American Society of Addiciton Medicine

The ASAM Weekly for April 9th, 2024

by ASAM Weekly Editors

This Week in the ASAM Weekly

There are many ways to stay updated in the field of addiction medicine. The ASAM Weekly is one (and thank you readers for making that possible!), but the ASAM Annual Conference is truly a behemoth when it comes to updating one’s knowledge in the field. 

There are pre-conference activities, focus sessions, special interest group meetups, exhibits, roundtable discussions, live recordings of podcasts, Principles of Addiction Medicine 7th launch parties, networking activities, impromptu reunions, a movie night, as well as auditorium-packed presentations -- just to name a few. The options are exhaustive but far from exhausting. 

If you didn’t make it to the conference this past week then you might have missed out on important presentations about methadone treatment and policy, treatment gaps, buprenorphine induction, patient-centered approaches, toxicology, behavioral addictions, The ASAM Criteria, 4th Edition, justice-involved care, harm reduction…the list goes on. 

But this is not meant to instill a fear of missing out. It is a reassurance that ASAM will continue to provide opportunities for you to stay updated in an ever-changing field. Rest assured, the ASAM Weekly will also be a part of this. We’ll embed those conference pearls throughout our commentaries, guest editorials, and summaries in the weeks to come. 

Now, if you missed out on the delicious Texas-inspired food that was provided at the conference, well then, you’re just out of luck.

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

Impact of jail-based methadone or buprenorphine treatment on non-fatal opioid overdose after incarceration

Drug and Alcohol Dependence

The authors studied the effect of receiving MOUD during incarceration in New York City jails on non-fatal overdose events during the year after discharge. Data were analyzed for patients with OUD incarcerated between 2011-2017 who either received MOUD during the 3 days before release (n=8660) or did not receive MOUD just prior to release (n=10,163). After controlling for covariates, those receiving MOUD had a significant reduction in non-fatal overdoses during the 14 days after release (adjusted HR: 0.49; 95% CI = 0.33-0.74). However, there was no reduction in non-fatal overdoses during the remainder of the 1 year after release. The authors speculate that this lack of benefit beyond 14 days may be due to failure to transition to outpatient MOUD after release. They conclude that MOUD in jail could be lifesaving and that it is important to ensure MOUD continues after release.

Research and Science

Adolescent nicotine exposure induces long-term, sex-specific disturbances in mood and anxiety-related behavioral, neuronal and molecular phenotypes in the mesocorticolimbic system

Neuropsychopharmacology

The authors use an adolescent rat model to examine sex-specific short- and long-term effects of nicotine exposure. The study found an increase in anxiety-like behavior, increased neuronal firing in the medial prefrontal cortex (mPFC) and ventral tegmental area (VTA), and increased anxiety-related protein expression in mPFC and nucleus accumbens (NAc) in male rats exposed to nicotine. However, these differences were not found between nicotine exposed and unexposed female rats. The author suggests these variances between sexes may be due to sex hormone differences in adolescence. These findings are unlike clinical populations, where female smokers tend to experience more anxiety disorders than male smokers. 

Impact of overdose on health plan disenrollment among patients prescribed long-term opioids: retrospective cohort study 🔓

Drug and Alcohol Dependence

Researchers obtained claims data for commercial insurance and Medicare Advantage plans from Optum Labs Data Warehouse. They identified (n=404,151) patients receiving long-term (6 months or more) opioid therapy for non-cancer pain. Buprenorphine claims were omitted, removing patients receiving opioids for OUD. The primary insurance was commercial for 28.5% of these patients and Medicare Advantage for 71.5%. During the follow-up period overdose events occurred in 1.3%. Overdose events were associated with a significantly increased risk of subsequent insurance disenrollment: risk ratio 1.15 for Medicare Advantage and RR 1.48 for commercial insurance. The authors point out that since commercial insurance is tied to employment, job loss related to the overdose event could be a cause for disenrollment. They suggest that some overdose events may result from OUD and that disenrollment would be a barrier to OUD treatment.

Safety and compliance of long-term low-dose ondansetron in alcohol use disorder treatment 🔓

European Journal of Internal Medicine

Low-dose ondansetron (AD04, a 5-HT3 antagonist) was shown recently to be a promising treatment for alcohol use disorder (AUD) with a specific genotypic profile (5-marker). The aim of this study was to assess the liver safety profile of AD04 compared with placebo in subjects with AUD. Low-dose AD04 did not significantly change biochemical markers of liver injury, such as ALT, AST, and Serum Bilirubin. While patients with AUD displayed elevated GGT levels, typically associated with increased alcohol consumption, this parameter remained unaffected by low-dose AD04. Notably, no significant adverse effects were observed due to oral low-dose AD04 treatment. Low-dose AD04 has the potential to be a safe treatment option for subjects with AUD and alcohol-associated liver disease (ALD), indicating the need for a randomized control trial for this specific cohort. Such a trial would pave the way for the design of a precision treatment for combined AUD with ALD. 

96-week retention in treatment with extended-release subcutaneous buprenorphine depot injections among people with opioid dependence: Extended follow-up after a single-arm trial 🔓

International Journal of Drug Policy

This study is a follow-up at 96 weeks of a prior single-arm open label study that enrolled 100 patients with an opioid use disorder (OUD) on extended-release injectable buprenorphine (BUP-XR). Forty-seven of the original 100 patients remained on BUP-XR at 96 weeks, and researchers found that past four-week use of heroin at baseline was associated with lower odds of retention. Older age of initial use of opioids and longer duration of medication for OUD treatment prior to starting trial were associated with increased odds of retention. Overall, those retained in treatment reported improved quality of life, satisfaction with BUP-XR, and decreased depression. The study was funded by a grant from Indivior LLC.

ASAM Criteria 4th Edition

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Increasing Exposure of Young Children to Illicit Fentanyl in the United States

The New England Journal of Medicine

This letter reported data from The National Poison Data System concerning children under 6 years old poisoned by illicit fentanyl from 2013 to 2023. There were 1,466 cases of children under 6 exposed to illicit fentanyl with a dramatic increase during the period (5 cases in 2013 to 539 in 2023). The rate of increase rose in 2020 and the years since. The average age was 1.6 years and 84% were less than 2 years old. Respiratory depression or arrest was reported in 50%, 10% received CPR, and 3.5% died. Most exposures (82%) were in the home. Oregon Poison Center had 27 cases during the same 11 years with an average age of 1.2 years. In Oregon, 30% were witnessed handling or ingesting counterfeit pills.

Large-scale network abnormality in behavioral addiction 

Journal of Affective Disorders

This meta-analysis aims to ascertain the network dysfunction associated with behavioral addiction (BA) through the utilization of resting-state functional connectivity. Individuals with BAs exhibited (1) hypo-connectivity within the fronto-parietal network (FN) and hypo- and hyper-connectivity within the ventral attention network (VAN); (2) hypo-connectivity between the FN and regions of the VAN, hypo-connectivity between the VAN and regions of the FN and default mode network (DMN), hyper-connectivity between the DMN and regions of the FN; (3) hypo-connectivity between the reward system and regions of the sensorimotor network (SS), DMN and VAN; (4) hypo-connectivity between the FN and regions of the SS, hyper-connectivity between the VAN and regions of the SS. These findings provide impetus for a conceptual framework positing a model of BA characterized by disconnected functional coordination among large-scale networks.

Unraveling the Complexities of Substance-Induced Psychosis and its Transition to Independent Psychosis: a Ten-Year Retrospective Cohort Study

International Journal of Mental Health and Addiction

The retrospective study describes patients in North India between 2012 and 2021 who were diagnosed with a substance use disorder (SUD) and psychosis. Initially, the majority were diagnosed with substance induced psychosis (SIP) (95.6%); however, in subsequent visits, the majority’s diagnosis (70.3%) was converted to independent psychosis (IP). The transition rate is higher than previously reported in studies. The authors do note cannabis use is associated with higher transition rates and was the predominant substance used (50.9%) in this study population, but they also note cannabis in this region is of lower potency than that used in North America and Europe. They consider this may indicate this population has increased vulnerability to psychotic disorder. While additional research is needed, the authors suggest these findings support more intensive interventions in this population.