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The ASAM Weekly for October 29th, 2024

This Week in the ASAM Weekly

Addressing the Addiction Treatment Gap 

Gary Tsai, MD, FAPA, FASAM
Director, Substance Abuse Prevention and Control Bureau, County of Los Angeles, Department of Public Health

If the data around substance use disorder (SUD) treatment-seeking teach us anything, it’s that most people with these conditions are not actually interested in the services we offer.

A big part of the reason for this is not because the SUD field doesn’t have an amazingly dedicated workforce or offer lifechanging services. Instead, the fact that readiness for SUD treatment is often defined as synonymous with readiness for complete abstinence from substances has set a treatment bar that is too high and unrealistic for most. While the influences of stigma and the criminalization of addiction on treatment-seeking cannot be ignored, it is generally easier to shape our practices than to solve these bigger societal issues.

In recognition of the need for fresh approaches to address addiction, ASAM recently approved a clinical considerations document focused on the Engagement and Retention of Nonabstinent Patients in Substance Use Treatment.

Developed via an extensive literature review and expert consensus and refined through a robust public comment process, the strategies highlighted in this document serve as a roadmap for designing treatment systems, services, and processes that can better engage all populations with SUDs, particularly those who are more upstream on the readiness to change continuum. 

Read the full editorial here. 

Lead Story 

Buprenorphine/Naloxone vs Methadone for the Treatment of Opioid Use Disorder

JAMA 

This population-based retrospective cohort study assessed whether the use of buprenorphine/naloxone is associated with lower risk of treatment discontinuation and mortality compared with methadone. It included 30,891 individuals initiating treatment for the first time during the study period and found that the risk of treatment discontinuation was higher among recipients of buprenorphine/naloxone compared with methadone (88.8% vs 81.5% within 24 months), and the risk of mortality was low while in either form of treatment (0.08% vs 0.13%).  


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 

The association between glucose-dependent insulinotropic polypeptide and/or glucagon-like peptide-1 receptor agonist prescriptions and substance-related outcomes in patients with opioid and alcohol use disorders: A real-world data analysis ðŸ”“ 

Addiction

This retrospective cohort study aimed to estimate the strength of association between prescriptions of glucose-dependent insulinotropic polypeptide (GIP) and/or glucagon-like peptide-1 receptor agonists (GLP-1 RA) and the incidence of opioid overdose and alcohol intoxication in patients with opioid use disorder (OUD) and alcohol use disorder (AUD), respectively. It also aimed to compare the strength of the GIP/GLP-1 RA and substance use-outcome association among patients with comorbid type 2 diabetes and obesity. The authors found that prescriptions of GIP and/or GLP-1 RA appear to be associated with lower rates of opioid overdose and alcohol intoxication in patients with OUD and AUD. The protective effects are consistent across various subgroups, including patients with comorbid type 2 diabetes and obesity.

Layperson-Administered Naloxone Trends Reported in Emergency Medical Service Activations, 2020-2022 ðŸ”“

JAMA Network Open

This study examined the prevalence of layperson-administered naloxone (LAN) between 2020 and 2022. In cases of opioid overdose, time is critical, and LAN typically occurs 5 minutes prior to EMS arrival. A national database of EMS responses to 911 calls reported over 65 million calls during these 2 years, of which 744,078 involved naloxone administration. LAN accounted for 24,990 or 3.4% of naloxone administrations, the rest being EMS-administered naloxone. While naloxone administrations decreased by 6.1% between 2020 and 2022, LAN increased by 44%. This increase reflects improving naloxone education and access. However, bystanders made the 911 calls in all of these cases, and despite bystander presence, only 3.4% had LAN. This suggests that there is a need for improved naloxone education and access.

30-Month Impact of Medications for Opioid Use Disorder on Acute Care Utilization in Rural Communities

Journal of Addiction Medicine

This study examined the effect of medications for opioid use disorder (MOUD) on emergency department (ED) visits and inpatient admissions (IP) in a group of rural Medicaid recipients with OUD. A group of patients receiving MOUD (n = 5370) was compared with a matched group of patients with OUD not receiving MOUD. In the MOUD group, 82% received buprenorphine, 10% naltrexone, and 8% methadone. The greatest reductions were seen in the first 6 months, with 33% fewer ED visits and 65% fewer IP admissions (p < 0.001). By the eighth month, fewer than 60% were receiving any MOUD. Over the entire 30-month follow-up, there were 24% fewer ED visits and 52% fewer IP admissions (p < 0.001). The authors concluded that the reduction in health care utilization costs provide an incentive for payers to provide MOUD without arbitrary limits.

Learn More 

Tranq Dope: Characterization of an ED cohort treated with a novel opioid withdrawal protocol in the era of fentanyl/xylazine ðŸ”“ 

The American Journal of Emergency Medicine

The advent of xylazine in the opioid supply, in addition to synthetic opioids, has clinical implications, one of which is managing withdrawal symptoms in the emergency department (ED). Researchers evaluated a protocol for managing withdrawal initiated in an ED in Philadelphia. Participants were assessed on Clinical Opiate Withdrawal Scale (COWS) scores and patient-directed discharge. The protocol involved various strategies, including buprenorphine initiation, short-acting opioids, and other adjunctive medications. Patients who received the intervention had a significant reduction in median COWS scores (12 vs 4, p<0.001), and patient-directed discharge rates decreased from 10.7% prior to initiation of the protocol to 3.9% post-initiation. Overall, the protocol improved patient symptoms, decreased patient-directed discharges, and had few adverse events. 

Tobacco Product Use Among Middle and High School Students — National Youth Tobacco Survey, United States, 2024🔓

Morbidity and Mortality Weekly Report

Tobacco use continues to be a significant public health concern and typically begins during adolescence. In this report, the authors use the National Youth Tobacco Survey to review tobacco use in middle school (grade 6-8) and high school (grade 9-12) students in 2024. Overall, 8.1% of students reported current tobacco product use, with a rate of 10.1% in high school students and 5.4 % in middle school students. E-cigarettes were the most used product, and notably, nicotine pouches were second-most reported. Researchers found a decrease in tobacco use from 2023, mostly attributable to a decrease in e-cigarette use. While public health efforts have been successful, interventions are still needed to decrease tobacco use in adolescence, and future research is needed to understand the use of nicotine pouches.