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The ASAM Weekly for July 23rd, 2024

This Week in the ASAM Weekly

To Address the Fentanyl Crisis, Greater Access to Methadone Is Needed

By Nora D. Volkow, MD
Director, National Institute on Drug Abuse (NIDA) at the National Institutes of Health.
NIDA is the world’s largest funder of scientific research on the health aspects of drug use and addiction.

Over the past several years, the increasing prevalence of fentanyl in the drug supply has created an unprecedented overdose death rate and other devastating consequences. People with an opioid use disorder (OUD) urgently need treatment not just to protect them from overdosing but also to help them achieve recovery, but highly effective medications like buprenorphine and methadone remain underused. Amid this crisis, it is critical that methadone, in particular, be made more accessible, as it may hold unique clinical advantages in the age of fentanyl.

Growing evidence suggests that methadone is as safe and effective as buprenorphine for patients who use fentanyl. In a 2020 naturalistic follow-up study, 53% of patients admitted to methadone treatment who tested positive for fentanyl at intake were still in treatment a year later, compared to 47% for patients who tested negative. Almost all (99%) of those retained in treatment achieved remission. An earlier study similarly found that 89% of patients who tested positive for fentanyl at methadone treatment intake and who remained in treatment at 6 months achieved abstinence.

Methadone may even be preferable for patients considered to be at high risk for leaving OUD treatment and overdosing on fentanyl. Comparative effectiveness evidence is emerging which shows that people with OUD in British Columbia given buprenorphine/naloxone when initiating treatment were 60% more likely to discontinue treatment than those who received methadone.1 More research is needed on optimal methadone dosing in patients with high opioid tolerance due to use of fentanyl, as well as on induction protocols for these patients. It is possible that escalation to a therapeutic dose may need to be more rapid. 

Read the full editorial here.

ASAM News

ASAM Submits Comments on DEA's Proposed Rescheduling of Marijuana

On July 19th, ASAM provided comments to the Drug Enforcement Administration (DEA) on a proposed rule that if finalized, would move marijuana from Schedule I of the Controlled Substances Act (CSA) to Schedule III. This proposed transfer is based on a determination by the US Department of Health and Human Services (HHS) that marijuana has a currently accepted medical use (CAMU) and lower “abuse potential and level of physical and psychological dependence” than other controlled substances that are in schedule I. While such a “wholesale” transfer may result in beneficial impacts to scientific research and/or pharmaceutical development, ASAM recommended that the DEA consider the possible failure of marijuana with higher tetrahydrocannabinol (THC) concentrations to meet HHS’ new, alternative test for CAMU.


Lead

Secondhand Nicotine Absorption From E-Cigarette Vapor vs Tobacco Smoke in Children 🔓

JAMA Network Open

This cross-sectional study of 1,777 US children aged 3 to 11 years examined how children’s nicotine absorption, as indexed by serum cotinine level, differ among those exposed to (1) secondhand tobacco smoke only, (2) secondhand e-cigarette vapor only, or (3) neither. Compared with children exposed to secondhand smoke only, nicotine absorption was 83.6% lower in those exposed to secondhand vapor only and 96.7% lower in those exposed to neither. These findings suggest that children absorb much more nicotine from secondhand smoke than from secondhand vapor; switching from smoking to vaping indoors may substantially reduce children’s secondhand exposure to nicotine and other noxious substances, but both smoke and vapor increase children’s absorption vs no exposure.

Research and Science

Extended-Release 7-Day Injectable Buprenorphine for Patients With Minimal to Mild Opioid Withdrawal 🔓

JAMA Network Open 

This nonrandomized trial examined the feasibility of a 7-day preparation of extended-release buprenorphine for patients with minimal to mild opioid withdrawal. Of 100 adult patients with opioid use disorder who presented with minimal to mild Clinical Opiate Withdrawal Scale scores (0-7), 7% of patients experienced precipitated withdrawal within 4 hours of 7-day extended-release buprenorphine administration; these included 3% with higher scores (4-7) and 14% with lower scores (0-3). Results of this study suggest that 7-day extended-release buprenorphine may be feasible in patients with opioid use disorder presenting with minimal to mild Clinical Opiate Withdrawal Scale scores (4-7), which could increase the number of patients receiving buprenorphine induction.

Effect of Acupuncture for Methadone Reduction: A Randomized Clinical Trial

Annals of Internal Medicine

In this randomized sham-controlled trial, researchers examined the effects of acupuncture on the ability of patients receiving methadone maintenance therapy (MMT) to reduce their dose and experience of opioid cravings. After 8 weeks of treatment, patients who received acupuncture were more likely to be able to decrease their methadone dose by 20% or more (P<0.001). In addition, patients receiving acupuncture reported greater reductions in opioid cravings (P<0.001). The study does demonstrate the potential benefits of acupuncture in this population, but the long-term results are limited by the relatively short length of observation.

Patient perceptions of and experiences with stigma using telehealth for opioid use disorder treatment: a qualitative analysis🔓

Harm Reduction Journal

The authors interviewed patients receiving treatment for opioid use disorder (OUD) about their experience with stigma in telehealth visits vs in-person. The experience of stigma overall was mixed. Patients reported that telehealth provided a greater sense of agency and control which decreased internalized stigma and could also increase perceptions of enhanced clinician trust. However, there were mixed results regarding stigma from others, with decreased concern about co-workers learning of treatment but an increased risk of family or friends becoming aware of telehealth appointments at home. Depending on the patient's perspective, telehealth could increase or decrease perceptions of stigma from their clinician. The study supports the importance of patient-centered care and allowing patients to have the option of in-person or telehealth appointments. 

Learn More 

Unlocking opioid neuropeptide dynamics with genetically encoded biosensors 🔓

Nature Neuroscience

This technical report described new fluorescent techniques useful for studying the response of mu, kappa, and delta opioid receptors to opioid neuropeptides. Unlike neurotransmitters, neuropeptides are released into the extracellular space and diffuse through tissue affecting all nearby neurons. Opioid receptors were genetically modified to include a region that emitted fluorescent light when the receptor was activated. The performance of these light-emitting receptors was tested with a variety of opioid agonists in individual neurons as well as tissue slices. Finally, living mice had optical fibers implanted in the nucleus accumbens to observe, in vivo, the response of opioid receptors to endogenous release of opioid peptides provoked by aversive and rewarding stimuli. These tools should lead to an increased understanding of the role of endogenous opioid peptides in pain, stress, reward, and addiction.

Zero alcohol products and adolescents: A tool for harm reduction or a trojan horse? 🔓

Appetite

Focus groups and a national online survey of adolescents in Australia explored their involvement with zero alcohol products (ZAPs). Many of these ZAPs come from companies that produce alcoholic beverages and mimic the packaging, branding, and taste of these products. Examples include alcohol-free Heineken beer and Gordon’s gin. Almost all adolescents have seen these products for sale, and over a third have consumed them. Many felt ZAPs offer an alternative to drinking in social situations, thus avoiding peer pressure to use alcohol. Many also thought ZAPs could serve as gateways to alcohol use. Results show adolescents who use alcohol were also 1.8 times as likely to use ZAPs. The authors conclude that it is unclear if ZAPs are a useful harm reduction tool or a trojan horse for industry.