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The ASAM Weekly for October 15th, 2024

This Week in the ASAM Weekly

Emergency departments (ED) are often at the forefront of the opioid crisis, and there are many examples of successful OUD ED care in the scientific literature. Yet generalizing these successes equitably encounters many structural, cultural, interpersonal, political, financial, and other challenges. The list goes on, but ultimately a scoping review from The Lancet Regional Health - Americas hones in on the need for “structural normalization of OUD care.” 

But what should that structure look like exactly? Primary care can function as a facilitator or barrier of OUD care, also but a retrospective policy analysis questions whether a primary care/chronic disease model is even the right conceptual structure to support all of this. Should we instead frame OUD care more like that of a cancer care model (BMC Primary Care)?

It is interesting and important to conceptualize care models, but in the meantime, the gaps are being filled with implementation strategy. Seattle is extending the OUD ED care model with EMT-administered buprenorphine, and other cities will likely adopt this as well (Office of the Mayor, Seattle). Telehealth flexibilities are a big concern for maintaining access to buprenorphine treatment, and all eyes are on the DEA and Congress (Modern Healthcare). But while we are talking about OUD care models, we must acknowledge that for any model to be sustainable, it must address more than just OUD. Alcohol use disorder persists with its own treatment gaps (Substance Use and Addiction Journal) and we’ve only just begun with cannabis (UPI).

However we look at it, scientific literature is limited, by design, so the complexity of care can’t be easily condensed and conveyed in models of care. The humanities, on the other hand, are limitless in their ability to describe the human experience, providing the opportunity to complement the scientific gaps of understanding in how we care about addiction (Inside Higher Ed).

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

Facilitators of and barriers to buprenorphine initiation in the emergency department: a scoping review ðŸ”“

The Lancet Regional Health - Americas

In the context of the opioid overdose epidemic, great efforts have been made to increase access to medication for opioid use disorder (MOUD), specifically buprenorphine. Initiation of buprenorphine in emergency departments (ED) has been a focus of these efforts. While initiation has been increasing, only 3-15% of persons treated in EDs fill a prescription. In this summary literature review, authors examined potential barriers and facilitators to initiation. Having care-coordination with streamlined and easy connection to outpatient treatment was associated with increased initiation. Conversely, the absence of care-coordination was associated with decreased uptake. Additionally, provider training and comfort increased uptake as did flexibility in induction strategies.  


Adolescent and Transition Aged Youth volume of The ASAM Criteria®

Now through November 15th, the American Society of Addiction Medicine (ASAM) has made available for public comment a draft of the proposed standards for the Adolescent and Transition Aged Youth volume of The ASAM Criteria, Fourth Edition. For more information and instructions to review, please click here.

Research and Science

Masked Taper With Behavioral Intervention for Discontinuation of Benzodiazepine Receptor Agonists 

JAMA Internal Medicine

This randomized clinical trial including 188 middle-aged and older adults explored whether targeting placebo effect mechanisms with a masked drug taper and augmented cognitive behavioral therapy for insomnia (CBTI) improve discontinuation of benzodiazepine receptor agonists. The percentage achieving benzodiazepine receptor agonist discontinuation was 64 (73.4%) with the masked tapering plus augmented CBTI vs 52 (58.6%) with open taper plus standard CBTI, a significant difference. Masked tapering and the addition of a behavioral intervention targeting placebo effect mechanisms to standard CBTI were associated with improved benzodiazepine receptor agonist discontinuation success.

Adverse Cardiovascular Effects of Nicotine Delivered by Chronic Electronic Cigarettes or Standard Cigarettes Captured by Cardiovascular Intrinsic Frequencies ðŸ”“ 

Journal of the American Heart Association

This study explored the cardiovascular effects of electronic cigarettes (EC). A prior study found that daily EC users had a 70% increase in the likelihood of having had a myocardial infarction. Rats (n=117) were exposed 5 hours a day for 8 weeks to one of four conditions: pure air, EC without nicotine, EC with nicotine, or cigarette smoke. Cardiovascular effects were measured using the intrinsic frequency method which analyzes the arterial pulse waveform to assess LV function and arterial stiffness. The group exposed to cigarette smoke showed significant reduction in LV function compared to the other 3 groups. The group exposed to EC with nicotine showed a significant increase in arterial stiffness when compared to the other 3 groups. There was no significant difference between the pure air and EC without nicotine groups. These results suggest that vaping can pose long-term cardiovascular health risks.

Cannabis Use During Adolescence and Young Adulthood and Academic Achievement 

JAMA Pediatrics

This meta-analysis of 63 studies including 438,329 individuals examined the association between cannabis use during adolescence or young adulthood and academic achievement. Moderate-certainty evidence showed cannabis use during adolescence and young adulthood is likely associated with lower school grades; a lower likelihood of high school completion, university enrollment, and postsecondary degree attainment; and increased school dropout rate and school absenteeism. Low-certainty evidence suggested cannabis use may be associated with increased unemployment. Cannabis use during adolescence and young adulthood was associated with worse academic performance, and further research is needed to mitigate upstream and downstream factors associated with early cannabis exposure.

Interactive effects of genetic liability and combat exposure on risk of alcohol use disorder among US service members 

Drug and Alcohol Dependence

Several prior studies have identified a link between combat exposure and alcohol use disorder (AUD). This study examined the effect of genetic susceptibility to AUD on this link. Associations between gene variants and AUD have allowed development of a polygenetic risk score for genetic liability to AUD (AUD-PRS). Soldiers (n=1203) deployed to Afghanistan in 2012 were studied several years later. The degree of combat exposure was expressed on a scale of 1 to 7 and a diagnosis of AUD was made for 116 soldiers based on DSM criteria. The risk of AUD with higher combat exposure (OR=1.1) just failed statistical significance (p=.051). However, among those with high AUD-PRS, higher combat exposure was associated with higher AUD risk (OR=1.60, p=.033). These results suggest that AUD-PRS could identify soldiers at risk for AUD following combat exposure.

Learn More 

Reframing conceptualizations of primary care involvement in opioid use disorder treatment ðŸ”“

BMC Primary Care

Primary care may be an ideal setting for provision of treatment for opioid use disorder (OUD) given it is often a site of first contact with the health system and can provide continuity of care and coordinate with other services. In this study, researchers examined potential barriers to uptake of OUD treatment in primary care in Australia and Canada. Some of the barriers identified are specific to OUD, including regulatory hurdles to providing medications for OUD (MOUD) in primary care settings and patient and provider perceptions. However, there were significant issues in the broader context of managing chronic conditions in general, including lack of resources and support within primary care. 

Disparities in Alcohol Treatment Use at the Intersection of Race, Ethnicity, Gender, and Insurance 

Substance Use and Addiction Journal

Alcohol use disorder (AUD) is the most common substance use disorder (SUD) in the United States, with over 14 million persons affected, but treatment is underutilized. In this study, researchers looked at past year utilization of AUD treatment to assess for racial, ethnic, and gender disparities. Overall, only 5.4% of adults with AUD accessed care in the prior year; researchers did not find any disparities by race, ethnicity, or gender. However, when looking at populations with Medicaid or underinsured, it was found that LatinX men and women were less likely to access care. The authors note that strategies are needed to increase AUD treatment uptake in general, but additional strategies may be needed for minoritized populations within insurance types. 

Clinical Features of Typically Developing Children With and Without Prenatal Alcohol Exposure

The Journal of Pediatrics

High levels of maternal drinking result in fetal alcohol spectrum disorder (FASD). This study attempts to determine if lower levels of prenatal alcohol exposure (PAE) cause harm. Children of maternal child dyads (n=1760) were examined during first grade. Tests included growth, morphology, and cognitive/behavioral assessments. The maternal child dyads fell into 3 groups: those with FASD, those with PAE without FASD, and those without PAE. Regarding growth and morphology, those with PAE without FASD were significantly different from the other two groups. Cognitive/behavioral tests showed those with FASD were significantly different from the other groups. Differences between those with and without PAE did not reach statistical significance. However, results for PAE without FASD were intermediate between those without PAE and those with FASD. These results support the benefit of no PAE.