ASAM Weekly for March 14, 2023
This Week in the ASAM Weekly
It took a pandemic to loosen many of the rules around opioid use disorder treatment, but will an ongoing overdose crisis be enough to sustain them? US policymakers are considering the path forward.
A Health Policy review from the Lancet Public Health lays out the evidence around methadone take-home flexibilities and evaluates important policy questions such as implementation, patient/provider experience, overdose, diversion, and retention. These are important considerations as many states have few OTP clinics. For example, Wyoming has none (Washington Post).
Relaxation of buprenorphine prescribing regulations (Ryan Haight Act) allowed the first legal syringe services program in Florida to expand its services into low-barrier, buprenorphine tele-treatment. This created an opportunity to provide life-saving medication within a destigmatizing, harm reduction setting (Annals of Medicine). Such programs give agency to individuals with OUD who for years were subjected to overly paternalistic treatments and (finally) deserve a say with regard to related policies (BMJ). Even some Good Samaritan Laws can be punitive and may need a re-evaluation (ATTC).
The dynamic simulation tool, SOURCE, can help policymakers manage finite resources. A study in the Journal of Addiction Medicine urges policymakers to aggressively increase buprenorphine treatment capacity and duration, ahead of entry, to more effectively reduce opioid overdose deaths. Even the Chantix recall has lessons to be learned. A sharp drop in varenicline prescriptions was not balanced by an increase in other nicotine cessation interventions and unfortunately the drop in varenicline use persisted beyond the recall (JAMA Network Open). Let’s hope something like that never happens with buprenorphine.
Thanks for reading,
Nicholas Athanasiou, MD, MBA, DFASAM
Editor in Chief
with Co-Editors: Brandon Aden, MD, Debra R. Newman, PA-C, MSPAS, MPH, Jack Woodside, MD, John A. Fromson, MD
Synthesising evidence of the effects of COVID-19 regulatory changes on methadone treatment for opioid use disorder: implications for policy 🔓
The Lancet Public Health
In this review article, methadone take-home dosing considerations during the COVID-19 pandemic were examined. A search of published research on the flexibility of these practices, patient-provider experience, health outcomes, and how these findings might influence updated regulations was performed. The review found no evidence of increased methadone overdose risk as a result of greater pandemic flexibility. Benefits of such a policy include potentially improved treatment retention and impressive improvements in patient quality of life. This is key for SAMHSA as it ponders the steps to make these flexibilities permanent.
Research and Science
State Cannabis Legalization and Cannabis Use Disorder in the US Veterans Health Administration, 2005 to 2019 🔓
In this observational study of sequential yearly Veterans Health Administration electronic health record data from 2005 to 2019, cannabis use disorder (CUD) rates increased from 1.38% to 2.25% in states with no cannabis legalization, 1.38% to 2.54% in states that legalized medical use, and 1.39% to 2.56% in states that legalized recreational use. Significant but small effect sizes were found for medical and recreational legalization, accounting for 4.7% and 9.8% of the overall increases in the respective states. Although legalization contributed to increasing CUD rates, the role of the laws in these increases may not have been state-specific or other factors may have played a larger role.
Long-Term Effects of Increasing Buprenorphine Treatment Seeking, Duration, and Capacity on Opioid Overdose Fatalities: A Model-Based Analysis
Journal of Addiction Medicine
Because buprenorphine treatment of opioid use disorder reduces opioid overdose deaths (OODs), expanding access to care is an important policy and clinical care goal. This study used a validated simulation model to project the effects of increasing buprenorphine treatment-seeking, average episode duration, and capacity (patients per provider) on OODs in the US from 2023 to 2033. Results show that increasing treatment duration alone could cost lives in the short term by reducing capacity for new admissions yet save more lives in the long term than accomplished by only increasing treatment seeking. Increasing provider capacity had negligible effects. The most effective 2-policy combination was increasing capacity and duration simultaneously, which would reduce OODs up to 18.6% over a decade.
Association between clinical measures of unhealthy alcohol use and subsequent year hospital admissions in a primary care population
Drug and Alcohol Dependence
The relationship between levels of alcohol use and likelihood of hospitalization was explored for 305,376 patients who received routine annual screening using the AUDIT-C. The AUDIT-C is a three-item measure of alcohol use scored 0-12. Those with AUDIT-C of 7 or above completed the Alcohol Symptom Checklist consisting of 11 items reflecting the DSM-5 criteria for AUD. Of those with AUDIT-C <3, 3.7% were hospitalized in the following year, whereas those with AUDIT-C of 9-12, 12.1% were hospitalized. Those with AUDIT-C of 7 or over and an Alcohol Symptom Checklist indicating severe AUD had a hospitalization rate of 14.6%, and over 2/3 had a diagnosis that could be attributed to alcohol. These screening tools can identify people with increased risk of adverse health outcomes related to alcohol use.
Adaptation of the Tele-Harm Reduction intervention to promote initiation and retention in buprenorphine treatment among people who inject drugs: a retrospective cohort study 🔓
Annals of Medicine
This study evaluated a tele-harm reduction intervention, previously utilized to deliver HIV care in syringe services programs, that was adapted to deliver buprenorphine treatment in the same setting to patients with opioid use disorder. Overall, the authors found 58.7% retention of patients at 90-days, meaning patients received 3 consecutive prescriptions for buprenorphine. In the logistic regression model, they found patients who received at least one provider visit via telehealth were more likely to stay in treatment (aOR=7.53) as were patients who received dose increases from initial dose (aOR=8.09). They do note patients with co-occurring stimulant use were less likely to stay in treatment (aOR=0.29). The low-barrier care delivery model in harm reduction settings may serve as a model to increase uptake of buprenorphine in high-risk vulnerable populations.
Alcohol and the Etiology of Depression 🔓
The American Journal of Psychiatry
Alcohol use has been associated with at least double the odds of depression and cessation is associated with decreased depressive symptoms. In observational studies, the association follows a U-shaped pattern, meaning abstinence and heavy use are associated with higher odds of depression, while compared to low-level drinking, which was also found in a recent study the author discusses. There have been potential explanations for these findings, including potential positive effect on GABA or dopamine systems of low-level drinking, but may also be due to its association with a healthy social life which would be protective for depression. Implications for clinicians are that low-level drinking may be generally safe and screening for escalating drinking or heavy drinking should be the priority.
Association of the Chantix Recall With US Prescribing of Varenicline and Other Medications for Nicotine Dependence 🔓
JAMA Network Open
Varenicline is an effective strategy for treatment of nicotine dependance. This cross-sectional study investigated the recall of Chantix (varenicline) in July 2021 in terms of available medications prescribed for nicotine dependence. Less than one month later, the FDA allowed distribution of the Canadian generic varenicline product. The number of patients prescribed varenicline decreased from 536 per 1 million in June 2021 to 146 per 1 million in August. It should be noted that there was no concomitant increase in NRT or bupropion prescribing. The authors suggest that changes in policy improve procedures surrounding medication recall.
Rigid opiate agonist treatment programmes risk denying people their agency 🔓
This opinion piece notes that COVID led to a relaxation of strict MOUD treatment policies such as daily supervised dosing and mandatory drug testing. Such policies have been based on treatment providers' concerns, such as diversion, misuse, and abstinence and leave people who use drugs little agency in their treatment. Power needs to be shifted from clinics to clients to deliver person centered care. Clients should be allowed to take their medications at home and relieved of requirements for drug testing and abstinence. There needs to be research about clients’ preferences for services. People who use drugs should not have to conform to rigid and arbitrary rules that would not be tolerated in other healthcare settings.
In The News
Opinion | Why Are Ketamine Ads Following Me Around the Internet?
The New York Times
Experts, lawmakers push for expanded access to methadone to save lives
The Washington Post
Mississippi Votes to Ban Zaza Pills and Other Tianeptine Drugs
Opioid Distributors Cleared of Liability to Georgia Families Ravaged by Addiction
The New York Times
The Good, the Bad, and the Ugly of Good Samaritan Laws
Addiction Technology Transfer Center Network (ATTC)