This Week in the ASAM Weekly

Access to treatment can have profound effects on individuals with addiction. Families in search of residential addiction treatment for adolescents encounter a disheartening mix of little access, high costs, and lack of evidence-based treatment (Health Affairs). This is unfortunate because evidence-based residential treatment can be highly effective for adults. A recent study of veterans found it resulted in about a two-thirds lower risk of death (Drug and Alcohol Dependence).

Naloxone is distributed widely to save lives even though there have been surprisingly few population-level studies demonstrating a mortality reduction -- until now (BMJ Open). On the other hand, buprenorphine has a storied history of barriers -- from ominously named waivers to prior authorizations -- but the evidence is mounting that fears of diversion should no longer be one of them. In fact, “diversion is a form of harm reduction” (STAT). In other words, diversion is (can be) a good thing.

Whether confronting an adolescent overdose crisis (NEJM) or providing low-barrier buprenorphine treatment (Medical Economics), our primary care colleagues play an important role in improving access. While we ask more of them, we must also do more to support the work they do so that primary care remains accessible to everyone.

Thanks for reading,

Nicholas Athanasiou, MD, MBA, DFASAM
Editor in Chief

with Co-Editors: Brandon Aden, MD, MPH, FASAM, Jack Woodside, MD, John A. Fromson, MD

Journal of Addiction Medicine Co-Editor Nominations

On behalf of the American Society of Addiction Medicine (ASAM), the Journal of Addiction Medicine is asking for your help in identifying exceptional candidates to be the next Co-Editors for the Journal of Addiction Medicine (JAM).

Interested individuals are encouraged to learn more about the position online at ASAM Member Portal (membersuite.com)and the application process opens January 10, 2024 and closes March 8, 2024.

Lead Story

Adolescent Residential Addiction Treatment In The US: Uneven Access, Waitlists, And High Costs

Health Affairs

Residential treatment facilities are one treatment option for adolescents with substance use disorders, yet little is known about their accessibility or cost. This study identified 160 residential addiction treatment facilities that treated adolescents with opioid use disorder as of December 2022. Eighty-seven facilities (54.4 percent) had a bed immediately available. Among sites with a waitlist, the mean wait time for a bed was 28.4 days. Of facilities providing cost information, the mean cost of treatment per day was $878. Daily costs among for-profit facilities were triple those of nonprofit facilities. Half of facilities required up-front payment by self-pay patients. The mean up-front cost was $28,731. The authors were unable to identify any facilities for adolescents in ten states or Washington, D.C. Access to adolescent residential addiction treatment centers in the United States is limited and costly.

Public Comment on Adolescent Framework

ASAM is seeking input from diverse stakeholders on the framework for the Adolescent and Transition Age Youth Volume of the 4th Edition of The ASAM Criteria®. Feedback received during the public comment period will be instrumental in refining the framework which will be used to guide development of the comprehensive standards and decision rules of the Adolescent and Transition Age Youth Volume. Feedback must be submitted through the online submission form in order to be considered. Deadline: February 7, 2024.

View draft framework.

Research and Science

Distribution of intranasal naloxone to potential opioid overdose bystanders in Sweden: effects on overdose mortality in a full region-wide study 🔓

BMJ Open

This study examined the effect of naloxone distribution on opioid overdose deaths in Skane county, Sweden. In 2018, legislation permitted naloxone distribution to the public in Skane. Opioid overdose death rates after this (2019-2021) were compared to historic controls prior to naloxone distribution (2013-2017). Hospital and social service data confirmed that problems related to opioids were stable or increased during the period of the study. Overall opioid overdose death rates decreased during naloxone distribution compared to the historic controls (3.9 to 2.8/100,000). More specifically, the rate for men decreased (6.7 to 4.3/100,000), while the rate for women did not (1.2 to 1.3/100,000). The sample of women was too small to draw firm conclusions, and the authors call for further studies of women. They conclude that naloxone distribution was associated with significant decreases in opioid overdose deaths.

Association of semaglutide with risk of suicidal ideation in a real-world cohort

Nature Medicine

In this retrospective cohort study, the authors investigate associations between the glucagon-like peptide 1 receptor (GLP1R) semaglutide and suicidal ideation (SI). The authors examine SI in 4 cohorts: 1) patients with obesity and not history of SI, 2) patients with obesity and history of SI, 3) patients with type 2 Diabetes Mellitus (T2DM) and not history of SI and 4) patients with T2DM and history of SI. In all 4 groups, patients treated with semaglutide versus non-GLP1R anti-obesity or non-GLP1R anti-diabetes medication respectively had lower risk of SI at 6 months follow-up (Group 1: HR=0.27, Group 2: HR=0.44, Group 3: HR=0.36, Group 4: HR=0.51). In addition, in the T2DM patients, those treated with semaglutide also had lower risk of SI at 1, 2, and 3 years of follow-up.

Effectiveness of Residential Treatment Services for Veterans with Substance Use Disorders: A Propensity Score Matching Evaluation

Drug and Alcohol Dependence

This study evaluates the effectiveness of Veterans Affairs (VA) residential treatment for substance use disorders (SUD) compared with their outpatient programs. Researchers identified 6177 veterans who were screened and accepted for VA SUD residential treatment during the first half of 2019. Of these, 883 ended up receiving non-residential VA treatment and served as the comparison group. There were improvements in SUD symptoms throughout the year following treatment in the residential group that were significantly greater than in the comparison group (p<.001). There were also improvements in PTSD symptoms. However, improvements in depression and anxiety at 6 months were not sustained at 12 months. Finally, the authors found an impressive 66% reduction in mortality following VA residential treatment (p<.001). These results support the effectiveness of VA SUD residential treatment.

Clinical Implications of the Relationship Between Naltrexone Plasma Levels and the Subjective Effects of Heroin in Humans

Journal of Addiction Medicine

This study recruited 12 men with OUD (heroin) for an 8-week inpatient detoxification and induction onto extended-release naltrexone (XR-NTX). Then weekly, for 6 weeks, they rated “drug liking” after a 25mg dose of IV heroin or placebo. Their plasma NTX levels were also measured. In the first 3 weeks after the XR-NTX, there was adequate blockade of drug liking for heroin. After 3 weeks some individuals, then experienced drug liking for the heroin dose. The authors found that NTX levels above 2 ng/mL adequately blocked drug liking for heroin. NTX levels between 1 and 2 ng/mL resulted in drug liking greater than placebo. After the commercial XR-NTX product, the NTX levels 28 days later averaged 1.33 ng/mL (with considerable variability). The authors conclude that some individuals may benefit from more frequent dosing of XR-NTX.

Learn More

Prenatal Exposure to Cannabis: Effects on Childhood Obesity and Cardiometabolic Health 🔓

Current Obesity Reports

This study sought to consolidate information from 47 epidemiologic studies and 12 animal studies on the obesogenic and cardiometabolic effects of prenatal exposure to cannabis. Prenatal exposure to cannabis was consistently associated with small for gestational age and low birth weight. After birth, these offspring gain weight rapidly and have increased adiposity and higher glucose (fat mass percentage) in childhood. More preclinical and prospective studies are needed to deepen our understanding of whether these associations vary by sex, dose, timing, and composition of cannabis (e.g., ratio of delta-Δ9-tetrahydrocannabinol [Δ9-THC] to cannabidiol [CBD]). Addressing these gaps may help to solidify causality and identify intervention strategies.

Cannabidiol as a potential cessation therapeutic: Effects on intravenous nicotine self-administration and withdrawal symptoms in mice 🔓

Neuropharmacology

Some preliminary data have suggested that cannabidiol (CBD) may have some efficacy in treating nicotine dependence and may be potentially a new intervention for treatment. In a mouse model, the authors examine effects of orally dosed CBD on self-administration of low and moderate dose nicotine and withdrawal symptoms after nicotine cessation. The study showed a significant decrease in self-administration of nicotine at low or moderate dose (P<0.05). In addition, CBD pretreatment was associated with decrease in anxiety-like behavior, hyperalgesia behaviors, and somatic signs of withdrawal after nicotine cessation. Additional research will be needed to understand the mechanism of action and determine longer term efficacy.

The Overdose Crisis among U.S. Adolescents

The New England Journal of Medicine

While non-cannabis drug use has decreased among adolescents, overdose deaths have increased significantly in the last few years. The increase is likely driven by fentanyl found in counterfeit pills resembling prescription drugs with which adolescents are more likely to experiment. To address this epidemic, the authors suggest universal screening of adolescents in medical visits for substance use, providing education to adolescents about counterfeit pills, signs of overdose, how to access and to use naloxone. Dissemination of this knowledge should be done in medical offices, schools, and social media, specifically partnering with social media users with large adolescent followers. Finally, low-barrier and evidence-based treatment is needed for substance use and mental health for adolescents.

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