This Week in Addiction Medicine from ASAM

ASAM Weekly Special Episode: Dr. David Fiellin & Dr. Eric Strain sit down to discuss the concept of Treatment Refractory Addiction

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]
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Lead: Review of Evidence on Alcohol and Health

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.
 
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Lead: 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

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. 
 
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Lead: Prevalence of pharmacotherapy for attention-deficit/hyperactivity disorder and prescription stimulant misuse: A national study of US college students

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.
 
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Lead: Xylazine Pharmacokinetics in Patients Testing Positive for Fentanyl and Xylazine

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

Suicide in people prescribed opioid-agonist therapy in Scotland, United Kingdom, 2011–2020: A national retrospective cohort study 🔓
Addiction
This retrospective cohort study aimed to determine if opioid agonist therapy (OAT) in Scotland is protective against suicide, and measure trends in suicide rates in those with opioid dependence over time. The study included 46,453 individuals who received at least one prescription for OAT between 2011 and 2020 with over 304,000 person-years (pys) of follow-up. Results suggested that people with opioid dependence in Scotland have a greater risk of suicide than the general population. Treatment is protective, with rates of suicide lower among those on opioid agonist therapy. Suicide rates have decreased over time, during a period in which drug-related death rates in Scotland have risen to globally high levels.
 
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Lead: Links between adolescent binge drinking and midlife alcohol use behaviors by age, sex, and race/ethnicity

Links between adolescent binge drinking and midlife alcohol use behaviors by age, sex, and race/ethnicity 🔓
Alcohol Clinical and Experimental Research
Using data from the Monitoring the Future study, which enrolled cohorts of high school seniors annually starting in 1976, this analysis evaluated alcohol drinking patterns in adults 35-60 and potential association with their drinking patterns at age 18. Overall, the reported mean number of drinks at a time ranged from 1.7 to 1.4, and the mean maximum number of drinks ranged from 3.2 to 2.3. The reported number of drinks was generally lower at older ages. Those who reported binge drinking at 18 versus those who did not report a significantly higher mean (2.3 vs. 1.3) and maximum (4.0 vs. 2.3) number of drinks as adults. Additionally, they were more likely to report binge drinking (39.5% vs 19.1%) and high-intensity drinking (10.5% vs 4.4%) as adults. Further, this association was even stronger in older age groups, suggesting adolescent binge drinking is a risk factor across the lifespan.
 
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Lead: Buprenorphine/Naloxone vs Methadone for the Treatment of Opioid Use Disorder

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.
 
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Lead: Association of Daily Doses of Buprenorphine With Urgent Health Care Utilization

Association of Daily Doses of Buprenorphine With Urgent Health Care Utilization 🔓
JAMA Network Open 
This cross-sectional study using health care claims data from 35,451 US adults with an opioid use disorder diagnosis assessed whether buprenorphine treatment using doses higher than Food and Drug Administration recommendations is associated with subsequent acute health care utilization. Those receiving higher maximum doses of buprenorphine (i.e., doses above 16 mg and 24 mg) had significantly lower rates of acute care utilization than their peers receiving FDA-recommended doses (between 8 mg and 16 mg). These results suggest that higher doses of buprenorphine are associated with lower acute care utilization and could provide benefits to patients, particularly those using fentanyl who might need these higher doses.
 
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Lead: Facilitators of and barriers to buprenorphine initiation in the emergency department: a scoping review

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. 
 
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