This Week in Addiction Medicine from ASAM

Lead: Spirituality and Harmful or Hazardous Alcohol and Other Drug Use

Spirituality and Harmful or Hazardous Alcohol and Other Drug Use 
JAMA Psychiatry
This meta-analysis of 55 rigorous studies on spirituality and harmful or hazardous drug use (alcohol, tobacco, marijuana, or illicit drugs) examined the association between spiritual exposures and related drug use outcomes.  It documented a significant protective association of 13% related to both prevention and recovery. The risk reduction, which extended across all 4 drug categories, reached 18% for individuals with greater than weekly religious service attendance.  These results have implications for clinicians and communities regarding future strategies to address harmful or hazardous alcohol or other drug use.
 
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Lead: Emergency Department–Initiated Buprenorphine for Opioid Use Disorder

Emergency Department–Initiated Buprenorphine for Opioid Use Disorder
JAMA Network
This multicenter randomized study examined if 7-day extended-release injectable buprenorphine compared with sublingual buprenorphine to improve treatment engagement at 7 days.  It included 1,994 adult patients presenting to the emergency department with untreated opioid use disorder and a Clinical Opiate Withdrawal Scale (COWS) score of 4 or higher.  In treatment at 7 days, 40.5% were in the extended-release group and 38.5% were in the sublingual buprenorphine group, demonstrating no significant difference between groups. The study concluded that a 7-day extended-release injectable preparation of buprenorphine does not improve treatment engagement.
 
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Lead: Use of gabapentin with or without a prescription in substance use treatment settings: A national analysis of urine drug testing data, 2016–2023

Use of gabapentin with or without a prescription in substance use treatment settings: A national analysis of urine drug testing data, 2016–2023 
Drug and Alcohol Dependence
Gabapentin prescriptions have increased due to off-label use, including managing withdrawal/comorbidities in substance use disorder (SUD) treatment, despite gaps in evidence bases and corresponding increases in nonmedical use. This retrospective, serial cross-sectional study sought to identify trends in gabapentin use with and without a prescription in SUD treatment settings.  Researchers found that gabapentin prescribing significantly increased in SUD treatment settings despite a lack of strong evidence bases for its utility. While rates of gabapentin use outside a prescription were nearly double that for prescribed use, this appears to be decreasing over time. Polysubstance use and potential gaps in multimorbidity care may contribute to the use of gabapentin without a prescription.
 
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Lead: Association of alcohol intake over the lifetime with colorectal adenoma and colorectal cancer risk in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial

Association of alcohol intake over the lifetime with colorectal adenoma and colorectal cancer risk in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial
Cancer
This study analyzed data from the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial to look for an association between alcohol intake and colorectal cancer (CRC) or colorectal adenoma. Participants' lifetime pattern of alcohol intake was determined from a dietary history recorded as part of the PLCO trial. Current drinkers with a lifetime average of over 14 drinks per week had a higher CRC risk than those with under 1 drink per week (HR 1.25, p = .003) and an even higher risk of rectal cancer (HR 1.95). There was no consistent association between alcohol intake and colorectal adenoma risk, however results suggested that former drinkers may have a reduced risk of adenoma. They discussed potential mechanisms such as acetaldehyde, a known carcinogen and product of alcohol metabolism, and effects of alcohol on gut microbiome. They conclude that heavy alcohol intake increases CRC risk and that alcohol cessation may lower adenoma risk.
 
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Lead: Medication Availability for Alcohol Use Disorder in Substance Use Disorder Treatment Facilities

Medication Availability for Alcohol Use Disorder in Substance Use Disorder Treatment Facilities
JAMA Network Open
This study examined the availability of medications for alcohol use disorder (MAUD) in SUD treatment facilities (SUDTF) from 2017 to 2023.  Data was obtained from SAMSA’s Mental Health and Addiction Treatment Tracking Repository. The percentage of counties with a SUDTF offering MAUD increased from 34% in 2017 to 50% in 2021. This increase leveled out between 2021 and 2023 perhaps related to the pandemic. Counties with a MAUD-offering facility were more likely to be metropolitan (57% vs 25%, p<.001) with substantially more population (mean 220,100 vs 26,650, p<.001), and fewer uninsured residents (8.5% vs 10.7, p<.001).  They call for policies supporting MAUD-offering facilities, particularly in underserved counties.
 
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Lead: Public Views About Opioid Overdose and People With Opioid Use Disorder

Public Views About Opioid Overdose and People With Opioid Use Disorder
JAMA Network Open
This study completed a national web-based survey of 1552 adults in the United States in April 2025 to assess perceptions of opioid overdose deaths and opinions of people who use opioids. Those who responded to the survey primarily identified as female (60.5%) and aged 30-44 (33.7%). Political views varied, with 28.9% conservatives, 39.6% moderates, and 31.5% liberals. Most respondents viewed opioid overdose deaths as serious (88.2%). Respondents felt that people who use opioids (81%) and pharmaceutical companies (72.7%) were most responsible for reducing overdose deaths, with more liberals identifying pharmaceutical companies as responsible while moderates and conservatives more often identified individuals as responsible. 38.3% of respondents reported they were unwilling to have a person with OUD as a neighbor and 58.4% were unwilling to have a person with OUD marry into their family, with higher percentages of conservatives than liberals endorsing these beliefs.
 
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Lead: Did the illicit fentanyl trade experience a supply shock?

Did the illicit fentanyl trade experience a supply shock?
Science
In the United States overdose deaths (ODDs) from synthetic opioids peaked in mid-2023 and then began a sharp decline decreasing by over one third by the end of 2024. One possible explanation is a decrease in fentanyl supply. The purity of fentanyl powder rose in 2022, cresting at 25% in early 2023, but by the end of 2024 purity had fallen to 11%. From 2019 to 2024 the rate of ODDs correlated with the purity of fentanyl in both powder and pills. Drug seizures also peaked in early 2023 and then decreased by 37% in 2024. Analysis of Reddit posts by drug users found increased mentions of “drought” in 2023 that remained high at the end of 2024. All these indicators suggest a reduction in fentanyl supply beginning in 2023. In 2023 China took aggressive action against suppliers of synthetic opioid precursor chemicals, likely a result of meetings between Presidents Biden and Xi. This suggests international cooperation can help reduce ODDs. 
 
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Lead: Barriers to Buprenorphine Initiation in Patients Using Fentanyl

Barriers to Buprenorphine Initiation in Patients Using Fentanyl
JAMA Network Open
This is a survey study of 396 buprenorphine-prescribing clinicians in the US to determine if they faced problems initiating buprenorphine among patients using fentanyl, and whether their practice had changed as a result. Participants were selected from a stratified random sample of X-waivered clinicians registered with the DEA who had prescribed buprenorphine in 2022, with representation across all regions nationally. 72.8% of participants reported difficulty with buprenorphine initiation (either precipitated and/or prolonged withdrawal). Clinicians with waivers to treat larger numbers of patients, those reporting fentanyl use by their patients, and those in outpatient settings were more likely to report challenges with buprenorphine initiation. 67.3% of participants reported they had modified their standard buprenorphine treatment protocols for patients using fentanyl.
 
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Lead: Productivity Losses From Substance Use Disorder in the U.S. in 2023

Productivity Losses From Substance Use Disorder in the U.S. in 2023
American Journal of Preventive Medicine
Information on morbidity-related productivity losses attributable to substance use disorder is limited. This study estimates morbidity-related productivity losses attributable to substance use disorder among U.S. adults aged ≥18 years in 2023. It found that total morbidity-related productivity losses attributable to substance use disorder in the U.S. are substantial, amounting to $92.65 billion in 2023. Inability to work cost accounted for $45.25 billion, followed by absenteeism cost of $25.65 billion, presenteeism cost of $12.06 billion, and cost of household productivity loss of $9.68 billion. Given that these estimates depend on the prevalence of substance use disorder and the amount of lost productive time, evidence-based prevention efforts and policies addressing them can help reduce these losses.
 
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Lead: Expanding Access to Buprenorphine and Methadone: Global Perspectives and Policy Recommendations

Expanding Access to Buprenorphine and Methadone: Global Perspectives and Policy Recommendations
Substance Use and Addiction Journal
This is a narrative review of methadone and buprenorphine regulations, prescriber eligibility, dispensing models, and coverage across eight countries: the United States, Canada, the United Kingdom, Russia, France, Iran, Australia, and Portugal. The study identified several key barriers to MOUD: requirements for daily supervised dosing, restricted community prescribing, and stigmatizing drug scheduling. The authors highlight policies that improved MOUD access without compromising safety such as: 1) community pharmacy dispensing supports in the U.K. and Australia, 2) liberal buprenorphine prescribing in primary care in France, and 3) decriminalization and expansion of low-threshold public health models in Portugal and Iran.
 
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