ASAM Weekly for October 4, 2022
4th Edition of The ASAM Criteria® – October Public Comment
R. Corey Waller, MD, MS, FACEP, DFASAM
The Next Chapter of The ASAM Criteria – Public Comment Requested by Nov 11th
If you walk into any emergency department in the United States and complain of chest pain, you will set off a cascade of events that are specially constructed to ensure you are placed in the right level of care, for the shortest amount of time, and with the correct array of services. These protocols weren’t developed by mistake or happenstance but by utilizing all available evidence to determine the best course of treatment given the severity of the illness identified.
Over the past 30 years, ASAM has led the establishment and expansion of such a system with The ASAM Criteria. This framework has provided invaluable guidance for the treatment of addiction in the context of the American healthcare system.
In February of this year, the proposed major updates to the 4th Edition of The ASAM Criteria were shared for public comment. These updates were designed to decrease ambiguity and improve the implementation of The ASAM Criteria. The feedback we received during that time has been critical for guiding our work developing detailed standards over the last seven months. This work has included the convening of 17 writing groups comprised of a multidisciplinary set of expert volunteers representing different levels of care and patient subpopulations. Each expert group has been guided by a streamlined methodology, including structured literature searches, facilitated consensus development meetings, and a modified Delphi process.
Through their dedicated and collaborative work, these groups have generated core standards that reflect the basic elements of the 4th Edition of The ASAM Criteria. As such, we are again requesting public feedback from diverse stakeholders on these standards from Monday, October 3rd to Friday, November 11th.
While the varied levels of care and treatment challenges associated with addiction may seem daunting, so is the treatment of acute myocardial infarction. Yet we have managed to build systems of care that allow for access to high-quality specialty level care for the latter.
We owe it to those suffering from addiction to develop nothing less sophisticated and predictable.
Please join us in making this vision a reality by sharing your views today.
R. Corey Waller, MD, MS, FACEP, DFASAM
In this cross-sectional study, using the benchmark multiplier method and Medicaid administrative data in combination with data from the National Survey on Drug Use and Health for 2018 and 2019, the 12-month prevalence estimates of alcohol use disorder, cannabis use disorder, opioid use disorder, and stimulant use disorder were higher than estimates from the National Survey on Drug Use and Health. The findings suggest that the prevalence of substance use disorders may be considerably higher than National Survey on Drug Use and Health estimates indicate.
Call for Reviewers
The Journal of Addiction Medicine is seeking to expand its cadre of manuscript reviewers. We are seeking reviewers with expertise in the following areas: Stimulants, Psychiatric epidemiology, Qualitative methodology, Genetics, Neurology, Emerging substances, Kratom, Novel Psychoactive Substances, Psychedelics, New pharmaceutical treatments, Toxicology, Criminal justice and addiction medicine, Machine Learning, Pain and Palliative Care, Adolescent Medicine, Maternal Child Health, and Behavioral Addictions. View the full opportunity here.
Research and Science
Journal of General Internal Medicine
The authors note the expert consensus that buprenorphine should be continued during the perioperative period and permits adequate pain control. This study describes actual clinical practice regarding buprenorphine in the perioperative period. Data came from the Veterans Health Administration for 183 patients prescribed buprenorphine at the time of surgery. More than 1/3 of patients (40%) were asked to hold buprenorphine prior to surgery. Buprenorphine was held on the days of surgery for 62% and 55% did not receive buprenorphine the day following surgery. Overall 66% had a perioperative dose hold. One month after surgery only 87% were receiving buprenorphine, and 8% had returned to substance use. At one, year 6% had overdosed and 8% had died. The authors conclude that a perioperative buprenorphine hold is not consistent with guidelines and carries significant risk.
Canadian Journal of Emergency Medicine
This study was a chart review from a supervised consumption site in Vancouver Canada covering 2012-2017. Patients apneic and unresponsive from opioid overdose (n=767) were identified. All patients received oxygen and noninvasive (bag mask) ventilation, and 93% received naloxone. No patients received chest compressions or intubation. Complete follow up was available for 763 patients, all of whom were neurologically intact at the end of care. Complications were noted in 2%, mostly minor (emesis, dyspnea, etc.). One patient had a severe complication, aspiration pneumonia, resulting in hospitalization. These results support the effectiveness of noninvasive ventilation (without chest compressions) and naloxone in treating opioid overdose.
Journal of Studies on Alcohol and Drugs
Substance-related bicycle injuries are a significant public health issue. In this study, the authors examined 2019-2020 data from the National Electronic Injury Surveillance System (NEISS) for bicycle injuries related to the use of psychoactive drugs independent of alcohol. Of the 480,286 patient visits to EDs related to bicycle injuries during the study period, 11,314 (2.6%) were related to substance use. Methamphetamine (36.4%), marijuana (30.7%), and opioids (18.5%) were the most frequent substances used. Most patients were between 25 and 44 years of age, and almost 70% were non-Hispanic White. Further study is needed to identify which substances may pose increased risk, the circumstances surrounding those injuries, and identifying possible mitigation/prevention efforts.
This article addresses preventing youth uptake of e-cigarettes and the desire to realize the potential of e-cigarettes to increase adult cigarette smoking cessation. It organizes interventions according to the “four Ps” of marketing: product, price, place, and promotion. Policies include decreasing the addictiveness of combusted tobacco products while ensuring the availability of consumer-acceptable reduced-risk nicotine products, imposing large taxes on combustible products and smaller taxes on e-cigarettes, limiting the sale of all tobacco and (nonmedicinal) nicotine products to adult-only retailers, and developing communications that accurately portray e-cigarettes’ risks to youth and benefits for inveterate adult smokers.
Attention-deficit/hyperactivity disorder (ADHD) and substance use disorders (SUDs) share considerable neuropsychological features and diagnostic co-occurrence among adolescents and young adults. In this study, the authors conducted a voxel-based neuroimaging meta-analysis, looking at the overlapping and distinct brain regional volumetric changes between young people with these two conditions. Decreased gray matter volume (GMV) was observed in the motor cortex and frontal lobes in ADHD patients; increased volumetric pattern in the left putamen presented in those with SUDs. The ADHD group showed larger regional GMV in the right inferior parietal lobule (IPL) and smaller volumes in the left putamen and left precentral gyrus (preCG) than the SUD group. These findings may promote a greater understanding of these conditions in clinical settings.
Social media platforms have become integral to adolescents and young adults’ daily lives and can influence social norms, attitudes, and behaviors. In this study, the authors conduct a systematic review to evaluate the sentiments around portrayal of substances in social media. The preponderance of posts about substances overall were positive (76.3%), including for tobacco (59.8%), alcohol (91.6%), cannabis (79.5%), and e-cigarettes (85.9%). Opiates were the only substance with majority of postings having negative sentiment, but still only 55.5% of posts were negative. Postings on personal (user-generated) and commercial accounts both tended to be positive. Given these findings and the potential public health impact, the authors suggest the need for further regulation around postings involving substances on social media.
Drug and Alcohol Dependence
Prescription opioids are still a significant cause of overdoses and served as a major factor in the opioid crisis. Many states implemented opioid prescribing cap laws that limit initial duration, daily dose (morphine milligram equivalents (MME)/day), or both in response. Using commercial and Medicare advantage claims data the study examines opioid prescribing patterns, including duration and dosing, and opioid overdoses. The study did not find any statistically significant change in opioid prescribing patterns, including proportion of patients receiving prescriptions, duration, or dosage. In addition, there were no statistically significant changes in opioid overdoses, including no shift in cause from prescription to heroin/synthetic opioids. The authors do note that overall opioid prescribing patterns trended down but that may be due to broader social changes.
In The News
The White House