ASAM Weekly for October 11, 2022
This Week in the ASAM Weekly
This week we present several pragmatic models of delivering addiction treatment to individuals with substance use disorders. Emergency medical services (EMS) truly operate in the last-mile of health care delivery, and a novel, low-cost approach to closing the treatment delivery gap is physician supported/paramedic-administered buprenorphine. In survivors of overdose, this led to improved opioid withdrawal symptoms and outpatient follow-up but also more refusals (less need?) of ED transport (Annals of Emergency Medicine).
Bridge programs are a next link in the treatment delivery system. UPMC’s OUD Bridge Clinic had high engagement rates (96%) and low-cost scalability. The clinic also had over 80% audio visits without the availability of urine drug testing in a mostly disadvantaged population -- practically unheard of only a few years ago (JAM). Telephone-based cognitive and behavioral therapy can be effective in reducing some alcohol-related harms after minimal engagement, but more importantly this intervention was applied in a population with high rates of severe alcohol use that rarely sought treatment previously (JAMA Psychiatry).
Unfortunately for individuals actively seeking OUD treatment, stigma can still be a barrier within primary care, as patients with OUD are 3 times less likely to be offered new patient appointments. But one study’s secondary analysis of generational differences among physicians highlights the sustainable progress addiction education and awareness has had on younger physicians (JAMA Network Open).
Some of this edition’s publications touch upon broader questions, such as:
How should we frame our conversations around cannabis and quality-of-life issues (The Lancet Healthy Longevity)? What are we going to do about gabapentin (JAM)? Can electronic health records better identify individuals with intravenous drug use (Open Forum Infectious Diseases)?
Thanks for reading,
Nicholas Athanasiou, MD, MBA, DFASAM
with Co-Editors: Brandon Aden, MD, Debra R. Newman, PA-C, MSPAS, MPH, Jack Woodside, MD, John A. Fromson, MD
Annals of Emergency Medicine
Initiation of buprenorphine in emergency departments (EDs) after opioid overdose is increasing, but many patients seen by emergency medical services (EMS) in the field refuse transport to the ED or leave the ED prior to evaluation. This study evaluated a program in which EMS was able to provide buprenorphine to patients in the field after opioid overdose, along with a same or next-day appointment in a substance use disorder clinic. Patients evaluated by EMS units with buprenorphine were significantly more likely to engage in treatment within 30 days (OR 5.62) than those evaluated by non-buprenorphine units. In addition, those evaluated by EMS units with buprenorphine who received buprenorphine were significantly more likely to engage in treatment (OR 12.83) than those who did not. There were no significant differences in subsequent opioid overdoses between groups.
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
In this randomized clinical trial of 344 participants with problem alcohol use, reductions in the primary outcome-- alcohol problem severity-- were not significantly different between stand-alone telephone-delivered intervention and control groups at 3 months. However, the intervention was associated with a significantly greater reduction in hazardous alcohol use and a reduction in alcohol problem severity when 2 or more sessions were delivered. Although reductions in alcohol problem severity were not significantly different between treatment groups at 3 months, results demonstrate the potential benefits of this highly scalable and accessible model of alcohol treatment.
Journal of Addiction Medicine
This article is a summary of current knowledge about gabapentin use during pregnancy and breastfeeding. A large study of gabapentin-exposed pregnancies found only a possible risk of cardiac malformations. The authors did note increased preterm birth and increased NICU admissions. Others have reported neonatal withdrawal after in utero gabapentin exposure that is relieved by lorazepam or gabapentin. In infants exposed to opioids in utero, risk of NAS was increased when also exposed to gabapentin (OR 1.6). Gabapentin is secreted in breastmilk but the impact on neonates is unknown. It is known to increase fatality risk in OUD and misuse is usually seen in those using other substances, particularly opioids. A study of patients with OUD treated with methadone found 15% to 38% misused gabapentin. The authors conclude that caution is warranted about gabapentin use during pregnancy.
JAMA Network Open
This randomized clinical trial conducted in Ontario, Canada assessed 383 family physicians. They were found to be almost 3 times less likely (4% vs 11%) to offer a new patient appointment to a prospective patient with opioid use disorder than those with diabetes. These findings suggest that physician discretion in accepting new patients contributes to poor primary care access for patients with opioid use disorder, indicating a need for health system changes. Potential solutions to this disparity include strengthening policies for accepting new patients, improved compensation, and clinician anti-oppression training.
Journal of Addiction Medicine
The University of Pittsburgh Medical Center Telemedicine Bridge Clinic coordinates care with local treatment providers, with evaluations completed via secure audiovisual technology or telephone, M-F, 8AM-8PM. This study looked at the feasibility of this low-barrier clinic to initiate patients on MOUD. Although the service is for treatment of any urgent SUD, patients with OUD accounted for nearly all (96%) visits. For all patients with OUD, 96% filled a buprenorphine prescription within 30 days; 77% filled 2 or more prescriptions subsequent to the initial evaluation. Such clinics allow for improved cost-effectiveness for those patients who may not have rapid access to care.
Harm Reduction Journal
In 2016, North Carolina enacted a law protecting syringe service programs (SSP) and their participants. SSPs issue a card participants can present to law enforcement. This study surveyed 441 participants and interviewed 20 in 2019 from 7 SSPs in North Carolina. They found that 51% had at least one negative interaction with law enforcement. Of the respondents, 27% reported law enforcement being unfamiliar with the law or card, 19% had syringes confiscated, and 13% were arrested. One noted that even if the judge dismissed charges, they would have to post bond or spend a week to a month jailed awaiting a court date. As a result, many doubted the value of the law or card. The authors conclude that despite the law, law enforcement practices present a significant barrier to syringe access.
The Lancet Healthy Longevity
This longitudinal study tested the hypothesis that long-term cannabis users show accelerated biological aging in midlife along with poorer health, and poorer financial and social preparedness. Subjects were a cohort from New Zealand born between April 1972 and March 1973 and followed for 45 years. Cannabis, tobacco, and alcohol use and dependence were assessed at routine intervals: ages 18, 21, 26, 32, 38, and 45 years. Biological aging and health, and financial and social preparedness for old age were assessed at 45 years. Long-term cannabis users demonstrated statistically significant accelerated biological aging and were less equipped to manage a full range of demands encountered in later life than non-users.
Open Forum Infectious Diseases
As injection drug use (IDU) and its complications have significantly increased, the accurate identification of patients with IDU in medical records is essential to clinical, epidemiological, and health services research, and for resource allocation. Historically, International Classification of Diseases (ICD) codes have been used to try to identify these patients, but there is no specific ICD code for IDU, and these methods are inadequate. The authors developed a natural language processing (NLP) and machine learning (ML) algorithm to identify people who inject drugs (PWID) in large datasets and found that it outperformed ICD code-based algorithms. The authors note continued research is needed but that NLP/ML models offer improved accuracy for research and have potential for use in surveillance and clinical decision support.
In The News
The White House