022. The increase in seizures likely represents an increase in non-medical use and supports a need for prevention and harm reduction education interventions.

Comparison of Administration of 8-Milligram and 4-Milligram Intranasal Naloxone by Law Enforcement During Response to Suspected Opioid Overdose — New York, March 2022–August 2023 🔓

Morbidity and Mortality Weekly Report

Given evidence of the need for multiple doses of naloxone to reverse overdoses due to synthetic opioids, it was suggested higher concentration initial doses were needed. In response, 8-mg naloxone was approved, and this retrospective study evaluates outcomes in New York, where law enforcement was provided either 4-mg or 8-mg formulations. The study did not find any differences in survival, number of doses administered, post-administration combativeness, or hospital transport refusal between the two formulations. Opioid withdrawal symptoms were more prevalent in the 8-mg group (37.6 % vs 19.4%). The study outcomes do not support a need for higher concentration formulation.

Buprenorphine Receipt and Retention for Opioid Use Disorder following an Initiative to Increase Access in Primary Care

Journal of Addiction Medicine

Access to buprenorphine (BUP) for treatment of opioid use disorder (OUD) is essential to help curb the mortality seen in the opioid epidemic, but access has been limited. The Veterans Health Administration implemented a program to expand access in primary health clinics and evaluate factors associated with initiation and retention on BUP. Overall, 11.7 % of patients with OUD were initiated on BUP and of those 58.2% were retained in treatment at 180 days. In the multivariate model, persons with alcohol use disorder (OR=0.39), non-opioid use disorder (OR=0.64), or serious mental illness (OR=0.60) were less likely to be initiated on BUP. Non-Hispanic Black persons were less likely to be initiated on buprenorphine (OR=0.55) and retained in treatment (OR=0.40). The study demonstrates an ongoing need to expand access to BUP and interventions to address disparities.

Opioid-induced hypogonadism in opioid use disorder, its role in negative reinforcement, and implications for treatment and retention

The American Journal of Drug and Alcohol Abuse

This perspective article highlights the striking parallels between the symptom domains of hyperkatifeia (the heightened salience of negative emotional and motivational states brought on by chronic opioid use) and hypogonadism in males. It proposes that future research and clinical care should focus on the identification and treatment of opioid-induced hypogonadism (OIH) in opioid use disorder (OUD) patients to help address poor treatment retention despite efficacious therapies. Evidence is then reviewed from chronic pain patients that testosterone replacement provides clinically significant benefits to men with OIH. It also compares extant OUD therapeutics and discusses critical gaps in the clinical literature—including the relative dearth of data regarding hypothalamic-pituitary-gonadal function in females who use opioids—where future study should be focused.

Learn More

Prevention: The Missing Link In Our Efforts To Support Families Impacted By The Opioid Epidemic 🔓

Health Affairs

This article discusses The Northwest Center for Family Support, in Washington state, which aims to increase access to treatment for the families of people receiving services for OUD. This includes prevention efforts directed at the children. The center works with opioid treatment programs, behavioral health agencies, and others, and offers training for providers in delivering family-friendly services. The authors note that staffing is a significant barrier with staff already struggling to meet a rise in mental health symptoms. Poor reimbursement for these services or uncertainty as to how to bill for family services is also a problem. They note that shame and guilt often make parents reluctant to tell their children about their OUD or engage in comprehensive family services. The authors call for improved funding as well as efforts to reduce stigma.

Relationships Between Alcohol Policies and Infant Morbidities and Injuries 🔓

American Journal of Preventive Medicine

This study examined the effect of state policies regulating liquor sales on infant morbidities (associated with alcohol use during pregnancy) and injuries (consistent with maltreatment). Infants (n=1,432,979) born between 2006 and 2019 were included. Overall, 3.1% of infants had a morbidity and 2.1% an injury. States with a government monopoly on liquor sales had decreased morbidities (OR=0.85) and injuries (OR=0.59). Allowing liquor sales in gas stations increased morbidities (OR=1.39) and injuries (OR=2.32). Allowing liquor sales after 10PM was associated with increased injurie (OR=1.38). There was no effect of allowing liquor sales in grocery stores or on Sundays. They conclude that state policies that expand alcohol availability were associated with infant morbidities and injuries.

Trends in Out-of-Pocket Costs for and Characteristics of Pharmacy-Dispensed Naloxone by Payer Type

JAMA

This study examined the mean yearly out-of-pocket (OOP) cost for naloxone dispensed from retail pharmacies. Price negotiations, market competition, and shifts in pharmacy benefit designs for insurance-paid prescriptions may have lowered OOP costs between 2018 and 2022. Costs continued to vary by payer, and in 2022 were highest for self-pay and assistance prescriptions. High OOP costs among assistance prescriptions were associated with brand-name naloxone (Narcan). Costs for injectable naloxone were lower than nasal naloxone. Higher OOP cost was observed among individuals aged 65 years or older, likely due to higher OOP requirements in Medicare. Individuals aged 65 years or older had the largest relative increase in 2020 to 2021 drug overdose death rates, highlighting the importance of expanding naloxone access among this population.

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