This Week in Addiction Medicine from ASAM

Access to Medications for Opioid Use Disorder Among Veterans With Homeless Experience in Permanent Supportive Housing JAMA Network Open This cohort study assessed 10,110 US veterans with homeless experience and opioid use disorder (OUD) residing in permanent supportive housing (PSH), in terms of what factors are associated with receipt of medications for opioid use disorder (MOUD).  Only 17% received MOUD within 12 months. Greater behavioral health engagement was associated with MOUD receipt, while older age, race minority status, and prior inpatient hospitalization were associated with lower odds. These results suggest that MOUD access in supportive housing should be expanding, which could require embedding addiction care into PSH teams, leveraging behavioral health touchpoints, and addressing persistent disparities.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Medicaid Managed Care Plan Alignment With State Substance Use Disorder Treatment Coverage Requirements The Milbank Quarterly Medicaid managed plan coverage for medications for alcohol use disorders (AUD) and opioid use disorder (OUD) varies across states but is generally lower in Republican-leaning states. Researchers conducted a national survey to evaluate if these differences in coverage were due to variation in state policy or variations in Medicaid managed plan alignment with state policy. Researchers found that while Republican-leaning states were generally a little less likely to require coverage of most or all medications for AUD and OUD and place limits on prior authorization, managed plans in Republican-leaning states were much less likely to follow state requirements. Given these findings, efforts to increase access to medications for AUD and OUD will need to address misalignment between managed care plans and state policy, and not just focus on making changes to state policy.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Outpatient Direct Initiation of Injectable Buprenorphine in a Harm Reduction Agency and Primary Care Clinic: A Retrospective Case Series Journal of Addiction Medicine Initiating weekly long-acting injectable buprenorphine (LAIB) without prior sublingual buprenorphine (“direct-to-inject” or DTI) may reduce buprenorphine initiation barriers. In this case series, outpatient DTI outcomes are described. Of the 23 patients with available data, 19 (83%) had no withdrawal symptoms pre-DTI. Of the 20 patients with documented post-DTI withdrawal symptoms, 3 (15%) had no withdrawal, 12 (60%) had mild, 4 (20%) had moderate, and one (5%) patient had severe withdrawal. Thirty days post-DTI, 14 (58%) patients were retained on any buprenorphine formulation, and 11 (46%) patients were retained at 90 days. The median post-DTI buprenorphine treatment days were 77 (range: 9–90).  The majority of patients had no pre-DTI withdrawal symptoms, no or mild withdrawal symptoms post-DTI, and were retained on buprenorphine at 30 days post-DTI, with nearly half retained at 90 days. DTI is a promising buprenorphine initiation strategy, but further research is warranted.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

A µ-opioid receptor superagonist analgesic with minimal adverse effects Nature This study identifies a novel µ-opioid receptor (MOR) agonist with supramaximal intrinsic efficacy and a unique pharmacological profile that produced effective analgesia in rodents with minimal adverse effects. N-desethyl-fluornitrazene (DFNZ) was derived from a class of synthetic benzimidazole opioids called nitazenes. DFNZ has impaired brain penetrance, a unique spatiotemporal MOR cellular signaling profile, and diminished efficacy at the MOR–galanin 1 receptor (GAL1) heteromer. DFNZ does not induce respiratory depression, tolerance, or MOR downregulation after repeated exposure. Compared with other MOR agonists, DFNZ has limited effects on dopamine neurotransmission in the nucleus accumbens and weaker reinforcing effects in the drug self-administration procedure. These results provide novel insights about MOR and nitazene pharmacology, have important implications for pain and addiction treatment, and challenge the prevailing dogma that high-efficacy MOR agonists cannot constitute safe and effective therapeutic agents.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Methadone Dose and Patient-Directed Discharge in Hospitalized Patients with Opioid Use Disorder JAMA Network This retrospective observational cohort study of 554 individuals examined rates of patient-directed discharge (PDD) among hospitalized patients with opioid use disorder who received methadone during the first 72 hours of hospitalization from July 2019 to June 2022. Higher doses of methadone were associated with a decreased rate of PDD. For each additional 10 mg of methadone received in the first 24 hours, there was a decrease in odds of PDD at 48 hours (adjusted OR 0.71). This study highlights the importance of adequate treatment of opioid withdrawal to reduce the risk of PDD.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Do US Adults View Drug and Alcohol Addiction as a Health Condition? Journal of Addiction Medicine  Participants (n=5250), part of Gallup’s random sample of US households, completed a web-based survey that explored their beliefs about addiction.  Asked if addiction is a health condition 77% of US adults agree, 16% disagree, and 6% don’t know. Men are more likely to disagree (20%) than women (15%). Those who have struggled with addiction but not in recovery were more likely to disagree (22%) than those in recovery (13%) or with no personal addiction experience (16%). Those with less education and income were more likely to disagree. Those who disagree that addiction is a health condition are less likely to believe it is treatable by doctors (OR=0.3), believe that medications are effective treatments (OR=0.4), or help friends or family with addiction (OR=0.5).    Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Cannabis cessation and neurocognitive recovery: Patterns, predictors, and clinical implications—a systematic review The American Journal on Addictions  Researchers conducted a literature review of the neurocognitive effects of cannabis use and recovery from those effects. They found a range of neurocognitive effects including neuroreceptor adaptation, decrease in memory, processing speeds, and attention. Deficits increased with higher frequency and amount of use, but recovery can occur.  Receptor normalization can occur within weeks of abstinence while cognitive recovery can take months and years. Adolescent-onset users have more severe and persistent deficits, suggesting effects to neurodevelopment beyond reversible neuroadaptation. The authors suggest treatment for cannabis use disorder should focus on both the disorder and its neurocognitive effects.    Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Cost-effectiveness of contingency management for methamphetamine use disorder: A model-based analysis Addiction This study used a microsimulation model of methamphetamine use behavior among individuals with methamphetamine use disorder (MethUD) to assess the cost-effectiveness of contingency management (CM) for MethUD. Both 12-week and 24-week CM programs were modeled, using a maximum incentive of $750/patient, per SAMHSA guidelines. The model simulation was run for a cohort of 10,000 individuals with MethUD and looked at lifetime cost. Compared to no treatment, the model predicted an estimated net gain of 0.70 QALYs per person at a cost of $6850/QALY for a 12-week program, with an incremental cost-effectiveness ratio (ICER) of $9830/QALY. For a 24-week program, the benefit was 0.81 QALYs at a cost of $10,000, yielding an ICER of $12,312/QALY. This suggests that both durations of CM for MethUD are highly cost-effective, even at the maximum level of incentives.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Glucagon-like peptide-1 receptor agonists and risk of substance use disorders among US veterans with type 2 diabetes: cohort study The BMJ This study investigated whether initiation of glucagon-like peptide-1 (GLP-1) receptor agonists is associated with both reduced risks of incident alcohol, cannabis, cocaine, nicotine, opioid, and other substance use disorders (SUDs) in people with no history of SUDs (protocol 1) and with reduced risk of SUD-related adverse clinical outcomes among people with a pre-existing SUDs (protocol 2).  Researchers found that use of GLP-1 receptor agonists was consistently associated with reduced risks of developing various incident SUDs, suggesting a broad preventive effect across multiple substance types. Use was also associated with reduced risks of adverse clinical outcomes in people with pre-existing SUDs. These observational data suggest a potential role for GLP-1 receptor agonists in both the prevention and treatment of various SUDs, warranting further evaluation.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Does the total consumption model apply to cannabis use? Addiction This repeated cross-sectional study based on annual surveys tested whether the total consumption model and its extension, the theory of collectivity, apply to adolescent cannabis use in Sweden. Frequency of cannabis use was measured by a question on how many occasions the respondent has used hashish or marijuana. The seven response alternatives ranged from 0 to 50 times or more. Increases in mean frequency use were associated with a higher prevalence of high-frequency users.  Adolescent cannabis use in Sweden appears to conform to key predictions of the total consumption model and its extension, the theory of collectivity.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Spirituality and Harmful or Hazardous Alcohol and Other Drug Use  JAMA Psychiatry This meta-analysis of 55 rigorous studies on spirituality and harmful or hazardous drug use (alcohol, tobacco, marijuana, or illicit drugs) examined the association between spiritual exposures and related drug use outcomes.  It documented a significant protective association of 13% related to both prevention and recovery. The risk reduction, which extended across all 4 drug categories, reached 18% for individuals with greater than weekly religious service attendance.  These results have implications for clinicians and communities regarding future strategies to address harmful or hazardous alcohol or other drug use.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Emergency Department–Initiated Buprenorphine for Opioid Use Disorder JAMA Network This multicenter randomized study examined if 7-day extended-release injectable buprenorphine compared with sublingual buprenorphine to improve treatment engagement at 7 days.  It included 1,994 adult patients presenting to the emergency department with untreated opioid use disorder and a Clinical Opiate Withdrawal Scale (COWS) score of 4 or higher.  In treatment at 7 days, 40.5% were in the extended-release group and 38.5% were in the sublingual buprenorphine group, demonstrating no significant difference between groups. The study concluded that a 7-day extended-release injectable preparation of buprenorphine does not improve treatment engagement.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Use of gabapentin with or without a prescription in substance use treatment settings: A national analysis of urine drug testing data, 2016–2023  Drug and Alcohol Dependence Gabapentin prescriptions have increased due to off-label use, including managing withdrawal/comorbidities in substance use disorder (SUD) treatment, despite gaps in evidence bases and corresponding increases in nonmedical use. This retrospective, serial cross-sectional study sought to identify trends in gabapentin use with and without a prescription in SUD treatment settings.  Researchers found that gabapentin prescribing significantly increased in SUD treatment settings despite a lack of strong evidence bases for its utility. While rates of gabapentin use outside a prescription were nearly double that for prescribed use, this appears to be decreasing over time. Polysubstance use and potential gaps in multimorbidity care may contribute to the use of gabapentin without a prescription.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Association of alcohol intake over the lifetime with colorectal adenoma and colorectal cancer risk in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial Cancer This study analyzed data from the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial to look for an association between alcohol intake and colorectal cancer (CRC) or colorectal adenoma. Participants' lifetime pattern of alcohol intake was determined from a dietary history recorded as part of the PLCO trial. Current drinkers with a lifetime average of over 14 drinks per week had a higher CRC risk than those with under 1 drink per week (HR 1.25, p = .003) and an even higher risk of rectal cancer (HR 1.95). There was no consistent association between alcohol intake and colorectal adenoma risk, however results suggested that former drinkers may have a reduced risk of adenoma. They discussed potential mechanisms such as acetaldehyde, a known carcinogen and product of alcohol metabolism, and effects of alcohol on gut microbiome. They conclude that heavy alcohol intake increases CRC risk and that alcohol cessation may lower adenoma risk.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Medication Availability for Alcohol Use Disorder in Substance Use Disorder Treatment Facilities JAMA Network Open This study examined the availability of medications for alcohol use disorder (MAUD) in SUD treatment facilities (SUDTF) from 2017 to 2023.  Data was obtained from SAMSA’s Mental Health and Addiction Treatment Tracking Repository. The percentage of counties with a SUDTF offering MAUD increased from 34% in 2017 to 50% in 2021. This increase leveled out between 2021 and 2023 perhaps related to the pandemic. Counties with a MAUD-offering facility were more likely to be metropolitan (57% vs 25%, p<.001) with substantially more population (mean 220,100 vs 26,650, p<.001), and fewer uninsured residents (8.5% vs 10.7, p<.001).  They call for policies supporting MAUD-offering facilities, particularly in underserved counties.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM  

Public Views About Opioid Overdose and People With Opioid Use Disorder JAMA Network Open This study completed a national web-based survey of 1552 adults in the United States in April 2025 to assess perceptions of opioid overdose deaths and opinions of people who use opioids. Those who responded to the survey primarily identified as female (60.5%) and aged 30-44 (33.7%). Political views varied, with 28.9% conservatives, 39.6% moderates, and 31.5% liberals. Most respondents viewed opioid overdose deaths as serious (88.2%). Respondents felt that people who use opioids (81%) and pharmaceutical companies (72.7%) were most responsible for reducing overdose deaths, with more liberals identifying pharmaceutical companies as responsible while moderates and conservatives more often identified individuals as responsible. 38.3% of respondents reported they were unwilling to have a person with OUD as a neighbor and 58.4% were unwilling to have a person with OUD marry into their family, with higher percentages of conservatives than liberals endorsing these beliefs.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Did the illicit fentanyl trade experience a supply shock? Science In the United States overdose deaths (ODDs) from synthetic opioids peaked in mid-2023 and then began a sharp decline decreasing by over one third by the end of 2024. One possible explanation is a decrease in fentanyl supply. The purity of fentanyl powder rose in 2022, cresting at 25% in early 2023, but by the end of 2024 purity had fallen to 11%. From 2019 to 2024 the rate of ODDs correlated with the purity of fentanyl in both powder and pills. Drug seizures also peaked in early 2023 and then decreased by 37% in 2024. Analysis of Reddit posts by drug users found increased mentions of “drought” in 2023 that remained high at the end of 2024. All these indicators suggest a reduction in fentanyl supply beginning in 2023. In 2023 China took aggressive action against suppliers of synthetic opioid precursor chemicals, likely a result of meetings between Presidents Biden and Xi. This suggests international cooperation can help reduce ODDs.    Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Barriers to Buprenorphine Initiation in Patients Using Fentanyl JAMA Network Open This is a survey study of 396 buprenorphine-prescribing clinicians in the US to determine if they faced problems initiating buprenorphine among patients using fentanyl, and whether their practice had changed as a result. Participants were selected from a stratified random sample of X-waivered clinicians registered with the DEA who had prescribed buprenorphine in 2022, with representation across all regions nationally. 72.8% of participants reported difficulty with buprenorphine initiation (either precipitated and/or prolonged withdrawal). Clinicians with waivers to treat larger numbers of patients, those reporting fentanyl use by their patients, and those in outpatient settings were more likely to report challenges with buprenorphine initiation. 67.3% of participants reported they had modified their standard buprenorphine treatment protocols for patients using fentanyl.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Productivity Losses From Substance Use Disorder in the U.S. in 2023 American Journal of Preventive Medicine Information on morbidity-related productivity losses attributable to substance use disorder is limited. This study estimates morbidity-related productivity losses attributable to substance use disorder among U.S. adults aged ≥18 years in 2023. It found that total morbidity-related productivity losses attributable to substance use disorder in the U.S. are substantial, amounting to $92.65 billion in 2023. Inability to work cost accounted for $45.25 billion, followed by absenteeism cost of $25.65 billion, presenteeism cost of $12.06 billion, and cost of household productivity loss of $9.68 billion. Given that these estimates depend on the prevalence of substance use disorder and the amount of lost productive time, evidence-based prevention efforts and policies addressing them can help reduce these losses.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Expanding Access to Buprenorphine and Methadone: Global Perspectives and Policy Recommendations Substance Use and Addiction Journal This is a narrative review of methadone and buprenorphine regulations, prescriber eligibility, dispensing models, and coverage across eight countries: the United States, Canada, the United Kingdom, Russia, France, Iran, Australia, and Portugal. The study identified several key barriers to MOUD: requirements for daily supervised dosing, restricted community prescribing, and stigmatizing drug scheduling. The authors highlight policies that improved MOUD access without compromising safety such as: 1) community pharmacy dispensing supports in the U.K. and Australia, 2) liberal buprenorphine prescribing in primary care in France, and 3) decriminalization and expansion of low-threshold public health models in Portugal and Iran.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Very Low Nicotine Content Cigarettes for Smoking Cessation: Examining a Facilitated Extinction Approach and Dosing Schedule Drug and Alcohol Dependence Very low nicotine cigarettes (VLNC, 0.4 mg nicotine/g tobacco) have been shown to reduce smoking behavior when compared to normal nicotine cigarettes (NNC,17 mg nicotine/g tobacco). Participants (n=208) were randomly assigned to 4 experimental groups, immediate versus gradual (over 5 weeks) transition to VLNC, and standard counseling versus facilitated extinction counseling (weekly for 5 weeks). Facilitated extinction had participants smoke only in relevant contexts (e.g., places, affects, triggers). The immediate nicotine reduction group reported less smoking satisfaction and lower completion rates (72% immediate reduction versus 88% gradual reduction, p=.02). Abstinence (biochemically verified) at 2 months post study was 29%. There were no significant differences between the 4 study groups. VLNC were beneficial in smoking cessation.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Fatal Opioid Overdoses by Historical and Contemporary Neighborhood-Level Structural Racism🔓 JAMA Health Forum  This cross-sectional study of 796 census tracts prior to the COVID-19 pandemic (2017-2019) and 792 census tracts during the COVID-19 pandemic (2020-2022) in Chicago, Illinois, assessed the extent to which there is a spatial association between neighborhood-level structural racism and opioid-involved overdose deaths. Researchers found that neighborhoods exposed to high levels of structural racism in the past (historical redlining) and present (contemporary segregation) had the highest fatal overdose incidence rates before the COVID-19 pandemic (2017-2019). Neighborhoods that experienced high levels of contemporary racism had the highest fatal overdose incidence rates during the pandemic (2020-2022).    Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM  

State Laws Banning Prior Authorization For Medications For Opioid Use Disorder Increased Substantially, 2015–23 Health Affairs While medications for opioid use disorder (MOUD) is effective treatment, most patients with OUD don’t receive it and prior authorization (PA) has been a barrier to access. Researchers looked at state policies trying to address this barrier, specifically for private health insurance, between 2015 and 2022. Some states adopted “full prohibitions” against PAs while others adopted “partial prohibitions” that allowed PA under some circumstances. Overall, the number of states with at least some prohibition increased from 2 in 2015 to 22 in 2023. In addition, 7 states adopted “full prohibitions” initially, while 15 adopted “partial prohibitions”, with 4 of those 15 transitioning to “full prohibitions” later. Additional research will be needed to assess the impact of these prohibitions, but this study elucidates the current landscape of policy.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Rapid vs Standard Induction to Injectable Extended-Release Buprenorphine JAMA Network This industry-sponsored, multicenter, open-label randomized clinical trial with 729 participants, assessed if  rapid induction (RI) for initiating extended-release buprenorphine is as safe and effective as standard induction (SI) in individuals who inject opioids or use fentanyl.  RI was well tolerated and had higher retention than SI at extended-release buprenorphine injection 2 overall and in fentanyl positive participants. Administering the second extended-release buprenorphine injection 1 week after the first was well tolerated in both the RI arm and SI arm. These findings suggest support RI for extended-release buprenorphine induction in high-risk patients and demonstrate the feasibility of administering the first 2 doses at least 1 week apart.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

States With Substantial Increases In Buprenorphine Uptake Did So With Increased Medicaid Prescribing, 2018–24 Health Affairs Multiple federal policy changes since 2018 intended to increase buprenorphine prescribing in response to a persistent treatment gap for opioid use disorder (OUD) in the US. Anticipated national increases did not occur, but highly variable state-level trends provide important insights. This study used IQVIA data to examine all-payer and per payer prescribing across states during the period 2018–24.  Researchers found that highly disparate state-level changes suggest that federal policy impacts were mediated by state-specific factors. Medicaid’s key role in driving overall prescribing highlights the public health urgency of maintaining expansions and sustaining enrollment for the single adult population.    Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Ultra-processed food addiction in a nationally representative sample of older adults in the USA  Addiction Using a cross-sectional online and telephone survey of a nationally representative sample of older adults (aged 50–80 years) in the US, this study examined the prevalence of ultra-processed food addiction (UPFA) in older US adults and its association with various health domains.  It found that ultra-processed food addiction appears to be prevalent among older adults in the US, particularly among women who were in adolescence and early adulthood when the nutrient quality of the US food supply worsened. Addictive patterns of UPF intake appear to be associated with poorer physical health, mental health, and social well-being.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Alcohol Consumption Per Capita and Suicide: A Meta-Analysis JAMA Network Open  This meta-analysis that included 13 studies assessed if alcohol consumption per capita is associated with suicide mortality and, if so, does the association differ by sex. Researchers found that a 1-L increase in alcohol consumption per capita was associated with a 3.59% increase in the suicide mortality rate. There was no evidence of a sex difference in this association. These findings suggest alcohol consumption per capita may be a useful target to consider within comprehensive national suicide prevention strategies.    Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Measures of General Intelligence and Risk for Alcohol Use Disorder JAMA Psychiatry This male Swedish cohort study that included 573,855 participants assessed if there is an association between IQ and risk for alcohol use disorder, and if so, what is the nature of this association.  It found that IQ at age 18 years was associated with subsequent alcohol use disorder risk. Mendelian randomization analyses suggest a causal association, albeit with context-dependent differences; genetic liability for cognitive performance also predicted alcohol use disorder in a US-based sample. Results suggest that there was a clear impact of genetic liability for cognitive performance on alcohol disorder risk, but the association varies based on the sociocultural context.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

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.    Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

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.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM  

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.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

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.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

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.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

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.    Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

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.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

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.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Oral methadone versus sublingual buprenorphine for the treatment of acute opioid withdrawal: A triple-blind, double-dummy, randomized control trial  Drug and Alcohol Dependence Researchers 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.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM  

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.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

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.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

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.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

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.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

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.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

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.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

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.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

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.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

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.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

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.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

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.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

The IARC Perspective on the Effects of Policies on Reducing Alcohol Consumption New England Journal of Medicine In 2020, alcohol use was responsible for over 740,000 new cancer cases worldwide. In response, The International Agency for Research on Cancer (IARC) released a two-part handbook assessing the effectiveness of public policy measures in reducing alcohol-related cancer risk. The report found that reducing or stopping alcohol consumption lowers the risk of certain cancers and that several policy interventions, such as increasing alcohol taxes; setting minimum pricing; restricting sales by time, place, and age; implementing total sales bans; and enacting strong marketing restrictions, effectively reduce alcohol consumption. Government-run alcohol monopolies and coordinated national strategies were also associated with decreased use. However, bans on alcohol discounts produced inconsistent results. These findings align with the WHO’s Global Alcohol Action Plan and SAFER initiative, highlighting the importance of targeted, enforceable strategies to reduce alcohol-related harm globally.    Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Building Multidisciplinary Consensus on Inpatient Xylazine Management through Clinical Protocols Substance Use and Addiction Journal Xylazine in the unregulated drug supply produces significant morbidity and this paper describes utilizing a multidisciplinary team to develop protocols for inpatient setting to manage patients with xylazine exposure. Protocols developed included use of scheduled clonidine or tizanidine to manage withdrawal with hold parameters. As there is no FDA approved immunoassay screen, they recommended assuming xylazine exposure in areas with high prevalence and limited testing. The team also developed guidelines for cases in which surgical interventions would be considered, when to culture wounds, antibiotic usage, and consistent wound care based on size and clinical characteristics. In addition, they developed standardized discharge instructions, including referral to substance use disorder treatment, harm reduction and education around xylazine test strip use.     Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM