The ASAM Weekly for May 28th, 2024
This Week in the ASAM Weekly
Drug overdose deaths dropped in the US for the first time in years (New York Times). Although this is welcomed news, it is far from an indication that we are in a “final phase,” as stated in a different, more myopic New York Times article. In reality, we’re still grappling with fentanyl, the fourth wave, and “seem to be sinking deeper into the crisis rather than extricating ourselves” out of it (JAMA Network Open). Several publications this week shine a light on how we'll find our way out.
New induction protocols for OUD medications will be a part of this. A scoping review shows us that high-dose buprenorphine can be initiated safely, while further study is needed to optimize dosing and expand beyond inpatient settings (Journal of Addiction Medicine). Use of full-opioid agonists in addition to methadone or buprenorphine could be a reasonably straightforward and effective strategy for improving retention - in Canada (JAMA Network Open). While the traditional induction period needed for extended-release naltrexone might seem insurmountable, a new rapid procedure could cut that time in half (JAMA Network Open).
Another way to save lives is by getting more buprenorphine to more people who need it, which happens at the pharmacy level. Regulators need to shift from seeing pharmacies as conduits for diversion and start seeing them for what they are - critical access points for care (Health Affairs Forefront). The economics of pharmacy benefit managers also need to change so that they actually benefit buprenorphine treatment, which costs more to dispense than is reimbursed (Pittsburgh Post-Gazette).
However one might interpret the recent drop in overdose deaths, we still have a ways to go and many things to do along the way. Only in hindsight will we know when this crisis actually ends, but for now, we know that it will continue to evolve (Philadelphia Inquirer).
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
ASAM Clinical Considerations for Engagement and Retention of Non-Abstinent Patients in Substance Use Treatment
ASAM has made available for public comment a draft of its Clinical Considerations for Engagement and Retention of Non-Abstinent Patients in Substance Use Treatment document. The deadline for feedback is June 3.
Lead Story
Rapid Initiation of Injection Naltrexone for Opioid Use Disorder 🔓
JAMA Network Open
Standard initiation procedures (SP) for extended-release (XR)-naltrexone can be a barrier to initiation for patients. In this stepped-wedge cluster-randomized trial, the authors compared SP initiation (3-5 days buprenorphine taper, 7-10 days opioid-free) to a rapid procedure (RP) initiation (1 day buprenorphine, 1 day opioid free, 3-4 days ascending dose of oral naltrexone). Patients in the RP group (62.7%) were more likely to receive the initial XR-naltrexone dose (OR 3.6, P<0.001) than the SP group (35.8%). There was not a statistically significant difference between the groups in rate of 2nd and 3rd doses. The study demonstrates that RP for initiation of XR-naltrexone is non-inferior to SP and may lead to shorter in-patient stay.
ASAM Clinical Algorithm Subcommittee
CALL FOR APPLICATIONS!
The ASAM Clinical Algorithm Subcommittee is looking for members to collaborate on refining the 4th Edition clinical algorithms for ASAM Criteria-based assessment tools! Click the link below to learn more and apply.
Applications due May 31, 2024.
Research and Science
High-Dose Buprenorphine Initiation: A Scoping Review
Journal of Addiction Medicine
In this review, the authors looked at 15 studies with high-dose buprenorphine initiation, starting dose >12 mg (range 16-96 mg), to assess safety and adverse outcomes. Across the studies, 580 patients were initiated on high-dose buprenorphine, most frequently 24 or 32 mg, with no events of overdose or respiratory depression. Further, precipitated withdrawal was only seen in 7 individuals and all studies reported improvement in withdrawal symptoms, either qualitatively or through improved withdrawal severity scores. The authors note that while additional studies, specifically comparing initiation strategies, are needed, these findings suggest higher dose buprenorphine on day one should be considered for initiation for at least some patients.
Short-Acting, Full Agonist Opioids During Initiation of Opioid Agonist Treatment in the Fentanyl Era 🔓
JAMA Network Open
In medical settings, fentanyl is valued for its short duration of action. However, with chronic use there is significant tissue accumulation, turning it into a long-acting opioid that can take days to eliminate. Precipitated withdrawal with buprenorphine can occur days after stopping fentanyl, and even longer with naltrexone. Patients attain high levels of tolerance due to fentanyl’s potency and may require a high methadone dose. Methadone requires slow titration so patients may not experience relief from withdrawal for some time. These problems can hurt retention in treatment. Early in COVID, British Columbia, Canada allowed additional full-agonist opioids for patients receiving opioid agonist treatment, and a recent study shows improved retention. The addition of full agonist opioids could help with initiating MOUD in patients using fentanyl.
PLOS ONE
E-cigarettes are increasingly being used by individuals to try quitting smoking. This study used an anonymous, cross sectional, online survey to examine sources of information and type of information received when using e-cigarettes to quit smoking and their associations with the duration of abstinence achieved. The two most commonly reported information sources were friends (43.9%) and the internet (35.2%), while 14.0% received information from a healthcare provider. People received information on type of device (48.5%), flavor (46.3%), and nicotine concentration (43.6%). More respondents received information about gradually switching from smoking to vaping (46.7%) than abruptly switching (30.2%). While few received information from healthcare providers, obtaining information about abruptly switching to e-cigarettes and what nicotine concentrations to use were associated with longer quit durations.
BMC Public Health
This study looked for associations between policies of prescription drug monitoring programs (PDMP) and adolescent prescription pain medication misuse. These policies include mandatory PDMP use by prescribers, and reports sent to prescribers, licensing bodies, or law enforcement. Data came from 8,677 respondents in 25 states via the 2019 National Youth Behavior Risk Survey. Previous studies with adults have found no effect on prevalence of misuse, but a reduction in number of days of misuse. This study found no association between PDMP policies and any measure of adolescent misuse. The authors note that some of these PDMP policies were added recently and may need time to show effect.
Learn More
How Our Overdose Crisis Response Is Delayed At The Pharmacy 🔓
Health Affairs Forefront
To stem the opioid crisis, the DEA and state legislatures must clarify that prescribing buprenorphine for opioid use disorder (OUD) is categorically different than prescribing opioids for pain management. Buprenorphine prescribed for OUD should be exempt from federal and state red flag laws. State regulators and the DEA must explicitly instruct distributors and pharmacies not to apply diversion protocols to medications for opioid use disorder (MOUD). Federal regulators must work with manufacturers and distributors to ensure adequate production and supply of naloxone and MOUDs. Legal settlements relating to the overdose epidemic should separate buprenorphine from other prescription opioids and incentivize the manufacturing, distribution, and dispensation of this medication and other MOUDs. Major retail pharmacies bear responsibility for adopting store protocols that direct staff to fill MOUD prescriptions and stock and promote over-the-counter naloxone.
Ultra-Processed Food Addiction: A Research Update 🔓
Current Obesity Reports
This article presents a review of the current evidence around ultra-processed foods (UPF), which have been demonstrated to trigger addiction-like responses. Current evidence suggests UPF addiction prevalence at around 14% for the general adult population, and even higher among adults with obesity (28%). In addition, alterations in brain-gut-microbiome have been demonstrated, including disrupted dopaminergic signaling, dysregulated hunger/satiety hormone, and alteration in gut microbiome. There is also some evidence that persons can experience a withdrawal syndrome from UPF. While significant additional research is needed, the authors suggest that addiction-based treatments for UPF may be important to improve clinical outcomes, particularly for underserved populations and those with obesity.
The Lancet Regional Health - Americas
Half-a-decade into legalization and its consequential ‘normalization’ environment for cannabis, a mixed picture has emerged of developments for main outcome indicators among underage/adolescent youth in Canada. While cannabis use rates have remained steady at best at comparably high levels, selected adverse cannabis-related health outcomes (e.g., hospitalizations), and some risk-behaviors have increased. With exposure to cannabis commercialization common, adolescents' cannabis sourcing practices have shifted from predominantly ‘illegal’ to ‘legal’ (albeit so only for adults) and ‘grey’ (e.g., ‘social’) sources. The objective of effective cannabis access and use reduction for this particular age group has not been achieved through legalization. The mixed results for Canada are generally similar to those observed in US-based legalization settings.
In The News
Matthew Perry’s death under investigation in connection with ketamine level found in actor’s blood
AP News
The New York Times
Overdose Deaths Dropped in U.S. in 2023 for First Time in Five Years
The New York Times
Daily marijuana use outpaces daily drinking in the US, a new study says
AP News
Editorial: Reforms meant to combat opioids are now hampering addiction care
Pittsburgh Post-Gazette
‘We were shocked’: Vaping considerably increases lung cancer risk among people who smoke
Healio
Medetomidine and nitazenes, two new drug additives, showing up in Philly
The Philadelphia Inquirer