This Week in Addiction Medicine from ASAM

Special Episode: ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder

Special Guest:
Melissa Weimer, DO, MCR, FASAM
Treatment of opioid use disorder (OUD) with buprenorphine has evolved considerably in the last decade as the scale of the OUD epidemic has increased along with the emergence of high-potency synthetic opioids (HPSOs) and stimulants in the drug supply. These changes have outpaced the development of prospective research, so a clinical consideration document based on expert consensus is needed to address pressing clinical questions. 
Article Referenced:
The Journal of Addiction Medicine abstract article can be found here>>>
 
ASAM Resources:
ASAM Clinical Guidelines
2020 National Practice Guideline for the Treatment of Opioid Use Disorder
ASAM's Treatment of Opioid Use Disorder Virtual Course
ASAM's Moving Beyond the Barriers of Treating Opioid Use Disorder Live CourseOUD Treatment Education
 
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Lead: Marijuana and hallucinogen use, binge drinking reached historic highs among adults 35 to 50

Lead Story:
Marijuana and hallucinogen use, binge drinking reached historic highs among adults 35 to 50 
NIDA News
According to data from the Monitoring the Future (MTF) study, use of marijuana and hallucinogens reached their highest levels ever for people 35-50 years of age in 2022. Binge drinking among this age group also reached peak levels. For those 19-30 years of age, marijuana and vaping reached their highest levels since reporting MTF data. Past year use of other substances including sedatives, cigarettes, and non-prescribed opioids, however, revealed a 10-year decline for both age groups. According to NIDA director Dr. Nora Volkow, “Understanding these trends is a first step, and it is crucial that research continues to illuminate how substance use and related health impacts may change over time.”
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Lead: Perceptions of Safety of Daily Cannabis vs Tobacco Smoking and Secondhand Smoke Exposure

Perceptions of Safety of Daily Cannabis vs Tobacco Smoking and Secondhand Smoke Exposure, 2017-2021 
JAMA Network Open
This study investigated perceived safety of cannabis vs. tobacco from 2017-2021 via daily smoking or secondhand exposure. The study found a significant shift in beliefs about the safety of daily smoking of cannabis vs. tobacco, with more than one-third reporting cannabis was safer than tobacco, and these numbers increased over time. Results were similar regarding secondhand cannabis smoke, with over 40% reporting it safer than secondhand tobacco smoke. Younger people and those who were unmarried were more likely to view cannabis as safer. A public health and regulatory response is therefore imperative to inform people of the known health risks associated with both daily cannabis smoking as well as secondhand exposure.
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Lead: Alcohol Intake and Blood Pressure Levels

Alcohol Intake and Blood Pressure Levels: A Dose-Response Meta-Analysis of Nonexperimental Cohort Studies 🔓
Hypertension
Employing a systematic search of longitudinal studies, the authors investigated links between blood pressure and alcohol intake. A considerable linear positive association was found between baseline alcohol intake and changes over time in both systolic blood pressure (SBP) and diastolic blood pressure (DBP). Average SBP was 1.25 and 4.90 mm Hg higher for 12 or 48 grams of alcohol compared with no drinking. The differences were for DBP were 1.14 and 3.10 mm Hg. There was no evidence of a threshold for this connection. 
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Special Episode: The Future of Psychedelic Therapy and Addiction Treatment

Special Guest:
David E. Smith, MD, DFASAM
Editorial Referenced: 
The Future of Psychedelic Therapy and Addiction Treatment 
ASAM Resources: 
ASAM Clinical Guidelines
On-Demand Session: Psychedelics for Substance Use Disorders: Preparing for the Impending Paradigm Shift
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Lead: ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder

Lead Story
ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder for Individuals Using High-potency Synthetic Opioids 🔓
Journal of Addiction Medicine
This clinical considerations document is based on a narrative literature review and expert consensus and addresses considerations for changes to the clinical practice of treatment of opioid use disorder (OUD) with buprenorphine for individuals using high-potency synthetic opioids (HPSOs). Broadly, it suggests that individualized strategies for buprenorphine initiation may be needed. The experience of opioid withdrawal negatively impacts the success of buprenorphine treatment, and attention to withdrawal management before and during buprenorphine initiation should be proactively addressed. Buprenorphine dose and dosing frequency should be individualized based on patients’ treatment needs, the possibility of novel components in the drug supply should be considered during OUD treatment, and all forms of opioid agonist treatment should be offered and considered for patients.
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Lead: Recommendations for Reducing the Risk of Cannabis Use-Related Adverse Psychosis Outcomes

Lead Story: 
Recommendations for Reducing the Risk of Cannabis Use-Related Adverse Psychosis Outcomes: A Public Mental Health-Oriented Evidence Review 🔓
Journal of Dual Diagnosis
As legal controls liberalize around cannabis, the authors reviewed the literature about links between cannabis use and psychosis to make recommendations for consumers, health professionals, and policy makers to decrease risk of developing psychosis symptoms. The authors provide 11 recommendations and the level of evidence for each. Recommendations based on the most substantial evidence of linkage to psychosis include: 1) avoid use in adolescence (<16), 2) avoid cannabis with high tetrahydrocannabinol (THC) concentration, 3) limit frequency of use, 4) avoid use if experiencing psychosis symptoms or receiving treatment, and 5) avoid use if one has other risk factors for developing psychosis.
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Lead: Examining the prevalence of mono-versus polysubstance use in the general population

Why do we focus on the exception and not the rule? Examining the prevalence of mono- versus polysubstance use in the general population.
Addiction
Most literature on substance use disorders (SUD) is focused on single drug classifications and does not typically include polysubstance use (PSU), particularly in treatment studies where persons with PSU are often excluded. Using the National Survey on Drug Use and Health (NSDUH) from 2015 to 2019 this study assesses the prevalence of PSU versus mono-use patterns. They found that among those who reported use of at least one substance in the last year, the majority (64%) reported mono-use, primarily alcohol use (90%). However, among those with 2 or more diagnostic criteria for SUD, mono-use was much less frequent (26%) and even less frequent among those who sought care for SUD (22%). Given these findings the authors contend research should include those with PSU whenever possible and consideration of PSU should be part of clinical evaluations and treatment.  
 
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Lead: Questioning the Right to Pain Relief and Its Role in the Opioid Epidemic

Lead Story:
 
Questioning the Right to Pain Relief and Its Role in the Opioid Epidemic
Mayo Clinic Proceedings
The Harrison Act of 1914 helped establish opioids as specific painkillers that had a distinct capacity to induce addiction. This understanding of opioids as having distinct and separable analgesic and addictive potential was challenged by the 1970s discovery of an endogenous opioid system, which integrates pain and reward functions to support survival.  Modern pain neurophysiology places the patient with pain in a passive position from which it makes sense to assert a right to pain relief. To prevent future opioid epidemics, the authors advocate for the abandonment of clinical outpatient use of pain intensity scores. They redefine the medical necessity of pain treatment as less about the reduction of pain intensity and more about the capacity to pursue personally valued activities.
 
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Lead: Xylazine effects on opioid-induced brain hypoxia

Xylazine effects on opioid-induced brain hypoxia
Psychopharmacology
Xylazine has emerged in recent years as an adulterant in an increasing number of opioid-positive overdose deaths in the United States. Although its exact role in opioid-induced overdose deaths is largely unknown, xylazine is known to depress vital functions and cause hypotension, bradycardia, hypothermia, and respiratory depression. This study examined the brain-specific hypothermic and hypoxic effects of xylazine and its mixtures with fentanyl and heroin in freely moving rats. It found that xylazine exacerbates the life-threatening effects of opioids, proposing worsened brain hypoxia as the mechanism contributing to xylazine-positive opioid-overdose deaths.
 
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