ASAM Weekly for February 27, 2023
This Week in the ASAM Weekly
The economics of addiction are far-reaching. For example, supervised consumption programs in the US primarily exist underground but the few above-ground programs often rely on private donations while navigating political pressures at both the local and federal level (NY Times). Even as the price of buprenorphine has dropped in recent years, a price elasticity still exists such that only a dollar a day (of out-of-pocket costs) can incrementally reduce treatment retention (JAMA Network Open). Such a price barrier speaks volumes when considering over-the-counter naloxone could likely cost $18 or more (The American Journal of Medicine). It must be over-the-counter and affordable to save lives (Medpage Today).
A study on the Howard Street Method is remarkable not only for being one of the larger case series on low dose buprenorphine induction, but also because it was successful in a seemingly economically-resistant setting (Journal of Addiction Medicine). Similarly, SUD programs are oftentimes small or financially unstable. Understanding their financial capacities helps maintain access and improve outcomes, even when there is increased funding (BMC Health Services Research).
All this might seem like a drop in the bucket when considering the millions in resources General Garcia Luna received simultaneously from the DEA and the Sinaloa Cartel to fight the War on Drugs in Mexico (NPR). On the same day he was found guilty, the NY Times editorial board wrote of the war on drugs in past-tense while laying down a concisely compelling plan going forward. Obviously, it is more far-reaching than economics.
Breaking News: The DEA published its proposed guidelines for telemedicine and is seeking public comment.
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
The Howard Street Method: A Community Pharmacy-Led Low Dose Overlap Buprenorphine Initiation Protocol for Individuals Using Fentanyl
Journal of Addiction Medicine
Concerns about precipitated withdrawal can be a barrier for patients initiating buprenorphine. This case series examined the implementation of buprenorphine low dose overlap initiation (LDOI) utilizing a community pharmacy. A blister pack was provided with a 7-day titration schedule increasing from 0.5 mg to 4 mg daily. Of the twenty-six patients who started treatment, fourteen completed the protocol with 79% reporting no withdrawal symptoms and 21% reporting only mild symptoms. At thirty days of follow-up, 71% were still receiving buprenorphine, and at 180 days 43% were retained in care but only 14% were still receiving buprenorphine. The study suggests that this community-based pharmacy approach is novel and may offer a new way to initiate buprenorphine in high-risk populations.
2023 Addiction Medicine Research Priorities Listening Session
The National Institute on Alcohol Abuse and Alcoholism (NIAAA), National Institute on Drug Abuse (NIDA), and Agency for Healthcare Research and Quality (AHRQ) have requested input from addiction medicine specialists on how to improve the clinical relevance of their addiction medicine research portfolios.
Please provide input on their questions below and add any questions or comments you may have at the end of the form. We will also discuss these questions at the "Bridging the Gap between Science and Clinical Practice in Addiction Medicine" session during the ASAM 2023 Annual Conference.
If you have any questions, please email Ray Denny, PhD, Associate Director of Science, at rdenny@ASAM.org. Thank you!
Research and Science
Estimating the impact of stimulant use on initiation of buprenorphine and extended-release naltrexone in two clinical trials and real-world populations 🔓
Addiction Science and Clinical Practice
Concomitant use of stimulants with opiates has increased by 80% over the last decade. The current study postulates that stimulant use may have a negative effect on initiation of MOUD. Data for 673 participants in two previous clinical trials (X:BOT 2014-2017 and CHOICES 2018-2019) were analyzed for the effect of stimulant use (cocaine, methamphetamine, other amphetamines) on the likelihood of initiating MOUD. Stimulant use reduced the likelihood of initiating MOUD (aHR=0.68, p=0.02); this reduction was greater for XR-NTX (aHR=0.49, p=0.01) than for buprenorphine (aHR=0.67, p=0.02). The authors conclude that stimulant use has negative effects on MOUD initiation; hence, an urgent need to address stimulant use in patients with OUD.
Trends in Out-of-Pocket Costs for and Characteristics of Pharmacy-Dispensed Buprenorphine Medications for Opioid Use Disorder Treatment by Type of Payer, 2015 to 2020 🔓
JAMA Network Open
This cross-sectional study looked at retail pharmacy–dispensed buprenorphine prescriptions for OUD for US adults from 2015 through 2020. Some 7,375,508 buprenorphine prescriptions were dispensed in 2015 and 13,486,822 in 2020. Mean daily out-of-pocket costs decreased over the study period from $4.79 in 2015 to $1.91 in 2020. Costs varied by insurer, with Medicaid costing the least and self-pay/assistance the highest; Medicaid also paid for the highest number of prescriptions, and this increased over time. Strategies that target reduced out-of-pocket costs may improve buprenorphine treatment retention.
Hospitalization Associated With Comorbid Psychiatric and Substance Use Disorders Among Adults With COVID-19 Treated in US Emergency Departments From April 2020 to August 2021 🔓
In this cross-sectional analysis of more than 1.2 million emergency department patients with COVID-19, patients with both psychiatric and substance use disorders had a greater probability of hospitalization, compared with those with psychiatric disorder alone, substance use disorder alone, or neither disorder. Substance use disorders appear to have a greater association than psychiatric disorders with the probability of hospitalization. Among emergency department patients with COVID-19, ascertainment of both psychiatric and substance use disorders is important to accurately determine the likelihood of hospitalization.
Understanding the role of financial capacity in the delivery of opioid use disorder treatment 🔓
BMC Health Services Research
The current substance use disorder (SUD) treatment system has struggled to meet the service needs of an increasingly diverse population, particularly those experiencing opioid use disorder (OUD). Because many SUD treatment programs are small and financially unstable, they face heightened risk of discontinuing services or reducing the quality of care. This literature review showed inconsistencies in the definition and application of concepts associated with financial capacity across business and social service delivery fields. There were significant differences in components of financial capacity across years and an increase in average earned revenue and markup in 2017 compared to prior years. The interaction between minorities and markup was significantly associated with higher likelihood of waiting.
The therapeutic potential of psychedelics: the European regulatory perspective 🔓
This article describes several questions that need resolution as the European Union considers regulating the use of psychedelics as treatment for various mental health conditions. Double blinding of research is difficult since the difference in effects of active drug and placebo is evident to both research staff and participants. Psychotherapy is standard in trials of psychedelics; so, are psychedelics adding value or are the effects of psychotherapy primarily the result of psychological support? More work on safety is needed, such as investigating long-term effects and interaction with other medications; additionally, who may administer treatment and what training is required needs to be defined. Further research is needed to establish optimum dose. Challenges such as these need to be addressed before the therapeutic potential of psychedelics is realized.
Naloxone over the Counter: Increasing Opportunities and Challenges for Health Providers 🔓
The American Journal of Medicine
In anticipation of FDA approval of over-the-counter (OTC) naloxone, this commentary highlights the opportunities and challenges of such a harm reduction strategy. At the forefront is far wider availability. The authors state that improved access through availability and education should involve healthcare providers in SUD treatment programs; emergency medicine providers; and providers at college-based student health services. Finally, naloxone should be available wherever a portable defibrillator is present. The authors endorse state medical societies advocating for greater naloxone access as well.
Examining associations between MDMA/ecstasy and classic psychedelic use and impairments in social functioning in a U.S. adult sample 🔓
Utilizing the National Survey on Drug Use and Health (NSDUH) from 2015 to 2019, the authors examine associations between MDMA and other psychedelics and social functioning. MDMA was found to be associated with lowered difficulty dealing with strangers (aOR 0.92), difficulty participating in social activities (aOR 0.90), and being prevented from engaging in social activities due to mental health (aOR 0.84). Among psychedelics, only mescaline was associated with lowered difficulty dealing with strangers (aOR 0.85). All other psychedelics either had no association or associated with increased difficulty with social functioning. It should be noted, no causality can be determined from this study, but the authors do offer multiple potential mechanisms for the improved social functioning and suggest future experimental studies are needed.
In The News
DEA Announces Proposed Rules for Permanent Telemedicine Flexibilities
Over-the-Counter Naloxone Has the Power to Save Lives
Mexico's ex-public security head is convicted in the U.S. of taking cartel bribes
Ketamine can be mind-altering, and getting it has become much easier.
The New York Times
One Year Inside a Radical New Approach to America’s Overdose Crisis
The New York Times
America Has Lost the War on Drugs. Here’s What Needs to Happen Next.
The New York Times