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The ASAM Weekly for March 25th, 2025

This Week in the ASAM Weekly

Addiction is about (but not limited to) prevention, treatment, and surveys — lots of surveys. Unfortunately, one of our best national surveys (NSDUH) is known for not capturing people who are homeless or unstably housed, missing a crucial population at high risk of co-using stimulants and opioids. Attempts at using other surveys, such as the National HIV Behavioral Surveillance-People Who Inject Drugs (NHBS-PWID), can compensate in some ways but miss out in others, like not capturing all patients who use drugs (PWUD) because PWID is just a subset (Drug and Alcohol Dependence).

Sometimes survey data are not granular enough, so other methods are needed. Monitoring drug paraphernalia from overdose decedents can help by informing on polysubstance use or route/method of use and even identifying emerging substances — in close to real time (American Journal of Public Health). In a similar way, point-of-care surveillance can help alert both the individual user and local officials in identifying drug supply contaminants (like benzodiazepines), but accuracy, portability, and cost significantly influence utility (Drug and Alcohol Dependence).

Sometimes data from surveys can be problematic only because they’re lacking — a point made evident by the fact that ADHD was not included in two major US psychiatric surveys of the past 20 years, yet the US consumes over 80% of ADHD medications globally (Frontiers in Psychiatry). Does this mean we have another epidemic on our hands, or is it something else?

Surveying data can even help keep payers honest…sometimes. An analysis of Medicaid benefits documentation found that less than half of managed care plans (MCP) provide all three FDA-approved medications for alcohol use disorder (MAUD) (JAMA Network Open). But if you spin it differently, over 90% of the same MCPs cover at least one medication for AUD. Funny how that works.

In a perfect setting, survey data would represent addiction in real life. A homelessness survey in San Francisco helped expand the narrative that homelessness can often drive mental illness and addiction (SF Examiner). But survey data can only go so far, leaving the rest open (or vulnerable) to interpretation (or legislation). Take Oregon for example; numbers won’t change its image as a failed harm-reduction state. No matter what the surveys might say, the trickle-down effects have cemented its narrative (Newsweek). 

Thanks for reading,

Nicholas Athanasiou, MD, MBA, DFASAM
Editor in Chief

with Co-Editors: Brandon Aden, MD, MPH, FASAM; John A. Fromson, MD; Jack Woodside, MD

ASAM Weekly is looking for a Co-Editor to join the ASAM Weekly Team.

Please click here for details and to apply. 


Benzodiazepine Tapering Webinar Series

Registration is now open for ASAM's Benzodiazepine Tapering Webinar Series, which was designed to support implementation of the Joint Clinical Practice Guideline on Benzodiazepine Tapering: Considerations When Risks Outweigh Benefits. 

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Call for Applications: Fourth Edition ASAM Criteria Correctional Settings and Reentry Volume 

Applications to join the writing committees for the Correctional Settings and Reentry Volume of the Fourth Edition of The ASAM Criteria are now being accepted until May 9, 2025. 

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Lead Story

Alcohol Use Disorder Medication Coverage and Utilization Management in Medicaid Managed Care Plans 🔓

JAMA Network Open

This cross-sectional study examined how Medicaid managed care plans (MCPs) cover and manage medications for alcohol use disorder (AUD). A content analysis of publicly available data from all 241 comprehensive Medicaid MCPs in 2021 revealed that 103 plans (42.7%) covered all approved medications (acamprosate, naltrexone, and disulfiram) for AUD. Prior authorization and quantity limits were used rarely, except for injectable naltrexone. This study suggests that expanding medication use for AUD and providing patient-centered care may be undermined by insurance coverage limitations.

Research and Science 

A cryptic pocket in CB1 drives peripheral and functional selectivity 

Nature

There is a significant need for treatment for chronic pain and the cannabinoid receptor type 1 (CB1) is a potential non-opioid target for treatment. Still, concerns about centrally mediated psychoactivity and tolerance have limited the clinical use of CB1 agonists. To address these concerns, the authors used simulations to develop potential ligands that are peripherally restricted and wouldn’t stimulate the β-arrestin pathway, which is thought to mediate tolerance. The VIP36 ligand was identified and tested in 3 mouse pain models (inflammatory, neuropathic, and migraines) and provided pain relief; it was highly restricted to the periphery with a 100-fold dose separation between analgesic efficacy and centrally mediated side effects. In addition, the ligand did not stimulate the β-arrestin pathway and limited tolerance. These findings have potentially significant implications for chronic pain treatment.

The Fourth Wave of the Opioid Epidemic: Increasing Combination of Fentanyl With Stimulants

American Journal of Public Health

Researchers analyzed drugs and paraphernalia (409 items) found at the scene of 137 accidental overdoses involving fentanyl in San Francisco in 2022. Fentanyl was detected in materials from 77% of cases: 33% had fentanyl alone, 27% had fentanyl plus cocaine, and 15% had fentanyl plus methamphetamine. The frequent use of fentanyl with stimulants is consistent with the fourth wave of the opioid epidemic as described by Ciccarone in 2021. Fentanyl analogs were detected in 24% of cases, and 5% had fentanyl analogs alone. A total of 38 fentanyl analogs were detected, with fluorofentanyl being the most common. Xylazine, always with fentanyl, was detected in 10% of cases, reflecting the spread of this veterinary tranquilizer from the East Coast to the West. The authors also found an increase in smoking fentanyl with a decrease in injecting. 

National trends in co-use of opioids and methamphetamine among people who inject drugs, 2012-2018

Drug and Alcohol Dependence

This study examined patterns of co-use of opioids and methamphetamine, using data from the 2012, 2015, and 2018 National HIV Behavioral Surveillance among people who inject drugs. The co-use of methamphetamine and opioids increased during this period from 4.3% of respondents in 2012 to 14.3% in 2018. The prevalence of co-use was highest in the West with the most rapid increase in co-use in the Northeast. This is attributed to the methamphetamine supply from Mexico being first apparent in the West and spreading east. Co-use was associated with younger age, recent incarceration, injecting more than once daily, overdose in the past year, and sharing syringes. The authors conclude that the co-use of opioids and methamphetamine is increasing and associated with high-risk patterns of substance use. 

Telephone Counseling and Messaging Guided by Mobile Profiling of Tobacco Users for Smoking Cessation: A Randomized Clinical Trial 🔓

JAMA Network Open 

This randomized clinical trial assessed if personalized smoking cessation intervention guided by mobile health profiling of ecological momentary assessment (EMA) is effective for individuals who smoke with no intention to use smoking cessation aids.  Among the 459 individuals who smoked daily, providing personalized nurse-led telephone counseling and instant messaging guided by mobile health profiling of EMA was associated with higher biochemically validated tobacco abstinence at 3 months compared with completing 7-day EMAs alone. The intervention group also had higher usage of smoking cessation aids compared with the control group. Results of this study suggest that personalized telephone counseling and instant messaging guided by mobile health profiling of EMA can be used to supplement conventional smoking cessation promotion for individuals who use tobacco and are unwilling to use smoking cessation aids. 

Detection of benzodiazepines in the unregulated drug supply using point of care and confirmatory drug checking technologies: A validation study 🔓

Drug and Alcohol Dependence

As the opioid overdose epidemic continues, there has been an increase in the detection of other substances in overdose deaths and in the unregulated drug supply. Involvement of benzodiazepines or related compounds (etizolam) in overdose deaths in British Columbia has increased significantly, and this study evaluated 2 point-of-care technologies to detect benzodiazepines as potential harm reduction strategies. The study evaluated Fourier-transform infrared spectroscopy (FTIR) and immunoassay strips compared to spectroscopy, the gold standard.  FTIR was found to have a sensitivity of 26% and specificity of 99%, while the immunoassay strips had a sensitivity of 67% and specificity of 82%. When the methods were combined, the sensitivity was 75% and specificity was 82%. Notably, the test struggled with detecting etizolam.  

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Risk of Oral Health Problems in Adults with Opioid Use Disorder Treated with Transmucosal Buprenorphine 

Journal of Addiction Medicine

In 2022 the FDA warned, based on adverse event reports, that transmucosal (sublingual and buccal) buprenorphine may cause dental problems, such as tooth decay, cavities, oral infections, or loss of teeth. This study used insurance claims data from 2002 to 2019 for 721,878 adults with OUD; 22% had received transmucosal buprenorphine (3 or more prescriptions in 6 months) and the remaining 78% served as controls. The authors found that transmucosal buprenorphine was associated with increased oral health problems compared to controls at all time points from 1 month to 5 years. The hazard ratio at 1 year was 1.30 and at 5 years was 1.24 (p<0.001 for both). The authors also found a similar increased risk for periodontal problems: greater exposure to buprenorphine (9 or more prescriptions in a year) was associated with an even greater risk (HR at 1yr = 2.75, at 2yrs = 10.1, and at 5 yrs = 1.38, p<0.001 for all 3).  

Amphetamines: A Current Epidemic 🔓 

Frontiers in Psychiatry

In this opinion piece, the author raises concerns about prescription amphetamines in the United States while drawing parallels to prescription opioids, noting that prescription amphetamines have increased significantly in the last decade, with the US now accounting for 83.1% of all ADHD medications. The author attributes some of this to the overdiagnosis of ADHD, highlighting that many of the symptoms of ADHD overlap with other mental health disorders and also noting the misdiagnosis has a twofold problem of not treating the actual disorder and prescribing a potentially addictive medication. In addition, the author underscores the lack of studies and evidence around long-term efficacy, addiction potential, or treatment of addiction to amphetamines. The author recommends additional research in these areas and urges caution when diagnosing ADHD.