This Week in Addiction Medicine from ASAM

Lead: The IARC Perspective on the Effects of Policies on Reducing Alcohol Consumption

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. 
 
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Lead: Building Multidisciplinary Consensus on Inpatient Xylazine Management through Clinical Protocols

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.  
 
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Lead: Varenicline for Youth Nicotine Vaping Cessation: A Randomized Clinical Trial

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

Comprehensive drug policies increase trust in local government: an analysis of authorities’ and residents’ perspectives in rural US Appalachian and Midwestern counties 🔓
Harm Reduction Journal
Implementation of harm reduction intervention policies by local governments may be met with caution because of concern about potential backlash from communities and erosion of public trust. The authors conducted two studies to assess the influence of perceptions of government support for comprehensive drug policies (including harm reduction) on public trust in local government. In both a field study and an experimental study, the authors found that public trust was positively associated with increased perception of government support for comprehensive drug policies. The authors note residents recognized harm reduction policies as a step to address the issue of drug use, and these findings may ease some concerns about public pushback for local government officials when considering these policies. 
 
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Lead: Hospital Addiction Consultation Service and Opioid Use Disorder Treatment

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.
 
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Lead: Averted lung cancer deaths due to reductions in cigarette smoking in the United States, 1970–2022

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. 
 
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Lead: Prescription Stimulant Use, Misuse, and Use Disorder Among US Adults Aged 18 to 64 Years

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. 
 
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Lead: Alcohol Use Disorder Medication Coverage and Utilization Management in Medicaid Managed Care Plans

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.
 
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Lead: Association Between Telehealth Initiation Of Stimulant Therapy And New Substance Use Disorder Diagnoses

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.
 
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Lead: The association between buprenorphine doses above 16 milligrams and treatment retention in a multi-payer national sample in the United States, 2014 to 2021

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.
 
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