#401 Updates in Addiction Medicine – SGIM 2023

June 26, 2023 | By Carolyn Chan

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We are far too classy for a “Rocky Mountain High” joke.

Live from SGIM 2023 in Aurora, Colorado!  We talk to a panel of Addiction Medicine specialists who recap their outstanding talk on all of the exciting developments in treating addiction.  We review major policy changes, trends in drug overdose, outpatient screening for alcohol use, and all of the ways we might be using psychedelics to treat addiction.  We are joined by Stefan Kertesz, MD @StefanKertesz (University of Alabama at Birmingham), Ximena Levander, MD, MCR, FACP @XimenaLevander (OHSU), Kenneth L. Morford MD, FASAM (Yale), and Katherine Mullins, MD, AAHIV @_kmullins_ (NYU Langone).

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Addiction Medicine Updates Pearls

1. The Mainstreaming Addiction Treatment (MAT) Act has removed the X-waiver requirement for the use of buprenorphine for the treatment of opioid use disorder
2. The Medication Access and Training Expansion (MATE) Act does outline specific training requirements for new or renewing DEA registrants
3. Naloxone has been approved for OTC use by the FDA – pricing and timing have yet to be determined
4. Xylazine has been increasingly implicated in opioid overdoses, as many as 25.8% of opioid overdose deaths in Philadelphia in 2020
5. Telemedicine for the provision of medications for opioid use disorder appears to be as effective as reducing overdoses as office-based visits
6. Illicit drug use has decreased among adolescents, but overdose deaths have increased in this population
7. A review of electronic health record data showed that we continue to under-screen for alcohol use
8. A recent study shows promise in the treatment of alcohol use disorder with psilocybin
9. Similarly, subanesthetic doses of ketamine were shown to decrease alcohol use in patients with alcohol use disorder
10. Artificial intelligence has been used to identify potential medications for the treatment of cocaine use disorder

Major Policy Changes!

The X-waiver is dead!

In January of this year, Congress passed the Omnibus Bill, which included the removal of the federal requirement for clinicians to submit a Notice of Intent (AKA a waiver) to prescribe buprenorphine for the treatment of opioid use disorder as part of the Mainstreaming Addiction Treatment Act.  Clinicians who have a current DEA registration with Schedule III authority may now prescribe buprenorphine if permitted by state law.  Previous requirements and restrictions, such as patient limits and discipline restrictions have also been lifted.  It is important to note that state law takes precedence here, so make sure you check on your own state’s requirements, and consider contacting your state’s medical board if anything seems unclear..  The act also directs the Substance Abuse and Mental Health Services Administration (SAMHSA) to conduct a national campaign to educate clinicians on the treatment of substance use disorder.

The Omnibus Bill also included the MATE act, which requires new or renewing DEA registrants to have undergone training on opioid or other substance use disorders.  This training can include eight hours of training (not necessarily all at once), board certification in Addiction Medicine, or having graduated from a medical, dental, physician assistant, or advanced practice nursing school within five years of June 27, 2023, provided that program had a comprehensive curriculum of at least 8 hours in managing substance use disorder.  The Curbsiders Addiction Medicine Podcast is a great resource for this training!

Naloxone goes over the counter!

On March 29, 2023, the United States Food and Drug Administration (FDA) approved the first naloxone product for use without a prescription.   The advisory committee unanimously voted to recommend approval of  4 mg naloxone hydrochloride (AKA Narcan) for over-the-counter use.  The timeline for availability and cost is determined by the manufacturer, but is anticipated by late summer of 2023.  While this is arguably great news in terms of access, cost may be a consideration, and the manufacturer has stated it will be less than fifty dollars.

Overdose Considerations

Xylazine and overdose

Xylazine is a centrally acting alpha-2 agonist used in veterinary medicine that is now increasingly being found mixed with the street opioid supply.  A sequential mixed methods study by Friedman et al. combined ethnographic research and overdose mortality data to examine this trend.  Xylazine, often referred to as “tranq,” is sometimes used to extend the high from fentanyl, which can be seen as too brief.  According to this ethnographic research, xylazine without fentanyl causes sedation without euphoria.  Additionally, xylazine has been known to cause profound skin lesions, and to result in overdoses that do not respond to administered naloxone.

Adulteration with xylazine can occur with any drug, and overdoses involving xylazine have increased by nearly 50% from 2019 to 2020 alone.  In Philadelphia, where xylazine is most prevalent, xylazine was present in 25.8% of overdose deaths in 2020.  Xylazine test strips are sometimes used by harm reduction organizations, but these are not yet FDA approved.

Telehealth and overdose prevention

During the COVID-19 pandemic, the DEA made allowances for the expansion of telehealth for the management of opioid use disorder.  A study by Jones et al. in JAMA Psychiatry examined longitudinal data in two large Medicare cohorts, a pre-pandemic and a pandemic cohort, of patients who initiated OUD-related care.  In multivariable analysis of the pandemic cohort, receipt of telehealth services for OUD was associated with a significantly lower adjusted odds ratio for fatal drug overdose.  This was also true for receipt of office-based OUD services, but the broader takeaway is that telehealth-based treatment of OUD is achievable and effective.  The rules governing telehealth for OUD are currently being reconsidered, so stay tuned.

Overdose deaths among adolescents

According to data from the Centers for Disease Control and Prevention, illicit drug use declined among high schoolers, but deaths from overdose increased.  60% of these occurred at home, and even more tragically, 67% occurred with a bystander nearby.  85% of these overdoses were attributable to illicitly manufactured fentanyl (IMFs).  Approximately 25% of these overdose deaths were thought to be due to counterfeit medications that mimicked the appearance of oxycodone or alprazolam, although this is likely an underestimation.  The key takeaways here are the importance of educating adolescents about the dangers of IMFs, promoting safer drug use (such as not using alone), expanding naloxone access, and preventing substance use initiation.

Screening for alcohol use 

Room for improvement in primary care

As a reminder, the United States Preventive Service Task Force recommends screening adults for unhealthy alcohol use in the primary care setting.  A 2022 study by Chatterton et al. examined how often alcohol screening was done with a validated tool in the primary care setting by looking at electronic health record level data.  In their study, alcohol screening occurred at 2.6% of patient visits.  Not surprisingly, counseling regarding alcohol use occurred even less frequently.  Factors that increased the likelihood of screening included the patient having three or more chronic conditions, the patient being new to the practice, and the patient being seen by their assigned primary care clinician.  Factors that decreased the likelihood of screening included presenting with a new problem and presenting for a  pre- or post-surgery visit.

Hallucinogens for the treatment of everything

Psilocybin to treat alcohol use disorder

Some of you are doubtless aware of our groundbreaking Hotcakes episode that discussed this 2022 paper by Bogenschutz et al.  The authors evaluated the use of psilocybin for the treatment of alcohol use disorder.  Patients with alcohol use disorder were randomized to either psilocybin or placebo (diphenhydramine in this case), and all patients received extensive therapy sessions.  Indeed, as part of the protocol, they had to remain in the room with the therapist for eight hours on days when they received the study drug.  The patients in the psilocybin arm had significantly fewer days of heavy drinking compared to the control arm, and lower drinking days and number drinks per day.  There were several limitations here–the participants were predominantly white, and blinding remains a challenge in studies of psychedelics.  Regardless, this is extremely promising, but it’s worth remembering that the effective medications we have for alcohol use disorder remain underutilized.

But what about ketamine?

Ketamine is a dissociative medication that acts as an NMDA receptor antagonist.  It has known antidepressant effects at subanesthetic doses, which may allow for psychological therapies to embed more readily.  Grabski and colleagues conducted a double-blind placebo-controlled phase 2 clinical trial in which patients with severe alcohol use disorder were randomly assigned to 1) ketamine infusions plus psychological therapy, 2) saline infusions plus psychological therapy, 3) ketamine infusions plus alcohol education, or 4) saline infusions plus alcohol education.  At the end of the study, there were significantly more days of abstinence from alcohol in the ketamine groups, although the confidence intervals were wide.  No serious adverse events were observed, and the effect persisted at 6 month follow up.

Robots think you should try ketamine if you use cocaine

Artificial intelligence (AI) is poised to replace us all, and this study by Gao and colleagues outlines how this may happen on the addiction medicine front.  They utilized a knowledge-driven AI-based system to identify potential drugs for cocaine use disorder.  The AI prioritizes candidate drugs by modeling connections between drugs, diseases, and genetics from publicly available databases.  An expert advisory committee (made up of humans) reviewed the top 35 candidates and ketamine was selected to further investigate, as it was the only drug candidate recommended by all committee members for further analysis.  The researchers then reviewed millions of medical records to identify patients with cocaine use disorder who had received ketamine for either anesthesia and depression.  Using propensity matching, they found that patients who received ketamine at some point had higher rates of remission from cocaine use than those who did not.  While this is far from definitive, it does point to an area that warrants further research.  

Links

NEXT Distro – online and mail-based harm reduction service

Goal

Listeners will summarize recent relevant updates in the field of Addiction Medicine

Learning objectives

After listening to this episode listeners will…  

1. Outline the recent policy changes impacting the prescription of buprenorphine and naloxone
2. Describe the impact of xylazine on the epidemic of opioid overdoses
3. Compare the efficacy of telemedicine to office-based visits in the treatment of opioid use disorder
4. Describe trends in overdoses among adolescents
5. Discuss factors that impact screening for alcohol use disorder in primary care
6. Recognize the potential role of psychedelic medications in the treatment of substance use disorder

Disclosures

Dr. Kertesz, Levander, Morford, and Mullins report no relevant financial disclosures.. The Curbsiders report no relevant financial disclosures. 

Citation

Chan C, Kertesz S, Levander X, Morford K, Mullins K, Williams PN, Watto MF. “#401 Updates in Addiction Medicine – SGIM 2023”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast June 26, 2023.