This Week in Addiction Medicine from ASAM

Lead Story: 
Ketamine versus ECT for Nonpsychotic Treatment-Resistant Major Depression
The New England Journal of Medicine
While electroconvulsive therapy (ECT) has been used for several years for treatment-resistant major depression, ketamine has been relatively recently approved. The authors conducted an open label, randomized, noninferiority trial with 403 patients to compare the effectiveness of ketamine to ECT. The ketamine was found to be noninferior to ECT for treatment response as reported by decrease in depressive symptoms. Further, both were associated with improved quality of life, but the ECT group did have a greater decline in memory performance. Of note, this trial excluded patients with major depression with psychosis, and previous studies have found that ketamine is inferior to ECT among those patients.
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Special Guests:
Ashish P. Thakrar and Jarratt D. Pytell
 
Article Referenced:  
Ashish P. Thakrar, Jarratt D. Pytell, Kenneth B. Stoller, Vickie Walters, Roger D. Weiss, Geetanjali Chander, Transitioning off methadone: A qualitative study exploring why patients discontinue methadone treatment for opioid use disorder, Journal of Substance Use and Addiction Treatment, Volume 150, 2023, 209055, ISSN 2949-8759. 
 
ASAM Resources: 
2020 National Practice Guideline for the Treatment of Opioid Use Disorder 
OUD Treatment Education 
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Lead Story
Increasing overdose deaths among Black Americans: a review of the literature
The Lancet Psychiatry
This scoping review analyzed the many and varied factors contributing to the recent rise in opioid overdose death rates among Black Americans. Differences in structural and social determinants of health; unequal access, use, and continuity of SUD and harm reduction services; variability in fentanyl exposure and risk; and changes in social and economic conditions were all found to play a role. Black Americans historically are less likely to have access to treatment services than White Americans. Work to reform the criminal legal system, expand access, address provider bias, and fund equity-improving programs need to happen to affect change.
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Lead Story
The glucagon-like peptide-1 (GLP-1) analogue semaglutide reduces alcohol drinking and modulates central GABA neurotransmission 
JCI Insight
Evidence suggests that the glucagon-like-peptide-1 (GLP-1) system may be involved in the neurobiology of addiction. The authors studied the impact of semaglutide, a long acting GLP-1 analogue, on alcohol use in mice and rat models and found a decrease in binge-like alcohol drinking in both mice and rats. They also found  reduced alcohol intake in rates with dependence. The proposed mechanism for this effect is modulation of central GABA neurotransmission and supports the potential role of the GLP-1 system as a potential pharmacotherapeutic target for alcohol use disorder.  
 
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Lead Story
Racial Inequality in Receipt of Medications for Opioid Use Disorder
The New England Journal of Medicine
Opioid overdose mortality has increased over the last ten years, but disproportionately among Black persons. The authors examine racial disparities in receipt of buprenorphine and naloxone after opioid use disorder (OUD) related events using Medicare data from 2016-2019. They found that Black persons were less likely to receive buprenorphine (12.7 vs 23.3%) and naloxone (14.4% vs 22.9%) than White persons within six months after the event. Further, Black persons received lower day supply of buprenorphine and were less likely to be retained on treatment. Of note, Black and White persons had similar rates of ambulatory visits in the 6 months after the event, indicating patient and provider-level barriers to access.
 
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Lead Story: 
Eat, Sleep, Console Approach or Usual Care for Neonatal Opioid Withdrawal
The New England Journal of Medicine
This multicenter randomized controlled trial was undertaken to evaluate the the Eat, Sleep, Console Care Tool vs usual care for neonatal opioid withdrawal with the primary outcome being medically ready for hospital discharge. The Eat, Sleep, Console Care Tool relies on an assessment of withdrawal severity focused on an infant’s ability to eat, sleep, and be consoled, along with the use of nonpharmacologic interventions as first line of treatment. The Eat, Sleep, Console care approach decreased the time until infants with opioid withdrawal were medically ready for discharge by a mean of 6.7 days, and the proportion of infants receiving pharmacologic treatment by 32.5%. Hence, this approach facilitates more judicious use of medication for these infants.
 
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Article Referenced:  
Noel, Marnie PharmD, BCPP; et all. The Howard Street Method: A Community Pharmacy-Led Low Dose Overlap Buprenorphine Initiation Protocol for Individuals Using Fentanyl. Journal of Addiction Medicine.
 
ASAM Resources: 
2020 National Practice Guideline for the Treatment of Opioid Use Disorder 
OUD Treatment Education 
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Lead Story
Subtypes in addiction and their neurobehavioral profiles across three functional domains 
Translational Psychiatry
Over two-thirds of the 40.3 million people in the U.S. who have a substance use disorder (SUD) return to use within weeks to months of initiating treatment, and up to 85% of individuals return to substance use within one year of treatment completion. This study hypothesized that considerable individual differences exist in the three functional domains underlying addiction — approach-related behavior, executive function, and negative emotionality. Results support functionally derived subtypes, demonstrating considerable individual heterogeneity in the multi-dimensional impairments in addiction. This confirms the need for mechanism-based subtyping to inform the development of personalized addiction medicine approaches.
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Lead Story:
The conserved endocannabinoid anandamide modulates olfactory sensitivity to induce hedonic feeding in C. elegans 
Current Biology
Laboratory worm Caenorhabditis elegans apparently gets the ‘munchies’ when exposed to cannabis. After soaking in an endocannabinoid bath, worms preferred to eat nutrient-rich, rather than nutrient-poor, bacteria. They fed for longer than worms not exposed to endocannabinoid or worms without working endocannabinoid receptors. This shared trait points to the deep evolutionary origin of cannabinoid receptors and behaviors influenced by the molecules.
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Lead Story:
Opioid Prescribing and Suicide Risk in the United States
The American Journal of Psychiatry
Approximately 40% of overdose suicide deaths in the United States involve opioids. Because of their respiratory depression effects and narrow therapeutic window, opioids pose a greater risk than any other drug class of an intentional overdose proving to be lethal.  In this retrospective study of US commuting zone–level opioid prescriptions and mortality, regional decreases in opioid prescriptions were consistently associated with declines in total suicide deaths, including suicide overdose deaths involving opioids. For some opioid prescribing measures, negative associations were observed with unintentional overdose deaths involving opioids among younger people. Individual-level inferences are limited by the ecological nature of the analysis.
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