This Week in Addiction Medicine from ASAM

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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Lead: Illicit Substance Use and Treatment Access Among Adults Experiencing Homelessness

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.
 
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Lead: Once-Weekly Semaglutide in Adults With Alcohol Use Disorder

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.
 
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Lead: Cannabis Use Disorder Emergency Department Visits and Hospitalizations and 5-Year Mortality

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.
 
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Lead: Real-Time Assessment of Alcohol Reward, Stimulation, and Negative Affect in Individuals With and Without Alcohol Use Disorder and Depressive Disorders

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. 
 
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Lead: Outpatient Low-Dose Initiation of Buprenorphine for People Using Fentanyl

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.
 
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Lead: Association of State Cannabis Legalization With Cannabis Use Disorder and Cannabis Poisoning

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.
 
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Lead: Current Advances in Behavioral Addictions: From Fundamental Research to Clinical Practice

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.
 
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