This Week in Addiction Medicine from ASAM

The Use of Opioids in the Management of Chronic Pain: Synopsis of the 2022 Updated U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline 
Annals of Internal Medicine 
The VA, along with the Department of Defense, recently approved an updated guideline regarding the management of chronic pain with opioids (updated from the 2017 version). This includes considerations regarding initiation and continuation of therapy; dose, duration, and taper of opioids; screening, assessment, and evaluation; and risk mitigation. A new recommendation for patients receiving chronic opioid therapy is using buprenorphine in place of full agonists due to its lower risk of overdose and misuse. Other new recommendations suggest screening for additional psychiatric comorbidities that could increase risk and screening for pain catastrophizing.
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State Cannabis Legalization and Psychosis-Related Health Care Utilization 
JAMA Network
Psychosis has long been considered a potential consequence of cannabis use. In this retrospective cohort study, the association of state cannabis legalization with psychosis-related health care claims among some 63,680,589 privately insured individuals were investigated. There were 7,503,907 psychosis-related diagnoses and 20,799,285 prescriptions filled for antipsychotics over the study period. State medical and recreational cannabis policies were not found to be associated with a statistically significant increase in rates of psychosis-related health outcomes.
 
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Buprenorphine Dispensing Among Youth Aged ≤19 Years in the United States: 2015–2020
Pediatrics
Opioid related overdose among adolescents and young adults in the United States is rising. Medications for opioid use disorder (MOUD), including buprenorphine, can reduce the risk of overdose; however, they are underutilized.  Given rates of opioid use disorder (OUD) among youth, these findings suggest that many young people who could benefit from MOUD are not receiving it. Pediatricians could play a role in expanding access to MOUD for this high-risk population. Efforts to expand access to MOUD for adolescents could include improving pediatrician training in OUD treatment and encouraging all clinicians who care for adolescents and young adults to prescribe buprenorphine for MOUD.
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Trends and Characteristics of Buprenorphine-Involved Overdose Deaths Prior to and During the COVID-19 Pandemic 
JAMA Network Open
Questions remain about emergency authorizations permitting telehealth services for buprenorphine, and whether these measures resulted in overdose deaths involving buprenorphine. This cross-sectional study examined 74,474 opioid-involved overdose deaths in 46 states and the District of Columbia prior to and during COVID-19. From July 2019-June 2021 there was a total of 89,111 total overdose deaths and 74,474 opioid-involved overdose deaths; buprenorphine was involved in 1,955 deaths, 2.2% of all drug overdose deaths and 2.6% of opioid-involved overdose deaths.  Of these, a higher proportion were female, non-Hispanic White, and lived in rural areas. While opioid-involved overdose deaths increased during this period, those involving buprenorphine did not increase.
 
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Availability of best practices for opioid use disorder in jails and related training and resource needs: findings from a national interview study of jails in heavily impacted counties in the U.S. 
Health & Justice
This study investigated OUD best practices in US jails in those counties heavily impacted by overdose. Core best practice domains included screening, clinical assessment by qualified treatment provider, medically managed withdrawal, medication for opioid use disorder (MOUD) administration, services for pregnant women, counseling/wrap-around services, collaboration with community MOUD providers, assistance with Medicaid/insurance coverage, re-entry services, and overdose prevention. Some 92% reported some MOUD availability, but only 20% provided it to persons assessed with OUD. Best practices were more common in counties with larger populations, a higher percentage of Hispanic residents, fewer people living below the poverty line, and fewer jail admissions. A number of challenges including MOUD funding, training, and addressing stigma were reported. This study highlights the impact of lost opportunities for reducing disease, death, and recidivism that result from the lack of greater MOUD availability and accessibility.
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Postoperative Restrictive Opioid Protocols and Durable Changes in Opioid Prescribing and Chronic Opioid Use
JAMA Oncology
This prospective cohort study investigated whether postsurgical acute pain using a restrictive opioid prescription protocol (ROPP) of 3 days or less after discharge would result in reduced opioid use. Mean opioid prescribing days decreased from a mean (SD) of 3.9 (4.5) days in the pre-ROPP group to 1.9 (3.6) days in the post-ROPP group (P 

A neuromarker for drug and food craving distinguishes drug users from non-users
Nature Neuroscience
Functional MRI images were obtained while subjects were exposed to visual cues for drugs and palatable foods and asked to rate their level of craving. Subjects were individuals who use drugs (cigarette users=21, alcohol users=17, and cocaine users n=21) and matched controls (n=40). Machine learning was used to identify a pattern of neural activation associated with craving, the Neurobiological Craving Signature (NCS), that extended throughout the brain including areas such as the parietal and temporal areas and cerebellum, not usually associated with craving. The same NCS was found for food and drugs indicating the similarity of these cravings. NCS response to drug cues was able to identify individuals who use drugs with an 82% accuracy. The authors suggest that the NCS has promise for diagnosing SUD as well as measuring responses to treatment.
 
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The ASAM Weekly's most read news items from 2022 were as follows:
 
On ‘Last Week Tonight,’ John Oliver Takes on the Nation’s Dumbest Drug Myth
Rolling Stone
High-dose drug treats fentanyl overdose, if you can get it
New Haven Register
A man who lost 80 pounds on a 'game changer' weight-loss drug also lost his desire to drink alcohol. Experts say the drug could be a treatment for addiction. 
MSN/Insider 
The Next Big Addiction Treatment
The New York Times 
What Is Delta-8, and Why Is It So Popular?
The New York Times 
Can a monthly injection be the key to curbing addiction? These experts say yes
Los Angeles Times 
They Call It ‘Tranq’ — And It’s Making Street Drugs Even More Dangerous
KHN 
Medication for Drinking Addiction May Thwart Liver Disease 
MedPage Today 
The Most Important Question About Addiction
The New York Times 
Gabapentin's link to fatal drug overdoses draws concern
UPI News  
 
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Defining Recovery From Alcohol Use Disorder: Development of an NIAAA Research Definition
The American Journal of Psychiatry
The authors present a newly developed National Institute on Alcohol Abuse and Alcoholism (NIAAA) definition of recovery from the DSM-5 diagnosis of alcohol use disorder (AUD). This definition views recovery as a process of behavioral change and an outcome, incorporating two key components of recovery: remission from DSM-5 AUD and cessation from heavy drinking, a non-abstinent recovery outcome. It also emphasizes the importance of biopsychosocial functioning and quality of life in enhancing outcomes. By adopting a uniform definition, researchers and health care professionals can more precisely operationalize and measure recovery-related processes.
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Genetic diversity fuels gene discovery for tobacco and alcohol use 
Nature
This study leverages global genetic diversity across 3.4 million individuals from four major clines of global ancestry to power the discovery and fine-mapping of genomic loci associated with tobacco and alcohol use, to inform function of these loci via ancestry-aware transcriptome-wide association studies, and to evaluate the genetic architecture and predictive power of polygenic risk within and across populations. The authors found that increases in sample size and genetic diversity improved locus identification and fine-mapping resolution, and that a large majority of the associated variants showed consistent effect sizes across ancestry dimensions. However, polygenic risk scores developed in one ancestry performed poorly in others, highlighting the continued need to increase sample sizes of diverse ancestries to realize any potential benefit of polygenic prediction.
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