This Week in Addiction Medicine from ASAM

Lead: Co-involvement of stimulants with opioids in North America: A 'silent epidemic’

Co-involvement of stimulants with opioids in North America: A 'silent epidemic’
Plos Mental Health
The opioid epidemic unfolded in three distinct waves, with the latest being deaths attributed to illegally manufactured synthetic opioids. Using U.S. and Canadian data, this study reviews evidence for a 'silent epidemic' alongside the opioid epidemic that is characterized by the co-ingestion of stimulants including methamphetamine and cocaine leading to an increasing number of deaths. Trends for stimulant and opioid use were analyzed using Joinpoint regression and public interest in the substances was assessed via Google Trends. While stimulant use and its role in deaths are rising, public interest in stimulants has declined since its peak in 2004-05. Co-use leads to more deaths than either drug alone. Urgent strategies are needed to reduce harm and raise awareness among health professionals, policymakers, and the public about the dangers of stimulant-opioid co-use.
 
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Lead: Did alcohol facilitate the evolution of complex societies?

Did alcohol facilitate the evolution of complex societies? 
Humanities and Social Sciences Communications
This study tested the “drunk” hypothesis, which claims that alcohol promoted social bonding and cooperation, aiding the rise of complex societies. Using data from 186 non-industrial societies, they found a modest positive link between indigenous alcoholic beverages and political complexity, even after controlling for ancestry, environment, and agriculture. Results suggest traditional fermented alcohols provided social benefits that helped societal evolution. However, other factors like agriculture and religion were likely more effective drivers.
 
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Lead: Disparities in Treatment and Referral After an Opioid Overdose Among Emergency Department Patients

Disparities in Treatment and Referral After an Opioid Overdose Among Emergency Department Patients 
JAMA Network Open
This cohort study of 1,683 patients assessed if there are racial and ethnic disparities in treatment referral rates among patients in the emergency department (ED) with opioid overdose.  It found a statistically significant difference in the proportion of Black patients who received an outpatient treatment referral (5.7%) compared with White patients (9.6%). These findings suggest that Black patients presenting to the ED with opioid overdose may be less likely to receive outpatient treatment referrals, underscoring the need for targeted intervention and enhanced referral processes.
 
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Lead: Prescriber-Level Changes in Buprenorphine Dispensing in the USA Before and After Federal Policy Changes Aimed at Increasing Prescribing

Prescriber-Level Changes in Buprenorphine Dispensing in the USA Before and After Federal Policy Changes Aimed at Increasing Prescribing
Journal of General Internal Medicine
This study used interrupted-time-series analysis to model prescriber-level trends in buprenorphine prescriptions after recent federal policy changes.  It found that the elimination of the waiver requirement to prescribe buprenorphine in December 2022 was associated with a significant increase in the number of buprenorphine prescribers, but a decrease in the mean number of patients and the mean number of prescriptions per prescriber. Changes in telehealth flexibilities and relaxed training requirements were largely not associated with prescribing changes. This study expands on prior research by providing further insight as to why waiver elimination has not increased the number of patients receiving buprenorphine, as expected.
 
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Lead: Joint Clinical Practice Guideline on Benzodiazepine Tapering: Considerations When Risks Outweigh Benefits

Joint Clinical Practice Guideline on Benzodiazepine Tapering: Considerations When Risks Outweigh Benefits 
Journal of General Internal Medicine
The American Society of Addiction Medicine (ASAM), in collaboration with nine other medical societies and professional associations, developed evidence-based guidelines for tapering benzodiazepine (BZD) medications across various clinical settings. These guidelines were created using a modified GRADE methodology and a clinical consensus process, which included a systematic literature review and several targeted supplemental searches. The guidelines were also revised based on feedback from external stakeholders. Key recommendations include that clinicians should continually assess the risks and benefits of BZD use and tapering. They should engage in shared decision-making with patients and avoid abrupt discontinuation in individuals who may be physically dependent or at risk of withdrawal. Tapering strategies should be personalized and adjusted based on the patient’s response. Additionally, clinicians are encouraged to provide psychosocial support to help patients successfully taper off BZDs.
 
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Lead: Receipt of addiction treatment after nonfatal opioid overdose and risk of subsequent overdose: A retrospective cohort study

Receipt of addiction treatment after nonfatal opioid overdose and risk of subsequent overdose: A retrospective cohort study
Drug and Alcohol Dependence
People who experience a nonfatal opioid overdose are at increased risk of subsequent overdose but is also a potential moment to intervene. In this cohort study, they used statewide data from Connecticut to assess differences in overdose outcomes in the year following a nonfatal overdose by treatment type received. Overall, 56% of patients received no treatment, while 35% received medication for opioid use disorder (MOUD) (25% buprenorphine and 11% methadone) and 21% received inpatient treatment (detox and/or extended inpatient). Both methadone (aHR=0.41) and buprenorphine (aHR=072) were associated with decrease in subsequent overdose, whereas neither detox nor prolonged inpatient treatment were associated with decreased overdose. These findings further support the importance of MOUD and the need to increase access to treatment in this high-risk population.
 
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Lead: Bitter sensing protects Drosophila from developing experience-dependent cocaine consumption preference

Bitter sensing protects Drosophila from developing experience-dependent cocaine consumption preference
The Journal of Neuroscience
Cocaine use disorder (CUD) is a highly heritable condition for which there are no effective treatments. Testing the many human genetic variants linked to CUD requires a cost-effective, genetically tractable model. This study showed that bitter-sensing neurons prevent cocaine self-administration in Drosophila. Disrupting Drosophila bitter perception enables a model for experience-dependent cocaine preference. The findings underscore the potential of Drosophila as a crucial tool for identifying the genetic mechanisms underlying CUD, aiding in the discovery of new therapeutic targets, and contributing to the development of effective treatments for this highly heritable disease.
 
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Lead: Memory function in patients with opioid dependence treated with buprenorphine and methadone in comparison with healthy persons

Memory function in patients with opioid dependence treated with buprenorphine and methadone in comparison with healthy persons 
Scientific Reports
This study compared memory performance in patients treated with methadone or buprenorphine for drug abuse to healthy controls using the Wechsler Memory Scale. Healthy controls performed better than both treatment groups in mental control. Methadone patients scored higher than controls in personal and general information, while buprenorphine patients scored lower in associate learning. Longer buprenorphine treatment was linked to better overall memory scores, and patients on methadone for over two years showed better awareness of place and time compared to long-term buprenorphine users. Overall, neither medication showed major negative effects on memory except for mental control, which was impaired in both groups. Buprenorphine appeared to better preserve memory function over time than methadone.
 
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Lead: Medicaid Unwinding and Changes in Buprenorphine Dispensing

Medicaid Unwinding and Changes in Buprenorphine Dispensing 
JAMA Network Open
Among Medicaid-insured adults with buprenorphine use, this cross-sectional study examined if changes in buprenorphine dispensing were greater among those residing in states with the highest vs lowest decreases in Medicaid enrollment after “Medicaid unwinding” began in April 2023. Researchers used 2017-2023 data from a national prescription dispensing database that included 754,675 person-years from 569,069 patients. They found that patients in states with the highest decreases in Medicaid enrollment were more likely to decrease buprenorphine use, discontinue buprenorphine therapy, and use private insurance or cash to pay for buprenorphine prescriptions. The finding that Medicaid unwinding was associated with disruptions in buprenorphine therapy raises concerns about the potential for increased opioid-related morbidity and mortality.
 
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Lead: Loneliness Among US Veterans With Problematic Substance Use: Results From the National Health and Resilience in Veterans Study

Loneliness Among US Veterans With Problematic Substance Use: Results From the National Health and Resilience in Veterans Study
Journal of Addiction Medicine
Loneliness is a major public health concern, especially among individuals with problematic substance use (PSU), but little research has focused on vulnerable groups like US military veterans. This study, using data from the National Health and Resilience in Veterans Study, found that nearly half of veterans with PSU (47.4%) experience clinically significant loneliness. Factors contributing to loneliness included being unmarried, higher psychological distress (depression and PTSD), a history of suicide attempts, physical disability, smaller social networks, and lower purpose in life and optimism. The analysis highlighted that depressive and PTSD symptoms had the strongest impact on loneliness, followed by social network size and sense of purpose. Furthermore, veterans with depressive symptoms who had a strong sense of purpose were less likely to feel lonely. The study underscores the need for strategies targeting psychological distress, fostering social connections, and enhancing purpose to help alleviate loneliness in this population.
 
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