The ASAM Weekly for November 12th, 2024

This Week in the ASAM Weekly

The publications this week come with some great questions. 

An editorial from the Journal of Hepatology asks a tough one – is there a safe limit for drinking alcohol? Although the authors do not claim to answer it, because the evidence indicates there is no safe amount, they do bring attention to a gap in public health guidance that leaves the public to risk stratify for themselves. 

Has cannabis legalization changed perceptions about safety? A study from Kaiser Permanente found a sharp rise in prenatal cannabis use across Northern California communities that legalized retail sales (JAMA Health Forum). We have yet to understand the full impact of these findings.  

An article from Pediatrics examines the circumstances behind fatal pediatric opioid poisonings. Consistent with prior studies, these deaths occur most often in the home, but in addition, this study found a prevalence of adolescent substance use and a history of child abuse among the decedents. Does this mean we should make naloxone universal for such households, as the authors propose? 

A special issue of the American Journal of Psychiatry covers a range of topics related to substance use disorders, but one study in particular asks a fundamental question - what changed when we transitioned from DSM-IV to DSM-5 SUD diagnoses? Not too much evidently, but study findings did confirm that a disease spectrum is much more reliable than the previous bifurcation. (AJP).       

Lastly, a study from the Journal of Addiction Medicine examined clinician characteristics and support of office-based methadone prescribing. Although it is limited from making broad generalizations, it is asking something extremely important - are we ready to prescribe methadone?  

If you want to learn more about these questions, please see below. Even when we might be looking at the same data, we can still come to different conclusions - and that’s OK.  

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 Use During Early Pregnancy Following Recreational Cannabis Legalization 🔓

JAMA Health Forum

Using data from a large health care system in California with universal screening for cannabis use during early pregnancy, the authors examined cannabis use between 2012 and 2019 and the potential impact of recreational cannabis legalization (RCL). Prenatal cannabis use steadily increased from 4.5% to 7.1% prior to implementation of RCL in California, but there was a significant increase in the first month after RCL implementation (8.6%) in 2018. This significant increase was only seen in locales that allowed adult-use retail of cannabis. While the authors note longer term studies are needed to see if this disparity persists, the difference in rates of use in jurisdictions that allowed the sale (8.4%) vs banned (7.4%) remained at the end of 2019.  

Research and Science 

The Circumstances Surrounding Fatal Pediatric Opioid Poisonings, 2004–2020 🔓 

Pediatrics

Using data from the National Fatality Review-Case Reporting system, this study examined opioid overdose deaths in children 0 to 17 years of age between 2004 and 2020. Most deaths occurred in the child’s home (65.3%), with most deaths involving prescription opioids (91.8%), followed by fentanyl (7.7%) and heroin (5.4%), with fentanyl increasing in frequency over time. A significant proportion of children had a history of maltreatment (30.6%) themselves and/or having a caregiver with a history of being a perpetrator to any child. Among children 10-17, 68.4% had a history of substance use/abuse, and overall, 25.9% of children had a primary caregiver with a history of substance use/abuse. The authors support making naloxone universally available to all families with a history of maltreatment or substance use.  

Clinician and Practice Characteristics Associated With Support of Office-Based Methadone: Findings From a National Survey

Journal of Addiction Medicine

During the height of the COVID-19 pandemic, restrictions on methadone dispensing were relaxed. Many of these policy changes have since been made permanent, suggesting further changes are possible. In this study, the authors surveyed providers of adults with opioid use disorder (OUD) in outpatient longitudinal care to assess characteristics associated with support for office-based methadone. Overall, 28% of respondents supported office-based methadone; more likely supporting this policy were providers with >15 years of experience, having previously provided methadone, treating 51-100 patients monthly with medication of OUD (MOUD), being Black/African American, and working in academic or urban settings.. The authors suggest that efforts to support office-based methadone should address implementation barriers and engage clinician champions.

Effectiveness of exercise intervention in improving physical and mental status of patients with alcohol use disorders: A systematic review and meta-analysis 🔓

PLOS ONE

This study reviewed the effectiveness of exercise in the treatment of alcohol use disorder (AUD). An extensive literature search produced 17 randomized controlled trials that included 1,905 patients with AUD. A variety of exercise interventions (aerobic, resistance, yoga, etc.) ranged in duration from 3 to 24 weeks (mainly, 12 weeks). Exercise reduced drinks per day by 0.66 and AUDIT scores by 0.36. There were reductions in anxiety (p=.007), depression (p=.002), and stress (p=.02). Resting heart rate was reduced and oxygen delivery to tissue improved. In conclusion, exercise resulted in improvements in measures of AUD as well as improvements in the patients’ mental and physical states.

12-month Prevalence Estimates of Substance Use Disorders Using DSM-5 Versus DSM-IV Criteria Among U.S. Nonelderly Adults With Substance Use 

The American Journal of Psychiatry

Using 2021 National Survey on Drug Use and Health (NSDUH) data, this study found that among US adults ages 18–64 who used substances in the past 12 months, the shift from DSM-IV to DSM-5 was associated with marked increases in 12-month prevalence estimates of common SUDs. While the addition of craving as a criterion in DSM-5 SUDs (and withdrawal for cannabis) explains some of the increase (particularly for mild SUDs), marked increases in prevalence for all four common SUDs were found, confirming that the threshold of any two criteria for an SUD using DSM-5 criteria, as assessed by the NSDUH, is associated with higher SUD prevalence than DSM-IV criteria. Higher prevalence estimates of DSM-5 SUDs compared to DSM-IV criteria based on recent NSDUH data suggest that significantly larger proportions of adults who use common substances may have SUDs. These adults may need interventions than has been previously reported.

Learn More 

Is there a safe limit for consumption of alcohol? 🔓 

Journal of Hepatology 

This paper reviews the evidence and discussion about safe amounts of alcohol consumption. Levels of alcohol consumption are increasing in many countries around the world, and the authors discuss the costs to society. Current American dietary guidelines limiting the number of drinks per day reflect early studies suggesting a health benefit from moderate alcohol consumption. However, a 2023 review and meta-analysis concluded there is no health benefit from any level of alcohol consumption. Abstinence is the healthiest policy for patients with several medical conditions, including chronic liver disease, type II diabetes, hypertension, and obstructive sleep apnea. The authors propose that for healthy individuals consuming a single drink per session with intervening abstinent days is not a “meaningful risk to health.”

Endocannabinoid concentrations in major depression: effects of childhood maltreatment and relation to hippocampal volume 🔓

Translational Psychiatry

This study examined whether the relation between major depressive disorder (MDD) and peripheral endocannabinoid (eCB) concentrations would vary as a function of childhood maltreatment (CM) history. It also examined whether eCBs moderate the relation of CM/MDD and hippocampal volume. MDD was associated with eCBs, though not all associations were moderated by CM or in the direction expected. Specifically, MDD was associated with higher anandamide (AEA) relative to healthy comparison participants (HCs) regardless of CM history, a difference that could be attributed to psychotropic medications. MDD was also associated with higher 2-arachidonylglycerol (2-AG), but only for participants with CM. Consistent with hypotheses, the authors found lower left hippocampal volume in participants with versus without CM, but only for those with lower AEA, and not moderate or high AEA. This study presents the first evidence in humans implicating eCBs in stress-related mechanisms involving reduced hippocampal volume in MDD.

Factors associated with medications for opioid use disorder (MOUD) treatment success during the pregnancy and postpartum periods: A scoping review 

Drug and Alcohol Dependence

The authors reviewed articles on MOUD use during pregnancy to identify factors affecting MOUD success. A literature search identified 15 studies meeting their inclusion criteria - 13 observational studies and 2 controlled trials (one randomized). Markers of success included treatment adherence, treatment retention, and abstinence. Higher MOUD dose, early initiation (including before conception), and longer duration of MOUD were associated with success. Legal involvement, rural residence, homelessness, and benzodiazepine use had a negative impact. Psychiatric and other substance use disorders should be addressed. Use of telemedicine did not influence outcomes.

In The News 

Fentanyl Overdoses May Cause Brain Injury

Psychology Today

Uptake Of New Non-Opioid Drug Suzetrigine May Benefit From No Pain Act

Forbes

This kratom drink was marketed as an alcohol alternative to be sold over the counter. Some consumers say it led to addiction.

CBS News

How Cannabis Use is Changing Across the U.S.

The New York Times

This Week's Election Results Are a Discouraging Sign for Drug Policy Reformers

Reason