American Society of Addiciton Medicine

The ASAM Weekly for January 30, 2024

by ASAM Weekly Editors

This Week in the ASAM Weekly

It’s time to embrace reduced use in the language of abstinence, sobriety, and recovery. This change has been developing for some time, but a recent NIH-supported study involving stimulant use disorders really adds to the evidence that reduced use is a meaningful and desirable outcome within recovery (Addiction).

This added understanding doesn’t distract us from the significance of abstinence, but it helps acknowledge and support different paths toward a shared goal, which could simply be one of “feeling better.” A recent study explores this and the influence of various AA participation dimensions (independent of abstinence) with different types of positive affect (Alcohol and Alcoholism). Essentially, relationships do help build recovery. 

Pregnant individuals living with opioid use disorder need particular support in their paths toward recovery, because of the unique obstacles they face -- from urine drug tests to parental shaming. A new study might add to this complexity by comparing the risks of congenital malformations from buprenorphine vs. methadone treatment, but two invited commentaries reenforce the study’s most fundamental points -- MOUD in pregnancy is essential and a part of shared-decision making (JAMA Internal Medicine). 

As shown above, even if our research outcomes, treatments, or language don’t always or completely address an individual’s experience with addiction, we’ll continue to improve because scientific knowledge over time embraces the human experience. 

Hopefully, that’s all Oregon needs to figure out decriminalization -- more time. It makes sense if you think about it, given how long it took us to accept reduced use. Unfortunately, we need Oregon to hurry it up with this one (MedPage Today). 

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

Lead Story 

First Trimester Use of Buprenorphine or Methadone and the Risk of Congenital Malformations 🔓

JAMA Internal Medicine

In this cohort study of 9,514 pregnancies with first-trimester buprenorphine exposure and 3,846 with methadone exposure, the prevalence of congenital malformations overall and several malformation subtypes was lower among pregnant individuals treated with buprenorphine compared with methadone, except for gastrointestinal malformations. There was an 18% relative risk reduction for malformations overall, which translates to 1 less event per 100 patients treated with buprenorphine vs methadone. When determining optimal treatment for pregnant individuals with opioid use disorder, considerations should include the relative risk reduction for malformations overall with buprenorphine vs methadone, as well as treatment access, previous success on a particular treatment, and the likelihood of retention in treatment.

Research and Science 

Reduced drug use as an alternative valid outcome in individuals with stimulant use disorders: Findings from 13 multisite randomized clinical trials 🔓

Addiction

This study assessed the validity of reduced stimulant use as an outcome measure in a pooled dataset of 13 randomized controlled trials of pharmacological interventions for stimulant use disorder. Participants were individuals seeking treatment for cocaine or methamphetamine use disorders (N = 2062) in a wide range of treatment facilities in the US. More participants reduced frequency of primary drug use than achieved abstinence. Reduced use was significantly associated with decreases in craving for the primary drug, drug seeking behaviors, and depression severity, as well as multiple measures of global improvement in psychosocial functioning and severity of drug-related problems, albeit less strongly so than abstinence. Moreover, reduced use was associated with sustained clinical benefit at follow-up, as confirmed by negative urine tests.

Meeting-makers make meaning: alcoholics anonymous participation and personal meaningfulness

Alcohol and Alcoholism

This study explored associations between specific dimensions of involvement with Alcoholics Anonymous and changes in affect. These dimensions were: meeting attendance (simple presence at meetings), fellowship involvement (speaking in meetings, help setting up, being sponsored or sponsoring, etc.), and 12-step work (study and practice of the steps). Positive and negative affect were assessed on standard scales. Participants in AA (n=30) were recruited with Alcohol Use Disorder (AUD) and at least 1 month of abstinence (duration of abstinence: mean 11 yrs ± SD 13 yrs). A significant association was found between positive affect and meeting attendance and fellowship participation but not 12-step work. There were no significant differences in these associations comparing female (n=13) and male (n=17) participants.

Cannabis for chronic pain: cardiovascular safety in a nationwide Danish study 🔓

European Heart Journal

Prior studies have shown recreational cannabis use to be associated with an increased risk of arrhythmia. This study explored the arrhythmia risk associated with cannabis use for chronic pain. Data were obtained from the Danish health registry on chronic pain patients prescribed cannabis for chronic pain and compared to chronic pain patients using other medications for pain. The outcome variable was a new diagnosis of arrhythmia during the 180 days following initiation of medical cannabis. The medical cannabis patients had twice the risk of new onset arrhythmia compared to controls (risk ratio 2.07). Arrhythmia was diagnosed in 0.8% of medical cannabis patients and 0.4% of controls. There was no association of medical cannabis use and acute coronary syndrome, stroke, or heart failure.

Substance use outcomes from the Child/Adolescent Anxiety Multimodal Extended Long-term Study (CAMELS)

The Journal of Child Psychology and Psychiatry

Anxiety and substance use disorders are prevalent and frequently co-occur, with prior evidence suggesting anxiety precedes and often predicts substance use disorders (SUD). In this study, researchers examined the prevalence of substance use in a follow-up study of the Child/Adolescent Anxiety Multimodal Study (CAMS), in which youth were randomized to medication, cognitive behavioral therapy (CBT), combination, or placebo for anxiety treatment. Participants were assessed annually over 4 years, starting on average 6.5 years after CAMS study. In all 4 follow-ups, the study participants had significantly lower rates of SUD than the overall population. In addition, alcohol use was significantly lower than the general population. The study is consistent with other evidence and supports treatment of anxiety in youth as potential secondary prevention for SUD.

Learn More

Medications For Opioid Use Disorder Increased Among Louisiana Medicaid Enrollees During Policy Reforms, 2018–21

Health Affairs

This study analyzed trends in medications for opioid use disorder (MOUD) between enrollees treated in residential and nonresidential settings and across demographic subgroups and compared trends by MOUD type. MOUD use more than tripled from 2018 to 2021 among Louisiana Medicaid enrollees diagnosed with OUD. Most of the increase in MOUD was attributable to buprenorphine use. Methadone uptake also contributed to greater MOUD use but was almost exclusively used by enrollees treated in nonresidential settings, whereas naltrexone was consistently used more commonly in residential treatment. By 2021, differences persisted across demographic groups: MOUD use was highest among enrollees who were White, were older, had comorbidities, and lived in a metropolitan area.

Intranasal Naloxone for Opioid Overdose

JAMA

This paper reviews the use of intranasal naloxone for reversal of opioid overdose. Although intramuscular naloxone is more effective, intranasal naloxone significantly increases the odds of surviving opioid overdose (OR = 8.6, 95% CI, 3.9 – 13.3). Communities that trained more than 100 people/100,000 in the use of intranasal naloxone had a 46% reduction in opioid death rates. The CDC recommends naloxone be prescribed when opioid prescriptions exceed 50 morphine equivalents daily, or when opioids are coprescribed with benzodiazepines. Naloxone is also advised for settings where children could access opioids. There have been reports of fentanyl overdoses requiring more than 2 doses of naloxone. However, these cases may represent opioid overdoses involving other respiratory depressants not reversed by naloxone.

An update on the clinical pharmacology of kratom: uses, abuse potential and future considerations

Expert Review of Clinical Pharmacology

In this article, the authors discuss the pharmacokinetics, effects, and potential toxicity of kratom. Kratom contains 40 alkaloids, primarily mitragynine, and these alkaloids bind to opioid, serotonin, and adrenergic receptors. Anecdotally, kratom has been used to treat pain, opioid withdrawal symptoms, and psychiatric disorders including depression and anxiety. This article reviews the limited studies and evidence of kratom’s use for pain and opioid withdrawal. The authors also reviewed the potential toxicity of kratom, including opioid-like deaths, serotonin syndrome, cardiotoxicity, and liver injury; however, the picture is complicated as kratom is frequently used with other substances. Research is needed to better understand kratom’s potential therapeutic effects and toxicity and the role of each of its components.