ASAM Weekly for May 9th, 2023
This Week in the ASAM Weekly
Advocacy is working when sources talk about addiction policy under the condition of anonymity. After being met with over 40,000 public comments as well as strong opposition from leaders in addiction medicine, the DEA is seeking to temporarily extend telehealth flexibilities (Washington Post). Federal officials are even acquiescing to states on rules about past drug use and hiring (NY Times). But our focus should not only be on federal agencies -- (bipartisan) politicians throughout the states continue to regress with policies that undermine harm reduction (NPR). It’s a constant balance between the collective wants of constituents and the collective health of the public.
The trajectory of OUD treatment seems to exemplify this. The removal of training requirements was necessary but not sufficient to improve access to buprenorphine (JAMA). Not-in-my-backyard policies and strict regulations have often pushed methadone treatment to the outskirts creating disparities in access between those who can afford it (buprenorphine) and those who cannot (methadone) (NEJM). Ultimately, structural change (or dismantling) is needed to improve retention in methadone maintenance (Journal of Substance Use and Addiction Treatment).
Such politics are very American, but so are the advocates. The American Society of Addiction Medicine and The American Academy of Addiction Psychiatry (AAAP) are seeking public comment for the much-anticipated Clinical Practice Guideline on the Management of Stimulant Use Disorders. The UCLA - Integrated Substance Abuse Programs recently made available a valuable toolkit for treating patients with StimUD and OUD in primary care. Even public health experts in Maryland are innovating to make a dangerous drug supply safer (MMWR).
There are a lot of "backyards" to advocate from.
Thanks for reading,
Nicholas Athanasiou, MD, MBA, DFASAM
Editor in Chief
with Co-Editors: Brandon Aden, MD, MPH, FASAM, Debra R. Newman, PA-C, MSPAS, MPH, Jack Woodside, MD, John A. Fromson, MD
Subtypes in addiction and their neurobehavioral profiles across three functional domains 🔓
Over two-thirds of the 40.3 million people in the U.S. who have a substance use disorder (SUD) return to use within weeks to months of initiating treatment, and up to 85% of individuals return to substance use within one year of treatment completion. This study hypothesized that considerable individual differences exist in the three functional domains underlying addiction — approach-related behavior, executive function, and negative emotionality. Results support functionally derived subtypes, demonstrating considerable individual heterogeneity in the multi-dimensional impairments in addiction. This confirms the need for mechanism-based subtyping to inform the development of personalized addiction medicine approaches.
Research and Science
Characteristics and impact of physical activity interventions during substance use disorder treatment excluding tobacco: A systematic review 🔓
This systemic literature review examined physical activity as a component in the treatment of substance use disorders (excluding nicotine). Following a literature search 43 studies met inclusion criteria with a total of 3135 participants; and 81% of the studies were randomized controlled trials. Types of physical activity included jogging, walking, resistance exercise, cycling, elliptical training, etc. Typically, sessions were of moderate intensity for 60 minutes, 3 times weekly for 13 weeks. A decrease in substance use was observed in 75% of studies. Over half of the studies included psychological outcomes and showed improvements in depressive symptoms (50%of studies) and anxiety symptoms (71% of studies). Four studies included sleep quality, and all showed improvement. The authors concluded that physical activity can be beneficial for these patients.
Transitioning off methadone: A qualitative study exploring why patients discontinue methadone treatment for opioid use disorder
Journal of Substance Use and Addiction Treatment
This study considered reasons patients discontinue methadone through interviews conducted at two treatment facilities in Baltimore, MD. Reasons for discontinuing methadone, the ideal length of treatment, and ways to improve retention were considered. Patients reported methadone as a bridge to recovery, but felt long-term use causes damage, and that it increases cravings for cocaine. Patients also report external factors such as inaccessibility, burdensome dosing, and stigma. To keep patients engaged in treatment, any clinical and policy changes should consider these important factors.
Chronic alcohol induced mechanical allodynia by promoting neuroinflammation: a mouse model of alcohol-evoked neuropathic pain
British Journal of Pharmacology
Unrelieved chronic pain may be a factor in alcohol use disorder (AUD). In this study the authors explore pain related to alcohol use in a mouse model. Among mice with dependence, 100% developed abstinence-related hypersensitivity as indicated by allodynia, experiencing normal stimuli as pain, which was relieved by alcohol intake. Among mice without dependence, 50% developed alcohol-evoked neuropathic pain. In both models, microglial activation occurred in the spinal cord, but with different pathways. The authors suggest investigation of these two pathways could lead to targeted therapies and potentially address pain as a factor in AUD.
Beyond the X — Next Steps in Policy Reforms to Address the Overdose Crisis
In this perspective, the authors consider the new 8-hour training requirement for prescribers of buprenorphine with the application or renewal of DEA registration. The authors find this requirement problematic, instead suggesting the provision of addiction medicine education in medical school and training programs so providers meet this requirement. There is the additional concern of certain state buprenorphine restrictions still in place and the treatment barriers these pose. Several suggested policy changes, including incentives for low-barrier treatment, could ensure patients seeking MOUD get the care that they need.
Trends in Buprenorphine Initiation and Retention in the United States, 2016-2022
This study used data from the Longitudinal Prescription Database, which includes 92% of retail prescriptions in the US, to calculate rates of initiation of buprenorphine treatment and treatment retention (180 days or more of continuous treatment). Researchers were looking for increased buprenorphine use because of relaxed waiver requirements in April 2021 and eased pandemic restrictions allowing better access to health care. Between 2016 and 2018 buprenorphine initiation rate increased from 12.5 to 15.9 per 100,000; however between 2018 and 2022 the initiation rate did not increase. This flattening occurred prior to the onset of the pandemic. Between 2016 and 2022 the retention rate remained unchanged at 22%. The authors conclude that efforts to increase buprenorphine use have been insufficient.
How the FDA Can Improve Public Health — Helping People Stop Smoking
There is a critical need for development and marketing of therapies for smoking cessation that are more effective than currently approved therapies. The FDA has approved only three types of drugs (nicotine-replacement therapy [NRT], bupropion, and varenicline) for helping people quit smoking, and there have been no substantial advances in FDA-approved smoking-cessation products in the past 17 years. Reviewing the Center for Drug Evaluation and Research (CDER) approval processes and requirements and the Center for Tobacco Products (CTP) parallel regulation of nicotine-containing products, including e-cigarettes, will be challenging. But encouraging the development and marketing of consumer-desirable, effective smoking-cessation aids could represent a profound contribution to public health.
Rapid Analysis of Drugs: A Pilot Surveillance System To Detect Changes in the Illicit Drug Supply To Guide Timely Harm Reduction Responses — Eight Syringe Services Programs, Maryland, November 2021–August 2022 🔓
The illicit drug supply can rapidly change, as demonstrated by fentanyl in the opioid supply, and timely identification of those changes are important to public health response. Between 2021 and 2022 at Maryland syringe service programs, the National Institute of Standards and Technology tested 496 samples, of which 74% were positive for opioids. Among the 367 samples that tested positive 98.9% tested positive for fentanyl or an analog while only 1.9% contained heroin and 80.5% contained xylazine. The authors note that being able to provide timely data to persons who use drugs about the drugs they use versus what they intend to use could reduce public health harms and guide interventions.
In The News
DEA seeks to temporarily extend virtual prescribing for controlled substances
The Washington Post
The ASAM/AAAP Clinical Practice Guideline on the Management of Stimulant Use Disorder: Public Comment Period Open until May 31, 2023
American Society of Addiction Medicine and American Academy of Addiction Psychiatry
Needing Younger Workers, Federal Officials Relax Rules on Past Drug Use
The New York Times
Now world’s no. 1 opioid consumer per capita, Israel faces addiction epidemic
The Times of Israel
As fentanyl deaths rise, state legislatures resist 'harm reduction' method
How the Opioid Backlash Went Wrong
Cigarette Smoking in U.S. Drops to Lowest Level Since 1965