This Week in the ASAM Weekly

Benzodiazepines have a storied history in medicine. Their effectiveness for certain diseases is undisputed, while concerns for negative effects have grown over the years. More recently though, a consensus has emerged around an experience that may best represent this class of medications:

Tapering benzodiazepines is not easy for the patient or clinician.

Enter “The Joint Clinical Practice Guideline On Benzodiazepine Tapering." This FDA commissioned guideline represents a diverse collaboration of ten medical and professional societies, including ASAM, and aims to help clinicians help patients safely taper their benzodiazepine medication (Journal of General Internal Medicine).

One of the most notable aspects about this guideline is how centered it is to the patient experience. Individuals with lived experience were closely involved in the Guideline's development and an emphasis on heterogenous presentations is evident throughout (Journal of General Internal Medicine).

The Guideline is also thoroughly detailed. It starts with careful consideration of the risks and benefits, provides strategies for the tapering process, and troubleshoots some of the most challenging scenarios. There’s even a bit of refreshing self-awareness as the authors acknowledge the consequences if clinicians misinterpret the spirit of this scientific document (JAMA Network).

And even though the Guideline is comprehensive, the work doesn’t end here. ASAM has developed a number of resources, from webinars to pocket guides, with more content expected soon (Medscape). In fact, the only thing missing would be another joint clinical practice guideline but this time on initiating and continuing benzodiazepines.

Maybe this is how that next guideline begins.

Thanks for reading,

Nicholas Athanasiou, MD, MBA, DFASAM
Editor in Chief

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

New Buprenorphine for OUD Labels Clarify Higher Doses Appropriate for Some Patients

Suboxone and Zubsolv have modified their labels to clarify that there is no maximum daily dosage. This follows the FDA’s December recommendation that transmucosal buprenorphine product labels be updated to address misperceptions of a daily maximum dose of 16 or 24 milligrams.

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Lead Story

Joint Clinical Practice Guideline on Benzodiazepine Tapering: Considerations When Risks Outweigh Benefits 🔓

Journal of General Internal Medicine

The American Society of Addiction Medicine (ASAM), in collaboration with nine other medical societies and professional associations, developed evidence-based guidelines for tapering benzodiazepine (BZD) medications across various clinical settings. These guidelines were created using a modified GRADE methodology and a clinical consensus process, which included a systematic literature review and several targeted supplemental searches. The guidelines were also revised based on feedback from external stakeholders. Key recommendations include that clinicians should continually assess the risks and benefits of BZD use and tapering. They should engage in shared decision-making with patients and avoid abrupt discontinuation in individuals who may be physically dependent or at risk of withdrawal. Tapering strategies should be personalized and adjusted based on the patient’s response. Additionally, clinicians are encouraged to provide psychosocial support to help patients successfully taper off BZDs.

Research and Science

Cardiovascular risk associated with the use of cannabis and cannabinoids: a systematic review and meta-analysis 🔓

Heart

Cannabis use has increased significantly in the last several years and the authors conducted a systematic review to assess its association with major adverse cardiovascular events (MACE). The meta-analysis included 24 studies (17 cross-sectional, 6 cohort, and 1 case-control).The authors found a significant association between cannabis use and MACE, as well as an association with increased acute coronary syndrome (OR=1.29), stroke (OR=1.20), and cardiovascular mortality (OR=2.10). Of note, there was significant heterogeneity among the studies, but the authors found that when they limited analysis to the cohort studies, the findings were consistent. These findings are also consistent with prior findings and highlight potential risk associated with cannabis use.

Comparing Prescription Opioid, Benzodiazepine, and Stimulant Misuse Rates Among Patients With and Without Telehealth Service Use

American Journal of Psychiatry

Telehealth has become a key part of outpatient mental health and prescribing in the US, especially after COVID-19 eased in-person visit requirements for controlled substances under the Ryan Haight Act (RHA). The DEA has extended COVID-19 telehealth rules due to concerns that returning to prior rules would reduce mental health access. This study used 2021–2022 NSDUH data on adults with health care visits, comparing prescription opioid, benzodiazepine, and stimulant misuse among telehealth users versus non-users. Telehealth users had higher lifetime misuse and mental health issues, but after adjusting for misuse history and demographics, telehealth was not linked to increased past-year misuse. Findings suggest telehealth serves higher-risk patients but does not independently raise misuse risk, highlighting the need for targeted policies to balance access and safety without overly restricting telehealth.

Cognitive-behavioral interventions for co-occurring substance use and mental health disorders

Drug and Alcohol Dependence

Mental health disorders (MHD) and SUD often coexist. Combining SUD treatment with cognitive-behaviorally-based interventions (CBI) has promise for improving outcomes. This meta-analysis reviews 47 randomized trials integrating CBI with SUD treatment. CBI compared to usual care improved consumption (p=.02) but not psychosocial outcomes (p=.06). CBI + usual care compared to usual care alone showed significant improvement in psychosocial outcomes (p=.02) but not consumption (p=.17). However, when individuals treated with CBI were compared before and after treatment there was significant improvement in consumption (p<.0001) and psychosocial outcomes (p<.0001), demonstrating that 65-79% of individuals will show improvement. The authors conclude that these results show CBI interventions were modestly effective.

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Addictive-like Dimensions of Problematic Use of Social Media

Journal of Addiction Medicine

Problematic compulsive social media use shows behavioral similarities to substance use disorders. Preliminary brain imaging studies have found structural and functional deficits like those seen in substance use disorders, suggesting an addictive dimension to problematic social media use. Excessive or maladaptive use of social media can trigger or worsen symptoms of depression and anxiety, especially in young people, which may further reinforce its use and increase adverse effects. To address potential negative public health outcomes, increased oversight of social media algorithms and business models is needed, along with rigorous research to identify at-risk groups, understand consequences, and develop evidence-based prevention and treatment strategies.

New Benzodiazepine Tapering Guide—Slow and Patient Centered

JAMA Network

The authors discuss the new Guideline for benzodiazepine tapering and need for providers to be patient centered. While long-term benzodiazepine use is generally not recommended, physical dependence and withdrawal can develop within weeks of use and tapering may be needed in both short- and long-term use. No standardized evidence-based tapering protocol currently exists. Furthermore, significant heterogeneity in patient response exists with risk of not only withdrawal but also rebound of the underlying condition being treated. In this context, a slow, patient centered taper is recommended while optimizing treatment for underlying condition and focusing on patient experience and outcome beyond just reduction in dose.

Supporting Patients Through Benzodiazepine Tapering: A New Joint Clinical Practice Guideline 🔓

Journal of General Internal Medicine

Most benzodiazepines are prescribed in primary care settings, but many providers don’t feel comfortable managing tapers, resulting in patients staying on prescribed benzodiazepines beyond their clinical usefulness. The guidelines first recognize the difference between physical dependence and benzodiazepine use disorder (BUD), and the need for additional support to manage BUD. The authors recommend ongoing assessment of risks and benefits of benzodiazepine use, as well as considering tapering when risks are greater and in older populations. They support starting low and going slow (5-10% every 2-4 weeks) and note tapers are often non-linear and prolonged pauses may be needed; still some patients may require long-term use at lower doses. The authors also voice the need for careful consideration when starting these medications and continuing them given potential risks.

Cortisol and β-Endorphin Responses During a Two-Month Exercise Training Program in Patients with an Opioid Use Disorder and on a Substitution Treatment 🔓

International Journal of Molecular Sciences

During Opioid abstinence cortisol levels are increased contributing to anxiety and dysphoria, while b-endorphin levels are decreased, known to be associated with craving and relapse. Regular exercise reduces cortisol response to stress and elevates b-endorphin levels. Participants with OUD receiving OST (n=90, 57% buprenorphine and 43% methadone) were randomly assigned to exercise on a treadmill to 70% HRmax for 20 minutes, 3 times a week for 8 weeks, or serve as a control. After 8 weeks b-endorphin levels were significantly higher in the exercise group compared to baseline and had decreased slightly in the control group. Likewise, cortisol levels were significantly lower in the exercise group compared to baseline and had increased in the control group. Results in the methadone group and buprenorphine groups did not differ significantly. The authors conclude that aerobic exercise has the potential to reduce the risk of relapse.

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