This Week in Addiction Medicine from ASAM

Lead: Medications for Opioid Use Disorder Playbook

Medications for Opioid Use Disorder Playbook
Agency for Healthcare Research and Quality (AHRQ) 
The AHRQ Integration Academy developed the Medications for Opioid Use Disorder Playbook as a practical guide for providing medications for opioid use disorder (MOUD) and immediate care for patients with OUD in primary care and other ambulatory care settings. It is interactive, web-based, and has the latest guidance, tools, resources, and examples that address key aspects of MOUD implementation. The MOUD Quick Start Guide covers the essentials of low-threshold care, while the balance of the Playbook offers more in-depth resources and guidance for those practices interested in working toward more comprehensive, whole-person care. The low-threshold approach ensures immediate access to MOUD, eliminating barriers for both patients and providers. 
 
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Lead: Cannabis Use During Pregnancy and Lactation

Cannabis Use During Pregnancy and Lactation
American College of Obstetricians & Gynecologists
Cannabis is the most commonly used illicit drug under U.S. federal law. With increasing social acceptability, accessibility, and legalization in many states, the prevalence of cannabis use among pregnant and lactating individuals has increased significantly. Substance use in pregnancy, including cannabis use, has been associated with adverse outcomes such as spontaneous preterm birth, low birth weight, and developmental delay. Clinicians should be aware of the possibility of pregnant and lactating patients' use of cannabis and be prepared to counsel and screen all patients and use evidence-based strategies to reduce cannabis use.  These include supportive home visits, psycho-behavioral strategies, or brief electronic or text messaging interventions to reduce cannabis use in pregnancy and the postpartum period to promote parental and newborn health.
 
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Lead: Contingency Management for Stimulant Use Disorder and Association With Mortality: A Cohort Study

Contingency Management for Stimulant Use Disorder and Association With Mortality: A Cohort Study
American Journal of Psychiatry
This national retrospective cohort study found that veterans with stimulant use disorder who received contingency management (CM) were 41% less likely to die in the year following treatment initiation relative to matched comparison subjects. These findings provide the strongest real-world evidence to date that CM is associated with reduced all-cause mortality, underscoring its potential as a life-saving intervention in routine care. Results support expanding access to CM across healthcare systems and public health settings.
 
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Lead: Machine learning– and multilayer molecular network–assisted screening hunts fentanyl compound

Machine learning– and multilayer molecular network–assisted screening hunts fentanyl compounds
Science Advances
Fentanyl and its analogs are a global concern, making their accurate identification essential for public health. This article introduces Fentanyl-Hunter, a screening platform that uses a machine learning classifier and multilayer molecular network that covers more than 87% of known fentanyls to select and annotate fentanyl compounds using mass spectrometry (MS). Fentanyl-Hunter identified fentanyl members in biological and environmental samples. During biotransformation, 35 metabolites from four widely consumed fentanyl derivatives were identified. Norfentanyl was the major fentanyl compound in wastewater. Retrospective screening of these biomarkers across more than 605,000 MS files in public datasets revealed fentanyl, sufentanil, norfentanyl, or remifentanil acid in more than 250 samples from eight major countries, indicating the potential widespread presence of fentanyl.
 
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Lead: Evaluation of a Novel Patient-Centered Methadone Restart Protocol

Evaluation of a Novel Patient-Centered Methadone Restart Protocol 🔓
JAMA Network Open
Restarting methadone for patients who have had a gap in treatment is often a frustratingly slow process for both the patient and provider. This cohort study of individuals examined outcomes for patients of a public, safety-net opioid treatment program before (n=786 patients) and after (n=780 patients) implementation of a 2022 clinical protocol focused on individualized methadone restart doses based on opioid tolerance. Preimplementation restart doses were 32.8% lower than the last prior methadone dose, whereas postimplementation restart doses were only 3.4% lower than the last prior methadone dose. There was no significant change in patient safety (emergency department visits within 7 days after restart and all-cause mortality within 7 and 90 days after restart) or 90-day retention in care.
 
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Lead: Recommendations for Addressing In-Hospital Substance Use From a National Delphi Consensus Process

Recommendations for Addressing In-Hospital Substance Use From a National Delphi Consensus Process
JAMA Network Open
This survey study utilized a 3-round Delphi consensus process to identify best practices for addressing in-hospital substance use. A panel of 38 addiction experts developed 84 consensus-based and patient-centered recommendations which can inform local responses, including policies, to address in-hospital substance use. 
 
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Lead: Injectable-Only Overlapping Buprenorphine Starting Protocol in a Low-Threshold Setting

Injectable-Only Overlapping Buprenorphine Starting Protocol in a Low-Threshold Setting 
JAMA Network Open 
Injectable-only buprenorphine protocols are an exciting new strategy for buprenorphine initiation, particularly in the fentanyl era. This is a cohort study of 95 patients with moderate to severe opioid use disorder who received care in a low-threshold setting in Seattle. 79% of patients included in the study were experiencing homelessness or living in permanent supportive housing. Patients selected a long-acting injectable (LAI) buprenorphine initiation protocol which included three escalating doses of LAI buprenorphine over three days, with no sublingual buprenorphine and without cessation of fentanyl/opioid use. 75% of the patients completed the protocol, and 64% received a second monthly dose of LAI buprenorphine.
 
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Lead: Association between housing status and mental health and substance use severity among individuals with opioid use disorder and co-occurring depression and/or PTSD

Association between housing status and mental health and substance use severity among individuals with opioid use disorder and co-occurring depression and/or PTSD 
BMC Primary Care 
This is a cross-sectional analysis of associations between housing status and mental health and substance use severity among primary care patients with co-occurring disorders. The study is a sub-analysis using data from the Collaboration Leading to Addiction Treatment and Recovery from other Stresses randomized controlled trial, which tested the Collaborative Care Model for primary care patients with OUD and co-occurring depression and/or PTSD. Of 797 patients in the study, 13% were currently unhoused, 24% were unstably housed, and 63% were stably housed. Those who were unhoused were on average younger and had not used prescribed MOUD in the past 30 days. The analysis found that being unhoused or unstably housed was significantly associated with higher PTSD symptom severity, depression symptom severity, opioid use severity, and opioid overdose risk behaviors compared to those who were stably housed.
 
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Lead: Oral methadone versus sublingual buprenorphine for the treatment of acute opioid withdrawal: A triple-blind, double-dummy, randomized control trial

Oral methadone versus sublingual buprenorphine for the treatment of acute opioid withdrawal: A triple-blind, double-dummy, randomized control trial 
Drug and Alcohol DependenceResearchers compared oral methadone to sublingual buprenorphine for the management of acute opioid withdrawal. Patients at an inpatient drug treatment center in India were randomly assigned to receive either methadone or buprenorphine titrated over days 1-3 to control opioid withdrawal symptoms. Over days 4-10 medications were tapered and stopped by day 11. Completion of treatment was similar in both groups (83% methadone, 82% buprenorphine). Both subjective (SOWS) and objective (COWS) withdrawal symptoms decreased during the treatment, however the buprenorphine group had significantly greater withdrawal symptoms than the methadone group (p=0.009) at the end of treatment (day 10). Opioid craving also decreased in both groups with no significant difference between groups. Authors conclude that methadone is a safe and effective alternative to buprenorphine for management of opioid withdrawal.
 
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Lead: Implementation Gaps in US Syringe Service Programs, 2022

Implementation Gaps in US Syringe Service Programs, 2022 
JAMA This study performed a cross-sectional analysis of the Syringe Services Programs in the US (SSPUS) dataset to determine implementation gaps. 613 syringe service programs (SSPs) included in the dataset were geocoded to county boundaries, which were then analyzed for urbanicity and SSP need (based on HCV mortality, HIV incidence, and drug overdose mortality). The study found that most high need counties did not have an SSP: 81.2% of high HCV need counties, 69.5% of high HIV need counties, and 75.7% of high overdose need counties did not have an SSP. SSPs were more commonly located in urban counties than suburban or rural counties. The study is limited in that not all SSPs are represented within the SSPUS database; however it highlights important implementation gaps.
 
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