This Week in Addiction Medicine from ASAM

Lead: Tobacco industry contributions to the development of ultraprocessed food in the United States, 1985–2007: A case study of Lunchables

Tobacco industry contributions to the development of ultraprocessed food in the United States, 1985–2007: A case study of Lunchables
American Journal of Public Health
Tobacco firms began acquiring US food companies in the 1960s-1990s to increase revenues and leverage research and development across holdings in tobacco, alcohol, and ultra-processed foods (UPF) subsidiaries. In this case study, the authors examine the development of Lunchables® following Phillip Morris (PMC) acquisition of Kraft and General Foods (KGF). PMC applied a “consumer-driven product development” strategy, previously used for tobacco, in the development process to maximize consumer appeal. PMC also used technologies from KGF to make lower-nicotine cigarettes and then low-fat versions of Lunchables®, in a “better-for-you” strategy to preserve market share in the face of health concerns about both products. The authors suggest public health strategies and policies used to address tobacco could be expanded to UPFs to reduce harm to children.
 
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Lead: GLP-1 receptor agonist treatment and health outcomes in methadone-treated patients with opioid use disorder and diabetes

A retrospective comparison of two state-funded smartphone-based contingency management programs with different incentives 
Drug and Alcohol Dependence
This retrospective study compared outcomes for patients with stimulant use disorder enrolled in a smartphone-based contingency management program based on the amount of total incentives possible, either $75 (“low-value”) or $599 (“moderate-value”). The low-value program was based in New Jersey, funded through SAMHSA (which limited reimbursement to $75/patient at the time of implementation, which has since been increased), and rewarded completing drug testing, attending counseling visits, and completing CBT modules rather than abstinence over 16 weeks. The moderate-value program was funded by West Virginia’s Medicaid managed care organizations, lasted up to 26 weeks, and largely rewarded negative drug screening results, with additional rewards for counseling and CBT modules. Patients in the moderate-value program submitted significantly higher rates of negative substance tests (36%, with an average of 3.2 negative tests) compared to those in the low-value group (24.7%, with an average of 24.8 negative tests).
 
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Lead: Methamphetamine use among adult patients presenting with acute coronary syndrome: A single‐center retrospective cohort study

Methamphetamine use among adult patients presenting with acute coronary syndrome: A single‐center retrospective cohort study🔓
Journal of the American Heart Association
This study included 1,309 patients treated for an acute myocardial infarct (MI) at a California health system between 2012 and 2022. A total of 194 patients (15%) were methamphetamine users. The Meth-MI group had less diabetes than the No-Meth-MI group (38% vs 51%, p=.001) but many more smokers (72% vs 28%, p<.001). Nonobstructive coronary disease (eg, vasospasm) was more common in the Meth-MI group (24% vs 11%, p<.001), which consequently had lower rates of revascularization, aspirin, and statin therapy. The Meth-MI group had double the mortality (HR, 2.1, p<.001), and methamphetamine use was the strongest predictor of mortality, greater than diabetes. The Meth-MI group was more likely to have a subsequent MI (42% vs 27%, p<.001). The risk of MI with methamphetamine use is 19% higher than the risk with cocaine use (this study excluded cocaine users). The authors believe presentations with methamphetamine use and angina, without MI, is even more common. 
 
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Lead: Best practices for hospital-based initiation of medications for opioid use disorder: A consensus statement

Best practices for hospital-based initiation of medications for opioid use disorder: A consensus statement
JAMA Network Open
This survey study used a 2-round Delphi process to develop expert consensus on best practices for hospital-based MOUD initiation for patients with OUD, with a goal to provide guidance on changing inpatient addiction treatment in response to increased synthetic opioids in the unregulated drug supply. A total of 42 expert clinicians participated; clinicians were considered a national expert if they had cared for at least 100 hospitalized patients with OUD in the last two years. There was consensus that buprenorphine and methadone initiation in the hospital setting were appropriate, with less support for hospital-based naltrexone initiation. Consensus was also reached to support rapid methadone initiation; high- and low-dose buprenorphine initiation; and provision of non-MOUD full agonist opioids for treatment of opioid withdrawal during methadone initiation, as a bridge to buprenorphine initiation, and for those declining MOUD.
 
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Lead: Access to medications for opioid use disorder among veterans with homeless experience in permanent supportive housing

Access to Medications for Opioid Use Disorder Among Veterans With Homeless Experience in Permanent Supportive Housing
JAMA Network Open
This cohort study assessed 10,110 US veterans with homeless experience and opioid use disorder (OUD) residing in permanent supportive housing (PSH), in terms of what factors are associated with receipt of medications for opioid use disorder (MOUD).  Only 17% received MOUD within 12 months. Greater behavioral health engagement was associated with MOUD receipt, while older age, race minority status, and prior inpatient hospitalization were associated with lower odds. These results suggest that MOUD access in supportive housing should be expanding, which could require embedding addiction care into PSH teams, leveraging behavioral health touchpoints, and addressing persistent disparities.
 
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Lead: Medicaid Managed Care Plan Alignment With State Substance Use Disorder Treatment Coverage Requirements

Medicaid Managed Care Plan Alignment With State Substance Use Disorder Treatment Coverage Requirements
The Milbank Quarterly
Medicaid managed plan coverage for medications for alcohol use disorders (AUD) and opioid use disorder (OUD) varies across states but is generally lower in Republican-leaning states. Researchers conducted a national survey to evaluate if these differences in coverage were due to variation in state policy or variations in Medicaid managed plan alignment with state policy. Researchers found that while Republican-leaning states were generally a little less likely to require coverage of most or all medications for AUD and OUD and place limits on prior authorization, managed plans in Republican-leaning states were much less likely to follow state requirements. Given these findings, efforts to increase access to medications for AUD and OUD will need to address misalignment between managed care plans and state policy, and not just focus on making changes to state policy.
 
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Lead: Outpatient Direct Initiation of Injectable Buprenorphine in a Harm Reduction Agency and Primary Care Clinic: A Retrospective Case Series

Outpatient Direct Initiation of Injectable Buprenorphine in a Harm Reduction Agency and Primary Care Clinic: A Retrospective Case Series
Journal of Addiction Medicine
Initiating weekly long-acting injectable buprenorphine (LAIB) without prior sublingual buprenorphine (“direct-to-inject” or DTI) may reduce buprenorphine initiation barriers. In this case series, outpatient DTI outcomes are described. Of the 23 patients with available data, 19 (83%) had no withdrawal symptoms pre-DTI. Of the 20 patients with documented post-DTI withdrawal symptoms, 3 (15%) had no withdrawal, 12 (60%) had mild, 4 (20%) had moderate, and one (5%) patient had severe withdrawal. Thirty days post-DTI, 14 (58%) patients were retained on any buprenorphine formulation, and 11 (46%) patients were retained at 90 days. The median post-DTI buprenorphine treatment days were 77 (range: 9–90).  The majority of patients had no pre-DTI withdrawal symptoms, no or mild withdrawal symptoms post-DTI, and were retained on buprenorphine at 30 days post-DTI, with nearly half retained at 90 days. DTI is a promising buprenorphine initiation strategy, but further research is warranted.
 
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Lead: A µ-opioid receptor superagonist analgesic with minimal adverse effects

A µ-opioid receptor superagonist analgesic with minimal adverse effects
Nature
This study identifies a novel µ-opioid receptor (MOR) agonist with supramaximal intrinsic efficacy and a unique pharmacological profile that produced effective analgesia in rodents with minimal adverse effects. N-desethyl-fluornitrazene (DFNZ) was derived from a class of synthetic benzimidazole opioids called nitazenes. DFNZ has impaired brain penetrance, a unique spatiotemporal MOR cellular signaling profile, and diminished efficacy at the MOR–galanin 1 receptor (GAL1) heteromer. DFNZ does not induce respiratory depression, tolerance, or MOR downregulation after repeated exposure. Compared with other MOR agonists, DFNZ has limited effects on dopamine neurotransmission in the nucleus accumbens and weaker reinforcing effects in the drug self-administration procedure. These results provide novel insights about MOR and nitazene pharmacology, have important implications for pain and addiction treatment, and challenge the prevailing dogma that high-efficacy MOR agonists cannot constitute safe and effective therapeutic agents.
 
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Lead: Methadone Dose and Patient-Directed Discharge in Hospitalized Patients with Opioid Use Disorder

Methadone Dose and Patient-Directed Discharge in Hospitalized Patients with Opioid Use Disorder
JAMA Network
This retrospective observational cohort study of 554 individuals examined rates of patient-directed discharge (PDD) among hospitalized patients with opioid use disorder who received methadone during the first 72 hours of hospitalization from July 2019 to June 2022. Higher doses of methadone were associated with a decreased rate of PDD. For each additional 10 mg of methadone received in the first 24 hours, there was a decrease in odds of PDD at 48 hours (adjusted OR 0.71). This study highlights the importance of adequate treatment of opioid withdrawal to reduce the risk of PDD.
 
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Lead: Do US Adults View Drug and Alcohol Addiction as a Health Condition?

Do US Adults View Drug and Alcohol Addiction as a Health Condition?
Journal of Addiction Medicine 
Participants (n=5250), part of Gallup’s random sample of US households, completed a web-based survey that explored their beliefs about addiction.  Asked if addiction is a health condition 77% of US adults agree, 16% disagree, and 6% don’t know. Men are more likely to disagree (20%) than women (15%). Those who have struggled with addiction but not in recovery were more likely to disagree (22%) than those in recovery (13%) or with no personal addiction experience (16%). Those with less education and income were more likely to disagree. Those who disagree that addiction is a health condition are less likely to believe it is treatable by doctors (OR=0.3), believe that medications are effective treatments (OR=0.4), or help friends or family with addiction (OR=0.5). 
 
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