This Week in the ASAM Weekly

Guest Editorial: A Reality Check
By R. Corey Waller, MD, MS, FACEP, DFASAM 

This guest editorial is part two of a two-part series on drug testing. 

In addiction medicine, we use controlled substances to treat patients who have an addiction to controlled substances. This is arguably the highest-risk outpatient treatment that exists for medical providers. We are overseen and monitored by the Centers for Medicare and Medicaid Services (CMS), the Drug Enforcement Administration (DEA), state licensing boards, and local law enforcement. Each of these entities has policies that mandate the efforts we must undertake to ensure the safety of the patient, household, and broader community. Along with this is a reality that a large portion of addiction care is delivered by non-specialist providers who need as much information as possible to create an environment of safety for both their patients and themselves. As medical professionals, it is our duty to use objective information to guide the care of the patients we treat. Currently, the only true objective test we have in addiction treatment is a toxicology test. Given this, I argue that the issue is not the toxicology test itself, but rather the lack of knowledge around how to use and interpret it. 

A few guiding scientific principles 

• A test for something (lab, radiology, etc.) is not to be confused with the treatment itself. For example, a positive troponin level doesn’t change the outcome of a patient with chest pain; rather, it is the reaction to this lab result and the associated clinical factors that are responsible for the patient’s outcome. 

• Stigma is not a reason to disregard pertinent clinical information. If this were the case, we would have never tested for HIV in the 90s. 

• A lack of knowledge about interpreting a clinical test does not excuse avoiding it. Train providers to interpret the test correctly. 

Read the full editorial here.

Lead Story 

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. 

Research and Science

Evaluation of nitazene immunoassay test strips for rapid in-situ detection of nitazene and nitazene analogs in illicit drug samples 🔓

Harm Reduction Journal

Nitazenes, a group of synthetic opioids, are being identified in the drug supply with increasing prevalence and can contribute to overdose deaths. Researchers in this study evaluated a commercially available nitazene test strip, testing it against 36 nitazene compounds and 93 other drugs and adulterants. The test strips appropriately detected 28 of the 36 nitazene compounds but failed to detect 8. In addition, there was significant variability in the lower limit of detection across the various nitazene compounds that were detected. The authors note while test strips may assist with harm reduction, validation testing is needed, and limitations and risk need to be clearly communicated.

Hospital-Based Methadone and Buprenorphine Initiation Practices by Addiction Consult Services🔓

JAMA Network Open

This national cross-sectional survey of 58 addiction fellowship-associated hospital consult service directors sought to outline the novel methadone and buprenorphine initiation practices being utilized to address high-potency synthetic opioid use. The survey found that the majority (87%) of consult services were utilizing rapid methadone initiation (defined as more rapid than the standard of 40 mg on day 1 with an up-titration of 5-10 mg every 3 days), with 67.4% reporting using a rapid methadone initiation protocol for more than half of patients. Of the respondents, 93.1% stated they had changed buprenorphine initiation practices due to high-potency synthetic opioids; 92.9% of services offered low dose initiation, 87.7% offered traditional initiation, and 75.4% offered high dose initiation. The survey findings suggest hospital addiction consult service practices are adapting to a changing opioid supply, potentially outpacing research and clinical guidelines. 

Alkyl Nitrite (“Poppers”) Exposures in the US 🔓

JAMA Network Open

Alkyl nitrites, or poppers, are drugs that are commonly used for their short-acting vasodilatory properties and purported ability to enhance sexual intercourse.  Whereas inhalation is the typical route of administration, ingestion has recently become more common, possibly because of packaging that closely resembles energy shot beverage products. Poppers use can cause methemoglobinemia, a potentially life-threatening condition characterized by impaired ability of hemoglobin to carry oxygen to tissues. In this case series study, researchers analyzed poison center reports during an 11-year period and found a disproportionate increase in severe clinical outcomes among patients who reported ingestion. Prevention and harm reduction efforts are needed for those who use poppers.

Distinct oral microbiomes in individuals with tobacco smoking compared to nonsmoking healthy individuals

The American Journal on Addictions

Chronic tobacco smoking contributes to oral health problems, such as periodontitis and tooth decay, which can result from smoking-altered oral microbiomes. This cross-sectional study compared the oral salivary microbiomes of 20 chronic tobacco smokers and 23 nonsmoking controls, all of whom were Chinese males, using microbial 16S rRNA sequencing. The duration of smoking, age, and information on gingivitis were collected and analyzed using the nonparametric Mann–Whitney test and a regression model. After adjusting for age, gingivitis, smoking duration, and FDR, only the abundance of the Pectinatus genus and Streptococcus australis species was significantly increased in smokers compared to controls. Maintaining good oral hygiene, using oral probiotics that reduce proinflammatory microbiomes, or treating oral diseases may help prevent the pathogenesis of tobacco-enriched commensal pathobionts.

Learn More

Why is substance use missing from my patient's problem list? CTN research to advance screening, prevention, and treatment of substance use in primary care 

Journal of Substance Use and Addiction Treatment 

While only about 20% of Americans with a substance use disorder (SUD) receive treatment in addiction treatment programs the majority will have had primary care visits within the last year. The authors of this commentary review studies by the Clinical Trials Network (CTN) focused on primary care settings, including studies on screening tools and treatment interventions. The authors identify the need for future research in the following 3 areas: 1) treatment interventions for polysubstance use, 2) improved screening and treatment for cannabis use, and 3) interventions for unhealthy substance use for those not seeking SUD treatment. The authors also note future research needs to address implementation as well as effectiveness. 

In the News 

CDC to Clinicians: Look Out for Medetomidine in Opioid Overdose 🔓

MedPage Today

The Case for Higher-Dose Buprenorphine 🔓

Filter

What to know about marijuana policies under Trump 🔓

The Associated Press

U.S. Drinking Rate at New Low as Alcohol Concerns Surge 🔓

Gallup

Why Women, Especially Mothers, Often Can’t Get Addiction Treatment 🔓

The Marshall Project

Opinion | Not Everyone in Addiction Recovery Is Sober, and That’s OK

The New York Times