This Week in Addiction Medicine from ASAM

Top Publication of 2023:
ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder for Individuals Using High-potency Synthetic Opioids 🔓
Journal of Addiction Medicine
This clinical considerations document is based on a narrative literature review and expert consensus and addresses considerations for changes to the clinical practice of treatment of opioid use disorder (OUD) with buprenorphine for individuals using high-potency synthetic opioids (HPSOs). Broadly, it suggests that individualized strategies for buprenorphine initiation may be needed. The experience of opioid withdrawal negatively impacts the success of buprenorphine treatment, and attention to withdrawal management before and during buprenorphine initiation should be proactively addressed. Buprenorphine dose and dosing frequency should be individualized based on patients’ treatment needs, the possibility of novel components in the drug supply should be considered during OUD treatment, and all forms of opioid agonist treatment should be offered and considered for patients.
Read this issue of the ASAM Weekly
Subscribe to the ASAM Weekly
Visit ASAM

Lead Story:
Examining the benefit of a higher maintenance dose of extended-release buprenorphine in opioid-injecting participants treated for opioid use disorder 
Harm Reduction Journal 
This is a secondary analysis of a randomized, double-blind study comparing 100 mg and 300 mg maintenance doses of extended-release buprenorphine (BUP-XR). All patients (n=311) received 2 monthly induction doses of 300 mg BUP-XR followed by 4 monthly maintenance doses of either 100 mg or 300 mg BUP-XR. For patients who had not been using opioids by injection, there was no difference in weekly abstinence or treatment retention comparing the two maintenance doses. However, for patients with a history of injecting opioids, the 300 mg maintenance dose resulted in significantly higher percentages of weeks abstinent as well as improved treatment retention. The authors speculated that opioid injecting patients may have had higher levels of tolerance that required a higher maintenance dose.
Read this issue of the ASAM Weekly
Subscribe to the ASAM Weekly
Visit ASAM

Lead Story: 
Relationship between alcohol use and firearm-involved suicide: Findings from the National Violent Death Reporting System, 2003-2020
American Journal of Preventive Medicine
This study evaluated the sex- and age group-specific relationship between alcohol intoxication and firearm-involved suicide. Among males of all ages and young and middle-aged females, alcohol intoxication was associated with increased risk of suicide by firearm, an extremely lethal method that accounts for a majority of suicides in the US, compared to their non-intoxicated counterparts. Interventions targeting excessive alcohol consumption may be effective in reducing suicide mortality rates
Read this issue of the ASAM Weekly
Subscribe to the ASAM Weekly
Visit ASAM

Lead Story:
 
Pregnancy and Postpartum Drug Overdose Deaths in the US Before and During the COVID-19 Pandemic
JAMA Psychiatry
This cross-sectional exploratory study examined knowledge gaps in overdose deaths among pregnant and postpartum persons from 2018-2021 as compared to nonpregnant overdose deaths and obstetrical deaths. Overdose deaths among pregnant and postpartum women consistently increased among those aged 10 to 44 years, and more than tripled among those aged 35 to 44 years, from 4.9 per 100,000 from January-June 2018 to 15.8 from July-December 2021. These deaths differed from nonpregnant overdose deaths and obstetrical deaths in sociodemographic characteristics and place of death. Among overdose deaths in total (pregnant and nonpregnant), nearly 75% occurred outside of health care settings. Clearly more work needs to be done to treat SUDs in this population. 
Read this issue of the ASAM Weekly
Subscribe to the ASAM Weekly
Visit ASAM

Lead Story:
2022 National Survey on Drug Use and Health (NSDUH) 
SAMHSA 
Key findings include that in 2022, 70.3 million people aged 12 or older (or 24.9%) used illicit drugs in the past year. Marijuana was the most used illicit drug, with 22.0% of people aged 12 or older (or 61.9 million people) using it in the past year. In 2022, 48.7 million people aged 12 or older (or 17.3%) had a substance use disorder (SUD) in the past year, including 29.5 million who had an alcohol use disorder (AUD), 27.2 million who had a drug use disorder (DUD), and 8.0 million people who had both an AUD and a DUD. Almost 1 in 4 adults aged 18 or older had any mental illness (AMI) in the past year (59.3 million or 23.1%) and among adolescents aged 12 to 17 in 2022, 19.5% (or 4.8 million people) had a past year major depressive episode (MDE).
Read this issue of the ASAM Weekly
Subscribe to the ASAM Weekly
Visit ASAM

Lead Story:
Neural circuit selective for fast but not slow dopamine increases in drug reward🔓
Nature Communications
The authors note that rapid delivery to the brain when drugs are injected or smoked results in more severe substance use disorders. They used functional MRI and PET scans to monitor dopamine increases while subjects (n=20) received methylphenidate either orally or intravenously. Intravenous methylphenidate caused a more rapid increase in dopamine than oral. Activity in the medial prefrontal cortex decreased in both groups but was more pronounced with intravenous methylphenidate. However, only intravenous methylphenidate produced increased activity in the dorsal anterior cingulate cortex and insula that was reflected in the subjective rating of “high.”  This brain region was activated only by intravenous methylphenidate and the associated rapid increase in dopamine.
Read this issue of the ASAM Weekly
Subscribe to the ASAM Weekly
Visit ASAM

Lead Story:
Public health approaches to gambling: a global review of legislative trends 
The Lancet Public Health
Authors of this article systematically reviewed legislation of jurisdictions that introduced major gambling legislation change (i.e., restricting or extending gambling provision) between Jan 1, 2018, and Dec 31, 2021. More than 80% of countries worldwide now legally permit gambling. Harmful gambling was recognized as a health and wellbeing issue in most of the analyzed jurisdictions, but near-exclusive focus was given to individual-level harms rather than to wider social and economic harms or harms to others. Most of the proposed prevention measures focused on individual responsibility. Gambling policies worldwide are changing, but addressing gambling as a public health issue has not yet translated into comprehensive policy action across jurisdictions.
Read this issue of the ASAM Weekly
Subscribe to the ASAM Weekly
Visit ASAM

Lead Story:
Clinical Practice Guideline on the Management of Stimulant Use Disorder 
American Society of Addiction Medicine and American Academy of Addiction Psychiatry
Overdose deaths involving stimulant drugs – including cocaine, methamphetamine, amphetamine, and prescription stimulants – have been rising precipitously over the past decade. In 2021, over fifty percent of overdose deaths in the US involved stimulant drugs. Beyond the mortality risk, stimulant use disorders (StUD) can also lead to long term health problems including infectious diseases, cardiac, pulmonary, psychiatric, dental, nutritional, skin, and cognitive issues.  The Clinical Practice Guideline on the Management of Stimulant Use Disorder, developed by the American Society of Addiction Medicine (ASAM) and the American Academy of Addiction Psychiatry (AAAP), provides information on evidence-based strategies and standards of care for the prevention and treatment of stimulant use disorders (StUD), stimulant intoxication, and stimulant withdrawal.
 
Read this issue of the ASAM Weekly
Subscribe to the ASAM Weekly
Visit ASAM

Lead Story:
Chronic pain, cannabis legalisation, and cannabis use disorder among patients in the US Veterans Health Administration system, 2005 to 2019: a repeated, cross-sectional study
The Lancet Psychiatry
The prevalence of cannabis use disorder (CUD) in patients with chronic pain is increasing. This study considered the impact of both recreational (RCL) and medical cannabis laws (MCL) on the diagnosis of CUD using a VA population with chronic pain. Results demonstrate that MCL led to a 0.135% increase in the prevalence of CUD. Enacting RCL led to a 0.188% increase in its prevalence. The authors emphasize the importance of these findings and their public health implications, with a focus on clinician monitoring and patient education.
 
Read this issue of the ASAM Weekly
Subscribe to the ASAM Weekly
Visit ASAM

Lead Story:
 
Xylazine Adulteration of the Heroin–Fentanyl Drug Supply
Annals of Internal Medicine
Since 2016, xylazine has appeared in the illicitly manufactured fentanyl supply and has increased in prevalence, due to its low cost, easy availability, and presumed synergistic psychoactive effect. It remains unclear whether a distinct xylazine withdrawal syndrome occurs. Xylazine may alter the findings and management of patients with fentanyl overdose and withdrawal. Inadequately treated opioid (and possibly xylazine) withdrawal contributes to the increase in self-directed discharges from treatment settings. Initiation of buprenorphine and perhaps methadone may be compounded by the concomitant use of xylazine. The presence of extensive wounds in people who use xylazine prevents them from accessing resources, including medically managed withdrawal treatment, leading to a cycle of continued and escalating use.
 
Read this issue of the ASAM Weekly
Subscribe to the ASAM Weekly
Visit ASAM