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This Week in the ASAM Weekly

This week we present several pragmatic models of delivering addiction treatment to individuals with substance use disorders. Emergency medical services (EMS) truly operate in the last-mile of health care delivery, and a novel, low-cost approach to closing the treatment delivery gap is physician supported/paramedic-administered buprenorphine. In survivors of overdose, this led to improved opioid withdrawal symptoms and outpatient follow-up but also more refusals (less need?) of ED transport ().

Bridge programs are a next link in the treatment delivery system. UPMC’s OUD Bridge Clinic had high engagement rates (96%) and low-cost scalability. The clinic also had over 80% audio visits without the availability of urine drug testing in a mostly disadvantaged population -- practically unheard of only a few years ago (). Telephone-based cognitive and behavioral therapy can be effective in reducing some alcohol-related harms after minimal engagement, but more importantly this intervention was applied in a population with high rates of severe alcohol use that rarely sought treatment previously ().

Unfortunately for individuals actively seeking OUD treatment, stigma can still be a barrier within primary care, as patients with OUD are 3 times less likely to be offered new patient appointments. But one study’s secondary analysis of generational differences among physicians highlights the sustainable progress addiction education and awareness has had on younger physicians ().

Some of this edition’s publications touch upon broader questions, such as:

How should we frame our conversations around cannabis and quality-of-life issues ()? What are we going to do about gabapentin ()? Can electronic health records better identify individuals with intravenous drug use ()?

Thanks for reading,

Nicholas Athanasiou, MD, MBA, DFASAM
Editor-in-Chief

with Co-Editors: Brandon Aden, MD, Debra R. Newman, PA-C, MSPAS, MPH, Jack Woodside, MD, John A. Fromson, MD

Lead Story

Annals of Emergency Medicine

Initiation of buprenorphine in emergency departments (EDs) after opioid overdose is increasing, but many patients seen by emergency medical services (EMS) in the field refuse transport to the ED or leave the ED prior to evaluation. This study evaluated a program in which EMS was able to provide buprenorphine to patients in the field after opioid overdose, along with a same or next-day appointment in a substance use disorder clinic. Patients evaluated by EMS units with buprenorphine were significantly more likely to engage in treatment within 30 days (OR 5.62) than those evaluated by non-buprenorphine units. In addition, those evaluated by EMS units with buprenorphine who received buprenorphine were significantly more likely to engage in treatment (OR 12.83) than those who did not. There were no significant differences in subsequent opioid overdoses between groups. 

Research and Science 

JAMA Psychiatry

In this randomized clinical trial of 344 participants with problem alcohol use, reductions in the primary outcome-- alcohol problem severity-- were not significantly different between stand-alone telephone-delivered intervention and control groups at 3 months. However, the intervention was associated with a significantly greater reduction in hazardous alcohol use and a reduction in alcohol problem severity when 2 or more sessions were delivered. Although reductions in alcohol problem severity were not significantly different between treatment groups at 3 months, results demonstrate the potential benefits of this highly scalable and accessible model of alcohol treatment.

Journal of Addiction Medicine

This article is a summary of current knowledge about gabapentin use during pregnancy and breastfeeding. A large study of gabapentin-exposed pregnancies found only a possible risk of cardiac malformations. The authors did note increased preterm birth and increased NICU admissions. Others have reported neonatal withdrawal after in utero gabapentin exposure that is relieved by lorazepam or gabapentin. In infants exposed to opioids in utero, risk of NAS was increased when also exposed to gabapentin (OR 1.6). Gabapentin is secreted in breastmilk but the impact on neonates is unknown. It is known to increase fatality risk in OUD and misuse is usually seen in those using other substances, particularly opioids. A study of patients with OUD treated with methadone found 15% to 38% misused gabapentin. The authors conclude that caution is warranted about gabapentin use during pregnancy.