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Lead Story 

Health Affairs 

While medications for opioid use disorder (MOUD) are an effective treatment, most patients with OUD don’t receive them, and prior authorization (PA) has been a barrier to access. Researchers looked at state policies trying to address this barrier, specifically for private health insurance, between 2015 and 2022. Some states adopted “full prohibitions” against PAs while others adopted “partial prohibitions” that allowed PA under some circumstances. Overall, the number of states with at least some prohibition increased from 2 in 2015 to 22 in 2023. In addition, 7 states adopted “full prohibitions” initially, while 15 adopted “partial prohibitions,” with 4 of those 15 transitioning to “full prohibitions” later. Additional research will be needed to assess the impact of these prohibitions, but this study elucidates the current landscape of policy. 

Research and Science

Journal of General Internal Medicine 

This is a retrospective cohort study of 5,098 patient encounters utilizing a quasi-experimental design with propensity score weighting to assess effectiveness of a hospitalist-led OUD consult service (Project Caring for patients with Opioid Misuse through Evidence-Based Treatment – COMET) at Duke University Hospital. The study compared COMET patients to 2 different control groups: a historical control group (prior to COMET implementation) and a concurrent control group (patients with OUD admitted at the same time but without a COMET consult). COMET patients were more likely to receive inpatient MOUD, had decreased 30-day all-cause mortality (although a lessened effect on 90-day all-cause mortality), fewer 30-day readmissions, and longer length of stay. Buprenorphine and naloxone prescriptions at discharge were also higher among COMET patients. There was no association between COMET consultation and emergency department visits within 30 days. 

Neurology 

Heavy alcohol use (HAU) is a modifiable risk factor that may influence intracerebral hemorrhage (ICH) severity and cerebral small vessel disease (cSVD), but its role remains insufficiently understood. This cross-sectional study investigated how HAU is associated with acute ICH characteristics and cSVD burden. HAU was defined as regular alcohol consumption of ≥3 drinks per day.  HAU was associated with younger age at ICH onset, larger hematoma size, and imaging features consistent with more advanced hypertensive cSVD, including a greater burden of white matter hyperintensities. These findings suggest HAU may exacerbate acute ICH severity and accelerate long-term cerebral small vessel pathology. 

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Smoking continues to be a leading cause of preventable death worldwide and while approximately half of adult smokers try to quit, less than 10% succeed. Researchers conducted a systematic review to assess if varenicline, nicotine replacement therapy (NRT), or the combination may improve cessation outcomes. The researchers included 5 studies comparing varenicline to varenicline + NRT with follow-up of 6 months or greater. Combination therapy had better cessation outcomes (RR = 1.33, 95% CI 1.04-1.69). Only one study compared NRT to NRT + varenicline and did not find a significant difference (RR = 0.94). Researchers noted that in risk of bias evaluation 2 studies were classified as high risk and when excluded from analysis varenicline + NRT was not statistically better than varenicline alone (RR = 1.26, 95% CI 0.94-1.68). 

Learn More

JAMA Psychiatry  

This viewpoint article highlights the high prevalence of unhealthy alcohol use in the United States, in contrast with the fact that less than 2% of individuals with alcohol use disorder (AUD) use naltrexone, despite its safety and efficacy. The authors advocate that oral naltrexone should be made available over the counter (OTC) without a prescription as a way to address the public health impact of unhealthy alcohol use and barriers leading to underutilization of medications for AUD. In this way, naltrexone could be utilized as a harm reduction tool for individuals with unhealthy alcohol use who are otherwise not able to access treatment—ideally before more serious consequences of alcohol use occur. The authors draw a parallel to nicotine replacement therapy becoming OTC in the 1990s, which significantly expanded access to smoking cessation treatment. 

JAMA Psychiatry 

Preclinical evidence has shown that repeated experiences of aversive withdrawal promote avoidance behavior and compulsive opioid use, but it is unknown whether this applies to humans.  In this case-control study, individuals with chronic opioid use, regardless of whether they were addicted or using opioids chronically, showed increased learning from negative reinforcement, even in individuals with a history of prior detoxifications or varying levels of opioid use chronicity. The findings confirm that negative reinforcement is a core mechanism in opioid addiction; this is well established in preclinical research but less represented in treatment. Importantly, negative reinforcement is not limited to the later stages of addiction but is even observed after regular opioid use, potentially contributing to the development of addiction, which may have important implications for the development of more effective preventive and therapeutic interventions. 

The New England Journal of Medicine 

This Perspective piece describes a series of recent actions undermining harm reduction. Funding cuts have stopped overdose data collection and all SAMHSA employees working on the National Survey on Drug Use and Health have been fired. A July executive order prohibits funding of harm reduction because it “… facilitate(s) illegal drug use…” and the order threatens legal action against harm reduction organizations. Overdose prevention centers providing naloxone could be targets for legal action. Some states have imposed penalties for possession of even small amounts of fentanyl that will affect people who use fentanyl along with drug traffickers. The authors conclude that this “is an assault on an approach to health care that prioritizes evidence, compassion, and dignity— values central to the medical profession.” 

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Journal of Addiction Medicine

People who accessed online Narcotics Anonymous (NA) meetings using Zoom were asked to complete an anonymous survey. Of 1,645 completing the survey 356 indicated that methamphetamine was their primary drug problem. Of these, 70% were female and 84% had attended face-to-face NA meetings and had been drug-free for an average of 2.3 years. Those using the online site for the first time (44%) were half as likely to have a sponsor or to have worked any steps. Those having used methamphetamine in the past month had attended significantly fewer NA meetings in the past month (p<.001). Those reporting a spiritual awakening (74%) had half the craving of those still using methamphetamine, attended more meetings, and were more likely to have a sponsor and to have worked some of the steps. The authors note that online meetings, where you have the option to turn your camera off, may appeal to those with social anxiety in face-to-face meetings. 

In the News

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