This Week in Addiction Medicine from ASAM

Memory function in patients with opioid dependence treated with buprenorphine and methadone in comparison with healthy persons  Scientific Reports This study compared memory performance in patients treated with methadone or buprenorphine for drug abuse to healthy controls using the Wechsler Memory Scale. Healthy controls performed better than both treatment groups in mental control. Methadone patients scored higher than controls in personal and general information, while buprenorphine patients scored lower in associate learning. Longer buprenorphine treatment was linked to better overall memory scores, and patients on methadone for over two years showed better awareness of place and time compared to long-term buprenorphine users. Overall, neither medication showed major negative effects on memory except for mental control, which was impaired in both groups. Buprenorphine appeared to better preserve memory function over time than methadone.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Medicaid Unwinding and Changes in Buprenorphine Dispensing  JAMA Network Open Among Medicaid-insured adults with buprenorphine use, this cross-sectional study examined if changes in buprenorphine dispensing were greater among those residing in states with the highest vs lowest decreases in Medicaid enrollment after “Medicaid unwinding” began in April 2023. Researchers used 2017-2023 data from a national prescription dispensing database that included 754,675 person-years from 569,069 patients. They found that patients in states with the highest decreases in Medicaid enrollment were more likely to decrease buprenorphine use, discontinue buprenorphine therapy, and use private insurance or cash to pay for buprenorphine prescriptions. The finding that Medicaid unwinding was associated with disruptions in buprenorphine therapy raises concerns about the potential for increased opioid-related morbidity and mortality.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Loneliness Among US Veterans With Problematic Substance Use: Results From the National Health and Resilience in Veterans Study Journal of Addiction Medicine Loneliness is a major public health concern, especially among individuals with problematic substance use (PSU), but little research has focused on vulnerable groups like US military veterans. This study, using data from the National Health and Resilience in Veterans Study, found that nearly half of veterans with PSU (47.4%) experience clinically significant loneliness. Factors contributing to loneliness included being unmarried, higher psychological distress (depression and PTSD), a history of suicide attempts, physical disability, smaller social networks, and lower purpose in life and optimism. The analysis highlighted that depressive and PTSD symptoms had the strongest impact on loneliness, followed by social network size and sense of purpose. Furthermore, veterans with depressive symptoms who had a strong sense of purpose were less likely to feel lonely. The study underscores the need for strategies targeting psychological distress, fostering social connections, and enhancing purpose to help alleviate loneliness in this population.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

The IARC Perspective on the Effects of Policies on Reducing Alcohol Consumption New England Journal of Medicine In 2020, alcohol use was responsible for over 740,000 new cancer cases worldwide. In response, The International Agency for Research on Cancer (IARC) released a two-part handbook assessing the effectiveness of public policy measures in reducing alcohol-related cancer risk. The report found that reducing or stopping alcohol consumption lowers the risk of certain cancers and that several policy interventions, such as increasing alcohol taxes; setting minimum pricing; restricting sales by time, place, and age; implementing total sales bans; and enacting strong marketing restrictions, effectively reduce alcohol consumption. Government-run alcohol monopolies and coordinated national strategies were also associated with decreased use. However, bans on alcohol discounts produced inconsistent results. These findings align with the WHO's Global Alcohol Action Plan and SAFER initiative, highlighting the importance of targeted, enforceable strategies to reduce alcohol-related harm globally.    Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Building Multidisciplinary Consensus on Inpatient Xylazine Management through Clinical Protocols Substance Use and Addiction Journal Xylazine in the unregulated drug supply produces significant morbidity and this paper describes utilizing a multidisciplinary team to develop protocols for inpatient setting to manage patients with xylazine exposure. Protocols developed included use of scheduled clonidine or tizanidine to manage withdrawal with hold parameters. As there is no FDA approved immunoassay screen, they recommended assuming xylazine exposure in areas with high prevalence and limited testing. The team also developed guidelines for cases in which surgical interventions would be considered, when to culture wounds, antibiotic usage, and consistent wound care based on size and clinical characteristics. In addition, they developed standardized discharge instructions, including referral to substance use disorder treatment, harm reduction and education around xylazine test strip use.     Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Varenicline for Youth Nicotine Vaping Cessation: A Randomized Clinical Trial Journal of the American Medical Association This 12-week randomized clinical trial in 261 treatment-seeking youth aged 16 to 25 years assessed if varenicline, when added to brief, remotely delivered behavioral support, was efficacious and well tolerated for nicotine vaping cessation in youth.  Researchers found that continuous abstinence rates were higher in the varenicline group than in the placebo group in the last month of treatment (51% vs 14%) and at 6-month follow-up (28% vs 7%). Treatment-emergent adverse events did not differ significantly between groups. Varenicline, when added to brief cessation counseling, is well tolerated and promotes nicotine vaping cessation compared with placebo in youth with addiction to vaped nicotine.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Comprehensive drug policies increase trust in local government: an analysis of authorities' and residents' perspectives in rural US Appalachian and Midwestern counties 

Hospital Addiction Consultation Service and Opioid Use Disorder Treatment JAMA Internal Medicine While medication for opioid use disorder (MOUD) is effective, many patients with OUD do not receive it, particularly in hospitalized settings. In this randomized trial they evaluated the Substance Use Treatment and Recovery Team (START) model, a team of an addiction medicine provider and a care manager, and provided motivational interviewing, discharge planning and telephone follow-up for one month. Patients who received the START intervention were more likely to receive MOUD (aRR=2.10) and connect to OUD care after discharge (aRR=1.49). In addition, these patients were more likely to have an OUD-focused discharge plan (aRR=1.8), initiate or continue MOUD post discharge (aRR=1.71), and see a clinician for OUD post discharge (aRR=1.89). These findings support use of hospital-based addiction consult services to address this healthcare gap.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Averted lung cancer deaths due to reductions in cigarette smoking in the United States, 1970–2022  Cancer Smoking prevalence peaked in the 50s and 60s but has declined following the US Surgeon General's report in 1964 on its health risk. As 85% of lung cancer is attributable to smoking, the authors evaluated this impact by assessing lung cancer deaths averted, and person-years of life (PYL) gained between 1970 and 2022 using cancer mortality data from the CDC. The authors estimated 3,856,240 lung cancer deaths were averted and 76,275,550 PYL were gained during the study period (average of 19.8 PYL gained per death averted). The deaths averted were higher in men (2,246,610), but average PYL gained per death averted was higher in women (22.4 years). Lung cancer deaths averted accounted for 51.4% of the estimated decrease in overall cancer deaths.  The findings highlight the importance of tobacco controls and interventions and need for ongoing efforts to decrease tobacco use.    Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Prescription Stimulant Use, Misuse, and Use Disorder Among US Adults Aged 18 to 64 Years  JAMA Psychiatry This study examined the prevalence of prescription stimulant use, prescription stimulant misuse, and prescription stimulant use disorder (PSUD) among adults aged 18 to 64 years in the US. Researchers found that 25.3% of adults in the study reported misuse, and 9.0% had PSUD. Among those with PSUD, 72.9% solely used their own prescribed stimulants, 87.1% used amphetamines, 42.5% reported no misuse, and 63.6% had mild PSUD. The prevalence of misuse was 3.1 times higher and the prevalence of PSUD was 2.2 times higher among those using prescription amphetamines than among those using methylphenidate. Regardless of prescription stimulant misuse status, screening for and treating PSUD is needed for US adults aged 18 to 64 years using prescription stimulants, especially those receiving prescription amphetamines.    Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

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.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Association Between Telehealth Initiation Of Stimulant Therapy And New Substance Use Disorder Diagnoses Health Affairs During the COVID-19 pandemic, the Drug Enforcement Administration (DEA) temporarily allowed for prescribing of controlled substances via telehealth and extended the policy through the end of 2025. With concern about potential adverse outcomes with this policy, there is debate about making it permanent. The authors utilized commercial and Medicaid claims data to assess newly diagnosed substance use disorders (SUD) after initiation of stimulants via telehealth versus in-person visits to inform this policy decision. In unadjusted analysis, patients initiated on stimulants via telehealth visits had higher rates of non-ADHD psychiatric comorbidities and new diagnoses of SUD in the year following initiation. In the adjusted analysis, controlling for psychiatric comorbidities, they did not find a difference in SUD outcomes. The authors suggest additional research to inform policy decisions.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

The association between buprenorphine doses above 16 milligrams and treatment retention in a multi-payer national sample in the United States, 2014 to 2021 Addiction Buprenorphine labeling identifies 16 mg as the “target dose,” supported by prior evidence that higher doses (≥16 mg) were associated with increased retention in treatment. Studies comparing doses above 16 mg to 16 mg, particularly in the era of fentanyl, have been very limited. The authors conducted a cohort study to look at retention for those receiving 24, 32, and 40 mg compared to 16 mg. Overall, higher doses were associated with increased retention, as follows: 1) 24 mg was more effective than 16 mg at 1 (aOR=1.52) and 18 months (aOR=1.17), 2) 32 mg was more effective than 24 mg at 6 (aOR=1.06), 12 (aOR=1.09), and 18 months (aOR=1.12), and 3) 40 mg was more effective than 24 mg at 12 (aOR=1.10) and 18 months (aOR=1.18). The authors suggest updates to label language and recommendations are prudent, while also supporting more research on long-term treatment with these higher doses.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Illicit Substance Use and Treatment Access Among Adults Experiencing Homelessness Journal of the American Medical Association Utilizing a multistaged probability-based survey, this study assessed the prevalence of illicit substance use, treatment, nonfatal overdose, and naloxone possession among 3,200 adults experiencing homelessness in California from October 2021 to November 2022.  An estimated 37% of respondents reported using any illicit substance regularly (≥ 3 times per week) in the last 6 months; methamphetamine use (33%) was the most common. Of those who reported regular use, an estimated 21% wanted but were unable to receive treatment. Approximately 20% of participants reported a nonfatal overdose, and 25% reported being in possession of naloxone. Substance use and nonfatal overdose were common among people experiencing homelessness in California. There was a high unmet need for substance use treatment and naloxone.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Once-Weekly Semaglutide in Adults With Alcohol Use Disorder  JAMA Psychiatry  This randomized clinical trial explored if glucagon-like peptide 1 (GLP-1) receptor agonist semaglutide reduces alcohol consumption and craving in adults with alcohol use disorder (AUD). Relative to placebo, low-dose semaglutide reduced the amount of alcohol consumed during a posttreatment laboratory self-administration procedure. Over the course of nine weeks of treatment, semaglutide led to reductions in some but not all measures of weekly consumption, significantly reduced weekly alcohol craving relative to placebo, and led to greater relative reductions in cigarettes per day in a subgroup of participants with current cigarette use. These results justify larger clinical trials of incretin therapies for AUD.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM  

Cannabis Use Disorder Emergency Department Visits and Hospitalizations and 5-Year Mortality JAMA Network Open This cohort study of 11.6 million people who were studied for a median of five years investigated if individuals who have hospital-based (emergency department or hospitalization) care for a cannabis use disorder (CUD) were at increased risk of death. Researchers found that individuals with incident hospital-based care for a CUD were at a 2.8-fold increased risk of death within five years relative to the general population. These results suggest that individuals who require hospital-based care for a CUD may be at increased risk of premature death.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Real-Time Assessment of Alcohol Reward, Stimulation, and Negative Affect in Individuals With and Without Alcohol Use Disorder and Depressive Disorders American Journal of Psychiatry A commonly held model of addiction posits that as addictions develop, there is progression from positive reinforcement to negative reinforcement to ameliorate withdrawal symptoms. In this study, researchers examined the subjective response to alcohol among persons with and without alcohol use disorder (AUD) and with or without comorbid depression. Regardless of the presence of comorbid depression, persons with AUD reported pleasurable effects, including stimulation and hedonic reward, after consumption of alcohol. In contrast, among those without AUD, the positive effects were less substantial. Participants did report reduction in negative affect, but the effects were relatively small. These findings suggest that positive reinforcement is sustained in the progression of AUD and the reward-sensitive stage may exist along with negative reinforcement.    Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Outpatient Low-Dose Initiation of Buprenorphine for People Using Fentanyl JAMA Network Open The accumulation of fentanyl in fat is likely responsible for the risk of precipitated withdrawal when buprenorphine is initiated. Low dose initiation (LDI) of buprenorphine attempts to minimize this risk. This retrospective study included 126 individuals making 175 LDI attempts in an outpatient setting. Patients chose either a 4 day or 7 day LDI protocol with buprenorphine monoproduct. Both protocols begin with buprenorphine 0.5mg, increasing to 8mg tid. Overall LDI was successful in 34% of attempts (with no difference between the protocols) and one month retention on buprenorphine was 21%. Repeated LDI attempts were less likely to be successful (second attempt aOR 0.3). Unhoused people had lower odds of success (OR 0.4). The authors conclude that people with OUD using fentanyl attempting outpatient LDI of buprenorphine had low odds of success.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Association of State Cannabis Legalization With Cannabis Use Disorder and Cannabis Poisoning JAMA Psychiatry This longitudinal cohort study examined the association of state-level medical and recreational cannabis laws with cannabis use disorder (CUD) and cannabis poisonings in the adult population with employer-sponsored health insurance. The study showed that from 2011 to 2021, states with legalized medical cannabis experienced 42.7% and 88.6% increases in CUD and cannabis poisoning, respectively, compared to states without legalized medical cannabis. States with legalized recreational cannabis experienced a 31.6% increase in cannabis poisoning compared to states without legalized recreational cannabis. Thus, state medical cannabis legalization was associated with increased CUD and cannabis poisonings, and state recreational cannabis legalization was associated with increased cannabis poisoning in the adult population with employer-sponsored health insurance.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Current Advances in Behavioral Addictions: From Fundamental Research to Clinical Practice American Journal of Psychiatry This narrative review discusses five clinically relevant and prevalent behavioral addictions that are common and often co-occur with psychiatric disorders such as depression and anxiety. Gambling disorder is the only behavioral addiction recognized as a clinical disorder in DSM-5, and Internet gaming disorder is included as a condition requiring further research. ICD-11 categorizes gambling and gaming disorders as disorders due to addictive behaviors. Additional behavioral addictions may include compulsive sexual behavior disorder, compulsive buying-shopping disorder, and problematic use of social media. Validated diagnostic instruments exist, with empirical support varying across conditions. No medications have approved indications from regulatory bodies for behavioral addictions, and cognitive-behavioral therapy has the most empirical support for efficacious treatment. Treatment optimization involving pharmacotherapy, psychotherapy, neuromodulation, and their combination warrants additional investigation.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Host Dr. Nick Athanasiou is joined by Dr. David Fiellin and Dr. Eric Strain to discuss the concept of Treatment Refractory Addiction.  Why does the field of addiction medicine need this term, how is it defined and how the current treatment system aligns with the idea? Listen to the full interview to learn more!   Treatment Failure Versus Failed Treatments: The Risks of Embracing Treatment Refractory Addiction [Dr. David Fiellin] The Concept of Treatment-Refractory Addiction: A Call to the Field [Dr. Eric Strain] The Concept of Treatment-Refractory Addiction: Implications for Addiction Treatment Systems and Research [Dr. Edward Nunes & Dr. Thomas McLellan] - Subscribe to the ASAM Weekly

Review of Evidence on Alcohol and Health National Academies of Sciences, Engineering, and Medicine To inform the next edition of the Dietary Guidelines for Americans (DGA), Congress tasked the National Academies with convening an expert committee to independently review the evidence on the relationship between moderate alcohol consumption and eight health outcomes including obesity, cancer, and cardiovascular disease. This controversial report found that a pattern of moderate drinking was associated with 18 percent fewer cardiovascular disease deaths, a 16 percent lower risk of all-cause mortality, and a 10 percent heightened risk of breast cancer for women.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

The impact of schizophrenia genetic load and heavy cannabis use on the risk of psychotic disorder in the EU-GEI case-control and UK Biobank studies Psychological Medicine Using data from the EU-GEI case-control study and UK Biobank, researchers examined the independent and combined effect of heavy cannabis use and schizophrenia polygenic risk score (PRS), on risk for psychosis. Schizophrenia PRS and cannabis use independently increased risk of psychosis. Schizophrenia PRS was not associated with patterns of cannabis use. It was associated with lifetime and daily cannabis use without psychosis, but the effect was substantially reduced when cannabis use disorder (CUD) PRS was included in the model. Regular users of high-potency cannabis had the highest odds of being a case independently of schizophrenia PRS. Regular use of high-potency cannabis remains a strong predictor of psychotic disorder, independent of schizophrenia PRS. Schizophrenia PRS does not seem to be associated with heavy cannabis use. These are important findings, at a time of increasing use and potency of cannabis worldwide.    Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Prevalence of pharmacotherapy for attention-deficit/hyperactivity disorder and prescription stimulant misuse: A national study of US college students Addiction This is an observational study using cross-sectional data from the American College Health Association–National College Health Assessment III. It measured the association between university-level prevalence of attention deficit/hyperactivity disorder (ADHD) medication treatment and prevalence of prescription stimulant misuse (PSM) among college students.  Among university students in the United States, there appears to be a positive association between attending universities with a greater prevalence of ADHD medication treatment and risk of prescription stimulant misuse (PSM). This study provides further support for the possibility that ADHD medication treatment prevalence is a risk factor for PSM.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Xylazine Pharmacokinetics in Patients Testing Positive for Fentanyl and Xylazine  Clinical Chemistry This study of xylazine pharmacokinetics used plasma samples from 28 patients who had urine screens positive for xylazine and fentanyl. The patients were being treated for skin lesions, most commonly, then shortness of breath or opioid overdose. At least two subsequent plasma samples were analyzed for xylazine and xylazine metabolites by LC-MS/MS. The median terminal half-life for xylazine in plasma was 12 hours (range 6-21 hours). Animal studies show xylazine to be extensively metabolized, with little unchanged xylazine eliminated in urine. The two most abundant metabolites were oxo-x and sulfone-x, which did not have a window of detection longer than xylazine. Researchers had no information as to the timing or route of xylazine ingestion or if additional xylazine was consumed during the study period. These factors could affect the accuracy of the results.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Suicide in people prescribed opioid-agonist therapy in Scotland, United Kingdom, 2011–2020: A national retrospective cohort study 

Links between adolescent binge drinking and midlife alcohol use behaviors by age, sex, and race/ethnicity 

Buprenorphine/Naloxone vs Methadone for the Treatment of Opioid Use Disorder JAMA Network 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). The risk of mortality was low while in either form of treatment (0.08% vs 0.13%).  Individuals receiving methadone had a lower risk of treatment discontinuation compared with those who received buprenorphine/naloxone. The risk of mortality while receiving treatment was similar between medications.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Association of Daily Doses of Buprenorphine With Urgent Health Care Utilization 

Facilitators of and barriers to buprenorphine initiation in the emergency department: a scoping review  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.    Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM  

Cannabis Policy Impacts Public Health and Health Equity National Academy of Sciences Engineering Medicine This report from the National Academies of Sciences, Engineering, and Medicine urges the federal government to provide policy guidance to states that have legalized cannabis, close regulatory loopholes on intoxicating products derived from hemp, and create a public health campaign aimed at parents and vulnerable populations, among other measures that would protect public health and reduce the harms of rising cannabis use. Federal action includes closing regulatory loopholes for hemp-derived cannabinoids, a cannabis public health campaign, best practices for cannabis policy, and improved cannabis public health data and allowing research. State action includes required training for cannabis retail staff, automatically expunging criminal records, a model for state cannabis policy, and setting product standards.    Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

In this episode recorded live at ASAM's 55th Annual Conference in Fort Worth, TX, host Dr. Nick Athanasiou sat down with Dr. Shannon Miller to discuss his work on PAM-7, and his path to addiction medicine.   Subscribe to the ASAM Weekly

Risk of Incident Psychosis and Mania With Prescription Amphetamines The American Journal of Psychiatry This case-control study used electronic health records to examine the impact of dose levels of prescription amphetamines on the risk of incident psychosis and mania with prescription amphetamines. Among 1,374 case subjects and 2,748 control subjects, the odds of psychosis and mania were increased for individuals with past-month prescription amphetamine use compared with no use. A dose-response relationship was observed; high doses of amphetamines (>30 mg dextroamphetamine equivalents) were associated with 5.28-fold increased odds of psychosis or mania. Past-month methylphenidate use was not associated with increased odds of psychosis or mania compared with no use. Caution should be exercised when prescribing high doses of amphetamines, with regular screening for symptoms of psychosis or mania.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Cannabis Laws and Utilization of Medications for the Treatment of Mental Health Disorders  

State-level racial and ethnic disparities in buprenorphine treatment duration in the United States  The American Journal on Addictions National trends reveal a concerning escalation in racial and ethnic disparities in buprenorphine treatment duration for opioid use disorder. This study examined such disparities at the state level. Analyzing 9,040,620 buprenorphine prescriptions dispensed between January 2011 and December 2020 from IQVIA Longitudinal Prescription data, the study revealed substantial statewide variations in racial and ethnic disparities. Specifically, 21 states showed longer treatment durations for White people across all episodes, and 8 states displayed similar trends among episodes lasting ≥180 days. Longer treatment durations for White people in both overall and long-term episodes were exhibited in 5 states, and 15 states showed no racial and ethnic disparities.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM  

Virtual reality-based Mindfulness-Oriented Recovery Enhancement (MORE-VR) as an adjunct to medications for opioid use disorder: a Phase 1 trial 

The Lancet Psychiatry Commission on youth mental health

Alcohol Consumption Patterns and Mortality Among Older Adults With Health-Related or Socioeconomic Risk Factors  JAMA Network Open  This British study included 135,103 older (median age 64) adults and compared drinking patterns with mortality during a median follow-up of 12 years. Compared to occasional drinkers, low-risk drinkers had higher cancer mortality (HR, 1.11), moderate-risk drinkers had higher all-cause and cancer mortality (HRs, 1.10 and 1.15), and high-risk drinking had higher all-cause, cancer, and cardiovascular mortality (HRs, 1.33, 1.39, and 1.21). These results contrast with earlier studies showing protective effects of low- to moderate-risk drinking. Researchers used occasional drinkers as the control group, where previous studies used abstainers including former drinkers with residual health effects. There was a small protective effect of drinking only with meals and drinking wine. In conclusion, the authors failed to find a protective effect of low-risk drinking on mortality.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Physician Reluctance to Intervene in Addiction: A Systematic Review 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.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM  

Host Dr. Nick Athanasiou sat down with Drs. Matisyahu Shulman and Adam Bisaga to discuss the study they recently authored titled Rapid Initiation of Injection Naltrexone for Opioid Use Disorder: A Stepped-Wedge Cluster Randomized Trial. The doctors share their findings and the impact and implications of the study.    Subscribe to The ASAM Weekly to read the guest editorial:  Guest Editorial: Rapid Initiation of Injectable Extended-Release Naltrexone for Opioid Use Disorder: A Time for Paradigm Shift in Treatment Protocols   This project has been funded as a whole or in part with Federal funds from the National Institute on Drug Abuse, National Institutes of Health, Department of Health and Human Services, under Contract No. 75N95020C00028.

Social Vulnerability and Prevalence and Treatment for Mental Health and Substance Use Disorders JAMA Psychiatry This is a survey study of 4,674 participants from US households that examined the association between social vulnerability and mental health and substance use disorders and related treatment in the US noninstitutionalized population of adults aged 18 years and older. Large increases in several mental health and substance use disorders and corresponding decreases in treatment were found in the most socially vulnerable communities. The findings suggest that routine measurement of social vulnerability might assist in developing more comprehensive care models that integrate medical and social care for mental health and substance use disorders.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Psilocybin desynchronizes the human brain  Nature To assess how human brain network changes relate to the subjective and lasting effects of psychedelics, this study tracked individual-specific brain changes with longitudinal precision functional mapping (roughly 18 magnetic resonance imaging visits per participant). Psilocybin massively disrupted functional connectivity (FC) in the cortex and subcortex, acutely causing more than threefold greater change than methylphenidate. These FC changes were driven by brain desynchronization across spatial scales (areal, global), which dissolved network distinctions by reducing correlations within and anticorrelations between networks. Persistent reduction of hippocampal-default mode network connectivity may represent a neuroanatomical and correlate of the proplasticity and therapeutic effects of psychedelics.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

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.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM  

Benzodiazepine use in relation to long-term dementia risk and imaging markers of neurodegeneration: a population-based study 

Extended-release ketamine tablets for treatment-resistant depression: a randomized placebo-controlled phase 2 trial  Nature Medicine The safety and tolerability of racemic ketamine may be improved if given orally, as an extended-release tablet (R-107), compared with other routes of administration. In this phase 2 multicenter clinical trial, male and female adult patients with treatment-resistant major depression (TRD) and Montgomery–Asberg Depression Rating Scale (MADRS) scores ≥20 received open-label R-107 tablets 120 mg per day for 5 days and were assessed on day 8 (enrichment phase). On day 8, responders (MADRS scores ≤12 and reduction ≥50%) were randomized to receive double-blind R-107 doses of 30, 60, 120, or 180 mg, or placebo, twice weekly for 12 weeks. Nonresponders on day 8 exited the study. Tolerability was excellent, with no changes in blood pressure, minimal reports of sedation, and minimal dissociation. The most common adverse events were headache, dizziness, and anxiety. R-107 tablets were effective, safe, and well tolerated in patients with TRD, enriched for initial response to R-107 tablets.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Global status report on alcohol and health and treatment of substance use disorders World Health Organization This report utilizes data from the WHO member states to summarize alcohol consumption, its health consequences, and alcohol policies around the world. Overall, there was a decrease in alcohol consumption between 2010 and 2019, but alcohol-related deaths still accounted for 4.7% of all deaths in 2019. Despite the burden, there are still significant gaps in access to and types of treatment available worldwide, with the percentage of patients with substance use disorder receiving care ranging from 1% to 30% in countries that gather that data. The report makes several recommendations to address the concern, including a global advocacy campaign, increased training for health professionals at all levels, international knowledge transfers, and resource mobilization.    Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Community-Based Cluster-Randomized Trial to Reduce Opioid Overdose Deaths The New England Journal of Medicine  HEALing (Helping to End Addiction Long-term Initiative) Communities Study (HCS) investigators examined the potential of the community-engaged, data-driven Communities That HEAL (CTH) intervention to reduce the rate of opioid-related overdose deaths in highly affected communities. Intervention communities implemented hundreds of strategies to expand opioid overdose education and naloxone distribution, the use of medications for opioid use disorder, and safety measures for prescription opioid use, as well as communication campaigns to support these efforts. Although there were no significant between-group differences in the rate of opioid-related overdose deaths, the trial showed that the CTH community-engaged intervention, with its leveraging of community coalitions and a data-driven approach, can bring about meaningful progress in implementing evidence-based practices.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Piloting a Hospital-Based Rapid Methadone Initiation Protocol for Fentanyl  Journal of Addiction Medicine The epidemic of fentanyl has led to increased opioid tolerance and made traditional dosing for methadone initiation insufficient. In this study, the authors examine an inpatient rapid titration of methadone initiation among patients with opioid use disorder (OUD). The protocol recommended dosing of 60 mg on day 1, 70 mg day 2, 80 mg day 3 and 100 mg day 4-7. After patients with significant underlying medical conditions, benzodiazepine or alcohol use and age >65 were excluded, 25 patients underwent the rapid initiation. No patients in the study experienced an adverse event and while additional research is needed, the study demonstrated the feasibility of rapid initiation of methadone for OUD in select patients in an inpatient setting.    Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Associations of semaglutide with incidence and recurrence of alcohol use disorder in real-world population Nature Communications In this retrospective cohort study of patients receiving medication for treatment of obesity, the authors evaluated the association of semaglutide with incidence of and recurrence of alcohol use disorder (AUD). In the cohort patients received semaglutide or non-GLP1RA medications, including naltrexone and topiramate. In matched cohort analysis, patients who received semaglutide had much lower rates of incident AUD (HR=0.5) compared to those receiving non-GLP1RA medications and in sub-analysis comparing semaglutide to naltrexone/topiramate the also had lower incident AUD (HR=0.44). Among those with a history of AUD, semaglutide was also associated with lower recurrence of AUD (HR=0.44) overall and in sub-analysis (HR=0.25). These findings support potential benefit of semaglutide for AUD in a real-world population and need for randomized clinical trials.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Innovation and adaptation: The rise of a fentanyl smoking culture in San Francisco Plos One This is a qualitative study describing the growing practice in the San Francisco area of smoking rather than injecting fentanyl. Fentanyl salts are stable up to 350°C making heating and inhalation more effective than for heroin. Some of the increase in smoking is driven by users' difficulty finding accessible veins. There is also the perception that smoking presents less of a risk of overdose compared to injection. It is unclear if smoking is safer and overdose deaths continue to rise in San Francisco. Over time a brown residue accumulates that contains a high concentration of drug. The smoking equipment is often used for both methamphetamine and fentanyl so this residue contains an unknown mixture of the history of the drugs consumed. The residue is valued for potency but presents a new overdose risk due to the unknown amounts of drugs it contains.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Rapid Initiation of Injection Naltrexone for Opioid Use Disorder JAMA Network Standard initiation procedures (SP) for extended-release (XR)-naltrexone can be a barrier to initiation for patients. In this stepped-wedge cluster-randomized trial, they compared SP initiation (3-5 days buprenorphine taper, 7-10 days opioid-free) to a rapid procedure (RP) initiation (1 day buprenorphine, 1 day opioid free, 3-4 days ascending dose of oral naltrexone). Patients in the RP group (62.7%) were more likely to receive the initial XR-naltrexone dose (OR 3.6, P