This Week in the ASAM Weekly

Guest Editorial: One of These Things Is Not Like the Others
Stephen A. Martin, MD, EdM, FAAFP, FASAM

This guest editorial is part one of a two-part series on drug testing.

Over the past decade, addiction practice in America has been slowly evolving from an abstinence-based to a low-threshold model. For opioid use disorder (OUD), low-threshold models deliberately make it easy to start and continue life-saving buprenorphine or methadone.^1-4

Yet we continue to drug test in nearly the same ways as before, seemingly oblivious to the internal inconsistency embedded in this practice.⁵ Drug testing, derived from an abstinence-based model, is poisoning the well of low-threshold practice.

How we got here isn’t a pretty story, and an understanding of contemporary care requires historical inquiry, skill in clinical reasoning, and an awareness of one of medicine’s tragic flaws: hubris.^6-8 Below is a short summary, hewing closely to the original sources and framed as a set of rhetorical questions.

Read the full editorial here.

Lead Story

Oral methadone versus sublingual buprenorphine for the treatment of acute opioid withdrawal: A triple-blind, double-dummy, randomized control trial

Drug and Alcohol Dependence

Researchers compared oral methadone to sublingual buprenorphine for the management of acute opioid withdrawal. Patients at an inpatient drug treatment center in India were randomly assigned to receive either methadone or buprenorphine titrated over days 1-3 to control opioid withdrawal symptoms. Over days 4-10 medications were tapered and stopped by day 11. Completion of treatment was similar in both groups (83% methadone, 82% buprenorphine). Both subjective (SOWS) and objective (COWS) withdrawal symptoms decreased during treatment; however, the buprenorphine group had significantly greater withdrawal symptoms than the methadone group (p=0.009) at the end of treatment (day 10). Opioid craving also decreased in both groups with no significant difference between groups. The authors concluded that methadone is a safe and effective alternative to buprenorphine for management of opioid withdrawal.

Research and Science

Feasibility and acceptability of a contingency management program for stimulant use disorder in a pallet shelter community for homeless-experienced veterans 🔓

Journal of Substance Use and Addiction Treatment

Contingency management (CM) is the most effective psychosocial treatment for stimulant use disorder, yet it remains underutilized. This study implemented a 12-week pilot CM program following the standard VA CM protocol within a pallet shelter community for homeless-experienced veterans in Los Angeles. Researchers used mixed methods to evaluate feasibility and acceptability, including measures of attendance, stimulant abstinence, and qualitative interviews with participants (n=10) and staff (n=6). The average attendance rate was 32% with 49% of urine drug screens negative for stimulants. Participants found CM to be accessible and supportive, and they appreciated that it met immediate needs and enhanced engagement with health services; however, participants reported concerns regarding privacy, stigma, and perceptions of insufficient rewards. Findings from this study should be considered as CM programs are developed in community-based settings.

Neurological Injury and Outcomes in Fentanyl-related Cardiac Arrest

Journal of Addiction Medicine

Researchers reviewed medical records of patients at San Francisco General Hospital who had out-of-hospital cardiac arrest (CA), circulation reestablished, and survived > 6 hours (sufficient time for neurological assessment). Fentanyl-related CA (n=36) was compared to other opioid-related CA (n=13) and CA not related to opioids (n=184). The fentanyl-related CA group had a lower rate of bystander CPR than the opioid and nonopioid groups (19% vs 39% vs 44%, p=0.02) and a lower rate of shockable rhythm (3% vs 17% vs 25%, p=0.01). There was no difference in the proportion with good neurologic outcome at discharge (22% fentanyl, 39% opioid, 26% nonopioid, p=0.52). The fentanyl group was younger than the other groups (42yrs vs 55yrs vs 64yrs, p<0.001) but additional analysis concluded that age was not a significant factor in neurological outcome.

Implementation of a Statewide Fentanyl Possession Law and Opioid-Related Overdose Deaths 🔓

JAMA Health Forum

High-potency synthetic opioids such as fentanyl have led to a significant increase in opioid-related overdose deaths (OODs). In attempts to address this issue, many states have classified fentanyl possession—even small amounts—as a felony. Colorado passed a bill in 2022 that made possession of more than 1 g of a drug containing any amount of fentanyl a felony punishable by up to 180 days in jail. Researchers conducted a cross-sectional study of adults in Colorado that experienced an OOD from January 2018 to November 2023 to evaluate if the 2022 law resulted in any change in OODs. The yearly overdose rate increased from 11.99 per 100,000 in 2018 to 25.0 per 100,000 in 2023. Overall OODs did not significantly differ from the predicted number; however, among the non-Hispanic Black population, rates of OODs were significantly higher than predicted. Given the growing push to increase criminal penalties for drug possession, this study is important as it suggests these policies do not decrease—and may worsen—OODs.

Learn More

Trends in Medical and Nonmedical Use of Prescription Stimulants Among US Adolescents

Journal of the American Medical Association

Researchers examined trends in medical and nonmedical prescription stimulant use patterns for attention-deficit/hyperactivity disorder (ADHD) among US adolescents. Current medical use of prescription stimulants for ADHD increased between 2005 and 2023, while nonmedical use decreased. Lifetime nonmedical use was more prevalent than medical use in early cohorts but shifted to being less prevalent in recent cohorts. These findings are consistent with declines in peer-to-peer diversion among adolescents following COVID-related school closures and findings from adult studies. Despite concerns about increased stimulant prescribing, findings indicate no associated increase in nonmedical prescription stimulant use at this time, although longitudinal research and continued monitoring is necessary. These findings enable clinicians and policymakers to consider population-level trends in medical and nonmedical use patterns when weighing the risks and benefits of prescription stimulants.

US Nitrous Oxide Mortality 🔓

JAMA Network Open

More than 13 million people in the US report using the inhalant drug nitrous oxide (also known as laughing gas or whippets) in their lifetime. Nitrous oxide misuse poses serious health risks, such as oxygen deprivation, which may result in hypoxia, neurological damage, and even death. This cohort study examined national trends in nitrous oxide poisoning mortality in the US. Nitrous oxide-related mortality increased markedly from 2010 to 2023. This upward trend was significant through 2018 but plateaued from 2019 to 2023. These patterns align with increasing recreational use, particularly among adolescents and young adults. Contributing factors may include increased availability and low cost, although these were not assessed directly.

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