The ASAM Weekly for September 17th, 2024

This Week in the ASAM Weekly

Two publications this week are part of special issues in their respective journals. The HEALthy Brain and Child Development (HBCD) Study is a first-of-its-kind on brain development, and the journal Developmental Cognitive Neuroscience includes 17 publications written by the teams involved with the design and implementation of specific components of the study. 

A six-paper series in The Lancet Public Health calls for changing the narrative around suicide prevention, and one of its publications focuses on the role of social and commercial determinants of health. The authors advocate for further expanding current prevention models beyond individual risk factors and mental health interventions but articulate this in a way that will resonate well with those interested in addiction prevention - suicide is more than a mental illness. 

Keeping that in mind, The New York Times has published (yet again) an article that tries to say there is an “us against them” view about the definition of addiction, but there isn’t. No one is “discounting the many genetic, social, environmental and other factors” involved with addiction. So, it’s ok for us to all agree that addiction is a brain disease while also agreeing it is a disease of not only the brain.  

A profile of William Cope Myers demonstrates this well as he describes the complexity of opioid addiction after more than a decade of recovery from crack cocaine. When his approach to recovery, at first, did not work the second time around, buprenorphine did, and from there his recovery flourished (The New York Times).  

So, while we better understand the roles of social and commercial determinants of health, prenatal and protective factors of child development, and dialogue about the definition of addiction, we will continue to make progress in understanding the discontinuation of MOUD (Addiction), the impact of cannabis laws on mental health treatment (JAMA Network Open), and even the role of ketamine in buprenorphine induction (Addiction Science and Clinical Practice).  

 If it all seems very complicated, that's because it is. The brain is the only existential organ we’ve got, and addiction is one of its diseases. 

Thanks for reading,

Nicholas Athanasiou, MD, MBA, DFASAM
Editor in Chief

with Co-Editors: Brandon Aden, MD, MPH, FASAM, Jack Woodside, MD, John A. Fromson, MD

Lead Story 

Cannabis Laws and Utilization of Medications for the Treatment of Mental Health Disorders  🔓

JAMA Network Open

This cross-sectional study of 9,438,716 commercially insured patients examined if access to cannabis, via medical or recreational legalization, is associated with changes in the dispensing of prescription medications to treat mental health disorders. Researchers found statistically significant reductions in benzodiazepine dispensing after increases in both medical and recreational cannabis access. However, evidence suggests increases in other types of psychotropic dispensing. The study suggests that cannabis laws may be significantly associated with the population-level use of prescription drugs to treat mental health disorders, although the associations vary by drug class and state.

Naloxone Stigma Among People Who Use Drugs: Characteristics and Associations With Stigma Toward Medication for Opioid Use Disorder 

Journal of Addiction Medicine

The authors describe naloxone stigma based on “risk compensation beliefs” that the safety afforded by naloxone allows increased opioid use and decreases treatment seeking. These beliefs are common among the general public, physicians, pharmacists, police officers, and EMTs. This study surveyed 195 people who use drugs (PWUD) regarding stigma towards naloxone and MOUD. About 1 in 5 PWUD reported risk compensation beliefs regarding naloxone. Cis women were less likely to have naloxone stigma than cis men. Naloxone stigma was associated with nonopioid substance use, recent stimulant use, no experience with overdose, and fewer recovery attempts. MOUD stigma had similar trends so that stigma for naloxone and MOUD were highly correlated. Depression symptoms were associated with MOUD stigma but not naloxone stigma. The authors suggest that PWUD receive more overdose and naloxone education.

Alcohol pharmacotherapy dispensing trends in Australia between 2006 and 2023 🔓

Alcohol and Alcoholism

Australia’s pharmaceutical benefit supports treatment of AUD with naltrexone and acamprosate. This study looked at benefit data between 2006 and 2023 to assess the use of these pharmacotherapies for AUD. Prescriptions for naltrexone made up 45%, acamprosate 43%, and 12% were prescribed both concurrently. Over the 17 years studied, individuals treated with naltrexone increased 2.6 fold with only modest increases for acamprosate. Treatment guidelines suggest 3-6 months of medication; however, 79% completed only 1 month, and only 5% completed 3 months. Using estimates of prevalence of AUD in Australia, it was estimated that only ~3% of individuals with AUD receive pharmacotherapy. Naltrexone individuals were more likely to refill prescriptions and to complete the recommended 3-month treatment. The authors conclude that naltrexone dispensing has increased substantially; however, use of pharmacotherapy for AUD remains low.

Learn More 

Preventing suicide: a public health approach to a global problem 🔓

The Lancet Public Health

Suicide is prevalent in all countries and is largely preventable. The causes of suicide are multiple and varied. Social determinants of suicide are crucial, but to date, these have received insufficient policy attention. This paper, which is the first in a Lancet Series on taking a public health approach to suicide prevention, argues for a major change in the way we think about suicide and its prevention. The authors present a public health model that emphasizes the broad social determinants of suicide and describe a framework through which these might be addressed. They also argue for a policy reset that would take national suicide prevention strategies to the next level. Such policies would become whole-of-government endeavors that tackle major social determinants of suicide at their source. High-quality data and methodologically rigorous evaluation are integral to this public health approach.

An Introduction to the HEALthy Brain and Child Development (HBCD) Study 🔓 

Developmental Cognitive Neuroscience

This article gives an overview of the HEALthy Brain and Child Development (HBCD) Study, which is featured in a special issue of Developmental Cognitive Neuroscience along with 17 other articles describing various components of the HBCD study. The authors note that exposure to a variety of hazards and events prenatally and in early life can affect brain development. Specifically, 10% of births are exposed prenatally to risky levels of alcohol and drugs. Protective factors, such as stable caregiving, will be included. Researchers plan to recruit over 7,000 mother/infant pairs from 27 sites nationwide and follow child development to age 10 years. Prenatal substance use exposure will make up 25% of the HBCD cohort. Assessments will include neurobehavioral performance, surveys, neuroimaging, EEG, biospecimens, and wearable biosensors. Data will be made available yearly.

The interaction of oxytocin and nicotine addiction on psychosocial stress: an fMRI study 🔓 

Translational Psychiatry

There is prior evidence that oxytocin (OXT) has anxiolytic effects, reducing subjective and cortisol responses to psychosocial stressors, but this response is moderated among those with nicotine dependence. In this study, researchers examine the response to OXT in smokers and non-smokers during psychosocial stressors utilizing functional neuroimaging, salivary cortisol levels, and subjective responses to better understand this relationship. The authors found the anterior right superior temporal gyrus (rSTG) to be a site of interaction, with an altered response to OXT among smokers. In addition, they found when transcranial direct current stimulation (tDCS) was applied to the rSTG, the anxiolytic effects of OXT were restored. The authors note these findings can help support the development of interventions among smokers. 

Ketamine-assisted buprenorphine initiation: a pilot case series 🔓 

Addiction Science and Clinical Practice

Buprenorphine-precipitated opioid withdrawal (BPOW) can be a barrier to buprenorphine induction, and while new strategies including low-dose and rapid high-dose initiation have been developed, they may not work for everyone. Ketamine has been used in inpatient settings intravenously to relieve opioid withdrawal symptoms, but its use in outpatient settings is not feasible. In this case series, researchers examined sublingual ketamine use along with buprenorphine induction and its impact on BPOW and initiation. Among 37 patients prescribed ketamine, 24 took it, 16 completed buprenorphine initiation, and 12 were retained in treatment at 30 days. In addition, patients reported that the ketamine relieved opioid withdrawal symptoms and BPOW symptoms without any significant side effects. 

In The News 

Broken Again. A National Advocate for Drug Recovery Relapses

The New York Times

Rethinking Addiction as a Chronic Brain Disease

The New York Times

A new fentanyl vaccine looks promising – but treating drug addiction needs a more complex approach

The Conversation

Gambling addiction: A looming public health crisis in the US

The Hill

With marijuana at a new level of scrutiny, here’s what the research says

The Charlotte Observer

Map Shows States With the Highest Drug Deaths

Newsweek