The article, “Harms Versus Harms: Rethinking Treatment for Patients on Long-Term Opioids,“ has been published in SAj.

In this commentary, the authors state that in 2022, the CDC began encouraging clinicians to weight the risks versus harms of continued therapy and empathetically engage patients in patient-centered discussions around continued therapy while avoiding patient abandonment. This commentary discusses how the emphasis on “benefit” will almost always lead to discordance between the patient and provider since many clinicians find little benefit in opioid therapy for chronic pain with evidence questioning its efficacy for chronic pain. The authors believe this disagreement between patients and providers has the potential to lead to unilateral tapers or patient abandonment and further increase patient harm. Considering this dilemma, they propose a revised framework that emphasizes weighing the harms of continuation of therapy against the harms of discontinuation of therapy when caring for patients on long-term opioid therapy. The authors state that this revised harm-reductive decisional framework has the potential to retain patient-provider trust and increase opportunities for engagement in evidence-based multi-modal pain treatment, including non-opioid based treatment options.

In the AUTHORS’ OWN WORDS, they relate the importance of their work:

“In patient care, physicians are counseled to weigh each treatment’s risks against its benefits. But what happens when patients and doctors don’t agree on the benefits of continuing opioid therapy when the risks are almost never negligible and are difficult to predict? A physician-initiated opioid taper without patient buy-in may seem inevitable, despite its potential to precipitate harm. To prevent such harm, we propose a revision to the risk-benefit framework that could help both clinicians and patients approach this fraught decision in a more thoughtful way.”

The article, “Low Dose Buprenorphine Initiation: A Guide for the Inpatient Clinician,” has been published in SAj.

In this commentary, the authors state that no literature exists directly comparing traditional buprenorphine initiation to low dose buprenorphine initiation (LDBI). Until information on long-term outcomes is available, these dosing strategies should be reserved for patients unable to tolerate traditional buprenorphine initiation. Available published research suggests LDBI strategies will allow some patients to successfully transition to buprenorphine with minimal or no symptoms of withdrawal. Ensuring access to pharmacotherapy during hospital admission is a crucial time for potential intervention and should be considered when appropriate. This narrative review discusses the background of LDBI strategies as well as practical clinical and operational considerations for the inpatient clinician.

In the AUTHORS’ OWN WORDS, they relate the importance of their work:

“While vast, evidence surrounding LDBI is limited to case series, feasibility studies, single-arm retrospective cohort studies, and comparative studies using historical controls. There are no prospective, randomized studies directly comparing clinical outcomes of varying buprenorphine dosing strategies.”

“Due to lack of high-quality evidence supporting LDBI, these strategies should be reserved for patients who cannot tolerate traditional buprenorphine initiation and would otherwise be precluded from receiving buprenorphine. Patients with concomitant pain, high distress, medically fragile, or those with concurrent illicit fentanyl use may prove the best candidates for these strategies.”

The article, “Effects of Smoking Marijuana on the Respiratory System: A Systematic Review,” has been published in SAj.

In this commentary, the authors state that the prevalence of marijuana use and its derivatives has surged over the past century, largely due to increasing legalization globally. Despite arguments advocating its benefits, marijuana smoking exposes the lungs to harmful combustion byproducts, leading to various respiratory issues such as asthma, pneumonia, emphysema, and chronic obstructive pulmonary disease.

In the AUTHORS’ OWN WORDS, they relate the importance of their work:

“Despite existing research, significant knowledge gaps remain. Few studies have isolated the effects of individual components of marijuana smoke on lung tissue, meaning our understanding of how marijuana smoke impacts the lungs and how these effects compare to tobacco smoke remains limited. Additionally, the long-term effects of marijuana use on lung health are inadequately understood, making it difficult to develop effective risk minimization strategies. Further complicating matters, varying legal statuses and stigma attached to marijuana use impede large-scale, longitudinal studies, contributing to these knowledge gaps.

There is an undeniable need for more research to shed light on the unknowns, particularly given the increasing usage and changing legal landscape. This study aims to consolidate available information on the immediate and long-term effects of marijuana on the respiratory system and underscore areas requiring further investigation.”

The article, “Leveraging National Data and Regional Innovations to Right-Size Tobacco Treatment Policy for Behavioral Health in a Midwestern State,” has been published in SAj.

In this commentary, the authors state that people with mental health (MH) and substance use disorders (SUD) have high rates of tobacco use and tobacco-related mortality. They want to stop smoking and studies have shown they can quit, but few behavioral health facilities provide tobacco treatment.

In the AUTHORS’ OWN WORDS, they relate the importance of their work:

“Tobacco use remains the leading preventable cause of death worldwide, estimated to cause more than 7 million deaths per year. People with mental health or substance use disorders (MH/SUD) are disproportionately affected by high smoking prevalence, being 2 to 4 times more likely to smoke cigarettes than the general population. They also die 5 or more years earlier from smoking-related diseases compared to people with MH/SUD who do not smoke.”

“The purpose of our study was to summarize data on tobacco services in MH/SUD facilities in states similar to our own, identify policies these states that were associated with high rates of tobacco treatment, and present these data to state leaders to encourage them to adopt similar policies to potentially increase support for tobacco recovery in behavioral health facilities. This descriptive ecologic study may serve as a model for how other states can leverage readily available data to help their states identify locally feasible policies to reduce tobacco-related illnesses and deaths among people with MH/SUD.”

The article, “Will the End of the X-Waiver Expand Access to Buprenorphine Treatment? Achieving the Full Potential of the 2023 Consolidated Appropriations Act,” has been published in SAj.

In this commentary, the authors state that the expansive Consolidated Appropriations Act of 2023 was the last major law passed by the 117th Congress, and for opioid use disorder (OUD), it may prove its most consequential. The Act repeals the requirement that clinicians who prescribe buprenorphine, a life-saving medication for OUD, obtain a special license (the “X-waiver”) from the Drug Enforcement Administration (DEA). The repeal of the waiver was long sought by advocates and had bipartisan support. The Drug Addiction Treatment Act of 2000 (DATA), which created the waiver requirement, was a Congressional compromise allowing office-based prescribing of opioids to treat OUD; but the law was constrained by decades of arcane federal controlled substances law.

In the AUTHORS’ OWN WORDS, they relate the importance of their work:

“The repeal of the X-waiver sets the stage for the expansion of buprenorphine treatment, but this potential can only be fully achieved by eliminating the bottlenecks that often cause patients to miss the chance to receive life-changing treatment. The difficult task that lies ahead is ensuring that the greater flexibility in the federal law is met by an educated workforce, empowered by state regulations, with the capacity to get patients into treatment when they need it the most.”