This Week in Addiction Medicine from ASAM

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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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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