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The ASAM Weekly for August 13th, 2024

This Week in the ASAM Weekly

Physicians not widely adopting evidence-based practices to help reduce addiction morbidity and mortality

Melinda Campopiano von Klimo, JBS International, Inc.
Laura Nolan, JBS International, Inc.
Wilson M. Compton, National Institute on Drug Abuse, National Institutes of Health

By now, addiction specialists understand the depth and impact of the drug overdose death crisis in the United States. We’ve read that, “Drug overdoses are one of the leading causes of injury death in adults and have risen over the past several decades… In 2022, 107,941 drug overdose deaths occurred.” Studies published in the past year alone highlight the toll overdose is taking on communities and families, with health disparities and inequities in care often exacerbating negative health outcomes for those most in need. For example, “Overdose deaths increased in pregnant and postpartum women from early 2018 to late 2021,” “More than 321,000 U.S. children lost a parent to drug overdose from 2011 to 2021,” and “Unintentional drug overdose deaths among teens 15-19 remained elevated well into 2022.” These trends have been fueled by the inclusion of illegally made fentanyl, which is increasingly found in the illegal drug supply, as evidenced by, “Over 115 million pills containing illicit fentanyl seized by law enforcement in 2023.” 

Despite these grim statistics and headlines, widespread efforts to support people with substance use disorders have been implemented, including the development of evidence-based practices to identify and treat opioid use disorder and other substance use disorders in practice. For example, screening, brief intervention, and referral to treatment is an effective approach in general medical settings to reduce drug and alcohol use.1-4 And safe and effective behavioral therapies and pharmacotherapies for nicotine, alcohol, and opioid use disorders were approved over the last 25 years.5-7 In addition, medication monitoring and psychosocial interventions can support people in recovery to reduce current use or to avoid a recurrence of use by helping them identify and cope with triggers.8 Finally, harm reduction strategies (eg, naloxone co-prescribing, drug checking and testing, syringe service programs) provide substantial benefits for people who use drugs and for those not seeking abstinence-based treatment9-11; these approaches help prevent overdose deaths and reduce the transmission of infectious diseases.

The problem is that clinicians’ use of evidence-based practices to address the ongoing morbidity and mortality related to substance use disorders is lacking. Interdisciplinary teams, including advanced practice nurses, physician assistants, counselors, and social workers, are essential to provide a comprehensive response to addiction and to successful treatment outcomes. These professionals’ practice and collaborative care models are often contingent upon physician participation, making physician engagement critical to addressing substance use disorder care deficiencies.12

Read the full editorial here.

Lead Story 

Physician Reluctance to Intervene in Addiction: A Systematic Review ðŸ”“

JAMA Network Open 

This systematic review of 283 articles explored the reasons physicians give for not addressing substance use and addiction in their clinical practice. The institutional environment (81.2% of articles) was the most common reason given for physicians not intervening in addiction, followed by lack of skill (73.9%), cognitive capacity (73.5%), and knowledge (71.9%). These findings suggest that efforts should be directed at creating institutional environments that facilitate the delivery of evidence-based addiction care while improving access to education and training opportunities for physicians to practice the necessary skills.

ASAM News

ASAM Summarizes Changes Proposed Medicare Physician Fee Schedule (PFS) Rule Will Bring to Medicare Coverage of SUD Treatment

ASAM published an analysis of the CY 2025 Medicare PFS, finding the proposed rule builds on previous coverage expansions of the substance use disorder care continuum, but that extensive coverage gaps remain.

Read more.

Read an in-depth summary of the proposed rule here.

Research and Science

The Efficacy of GLP-1 Agonists in Treating Substance Use Disorder in Patients: A Scoping Review

Journal of Addiction Medicine

Glucagon-like peptide-1 agonists (GLP-1) are effective in diabetes and weight loss. Animal studies and anecdotal reports suggest they may have potential in treating SUDs. This literature review identified 5 studies that looked for the benefit of GLP-1 in the treatment of tobacco use disorder (2 studies), alcohol use disorder (2 studies), and cocaine use disorder (1 study). For tobacco, one study found significant increases in abstinence at 6 weeks (46% v. 27%); however, the second found no difference (but did find a reduction of weight gain after cessation). One alcohol study found no effect overall, but did find a reduction in drinking in obese patients (BMI>30) with an increase in those with BMI<25. The other alcohol study found a 50% reduction in alcohol-related medical events in those taking GLP-1. The cocaine study found no effect. The authors conclude that the results are mixed, and more research is needed.

Patterns of substance use recovery following residential treatment: A repeated measures latent profile analysis ðŸ”“

Drug and Alcohol Review

In this latent profile analysis of patients with substance use disorders (SUD) in residential treatment, the authors evaluate patterns of patient characteristics that may indicate the need for more intensive treatment. The study identified 5 patient profiles based on baseline disease severity and 3 months post-discharge, from which 2 profiles were identified that did not improve or worsen. Individuals with worse baseline mental health were more likely to have shorter courses of treatment and poorer outcomes. Additional strategies are needed to address comorbid conditions and increase retention in treatment. The authors note additional research is needed on longer-term outcomes.

The associations of supervised consumption services with the rates of opioid-related mortality and morbidity outcomes at the public health unit level in Ontario (Canada): A controlled interrupted time-series analysis ðŸ”“

Drug and Alcohol Review

Supervised consumption sites (SCS) have existed in Canada for 20 years and research has consistently shown they reduced opioid overdose morbidity and mortality for participants. This study examined the impact of SCS at the population level on opioid overdose deaths, monthly opioid-related ED visits, and hospitalizations in Ontario between 2014 and 2021. In areas with SCS, rates of deaths did not decrease, though they also did not increase while they did increase in areas without SCS. There was no decrease in ED visits or hospitalizations related to SCS. Overall, SCS was not found to decrease morbidity or mortality at the population level, though it may have mitigated increases in overdose deaths. Authors note that the non-effects of SCS in reducing deaths at the population level may be related to the limited availability of SCS relative to the number of overall incidences.

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Buprenorphine/naloxone - one formulation that doesn't fit all: a case report ðŸ”“

Harm Reduction Journal

This case report describes a patient with nausea 30 minutes after sublingual buprenorphine/naloxone (bup/nx) that resolved when switched to buprenorphine monoproduct. Despite poor bioavailability, naloxone can be detected in nearly all patients taking sublingual bup/nx. The authors cite studies showing some patients experience headache, nausea, or anxiety during the hour after taking bup/nx that resolves when naloxone is eliminated. They suggest that these naloxone side effects could decrease treatment retention. They acknowledge concerns about IV use of the monoproduct but note that IV use of bup/nx is already well described. One alternative to sublingual buprenorphine monoproduct is subcutaneous buprenorphine injections which do not contain naloxone.

A detox dilemma beyond benzodiazepines; clonidine's quandary in alcohol withdrawal management

The American Journal on Addictions

Benzodiazepines are the primary method of treatment for alcohol withdrawal, though ASAM guidelines also include alternative agents for consideration. Due to concerns about potential more-than-necessary benzodiazepine use, this study used a single-site VA retrospective chart review to analyze adjunctive clonidine use for elevated blood pressure/pulse in alcohol withdrawal among veterans with alcohol withdrawal managed on a CIWA protocol in a psychiatric emergency room. The study sheds light on the potential underutilization of clonidine and its possible role in improving alcohol withdrawal syndrome management. By addressing elevated blood pressure/pulse and curbing the potential overuse of benzodiazepines, the study may contribute to further optimizing patient care.